Trichobezoar is a rare cause of small bowel obstruction, whereby a mass forms most commonly in the stomach and duodenum of young females, from ingestion of hair, a condition known as trichophagia. We present a case of recurrent small bowel obstruction due to a residual hair mass that was removed surgically in a young female patient who had a laparotomy and gastrotomy for removal of a large gastric trichobezoar just two weeks prior to the current admission. This case illustrates the importance of a thorough inspection of the whole bowel to ensure that no residual bezoars remain after surgery. Bezoars are concretions of indigestible matter that accumulate in the gastrointestinal tract. Trichobezoars, specifically, are defined as masses of swallowed hair usually in the stomach , 2 due tAn 18-year-old female was admitted to the surgical department with a two-week history of colicky epigastric abdominal pain, indigestion, and multiple episodes of emesis. Physical abdominal examination revealed tenderness of the epigastrium and a palpable epigastric mass which was misdiagnosed as an epigastric hernia. Patient's vital signs were normal. Rectal examination did not show any abnormal pathology. Laboratory blood tests revealed only a mild microcytic anemia and a mild leukocytosis. Multiple investigations were performed. Abdominal plain X-ray was not indicative and magnetic resonance imaging (MRI) showed two well-defined T2 hypointense and T1 isointense filling defects mass lesions within the stomach. The larger of these within the body of stomach measured approximately 100 × 50 mm and the smaller of these in the gastric fundus measured 40 mm, differentiating between gastric leiomyoma and a bezoar . HistoryAn upper GI gastroscopy test was recommended and the patient was transferred to a nearby upper gastrointestinal unit for further management where she was investigated additionally with Computed Tomography (CT)  and had Two weeks postoperatively the patient presented with generalized cramping abdominal and intermittent back pain, nausea, and vomiting undigested bowel content all consistent with a small bowel obstruction.On examination a distended abdomen was apparent with a palpable, hyporesonant mass in the right lower quadrant region. Abdominal X-ray was not indicative of bowel obstruction; however, CT scan imaging identified a high grade small bowel obstruction which was due to an intraluminal mass .The patient underwent an urgent laparotomy and a residual trichobezoar mass was found in the jejunum which was removed by enterotomy . CarefulTrichobezoar is a rare condition presenting in just 0.06–4% of the population  defined Presence of trichobezoar is associated with the conditions trichotillomania and trichophagia. Trichotillomania is a psychosomatic condition, involving the pulling out of one's hair. As in our case, it is most commonly seen in adolescent Caucasian females –6. 5–18%Trichophagia is often associated with mental retardation and psychiatric conditions such as personality and eating disorders  and thesAlthough rare and usually asymptomatic , trichobUltrasound and abdominal radiographs are often sufficient to diagnose trichobezoar  but CT iSmall gastric bezoars can be removed endoscopically however; there is limited evidence of success with only a 5% success rate in a recent study . EndoscoAccording to the reviewed literature and from our recent experience, the gold standard for managing trichobezoar gastric outlet obstruction is the laparotomy, especially when it is presenting as Rapunzel's syndrome. Although highly invasive, laparotomy has the highest success rate of the methods mentioned above and is the only method whereby the whole bowel can be examined for residual and satellite bezoars and enables effective removal .To the best of our knowledge there is only one other reported case of missed ileal trichobezoar that was discovered after laparotomy . Even thPossible explanations for residual bowel bezoar masses could be (a) endoscopic fragmentation and enzyme dissolution that could cause satellite migration of smaller hair masses , 10, (b)Once more we need to highlight the importance of the exploration of the duodenum through the gastrotomy, especially if there is evidence of Rapunzel's syndrome, and the importance of a meticulous exploration of the whole bowel before closing the abdomen. In order to minimize the risk of migration of fragments while manipulating the primary hair mass occlusion of the proximal jejunum (using bowel clump) prior to gastrotomy could be a useful surgical technique.Trichobezoar is indeed a rare cause of bowel obstruction and the diagnosis usually can be guided by a detailed history positive for coexisting psychiatric disorders. Once diagnosis is confirmed and surgical approach is necessary, it is vital that the entire gastrointestinal tract is traced via laparotomy to avoid satellite trichobezoars being missed as what happened in our case.


Congenital agenesis of the unilateral adnexa is a condition that has rarely been described in the literature. The current study presents the case of a 26-year-old female who was admitted to the Department of Gynecology at the Women’s Hospital of Zhejiang University  for primary infertility. The patient was diagnosed with unilateral ovarian and fallopian tubal agenesis, without malformations of the uterus and urinary tract, during diagnostic laparoscopy and hysteroscopy. A literature review was conducted with the aim of determining the possible causes of these anomalies. However, the etiology of the adnexal anomaly remained unclear, although torsion or congenital defects were the most likely explanation. Therefore, the observations of the present study indicate that contralateral tubal pathologies may contribute to sterility. Congenital agenesis of the unilateral adnexa is an uncommon condition that has rarely been described in the literature. In addition, the incidence of adnexal malformations is difficult to determine. It has been suggested to be 1:11,240 ,5. AdnexA 26-year-old nulligravida was admitted to the Department of Gynecology at the Women’s Hospital of Zhejiang University  with a diagnosis of primary infertility. Informed consent was obtained from the patient for the present study. The patient had not conceived despite regular unprotected intercourse for two years. Menarche occurred at 12 years of age, and the menstrual cycle was regular with 27–28 day intervals and a 5–6-day menstrual period without dysmenorrhea. The overall health of the patient was good and there was no history of abdominopelvic surgery or pelvalgia. On physical examination, no surgical scars were observed. The external genitalia, vagina, cervix and uterus appeared normal on gynecological examination, and the results of sex hormone analysis were also normal. The patient’s husband submitted a semen analysis, which was within the normal limits. Transvaginal ultrasonography revealed that the uterus and ovaries  were normal. Hysterosalpingography was performed in the Wenling Ruoheng Hospital  additional local hospital, which revealed a normal uterine cavity; however, the fallopian tubes did not fill bilaterally; the hysterosalpingography was not repeated. Furthermore, genetic analysis revealed a normal karyotype .Subsequently, a diagnostic laparoscopy and hysteroscopy were performed. During the hysteroscopy, the endometrial cavity was observed to be normal, as well as the left and right tubal ostia. The laparoscopy revealed a single, normal-sized uterus with a smooth surface. No adhesion between the uterus and the intestinal serosa, the cecum and the pelvic wall was observed. The rectouterine pouch was inspected and no ectopic tissues were identified. The left adnexa was not completely visualized; however, a 2-cm tubal remnant with an intact left round ligament was observed. The right fallopian tube, right ovary (with a corpus luteum) and right round ligament were found to be normal . The broSince adnexal agenesis often coexists with malformations of the urinary tract, abdominopelvic magnetic resonance imaging (MRI) was performed to investigate the urinary system. The MRI scan revealed that the kidneys and ureters were normal bilaterally, while the left ovary was unable to be imaged .Unilateral absence of the adnexa is rarely reported without a uterine deformity. Therefore, the present case report prompted a comprehensive literature review. Similar cases reported in the literature, describing unilateral agenesis or the absence of the ovary and fallopian tube without uterine anomalies, are presented in Congenital absence of the ovary is a rare condition, with one in every 11,240 individuals affected ; howeverAdnexal agenesis is often associated with malformations of the uterus and/or urinary tract, including a unicornuate uterus and unilateral renal agenesis . CongeniThe true etiology of ipsilateral ovarian and/or tubal absence has yet to be elucidated –3. The tet al (et al (A number of studies have indicated that unilateral absence of the fallopian tube and ovary is the result of adnexal torsion with necrosis and resorption, which may occur antenatally or postnatally ,5. Furthet al  also supl (et al  reportedA number of previous cases have demonstrated that unilateral ovarian absence coexists with teratomas on the great omentum or the uterine surface –17. Omenet al (Developmental abnormalities have been observed in the female reproductive tract, including the fallopian tubes, ovaries, uterus, cervix, vagina and external genitalia. Usually, abnormalities include organs that originate from the Mullerian ducts. In the sixth week of gestation, the bilateral Mullerian ducts migrate towards the midline, meet, form luminal structures, fuse and finally form the uterus and upper one-fifth of the vagina. Rostrally, the Mullerian ducts form fallopian tubes. Any disturbance in the migration, fusion or resorption of these ducts may result in a Mullerian anomaly . Paternoet al  presenteIn comparison to Mullerian duct-derived organs, congenital defects of the ovary are rare. Gonadal development depends on accurate germ cell migration, as well as appropriate formation of the urogenital ridge. These processes are regulated by multiple factors and genes , and a uet al (A number of similar patients have been reported in the literature, with anatomic abnormalities observed during evaluations for primary infertility. It is unknown whether unilateral adnexal absence may be a cause of infertility. Several authors have hypothesized that unilateral adnexal absence does not diminish female fertility, particularly when the condition is not accompanied by a uterine malformation . Uckuyu et al  also invet al . The patet al ,6,5. We In conclusion, unilateral ovarian and fallopian tube agenesis is a rare condition. The true etiology of adnexal anomalies remain unclear, although torsion or congenital defects may be the most likely explanations. In addition, the observations of the present study indicate that contralateral tubal pathologies may contribute to infertility.


