Retroperitoneal cysts are uncommon, with an estimated incidence of 1/5750 to 1/250,000.A male patient was admitted with an abdominal pain, jaundice and fever. Clinical examination and investigations confirmed an idiopathic benign retroperitoneal cyst. He underwent surgery and was discharged after making good recovery.Retroperitoneal cysts are very rare, and most of the time they are discovered incidentally. Patients may be asymptomatic or present with abdominal pain, referred pain to the legs or weight loss. Imaging may help diagnose these lesions, but surgery is the keystone in confirming the diagnosis. This case is very rare and very educational as it highlights an unusual presentation of a benign retroperitoneal cyst. In our patient, the course of the disease was unique as the patient presented with jaundice. Retroperitoneal cysts (RPCs) are uncommon with an estimated incidence of 1/5750 to 1/250,000 [3/mm3), bilirubin (103 mg/dl) and ESR (75 mm/h). All other blood tests were normal. Ultrasound and CT scans of the abdomen revealed fluid collection/mass measuring 14 cm in the right hepato-renal space. The mass was separated from the liver, pancreas and the right kidney, but there was lack of definition of the right suprarenal gland. Because the patient was jaundiced, we thought that draining the cyst would relieve the pressure on the biliary system and resolve jaundice. About 150 ml brown-coloured fluid was aspirated from the mass under CT guidance and a sample was sent for histology. Cytological examination of the sample reported presence of amorphous material with occasional histiocytic cells. There was no evidence of malignancy. The patient was discharged in December 2003 after making good recovery.A 51 year-old man was admitted on the surgical ward in November 2003 for a right-sided abdominal pain which had been present for three days. Clinically, he was jaundiced with a high temperature. Blood tests showed white cell count : Urogenital; (b): Mesocolic; (c): Cysts arising in cell inclusions; (d): Traumatic; (e): Parasitic and (f): Lymphatic ,2. Only There are no pathognomonic signs or symptoms for RPCs, and in approximately one third of patients, the cyst is found incidentally ,5. Two tCT is ideal for assessing RPCs because it provides discrete sectional images of the organs and retoperitoneal compartments, and in some case, familiarity with the most relevant radiologic features, in combination with clinical information, allows adequate lesion characterization . MulleriSymptomatic cysts should be enucleated or excised, while preserving the surrounding vital structures. At times, the cyst can be marsupialised or drained if surgical enucleation is difficult or the cyst is infected . HoweverCysts arising within the retroperitoneum outside the major organs within that compartment are very rare. Approximately one third of patients with retroperitoneal cysts are asymptomatic and the cyst is found incidentally. CT may help diagnose these lesions, but surgery remains the keystone in determining the diagnosis.The author(s) declare that they have no competing interests.A A: Reviewed literature and wrote the manuscript, H M: Contributed to the concept of the manuscript, P D: Evaluated histopathology, J A: Searched literature, A B: Operated on the patient. All authors have read and approved the manuscript.Written informed consent was obtained from the patient for publication of this report and any accompanying images.


Inflammatory myoglandular polyp (IMGP) is a rare non-neoplastic polyp of the large bowel, commonly with a distal localization (rectosigmoid), obscure in its pathogenesis. Up till now, 60 cases of IMGP have been described in the literature, but none located in the cecum.We report a case of a 53-year-old man who was admitted to our hospital for further evaluation of positive fecal occult blood test associated to anemia. A colonoscopy identified a red, sessile, lobulated polyp of the cecum, 4.2 cm in diameter, partially ulcerated. The histological examination of the biopsy revealed the presence of inflammatory granulation tissue with lymphocytic and eosinophil infiltration associated to a fibrous stroma: it was diagnosed as inflammatory fibroid polyp. Considering the polyp's features (absence of a peduncle and size) that could increase the risk of a polypectomy, a surgical resection was performed. Histological examination of the specimen revealed inflammatory granulation tissue in the lamina propria, hyperplastic glands with cystic dilatations, proliferation of smooth muscle and multiple erosions on the polyp surface: this polyp was finally diagnosed as IMGP. There was also another little polyp next to the ileocecal valve, not revealed at the colonoscopy, 0.8 cm in diameter, diagnosed as tubulovillous adenoma with low grade dysplasia.This is the first case of IMGP of the cecum. It is a benign lesion of unknown pathogenesis and must be considered different from other non-neoplastic polyps of the large bowel such as inflammatory cap polyps (ICP), inflammatory cloacogenic polyps, juvenile polyps (JP), inflammatory fibroid polyps (IFP), polyps secondary to mucosal prolapse syndrome (MPS), polypoid prolapsing mucosal folds of diverticular disease. When symptomatic, IMGP should be removed endoscopically, whereas surgical resection is reserved only in selected patients as in our case. Inflammatory myoglandular polyp (IMGP) is a rare non-neoplastic polyp of the large bowel, commonly with a distal localization but it has been also described in the descending and transverse colon -11. IMGP3, HTC 31,4%) associated to positive fecal occult blood test. He had been treated for an autoimmune haemolytic anemia 4 years before, but immuno-haematological tests excluded signs of haemolysis. He also had an autoimmune thyroiditis. He had neither bleeding from rectum nor diarrhea or other gastrointestinal symptoms. Abdominal examination was negative. Rectal exploration did not reveal any pathological sign. A colonoscopy identified the presence of a spherical, sessile, lobulated polyp of the cecum, 4.2 cm in diameter, with a red and not bleeding but partially ulcerated surface  inflammatory granulation tissue in the lamina propria; 2) proliferation of smooth muscle from the muscolaris mucosae; 3) hyperplastic glands with occasional cystic dilatation .IMGP can be asymptomatic ,4,6,8,11Large bowel is the only gastrointestinal tract where IMGP has been described, with the exception of the case in the terminal ileum reported by Griffiths et al. . It is mThe final diagnosis of IMGP is achieved by histological examination through endoscopic mucosal resection (EMR) or polypectomy, whereas the simple biopsy alone is not enough for a correct diagnosis as in our case. Some authors ,12 reporIMGP must be differentiated from other non-neoplastic polyps such as inflammatory cap polyps (ICP), inflammatory cloacogenic polyps, juvenile polyps (JP), inflammatory fibroid polyps (IFP), polyps secondary to mucosal prolapse syndrome (MPS), polypoid prolapsing mucosal folds of diverticular disease . Bathal Concerning therapy, endoscopic treatment of IMGP is the gold standard because it is clinically and histologically benign as reported in literature -9,11-13,The causes of IMGP are still unclear. Nakamura et al.  think thWe reported the first case of sessile and lobulated IMGP of the cecum. Concerning its benign biology, it should be removed endoscopically when it is symptomatic . Surgical treatment is reserved only in selected cases. It must be considered different from other non-neoplastic polyps for its clinical and histopathological features. More studies are required to understand its pathogenesis.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journalThe authors declare that they have no competing interests.RLM collected clinical data, reviewed the literature and drafted the manuscript; RC and MB reviewed the manuscript for intellectual content; MS, FP and FF were involved in the care of the patient; AC studied the specimen; GF performed the endoscopy; PC supervised the whole process. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/10/10/prepub


Epitheloid hemangioendothelioma is an uncommon vascular neoplasm and has an unpredictable clinical behavior. It is characterized by round or spindle-shaped endothelial cells with cytoplasmic vacuolation. Most often, epitheloid hemangioendothelioma arise from the soft tissues of the upper and lower extremities and it has borderline malignant potential. We describe the first reported case of epitheloid hemangioendothelioma in the urinary bladder, which was treated by transurethral resection. The diagnosis was confirmed by immunohistochemistry. Vascular tumors are uncommon and show a wide clinicopathological variation ranging from benign to borderline malignant to complete malignant lesions. Epitheloid vascular neoplasms are a rare group of tumors characterized morphologically by the presence of epitheloid endothelial cells. Vascular tumors composed of these cells are further divided into three distinct varieties: epitheloid hemangioma, epitheloid hemangioendothelioma (EHE), and epitheloid angiosarcoma. HemangioVascular tumors like cavernous hemangiomas and few cases of angiosarcoma have been reported to occur in the urinary bladder. However,A 17-year-old male patient presented with history of episodic painless hematuria of 7-year duration and obstructive voiding symptoms with overflow incontinence for 2 years. There was no history of any bowel symptoms or neurological deficit in the lower half of the body. Physical examination revealed a palpable distended bladder. A firm mass was palpable above the prostate on digital rectal examination.3 mass at the bladder base. Multiple biopsies were done at different centers and were reported as cystitis, histiocytic neoplasm, inflammatory myofibroblastic tumor, and rhabdomyosarcoma. The IHC was not done at any point of time for pathological diagnosis. The patient never received definitive treatment before presenting to us with the above-mentioned complaints.This patient had his first episode of hematuria 7 years prior to his presentation to our hospital. At that time he was evaluated in another hospital where a computerized tomographic scan (CECT) of the abdomen was done which revealed a 2.4 × 2.5 × 2.3 cm3 mass in the trigone with a thickened urinary bladder and bilateral HDUN. Micturition cystourethrogram revealed elongated diverticulated bladder (mimicking neurogenic bladder) with no vesicoureteric reflux and high-postvoid residual urine (PVR). Magnetic resonance imaging of the spine was normal. The CECT of the abdomen revealed a 4-cm solid enhancing mass over the base of the bladder with no perivesical extension or lymphadenopathy [This patient had normal renal parameters (blood urea and serum creatinine) at presentation. Urine cytology was negative for malignant cells. Owing to incontinence and bilateral hydroureteronephrosis (HDUN), per urethral catheterization was done and subsequently imaging studies were performed. Ultrasound (U/S) of the abdomen revealed 4 × 4.3 × 4.3 cmenopathy . CystoscPathological examination revealed polygonal to spindle-shaped tumor cells with abundant eosinophilic cytoplasm and at places showing intracellular vacuolization . Mucin sThe EHE was first described by Weiss and Enzinger in 1982 as a borderline or low-grade neoplasm. Owing toThe differential diagnoses that were considered based on the pathological findings are shown in It is commonly held that EHE represents a low-grade malignant or borderline vascular neoplasm and in the World Health Organization (WHO) classification of soft-tissue tumors it has been placed under the heading of “intermediate endothelial tumors”. Due to iThis case is the first of its kind to report the occurrence of EHE in the urinary bladder and also highlights the importance of immunohistochemical diagnosis for identifying such rare non-urothelial bladder tumors. Owing to the rarity and varying histologic appearance of vascular neoplasms, examination by more than one pathologist should be advocated.


