The aim of the present study was to report the initial clinical experience of adopting the da Vinci Surgical System  to perform a retroperitoneal tumor resection. The patient was a 56-year-old female who presented with a five-year history of hypertension. Abdominal dynamic computed tomography (CT) and positron emission tomography-CT scans revealed a mass measuring ~6 cm in diameter that was located anterior to the abdominal aorta, and between the abdominal aorta and the inferior vena cava (at the level of the third lumbar vertebra). The tumor was excised via a five-port, robot-assisted, transperitoneal laparoscopic approach. Careful dissection of the tumor away from the abdominal aorta and the inferior vena cava was accomplished without resulting in major vascular injury. There were no complications and the patient was discharged in a good condition on the eleventh postoperative day. Pathological analysis of a tumor specimen demonstrated a benign pheochromocytoma (PHEO). During the three-month follow-up, no recurrence was identified through CT scans or measurement of the patient’s endocrine hormone levels. Thus, the da Vinci robot-assisted laparoscopic system may be safely employed in the treatment of extra-adrenal PHEOs that occur in difficult locations for which a laparoscopic surgical excision may be challenging. Laparoscopic minimally invasive surgical techniques are not routinely adopted for the excision of retroperitoneal tumors, which are often located adjacent to vital organs and blood vessels. Indeed, minimally invasive surgery is even more rarely adopted for retroperitoneal tumors that are located between the vena cava and the abdominal aorta .131I]-MIBG, systemic chemotherapeutic intervention and genetic analysis under development (A pheochromocytoma (PHEO) is a type of catecholamine (CA)-producing neuroendocrine tumor, which originates in the chromaffin cells of the paraganglia. Worldwide, the incidence of PHEO ranges between 0.005 and 0.1%. In total 10% of PHEOs occur at extra-adrenal sites. Extra-adrenal paraganglionic tumors are termed paragangliomas or extra-adrenal PHEOs  and are elopment . Recentlelopment ,5. In thThe patient was a 56-year-old female with a five-year history of hypertension. The patient’s preoperative blood norepinephrine (NE) and epinephrine (E) levels were 9,866.9 pg/ml  and 188 pg/ml , respectively, which were accompanied by a headache, palpitations and sweating. The highest blood pressure reading was 240/110 mmHg . Preoperative positron emission tomography-computed tomography (PET-CT), and CT angiography (CTA) revealed a round-shaped mass that was ~6 cm in diameter and located anterior to the abdominal aorta, proximal to the inferior vena cava at the level of the third lumbar vertebra (termed L3). The tumor was in close proximity to, and located between, the abdominal aorta and the inferior vena cava; furthermore, the mass was posterior to the duodenum and the uncinate process of the pancreas, as well as being tightly adhered to the inferior vena cava. The tumor had a rich blood supply and no obviously swollen retroperitoneal lymph nodes or distant metastases were observed .Prior to surgery, the patient was suspected to have an ectopic PHEO and was treated using orally administered Cardura  to lower and control the elevated blood pressure to 120/80 mmHg. The preoperative assessment of the patient’s heart and lung function indicated that she was able to tolerate the surgical procedure. The patient had no previous history of upper abdominal surgery, however, had previously undergone a cesarean section.The preoperative preparations were similar to those of laparotomic resections of ectopic adrenal PHEOs . The patBased on the preoperative positioning and CT images, the pneumoperitoneum was established by puncturing the point of intersection of the left mid-clavicular line and the costal margin. A trocar was inserted to establish the camera port, and a robotic camera was inserted to determine whether tumor metastases were present in the abdominal cavity and whether there were obvious indications against performing the surgery. A four-port approach was used to insert the remaining trocars . The robThe lower abdominal adhesions were dissected, a Kocher incision was made to mobilize the duodenum, and the pancreatic head and the duodenum were shifted to the left. This was to facilitate the investigation of the association between the tumor and major blood vessels, such as the abdominal aorta and the inferior vena cava.The tissue that was posterior to the tumor was progressively freed from right to left and from bottom to top until the level of the vena cava was reached. The abdominal aorta was protected, using an electrical hook and bipolar coagulator to seperate the tumor from the abdominal aorta and inferior vena cava, while the tumor was dissected away from it . The bloThe tumor was placed in a specimen bag and a separate incision was made to remove the specimen bag. The specimen subsequently underwent pathological examination. In addition, the wound surfaces were washed, examined and subjected to strict hemostasis.A drainage tube was placed in the surgical area between the abdominal aorta and the vena cava, and exited via the trocar hole.There were no complications during surgery, the intraoperative blood pressure was stable (without significant fluctuation) and there was no requirement to convert to a laparotomy. The patient’s drainage tube was removed after seven days, and the patient was discharged 11 days following the surgery. The postoperative pathological report obtained via analysis of a tissue slice indicated a diagnosis of paraganglioma with visible extracapsular vascular invasion .The patient was followed up for three months and no clear tumor recurrence was identified by CTA during the follow-up examinations. The blood NE and E levels were restored to within their normal ranges of 19.0–121 and 14.0–90.0 pg/ml, respectively.The clinical manifestations of extra-adrenal PHEOs are diverse, including paroxysmal symptoms , hypertension, an adrenal or abdominal mass, high blood sugar, lactic acidosis, weight loss and other symptoms of the metabolic syndrome . Extra-aThe emergence of laparoscopic techniques enables the removal of adrenal tumors in a minimally invasive manner and the laparoscopic resection of adrenal PHEOs has been used in clinical practice for many years . An inveTM  instrument (which mimics the human wrist with seven degrees of freedom), hand-tremor elimination, motion scaling and motion indexing  may be stanched using an ultrasonic scalpel and electrocoagulation; however, during traditional laparoscopic surgery, there is practically no ligation or suturing. When flexible robotic arms are adopted for surgery, the vessels surrounding the tumor may be smoothly manipulated to achieve satisfactory hemostasis and a successful dissection.As a result of our past experience –19, the In conclusion, retroperitoneal ectopic adrenal PHEOs are particularly rare. This type of tumor is located deep within the abdominal cavity, often in the deep retroperitoneal anatomical structures. Consequently, PHEOs are complex to treat, even when adopting the laparotomic surgical approach. The associated risk is particularly significant for tumors that affect the endocrine functions. The robot-assisted laparoscopic surgical system provides a novel, minimally invasive solution for treating retroperitoneal tumors. Furthermore, this technique reduces stimulation of the tumor and prevents or minimizes complications. To the best of our knowledge, the patient in the present study is currently the first known patient in China that has successfully undergone a robot-assisted resection of a retroperitoneal ectopic adrenal PHEO, making this study particularly significant.


Sertoli - Leydig cell tumors (SLCTs) are sex-cord stromal tumors that account less than 0.5 % of primary ovarian neoplasms. They are mostly benign and occur in reproductive age women. Variants with heterologous mesenchymal elements are exceptionaly rare. The usual presentation of SLCTs is with signs of androgen excess as majority of them produce androgens.We present a case of a SLCT occurring in a 70 year old woman. Her presenting complaint was abdominal distension and pain. She had no signs of androgen or estrogen excess. Transvaginal ultrasound (TVUS) and CT scan showed a multilocular adnexal tumor and level of CA 125 was raised. A complete cytoreduction was achieved with surgical procedure. Histopathological examination revealed moderately differentiated SLCT with retiform areas and owergrowth of heterologous component in form of embrional rhabdomyosarcoma (RMS). She returned 7 months after the surgery with a large abdominal mass, ascites, right- sided hydronephrosis and massive pulmonary embolism. Due to the widespread disease and her poor general condition, she received only palliative care. She died 15 days after the admission. No autopsy was performed.Due to the rarity of SLCTs, especially those with retiform areas and heterologous elements, their management remains challenging. There is no firm evidence that adjuvant chemotherapy is effective in improving survival in SLCTs with malignant heterologous elements. Further studies with a higher number of cases and a longer follow-up are needed to better predicting the prognosis and determine the role of chemotherapy in such cases. Sertoli – Leydig cell tumors (SLCT) are sex cord-stromal tumors that account for less than 0.5 % of primary ovarian neoplasms . BecauseThe vast majority of SLCT (90 %) occur in the reproductive age and the rest before menarche or after menopause . They arAccording to the WHO classification  SLCTs arWe report an extremely rare case of moderately differentiated retiform SLCT with extensive owergrowth of heterologous rhabdomyosarcomatous (RMS) component occurring in a postmenopausal patient.A 70 – year-old, para 2, was referred to our centre with severe right-sided lower abdominal pain that started a few days prior to her visit. She had gained 4 kg, noticed abdominal distension and occasional dull right-sided lower abdominal pain in the 2 months prior to admission. She was otherwise healthy, without any regular medical therapy. She had two vaginal deliveries and her last period was at the age of 46. She had no significant gynecological history. Speculum examination revealed normal-looking vagina and cervix. Upon bimanual palpation a large, smooth and mobile tumor formation, extending from the top of a normal sized uterus up to the umbilicus, was felt. Transvaginal ultrasound (TVUS) examination showed a large, well-vascularized, pelvic mass with solid and cystic components above the uterus and a small amount of ascites in the pouch of Douglas. Contrast enhanced computed tomography (CT) scan of the abdomen showed a well circumscribed, multilocular, complex tumor formation measuring 19 × 12 × 21 cm that appeared to originate from adnexal area, and a thickened, 15 mm, non-homogenous endometrium. Chest X ray showed no evidence of pulmonary nodules. Laboratory tests showed increased serum level of CA-125 at 135.5 U/ml whereas CA 15–3, CA 19–9, CEA were within the normal range. Serum testosterone levels were not determined as there were no signs of androgen excess and they are not a part of a routine pre-operative evaluation at our clinic. Subsequently, exploratory laparotomy was performed. Right ovary with the tumor was removed and sent for intra-operative frozen section evaluation, which revealed features of ovarian malignancy. Hysterectomy with left salpingo-oopherectomy, appendectomy, omentectomy, peritoneal biopsies, pelvic and para-aortic lymphadenectomy were therefore performed and there was no macroscopic disease remnant at the end of the procedure.On gross examination the tumor was cystic and solid with extensive areas of necrosis and hemorrhage.Microscopically, most of the tumor consisted of a high grade spindle cell sarcoma with numerous mitoses, areas of necrosis and focal cells with ample eosinophilic cytoplasm, consistent with rhabdomyoblasts. Immunohistochemically, this component was diffusely positive for desmin and myogenin. At the periphery of this mass the tumor was composed of cords and nests of cells with clear cytoplasm intimately admixed with cells with more abundant eosinophilic cytoplasm; some cystically dilated structures were also present. Immunohistochemically, both types of cells were diffusely positive for inhibin and calretinin. A diagnosis of a Sertoli-Leydig cell tumor with retiform areas and heterologous rhabdomyosarcomatous component overgrowth was rendered. Morphological and immunohistochemical characteristics of the tumor are depicted in Figs. The tumor was staged IA and we decided not to administer postoperative chemo- or radiotherapy.At her first post-operative check up, 8 weeks post procedure, clinical exam and TVUS showed no signs of disease recurrence and the patient was well. She returned to our clinic 7 months after the procedure with abdominal pain, ascites and a large palpable abdominal mass. She lost 5 kg in 1 month and noticed leg swelling 2 weeks before the admission. CT scan showed a large tumor mass extending from the pelvis measuring 21 × 16 × 20 cm Fig. . AdditioSLCTs are mixed sex cord-stromal tumors composed of variable proportions of Sertoli cells, Leydig cells and in the case of moderately and poorly differentiated neoplasms primitive gonadal stroma and sometimes heterologous elements. When the tumor shows pattern wich can vary from anastomosing, slit-like spaces resembling rete testis to areas of papillary or multicystic pattern with sieve-like spaces, the term retiform SLCT is used. Retiform pattern is found in approximately 15 % of SLCTs . RetiforDICER1 have been shown to be related with the development of benign tumors that are susceptible to malignant transformation [DICER1 mutations in SLCT. Similarly, in the study of Conlon et al. [DICER1 mutations were present in 63 % of SLCT. They also report that there is no association between DICER1 mutation and tumor differentiation as mutations in poorly differentiated and moderately differentiated SLCT were found to have similar frequencies. It has been established, that reduced expression of DICER1 is associated with a poor cancer outcome [DICER1 mutations remains to be determined, however.Little is known about the pathogenesis of ovarian SLCT however, germ-line mutations in the microRNA processing gene ormation . These tormation –14. Heraormation  report an et al.  