Malignant transformation of intestinal endometriosis is a rare event with an unknown rate of incidence. Metachronous progression of endometriosis to adenocarcinoma from two distant intestinal foci happening in the same patient has not been previously reported.We describe a case of metachronic transformation of ileal and rectal endometriosis into an adenocarcinoma occurring in a 45-year-old female without macroscopic pelvic involvement of her endometriosis. First, a right colectomy was performed due to intestinal obstruction by an ileal mass. Pathological examination revealed an ileal endometrioid adenocarcinoma and contiguous microscopic endometriotic foci. Twenty months later, a rectal mass was discovered. An endoscopic biopsy revealed an adenocarcinoma. En bloc anterior rectum resection, hysterectomy and bilateral salpingectomy were performed. A second endometrioid adenocarcinoma arising from a focus of endometriosis within the wall of the rectum was diagnosed.Intestinal endometriosis should be considered a premalignant condition in premenopausal women. The development of a malignancy is a relatively common complication of endometriosis . In factA 45-year-old woman was admitted to the hospital because of a 5 month history of paroxistic abdominal pain and vomiting. The patient's past medical history included ovarian endometriosis treated with bilateral oophorectomy in another hospital seven years earlier. She subsequently received treatment with medroxyprogesterone and transdermal estrogens.On physical examination the abdomen was distended and bowel sounds were increased. Laboratory values were unremarkable, and abdominal x-rays confirmed the diagnosis of intestinal obstruction. Laparotomy revealed an ileal mass protruding into the lumen. A right hemicolectomy including 40 cm of ileum was performed. The female genital tract and pelvis had no macroscopic evidence of endometriotic lesions.Histopathology revealed the following: the resection specimen consisted of 16 cm of right colon and 39 cm of ileum. A tumor measuring 5.5 cm was found within the wall of the ileum 2 cm from the ileocaecal valve. Morphologic and immunohistochemical features were typical of an endometrioid adenocarcinoma (cytokeratin (CK) 7-positive, vimentin-positive, CK20-negative)  and 5-Fluorouracil. After five years, she remains asymptomatic and has no evidence of recurrence.Histopathology revealed the following: The resection specimen consisted of 18 cm of rectum, the uterus and the fallopian tubes. Histological examination confirmed the presence of a tumor measuring 3.5 cm in diameter, located in the anterior wall of the rectum and embedded to the posterior wall of the uterus. The poorly differentiated adenocarcinoma involved all layers of the intestine up to the uterus which was not invaded microscopically. The uterus and the fallopian tubes had no major microscopic changes. Morphological and immunohistochemical features of this endometriotic adenocarcinoma were similar to the previously removed tumor   declare that they have no competing interests.JMG conceived the study, participated in its design and coordination and helped to draft the manuscript.ACM participated in the sequence alignment and drafted the manuscript.MHM participated in the sequence alignment and translated the manuscript.AAF carried out the histopathology studiesAll authors read and approved the final manuscript


Primary intra-abdominal malignant mesenchymal tumours are very rare and there are not many cases of visceral malignant fibrous histiocytoma in the English literature. We report a new case of abdominal malignant fibrous histiocytoma presenting as abdominal pain and pyrexia of unknown origin in a 54 year old female followed by a brief review of literature. Presentation with pyrexia of unknown origin is extremely rare in this condition. The term Malignant Fibrous Histiocytoma (MFH) was originally described by O'Brien and Stout in 1964 [0), intermittent, and most common in the early morning. Clinical examination revealed a firm, vaguely defined, tender mass in the left upper quadrant of the abdomen. Blood results showed persistently high ESR (>100), high CRP (>240), leukocytosis, mildly raised Alkaline Phosphatase and anaemia . There was no overt source of infection that could account for the fever. Repeated blood cultures did not yield any bacterial growth. NM Leukocyte HMPAO scan showed no convincing abnormality to help localise an infective focus. There was no improvement in pyrexia after treating the patient with broad-spectrum antibiotics.A 54 year old female presented to our surgical outpatient clinic with abdominal pain and pyrexia. Abdominal pain was of recent onset and mainly in the left upper abdomen but she had fever for at least 6 months. Her pyrexia was high grade  to be focally positive, but Desmin, CD34, S-100, Neurofilament, EMA, CAM 5.2, CD117, CD21 and CD23 were negative. All these appearances were suggestive of a high-grade sarcoma with no discernible line of differentiation; hence it was best classified as grade 3 malignant fibrous histiocytoma. Specimen B showed spindle cell sarcoma with cells showing elongated thin cytoplasmic processes and wavy nuclei. Specimen C showed spindle-pleomorphic sarcoma 3. Giant cell 4. Inflammatory 5. Angiomatoid.Investigations for the diagnosis of MFH include routine haematological, biochemical and radiological tests. A CT scan of the abdomen should be performed early in a patient who presents with abdominal pain and pyrexia of unknown origin but no obvious source of symptoms. This can help identify and localise tumours, if and define extent of growth and presence of metastatic disease. The final diagnosis of MFH is based primarily on the histopathological examination and immunohistochemical reactivity. These diagnostic procedures rely on several criteria, which include the presence of typical spindle and polygonal (strap-like) cells that are filled with an abundant eosinophilic cytoplasm, cells with cross-striations, and, particularly, desmin- and myoglobin-positive immunoreactivity ,13. HoweMFH is an aggressive tumour with a high potential of metastasis to other parts of the body. The Liver is the most commonly involved site of metastatic sarcomas, occurring in 64%–70% of patients ,16. The In order to improve survival in patients with MFH, complete resection of the primary tumour as well as isolated peritoneal or hepatic metastases should be attempted where possible. An early multidisciplinary approach is important to improve clinical outcome. Our case report shows that primary intra-abdominal MFH can present in unusual ways including high-grade fever of unknown origin. Clinicians must remember this while establishing differential diagnosis for patients with PUO and abdominal pain.The author(s) declare that they have no competing interests.


Extra-adrenal, intra-abdominal paraganglioma constitutes a rare neoplasm and, moreover, its location in the greater omentum is extremely infrequent.th postoperative day. She remains free of disease for 2 years as appears on repeated CT scans as well as magnetic resonance imaging (MRI) and scintigraphy performed with radiotracer-labeled metaiodobenzyl-guanidine (MIBG) scans.A 46-year-old woman with an unremarkable medical history presented with an asymptomatic greater omentum mass that was discovered incidentally during ultrasonographic evaluation due to menstrual disturbances. Clinical examination revealed a mobile, non-tender, well-circumscribed mass in the right upper and lower abdominal quadrant. Blood tests were normal. Contrast-enhanced abdominal computed tomography (CT) scan confirmed a huge (15 × 15 cm), well-demarcated, solid and cystic, heterogeneously enhanced mass between the right liver lobe and right kidney. Exploratory laparotomy revealed a large mass in the greater omentum. The tumor was completely excised along with the greater omentum. Histopathology offered the diagnosis of benign greater omentum paraganglioma. After an uneventful postoperative course, the patient was discharged on the 4This is the second reported case of greater omentum paraganglioma. Clinical and imaging data of patients with extra-adrenal, intra-abdominal paragangliomas are variable while many of them may be asymptomatic even when the lesion is quite large. Thorough histopathologic evaluation is imperative for diagnosis and radical excision is the treatment of choice. Since there are no definite microscopic criteria for the distinction between benign and malignant tumors, prolonged follow-up is necessary. Extra-adrenal paragangliomas of the sympathoadrenal neuroendocrine system consist 5%–15% of sporadic pheochromocytomas and are located anywhere extending from the upper neck to the pelvic floor, parallel to the autonomic nervous system . Extra-aHerein, we report such a case of a paraganglioma occurring in the greater omentum in a 46-year-old woman along with a review of the literature. To the best of our knowledge, this is the second reported case of greater omentum paraganglioma in the literature . Apart fA 46-year-old woman with an unremarkable medical history presented with an asymptomatic greater omentum mass incidentally found during ultrasonographic evaluation due to menstrual disturbances. Clinical examination showed a non-tender, mobile, well-circumscribed mass in the right upper and lower abdominal quadrant. Esophagogastroduodenoscopy revealed mild extrinsic compression of the stomach and duodenum. Contrast-enhanced abdominal computed tomography (CT) scan, with oral and i.v. contrast, confirmed a large 15 × 15 cm), well-demarcated, solid and cystic, heterogeneously enhanced mass between the right liver lobe and right kidney  was identified. A few nuclei were immunoreactive in Ki-67/MIB-1 but proliferative activity as the percentage of Ki-67 immunoreactive cells (proliferative index) was <1% while immunostaining for cytokeratin, c-kit, and CD34 was negative. No telomerase activity (TA), human telomerase reverse transcriptase expression , topoisomerase IIa expression, or mRNA expression of matrix metalloproteinase (MMP)-2 and EMMPRIN  was detected. Based on histologic and immunohistochemical features, a diagnosis of benign greater omentum paraganglioma was offered.On histopathologic evaluation, the tumor contained small round cells (chief cells) arranged in well defined nests, having a mixture of trabecular and alveolar pattern. These groups of cells were separated by fibrovascular septa, giving a characteristic "zellballen" nested pattern. The tumor cells were polyhedral, with round or oval nuclei, and contained intracytoplasmic hyaline globules; no cytologic atypia or mitosis was observed, although there were some nuclear pleomorphisms Figure . No locaDue to histopathologic diagnosis, genetic testing for familial paraganglioma, neurofibromatosis type 1, von Hippel-Lindau disease, the Carney triad, multiple endocrine neoplasia type 2, and mutations of the succinate dehydrogenase genes  was performed that was negative.th postoperative day. She remains free of disease for 2 years as appears from repeated biochemical testing , CT scans as well as magnetic resonance imaging (MRI) and scintigraphy performed with radiotracer-labeled metaiodobenzyl-guanidine (MIBG) scans.After an uneventful postoperative course, the patient was discharged on the 4The paraganglion system is formed by numerous collections of neuroepithelial cells. Their common morphologic characteristic is the presence of numerous cytoplasmic neurosecretory granules containing catecholamines. Paraganglioma is the generic term applied to tumors of paraganglia regardless of location. Paragangliomas of the adrenal medulla, the most common site of paragangliomas, are known as pheochromocytomas while those located outside the adrenal gland as extra-adrenal pheochromocytomas .Extra-adrenal paraganglia are divided into two categories: those related to the parasympathetic system and those connected with the orthosympathetic system. The former, usually nonchromaffin, lie in the head and neck including the carotid body, intravagal, jugulotympanic, and mediastinal and aorticopulmonary paraganglia ,8. The lExtra-adrenal, intra-abdominal paragangliomas are divided into three groups: superior para-aortic, inferior para-aortic, and urinary bladder paragangliomas ,11. RareParagangliomas may be hereditary and can be associated with familial paraganglioma, neurofibromatosis type 1, von Hippel-Lindau disease, the Carney triad, multiple endocrine neoplasia type 2, and mutations of the succinate dehydrogenase genes  [Histologically, paraganglia contain nests of neuroendocrine cells surrounded by sustenacular cells. This pattern is most clearly seen in parasympathetic paraganglia as the characteristic "zellballen". In sympathetic paraganglia, neuroendocrine cells are referred to as chromaffin cells and in parasympathetic as chief cells. These cells are immunopositive for neuroendocrine markers including synaptophysin and chromogranin A and for several neuropeptides. Features that may predict malignancy include extra-adrenal location, confluent tumor necrosis, vascular invasion, local invasion, coarse nodularity, and absence of hyaline globules . MoreoveMost patients with extra-adrenal, abdominal paragangliomas present with abdominal pain or a palpable abdominal mass ; howeverEven though imaging studies are helpful, diagnosis of extra-adrenal, intra-abdominal paragangliomas can be safely done only with careful histologic and immunohistochemical evaluation. Contrast-enhanced abdominal CT scan is useful for diagnosis; however, no CT feature unique for paragangliomas has been found . AbdominThe majority of abdominal tumors are benign; 10%–50% of intra-abdominal, extra-adrenal paragangliomas are reported to be malignant -11,19,22Clinical and histological distinction between benign and malignant cases is difficult ,23,24. TThe treatment of choice for paragangliomas is complete surgical resection. Traditional treatment consists of open exploration and resection. However, laparoscopic management is nowadays increasingly being used for their management due to the advances in laparoscopic technique and refined preoperative imaging even though few studies regarding the laparoscopic treatment of extra-adrenal intra-abdominal paragangliomas exist in the literature because of the rarity of this clinical entity . IntraopSince clinical presentation and imaging data of these patients are variable and non specific, histological distinction between benign and malignant cases as well as prediction of malignant potential are difficult, and local recurrence or distant metastases are not infrequent, a multidisciplinary approach regarding effective diagnosis, management and follow-up is essential and should involve the close collaboration of endocrinologists, surgeons, anesthesiologists, geneticists, laboratory specialists, radiologists, oncologists, and pathologists.Paraganglioma of the greater omentum is extremely infrequent. Recognition of this tumor as a cause of an abdominal mass is important. Clinical and imaging data of patients with extra-adrenal, intra-abdominal paragangliomas are highly variable and non specific while many of them may be asymptomatic even when the lesion is quite large, such as the presented case. Thorough histological and immunohistochemical evaluation is, therefore, imperative and the only safe modality for diagnosis. The first line treatment is surgical resection, while chemotherapy and radiotherapy seem to be useless in benign lesions ,22. SincThe author(s) declare that they have no competing interests.FA contributed to manuscript conception, research, acquisition of data, drafting and writing of the manuscript. HM contributed to manuscript conception, research, acquisition of data, drafting and writing of the manuscript. CD carried out the histopathologic evaluation and contributed to writing of the manuscript. PD assisted in the operation and contributed to organising and drafting of the manuscript. KGT assisted in the operation and critically revised the manuscript. DT assisted in the operation and critically revised the manuscript. SK carried out the operation and contributed to acquisition of consent and critical review of the manuscript.All authors read and approved the final manuscript.


