Both the clinical and the histopathological diagnostic difficulties of oxyuriasis in unusual sites and their importance from a clinical point of view are pointed out. The authors report two ectoptic cases of enterobiasis observed in Northern Italy, one located in a fallopian tube of a 57-year-old woman and the other in a perianal subcutaneous tissue of a 59-year-old man, mimicking tumor-like lesions. The authors take advantage of the occasion to focus the attention of the medical world on this subject, lamenting the scarce importance given to this parasitosis in university courses of medical schools and in medical textbooks as it is incorrectly considered “out-of-fashion.” Enterobius vermicularis   is a very common parasite, perhaps the most common among the helminths which are considered strictly specific for man [E. vermicularis causes infection in captive chimpanzees [ for man , even ifmpanzees –4. The pmpanzees .E. vermicularis may occur only in particular condition, including perianal manipulation and anal sex, but is not the usual route. In female subjects, E. vermicularis can sometimes take another path and be found in the genitals, going from the vulva back up to the Fallopian tubes [Its existence, well known since ancient times, is not clearly influenced by climatic differences so that the helminths can really be considered cosmopolitan, found from tropical zones  to polaran tubes , 12, soman tubes , 14 and an tubes . Other tan tubes –18, the an tubes , the urian tubes , the urean tubes , the splan tubes , the peran tubes , 23, thean tubes , the intan tubes , the livan tubes , 27, thean tubes , 29, thean tubes , and thean tubes . In suchA 57-year-old nomadic Yugoslavian woman without a fixed abode, was referred urgently to Voghera Hospital  in January 2003 for an acute abdomen. From the anamnesis, collected with difficulty due to the language problems, it turned out that the patient had been suffering from painful crises in the lower abdominal quadrants for many years. As the pain had become unbearable, the patient asked for medical aid. When the abdomen was opened, the surgeon found a bilateral tubal-ovarian abscess, associated with diffuse peritonitis. Both adnexa were removed. In the left tubal wall, a nodular lesion was also discovered, hard in consistency, measuring 1 × 2 cm, under the peritoneal serous membrane.μm in length and 20 μm in width, referable to eggs of E. vermicularis  in March 2006 for perianal swelling which had been present for about a year but which had become highly painful about three weeks before, in particular while defecating. Fifteen years previously, the patient had undergone chemotherapy because he had a non-Hodgkin's lymphoma which had regressed but recurred after 8 years and was currently inactive under pharmacological control. On physical examination, a rounded mass having a diameter of about 2 cm, externally palpable in the posterior quadrants of the perineum, highly painful at palpation, having a hard-elastic consistency, with the skin moderately reddened was noted. Rectal exploration, which was painful, demonstrated that the mass was located in the perianal subcutaneous tissue. Neither fistulas nor rhagades were observed. The nodular tumor-like lesion, enucleated surgically through the skin was examined histologically and was composed of cutaneous and subcutaneous tissues with partially obliterated fistulous pathways which communicated deeply into the suppurative area with inflammatory and chronic infiltrations and with the presence of a plurinucleate giant cell granuloma, foreign body type, fibrous tissue, lymphocytes, and numerous eosinophilic granulocytes mingled with necrotic material . In the ris eggs . Some elIn the context of the fistula, minute pilar fragments and keratin lamellae remnants of a pilonidal cyst were found. Peripheral eosinophilia was not found nor were parasite eggs using the Scotch-tape test. Therefore, a diagnosis of pilonidal cysts with oxyuris eggs was made in an individual under chemotherapeutic treatment for non-Hodgkin's lymphoma.E. vermicularis eggs in the context of the suppurative swelling makes it possible to hypothesize that a gravid female parasite re-ascended into the depth of the perianal tissue by means of a fistulous pathway and remained trapped by the occlusion of the pathway itself, dying and causing a granulomatous inflammatory reaction which caused the destruction of its structure, thus releasing the eggs in the phlogistic tissue. The state of evident immunodepression may most likely have favored this unusual location. From a review of the literature, location in the female genital tracts, considering as such also those peritoneals at the pelvic level  [E. vermicularis to be located in these ectopic sites. The ova appear to be considerably more resistant than the worm itself, and they remain well-preserved even when the latter is scarcely recognizable in the lesions or has completely disappeared. A good review of cases with such locations was already published in 1950 by Symmers [In the first case, it would seem, therefore, that the worm had gone back up the genitals and, after penetrating the thickness of the tubal wall which had probably already been damaged by other infective agents, it was halted by the defensive reaction of the host tissues and remained among the inflammatory cells. Similar cases have been reported over the last decade by many authors , 32–34. s, 1950)  describe Symmers  and then Symmers  and agai Symmers .E. vermicularis in the female genital tract usually represent a casual finding especially if asymptomatic. In symptomatic cases, they can cause bleeding, infertility and peritoneal adhesions; in still other cases, they can cause diffuse pelviperitoneal inflammation, tubal-ovarian abscesses responsible for hysterectomies, and/or ovariectomies, as in our case. In the differential diagnosis of these locations, granulomas of different origins can be taken into consideration: sarcoid, tuberculous, endometriotic, Crohn's disease, foreign body inflammatory reaction, due to the presence of different substances such as talc, silicon, and other surgical material, vegetable fragments from intestinal perforation, pilo-sebaceous material from broken ovarian dermoid cysts, malpighian squamae in which the keratin laminae derive from an ovarian and/or endometrial adenocarcinoma or from a squamous carcinoma of the cervix of the uterus. Finally, some granulomas correlated to the presence of Schistosoma spp. eggs in zones of endemic bilharziasis or in people coming from those zones can be observed.Granulomas from E. vermicularis, mainly in males, frequently children and adolescents. A review of cases of enterobiasis in this location was reported in 1998 by Avolio et al. [Cases of perianal locations are less frequently reported; from the first case published by Froelich in 1897  to the po et al.  Clinicalo et al. , 38.E. vermicularis are those due to tubercular nodules, leiomyomatosis nodules, and granulomas from foreign body. If the patient comes from a zone endemic for bilharziasis, the differential diagnosis must include the granulomas caused by the eggs of Schistosoma haematobium or other species of trematodes of the same genus. Many cases located both in the female genital tract and in the ano-rectal zone could also be not diagnosed since sometimes notable symptoms are not present and other times due to the diagnostic error of the histopathologist.Digital exploration of the rectum detects the presence of the nodule, more or less firm, painful at palpation, having a diameter of 1-2 cm. If it is not very painful, the nodule is tolerated by the patient, even for a number of months, before seeing a doctor  ; also seThe current teaching in medical schools, unjustly relegates oxyuriasis to a very limited space. But its impact on human health is not irrelevant, given the possible long duration of the infection, the possible obstinate resistance to the therapy and the possible ectopic locations which are difficult to diagnose clinically.Enterobius gregorii by which Hugot 1983 supposed to be a new parasite for humans. Indeed, according to Nakano et al. 2006 [gregorii- and vermicularis-types are identical in the ITS2 region and intermingled in the clusters of the CO1 gene. Consequently, molecular evidence is that E. gregorii and E. vermicularis are two different names for the same pinworm.Nowadays, recent progress in the biology of pinworms based on techniques of extractive molecular biology can be used to overcome the difficulty of the clinical diagnosis and also to identify the provenance of the pinworm: from human patient or on the other hand from a captive chimpanzee. Moreover, molecular biology succeeded in clarifying the taxonomy of al. 2006 , gregoriBy means of reporting the two ectopic cases described above, the authors wanted, among other things, to focus the attention of the medical world on this subject, shedding light on this unjustly neglected parasitosis, for the most part considered “out of fashion.”


A low grade fibromyxoid sarcoma is a rare soft tissue tumor that has a tendency to develop in the deep soft tissue of young adults and the potential for local recurrence or distant metastasis. There have been several case reports and sporadic reports in the literature. However, only 1 case has been reported in Korea but without a follow-up result. We describe a 54-year-old female patient with a low-grade fibromyxoid sarcoma of the thigh that had been growing slowly for 34 years. A marginal resection of this tumor was performed. Currently, the patient is doing well without evidence of local recurrence or distant metastasis at 5 years after surgery. A low grade fibromyxoid fibrosarcoma is a recently recognized, uncommon soft tissue neoplasm. The condition was reported originally by Evans in 1987, who subsequently described ten additional cases in 1993. Since then, a few sporadic case reports and series have been reported.A 54-year-old female complained of a slowly growing mass in her thigh over a 34 year period. She has a two year history of hemodialysis due to chronic renal failure. A physical examination demonstrated a small melon sized mass on the anterior side of the distal thigh. The mass was not tender but rubbery hard and mobile.The plain radiographs revealed a huge soft tissue mass with irregular calcification in the distal thigh. On MRI, the tumor was 17 × 11 × 9 cm in size located under the quadriceps muscle. The tumor matrix was partially calcified and relatively well defined with irregular low signal intensity in the T1 weighted image and heterogeneous low and high signal in the T2 weighted image. There was no abnormal signal of the underlying bony cortex and bone marrow .Grossly, the excised tumor was a well circumscribed, lobulated round and firm mass. The cut surface was yellowish-white and fibrous to myxoid without any areas of hemorrhage or necrosis.The optical microscopy examination demonstrated a mass with sharp demarcation, a nodular growth pattern and intervening hypocellular collagenous stroma . The tumImmunohistochemically, the tumor cells were diffusely and strongly positive for vimentin, but were negative for cytokeratin, smooth muscle actin, S-100 protein and neuron specific enolase. The tumor was identical immunohistochemically to a low grade fibromyxoid sarcoma with strong positivity to vimentin .Five years after the excision, the patient is alive with no evidence of local recurrence or distant metastasis. The ranges of knee and hip joint motion were normal and the strength of the quadriceps muscle was good .Low grade fibromyxoid sarcoma is a bland soft tissue tumor histologically. The tumor has aggressive behavior in that a complete excision does not necessarily prevent the development of local recurrence or distant metastasis many years later.Among the 27 cases reviewed, 16 showed local recurrences and 9 had lung metastases.A review of the literature revealed the mean age at the first operation to be 33.2 years  with 66.7% being male. Frequent sites were the thigh, shoulder, inguinal area and chest wall . The pre7)The main pathologies to be considered in a differential diagnosis include desmoid fibromatosis, peripheral nerve sheath tumor, myxoid liposarcoma, spindle cell liposarcoma and low grade myxofibrosarcoma.6)Desmoid fibromatosis is poorly defined and shows a greater degree of cellularity, prominent fascicular proliferation, and more interstitial collagen fibers. Low grade fibromyxoid sarcoma can be distinguished readily from a nerve sheath tumor by the absence of the S-100 protein or an association with any nerve, and a lesser degree of waviness of the individual nuclei than a nerve sheath tumor.Low grade fibromyxoid sarcoma lacks lipoblast and arborizing vascular vessels, which are characteristic of myxoid liposarcomas. The absence of adipose elements excludes the possibility of spindle cell liposarcoma.Low grade myxofibrosarcoma differs from low grade fibromyxoid sarcoma in that it generally occurs in older adults, is always predominantly myxoid and composed of fusiform cells with hyperchromatic atypical nuclei, and does not metastasize.Low grade fibromyxoid sarcoma is a distinct neoplasm with a tendency to recur or metastasize. Histologically, it is characterized by the presence of bland spindle cells with a mainly whorled pattern of growth, set in alternating areas with a myxoid or fibrous stroma. Immunohistochemical studies allow a discrimination of this entity from other benign and malignant lesions.We report a patient with of low grade fibromyxoid sarcoma, who was treated with a marginal resection, and had no sign of recurrence or metastasis during a 5 year follow-up. However, close observation will be needed for several decades.