Infarctions of the greater omentum and appendices epiploicae are uncommon, but well documented causes of acute abdominal pain. We present a rare case of torted fat on the parietal peritoneum over the anterior abdominal wall, mimicking clinical signs of acute appendicitis, which was diagnosed at laparoscopy. We are aware of only two other similar reported cases, both of which were diagnosed at the time of laparotomy.A 41-year-old Caucasian woman presented with clinical signs of acute appendicitis. On diagnostic laparoscopy, a non-inflamed appendix was found. Further exploration revealed a necrotic torted appendage of fat overlying the parietal peritoneum of the right iliac fossa of the anterior abdominal wall.Torted fatty appendages can be a diagnostic dilemma often mimicking more common causes of an acute abdomen. Laparoscopy is an excellent tool making the correct diagnosis in such cases. Appendices epiploicae are small pouches of fat-filled peritoneum, which protrude from the serosal surface of the colon, and are usually arranged in two separate longitudinal rows extending from the caecum to the recto-sigmoid junction. They are typically between 1 and 2 cm wide and 2 to 5 cm long, and approximately 50 to 100 are present on average. They are usually supplied via their stalk by one or two arterioles from the vasa recta of the colon and drained by a single tortuous venule [Infarctions of appendices epiploicae and the greater omentum are uncommon, but well documented causes of acute abdominal pain. Torsion of intraperitoneal fat on the parietal peritoneum is an even rarer phenomenon, with only two previously reported cases, both of which were found at laparotomy ,3. One c9/L (neutrophil count 8.1 × 109/L). A diagnosis of acute appendicitis was suspected and a diagnostic laparoscopy was performed. At laparoscopy, a non-inflamed appendix was seen and there was no free intraperitoneal fluid. No gynaecological pathology was seen. On the anterior abdominal wall above the right iliac fossa was a 3 cm × 2 cm piece of fat adherent to the peritoneum via a pedicle, around which it had torted , and abdominal examination revealed marked tenderness over the right iliac fossa with signs of localized peritonism. Blood tests were normal apart from a slightly elevated white cell count of 12.2 × 10The aetiology of such fatty pedicles overlying the peritoneum is somewhat of a mystery. The anatomist Richard Snell was unable to offer any embryological explanation for such a finding on personnel communication with Perry and Hawksley . ExtrapeTorsion of intraperitoneal fat is a rare but well recognised cause of acute abdominal pain, often mimicking more common causes of an acute abdomen such as appendicitis, diverticulitis and cholecystitis. It has been estimated that abdominal fat necrosis including omental torsion accounts for 1.1% of patients presenting with abdominal pain . Whilst Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.KSH was responsible for the first draft of the manuscript. KSH, EDC and TYT were responsible for reviewing subsequent drafts and approving the final draft. All authors were involved with the General Surgery Department medical care of the patient. EDC was the primary surgeon and KSH was the assisting surgeon during the laparoscopy establishing the diagnosis. SG was the consultant surgeon responsible for the care of the patient.


A 70 year old man presented with complaints of moderate pain chest which was generalized in nature & difficulty in breathing for the past 6-7 month. He also had cough off and on. Clinical and routine hematological examination was unremarkable except for reduced breath sounds in left lower lobe. Imaging studies were advised. Figures –3 Fine nWhat are the findings on chest radiographs ?What are the findings on computed tomogram (CT)  and magnWhat is the differential diagnosis?Radiograph chest postero-anterior and lateral views reveal a large homogenous mass of soft tissue density in the left lower zone posterior to and inferior to the cardiac shadow. There is also left sided pleural effusion.Computed tomographic images in the axial orientation and reconstructed coronal images reveal a large heterogeneously enhancing mass lesion with central necrosis along the left hemidiaphragm displacing the spleen and lower lung fields. On MR imaging the lesion is hypointense on both T1-weighted and T2-weighted images with central area of necrosis. In addition there was a loculated left sided effusion. Magnetic Resonance Imaging with its better soft tissue delineation is able to define the structure of origin better which is the diaphragm in this case.Differential diagnosis includes retroperitoneal tumors like leiomyosarcoma and malignant fibrous histiocytoma and pleural tumors like fibroma and mesothelioma with secondary involvement of the diaphragm.Leiomyosarcoma of the diaphragm.Primary neoplasms of the diaphragm are extremely rare and their diagnosis is often difficult. Most patients present with nonspecific symptoms like chest wall or abdominal pain, cough, and dyspnea and 20% of the patients are discovered incidentally on routine chest X-rays. Arthralgias and hypertrophic pulmonary osteoarthropathy presenting as clubbing are rare manifestations, which may resolve following excision of the tumor.2et al.[Grancher was the first to discover the primary tumor of the diaphragm during an autopsy study. Wiener aet al. describeet al. There haet al. ThereaftPatients with diaphragmatic tumors often present between 40 and 60 years of age. Men and women are affected equally. Malignant lesions outnumber benign and the ratio of malignant to benign tumors as reported in the literature is 3:2. DiphragmLeiomyosarcoma develops relatively frequently in the uterus and digestive tract, and somewhat less frequently in the skin, ovary, retroperitoneum and mesentry. On the other hand, primary leiomyosarcoma of the diaphragm is extremely rare. It was first discovered by Kirschbaum in 1935. Only appDiphragmatic tumors are often found on chest radiograph first, which reveals, however, non-specific findings such as deformation or elevation of diaphragmatic shadow. UltrasonThe treatment of choice for diaphragmatic tumors is surgical excision with thoracotomy providing optimal exposure. However, laparatomy with subcostal incision has been reported as an alternative for surgical approach of the diaphragmatic tumors.


Intussusception of the appendix is an extremely rare condition that ranges from partial invagination of the appendix to involvement of the entire colon. Endometriosis is an exceptionally rare cause of appendiceal intussusception and only very few cases have been reported in the literature to date.A 40 year-old woman presented to clinic with a long history of lower abdominal pain, loose motions and painful, heavy periods. Subsequent colonoscopy revealed submucosal endometriotic nodules in the sigmoid as well as a polyp thought to be arising from the appendix, which had inverted itself. She was referred to a colorectal surgeon because the polyp could not be removed endoscopically despite several attempts. At laparotomy, the appendix had intussuscepted but it was possible to reduce it and therefore a simple appendicectomy was carried out. On histology, there were widespread endometrial deposits within the wall of the appendix and this was thought to be the basis for the intussusception.Histological evidence of the lead point is of crucial importance in cases of appendiceal intussusception, in order to exclude an underlying neoplastic process. Consequently, surgical resection is necessary either through an open or a laparoscopic approach. Gastrointestinal endometriosis should be considered as a cause of appendiceal intussusception in post-menarchal women with episodic symptoms and proven disease. Intussusception of the appendix is an extremely unusual clinical entity. A study by Collins  describeThe coincidence of endometriosis and intussusception is even more rare with few cases reported in the literature.A 40-year-old woman presented to gastroenterology outpatients clinic with a several month history of right iliac fossa pain and loose motions. Apart from longstanding dysmenorrhoea and menorrhagia, she did not have any other symptoms. There was no past medical history to note and no family history of endometriosis. A clinical examination of the patient, including a full gynaecological examination, was within normal limits. Preliminary investigations revealed an iron deficiency anaemia with a haemoglobin level of 11.1 g/dl, a mean corpuscular volume of 71 fl and a low ferritin level of 8.4 ng/ml. A colonoscopy was duly organised which showed a sessile 1 cm polyp in the caecum [see figure A preoperative CT scan of her abdomen and pelvis did not reveal any firm evidence of endometriosis and only noted small cysts on both ovaries.At the time of the operation, the appendix had intussuscepted and a simple appendicectomy, rather than a right hemicolectomy, was carried out in the absence of any other findings at laparotomy.On histology, the wall of the appendix had widespread endometrial deposits [see Figures Appendiceal intussusception is uncommon and typically found at the time of operation. An incidence rate of 0.01% has been reported in the literature [Endometriosis is defined as the proliferation and function of endometrial tissue outside the endometrial cavity. The reported incidence in pre-menopausal women is in the order of 8–15%. Although the disease classically involves the pelvic organs and pelvic peritoneum, seeding has been observed in surgical scars, around the umbilicus, in the inguinal canal, intestines, bladder, heart and lungs. The exact aetiology of endometriosis is unknown but there are two main theories on its pathogenesis. The transportation theory presumes that endometrial cells are transported to distant sites through surgical manipulation, menstrual shedding via the fallopian tubes or through lymphatic or vascular spread. Alternatively, the metaplastic theory suggests that embryonic coelomic mesothelium dedifferentiates into endometrial tissue in response to inflammation or trauma ,5. The mThe incidence of gastrointestinal endometriosis varies between 3–37% of those women who have proven disease. The rectum and sigmoid colon are most commonly involved, followed by the rectovaginal septum, small intestine, caecum and appendix. It usually takes the form of asymptomatic, small, serosal deposits. Under cyclical hormonal influences these deposits may proliferate and infiltrate the bowel wall. Cyclical haemorrhage from the endometrioma then leads to an intense, localised fibrosis within the bowel wall that can result in the formation of strictures. In addition, serosal deposits can lead to the formation of adhesions between neighbouring pelvic structures or bowel loops .Appendiceal endometriosis is usually asymptomatic. When symptomatic it frequently presents as appendicitis. Acute appendiceal inflammation arises due to partial or complete luminal occlusion by the endometrioma . AppendiAs in all cases of intussusception, the index of suspicion must be high as 90% of all intussusceptions in adults are due to an underlying neoplastic process. Intestinal endometriosis should be considered as a differential diagnosis in post-menarchal women who present with episodic gastrointestinal symptoms particularly in conjunction with gynaecological symptoms. The gold standard in the investigation of similar cases would appear to be laparoscopy or laparotomy followed by surgical resection in order to obtain histological evidence of the lead point.The author(s) declare that they have no competing interests.All of the named authors were involved in the preparation of this manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Endobronchial hamartoma is a rare benign tumor of lung that may present with symptoms of airway obstruction with wheezing, stridor, recurrent pneumonia or atelectasis. We report a case of a patient with endobronchial hamartoma, recurrent pneumonia, who presented to us with sputum smear and culture positive pulmonary tuberculosis. He was treated with antitubercular treatment and endobronchial hamartoma was resected completely by diode laser through fiberoptic bronchoscope. However,Endobronchial hamartomas have been successfully removed both endoscopically and surgically without significant complication.–4 EndobrA 40-year-old male presented to us with two weeks history of cough, low grade fever, anorexia and three kg weight loss. Contrast enhanced computerized tomography (CECT) chest and bronchoscopy had shown large endobronchial mass occluding left main bronchus in Jun 2006 during evaluation for obstructive pneumonia (left). Endobronchial biopsies done twice were inconclusive. Since then he had received antibiotics for recurrent pneumonia (once every two to three months). On examination he was found to have features of collapse consolidation left lung with monophonic wheeze over left hemithorax. Other systems were normal.The chest radiograph showed collapse of left lower lobe with fibrocavitary lesion involving left upper lobe. Sputum smear and MTB culture were positive and it was sensitive to primary antitubercular drugs. Routine hematological, urinalysis and biochemical parameters were normal. CECT chest revealed endobronchial mass obstructing left main bronchus and collapse consolidation of left lung . FiberopHamartomas are lesions which represent abnormal mixtures of tissue elements or an abnormal proportion of a single element normally present in an organ resulting in changes that are tumor like but not neoplastic; however, chondroid hamartomas despite their popular name, are more likely to be benign connective tissue neoplasms rather than tumor like malformations. PulmonarBronchoscopically, the lesions are smooth, fleshy, pedunculated mass that may be tan to pink. The lesions are often polypoid, either sessile or with a thin pedicle. Radiographic findings–10 incluHistologically the mesenchymal components of the endobronchial hamartomas are highly varied. There is predominance of adipose tissue over other mesenchymal components. They have also been found to contain cartilage, myxomatous connective tissue, smooth muscle and epithelial structures. The mainThe mainstay of treatment for endobronchial hamartoma is surgical resection with particular focus on lung sparing or bronchoplastic surgery. Endoscopic resection of mass by laser has been described earlier.–47 It ca4