Percutaneous fine needle aspiration cytology (FNAC) became a popular method for diagnosis of hepatic masses. Abdominal wall implantation from FNAC is rare.We report a female patient who presented with a right upper abdominal wall mass 3 years following a fine needle aspiration cytology (FNAC) and resection of a solitary hepatocellular carcinoma (HCC) from the liver. The mass proved to be a metastatic HCC; it was locally resected with safety margins. To date (20 months later) she remains well with no recurrence.Implantation of tumor cells after FNAC for HCC is rare, but can happen. The availability of dynamic imaging of the liver should reduce the need for this technique in the diagnostic workup of patients suspected of having HCC Percutaneous fine needle aspiration cytology (FNAC) became a popular method for diagnosis of hepatic masses. The reported mortality rate following this procedure ranges between 0.006% and 0.03%. The associated morbidity is 0.05% – 0.18%, this includes: hemoperitoneum, hematoma, local infection, bile peritonitis and anaphylactic shock [A 61-year-old female, known to suffer from chronic hepatitis C (Child Pugh A), presented in Jan 2001 to another hospital complaining of abdominal pain. CT-Scan of the abdomen showed a solitary 5 × 5 cm mass in segment VII of the liver. Fine needle aspiration cytology (FNAC) showed features consistent with HCC. AFP level at the time was normal 2.23 ng/ml . She traveled abroad (outside Kuwait), underwent resection of the tumor and returned back to Kuwait. A brief report stated that the tumor was resected from segment VII with about 1.5 cm safety margin with an uneventful postoperative course. Histopathology of the original tumor proved to be a well differentiated HCC with clear margins and no vascular invasion.Upon return to Kuwait, she was under the care of the hepatologist who treating her chronic hepatitis with Pegelated Interferon and Ribaverin for 6 months. Unfortunately she remained HCV positive.En-bloc resection of the mass  was performed under general anesthesia with primary closure. Histopathology of the removed specimen confirmed implantation of HCC in the abdominal muscles with free surgical margin and no peritoneal penetration  and the AASLD (American association for the surgery of liver disease) in Barcelona 2005 indicated that a diagnosis of HCC in the setting of cirrhosis can confidently be made by two dynamic imaging techniques if both show increased vascularity characteristic of HCC. The panel accepted the concept of "washout" in the portal venous phase of a CT-Scan as specific for HCC; this is shown as hypo-attenuation in the late portal phase of a liver lesion which was hypervascular in the hepatic arterial phase . In addiImplantation of tumor cells after FNAC for HCC is rare, but can happen. The availability of dynamic imaging of the liver should reduce the need for this technique in the diagnostic workup of patients suspected of having HCC.The author(s) declare that they have no competing interests.AAk: Study design, data collection, data analysis and manuscript drafting. SB: Histopathology studies and final reporting. AA: Literature review and manuscript drafting. AAf: Data collection and literature review. SA: Idea originator, Critical reviewing of manuscript and final writingAll authors have read and approved the manuscript


Metastatic tumors of the intestinal tract from extra-abdominal sites are rare. In esophageal cancer, the liver, lung and the bones are the most common sites of metastases. Metastasis to intestines are very rare.A 54-year old male was admitted with esophageal squamous cell carcinoma (SCC) associated with dysphagia II-III and weight loss of 20 kg. Preoperative routine staging failed to detect any metastases. A transthoracic esophagectomy and orthotopic gastric pull-up with collar esophago-gastrostomy, associated with 2-field lymphadenectomy was perfromed. During the digital placement of the naso-jejunal feeding catheter a submucosal jejunal nodule with a diameter of 1 cm, about 40 cm distal to the duodeno-jejunal fold was detected which was completely resected by jejunotomy. Histopathology of jejunal nodule showed metastasis from esophageal squamous cell carcinoma.Because of the extensic esophageal lymphatic system, an occult widespread dissemination of the tumor cells into the abdominal cavity is possible. Additional intraoperative evaluation of the small intestine and the complete abdominal cavity should be performed in every operation of esophageal carcinoma to detect possible occult intraabdominal metastases. Metastatic tumors of the intestinal tract from extra-abdominal sites are rare. In esophageal cancer, the liver, lung and the bones are the most common sites of metastases. Metastases to the small intestine are very rare. We describe the case of a 54-year-old man suffering from esophageal carcinoma, who underwent transthoracic esophagectomy and 2-field lymphadenectomy, the reconstruction was done by orthotopic gastric pull-up. During the operation, a solitary submucosal jejunal metastasis of the esophageal carcinoma was detected and excised.A 54-year-old male, alcohol and tobacco user, was admitted with squamous cell carcinoma of the esophagus associated with the clinical symptoms of high-grade dysphagia and weight loss of 20 kg. Routine staging was done by computerized tomography (CT)-scan of the thorax and abdomen, ultrasonography, positron emission tomography (PET) scan, esophago-gastro-duodenoscopy and bronchoscopy. Functional evaluation was done by electrocardiogram (ECG), cardiac ultrasonography and spiroergometry.The CT-scan of the thorax and the mediastinum showed a tumor of the middle third of the esophagus with a suspicion of tumor infiltration of the thoracic aorta and the left main bronchus. However, infiltration of the main bronchus could be excluded by bronchoscopy. Infiltration of the thoracic aorta could also be excluded by MRI-angiography. The CT-scan of the abdomen and the abdominal ultrasound showed no signs of tumor spread. The PET-scan demonstrated a pathological tracer uptake at the level of the middle third of the esophagus with no signs of distal metastasis. Esophago-gastro-duodenoscopy showed a tumor stenosis of 7 cm length, from 30 to 37 cm, and a diameter of 4 – 6 mm, further there was an intraluminal obstruction about more than 50 % which was additional confirmed by an esophagogram.Transthoracic esophagectomy and 2-field lymphadenectomy was carried out as reported in literature ,2. IntraDuring the digital placement of the naso-jejunal feeding catheter a submucosal jejunal nodule with a diameter of 1 cm was detected about 40 cm distal to the duodeno-jejunal fold. The nodule was completely resected by jejunotomy. Intraoperative frozen section showed a submucosal metastasis of the esophagus. Further evaluation of the small intestine and the complete abdominal cavity showed no signs of metastasis.3, N0, M1, L1, G3, R0.Finally histopathological work-up of the specimens confirmed the diagnosis of squamous cell carcinoma of the esophagus Figure  and a soth postoperative day. As this was stage IV squamous cell carcinoma of the esophagus adjuvant chemotherapy was not offered to the patient [The further course of the patient was uneventful and he could be discharged on the 14 patient . HoweverMetastatic tumors of the intestinal tract from extra- abdominal sites are rare ,5. In esSquamous cell carcinoma of the esophagus is characterized by an extensive lymphatic dissemination via the longitudinal lymphatic system along the esophagus, which drains in to a large number of widespread lymph nodes of the thorax and the abdomen depending on the location of the tumor . RetrogrIn this case, the operation was absolutely indicated to prevent the patient from further progression of his dysphagia, to avoid the development of a malignant esophagotracheal fistula with its typical complication, mainly bronchopneumonia due to nocturnal aspiration and to avoid the development of an jejunal ileus caused by intraluminal obstruction by that solitary jejunal metastasis. A quite interesting aspect is, why this solitary metastasis could not be discovered by the PET-scan, which showed a pathological tracer uptake at the level of the middle third of the esophagus, further an unspecific tracer uptake due to inflammatory disease in the subhepatic region of the right upper abdomen was seen but there was no suspicion of further distal metastases. The main reason for this failure of the PET-scan could be the high incidence of artifacts caused by many different small intraabdominal focuses of inflammation which make the correct assessment of the abdominal cavity quite difficult.Additional intraoperative evaluation of the small intestine and the complete abdominal cavity should be performed in every laparotomy for esophageal carcinoma to detect possible occult intraabdominal metastases. PET is not sensitive enough to pick small metastasis.The author(s) declare that they have no competing interests.JL: Preparation of draft manuscript, Surgical management, Revision of manuscript and preparation of final manuscript.VM: Preparation of manuscript, surgical managementAM, Surgical management, Revision of manuscript and preparation of final manuscriptCP, Surgical managementFG: Histopathological work-up, immunhistochemical tests, photomicrograph of specimen.FMSJ: Revision of manuscript and preparation of final manuscript.All authors read and approved the final version of the manuscript.