DICER1 m outcome . The exaThe prognosis of SLCTs is overall favorable and depends on the stage and histological grade of the tumor and the age of the patient. The overall 5- year survival rate for stage I is 95 % and for stages III and IV almost 0 %. Histological grade also correlates with prognosis as a study of 207 cases of SLCTs reported that well-differentiated tumors behaved benign whereas 11 % of moderately differentiated, 19 % of those with heterologous elements and 59 % of poorly differentiated were clinically malignant . Also, tBecause SLCTs are very rare, a standardized approach for treatment has not been established yet. Unilateral salpingo-oopherectomy seems to be sufficient in well-differentiated unilateral SLCTs . In caseIn our case, a moderately differentiated retiform SLCT with retiform areas and overgrowth of the heterologous RMS component occurred in a postmenopausal patient. Two of the previously described cases of moderately differentiated SLCTs with RMS elements occupying only small parts of the tumor had a benign disease course , 24. In Our patient had a FIGO stage IA tumor at the time of the surgical treatment and complete macroscopic cytoreduction was achieved. Despite that, her disease recurred in 7 months confirming the aggressive behavior of SLCT containing RMS and/or retiform elements. We assume that the recurrent tumor was mainly composed of RMS elements due to the aggressive disease course and only slightly elevated serum testosterone levels. The rapid disease progression implies that the presence of RMS and/or retiform component in primary SLCTs causes an unfavorable disease course and that it is the heterologous component in the SLCTs that affects the prognosis and not the grade of the Sertoli – Leydig component itself, as it has already been suggested . HoweverOvarian RMS is an extremely rare tumor with a very aggressive disease course and poor outcome regardless of treatment . It has There are no specific guidelines about the follow-up of patients after the surgery for SLCTs. In our case, the patient was followed up as patients with epithelial ovarian cancer. Despite the fact that at her first post-operative check-up, when clinical and TVUS examination were performed, she was disease free, the recurrent tumor 6 months later was widespread and therefore considered as not suitable for surgical treatment. Thus, we believe that imaging examination with a higher specificity and sensitivity should be used for detection of SLCTs recurrence. Recently, positron emission positron emission tomography (PET) combined with computed tomography (CT) has been proposed as an imaging modality for early detection of recurrence of ovarian cancer . Gu et aManagement of ovarian SLCTs with malignant disease course is challenging due to the rarity of the disease and lack of experience. It seems that overgrowth of the SLCTs with RMS elements causes a very unfavorable disease course. Further reports of individual cases as well as randomized controlled studies are needed for establishment of management guidelines and the role of adjuvant chemotherapy in these tumors. At present, there is no good evidence that postoperative adjuvant chemotherapy is effective in preventing recurrence of malignant SLCTs. Toxicity and the ability to complete the chemotherapy regimen should be kept in mind when deciding about application of toxic medications.CT, comuted tomography; PET, positron emission tomography; RMS, rhabdomyosarcoma; SLCT, Sertoli Leydig cell tumor; TVUS, transvaginal ultrasound


The term plexiform unicystic ameloblastoma refers to a pattern of epithelial proliferation that has been described in cystic cavity. Because of unilocular presentation, it is commonly misdiagnosed as an odontogenic cyst. However, they may often behave clinically as biologically aggressive tumors. These tumors show high incidence of cortical perforation, tooth resorption and a high rate of recurrence after simple enucleation. This paper aims to provide an insight into this biologically distinct entity. A literature review on the topic has been added along with a case report highlighting the approach of diagnosis and management of such ameloblastomas. Churchill is credited with the first use of the term ameloblastoma in 1934 [The relative frequency of unicystic ameloblastoma has been reported as 5% and 22%. Robinson and Martinez in 1977 were the first to describe unicystic ameloblastoma and to call for recognition of the entity [A 15-year-old male patient reported with the chief complaint of swelling on the left side of lower jaw since 9-10 months. He noticed a swelling in the lower jaw in the posterior region, which was initially small in size and gradually increased to the present size. It was initially painless, but the patient now complains of mild intermittent pain, occasionally. The patient was prescribed antibiotics and analgesics by a general practitioner 3-4 times in the last 9 months.Extraoral examination revealed a solitary swelling in the left mandibular ramus area. The swelling was roughly oval in shape with approximate size of 2 cm × 3 cm. The margins of the swelling were diffuse. The skin overlying the swelling was smooth and normal in color .On palpation, temperature of overlying skin of swelling was slightly elevated. The consistency of the swelling was bony hard. Medio-lateral expansion of the cortical plates was noted at angle of mandible. A single left submandibular lymph node of size approximately 1 to 1.5 cm was noted, which was slightly tender and mobile.Intraoral examination revealed a single small swelling in retromolar area, slightly obliterating the pterygopalatine raphe. Expansion of buccal and lingual cortical plate was noted. A deep periodontal pocket was noted distal to 37 .Provisional diagnosis on clinical examination was made as benign odontogenic lesion. Differential diagnosis of ameloblastoma, odontogenic keratocyst, dentigerous cyst associated with 38, calcifying odontogenic cyst, calcifying epithelial odontogenic tumor, and ameloblastic fibroma was considered.Radiographic examination of the lesion showed a well-defined unilocular radiolucency involving the left side of the mandible which extended anteroposteriorly from the distal surface of the left mandibular second molar to the posterior border of ramus of mandible and superoinferiorly from coronoid notch to the inferior border of mandible. It showed well corticated borders. Resorption of the distal surface of root of the mandibular second molar was also noted .CT and 3D CT scan of the lesion showed a unilocular osteolytic lesion in the posterior part of body and ramus of the mandible. Bilateral cortical plate expansion was noted. Perforation of the lingual cortical plate was also revealed Figures  and 5. RRoutine hemogram was performed and all the blood indices were within normal limits. An incisional biopsy was then performed, which on histopathologic examination revealed a cystic cavity lined by odontogenic epithelium and a connective tissue capsule. Epithelium shows palisaded basal layer resembling ameloblast-like cells and a superficial layer showing stellate reticulum-like cells. The connective tissue was dense, fibrous with collagen fibers arranged haphazardly. Numerous engorged and dilated blood vessels were seen .From the above clinicopathological features, a diagnosis of unicystic ameloblastoma was made. The patient then underwent a mandibular segmental resection involving condyle and reconstruction was done with 2.7 mm titanium reconstruction plate and iliac crest graft, under general anesthesia. Healing was uneventful. Patient was followed up after 1 month with radiographic evaluation which showed complete healing of wounds and well maintained graft .We received a segmental resected specimen involving condyle, coronoid process, upto ascending ramus, which showed perforation in the anterior border of ascending ramus. Histopathological examination of the excisional biopsy specimen showed lesional tissue that consisted of a cystic cavity lined by odontogenic epithelium and connective tissue capsule. The epithelium showed cuboidal or columnar basal cells with hyperchromatic nuclei, nuclear palisading with polarization, cytoplasmic vacuolization with intercellular spacing, and subepithelial hyalinization and superficial layer showing stellate reticulum-like cells. There was also proliferation of these cells in cystic lumen in a plexiform pattern. The cells are arranged in interconnecting strands and cords with peripheral palisaded layer and central stellate reticulum-like cells . Tissue According to the classification suggested by Ackermann et al. , it was The unicystic ameloblastoma, a variant of ameloblastoma, is reported to have less aggressive biologic behavior and lower recurrence rate than the classic solid or multicystic ameloblastoma. Although the unicystic ameloblastoma is a “cystic” appearing lesion on gross examination, subsequent microscopic examination shows the presence of an ameloblastoma within the cyst wall. Prior to the report by Robinson and Martinez, this variant had been referred to as a mural or intraluminal ameloblastoma. The minimum criterion for diagnosing a lesion as UA is the demonstration of a single (often macro-) cystic sac, with an odontogenic (ameloblastomatous) epithelium, which is usually present only in focal areas. (1) luminal UA; (1.2) luminal and intraluminal UA; (1.2.3) luminal, intraluminal, and intramural UA; (1.3) luminal and intramural UA.The histologic features of UA have been established by several authors, all of whom recognize various subtypes. The most accepted histologic classification of UA is that suggested by Ackermann et al.  who clasThe luminal type of tumor is called UA subgroup (1) which is defined as a cystic cavity lined by an epithelial lining of which parts show transformation to cuboidal or columnar basal cells with hyperchromatic nuclei, nuclear palisading with polarization, cytoplasmic vacuolization with intercellular spacing, and subepithelial hyalinization. This definition was originally suggested by Vickers and Gorlin .UA subgroup (1.2) shows simple and intraluminal features. The intraluminal proliferation of ameloblastic epithelium is in the form of plexiform pattern. Hence, this subgroup is sometimes referred to as the plexiform unicystic ameloblastoma.UA subgroup (1.2.3) covers cases where there is an occurrence of intramural ameloblastoma tissue as well as subgroup (1.2) features.The last subgroup (1.3) exhibits a cyst with a luminal lining in combination with intramural nodules of SMA tissue. It is important to stress that these four subgroups occur in both the dentigerous and the nondentigerous variants.The present case shows presence of plexiform ameloblastoma in continuity with the cyst lining proliferating into the cystic lumen and hence was diagnosed as subgroup (1.2) plexiform unicystic ameloblastoma.Philipsen and Reichart  in theirn ~ 23) occurred in much younger patients (mean 16.5 years) than those diagnosed as nondentigerous  [The cases diagnosed as dentigerous  and proliferating cells (proliferating cell nuclear antigen and Ki-67) may be helpful in differentiating UA from any other cyst [Immunocytochemical markers for lectins , while resection of PUA results in the lowest recurrence rate (3.6%) . In our In most cases, unilocular lesions are diagnosed as odontogenic cyst both clinically and radiographically. Hence the chances of treating the lesion conservatively are more. Enucleation or excisional biopsy is the most preferred and planned treatment in case of odontogenic cysts. An accurate and timely diagnosis of the character and extent of unicystic ameloblastoma should be done which is only possible after a thorough microscopic examination of the lesion. We would like to emphasize the importance of the microscopic examination of all lesions mimicking odontogenic cyst prior to the treatment plan. Adequate radical resection of unicystic ameloblastomas is important to avoid further complications and recurrence.