Renal cysts presenting in childhood are rare. Historically, renal cysts have been subject to variable nomenclature which has contributed to diagnostic difficulties. They can occur as solitary, unilateral or multiple lesions. Cysts can be further classified according to loculation, communications within the structure and tissue types present.We report the case of a 15-month-old Caucasian boy presenting with abdominal distension as the only clinical symptom. On examination, an ill-defined abdominal mass was found. This was confirmed on ultrasound to be a multiseptated cystic mass with a solid element, arising from the right side of the abdomen. Despite further imaging, the origin of the mass could not be identified. The mass was suspected of malignancy but all blood tests and tumour markers were normal. The mass proved to be a diagnostic challenge. The renal origin of the mass was only confirmed at surgery.Imaging appears to be unreliable in differentiating benign cysts from malignant renal tumours, raising a diagnostic dilemma where surgery seems the only way to reliably establish aetiology of the mass. A multilocular cystic lesion of the kidney presents a diagnostic dilemma. Using current diagnostic techniques, it is extremely difficult to differentiate renal neoplasms from essentially benign conditions with little malignant potential.This condition has been reported in the literature under many different names. Fifteen years ago, a literature review highlighted the various synonyms given to this condition, including cystic nephroma, cystic partially differentiated nephroblastoma, polycystic nephroblastoma, multilocular cystic nephroma, unilateral polycystic kidney, cystic adenoma and papillary cystadenoma .We report a case of a multilocular renal cyst and a recent literature summary.A 15-month-old Caucasian boy presented with a history of progressive abdominal distension for a 6-week duration. He was experiencing no renal or gastrointestinal symptoms and his routine antenatal scans at 20 weeks gestation were reported as normal. Physical examination showed him to be unwell, with a pulse rate of 150 beats/minute and blood pressure of 108 per 82 mmHg. He had a largely distended and tense abdomen, with general discomfort on palpation but no signs of peritonitis. There was, however, an ill-defined cystic mass palpable in the right side of his abdomen.No abnormalities were evident from routine blood tests . Further laboratory measurements of urinary electrolytes, alpha-feto protein and beta human chorionic gonadotropin levels were also all within normal limits. An abdominal ultrasound scan showed a large, cystic, multiseptated mass containing a small solid nodule, which was suspected of malignancy. The lesion was located in his right flank which extended across the midline and inferiorly into the pelvis. The origin of this mass could not be identified. A chest, abdominal and pelvic computed tomographic scan was performed, that showed a 14.7 × 13.6 × 15.2 cm complex septated cystic mass arising from the peritoneum, containing enhancing septae and solid nodules (Figure On day 6 of his admission, an exploratory laparotomy was performed due to increasing pain and distress suffered by the patient. The operative finding was a large cyst arising from the lower pole of the right kidney which was adherent to the duodenum, caecal mesentery, and colonic mesentery. The cyst was completely excised and a right nephro-ureterectomy was also carried out. The histology of the mass was reported as originating from the kidney with segmental dysplasia and haemorrhagic cyst formation, suggesting a benign multilocular renal cyst. The postoperative course was uneventful, and the patient is well at 5 years of age.The first description of a multilocular renal cyst was made in 1892 by Edmunds, who called it a "cystic adenoma of the kidney". It was not until 1951 that Powell suggested further diagnostic criteria, which included site, complexity and association with renal tissue [These criteria were later modified by Boggs and Kimmelstiel in 1956 to include the presence of immature tissue in the intervening septa as a feature of the cyst . The conThe condition seems to present predominantly among Caucasian children, with males affected twice as often as females. Conversely, the ratio increases eight-fold among females who develop the condition during adulthood .In the last 10 years only two cases of this condition have been reported, with no discernable diagnostic improvement. This is suggestive of a trend, though not conclusive.A multilocular renal cyst usually presents with a painless abdominal mass in the majority of cases, but it can also present less often with abdominal or flank pain, haematuria, hypertension or as an incidental finding . There aImaging is useful in identifying a mass. Diagnostic difficulties, however, have been reported, as noted in our case. Computed tomography and ultrasound scans may identify a complete cyst but are unable to specify the origin of the lesion in all cases .There have been no reported cases of malignant behaviour or potential in multilocular renal cysts ,7,8. ImaThe authors declare that they have no competing interests.GP drafted the manuscript of this case report. MC provided the literature review. KL contributed to the conceptualization, review, data preparation, analysis, interpretation and coordination of this study. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's parents for the 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 melanoma of the oesophagus is an exceedingly rare oesophageal neoplasm. It accounts for less than 0.1% of all primary oesophageal tumours. Less than 262 cases have been documented till today. Surgical resection with re-establishment of gastrointestinal continuity is the treatment of choice. However, haematogenic and lymphogenic metastases are common and despite advances in surgery, radiotherapy and chemotherapy, this tumour continues to be a highly aggressive neoplasm with poor prognosis. The case of a 64 year-old lady with this tumour is presented. Primary malignant melanomas of the oesophagus are extremely rare oesophageal neoplasms and an uncommon presentation of the malignant melanoma. Less than 262 cases have been described in world literature and incidence figures quoted a range from 0.1 – 0.4 of all oesophageal carcinomas [A 64 year-old Chinese female with well-controlled essential hypertension presented with a 2 month history of dysphagia and retrosternal discomfort and occasional blood-tinged vomitus. This was not associated with significant anorexia or weight loss. Digital rectal examination revealed malaena, the rest of the physical examination was normal and did not reveal any melanomas.An oesophago-gastro-duodenoscopy was performed, which revealed a large exophytic tumour at the gastric cardia and gastro-oesophageal junction. Histological analysis of biopsy specimens from the tumour suggested the possibility of a malignant melanoma.A computed tomographic scan of the thorax and the abdomen revealed the presence of irregular thickening of the gastro-oesophageal junction which extended into the lesser curve of the stomach. Small lymph nodes were also seen at the coeliac axis on the CT scan. No pulmonary lesions were noted. A whole body Tc-99m MDP bone scan did not reveal any evidence of bone metastases. Early elective surgical resection was planned as the patient had continued to suffer from intermittent upper gastrointestinal haemorrhage.th post-operative day after a gastrograffin swallow confirmed the absence of any leaks. The feeding jejunostomy was removed on the 16th post-operative day and the patient subsequently discharged the day after.A subtotal oesphagectomy with proximal gastric resection was performed with a feeding jejunostomy. The patient was started on jejunostomy feeds on the third post-operative day to ensure early enteral nutrition. Oral feeding was commenced by the 12The margins of the resected specimen were clear of malignant tissue. A 5.5 cm diameter pigmented tumour nodule located at the gastro-oesophageal junction was diagnosed as a nodular malignant melanoma of the oesophagus which extended into the stomach. Histologically, this tumour was found to be composed of epitheloid cells with pleomorphic vesicular nuclei with prominent nucleoli and intranuclear inclusions, eosinophilic cytoplasm containing abundant melanin pigment, confirmed by immunostaining with HMB 45. Two of the eight resected peri-gastric lymph nodes contained metastatic malignant melanoma.th and 7th decade, although younger patients have been documented as well [While malignant melanoma is a common skin tumour, primary growth of this tumour in other organs is exceedingly uncommon. Primary malignant melanoma occurs twice as frequently in men as in women  The exce as well ,4 The me as well  No predi as well .From the increasing number of case reports, a fairly consistent clinical presentation of such patients has emerged. Most would complain of dysphagia, non-specific retrosternal pain and weight loss  OccasionPrimary malignant melanomas of the oesophagus are grossly polypoidal and may vary greatly in size  Biopsy sSurgical resection in the form of a subtotal oesophagectomy is the treatment of choice, with a mean survival of 14.8 months and a 5-year survival rate of 4%. .Primary malignant melanoma of the oesophagus is a rare but aggressive disease, often associated with metastatic spread at the time of presentation. Early detection, establishing a definitive diagnosis and effective treatment remain a challenge. Radical surgical resection has achieved the longest survival and the best prospect of a cure. Chemotherapy and radiotherapy are mainly deployed for palliative purposes only.Written informed consent was obtained from the patient for publication of this case report. 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.QML and JHK summarized the case notes, performed the literature search and were major contributors in writing the manuscript. All authors read and approved the final manuscript.


