Thymomas generally arise from the thymus in the anterior mediastinum. Ectopic thymomas arising in the middle mediastinum are rare. We present a case of a thymoma arising from the ectopic thymic tissue in the right paratracheal region.The patient was a 67-year-old male who underwent an enhanced-computed tomography examination as preoperative staging for colon cancer. A 20-mm nodule in the right paratracheal region was found incidentally. Fluorodeoxyglucose (FDG) accumulation was detected in this solitary nodule by FDG-positron emission tomography, mimicking an enlarged, possibly malignant lymph node. The tumor was removed by thoracoscopic surgery, and a postoperative pathological diagnosis of type AB thymoma was made. Foci of ectopic thymic tissues were found adjacent to the thymoma. The patient was disease-free and without recurrence 2 years postoperatively.Including the present case, 13 cases of ectopic paratracheal thymoma have been reported in the English literature, all of which were found on the right side of the paratracheal region. Although ectopic thymomas in the paratracheal region are rare, thymomas may be considered as a differential diagnosis for a paratracheal nodule. In general, thymomas originate from the thymus in the anterior mediastinum. Occasionally, an ectopic thymoma is found outside the anterior mediastinum, including in the neck, middle or posterior mediastinum, lung, and pleura . EctopicA 67-year-old male was admitted to our hospital for treatment of sigmoid colon cancer. Contrast-enhanced CT showed a homogenous enhanced nodule with a 20-mm diameter in the right paratracheal region. The nodule mimicked an enlarged paratracheal lymph node (LN) Fig. a. DuringTumor resection was performed by thoracoscopic surgery using four ports in the left lateral position. The tumor was located between the superior vena cava and trachea in the cranial side of the arch of azygos vein. After dissecting the mediastinal pleura, the tumor together with surrounding paratracheal LN was resected using a vessel sealing system, in accordance with LN dissection in lung cancer.The resected specimen measured 2.3 × 1.7 cm, and showed a well-encapsulated tumor with a lobulated appearance separated by fibrous bands. Microscopic examination showed that the specimen comprised lymphocyte-poor and lymphocyte-rich areas. In lymphocyte-poor areas, the oval- to spindle-shaped neoplastic cells were arranged in a fascicular pattern  of ectopic thymoma in the paratracheal region is presented in Table Differential diagnoses for paratracheal nodules include LN hyperplasia, lymphoma, metastatic LN, sarcoidosis, Castleman disease, and infectious disease. Neurogenic tumors and mediastinal goiters may also occur in the middle mediastinum. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) may be useful for diagnosing a paratracheal tumor. Although the main application of EBUS-TBNA is mediastinal LN staging for lung cancer, it has been found useful in the diagnosis of other diseases, such as sarcoidosis and lymphoma. Successful diagnosis and sub-classification using EBUS-TBNA has been reported in four cases of thymoma with an anterior mediastinal mass invading the paratracheal region . AnotherSurgical procedures for the treatment of ectopic thymomas are not well established. Thymothymomectomy is the standard surgical procedure for usual anterior mediastinum thymomas. However, almost all cases of paratracheal thymoma underwent simple tumor resection, based on a preoperative diagnosis of a benign tumor by imaging examination. A recent report suggested that simple resection of the tumor, including an adequate surgical margin from the tumor, was acceptable for the treatment of stage I thymoma, with regard to postoperative complications and prognosis . Post-thThymomas are not often considered in the differential diagnosis of paratracheal nodules. However, because of the malignant potential and long-term survival of patients after complete resection, thymomas should be considered as a differential diagnosis for paratracheal tumors. Complete resection should be attempted at the time of the operation.


Teeth with furcal perforation present difficult resolution and dubious prognosis. Several materials have been proposed and calcium silicate-based cements such as mineral trioxide aggregate (MTA) are the most recommended. However, its long-term clinical behavior still remains poorly understood. The present study reports a clinical case of furcal perforation repair using Angelus MTA, with a 7-year follow-up. Patient sought treatment 2 months after iatrogenic accident. First lower right molar presented clinical signs such as fistula and bone loss between mesial and distal roots. Firstly, all root canals were treated and then furcal perforation was sealed with MTA Angelus and the dental crown was restored with composite resin. Radiographic evaluation was immediately performed to analyze the furcal perforation filling. After 7 years, a new clinical and imaging evaluation using periapical radiography and cone-beam computed tomography (CBCT) showed absence of clinical signs and symptoms, and alveolar bone reconstitution with periodontal space reduction. Angelus MTA presented good clinical behavior in the iatrogenic furcal perforation resolution based on long-term clinical evidence. Furcal perforation is one of the most unpleasant and frequent accidents that can occur during endodontic treatment. Burs wiFurcal and/or root perforation prognosis is unfavorable . Dental However, large-sized furcal perforations do not respond favorably to calcium hydroxide, possibly due to its restricted physical and chemical properties, 8, 9. TThese cements have, currently, caused some scientific enthusiasm including new chemical modifications and/or associations with different vehicles in order to improve their clinical behavior, handling as well as biological properties , 15. On The present case report presents shows the clinical behavior of Angelus MTA after a perforation repair in a first mandibular molar using clinical, radiographic and bean-computed tomography evaluation after seven years.A 40-year-old female patient sought clinical treatment due to unsuccessful endodontic treatment in right mandibular first molar. Clinical history revealed that the dentist was unable to locate the root canals and an iatrogenic accident occurred during pulp chamber access. Then, the endodontic treatment was interrupted, the pulp chamber was filled with calcium hydroxide paste , and the coronary access was temporarily restored using glass ionomer cement .Initial clinical examination showed presence of fistula in gingival mucosa near to the radicular cervical region. Absolute isolation was carried out and then temporary restorative material and calcium hydroxide-based medication were removed. Pulp chamber was irrigated with saline solution, aspirated, and a visual inspection revealed a furcal perforation between the mesial and distal roots that presented measure similar to spherical bur #8 . PeriapiFurcal perforation was immediately filled with calcium hydroxide paste and sealed with glass ionomer cement. Then, the root cervical preparation was performed using ProTaper SX instrument . After obtaining glyde path was with a #10 K-file , real tooth length was obtained using an apex locator , and apical patency was performed with a Pathfile instrument (19/0.02) . The root canals were instrumented up to F2 instrument (25/0.08). The root canals were irrigated with 2.5% sodium hypochlorite solution  between instruments. Final irrigation was performed using 17% EDTA for 3 min and rinsed with 2.5% sodium hypochlorite solution .Root canals were aspirated and dried with absorbent paper points, then endodontic obturation was performed with F2 gutta-percha  and epoxy resin-based sealer  using the single-cone technique . EndodonPerforation was then aspirated with specific endodontic tips . MTA powder  was handled in a 1:1 ratio (powder and liquid), according to the manufacturer's instructions and inserted in the perforation zone. All the periodontal ligament was covered with MTA and confirmed by radiographic evaluation . The areA new clinical and radiographic evaluation was performed after 180 days, showing bone repair in the inter-radicular region  and the The prognosis of accidents involving pulp chamber floor anatomy is doubtful, and during decades, the only treatment was the tooth extraction. Calcium hydroxide was developed as an alternative treatment; however, due to its limited physical and chemical properties, some cases did not present good clinical results, especially for larger perforations , 8, 9.Calcium silicate-based materials (MTA) have created new expectations in endodontic treatments, especially in cases that were considered lost in the past . Currentet al. [et al. [Due to the rather large perforation size in the present case, calcium hydroxide was avoided as partial or definitive treatment option, in accordance to Bryan et al. . In addi [et al.  have obs2, K2O, Al2O3, Na2O, Fe2O3, SO3, CaO, Bi2O3, MgO and CaO, KSO4, NaSO4 insoluble residues and crystalline silica. It presents favorable biological compatibility, favoring alkaline phosphatase activity, mineralized nodules formation and cell proliferation, as well as lower incidence of inflammatory chemical mediators favoring local tissue repair [MTA is composed of SiOe repair . Althouge repair .MTA was selected as material of choice owing to its satisfactory biological properties. Radiographic and computed tomography analysis showed periodontal space regression confirming previously described microscopic findings . TherefoVarious modifications in composition and/or handling techniques have been proposed to optimize the MTA use , 15, 22,Long-term furcal perforation treatment clinical and imaging evaluation showed satisfactory clinical result after furcation repair with MTA which is a conservative and proper alternative for accident resolution and complications of endodontic origin.This clinical case concluded that mineral trioxide aggregate (MTA) presented a proper long-term clinical behavior for iatrogenic furcal perforation clinical and imaging evaluation confirmed by radiographic images and cone-beam computed tomography.