Plexiform schwannoma (PS) is a rare, peripheral nerve sheath tumor arranged in a plexiform pattern.We report an unusual case of a 19-year-old woman, who complained of pain in the plantar aspect of the left foot. Magnetic resonance image (MRI) demonstrates three solitary nodules of varying sizes in the deep soft tissue of the plantar aspect of the foot that are homogeneously isointense to skeletal muscle on T1-weighted images and hyperintense on T2-weighted fat-suppressed images, especially the rim of the lesion. Subsequent pathological examination confirmed the diagnosis of PS.MRI characteristic plays an important role in detecting this rare lesion. A review of the literature on PS is also presented.The online version of this article (doi:10.1186/1471-2474-15-342) contains supplementary material, which is available to authorized users. Schwannoma is a benign, peripheral nerve sheath tumor, occurring commonly in the persons of 20–50 years old , and manA 19-year-old woman complained of pain in the plantar aspect of the foot for eighteen months. The pain was moderate and tolerable in the initial stage, and often worse at night, and even much worse with compression and low temperature. The patient visited the department of radiology due to aggravation of the local pain for the last four months. Physical examination revealed three prominent soft tissue nodules with swelling and tenderness, in the plantar aspect of the left foot, but without adhesion to the surrounding tissue. Neurological examination showed numbness in the medial aspect of the distal plantar aspect of the left foot. The movement and strength of both toes and foot were normal. The patient denied any history of trauma. The family history of neurofibromatosis type 2 (NF-2) was also negative.The MRI examination was performed to characterize the nodules detected during physical examination. On MR imaging, a linear nodular distribution of the lesions, located in the mid part of the plantar aspect of the left foot was observed Figures . No evidAfter operation, the patient reported hypoesthesia in the distant third and fourth toes. The patient was followed up for two and a half years postoperatively, and there was no evidence of local recurrence or new lesions at other parts of the body.PS is a rare variant of schwannoma . It occuMRI is a useful tool in detecting soft tissue neoplasms. MRI is also used in the diagnosis of multiple PSs , 11. GroIn the current study, MRI showed three round-shape nodules located in the plantar aspect of the foot. These nodules were not scattered and they had a peculiar linear distribution originating from the branches of the common plantar digital nerves. The MR signal of these nodules was homogeneous, maybe partially due to the small size of the nodule. No evident cystic degeneration was noted in any of the three lesions, which were different from conventional schwannomas. The mass of the solitary nodule was surrounded by a hyperintense rim on T2-weighted images with fat suppression, which have not been reported and required further investigation to identify the reason. Particularly, the surrounding nerve of the tumor appeared like a mouse-tail, which implied the neurogenic tumor.It is important to differentiate PS from plexiform neurofibroma, because there are some similarities in clinical and imaging characteristics of them. In contrast to PS, plexiform neurofibroma originating from peripheral nerves usually occurs in early childhood with a positive family history of neurofibromatosis , 26, 27,Some authors reported , 29 thatThe histopathologic differential diagnosis of PS includes plexiform neurofibroma and plexiform fibrohistiocytic tumor , which rBecause the study was a retrospective study, no contrast MR examination was done and intraoperative photos were not acquired. Thus it must be assumed that the outcome of this case report would be more worth to study.We present a case of multiple PSs in the plantar aspect of the foot. In contrast to conventional schwannomas, multiple PSs are rare, and the imaging features of this lesion include the homogeneously hyperintense signal without multinodular and cystic degeneration on T2 MRI. We report this case with an effort to describe its MRI characteristics for diagnosis and also hope to provide informative data for further comprehensive analysis.We conform that the patient has given his written consent for the case report to be published. A copy of the signed consent is available for review upon request.This material has not been published and is not under consideration elsewhere. This study receives no financial support.


Pseudomyxoma peritonei is usually a benign tumor that is slightly more common in women. However, it requires aggressive surgical treatment and chemotherapy, often compromising future reproductive function. This report presents a case of pregnancy in a 35-year-old woman who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei. The tumor was diagnosed during a laparoscopic examination on a workup for infertility in 2008. Two months later, she underwent a peritonectomy followed by hyperthermic intraperitoneal chemotherapy and, regarding her will to conceive, ovaries and fallopian tubes were preserved. In March 2011, she went through an in vitro fertilization followed by an uneventful pregnancy and delivered a healthy child 39 weeks later. Ovaries are usually resected during the cytoreductive surgery, since they are common sites for neoplastic implants, and, even when not performed, little is known about the effects of local chemotherapy on female fertility. The largest international survey on this matter only describes seven similar cases. This particular report not only describes a rare condition but also adds to the upcoming discussion about whether ovaries can be preserved in specific situations, therefore keeping the prospect of conceiving after this treatment. Pseudomyxoma peritonei (PMP) is a rare clinical condition characterized by mucinous ascites due to the growth of a tumor on the peritoneal surface. PMP usually develops from primary appendiceal epithelial neoplasms, which leads to its own lumen obstruction and subsequent perforation. Subsequently, the neoplastic cells colonize the peritoneal cavity and begin to produce a great amount of mucin , 2. The PMP's incidence is reported as being 1 per 1.000.000 people annually, is more commonly diagnosed in women, and has a mean diagnostic age of 52 years .The classical PMP treatment is surgical debulking of the tumor in order to alleviate the effects of abdominal pressure. It is a palliative treatment and has an increased probability of leaving the remaining neoplastic cells in the peritoneal cavity. Subsequent surgeries may be necessary and are much more difficult due to intra-abdominal adhesions . NeverthAlthough the median age of diagnosis is around 50 years, some young patients in fertile age present with PMP and maintain the desire to conceive. The pelvic peritonectomy generally involves the resection of both ovaries, since these organs are common sites of occurrence and recurrence of peritoneal seeding. Therefore, the preservation of the ovaries in this setting is controversial. With the current perspective of an increasing life expectancy after PMP surgery and the known effects of chemotherapy on the female reproductive system, much has been questioned about the fertility of these women and the prognosis of pregnancy after CRS and HIPEC. The largest international study on this matter has reported only seven cases of successful pregnancies after the treatment suggested by Sugarbaker .We report here the case of a 35-year-old woman diagnosed with PMP and submitted to CRS and HIPEC that conceived a healthy child 3 years after surgery.On August, 2006, a 35-year-old nulliparous female presented to her gynecologist for evaluation of infertility due to polycystic ovary syndrome, which was confirmed by clinical findings and laboratory tests. At that time, three ovulation induction cycles with clomiphene citrate and gonadotropins were performed with no success.On October, 2007, she went through another three ovulation induction cycles along with intrauterine insemination. Although ovulation was confirmed by ultrasound examination, no embryos were detected.Due to failure on later treatments, she was submitted to a laparoscopic examination in May, 2008, which demonstrated several peritoneal implants of neoplastic cells. Biopsy showed low-grade mucinous neoplastic cells, which it is a diagnostic compatible with PMP.The patient was completely asymptomatic and no abdominal masses or ascites were found on clinical examination. All laboratory tests were normal  and a hysterosalpingography showed pervious fallopian tubes.On July, 2008, after evaluation at our colorectal unit, the patient underwent an exploratory laparotomy in order to perform CRS and HIPEC. The appendix was the primary tumor site and there was no macroscopic disease in both ovaries, enabling their preservation. Peritonectomy of the right subphrenic space, greater omentectomy, and appendicectomy were performed, followed by hyperthermic intraperitoneal chemotherapy with mitomycin C (25 mg) at 41°C over 90 minutes. The completeness of cancer resection (CCR) was classified as CCR-0, meaning no macroscopic neoplastic implants, and the patient's recovery was uneventful.The histological examination showed a disseminated peritoneal adenomucinosis (DPAM) type of appendiceal PMP, according to Ronnett's classification , on the The patient remained asymptomatic, with only one sporadic episode of acute abdominal colicky pain and diarrhea. Subsequent magnetic resonance and ultrasound imaging of the abdominal cavity were done the following 5 years and no recurrences or ascites were found.At 39 years of age, on September, 2010, she decided on in vitro fertilization and three embryos were implanted on March, 2011, with positive beta HCG twelve days later.She had an uneventful pregnancy and delivered from caesarean section a healthy female fetus on the 39th week, on November, 2011. Fifteen days after the delivery, she presented with a hypertensive crisis and was clinically treated with good response.The introduction of CRS and HIPEC for the treatment of PMP has substantially increased overall and disease-free survival rates, turning it into the gold standard treatment not only for PMP specifically, but for other types of peritoneal carcinomatosis (PC) as well , 8, 9. UNevertheless, recent evidence depicts the possibility of ovary preservation and childbearing after CRS and HIPEC . Elias eAdditionally, an international survey taken among the International Peritoneal Surface Malignancy Group was able to detect seven pregnancies in women who have undergone CRS and HIPEC. The women's ages varied from 17 to 34 years and 5 of them had the diagnosis of PMP. The most frequent delivery was vaginal, all of them within 2 years after the procedure, and only 1 newborn had a congenital problem (diaphragmatic hernia) .This case report, along with the data presented, shows that pregnancy after CRS and HIPEC is a possibility. Our patient conceived only after in vitro fertilization because she had a previous fertility problem, but there was no alteration of her reproductive function.The PMP diagnosis was made during the workup for infertility, such as one of the cases in the Ortega-Deballon et al. study . RecentlIn conclusion, there is plenty of consistent evidence showing that CRS and HIPEC are the gold standard approach for PMP and that pregnancy in fertile female patients who underwent these procedures is possible. In addition, preservation of ovaries and adnexa may be considered among these women based on specific criteria . Finally