Schwannomas are rare encapsulated tumors that derive from the nerve sheath and should be removed due to their infrequent, but existent possibility of malignancy.We report a case of a mass located in the L5 lumbar spine in a 42 year old man, presented with intermittent lumbar pain. Ultrasound, CT and MRI were used to examine the characteristics of the lesion. Fine needle aspiration showed cytologic characteristics of benign schwannoma and final histological diagnosis was ancient schwannoma. An extraperitoneal approach, through a left paramedian incision was used to approach the site of the mass. The lesion originated from the nerve root of the L4-L5 lumbar spinal space and a complete excision was achieved.A great variety of tumors should be differentiated when a paraspinal mass is discovered, including neurogenic, neuroendocrine and vascular tumors, as well as malignancies, cystic and inflammatory masses. Fine needle aspiration is a useful and reliable tool in the preoperative evaluation of paraspinal masses. A review of the literature is also presented. Paraspinal tumors often pose a diagnostic dilemma for the surgeon, due to their commonly silent clinical course and great similarities in radiological characteristics. A variety of heterogeneous lesions should be investigated when a paraspinal lesion is discovered. CT and MRI have improved our ability to differentiate these masses, although significant limitations persist. Preoperative biopsy or fine needle aspiration (FNA) may be very useful, however only the final histological examination can definitively establish the real nature of the lesion.We present a 42 year old man in whom an ultrasound scan accidentally revealed a paraspinal mass. The mass was surgically removed and the final histology revealed ancient schwannoma of the lumbar spine, a diagnosis that was also suggested by preoperative FNA.A 42-year-old man of Greek origin presented with an episode of left intermittent lumbar pain. Abdominal examination did not reveal any tenderness and laboratory data were not remarkable.Ultrasound sonography revealed a 5 cm, solid, well-defined mass with mixed echogenicity in the left paraspinal region, with no further pathology. A 5 cm, well-defined mass in the left paraspinal region at the L5 level was also showed in CT Figure  and MRI The patient was operated with extra peritoneal approach, through a left paramedian incision. The mass seemed to originate from the nerve root of the L4-L5 lumbar spinal space and the excision was complete. On the third postoperative day, the patient complained for strong postural headache that worsened when sitting up and improved after lying down. This was attributed to a leak of the cerebrospinal fluid (CSF) in the spinal membrane, probably caused by minor laceration of the CS canal. The patient's condition was improved with bed rest, paracetamol and hydration. He was discharged on the fifth postoperative day, with no headache, but with a sensory deficit at the site of the left lateral femoral region. The deficit was attributed to left L5 spinal nerve's branch excision, probably occurred during the removal of the mass.Histology showed a well circumscribed spindle-cell tumor with hemorrhage and necrosis, cellular atypia but no mitotic figures, myxoid degeneration, and vessels with hyalinized walls, while S100 immunohistochemistry was strongly positive Figure . ProlifeThe differential diagnosis of paraspinal lumbar masses includes a variety of lesions Appendix 1). Schwannoma, neurofibroma, meningioma, ependymoma, sarcoma, ganglioneuroma, tumor arising from lymphoid, connective and bone tissue, abscess, herniated disc, hematoma, spinal arteriovenous malformation (AVM) and spinal aneurysm, as well as metastatic disease should be under consideration [. SchwannSchwannomas or neurilemmomas comprise neurogenic benign tumors that derive from the nerve sheath. Microscopic evaluation has proved their origin from myelinated Schwann cells, contrary to neurinomas that are nerve-fibre tumors . SchwannHistological stains show two types of tissues; Antoni A and Antoni B, which have been established as the suggestive histological patterns for schwannoma. Nuclear palisading and associated Verocay bodies, which may reflect their prominent extracellular matrix and secretion of laminin are the dominant characteristics of Type A tissue, whereas a loose organization with myxomatous and cystic changes that may represent degenerated Antoni A tissue are the main features of Type B . Sparse Although rare, approximately 1% of retroperitoneal schwannomas are malignant , especiaApart from schwannomas, a great variety of lesions should be taken into consideration when facing a mass found in lumbar paraspinal region, due to their similarities in radiological imaging and clinical manifestations.Neurofibromas usually present similar clinical, radiological and histological characteristics, although useful differences may occur. Spontaneous pain and neurological deficit appear more frequently in neurofibromas than in schwannomas and they are more often associated with neurofibromatosis type 1. MRI may reveal multinodular and fusiform shaped masses, especially in the plexiform type of the tumor. Non-plexiform types and schwannomas are of very similar appearance on CT and MRI, a fact which makes their differential diagnosis difficult, although neurofibromas tend to have a more nodular fusiform shape. As regards histological features, presence of axons on axonal staining, is a distinct characteristic of neurofibromas [Extradural meningiomas are difficult to diagnose and can be easily confused with malignant neoplasms . Low sigEpendymoma is another lesion that mimics schwannoma and neurofibroma and poses a diagnostic challenge to the surgeon. Due to the fact that radiological imaging is usually difficult to distinguish among these entities and prognosis depends on the extent of resection, ependymomas should be treated surgically .Ganglioneuromas are slow growing benign tumors that derive from the sympathetic chain . They arParagangliomas are neuroepithelial tumors, which, when located in the lumbar region, may be misdiagnosed as schwannomas or ependymomas. They are usually hypo - isointense to the conus medullaris on T1-weighted and hyperintense on T2-weighted images. Additionally, the presence of hemorrhage and cyst formation in schwannomas and calcifications in meningiomas are useful differential-diagnostic criteria .Extradural lumbar spinal arteriovenous malformations (AVM's) are rare masses that are often associated with vertebral body (cavernous) hemangiomas. Spinal angiography is of the utmost importance and embolization of supply vessels combined, when required, with laminectomy is the treatment of choice .Furthermore, lumbar region can be the location for 20% of spinal metastases, mainly spread from lung, breast, and prostate malignancies. Surgical treatment, assisted by radiotherapy, vertebral body augmentation and spinal radiosurgery can prove beneficial. Ewing sarcomas in children, soft tissue sarcomas and osteosarcomas and chondrosarcomas usually cause bone erosion in CT and MRI images and, therefore, may be preoperatively distinguished .The use of fine needle aspiration (FNA) in above lesions is supported by many studies and along with CT and MRI, it may increase the accuracy of preoperative diagnosis . Tumors It is evident that paraspinal lumbar region can be the source of heterogeneous lesions that extend from the most benign to the most aggressive tumor. It is therefore a necessity for the surgeon to fully understand their pathology, in order to be very comfortable when selecting the optimal treatment. The role of preoperative biopsy is highlighted in several studies and is thought to be essential so as to orientate therapy, determine the operative strategy and avoid overtreatment and major complication.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review from the journal's Editor-in-Chief.The authors declare that they have no competing interests.AC undertook a literature review, designed the study and wrote the manuscript. LC undertook a literature review and contributed to the manuscript preparation. KM performed the histological examination. DD performed the FNA examination and contributed to the manuscript revisions. KT contributed to the final version of the manuscript. VC supervised the preparation of the manuscript and reviewed the drafts. All authors read and approved the final manuscript.Lumbar Paraspinal Lesions NeurogenicSchwannomas/Neurinomas/NeurofibromasMeningiomasEpendymomasGanglioneuromasNeuroendocrineParagangliomasVascularSpinal Arteriovenous MalformationsSpinal AneurysmMalignanciesMetastasesSoft tissue sarcomasOsteosarcomasChondrosarcomasOtherCystic lesionsAbscessHaematomaHerniated disk


