Although rectal cancer is by far and large the most common pathology involving the rectum that needs imaging, there are many other important but less common pathological conditions affecting anorectal region. The objective of this pictorial review is to discuss the cross-sectional imaging features of less common anorectal and perirectal diseases.Although a specific histological diagnosis cannot usually be made due to considerable overlap in the imaging appearances of anorectal diseases, this review illustrates the cross-sectional imaging findings with emphasis on magnetic resonance imaging (MRI) that can help in narrowing down the differentials to a reasonable extent.Variety of pathology exists in the anorectum apart from common rectal carcinoma• Anorectal diseases present as non-specific wall thickening indistinguishable from rectal carcinoma• Computed tomography (CT) and MRI can help in narrowing down the differentials, although often biopsy is warranted.•  Primary rectal adenocarcinoma is a common malignancy with a high mortality rate in the western world. Initially computed tomography (CT) and endoluminal ultrasound (EUS) have been the mainstay of diagnosis and staging. In the past decade magnetic resonance imaging (MRI) has become the imaging modality of choice for loco-regional staging of rectal cancer. The complex anatomy of the anorectal region makes imaging and interpretation challenging. The advent of MRI, with its high soft tissue contrast, multiplanar capability and no radiation risk, has simplified imaging of the anorectal region. The role of MRI in preoperative staging of rectal cancer has been well established now. Though rectal cancer is the commonest cause of rectal mass, there are many other common and uncommon diseases which affect rectum and perirectal region, many of which can mimic rectal carcinoma and their distinction is essential as the management strategy changes significantly . The objMRI of the rectum may be performed with either an endorectal coil or a phased-array surface coil. The decision depends on the availability of coils, technical expertise of radiologists, surgeon’s preference and practical issues like time constraints. In our institution we use phased array surface coils routinely for all rectal diseases. The advantage of an endorectal coil lies in its high-resolution images that fully depict the wall layers of the bowel but has the disadvantage in evaluating rectal strictures, high rectal carcinomas and assessment of the perirectal structures due to its smaller field of view (FOV). Phased-array surface coil yields high-spatial-resolution images, albeit with less distinction of bowel wall layers but with additional advantage of a large field of view, patient comfort and ease of use in structuring cancers and high rectal, rectosigmoid tumours , 3.In our institution we do no routine bowel preparation, rectal contrast or antispasmodic agents. Opacification rectal lumen with contrast is still controversial with use of various agents like super paramagnetic iron oxide solutions, methylcellulose, barium suspensions and aqueous gel .A sagittal T2-weighted turbo spin-echo (TSE) sequence is obtained first to locate the rectal lesion. Based on the sagittal sequence, axial and coronal T2-weighted TSE sequences are planned, and they are angled to the plane exactly perpendicular and parallel to the lesion. We have a standard rectal cancer protocol which is applied for all other rectal lesions as well . Be. Be24]. Rare benign vascular malformation or hamartoma and is not a true neoplasm. The classical clinical triad of hematochezia, cutaneous haemangioma and ectopic pelvic phleboliths on radiograph should make one suspicious of intestinal haemangioma before the advent of cross-sectional imaging. Markedly thickened rectosigmoid wall showing moderately high T2-weighted signal intensity with high signal heterogeneous perirectal tissue with enhancing serpiginious structures  are the characteristic MRI findings Fig.  25, 26], 2625, 2Mucinous (colloid) and signet ring are two uncommon histological subtypes of rectal cancer with different biological behaviour and imaging appearances. Mucinous or colloid carcinoma is characterised by the production of an abundant amount of extracellular mucin. It has greater tendency for metastases and local recurrence with 5-year survival rate of 11 % compared with 57 % for non-mucinous carcinomas. Typical MRI features include high signal intensity on T2-weighted images with higher tumour-to-muscle, tumour-to-fat and tumour-to-urine signal intensity ratios. The solid component of the tumour can show diffusion restriction. Contrast-enhancement pattern is peripheral or heterogeneous with lace-like peripheral enhancement being characteristic Fig.  27].Fig.Fig27].FSignet ring carcinoma is a rare type of rectal carcinoma, similar to the mucinous type in having a mucinous component, but with more aggressive behaviour in the form of a more advanced stage of initial diagnosis, more lymphatic and local spread and poor response to surgery. The most common imaging features are long segment of concentric wall thickening and a target appearance similar to those of metastatic linitis plastica consisting of thickened inner (mucosa and submucosa) and outer (serosa) layers and a relatively thin hypoattenuated middle layer (muscularis propria), or bowel wall thickening with homogeneous attenuation –30.Primary rectal lymphoma constitutes only 0.1 % of rectal tumours. The diagnosis of primary rectal lymphomas requires that there is a lymphoproliferative disorder confined to the rectum and regional lymph nodes without involvement of abdominal organs, bone marrow and without retroperitoneal or mediastinal lymphadenopathy. Risk factors include AIDS, inflammatory bowel disease and post-transplant status. Rectal lymphoma can present as intraluminal polypoidal mass or diffuse concentric wall thickening. Aneurismal dilatation with minimal or no obstruction is typical with occasional excavating mass with or without fistulisation . It is uGastrointestinal stromal tumours are characterised by unique expression of the c-kit receptor , which makes them targets for kit inhibitor therapy. The stomach (60–70 %) and small intestine (20–25 %) are the commonest sites, with the rectum involved in 5–7 % of cases. It is common in males over 50 years. MRI features include well-defined eccentric submucosal masses with an exophytic component showing low signal intensity on T1-weighted imaging, isointense to hyperintense on T2-weighted imaging with marked heterogeneous enhancement. T1 hyperintense areas may suggest haemorrhage and T2 hyperintensity suggest cystic change Figs.  and 10. Neuroendocrine tumours (NET) are categorised into three groups: well-differentiated neuroendocrine tumour , well-differentiated neuroendocrine carcinoma  and poorly differentiated neuroendocrine carcinomas  . Rectum Primary melanoma of anorectum is a rare tumour accounting for 0.2–0.3 % of rectal cancers. Typical imaging findings include polypoid intraluminal fungating mass expanding the rectum without obstruction. Bulky perirectal lymphadenopathy is almost always seen Fig. . High T1Kaposi sarcoma is a low-grade mesenchymal tumour that involves the blood vessels and lymphatics. It primarily affects skin and disseminates in multiple organs usually seen in AIDS or other immunosuppressive states. Digestive tract is involved in more than 50 % of patients, the rectum being second most commonly involved after the duodenum. Commonly present as polypoidal submucosal masses or irregular fold thickening with hyperattenuating disseminated lymphadenopathy in 80 % of patients Fig.  41]. Bl. Bl41]. Secondary neoplastic involvement of rectum is uncommon and it is usually by direct invasion from adjacent organs such as the prostate, urinary bladder, uterus and vagina. Prostatic carcinoma, though, grows close to the anterior wall of the rectum, uncommonly involving the rectum as Denonvillier’s fascia is very firm Fig.  42]. Re. Re42]. Deeply infiltrating endometriosis is characterised by fibro-muscular hyperplasia that surrounds sparse ectopic endometrial glands. The rectosigmoid is the most common segment of bowel involved. Implants are usually serosal but can erode through subserosal layers and cause thickening and fibrosis of muscularis propria with development of adhesions, bowel strictures and gastrointestinal obstruction. Implants appear as irregular thickening of anterior rectal wall or extramural rectal mass with spiculation and retraction frequently extending to uterosacral ligaments , 45, 46.Chlamydia trachomatis. It causes ulcerative proctitis mimicking inflammatory bowel disease. Chronic disease leads to strictures and fistulas. Definitive diagnosis is by biopsy and identification of the organism on microbiology , 5251, 5A wide variety of tumours and non-tumorous conditions involve the anorectal region apart from the common adenocarcinoma, inflammatory bowel disease, rectal varices and post-radiation proctitis. A summary of characteristic CT and MRI features are given in Table