Tracheobronchopathia osteochondroplastica (TO) is a rare disorder of unknown cause affecting the large airways. It is characterized by the accumulation of bony and cartilaginous nodules in the tracheal and bronchial mucosa.Approximately 300 cases of tracheobronchopathia osteochondroplastica have been reported since Wilks first identified it in 1857. Tomography and computed tomography scanning (CT) can be suggestive but final verification requires biopsy.Neoplastic disorders are, among others, blamed in etiology. We describe here, for the first time, a case of TO associated with skin cancer.A 40-year-old man with a scalp cancer was admitted for further evaluation of an occasional dry cough. Her medical history was otherwise unremarkable, and physical examination showed no abnormalities.The chest CT scan demonstrated multiple nodular densities in the trachea and proximal bronchi. The fiberoptic bronchoscopy showed multiple nodules in the trachea suggesting a malignant infiltration.Microscopic examination of the biopsy material revealed fragments of normal cartilage and bone formation with normal mucosa which confirmed the diagnosis of TO.Patient underwent surgery for scalp cancer. For TO, case has followed up. At twelve-month follow up, scalp tumor did not recur and cough ceased.TO is a rare, benign disease that should be kept in mind especially in patients with tracheal irregularities in their chest imaging. Association with malignant tumors is reported.In patients with malignancy, TO can easily be misdiagnosed if it is not known as a diagnosis possibility of malignant invasion of the trachea. Therefore, it is important to be aware of this possibility, in order to prevent unnecessary treatments to patients. Tracheobronchopathia osteochondroplastica (TO) is a rare benign disorder that affects the tracheobronchial tree. It is characterized by the presence of multiple osseous and/or cartilaginous submucosal nodules protruding into the lumen of the trachea and large bronchi , 2. TO wThe bronchoscopic and computed tomography appearance of TO are highly suggestive. However, pathologic examination of bronchial biopsy is needed to make a definitive diagnosis. We report a case of TO associated with skin cancer. To our knowledge, this association has never been previously reported.A 40-year-old Moroccan man, recently diagnosed with a scalp cancer Figure  presenteBronchoscopy Figure , revealeThe case was considered TO associated with skin cancer.Scalp tumor staging procedure, including bone scintigraphy, chest-abdomen and brain CT, did not detect distant metastasis. The case was classified stage 2 of TNM classification.Patient underwent surgery for scalp cancer. For TO, he has followed up. Any special treatment was not performed. At twelve-month follow up, scalp tumor did not recur and cough ceased. Endoscopic follow up confirmed that the endotracheal and bronchial lesions were not progressive.A timeline in the form of a table gives the specific dates of important components of the case Table .Table 1Tracheobronchopathia osteochondroplastica (TO) is a rare benign disorder characterized by numerous osseous and cartilaginous submucosal nodules projecting into the lumen of the trachea and bronchi. TO was originally described by Wilks in 1857. At autopsy, he found the larynx, trachea and bronchi to be covered by a number of bony plates .Since then, around 300 cases have been reported in literature . Most caThe nodules originate in the airway cartilages and thus typically spare the posterior membranous wall of the airways.The disease is usually identified in adults older than 50 years, but it has also been described in children. There is no sex predominance and no clear link with smoking .Clinically, TO is usually asymptomatic and incidentally discovered, but can present with wheezing, cough, hemoptysis, dyspnea, and rarely obstructive symptoms . Few casCT can reveal multiple nodular submucosal irregularities, some of which calcified, with sparing of the posterior tracheal wall. It is also important in detecting the complications such as lobar collapse and post obstructive bronchiectasis . DetectiIn our case, the chest radiography was normal, but the CT scan demonstrated multiple nodular densities in the trachea.If CT scanning may be suggestive, final verification requires bronchoscopy with biopsy.Endoscopic features are typical and pathognomonic. TO appears as whitish, hard spicules projecting into the tracheal lumen from the anterior and lateral walls, with sparing of the posterior wall. Also the larynx and the main bronchi could be involved . The spiHistological examination of the nodules is non-specific, it usually reveals varying combinations of cartilaginous, osseous and haemopoietic tissue within a calcified protein matrix, protruding into the bronchial lumen. The overlying mucosa is often the site of squamous metaplasia .Lesions do not carry any malignant transformation potential. They progress slowly and rarely need treatment. In a long time period, obstruction and recurrent infections might occur .There is no definitive therapy: treatment is only symptomatic, which includes antibiotics in case of bacterial infections, mechanical measures to remove obstructing nodules using either cryotherapy, laser excision, external beam irradiation, radiotherapy, stent insertion or surgical resection therapy –15.The differential diagnosis to the bronchoscopic picture of multiple nodules includes TO, amyloidosis, endobronchial sarcoidosis, calcific tuberculosis, papillomatosis and tracheobronchial calcinosis .The etiology of TO remains obscure. Hypotheses include acquired connective tissue metaplasia, cartilaginous ring exotoses, ossification of elastic cartilage, and reactive inflammation secondary to chronic infection. The potential for genetic predisposition has also been considered, given the rare occurrence of familial cases .A few cases have been associated with lung cancer , 17, andIn the Japanese literature, approximately 140 cases have been published since the first one reported by Kidokoro in 1938 .Yokoyama , referriOur patient was diagnosed as TO and skin cancer. To our knowledge, skin cancer has never previously been reported in association with TO.In our case, we didn’t consider TO initially given its rarity and the context of malignancy. The histological findings confirmed the diagnosis.If TO is not suspected in the differential diagnosis of malignant invasion of the trachea, it can easily be misdiagnosed especially in the patients complicated with malignancy at the same time.Therefore, in cases of TO complicated with cancer, careful examination is necessary, including bronchoscopy and biopsy of tracheal lesions.TO is a rare, benign disorder of tracheobronchial tree. Neoplastic disorders are, among others, blamed in the etiology. We reported here, for the first time, a case associated with skin cancer.In patients with malignant tumors, TO can easily be misdiagnosed if it is not known as a diagnosis possibility of malignant invasion of the trachea. Therefore, it is important to be aware of this possibility, in order to prevent unnecessary treatments like chemotherapy to patients.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written informed consent is available for review by the Editor-in-Chief of this journal.