Acute red eye is a common presentation in both primary and secondary care. Presentation in combination with other systemic symptoms can indicate serious underlying pathology.73-year-old lady presenting with endogenous endophthalmitis and thoracic discitis secondary to sub-acute bacterial endocarditis.Acute red eye in combination with systemic symptoms requires immediate investigation. If endogenous endophthalmitis is diagnosed, a source of sepsis should be comprehensively investigated and referral made to individual specialities if necessary. Acute painful red eye is a common presenting complaint. The differential diagnosis is broad and consideration needs to be given to both local and underlying systemic conditions .We report the presenting combination of an acute red eye and new onset back pain, in a well 73-year old lady diagnosed with endogenous endophthalmitis and thoracic discitis secondary to a subacute bacterial endocarditis. This case emphasises the need for consideration of systemic illness as a cause for red eye, especially in combination with other symptoms.A 73-year old lady was referred to the Ophthalmic Accident and Emergency Department with a five-day history of decreased visual acquity and floaters in the vision of her left eye. The patient had no previous medical or ophthalmic history and had been well over the preceding weeks, other than a treated urinary tract infection. Initial examination revealed visual acuity in the right eye – 6/9, in the left – finger counting. Conjunctival chemosis was present in the left eye, posterior synechiae and a cloudy vitreous with no fundal view.Ocular ultrasound and vitreal biopsy (no growth) enabled a diagnosis of endogenous endophthalmitis to be made. Treatment with intravitreal and systemic antibiotics improved the patient's symptoms and she was discharged. Investigation into the source of the sepsis before discharge included an ultrasound of her abdomen, which revealed no intra-abdominal focus.Streptococcus and MRI showed a discitis at T11/12 consistent with infection.Two days later the patient was readmitted as a medical emergency with symptoms of acute left ventricular failure and worsening lower back pain. Examination demonstrated marked tenderness in the lower thoracic region, previously undocumented systolic and diastolic murmurs and signs of pulmonary oedema. Investigation revealed elevated inflammatory markers, blood cultures grew Group B Transoesophageal Echocardiography showed a mobile echo dense mass on the right coronary cusp of the aortic valve (See Figure After a six-week course of intravenous antibiotics and two months of oral antibiotics a successful aortic valve replacement was performed. The discitis resolved on the above regimen with no sequelae and vision in the left eye improved to 6/9.Streptococcus accounts for approximately 7% of cases of endogenous endophthalmitis [Endogenous endophthalmitis accounts for a small proportion of all cases of endophthalmitis . Review halmitis . Prompt halmitis .The combination of endophthalmitis and discitis in the presentation of endocarditis is unusual, and to our knowledge has not previously documented in the literature. The case demonstrates important points for both general physicians and ophthalmologists:• The presentation of an acute red eye with systemic symptoms, particularly new onset back pain, can indicate a serious underlying medical condition.• If systemic illness is suspected in combination with acute red eye, referral to ophthalmology should be sought.• If endogenous endophthalmitis is diagnosed then a source of sepsis should be investigated as comprehensively as possible. Dependent on systemic findings this may require referral to individual specialities. In this case further investigation into the underlying cause of the endophthalmitis during the initial admission could have led to earlier diagnosis of the underlying endocarditis, and perhaps reduced subsequent sequelae.All authors of this article declare they have no conflict of interest.All authors were involved in patient management or writing of the manuscript.The pre-publication history for this paper can be accessed here:


Solitary fibrous tumour (SFT) is an uncommon mesenchymal neoplasm that most frequently affects the pleura, although it has been reported with increasing frequency in various other sites such as in the peritoneum, pericardium and in non-serosal sites such as lung parenchyma, upper respiratory tract, orbit, thyroid, parotid gland, or thymus. Liver parenchyma is rarely affected. Clinically, SFTs cause symptoms after having reached a certain size or when vital structures are involved. In recent years, SFTs are more often identified and distinguished from other tumours with a similar appearance due to the availability of characteristic immunohistochemical markers.In this manuscript we report the case of a large tumour of the liver, which was histologically diagnosed as a SFT, and showed involvement of a single hepatic segment. Because of the patient's presentation and clinical course, it may represent a radiation-induced lesion.When a SFT has been diagnosed, surgery is the treatment of choice. The small number of patients with a SFT of the liver and its unknown natural behaviour creates the need to a careful registration and follow-up of all identified cases Solitary fibrous tumour (SFT) is an uncommon mesenchymal neoplasm that most frequently affects the pleura ,2, althoIn this manuscript we report the case of a large tumour of the liver, which was histologically diagnosed as a SFT, and showed involvement of a single hepatic segment. Because of the patient's presentation and clinical course, it may represent a radiation-induced lesion.A 74-year-old man was referred to our department with complains of gastric fullness, frequent episodes of post-prandial nausea, and weight loss over the previous 3 months. Medical history revealed a high-grade mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach in 1996. The lymphoma was staged as IE according to the Ann Arbor staging system, and showed complete response after chemotherapy followed by radiation therapy (60 Gy) of the local nodal regions. On physical examination, a large mass was palpated in the epigastrium that filled the entire right upper quadrant of the abdomen. Routine laboratory investigations, including blood glucose levels, and serum levels of tumour markers  were within normal limits. Computed tomography (CT) of the abdomen demonstrated a large, heterogeneous mass in the left hepatic lobe, measuring 24 cm in largest diameter, with necrosis and calcification  declare that they have no competing interests.CV and JHW carried out the surgical procedure and contributed to the design of the study. TT and CV gathered the data from the literature search and made the first draft of the manuscript. MK performed the histological analysis of the surgical specimen and provided histological sections as figures for the manuscript. ANG, AMME and JHW revised and finally approved the manuscript for been published. All authors approved the final manuscript.


Few cases of malignant tumors arising in a blind painful eye have previously been described. We described two cases of a blind painful eye containing an unsuspected tumor, which were enucleated to relieve the pain.Case 1: A 57 year-old Caucasian man presented with recurrent orbital cellulitis and endophthalmitis in the left eye (OS). The OS was blind and painful and an enucleation was performed showing a uveal melanoma by histopathological exam. Case 2: A 54 year-old Caucasian man with previous history of a rhegmatogenous retinal detachment in his left eye presented a blind painful eye. Enucleation was performed revealing a well-differentiated B-cell lymphoma of uveal tract with extra ocular extension.In the management of a blind painful eye, it is extremely important to rule out an intraocular malignancy particularly in those patients who have not been followed by an ophthalmologist. A blind eye may be associated with pain, which is a challenge for the ophthalmologist. The most common conditions leading to the development of a blind painful eye (BPE) are trauma, miscellaneous retinal disorders and retinal detachment, and the majority of these eyes are enucleated to relieve the pain.Few cases of malignant tumors arising from BPE have previously been described. -7 From lCase 1: A 57 year-old Caucasian man had a previous history of cataract surgery, left eye (OS), in 1984. In 2000, the patient presented with recurrent orbital cellulitis and endophthalmitis OS. The OS was blind and painful and an enucleation was performed  and a rhegmatogenous retinal detachment (1978). In 1992, the patient presented with pain in the OS and an uneventful enucleation was performed  declare that they have no competing interests.PRP wrote the manuscriptANO, JPSP and VS revised the histopathology of the cases and the manuscriptDGC prepared the pictures and revised the manuscriptMNB revised the entire manuscript


Inflammatory fibroid polyp of the oesophagus is an uncommon lesion and very rarely it grows rapidly.We present the case of a patient with a rapidly growing inflammatory fibroid polyp (IFP) of the oesophagus, which showed up within five months after a normal endoscopy.The treatment of IFP is by surgical excision, either open or endoscopic. Laser or other form of ablative treatment like thermo cautery can also be tried. Inflammatory fibroid polyp (IFP) is a benign, nonmetastasing tumour of the digestive tract. It has been described to occur commonly in the stomach and intestines. Cases have been reported in rectum , duodenuA 76-year-old man presented with epigastric pain and dysphagia. Endoscopy revealed grade 1 oesophagitis with a normal stomach and duodenum. Five months later he was readmitted with anorexia, weight loss, dysphagia and anaemia. Endoscopy on this occasion revealed a large pedunculated polypoidal lesion arising from the gastro-oesophageal junction within a hiatus hernia. Pathological examination of biopsies taken from the polyp showed inflammatory changes in squamous mucosa with no evidence of malignancy. As the lesion was pedunculated it was decided to attempt endoscopic snare excision which proved unsuccessful, as the lesion was too large for the snare. At laparotomy a large polypoidal mass was found arising from the distal oesophagus. Through a gastrostomy the lesion was delivered into the abdomen, a linear stapler was applied to the base of the stalk and the lesion was excised. The patient made an uneventful recovery.The resected specimen figure  measuredThe patient underwent endoscopy 6 months after resection and there was no evidence of recurrence. He is currently asymptomatic 1 year after resection.rd of the oesophagus being the commonest site for this tumour. Inflammatory fibroid polyp is a benign lesion of uncertain origin [Inflammatory fibroid polyp (IFP) is a rare tumour of the digestive system. It was first described as a distinct pathological entity by J.Vanek in 1949 when he described 6 case reports of gastric submucosal granulomas with eosinophilic infiltration . Since tn origin  some repn origin  in origin origin . The main origin  to physiThe presentation is dependant on the size, location or complications of the tumour. In those of the stomach, epigastric pain and bleeding are the common symptoms and those of the intestine  colicky The patient was initially evaluated with an endoscopy, which showed grade1 oesophagitis. Subsequent endoscopy localised the lesion as arising from the distal oesophagus near to the gastro-oesophageal junction, and had a benign appearance. The discovery of the lesion on endoscopy within five months of a previous normal endoscopy does give an indication that it may be rapidly growing The previously reported studies showed that the usual presentation of IFPs varied from months to years, but we could not attribute any cause for the rapidity of growth of this lesion in our patient. Investigation modalities that are used for these lesions include radiographs, endoscopic ultrasound, CT scan and MRI. In our case in view of the acute presentation these were deferred.The treatment is confined to surgical excision of the lesion by endoscopic or open method, the decision based on the site and size of the tumour. There are cases which had to be resected by a lateral oesophagotomy or formal oesophagectomy . There hThe commonest site of IFP in the GI tract is stomach; IFP of the oesophagus is rare. Treatment is by excision that can be carried out endoscopically. LASER ablation and coagulation has been tried.The author(s) declare that they have no competing interests.SKG- wrote the original manuscript, review of literature, prepared requested revisionsRTD- performed surgical resection, helped to draft the manuscript.All authors read and approved the final manuscript.


Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms of uncertain malignant potential, which have in common the co-expression of muscle and melanocytic immunohistochemical markers.A 48-year-old man presented with dysuria, passage of urinary sediment and lower abdominal discomfort. A three centimeter mass was identified by cystoscopy in the posterior midline of the bladder. Computerized tomography suggested an enterovesical fistula. The patient underwent laparotomy, partial cystectomy and partial small bowel resection. Pathological examination revealed PEComa of the bladder. The patient underwent adjuvant interferon-α immunotherapy. Subsequent follow-up procedures, including cystoscopy and imaging, have not revealed evidence of recurrence. The patient is clinically free of disease 48 months after surgery.This case represents the second documented PEComa of bladder and demonstrates that adjuvant therapies, including anti-angiogenic and immunotherapy, may be considered for patients with locally advanced or metastatic genitourinary PEComa. Primary perivascular epithelioid cell tumors (PEComas) are a rare and unusual group of mesenchymal neoplasms with unpredictable malignant potential. The term "PEComa" was originally coined by Zamboni et al and is the current nomenclature for tumors composed of PECs other than angiomyolipoma (AML), clear cell sugar tumor of lung (CCST) and lymphangioleiomyomatosis (LAM), which are related lesions with distinct clinical features . ConsequA 48-year-old man presented with dysuria, passage of urinary sediment and lower abdominal discomfort. A three-centimeter (cm) smooth, lobular mass with mild bullous edema was identified by cystoscopy in the posterior midline of the bladder. Laboratory and staging investigations were negative and computerized tomography (CT) suggested an enterovesical fistula. The patient underwent laparotomy, partial cystectomy and partial small bowel resection. Pathological examination revealed PEComa of the bladder. A search for primary melanoma was negative and there were no stigmata of tuberous sclerosis. The patient underwent adjuvant interferon (IFN)-α immunotherapy for primary PEComa of the bladder. Subsequent follow-up evaluations were performed 3 monthly for the first 12 months, then 6 monthly thereafter. Routine follow-up procedures included clinical examination, cystoscopy, chest roentgenography, CT of abdomen and pelvis and routine blood work. On one occasion, positron emission tomography was performed in order to detect neoplastic metabolic activity. None of these follow-up procedures revealed evidence of recurrence. The patient is clinically free of disease 48 months after surgery.A fragmented specimen, 11 cm in aggregate, containing pieces of friable, tan-colored tumor, as well as bladder and small bowel tissue, was received for pathological examination. Histologically, the tumor was located in the bladder wall, but also showed infiltration into subserosal, muscularis propria and submucosal layers of the small bowel. The neoplastic cells were mainly epithelioid but occasionally spindled, with abundant cytoplasm that varied from eosinophilic and granular to clear , Melan-A (cytoplasmic) and smooth muscle actin (membranous), while smooth muscle myosin heavy chain, desmin and CD117 were weakly positive in <20% of the tumor cells Figures . The neoThe WHO has offered formal recognition to a group of neoplasms with perivascular epithelioid cell differentiation . These tWhile distinct clinicopathological entities included within the PEComa group include AML, LAM and CCST, other PEC-derived tumors have been documented at an increasing number of anatomical sites, including pancreas, small and large intestine, ligamentum teres/falciform ligament, common bile duct, bladder, prostate, breast, uterus, cervix, vulva, ovary, broad ligament, heart, base of skull, and soft tissue -8. The tPEComas demonstrate uncertain tumor biology and unpredictable clinical behavior. While the majority of reported "PEComas" have behaved in a benign fashion, an important minority have demonstrated malignant behavior with locally destructive recurrences, distant metastases and patient death, underscoring the need for accurate identification and effective treatment strategies ,5,7. WheOptimal treatment for PEComas is not known at this time. Primary excision is usually curative, as most tumors are benign. However, locally advanced or metastatic disease portends a poor prognosis and strategies incorporating chemotherapy, radiation and immunotherapy have been reported. In this patient, a one-year course of adjuvant IFN-α 2b at 10 million units given subcutaneously three times per week was initiated based on the vascular nature of this tumor and IFN-α's additional anti-angiogenic effect . While IIn summary, we report the first case of PEComa of the bladder treated with adjuvant IFN-α immunotherapy, with long-term follow-up. Given the uncertainty of PEComa tumor biology, adjuvant therapies, including anti-angiogenic and immunotherapy, may be considered for patients with locally advanced or metastatic genitourinary PEComa.The author(s) declare that they have no competing interests.JRP prepared the manuscript.AJB helped to provide patient history and helped in the writing of the manuscript.BMW was involved with diagnosis of the pathologic specimen and contributed to the writing of the manuscript.JII performed the surgery, provided patient history, obtained patient consent and contributed to the writing of the manuscript.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Mixed epithelial and stromal tumor (MEST) is a distinctive benign composite neoplasm of the kidney predominantly seen in females mostly in the perimenopausal period. Although these tumors are known to arise from renal pelvis, our case was distinct in that it had no intrapelvic component growing in exophytic fashion.A 35 year old female patient presented to us with vague abdominal pain. She had undergone excision of bilateral ovarian cystic masses for cystic teratoma twelve years earlier. A computed tomography scan of abdomen and pelvis showed a 9 × 7 cm uniformly solid mass with poor contrast enhancement situated in the inferomedial aspect of the left kidney. On exploration, the mass was arising from the inferior and anterior aspect of left renal pelvis, and was attached to it with a narrow pedicle. There was no adherence or attachment to the renal parenchyma. The mass was excised preserving the kidney. Microscopically, the tumor was composed of large collagenized areas containing bundles of spindle cells and several 'microcysts' lined by cuboidal epithelium suggestive of a benign mixed epithelial stromal tumor.Mixed epithelial tumors usually present in perimenopausal women as a partially cystic mass. Tumors are composed of irregular mixtures of cystic and solid areas, glands with variable complexity and distribution and the stromal component is characterized by a spindle cell proliferation. Commonly, it arises from the renal parenchyma and pelvis and nephrectomy is advocated to manage these tumors.MEST is a distinctive benign tumor of the kidney that should be distinguished from other renal neoplasms. MEST arising from the renal pelvis and growing exophytically is a rare entity. The overall prognosis is favorable. The mixed epithelial and stromal tumor (MEST) is a distinctive benign tumor of the kidney that should be distinguished from other renal neoplasms. The name MEST was suggested by Michal and Syrucek in 1998 ,3. Most We report an unusual case of benign mixed epithelial stromal tumor arising from the renal pelvis and growing in an exophytic fashion. This was treated by excising the mass without nephrectomy.A 35 year old unmarried female patient presented to us with abdominal pain. On examination, a vague mass was palpable in the left lumbar region. The patient had history of excision of bilateral ovarian cystic masses for cystic teratoma twelve years earlier. Computerized tomographic scan of the abdomen and pelvis showed a 9 × 7 cm uniformly solid mass with poor contrast enhancement situated in the inferomedial aspect of the left kidney Fig . It was On pathological examination, the tumor was well-defined and capsulated. On cut section it had a firm, whitish solid appearance without areas of necrosis or hemorrhage.Microscopically, the tumor was composed of large collagenized areas containing bundles of spindle cells. These areas were interspersed with thick walled, blood vessels, fatty tissue and several 'microcysts' lined by cuboidal epithelium Fig . Normal The mixed epithelial and stromal tumor is a recently established tumor of the kidney of unknown etiology. It has a well defined capsule and solid and cystic areas, either of which may predominate. The solid parts are homogeneous, yellow-white, and firm and rubbery in some areas; they are fleshy and tan in other areas, corresponding to variable stromal cellularity .The cysts range from millimeters to several centimeters in diameter and may be clustered in separate foci or dispersed in solid areas in a "Swiss cheese" pattern. The solid areas show mesenchymal elements which may be spindle cells or may resemble smooth muscle cells; but do not show atypia or increased mitoses or blastema. The epithelial component of this tumor consists of glands with variable complexity and distribution, and the stromal component is characterized by a spindle cell proliferation with cellularity akin to scar tissue to appearances that are reminiscent of leiomyoma, ovarian stroma or solitary fibrous tumor. The spindle cells of this tumor frequently express estrogen/ progesterone receptors.A possible cell of origin for these tumors is the primary mesenchymal metanephric blastema that has the capacity for mesenchymal and epithelial differentiation. An alternative theory is based on the distinctive clinical and pathologic features of this lesion that characterize a hormonal mechanism of pathogenesis. It is postulated that a deranged hormonal milieu  induces proliferation of periductal foetal mesenchyme, which in turn drives the growth of the epithelial component .About 50 cases of MEST have been reported in the literature. It usually presents in perimenopausal women as a partially cystic mass and its growth may be influenced by hormones. Most patients present with flank pain, hematuria, or symptoms related to genitourinary infections. About 20% are asymptomatic, and tumors are detected incidentally during investigation for other diseases. MEST occurs in women at a 6:1 ratio over men, at a mean age of 46 years. In one reported series, 7 of 10 women had long histories of treatment with estrogen, in 6 of these following oophorectomy several years earlier [Although benign, cases of malignant mixed epithelial and stromal tumors of the kidney have been reported with fatal outcome by Svec et al, Bisceglia and Bacchi -6.MEST is previously reported under different names as 'Adult mesoblastic nephromas' 'Cystic hamartoma of renal pelvis' 'Cystic nephroma'. The tumor frequently contains areas of smooth muscle in which epithelial structures are embedded, hence, some have concluded that it is an adult form of congenital mesoblastic nephroma but this is contentious . MEST ofOther differential diagnoses of mixed epithelial and stromal tumor include rare biphasic renal tumors with a malignant spindle cell component: cystic embryonal sarcoma and sarcomatous transformation in cystic nephroma, both of which can be distinguished from mixed epithelial and stromal tumors by their overtly malignant stroma with cytologic atypia, mitotic figures and necrosis.Immunohistochemical stains, such as HMB 45 (frequently positive in angiomyolipoma) and CD34 (a sensitive marker of solitary fibrous tumor), may be helpful in excluding some of these alternative diagnoses.A series of 22 patients showed that all tumors were arising from renal parenchyma and six having tumor bulging into the renal pelvis . YamasakIn summary, "mixed epithelial and stromal tumor" is a distinctive benign tumor of the kidney that should be distinguished from other renal neoplasms. MEST arising from the renal pelvis and growing exophytically has not reported previously. It is difficult to distinguish between benign or malignant nature on imaging studies. Intra-operative frozen section is necessary to exclude a malignancy and an attempt for a conservative surgery is worthwhile. The overall prognosis is favorable.The author(s) declare that they have no competing interests.