Bouveret's syndrome is characterized by gastric outlet obstruction due to a gallstone in the duodenum, usually in association with a cholecystoduodenal fistula.We report the case of a 69-year-old Caucasian man who developed duodenal stump obstruction due to an impacted gallstone after having previously undergone Roux-en-Y gastrectomy.Duodenal stump obstruction after Roux-en-Y gastrectomy is rare, and may be difficult to manage. Patients who present with upper gastrointestinal or pancreatobiliary pathology after previous gastric surgery should be managed in centres with the availability of appropriate endoscopic and surgical experience. Bouveret's syndrome is a rare complication of gallstone disease that is characterized by gastric outlet obstruction secondary to an impacted gallstone in the duodenum . This isA 69-year-old Caucasian man presented with intermittent upper abdominal pain, nausea and bloating for the previous 12 months. There was no history of fever, jaundice, pale stools or dark urine. His past medical history included a Billroth II gastrectomy and Roux-en-Y reconstruction for peptic ulcer disease 11 years earlier. On examination, he was haemodynamically stable and afebrile. Abdominal examination was unremarkable. Laboratory tests, including liver function tests and inflammatory markers were all normal. Transabdominal ultrasound examination revealed gallstones and intra- and extrahepatic biliary dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful. Magnetic resonance cholangiopancreatogram (MRCP) and computed tomography (CT) confirmed gallstones within the gallbladder and biliary dilatation to the level of the ampulla, and demonstrated a 4 × 3 cm low density filling defect in the second part of the duodenum (Figure After he was admitted to a specialist centre, endoscopic ultrasonography and repeat ERCP were attempted but failed due to inability to cannulate the duodenal limb of the Roux-en-Y. Two hours after the procedure he developed severe, generalized abdominal pain and hypotension. This raised the possibility of iatrogenic intestinal perforation. However, it was decided to proceed directly to laparotomy rather than repeat imaging, since it was apparent that surgical exploration would be required in the event of unsuccessful ERCP. During the operation, there was no evidence of intestinal perforation. A 3.5 cm gallstone was found proximal to a stricture in the second part of the duodenum. There was no evidence of a cholecystoduodenal fistula. The duodenal papilla and pancreas were normal. The common bile duct, which was dilated due to extrinsic compression by the intraduodenal gallstone, was explored and found to be normal, and contained no stones. The gallstone in the duodenum was extracted via a duodenotomy, the duodenal stricture was dilated digitally and a cholecystectomy was performed. A t-tube was placed in the common bile duct. He made an uneventful postoperative recovery and was discharged 10 days later after a normal t-tube cholangiogram. The t-tube was removed six weeks post-operatively.The diagnosis and management of suspected biliary pathology in patients following a Billroth II Roux-en-Y gastrectomy is a considerable challenge. Non-invasive investigations, such as CT or MRCP may be helpful to detect intraductal stones and exclude other pathologies. In view of the distorted anatomy, an ERCP should be performed by an experienced endoscopist in a centre with access to surgical and radiological support . RetrogrBouveret's syndrome is a rare complication of gallstone disease , and is This case is an unusual variant of Bouveret's syndrome with some interesting differences. There have been reports of gallstones causing afferent loop obstruction after Billroth II gastrectomy in patients with a cholecystoduodenal fistula . In our Investigation of the biliary tree after Roux-en-Y gastrectomy presents a significant challenge. Noninvasive imaging, such as CT or MRCP may provide useful information to guide management. ERCP may be possible but should be performed by an experienced endoscopist in a specialist centre with availability of radiological and surgical expertise. In the presented case, an impacted gallstone in the duodenal stump could not be removed endoscopically and required surgical intervention.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SM and RS collected the data and drafted the manuscript. AR performed a literature review and helped draft the manuscript. SA conceived the study. All authors have read and approved the final manuscript.


This condition was renamed as “abdominal cocoon” in 1978. It presents as small bowel obstruction clinically. 35 cases of abdominal cocoon have been reported in the literature over the last three decades. Abdominal cocoon is more common in adolescent girls from tropical countries. Various etiologies have been described, including tubercular. It is treated surgically by releasing the entrapped bowel. We report a laparoscopic experience of tubercular abdominal cocoon and review the literature. Abdominal cocoon is a rare cause of small bowel obstruction. Diagnosis of this rare condition is usually made perioperatively and the treatment of choice is surgical release of the entrapped bowel. Nine cases of tubercular abdominal cocoon have been reported in literature. We report a unique case of laparoscopic management of abdominal cocoon with tuberculous ascites.A 21-year-old Nepali woman was admitted with complaints of abdominal pain and vomiting of one day duration. She had colicky pain in the periumbilical region and left iliac fossa with intermittent vomiting and abdominal distension.On examination, the abdomen was mildly distended and tenderness was present in the left iliac fossa. A soft to firm, mobile, mass measuring 10 × 10 cm was palpable in the left iliac fossa. It was an intraabdominal, intraperitoneal mass. Bowel sounds were exaggerated. Per rectal examination was normal. Laboratory workup revealed normal findings except raised ESR of 24 mm/h. Plain X-ray abdomen revealed localized dilated small bowel loops . UltrasoDiagnostic laparoscopy was done using Hasson's technique. Accessory ports were placed in the suprapubic and left lumbar regions under vision. There was approximately 100 ml of straw colored fluid in the peritoneal cavity, which was sent for PCR-DNA for tuberculosis. The proximal small bowel was dilated and was covered by a dense, thick, whitish membrane which appeared like a cocoon. The membrane was lifted up working between it and the bowel with a scissors. Blunt tipped scissors was used with the concavity facing upwards . The bowHistology of the membrane revealed fibrocollagenous tissue with congested blood vessels. Peritoneal biopsy revealed fibrocollagenous and fibro fatty tissue with mild lymphocytic infiltrate. Congested blood vessels were seen. There was no evidence of granuloma/malignancy.Peritoneal fluid for PCR-DNA was positive for Mycobacterium tuberculosis.et al. described this condition in adolescent girls and named it “abdominal cocoon”. 35 cases of abdominal cocoon have been reported in the English literature.[Abdominal cocoon is a rare cause of small bowel obstruction which is characterized by partial or total encasement of the small bowel by a thick fibrous membrane. Foo terature. We couldterature.–4 Six caPatients are usually adolescent girls who present with clinical features of intestinal obstruction. Abdominal mass may be palpable. Radiological findings are nonspecific. Barium small bowel series is suggestive when the characteristic “cauliflower sign” is detected. Definitive diagnosis of abdominal cocoon is made perioperatively.Histology of the membranous tissue in a primary cocoon shows proliferation of fibro connective tissue with non-specific chronic inflammatory reaction. In a tubercular abdominal cocoon, histology shows caseating epitheloid cell granulomas.In our case, the patient had abdominal cocoon encasing the proximal small bowel with fluid in the peritoneal cavity. The histology of the encasing fibrous membrane was suggestive of inflammatory pathology. There was no histological evidence of tuberculosis. Biopsy of the peritoneum was also suggestive of nonspecific chronic inflammatory response. Ascitic fluid for PCR-DNA revealed tuberculosis. Abdominal cocoon in our case - idiopathic or secondary to tuberculosis remains unresolved. Laparoscopy was diagnostic and therapeutic in this case, with less morbidity to the patient (patient was discharged on the first postoperative day). Patient was asymptomatic postoperatively as the membrane was excised. Antitubercular therapy was started.Preoperative diagnosis requires a high index of clinical suspicion. Adolescent girls presenting with small bowel obstruction and a palpable abdominal mass without any obvious cause, the possibility of an abdominal cocoon should be considered. Excision of the membrane is the treatment of choice and the prognosis is excellent. Diagnostic laparoscopy, in this era, has a major role in the management of rarer causes of intestinal obstruction, such as abdominal cocoon. Laparoscopic treatment of abdominal cocoon needs surgical expertise, considering the risk of intestinal injury.


We describe two cases where patients undergoing hepatic resection for metastatic disease of colorectal origin were found to have concomitant sclerosing haemangiomas. The typical radiological and histological appearances of these lesions are discussed. Haemangiomas constitute the largest group of noncystic liver lesions , as a reThe first patient, a 72-year-old male, presented with large bowel obstruction secondary to a rectal cancer which was treated with a defunctioning colostomy and adjuvant chemoradiotherapy. Having completed the course of chemotherapy a staging CT was performed which demonstrated an ill-defined low density lesion in segment 4a. Dynamically this had enlarged from a CT scan 2 months previously. There was mild contrast enhancement of the lesion between arterial and venous phases with an increase of approx 5HU in density between the two phases. Another lesion was noted in segment 7, again low density, but stable in size when compared to the previous study. This showed less enhancement when compared to the lesion in 4a. Both these lesions were thought to be consistent with metastatic deposits. The patient underwent a routine ultra-low anterior resection with covering loop ileostomy. It was noted at the time of the laparotomy that there was a palpable metastasis adjacent to the falciform ligament. Further imaging for planning of the liver resection showed both lesions to have enlarged in size although the lesion in segment VII showed a smaller increase and was indeterminate in nature. At operation two surface liver lesions were seen and wedge excision was performed. The histology revealed a metastatic deposit of adenocarcinoma within segment 4a whilst segment VII showed a sclerosed haemangioma.The second patient, an 84-year-old male, had previously undergone a right hemicolectomy for adenocarcinoma and was noted at the time of the resection to have hepatic metastases. Having received chemotherapy postoperatively he was restaged to assess the feasibility of hepatic resection. The CT demonstrated four lesions in total, with sub centimetre hypodense lesions in segments 2 and 5, and larger lesions in segments 4b and 6 . The twoThese cases highlight the difficulty in differentiating between benign and malignant diseases in staging colorectal hepatic metastases. Furthermore we demonstrate the occurrence of rare hepatic lesions in mimicking malignant disease. Some authorities consider haemangiomas to be benign congenital hamartomas. They are composed of masses of blood vessels that are atypical or irregular in arrangement and size. Aetiology remains unknown with no definite familial or genetic mode of inheritance being described. When fibrosis occurs in an existing haemangioma then it may progress to the sclerosed variant. It is difficult to ascertain the precipitating event for this to occur. There are numerous reports of haemangiomas rupturing spontaneously or in association with trauma. It would therefore seem plausible that minor haemorrhage and thrombosis within a haemangioma may instigate fibrotic progression to a sclerosed haemangioma. Makhlouf et al. suggested that mast cells play a pivotal role in the development of a sclerosed haemangioma, perhaps representing a distinct histological subtype of liver lesion . Not all haemangiomas remain stable in size or display typical appearances on imaging (due to the development of fibrous change) and this may lead to difficulty in accurately predicting the true nature of these incidental lesions when they occur. CT features suggestive of sclerosed haemangiomas include geographic outline, capsular retraction, decrease in size over time, and loss of previously seen regions of enhancement. Additional features include the presence of transient hepatic attenuation difference, rim enhancement, and nodular regions of intense enhancement as seen in typical haemangiomas . AlternaThe common histological appearances of sclerosed haemangiomas consist of multiple thin walled vessels within a hypocellular stroma demonstrating varying degrees of fibrosis and sclerosis . MacroscWhilst the prevalence of haemangioma has been reported as high as 20% when found incidentally at autopsy , the sclOne of the key questions in the management of patients in this scenario is whether to biopsy the lesion in question at the time of the operation or to proceed straight to formal resection. Whilst thorough preoperative investigation will guide the surgeon in their management, this decision can only be made at the time of operation. We would certainly not condone preoperative biopsy of any liver lesions in the context of planning definitive treatment for suspected colorectal hepatic metastases. However, it is conceivable that if excision of an indeterminate lesion may significantly increase the length or risk of surgery  then an intraoperative biopsy with frozen histology could be considered. Patients should always be informed of the potential for benign pathology when surgery is recommended for indeterminate lesions. Hepatic resection for benign conditions is only indicated where there are persistent symptoms, uncertainty regarding the diagnosis or the risk of malignant transformation . HoweverCross-sectional imaging, whilst continually improving in detail, can still not always differentiate between certain benign lesions and malignant disease. This is particularly true for small lesions less than 5 mm. In the context of multiple mixed lesions tumour makers will not help quantify or localise metastatic deposits. Whilst a PET scan may help distinguish between benign and malignant disease there are still instances where benign pathologies can mimic malignancy.In both cases the clinical index of suspicion for metastatic spread was high given the advanced nature of the colorectal cancers. Despite accurate preoperative investigation it may not always be possible to delineate between a benign lesion such as a sclerosing haemangioma and a true metastatic deposit, especially when the two coexist. The typical imaging features of sclerosed haemangioma have recently been published as discussed earlier. However no imaging technique can be 100% accurate. Tumour markers will not differentiate between the two pathologies in this scenario whilst both false positives and negatives can occur with PET scans . If a le