Spontaneous intramural intestinal haematoma is a rare complication of anticoagulation therapy. A misdiagnosis may lead to an unnecessary and even hazardous surgical intervention.An 85 year old lady presented to us with acute abdomen. She was on Warfarin and was found to have grossly deranged clotting parameters. Computed Tomography Scan revealed a long loop of markedly thick-walled proximal jejunum. A diagnosis of spontaneous intramural jejunal haematoma was made.She was successfully treated with conservative management with Vitamin K and blood products. Spontaneous intramural bowel wall haematoma is an often forgotten, rare clinical entity which may pose considerable diagnostic dilemma. It is important to correctly diagnose this condition in order to avoid unnecessary surgical intervention. We present here an interesting case and a brief review of the available literature.An 85-year old lady presented as an emergency with sudden onset of severe left sided abdominal pain and vomiting for two days. This was associated with constipation for 3 days. She had a past medical history of atrial fibrillation, angina, and pulmonary embolism for which she was anticoagulated with warfarin. There was no history of trauma.On examination she was haemodynamically stable. Her abdomen was generally tender, maximal tenderness being in the left hypochondrium and left lumbar region, associated with some guarding and rigidity. Bowel sounds were present and the rectal examination was unremarkable.The blood tests revealed normal haemoglobin, marginally raised white cell count 12.5) and C- reactive protein (25.3), and a grossly deranged International Normalised Ratio (INR) of 8.9. Her renal and liver functions function tests were within normal limits. An erect Chest X-ray and supine abdominal films were both unremarkable. Computed Tomography (CT) Scan showed a long abnormal loop of thick walled jejunum with a small amount of free fluid in the intraperitoneal cavity  scan  or an upCT Scan is the investigation of choice. It has been suggested that an initial non-contrast scan should be performed to help demonstrate high attenuation haemorrhage in the bowel wall . The finHistorically, most cases of spontaneous intestinal haematoma have been diagnosed at laparotomy ,3. If coSpontaneous small bowel haematoma is a rare clinical entity. It should be considered in any patient on long term anticoagulation therapy presenting with an acute abdomen. The jejunum is the commonest site. A high index of suspicion is required to manage these patients appropriately and avoid unnecessary laparotomy.INR: International Normalised Ratio; US: Ultrasound; CT: Computed Tomography.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.ES collected the data on the patient and contributed to the literature search in the manuscript. RB helped with writing the manuscript. KM conceived the idea and helped with the draft of the case report. AR was involved in the care of patient. MT was the consultant-in-charge of patient and supervised the effort. PW interpreted the radiological scans, contributed the images and helped to write the manuscript. All authors read and approved the final manuscript.


Epididymitis and epididymo-orchitis are an uncommon causes of acute testicular pain in neonatal boys, epididymo-orchitis is infection or inflammation of epididymis and testis it's may be associated with urinary tract infections or reflux of urine predisposed by an underlying vasal anomaly. Pediatricians should examine the testicles meticulously after a baby is born.We report a 7 day-old boy with urinary malformations  who presented with acute scrotum. The ultrasonography exploration of the testis showed findings consistent with epididymo-orchitis, confirmed by the needle scrotal aspiration of the pus. Further radiological investigations of urinary tract showed the multiples malformations. Epididymo-orchitis should be suspected initially with abnormal physical signs and laboratory findings. Prompt prescription of antibiotics is mandatory, and appropriate therapeutic measures (antibiotics) should be undertaken to prevent recurrences and sequelae. Neonatal testicular torsion and epididymo-orchitis are confusing and very difficult for medical doctors to diagnostic. Scrotal swelling in newborn is not rare and more diagnosis must be distinguished like: hydrocele, testicular torsion, orchitis, orchi-epididymitis, inguinal hernia, scrotal hematoma and tumors. The emergency cause is testicular torsion that requires surgical intervention but epididymo-orchitis is treated medically.9ml-1, C reactive protein of 71 mg/l, the blood culture was positive (presence of Pseudomonas aeruginosa). Cultures of the cerebrospinal fluid and Urine were negative.A newborn Moroccan male was admitted in the intensive care unit at 2 hours with neonatal asphyxia signs. The infectious laboratory exams were normal. He was intubeted with good evolution. At 7 days the patient was presented the signs of infection: was tachycardic, his body temperature was 38.5°C. The clinical examination revealed a firm, dolorous, and erythematous right hemiscrotum Figure . The labThe color Doppler echography of testicular revealed increased vascular flow and heterogeneous aspects of the testis and epididymis with scrotal infusion. The needle punction aspirated the pus and the culture finds pseudomonas aeruginosa.The abdominal ultrasonography revealed a left hydro-ureteronephrosis with ureteral duplication and ureterocel. This malformative association was confirmed by abdominal magnetic resonance imaging (MRI) with Gadolium contrast Figure .The antibiotics were started with the imepinime 30 mg/kg/j for 10 days and Amikacine 15 mg/kg/j for 3 days. The evolution was good and ultrasonographic control of the testis was normal.Epididymo-orchitis (EO) is a rare affection in the neonatal period. It's should be distinguished from testicular torsion to avoid unnecessary surgical exploration. Testicular torsion requires surgical intervention, but EO is managed medically .The physical examination revealed a swollen testis, pain and fever, but these signs are not specific for EO ,2.The Color Doppler ultrasonography of the scrotum is capable to confirm the diagnosis and eliminated the testicular torsion. In EO, Doppler ultrasonography objective the increased vascular flow and the inhomogeneous echogenicity of the epididymis and the testis .Retrograde passage of sterile or infected urine along the patent vas deferens is the most frequent cause of EO. Bloodstream infection is also reported ,4. EO isEscherichia coli is an important gram-negative bacteria causing diverse neonatal infections and is also the common bacteria causing epididymo-orchitis from an ascending route. In our case it is the pseudomonas which is accused because it was about a nosocomiale infection. The choice of the imepineme is motivated by the bacterial ecology of service constituted by pseudomonas resisting to C3G, sensitive to the imipinème. Fact confirmed in the antibiogram.During the neonatal period, pseudomonas aeruginosa is responsible for nosocomial infection and it's difficult to treat. The acute epididymo-orchitis caused by pseudomonas aeruginosa is unusual and the clinical manifestations are similar to those caused by other micro organisms. Epididymo-orchitis is a rare affection in the neonatal period. After eliminate the torsion of the testicle, when EO is suspected, laboratory exams must done (urine exam, blood culture, and culture of the pus, and prompt antibiotics is prescribed to avoid serious sequelae.EO: Epididymo-orchitis.Written informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AB was major contributor in writing the manuscript and interpreted the data regarding the treatment and outcomes. NA, RD gathered and analysed the data regarding the radiological imaging. HEJ was also a major contributor in writing the manuscript. NLB was the neonatologist consultant in charge of the patient and provided the intellectual basis for the report; in addition, she was a major contributor to the discussion. All authors read and approved the final manuscript.


Patients with paraesophageal hernias often present secondary to chronic symptomatology. Infrequently, acute intestinal ischemia and perforation can occur as a consequence of paraesophageal hernias with potentially dire consequences. An 86-year-old obtunded male presented to the emergency department with hypotension and severe back and abdominal pain. An emergency abdominal CT scan was ordered with a presumptive diagnosis of ruptured abdominal aortic aneurysm. CT topograms revealed extensive free intra-abdominal air and herniated abdominal viscera into the right hemithorax. Prior to completion of the CT study, the patient sustained a cardiopulmonary arrest. Surgery was consulted, but the patient was unable to be revived. Post-mortem examination revealed gross contamination within the abdomen and a giant, incarcerated, hiatal hernia with organoaxial volvulus and ischemic perforation.Current recommendations call for prompt repair of giant hiatal hernias before they become symptomatic due to the increased risk of strangulation. Torsion of the stomach in large hiatal hernias frequently leads to a fatal complication such as this warranting elective repair as soon as possible. Paraesophageal hernias occur when intra-abdominal contents herniate through the esophageal hiatus into the mediastinum. There are four types: type I occurs when the stomach slides into the mediastinum thus displacing the gastroesophageal junction into the thorax , type II and III paraesophageal hernias result from herniation of the stomach through the esophageal hiatus and subsequent organoaxial and mesoaxial rotation respectively, and type IV hernias involve organs other than the stomach herniating through the hiatus into the thorax. Current recommendations are for prompt repair secondary to the possibility of complications including hemorrhage, ischemia, and perforation .An 86-year-old white, American, male presented to the emergency department hypotensive and obtunded with severe abdominal and back pain of unknown duration. A ruptured abdominal aortic aneurysm was initially suspected and the patient was taken for an abdominal CT scan at the request of the emergency room physicians. After completion of a thoracoabdominal topogram, a large quantity of free intra-abdominal air was seen on the lateral view and herniated abdominal viscera were identified in the right chest on the supine view Figure . Prior tThe patient's past medical history was uncovered post-mortem and was significant for a prior coronary artery bypass, congestive heart failure, and previous hiatal hernia repair. The initial discovery of a giant hiatal hernia was made thirteen years prior by esophagogastroduodenoscopy during an evaluation for coffee ground emesis and chronic anemia. Repair was performed at that time and consisted of primary crural re-approximation and gastropexy. Late recurrence of the giant hiatal hernia was also documented but re-operation was not undertaken due to his poor cardiac reserve.Torsion of the stomach in these very large hiatal hernias can lead to fatal complications with considerable frequency, and as a result, elective repair is warranted upon discovery except in the moribund patient . EmergenIt is evident that this patient's pathology was the consequence of a chronically incarcerated giant hiatal hernia left untreated, which ultimately led to his demise. While it remains unclear as to what his true surgical risks were, we currently recommend that most patients can be repaired with low morbidity and nearly zero mortality.CT: Computerized tomography.Written informed consent has been attained from the deceased patient's family to publish information related to the case as well as images associated with the case.The authors declare that they have no competing interests'.AS and EZ were both involved in the conception and data gathering for the case report. SA was involved in drafting and revising the manuscript. AS, EZ and SA were involved in the literature review and obtaining the critical intellectual content used in this case report. These three authors have also given final approval for publication.