Hemangiomas of the gastrointestinal tract and mesentery are uncommon benign vascular lesions. While spontaneous bleeding is the hallmark of the gastrointestinal tumor variant, clinical signs of mesenteric hemangiomas are mostly unspecific. Despite the increasing imaging quality of computerized tomography (CT), in most cases the final diagnosis is established through surgery and histopathologic analysis of a macrobiopsy.We present a case report of a 20-year-old female patient who was admitted with progressive abdominal distension and suffered from persistent abdominal pain for 3 months. A large retroperitoneal tumor mass was detected on the CT scan. Due to radiographic signs of an intraabdominal liposarcoma, an explorative laparotomy was performed revealing a large hemangioma originating from the mesosigmoid.Although rare, gastrointestinal hemangiomas should be kept in mind by oncological visceral surgeons as one differential diagnosis of large intraabdominal tumorous masses, especially in young adults. Hemangiomas are benign tumor lesions, defined as vascular hamartomas of mesodermal origin -5. HemanThe symptoms of hemangiomas depend on the localization of the primary tumor. Nevertheless the most common primary manifestation is spontaneous bleeding ,10. In cComplete surgical tumor resection is the gold standard for the treatment of mesenterial hemangiomas. After complete removal of this tumor a recurrence has not been reported so far. Minimally invasive surgery is, of course, preferred to open surgery, but carries a risk of tumor bleeding, especially in cases of huge intraabdominal masses.The purpose of this article is to highlight the clinical, radiological and histological characteristics of gastrointestinal and mesenteric hemangiomas, which are important differential diagnoses for large intraabdominal tumor masses.A 20-year old female patient was admitted to the University Hospital of Giessen, Giessen, Germany, with a progressive abdominal distention and increasing diffuse abdominal pain. The patient negated nausea, vomiting or any other significant constitutional symptom. The patient had no history of previous abdominal surgery or trauma and had never been in a hospital before.Physical examination revealed a severe, central distention of the abdomen, with diffuse pain caused by digital pressure, but without any signs of peritonism. A large tumor mass was palpable extending to the whole lower abdomen on both sides. There were no abnormal findings in the routine laboratory tests. Measurement of tumor markers revealed normal levels of alpha-fetoprotein (1.8 μg/L), beta-human chorionic gonadotropin (<2.0 IU/L), β2-microglobulin (1.2 mg/L) and lactate dehydrogenase (129 IU/L). The ultrasound examination revealed an enormous tumor mass of the lower abdomen with an inhomogeneous echo pattern.An abdominal computerized tomography (CT)scan with application of both oral and intravenous contrastmedium showed a large space-occupying intraabdominal tumor originating from the retroperitoneum, with regular borders and contrast-enhanced septation. The tumor size was approximately 12 cm x 26 cm x 28 cm. The tumor displaced the intestine and caused a compression of the bladder, without any signs of infiltration.The tumor extended from the level of the pancreatic head into the pelvis. There were no signs of ascites or further lesions of the intraabdominal organs Figure .Surgical removal of the mass was indicated and an exploratory laparotomy was performed. The exploration of the peritoneal cavity revealed a large mass originating from the mesosigmoid, consisting of both solid and cystic components. The tumor was divided from the retroperitoneum by a tumor capsule Figure . Both arThe patient was discharged on the seventh postoperative day. Three months of follow-up was uneventful.Histopathologic examination of the resected specimen revealed an angiomatous malformation embedded in the fatty tissue of the mesosigmoid. It consisted of irregular arterial and venous blood vessels with characteristic cavernous-like dilatation and variable wall thickness. Further immunohistochemical examinations could exclude any lymphoma or mesenchymal tumor as differential diagnoses Figure . The sigHemangiomas are uncommon hamartomatous lesions that originate from the embryonic sequestrations of mesodermal tissue and can be found in any organ -5. WhileGastrointestinal hemangiomas can occur in any age group, but are more common in young adults, often in the third decade of life ,3,4. No Hemangiomas are classified histologically and named according to their major components. There are three principal types: capillary, cavernous and mixed. The cavernous variant is the most common .Cavernous hemangiomas are bluish purple, soft, compressible lesions consisting of large blood-filled spaces or sinuses lined by single or multiple layers of endothelial cells histologically. Degenerative changes such as hyalinization and focal calcification develop as a consequence of thrombosis within sinuses, caused by perivascular inflammation and stasis of blood flow . CalcifiDepending on the tumor localization, various manifestations and symptoms have been reported in the literature. In cases of gastrointestinal localization, 80% of patients present with symptoms such as bleeding or mechanical bowel obstruction ,10. HemoBleeding of extraluminal hemangiomas, therein hemangiomas of the mesenterium or omentum, can cause a hematoperitoneum. Abdominal pain and progressive distention are the major complaints of these patients -15. In tGastrointestinal bleeding, palpable abdominal mass as well as asymptomatic cases of mesenteric hemangiomas have also been described ,10,16,17Despite advanced imaging techniques, gastrointestinal and mesenteric hemangiomas are often misdiagnosed. Due to unspecific symptoms, an average duration of 19 years from symptom onset until the final correct diagnosis is described in the literature [On plain radiograph and barium studies, multiplephleboliths, especially in atypical position, should indicate a hemangioma as a possible diagnosis ,21. OtheUltrasound examination usually reveals a solid mass of mixed echogenicity, whereas CTscan additionally provides information concerning the tumor extent, multiplicity, vascularization and involvement of the intestine or other intraabdominal or retroperitoneal structures . Due to Mesenteric angiography can be a useful tool in cases of acute bleeding, providing both a precise tumor localization and the possibility of an interventional ablation of the arterial inflow. The technique requires an adequate rate of bleeding (0.5 mL/min) to be successful. In patients with diffuse hemangiomatosis of the mesentery, where a bleeding out of a single vessel cannot be identified, a selective mesenteric angiography can be useful in determining the exact localization of the bleeding as well as the extent of resection to be undertaken . MagnetiThe treatment of cavernous hemangioma of the gastrointestinal tract or mesentery is either open or laparoscopic surgical excision. A minimally invasive laparoscopic approach to diagnose the tumor dignity by surgical macrobiopsy could be considered as the gold standard for intraabdominal tumors of unknown origin and entity. Nevertheless, we preferred open surgery due to the tumor size and bleeding risk. Nonoperative techniques such as sclerotherapy, cryosurgery or interventional angiography usually result in symptom recurrence and are therefore temporary solutions. Recurrence after complete resection has not been reported ,25.Hemangiomasof the mesentery, although extremely rare, should be considered as a differential diagnosis in patients presenting with episodes of abdominal pain and imaging showing large intraabdominal tumorous masses. Despite modern radiographic imaging techniques the differential diagnosis of a soft tissue sarcoma is more common and might lead to a tumor biopsy. Bearing in mind that a percutaneous biopsy of hemangiomas could have aggravating consequences, exploratory laparotomy or laparoscopy should be indicated, if imaging techniques leave place for doubt.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.CT: Computerized tomography; HE: Hematoxylin and eosin; MRI: Magnetic resonance imaging.The authors declare that they have no competing interests.AA and AH wrote the manuscript. TS, JH, HG and MR performed histological stainings and radiographic imaging. WP is the responsible chief of the department. Surgical treatment of the patient was performed by him. All authors read and approved the final manuscript.Summary of the single-case reports on mesenteric hemangiomas published in the literature ,22,26-36Click here for file


Chronic indwelling catheters may induce histologic changes within the bladder, and these changes are sometimes pre-malignant. There are many documented cases of squamous cell carcinoma associated with indwelling catheters, but only three cases of catheter-associated adenocarcinoma have been reported. In this case report, we present radiographic findings of a case of mucinous adenocarcinoma of the bladder and suprapubic (SP) tract in a quadriplegic patient.A 71-year-old male with a history of spinal cord injury presented with hematuria and SP discharge after SP catheterization for 51 years. CT urography was performed and revealed an irregular, infiltrative, and heterogeneous mass arising from the anterior bladder at the level of the suprapubic catheter and extending along the SP tube tract. Cystoscopy and biopsy revealed an adenocarcinoma of the anterior bladder and stoma with extensive associated mucin production and a background of acute and chronic inflammation. Surgical therapy included cystoprostatectomy, abdominal wall resection, ileal conduit creation, and abdominal wall reconstruction. The final diagnosis was a high-grade, T2a/N0/M0 (Stage II) mucinous adenocarcinoma of the bladder. There has been no evidence of tumor recurrence over the previous 5 years.Few cases of adenocarcinoma associated with long term indwelling catheter have been reported in the literature, and due to the rarity of this disease process, the prognosis with surgical therapy is not well known. The patient described herein has been free of recurrence for the previous five years, suggesting that surgery is a viable management option for these patients. Quadriplegia due to spinal cord injury (SCI) compromises normal urinary function. Suprapubic (SP) tube placement is favored in quadriplegic patients who are unable to perform clean intermittent catheterization, have acquired complications from urethral catheterization, or require continuous bladder drainage , 2. HoweA 71-year-old C6 quadriplegic male with a chronic indwelling SP catheter presented with hematuria and discharge from the SP tube. The patient suffered a traumatic spinal cord injury at age 19 and an indwelling SP catheter has been present for 51 years, changed monthly. Past medical history was significant for urinary tract infections (UTIs) and nephrolithiasis. Patient endorsed a 25-year history of smoking.Computed tomography (CT) urography was performed and revealed an irregular, infiltrative, and heterogeneous mass arising from the anterior bladder at the level of the suprapubic catheter and extending along the SP tube tract Fig. . The masExtirpative therapy included cystoprostatectomy, abdominal wall resection, ileal conduit creation, and abdominal wall reconstruction. The surgical defect at the level of the skin was approximately 8 cm in diameter, and there was a 3 cm margin circumferentially around the suprapubic tube tract at the skin level. The umbilicus was superior to the involved abdominal wall, and the suspicion of a primary urachal adenocarcinoma was low based on the clinical presentation and history. As such, the umbilicus was not resected as part of the surgical specimen. The differential diagnosis included urachal carcinoma, but these cancers typically arise in the dome of the bladder and no urachal remnant was identified on imaging or at surgery . PatholoThe long-term management of the urinary function of quadriplegic patients presents unique challenges for the urologist, including elevated rates of kidney and bladder stones, renal damage, UTIs, and urinary cancers , 8. ApprCancers arising from a SP catheter tract are also a rare occurrence. As of 2014, there have been fewer than 10 reported cases of squamous cell carcinoma (SCC) of the SP tract or bladder associated with SP catheters . FurtherWritten informed consent was obtained from the patient for publication of this care report and any accompanying images. A copy of the written consent is available for review by the editor of this journal.