Langerhans cell histiocytoses (LCH) are a rare group of disorders that comprise a large spectrum of diseases initially known as histiocytosis X. In this case report, we relate a case of LCH affecting the vulva of a 47-year-old female. The patient presented since 3 years with a vulvar lesion characterized by non-healing ulcers and a perineal granuloma on which she underwent surgery. Professionals should keep in mind not to treat straightforwardly lesions of the genital tract as simple sexually transmitted diseases. Chronic, atypical genital lesions seen in women need to be worked up and dealt with accordingly. Langerhans cell histiocytoses (LCH) are a rare group of disorders that comprise a large spectrum of diseases initially known as histiocytosis X. They present as a clonal neoplastic proliferation of Langerhans type cells. Three main clinical manifestations of Langerhans cell histiocytosis have been identified  but many intermediate and acute forms of the disease have been described. They vary from a local invasion requiring local treatment (60%) to an acute, more disseminated type. Genital LCH as the unique manifestation of this disease is rare. We present a case of a woman with LCH affecting solely the vulva.3). Renal function, hemogramme, liver function tests were all normal. We noticed minimal elevation in alkaline phosphatase reaching 260 U/l. Protein electrophoresis was in favor of an inflammation with elevated alpha-2 globulins: erythrocyte sedimentation rate was at 69mm/H with a normal C-reactive protein measuring 0.19mg/dl. Thyroid hormone levels as well as LH, FSH, Prolactin, cortisol, were all within normal limits. Urine osmolarity was normal and chest/abdominal CT scan was unremarkable. Bone scintigraphy did not show any specific lesion. There was no evidence of disease beyond the vulva. After working up the patient, we concluded to the diagnosis of Langerhans cell histiocytosis located in the vulvar area.The patient is a 47 year old, with no significant past medical history, presenting since 2009 with a perineal lesion for which a histopathological examrevealeda perineal granuloma. The patient sought consultation in June 2012 with the same complaint: a vulvar lesion for which she was operated a month later in July 2012. The lesion was excised, sent to the lab and the diagnosis of Langerhans cell histiocytosis surfaced . In thisLangerhans cells are peripheral dendritic antigen processing cells of bone marrow origin. They are found throughout the body but primarily in the stratum spinosum of the epidermis . They plLangerhans cell histiocytosis (LCH) is a rare disorder characterized by abnormal proliferation of Langerhans cells. The Histiocyte Society classifies LCH as Single System LCH (SS-LCH) or Multisystem LCH (MS-LCH) depending on the extent and localization of disease . For diaThe pathogenesis of the disease still remains debatable. Two main theories emerge: neoplasticversus reactive processes. The first is supported by the fact that the proliferation of Langerhans cells appears to be monoclonal in nature due to somatic changes in tumor suppressor genes  as well The clinical manifestations of LCH are diverse. They range from non-specific inflammatory responses such as fever, fatigue, to more specific symptoms depending on the organ involved. In our case, genital lesions are mucocutaneous in nature. They are erythematous plaques often ulcerated. Biopsy of the affected area should be performed in order to start adequate management.Due to the scarcity of reported cases of vulvar Langerhans cell histiocytosis, there are no gold standard or guidelines of treatment. Many regimens have been suggested ranging from local surgery, topical corticosteroids to chemotherapeutic agents . The useThalidomide, a hypnosedative drug has been used successfully for treatment of localized LCH such as perianal lesions , genitalFinally, professionals should keep in mind not to treat straightforwardly lesions of the genital tract as simple sexually transmitted diseases. Chronic, atypical genital lesions seen in women need to be worked up and dealt with accordingly.Langerhans cell histiocytosis of the vulva remains a rare disorder with very few described cases in the literature. Two main subtypes are described by the histiocyte society, which are single and multi system LCH . The pat


She presented to the emergency department of our hospital with a diffusely tender abdomen and 2 weeks history of frequent non-bloody loose stools. She had a relevant past medical history of poorly controlled type 1 diabetes mellitus and hypertension. Abdominal computerized tomography revealed massive right abdomino-pelvic mass measuring 17.6 × 12.1 × 20 cm and diffuse HPVG. Patient underwent exploratory laparotomy, salpingo-oophorectomy, peritoneal lavage with antibiotics and treatment for septic shock. No similar case known to us has been reported in the literature previously. Tubo-ovarian abscess (TOA) is a serious sequela of pelvic inflammatory disease that occurs most frequently in women of ages 20–40 but can also be seen in older or younger women . Tubo-ov3, hemoglobin 15.6 g/dl and blood glucose 249 mg/dl. On examination, we found a hypotensive, dehydrated, obese female in septic shock with a tense, massively distended abdomen, which was diffusely tender. CT of the abdomen and the pelvis revealed pneumoperitoneum, a large right abdomino-pelvic mass measuring 17.6 × 12.1 × 20 cm, that appeared to be a septic ovarian cyst  complication of TOA. Hepatic portal venous gas is attributed to gas-forming organisms resulting from intra-abdominal conditions such as intestinal mucosal damage or ischemia and infection in other tissues, which may be secondary to mesenteric ischemia, ulcerative colitis perforated peptic ulcer disease, gangrenous cholecystitis and ascending cholangitis; such injuries provide a portal for intraluminal gas to enter the portal venous system . Our patClearly, ours is a rare case of complicated TOA that required emergent surgical intervention due to ongoing septic shock, which carries a high mortality rate in the presence of HPVG . SurgeryNone declared.


Gastrocolic fistula is a rare complication of adenocarcinoma of the colon. Despite radical resections, these patients usually have a poor prognosis with a mean survival of 23 months and long-term survival is rarely reported.A 48-year-old Latino-American man presented with watery diarrhea, diffuse abdominal pain and weight loss for 3 months. A computed tomography scan revealed a mass in the splenic flexure that had infiltrated his stomach and diaphragm. Panendoscopy and colonoscopy confirmed the presence of a fistula between the distal transverse colon and the stomach, which was secondary to a colon cancer. His colon, stomach and left diaphragm were resected en bloc. A histological examination revealed a moderately differentiated adenocarcinoma of the colon that had infiltrated the full width of the gastric wall with 37 negative lymph nodes and clear surgical margins. Adjuvant chemotherapy with capecitabine and oxaliplatin was administered after surgery. Our patient is alive and without any recurrence 5 years after surgery.En bloc resection with adjuvant chemotherapy offers the best treatment option for gastrocolic fistulas. This is one of the patients with greater survival reported in the medical literature. Cologastric or gastrocolic fistula is a pathologic communication between a segment of the colon and the stomach, and may be caused by benign or malignant diseases of the gastrointestinal tract. It has been associated with diseases such as gastric tumors –3, gastrA 48-year-old Latino-American man was admitted to our hospital because of a 3-month history of intermittent watery diarrhea. Initially, the diarrhea was self-limited, and the stools did not contain mucus or blood. One week before his admission, the diarrhea became persistent and was accompanied by black, tarry, malodorous feces. In addition, our patient had a dull abdominal pain, predominantly in the left upper quadrant, which radiated to the lumbar region . Our patient had no family history of colon cancer. He smoked one pack of cigarettes daily and occasionally consumed alcohol. His weight had decreased by 10 kg during the last 6 weeks before his admission. He had no history of peptic ulcer disease, inflammatory bowel disease, trauma or abdominal surgery. His body temperature was 37 °C, heart rate was 70 beats per minute, respiration rate was 19 breaths per minute, and blood pressure was 100/70 mmHg.3, and platelet count was 623,000/mm3. His lactate dehydrogenase concentration was 121 U/L, and his gamma glutamyl transpeptidase level was elevated (71 U/L). His albumin level was low (2.4 g/dL). Other blood chemical and enzyme values were normal. An electrocardiogram showed no abnormalities.Our patient experienced abdominal pain in response to deep palpation of the left upper quadrant of his abdomen. There were no palpable masses. Auscultation revealed an elevated frequency of bowel sounds. His hemoglobin level was 9.2 g/dL, hematocrit was 28.2 %, white blood cell count was 8,900/mmA computed tomography (CT) scan of his abdomen showed a mass in the splenic flexure of the colon that had infiltrated the greater curvature of the stomach and revealed the presence of a gastrocolic fistula; the mass also involved the left anterolateral region of the diaphragm Fig. . The endIn view of these findings, a radical en bloc resection was performed involving a subtotal gastrectomy, a transverse left-side colectomy, small bowel resection, and left diaphragm Fig. . HistoloGastrocolic fistula is an uncommon complication of benign and malignant diseases of the gastrointestinal tract . In the The classic clinical presentation of a gastrocolic fistula is a triad of diarrhea, weight loss and feculent vomiting . Other set al., reported that 5-year survival after en bloc resection of colon cancer is higher compared to colectomy with separation of adherent organs (61 % versus 23 %) [Surgical options for gastrocolic fistula have changed over time, from second- and third-stage surgeries in the 1940s to the current one-stage en bloc resection technique . Practicus 23 %) . In a Geus 23 %) .In a Japanese report of 14 gastrocolic fistulas, mean age was 50 years with a male to female ratio of 10:4; it is similar to our patient, who is male, and 48 years old. The fistulous formation between the distal half of the transverse colon and the greater curvature of the stomach was seen in 13 of 14 cases (93 %), similar to ours. These patients usually have a poor prognosis; the mean survival is 23.4 months  [Gastrocolic fistula is a rare complication of adenocarcinoma of the colon. En bloc resection with adjuvant chemotherapy offers the best treatment option for gastrocolic fistulas. This is one of the patients with longest survival reported in the medical literature.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