The patient was a 45-year-old man with a progressive headache. Evaluation in detail revealed it as a case of left lateral ventricular space occupying lesion (SOL) resembling choroid plexus papilloma. A left parietal craniotomy was done and the lesion was removed completely through intraparietal approach. Surgical removal resulted in complete symptomatic relief. Histopathology revealed that it was a case of the enterogenous cyst. One year after surgery, the patient again experienced the same symptom and the images revealed recurrence of the lesion. The patient has undergone 2nd surgery and histopathology was the same as before. The patient was given radiotherapy and now he is completely relieved and well. Although intracranial enterogenous cyst is not uncommon, intraventricular enterogenous cyst as well as recurrent intraventricular enterogenous cyst is a rare entity. Enterogenous cysts of CNS are unusual cystic lesions which have an epithelial lining resembling gastrointestinal mucosa . These mThe patient was a 45-year-old man who presented with a headache for 3 months which was progressive and had been intolerable for 2 weeks. However, the patient was a football player with good health. There was no such family history and family members were perfectly well. There were no other clinical symptoms reported by the patient.The patient was advised to do CT-scan and MRI. Interestingly both CT-scan and MRI revealed brilliantly enhancing left lateral ventricular lesion with unilateral hydrocephalus . T1 ImagFlare image  was examThe tumor was well defined preoperatively and was removed under microscopic surgery meticulously. The patient was very poor to bear the cost of postoperative CT-scan and hence it was not done. The biopsy was sent for histopathological examination. The lesion was nearly spherical measuring 3.0 cm + 2.5 cm, whitish, and firm.There was no evidence of necrosis. Microscopy revealed multicystic appearance with cyst lined by columnar epithelium with apical mucin. Few goblet cells were seen. Few areas had shown pseudostratified lining epithelium with nuclear hyperchromasia, nuclear enlargement, and increased mitosis.There was no evidence of stromal invasion. The mucinous material was seen within the lumen. Hemosiderin laden macrophages were present in the stroma. It was confirmed as a lateral ventricular enterogenous cyst. Then the patient was well in around one year. After about one year of the surgical removal of the lesion, there was a recurrence of a headache whose intensity was more than the previous one.Then the patient was advised to do a CT-scan which revealed lesion of the same pattern in the same location as before . The patCNS cyst is lined by endothelium which is primarily resembling that of GIT. It is also less often similar to respiratory tract which is known as a neurenteric cyst. Neurenteric cysts, colloid cysts, and Rathke cleft are derived from endoderm and these are the endodermal lesions of CNS. Neurenteric cysts have several names which include gastroenterogenous cyst, enterogenous cyst, astrocytoma, enteric cyst, endodermal cyst, and intestinal and archenteric cyst. Most reported enterogenous cysts occur in the spine which is usually ventral to the cord , 7. AssoOn the other hand, intracranial NECs are usually uncommon with less than 60 cases reported before this series. Most often these intracranial cysts are found in the posterior fossa. These are situated in the midline, anterior to the brainstem, or in the CP angle. These occur in all age groups but supratentorial EC is usually present at a later age, third and fourth decades . With raThe precise etiology of the NEC is not known. It has been postulated that these cysts arise at the time of notochordal development at the time of transitory existence of the NE canal. In this situation the notochord as well as the foregut has failed to separate causing primitive endodermal cells to be incorporated into the notochord. This displaced nest of alimentary tissue leads to the cyst. Explanation of the supratentorial cyst cannot be ruled out by this theory; additionally, the posterior glenoid portion of clivus is formed by the cranial aspect of notochord. There are different lesions found in the cranial up to the diverticulum which are behind the oropharyngeal membrane and these may be the embryologic progenitor of midline supratentorial cysts. Again, the above-mentioned theory has failed to explain the midline supratentorial cysts formation .In the spine, it most frequently occurs in spinal canal where these are well recognized but uncommon cause of spinal cord compression. Anatomically these occur most frequently near the junction of cervical and thoracic cord, particularly in young patients . NeurentThere is no topographical classification of the enterogenous cyst. These cysts are classified depending on histological characterization of the wall as well as the presence or the absence of components specific to respiratory or gastrointestinal tracts. Simple lining cuboidal or columnar epithelium on a basal membrane with or without cilia is found in type A cysts, resembling gastrointestinal or respiratory epithelium. The presence of other components are usually seen along the gastrointestinal or respiratory tracts which is typical of type B cysts; however, glial or ependymal elements are seen in type C cysts .Nonspecific radiological features make it difficult to differentiate enterogenous cyst from arachnoid cysts, epidermoids, or glioependymal cysts . EnterogBrilliantly enhancing lateral ventricular mass should be considered endothelial origin. The ideal treatment is complete excision. Proper and adequate management should be taken during surgery, so that spillage of tumor component will be prevented; thus, dissemination and recurrence of the tumor will be occurred.


Upper endoscopy showed a 2-cm sized mass covered with intact mucosa, and a central depression located on the posterior wall of the mid body.Diagnoses: Biopsy of the mass showed focal atypical cells proliferation in mucosa on hematoxylin & eosin (H&E) staining. Endoscopic ultrasound showed a 17-mm homogenously hypoechoic mass within the submucosal layer. After diagnostic endoscopic submucosal dissection was performed, H&E and immunohistochemical staining showed synovial sarcoma (SS). To confirm the diagnosis, reverse transcriptase-polymerase chain reaction was performed, revealing a chimeric transcript of the SYT-SSX1 fusion gene. The diagnosis of primary gastric SS was confirmed because no evidence of possible primary lesions or metastatic lesions was observed.Interventions: The patient underwent distal gastrectomy.Outcomes: After surgery, the surgical specimen demonstrated no residual tumor cells. The patient received no adjuvant therapy, and there has been no evidence of local recurrence or distant metastasis for 2 months after the operation.Lessons: When gastric subepithelial tumor is suspicious, we should also consider gastric SS.Abbreviations: ESD = endoscopic submucosal dissection, RT-PCR = reverse transcriptase-polymerase chain reaction, SS = synovial sarcoma.Keywords: endoscopy, gastric neoplasm, synovial sarcomaThe following funding information should appear:Funding: This work was supported by the research promoting grant from the Keimyung University Dongsan Medical Center in 2005 and 2013. The funders had no roles in study design, data collection and analysis, preparation of the manuscript, or decision to publish. The corresponding authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.


Burkitt's lymphoma is a very aggressive type of B-cell NHL with replication approaching 100%. Primary gastrointestinal lymphoma is rare. In our case, a 24-year-old male initially presented with symptomatic anemia. He was initially evaluated with colonoscopy and EGD, both of which were unremarkable. A capsule endoscopy was then performed to further evaluate his significant anemia which revealed friable inflamed ulcerated mass in the jejunum. A push enteroscopy was then performed to obtain tissue from the jejunal mass. Biopsy results and immunohistochemical stains were consistent with Burkitt's lymphoma. PET/CT scan revealed only jejunal involvement. Treatment consisted of bowel resection prior to chemotherapy due to concern for perforation with chemotherapy. Patient achieved complete remission after the treatment. Primary gastrointestinal (GI) non-Hodgkin's lymphoma (NHL) is rare, and it is the most common extranodal lymphoma site. NHL most occurs in the stomach followed by ileum and ileocecum . DiffuseA 24-year-old US Army soldier was found to be anemic on routine blood work while he was in Kuwait. He was referred to gastroenterology for further evaluation. A colonoscopy and an esophagogastroduodenoscopy (EGD) performed in Kuwait were unremarkable. One month later, he started experiencing weakness, dyspnea, reduced exercise tolerance, dizziness, and lightheadedness. At that time, he was not experiencing any diarrhea, abdominal pain, night sweats, melena, or hematochezia. After further evaluation, the patient was found to be severely anemic with hemoglobin of 5.6 g/dL, MCV of 77 fL, iron saturation < 2%, and ferritin of 2.0 ng/mL. He received 4 units of PRBCs in Kuwait. The patient was immediately medically evacuated to Fort Bliss, TX, for further evaluation and treatment of his anemia. A colonoscopy and EGD were repeated with normal findings. Due to concern for obscure GI bleed, a capsule endoscopy was performed, which showed a 10 cm long questionable jejunal lesion. A push enteroscopy was performed and a biopsy was taken from a friable, ulcerated mass in the 3rd part of the jejunum . A compuBurkitt's lymphoma is a very aggressive type of B-cell NHL with replication approaching 100%. BL has three clinical forms: endemic, sporadic, and immunodeficiency-associated. The sporadic variant is seen in the US and Western Europe. Sporadic type BL comprises 30% of pediatric lymphomas and less than 1% of adult non-Hodgkin lymphomas in the US . The GI The presentation and symptoms of lymphomas of the small intestine are nonspecific and can be misleading. BL can present as GI bleeding, bowel obstruction, intussusceptions, colicky abdominal pain, nausea, vomiting, and weight loss. GI lymphomas can mimic acute appendicitis and Crohn's disease . PrimaryTissue biopsies are critical for diagnosis. Criteria for diagnosis BL include immunohistochemical stains CD 20 (+), CD10 (+), BCL-6 (+), and BCL-2 (−) and a proliferative fraction >95% as per WHO classification . c-Myc gRadiological findings of small intestinal lymphoma are nonspecific and biopsy is required for definitive diagnosis. BL usually presents as a bulky mass in the right lower quadrant on a CT scan . EvaluatBL is a rapidly growing tumor and prophylactic surgery can be considered if a high risk of perforation or other complications are suspected. The role of elective surgery in the management of intestinal lymphoma is not well defined. In a retrospective study, 9% (92 of 1062) of the patients with primary GI lymphomas developed perforation, of which 55% occurred after chemotherapy. The risk of perforation was higher with aggressive B-cell lymphomas such as DLBCL and BL compared to indolent B-cell lymphomas. DLBCL was the most common lymphoma (59%) and small intestine was the most common site (59%) associated with perforation . A recenShort term multiregimen chemotherapy such as CALGB 10002, CODOX-M/IVAC, EPOCH, and HyperCVAD with rituximab is highly effective with a complete remission rate up to 90% . In a sm