Follicular dendritic cell (FDC) sarcoma is a rare neoplasm arising in lymph nodes but also in extranodal sites from accessory cells of the immune system that are essential for the function of antigen presentation and germinal center reaction regulation. FDC sarcoma has a significant recurrent and metastatic potential and for these reason it should be viewed as an intermediate grade malignancy.We report the case of a 49-year old woman patient who showed persistent, enlarged, hard, cervical lymph node. The most common histologic feature was the presence of oval to spindle cells with elongated nuclei, vesicular or stippled chromatin and scant eosinophilic cytoplasm. Immunohistochemically, tumor cells were diffusely positive for follicular dendritic cell markers CD21, CD23 and negative for cytokeratin.The patient after complete excision of the lymph node underwent five courses of adjuvant chemotherapy with COP plus PEG-liposomal doxorubicin, considering the propensity of the tumor to metastasize.No hematological or cardiac toxicity were registered and among the other extra hematological effects only transitory palmar erythrodysesthesia is worthy of mention. After a follow up of 5 years the patient is alive and in CR.These results suggest that this therapeutic modality may be useful in the management of FDC sarcoma. Follicular dendritic cell sarcoma is a rare tumor arising from antigen-presenting cells of the B-cell follicles of nodal and extranodal sites; these cells are important for germinal center reaction regulation. It was first described in 1986 by Monda et al  , platelets 214 × 109/l, all the other biochemical parameters were normal. Hepatitis B and C, HIV serology were negative, EBV serology showed no IgM antibodies but positivity for IgG anti VCA and IgG anti EBNA.Routine hematological parameters showed hemoglobin 13.1 g/dl, WBC 5.9 × 10Bone marrow aspiration and trephine yielded a normal hemopoiesis. A total body computed scan was made showing multiple hepatic angiomas (confirmed by MRI scan) and small subpleural fibrocalcific residuals, the rest of the exploration was normal. The patient also underwent an echocardiography that disclosed a good cardiac function with normal ejection fraction.2 i.v. (day 1), Vincristine 1.4 mg/m2 (day 1), PEG-liposomal doxorubicin (Caelyx) 40 mg/m2 i.v (day 1) and Prednisone 100 mg po days 1–5, every 3 weeks.Postoperative adjuvant chemotherapy was administered; the patient received five courses of COP+PEG-liposomal doxorubicin according to the following schedule: Cyclophosphamide 750 mg/mNo hematological toxicity was reported, but WHO grade 3 skin toxicity was observed. In particular the patient after the fourth cycle developped a palmar erytrodysesthesia with painful erytema that was attributed to PEG-liposomal doxorubicin and consequently we reduced at 70% the dose of Caelyx in the last course of treatment. The erytrodysesthesia was transitory and successful treated with mild dose of prednisone per os.A total body CT scan performed one month after the last course of chemotherapy was negative for lymphoadenophaty Figure  and prevFollicular dendritic cell sarcoma is a rare neoplasm that can involve lymph nodes or extranodal sites ,4,5. OncFDC sarcoma was considered an indolent tumor with low tendency of recurrence or metastasis; but recent larger reports with longer follow up have showed that FDC sarcoma is more aggressive tumor and should be considered an intermediate-grade malignancy. Chan et al. have reported that at least 40% of documented FDC sarcomas have recurred and 25% have metastasized with a mortality rate of 16.7% .Because this significant recurrent and metastatic potential it is reasonable that resected localized disease may be prevented from recurrence by adjuvant radiotherapy or chemotherapy -13.In our case report, the patient underwent surgical excision and postoperatively was given five cycles of COP plus Caelyx, utilizing cyclophosphamide, vincritine, prednisone and pegylated liposomal doxorubicin.PEG liposomal doxorubicin is an alternative preparation of doxorubicin, which has been shown to have reduced cardiotoxicity and is characterized by a very long circulation half-life, favorable pharmacokinetic behaviour and specific accumulation tumor tissues ,15. PEG Based on these encouraging experiences and in consideration of the higher response rate, shorter time to response and less toxicity obtained with PEG liposomal doxorubicin also in the treatment of AIDS-related Kaposi's sarcoma , compareIn the literature treatment modality of FDC sarcoma varied widely although surgical resection was often included. With a median follow up of 18 months, about 40% of the cases recurred and the 5 years recurrence-free survival was 27.4%, further the role of chemotherapy and radiotherapy in the treatment of this neoplasm is not yet clearly defined . ClinicaA longer follow-up and further studies are warranted to determine whether this combination treatment may be useful in the management of FDC sarcoma, at least in localized nodal disease, once it is identified and well characterized by the appropriate application of immunohistochemical staining.


Endometrial stromal sarcoma (ESS) is a rare malignant tumor of the endometrium, occurring in the age group of 40–50 years. This is a case of low-grade ESS presenting as rapid enlargement of a fibroid uterus. Because of her secondary infertility, she was planned for myomectomy. However, due to the high degree of suspicion of a sarcomatous change in the fibroid, in view of rapid enlargement of uterus within the last 4 months, we planned for a preoperative endometrial aspiration. It showed low-grade ESS, which was later confirmed by histopathology examination of total hysterectomy specimen. As surgery was the main treatment for ESS, because of the proper preoperative diagnosis, we could plan the treatment accordingly. Despite the rarity of the tumor, one has to consider the possibility of ESS in cases with presentation of rapid enlargement of a fibroid uterus. Cancers arising from mesodermal structures like muscles and connective tissue are called sarcomas. Sarcomas of the uterus are uncommon, and may arise from connective tissue, smooth muscle or the endometrial stroma. Uterine sarcoma is a rare form of malignancy, occurring in 2–5% of all patients with uterine malignancy, with an incidence of approximately one to two cases per 100,000 women in the general population. Endometrial stromal sarcomas (ESSs) are very rare malignant tumors that make up approximately 10% of all uterine sarcomas but only around 0.2% of all uterine malignancies.[A 30-year-old lady presented with increased bleeding per vagina during periods since 1 year. She was a Para1, Live1, with last child birth 10 years back and no history of contraceptive use. She had attained menarchy at the age of 14, and her previous cycles were normal. However, for the past 1 year, her cycles were prolonged, lasting for 15–20 days/2–3 months. She was investigated for secondary infertility in a local hospital 1 year back and was treated with clomiphene citrate for three to four cycles. A pelvic scan taken 11 months back showed normal-sized uterus with a fibroid 3.7 cm×3.4 cm in the anterior myometrium. Endometrial thickness was 8 mm. A dilatation and curettage was performed and microscopy showed a disordered proliferate endometrium. She was given symptomatic treatment for menorrhagia. An ultrasound scan carried out 4 months back, showed enlarged uterus (12 cm×7 cm×7 cm) with diffuse coarse heterogeneous myometrial echoes. A later scan showed further enlargement of the uterus (16 cm×13 cm×10 cm) with the intramural fibroid 10 cm×7 cm in posterior wall. She was advised myomectomy and was referred to our tertiary care institute. Her general and systemic examinations were normal. Abdominal and pelvic examinations revealed a uniformly enlarged uterus, 24 weeks size, firm in consistency, with restricted mobility. Doppler ultrasound showed a fibroid uterus 16 cm and 12 cm, with normal vascularity. Endometrial aspiration was performed due to suspected sarcomatous changes in view of the rapid enlargement of the uterus within the past 4 months. Microscopy showed endometrial glands in the secretory phase with neoplastic cells, suggestive of low-grade endometrial stromal sarcoma (LGESS) .A total abdominal hysterectomy with bilateral salpingooopherectomy was performed through a vertical midline incision. The findings were a uniformly enlarged uterus with normal-looking tubes and ovaries The tumor had infiltrated the myometrium anteriorly. There were no metastatic deposits elsewhere. The lymph nodes were not enlarged. Grossly, the specimen had a yellowish tan. Microscopically, no malignant cells could be demonstrated in the peritoneal washings. Characteristically uniform oval and spindle-shaped cells, suggestive of low-grade ESS , infiltrESSs are very rare malignant tumors. Based on tumor margin status and cytological features, the WHO has classified endometrial stromal tumor into benign endometrial stromal nodule (ESN) and endometrial stromal sarcoma. ESN does not infiltrate the myometrium. They are well circumscribed, with a pushing margin. ESSs infiltrate the myometrium and are characterized by proliferation of uniform small cells closely resembling those of endometrial stroma in the proliferative stage. ESS can Most ESSs involve the endometrium, and uterine curettage usually leads to diagnosis. The mainSurgery is the final resort for diagnosis and primary treatment of ESS. Preoperative diagnosis is mostly a uterine fibroid. Ultrasound and magnetic resonance imaging are inconclusive. If the diagnosis is known, the extent of surgery is planned according to the stage of the tumor. The FIGO staging for carcinoma of the corpus uteri has been applied to ESS.The treatment is total abdominal hysterectomy, bilateral salpingooophorectomy and pelvic and periaortic selective lymphadenectomy. Cytologic washings are obtained from the pelvis and abdomen. Hormone therapy with medroxy progesterone, tamoxifen, gonadotropin releasing hormone (GnRH) analogues and aromatase inhibitors are suggested for low-grade ESS stage 3–4 and for recurrent disease.9Because of the rarity of the tumor, ESS may not be familiar to the gynaecologists. In young patients, it could be mistaken for a fibroid and more conservative management may have been planned accordingly. High degree of suspicion in a rapidly enlarged uterus led to an endometrial aspiration in this case, which showed low-grade ESS. Therefore, the treatment plan was shifted from a conservative myomectomy to a laparotomy, total abdominal hysterectomy and bilateral salpingo-opherectomy. The case highlights the necessity for high degree of suspicion and proper preoperative diagnosis in this rare type of tumor, especially in young patients.