Although rare, paratesticular inflammatory myofibroblastic tumor (IMT) represents the second most common paratesticular mass after adenomatoid tumor and comprises roughly 6% of such lesions. Only approximately four cases have been reported in patients younger than 18 years of age. We report an incidentally discovered paratesticular IMT in a 17-year-old male successfully treated with wide excision and testis sparing. To our knowledge, no recurrence has been reported after complete excision of paratesticular IMT; however, continued follow-up is recommended. Inflammatory myofibroblastic tumor (IMT) is an uncommon spindle tumor that may arise in multiple anatomic sites, including the lung, gastrointestinal tract, retroperitoneum, central nervous system, extremities, and the genitourinary tract. Although rare, paratesticular IMT represents the second most common paratesticular mass after adenomatoid tumor and comprises approximately 6% of such lesions . The peaWe report an incidentally discovered paratesticular IMT in a 17-year-old male treated with wide excision and testis sparing.A 17-year-old male was referred for urologic evaluation of a right paratesticular mass noted on routine physical examination by his pediatrician. The patient had a history of congenital adrenal hyperplasia, treated with dexamethasone. He had not noticed any scrotal masses and denied any scrotal pain, swelling, or discomfort. The patient denied any history of dysuria, hematuria, urinary tract infection, or sexually transmitted diseases. No history of trauma, fevers, or any other constitutional symptoms was elicited.Physical examination revealed Tanner stage 5 genitalia with a circumcised phallus and normal urethral meatus. Both testes were descended and were symmetric and nontender, with no intratesticular masses. A nontender, firm 0.8 cm mobile mass was palpated superior to the right testicle and was noted to be completely separate from the testis. Scrotal examination was otherwise normal. The patient had no inguinal lymphadenopathy bilaterally, and his abdominal examination was normal.Scrotal sonography confirmed a 0.7 × 0.8 × 0.6 cm hypoechoic, vascular, slightly heterogeneous lesion superior to the right testicle . The tesDespite a low suspicion for malignancy, surgical exploration was performed through a right inguinal approach with proximal control of the spermatic cord. The lesion was identified superior to the right epididymis and was noted to be mobile and completely separate from the epididymis, vas deferens, and testis . A moderFinal gross pathologic analysis revealed a white, smooth nodule measuring 1.3 × 0.6 × 0.3 cm . MicroscThe patient recovered uneventfully. Physical examination three months postoperatively revealed a well-healed incision and no evidence of recurrence.IMT is a rare spindle tumor that has been assigned many names, including inflammatory pseudotumor, plasma cell pseudotumor, xanthomatous pseudotumor, atypical myofibroblastic tumor, atypical fibromyxoid tumor, pseudosarcoma, plasma cell granuloma, and fibrous pseudotumor –6. This IMT is the second most common paratesticular mass after adenomatoid tumor and comprises about 6% of paratesticular lesions . ApproxiGrossly, IMT is typically a circumscribed, firm, gray-white or yellow lesion . Foci ofThe etiology of IMT remains unclear. It is postulated that these lesions may represent an exaggerated reparative response to trauma, chronic irritation, or infection . Epstein ALK gene. The human ALK gene encodes ALK, a tyrosine kinase receptor and member of the insulin growth factor receptor superfamily [ ALK gene alterations lead to fusion with other genes, and several translocations have been reported [A neoplastic etiology is suggested in some cases that demonstrate genetic aberrations in the short arm of chromosome 2 in region p21–p23, involving a 2p23 rearrangement in theSome pseudotumors demonstrate elevated levels of intralesional IgG4-expressing plasma cells. Thus, it has also been proposed that IMT may represent a localized form of IgG4-related sclerosing disease, which refers to a group of disorders characterized by chronic fibroinflammatory processes at various anatomic sites .Scrotal ultrasonography is usually the initial diagnostic modality and assists in distinguishing between an intratesticular versus extratesticular lesion as well as a solid versus cystic mass. IMT may appear as a hypoechoic or hyperechoic lesion, depending on its degree of collagen, calcifications, or fibroblasts . Unlike Radiologic studies usually cannot differentiate between benign and malignant lesions; therefore, wide surgical excision is the treatment of choice for paratesticular IMT, with testis sparing when possible. Frozen section assessment is useful for intraoperative decision making. A recent study demonstrated that frozen section assessment aided in preventing unnecessary radical orchiectomy in 36 out of 43 (83.7%) benign testicular and paratesticular lesions . HoweverPrognosis after complete surgical resection of paratesticular IMT is excellent. Recurrence rates of 23% to 37% have been reported in abdominal and retroperitoneal IMT ; howeverAlthough rare, IMT should be considered in the differential diagnosis of paratesticular lesions. The treatment of choice is wide excision with testis sparing when possible; however, preoperative counseling should address the possibility of radical orchiectomy. Frozen section assessment is useful for intraoperative decision making. Prognosis after complete excision of paratesticular inflammatory pseudotumor is excellent. To our knowledge, no recurrence has been reported; however, continued follow-up is recommended.


Primary carcinoma of the frontal sinus is quite rare, with an incidence of 0.3–1.0% of all paranasal sinus carcinomas. The early diagnosis is often difficult and the condition is often mistakenly considered to involve mucoceles, pyoceles or osteomyelitis. The present study reports the case of a 66-year-old male with squamous cell carcinoma originating in the frontal sinus. The presenting symptoms were a cutaneous nodule on the left side of the forehead and a gradually progressive headache. Magnetic resonance imaging (MRI) demonstrated erosion of the ethmoid sinus, frontal lobe and orbit. The radical resection under frontal craniotomy was performed followed by post-operative radiotherapy. Six months after the surgery, the MRI examinations did not find any recurrence, and the patient currently lives symptom-free. The present study illustrates that frontal sinus cancer should be diagnosed early with caution. Total surgical resection followed by radiotherapy and chemotherapy, used singly or in combination, may result in favorable outcomes. The current study discusses the diagnosis, treatment and prognosis of the present case and reviews the associated literature to emphasize the importance of an early identification of this rare disease. Primary carcinoma of the frontal sinus, accounting for 0.3–1.0% of all paranasal sinus carcinomas, is extremely rare . The tumA 66-year-old male visited Yizheng People’s Hospital  due to a nodule on the left side of the forehead, which was accompanied by orbital pain and occasional headaches that had been apparent for 4 months. The patient was administered several courses of antibiotics, however, these did not relieve the symptoms. One month prior to the patient being admitted to the Northern Jiangsu People’s Hospital  the headaches became continuous and extremely severe in the left side of the forehead over the frontal sinus region. The patient was consequently transferred to the Department of Neurosurgery in December 2012. A physical examination revealed a giant, solid and low mobility ~4×6-cm subcutaneous nodule on the left side of the forehead . The patA frontal craniotomy was performed with the aim of removing the tumor in December 2012. Subsequent to opening a skin flap, the tumor was found to invade through the frontal bone and to extend to the left frontal lobe . The extHistopathological examination of a biopsy revealed a proliferation of large round cells with abundant cytoplasm . The reset al  The radiological result shows that the tumor originates from the frontal sinus; ii) the histologically predominant type of tumor sample is SCC, adenocarcinoma or basal cell carcinoma; and iii) there is no positive finding in the investigation of other organs, aiming to eliminate a metastatic tumor. The present case showed a subcutaneous nodule with skin symptoms, including pruritus, pain and numbness. It is important to perform radiological examinations for such patients, aiming to find lesions in the frontal sinus. The diagnosis of a malignant tumor in the frontal sinus should also be considered when patients present with several predictors in the CT/MRI scan, including intracranial invasion, destruction of the anterior skull base and deep orbital spread.et al (The treatment for frontal sinus tumors remains controversial, and there are no uniform standard treatment strategies. It is consequently difficult for surgeons to choose the correct treatment for frontal sinus tumors due to their rarity and the diversity of treatment. Therefore, conclusions can only be drawn from a limited number of case studies. One previous study revealed that radical resection may be of benefit by significantly alleviating the symptoms and decreasing the recurrence rate . A cliniet al  describeThe adjuvant treatment for this condition is the same as for conventional SCC. It is unclear whether the use of chemotherapy and radiotherapy could improve the prognosis of frontal SCC. The overall response to chemotherapy is ~82%, and regimens based on cisplatin appear to be reasonably effective, particularly in association with 5-fluorouracil and bleomycin . A previet al (et al (With regard to the prognostic situation, previous studies have shown a poor prognosis for this advanced tumor. In 1969, Frew  reportedet al  reportedet al  reportedl (et al  reportedFrontal sinus tumors can easily be mistaken for certain benign lesions, including mucoceles, pyoceles or osteomyelitis. CT/MRI scans are necessary for the early detection of frontal sinus lesions and to aid in the evaluation of the precise extent of the tumors. The present case illustrates the fact that neurosurgeons should try to increase the accuracy of the early diagnosis of suspicious cases using CT/MRI scans, which can aid in the selection of an appropriate therapy. Surgeons should clarify the border of the lesion prior to surgery, and perform the extended resection based on these findings. Therefore, the use of a complete resection with a clear margin and adjuvant therapy is an essential strategy for the treatment of such a malignant tumor.


Embryonal rhabdomyosarcoma of the female genital tract is rare in the cervix. It has been mainly discussed in the context of individual case studies. It tends to occur in children and young women. Treatment ranges from radical surgery to conservative surgery, followed by chemotherapy.A 16-year-old Moroccan adolescent girl presented to our center with a protruding mass from her vaginal introitus, as a polyp of 6cm. An examination revealed a polyp within her vagina, thought to be arising from her cervix and a polypectomy was performed. Microscopic findings are consistent with an embryonal rhabdomyosarcoma (botryoide type). A computed tomography of her thorax, abdomen and pelvis were performed and residual disease was found as a mass located at her cervix, which measured approximately 4.5cm in its widest dimensions, without evidence of metastatic disease. Due to the fact that she is young, after discussions in a multidisciplinary meeting, she was subsequently treated with four cycles of multi-agent chemotherapy. Two cycles of chemotherapy and radiotherapy were administered due to the lack of response, but she presented vaginal bleeding with persistence of the same mass in computed tomography. Hence a total interadnexal hysterectomy was made. A histologic examination found residual embryonal rhabdomyosarcoma (botryoide type) located in all her cervix and she is currently under chemotherapy.The presence of a cervical polyp in an adolescent is a gynecologic oddity and must necessarily be examined histologically because it might be a rhabdomyosarcoma. This is extremely important because diagnosis at an early stage of the disease is a highly favorable prognostic factor that allows “fertility-sparing surgery” for these young patients. Rhabdomyosarcoma (RMS) is a tumor of skeletal muscle that is classified by the World Health Organization 2013) into embryonal RMS , alveolar RMS , pleomorphic RMS and spindle cell/sclerosing RMS 3 into em in whichWe report a case of embryonal RMS that presented as a cervical polyp protruding from the vaginal introitus in a young teenager, treated by hysterectomy after chemotherapy and radiotherapy. Through this case, we emphasize the diagnosis, management and prognosis factors.A 16-year-old Moroccan girl presented to our center with a protruding mass from her vaginal introitus which she had had for 3 years. It presented as a 6cm polyp with a ‘grape-like’ appearance, smooth, glistening, and focally hemorrhagic. A computed tomography (CT) scan of her pelvis was requested but the family refused due to lack of finance. She was taken to the operating room, at which time the examination revealed a polyp within her vagina, thought to be arising from her cervix and a polypectomy was performed.On microscopic examination, the polyp was covered by squamous and endocervical mucosa. The rhabdomyoblastic nature of the tumor cells was noted by the small-rounded tumor cells, and an eosinophilic cytoplasm with atypical nuclei. Immunohistochemical analysis revealed that tumor cells were immunoreactive to desmin. Nuclear reactivity to myogenin was strong on less than 50% of nuclei. However, the tumor cells were not immunoreactive to cytokeratin. These findings are consistent with an embryonal RMS . Because of a lack of response, two cycles of chemotherapy (cisplatin and etoposide) and radiotherapy were administered, but she presented vaginal bleeding with persistence of the same mass in CT, hence a total interadnexal hysterectomy was made. A histologic examination found residual embryonal RMS located in all her cervix; she is currently under chemotherapy.After discussions in a multidisciplinary meeting (because she is young) she was subsequently treated with four cycles of multi-agent chemotherapy: vincristine, Adriamycinet al. also found a link to the pleuropulmonary blastoma family of tumors with confirmed DICER1 mutations, and reports that RMS in children should be viewed and managed in a broader context to include the possibility of familial pleuropulmonary blastoma tumor predisposition syndrome [When an embryonal RMS affects the genitourinary tract, the vagina is the most common site . Only 0.syndrome . Our patMost patients present with a feeling of a mass in the introitus. The tumor, as is the case in our patient, may form soft, grape-like clusters, present as single or multiple polyps ,4,9. AddThe gross examination showed that the tumors are polypoid with a ‘grape-like’ appearance, smooth, glistening, and focally hemorrhagic ,10. TheyPrimaries RMSs of the cervix are so rare that no single institution has adequate experience to identify superior therapeutic strategies -11, but The embryonal botryoide variant is associated with a much more favorable outcome than the alveolar and the undifferentiated subtypes, which are associated with a particularly poor prognosis . MetastaThe presence of a cervical polyp, particularly one that has achieved a size large enough to protrude from the vagina in a young teenager, is a gynecologic oddity and must necessarily be examined histologically because it might be a RMS. This is extremely important especially as an early disease stage at diagnosis is a highly favorable prognostic factor. Surgery and chemotherapy are the mainstays of treatment of cervical RMS, and the prognosis of patients treated with multimodal therapy is very good.Written informed consent was obtained from the patient and her parents 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.® (doxorubicin), cyclophosphamide.CT: Computed tomography; IRSR: The Intergroup Rhabdomyosarcoma Study Group; RMS: Rhabdomyosarcoma; VAC: Vincristine, AdriamycinThe authors declare that they have no competing interests.SJ was the principal author and major contributor in writing the manuscript. HB reviewed the literature. LC, IH and AL made the histological study. IK and ST made the radiological study. SA and NM treated the patient in oncology. TB and KH treated the patient in radiotherapy. FZF and HC analyzed and interpreted the data from our patient. MAM corrected the manuscript. All authors read and approved the final manuscript.