Cough can be associated with many complications. In this article, we present a 59 year old male patient with a very rare combination of a cough related stress fracture of the ninth rib, a traumatic rupture of the diaphragm, and an abdominal wall herniation. The hernia was repaired through surgical treatment without bowel resection, the diaphragm and the internal and oblique abdominal muscle were adapted, and the abdomen was reinforced with a prolene net.Although each individual injury is well documented in the literature, the combination of rib fracture, abdominal herniation and diaphragm rupture has not been reported. We report a rare case of a cough related stress fracture of the ninth rib, traumatic rupture of the diaphragm and abdominal herniation in a patient with a chronic cough history.A 59 year old male patient  collapsed at home following intensive coughing. The medical history includes hypertension being treated with a beta-blocker, house-dust-allergy, chronic bronchitis related cough, and two operations on a spinal disc prolaps. The patient is known to have smoked (15 pack years).There was no previous history of trauma.On admission to hospital examination revealed a 10 cm well demarcated area of haemorrhage in the right side of the epigastrium. The abdomen was painful, but soft with no palpable mass or herniation. An abdominal computed tomography showed a fracture of the ninth right rib with a surrounding haematoma and hematothorax; however, no bowel herniation or muscle tear was evident Fig. . A thoraPost operation the patient remained intubated for six days to prevent coughing.At the time of discharge the patient was well. A clinical and radiographic investigation six months later showed no renewed herniation, and the patient remained well.Violent or sustained coughing can be associated with many complications. The most frequent and best documented complications are rib fractures . TypicalThe diaphragm is mainly an inspiratory muscle, but it also contracts during the expiratory phase of a cough . During Defects of the abdominal wall after coughing are rare and require a surgical intervention . Both abIn summary, since both the diaphragm and abdominal muscles are attached to the lower ribs, opposing forces can result in a rib fracture, diaphragmatic rupture and abdominal herniation due to cough.Coughing can be associated with many complications. Rib fractures are easily diagnosed, but abdominal muscle tears are frequently missed. They usually appear delayed and a computed tomography seems to be essential for an accurate diagnosis.Although each individual injury is well documented in the literature, the combination of rib fracture, abdominal herniation and diaphragm rupture however has not been reported so far.


Necrotising Fasciitis is a life threatening soft tissue infection which requires aggressive, early surgical management.We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall.This case highlights the importance of early aggressive debridement to healthy tissue limits, the consideration of a rare underlying cause, and the scope for plastic surgical reconstruction in order that aggressive initial surgery can be adequately performed. Necrotising Fasciitis is a life threatening soft tissue infection which requires aggressive, early surgical management. The precise aetiology of necrotising fasciitis is unclear in many cases. We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall.A 52 year old male presented with a one week history of discomfort and swelling in the right iliac fossa, and 12 hours of skin erythema which was rapidly progressing. Within 2 hours of assessment, the cellulitis was noted to have spread outside the boundaries marked on admission. He was hypotensive, tachycardic, febrile and noted to have an elevated white cell count.On examination of the area there was diffuse oedema of the skin with marked erythema and heat in the area of skin from the right loin to groin across to midline. Subcutaneous crepitus was present. A lateral abdominal X-Ray revealed free gas within the subcutaneous tissues Fig. .A presumed diagnosis of necrotising fasciitis was made and the patient commenced on intravenous antibiotics, resuscitated with intravenous fluids, and taken immediately to the operating theatre.Extensive debridement of the affected cutaneous, subcutaneous tissue, and muscle was performed and pus noted to extend to the right loin area. Histology and bacteriology confirmed a diagnosis of necrotising fasciitis, with a β-haemolytic group streptococcus cultured. Exploration revealed a retroperitoneal abscess arising as a result of a perforation of a caecal carcinoma. The caecum was resected and a right hemicolectomy performed, with a large defect resulting in the anterior abdominal wall from the extensive debridement Fig. .The patient was admitted to the intensive care unit for inotropic support and management of sepsis, and 2 days later proceeded to have a rectus femoris myocutaneous flap fashioned to close the defect in the abdominal wall. He made a good post-operative recovery, with adequate skin closure on the abdominal wall Fig. , and wasRetroperitoneal, or psoas, abscess is an unusual problem, which has insidious and occult characteristic. There ath century BC[Conversely, necrotising fasciitis is a soft tissue infection associated with high morbidity and mortality. Necrotientury BC. A rapidentury BC. Wilson entury BC.Necrotising fasciitis is rare within the UK with an estimated at 500 new cases each year, however this is difficult to confirm, as different eponyms are given to describe the same condition, as outlined above. The aetThe cornerstone of management of necrotising fasciitis is recognised as being aggressive surgical debridement and intensive support, whilst other severe soft tissue infections do not necessarily require the same amount of aggressive debridement. Therefore it is important that clinicians are able to differentiate between the two.Necrotising fasciitis should be considered in those patients who have rapidly progressing cellulitis, and palpable subcutaneous crepitus, in association with tachycardia, hypotension, neutropenia or neutrophilia, and hyponatraemia.Adjuvant diagnostic tools for necrotising fasciitis include CT scanning and plain radiography. In thisThe finding of necrotising fasciitis of the anterior abdominal wall associated with a carcinomatous perforation of the colon is rare, having only previously been described with perforation of a sigmoid colon carcinoma directly adherent to the anterior abdominal wall. In addiThis case illustrates that the principles of management should be two-fold; 1) To rapidly and unequivocally control infection and sepsis through extensive radical debridement of necrotic tissue and; 2) Identify and treat any underlying condition giving rise to the infection, in this case removing the caecal tumour.Intravenous antibiotics should be started promptly and modified when sensitivities return. However, it is essential to ensure that adequate necrotic material is removed at the first opportunity to reduce the risk of further progression, regardless of the defect that will remain. Defects may be closed using a variety of techniques, including split skin grafts, Vacuum Assisted Closure (VAC) therapy, and flaEarly recognition of important signs of necrotising fasciitis is essential to effective management of this condition, and clinicians assessing patients with rapidly progressive cellulitis should be aware of these vital features.In cases presenting with necrotising fasciitis there should be consideration given to an underlying cause for the infection.Aggressive surgical management is the cornerstone to management of this condition, and is the key to survival for these patients. This case demonstrates that extensive debridement can be performed with resulting large defects, which can be adequately closed at a later time, and therefore this should not be thought of as a barrier to adequate surgical debridement and definitive treatment.The author(s) declare that they have no competing interests.All authors have read and approved the final version of the manuscript.CM was involved in the conception for the idea for the report, and was involved with the diagnosis, operative, and post-operative management of the patient. He is responsible for preparation of the manuscript for submissionGMcA was responsible for up to date literature review, re-writing of manuscript prior to submission, gaining of consent for use of images, and management of the patient.MR was responsible for ward care of the patient, review, and re-writing of manuscript prior to submission.SS was the senior consultant Plastic Surgeon responsible for the patients operative management and post-operative care and was involved in review and alteration of the manuscript prior to submission.RM was the Senior Consultant General Surgeon involved with operative and post-operative management of the patient and was responsible for critical review of the manuscript prior to submission.The pre-publication history for this paper can be accessed here:


Very few cases of small bowel obstruction due to ingested fruits have been described in literature, and most of these have managed by a laparotomy. Laparoscopic assisted surgery can effectively deal with such impacted foreign bodies, thereby avoiding a formal laparotomy.A 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. Investigations were suggestive of acute small bowel obstruction. On laparoscopy, there was an area of sudden change in calibre of small bowel with dilated proximal and collapsed distal segment in distal jejunum. A foreign body, dried undigested apricot, was extracted by mini-laparotomy.Small bowel obstruction is a frequent cause of emergency surgery, and aetiology may include food bolus obstruction. Diagnosis is usually confirmed intra-operatively. Foreign body impacted in small bowel can be removed by open or laparoscopic methods.Generally, laparotomy is performed for diagnosis and management in acute bowel obstruction, but with increasing expertise, laparoscopy can be equally effective with all the other advantages of minimal access approach. Foreign bodies are a known cause of bowel obstruction, especially so in children and the elderly. They present a diagnostic challenge because of the lack of history and the inability of the patient to correlate preceding events with the episode of bowel obstruction. Radiological investigations while helpful may not be diagnostic. Laparoscopy and laparoscopic assisted surgery can help resolve the problem with minimal trauma; and may help avoid a formal laparotomy in the unfortunate group of patients.We would like to discuss the role of minimal access surgery in dealing with an intriguing case of small bowel obstruction due to an ingested apricot!A 75 years old lady was admitted via the Accident and Emergency to the surgical ward with a three-day history of abdominal pain and vomiting. The pain had started suddenly in the evening three days ago accompanied with vomiting three to four times. The vomitus consisted of dark brown fluid. The pain was initially in the left hypochondrial region and had lately become more generalised, constant, and increased in intensity. Her General Practioner, who had prescribed antiemetics for her symptoms, initially saw the patient. She had appendicectomy in the past, and had been diagnosed with diverticular disease on Barium enema and colonoscopy.On examination, her vital parameters were normal. She had abdominal distension with generalised tenderness, abdomen was resonant on percussion, and she had decreased bowel sounds. Her routine blood tests were normal, and urine analysis showed increased ketones.X-rays of the abdomen and chest were suggestive of dilated loops of small bowel figure . A CT scA clinical decision was made to proceed with laparoscopy. On laparoscopy, there was dilatation of the small intestine up to the distal jejunum figure  with colThe patient had an uneventful post-operative recovery, and went home after ten days. On questioning she informed us that she had eaten few dried apricots while shopping three days before admission in A&E. She was followed up in the outpatient clinic with a Barium meal and follow-through, which was normal and did not show any abnormality in small intestine figure .Small bowel obstruction is a frequent cause of emergency surgery. Causes of small bowel obstruction are adhesion (60%), hernia 15%), neoplasm (6%), inflammatory (5%), and sometimes ingested foreign body, but rarely food bolus [5%, neoplPatients with ingested foreign body are commonly children, elderly with dental prosthesis, alcoholic, prisoner inmates, and psychiatric patients -3. Our pFood bolus impaction is common with meat, fish bones, and very few cases due to fruits have been reported . It is sPatients with impaction in small intestine present with symptoms of vomiting, abdominal distension, and constipation. There are cases of cholangitis  and recuSharp foreign bodies can perforate and present with mediastinitis or perforative peritonitis depending on site of perforation. Majority of the foreign bodies pass spontaneously and only 1% or less will require surgery .Radiological investigations have limitations in studying bowel obstruction from foreign bodies, especially if when they are not radio-opaque. Plain abdominal film has sensitivity of 86% to diagnose high-grade bowel obstruction and will show air fluid level with dilated loops of small bowel ,7. An inMost ingested foreign bodies that have passed pylorus pass through rest of the gastro-intestinal tract, within a mean of 4 days. Ingested blunt foreign body distal to stomach are monitored by weekly abdominal X-rays, and daily X-rays in case of sharp objects. Intervention is required if the blunt foreign body remains in same place for more than a week, and sharp object remains in same place for more than 3 days .Foreign bodies in oesophagus or stomach can be successfully removed endoscopically. Urgent endoscopic intervention is required in case of sharp objects, disk battery or if there is risk of aspiration. Under no circumstances should a foreign object or food bolus impaction be allowed to remain in the oesophagus beyond 24 hours from presentation [Early diagnosis and therapeutic management has considerable importance. Obstruction of the bowel due to impacted food bolus is difficult to diagnose preoperatively unless there is clear history and the diagnosis is usually made intraoperatively . General


Adenomatoid odontogenic tumor (AOT) is a rare odontogenic tumor which is often misdiagnosed as odontogenic cyst. To acquire additional information about AOT, all reports regarding AOT and cited in "pubmed" since 1990 onward were reviewed. AOT accounts for about 1% until 9% of all odontogenic tumors. It is predominantly found in young and female patients, located more often in the maxilla in most cases associated with an uneruppted permanent tooth. For radiological diagnose the intraoral periapical radiograph seems to be more useful than panoramic. However, AOT frequently resemble other odontogenic lesions such as dentigerous cysts or ameloblastoma. Immunohistochemically AOT is characterized by positive reactions with certain cytokeratins. Treatment is conservative and the prognosis is excellent. For illustration a rare case of an AOT in the mandible is presented. Adenomatoid odontogenic tumor (AOT) is a relatively uncommon distinct odontogenic neoplasm that was first described by Steensland in 1905  producedFrom the early 1990s onwards 65 single cases of AOT (excluding case series of more than 10 cases) have been published. The mean age was 13.2 years (range 3 until 28 years) and the female:male ratio was 2.3 : 1. The AOT was predominantly found in the upper jaw (maxilla:mandible = 2.6 : 1). Regarding the various case series published in the literature [e.g. -8] and cClinical features generally focus on complaints regarding a missing tooth. The lesion usually present as asymptomatic swelling which is slowly growing and often associated with an unerupted tooth. However, the rare peripheral variant occurs primarily in the gingival tissue of tooth-bearing areas . UneruptThe radiographic findings of AOT frequently resemble other odontogenic lesions such as dentigerous cysts, calcifying odontogenic cysts, calcifying odontogenic tumors, globule-maxillary cysts, ameloblastomas, odontogenic keratocysts and periapical disease . WhereasRemarkably, all variants of AOT show identical histology. The histological typing of the WHO defined the AOT as a tumor of odontogenic epithelium with duct-like structures and with varying degrees of inductive change in the connective tissue. The tumor may be partly cystic, and in some cases the solid lesion may be present only as masses in the wall of a large cyst . MoreoveDuring the last few years several studies have been published dealing with the immunhistological properties of AOT. Immunohistochemically, the classical AOT phenotype is characterized by a cytokeratin (CK) profile similar to follicular cyst and/or oral or gingival epithelium based on positive staining with CK5, CK17 and CK19 . On the Interestingly, Takahashi et al.  observedConservative surgical enucleation is the treatment modality of choice. For periodontal intrabony defects caused by AOT guided tissue regeneration with membrane technique is suggested after complete removal of the tumor . RecurreA 23-year-old man was referred by his general dental practitioner. One year ago the dentist diagnosed a cyst with a ectopic lower right canine tooth by an x-ray. Beside an uneventful medical history the patient presented no conspicuous intraoral clinical findings except the absence of the tooth 43. Radiologically, he showed a 3 cm unicystic radiolucent image with a comparatively clear demarcation. The tooth 43 was located on the floor of this process. No resorption of the root apices was observed Fig. .Under general anesthesia the lesion was enucleated and afterwards filled with pelvic spongiosa. Separating the lesion from mandibular bone caused no problems. The postoperative course was uneventful.After the operation, the specimen was fixed in 4 per cent formal saline and prepared for histological examination. Some sections were stained with haematoxylin-eosin.Histologically, the tumor is solid and there is a cyst formation Fig. . The epiHalf a year after surgery a clinical and radiographic follow-up examination was performed. There was no evidence of recurrence and no apical resorption of the adjacent teeth could be observed Fig. .With respect to the age of the patient and the localization of the AOT in the lower jaw, the reported case is a rare example of this tumor entity. Beyond it our case supports the above mentioned general description of AOTs.All authors disclaim any financial or non-financial interests or commercial associations that might pose or create a conflict of interest with information presented in this manuscript.JH, RD and NK made substantial contribution to the conception and design of the manuscript. SB and AZ carried out the pathohistological investigations and participated in creating this part of the manuscript.All authors were involved in revising the manuscript critically and have given final approval of the version to be published.


Primary carcinoid tumor arising within mature teratoma of the kidney is extremely rare, and their clinicopathologic features are not well described. Our objective was to further define the clinical features and pathologic spectra of primary carcinoid tumor arising within mature teratoma of the kidney.Six previously reported case reports were identified using MEDLINE and a subsequent bibliographic search of all pertinent reports and reviews was performed. We also searched the electronic medical archival records of our institution and identified one additional unreported case. Data were extracted on the demographics, predisposing factors, clinical presentation, radiographic features, gross pathology, microscopic pathology, immunophenotype, therapy, and outcome of each of these seven cases.Primary carcinoid tumor arising within mature teratoma of the kidney was found at a mean age of 41.4 years. Of the 7 cases, 3 were female and 4 were male. Two of the 7 cases (28.6%) were associated with horseshoe kidney. It typically presented with abdominal pain without carcinoid syndrome. It typical radiologic appearance was well circumscribed partly calcified Bosniak II-III lesion. Histologically, the carcinoid tumor showed monotonous small round cells arranged in classic anastomosing cords/ribbons intermixed with solid nests. Surgery was curative, no additional treatment was required, no local recurrences occurred, and no metastases occurred in all 7 cases. The 3 cases with available outcome data were alive at the time of publication of their respective cases .Primary carcinoid tumor arising within mature teratoma of the kidney is a rare tumor that typically presents with abdominal pain without carcinoid syndrome. It is not associated with local recurrence and metastasis, is surgically curable, and has excellent prognosis. Primary carcinoid tumor and mature teratoma involving the kidneys are rare. The two entities existing simultaneously in the same kidney are exceptionally unique and extremely rare. Only 6 cases of primary carcinoid tumor arising in a mature teratoma of the kidney have been reported in the world medical literature to date -6, sinceSix prior case reports of primary carcinoid tumors arising within mature teratoma of the kidney were found in a MEDLINE search. Additionally, the computerized medical archival records of the University of Pittsburgh Medical Center (1986 to present) was searched and 1 additional unreported case of primary carcinoid tumor arising within mature teratoma of the kidney was found. Formalin-fixed, paraffin-embedded tissue sections and the following immunohistochemical stains from this case were reviewed: Synaptophysin , CD 56 , CK 7 , CK 20 , Pancytokeratin cocktail , Calretinin , Thyroxine , Chromogranin , Thyroid transcription factor (TTF)-1 , S-100 protein , Melan-A , Insulin , Estrogen receptor (ER) , and Progesterone receptor (PR) . Tissue sections that had been shown to be positive or negative for each marker were used as controls.Clinical characteristics of the 7 cases of primary carcinoid tumor arising within mature teratoma of the kidney are summarized in Table Gross, microscopic, and immunohistochemical features of the 7 cases of primary carcinoid tumor arising within mature teratoma of the kidney are summarized in Table The size of the tumors in the 7 cases of primary carcinoid tumor arising within mature teratoma of the kidney ranged from 1 to 17 cm in greatest dimension . Of the 7 cases, there was a right-sided predominance with 5 tumors involving the right kidney and 2 tumors involving the left kidney. The tumors were most commonly found in the middle and lower poles of the kidney. On gross examination, most of the tumors revealed circumscribed complex solid and cystic lesions with areas of calcification  because of the slow growth pattern of renal carcinoid tumors in the retroperitoneum, which is a highly distensible potential space. Despite the absence of follow-up data for some of the cases, the biologic behavior and prognosis of primary carcinoid tumor arising within mature teratoma of the kidney appeared excellent. None of the 7 patients had local recurrences or metastases, though follow-up was incomplete for 4 cases. The remaining 3 patients with complete follow-up were alive and well at the time of their respective publications (mean follow-up of 5 months). Hence, although definitive conclusions cannot be drawn from such a small set of patients without long term 5-year follow-up, the ultimate biologic behavior of primary carcinoid tumor arising within mature teratoma of the kidney may be excellent, and may be much better than that for carcinoid tumors elsewhere . InteresPrimary carcinoid tumor arising within mature teratoma of the kidney is a rare tumor that typically presents with abdominal or flank pain without carcinoid syndrome. It was associated with horseshoe kidneys, and hence the presence of horseshoe kidney on radiographic evaluation should lead to further careful investigation. Additionally, when a renal carcinoid tumor arising in mature teratoma is diagnosed, a search should be performed for a possible primary elsewhere. Although follow-up was lacking in some of the cases herein reviewed, primary carcinoid tumor arising within mature teratoma of the kidney was not associated with local recurrence and metastasis, was surgically curable, and had a rather favorable prognosis.The author(s) declare that they have no competing interests.HBA participated in the histopathological evaluation, performed the literature review, acquired photomicrographs and drafted the manuscript. AVP conceived and designed the study, gave the final histopathological diagnosis and revised the manuscript for important intellectual content. Both authors read and approved the final manuscript.