There was a partial response to decitabine according to RECIST criteria. As decitabine therapy was well tolerated, we are continuing in the same way until disease progression without any complications. The patient is undergoing regular follow-up at our centre.Myeloid sarcoma  is an extramedullary mass forming neoplasm composed of myeloid precursor cells. It is usually associated with myeloproliferative disorders but very rarely may precede the onset of leukemia. Here, we are presenting a rare case of primary vaginal myeloid sarcoma in a geriatric female patient without initial presentation of acute myeloid leukemia (AML). A 68-year-old female patient with ECOG Performance Score of 1 presented with pervaginal bleeding for 20 days. On colposcopic examination, she was found to have mass in the anterior fornix of vagina. A punch biopsy specimen revealed chloromatous infiltration of the vagina. LCA (leukocyte common antigen), MPO (myeloperoxidase), and c-kit were strongly positive on IHC (immunohistochemistry). The patient's routine blood investigations were normal including peripheral smear, lactose dehydrogenase, uric acid, 2D echocardiography, conventional cytogenetics, bone marrow aspiration, and biopsy. The patient was given 4 cycles of decitabine , 20 mg/m Myeloid sarcoma  is an extramedullary tumour composed of immature myeloid cells with varying degree of maturation. Isolated myeloid sarcoma, defined by the absence of history of leukemia, myelodysplastic syndrome (MDS) or myeloproliferative neoplasm, and a negative bone morrow biopsy, has been described in limited case reports. Myeloid sarcoma is a rare manifestation of leukaemia and has been reported in 3–5% of acute myelogenous leukemia (AML) patients .A 68-year-old female with ECOG (Eastern Cooperative Oncology Group) Performance Score of 1 presented with complains of irregular vaginal bleeding for 20 days. There was no history of weight loss, fever, or night sweats, and the blood pressure was 136/84 mmHg. On examination, her height, body weight, and body mass index were within normal range for her age.On colposcopic examination, she was found to have a 5 × 6 cm polypoidal mass in the anterior fornix and left lateral wall of vagina. The rest of the systemic examination was unremarkable. Histopathological examination of the punch biopsy specimen from the mass revealed diffuse infiltration of the vagina by mononuclear cells which had prominent nucleoli with scanty cytoplasm . The bio2 for 5 days at an interval of 28 days for 4 cycles. There was a partial response to decitabine according to RECIST criteria in CT scan done after 4 cycles. As there were no tolerance issues, we are continuing with decitabine until disease progression without any complications.A diagnosis of primary (isolated) vaginal sarcoma was made from the above reports. Considering her age and comorbidity, we offered her hypomethylating therapy with decitabine . Decitabine was given intravenously at the dose of 20 mg/mAcute myeloid leukemia may present in a variety of extramedullary (EM) tissues with or without bone marrow disease. Extramedullary involvement by AML is relatively rare, but clinically often poses diagnostic challenge and therapeutic dilemma. It was first described in 1811 and later named “chloroma” by King in 1853 because of its green colour caused by the presence of myeloperoxidase (MPO) . AlthougVery rarely, myeloid sarcoma can occur without a known preexisting or concomitant diagnosis of acute leukemia, acute promyelocytic leukemia, or MDS/myeloproliferative syndrome (MPS); this is known as primary myeloid sarcoma. In almost all reported cases of primary myeloid sarcoma, acute leukemia had developed shortly afterward  . TherefoMyeloid sarcoma is reported in 2.5–9.1% of patients with AML and occurs concomitantly, following, or, rarely, antedating, the onset of systemic bone marrow leukemia . CertainThe diagnosis is not always easy when chloroma appears at an EM site especially when AML is not present. Most of them are poorly differentiated, and only in 44% of cases the correct diagnosis is made or suspected. The most common misdiagnosis is the high grade non-Hodgkin lymphoma because both the conditions are composed of diffusely infiltrating, discohesive cells that tend to spare normal structures and which may contain scattered lymphocytes. In myeloid sarcoma, however, the nuclei are typically slightly smaller with more finely dispersed chromatin, and some cell may show recognizable myeloid differentiation. The immunohistochemical stains are usually diagnostic .The optimal treatment of isolated myeloid sarcoma (MS) is unclear, given the rarity of the diagnosis, variability in presentation, and the lack of prospective studies. Treatment is variable and often delayed. Treatment of isolated MS similar to leukemic AML and induction chemotherapy is now the standard of care. It is notable that isolated MS almost always proceeds to frank leukemia, although cases without progression even upon long-term follow-up have been reported . CurrentP = 0.0009) and we found no difference in the 5-year survival rate among the patients undergoing chemotherapy combined with radiation or surgery [Lan et al. studied 24 patients of myeloid sarcomas and found that 5-year survival rate was approximately 20%. In this study, patients undergoing chemotherapy had a significantly longer survival time compared to those who did not  drug. Incorporation of decitabine triphosphate into DNA results in inhibition of DNA methyltransferases (DNMT). This reduces the DNMT activity in cells and leads to hypomethylation of DNA, resulting in the reexpression of genes necessary for the control of cellular differentiation and proliferation .2 body surface area each day for the first 5 consecutive days of a 4-week cycle. It is recommended that patients receive at least 4 cycles; however, it may take longer than 4 cycles to obtain a complete or partial remission. Treatment may be continued as long as the patient shows response, continues to benefit, or exhibits stable disease. It is generally well tolerated, with most adverse events being related to myelosuppression [P = 0.037). This significant survival benefit was not observed at the time of the primary analysis [Decitabine has been approved by the European Medicines Agency (EMA) for the treatment of adult patients aged ≥65 years with newly diagnosed de novo or secondary AML, according to the WHO classification, who are not candidates for standard induction chemotherapy. Decitabine should be administered by intravenous infusion over 1 h at a dose of 20 mg/mpression . Phases pression –15. Kantanalysis .There are few published case reports validating efficacy of hypomethylating agents in extramedullary AML , 17. SinIsolated myeloid sarcoma patients require long term follow-up as extramedullary recurrences are frequent. Recurrences may be at the same or distant sites . RelapseMyeloid sarcoma involving vagina in a geriatric patient without AML is a very unusual presentation and it is a diagnostic and therapeutic challenge. Clinical suspicion is the key to correct diagnosis and expert pathology opinion and immunochemistry tests are required to confirm it. Treatment options include systemic treatment for AML, with or without local therapies. It is important to consider individual case differences, for example, age (elderly) as in our case. Our case illustrates the fact that isolated vaginal chloroma can be treated palliatively with hypomethylating agent decitabine in an appropriate setting.


Bleomycin has become an integral part of chemotherapy in patients with germ-cell tumors. One of the most feared side effects is bleomycin-induced pneumonitis. In patients with mild or moderate BIP, radiological signs disappear almost completely within nine months after discontinuation of bleomycin treatment.We present a patient with a history of non seminoma of the testis and bleomycin-induced pneumonitis. During follow-up, regression of the hypothesis of eosinophilic migration to the liver after regression of bleomycin-induced pneumonitis is highly suspicious based on transient eosinophilia and focal eosinophilic liver disease.As follow up may consist of CT scanning in germ-line tumor patients, transient eosinophilic liver lesions reported during regressive bleomycin-induced pneumonitis should not be presumed automatically as metastatic tumor relapse and require further sequential imaging and pathological examination. Streptomyces verticillus. Bleomycin acts as an oncolytic agent by inducing DNA strand breakage and subsequent has become an integral part of chemotherapy in patients with germ-cell tumors[Bleomycin is a glycopeptide antibiotic produced by the bacterium l tumors,2. Bleoml tumors. One of l tumors. BIP is l tumors. Treatmel tumors,5. In pal tumors. In thisA 41-year-old man was diagnosed with stage IIA good risk non seminoma of the left-sided testis and treated with hemiorchidectomy and adjuvant three cycles of bleomycin, etoposide and cisplatin. He received a total dose of 270 mg bleomycin during treatment. After the last course of chemotherapy, a chest and abdominal CT-scan (CT 1) revealed complete remission of the metastatic lesions. However, we unexpectedly discovered fibrosis in both lungs with signs of bronchiolitis obliterans and focally organizing pneumonia, probably induced by bleomycin Figure a and3b.This CT revealed further regression of pulmonary fibrosis, and regression of liver lesions in segment 2 (n = 1) and in segment 8 (n = 3). At 10 months one lesion was further decreased 3 lesions were stable. Interestingly, subsequent blood measurements showed a normalization of the percentage eosinophils in the three months between the first occurrence of liver lesions on CT and second CT with diminishment of these liver lesions and eventually calcification. This leads to the hypothesis that both findings are related to each other Figure .We have seen the concomittant regression of BIP and onset of focal eosinophilic liver disease (FELD) with eosinophilia. By exclusion diagnosis and thorough pathologic examination, this relationship in time led to the hypothesis of eosinophilic migration. Our understanding of the pathogenesis of BIP is mainly based on data derived from animal studies. Endothelial damage of the lung vasculature by bleomycin-induced free radicals is associated with an acquired loss of bleomycin hydrolase activity and followed by an influx of inflammatory cells. There iIn this patient the hypothesis of eosinophilic migration to the liver after regression of BIP is suggestive given the transient eosinophilia and presence of FELD. As follow up may consist of CT scanning in germ-line tumor patients, transient eosinophilic liver lesions reported during regressive BIP should not be presumed automatically as metastatic tumor relapse and require further sequential imaging and pathological examination.Patient has given his consent for publication of case-report.BIP: Bleomycin-induced pneumonitis; CT: Computer tomography; FELD: Focal eosinophilic liver disease; MRI: Magnetic resonance imaging.No funding sources need to be credited. No conflicts of interest should bementioned.IN provided the figures of pathological findings. JF provided the figures of radiological findings. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/13/491/prepub


Premature implant loosening following total knee arthroplasty (TKA) can have several causes. In this article we report on a rare case of a 74 year old male patient suffering tibial component loosening 14 month after primary TKA. The patient did neither have any malignancies nor joint arthroplasty before. Upon clinical examination the range of motion in the diseased knee was painfully restricted to 80° of knee flexion, with the patient increasingly suffering sleeping and resting pain, and also at weight bearing. In standard radiographs, loosening of the TKA due to a large osteolysis at the tibial component was evident. Local computed tomography (CT) of the right knee revealed loosening of the tibial component due to a presumably malign bone tumor. For determination of the final diagnosis a representative biopsy of the tumor was taken by open surgery prior to the tumor resection. Histopathologic evaluation of the biopsy revealed a periprosthetic myxoid chondrosarcoma of the proximal tibia. Pre-operative staging examination included CT scans of lung and abdomen, as well as a bone scintigraphy which revealed no signs of tumor metastasis in the body. Surgical management comprised wide tumor resection and implantation of a hinged tumor knee arthroplasty with replacements of the distal femur and proximal tibia, as well as a patella tendon replacement using a synthetic ligament. Revision surgery was necessary twice due to impaired wound healing and critical soft tissue coverage, and treatment included a gastrocnemius muscle flap with skin mesh graft covering. Unfortunately long-term follow-up examinations could not be obtained, as the patient deceased due to an alveolitis during rehabilitation. In summary, the specifics of this rare case of aseptic TKA loosening, and the unusual circumstances of chondrosarcoma diagnosis and treatment are informative for those providing surgical treatment of similar cases. Chondrosarcoma is an invasive musculoskeletal neoplasm, which is assumed to originate from malign transformed mesenchymal precursor cells, capable of forming a collagenous matrix Aigner . AccordiWhen specified, the most common histological subtype is the myxoid chondrosarcoma (56%), followed by the mesenchymal (25%), dedifferentiated (10%), juxtacortical (4%), malignant chondroblastoma (4%) and clear cell subtype (2%)  being related with the rate of local recurrence  elsewhere. The pre-operative radiographs with anterior-posterior (ap.) and lateral view of the right knee are shown  and lateral view of the right knee Figure c and d sStaging was then completed and the case was discussed in the local interdisciplinary tumor board. In summary a local disease stage, without infiltration of popliteal structures or metastases was present, and a wide resection of the tumor with inclusion of the knee prosthesis was indicated according to the disease stage. Since limb-preserving resection and reconstruction is technically tedious and carries the risk of incomplete resection and local recurrence, amputation was also discussed with the patient and his family. In consideration of all pros and cons of the respective approaches, the patient wished to undergo wide tumor resection and reconstruction with a distal femur and proximal tibia replacing hinged knee prosthesis. This was then planned using the radiographs and CT-scans Figure c-f, withThe final histopathological examination revealed a pT2 pN0 L0 V0 tumor stage, with proof of the prior G2 grading. Resection status was proven as R0. While the postoperative radiographs Figure a, b showThe described case presented with symptomatic loosening 14 months after TKA. Although reports of implant-related sarcoma formation do exist, in these the minimal observed interval from implantation to sarcoma diagnosis was 2.5 years  is hardly possible, due to the low incidence and different stages of the disease. To date, no clinical trial comparing outcomes of tumor replacing joint arthroplasty and amputation in joint-involving chondrosarcoma does exist to our knowledge. Therefore decision of surgical management is highly individual, primarily depending on disease stage, grade and patient preferences.