Stereotactic radiosurgery (SRS) is a minimally invasive, focal treatment option for brain metastases. Multiple studies support its use in various settings as an effective, comparable alternative to surgery and whole-brain radiation therapy (WBRT). Here, we present excellent outcomes in a 90-year-old patient who underwent SRS after initially presenting at age 84 with multiple brain metastases of an unknown primary, as well as undergoing SRS to a site of tumor recurrence that was initially treated with surgical resection and intraoperative cesium-131 (Cs-131) brachytherapy. To our knowledge, this is one of the first reports describing the effective use of both intraoperative brachytherapy and SRS in the management of multiple brain metastases.  Brain metastases are the most prevalent central nervous system (CNS) tumors, developing in up to 40% of patients with cancer. Brain metastases portend a poor prognosis, and patients often succumb to a plethora of symptoms secondary to the tumor burden, including nausea and vomiting, mental status alterations, seizures, and focal neurological deficits . MultidiThe current therapeutic approach to brain metastases is in the midst of a paradigm shift with the refinement of stereotactic radiosurgery (SRS). Enabling high-dose radiation delivery with millimeter precision, SRS is applied as the primary therapeutic modality, as well as adjuvant therapy following surgical resection or WBRT. While initially reserved for patients with up to four brain metastases, numerous recent studies demonstrating comparable or improved outcomes compared with traditional treatments have culminated in National Comprehensive Cancer Network guidelines promoting SRS for multiple metastases, which notes that the total treatment volume is more prognostic for survival than the number of lesions . The expAn 84-year-old female, never a smoker, with a history of hyperlipidemia and well-controlled hypertension, presented with sudden-onset dysgraphia, right lower and upper extremity weakness, and mild confusion. A brain magnetic resonance (MRI) scan with contrast revealed a 3.6 x 2.3 x 3.2 cm left inferior parietal lobe lesion with a hemorrhagic component; a heterogeneously enhancing 2.3 x 2.0 x 2.3 cm right pontine lesion extending to the anterior brachium pontis, and a 9 mm left supramarginal gyrus lesion Figure . There wFollowing a discussion at the institutional multidisciplinary neuro-oncology tumor board, the patient underwent a left parietal craniotomy and resection of the left inferior parietal lobe lesion with an implantation of Cs-131 in the surgical cavity . The resected tumor was approximately 3.6 x 2.3 x 3.2 cm. A total of 22 Cs-131 seeds was used, with a delivered dose of 80 gray (Gy) to the 100% isodose line  at an affiliated institution was recommended, with the patient undergoing 20 Gy in five fractions to the 83% isodose line. She also received 18 Gy in one fraction to the left supramarginal gyrus lesion using CyberKnife. The patient tolerated surgery and SRS well, without any significant acute or long-term side effects. She underwent both inpatient and outpatient physical therapy after her initial surgery and continued to live independently and lead an active life.One year later, a screening MRI of the brain with contrast revealed a new 4 mm enhancing lesion in the right postcentral gyrus. She underwent SRS to the right postcentral gyrus lesion: 24 Gy to the 84% isodose line in three fractions using a Varian iX linear accelerator  Figure .Interval studies were unremarkable until four years following her initial presentation (88-years-old at this time point), when a routine surveillance MRI revealed a 6 x 5 mm nodule of enhancement to the right of the midline, approximately 6.5 mm adjacent to the inferomedial aspect of the resection cavity. There was a mild degree of vasogenic edema adjacent to this new lesion in the parasagittal right occipital lobe. As this finding could be attributed to tumor recurrence, or to delayed treatment effect, it was decided to perform a follow-up MRI three months after this initial scan, which showed an increase in the aforementioned nodular focus of enhancement. This was concerning for regional recurrence, which was defined in our institution's Cs-131 guidelines as the presence of a new nodular or contrast enhancement greater than 5 mm from the resection cavity on MRI [The patient’s most recent MRI  showed stable irregular/nodular enhancing lesions in the right lateral pons, the left parietal lobe at the supramarginal gyrus, and the left parieto-occipital white matter; all consistent with edema and/or treatment effects Figure . There wThis case highlights several clinical concepts commonly considered in the management of brain metastases with SRS. The patient's overall excellent performance status, symptomatic presentation, and need for establishing a histological diagnosis were all factors favoring the resection of her dominant lesion -2. The mRecurrence rates following surgical resection alone approach 46%, advocating adjuvant measures to improve local control. Intracavitary brachytherapy with Cs-131 was selected to offer an immediate RT to the resection bed, avoiding tumor cell repopulation in the interval between surgery and adjuvant treatment, while conformal seed placement confers adequate dosing to the irregularly-shaped resection bed ,8. Cs-13A single institution retrospective analysis reported 36% of 342 patients with newly diagnosed brain metastases had an undiagnosed primary site. Among this 36%, further evaluation revealed a primary lung lesion in 60% of the cases and non-lung primaries in 14% of the cases. Notably, 26% of primaries remained unknown . The autA more traditional approach to our patient may have been surgical resection followed by WBRT ,4,7. HowRegarding our patient, during her initial presentation, both she and her daughter emphasized the importance of preserving her cognitive function to maintain overall her quality of life (QoL). Continuing to lead an active life at age 90, six years removed from her initial diagnosis and treatment and two years from her last SRS course, supports the use of SRS in the elderly to treat several lesions without the immediate inherent risks of neurosurgery or the long-term morbidity conferred by WBRT. Our management protocol using Cs-131 brachytherapy and the judicious use of SRS has resulted in maintaining the QoL of our patient while controlling her brain disease. This is a unique approach  and is not being followed in the majority of centers in the country or abroad. The efficacy of surgical resection in recurrent brain metastases has not been prospectively studied. There is also a dearth of level-one evidence regarding SRS in the salvage setting. In similar settings, WBRT has been reported in case series but is not widely used due to the potential side effects . Repeat In this report, we presented an 84-year-old patient with excellent performance status who was diagnosed with multiple symptomatic brain metastases of an unknown primary. She underwent surgical resection and Cs-131 brachytherapy to one lesion and SRS to the other two metastases. She later underwent additional courses of SRS to a fourth metastasis, as well as for a regional recurrence near the resection site. She tolerated her treatments with minimal short- and long-term side effects, is currently without new or recurrent sites of disease, and is leading an active life at age 90. To our knowledge, this is one of the first reports describing the effective use of both intraoperative brachytherapy and SRS in the initial management of multiple brain metastases, as well as the use of SRS for regional recurrence following intraoperative brachytherapy. Her case exemplifies diversely applying definitive SRS treatment in brain metastases with excellent long-term outcomes.


Oral leiomyomas are rare, benign neoplasms of smooth muscle origin, presenting as a solitary, asymptomatic, nodular mass. Here we present the case of a 54-year-old male with a lesion in the midline of his hard palate, which was diagnosed as a localized benign leiomyoma, along with a review of the recent literature.th and 5th decade of life with uncertain gender predilection. Histological features include interlacing fascicles of smooth muscle small cells with eosinophilic cytoplasm. Complete excision is usually curative and recurrence is rare. Diagnosis of a leiomyoma must be based on the histopathological assessment of tissue as the clinical appearance is non-specific. The peak prevalence of head and neck leiomyoma is observed in the 4 Due to their rare nature, it is important that cases of oral leiomyoma can be reported in the literature to improve our understanding of this entity. The moset al. have proposed that tongue leiomyomas may originate from the ductus lingualis and circumvallate papilla [As smooth muscle is scarce in the oral cavity, it has been hypothesized that leiomyomas may originate from the tunica media, or the smooth muscle of excretory ducts of salivary glands . Glass e papilla . The mos papilla . Other l papilla Leiomyomas are generally asymptomatic, although tumors can occasionally become painful. The diagnosis is mainly determined by histological studies due to their non-specific clinical appearance . TypicalThe World Health Organization (WHO) classifies leiomyomas into three histological types: solid leiomyoma (25%), vascular leiomyoma, also known as angioleiomyoma or angiomyoma (74%) and leioblastoma, also known as leiomyoblastoma or ephitheloid leiomyoma (1%) , 10, 11.We hereby present a case of an oral leiomyoma involving the hard palate and a literature review.2A 54-year-old male patient presented with the chief complaint of an asymptomatic swelling in the midline of his hard palate, which he first noted about 2 months prior. The patient was not aware of any other oral mucosal problems. His medical history was essentially non-contributory. He suffered from allergic rhinitis and was taking systemic antihistamines and using a mometasone furoate nasal spray. He was a non-smoker but reported a brief past smoking history.1a). No other abnormalities were identified. Extraoral examination was unremarkable.Intraoral examination revealed the presence of a discrete, raised, mid-palatal ovoid lesion with a bluish appearance, measuring 6mm by 4mm. Subtle reticular, erythematous lesions were also noted to affect the gingiva and the left buccal mucosa. These reticular, erythematous lesions involving his gingiva are shown in  shows a post-operative photograph illustrating the site and extent of the excision.An excisional biopsy was performed of the palatal swelling and a tissue sample measuring 12mm x 7mm x 4mm was submitted for routine histopathology. Fig. . In view of the mucosal lesions, the patient was also referred for a series of routine blood tests to ensure the absence of haematinic deficiencies. Fasting glucose levels and the presence of anti-skin antibodies was also ascertained. All results returned within normal limits.2.12). This was composed of interlacing fascicles of smooth muscle with small angulated vasculature lined by a simple endothelium. No evidence of malignancy was seen. (Table 1) summarizes the histopathological features of a solid leiomyoma.A well-circumscribed, encapsulated mass was visible within the subepithelial collagen, as seen in Fig. (2.23a and 3b), immunochemistry for S100 was negative and smooth muscle actin was strongly positive.Immunohistochemically, leiomyomas are reactive with vimentin, desmin, α-smooth muscle actin (SMA), and muscle specific actin . Desmin,The diagnosis reached from his left gingival biopsy was oral lichen planus (OLP). Direct immunofluorescence was performed and revealed no diagnostic features.3To the best of our knowledge, this is the first case of concurrent OLP and leiomyoma in the same patient. Given that OLP is a common oral mucosal disease, the association is likely a coincidental one.2).The diagnosis of a leiomyoma must be based on the histopathological assessment of tissue as leiomyomas cannot be differentiated from other mesenchymal tumours on clinical presentation alone. The differential diagnoses of an oral leiomyoma are summarized in (Table 3) summarizes recent cases of oral leiomyoma as described in the available literature.Table  [Of particular importance is differentiating leiomyoma from its malignant counterpart, a leiomyosarcoma, especially a low-grade leiomyosarcoma. The presence of mucosal ulceration should raise suspicion of malignancy. Histopathologically, the presence of mitoses is concerning. Lesions with 5 or more mitotic figures per 10 high-power fields should be considered to have malignant behavior, while fewer than two mitotic figures per 10 high-magnification fields are Sanchez) . MoleculSanchez) .Treatment of leiomyoma is surgical and excision is considered curative. There is consensus across the literature that recurrences are extremely infrequent. The patient was reviewed 1 year post excision with no recurrence.Oral leiomyomas are rare, benign smooth muscle neoplasms. Intra-orally, they tend to occur on the posterior portion of the tongue, palate, buccal mucosa, lips and salivary glands. Because of their relative rarity and non-specific clinical appearance, diagnosis may be a challenge. Diagnosis requires histopathological assessment, and the use of stains such as smooth muscle actin may be invaluable. It is important that cases of oral leiomyoma are reported in the literature to improve our understanding of this entity. Treatment is surgical and excision is associated with a very low recurrence rate.