A 23-year-old male with a history of bone marrow transplant for acute myeloid leukemia. He presented a large mass in the right inguinal region 5 years ago. Upon physical examination, right-sided cryptorchidism was observed. The tumor markers alpha-fetoprotein and beta-HCG were within normalcy range and lactate dehydrogenase was raised. Computed tomography of the abdomen and pelvis revealed right testicular mass in contiguity with the inguinal canal to the ipsilateral retroperitoneum, associated with right hydronephrosis. Due to the risk of germ-cell tumor in undescended testicle, the patient underwent radical right orchiectomy. The pathological examination showed recurrence of acute myeloid leukemia in the testis. He was referred to oncology for adjuvant therapy. Our literature review found no similar cases described. Acute myeloid leukemia (AML) is a myeloproliferative syndrome and accounts for 20% of acute leukemias in childhood, and for 50% in patients aged up to 20 years, mainly white males. Treatment is based on bone marrow transplant and chemotherapy.,3Cryptorchidism is the absence of testis in the scrotum and is one of the most common disorders in childhood, affecting 0.8 to 1% of young adults. Its diagnosis and treatment with orchidopexy must be made early, since the condition is associated to testicular torsion, hernias, infertility and malignization. The risk of degeneration and developing a germ-cell tumor is 40-fold higher as compared to the general population.–6Approximately 4% of pediatric patients with lymphoma may have a primary testicular involvement or relapse. The testis is considered to have a vascular barrier that hinders chemotherapeutical action, and orchiectomy is the standard treatment.The objective was to report a case of unidentified testicular mass in a clinical evaluation before bone marrow transplant and difficulty in making diagnosis and treat this condition. Based on our literature review, this might be the only case reported of AML recurrence in cryptorchidism.versus host disease presenting diffuse sclerodermiform plaques. He was treated with pulse therapy, and progressed with partial regression of the lesions. Five years later, a hard bulky mass, fixed to adjacent tissues, was observed in the right inguinal region  in February 2004. One hundred days later he developed graft l region . On physThe hypothesis of testicular cancer associated to right cryptorchidism was raised. The tumor markers were alpha fetoprotein: 2.5ng/mL : up to 7ng/mL), beta-HCG: normal (RV: <3U/mL) and lactate dehydrogenase: increased 483UI/L (100 a 190UI/L). Computed tomography (CT) of abdomen and pelvis showed a right testicular mass with contiguity to the inguinal canal up to the ipsilateral retroperitoneum, associated to right hydronephrosis  and 2B.Right radical orchiectomy was indicated due to suspected primary tumor or recurrence of AML. Inguinotomy was performed and an enlarged and hard peritesticular lymph node was excised  and 3B. ,8 In this case reported, a rare type of neoplasm is observed and it corresponds to less than 0.5% of testicular tumors, caused by infiltration of leukemia/lymphoma of the testis. The most frequent subtype in testis is lymphoid leukemia. In the young adult population with acute lymphoid leukemia, up to 5% of patients can have primary involvement or relapse in testis. There are case reports in the literature of recurrent acute lymphoid leukemia after bone marrow transplant, in whom chemotherapy and radiation therapy were not efficient and orchiectomy was the treatment chosen for remission of the disease.,10Testicular cancer is frequent in young adult population, with an annual incidence of 4 per 100 thousand, and 95% are germ-cell tumors. In our patient, the interval was of 60 months. Several studies stated that testicular involvement in leukemias must be treated with orchiectomy due to the vascular barrier that hinders the action of chemotherapy.–6Testicular involvement is extremely rare in AML, and there are few cases reported, mainly in children; in that, bone marrow involvement occurred later in almost all patients. In these cases, the interval between remission and testicular recurrence ranged from 4 to 60 months, in average 21 months. The intraoperative frozen biopsy was performed to verify the presence of malignant lesion. The literature shows that relapsed AML or primary tumor of the testis should be addressed by orchiectomy, and the treatment complemented with adjuvant chemotherapy, based on the pathological examination.–6 The case was managed according to the current recommendations, considering the peculiar recurrence of AML, a rare event that affected a patient with cryptorchidism, which hindered making diagnosis.In this present case orchiectomy was indicated because of undefined testicular tumor, since the tumor markers did not suggest the diagnosis. Computed tomography of abdomen and pelvis is mandatory in cases of testicular tumors for staging and searching primarily retroperitoneal adenomegaly, for these lymph node basins are more affected in such neoplasms.


The mediastinum is an anatomically defined space in which organs and major blood vessels reside with surrounding soft tissue elements. The thymus is an important organ in the mediastinum, and many of the masses encountered in the mediastinum are related to this organ. Most neoplasms diagnosed in the mediastinum are epithelial tumours (thymomas and thymic carcinomas), lymphomas or germ cell tumours. In contrast, soft tissue tumours of the mediastinum are rare. In 1963, Pachter and Lattes systematically reviewed soft tissue pathology of the mediastinum, covering the hitherto described , 227 In  Soft tissue tumours arising in the mediastinum are rare. Their estimated incidence is between 2 and 6 % of mediastinal neoplasms –3. HowevMost soft tissue tumours described elsewhere in the body have been reported to occur in the mediastinum, of course with the exception of strictly site- or organ-specific neoplasms such as GIST. Because of their rarity, most mesenchymal tumours in the mediastinum have been reported as case reports or small series. Mediastinal sarcomas may either arise de novo or rarely as “somatic-type” malignancy in a mediastinal germ cell tumour (GCT). Development of a sarcomatous component has been reported to occur more frequently in mediastinal GCTs than in other sites . The twoLipomatous tumours are common in the mediastinum and may be located in any compartment. All subtypes of liposarcoma have been reported in the mediastinum.Lipoma has been frequently reported in the mediastinum and comprises between 1 and 9 % of primary thymic masses . MediastWhen a circumscribed mediastinal mass lesion is composed of mature fat and has a distinct component of thymic tissue, it is considered a site-specific tumour and is termed thymolipoma . A definThymolipoma Fig.  is mainlHistologically, thymolipomas are encapsulated tumours composed of mature fat cells and thymic tissue. The latter consists of epithelial cells and immature TdT-positive lymphocytes (“thymocytes”) and may contain Hassall’s corpuscles. The proportion of fatty tissue may vary considerably (in one series from 30 to 80 %) , 17. RarA number of unusual variants of thymolipoma have been described, including one with a prominent vascular component, designated thymohemangiolipoma . HoweverAlthough lipomatosis is considered a non-neoplastic increase of normal mature fat, this non-encapsulated mass lesion is mentioned here for differential diagnostic purposes. In the mediastinum, it is usually detected by imaging studies, where it causes widening of the mediastinum. Patients may complain of dyspnea. It is commonly associated with steroid use, Cushing’s disease or obesity. Idiopathic cases are very rare –34.Lipoblastoma (LPB) is a rare adipocytic tumour composed of fat cells in various stages of maturation, essentially restricted to the paediatric age group with 90 % occurring before 3 years of age without sex predilection. Mediastinal LPB is very rare with approximately 30 cases presented in case reports or small case series –66. MediHistologically, LPB is characterized by fatty tissue in varying degrees of maturation. Most cases are circumscribed, but rarely, a diffuse growth is seen . Although LPBs are benign tumours, recurrence may occur  and the Angiolipoma, an adipocytic tumour composed of small, often capillary-sized blood vessels, combined with mature fat cells has been described in the mediastinum Fig. . As the A few cases of mediastinal spindle cell lipoma with typical histological features including “ropey” dense collagen strands and bland spindle cells have been reported , 73. TheHibernoma is a rare distinctive benign adipocytic neoplasm composed of brown fat with microvesicular multivacuolated lipocytes, usually in a subpleural site  or assocLess than ten cases of myelolipoma have been reported in the mediastinum. Most cases of myelolipoma occurred in adults (sixth to eighth decade) with no gender predilection and were often discovered incidentally or at autopsy where death was due to other causes. Most cases were present in the posterior mediastinum, often in a paravertebral location , 80–89. Liposarcoma is a malignant adipocytic tumour with various subtypes which impact on behaviour and prognosis. It is, by far, the most common primary malignant mesenchymal tumour of the mediastinum. The age range is wide. Paediatric cases, even occurring in very young infants, have been reported , 91–98. FUS-DDIT-3 fusion in myxoid liposarcoma [mdm-2 in well-differentiated and dedifferentiated liposarcoma [All subtypes of liposarcoma have been reported in the mediastinum. Based on their own series and a comprehensive review of 142 published cases, Boland et al. concluded that the proportions of liposarcoma subtypes in the mediastinum differ from those in other sites . In partosarcoma  and amplosarcoma , 108.mdm-2, a marker for well-differentiated and dedifferentiated liposarcoma, was identified. Other unusual variants of liposarcoma that have been described in the mediastinum contained elements of smooth muscle (lipoleiomyosarcoma) or skeletal muscle [An unusual liposarcoma, termed pleomorphic myxoid liposarcoma (P-MLPS) by Alaggio et al., appears to have a predilection for the mediastinum of young patients  Fig. 4)4). Five l muscle , 109–111mdm-2 confirms the diagnosis of liposarcoma. So-called fat-forming solitary fibrous tumour may enter the differential diagnosis of liposarcoma. Mdm-2 amplification is absent in these tumours, and positive staining of STAT-6 on immunohistochemistry may further support a diagnosis of solitary fibrous tumour (SFT) (see below). Liposarcoma as a secondary malignancy developing in a GCT has very rarely been described [The main differential diagnostic considerations of mediastinal liposarcoma are benign lipomatous tumours. Attention to histological features and the use of molecular markers will lead to a correct diagnosis. Dedifferentiated liposarcoma may mimic undifferentiated pleomorphic sarcoma, particularly in biopsy specimens; demonstration of amplification of escribed . CurativSince many of the tumours in the fibroblastic/myofibroblastic category have a predilection for the skin and superficial soft tissues, it is not surprising that only very few of the entities in this category have been reported in the mediastinum. Desmoid tumours (aggressive fibromatosis), SFT and inflammatory myofibroblastic tumour (IMT) are among the more frequently reported types in the mediastinum.Aggressive fibromatosis is a locally invasive (myo)fibroblastic proliferation with bland cytology and without metastatic potential. About 30 cases of primary mediastinal aggressive fibromatosis (AF) have been reported as case reports, many of which were included in reviews by Nakagiri et al. and Bouchikh et al. , 114 AF SFT is an uncommon but well-known intrathoracic fibroblastic tumour and often of pleural origin. Since its description, numerous reports of extra-pleural SFT cases have been published with tumours arising in almost all locations in the body . MediastMediastinal SFT may arise in any compartment of the mediastinum. A number of mediastinal SFTs had also contact to the epicardium , and in NAB2-STAT6 gene fusion [NAB2-STAT6 gene fusion has not yet been formally shown for mediastinal SFT.The histomorphology of SFT is characterized by a “patternless” architecture with randomly distributed hypocellular and hypercellular areas, sometimes keloid-like collagen, and thin “stag-horn” branching capillary vessels that may show perivascular hyalinization. Tumour cells are generally spindle shaped with bland cytology and few mitoses. Immunohistochemistry is helpful in the diagnosis of SFT and shows usually strong expression of CD34 , 166. Ote fusion –172 has e fusion –175, alt2), high cellularity, pleomorphism and necrosis apply as outside the mediastinum [It has been suggested that mediastinal SFTs more frequently show aggressive behaviour compared to non-mediastinal SFTs . The samiastinum .mdm-2 amplification remains a robust marker for liposarcoma and has not been reported in SFT , mesothelioma, sarcomatoid carcinoma, synovial sarcoma and malignant peripheral nerve sheath tumour (MPNST). In addition to morphological differences, immunohistochemistry will help to diagnose SFT in most cases. Cytokeratin staining is seen in thymoma, mesothelioma, sarcomatoid carcinoma and synovial sarcoma and is very rare in SFT. In addition, STAT6 is a reliable marker for SFT and has not been described in the other tumours.Inflammatory myofibroblastic tumour (IMT), a tumour composed of (myo)fibroblastic cells and a variably dense non-neoplastic inflammatory component, has been reported in many sites, predominantly in young adults and children . Bona fiHistologically, IMT is an infiltrative tumour composed of (myo)fibroblastic cells admixed with an inflammatory infiltrate of lymphocytes, plasma cells and eosinophils. Three histological patterns (granulation tissue-like/compact fascicular spindle cell pattern with marked inflammation/low cellularity scar-like pattern) that can all occur within a single tumour have been described but do not portend a specific biological behaviour .ALK gene rearrangements. ALK aberrations have been reported in a single mediastinal case [Multifocality is not uncommon in IMT. Cytoplasmic expression of ALK protein is detectable in about half of cases and correlates well with presence of nal case .The biological behaviour of IMT is variable and recurrences are common, but distant metastasis is rare.ALK-rearranged IMT are potential candidates for treatment with specific inhibitors, although this has so far not been described for mediastinal cases.Similar to non-mediastinal sites, treatment rests mainly on complete local excision. Patients with Calcifying fibrous pseudotumour, a very rare soft tissue tumour with proposed but unconfirmed relationship to IMT, has been reported in the mediastinum –200. TheReports of fibrosarcoma arising in the mediastinum predate the current concept that adult fibrosarcoma is a very rare tumour. The most recent report of an adult mediastinal fibrosarcoma dates from 1995 . While iThree cases of low-grade fibromyxoid sarcoma have been reported in the mediastinum, among which one case was attached to the epicardium –204. AllA single case of infantile myofibromatosis with multifocal masses in the lung and mediastinal soft tissue in a 4-week-old male infant has been reported. Five years after surgical resection and pneumonectomy, no disease activity was recorded .A single case of mediastinal giant cell angiofibroma was reported in a 62-year-old female . HoweverFibrohistiocytic tumours are mainly encountered in superficial soft tissues or joints. Two cases of benign fibrous histiocytoma in the mediastinum have been reported , 209. DeGiant cell tumour of soft tissue (GCT) is most commonly observed in superficial soft tissue of the extremities, trunk and head and neck. Five primary mediastinal cases have been reported, occurring in individuals aged 18–53 years  –214. TheMalignant fibrohistiocytic tumours, previously referred to as malignant fibrous histiocytoma (MFH), are now classified as undifferentiated high-grade pleomorphic sarcomas and are not considered of true histiocytic lineage (see part 2 of this review). So-called MFH cases have been recorded in the mediastinum with generally poor prognosis.When a mediastinal sarcoma is diagnosed, the possibility must be considered that sarcomatous tissue remains as the sole component in a long-standing primary mediastinal GCT, particularly in younger male patients . Likewis