A rare case is presented of a 61-year-old man with a malignant peripheral nerve sheath tumor associated with neurofibromatosis type 1, with metastasis to the heart. The primary tumor originated in the right thigh in 1982. Since then, the patient has had repeated local recurrences in spite of repeated surgical treatment and adjuvant chemotherapy. He has developed previous metastases of the lung and heart. The patient died of cardiac involvement. Malignant peripheral nerve sheath tumor (MPNST) is an aggressive and uncommon neoplasm that develops within a peripheral nerve; most cases of which are associated with neurofibromatosis type 1 (NF1). Metastasis of MPNST usually occurs in the lung -4. In thA 61-year-old man presented with clinical stigmata of NF1. Genetic analysis had not been performed. He had no family history and had developed multiple neurofibromas and café-au-lait spots on his body Figure . The hisPatients with NF are at greatest risk for developing sarcomas, including MPNST. The incidence of MPNST arising in NF is 4.6%, which is much higher than the 0.001% in general population . The mosThe prognosis of patients with MPNST is generally poor. Aggressive surgery significantly improved disease-free survival ,8. AdjuvClinical features vary according to the site of cardiac involvement, such asNF1 tumor suppressor gene [NF1 and mutations of numerous additional tumor suppressor genes within the p19ARF-MDM2-TP53 and p16INK4A-Rb signaling cascades have been identified in MPNSTs [NF1, are not present in neurofibromas. It is therefore thought that the development of neurofibromas and their subsequent progression to become MPNSTs involves a sequential series of tumor suppressor mutations. Deletions and other mutations that result in loss of function of the TP53 tumor suppressor gene are some of the more common abnormalities found in MPNSTs. Biallelic inactivation of the TP53 locus is found rarely in MPNST, which has led to the suggestion that hemizygous TP53 mutations may suffice for neurofibromas to progress and become MPNSTs.Most NF1 patients carry a constitutional mutation of the sor gene . Bialleln MPNSTs ,13. ThesNF1 genes [A recent study has demonstrated that two MPNST cell lines derived from sporadically occurring MPNSTs have functional and intact F1 genes . ParadoxF1 genes ,15.For understanding of these complex neoplasms and the development of the effective new therapy, further investigation will be needed into the clinical features and the basic science.Although cardiac involvement of MPNST is rare, precise examination including occasional echocardiography is necessary when clinical signs of tumor development in the heart are suspected.Written informed consent was obtained from the patient's family 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.MK participated in the pathological examination of the case, the design of the study and drafting the manuscript.NW, SN, NI and CY participated in the pathological examination of the case.YFJ, MT, and MY participated in the immunohistochemical analysis.NN and NA participated in collecting clinical data and images.YT participated in its design and coordination and helped to draft the manuscript.All authors have read and approved the final manuscript.


Post-operatively her serum testosterone levels declined with near-complete reversal of symptoms over time.Virilism is the masculinization and enhancement of male secondary sexual characteristics in females. The etiology is usually of adrenal or ovarian origin. Here we report a case of virilizing Leydig cell type, steroid cell tumor of the left ovary, in a 40 year old female who presented with clinical signs and symptoms of virilization: deepening of voice, hirsutism , clitoromegaly, and androgenic alopecia. On further evaluation, laboratory investigations revealed hyperandrogenism in the male range. Basal testosterone values were elevated. Folicle Stimulating Hormone and Luteinising Hormone levels were within normal limits. Dexamethasone suppression test did not alter cortisol or testosterone levels. An ovarian mass was confirmed radiologically. Following a total abdominal hysterectomy with bilateral salpingoophorectomy, histopathological studies confirmed a left sided steroid-cell ovarian tumor, Leydig cell type (stage T Hirsutism is defined as excessive male-pattern hair growth. Virilization refers to a condition in which the androgen levels are sufficiently high to cause additional signs and symptoms such as deepening of the voice, breast atrophy, increased muscle bulk, clitoromegaly, and increased libido . VirilizA 40-year-old multiparous woman from South India was referred to our Gynecology department with a two year history of progressive deepening of voice, an increase in facial and body hair, and frontal balding; her symptoms have worsened over the past six months. She attained menarche at the age of 14 years, and has had irregular menses lasting 3 to 4 days, every three or four months since then. She is a mother of two healthy boys, aged 12 and 15 years, both of whom were delivered vaginally without complications. The patient has been amenorrheic for the past four and a half years. There is no history suggestive of hypothyroidism or hyperprolactinemia. There is no significant family history, other than the fact that her mother attained menopause at the age of 40 years. She is a known hypertensive on treatment with calcium channel blockers. She is not on any other medications.2. She had a low-pitched female voice. Head and neck examination showed male-pattern alopecia and obvious facial hair . Serum cortisol, 17-hydroxyprogesterone, prolactin, FSH, LH, thyroid hormone levels, blood sugars, and all other blood parameters were within normal limits . Radiolo1N0M0. The preoperative elevated serum testosterone level returned to normal. There was a gradual reversal of her symptoms over time; however, the deep voice remains persistent. The patient is being followed up on a regular basis.Macroscopically, both the ovaries were enlarged, tan-brown in color, and stony hard in consistency . The right ovary revealed a uniform solid grey-tan color covering the cut surface. The cut surface of the left ovary showed a solid grey-tan color with irregular grey-brown areas . On micrVirilizing ovarian tumors account for less than 5% of all ovarian neoplasms . Sex corSteroid cell tumors are further subclassified into stromal luteoma, Leydig cell tumors (hilar and nonhilar), and steroid cell tumors that are not otherwise specific . Most puThe clinical manifestations are to a large extent determined by the age of presentation, hormonal activity, and virilizing properties of the tumor. Virilization or hirsutism is encountered with three fourths of Leydig cell tumors .The clinical presentation may take many forms, including abdominal pain, abdominal distention, and bloating. However, the more noticeable presentations are those associated with the hormonal activity and virilizing properties of the tumor . Signs aWith regard to blood investigations, detecting the source of the androgenic tumor is a process of exclusion. In our patient, the high serum free and total testosterone confirmed the presence of a virilizing neoplasm. A dexamethasone suppression test failed to alter basal values, moreover, 17-hydroxyprogesterone levels were also within normal limits; this ruled out a potential adrenal source of the androgens ,12.On radiological imaging, appearances of virilizing tumors of the ovary depend, to some extent, on the tumor type. Virilizing steroid cell tumors of the ovary are usually one sided and often very small, measuring only slightly bigger than the normal ovary ,10. TheyThough steroid cell tumors of Leydig-cell subtype are usually benign, there is still a potential risk for malignant transformation ,9,10. SuA patient who presents with virilism should be investigated systematically to determine if the high testosterone levels are of an adrenal or ovarian origin. In this patient, hematological investigations ruled out an adrenal cause. Radiological imaging proved to find that the cause of virilization was of an ovarian etiology. Surgical intervention was sought and the diagnosis of virilizing ovarian tumor was made by histopathologic examination.It was a harrowing experience for me when I started balding and growing excessive hair all over my body. My fears increased as my friends and relatives started noticing a change in my voice. When the doctors told me I had a tumor, I felt my outcome was bleak. After the operation, my physical appearance improved, and my social life has returned to normal. I am grateful to the doctors for all they have done.