The occurrence of lung metastasis from benign uterine leiomyomas is rarely reported especially in post menopausal women. The pathogenesis of these metastatic benign tumors still remains a subject of various speculations.A 57-year-old woman presented with a chronic cough and dyspnea. She had undergone 8 years previously, hysterectomy for benign leiomyomas. A chest computed tomography scan showed a 4 cm solitary nodular parenchymal tumor that increased in size after 12 months. The histological analysis of the biopsy from this nodule showed a benign tumor with regular spindle cells disposed in intersected fascicles. At immunohistochemical analysis, the tumor cells were positive for smooth muscle markers and oestrogen-progesterone receptors with a low mitotic index assessed by Ki-67. These features were consistent with a benign metastasizing uterine leiomyoma. At the multidisciplinary meeting, prescription of an aromatase inhibitor has been decided for the patient.Benign metastasizing uterine leiomyomas of the lung are very rare tumors. Although extremely rare in post menopausal women, their diagnosis should be considered in symptomatic patients with a history of hysterectomy for leiomyomas. Extra-uterine locations of benign leiomyomas constitute a very rare phenomenon consisting of the occurrence of smooth muscle tumors with similar phenotype and genotype to those of benign uterine leiomyomas , 2. ThesActually, there are no specific guidelines for BML treatment. Surgery for therapeutic and diagnostic purposes has been widely reported. Hormonal manipulation (oophorectomy or drug prescriptions) is also another therapeutic option , 13.We present herein, a case of a BML of the lung in a 57-year-old symptomatic postmenopausal woman, previously treated by hysterectomy for a uterine leiomyomatous tumor.A 57-year-old woman presented with a chronic cough and dyspnea. The patient had a history of a total hysterectomy for leiomyoma 8 years ago. The histological diagnosis was benign leiomyoma. A thoracic computed-tomography scan (CT-scan) showed a 4 cm solitary, intraparenchymal and proximal nodular tumor of the right lung. The histological analysis of biopsies from this nodule revealed a benign leiomyoma of the lung. At multidisciplinary meeting (MDM), a regular surveillance has been decided as the surgery would be a total pneumonectomy given the proximal location of the tumor. The patient has been lost to follow-up as she did not come back to hospital for her regular surveillance. However, a year later, she was back to hospital for increased cough, dyspnea and a chest pain. The physical examination revealed a shortness of breath with wheezing at respiratory auscultation of the right side of the thoracic wall. There was no other organomegaly detected. A new CT-scan showed a significant increase in size (of about 4 cm) of the initial tumor discovered a year ago, with compression of the right bronchus Fig. . A leiom®). At our pathology department, for all antibodies, positive and negative controls were routinely performed, including processing of normal tissue or tumor sections known to be positive . We have used these antibodies: anti-smooth muscle actin , anti-desmin , anti-Ki-67 , anti-Estrogen receptor , anti-Progesterone receptor , anti-CD34 , anti-S100P .The histological analysis has been performed on a paraffin-embedded and formalin fixed tissue stained by hematoxylin–eosin-saffron (HES). The immunohistochemical analysis has also been performed on paraffin-embedded and formalin fixed tissue. We have used the antibodies according to the manufacturer’s guidelines, with an automated immunohistochemical stainer  Fig. a, oestroBenign metastasizing leiomyomas are tumors supposed to derive from uterine leiomyomas, that secondarily metastasize to distant organs. Uterine leiomyomas are smooth muscle derived benign tumors that are mostly encountered in women with reproductive age , 13, 14.Pulmonary BML are often diagnosed incidentally by imaging techniques, rarely patients present with clinical symptoms. Respiratory symptoms like shortness of breath, cough or chest pain are very rarely reported . The radAs radiological features are not specific, the histopathological examination remains the unique way to confirm the diagnosis of the BML. The pathological diagnosis can be achieved by biopsy or surgical specimens of the tumor. In fact, BML is not a malignant transformation of the uterine leiomyomas. These tumors have the same histologic characteristics as the initial uterine neoplasms and present as a well differentiated smooth muscle tumor with spindle cells disposed in intersected fascicles or in a diffuse pattern. Tumor cells have a benign appearance without significant nuclear atypia, mitosis or necrosis . HoweverThe pathophysiology of BML is not well elucidated an still to be a subject of many speculations. The most reported theory is the “transportation theory” . AccordiThe management of the BML is not well defined. As indolent tumors with a low progression rate, a long radiological surveillance is required, as tumors can regress after the menopause. Symptomatic cases should be treated by surgical lung resection or by hormonal manipulation  , 13. CasIn summary, metastasizing uterine leiomyomas of the lung are very rare neoplasms with clinicopathological features of benign tumors. Although extremely rare in post menopausal women, their diagnosis should be considered in any patient with pulmonary symptoms and a history of hysterectomy for leiomyomatous tumor.


Nasoalveolar cysts, which originate from epithelial remnants of nasolacrimal duct, are nonodontogenic soft tissue lesions of the upper jaw. These cysts are thought to be developmental and are presented with fullness in the upper lip and nose, swelling on the palate, and sometimes nasal obstruction. Because of cosmetic problems, they are often diagnosed at an early stage. These lesions are mostly revealed unilaterally but also can be seen on both sides. In this case report, a patient who complained of nasal obstruction and then diagnosed with bilateral nasoalveolar cysts and treated by sublabial excision is presented and clinical features and treatment approaches are discussed with the review of literature. Nasoalveolar cyst (NAC) is called nasolabial cyst or Klestadt's cyst. This developmental disorder which is defined as a nonodontogenic cyst of the upper jaw is seen four times more in women than men. It is mostly located unilaterally and left sided but rarely can be seen bilaterally. The patients are presented mainly in the fourth or fifth decade . These lA thirty-two-year-old female patient was admitted to our otolaryngology department with the complaints of having difficulty in breathing and rapidly growing painful swelling on the right side of the nose which has been existing for a few days and then caused purulent discharge by bursting. Anterior rhinoscopic examination revealed an infected cystic lesion at the base of the right nasal vestibule, towards the inferior turbinate by narrowing right nasal passage. A similar cystic lesion in the left nasal cavity was also observed, but it was painless and did not show signs of infection. Antibiotherapy  and anti-inflammatory therapy were begun. In computed tomography (CT) images were obtained with the following parameters: field of view: 150 mm; section thickness: 1 mm; 200 mA 120 kV . The CT scan showed well-bordered hypodense cystic lesions in both sides of the nasal vestibule floor which is about 2 cm in diameter on the left and about 1 cm in diameter on the right side Figures . The magNasoalveolar cyst (NAC) is a congenital pathology and two theories have been developed about its etiology. The first theory is about cysts developing as nasolacrimal canal residues and the other is about the cysts being embryonic fissure cysts. When first described they were thought to develop from the retention of the mucosal glands . Later, NAC usually is asymptomatic and is located next to the nasal wing. As the size of cyst increases it becomes symptomatic and usually causes swelling in the face and hard palate. The most common complaint is nasal congestion . Fluid-cNAC is a soft tissue lesion which usually is placed inside the maxillary bone. Therefore CT imaging is the preferred method of viewing since it shows the location of the cyst and its relationship with the nasal and oral cavity and the status of the bone structure in a detailed way . MR imagNAC is treated with surgical excision by sublabial approach , 3. OtheClinical and radiological findings are sufficient for the diagnosis of NAC but the definitive diagnosis is set by histopathological examination. Histopathological examination of NAC reveals cystic structure with fibrous capsule, which may contain goblet cells and is paved with pseudostratified columnar epithelium. As the size of the cyst grows, the intraluminal pressure increases and the columnar epithelium is replaced with stratified squamous epithelium. In our case, histopathological examination corrected the preoperative diagnosis compatible with NAC.Bilateral NAC seems very rare and may cause nasal obstruction. When assessing breathing difficulties NAC should be kept in mind.


Xanthogranulomatous inflammation is recognized as a subtype of cholecystitis; however, it can also occur in other organs. Xanthogranulomatosis of the kidney, bone, ovary, endometrium, vagina, prostate, lymph nodes and pancreas was reported. Herein, we report a case of laparoscopic splenectomy in a patient with xanthogranulomatosis of the spleen that was difficult to diagnose preoperatively.A 63-year-old man with a past medical history of hyperlipidemia had gradually growing multiple splenic masses, which were revealed on abdominal ultrasonography. Preoperative imaging suggested hamartoma, extramedullary hematopoiesis, or an inflammatory pseudotumor. Although metastatic splenic tumors and malignant lymphoma are atypical, they were considered in the differential diagnosis. Thus, laparoscopic splenectomy was performed. Pathological results confirmed a diagnosis of splenic xanthogranulomatosis. An increase in the postoperative triglyceride levels indicated that hyperlipidemia was the cause of xanthogranulomatosis of the spleen.Xanthogranulomatosis should be considered in the differential diagnosis of multiple splenic mass lesions in patients with splenomegaly. Additionally, fine-needle aspiration biopsy should be considered for the preoperative diagnosis. Although xanthogranulomatous inflammation is recognized as a subtype of cholecystitis, xanthogranulomatosis of the kidney, bone, ovary, endometrium, vagina, prostate, lymph nodes, and pancreas was reported , 2. Here2. Blood tests revealed an elevated triglyceride (TG) level of 963 mg/dL. On the other hand, total cholesterol (TC) level of 112 mg/dL, low-density lipoprotein cholesterol (LDL-C) level of 15 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level of 16 mg/dL were low. The plasma-soluble interleukin-2 receptor level was normal (Table A 63-year-old man with a past medical history of hyperlipidemia had multiple splenic masses, which were revealed on abdominal ultrasonography during a general checkup. His body mass index was 24.9 kg/mal Table . Uneven al Table . Contrasal Table . Magnetial Table . A low sal Table . On posial Table . There wal Table . Histoloal Table , which wXanthogranulomatous inflammation is characterized by the clumping of foamy macrophages and infiltration of inflammatory cells , 3. ThisXanthogranulomatosis should be considered in the differential diagnosis in patients with splenomegaly. Additionally, fine-needle aspiration biopsy should be considered for the preoperative diagnosis.