Inguinal hernias in girls are often irreducible when they contain ovaries. Rarely the hernial sacs may have unusual contents like vermiform appendix, uterus and urinary bladder. We report a case of a female infant who presented with bilateral irreducible inguinal hernias presumed to be due to ovaries. However at exploration, the hernial sacs contained bilaterally an omental mass with calcifications. Presence of mucin with meconium- laden macrophages in the mass on histology suggested an antenatal intestinal perforation. To the best of our knowledge no such case has been reported in a female neonate. We present this rare case and discuss the unusual findings and the outcome. Most inguinal hernias in female infants are reducible and indirect; however, the hernia can become incarcerated. In the absence of bowel obstruction, ovaries are the most likely content seen in female infants [1]. We report a case of a female infant who presented with bilateral irreducible inguinal hernias presumed to be due to ovaries. However at prompt exploration, the hernial sacs contained bilaterally an omental mass with calcifications. Histopathological examination confirmed the omental mass to be consistent with meconium peritonitis. We report this unusual case and herein discuss the unusual findings and the outcome. A preterm female baby born at 30 week gestational age was delivered by emergency caesarean section in view of maternal pre-eclampsia. Antenatal foetal scans did not reveal any abnormality. She was initially intubated for respiratory distress syndrome but was self ventilating by day 9 of life. She passed meconium on day 2 of life and was opening her bowels regularly. Abdominal and genitalia examination were unremarkable. Feeds were commenced on day 9 and were established slowly. She had an AXR to check the position of the umbilical catheter on day 2 of life and this did not reveal any abnormality.At 6 weeks of age she was referred to us with bilateral incarcerated inguinal hernias. She had no evidence of bowel obstruction and clinically there were firm masses on both groins suggesting ovary as the most likely content. Bilateral inguinal herniotomy was carried out promptly. However, Intra-operatively on either side the inguinal hernial sacs contained omentum attached to an irregular, grey coloured mass with nodules distally. This mass was excised, healthy omentum returned and a standard herniotomy carried out on both sides. Post-operatively she recovered well and was discharged the following day. Histopathological examination confirmed the excised mass to be made up of omentum with areas of dystrophic calcification reminiscent of the saponification with mucin and meconium-laden macrophages; consistent with antenatal perforation of intestine . At 3 months of follow-up, she remains well and opening her bowels regularly. Incarcerated inguinal hernias in female infants are commonly due to herniated ovaries in the absence of bowel obstruction. Ovaries are reported in almost 90 – 100% of girls less than 1 year of age with incarcerated inguinal hernias [1]. Although, the ovary is not at great risk of strangulation, there is an increased risk of torsion [27%] and therefore prompt surgery is recommended [1]. Given such a high incidence of irreducible ovaries in female infants with incarcerated inguinal hernias, it is extremely rare to find hernial contents other than ovaries. Meconium laden omental mass in inguinal hernias have been reported in many male infants [2-4], however not so in female infants. In our patient, meconium laden grey omental masses were noted to herniate through the inguinal canal bilaterally. The mass was excised off a normal looking omentum proximally on both sides and herniotomy carried out. The only case report in literature on a female infant similar to such a presentation was a term infant born with a right sided labial swelling consistent with meconium hydrocele within the canal of Nuck [5]. In the absence of signs of an acute bowel perforation, asymptomatic antenatal bowel perforation with meconium peritonitis should be considered in such cases.Meconium peritonitis is a sterile process resulting from in utero intestinal perforation. Any pathology causing bowel obstruction in utero can lead to meconium peritonitis; however the incidence is low and is reported almost as 1 in 30000 [6]. Antenatal bowel obstruction is commonly seen with intestinal atresias, but can be transitory as seen in cystic fibrosis with meconium ileus. In utero ischemia of bowel has also been reported to cause bowel perforation and subsequent meconium peritonitis [7]. Antenatal ultrasound can reveal findings suggestive of meconium peritonitis. Kamata et al described three types of meconium peritonitis based on ultrasound findings: Type 1: Meconium ascites, Type 2: Giant pseudocyst, Type 3: Peritoneal calcification and small pseudocyst. In their same series of 20 patients, intra-abdominal calcifications were seen in only 25% of the patients [8] suggesting that not all cases of meconium peritonitis have findings on antenatal ultrasound scans and therefore antenatal diagnosis of meconium peritonitis can be missed. In our patient routine antenatal ultrasound scans failed to reveal any evidence of meconium peritonitis. Clinical manifestation of meconium peritonitis after birth depends on the extent of peritonitis and the underlying abnormality of bowel. It can present as giant meconium pseudocysts [9] or meconium stained inflammatory masses. A patient with an unusual sequela of meconium peritonitis involving massive extension of a processes vaginalis to the contralateral anterior abdominal wall has been reported [4]. However, meconium peritonitis does not always produce significant inflammation and may resolve spontaneously without any sequelae. Estroff et al reported 2 cases of meconium peritonitis detected antenatally that resolved spontaneously without any sequelae [10]. Ekinzi et al reported a male infant who was incidentally found to have meconium mass at bilateral inguinal hernia surgery [2]. The abdomen was explored and loose small bowel adhesions with viable small bowel were noted. They recommended that with such findings in the absence of bowel obstruction, further abdominal exploration is unnecessary. In our patient, we did not explore the abdomen and performed a routine herniotomy excising the herniated omental mass. Our patient has remained well since the surgery and to date has not had any complications. In conclusion, meconium peritonitis can be asymptomatic and can present as omental mass herniating through the inguinal canal. Abdominal x-rays might not reveal intra-abdominal calcifications in all patients, as in our case. Clinically asymptomatic neonates with omental mass found incidentally at inguinal herniotomy can be managed with inguinal herniotomy alone and further exploration of bowel we believe is unnecessary. Source of Support: NilConflict of Interest: None