Sir,Biliary cystadenomas are rare hepatobiliary cystic tumors, more common in women. We report one such tumor that presented with obstructive jaundice and mimicked a hydatid cyst of the common bile duct (CBD). Cystadenoma was diagnosed only after biopsy but, due to wide excision, there was no residual or recurrent tumor.Biliary cystadenomas are rare cystic tumors that arise in the liver or less frequently in the extrahepatic biliary system. They are more common in middle-aged women, their most favored site being the right hepatic lobe. It is extremely rare for an intrahepatic cystadenoma to extend into the CBD. Less than 10 cases have been reported in the medical literature.[Presentation is frequently nonspecific: Patients may complain of abdominal pain, anorexia and nausea. Liver function tests are frequently abnormal and extrahepatic lesions tend to present with obstructive jaundice.A 20-year-old female was admitted with a 10-day history of jaundice and a 3-day history of increasing right upper quadrant colicky pain. She had also experienced previous intermittent episodes of jaundice. Liver function tests were abnormal on admission, with a serum bilirubin of 4.8 mg/dL and alkaline phosphatase of 22 KAU. An ultrasound scan revealed multiple coiled ascaris in the CBD, seen as bunches and also appearing calcified. Intrahepatic ducts and CBD were dilatated (16 mm). Periportal lymphadenopathy was present.in situ.There was a diagnostic dilemma with which an exploration was undertaken. At laparotomy, there were multiple cysts filling up the CBD and a perop diagnosis of hydatid disease was made. Excision of the cyst  with remth postop day. She was discharged and closely followed-up.Histology showed the tissue to be cystadenoma. The patient had a smooth postoperative course with T-tube removal performed on the 14Biliary cystadenomas are rare and their similarity to hydatid disease can make them difficult to diagnose. The radiological appearance of biliary cystadenomas is quite specific. Ultrasound may show an anechogenic mass with internal septations that are highly echogenic, which, in our case, led us to think of it as calcified ascaris. Computed tomography helps with the finding of a smooth thick-walled cyst with fine internal septae, but it cAt laparotomy, these lesions can be difficult to localize as they are usually soft, difficult to palpate and pose minimal or no resistance to biliary probes. Therefore, the use of intraoperative choledochoscopy and cholangiography has beenet al., who concluded that while formal lobar resection is frequently carried out, local complete excision is just as effective provided the neoplasm is entirely removed and is associated with low rates of morbidity.[In 1892, the first case of successful resection for a biliary cystadenoma was reported. Since thorbidity.In developing countries, a wide local excision with regular follow-up would be more appropriate considering the limited availability of adequate back up for a more radical procedure at most of the centers.


Introduction. Gossypiboma or textiloma is used to describe a retained surgical swab in the body after an operation. Intraabdominal surgical sponge is an uncommon surgical error. The incidence of gossypiboma has been reported as high as 1 in 1000 to 15,000 intraabdominal operations. Gossypiboma may cause serious morbidity and may lead to mortality. Case presentation. Herein, we report a 24 years-old man who was admitted due to the intraabdominal mass after evaluation of primary infertility. He had a surgical history of bilateral abdominal orchiopexy 5 years previously, performed at another hospital. Hydatid cyst was suspected by abdominal computed tomography. After laparotomy excision, the cyst wall opened incidentally, and draining of a large amount of thick pus with retained surgical gauze within the cyst was found, with final diagnosis of gossypiboma. Conclusion. The policy that prevention is far more important than cure is highly appreciated. Accurate sponge and instrument counts, along with radiologic evaluation when a discrepancy is found, can be helpful. Although human errors cannot be completely avoided, continuous medical training and strict adherence to rules of the operation room should reduce the incidence of gossypiboma to a minimum. Surgical sponges should be counted once at the start and twice at the end of all surgical operations.  Gossypiboma is a term used to describe a mass within the body that comprises a cotton matrix surrounded by a foreign body reaction. overlooking a foreign body can sometimes occur despite extreme caution during surgery. A foreign body can trigger a granulomatous reaction and may result in the formation of a sizeable mass. The word “Gossypiboma” is bilingually derived from Latin “gossypium” (cotton) and Kiswahili “boma”  .The patient is a 24-year-old Iranian infertile male that referred to our clinic for work up of infertility. He was a married gentleman since 4 years. In the past medical history no noticeable point is noted. In the past surgical history, he underwent laparotomy for the bilateral orchiopexy of intraabdominal testes 5 years ago in another center. Vital signs were normal and BMI was 22. Upon physical examination, positive findings were atrophic testes and a scar of pfannensteil incision. The findings of laboratory examinations were unremarkable, with a normal cell count and normal biochemistry. Azospermia was noted in the semen analysis. In the hormone prophile, we noted elevated FSH and LH, 2-3 times of normal with normal serum levels of testosterone and prolactin. Due to mild and chronic nonspecific abdominal pain, abdominal ultrasonography was requested, in which a round mass of 5 to 10 cm size with fluid echogenicity is found (in the right lower quadrant). Finally in the abdominopelvic CT scan, a heterogenous soft tissue mass was found in the same reported area of the abdomen near the bladder. He scheduled for laparotomy with hydatid cyst diagnosis. After opening of the layers and peritoneum with low midline incision, the mass was intraperitoneal, that lied between loops of the small intestine. We were very careful about the tearing or rupture of the cyst wall, but because of some adherence it was ruptured and yellow, thick pus released in which a sponge was found  . The preNewer technologies are being developed that will hopefully decrease the incidence of retained foreign body, like radiofrequency identification (RFID). In this system, commonly used surgical gauze sponges, which have been tagged with a radiofrequency identification (RFID) chip scanned with a barcode scanner . The ove Gossypibomas are uncommon, mostly asymptomatic, and hard to diagnose. Particularly chronic cases do not show specific clinical and radiological signs for differential diagnosis. Textiloma should be included in the differential diagnosis of soft-tissue masses detected in patients with a history of a prior operation. Patient-clinician and clinician-radiologist interactions and compliance enhance the possibility of accurate diagnosis.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.M. K. Moslemi is the corresponding author and responsible for the surgery team. M. Abedinzadeh is the editor of the text and data collector.


The risk of developing lymphoma is greatly increased in HIV infection. Musculoskeletal manifestations of the human immunodeficiency virus (HIV) are common and are sometimes the initial presentation of the disease. Muscle, bone, and joints are involved by septic arthritis, myopathies and neoplasms. HIV-related neoplastic processes that affect the musculoskeletal system include Kaposi's sarcoma and non-Hodgkin's lymphoma, the latter being mainly localized at lower extremities, spine and skull.The Authors report a case of a 34 year-old lady. In December 2003 the patient noted a painless mass on her right shoulder whose size increased progressively. In March 2004 she was diagnosed HIV positive and contemporary got pregnant. The patient decided to continue her pregnancy and to not undergo any diagnostic procedure and treatment. At the end of August she underwent a surgical ablation of the lesion that revealed a lesion of 7 cm × 7 cm × 3,3 cm. The histology showed B-cells expressing CD20, PAX-5, CD10, BCL-6 and MUM-1 with 70% Ki67 positive nuclei. The lesion was also negative for EBV infection and showed a monoclonal rearrangement of IgH chain and a polyclonal pattern for TCR gamma and beta. A final diagnosis of diffuse large B-cell lymphoma was made. The patient underwent postoperative chemotherapy. At four-years follow up the patient is symptom free and no local nor systemic recurrence of pathology has been noted on MRI control. HIV infection is still under control.In this report, we present a case of diffuse large B-cell lymphoma localized in the soft tissue of the shoulder in a HIV infected patient. Authors want to underline this case for the rare position, the big size and the association with HIV infection. The risk of developing lymphoma is greatly increased in HIV infection which induces a severe impairment of the immune system due to the progressive reduction of CD4 lymphocytes thus leading to the development of different infections and tumors. The improvement of the therapy with longer life expectancy has led to new associations and, among these, the involvement of other tissues such as the musculoskeletal system. Usually musculoskeletal lesions involve lower limb. Authors report a rare case of soft tissue lymphoma localized at right shoulder in a HIV-infected patient.A 37 years old lady (who was born in 1971) underwent a surgical goldbladder ablation and a excision of appendicitis in 2001. Two years later, in December 2003 the patient noted a painless mass on her right shoulder increasing progressively with time. Her last menstrual cycle was dated in November 2003. In March 2004 she was diagnosed with HIV and at the same time she started her pregnancy. At that time her blood count showed: WBC 6250, lymphocytes 680, CD4 184 (27%) and CD8 354 (52%), and analysis of HIV type 1 RNA detected 975 HIV RNA copies/ml. Even if the lesion kept on growing fast, the patient decided not to undergo any diagnostic procedure nor any possible treatment until the end of pregnancy. In the last period she suffered a mild diabetes, anyway in July gave birth with no further problems. Then she performed a MRI which showed, in T1W sequence, an homogeneous isointense lesion in the posterolateral aspect of the right shoulder below the deltoid muscle Figure . The TSEAt the end of August she underwent a surgical excision of the lesion. The procedure was performed under general anesthesia through a posterior incision. The split of the deltoid fibers revealed a large lesion  which was excised with free margins.The histology showed a diffuse proliferation of large lymphoid cells with irregular round or oval nuclei. For immunophenotypic studies the avidin-biotin-peroxidase complex (ABC) method was performed on paraffin sections using a commercially available kit  and the following commercially available monoclonal antibodies: CD3, CD10, CD20, PAX-5, BCL-6, CD138, MUM-1 and Ki67. EBV infection was evaluated by in-situ hybridization of EBV-encoded small RNAs (EBERs) on formalin-fixed, paraffin-embedded tissue sections. In-situ hybridization analysis was performed using a cocktail of fluorescein-isothiocyanate-labeled oligonucleotides complementary to the nuclear EBER RNAs, following the manufacturer's instructions , as previously described [The patient underwent postoperative chemotherapy according with CHOP  regimen. The split of the deltoid muscle allowed a fast and complete range of movement regain. After surgery patient also started HIV treatment with a combination of Combivir (Lamivudine plus Zidovudine) and Kaletra (Lopinavir/ritonavir). At four years follow up the patient is symptom free and no local or systemic recurrence has been noted; HIV infection is still under control.HIV musculoskeletal manifestations are common and are sometimes the initial presentation of the disease. Muscle, bone, and joints are involved and could be affected by infection , arthritis, myopathies, neoplasms and miscellaneous conditions such as avascular necrosis and hypertrophic osteoarthropathy .The association between HIV and lymphomas is relatively common. The most frequent localizations are brain, lung, tonsils and stomach followed by oral mucosa, neck, musculoskeletal, subcutaneous and cutaneous tissues. In about 70% of cases lymphomas are non-Hodgkin (NHL) while only 30% are Hodgkin lymphomas ,5. The mThe incidence of NHL in HIV patients is 3% and lesions are usually high grade and extra nodal ,5. ExtraWe report a lesion localized in the soft tissues of the shoulder not involving the bone which is not typical in literature for both the position and the large size. To the best of our knowledge, this is the only case in the literature of such a lesion developed in a HIV patient. The mass grew fast during the nine months of pregnancy that is the time spent between the first clinical presentation and the surgical excision, because of the patient decision to not undergo any diagnostic and therapeutic procedure before delivery.Different MRI appearances of primary muscle lymphomas have been reported in the literature ,15. The HIV positive patients can develop pyomyositis, polimyositis or muscle lymphomas which may be multifocal and produce bright signals on T2-weighted sequences with fat suppression ,20. TehrSurgery in soft tissue lymphoma is still controversial. Damron et al. are convinced that lymphoma is a non surgical disease in which chemotherapy and/or radiotherapy are adequate therapeutic strategies and they do not recommend the surgical excision since it would remove a clinical barometer of responsiveness to medical treatment. Biopsy should be only performed to confirm the nature of the lesion, especially in differential diagnosis with soft tissue sarcoma .On the contrary Bozas et al. described a case of abdominal wall mass (10 × 18 cm) situated between the abdominal muscles and in which a wide excision was performed followed by immuno-chemotherapy . BelaabiNo other cases of soft tissue lymphomas of the shoulder in HIV patients with dimensions compared to the one reported in this study have ever been described in the literature. Because of the large dimension, Authors performed an excision biopsy with tumor-free margins followed by chemotherapy. This combined treatment was expected to reduce the risk of local recurrences allowing good functional recovery of the shoulder. Radiotherapy alone without removing the mass was excluded for the high risk of infection. Follow up have confirmed the appropriateness of the treatment since the patient is still disease-free after four years with good range of motion.This study reports a very rare localization of a case of diffuse large B-cell lymphoma in the soft tissue of the shoulder in a HIV infected patient. Excision biopsy followed by chemotherapy allowed a good local and systemic control of the disease with a good functional recover after four years.Written consent was obtained from the patient for publication of this case report.The authors declare that they have no competing interests.DM prepared the draft of case report. GM conceived the idea of the case report and helped with the draft of it. AS, SC and AD helped the draft of the case report. MM and LMR performed the molecular analyses. NM performed the radiological studies and helped with draft of case report. All authors read and approved the final manuscript.