The report suggests that, when the patient's history, clinical examination, and findings do not lead to a clear diagnosis in case of an acute abdomen, a laparoscopic approach, that has both, diagnostic and therapeutic value, is advised. A 15‐year‐old girl, with a negative past medical history, was referred to our department with right lower quadrant pain, tenderness, and rebound pain. She presented with nausea and vomiting. She had no fever but complained of constipation. Blood tests demonstrated leukocytosis and an elevated C‐reactive protein. An abdominal X‐Ray showed centrally located bowel distension, with presence of gas‐fluid levels Fig. .Enterotomy revealed the intraluminal presence of a vinyl glove causing small bowel obstruction Figs , 4. AfteForeign body ingestion, by accidental means, is most commonly seen in the pediatric population, and the management is still controversial NS: participated in study conception and design. NS, IB, MF, DL, AL and SB: performed acquisition of data. NS, IB: involved in analysis and interpretation of data. NS: drafted the manuscript. NS, IB, MF, DL, AL and SB: made critical revision. NS: performed operation.None declared.


Atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDLS) is an intermediate or locally aggressive form of adipocytic soft tissue sarcoma. Muscular dystrophy (MD) is characterized by progressive muscle atrophy and its replacement by adipose and fibrous tissue. Recently, some authors have reported that MD genes are related to neoplastic formation, but there have been no detailed clinical reports of ALT associated with MD. A 73-year-old woman with a diagnosis of limb-girdle MD visited our department for recurrence of a huge tumor in her left thigh. She had undergone resection of a lipoma at the same site more than 20 years earlier. Imaging studies revealed a lipomatous tumor in her left thigh. We performed marginal resection including the adjacent muscles. Histological diagnosis was atypical lipomatous tumor. The postoperative course was uneventful, with no recurrence at 36 months of follow-up. We encountered a huge atypical tumor in a patient with MD. This is the first detailed report to describe an association between ALT and MD. We hypothesize that degenerative changes occurring in adipose tissue during muscle atrophy can cause lipomatous neoplasms and moreover that the mutation of MD-related genes may lead to the proliferation of tumor cells or to malignancy. Limb-girdle muscular dystrophy (LGMD) is characterized by progressive weakness of proximal muscles, of which one type involves the replacement of muscle by adipose and fibrous tissue –6. Most Recently, these genes have been shown to be strongly related to neoplastic lesions. Schmidt et al. suggested that these genes might serve as tumor suppressors . SeveralA 73-year-old woman with progressive weakness in the proximal muscles since age 50 was diagnosed with LGMD. Her parents were first cousins, and of her four younger siblings, three were diagnosed with LGMD. The patient underwent resection of a soft tissue tumor in the left thigh at age 49. The pathological diagnosis was lipoma.μIU/L. Plain radiography showed a soft tissue mass shadow in the left thigh without calcification or periosteal reaction. Magnetic resonance imaging (MRI) revealed high signal intensity on T1- and T2-weighted images and heterogeneous hyperintensity on short-TI inversion recovery images  was mildly elevated at 825 y images . In addiSurgical excision of the tumor was performed. On exploration, the tumor consisted of fat globules partially surrounded by a capsule and with poorly defined margins that was infiltrating different layers of the thigh muscles. We performed marginal resection including the semitendinosus muscle, semimembranosus muscle, and biceps femoris muscle . The resSince western blot analysis of muscle showed a deficit of dysferlin, the patient was finally diagnosed with LGMD2B.LGMD is characterized by progressive weakness of proximal muscles such as those of the hip or shoulder and was first proposed as a nosological entity by Walton and Nattrass in 1954 . Our patRecently, some authors have indicated an association between MD and neoplasms , 16–20. Liposarcoma is the most common soft tissue sarcoma and accounts for approximately 20% of all mesenchymal malignancies encountered by practicing surgical pathologists . AccordiTo obtain a definitive diagnosis of ALT based on imaging findings is sometimes difficult because the tumor resembles lipoma. Using standard imaging characteristics  provides high sensitivity but poor specificity for the diagnosis of ALT due to overdiagnosis of ALT/WDLS from imaging findings .Histologically, ALT is formed by the proliferation of relatively mature adipocytes, consisting of a mixture of mature adipocytes and fibrous connective tissue. The immunohistochemical expression of p16, MDM2, and CDK4 is useful for distinguishing ALT from other lipomatous tumors . In the Few reports have examined an association between lipomatous tumors and MD. Yagi et al. reported the association between lipoma and myotonic dystrophy in 2011 . We hypo


Malignant peripheral nerve sheath tumor is a malignant neoplasm that is rarely found in the oral cavity. About 50% of this tumor occurs in patients with neurofibromatosis type I and comprises approximately 10% of all soft tissue sarcomas of head and neck region. Intraosseous malignant peripheral nerve sheath tumor of the maxilla is rare. This article is the first to address malignant peripheral nerve sheath tumor of the maxilla presenting as a periapical radiolucency on nonvital endodontically treated teeth in the English medical literature. Surgical approaches to malignant soft tissue tumor vary based on the extent of the disease, age of the patient, and pathological findings. A rare case of intraosseous malignant peripheral nerve sheath tumor is reported in a 16-year-old woman. The patient presented clinically with a pain involving the upper left incisors region and with defined unilocular periapical radiolucency lesion involved between the upper left incisors. An incisional biopsy was made. Histological and immunohistochemical examination were positive for S-100 protein and glial fibrillary acidic protein showed that the lesion was an intraosseous malignant peripheral nerve sheath tumor of the maxilla. Nine years after the surgery, no regional recurrence was observed. Malignant peripheral nerve sheath tumor (MPNST) is a malignant neoplasm that is rarely found in the oral cavity. About 50% of this tumor occurs in patients with neurofibromatosis type 1 (NF-1) and comprises approximately 10% of all soft tissue sarcomas of both head and neck region . Its occThis article reports the unusual clinical case of intraosseous MPNST with no association with NF-1, presenting as a periapical lesion on nonvital endodontically treated teeth.A 16-year-old female was referred with pain involving the upper left incisors region. Patient history revealed endodontic treatment of the maxillary upper left incisors with necrotic pulp and periapical radiolucency six months earlier. A few months after the treatment, she experienced discomfort pain. Extraoral examination revealed an integrate mucosa with normal appearance, whereas, intraorally, the upper left lateral incisor presented chromatic alterations and mobility in the region. A periapical radiograph showed the presence of a defined radiolucency lesion between the upper left incisors of the endodontically treated teeth with a size of 2.5 × 1.0 cm in a high diameter . An inciThis paper describes an unusual case of intraosseous maxillary MPNST mimicking a periapical lesion in order to call attention of clinicians to the fact that several different diseases are able to mimic endodontic periapical lesions. The available literature shows that there are no reports of this tumor presenting as periapical lesion in the upper left incisors. It also shows the complexity of a diagnosis of rare bone tumors when based on clinical and radiographic features only. Besides, MPNST onset occurs in a peripheral nerve that may exhibit differentiation of nerve sheath elements, which is more common in the proximal extremities and stem of the nerve . AlthougPatient history, clinical examinations, pulp sensitivity tests, and endodontic treatment follow-up are essential for the diagnosis of inflammatory periapical lesions. The presence of periapical images and dental resorption are characteristic of endodontic and/or odontogenic origin lesions. Soft tissue tumor diagnoses are extremely difficult, and diagnosis of MPNST is particularly difficult because it lacks diagnostic criteria. Although no consensus exists regarding the classification of sarcomas as a type of MPNST, the reported lesion could be placed in this category because its onset occurred in a peripheral nerve or neurofibroma, and it fulfilled one of the three established diagnosis criteria, which include (1) the tumor originating in a peripheral nerve that does not exhibit lines of aberrant or heterologous differentiation; 2) the tumor originating from a preexisting benign nerve sheath tumor, usually a neurofibroma; or 3) the tumor exhibiting characteristics that are commonly observed in tumors originating from the aforementioned situations or malignant Schwann cell tumors [ the tumo the tumoDespite imaging features of MPNST being nonspecific and noncharacteristic, the role of radiologic diagnosis is to ensure that MPNST are preoperatively suggested as a diagnosis and are differentiated from malignant lesions through a series of specific imaging findings. It is important to highlight the aggressiveness of the lesion by a radiographic examination, once it is required to analyze bone destruction, extra bone invasion, structure of the lesion, and root resorption .Radiographic findings of intraosseous MPNST may show a great variation, from unilocular to multilocular, with or without well-defined borders of the lesion, and cortical expansion. Periapical radiographs of the presenting case of intraosseous MPNST showed a unilocular periapical lesion with a defined border and external dental resorption in the lateral region and apical region of upper left incisors. This radiographic appearance was suggestive of a periapical lesion of cyst, once external root resorption does not occur exclusively of malignancies, as what may occur for orthodontic movement, neoplasia, being more common in case of inflammatory origin, such as periapical lesion .Establishing a diagnosis requires immunohistochemistry technique because MPNST may be similar to fibrosarcoma. And a plethora of other bone tumors are included in differential diagnoses such as central giant cell lesion, fibrous dysplasia, ameloblastoma, myxoma, haemangioma, neurofibroma, leiomyoma, sarcoma, or simply periapical lesions . It is aMalignant peripheral nerve sheath tumors were most commonly located on the extremities 45%), then trunk (34%), and head and neck region 19%) . In head% . In he5%, then To establish the diagnoses of MPNST, it requires immunohistochemistry technique. Radiographically, maxillary intraosseous MPNST is difficult to differentiate from other bone lesions. The differential diagnosis of the case presented in this article included periapical inflammatory lesions, such as periapical granuloma or cyst. The root resorption is not a usual finding of the above lesions. Root resorption can be seen in central giant cell granuloma or an odontogenic neoplasm such as ameloblastoma or in malignant tumors. Nine years after the surgery, no regional recurrence was observed.