Hydatid disease is endemic in certain areas of the world and it is located mostly in the liver. Intraperitoneal rupture is rare. Rupture may result from trauma or may occur spontaneously from increased pressure of the cystic fluid. Ruptured hydatid cyst is a rare cause of ascites, but should be considered in the differential diagnosis, especially in endemic areas. The diagnosis of ruptured hydatid cyst should be prompt because it requires emergency intervention.The present case refers to a 62 year old Tunisian male admitted in our institution for diffuse abdominal distension. Physical examination was unremarkable except for the presence of ascites. Abdominal ultrasonography showed a large amount of fluid into the peritoneal cavity associated with many intraperitoneal cysts with a scalloping on the liver. It showed also a heterogeneous cystic lesion of the segment II of the liver. Abdominal computed tomography (CT) revealed in addition a fat infiltration and a thickening of the peritoneum. Thus intraperitoneal hydatid cyst rupture was suspected and emergency laparotomy was performed. A yellow serous fluid , containing many daughter vesicles disseminated through the peritoneal cavity was noted. A mass consistent with a hydatid cyst was noted at segment II of the liver with a tear on the inferior surface. Thus, intraperitoneal rupture of hepatic hydatid cyst was diagnosed.The rupture of hydatid cyst into the peritoneal cavity is rare but presents a challenge for the radiologist and the surgeon. This condition is included in the differential diagnosis of ascites in endemic areas. Human hydatid disease usually occurs by infestation with Echinococcus granulosus. Humans are affected by enteral dissemination and become accidental intermediate hosts . HydatidA 62 year old Tunisian male was hospitalized for exploration of abdominal distension in the preceding two months with progressive aggravation. The patient had no history of trauma, surgery or systemic disease earlier. The patient had no history of trauma, prior surgery or systemic disease. Physical examination found ascites without any other abnormality. The ascitic fluid was thick and yellow with high level of lipids. Because the ascites was so massive and chylous, without any sign of hepatic, cardiac or nephrological disorder, tuberculosis or neoplasic causes were suspected. Abdominal ultrasonography showed a large amount of fluid into the peritoneal cavity with associated with many intraperitoneal cysts with a scalloping on the liver Figure . It showEchinococcus granulosus is endemic in many sheep- and cattle-raising countries throughout the world. Definitive hosts are the canines . Intermediate hosts are usually grazing animals (sheep or cattle) or humans. Humans may become intermediate hosts through contact with a definitive host or the ingestion of contaminated water or vegetables. The usual locations are the liver and the lung. Other sites including the peritoneum are uncommon .Rupture of hydatid cyst of the liver is uncommon and may result from trauma or may occur spontaneously from increased pressure of the cystic fluid . Our patThe rupture of a hydatid cyst in the peritonium has two clinical forms with distinct outcomes: the minimal fissuring and the massive ruptures. The former, is the more frequent, and it is caused by a trauma which is often unrecognized and neglected.The usual clinical presentation is a progressive increase of the abdomen volume associated or not with a transient cutaneous eruption. Because the hydatid liquid is in feeble quantity in the great peritoneal cavity, it can either encysts and give rise to an encysted vesicular peritoneal echinococcus, or stay free resulting in a real military hydatid disease. The massive forms are much rarer and are found after a great effort. They make result in a rapid and complete draining of the cyst in the peritoneal cavity. They can either evolute at low rate realizing a subacute form or in a rapid way realizing an acute form including abdominal pain, urticaria, anaphylaxis and sudden death , 7.The diagnosis of ruptured hydatid cyst should be prompt because it requires an emergency intervention . PreoperUltrasound is a non invasive method. It is useful for identifying intra-abdominal fluid and a cyst with detached membrane , 9. CT iSerology is used to detect specific serum antibodies or circulating antigens by a variety of immunodiagnostic methods. The most commonly used technique is enzyme linked immunosorbent assay (ELISA) for detection of echinococcal antibodies (IgG) in the serum. A false positive value can occur in a normal pe-son especially in endemic area and similar results can also occur in patients with other parasitic infestations .The perforation of the hydatid cyst may cause dissemination of the parasite and increased morbidity and mortality rate. Immediate medical treatment against allergic reactions should be initiated, and emergency surgery should be performed after diagnosing rup-ture of hydatid cysts .The goal of the surgical treatment is to prevent complications, to eliminate local disease, and to minimize morbidity, mortality, and recurrence rates. Surgery is still the main modality for the treatment of hydatid disease, despite the developments in radiologic techniques and medical therapy. However, controversy exists about the choice of a radical versus a conservative approach; radical operations include pericystectomy and liver resection, whereas conservative techniques include external drainage, unroofing, and cavity-obliterating methods. Generally, conservative methods are favored in endemic areas .All of the cyst contents should be removed; the cyst and peritoneal cavity should be washed with saline solution and scolicidal agents. Hypertonic saline 3%, 15%, or 30%) is scolocidal [%, or 30%To prevent recurrences, medical treatment is mandatory. It should be started immediately after surgery and continued for 1 to 6 months, depending on individual circumstances, to reduce the risk of recurrence. Albendazole (10–15 mg/kg/d) is the drug used most commonly in previous studies and was used in the present patient .A ruptured hydatid cyst requires a meticulous postoperative follow-up. Patients may be followed with ultrasonographic examination and indirect hemagglutination test starting 6 months after surgery and repeated every 1 to 2 years. A CT scan may show a recurrence. Cysts that were overlooked during surgery may be erroneously interpreted as recurrences during long-term follow-up. Recurrences may also occur because of insufficient surgery or medical treatment after rupture of a hydatid cyst .The rupture of a hydatid cyst into the peritoneal cavity is rare but presents a challenge for the radiologist and the surgeon. This condition is included in the differential diagnosis of ascites in endemic areas. Specific imaging findings on ultrasonographic examination and CT allow definite diagnosis. Emergency surgery is the main treatment for intraperitoneal rupture of hydatid cysts, and medical treatment should be given postoperatively.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 of this journal.