Teratomas are bizarre neoplasms derived from embryonic tissues that are typically found only in the gonadal and sacrococcygeal regions of adults. Retroperitoneal teratomas are rare and present challenging management options. We report here the case of a histologically unusual retroperitoneal tumor detected on computed tomography during the workup of abdominal pain in a 32-year-old male. The evaluation and treatment of this condition and a review of the literature are included in this paper. Teratomas are tumors that are derived from embryonal tissue and composed of somatic cell types from two or more germ layers  . A teratA 32-year-old Hispanic male presented to the emergency department with a complaint of abdominal pain and fullness. The pain was mostly localized to his right lower quadrant and right flank. He was admitted to the hospital where, on computed tomography, he was found to have a large retroperitoneal mass containing bone and multiple different soft-tissue densities consistent with a teratoma Figures and 2.The patient's past medical history is significant for adult-onset diabetes, obesity, and hypercholesterolemia. Additionally, in April 2009, he was involved in a motor vehicle accident in Cuba where he underwent an exploratory laparotomy for reported peritonitis from a perforated viscus. Exact details of that operation and its findings were unavailable. The physical examination revealed a well-healed midabdominal surgical scar, abdominal distension, and minimal tenderness in the right flank. A recent barium upper GI study revealed an unremarkable stomach, duodenum, and small bowel series, with a large radiolucent mass in the right upper quadrant, corresponding to the previously diagnosed teratoma. Admission laboratory tests showed no abnormalities.The patient underwent resection of this lesion through a thoracoabdominal incision. The diaphragm was incised radially and the neoplasm was dissected from its attachments to the right kidney, vena cava, liver, hepatic veins, and diaphragm. The retroperitoneal dissection was tedious and difficult, but the mass was excised in its entirety. The chest was closed with a 36 French thorcostomy tube and the patient recovered without incident. The resected retroperitoneal mass was found to be a benign extragonadal teratoma, measuring 18.0 × 12.5 × 9.0 cm, partly covered with a smooth, gray-brown membrane. The external surface was lobulated and ragged in areas, with cut sections revealing mostly yellow, lobulated fat with cystic areas filled with brown, cheesy material and hair . Areas oTeratomas are the most common type of germ cell tumor in humans, and most of these neoplasms are benign. They are typically classified into three general categories: mature , immature , and mondermal  . Each ofRetroperitoneal teratomas are rare entities, representing only 1%–11% of all primary retroperitoneal tumors. Incidence is bimodal with peaks in the first 6 months of life and in early adulthood. Due to their location, they are usually identified only after they have grown to huge proportions . The diaSurgical resection remains the mainstay of therapy for mature teratomas and is required for definitive diagnosis . ResectaBenign tumors, when resected, yield a 5-year survival rate of 100%. A long-term study showed that complete surgical resection is associated with the best survival rates for primary retroperitoneal tumors . DiseaseTesticular ultrasound is necessary to rule out a coexisting testicular germ cell tumor in male patients. This is a necessary step since 50% of men with retroperitoneal tumors also have testicular carcinoma in situ, a precursor for testicular germ cell tumors .Primary retroperitoneal teratoma is a rare entity in adults. Although usually asymptomatic, large neoplasms can cause abdominal and flank pain. Preoperatively, the diagnosis can be established by its characteristic appearance on computed tomography. The definitive treatment for these neoplasms is surgical resection.


Rectal neuroendocrine carcinoma is rare with poor prognosis. We report herein a case of advanced moderately differentiated neuroendocrine carcinoma of the rectum with relatively favorable prognosis treated by postoperative adjuvant chemoradiation therapy. A 58-year-old Japanese female was referred and colonofiberscopy revealed an easy-bleeding irregular tumor in the lower rectum, which was pathologically diagnosed as a neuroendocrine carcinoma. Surgical treatment consisted of abdominoperineal resection and lymph node dissection. The tumor invaded deeply into perirectal tissues, and 9 of 11 lymph node metastases were observed. Immunohistochemically, chromogranin A showed diffuse and strong staining, and the MIB-1 labeling index was 18.3 ± 5.6, supporting the high proliferation of the tumor. Some nucleus of the tumor showed positive staining for p21/WAF1. A total dose of 46 Gy of radiotherapy was delivered with 800 mg of daily oral doxifluridine. At 5 years post-surgery, the patient demonstrated no clinical evidence of intrapelvic recurrence or distant metastases. Neuroendocrine carcinomas of the colon and rectum are rare tumors with aggressive behavior and poorer prognosis compared with adenocarcinomas, and the reported 3-year survival rates are 13-15%. SeveralWe herein report a case of advanced moderately differentiated neuroendocrine carcinoma of the rectum with relatively favorable prognosis by postoperative adjuvant chemoradiation therapy.A 58-year-old Japanese female was admitted to hospital with a two-month history of rectal bleeding. Colonofiberscopy revealed a tumor in the lower rectum, however, a biopsied specimen from the tumor showed no malignant findings. She was referred to our institution for further examinations.Colonofiberscopy showed an easy-bleeding yellowish tumor with a relatively regular surface with lateral submucosal elevation Fig.  and 5 biBased on these findings, the patient underwent abdominoperineal resection with total mesorectal resection and bilateral lymph node dissection. The postoperative course was uneventful. To prevent intrapelvic recurrence, a total dose of 46 Gy in 2 Gy fractions of radiotherapy was delivered through a linear accelerator using the 3-field technique (10 MV), 5 times a week. A daily dose of 800 mg of oral doxifluridine was administered for 5 years because of patient's rejection to intensive intravenous chemotherapy. At 5 years post-surgery, the patient demonstrated no clinical evidence of intrapelvic recurrence or distant metastases.IHC was done on formalin-fixed paraffin-embedded sections, using labeled streptoavidin-biotin-peroxidase and microwave antigen retrieval technique. Mouse monoclonal antibodies against chromogranin A , MIB-1 and p53 protein were used. Goat polyclonal antibodies against hASH1  and NeuroD were used in order to assess the neuroendocrine differentiation at a transcription level. Mouse IgG was used as a negative control, with dilution of 1:100. Appropriate positive controls known to contain the antigens in question were processed simultaneously.Macroscopically, the resected specimen showed a protruding lesion with an irregular surface, 35 × 20 mm in diameter. The tumor had lateral submucosal elevation and tumor size including lateral elevation was 60 × 30 mm. Microscopically, the tumor invaded the adjacent adipose tissue. Nine of 11 lymph node metastases were observed.ChromograninA showed a diffuse and strong staning in the tumor cytoplasm indicating neuroendocrine differentiation. MIB-1(Ki-67 antigen) labeling index showed 18.3 ± 5.6 supporting high proliferation of the tumor. Nuclear staining of p53 was also detected in approximately 10% of the tumor suggesting the tumor to be an endocrine cell carcinoma. Strong and diffuse nuclear staining of NeuroD and cytoplasmic staining  of hASH1 were also detected  is a key agent that is widely used in the treatment of colorectal cancers. TS is an essential DNA synthetic enzyme that catalyzes the methylation of dUMP to dTMP. DPD is p21 is a cyclin dependent kinase inhibitor and its expression is a marker of tumor radiosensitivity in patients with rectal cancer. This tuThis report indicated the difficult histological diagnosis of neuroendocrine carcinoma by endoscopic biopsied specimens. The reason for negative biopsies was speculated its submucosal location. Bernick et al. reported that the sensitivity of preoperative colonoscopic biopsy for colorectal neuroendocrine carcinoma was approximately 60%. We recoIn conclusion, we experienced a case of advanced neuroendcrine carcinoma of the rectum with relatively favorable prognosis by postoperative adjuvant chemoradiation therapy.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.HN: deta collection, drafting the manuscript. KS: drafting and revising the manuscript, surgical management of the patient. CK: surgical management of the patient and revising the manuscript. TS:pathological review of surgical specimens, preparing histopathological figures. KK: surgical management of the patient and revising the manuscript. KO: surgical management of the patient and revising the manuscript. SK: pathological review of surgical specimens, preparing histopathological figures. HI: pathological review of surgical specimens, preparing histopathological figures. MM: head of the department who supervised all steps of the work. All authors read and approved final manuscript.


Intralesional injection of corticosteroids has been used successfully in the treatment of adenexal hemangiomas, with advantages of easy administration, rapid action, repeatability, efficacy and safety. We report a case of an eight-month-old female infant who underwent intralesional corticosteroid injection for capillary hemangioma that had resulted in amblyopia of her left eye from ptosis. Two weeks after the injection, the hemangioma showed some regression but at that point iris depigmentation of the affected eye was noted. The iris depigmentation remained unchanged during her follow-up visit with significant regression of the hemangioma, associated ptosis and astigmatism. Capillary hemangioma is a benign vascular tumor of infancy that commonly involves the eyelids and orbit. The rate of incidence of these tumors among newborns is 1–2%.A three-month-old female infant, born via normal delivery, was examined for a mass involving the left upper eyelid. Her parents stated that her eyelids appeared normal at birth but at two weeks of age a mass appeared in the infants left upper eyelid which rapidly enlarged over a month.On examination, the fixation pattern was central, steady and maintained in the right eye, and she was able to follow light through a slit-like opening of the left palpebral fissure. There was a 3.5 × 3.00 cm elevated mass with an overlying red spot, involving the medial two third of the left upper eyelid, that caused a marked ptosis in that eyelid . Ocular Computed axial tomography with contrast showed a large hyperdense extraconal lesion located at the superomedial aspect of the left orbit causing inferolateral displacement of the globe. The rest of the examination was within normal limits and a diagnosis of infantile capillary hemangioma was made. Because of the high risk of developing amblyopia from visual deprivation and ptosis, the infant was started on a five-week course of tapering oral prednisone starting at a dose of 5 mg, twice a day for two weeks while being monitored by a pediatrician. At the end of treatment, there was some regression in the size of the tumor that now measured 2.50 × 2.00 cm. The cycloplegic refraction was now +3.00 D Sph –6.50 D Cyl × 40°.After several subsequent visits, there was no further regression in tumor size and astigmatic error remained. Therefore a mixture of 40 mg of triamcinolone acetonide and 8 mg of dexamethasone sodium phosphate was administered within the lesion under general anesthesia. The injection was given using a 27-gauge needle on a 1-ml tuberculin syringe at multiple injection sites throughout the lesion. A patch was applied over the treated eye and she was discharged. The immediate postoperative course was uneventful. At 3-4 weeks after treatment the patient followed light with both eyes, with nor mal fixation with marked reduction in the size of the tumor to 1.50 × 1.00 cm. On examination of the anterior segment, an area of hypopigmentation involving the left iris tissue was noted . The pupCapillary hemangiomas are benign tumors composed of proliferating endothelial cells and anastomosing blood filled channels.9The mechanism of iris depigmentation following intralesional corticosteroid injectionin our case remains unclear but steroids could possibly have been mediated by its effect in melanocytes. Steroids may reduce the number, or activity, of melanocytes.In summary this report highlights iris depigmentation as an unsual side effect of intralesional steroid therapy that has not been previously reported. Further studies are needed to determine the exact etiology of this complication.