Uterine myxoid leiomyosarcoma (MLMS) is an extremely rare variant of uterine leiomyosarcoma; only 56 cases were reported from 1982 to 2013. Uterine MLMS is characterized by a myxoid appearance and highly malignant behavior. We herein report a case involving a 65-year-old woman with uterine MLMS with a large tumor embolism that reached the right atrium. A total abdominal hysterectomy, bilateral salpingooophorectomy, and tumor embolism resection with the use of a heart-lung machine were performed. Epirubicin-ifosfamide chemotherapy in the adjuvant setting led to reductions in both the tumor emboli and peritoneal dissemination. The patient retained a good quality of life for 10 months after the initial surgery. She then developed progressive disease despite treatment with pazopanib. She died of her disease 14 months after the initial surgery. Although complete surgical resection of the tumor is desirable, tumor reduction surgery followed by adjuvant chemotherapy might help to retain a good quality of life. This is the first reported case of a primary uterine MLMS with tumor emboli. Myxoid leiomyosarcoma (MLMS) is a rare uterine tumor. Uterine MLMS was first described in 1982 by King et al. [2. The patient's medical and family histories were unremarkable. On pelvic examination, a firm, nontender, approximately 15 cm diameter mass was palpated. Magnetic resonance imaging demonstrated a lobular tumor with low T1- and high T2-signal intensity on the posterior wall of the uterus  presented with lower abdominal pain. Computed tomography revealed a pelvic tumor, and she was referred to us for further examination. At the first visit, the patient's general condition was good, her vital signs were stable, and her body mass index was 21.8 kg/me uterus . Transabe uterus . Cardiace uterus . Smear cA one-stage operation was performed by a combined team of gynecologists and general and cardiac surgeons. Surgical exposure was accomplished through a sternotomy and median laparotomy. Examination of the abdominal cavity revealed a 16 cm soft uterine mass as well as a soft intraligamentary tumor in the bilateral uterus. First, hysterectomy and bilateral salpingooophorectomy were performed. Next, the IVC was exposed by complete mobilization of the right hemiliver, and the falciform and coronary ligaments were transected. After cannulation of the aorta, superior vena cava, and femoral vein, cardiopulmonary bypass and cardioplegia were established. After clamping the superior vena cava and IVC at the entrance of the RA and pulmonary artery, respectively, the RA was opened. The string-like front edge of the tumor embolism inside the RA was resected. The IVC was clamped above the gonadal artery and opened. The tumor embolism, which measured 7 cm in length and 2 cm in width, was then resected. Next, the IVC and RA were reconstructed and cardiopulmonary bypass was uneventfully weaned. A tumor embolism in the right common iliac vein and bilateral gonadal artery and vein was also resected. Residual disease was present in the pelvic venous plexus upon completion of the surgery.Macroscopically, the 16 cm uterine tumor was soft with a gelatinous cut surface . The tum2 on day 1, gemcitabine at 800 mg/m2 on days 1 and 8) was initiated the day of this finding. However, the tumor emboli in the bilateral internal iliac veins extended to the IVC, and the front edge was located close to the RA after one course of docetaxel-gemcitabine chemotherapy. We determined that the chemotherapy was not effective. Thus, pirarubicin-ifosfamide chemotherapy was initiated . Six cycles of this chemotherapy led to reductions in both the tumor emboli and peritoneal dissemination. The patient retained a good quality of life without any pain or dyspnea for 10 months after the initial surgery. However, the peritoneal dissemination in the pelvis gradually worsened despite treatment with pazopanib. The pelvic mass increased to a diameter of 5 cm, and tumor-induced low abdominal pain appeared 12 months after the initial surgery. The patient died of postrenal uremia due to the pelvic tumor 14 months after the initial surgery.The patient was managed in the intensive care unit immediately postoperatively and moved to the general ward on postoperative day 2. Twenty-two days postoperatively, computed tomography revealed tumor emboli in the bilateral internal iliac veins and peritoneal dissemination around the liver and sigmoid colon. Docetaxel-gemcitabine chemotherapy , and common symptoms include atypical genital bleeding, a pelvic mass, and abdominal pain. Grossly, MLMS has a gelatinous appearance and circumscribed border. Microscopically, the tumor contains a large amount of myxomatous stroma and invades adjacent tissues and/or the lumens of surrounding veins. Traditionally, the mitotic count has been used to distinguish leiomyosarcomas from leiomyomas. However, the diagnosis of MLMS is currently based on the gross and microscopic features of the tumor rather than the mitotic index [Although intravenous leiomyomatosis is a well-known entity, the occurrence of intravenous extension of uterine leiomyosarcoma is extremely rare. To the best of our knowledge, only three other cases of intravenous uterine leiomyosarcomatosis have been described, and this is the first reported case of uterine MLMS –12. In tNo treatment of uterine MLMS has yet been established. Complete surgical excision appears to be an effective initial treatment. Burch and Tavassoli  reportedIn conclusion, we have described a rare case of MLMS of the uterus with gross intravascular extension that reached the RA. Although complete surgical resection of the tumor is desirable, tumor reduction surgery followed by adjuvant chemotherapy might help to maintain a good quality of life.


E. coli, indicating E. coli infection as a possible etiology of this lesion. Pathology was consistent with inflammatory pseudotumor.Inflammatory pseudotumor is a nonmalignant lesion that mimics malignant lesions and has been reported to occur at various sites throughout the body. Though it has been reported as a reaction to infection, the true etiology of the lesion is unknown. In this report, we present the case of a patient with a liver lesion of unknown origin. Through a series of imaging studies, we were able to observe the locally aggressive nature of this lesion as it rapidly eroded into the lung. Sputum cultures showed growth of  Inflammatory pseudotumor (IPT) is a rare, nonmalignant lesion that can present a diagnostic challenge because of its ability to clinically and radiographically mimic malignant processes –3. Howev Escherichia coli [The lungs are the most common locations for IPT , followehia coli . E. coli in the sputum. This strengthens the association between E. coli and IPT.We present here a unique case of pulmonary invasion by a liver IPT, followed by identification ofThe patient was a 67-year-old African-American male veteran with a history of diabetes mellitus type 2 (hemoglobin A1c 6.6%) who presented with a fever of 39.5 and tachycardia to 115 following a routine outpatient CT scan for a liver mass that was discovered about a month earlier on ultrasound.The patient had recently been treated empirically for a urinary tract infection with ciprofloxacin for seven days with symptomatic improvement. During the week prior to admission, he had been experiencing shaking chills and fevers, as well as a 4.5 kg loss due to anorexia and nausea without vomiting.His past medical history was significant for a remote history of prostate cancer, treated with brachytherapy and a thyroid nodule found on thyroid ultrasound. He had not traveled outside the United States since serving in Vietnam.Physical exam on admission was significant for fever and tachycardia, but otherwise, the patient appeared well, and the abdominal exam did not show tenderness or organomegaly. Liver function tests were within normal limits, and hepatitis B and C serologies were negative. Admission CT scan showed a multiloculated cystic mass within the liver . The difMRI with contrast was performed to further characterize the mass, but the differential diagnosis remained broad. The portal vein thrombus was observed again.The patient's fever had resolved shortly after admission, but he then again developed a fever up to 39.2 three days after admission. At that point, he was pancultured and started on vancomycin and piperacillin-tazobactam. Results of the sputum culture are shown in The patient underwent a CT-guided biopsy of the liver lesion six days after the initial fever. On CT imaging taken for the biopsy, the lesion was noted to have spread, creating a cavitary lesion in the right lung . An aspiDue to the equivocal result of the first biopsy, a second biopsy was performed to obtain tissue from the solid portion of the mass. Pathology eventually showed multiple foci liver parenchymal replacement by an inflammatory and spindle cell infiltrate. Immunohistochemical stains showed the infiltrate to be positive for CD68. Pancytokeratin staining highlighted the entrapped hepatocytes and ductular structures with CK7, a marker for epithelium. CD117 (receptor tyrosine kinase associated with cancer) and S100  were negative; nonspecific staining was noted with DOG1 (tumor repressor). These findings were consistent with inflammatory pseudotumor. E. coli found in the sputum. Follow-up ultrasound imaging showed a gradual decrease in the size of the lesion.The patient was discharged on intravenous ertapenem for three weeks and then transitioned to oral trimethoprim-sulfamethoxazole, to cover the E. coli was cultured from the sputum, further strengthening the association between E. coli and IPT.This patient had an inflammatory pseudotumor of the liver with radiographic evidence of the process of infiltration of the right lung. Soon after this process was observed on imaging,IPT is a rare condition that can affect any organ but most commonly affects the lungs and the liver . The symOn imaging, the CT scans showed an irregular, loculated mass, with at least partial blockage of the portal vein. Similar findings have previously been reported for IPT of the liver , 5, 7. I E. coli, which has been associated with IPT in a previous case report [ E. coli was cultured from the patient's sputum, corresponding temporally to when the mass eroded through the right diaphragm and invaded the lungs ( E. coli is an uncommon organism to be isolated from the sputum, we believe that we can attribute the presence of this organism in the sputum to the infiltration of the IPT into the lungs from the liver. Treatment of the E. coli infection with intravenous followed by oral antibiotics caused the mass to shrink, reinforcing the idea that the infection was the source of the mass. However, further research, especially basic science research, is needed to determine whether there is a causal relationship between the IPT and E. coli.One unusual feature in this case was our ability to identifye report , 9, as ahe lungs . Other sTreatment of IPT has been somewhat controversial , with deEscherichia coli infection in the presence of a rapidly changing mass can be a clue to the diagnosis of inflammatory pseudotumor.