The potentially serious complications of paraoesophageal hiatus hernias are known but its counterpart the sliding hernia, is thought to be more benign in nature. We describe a 72 year old female admitted with epigastric pain after gorging on her Christmas meal, who proved a diagnostic difficulty for both the medical and surgical registrars and was found to have a perforated incarcerated sliding hiatus hernia on CT scan. A transhiatal oesophagectomy was performed as laparotomy findings confirmed a gangrenous perforated stomach and a gangrenous lower oesophagus. She recovered fully from the operation and is well to date. This case provides evidence that sliding hernias can cause serious complications and may be difficult to differentiate from other cardiovascular and abdominal pathologies. A high index of suspicion is required by medical professionals treating chest and epigastric pain. Hiatus hernias are a common pathology and 95% of them are sliding whereby the oesophagus is shortened and the gastro oesophageal junction and part of the stomach are displaced into the chest through the hiatus of the diaphragm. The remainders are mostly paraoesophageal hernias where a portion of the stomach herniates into the chest adjacent to the oesophagus but the gastro-oesophageal junction remains within the abdomen. Many are asymptomatic especially the sliding variety, but presenting features can include reflux, regurgitation, postprandial breathlessness, early satiety and dysphagia especially in larger hernias. Most are identified during upper gastrointestinal endoscopy. Large paraoesophageal hernias can present acutely with gangrene or rupture of the intrathoracic stomach and are therefore repaired electively if the patient is willing and clinically fit . TreatmeAlthough the rarer variant, there are several reports in the literature of incarcerated, strangulated or ulcerated paraoesophageal hernias -4. This Even though incarcerated hiatus hernias are rare, it is important to consider them as a differential diagnosis for many surgical and medical presentations. The consequence of a delayed or missed diagnosis may be disastrous and the possible alternatives can be equally as important. These include acute coronary syndromes, acute respiratory pathology, intestinal perforation, aortic rupture or dissection and pancreatitis. Chest X-ray can provide clues such as left sided pulmonary effusion, visible large hernia above the diaphragm and pneumoperitoneum or mediastinum , 5. GiveWe report a 72 year old lady who reported to the Emergency Department in an early evening of December with a six hour history of severe epigastric pain after a Christmas meal. The pain radiated to the back, was worse on breathing and associated with several episodes of vomiting. Past medical history included a hiatus hernia, idiopathic leg oedema (treated with bendroflumethiazide), osteoporosis and previous appendicectomy. Alcohol intake was approximately seven units weekly and she was a non-smoker.On examination her blood pressure was 103/60 mmHg, pulse rate 70 per minute, temperature 36 °C and respiratory rate 22 per minute. Heart sounds were normal but there were bilateral inspiratory basal crepitations on respiratory examination. Abdominal examination revealed epigastric tenderness with some voluntary guarding but no rebound or rigidity. Bowel sounds were present and normal. Initial investigations were performed including ECG, routine bloods including amylase and troponins, arterial blood gas and lactate. All tests were within normal limits except for a lactate of 3.7  and marginally raised amylase of 170 . Chest X-ray revealed bibasal consolidation but with no air under the diaphragm visible  and abdoThe Emergency Department doctors made referrals to both the on call medical and surgical teams. Surgeons were the first to review who interpreted there being no acute surgical pathology but advised to repeat the chest X-ray to ensure there was no unidentified pneumoperitoneum. Medical review added bronchial breathing to the examination findings and considered a range of diagnoses including cardiac failure, bronchopneumonia, intestinal perforation or pancreatitis. Repeat X-ray was performed later in the evening which did not reveal any new changes. Fluid balance monitoring was initiated and she was treated for the possible medical diagnoses with intravenous furosemide and broad spectrum antibiotics by the medical team.Throughout this time, there was detailed discussion regarding the potential diagnoses and the best place for this patient’s treatment to continue. The on call Emergency Department Consultant was called into to resolve the situation. Considering the diagnostic uncertainty and potentially serious pathologies, he arranged a CT scan to clarify . This reShe was taken to theatre for a laparotomy during the early hours of the following morning. This showed that the upper one third of the stomach was within the sliding hernia which along with the distal half of the oesophagus, was gangrenous. There was a perforation of the stomach within this hernia with food debris within the sac. The remaining lower two thirds of the stomach although not within the hernia, were congested. In view of the distal gangrenous oesophagus, a transhiatal oesophagectomy was performed. A stomach tube was created and the oesophagogastric anastomosis lay within the neck.Her recovery began on ITU where she spent six days in total. She received treatment for sepsis in addition to total parenteral nutrition. Bilateral chest drains were sited. A further five days were spent on high dependency before she was discharged to the surgical ward for ten days. Prior to discharge to a community rehabilitation unit, hoarseness of the voice was noted. This was followed up as an outpatient with ENT where a paralysed left vocal cord was diagnosed. Voice therapy was commenced and on review two months later in the surgical clinic, her voice had returned to normal. Intermittent dysphagia had been a problem since discharge for which a gastroscopy was arranged showing no stricture or other new pathology.As this is the first case describing an incarcerated, perforated sliding hiatus hernia, we are unable to compare our presentation with others. Acute chest and epigastric pain can account for a large percentage of emergency department reviews. The main presenting features of this case were vomiting and acute epigastric pain following a large meal, which seem to be similar to the presenting features described for incarcerated or perforated paraoesophageal hernias -4. OtherDiagnostic difficulties are evident when it comes to epigastric pain with a range of cardiothoracic and intra-abdominal pathologies being possible. A perforated hiatus hernia is rarely identified as a differential. Routine bloods including cardiac enzymes and amylase, blood gases including lactate and ECG can all help rule out differential diagnoses. Chest X-ray may provide the first clues but in our case the chest X-ray provided no diagnostic certainty in that there was no pneumoperitoneum or visible hernia and pleural effusions which are typically left sided, were bilateral. In our case the CT findings made the diagnosis clear and can be very important in establishing the diagnosis when a clinician is aware of the gravity of the presentation, but is unsure of the diagnosis and subsequent management plan.It has been known for such cases to be treated as acute coronary syndromes with the usual anticoagulants resulting in subsequent marked operative implications when the real diagnosis is identified . TreatmeIn conclusion this case highlights the first serious complication of a sliding hiatus hernia and the need for both surgeons and medics to be aware and consider the diagnosis in patients with symptoms such as chest pain, epigastric pain, vomiting and dyspnoea.


Urethral hemangiomas commonly occur in men or elderly women. We presented a rare case of urethral hemangioma in a prepubertal female patient.An 8-year-old girl had the complaints of bloody staining of clothing, a foul perineal odor, and urethral pain. She was brought to our genitourinary outpatient department for survey and a single, 1-cm compressible reddish nodule at the 10-2 o’clock position in the distal urethra was found.Urethral hemangioma in a prepubertal girl was diagnosed after excision of the urethral nodule.Excision with 8 “stay” sutures in the protruding urethral mucosa was performed.Normal micturition without symptom recurrence was noted at the 3-month follow-up.Urethral hemangioma is also found in prepubertal female patient. Increased physician awareness and early recognition of a urethral hemangioma can avoid unnecessary examinations and patient anxiety. The procedure of excision with 8 “stay” sutures in the protruding urethral mucosa facilitates mobilization from the distal urethra and provides a good surgical view of abnormal proliferative blood vessels. Therefore, the lesion can be removed as clean as possible. The clinical manifestations of urethral hemangiomas include lower urinary tract symptoms, dysuria, hematuria, perineal discomfort, and urethral discharge. We report a case of urethral hemangioma in an 8-year-old girl, who was brought to our outpatient department because of bloody staining of clothing and a foul perineal odor. Urethral hemangioma was diagnosed after surgery. To the best of our knowledge, this is the youngest reported case ever.2A healthy, 8-year-old girl with no hereditary disease was brought to our genitourinary outpatient department because of bloody staining of clothing, a foul perineal odor, and urethral pain. A 1-cm compressible reddish nodule was noted at the 10 to 2 o’clock position in the distal urethra (Fig. ,2 Urethral catheterization was performed at the end of the operation.Cystourethroscopy before the operation revealed normal bladder mucosa and bladder neck. An erythematous, protruding mucosal lesion was found in the distal ventral urethra, and the mass was completely excised. The operative method was similar to that used for urethral prolapse. Initially, we performed cystourethroscopy. We placed 8 “stay” sutures in the protruding urethral mucosa to facilitate mobilization from the distal urethra. The transection zone was exposed as a fibrous groove surrounding the distal urethra. We meticulously incised the mucosa to avoid the muscular layer and prevent bleeding, and cautery was used for hemostasis. We carefully excised the protruding lesion held by the stay sutures. Finally, the residual mucosa was attached to the external urethra with 3-0 chromic catgut interrupted sutures.Grossly, the specimen measured 0.8 × 0.5 × 0.3 cm. It was red and had a soft texture Fig. B. MicrosThe patient agreed to publication of the case report and her parents gave informed consent. The procedure was approved by the Ethics Committee of the Tri-Service General Hospital.3 Hemangiomas are commonly present in the skin and liver, but are rare in the urinary tract. Urethral hemangiomas are more common in men and are very rarely reported in women.–11A hemangioma is an abnormal proliferation of blood vessels that may occur in any vascularized tissue. It is believed to be congenital, arising from embryonic remnants of unipotent angioblastic cells that develop into abnormal blood vessels. The differential diagnosis of a circular lesion of the external urethral meatus includes prolapse, polyp, caruncle, periurethral abscess, and malignancy. Urethral prolapse occurs most commonly in prepubertal black and postmenopausal white female patients.–14 Our patient was Asian and was not in a high-risk group.The clinical presentations include lower urinary tract symptoms, with dysuria, hematuria, perineal discomfort, and urethral discharge. Physical examination, cystourethroscopy, and 3-dimensional magnetic resonance imaging may help confirm the diagnosis.,16 The protruding nodule in our patient was located in the ventral lip of the urethral meatus, which is not the common location of a caruncle. Common malignancies of the urethra include squamous cell carcinoma, urothelial cell carcinoma, adenocarcinoma, sarcoma, and melanoma.Urethral prolapse is defined as the complete eversion of the terminal urethra from the external meatus. About a quarter of the urethral mucosa protrudes as a caruncle, which consists of connective tissue containing many inflammatory cells and blood vessels, and is often present at the posterior lip of the urethral meatus. excision, and various endoscopic treatments, such as electrocautery or laser ablation.,7 It has been reported that 8-week treatment of oral steroids may be used to treat the urethral and vaginal capillary hemangioma in a young child. In our case, the girl had symptoms of bloody staining of clothing and a foul perineal odor. The embarrassed condition bothered her and her family. Although treatment with oral steroids was not invasive, it may not solve the problem immediately and increase the concern of systemic side effects. On the other hand, endoscopic intervention may have a high recurrence rate and is not suitable for a distal urethral lesion. Therefore, we performed wide excision to treat the patient. The procedure provided a good surgical view of abnormal proliferative blood vessels and the lesion can be removed as clean as possible. No recurrence was noted at a 3-month follow-up.Treatment of urethral hemangiomas includes observation, oral steroids,4We presented a case of an 8-year-old girl with a reddish protruding mass in the distal urethra, with occasional bleeding. Wide excision of the urethral mass was performed and the final pathology report was compatible with urethral hemangioma, which is very rare in prepubertal girls. Increased physician awareness and early recognition of a urethral hemangioma avoids unnecessary examinations and patient anxiety. To the best of our knowledge, this is the youngest reported case ever.