This short report discusses a case of solitary colonic polypoid ganglioneuroma associated with melanosis coli in a woman with no systemic manifestations. To our knowledge this is the first ganglioneuroma reported in the literature in association with melanosis coli. The nature and significance of this event remains unclear, although this may be coincidental due to the laxative intake. Further investigation is necessary to clarify this point. The interest of this case lies moreover in the rarity of this entity and its endoscopic and histologic resemblance to sessile polyps frequent in the clinical practice. The hereditary syndromes of the gastrointestinal tract are classified as adenomatous or hamartomatous . As a paA 48-year old woman with arthrosis underwent colonoscopy because of a family history of colon cancer (father and cousin) and an episode of lower intestinal bleeding. The patient was an anthracene-type laxatives ("sacred rind") consumer due to usual constipation. No other symptoms were related. She and her family had no known history of multiple endrocrine neoplasia or neurofibromatosis. The laboratory tests were within the normal limits, including carcinoembryonic antigen (CEA). Physical examination revealed an anal fissure. No pigmented skin lesions were identified. The colonoscopy revealed a millimetric sessile polyp in the sigmoid colon that was removed with biopsy forceps Figure .The biopsy specimen consisted of three fragments. At low magnification they looked like a hyperplastic polyp. Microscopic examination of the fragments of the polyp showed a collection of nerve ganglion and stromal cells in the lamina propia that elevated the overlying elongated glands in a nodular configuration. No significant disarray of the mucosal architecture was observed. An additional finding of diffuse melanosis coli was noticed Figure . InmunohThe diagnosis was solitary polypoid ganglioneuroma of the colon.Shekita et al. categorized ganglioneuromas (GN) of the intestinal tract into three groups: polypoid GN, ganglioneuromatous polyposis and diffuse ganglioneuromatosis.The GN of the gastrointestinal tract have been found in patients with familial adenomatosis coli, Cowden's disease, tuberous sclerosis, juvenile polyposis, von Recklinghausen's disease and multiple endocrine neoplasia type II . The serPolypoid GN are small, sessile or pedunculated polyps with a histologic resemblance to hyperplastic polyps, juvenile polyps or adenomas ,3. In thThe link between intestinal ganglioneuromatosis and malignancy is not well established, although some investigators have described the coexistence of intestinal ganglioneuromatosis and colorectal adenocarcinoma ,6.To our knowledge this is the first ganglioneuroma reported in the literature in association with melanosis coli. The nature and significance of this event remains unclear although this may be coincidental due to the laxative intake. Further investigation is necessary to clarify this point. The interest of this case lies moreover in the rarity of this entity and its endoscopic and histologic resemblance to sessile polyps frequent in the clinical practice.GN: Ganglioneuroma; CEA: Carcinoembryonic antigen; NSE: Neuron-specific enolase; MEN: Multiple endocrine neoplasia.The authors declare that they have no competing interests.IMM and TP have contributed substantially to the conception and design of this work, giving final approval of the version to be published. IMM has attended the medical consultation of the patient and TP reported the pathologic diagnosis. Both edited the manuscript and made the required changes.FJR, RF and AS have been involved in drafting the manuscript and revising it critically for important intellectual content.All authors read and approved the final manuscript.


An osteolytic tumour of the mandible with prominent expansive growth on the alveolar ridge and displacement of the involved teeth is described in a 28-year-old man. The lesion was diagnosed as a central odontogenic fibroma, an uncommon benign neoplasm derived from dental apparatus, and was removed by curettage. The patient remains asymptomatic after thirteen years of follow-up, which supports the claimed indolent behavior of this poorly documented disease and the adequacy of a conservative surgical treatment. Central odontogenic fibroma (COF) is an uncommon benign neoplasm composed by varying amounts of inactive-looking odontogenic epithelium embedded in a neoplastic mature and fibrous stroma -12. The A 28-year-old man presented with a painless periodontal swelling in the right side of the mandible. The patient reported five years of evolution, with moderate discomfort during mastication as the only relevant symptom. Oral examination revealed a 2.5 cm sessile tumour on the right side of the alveolar ridge of the mandible, between canine and first premolar Figure . These tMicroscopically, the sample consisted in a fibrous connective tissue alternated with more vacuolated myxomatous areas. Individual nuclear morphology of the fibroblasts varied from spindle shaped to stellate. Abundant nests and strands of odontogenic epithelium were found, often with a clear or vacuolated cytoplasm, sometimes surrounded by juxtaepithelial hyalinization Figure . CalcifiThe lesion was then entirely removed by curettage under local anesthesia. The microscopic evaluation of this material reveals the same features of the previous biopsy. All options for rehabilitation were given to the patient, who choice to use a removable partial denture. There was not any relevant event after thirteen years of follow-up.Up to the present, specific information from approximately 80 patients were reported as single cases or case series in English literature ,14-17. IThere are two types of COF. The simple type of COF is composed by a delicate fibrous connective tissue with considerable ground substance yielding a fibromyxoid quality. Seldom rests of small and round odontogenic epithelium, often with vacuolated cytoplasm, may or may not be found . In thisAll fibrous lesions of the jaws should be considered to make a safe diagnosis, attempting to both clinical and histopathological aspects, as summarized in table Similarities between odontogenic myxomas and COF simple type leaded to the disputed hypothesis that the latter entity would merely represent the most collagenous variant of the histological spectrum of the odontogenic myxomas, the so-called myxofibroma . The cliAmeloblastic fibromas are distinguished from COF by the fact that both the epithelial and mesenchymal components are neoplastic, while in COF, is only the mesenchymal ,23. It uRecurrences are not uncommon to DF 17-72%), myxoma/myxofibroma (10-33%), and AF (33%) -23,25. T%, myxomaIn conclusion, it is essential that oral and maxillofacial surgeons, radiologists and pathologists integrate all relevant and available information to come up with a correct diagnosis and appropriate disease management. We demonstrated that conservative surgery can be performed to treat COF, which consists in a thorough curettage of the lesion. Cytogenetic and biomolecular studies are necessary to explain the true nature and pathogenesis of these diverse similar fibrous lesions, which have so distinct behaviors.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interestsAll authors read and approved the final manuscript. MT has been involved in drafting the manuscript revising it critically for important intellectual content, and to collect the results from follow-up examinations. SV conceived of the study, and participated in its design and coordination and helped to draft the manuscript. AV and AF have made the final treatment and the clinical follow-up of case, besides substantial contributions to conception and design. AM has given the final diagnosis of case after analysis and interpretation of data.