The objectives of this review are (1) to become acquainted with the long-term complications of surgery of the gastrointestinal tract, and (2) to appreciate the appropriate use of imaging in the assessment of long-term complications.Gastrointestinal tract surgery comprises a group of procedures performed for a variety of both benign and malignant diseases. In the late postoperative setting, adhesions and internal hernias are the most important complications. and they can be further complicated by volvulus and ischemia. At present, computed tomography (CT) is the workhorse for evaluating late postoperative complications. Accurate imaging assessment of patients is essential for adequate treatment planning.In this pictorial essay we will review the most frequent long-term complications after gastrointestinal surgery, including adhesions, afferent loop syndrome, closed-loop obstruction, strangulated obstruction, internal hernias, external hernias, anastomotic strictures and disease recurrence. Examples will be depicted using iconography from the authors’ imaging department.Knowledge of the most frequent complications after gastrointestinal surgery in the late postoperative period is of paramount importance for every radiologist, so that potentially life-threatening situations can be promptly diagnosed and adequate therapy can be planned.Long-term postoperative complications of gastrointestinal tract surgery can be divided intoprocedure-relatedanddisease-relatedcategories.• The most commonprocedure-relatedcomplications are internal hernias and adhesions.• The most frequentdisease-relatedcomplications are mainly associated with neoplastic or inflammatory recurrence.• Computed tomography is the most useful examination when such complications are suspected.•  An acquaintance with the types of surgery, including the most common anastomosis, and with their most frequent complications are the first steps in preventing misdiagnosis of potentially life-threatening complications following gastrointestinal surgery.The radiologist is often faced with altered anatomic findings that hamper the ability to differentiate between an expected postoperative finding and a real complication. Therefore, communication with the referring surgeon is strongly advised in such situations before performing a diagnostic examination.Gastrointestinal contrast studies are more commonly used to look for immediate postoperative complications, such as intestinal leak or anastomotic dehiscence.Computed tomography (CT) is currently the workhorse for evaluating late postoperative complications, with the exception of magnetic resonance imaging (MRI) for suspected recurrence of rectal cancer or inflammatory bowel disease.Late postoperative complications can be classified as procedure- or disease-related  Table 11.Table 1Adhesions and internal hernias are the most important procedure-related complications in the late postoperative period, and can be further complicated by volvulus and ischemia. Anastomotic strictures are also relatively frequent following GI tract surgery.Disease-related complications are typically related to disease recurrence involving both neoplastic and inflammatory conditions.Internal hernias (IH) are defined as the protrusion of the viscera through a normal or abnormal peritoneal or mesenteric aperture within the peritoneal cavity –4.These hernias can be either congenital or acquired. The major classifications of internal hernias include paraduodenal (53 %), pericecal (13 %) and transmesenteric hernias (8 %), hernias through the foramen of Winslow (8 %) and intersigmoid hernias (6 %) , 4.Although paraduodenal hernias are classically regarded as the most prevalent, the incidence of transmesenteric hernias (TMH) has been growing given the increased number of operative procedures that involve Roux-en-Y surgery, such as gastric bypass surgery and liver transplants , 3. In fClinically, IH can be asymptomatic, or cause nonspecific intermittent abdominal pain or full-fledged strangulated obstruction (the most common presentation). As these hernias are difficult to identify clinically, imaging plays a pivotal role in their evaluation. Herniation of the bowel loops through the defect can be a transient phenomenon that can further confound diagnosis. Clinical or imaging evaluation performed during a symptomatic period is more likely to reveal the abnormality .Transmesenteric hernias are particularly prone to complications (volvulus and strangulation), and symptom onset is usually more acute than in other types of internal hernias , 6. TheyIt is important to differentiate small-bowel obstruction (SBO) due to internal hernia from obstruction due to adhesions, since the former requires emergent surgical treatment . A combiMulti-planar reformation (MPR) oriented to the “intestine-mesentery-directed plane” and vertical to this plane should be performed in order to increase the likelihood of detection of the hernial orifice. This can be identified as an area where the mesentery of the closed loop converges on a given multiplanar view; on the plane vertical to the affected intestine, the hernial orifice shows a round/oval configuration of the converged mesentery .Among other signs of internal hernias following Roux-en-Y gastric bypass surgery, which include small-bowel obstruction, clustered small-bowel loops, small bowel other than duodenum located behind the superior mesenteric artery, presence of the jejunal anastomosis to the right of the midline, and engorged mesenteric lymph nodes, the swirling of the mesenteric vessels is most predictive  Fig. 1)1).Fig. 1Transmesenteric hernias are generally more difficult than other IH to diagnose by CT because they lack a confining sac and thus are located potentially anywhere within the abdomen , 6.Left-sided paraduodenal IH is the leading differential diagnosis of TMH, but has different distinctive characteristics, such as a sac-like mass of dilated bowel lateral to the ligament of Treitz that displaces and indents the transverse colon and stomach .Volvulus and ischemia of the herniated small bowel are frequent complications of TMH. Typical findings of strangulated closed-loop obstruction are seen  .A closed-loop bowel obstruction or incarceration is a type of mechanical intestinal obstruction in which a segment of bowel is occluded at two separate points along its length, almost always adjacent to each other, as the result of a single constrictive lesion. This anatomical configuration can lead to twisting of the loop along its long axis, and thereby produce a bowel volvulus, with subsequent compromise of the vascular supply and ischemia—strangulating obstruction. Although incarceration and strangulation are related phenomena, incarceration may occur without strangulation and may resolve spontaneously .Closed-loop obstruction is most commonly caused by postoperative adhesive bands, and is less frequently due to internal or external hernias .The beak sign, representing the beak-shaped morphology of the dilated loop toward the obstruction, when imaged in a longitudinal orientation Fig. Fig. 2a,The whirl sign, which corresponds to the whirled appearance of the mesenteric vessels in the middle of the obstruction point Fig. . The tigA radial distribution, which refers to stretched mesenteric vessels converging toward the central point of obstruction Fig. .Fig. 3PaThe U/C sign, which refers to the shape of the incarcerated distended loop Fig. . AlthougCT findings of closed-loop obstruction (incarceration) include the classical sign of mechanical obstruction (a distinct point of transition between dilated and collapsed bowel loops) and additional signs, such as:Multiplanar reformatted images may prove decisive in achieving correct diagnosis of a closed-loop obstruction .CT findings of strangulated obstruction include wall thickening, altered pattern of enhancement of the bowel wall, dilated mesenteric veins, mesenteric edema, ascites, pneumatosis intestinalis, pneumatosis portalis and pneumoperitoneum.The most common CT finding in bowel ischemia, although nonspecific, is bowel wall thickening. It is caused by mural edema (low attenuation before contrast administration), hemorrhage (high attenuation before contrast administration) and/or superinfection of the ischemic bowel wall. If unenhanced CT is not performed prior to contrast-enhanced CT, the ability to differentiate between intramural hemorrhage and hyperemia and/or hyperperfusion is impaired .On contrast-enhanced CT, a highly specific but less sensitive finding is absent or diminished parietal contrast enhancement. In some cases, prolonged enhancement due to delayed return of the venous blood, with subsequent slowing of the arterial supply, can also be seen .As ischemia advances, venules in the mesentery become engorged with blood. Mesenteric fat stranding due to edema and/or ascites is also a nonspecific CT finding in acute bowel ischemia Figs.  and 5. IWhen bowel wall thinning rather than thickening occurs, transmural small-bowel infarction has probably already ensued. In this setting, it is also more likely for pneumatosis intestinalis, pneumatosis portalis and pneumoperitoneum to develop Fig. . PneumatClinical and laboratory differentiation between simple obstruction and incarceration/ strangulation is very difficult, and treatment delay is a major prognostic factor for increased morbidity and poor survival. CT is extremely useful in discriminating between these two entities, and it plays an instrumental role in determining appropriate patient treatment . Findings of closed-loop obstruction should result in close monitoring, and if clinical symptoms persist, early surgery is suggested. In patients in whom signs of strangulation are already evident, emergency surgery is mandatory .An incisional hernia is a type of external hernia caused by an incompletely healed surgical wound. Typically, peritoneal fat, with or without incorporation of bowel loops, protrudes through the hernial defect Figs.  and 8e.FStomal and parastomal hernias are a subtype of incisional hernias that involve herniation of the bowel or the mesentery at the site of or adjacent to a stoma . Even afParastomal hernias are quite common, with an expected prevalence of 33–78 %, depending on clinical or CT evaluation. However, unless obstruction, perforation or stoma malfunction occur, there is no need for surgical repair –22.A recent study suggested a CT classification for parastomal hernias according to the possible contents of the hernial sac, as follows: type I , type II (sac containing omentum), type III (sac containing a bowel loop other than stoma) Table . Type 0 Incarceration and strangulation can supervene with incisional hernias, as with any other abdominal wall hernias elsewhere. Strangulation occurs with typical findings as described above, such as bowel wall thickening, free fluid and fat stranding  Fig. 9)9).Fig. 9Adhesive bands are funiculate structures that form between the peritoneum of tissues and organs, often as a result of injury during surgery. They are composed of fibrous tissue and abundant fat .Adhesions are the most common cause of bowel obstruction after surgery, and they constitute the leading cause of long-term reoperation following abdominal and pelvic surgery.Bowel loops that pass through the orifice between the adhesive band and the peritoneum form a type of internal hernia that can evolve to closed-loop obstruction. CT findings in this situation are similar to those in other internal hernias . Overt obstructive small-bowel disease related to adhesions can be further subdivided into simple obstruction and closed-loop or strangulated obstruction .Nevertheless, a non-obstructive subtype can also be found. These patients may have intermittent or low-grade small-bowel obstruction, for which CT has poor sensitivity. CT enteroclysis or dynamic MRI may be important options for better demonstrating the transition point , 23.The diagnosis of small-bowel obstruction due to adhesions is presumed when all other causes of obstruction have been ruled out on CT. The main CT findings that suggest adhesions as the culprit of the obstruction include a narrow zone of transition without an identifiable lesion , acute angulation of the small-bowel loops, traction deformities, stretching of the bowel loops, small-bowel loops closely applied to the anterior abdominal wall and the “fat-bridging sign” which represents the adhesive band itself as a cord-like structure containing mesenteric fat that bridges two peritoneal surfaces , 9 Figs, and 12.Small-bowel obstruction