Arterial tumor embolism (ATE) is a rare but life-threating complication.A 55-year-old man with acute lower-limb ischemia was referred to our hospital after endovascular intervention failed and underwent above-the-knee amputation for severe limb necrosis. On postoperative day 8, he developed small bowel necrosis and underwent resection. Histopathological examination of the resected bowel revealed that the submucosal arterial emboli were positive for the markers of squamous cells. He had unresectable lung squamous cell carcinoma with left atrium invasion. The subsequent embolisms were thought to be caused by the advanced lung cancer.ATE is rare but should be considered as a differential diagnosis for unidentified arterial occlusion. Arterial tumor embolism (ATE) is often a fatal and rare complication of tumors. We herein report a case of ATE that spontaneously occurred after chemoradiotherapy of primary lung cancer. The embolus eroded through the wall of a pulmonary vein and embolized through fragmentation with resultant showering of tumor emboli to multiple arterial sites.A 55-year-old man presented to a local hospital, complaining of acute severe pain in his right lower leg. He was diagnosed with acute lower limb arterial embolism and underwent endovascular intervention: percutaneous aspiration of thrombus and balloon angioplasty of right distal superficial femoral artery (SFA) Fig. . After iWhen he was transferred to our hospital, his right lower limb showed completely irreversible ischemic changes: pallorous and cold skin, loss of sensation, muscular rigidity of the right ankle, non-dopplerable right dorsalis pedis, and posterior tibial pulses with only the right femoral pulse above the inguinal ligament palpable. He had no medical history of chronic peripheral arterial occlusive diseases. He had well-controlled hypertension and diabetes mellitus. Eight months prior, he had been treated with chemoradiotherapy in another hospital for unresectable lung cancer: squamous cell carcinoma, located in the right median and inferior lobes of the lung.His white blood cell count was 21,350/μl. Other blood chemistry values were serum high-sensitivity C-reactive protein: 24.93 mg/dl; creatinine: 2.49 mg/dl; creatinine kinase: 18,375 U/l; myoglobin: 34,155 ng/ml; and PT-INR: 1.00; APTT 32.4 s. Abdominal contrast-enhanced computed tomography (CT) scan showed partial infarction of the spleen and right kidney Fig.  and no aOn postoperative day (POD) 1, he started his meal. However, on POD5, he became unable to eat because of abdominal distention. On POD8, the patient developed severe, constant abdominal pain. Abdominal contrast-enhanced CT scan showed diffuse intestinal and mesenteric emphysema Fig. . A smallHistopathological examination of the resected specimen revealed ischemic changes and submucosal arterial thrombosis, including denatured cells Fig. . ImmunohHe was withdrawn from central-vein nutrition with no complications on POD 22 after bowel resection. After the care and additional amputation of the femoral stump, he was transferred to a rehabilitation hospital in good condition on POD 84 after his initial amputation, continuing taking rivaroxaban according to the treatment of chronic atrial fibrillation.Acute arterial occlusion secondary to malignant tumor embolism is rare. Miroslav et al. reviewed 877 cases of arterial emboli, of which only three cases (0.3%) of ATE were identified . XiromerThe prognosis of ATE is very poor and embolectomy should be attempted for recovery. The longest recorded survival after tumor embolectomy was 20 months . In thatFactors that predispose a patient to ATE are size, rapidity of tumor growth, number, survival rate of malignant cells, and poorly differentiated cancer . InvasioTreatment of ATE includes early heparinization to prevent propagation of distal thrombus, and embolectomy using a Fogarty catheter, or laparotomy and embolectomy with resection of the infarcted intestine and primary anastomosis, which is same as that for atherosclerotic emboli.The patient in this case survived for three reasons. First, he did not have cerebral or cardiac ATE. Second, he underwent surgical treatment immediately. Finally, the remnant small bowel was not necrotic.Organ infarction or ischemia is occasionally the presenting feature of a previously undiagnosed primary tumor ; ATE shoThis patient had previously undergone chemotherapy with cisplatin + docetaxel (1st line), tegafur/gimeracil/oteracil (2nd line), nab-paclitaxel (3rd line), and nivolumab (4th line). Nivolmab was administered 8 months before admission. Nivolumab is reported to provide a durable response that persists after discontinuation. Tapalian et al. reported 12 71%) of 17 patients maintained responses off-therapy for at least 16 weeks (range 16–56 weeks) [1% of 17 ATE is rare but should be considered as a differential diagnosis for unidentified arterial occlusion.


Dedifferentiated liposarcoma is an uncommon variant of liposarcoma, with poor prognosis and higher preponderance to local recurrence. Only nine cases of dedifferentiated liposarcoma of small bowel mesentery have been reported till now. This is a case of giant dedifferentiated liposarcoma of the small bowel mesentery, weighing nearly 9 kg (19.8 lbs), with synchronous lesions in the extraperitoneal space, which is the first such case to be reported.We report a case of a 62-year-old man, who presented with a huge abdominal mass occupying nearly the entire abdomen. A contrast enhanced computed tomography of abdomen and pelvis revealed a large, poorly enhancing, heterogeneous, lobulated mass of size 27 × 16 cm, displacing the bowel loops peripherally. At laparotomy, a large mass arising from the small bowel mesentery was found. In addition, many other smaller synchronous lesions were studded in the entire small bowel mesentery and a couple more in the extraperitoneal space. A palliative excision of the giant mass along with the adjacent small bowel was done. The other smaller swellings were not causing any mass effect and were left behind as they were numerous, virtually ruling out any possibility of a curative excision. The histopathological examination suggested the diagnosis of dedifferentiated liposarcoma. On immunohistochemistry, S-100 was positive in the well-differentiated sarcomatous areas. The CD 117 and SMA were strongly negative ruling out the possibility of a gastrointestinal stromal tumour. The CD 34 however was positive in the tumour cells.Dedifferentiated liposarcoma of the small bowel mesentery is rare. Involvement of nearly whole of the small bowel mesentery in the disease process virtually rules out the possibility of a curative resection, the mainstay of management. This report would add to the knowledge of this rare disease and the possible therapeutic problem that may be encountered in case of multifocal disease. Liposarcoma is the most common soft tissue sarcoma in adults . Evans, A 62-year-old man presented to us with history of a palpable abdominal mass, vague left side abdominal pain and loss of appetite for 2 months. The bowel habits were normal, and there was no history of weight loss. He was a known hypertensive on medications. On examination, the patient was thin built and had a huge abdominal mass extending from the epigastrium to the hypogastrium including both the flanks.The routine hematogical and biochemical parameters were within normal limits. The tumour markers including CA19-9, carcinoembryonic antigen (CEA) and CA-125 levels were also within normal limits. Abdominal sonography revealed a heterogeneous, nodular, soft tissue mass nearly filling the abdominal cavity. Computed tomography showed a large, poorly enhancing, lobulated soft tissue mass of size 27 × 16 cm with fluid densities. The mass was displacing the bowel loops peripherally . Cut section showed a greyish yellow, soft to firm tumour with solid components along with myxoid area in less than 50 % area. The attached small bowel with mesentery measured 40 cm. There were multiple nodules over the mesentery, largest measuring 3.5 × 2.5 × 3 cm and smallest measuring 0.5 × 0.5 cm.Histopathological examination showed a partially encapsulated tumour composed of spindle cells, arranged in long and short fascicles and in storiform pattern. The neoplastic cells were oval to spindloid with round to oval pleomorphic hyperchromatic nuclei, with prominent nucleoli. Binucleated and multinucleated giant cells were seen. Round cells with nucleus pushed laterally with vacuolated cytoplasm resembling lipoblasts were present interspersed in between the tumour cells. There was a zone of transition between the well-differentiated area to a high-grade sarcomatous area with extensive coagulative necrosis, hyalinisation and myxoid changes. Mononuclear cell infiltration including lymphocytes and plasma cells were present. Mitotic rate was 8–10/10 per high power field. A diagnosis of dedifferentiated liposarcoma was made based on the basis of histological features. On immunohistochemistry, S-100 was positive in the well-differentiated sarcomatous areas. The CD 117 and SMA were strongly negative ruling out the possibility of a gastrointestinal stromal tumour (GIST). The CD 34 however was positive in the tumour cells. In the first follow-up after 1 month, the patient had gained weight and had regained his appetite. He had a general overall feeling of well-being. There was no significant problem at 10 months post surgery.According to the WHO, lipomatous tumours are classified into benign, intermediate and malignant types. The well-differentiated liposarcoma belongs to the intermediate variety being locally aggressive. The malignant type includes the dedifferentiated, myxoid, round cell, pleomorphic, mixed and liposarcoma not otherwise specified types. The dedifferentiated variant of liposarcoma is thrice more common in the retroperitoneum than in the extremities, where well-differentiated liposarcomas are more usual . DDLPS pThe early symptoms of this disease are nonspecific; they present as abdominal lumps when they attain large sizes and may cause pressure symptoms , 3. X-raDistinction of different subtypes of liposarcoma on histopathological examination and immunohistochemistry is important because DDLPS is the variant of liposarcoma having worse prognosis than the well-differentiated variety. Its clinical course however is less aggressive than other types of high-grade sarcoma. –3. Due tComplete surgical resection is the only effective treatment option available . EffortsDedifferentiated liposarcoma is a variant of liposarcoma having worse prognosis and higher risk of local recurrence than the well-differentiated variety. Hence, accurate histopathological diagnosis is essential for prognostication and closer follow-up. Complete surgical excision with negative margin is associated with overall survival and disease-free survival. However, DDLPS at multiple locations in the mesentery is a possibility which may exclude the chance of curative resection. Palliative resection upfront, of large offending masses, or upon recurrence will have the benefit by relieving pressure symptoms due to the tumour. The scope of adjuvant chemotherapy and radiotherapy is limited to recurrent, residual or poorly differentiated liposarcomas.