Primitive neuroectodermal tumour (PNET) is a rare tumour mainly found in children under ten years old. It may be broadly categorised into those occurring from the central or peripheral nervous system of which the majority arise centrally. We report a 61 year-old lady who had previous lobular breast cancer presenting with a rapidly expanding lesion in her anterior right upper abdominal wall. Clinically it appeared to be benign, however, histopathology of the excised lesion revealed a localised PNET. This case is an unusual case of a PNET in an adult that is peripheral in nature arising from subcutaneous tissue in the abdominal wall. PNETs are rare tumours that are more prevalent in children than adults and occurirng more commonly in the central nervous system than peripheral. Peripheral PNETs are similar to Ewing's sarcoma . We presA 61 year-old lady presented to clinic with a lesion in her anterior abdominal wall. It was present for four weeks and initially thought to be a sebaceous cyst but had rapidly expanded in that time frame. She had no other symptoms of note. On clinical examination the patient had a lesion measuring 4 × 3 cm firm, fixed, hemispherical with a smooth edge. There was a punctum and some indurated fat around it.Her past history was of a right-sided breast cancer, she underwent a wide local excision and axillary dissection for a grade 1 lobular carcinoma with no nodal involvement. She underwent adjuvant treatment with radiotherapy and tamoxifen.She was initially referred due to concern that this lesion was related to her previous breast cancer, however clinically it appeared benign and she underwent elective excision of the lesion under local anaesthesia.Histopathology revealed a tumour growing as solid sheets diffusely infiltrating the dermis and subcutaneous fat with significant areas of necrosis. The tumour was monomorphic with intermediate sized cells with scanty cytoplasm. There was a hint of rosette formation Figure  but no oShe was referred to Oncology for adjuvant therapy. Staging CT scan of the chest, abdomen and pelvis revealed ill defined haziness in the subcutaneous fat of the right upper abdomen but no solid or cystic lesions were apparent. No other significant abnormalities were seen. Whole body bone-scan showed no evidence of bony metastases. Bone marrow trephine biopsy showed normocellular marrow with no evidence of neoplasia.Although the lesion appeared to be completely excised the recommendation was for adjuvant chemotherapy. She was commenced on 6 cycles of Vincristine, Doxorubicin and Cyclophosphamide.Primitive neuroectodermal tumours (PNET) are rare tumours that are more prevalent in children. They may be broadly divided into those occurring in the central nervous system such as non pineal supratentorial PNET, medulloblastoma and pineoblastoma. Those occurring peripherally may resemble soft tissue sarcoma  and are similar to Ewing's sarcoma as they share common chromosomal change. Although Ewing's sarcomas are more common in bone there are examples of extraosseous tumours that may resemble PNET.There have been a number of case reports for peripheral PNETs including those in the eye ,3, maxilOn a histopathology level PNETs are highly cellular showing sheets of small round cells with hyperchromatic nuclei. They the progress with neuron-specific enolase expression then onto rosette formation as demonstrated by this case, cytoplasmic glycogen, phenotypic ganglion cell differentiation and finally neurofilament protein expression. Tumours that are undifferentiated by light microscopy, immunochemistry or electron microscopy have been diagnosed as Ewing sarcoma. The majority of Ewing's sarcomas and PNETs have a t translocation, there are smaller cases of t and t translocation. Treatment of PNETs depends on the type of PNET, position in the body, size of the tumour, spread and the age and health of the patient.PNETs are a rare form of tumours demonstrating neural differentiation. This case demonstrates an unusual presentation of a PNET in peripheral abdominal subcutaneous tissue in an adult. Treatment involves resection, chemotherapy with or without radiotherapy.The authors declare that they have no competing interests.DB Literature searches, writing the paper. BS Performed surgical procedure. RB Performed surgical procedure. KJ Examined surgical specimen, wrote pathological report and provided histological photographic slides. JRS Supervised final revision of the articleWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Low-grade myofibroblastic sarcoma is a rare entity, which mostly develops in the soft tissues of the head and neck. Within the oral cavity lingual lesions are the most common. It tends to recur locally rather than to metastasise.We present a 54-year-old man with a one-year history of buccal oedema. He also had arterial hypertension and clinical examination revealed distension of the left mandibular ramus with laminar deflection in the area of the retromolar triangle.We present a rare intramandibular encapsulated lesion that caused diagnostic difficulties. Our diagnostic methods included immunohistochemistry and molecular investigations. We emphasise the uncommon location of this tumour type. Low-grade myofibroblastic sarcoma (LGMS) represents a rare entity, which mostly develops in the soft tissues of the head and neck . Within In February 2006 a 54-year-old, white, Caucasian man was seen in the Outpatient Clinic of the Craniomaxillofacial Surgery Department in Katowice with a one-year history of buccal oedema. He also had arterial hypertension. A clinical examination revealed distension of the left mandibular ramus with laminar deflection in the area of the retromolar triangle. Pantomogram and cranial X-rays demonstrated a well-delineated osseous defect spreading throughout the left mandibular ramus, infiltrating and destroying the structures of the pterygopalatine fossa Figure .Fine needle aspiration biopsy (FNAB) was non-contributory. A computed tomography (CT) scan of the facial area revealed a tumorous lesion in the area of the mandibular angle and ramus 59 × 54 mm in size which was slightly and heterogeneously enhanced after an intravenous contrast agent was introduced, causing bone distension Figure . The masTumour enucleation was performed including the periosteum and capsule. The tumour, which had a gelatinous consistency, exhibited a tendency to invade the subtemporal fossa. Clear margins were obtained and the histology result was low-grade myofibroblastic sarcoma. The mitotic index was 5f.p. × 10eHPF. At the time of writing, no recurrence or metastases have been found.Macroscopically the tumour was approximately 5 cm in diameter, grey-white, hard and fibrous and there was no necrosis. It was removed, along with part of the bone, and microscopy demonstrated a tumour composed of spindle cells arranged in interlacing bundles. The nuclei were mostly fusiform and elongated with some round or polymorphic nuclei also present. Most tumour cells showed low grade atypia while polymorphonuclear cells showed high-grade atypia. The mitotic index was low (MI up to 5/10 HPF). The nuclei of some of the tumour cells were hyperchromatic with tiny acidophilic nucleoli and the cytoplasm was pale pink. No necrotic foci were seen. There was oedema in the central part of the tumour with pseudomyxoid and microcystic areas, and the inner and peripheral parts showed thick bundles of collagen fibres, local hyalinisation and the disappearance of tumour cells and keloid-like areas.Tumour blood vessels showed considerable variation from tiny, round and elongated to larger ones exhibiting wall thickening and hyalinisation. An analysis of the tumour pattern revealed mild chronic inflammation and microscopic examination also showed bone trabeculae invasion. The tissue margins were clear. At immunohistochemistry, the specimen stained positively for calponin Figure , vimentiAlthough the patient's age and gender were consistent with literature reports on low-grade myofibroblastic sarcomas, we would like to emphasise the uncommon location of this tumour type (within the mandible) as well as a non-typical macroscopic appearance (the presence of a capsule). Initial histological diagnosis was inconsistent with the clinical condition. However, problems with differentiation between sarcoma subgroups have been described in the literature with the most common locations being the oral cavity (tongue) followed by the limbs, pelvis, lungs and breasts, with a predilection for soft, perifascial and subcutaneous tissues -4]. Oth. Oth4]. Radiological examinations of a low-grade myofibroblastic sarcoma of pelvic bones and limbs reveal a well-demarcated osteolytic lesion with no periosteal reaction ; our resCT: computed tomography; FNAB: fine-needle aspiration biopsy; LGMS: low-grade myofibroblastic sarcoma; MDM-2: transformed 3T3 cell double minute 2; PDGFRα: platelet-derived growth factor receptor, alpha polypeptide.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.IN, TJ and BM were all involved in the management of the patient as well as writing the case report. All authors have read and approved the final manuscript.


Littoral cell angioma (LCA) is a recently described primary vascular neoplasm of the spleen that may be associated with other malignancies and may itself also have malignant potential.We present a case of LCA that was discovered incidentally in a 52-year-old woman who presented with biliary colic at the time of consultation for cholecystectomy. This vascular neoplasm was evaluated by ultrasound, CT, MRI, Tc-99m labelled red blood cell scintigraphy, and core biopsy. A splenectomy revealed LCA by pathological evaluation. Post-operative outcome was favourable with no evidence of complication or recurrent disease. Following this case presentation, clinical, radiographic, and pathological features of LCA will be reviewed as well as recent advances in our understanding of this uncommon splenic lesion.LCA is a rare, generally benign, primary vascular tumour of the spleen that typically is discovered incidentally. Individuals diagnosed with this tumour must be carefully evaluated to exclude primary, secondary, and synchronous malignancies. Littoral Cell Angioma (LCA) of the spleen was recently described by Falk et al. in 1991 . On. On25]. Gross pathology of LCA is characterized by single, or more commonly, multiple pigmented focal nodules well-delineated from normal spleen parenchyma ,30. The Microscopically, there are several distinguishing histological and molecular features of LCA. Histologically, LCA has specific features that differentiate it from other primary vascular tumours, including angiosarcoma . LCA areSymptomatic LCA are often relieved by splenectomy, and given the association of LCA with other malignancies and reported cases of metastasizing LCA, splenectomy is both diagnostic and therapeutic. While there have been reports of medical therapy with glucocorticoids and angioembolization of splenic haemangiomas , splenecLCA is a recently described primary vascular neoplasm of the spleen that may be associated with other malignancies and may itself also have malignant potential. Several radiological studies may suggest LCA, although a pathological diagnosis, either by core biopsy or diagnostic splenectomy is imperative. This rare case illustrates the importance of thoroughly evaluating incidental vascular splenic tumours. Although the vast majority of LCAs are benign, their differential diagnosis must include both primary and secondary malignancy, given LCA's association with other cancer types as well as their uncertain malignant potential. With this in mind, gold standard management remains splenectomy and long-term follow-up for the development of synchronous tumours or metastatic lesions is advised.The authors declare that they have no competing interests.MT performed the literature review and drafted the manuscript. PV reviewed and revised the manuscript and provided radiographic images. PZ reviewed and revised the manuscript and provided pathologic images. SW originated the idea and assisted with drafting and revising the manuscript. All authors read and approved the final manuscript.


Ascariasis is the most common helminthic infection to infest man. Usually the adult worm lives in the small intestine. Rarely it migrates through the ampulla of vater and enters the common bile duct. We are reporting a case of gall bladder ascariasis causing acute cholecystitis treated by laparoscopic cholecystectomy. Presence of Ascaris lumbricoides in gallbladder is rare entity as it is difficult to reach there due to the narrow and tortuous cystic duct. Ascariasis, a human disease caused by roundworm Ascaris lumbricoides. A common disease of the tropics. Parasites can migrate into the biliary tract and create problems such as recurrent pyogenic cholangitis, gall stones, and pancreatitis. Acalculond post operative day with antihelmenthic medications.18-year-old girl, of low socio-economic strata, presented with history of right upper abdomen pain of 1-month duration. Aggravation of pain, low-grade fever and non bilious vomiting since 1 day. There was no history of jaundice or of passage of worms in stools. On examination, there was no pallor, no icterus. Abdomen examination revealed tenderness in right hypochondriac region, no palpable mass, no hepatomegaly. Her investigations revealed hemoglobin: 11g%, total count of 12,000/dl, neutrophils: 62%, lymphocytes: 24%, eosinophils: 10%, ESR : 12 mm in first hour. Liver function tests were normal, Alkaline phosphatase was normal (64U/L). Ultrasonography showed a linear, ribbon-like, tubular, non-shadowing structure with an echogenic wall and a less echogenic centre in the GB, suggestive of biliary ascariasis. GB wall thickness was 5 mm, with dilated common bile duct (CBD) (9mm). There was no stone within the GB or CBD. A computerised tomographic (CT) scan  revealedAlthough intestinal and bile duct ascariasis is common, A. lumbricoides in the GB is uncommon, even in endemic areas.Biliary ascariasis may be complicated or uncomplicated. In uncomDiagnosis of biliary ascariasis can be established by hepatobiliary ultrasonography, CT scan. GB may be normal or have thickened wall. Dilatation of biliary duct may be present if worm obstructs the CBD.Ultrasonography is a highly sensitive and specific method of detection of worms in the biliary tree. It maybe repeated frequently to monitor the movement of worms in the duct.The established treatments for biliary ascariasis are antihelminthic drug therapy, endoscopic extraction, and surgical extraction.5Antihelminthic drug therapy is commonly performed before or after surgery.In this case, we gave the patient the antihelminthic drug after the laparoscopic cholecystectomy because in our patient the worm was located in the gallbladder, and cases with failed medical treatment have been reported.Conservative treatment usually fails in the presence of a dead worm, concomitant stones or stricture which prevents the returning of worm to the duodenum, requiring a cholecystectomy or CBD exploration. Laparoscopic or endosOur patient presented with ascariasis cholecystitis which was treated with antibiotics.She was evaluated by ultrasound abdomen and CT scan. After the patient recovered her acute phase, she was re-evaluated with a transabdominal ultrasonography. The worm persisted in the gall bladder with no evidence of worm in CBD. She was then taken up for a laparoscopic cholecystectomy which revealed a dead worm. This patient would have required CBD exploration (open/laparoscopic/endoscopic) if a worm was within the CBD.