caused by adhesions almost always requires surgery. When intestinal strangulation supervenes, immediate abdominal surgery is mandatory. However, the risk of additional adhesions increases as the number of surgeries increases.Afferent loop syndrome (ALS) represents mechanical obstruction of the afferent loop, occurring in 0.3–2 % of gastroenterostomies, both in Billroth II surgery (the duodenum is the afferent loop) and Whipple or Roux-en-Y procedures (the Roux segment is the afferent loop) , 24, 25.Most cases of ALS are due to adhesions, internal hernia, anastomotic stricture or recurrent tumor . It can The diagnosis may not be clinically suspected, as ALS may present many years after the initial surgery .Although gastrointestinal contrast studies can be helpful in the diagnosis of this condition by showing non-filling of the afferent loop, non-obstructed afferent loops are not normally filled in 20 % of cases. Preferential filling and retention of oral contrast in a dilated afferent limb for at least 60 min is another finding consistent with afferent loop syndrome , 26 Fig.Fig. 13UCT is the most important imaging tool in establishing the diagnosis and determining the site, degree and cause of ALS. A fluid-filled tubular or C-shaped structure containing small air bubbles in the right upper quadrant or crossing the midline between the aorta and the superior mesenteric vessels, with valvulae conniventes projecting into the lumen, in symptomatic patients after gastroenterostomy is characteristic Fig. . RecogniThe incidence of anastomotic strictures depends on the type of surgery performed. The causes for the stricture are not yet clearly understood. For example, in gastric bypass patients, it is thought that the period of time during which the anastomosis is exposed to an inappropriately large volume of gastric acid results in ongoing inflammation, ulceration and stricture formation . SeveralThe resulting symptoms reflect the degree of luminal stenosis, and include abdominal pain, distention, nausea and vomiting.Gastrointestinal contrast studies are the classical method for diagnosing anastomotic strictures. They allow a clear depiction of the stenosis with delayed passage of contrast material, pre-stenotic bowel distension and possible peri-anastomotic fistulae Figs.  and 17a.CT has become increasing important when an anastomotic stricture is being considered, and is now the preferred imaging modality in this particular setting, since it is able to demonstrate not only the anastomotic abnormality but extra-wall structures as well . CT findDepending on the location, strictures can be treated with manual/endoscopic dilation or surgery .Tumor recurrence can be the cause of obstruction several months or years after surgery.CT is the modality of choice in this setting, as it clearly shows an enhancing mass or asymmetric wall-thickening near the site of the initially resected tumor.Most patients who undergo abdominal perineal resection or anterior resection of the rectum will present an ill-defined presacral midline mass 3 to 5 cm in diameter that decreases in size with time  and becomes progressively more distinct in serial imaging—fibrosis / granulation tissue—a finding that can easily be mistaken for tumor recurrence  Fig. 1818.Fig. 1In contrast, tumor recurrence manifests as a well-defined soft tissue mass that grows on serial imaging and becomes ill-defined as it becomes more infiltrative  Figs. 1 and 20.FMost patients with Crohn’s disease (CD) require surgery at some point in their lives, and can develop relapses either at the intestinal anastomosis or far from it, at any other segment of the GI tract. These relapses can occur in the form of new strictures, fistulae or abscesses .A combination of symptom assessment plus endoscopy is still the gold standard for assessment of recurrence in postoperative CD patients .CT enterography/enteroclysis should be the first radiologic procedure performed in patients with acute symptoms when recurrence is suspected. MR enterography/enteroclysis is increasingly being considered as the first-choice examination in acute exacerbation in a child or young adult with known CD, because it is a radiation-sparing technique in a patient who will likely be subjected to multiple serial examinations . MRI is The ability to directly demonstrate the bowel wall, adjacent organs, mesentery and retroperitoneum renders CT and MR superior to any other examination in diagnosing the complications of CD. Both methods can evidence hyper-enhancing bowel wall thickening, mesenteric edema, prominent mesenteric vessels (the “comb sign”) and lymphadenopathy, as well as possible fistulae or abscesses Figs.  and 22.FAlthough CT is by far the most frequent examination undertaken in this setting, we cannot simply discard gastrointestinal contrast studies just yet. A recent study found small bowel follow-through (SBFT) to be more sensitive and specific than CT for detecting recurrent CD in the neo-terminal ileum because of its ability to depict aphthoid ulcers not detectable on CT. Other findings of Crohn’s recurrence at SBFT are luminal narrowing, thickened folds and deep ulcerations (“rose thorn” ulcers)  Fig. 2323.Fig. 2Ulcerative colitis is normally continuous from the rectum to the colon. Total proctocolectomy is the definitive treatment for the disease, but two other types of surgery are usually performed to obviate the disadvantages of a permanent colostomy.Patients who receive total colectomy with ileorectal anastomosis are at risk for disease recurrence at the rectum, and thus clinical and endoscopic follow-up are advised. When proctocolectomy with ileal-anal pouch is chosen, there is an increased probability of the patient developing pouchitis . The diagnosis depends on clinical, endoscopic and histopathological data, and there is usually no role for diagnostic imaging in this setting .In conclusion, knowledge of the normal appearance of the abdomen and pelvis after GI tract surgery is mandatory for every diagnostic radiologist, particularly in an emergency setting. An acquaintance with the most frequent complications in the late postoperative period, such as bowel obstruction due to internal or external hernias, adhesions, afferent loop syndrome and disease recurrence, is of paramount importance.Communication with the referring surgeon can be a valuable adjunct for achieving diagnosis in potentially life-threatening situations so that adequate therapy can be planned.


Ecchordosis physaliphora (EP) is a benign notochordal remnant derived from ectopic nests found along the craniospinal axis. It typically presents asymptomatically and is diagnosed using classic radiologic features, particularly location, T1-hypointensity, T2-hyperintensity, and lack of enhancement following gadolinium (Gd) contrast administration. Distinguishing EP from its malignant counterpart, chordoma, is of paramount importance, given the aggressive nature of the latter. Advances in imaging and immunohistochemistry have aided in diagnosis to an extent but, to our knowledge, identification of the genetic fingerprint of EP has yet to take place. Further cytological analysis of these lesions in search of a genetic link is warranted. We propose here a set of diagnostic criteria based on features consistently cited in the literature. In this literature review, 23 case reports were identified and collated into a summary of symptomatic cases of ecchordosis physaliphora. An illustrative case report of two patients was also included.  Ecchordosis physaliphora (EP) is a benign, congenital lesion representing a notochordal remnant thought to arise by perforation of ectopic nests through the axial skeleton. It occurs particularly at the level of the clivus and sacrum where a convoluted course provides a detour from these cells’ natural embryologic path . DistingA 69-year-old man with a three-month history of hearing loss and a clival lesion identified on an MRI of the internal auditory canal (IAC) presented for neurosurgical consultation. The patient had an occasional mild headache and some mild memory impairment but otherwise no relevant symptoms. Neurologic examination was unremarkable. An axial CT head bone window revealed a low-attenuating lesion with sclerotic margins and a bony stalk within the dorsal aspect of the clivus Figure . The lobA 52-year-old man presented for evaluation of multiple anomalies found on a brain MRI. He had no headaches, nausea, or vomiting. Neurologic examination was unremarkable. Prior to consultation, he was experiencing neck and back pain with paresthesias in his arms and legs. Imaging of his lumbar spine showed an L4-5 herniated disc. Imaging of his cervical spine was unremarkable but showed suspicious brain anomalies. Scalloping of the posterior clivus with a possible bony stalk was identified Figure . Brain Mhttp://www.ncbi.nlm.nih.gov/pubmed/). Search terms “ecchordosis physaliphora” were used and yielded 51 results; dates of publication were between 1982-2016. The titles and abstracts of these publications were screened and only articles containing actual case reports were included. Twenty-four case reports were identified and collated into a summary of symptomatic cases of ecchordosis physaliphora. Full texts of 19 of the 24 English articles , epithelial membrane antigen (EMA), S-100, galectin-3, and brachyury were consistent with notochordal remnants , as were negative staining for GFAP, CEA, and 5’-nucleotidase. 5’ nucleotidase staining was recognized as early as 1984, by Bottles and Beckstead, as particularly characteristic of chordomas . Lastly,To date, there is no published grading system or guidelines for the management of EP. Chihara, et al. recently proposed a new classification system based on MRI FIESTA (Fast Imaging Employing Steady-state Acquisition) (details found in the conclusion). FIESTA sequences provide a strong signal in tissues with high T2: T1 ratios, such as cerebrospinal fluid (CSF), and high spatial resolution with submillimeter section thickness allowing for reconstruction of multiplanar images. Therefore, steady-state free precession (SSFP) sequences are capable of depicting tiny intracranial lesions in contrast to the traditional MR techniques . AdvanceThe lack of symptomology is classically attributed to EP; however, the case reports we reviewed were all symptomatic cases of EP. EP is typically found incidentally, either at autopsy or on imaging sought for investigation of symptoms unrelated to the identified EP . We found two cases of EP with associated vestibular schwannoma. Özgür, et al. identified 11 cases of classical EP, with one patient presenting with concurrent schwannoma. Watanabe, et al. also described a case in which a patient presented with right hearing disturbance and reduction in sensation in the right side of his face due to a large cystic schwannoma , 16. 