Internal hernias include paraduodenal, pericecal, through foramen of Winslow, intersigmoid and retroanastomotic hernias. These hernias could be either congenital or acquired after abdominal surgery. They account for approximately 0.5-5 % of all cases of intestinal obstruction.A 48-year-old female was admitted to casualty with a history of abdominal distension and vomiting of 3 days duration. An abdominal X-ray supine film showed multiple small bowel loops with air fluid levels. On surgery she was found to have a transmesocolic hernia. The defect in the transverse mesocolon was repaired.The clinical signs and symptoms of lesser sac hernia are non-specific. These rare lesser sac hernias can be lethal. Therefore, immediate diagnosis and surgery is essential. Although a rare entity, they account for significant mortality form intestinal obstruction. We report an extremely rare case of an internal abdominal hernia through the transverse mesocolon, in a young woman. Internal hernia is protrusion of a viscus or part of a viscus through anatomical or pathological opening within the limits of peritoneal cavity. They could be either congenital or acquired. There are several main types of internal hernias based on the location as described by Meyers . SpecifiWe report a case of transmesocolic herniation of jejunal loops into supracolic compartment with intestinal obstruction which was diagnosed intraoperatively.A 48-year-old female was admitted to casualty with a history of abdominal distension and vomiting of 3 days duration. She had no past history of any gastrointestinal surgery but had undergone lower segment caesarean section 21 years earlier. The caesarean section was uneventful without any iatrogenic injury. On admission, she had bilious vomiting. Physical examination revealed tachycardia, generalized abdominal distension, rebound tenderness and rigidity over left upper quadrant. There was no evidence of organomegaly or free fluid and her external hernia orifices were normal. Her bowel sounds were sluggish. Digital rectal examination revealed an empty rectum. Laboratory investigation on admission revealed a normal full blood count with a white blood cell count of 5000/mm3 and normal renal and liver functions. Her serum potassium on admission was 3.5 mmol/l and she was started in intravenous potassium supplements. An abdominal X-ray supine film showed multiple small bowel loops with air fluid levels without free air under the dome of the diaphragm (Fig. The clinical signs and symptoms of lesser sac hernia are non-specific and include abdominal pain, nausea, vomiting and distension. These rare lesser sac hernias can be lethal. Therefore, immediate diagnosis and surgery is essential. In the literature, only few cases of internal hernias have been documented . The anoAlthough tansmesocolic hernia is a difficult preoperative diagnosis, CT abdomen might help the diagnosis by peripherally located small bowel, and lack of omental fat between the loops and the anterior abdominal wall , 15. ConIn conclusion, diagnosis of intestinal obstruction caused by a congenital mesocolic hernia remains difficult preoperatively despite the techniques currently available, so it is important to consider the possibility of a transmesocolic hernia in a patient with ileus even with no past history of gastrointestinal surgery.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.


Primary malignant tracheal tumors are not common and adenoid cystic carcinoma (ACC) of trachea is very rare. The diagnosis is often delayed due to the atypical symptoms. We report an extremely rare case of ACC of proximal trachea, in a 55-year-old female who presented with a 12 month history of progressive dyspnea. Laryngoscopy and computed tomography revealed a broad-based polypoidal mass arising from posterior wall of the proximal trachea. Biopsy confirmed the diagnosis of ACC. The patient underwent a complete surgical resection and post operative radiotherapy. Six months follow-up of the patient did not reveal local recurrence or distant metastases. The literature of tracheal ACC is reviewed. Primary tracheal tumors are rare, constitute only 2% of all respiratory tract tumors  and repr2) 93.1 mmHg, partial pressure of carbon dioxide in artery (PaCO2) 56.1 mmHg, arterial oxygen saturation (SaO2) 96%. White blood cell (WBC) was 14.103/L. Pulmonary function test showed forced vital capacity (FVC) of 1.9 L (80.6% of predicted), forced expiratory volume in one second (FEV1) of 1.74 L (88.3% of predicted). Fibrolaryngoscopy showed bilateral vocal cords were smooth and glottis was normal. Bronchoscopic examination showed an obvious obstruction in cervical trachea with a diameter of 1 cm in the posterior wall of the subglottic trachea, which was smooth and obstructed about 75% of the trachea. The sagittal and coronal reconstruction CT scan of trachea showed a soft tissue image in subglottic trachea . The ages reported for tracheal ACC ranged from 45 to 60 years. Patients with ACC usually present with symptoms such as coughing, wheezing and dyspnea and are often treated for asthma for months to years before being correctly diagnosed. Few patients presented with hoarseness and weight loss .Therefore, helical CT provides precise information about the extent of a tumor, which is important for planning a surgical resection. Unfortunately, this investigation could not be done in our case . BronchoThe surgical methods are primary tracheal resection and reconstruction, primary tumor resection, and endoscopic resection, either by coring or using a laser. Radiation therapy for ACC of salivary glands has been found to provide improved local control of tumors but did not affect survival. This treatment has not been investigated for tracheal ACC. The role of post-operative adjuvant radiotherapy remains uncertain. It is reasonable to assume that adjuvant radiation therapy may be beneficial and likely delays or reduces the incidence of local recurrence in the airway if surgical removal was complete. According to the results of previous studies the 5-year survival ranged from 66% to 100% and the 10-year survival ranged from 51% to 62% for patients with tracheal ACC regardless of the treatment .In summary, ACC is a rare primary tracheal malignancy. Hemoptysis, nonproductive cough, and dyspnea are the common initial and atypical symptoms. Complete surgical resection provides the patient with the best chance of prolonged survival or even complete remission. Post-operative radiotherapy may have some effect on local control but did not affect survival rate.


Pneumatosis intestinalis (PI) is a rare condition where the gas trapped inside the bowel wall. It is commonly found as an incidental finding on routine abdominal imaging or scans. We present a case of incidental laparoscopic finding of pneumatosis intestinalis on a 32-year-old male, who underwent a laparoscopic appendectomy for an acute appendicitis. Laparoscopic appendectomy was performed and pneumatosis intestinalis managed conservatively. Patient did well and was discharged home. Management of PI depends on clinical presentation; asymptomatic PI can be managed adequately by treating underlying causes. We report a case of incidental laparoscopic finding of Pneumatosis intestinalis, which was adequately managed by treating underlying appendicitis. Pneumatosis intestinalis (PI) is an uncommon condition where the air trapped inside the bowel wall. It is usually found as an incidental finding on routine abdominal imaging. PI can be cystic, linear, and microvesicular in appearance. Mostly it is recognized as a benign condition and treated conservatively . We repo9/L with absolute neutrophils 12.1 × 109/L, CRP 38 mg/L, and Hb 14.1 g/dL. All other blood tests were under normal limits. His urine dipstick showed no signs of infection or blood.A 32-year-old Caucasian male presented with 1 day history of right lower quadrant pain, without any bowel or urinary symptoms; vital signs were stable. On physical examination abdomen showed rebound tenderness and guarding in right iliac fossa. He recently had normal investigation for a nonspecific chest pain. He takes no regular medication and no known medical allergies. He has a significant family history for hyperlipidemia and cardiac problems. He is a nonsmoker and consumes alcohol occasionally. His white cell count was 14.2 × 10The presentation, clinical and bio chemical work up suggested acute appendicitis. Patient underwent a laparoscopic appendectomy. During laparoscopy we noted cystic gaseous changes of serosa of the ascending colon up to the hepatic flexure  with acuThe appearance of gas under the subserosal layers of the bowel wall was generally termed as pneumatosis intestinalis. It was initially recognized and reported in a French literature by Du Vernoi on 1754. Since then, there were several pseudonyms used to describe it.The historical classification divides pneumatosis intestinalis into primary (15%), which are benign cystic appearance in submucosal or subserosal layers from unknown origin . The secThe pathophysiology of PI is not well understood. The recent hypothesis suggests that mucosal integrity, intraluminal pressure, bacterial flora, and intraluminal gas have an interactive role in the formation of the pneumocysts .2 inflation was similar mechanism to chronic pulmonary diseases induced PI.In our patient, although we used a non-traumatic port introducer; our initial suspicion made us look for any iatrogenic injury to the bowel wall. Fortunately there was no obvious bowel injury noted on laparoscopy. It is important to note that the initial laparoscopy was performed via umbilical port, away from ascending colon and remaining two ports were inserted under laparoscopic guidance. There can be two possible explanations for this case scenario. Firstly the inflammatory changes in appendix lead to increased mucosal perfusion and secondly increased intra-abdominal pressure due to COIncidental findings of PI on radiology or endoscopy are normally asymptomatic and behave in a benign pattern . TreatinPIs rarely cause abnormal clinical signs, but most commonly they do express the features of underlying pathologies. A 919 cases review study on PI published in 1979 explains that the PI in small bowel predominantly causes vomiting, abdominal distension, and diarrhoea , 7. The Radiological investigations from plain film abdomen to CT scan can easily detect PI. Various other studies such as barium contrast study or MRI also can be used . The linPatients with acute abdominal signs and symptoms with radiological suggestion of PI should be given additional care to look for underlying abdominal catastrophe. PI is a sign not a disease; it could represent from benign to life threatening conditions of the gastro intestinal system.There is only handful of cases reported on PI associated with acute appendicitis. There is a case reported; PI was noted on CT scan in a patient with acute appendicitis. This led to the suspicion of small bowel ischemia. An emergency laparotomy was performed, which revealed an acute appendicitis without any ischemic signs of the small bowel. PI was managed conservatively after appendectomy .Incidental finding of PI during emergency laparoscopic appendectomy creates a challenging situation for the operating surgeon. A thorough examination of intra-abdominal organs and a good clinical judgement is necessary to manage these patients.Treatment options vary, from initiation of antibiotics therapy, oxygen inhalation, elemental diet, hyperbaric oxygen, and surgery.Pneumatosis intestinalis can be found as an incidental laparoscopic finding in acute appendicitis; after diagnostic laparoscopy, it can be managed exclusively by performing appendectomy. Laparoscopic incidental finding of pneumatosis intestinalis does not always indicate a life threatening bowel pathology and can be managed conservatively by treating underlying causes.