Reduction in visual acuity combined with blurred vision is rarely the first sign of lung cancer and very few cases have been announced globally.A case of a 46-year-old man who admitted with blurred vision is presented. His medical history, apart from a mild gastritis under treatment was negative. Ocular examination revealed a decrease in visual acuity due to a choroidal tumor. Further image body scans demonstrated a right lung lesion with dissemination to other organs. Diagnosis of a non-small cell lung cancer established after a VATS biopsy carried out.Blurred vision due to choroidal metastasis as the primary symptom of lung cancer is very uncommon. A great index of suspicion is essential when a choroidal lesion appears. The incidence of ocular metastases from lung cancer is reported to be 2-7% according to the international literature ,2. The mA 46-year-old man noticed, three months ago, that for the past two weeks his left eye suffered from reduction in vision with a concomitant blurredness. He had no medical history apart from a mild gastritis under treatment. He was a heavy smoker , while he was a social drinker. Examination showed visual acuity of 2/20 in the left eye and normal in the right eye. Fundus examination revealed the presence of a choroidal tumor located superior to the optic nerve measuring 921 mm  is the most commonly affected site followed by the iris (9%) and ciliary body (2%) . Breast 8% is theDecrease in vision and blurredness as the initial manifestation of lung carcinoma is therefore very rare. A review of the literature brought to light 12 cases of lung cancer patients suffering from choroidal metastases as the primary clinical sign. In all cases, the diagnosis of the choroidal metastases declares final stage disease and the dissemination seems to be almost certain. Prognosis is poor and life expectancy short.Treatment for ocular metastases is palliative because the presence of such metastases suggests hematogenous spread of cancer. In line with this, the aims for treatment are to maximize quality of life, and restore or preserve vision. This may be achieved with either radiotherapy or chemotherapy. Surgery has not played an important role other than diagnostic biopsy, as surgery carries great potential morbidity and often there is no need for tumor debulking.In conclusion, when a choroidal lesion is discovered, the differential diagnosis should include secondary metastases due to malignant tumors originated from distal organs.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.CA, DK, AK, DP, GS, and FP took part in the care of the patient and contributed equally in carrying out the medical literature search and preparation of the manuscript. NB participated in the care of the patient and had the supervision of this report. All authors approved the final manuscript.


Primary hepatic carcinoid tumours (PHCTs) are extremely rare neuroendocrine neoplasms. Only 58 cases have been reported in the literature and less than 10 cases were functional.We present a case of a 65 years old, Caucasian female with a large unresectable primary hepatic carcinoid tumor secreting 5-hydroxyindoleacetic acid (5-HIAA), presented with flushing and diarrhoea and treated with trans-catheter arterial embolization (TACE) and subsequent administration of lanreotide .The diagnosis of PHCTs is difficult due to their common radiologic characteristics with other liver lesions. Their diagnosis is based on the exclusion of other sites of disease and the histologic confirmation. Although the mainstay of treatment when is technically feasible is surgical resection with optimal 5-year survival and low recurrence rate, in cases of unresectable disease palliation with combination of TACE and administration of somatostatin analogues have good results in controlling the disease and the patients symptoms. Carcinoid tumours are of neuroendocrine origin, well-differentiated low-grade malignant neoplasms. They follow an indolent course in comparison with other malignant neuroendocrine carcinomas, which display varying degrees of pleomorphism, mitotic activity, vascular invasion, and necrosis . NonetheA 65 years old, Caucasian female patient presented on admission to our Liver Surgical Unit with a history of flushing, diarrhoea, vomiting and low grade fever. Ultrasound (US) demonstrated multiple hypoechoic lesions in both liver lobes. Computed Tomography (CT) revealed heterogeneous hypodense lesions invading most of the hepatic parenchyma. The lesions showed mild gradual enhancement during the arterial and portal phases, while cystic areas were also demonstrated. The larger of the lesions showed extrahepatic extension compressing and dislocating the duodenum. No vascular invasion was noted fig. . A 24 h-111, a MIBG scan and a [11C] 5HTP-PET showed intense uptake of the radiotracer exclusively in the liver. Based on the biochemical and thorough radiological investigation, the diagnosis of PHCT was made with certainty. Due to the extended liver invasion, resection wasn't feasible and palliation was performed with TACE and subsequent administration of lanreotide  30 mg/28 days subcutaneous for 22 months. TACE included streptozotocin 1.5 g/m2 dissolved in 10 ml of normal saline  combined with 10 ml of lipiodol. The emulsion was injected into the branches of the hepatic artery distal to the origin of gastro-duodenal artery. Two years later the patient is free of symptoms with no radiologic disease progression.In addition to these diagnostic modalities the patient underwent an abdominal and chest CT scan along with abdominal MRI, mammography and an upper and lower GI endoscopy which didn't reveal the primary. A total body octreoscan with InCarcinoid tumors are rare, slowly growing neuroendocrine neoplasms that account for only 2% of all gastrointestinal tumors . PHCTs aTheir histogenesis hasn't been clarified. It is hypothesized that they arise from scattered neuroendocrine cells in the intrahepatic biliary epithelium. Another possible explanation is that chronic inflammation in the biliary system may predispose to the development of neuroendocrine tumor by initiating intestinal metaplasia or even that these tumors originate from heterotopic pancreatic or adrenal tissue, mainly in the central part or perihilar areas of the liver, where heterotopic pancreatic tissue is most often located. However, the clinician must be aware of the possibility that an apparent PHCT might be a metastatic one of a primary tumor that remains obscure despite an extensive assessment.Diagnosis of primary hepatic carcinoid tumors is difficult as the radiologic appearance on ultrasound, CT, and MRI can mimic hepatocellular carcinoma, cholangiocarcinoma and metastases of unknown origin. A solid mass with cystic areas and hyperechoic or mixed pattern is a common finding detected by ultrasound. In addition calcifications are sometimes demonstrated along the margin of the cysts. Of note they are markedly hypervascular on contrast-enhanced US with significant enhancement . Contras11C] 5HTP-PET demonstrated the primary nature of liver carcinoid.Intra-lesion solid components are enhanced in the early arterial phase in a similar fashion with hepatocellular carcinoma. After the administration of a specific liver contrast (super paramagnetic iron oxide) the extent of the tumor is more clearly delineated due to the decrease of normal liver parenchyma signal intensity . On angiIt appears that most PHCTs are functionally silent. Presentation with abdominal distension and discomfort is most common, and carcinoid syndrome is rare although is documented in our case. This is the second case reported in the literature of carcinoid syndrome related to PHCT and proved by abnormal HIAA urine levels.The mainstay of treatment of primary hepatic carcinoid tumor is liver resection. In the literature up to 85% of patients with PHCT have resectable disease . When PHPHCTs represent a rare entity difficult to diagnose by the conventional radiology studies. Exclusion of another primary and liver biopsy is strongly warranted. The natural history of these lesions is long and a median survival of several years has been reported for patients who have been treated by resection. TACE with long acting somatostatin analogues might be helpful to offer long term palliation.PHCTs: Primary hepatic carcinoid tumours; 5-HIAA: 5-hydroxyindoleacetic acid; TACE: trans-catheter arterial embolization; SSAs: long acting somatostatin analogues; SRS: somatostatin receptor scintigraphy.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.ZT analyzed and interpreted the patient data and was a major contributor in writing the manuscript; SD analyzed and interpreted the patient data regarding and was a major contributor in writing the manuscript; CT performed the CT investigation of the patient and contributed in writing the manuscript; NG performed the histological examination of the liver biopsies and provided the histological images; CA contributed in writing and revising the manuscript; CD contributed in writing and revising the manuscript.All authors read and approved the final manuscript.