3) was described by Choudhri, et al. Therefore, the literature suggests that anything greater than 3 cm in diameter or 6 cm3 in volume is consistent with a so-called “giant” EP, and we have included this in the radiologic features under our proposed diagnostic criteria [As far as radiologic features, the three major criteria we identified were T1-hypointensity, T2-hyperintensity, and lack of enhancement with gadolinium (contrast) administration. These three features were the most consistently cited characteristics that allowed one to make a diagnosis of EP based on imaging alone  may demonstrate a bony stalk or pedicle and/or focal bone destruction along the posterior aspect of the clivus. MRI displays an intradural mass with T1-hypointensity, T2-hyperintensity, and gadolinium (Gd) non-enhancement. T1- and T2-intensities are due to the lack of fat and abundance of mucin, respectively, whereas sparse vascularity precludes enhancement. Chordomas, on the other hand, are often extradural, displaying intratumoral calcification, both T1- and T2-hyperintense, and enhance upon administration of Gd due to increased vascularity and disruption of the blood-brain-barrier, a feature common to most malignant lesions . ImagingSymptomatic EP warrants resection, via evolving surgical techniques, as made evident by our review of the literature. Unlike the conservative management of asymptomatic EP, chordomas require a more aggressive approach . The response of EP to radiation therapy  has not been described in the literature. Histologically, EP and chordoma are indistinguishable, owing to similar embryologic derivation. Both demonstrate large cells characterized by copious intracytoplasmic vacuoles and extracellular pools of mucin, which resemble bubbles, hence, the term "physaliphorous". Immunohistochemical methods have aided in demonstrating the aforementioned common notochordal origin of both EP and chordoma, allowing differentiation from other masses, such as neuroenteric cysts, but have provided little in the way of distinguishing EP from chordoma. Despite similar staining characteristics , the literature does describe subtle features, which favor the diagnosis of EP  -26. FurtThe two patients described in this literature review presented with classic features of EP (asymptomatic with the characteristic radiologic profile). Based on our proposed classification system, both tumors fall within the range of Grade I-III EP. Advances in imaging and immunohistochemistry have aided in diagnosis to an extent but, to our knowledge, identification of the genetic fingerprint of EP has yet to take place. Thus, further cytological analysis of these lesions in search of a genetic link is warranted, as is the call for reports of EP with other incidental findings. The diagnostic criteria we propose is based on features consistently cited in the literature; however, it is glaringly obvious that in order to meet histological and immunohistochemical criteria, one must obtain a tissue sample via biopsy. Although we reviewed many case reports that described novel techniques of resection, analysis of tissue was often performed after near-total or gross resection of the masses. We did not come across any case report describing biopsy undertaken without subsequent resection. It is conceivable that the benefit of biopsy of Grade III EP (based on our proposed classification system) with subsequent histopathologic and immunohistochemical confirmation outweighs the risks of complete resection and may obviate the need for serial MRI. Chihara, et al. recently proposed a new classification system of EP based strictly on radiologic characteristics identified using contrast-enhanced Fast Imaging Employing Steady-State Acquisition MR imaging (FIESTA). Chihara, et al. separated dorsal surface lesions into classical EP and possible EP. Classical EP was further subdivided into type A: hyperintense excrescence (cyst-like component) on the dorsal surface of the clivus and type B: hyperintense excrescence, plus a hyperintense lesion within the clivus. Possible EP was further subdivided into incomplete EP characterized by a T2-hypointense protrusion of the clivus and an EP variant characterized by hyperintense lesions within only the clivus . Our cla


Giant cell tumors (GCTs) are usually found in the epiphysis of the long bones, and represent ~5% of all bone tumors. Only <1% of GCTs are localized in the cranium. When localized in the cranium, GCTs are commonly observed in the sphenoid or temporal bones, and rarely in the parietal or frontal bones. Occipital bone posterior fossa involvement is an extremely rare occurrence. The current study presents a 22-year-old female patient was admitted to the Department of Radiation Oncology  with complaints of neck pain and headache. The patients cranial magnetic resonance images showed a 2.5 6-cm mass in the occipital bone, which was subtotally excised. The patient was treated with radiotherapy following the surgery. At present, the patient has shown no progression after 20 months of follow-up. Giant cell tumors (GCTs) of the bone are locally progressive and destructive borderline malignant neoplasms, which comprise ~5% of primary bone tumors and ~20% of benign tumors . The majThe majority of data on GCTs in the skull consist of case reports. Despite reports of a number of cases localized in the sphenoid, temporal and parietal bones, cases of occipital bone involvement are extremely rare ,4.Function-preserving surgery is the standard of care for GCTs. The achievement of local control is possible in 85–90% of all cases subsequent to complete resection . As a coThe current study presents and discusses, with a review of the available literature, the case of a 22-year-old patient with occipital GCT who was referred to to the Department of Radiation Oncology  with complaints of neck pain and headaches. Patient provided written informed consent.A 22-year-old female patient was admitted to the Department of Radiation Oncology  with complaints of neck pain and headaches. The cranial computed tomography images images showed a ground-glass appearance with lytic areas of 2.5×6 cm in the occipital bone . The craThe mass was subtotally excised, and the post-operative pathological examination showed a neoplasm characterized with dispersed osteoclast-like nuclear giant cells in the fibrohistiocytic stroma between the osseous spicules. A number of foreign body-like giant cells were also detected in the neoplasm. In the immunohistochemical study, histiocytes and multinuclear giant cells were possitively stained for CD68. As a result, a GCT was diagnosed .®, Varian Medical Systems, Inc., Palo Alto, CA, USA), with a 2-cm safety margin, and a dose of 50 Gy by external radiotherapy, with 200 cGy/fraction on the gross tumor volume of the subtotally resected mass. At present, the patient is being followed up and no progression has been observed for 20 months.The patient was referred to the Department of General Surgery , and post-operative RT was delivered using a 6-MV linear accelerator  also presented a series from the MD Anderson Cancer Center, which observed a local control rate of 70% when using doses of 36–66 Gy. The results of these series do not differ significantly, even when all patients with non-extremity tumors and those who have undergone gross total resection prior to RT have been excluded. As a consequence, the possibility of high tumor control rates can be offered by modern imaging and radiation techniques, without major side-effects.In a case series by Roeder et al  concernil (et al  achievedGCTs are generally benign, locally aggressive lesions, with pain and swelling as the most common symptoms. The preferred treatment of GCT is radical surgery, and RT is restricted to inoperable cases or those not undergoing radical surgery. In the current case, RT with a total dose of 50 Gy was delivered with 200 cGy/fraction post-operatively following subtotal excision, without chemotherapy. At present, the patient is being followed up and no recurrence or symptoms have been observed for 20 months since the RT.


Pathological lesions in and around a joint can arisefrom underlying dermis, subcutis, deep muscle, bone orsynovium. Clinical presentation can include joint pain,joint swelling, palpable masses and mechanical restriction.Whilst giant cell tumour of tendon sheath, pigmentedvillonodular synovitis, synovial chondromatosis, lipomaarborescens, juxta articular myxomas and inflammatoryarthritis are the better-known conditions of the joint.Intra-articular nodular fasciitis, on the other hand, is lesswell recognized both clinically and radiologically. It israrely seen in routine practice and is only described in casereports in the literature. Due to the non-specific clinicaland radiological findings as well as the unfamiliarity withthe entity, the diagnosis of intra-articular nodular fasciitisis usually clinched only after histological examination.We present a case of intra-articular nodular fasciitis arisingin the knee joint which was not suspected clinically orradiologically.Intra-articular, nodular fasciitis, joint, knee, MRI Nodular fasciitis is a well-known benign reactiveproliferation which typically presents with a history of arapidly growing single subcutaneous mass, usually in theupper limbs or trunk with men and women being equallyaffected. It can also occur in dermis, muscle or intravascularlocations. It tends to occur in adults who are between 20 to50 years of age. There is sometimes an association withprevious trauma. Local excision is usually curative with alow rate of recurrence. When present in infants and children,nodular fasciitis usually affects the head and neck region.Interestingly, nodular fasciitis has also been reported in alist of other unusual anatomical locations such as the parotid gland and urinary bladder. Of these rare sites, the joint isone addition. Here we present a case of an intra-articularnodular fasciitis which followed a history of trauma.A 17 year-old Chinese male was referred to our outpatientclinic by a general practitioner, for a persistent right kneeeffusion after a fall during Chinese wushu martial arts twomonths earlier. He had no other significant past medicalhistory. There was associated knee pain with limitedextension and flexion. There was no locking or any instabilityof the joint. No palpable mass or lymphadenopathy wasidentified and the joint was not warm to touch.There was a 3.2x3.1x1.5cm lobulated lesion in the lateralaspect of the suprapatellar pouch ,1B. ItdAn arthrotomy of the right knee was performed, showingsevere synovitis with a large yellowish serous effusion anda superolateral mass in the suprapatellar pouch. The lesionwas covered by and just deep to the synovium. It waslocalised and did not appear to involve the deep structuressuch as the periosteum. The lesion was excised and a partialsynovectomy of the suprapatellar pouch was performed.Macroscopically, the mass was polypoid in appearance andhad a smooth external surface and a tan-white homogeneoussoft cut surface. On microscopic examination, the lesionwas unencapsulated and well circumscribed The patient has been on six monthly follow-up for 17months so far and is free of recurrence. This has beenascertained with follow-up MRI. He has returned tohis martial art activities although unable to participateat competitive levels yet. He has a good range of kneemovements and is fully functional.The initial impression on clinical examination of the rightknee in this patient was that of haemarthrosis secondaryto possible ligament tear or an osteochondral fracture.However, based on the persistent knee effusion and MRIsuggestion of haemosiderin deposits, the working diagnosiswas changed to pigmented villonodular synovitis. Intranodularnodular fasciitis was not considered and the correctdiagnosis was reached only after histological examination.1. They highlighted the knee as the commonest jointto be affected by intra-articular nodular fasciitis. They alsonoted that intra-articular nodular fasciitis tended to havea longer preoperative history than the usual subcutaneousor intramuscular variants. Similar to our case, three ofthe 16 cases in the English literature reported a history oftrauma before the development of intra-articular nodularfasciitis1-4. In the case report by Yamamoto. et al 5, aninitial misdiagnosis of malignant fibrous histiocytoma wasmade with the patient receiving unnecessary irradiation.This illustrates the need for greater awareness of intraarticularnodular fasciitis even for pathologists so thatthe patients can be managed appropriately. Whilst intraarticularnodular fasciitis has a low recurrence rate afterwide excision, diffuse pigmented villonodular synovitis hasa high recurrence rate even after extensive synovectomy.Whilst intra-articular pigmented villonodular synovitis,juxta-articular myxomas, synovial chondromatosis,lipoma arborescens and fibroma of tendon sheath are wellrecognised entities, intra-articular nodular fasciitis is rarelyencountered and therefore not usually considered clinicallyduring the investigation of joint symptoms. To date, thereare 18 cases of intra-articular nodular fasciitis reported.Of these, 13 were in the knee, two in the hand, one inthe ankle and two in the shoulder. All were reported inthe English literature except two in the Japanese literature.Those patients in the English literature, presented withjoint swelling, extension restriction, palpable masses, jointeffusion and haemarthrosis. Their ages ranged from ninemonths to 52 years with a median age of 29 years. Theaverage duration of their symptoms prior to presentationranged from two months to one year. There were norecurrences during follow up. Nodular fasciitis was notconsidered in the differential diagnosis during the clinicalor radiological work-up in any of these cases. Ten of thecases were part of a case series by Hornick and Fletcher in2006 In conclusion, the key learning point is not to assume everyintra-articular mass in the knee with a persistent effusionand heterogeneous appearance on MRI with hemosiderindeposits to be pigmented villonodular synovitis. It isimportant to keep in mind rarer pathologies such as intraarticularnodular fasciitis, especially with a precedinghistory of trauma.