A prostatic utricle cyst is an epithelial lined diverticulum arising from the prostatic urethra and usually asymptomatic when small. When enlarged, it may be symptomatic and is typically accompanied by hypospadias. We present a case of a markedly enlarged prostatic utricle in a neonate without hypospadias, demonstrated on voiding cystourethrography (VCUG), ultrasound, and 1.5 Tesla MRI. Prostatic utricle cysts are believed to represent the incomplete regression of Müllerian ducts. They are commonly diagnosed during childhood as there is an association with hypospadias, pseudohermaphroditism/intersex disorders, and cryptorchidism. Prostatic utricles are often incidentally found on VCUG or sonography. The case presented is unique in that (1) the prostatic utricle was markedly enlarged, (2) detection has seldom been made with MRI, and (3) the presence of an enlarged prostatic utricle was without associated hypospadias.Prenatal ultrasound revealed a large cystic mass adjacent to the urinary bladder. Upon the initial neonatal exam, in this term baby, a 3-4 cm firm intra-abdominal mass was palpated in the umbilical region. Also, ambiguous genitalia were observed; specifically, no testes were palpated and a micropenis was seen. Subsequent karyotype revealed 46, XY.The initial postnatal ultrasound demonstrated moderate right hydronephrosis and a distended urinary bladder. No uterus was identified, but directed ultrasound failed to visualize testicles within the scrotum. Furthermore, the previously identified pelvic cystic mass was not visualized.Decreased urine output over the following two days prompted a repeat ultrasound examination. This study showed two large anechoic cystic structures within the pelvis. One of these structures was identified as the urinary bladder. The second cystic mass was larger and located posterior to the urinary bladder, displacing it anteriorly and toward the right .VCUG demonstrated a contrast-filled saccular structure. This structure was initially thought to represent the urinary bladder. However, closer inspection revealed that this structure was posterior to the bladder. Since the catheter terminated within this cystic structure, it confirmed its direct communication with the urethra, thus representing a prostatic utricle cyst .MRI at 1.5 T demonstrated a T2 hyperintense, T1 hypointense large cystic structure located between the rectum and urinary bladder, which was encapsulated by a rim of T2 isointense soft-tissue, representing prostatic tissue Figures . This cyFurther testing led to the diagnosis of congenital adrenal hyperplasia, for which pharmacologic treatment is in place. Low testosterone was also detected. However, the testes were identified on a 4-month follow-up MRI (not shown), which also showed an interval decrease in size of the prostatic utricle cyst. Definitive treatment of the prostatic utricle was accomplished through complete surgical resection approximately two months later. During this operation, orchiopexy was also performed, which revealed an abnormal appearing right testicle but normal appearing left testicle. The patient's left hydronephrosis resolved after the resection, and the right hydronephrosis improved but persisted to a mild degree. Moreover, follow-up imaging has shown no evidence for residual prostatic utricle and the patient is currently symptom free.Prostatic utricle cysts are generally believed to represent the incomplete regression of the Müllerian ducts. Others have proposed that they derive from the urogenital system in the prostatic urethra . The mosMost prostatic utricular cysts are asymptomatic, especially when small. If large, symptoms typically consist of urinary incontinence, recurrent infections, or stone formation, malignant degeneration has been reported in 3% of prostatic utricles with a peak incidence in the 4th decade of life [Although initial autopsy-based estimate for prostatic cysts was 1%, the incidence of a giant utricular cyst has not been definitively established . In any The differential for such a pelvic mass in males includes considerations other than a prostatic utricle, such as a bladder diverticulum, urachal cyst, Müllerian duct cyst, or seminal vesicle cyst. As described in this case, giant prostatic utricles communicate with the prostatic urethra and are located midline, posterior to the bladder, and anterior to the rectum. Although they are also midline, Müllerian duct cysts, on the other hand, do not typically communicate with the prostatic urethra. Furthermore, Müllerian duct cysts are frequently encountered during the 3rd to 4th decade of life and are without external genitalia abnormalities . UrachalWith regards to utricular cyst treatment, aspiration/puncture of the cyst has met only moderate success, with approximately half of the cases showing improvement without recurrence. Given these limitations, surgical excision is considered the treatment of choice. Various surgical approaches exist, including suprapubic, midline transvesical, and perineal. Endoscopic procedures improved or cured 82% of the patients in one series .Of note, MRI has been used only rarely to diagnose an enlarged prostatic utricle. To our knowledge, most of these MR evaluations have been reported in older children . AlthougWe have presented an unusual case of a neonate with an abnormally large prostatic utricle and an intersex disorder that was not associated with hypospadias, in which MRI was instrumental in the diagnosis. In a patient presenting with a large pelvic cystic mass perinatally with accompanying urological abnormalities, a prostatic utricle cyst should be included in the differential diagnosis.


Multiple mesenteric well-differentiated (WD) liposarcoma is an extremely rare entity. The present study describes a case of multiple mesenteric WD liposarcoma, complicated by purulent inflammation, in a 59-year-old male who presented with abdominal pain and pyrexia of unknown origin. A computed tomography scan of the abdomen revealed a large, non-encapsulated mass in the abdomino-pelvic cavity, which was characterized by two components, a main portion of fatty density and a non-adipose solid portion. A re-evaluated CT scan, performed eight days later, revealed an enlargement of the non-adipose mass. A laparotomy was performed, and numerous separated fatty nodules and masses of various sizes were identified within the mesentery of the small intestine. The histological findings were consistent with an adipocytic subtype of multiple mesenteric WD liposarcoma, with the largest of the tumors complicated by purulent inflammation. The multiplicity of these tumors and the concurrent purulent inflammation in the present case make it unique. Well-differentiated (WD) liposarcoma is the most common subtype of liposarcoma, accounting for 40–45% of all cases . The mos9/l , and a differential count of 86.0% neutrophils, which was consistent with infection. Physical examination revealed an ill-defined pelvic-abdominal mass with tenderness in the lower abdomen. A non-contrast abdominal computed tomography (CT) scan performed in the emergency department revealed a large abdomino-pelvic mass, which extended from the upper pole of the kidney to the pelvis. The mass was composed of two components, a main portion of fatty density and a non-adipose solid portion located within the lower part  with progressive distension of the abdomen that had been apparent for six months, pyrexia of unknown origin and worsening abdominal pain that had begun five days earlier. A peak body temperature of 38.8°C was recorded, with an associated loss of appetite and fatigue being reported. Blood tests revealed neutrophilic leukocytosis, with an elevated total white blood cell count of 27.94×10wer part . The fatThe patient was admitted to Yantai Yuhuangding Hospital and treated conservatively with broad-spectrum antibiotics. Over the following seven days, the fever remained constant, with temperatures between 37.8 and 38.6°C, and the peripheral white blood cell count remained elevated. On the eighth day post-admission, the mass was re-evaluated using CT intravenous contrast enhancement, which revealed an increase in the diameter of the non-adipose solid mass. The longest diameter measured 14.2×16.0 cm . The nonA laparotomy was performed for symptomatic relief and to obtain a definitive diagnosis. Intra-operatively, numerous separated fatty nodules and masses, with sizes ranging between 1 and 15 cm, were attached to the mesentery of the small intestine. The largest of the masses measured 14×15 cm, was greenish-yellow in color, and was solid with wide areas of necrosis, hemorrhage and abscess formation. The other masses were soft, yellow and homogeneous in consistency. There was no evidence of peritoneal dissemination, ascites or invasion to adjacent organs in the abdominal cavity. The majority of the tumors were separated and removed, but an en bloc resection was impossible to perform due to the large number of small nodular lesions.The histological analysis of the solid mass revealed atypical adipocytes with various sizes of fat vacuoles. The abundant inflammatory cells consisted predominantly of neutrophils, which were widely distributed throughout the tumor in the fibrous septa and the adipocytic areas. There were apparent regions of extensive necrosis and hemorrhage, which were densely infiltrated by neutrophils . The secLiposarcoma is a sarcoma of mesenchymal origin, which affects soft tissues of the body, in particular the extremities and the retroperitoneum. On rare occasions, the tumor may affect the mesentery. Primary mesenteric liposarcomas usually arise between 50–70 years of age, and exhibit a higher incidence in males compared with females . The cliHistologically, liposarcoma can be divided into five subtypes, myxoid, pleomorphic, dedifferentiated, round cell or WD . Upon CTMultiple mesenteric WD liposarcoma is an extremely rare entity, and at present only one case has been reported in the literature . A pre-oThe unusual aspect of the present case was the evidence of necrosis, hemorrhage and abscess formation on a WD liposarcoma. This occurrence appears to be rare, as a PubMed search using the keywords ‘well-differentiated liposarcoma’ and ‘abscess or purulent inflammation’ did not yield any results. The inflammatory tumor in the present study differs from the inflammatory variant of a WD liposarcoma, radiologically and histopathologically. CT revealed that the inflammatory tumor in the present study appeared as a large solid mass with inhomogeneous contrast-enhancement. The imaging features of inflammatory WD liposarcoma are not significantly different from their commoner counterparts . Upon miIt should be noted that the presence of large, low-density fat with a large, non-adipose mass may raise the possibility of a dedifferentiated liposarcoma, which is a biphasic WD liposarcoma with a high-grade pleomorphic sarcoma . Upon CTTo summarize, the present study reported a case of multiple mesenteric WD liposarcoma, which was complicated by purulent inflammation. The CT features of these multiple tumors were characterized by extensive infiltrative distribution of lipomatous tissue with coarse septa and patchy soft-tissue components. The inflammatory tumor appeared as a large, solid mass and demonstrated heterogeneous enhancement with hypodense areas, which corresponded to hemorrhage, necrosis and abscess formation. Multiple mesenteric WD liposarcoma is an extremely rare entity. This variant should be considered when evaluating a massive infiltration of dishomogeneous lipomatous tissue in the abdominal and pelvic cavity. The present study also revealed that abdomino-pelvic WD liposarcoma can be complicated by purulent inflammation. Radiologists should therefore consider this when establishing differential diagnoses for patients with a fever of unknown origin and the occurrence of a primarily fatty, WD liposarcoma in close proximity to a non-lipomatous mass, as observed in the present study.