Fetal adenocarcinoma of the lung is a rare subtype of pulmonary adenocarcinoma with a relative estimated incidence of 0.5% or fewer of all lung cancers. Because of its extreme rarity, there have been no controlled clinical trials investigating treatment regimens for fetal adenocarcinoma and, as a result, there are no guidelines for management.We report a case of a well-differentiated fetal adenocarcinoma, which is a variant of pulmonary blastoma, that is a low-grade malignancy and associated with a good prognosis. A 29-year-old Moroccan man presented with a well-differentiated fetal adenocarcinoma staged T3N0M0, who received 3 cycles of neoadjuvant chemotherapy followed by surgery, with no recurrence at 2 years follow-up.Fetal adenocarcinoma is a rare suptype of adenocarcinoma. Surgical resection is the treatment of choice for resectable disease. The role of chemotherapy in the neoadjuvant setting or adjuvant setting is not well defined. Fetal adenocarcinoma (FA) of the lung is a rare subtype of pulmonary adenocarcinoma that exhibits the same tissue architecture and cell characteristics to fetal lung tissue in microscopic examination. It was considered as a variant of blastoma but according to the latest World Health Organization (WHO) classification (2004), it is currently considered as a variant of solid adenocarcinoma with mucin production .FA is a rare tumor, with a relative estimated incidence of 0.5% or fewer of all lung cancers -5. BecauComplete surgical resection is the treatment of choice of FA, similarly to all subtypes of non- small cell lung cancer (NSCLC) . Some caWe report a case report of FA managed by neoadjuvant CMT and surgery.A 29-year-old Moroccan man without medical history, had a five pack-years smoking history and stopped smoking seven years ago. He presented with a four-month history of chest pain and minimal hemoptysis. The physical exam was normal. A chest X-ray Figure  showed aA chest computed tomography (CT) scan showed a tumoral lesion at the left upper lobe measuring 12.5 × 8 cm. This process was well limited, heterogeneous containing calcifications and areas of necrosis extended into the chest wall without bone lysis or lymph nodes  (as immunohistochemistry was unavailable).Bone scintigraphy, cerebral and abdominal CT scan showed no evidence of distant metastasis. Trans-thoracic biopsy was performed, histopathological study of the biopsy specimen showed a numerous glands showing an endometrioid morphology, occasional squamoid morules and relatively clear cytoplasm, the Ki-67 was 1% (low proliferation index) and based on these histopathological findings, the diagnosis of fetal adenocarcinoma was concluded Figure , then thThirty days after the last cycle of CMT the patient underwent a left upper lobectomy with lymphadenectomy Figure . The micThe patient underwent a chest CT scan assessment every 3 months during the first year and then every 6 months during the second year. At 2 years of follow-up, there is no evidence of disease recurrence .et al. reported the first case of locally advanced WDFA treated with concurrent chemoradiation therapy with docetaxel with partial response [Thus the role of neoadjuvant CMT in WDFA remains unknown, but we conclude that CMT is ineffective probably because the tumor is not proliferative, however it should be noted that Zaidi  has reporesponse . But we Fetal adenocarcinoma is a rare suptype of adenocarcinoma with a better prognosis and is most commonly diagnosed at early stage with no lymph node involvement. Surgical resection is the treatment of choice for resectable disease. The role of CMT in neoadjuvant setting or adjuvant setting is not well defined.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.FA: Fetal adenocarcinoma; WDFA: Well-differentiated fetal adenocarcinoma; WHO: World health organization; NSCLC: Non small cell lung cancer; RT: Radiotherapy; CMT: Chemotherapy; CT: Computed tomography; RECIST: Response evaluation criteria in solid tumors.The authors declare that they have no competing interests.SL was involved in the analysis of the data and the literature research, and she also wrote the manuscript, SB and MA helped with the literature research. NI helped with the patient management and revision of the manuscript. FO and BA contributed to the surgical treatment, HE approved the treatment and analyzed the literature data. All authors read and approved the final manuscript.


A 12-year-old boy presented to the clinic of ophthalmology because of watering and discharge from his left lower eyelid. The inspection examination revealed an orifice that was associated with congenital lacrimal fistula (CLF). He underwent a complete ophthalmologic and systemic evaluation to explore possible associated findings. Systemic evaluation revealed multiple renal anomalies: right renal agenesis and left ectopic pelvic kidney. This case is unique because this is the first reported case of CLF accompanied with ectopic pelvic kidney in the literature. Rasor described the first reported case of congenital lacrimal fistula (CLF) in 1675 . CLF migA 12-year-old boy presented to the clinic of ophthalmology because of watering and discharge from an orifice close to his left lower eyelid that were increasing on windy days. A lacrimal fistula was observed inferomedial to the medial canthus of his left eye. The opening was spheroidal and approximately 1 mm in diameter. There was a small amount of sebaceous material in the pit, and there was no evidence of excoriation, inflammation, or swelling . We syriAccording to the history obtained from his mother, he had CLF when he was born full term after uncomplicated pregnancy. His family history was negative for any congenital ocular or renal anomalies. Ophthalmic examination revealed uncorrected visual acuity of 20/20 for each eye. The pupils were equal and there was no evidence of a relative afferent pupillary defect. Slit-lamp biomicroscopy revealed normal anterior segments in both eyes. Funduscopic examination, intraocular pressure, and the rest of the ocular findings were within normal limits bilaterally. He underwent systemic evaluation to explore possible associated findings. Systemic evaluation by magnetic resonance imaging revealed multiple renal anomalies: right renal agenesis and left ectopic pelvic kidney on the coronal , sagittaAfter performing a fusiform incision around orifice along the skin tension lines, we held the tract with a tooth forceps and dissociated it from the adjacent tissue with Vannas scissors. After dissection we excised the tract partially and sutured surrounding tissue and skin with 6-0 Vicryl . HistoloAlthough bilateral CLFs have been reported in the literature , 4, 7, tThe embryogenesis of the nasolacrimal system begins as a stiffening of ectoderm in the nasooptic fissure that invaginates between the maxillary and frontonasal processes, giving rise to the canaliculi proximally and the lacrimal sac and nasolacrimal duct distally. Canalization of the buried ectodermal cord occurs throughout the length of the nasolacrimal apparatus. Incomplete separation of the cord from the surface epithelium or abnormal out-budding of the buried ectodermal cord can result in supernumerary canaliculi .CLFs have been systemically described with ectrodactyly-ectodermal dysplasia-clefting syndrome , hypospaThe choice of treatment for CLF is controversial. A wide range of treatment options for symptomatic CLF have been discussed in the literature, like cauterization, excision of the fistula, and excision with intubation alone or in combination with dacryocystorhinostomy –23. We mIn conclusion, CLF is a rare anomaly that might be associated with important systemic life threatening conditions. That is why the patients with CLF should be evaluated carefully for any possible associated anomalies like renal agenesis and ectopic kidney.


Introduction. Inverted papilloma (IP) is an uncommon, benign yet aggressive neoplasm characterised by high recurrence rates and tendency towards malignant transformation. The majority of IP cases originate in the ethmoid region, lateral wall of the nasal fossa, and maxillary sinus. The authors report a case of an IP originating primarily from the nasolacrimal duct (NLD). Case. A 69-year-old Caucasian gentleman presented with a lump in his right medial canthal region, epiphora, and discharge bilaterally. Radiological investigation revealed a well-defined, heterogeneous mass within the proximal NLD eroding the bony canal, protruding into the middle meatus and into the right orbit. The tumour was excised en bloc utilizing a combined external and endoscopic approach based on its location. Histology revealed hyperplastic ribbons of basement membrane-enclosed epithelium growing endophytically into the underlying stroma with no evidence of invasive malignancy. The patient made an uneventful recovery with unchanged visual acuity and normal extraocular movements. Conclusion. The case demonstrates variability within the sinonasal tract that IP can develop and the individuality of each case necessitating tailored operative techniques for complete excision whilst minimising recurrence rates. We also present a combined endoscopic approach for the en bloc resection of a NLD IP with no clinical recurrence at 15-month follow-up. Inverted papilloma (IP) is an uncommon, benign yet aggressive epithelial neoplasm, characterised by a high recurrence rate and its propensity to turn malignant. IP originates from the mucosal epithelial lining of the sinonasal tract which is in continuity with the nasolacrimal duct (NLD) and lacrimal sac, with the majority of cases originating in the ethmoid region, lateral wall of the nasal fossa, and maxillary sinus , 2. ThouA 69-year-old gentleman presented to the ophthalmology outpatient department with a varying lump in his right medial canthal region for two years. The patient reported chronic epiphora and discharge bilaterally, denying bloody tearing, pain, or diplopia. A nontender 1.5 cm smooth dome-shaped mass was palpable below the level of the right medial canthal ligament. Syringing revealed 90% flow and 10% reflux following dilatation of the puncta with no mucopurulent regurgitation. Visual acuity was 6/9 and 6/6 in the right and left eyes, respectively, without correction and there was no relative afferent pupillary defect or proptosis. The patient thirty years previously had conjunctival papilloma excised from the right eye with no extension into the medial canthus. He is otherwise fit and well.Computed Tomography (CT) of the orbits revealed a 2 cm round well-defined, heterogeneously enhancing soft tissue mass within the proximal right NLD causing pressure erosion and thinning of the bony canal, protruding medially into the middle meatus and laterally into the right orbit Figures  and 2.Magnetic Resonance Imaging (MRI) of the head confirmed a mass arising from the proximal NLD, mildly hypointense on T2 weighted images, isointense on T1 weighted images, and avidly enhancing on postcontrast images eroding the anterior lamina papyracea and bulging into the medial aspect of the right orbit. Right nasal bones were eroded with the mass extending into the nasal cavity to lie in the middle meatus anteriorly .An endoscopic biopsy under general anaesthesia revealed a benign squamous papilloma of the lacrimal duct with no evidence of dysplasia or malignancy.Following discussion at the Neuroradiology and Head and Neck Multidisciplinary meetings, complete resection as a joint case between Otorhinolaryngology, Oral and Maxillofacial Surgery, and Ophthalmology was planned.A lateral rhinotomy approach was utilized to gain access to the tumour, followed by dissection along the medial wall of orbit and around tumour. The tumour was dissected free from its remodelled lacrimal fossa and the common canaliculus divided laterally to the tumour. The anterior buttress of the frontal process of maxilla overlying the remodelled NLD was drilled away. Right inferior turbinate, middle turbinate, and its posterior stump were removed endoscopically to expose the ostium. The tumour was thereby excised en bloc using a combined external and endoscopic approach. The lacrimal drainage pathway was not reconstructed on this occasion.Histological examination revealed hyperplastic ribbons of basement membrane-enclosed epithelium growing endophytically into the underlying stroma Figures . The epiThe patient recovered with unchanged visual acuity and normal extraocular movements following surgery with no evidence of recurrence clinically at 15-month follow-up.The Schneiderian papilloma was first described in 1854 by Ward and Billroth  coined tThe lacrimal drainage system is an uncommon  primary Lacrimal system papillomas largely present with epiphora and a medial canthal mass if detected early during the course of the disease. In advanced cases, proptosis, nonaxial globe displacement, skin ulceration, and invasion of adjacent structures can occur .Preoperative radiological planning is an important step in determining the extent of the lesion and invasion into adjacent structures. CT and MRI together are the recommended technique for pretreatment staging in IP as they are complementary in the accurate evaluation of disease extension and in differentiating tumour from inflamed mucosa, retained secretions, and granulation tissue . FeatureIP has the ability to destroy adjacent bone even in the absence of malignant transformation; therefore, an early, well-planned wide excision of the lesion, diseased mucosa, and the underlying mucoperiosteum , 26 shouIn the last 25 years, treatment strategy for sinonasal IP has evolved due to advancements in endoscopic surgery. Traditionally, medial maxillectomies via lateral rhinotomy or midfacial degloving was considered gold standard , 27. MorA review of the literature by Lund et al.  found thWoodworth et al.  describeTumour location is an important factor influencing the choice of approach . Sham, 1A meta-analysis suggested that piecemeal resection of IP via an endoscopic approach did not compromise tumour control rates compared to en bloc external techniques. The authors advocate careful identification and complete removal of the site of attachment of the lesion . In contAdjuvant treatment with radiotherapy could be considered for patients with early or multiple recurrence, advanced stage lesions, aggressive tumours, incompletely resected lesions, lesions with positive margins, and tumours associated with malignancy .Several studies since the early 1980s have postulated the aetiological role of HPV in the development of IP. Syrjänen 2003  found HPTopical interferon alpha-2b therapy was first used successfully in 2002 on a 10-year-old patient presenting with a recurrent lacrimal system papilloma, with no recurrence at 12 months . WoodcocLong-term follow-up for IP is essential. Most recurrences are seen within 9 months but can occur many years later. An analysis of 3058 cases by Mirza et al.  found a The case presented demonstrates the variability of location within the sinonasal tract that IP can develop, and the individuality of each case necessitates tailored operative techniques for complete excision whilst minimising recurrence rates. We also present a combined endoscopic approach for the en bloc resection of a NLD IP with no clinical recurrence at 15-month follow-up.