As a result of improvements in diagnostic accuracy, the primary source of the tumour is identified in more than 99% of cases presenting with a malignancy. Whilst the axial skeleton is a common site of metastases, the sternum is rarely affected, especially by isolated metastases.We report a case of a 68 year old male who was referred to the surgical outpatient clinic with a six month history of sternal pain. The patient was known to have essential thrombocythaemia, which had recently transformed into acute myeloid leukaemia but a sternal biospy showed mucinous adenocarcinoma. He had not localising symptoms and full evaluation failed to localise the primary tumour.Solitary sternal metastases are rare and when found an underlying neoplasm is usually identified allowing targeted treatment. If however, there is no symptomatic tumour, the metastasis should simply be treated symptomatically. As a result of improvements in radiological imaging including cross-sectional and radiopharmaceutical studies, together with refinements in histological assessment of biopsy specimens such as the use of immunostaining, the primary site of a malignancy is usually identified and thus cancer of unknown origin now has an incidence of only 0.5–0.9% amongst all patients presenting with a malignancy .Bone is the commonest site for secondary spread of cancer, with 80% of metastases arising from breast, lung and prostatic primary tumours . The metA 68 year old male was referred to the surgical outpatient clinic with a six month history of sternal pain. The pain was an intense, continuous burning pain that disrupted his sleep. The patient was known to have essential thrombocythaemia, which had recently transformed into acute myeloid leukaemia. This had been confirmed by a previous marrow biopsy taken from the iliac crest just before the onset of his sternal pain.The patient had lost two stones in weight despite no loss of appetite. There had been no change in his bowel habit. He reported a single episode of rectal bleeding two months prior to his presentation that had been attributed to aspirin therapy. The patient admitted to smoking ten cigarettes a day but denied any respiratory symptoms.On examination he was acutely tender in the mid-sternal region, but no mass was palpable. No breast or axillary masses were detected. Examination of the abdomen revealed three centimetres of hepatomegaly, a normal spleen but no other masses. Prostatic and rectal examinations were normal. Flexible sigmoidoscopy was also normal. A full blood count was consistent with his leukaemia. His renal function, liver function tests and prostate specific antigen tests were within normal limits.The patient underwent a magnetic resonance imaging (MRI) scan which showed abnormal marrow signal in the body of the sternum with expansion and loss of the anterior and posterior cortical margins Figure . A compuCancer of an unknown primary site has a median survival of 9–12 months from initial detection [Abeloff and colleagues  recommenet al. [Bone is the commonest site for metastatic spread, especially in tumours involving the breast, lung, prostate, kidney and thyroid gland. The axial skeleton is usually affected, believed to be due to the vertebral-venous plexus, and the slow blood flow in the axial skeleton. Bony metastases present with pain and local tenderness, problems with mobility and pathological fractures. Although metastases to the vertebrae and ribs are common, sternal metastases are rare. Whilst there are several case reports of metastases from known primary tumours in the English language literature, there are only four series reported in the literature in the last sixty years ,4-6. HowMucinous adenocarcinoma such as described in this case may arise in the breast, lung, prostate, pancreas and bowel. Despite thorough investigation, we were unable to detect a source of the primary mucinous adenocarcinoma.This case demonstrates that bony pain in patients with a haematological malignancy may be due to a second primary carcinoma. Sternal pain has many causes including neuropathic, musculo-skeletal and infective. Although metastasis is a rare cause of sternal pain, it should not be overlooked.We question how aggressively a clinician should search for the primary site. With a life expectancy of less than a year, it may be kinder to the patient to restrict investigations to blood tests, a chest radiograph and a CT abdomen and pelvis. Further tests such as endoscopy, bone scans and barium enemas are uncomfortable for the patient and it may be argued that they should be avoided.Despite advances in medical imaging, there remain rare cases in which no primary can be identified for isolated metastases. In the case of bone metastases from adenocarcinoma, it may be appropriate to treat the metastasis symptomatically and not be too concerned with hunting the primary lesion.The author(s) declare that they have no competing interests.The original idea was that of MHL, the Consultant responsible for the case. The case report was written by EB and MC with assistance from GMS who edited the manuscript together with MHL. All authors approved the final version.


Sclerosing mesenteritis is a rare, idiopatic, usually benign, inflammatory process of the mesenteric adipose tissue. The most common site of involvement is the small bowel mesentery. We present a case of sclerosing mesenteritis of the rectosigmoid colon as a cause of severe abdominal pain, abdominal obstruction, and ischemic colic mucosal lesions. Contrast enema, colonoscopy, angiography, and CT were the imaging modalities used. A 20 cm diameter, fibrotic mass causing extensive compression of rectosigmoid colon was found at laparotomy. Histological examination showed extended fibrosis, inflammatory cells infiltration, lipophages, and granulomas within the mesenteric adipose tissue associated with erosive colitis. Clinical presentation and treatment are discussed. Sclerosing mesenteritis (SM) is a rare, usuallybenign disorder that affects the mesenteric fat tissue. This disease usuallyarises from the mesentery of the small bowel and rarely involves the mesocolon, 2. SM cA 59-year-old man complained oftwo-month history intermittent lower abdominal pain and constipation. About oneyear before, due to dyspeptic symptoms, an esophagogastroduodenoscopy wascarried out showing jatal hernia. His past medical history included only acutemyocardial infarction 13 years before. Laboratory tests were not contributory;tumor markers carcinoembryonicantigen, alpha-fetoprotein, andcarbohydraticantigen 19.9 were negative. Barium enema demonstrated ruggedmucosa and serrated contour with narrowing of the sigmoid colon by a probableextrinsic encasement. Then, a colonoscopy revealed reduction until 14 mm ofcalibre of the sigmoid colon, with rigid walls and aphtosis of the rectum. Histological examination of the endoscopic biopsies diagnosed ischemic colitis. Angiography of the celiac artery and of the mesenteric arteries showed noabnormalities.Patient's symptoms got worse over the nextmonth, mucous diarrhoea appeared and the patient presented to Emergency Room. On examination, he was afebrile. Physical examination of the abdomen revealedslight abdominal distension and, in the lower abdomen, a firm mass without tenderness,measuring approximately 10 cm in diameter, with mild pain on pressure,corresponding to the sigmoid colon. Rectal examination did not reveal anythingabnormal. A computed tomography (CT) scan showed rare sigmoid divertucula andthickened walls (about 1.5 cm) of the rectosigmoid colon, determining mildluminal narrowing, without signs of perivisceral inflammation; liver wasnormal; there was not lymphadenopathy either ascites. During the third day ofhospitalization, the patient developed obstructive symptoms with abdominalcramping and vomiting. A laparotomy identified a fibrous, partially necrotic,hyperaemic, 20 cm diameter mass in the mesocolon determining stenosis of thesigmoid colon and rectum, adherent to the parietal peritoneum. The mass was resectedin toto with rectosigmoid colon; transanal anastomosis according to Knight-Griffenand temporary protective ileostomy were performed. Postoperative course wasuneventful. Histological examination of surgical specimen revealed lipid-ladenfoamy cells and chronic granulomatous inflammation of mesocolon, associatedwith erosive colitis Figures .Three months later, Gastrographin enemaexcluded intestinal fistula, so patient underwent ileostomy surgical closure. At two years follow-up patient is asymptomatic.Sclerosing mesenteritis (SM) is an uncommonnonneoplastic inflammatory process in the mesenteric fat that rises as apseudotumor, usually involving the small bowel mesentery, the mesenteric fatand, less commonly, the mesentery of the large bowel. Young adults are mainlyaffected, more often men than women; about 2-3:1 , and theSeveral names are proposed for thisdisease, as SM, retractile mesenteritis, mesenteric nodular panniculitis,mesenteric Weber-Christian disease of the mesentery, and mesentericlipodystrophy, but they represent histological variants of a single pathologicentity that differs only in its proportion of fibrosis, lipid-ladenmacrophages, adiponecrosis, and nonspecific inflammatory infiltration. Microscopic diagnostic findings are chronic inflammatory process of themesentery, characterized by fibrosis, myofibroblasts, and inflammatory cellsinfiltration, degeneration of the fatty tissue or fat necrosis; aggregations oflipid-laden foamy macrophages are also present and they can be distributed inbands of variable width or in scattered areas , 8, 9. TThere is lack of consensus about the etiologyof SM. Several causes have been hypothesized, as ischemia, infections, previoustrauma, autoimmune disorders, previous abdominal surgery, coexistingmalignancies moslty urogenital or gastrointestinal lymphomas , 2, 10.Establishing the diagnosis of SM is both aclinical and histologic challenge. Clinical presentations are nonspecific andin common with numerous other diseases. Patients with SM may present withintestinal obstruction or ischemia, abdominal pain or distension, abdominalmass, weight loss, fatigue, fever of unknown origin, protein-losing enteropathywith diarrea, and minimal change nephropathy –14. SM mDifferential diagnosis take into accountmesenteric lipomas and liposarcoma, but radiographic tools (contrast studiesand CT or MRI ), even iSM has three modes of progression: partial orcomplete resolution of the inflammatory process, a nonprogressive course, or anaggressive course, characterized by a progressive fibrosis. That can causeshortening of the mesentery and compression of mesenteric vessels and thenthrombosis with secondary variceal bleeding, ischemia or life-threateningintestinal obstruction or ureteric obstruction with peritonitic or uremicstatus. In our case colonoscopy found ischemic mucosal lesions, probably due tothe compression of terminal colic vessels by the fibrotic process. SM usuallyhas a bening course with a favorable outcome , 9 and sThere is not any specific treatment for SM. Manymedical modalities—including corticosteroids, colchicines,immunosuppressive drugs, and progesterone—have been used with varying degrees of success, 18–22.