A 71-year-old female with a history of endometrial cancer presented to our hospital with bilateral lower quadrant abdominal pain, which had been worsening over the past two months. The pain was associated with constipation, pencil-thin stools, and a 60 lb weight loss. On physical examination, the patient had suprapubic and left lower quadrant abdominal tenderness. Contrast-enhanced CT scan revealed a 6 cm pelvic mass in the left lower quadrant. It was unclear if this mass was arising from the sigmoid colon or abutting it. A colonoscopy to further investigate the mass was pursued and this revealed a moderate 5 cm long stenosis in the sigmoid colon starting at 15 cm from the anal verge. The stenosis was not ulcerated but had a bluish/purplish hue to it circumferentially. Multiple biopsies were obtained from that area and these revealed architectural changes with mild fibrosis but no malignancy. The mass was further explored with CT-guided fine needle aspiration. The results obtained were positive for cytokeratin-7, CA-125, estrogen receptor protein, and PAX-8 confirming that the mass was endometrial in origin. Endometrial cancer is the leading cause of genitourinary cancers among women in the United States . In geneA 71-year-old Caucasian woman, with a remote history of stage 1 endometrial cancer treated more than 10 years ago with total abdominal hysterectomy and bilateral oophorectomy (TAHBSO) with no radiation, presented to our institution with intermittent cramping and bilateral lower quadrant abdominal pain, progressively worsening over a 2-month period. This was associated with constipation and thin stools. She also reported a 60 lb weight loss over the past year. She denied any nausea, vomiting, hematochezia, or melena. She also denied fevers, chills, or night sweats. Physical examination revealed a tender abdomen mainly over the suprapubic area and the left lower quadrant. No guarding or rebound tenderness was appreciated. Bowel sounds were normoactive.A CT scan was performed and showed a 6 cm pelvic mass in the left lower quadrant . It was Surgical resection of the pelvic mass was performed, followed by chemotherapy and pelvic radiation. The patient did not tolerate the chemotherapy and passed away from complications related to neutropenia and sepsis two months after presentation.Endometrial cancer is the seventh leading cause of cancer amongst women in the United States with approximately 42,160 new cases diagnosed every year and accounting for 7780 deaths as per 2009 cancer statistics . AdditioOur patient had a recurrence more than 10 years from diagnosis of endometrial cancer. Her presentation was interesting since she presented with symptoms of bowel obstruction, and her colonoscopy showed evidence of an obstructing colonic mass, which was thought to be primary colon cancer versus metastatic endometrial cancer in the colon wall. While most relapses occur within 3 years after hysterectomy for endometrioid carcinoma, vaginal recurrence 17 years after TAHBSO and adjuvant pelvic external-beam radiation therapy (EBRT) has been reported , but no


Clear cell adenocarcinoma (CCC) is generally thought to originate from ovarian, endometrial, or renal tissue. A CCC of the peritoneum (CCAP) is an extremely rare medical condition and is associated with a poor prognosis. To date, only 10 cases of CCAP have been reported, of which half resulted in death or recurrence within 6 months after initial treatment because CCAP is commonly resistant to multiple drugs. In this report, we present a case of CCAP of the pouch of Douglas coexisting with an endometriosis and we offer a review of the related literature. Clear cell adenocarcinoma of the peritoneum is an extremely rare medical condition with poor prognosis. Because of its reality, no standard treatment has been established. Here, we report a case with primary clear cell adenocarcinoma in the pouch of Douglas treated by debulking surgery followed by chemotherapy.A 59-year-old postmenopausal woman, gravida 2, para 2, was referred to our hospital for the treatment of a pelvic mass. Her initial complaints were appetite loss and 12 kg weight loss over 3 months. Her past medical history was unremarkable, except for an appendectomy, and her gynecological medical history included administration of a gonadotropin releasing hormone agonist for the treatment of adenomyosis manifesting as severe dysmenorrhea.On her first visit, a vaginal ultrasound revealed a heterogeneous solid mass with cystic areas which was located approximately 6 cm deep within the pelvis Figure a. PelvicOn macroscopic evaluation, a multilobular cyst with a yellowish necrotic solid part was found on the cut surface of the tumor Figure a. The tuSix courses of combination chemotherapy with paclitaxel and carboplatin (TC) as adjuvant therapy was planned. At 3 months after the primary surgery, the patient presented with strangulated ileus, which was corrected by a second surgery. No recurrent disease was observed in the abdomen at the surgery. Then, the patient completed the planned adjuvant therapy and has remained well with no evidence of disease 10 months after the primary surgery.Primary peritoneal carcinoma was first described by Swerdlow in 1959 . Our casTo investigate reports of the incidence of CCAP, we performed a search of the PubMed database using the key words “clear cell” or “peritoneal” and “primary”. The search was limited to the English literature and CCAP cases. We identified 10 cases that are summarized in Table We offered TC combination chemotherapy to our patient. One report had found that a TC combination therapy was effective for the treatment of CCAP. Outcomes were poor in five cases. Of these, three patients died within 6 months, and disease recurrence had occurred in two cases at 4 months and 32 months, respectively, after the initial therapy –11. ThreCCAP can closely resemble ovarian clear cell adenocarcinoma (OCC) and it is difficult to distinguish CCAP from OCC by preoperative imaging alone, especially if the tumor is located in the pelvis close to the ovary or uterus, even though the radiological features of CCAP have been reported in some cases. One report cited a multicystic mass with a multiseptate appearance and a heterogeneous solid part arising from the peritoneum, suggesting the occurrence of a CCAP .In our case, we did not observe such features and we were unable to determine whether the pelvic tumor originated from the peritoneum. We recommend further imaging studies to establish a definitive diagnosis of CCAP. An endometriosis coexisted with the CCAP in our case. CCC is seen most frequently in the ovary and is often associated with pelvic endometriosis , as an aThe pathogenesis of peritoneal serous carcinoma is similar to that of ovarian cancer and may be dependent on its origin from ovarian tissue remnants in the peritoneum remaining from embryonic development or from the mesoderm that gives rise to both the ovarian epithelium and peritoneum . TherefoHere, we report a case of primary clear cell adenocarcinoma arising from the pouch of Douglas. Although 10 similar cases have been reported, there is as yet no established treatment regimen for this disease. Combination chemotherapy with debulking surgery has been suggested for the treatment of residual tumors <2 cm with postoperative chemotherapy, such as TC or CPT-P. To establish an effective treatment regimen for CCAP, a review of a larger number of cases is still needed.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.


Decompressive surgery for acute subdural hematoma leading to contralateral extradural hematoma is an uncommon event with only few cases previously reported in the English medical literature.The present study describes the case of a 39-year-old White Brazilian man who had a motorcycle accident; he underwent decompressive craniectomy for the treatment of acute subdural hematoma and evolved contralateral extradural hematoma following surgery.The present case highlights the importance of close monitoring of the intracranial pressure of severe traumatic brain injury, even after decompressive procedures, because of the possible development of contralateral extradural hematoma. Traumatic brain injury (TBI) represents an important life-threatening disease. In 2009, the US Centers for Disease Control and Prevention estimated that at least 2.4 million emergency department visits, hospitalizations, or deaths were related to a TBI, either alone or in combination with other injuries. PosttraThe present report describes the case of a Brazilian man who evolved EDH following decompressive surgery for ASDH. We review similar cases previously published.A 39-year-old White Brazilian man was admitted to our Emergency Department after a motorcycle accident on a highway. Although he was hemodynamically stable, a neurological assessment revealed a Glasgow Coma Scale (GCS) of six points and right eye mydriasis. No clotting dysfunction was detected by laboratory test. Computed tomography (CT) of his brain revealed right side ASDH, hemispheric edema and midline shift of 15.7mm with compression of his right lateral ventricle Figure  and fronPosttraumatic intracranial mass lesions are commonly seen after severe TBI and are usually involved in the pathophysiology of intracranial hypertension. ASDH is frequently associated with other intracranial abnormalities, and only 30% to 40% of all ASDHs requiring surgery are isolated lesions,12. The et al.[Several neurosurgical procedures have been reported to be associated with contralateral EDH, such as ventriculoperitoneal shunt insertion and evacuation of acute and chronic ASDH-10,14,15et al., in 2013et al.. The preMany signs have been proposed as alert hints to the detection of contralateral EDH following drainage of ipsilateral ASDH, such as intra-operative brain swelling, postoperative neurological deterioration, pupillary dilation contralateral to the site of ASDH, grand mal seizure and intractable elevated ICP,14,15. IThe pathophysiology involved in the formation of delayed contralateral EDH following decompressive surgery is not fully understood, but may include loss of tamponade effect, vasomotor mechanisms, and coagulopathy, with the main cause appearing to be the upsetting of the equilibrium of the damaged vessels and the reactive ICP. In the In conclusion, the present case highlights the importance of close monitoring of the ICP of patients who have severe TBI, even after decompressive procedures, because of the possible development of contralateral EDH. Although most instances of increased ICP after ASDH drainage seem to be associated with brain swelling, these phenomena should raise the suspicion of evolution of contralateral hematoma.Written informed consent was obtained from the patient’s next of kin 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.LCM, GBS, ECA, RE and FR participated on the surgeries of the patient. All authors helped to draft the manuscript. All authors read and approved the final manuscript.