Background. Retroperitoneal lymphangioma is a rare, benign mesodermal tumor arising from the retroperitoneal lymphatics which usually presents in infancy and it is worthy to report a case when it has presented in an adult. After a thorough literature search in English we concluded that less than 200 cases of adult retroperitoneal lymphangioma have been reported so far. Apart from being a rare entity it also presents as a diagnostic dilemma and final diagnosis is often made on surgical exploration. Case Presentation. We report a case of retroperitoneal lymphangioma in a 55-year-old male who presented with abdominal distension and dull aching abdominal pain. Conclusion. Retroperitoneal lymphangiomas are rare tumors of infancy but may also present in adults where they are a diagnostic challenge. Differentiating cystic lymphangiomas from other cystic growths by imaging studies alone are often inconclusive and surgery is frequently required for definitive diagnosis and to ameliorate the symptoms. Cystic lymphangioma is a rare benign, mesodermal tumor arising from lymphatic vessels. 75% of these lesions are present in the neck, 20% are in the axillary region, and only 5% are intraabdominal, where they have been reported in the mesentery, gastrointestinal tract, spleen, and liver, and very rarely in retroperitoneum. Retroperitoneal lymphangiomas account for less than 1% of all lymphangiomas . Less coA 55-year-old man of Indian ethnicity, presented to the outpatient department of general surgery with lower abdominal distension for the past one and a half months and a continuous dull aching lower abdominal pain for past 15 days. Patient was a chronic smoker and gave no history of trauma, anorexia, weight loss, altered bowel habits, vomiting, fever, or any urinary symptoms such as hematuria. On examination, patient was moderately built, and abdominal fullness was apparent on inspection, more so in the left lower abdomen. A vague mass of approximate size of 20 × 15 cm was palpable, extending from left iliac and left hypogastrium to umbilical region, crossing the midline and reaching up to right midclavicular line at the level of iliac crest. The lump had a smooth surface, ill-defined margins and lower margin could not be reached on palpation. The lump was nontender with firm, cystic consistency, and restricted mobility in all the directions. There was no inguinal lymphadenopathy and digital rectal examination was unremarkable. Patient was further investigated for differential diagnoses of mesenteric cyst, pancreatic pseudocyst, duplication cyst, or cystic metastasis. Ultrasound abdomen showed a large cystic lesion with multiple septae, left to the urinary bladder in the pelvis. Liver, spleen, pancreas, and bilateral kidneys were within normal limits. A contrast enhanced computed tomography (CECT) scan of abdomen and pelvis showed a large 14.4 × 14.6 × 9.2 cm multilocular cystic mass with enhancing septations and lobulation, occupying the left side of abdominal cavity extending downwards into the pelvis and displacing the gut loops and the urinary bladder to the right side. Mass was encasing the left iliac artery and there were no enlarged lymph nodes in paraaortic and pelvic region. The attenuation coefficient of the mass was in the +10 to 15 HU range. There were no ascites and no evidence of small or large bowel obstruction .A fine needle aspiration cytology of the mass showed RBCs, neutrophils, and lymphocytes in a proteinaceous background, entertaining the diagnosis of lymphangioma. A provisional diagnosis of retroperitoneal lymphangioma/mesenteric cyst was made and the patient underwent an exploratory laparotomy. Upon laparotomy, a large (15 × 15 cm), retroperitoneal multicystic mass was found, which was encasing the left common iliac bifurcation, left iliac vessels, left ureter, left gonadal vessels, and left vas deferens. The mass was pushing the urinary bladder towards right side. There was a plane of dissection among the vessels, ureter, urinary bladder, and the cyst, which was dissected free completely using sharp and blunt dissection. It was filled with approximately 1000 cc of thick, cloudy fluid. Frozen-section study of a portion of wall of the cyst was suggestive of lymphangioma. After removing the cyst completely, the retroperitoneum and the mesentery were inspected closely for any remnants. The bowel was inspected twice and was found to be healthy, viable, and without any evidence of involvement. The patient tolerated the procedure well and his postoperative course was uneventful.Gross examination of the specimen, showed a mass of glistening white tissue and serial sectioning revealed multiple cysts filled with cloudy fluid.Histologically, the mass was composed of variable sized cystic spaces lined by flattened endothelial cells, which were positive for D2-40 immunostains, consistent with features of lymphatic vessels Figures . The larOur patient, a 55-year-old male, presented with a continuous dull aching pain and fixed lump in lower abdomen. A benign lesion was remotely a suspicion on clinical grounds because of his age and short duration of symptoms (2 months). Ultrasonography and CECT scan were suggestive of a multicystic lesion encasing iliac vessels and the possibilities of malignant mesothelial lesion, cyctic metastasis or a rare retroperitoneal lymphangioma were considered. FNAC did not reveal malignant cells and there was some amelioration of symptoms along with mild regression in size of lesion after the aspiration of about 100 mL of fluid. This regression in size was suggestive of a benign lesion. Surgical exploration revealed a multi-cystic lesion encasing iliac vessels, gonadal vessels, vas deferens and ureter. A clean plane of dissection could be demonstrated and all the structures were preserved while the whole lesion was excised in toto. Histopathology confirmed it to be lymphangioma. Diagnosis of lymphangioma of the retroperitoneum, in an adult, is a very rare clinical entity.A lymphangioma is a benign proliferation of lymphatic tissue believed to originate from the early sequestration of lymphatic vessels that fail to establish connections with normal draining lymphatics at about 14–20 weeks of intrauterine life . LymphanLymphangiomas at retroperitoneal location are rare. Commonly accepted hypothesis regarding their origin is the development of abnormal connections between the iliac and retroperitoneal lymphatic sacs, and the venous system, leading to lymphatic fluid stasis in the sacs. In 1877, Wegner histologically divided lymphangiomas into three categories: (1) lymphangioma simplex (capillary lymphangioma) with small, thin-walled lymphatic channels and not commonly found intraabdominally; (2) cavernous lymphangioma with larger thin-walled channels, more common than lymphangioma simplex, but still rare intraabdominally, and may undergo malignant transformation; (3) cystic lymphangioma  composed of large cystic spaces lined with flat endothelium. Retroperitoneal lymphangiomas are usually of cavernous or cystic types, of which most reported cases have been of a cystic type, as was in our case [A cystic tumor in the retroperitoneum creates a diagnostic confusion with varying differential diagnoses of cystic mesothelioma, teratoma, undifferentiated sarcomas like liposarcoma and leiomyosarcoma, metastatic lymphadenopathy, cystic metastases , benign tumors such as lymphangioma, adenoma, and other tumors such as retroperitoneal hematoma, abscesses, duplication cysts, ovarian cysts and pancreatic pseudocysts .Preoperative diagnosis of retroperitoneal lymphangioma is difficult. Ultrasound (US), contrast enhanced CT and MRI scans appear to be complementary to each other in the evaluation of cystic lymphangioma. US demonstrates the internal structure of lymphangiomas, particularly septations with clear fluid. CT may differentiate retroperitoneal and mesenteric lymphangiomas from adjacent bowel loops, and can also distinguish parapelvic renal lymphangiomatosis from hydronephrosis. In our case CT revealed a multi-loculated cystic mass with encasement of left iliac vessels. The ability of MRI scan to provide images in multiple planes without loss of resolution may demonstrate additional lesions and further delineate their boundaries . Even wiHistological diagnosis of lymphangioma is based on well-established criteria . These iSurgical excision in totality is the treatment of choice because of its potential to grow and invade surrounding organs . CompletAt one year follow-up our patient was completely free of any disease on clinical and radiological examination.Retroperitoneal lymhangioma is a rare clinical entity in adults. Differentiating cystic lymphangiomas from other cystic growths by imaging studies alone is often inconclusive and surgery is most frequently required for definitive diagnosis and to ameliorate the symptoms. It is possible to completely excise the lesion even if it is seen to encase major vessels as a clean plane of dissection usually exists.