Most of gastric adenocarcinoma can be simply diagnosed by microscopic examination of biopsy specimen. Rarely the structural and cellular atypia of tumor cells is too insignificant to discriminate from benign foveolar epithelium.A 67-year-old male presented with a gastric mass incidentally found on the abdominal computed tomography (CT) for routine medical examination. Gastric endoscopic examination revealed a huge fungating mass at the cardia and mucosal biopsy was performed. Microscopically the biopsy specimen showed proliferation of bland looking foveolar epithelia in the inflammatory background and diagnosed as foveolar epithelial hyperplasia. Because the clinical and endoscopic features of this patient were strongly suggestive of malignancy, the patient underwent radical total gastrectomy. The resected stomach revealed a huge fungating tumor at the cardia. The cut surface of the tumor was whitish gelatinous. Microscopically the tumor was sharply demarcated from surrounding mucosa and composed of very well formed glandular structures without significant cellular atypia, which invaded into the whole layer of the gastric wall. Tumor glands were occasionally complicated or dilated, and glandular lumina were filled with abundant mucin. Immunohistochemically the tumor cells revealed no overexpression of p53 protein but high Ki-67 labeling index. The tumor cells and intraluminal mucin were diffusely expressed MUC1 and MUC5AC and only focally expressed MUC2. On abdominal CT taken after 12 months demonstrated peritoneal carcinomatosis and multiple metastatic foci in the lung.The clinicopathologic profiles of gastric extremely well differentiated adenocarcinoma of gastric phenotype include cardiac location, fungating gross type, very similar histology to foveolar epithelial hyperplasia, foveolar mucin phenotype, lack of p53 overexpressoin and high proliferative index. Most of gastric adenocarcinoma can be simply diagnosed by microscopic examination of biopsy specimen. Extremely well differentiated adenocarcinoma (EWDA) of the stomach is histologically too bland and too similar to benign foveolar epithelium to make a diagnosis as malignancy. Till date, several cases of EWDA of the stomach were reported by Japanese authors. But the cases reported as EWDA were heterogeneous groups histologically and phenotypically. Most of reported cases revealed well differentiated adenocarcinoma mimicking complete type intestinal metaplasia with intestinal mucin phenotype ,2. Only Roux en Y anastomosis. The extent of lymph node dissection included first and second lymph node groups. The resected stomach revealed a huge fungating tumor (Borrmann type 1) at the cardia  for routine medical examination. Abdominal CT showed a fungating tumor at the gastric cardia and several lymph node enlargements at the left gastric and celiac axis. Gastric endoscopic examination revealed a huge fungating mass at the cardia, and subsequently mucosal biopsy was performed. Microscopically the biopsy specimen showed proliferations of bland looking hyperplastic foveolar epithelia with basally located small nuclei and fine nuclear chromatin in the heavy inflammatory background Figure . Some gla Figure . The tuma Figure . The rema Figure . Many gla Figure . Most ofa Figure  and 4C, a Figure . There wa Figure . The pata Figure . The tuma Figure  and MUC5a Figure  suggestia Figure . The patet al, described the usefulness of p53 and Ki-67 immunohistochemical analysis for preoperative diagnosis of EWDA of the stomach. However, in the present case as well as Nokubi et al [Traditionally, gastric carcinomas have been classified into two main types, the so-called intestinal and diffuse, based on the tendency toward gland-formation . RecentlEWDA of the stomach is a rare highly differentiated adenocarcinoma in which most of the glands are impossible to distinguish from benign foveolar glands, particularly in biopsy specimen . In the The clinicopathologic profiles of gastric extremely well differentiated adenocarcinoma of gastric phenotype include cardiac location, fungating gross type, very similar histology to foveolar epithelial hyperplasia, foveolar mucin phenotype, lack of p53 over expressoin and high proliferative index. In gastric EWDA of gastric phenotype, the unique criterion of malignancy is an evidence of deeper invasion. It is good reason for considering this tumor as gastric counterpart of adenoma malignum of the uterine cervix.The author(s) declare that they have no competing interests.WAL performed pathologic examination literature search and preparation of manuscript.


Pleuropulmonary blastoma (PPB) is a rare childhood dysontogenetic intrathoracic neoplasm associated with an unfavourable clinical behaviour.TP53 gene deletion was detected on metaphase FISH. To date, only few cytogenetic data have been published about PPB.We report pathological and cytogenetic findings in two cases of PPB at initial diagnosis and recurrence. Both tumors were classified as type III pneumoblastoma and histological findings were similar at diagnosis and relapse. In both cases, conventional cytogenetic techniques revealed complex numerical and structural chromosomal abnormalities. Molecular cytogenetic analysis (interphase/metaphase FISH and multicolor FISH) identified accurately chromosomal aberrations. In one case, The PPB genetic profile remains to be established and compared to others embryonal neoplasia. Our cytogenetic data are discussed reviewing cytogenetics PPBs published cases, illustrating the contribution of multicolor FISH in order to identify pathogenetically important recurrent aberrations in PPB. Pleuropulmonary pneumoblastoma (PPB) is a rare and aggressive form of childhood's malignancy . PPB exhPPB cases can occur within a family environment but PPB has not been described as a well-defined component of a familial childhood cancer/constitutional disease ,4.The clinical behavior of this neoplasia remains unpredictable. Despite aggressive multimodal treatment combined with chemotherapy and surgical resection, prognosis of PPB is poor.We report pathological and cytogenetic findings in two cases of PPB at initial diagnosis and at recurrence. Complex karyotypes were found in case 1 at recurrence and in case 2 at diagnosis. Conventional and molecular cytogenetic techniques were performed and showed complex chromosomal rearrangements.A 3-year-old girl had been treated for a type III left PPB in another institution. Initial treatment included surgical removal of the tumor together with 9 courses of chemotherapy in line with to the SIOP MMT95.3B recommendations containing vincristine, adriamycine, carboplatin, etoposide, actinomycin D and ifosfomide. Four years later, she developed, over a week increased vomiting and headaches. A computed tomography of the brain showed a large parietal lobe mass. After performing cerebral and medullar MRI, surgical removal of the tumor was performed. Postoperative computed tomography of the brain showed no residual tumor. Additional exploration for metastasis was negative. Histological diagnosis was PPB type III. She had since received 4 courses of chemotherapy and cerebral radiotherapy was planned to complete treatment. She relapsed 3 months later and was treated with gammaknife radiosurgery. 6 weeks after radiosurgery another cerebral localized relapse occurred. Surgery was performed and another tumour was found on a cerebral MRI 2 months after surgery despite chemotherapy with weekly Navelbine and daily Endoxan. She died shortly after the disease worsened.A 4-year old boy was transferred to our department for examination of the left pulmonary mass. Exploratory tests for metastasis were negative. Surgical removal of the tumor was performed. Histological diagnosis was PPB type III. He was treated according to the SIOP MMT95.3B. 29 months after completion of the treatment, routine computed tomography of the lungs showed a left paracardiac mass. Additional tests for metastasis were negative. The mass was surgically removed and histological analysis of the mass lead to the diagnosis of recurrence of type III PPB. The boy is currently being treated with chemotherapy and radiotherapy.Tumor specimens were put in formalin and paraffin-embedded for histologic and immunohistochemical analysis. Paraffin-embedded tissues were sectioned at 4 μm and stained with hematoxylin-phloxin-safron (HPS). For immunohistochemistry the sections were deparaffined and subjected to antigen retrieval. An automated immunohistochemistry was performed with avidin-biotin-peroxidase complex on a Ventana 320 device  with a Ventana kit  including AEC reagent. The following primary antibodies (dilution and source in parentesis) were used : glial fibrillary acidic protein , S-100 protein , alpha-smooth actin , desmin , myogenin .Chromosome analysis was performed on tumor fragments obtained from the primary (case2) or recurrent tumors (case1 and 2). For the culture, fragments of sterile tumor tissue were dissociated enzymatically using an RPMI medium containing 0.02% collagenase type II and incubated at 37°C for approximately 1 hour. A cell suspension obtained after centrifugation was sown over 25 cm2 tissue culture Falcon flasks with RPMI medium supplemented with 10% fetal bovine serum and antibiotics. The cells were then incubated at 37°C in a 5% CO2 atmosphere. After the culture entered exponential growth (10 days), chromosomal analysis was carried out using a routine cytogenetic technique. The R-banding technique was used for chromosomal identification. The description of the karyotypes and criteria for clonality follow the recommendations of the International System of Human Cytogenetic Nomenclature (ISCN 1995) /81~82<4n>,idemx2 [cp2]/46,XX/46,XY[ (q?),+8,in situ hybridization staining allowing us evoke a related clone (probably a doubled population) from initial tumor [Figure At recurrence karyotype was normal: 46, XY . In order Figure .PPB is among the rarest pediatric malignancies. The outcome is particularly unfavourable because of recurrence and/or metastases. The central nervous system represents the main site of metastases ,6-8.Only 23 cases with cytogenetic analysis  have been reported . Most ofBoth cases we report here represent additional cases studied by conventional and molecular cytogenetic techniques (FISH and M-FISH).Data found in literature corroborate numerical gains of chromosome 8 as the main recurrent chromosomal abnormality in PPB (22 cases published) -13,15-22TP53 gene have been described in sporadic Wilm's tumor, embryonal rhadomyosarcoma and in hepatoblastoma and seemed to be associated with a poor prognosis [TP53 gene are found in a large proportion of adult cancers but are not considered to be specific events of childhood embryonal tumors. In PPB, only one case of TP53 deletion was identified by molecular cytogenetic technique [TP53 status was not mentioned. Furthermore, Kusafuka et al., using PCR-SSCP method in 2 patients, raised the possibility that p53 inactivation is involved in the pathogenesis and outcome of PPB [TP53 gene deletion results in the loss of 17p11pter chromosomal region by an unbalanced translocation t [Figure TP53 deletion is a secondary change of importance in the progression of the neoplasia.Amongst pediatric tumors, mutations in rognosis . Howeverechnique  but fivee of PPB . In our ) Figure . The sam) Figure . This laWT1 gene at 11p13 and WT2 gene at 11p15 [Two cases studied by conventional cytogenetic showed a structural rearrangement of the short arm of chromosome 11: a der(11)t and a dup(11)(p13p15) [at 11p15 ,25. Polyat 11p15 . In hepaat 11p15 . These aat 11p15 . Comparaat 11p15 .Similarly, Bonner et al. demonstrated that transcriptome wide analysis of gene expression by DNA array technology showed numerous patterns associated with lung development in murines. The authors concluded that the genes identified as relevant to lung development and belonging to three regulatory pathways  may be suggested as candidate susceptibility genes for lung tumorigenesis . ChromosChromosomal instability appears to be characteristic of this tumor. Identification by M-FISH technique allowed the identification of recurrent complex structural chromosomal abnormalities. Furthers collegial studies, regrouping PPB cases as in the PPB Registry by Priest and colleagues , are reqPPB : Pleuropulmonary blastomaThe author(s) declare that they have no competing interests.BQ carried out the cytogenetic and molecular cytogenetic studies and drafted the manuscript.NA participated in the design and coordination of the study and helped to draft the manuscript.CB and MAC carried out the histologic and immunohistochemical analysis and helped to draft the manuscript.AR and CC helped to draft the manuscript.DI assisted in cytogenetical and molecular techniques and drafted the manuscript.GL participated in its design and coordination.HZ conceived the study, participated in its design and coordination and helped to draft the manuscript.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Table summarizing cases of pleuro-pneumoblastoma with cytogenetic data.Click here for file