Odontogenic myxomas are rarely occurring, slow-growing, asymptomatic, and locally aggressive odontogenic tumors with high rate of recurrence, mainly of ectomesenchymal origin. Three-dimensional imaging techniques can be used to diagnose such pathological lesions, but have limited use as they are not cost-effective and are selectively available for better outcome. Following is a case report of OM of a 5-year-old child with a brief discussion on its diagnosis and management.Mukherjee CG, Mukherjee U, Bansal A, Jha A. A Misdiagnosed Odontogenic Tumor: A Clinical Dilemma. Int J Clin Pediatr Dent 2017;10(2):205-207. It originates from the embryonic mesenchymal elements of the developing tooth. The World Health Organization has categorized OM as a benign tumor of ectomesenchymal origin with or without the presence of odontogenic epithelium.They are slow-progressing, asymptomatic, and site-aggressive tumors. The lesions may reach a questionable size before the patient realizes its existence and seeks treatment. Odontogenic myxoma is not easy to diagnose since it has variable histopathological and radiological features.In this study, we present a case of central OM of mandible with a brief review of the clinical, radiological, and histopathological features.A 5-year-old otherwise healthy boy presented with a slowly enlarging painless swelling on the lower right side of his face. The clinical examination revealed he had a bony hard, nontender swelling, extending from the posterior border of the mandible up to tragus of the right ear, while the overlying skin was normal in color without any secondary changes  and 2.The lateral oblique radiograph of the jaw revealed a unilocular radiolucent lesion extending from the distal surface of the first permanent mandibular molar, involving almost the entire ramus encapsulating an unerupted tooth , with inOn aspiration, as there was no cystic fluid available, provisional diagnosis of unilocular ameloblastoma was made. Routine blood investigation was done with no abnormal findings. Complete removal of lesion was planned under general anesthesia after obtaining a written consent and a thorough preanesthetic evaluation.The tumor was exposed intraorally with a midcrestal incision. With adequate exposure, the junction of normal bone and pathological tumor was identified, followed by thorough surgical curettage of the lesion. The lower border of mandible was intact and utmost care was taken to prevent pathological fracture. Since the growth and development of the mandible may be affected, bone plating was avoided.A solid tumor with an impregnated tooth approximately measuring 4 × 5 cm and the entire tumor were sent for histopathological evaluation.Hematoxylin and eosin staining (100x) revealed sheets of stellate-shaped cells with long anastomosing processes, scattered in mildly basophilic collagenous stroma along with a few strands of odontogenic epithelium, and foci of calcification was also found .The overall features were suggestive of central OM. The patient was recalled at regular intervals for clinical and radiographic examinations to monitor the healing and recurrence of the lesion .2 commonly seen in the age group between 10 and 50 years, OM affects mandible more often than maxilla.1Prevalence of OM is between 0.04 and 3.7%,3 Type I: Unilocular well-defined radiolucency; type II (multilocular): two or more compartments with multiple interlaced osseous trabeculae described as honey comb, soap bubble, or tennis racquet radiolucency; type III: lesion located in alveolar bone; type IV: lesion involving the maxillary sinus; type V (moth-eaten appearance): larger radiolucent area with irregular borders; type VI: combination of bone destruction and bone formation giving sun ray appearance. The tumor often shows scalloping between the roots; root resorption can occur but is rare.4 The abovementioned case is type I OM.Odontogenic myxoma has been classified based on radiographic appearances into six types by Zhang et al:5Odontogenic myxomas have uncertain pathogenesis. There are two school of thoughts, one of which says that OM is a tumor arising from mesenchymal portion of tooth germ, either from the dental papilla or follicle. Absolute proof of origin from odontogenic apparatus is lacking, but it is most likely due to its frequent occurrence in jaw bones and almost universal absence in any other skeleton. Another school of thought suggests that histopathologically it shows stellate cells with branching processes in mucopolysaccharide background. Occasionally, macrophages and islands of inactive odontogenic epithelium were also identified. The cells are similar to myofibroblast, thus confirming OMs are of ectomesen-chymal origin.Differential diagnosis includes odontogenic cyst, ame-loblastoma, intraosseous hemangioma, and metastatic lesions, and each should be ruled out finally by means of histopathologic examination and immunohistochemistry.6 In this case, the lesion was large with an intact lower border in a developing mandible, so utmost care was taken while removing a lesion, thereby preventing pathological fracture.Treatment of OMs varies depending on the extension of the lesion. Small tumors are usually treated by curet-tage, and for larger lesions, more extensive radical resection may be required.1 Cryotherapy as a supplementary technique to curettage can be used to reduce this risk.7Since OMs are bereft of a capsule and have an infiltra-tive growth pattern, there is a high rate of recurrence.8 They can be correlated with the histological features and are considered useful tools for diagnosis .9Advanced imaging techniques, such as three-dimensional computed tomography (3D CT), magnetic resonance imaging (MRI), or cone-beam CT (CBCT) should be employed, to ensure the true extent of the tumor.10Histopathologically, the OM is distinguished by the presence of loose, abundant mucoid stroma that contains rounded, spindle-shaped, or stellate cells. The stroma may be relatively avascular or may exhibit delicate capillaries.1A follow-up is necessary to confirm the healing and check the recurrence. Periodical clinical and radiographic screening should be maintained indefinitely irrespective of the treatment modality employed.Odontogenic myxoma is considered as a tumor of undecided pathogenesis. They possess a notorious habit of recurrence. Odontogenic myxoma may exhibit variable features on imaging, when we use plain radiographs in different projection, and can be misleading for the clinicians. Further diagnostic 3D imaging techniques, such as CBCT, CT scans, and MRI, should be preferred to give more radiological details about the size and nature of lesion. It helps the clinicians in deciding whether conventional or radical intervention should be planned. The drawbacks of these diagnostic modalities are that they cannot be afforded by patients of low socioeconomic status and their selective availability, which are to be considered for better outcome.


Locally advanced colon cancer with direct abdominal wall and skin invasion is an extremely rare finding with most data being derived from case reports, historical autopsy-based or single-center retrospective studies. We present a unique case of a colon cancer with direct cutaneous invasion and colocutaneous fistulization.en bloc excision of the hernia sac and infiltrating cutaneous mass.Eighty-six year old Caucasian female with multiple comorbidities, referred to Surgical Consultation due to ulcerated skin lesion in the abdomen. She had a long-standing large umbilical hernia but with no previous episodes of incarceration or occlusive symptoms. She denied any digestive or constitutional symptoms. Physical examination showed a large non-reducible umbilical hernia, with an associated painless firm mass within the hernia sac and cutaneous ulcerated growth. Colonoscopy revealed transverse colon cancer (endoscopic biopsy of the tumor and skin punch biopsy confirmed adenocarcinoma of the colon). Computed tomography showed a tumoral mass within the umbilical hernia, with cutaneous infiltration and enlarged regional lymph nodes. Rapid local progression led to colocutaneous fistula with total fecal diversion. We performed an extended right hemicolectomy with In the current era of widespread use of screening colonoscopies, initial diagnosis of locally advanced colon cancer is decreasing. However, this unique case presented an opportunity to recall the advantages of multivisceral resections. Malignant cutaneous infiltration has been reported to occur in 0.7–9% of all patients with visceral neoplasms –4. Skin Our patient was an 86-year old Caucasian female with multiple comorbidities. Past medical history included arterial hypertension, heart failure , obesity, hypercholesterolemia and hyperuricemia. There was no relevant family history.She was referred to Surgical Consultation due to a peri-umbilical cutaneous ulceration.She had a long-standing large umbilical hernia but with no previous episodes of incarceration or occlusive symptoms. She noticed a skin lesion adjacent to the umbilicus in the past 2 months with rapid growth and ulceration. She denied any digestive or constitutional symptoms.Physical examination revealed an exophytic cutaneous tumor with approximately 8 cm in diameter Fig. . There wFurther investigation with colonoscopy revealed transverse colon cancer; endoscopic biopsy of the tumor and skin punch biopsy confirmed adenocarcinoma of the colon. Thoracic and abdomino-pelvic computed tomography showed a tumoral mass within the umbilical hernia, with cutaneous infiltration Fig.  and enlaInitially considered for neoadjuvant therapy, rapid local disease progression led to colocutaneous fistulization with total fecal diversion (approximately 1 month), resulting in weight loss and significant quality of life impairment mainly due to colostomy appliance difficulties. The multiple therapeutic options were thoroughly discussed with the patient and family and surgery was decided.en bloc excision of the hernia sac and infiltrating cutaneous mass , with cardiovascular shock and progressive multiple organ failure which led to death on the 7th POD. Although no specific imaging evaluation was performed to exclude the possibility of anastomotic dehiscence, clinical and analytical parameters did not favor this diagnosis.This case report was reported according to CARE guidelines .In the ‘90s, a 7316-patient retrospective study showed cutaneous involvement in 2.3% of patients with colorectal cancer, all with metastatic nodules .Approximately 10% of patients with colon cancer have invasion of contiguous organs at diagnosis. Surgical excision remains the mainstay of treatment, although clinical T4b lesions can be considered for neoadjuvant therapy . MultiviScreening colonoscopies and overall colon cancer awareness has led to earlier diagnosis and locally advanced cancer is becoming less common. In our case, the unique combination of a transverse colon adenocarcinoma contained in a hernia sac facilitated the direct spread of the tumor. This is an extremely rare finding that reminds us that locally advanced neoplastic disease still presents a challenge and there is still opportunity for improvement.