This report firstly describes the application of high-resolution FDG-PET to a spontaneous pituitary microtumor in a dog.A 16-year-old, castrated, male English cocker spaniel dog was presented due to generalized alopecia. Routine clinical pathology, endocrine and abdominal ultrasonography results were consistent with a diagnosis of pituitary-dependent hyperadrenocorticism. The adenohypophyseal lesion was clearly visualized on both 3 T and 7 T magnetic resonance imaging (MRI) of the pituitary gland. Although biochemical and MRI findings were consistent with a functional pituitary microtumor, a pituitary lesion was not detected using  Hyperadrenocorticism is a common endocrine disorder in dogs, whose primary causes are pituitary and adrenocortical tumors , 2. HoweClassically, pituitary tumors have been divided into microtumors (less than 10 mm in greatest diameter) and macrotumors (over 10 mm in greatest diameter) . More th18F-fluorodeoxyglucose (FDG) has been used in the diagnosis of microtumors. Previous studies demonstrated that FDG-PET has the potential to provide valuable clinical information in the assessment of pituitary microtumors, especially in difficult cases of biochemically confirmed PDH when other MRI studies are negative or questionable [In human medicine, MRI with high-field strength (1.5 to 3 T) is considered to be the most sensitive imaging modality for the detection of pituitary microtumors . Howevertionable , 12, 13.Because of the potential value of FDG-PET for detecting microtumors and limited PET data in dogs, this imaging technique was applied in the present case of a pituitary microtumor. This case report firstly demonstrates the high-resolution PET characteristics of a pituitary microtumor in a dog.A 16-year-old, castrated male English Cocker spaniel dog was presented with a 4 year history of dermatological problems such as alopecia and pruritus. Polyuria and polydipsia were not noted by the client. Physical examination revealed a distended abdomen, generalized alopecia, and seborrheic dermatitis. Increased alkaline phosphatase activity  was observed on the serum chemistry panel. The levels of total cholesterol  and triglycerides  were within the reference range. Hepatomegaly and bilateral enlarged adrenal glands of relatively equal size  were identified on abdominal radiographs and ultrasonography, respectively. Because these findings suggested hyperadrenocorticism, an ACTH stimulation test and a high-dose dexamethasone suppression test (HDDST) were performed. The serum samples were obtained for the ACTH stimulation test before and 1 h after intravenous administration of 0.25 mg synthetic ACTH ; pre-ACTH cortisol concentration was 226.2 nmol/L (reference range: 14–166 nmol/L) and post-ACTH concentration was 717.3 nmol/L (reference range: 166–469 nmol/L). Serum cortisol concentration was suppressed after administration of dexamethasone : pre-HDDST cortisol concentration was 69.5 nmol/L and 4-h and 8-h post-HDDST cortisol concentrations were 40 nmol/L and <27.6 nmol/L, respectively. Based on these results, a diagnosis of PDH was made.2, slab thickness: 128 mm) and transverse T2-weighted turbo spin echo images  of the brain were obtained. To minimize personnel radiation exposure, the dog was remotely monitored in the approved holding facility during the recovery from anesthesia.To evaluate the pituitary gland region, intracranial imaging was performed using a high-resolution research tomography (HRRT)-PET and 7 T MRI fusion imaging system, with the owner’s permission. Written client consent was obtained prior to examination, and this procedure was performed with the approval of our institutional review board committee. The dog was fasted for 12 h, and then injected with FDG (0.4 mCi/kg IV); the dog was kept caged for 1 h to minimize movement and ensure a stable FDG uptake. The FDG-PET scan was conducted for 30 min on the HRRT device  under general anesthesia maintained by tiletamine/zolazepam  following medetomidine  premedication. Immediately after the PET scan, the shuttle system transported the dog to 7 T-MRI scanner , and then pre- and post-contrast T1-weighted 3D magnetization-prepared rapid gradient echo images  Figs.  and 2a aThe dog was treated with trilostane , and then post-ACTH cortisol concentration had been maintained between 2 and 5 μg/dL. Six months after initial MRI, a pituitary lesion was monitored by 3 T MRI scan  with following sequences: pre- and post-contrast T1-weighted spin echo imaging  and T2-weighted turbo spin echo imaging . Although the height (4.67 mm) and P/B ratio (0.31) of the pituitary gland were slightly increased, other MRI findings were not different from the first MRI scan Fig. –f. PreseTypical MRI characteristics of pituitary microtumors include the displaced neurohypophysis and the adenohypophyseal lesion with hypointensity and hyperintensity on T1- and T2-WI, respectively , 8, 14. High-field MRI is the imaging technique of choice in humans with pituitary tumors because of its superior contrast resolution. In human patients with PDH, the sensitivity of 3 T MRI in detecting pituitary microtumors is relatively higher than that of 1.5 T MRI . In addiAlthough CT and MRI have been commonly used in the diagnosis of PDH, detection of pituitary lesions still remains a problem. Pituitary tumors are detectable by CT or MRI in less than half of humans and dogs with PDH , 15, 23.The normal pituitary glands do not accumulate FDG and are not visualized by FDG-PET imaging of the human brain . Among t


Spindle cell lipoma is an uncommon adipocytic tumor. Intramuscular lesions of this tumor are very rare. In this report, we describe a case of a patient with intramuscular spindle cell lipoma localized in a deltoid.A 58-year-old Japanese man visited us because of a soft tissue mass on the lateral aspect of the left shoulder that had been noticed 2 years prior. The spherical tumor, which measured 5cm×4cm, was elastic and firm on palpation and immobile. Magnetic resonance imaging revealed that the lesion was localized in the left deltoid muscle. A needle biopsy was performed to make a histological diagnosis. With a pre-operative diagnosis of intramuscular lipoma, we removed the tumor with the patient under general anesthesia. The tumor was removed with surrounding musculature and fascia. The pathological diagnosis was intramuscular spindle cell lipoma in the left deltoid muscle.There are several kinds of lipomas. Spindle cell lipoma is a relatively rare variant  that is histologically distinct and characterized by the replacement of mature fat by a mixture of mature adipocytes and undifferentiated spindle cells. There are only five other reported cases of intramuscular spindle cell lipoma in the literature, to our knowledge. The case of our patient is very interesting, as to date there have been few reported patients with a diagnosis of an intramuscular spindle cell lipoma in a deltoid.The online version of this article (doi:10.1186/s13256-014-0509-0) contains supplementary material, which is available to authorized users. Spindle cell lipoma (SCL) is an uncommon adipocytic tumor that was first described by Enzinger and Harvey in 1975 . SCLs arA 58-year-old Japanese man visited us because of a soft tissue mass on the lateral aspect of the left shoulder that had been noticed 2 years prior. His past and family histories were not contributory. All other laboratory examinations showed no abnormalities. The spherical tumor, measuring 5cm×4cm, was elastic and firm on palpation and immobile. There were no other findings of inflammation. Magnetic resonance imaging (MRI) revealed that the lesion was localized in the left deltoid muscle. On MRI scans, the tumor showed low signal intensity or isointensity to skeletal muscle at the center. It showed high signal intensity at the periphery of the lesion on a T1-weighted image  or deeper . They arThe age, sex and histopathological findings of our patient are all typical of SCL cases. The MRI scans of the lesion clearly show its location within the deltoid muscle. On MRI scans, the presence of nonlipogenic components in the lipogenic tumor may modify the radiological findings to some extent. When the proportion of nonlipogenic components such as spindle cells, collagen fibers and myxoid matrix is small, MRI findings of SCL are similar to those of conventional lipomas . If the Histologically, SCLs are characterized by a mixture of lipocytes and fibroblast-like spindle cells . These SThe treatment method for SCL is marginal excision, together with the surrounding thin fibrous capsule . As SCLsThe present case is very interesting, as there have been few reported patients with a diagnosis of intramuscular SCL in a deltoid.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Inverted follicular keratosis is a benign tumor of the skin that is believed to arise from the infundibular portion of the hair follicle above the level of entrance of the sebaceous duct. It was described originally by Helwig in 1954 and since then a number of case reports have been reported in the dermatology and pathology literature. A 55-year-old woman was referred for evaluation of a keratotic lesion on the upper lip. The lesion had been noticed 12 weeks previously, and was asymptomatic. The patient was otherwise well. On examination, a pedunculated nodule, 8-12 mm in diameter, with a keratotic surface, was present over the upper lip midline skin. On histological examination, the lesion showed a papillomatous surface, with the formation of a central mass that invaginates into the connective tissue. The epithelium is sharply circumscribed and forms a cupshaped mass. The tumor mass was composed of a proliferation of basaloid cells, and concentric swirls of spinous cells called squamous eddies. There are no mitotic figures. The pathological diagnosis was of an inverted follicular keratosis.