Plaster ingestion forming gastric bezoar is a strange way to attempt suicide and this method has not yet been reported. It may lead to a mechanical obstruction of the gut, especially the pyloric region, and could manifest with abdominal pain, epigastric distress, nausea, vomiting, and fullness.Herein we report a case of a 37 year-old woman presenting with plaster ingestion and gastric outlet obstruction, who underwent surgery. At six months follow-up the patient was fully recovered.Plaster has no toxic or erosive effects. Endoscopic or surgical removing of such material is recommended. Moreover, psychiatric intervention and management is imperative to prevent recurrence in such cases. Bezoars are rare causes of gastrointestinal obstruction. They mostly originate in the stomach, and occur mainly in patients with psychiatric ailments who chew and swallow their hair (trichobezoar), vegetable fibres (phytobezoar), persimmon fibres (diospyrobezoar), or tablets/semi liquid masses of drugs (pharmacobezoar) -3. IndusIn Iran many strange ways are recently used for suicide attempts ,7. One oIn this paper, a case of acute formed gastric bezoar due to ingestion of plaster is reported.A 37 year old housewife with a previous history of marital conflict was brought to surgical emergency department of Shohadaye-Ashayer Hospital, in Lorestan province situated in the west of Iran. The patient was presented with ingestion of 450 grams of saluted plaster for suicidal attempt. She had eaten the plaster solution seven hours before. The main complaints of the patient were vague epigastric pain, nausea and vomiting.The Patient had two history of unsuccessful suicidal attempt before. However, beyond all our expectations she had not undergone psychiatric management. She neither smoked nor was an alcoholic, or drug addict.The patient was hemodynamically stable, but not cooperative. There were no signs of trauma and burning on head and neck. Chest and abdominal physical exams were normal except for a bulging in upper abdomen and a palpable hard mass filling the epigasteric and left upper quadrant area. Laboratory tests were normal.Plain abdominal radiography showed an opaque bezoar as a picture of stomach Figure-. AccordiAbdomen was opened with upper midline incision. Abdominal exploration was normal. Outer layer of stomach and serosa were normal, but there was a huge hard mass filling the whole cavity of stomach. With longitudinal gastrotomy in greater curvature, stomach was opened. From stomach a round, hard, whitish foreign body was removed Figure-. The mucth day and she was discharged after seven days. Postoperative upper gastrointestinal endoscopic studies did not reveal any inflammation in the stomach. She was referred to the psychiatric consultation and six months of follow-up revealed a satisfactory recovery.Liquid diet was started on the 4Most of the reported bezoars are concretions of poorly digested materials. They are usually initiated in the stomach; although some of them may migrate into the bowel or backwardly into esophagus ,2,4.Bezoars usually form after a chronic ingestion or consumption of indigestible materials/foods ,8. The cBezoars may present with abdominal pain, epigastric distress, nausea, vomiting, fullness or bloating. When coThe diagnosis often can be made on the basis of findings of conventional radiography and barium studies . On plaiEndoscopic investigations could show all of gastric bezoars . BezoarsGastric bezoar is commonly removed by longitudinal gastrotomy. If complicated, a few percent of cases can be treated by gastric resections . Our casThe other part of management of such a bizarre bezoar is thinking whether the ingested material is toxic or corrosive. Plaster or Gypsum  is a non-toxic agent, which can release nuisance dust in handling or during use. In this manner it may affect eye, skin, nose, throat and upper respiratory tract. Prolonged and repeated exposure can result in lung disease  and/or lung cancer. Incidental ingestion of a sufficient quantity could lead to a mechanical obstruction of the gut, especially the pyloric region. Also, wAs most of the patients with bezoar were suffering from psychiatric disorders, psychiatric intervention and management is found to be imperative to prevent recurrence in such cases. More importantly, suicidal attempt of our patient made this part of management more necessary.The author(s) declare that they have no competing interests.All four authors contributed equally in writing of this report.The pre-publication history for this paper can be accessed here:


Her left kidney tumor was discovered incidentally. Partial nephrectomy was performed. Histologically, the tumor was composed of three components: 1) epithelial cysts lined by cuboidal to hobnail cells; 2) compact subepithelial mullerian-like AML stroma with admixed chronic inflammation; and 3) muscle-predominant AML with dysmorphic blood vessels exterior to the subepithelial stroma. Immunohistochemically, the subepithelial stroma stained most intensely with HMB-45 and Melan-A, whilst the muscle-predominant AML areas stained most intensely with smooth muscle actin and desmin. Estrogen receptor (ER), progesterone receptor (PR), and CD10 stained most intensely in the subepithelial stroma. The cyst lining was positive for pancytokeratin, but negative for HMB-45, Melan-A, ER, PR, and CD10. The patient is alive with no evidence of disease, 12 months postoperatively, and yearly follow-up CT scans are planned.Angiomyolipoma with epithelial cysts (AMLEC) is a recently described distinct cystic variant of angiomyolipoma (AML). To date 15 cases of AMLEC have been reported in 2 case series. We report the 16 Angiomyolipomas (AMLs) are well-characterized triphasic tumors composed of varying amounts of vascular , smooth muscle (spindled or epithelioid with clear cytoplasm) and mature adipose elements . AML usuAMLs are typically solid lesions both radiologically and grossly , withoutA 39-year-old woman had a left kidney tumor incidentally discovered during CT scan as part of a diagnostic workup for colonic diverticulosis. She had no personal or family history of TSC, lymphangioleiomyomatosis, renal cyst, renal malignancy, or estrogen hormonal therapy. The CT scan revealed a 2.5-cm complex cystic mass in the upper pole of the left kidney with a 1-cm enhancing nodule in its wall, radiologically worrisome for cystic renal cell carcinoma. In view of this concern of malignancy, the patient elected to undergo laparoscopic left partial nephrectomy for definitive surgical treatment. The entire tumor was surgically resected with an excellent margin of 5-mm of normal parenchyma surrounding the entire cyst wall, and the tumor was confined to the kidney.Grossly, the tumor was well demarcated and partially cystic, with the largest cyst measuring up to 1.1-cm. Sectioning of the tumor revealed part of the cyst wall contained a single 1-cm mural nodule with homogenous tan cut surface. The entire tumor was submitted for histological examination and revealed three components. The first component was cystic or multicystic spaces lined by epithelium, that ranged from flat to cuboidal to columnar. Whilst the cuboidal to columnar cells had unremarkable clear cytoplasm, the flat cells had abundant eosinophilic cytoplasm with nuclei that often protruded into the lumen, resulting in a hobnailed appearance Figure . The secImmunohistochemically, HMB45 Figure  and MelaThe renal tumor herein presented was histologically and immunophenotypically diagnostic of muscle-predominant AML containing prominent and grossly evident epithelial cysts. This phenotype is distinctly unusual, as AMLs are typically solid , and remAMLEC are readily distinct from most adult cystic renal lesions. The chief differential diagnostic consideration for AMLEC or cystic AML is mixed epithelial and stromal tumor (MEST), previously classified as cystic hamartomas of the renal pelvis, adult mesoblastic nephroma, or renal pelvic or cortical hamartomas ,12. ImmuThe histogenesis of AMLEC or cystic AML is unclear. However, the histogenesis of the mullerian-like stroma in AMLEC has been postulated to be due to the embryological proximity between the urinary and genital systems . These tAMLEC should be routinely included in the differential diagnostic considerations for adult cystic renal neoplasms, which includes cystic renal cell carcinomas, cystic nephroma (CN), and mixed epithelial and stromal tumor (MEST). Although, AMLEC may be confused with MEST, the most distinctive feature is the fact that AMLEC is immunoreactive to melanocytic markers (HMB45 and Melan-A).The author(s) declare that they have no competing interests.HBA participated in the histopathological evaluation, performed the literature review, acquired photomicrographs and drafted the manuscript. MY participated in the grossing of the tumor, participated in the histopathological evaluation and contributed suggestions for drafting the manuscript. UNMR reviewed the histopathological diagnosis and critically revised the manuscript for important intellectual content. AVP conceived and designed the study, gave the histopathological diagnosis and revised the manuscript for important intellectual content. All authors read and approved the final manuscript.