Background: Malignant pleural mesothelioma (MPM) is an aggressive malignant neoplasm that was thought to be a localised disease with limited metastatic capability. However, recent post-mortem studies have identified metastases to the central nervous system (CNS) in about 3% of cases.Case Description: We present the case of a 65-year-old with a solitary supratentorial metastatic deposit of MPM treated with surgical resection and adjuvant whole brain radiotherapy. Despite a good surgical outcome with symptomatic recovery, the patient died of cardiopulmonary compromise five months postoperatively.Conclusions: Although rare, CNS metastasis of MPM is a condition that neurosurgeons should be aware of. CNS metastases may occur via three distinct mechanisms, namely perineural spread, leptomeningeal carcinomatosis and, most commonly, haematogenous spread leading to parenchymal deposits. Surgical resection of these deposits can lead to symptomatic improvement, and together with radiotherapy, to local disease control. However, the overall survival remains poor. Malignant mesothelioma is an aggressive malignant neoplasm that can arise from mesothelial cells of the pleura, peritoneum, pericardium, and tunica vaginalis of the testis. The main cause of malignant pleural mesothelioma (MPM) is asbestos exposure, which can occur as an occupational hazard, for example, in ship builders and construction workers. Presentation usually trails exposure by 20-30 years .For many years, MPM was thought to be a localised disease with limited metastatic capability, but a large post-mortem study of 318 MPM patients has identified that spread to the contralateral thoracic cavity and distant sites can be seen in a majority . MetastaWe present the case of a solitary supratentorial metastatic deposit and discuss the treatment strategy. We also conducted a literature review by searching the MEDLINE database for “malignant mesothelioma AND ". We examined the three purported mechanisms of spread of MPM to the CNS and potential treatment options for each, specifically looking at the treatment strategies and overall survival of patients with hemispheric metastases.Informed consent from the patient’s next of kin was sought and obtained.A 65-year-old left-handed gentleman presented to the emergency department with a focal seizure involving the left upper limb. His only past medical history of note was a left malignant pleural mesothelioma for which he had completed six cycles of pemetrexed and cisplatin chemotherapy one year previously. It had shown excellent partial radiological response and was now under surveillance with stable appearances on follow-up computed tomography (CT) scans. Neurological examination revealed isolated left upper limb weakness  and an unsteady gait. CT and magnetic resonance (MR) imaging revealed a heterogeneously enhancing intrinsic lesion centred around the right pre-central gyrus measuring 22 mm x 30 mm x 20 mm with extensive surrounding oedema Figure , highly After an uncomplicated recovery, he was discharged on postoperative day three. At follow-up on postoperative day 10, he was able to mobilise without a frame and went on to receive 20 Gy of whole brain radiotherapy in five fractions. Despite this, he died of cardiopulmonary compromise from his mesothelioma five months later.Informed consent from the patient’s next of kin (wife) was sought and obtained for the publication of this case report. We describe the case of a solitary metastatic deposit of MPM with overall survival of five months following successful surgical resection and adjuvant whole brain radiotherapy. Given the increasing incidence of the disease and the recognition that up to 3% of patients may have CNS metastasis, it is important to consider the different mechanisms of metastasis of MPM to the CNS and potential treatment strategies for each.Three distinct mechanisms for metastatic spread to the CNS have been described in the literature. The first is via perineural spread resulting in nerve root and spinal cord compression -9. WhilsThe second mechanism is haematogenous spread leading to diffuse leptomeningeal carcinomatosis -13. The The third, and most common, mechanism is haematogenous spread leading to solitary metastases to the supra- and infra-tentorial compartments . SolitarThe first report of successful neurosurgical intervention for solitary CNS metastasis of MPM was in 1995, where gross total resection of a solitary right frontal lesion followed by whole brain and local radiotherapy was found to improve neurological symptoms and result in a 36-month recurrence-free survival . Since tCNS metastasis of MPM is rare but a condition that neurosurgeons should be aware of. Surgical resection of symptomatic solitary metastases can lead to symptomatic improvement, and together with radiotherapy, to local disease control. However, the overall survival remains poor.


Pleomorphic adenoma accounts for 65 percent of all salivary gland tumors. It has been identified in several anatomical regions, but pleomorphic adenoma arising in the ear canal, first described in 1951, is extremely rare.A 40-year-old Japanese man’s left ear canal was obstructed by a pleomorphic adenoma that caused mild conductive hearing loss. The tumor was resected and he remains disease-free two years after surgery.Pleomorphic adenoma usually arises from a major and minor salivary gland, but pleomorphic adenoma of the ear canal is derived from the ceruminous gland. We discuss the present case and 37 other case reports in our effort to clarify the clinical features and the course of pleomorphic adenoma in the ear canal. Pleomorphic adenoma (PA) is a benign tumor that usually originates in a major salivary gland. It also arises from minor salivary glands and other structures in the head and neck region such as the lip and cheek . PA arisA 40-year-old Japanese man presented at an Ear, Nose and Throat clinic with left-side hearing loss and tinnitus without otalgia or vertigo that had been present in the prior 10 days. A tumor was identified at the opening of his left ear canal, and he was referred to our hospital. The tumor was smoothly covered by the skin, and it was not mobile. It obstructed his ear canal so that the tympanic membrane was hidden from view Figure .en bloc via a postaural and endaural approach with a margin including cartilage and skin. A significant amount of hyperkeratotic substances were present behind the tumor, apparently retained debris. The tympanic membrane was preserved without appreciable change. A full-thickness retroauricular skin flap and fascia temporalis were used to cover the cutaneous defect of the ear canal.The tumor size was 18×12×12mm. It was well circumscribed and its cut surface was whitish (Figure Considering these noninvasive findings, this tumor was suspected to be benign. Surgical treatment under general anesthesia was performed two months after the start of symptoms. The tumor was resected h Figure a. Microsh Figure b. The tuet al. reported 37 cases of PA arising from sites other than the major salivary glands, and only one of the 37 cases was observed in the ear canal [PA, a mixed tumor, accounts for 65 percent of all tumors of the salivary glands . They moar canal .Since the first report of a PA arising in the ear canal by Mark and Rothberg in 1951, there have been 37 similar cases reported in the English literature . There wHistorically, PA of the ear canal was called ceruminoma, indicating glandular tumors of the ear canal regardless of whether they were benign or malignant. Welti classified these tumors into four groups: ceruminous adenoma, adenoid-cystic carcinoma, ceruminous adenocarcinoma, and the most rare, pleomorphic adenoma . Based oPA of the ear canal is characterized by the presence of a subepithelial proliferation of glandular structures with nests of myoepithelial components in a chondromyxoid stroma, similar to the histology of PA of salivary gland origin . MyoepitEn bloc surgical excision with a sufficient margin is important in the treatment of PA of the EAC to prevent recurrence. Recurrence occurs in approximately 5 percent of PAs arising in the parotid gland after primary surgery, caused by capsule rupture, a positive margin, and tumor spillage [spillage . Additioet al.; it occurred because of incomplete resection but showed no malignant transformation [In contrast, the malignant transformation of a PA of the ear canal has been reported only by Botha and Kahn, as ‘aggressive chondroid syringoma’ . Chondroormation .Postoperative radiotherapy for PA is controversial. It has been reported as not effective and can induce malignant change, although it has improved the local control for patients with inadequate margins and/or multinodular recurrence ,15. BecaWe describe a case of PA arising in the ear canal. PA of the ear canal is very rare and it presents with various symptoms. Surgical excision with sufficient margins and a long follow-up are important in the treatment.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 the journal.PA: pleomorphic adenoma.The authors declare that they have no competing interests.AM designed the clinical review, performed most of the work, did most of the data analysis, and wrote most of the paper. TT helped with the data analysis. KK performed the surgery, helped with the data analysis and wrote parts of the paper. All authors read and approved the final manuscript.


Tuberculosis is known as a notorious mimicker and distinguishing between intestinal tuberculosis and Crohn’s disease is a huge diagnostic challenge. Mycobacterium tuberculosis from sputum, ascites, and stool samples. Ileostomy takedown was performed, and the continuity of the gastrointestinal tract was restored 6 months after the first surgery. The patient recovered well thereafter.Here, we report a case of hollow organ perforation due to intestinal tuberculosis that was previously mistreated as Crohn’s disease. Staged operation with emergency resection of the diseased small bowel and temporary ileostomy was performed for the perforation, followed by 6-month standard treatment for miliary tuberculosis, which was diagnosed on the basis of the presence of acid-fast bacilli in the diseased bowel and positive culture of Timely surgical intervention can help establish the finial diagnosis of tuberculosis, rescue the patient from abdominal emergency, and provide a chance for cure. Tuberculosis (TB) is known as a notorious mimicker and should be considered before a definite diagnosis has been made, especially in areas where TB is prevalent. Intestinal tuberculosis (ITB) represents the sixth most frequent extra-pulmonary form of tuberculosis, and distinguishing between Crohn’s disease (CD) and ITB is quite a diagnostic challenge. It is estimated that intestinal perforations occur in 1–15 % of all abdominal tuberculosis patients  in 2 years. The diagnosis of CD was made on the basis of abdominal computed tomography (ACT), barium radiographic study of small bowel, and colonoscopic findings. ACT showed skip lesions throughout the small bowel, and suspected healed enteroenteric fistula with multifocal mesenteric adhesion  may be helpful and have been proposed as a method for diagnosis of inflammatory bowel disease(IBD), including CD. The sensitivity was around 44–60% and the specificity was greater than 90% in distinguishing with control group (Peeters et al. TB is a globally prevalent infectious disease, and ITB accounts for 1–3% of all TB cases (Farer et al. Although ITB is primarily a medically treatable disease, surgical intervention is indicated in complicated cases, such as obstruction, perforation, or massive hemorrhage. Free perforation occurs in up to 15% of ITB cases, and ITB has been reported to account for 3.9–10% of all cases of small bowel perforation in India, where TB is prevalent; however, lower incidence rate has been reported in developed countries, where TB is uncommon (Jhobta et al. ITB perforation is difficult to diagnose before surgery. Therefore, specimen from surgical resection at the site of bowel perforation is essential in making the diagnosis. There is no obvious difference in surgical management of free perforation due to ITB or CD. The surgical strategy depends on the extent of the disease and the condition of the patient. If the region involved is limited, the patient’s condition is not toxic, and the residual bowel is relatively healthy, resection of the diseased bowel with primary anastomosis is usually feasible. Otherwise, temporary enterostomy or colostomy with clearance of the sepsis would be preferred. Nevertheless, ITB perforation has a poor prognosis, with mortality greater than 30% (Lee et al. We showed a case of ITB misdiagnosed and mistreated as CD, where the patient presented with intestinal perforation and received emergent surgical intervention. Differentiating between ITB and CD should be given more emphasis, and the similarity between the two conditions should be kept in mind whenever possible, especially in geographic areas endemic for TB or when treating immigrants from these endemic regions, as mistreatment may prolong the ITB course and even lead to fatal complications. The combination of serial biopsies/surgical pathology and endoscopic features is crucial in increasing diagnostic accuracy. Timely surgical intervention in complicated case can not only rescue the patient from abdominal emergencies, but also help establish the true diagnosis, and provide a chance for cure.