Solitary small bowel metastasis secondary to lung cancer is very uncommon. In this report, we present a patient with NSCLC and a metachronous solitary metastasis of the jejunum. She is alive without evidence of disease and doing well four years after palliative surgery, radiotherapy, and chemotherapy. To the best of our knowledge, this is the first case report describing a prolonged survival in a patient with a symptomatic solitary small bowel metastasis treated with palliative surgery, chemo- and radiotherapy instead of complete surgical resection. Lung cancer remains the leading cause of cancer-related death in Western countries. Nonsmall cell lung cancer (NSCLC) accounts for approximately 80% of these cases. At the time of diagnosis of NSCLC, around 40% will have stage IV disease with a median survival of 8–10 months and a 1-year survival rate of 30% [In the literature, unusual presentations with prolonged survival in patients with stage IV NSCLC are sporadically described, dictating a different therapeutic approach. For instance, potentially curative surgery for solitary brain metastasis or solitary adrenal gland metastasis has been described . Much leIn this report, we present a case of NSCLC with a metachronous solitary obstructive metastasis in the jejunum. The patient is still well and alive 4 years after subsequent treatment with palliative surgery, palliative radio- and chemotherapy. Moreover, a review of the literature on this subject is given.A 60-year-old woman, with a history of a superficially invasive urothelial cell carcinoma of the bladder, had undergone a lung bilobectomy in January 2004 for a carcinoma in the right upper lobe. At the time of diagnosis CT of the thorax and F-18-fluoro-positron emission tomography (FDG-PET) showed no evidence of lymph node involvement or distant metastases. Mediastinal lymph nodes were not sampled during surgery. Histopathological evaluation of the resected lung tissue revealed an undifferentiated large cell carcinoma of 3,3 cm in the lung parenchyma without pleural invasion or regional lymph node metastasis, T2N0M0 . No postEleven months later, the patient was referred again to our hospital because of of abdominal pain, weight loss, and fatigue. She had a performance score of 1. Physical examination showed that a mass was palpable in the left abdomen. Melena was not present at that time. All lymph node regions were found normal on palpation. Laboratory data showed no abnormalities.A CT of the abdomen and double-balloon enteroscopy showed a mass in the proximal jejunum . Double-Biopsies of the jejunal mass showed groups of large undifferentiated cells in the lamina propria . ImmunohTwo days after the initial histopathological diagnosis was made, intestinal obstruction occurred. Subsequent laparotomy showed a large tumor in the jejunum, which was adhered to the flexura lienalis region. Due to invasion of the mesothelium, tumor resection could not be carried out. Instead, side-to-side duodenojejunostomy was performed. Postoperatively, gastrointestinal bleeding with melena occurred. Gastroscopy showed no abnormalities. Palliative radiotherapy with a total dose of 15 GY in 5 fractions on the metastatic site was given after which the bleeding did not recur. Follow-up CT of the abdomen after 2 months showed complete absence of residual tumor in the jejunum .2 and vinorelbine 30 mg/m2 in a 3-week cycle. In total, she received 3 cycles. Chemotherapy was then cancelled because of serious side effects .It was chosen to further treat the patient with chemotherapy consisting of cisplatin 80 mg/m On follow up, the patient is doing well without any evidence of disease, 4 years after being diagnosed with a solitary metastasis of NSCLC in the jejunum.To the best of our knowledge, this is the first case report describing-prolonged survival in a patient with NSCLC and a symptomatic metachronous solitary small bowel metastasis treated with palliative surgery and palliative chemo- and radiotherapy instead of complete surgical resection. Rossi et al. described two patients with NSCLC and synchronous solitary small bowel metastasis who underwent small bowel resection, subsequent pulmonary lobectomy, and chemotherapy and are alive without evidence of disease . A solitary small bowel metastasis of NSCLC is very uncommon. The jejunum seems to be the most common gastrointestinal site in these cases. The biology of a single metastatic site in patients with lung cancer remains unclear. No predominant histological cancer subtype has been characterized –6.Screening for gastrointestinal metastases using CT of the abdomen has a low sensitivity. The use of whole-body FDG-PET for staging of lung cancer might increase the detection of small bowel metastases. Recently, two retrospective studies discuss the usefulness of FDG-PET in detecting gastrointestinal metastases in patients diagnosed with lung cancer , 9. ThesLittle can be said about survival period in patients with solitary small bowel metastasis of NSCLC as no firm data on this subject are available. Most patients described in the literature underwent surgical resection of the small bowel mass because of life-threatening complications and many times multiple metastatic sites were involved. A review by Garwood et al. describing cases with bowel perforation secondary to metastatic NSCLC showed a mean survival of 66 days . Only feThe choice of chemotherapy in our case remains arbitrary. Due to earlier palliative radiotherapy, residual metastatic tumor in the jejunum was not detectable anymore.Therefore, the effectiveness of chemotherapy could not be determined. It might have been solely the effect of radiotherapy on the metastatic mass that resulted in prolonged survival of our patient. A small bowel metastasis secondary to NSCLC is probably more frequent than expected, and physicians should always keep in mind this possibility. The rarity of solitary small bowel metastasis makes it difficult, if not impossible, to analyze these patient groups in randomized controlled trials. Without evidence-based medicine, an individualized approach is important.


A 68-year-old white female presented with two years of progressively worsening dyspnea. Echocardiography revealed a large right atrial mass and partial obstruction of the inferior vena cava. Further imaging revealed a cystic dense mass in the inferior vena cava and right atrium. Immunohistochemical stains were consistent with leiomyosarcoma. Intraoperatively, the tumor was noted to originate from the posterior aspect of the inferior vena cava. The patient underwent successful resection of the mass. Adjuvant radiation therapy was completed. The patient's dyspnea gradually improved and she continues to remain disease free five years post-resection. Leiomyosarcomas of vascular origin are rare tumors arising most frequently from the inferior vena cava (IVC). Only about 200 cases worldwide have been reported since 1871 . DiagnosOur patient is a 68-year-old white female with a two-year history of progressive dyspnea and a persistent non-productive cough. Past medical history included hypertension, lower extremity neuropathy of unknown etiology, and interstitial cystitis. She had a remote history of tobacco use but no exposures to other toxins. Family history was positive for stroke, diabetes, coronary artery disease, and gastric cancer. Physical exam was normal except for bilateral trace lower extremity edema. No jugular venous distension, heart murmur, or tumor plop was present.Four months previously, a CT scan of the chest, pulmonary function tests, and a pulmonary angiogram were normal. A sleep study showed no apnea but nocturnal hypoxia prompting a prescription for home O2 at night.At the time of re-evaluation, a transthoracic echocardiogram (TTE) demonstrated a normal ejection fraction of 60% with normal chamber dimensions but showed a large right atrial mass with high flow velocity around the echodensity. A small patent foramen ovale (PFO) was also present. Estimated pulmonary artery pressure was 44 mmHg. A transesophageal echocardiogram confirmed the large immobile right atrial mass, which involved the IVC. A CT scan revealed a cystic dense mass in the IVC and the right atrium with no evidence of pulmonary emboli or metastases Figure . The abdThere was mild cerebral atrophy without evidence of intracranial masses on a CT scan of the head. A combined PET (positron emission tomography)/CT scan of the chest showed a partially contrast-enhancing intraluminal mass within the intrahepatic and suprahepatic inferior vena cava extending into the right atrium. There was no extension into the hepatic veins. The mass markedly narrowed the suprahepatic inferior vena cava and right atrium with only a small amount of residual lumen noted medially. There was diffuse heterogeneity of the liver without evidence of mass lesion, suggesting hepatic venous congestion. The PET imaging demonstrated uptake in the tumor mass consistent with malignancy but no evidence of metastatic disease. Magnetic resonance angiography (MRA/MRI) showed that the large mass centered at the confluence of the inferior vena cava and right atrium and extended into the right atrium Figure . The masA fluoroscopically guided biopsy was preformed and histology revealed spindle shaped cells. Immunostains for smooth muscle actin and desmin were positive and those for melanoma and cytokeratin were negative, consistent with the diagnosis of leiomyosarcoma Figure .Intraoperatively, the tumor was noted to originate from the posterior aspect of the IVC and measured approximately 8 cm in length by 4 cm in width, with the widest part lying within the right atrium. Ten minutes of circulatory arrest was required and the tumor was excised along with a portion of the posterior inferior vena cava. The tumor mass was well demarcated with gross total resection. Of note, tumor margins at the time of resection were negative. The inferior vena cava was then closed primarily from the intraluminal side. Surgical clips were left in place to help identify the target for radiation therapy. In addition, the patient had her PFO surgically corrected. The patient tolerated the procedure well and was weaned from bypass without difficulty.Postoperatively, the patient received radiation therapy. The patient received a course targeting the resection bed of the origin of her tumor in the inferior vena cava. She was treated with photons of 18 megavolts (MV) at the isocenter at 2 Gray (Gy) per fraction for 25 fractions to a total dose of 50 Gy. This was followed by an additional boost to a small area for an additional five fractions to a total dose 10 Gy. The total dose to the tumor bed was 60 Gy. The patient tolerated the course of radiation well and reported no side effects, such as skin toxicity or gastrointestinal toxicity. There were no breaks during treatment.Subsequent clinical examinations every 6 months and imaging with yearly CT scans have confirmed that the patient has remained disease free 5 years after treatment.Tumors such as renal carcinomas, pheochromocytomas, hematomas or testicular tumors can secondarily invade the vena cava. Leiomyosarcomas of the inferior vena cava are primary vascular tumors that are relatively rare . They arClinical findings are nonspecific and may precede the diagnosis by several years . InitialIn 1992 the International Registry of Inferior Vena Cava Leiomyosarcomas collected 218 cases . Those aModern imaging modalities using computed tomography, magnetic resonance imaging, individually or in combination with cavography, ultrasound, and echocardiography, allow for an early and accurate preoperative diagnosis, resulting in a higher rate of surgical resection and improved survival ,3,5. It Despite advancing imaging technology, a biopsy is still indicated for formal diagnosis. Histopathology of leiomyosarcoma reveals spindle tumor cells, which are positive for markers of smooth muscle activity including vimentin, muscle actin, alpha-smooth muscle actin, and desmin .Because of limited experience with this disease, the optimal management of IVC leiomyosarcoma is unknown . AggressNeoadjuvant therapy may be given to downsize the tumor and increase resectability rates. Nonetheless, when complete resection is not possible, debulking combined with radiation therapy still provides good palliation . In anotThe International Registry of Inferior Vena Cava (IVC) Leiomyosarcomas analyzed their cohort of patients for predictive factors of clinical outcome. A radical tumor resection was undertaken in 134 61.5%) patients, 26 11.9%) had a palliative resection, and 58 (26.6%) were inoperable [% patient% had a pIn these patients, overall prognosis remains poor with a mean survival of 2 years but ranging from a few weeks to eight years . Even inLeiomyosarcomas are the most common malignancy involving the IVC. Although correlations between clinical manifestations and the location of the tumor within the IVC have been noted, patients often present with non-specific symptoms such as dyspnea, malaise, weight loss, and abdominal or back pain. Fluoroscopically guided biopsy is required for diagnosis, but various imaging modalities have allowed for earlier diagnosis and, subsequently, better outcomes. A combined PET/CT scan can be used for staging and to assist with treatment planning. Though chemotherapy and/or radiation therapy may serve as adjuncts to surgical resection, aggressive surgical treatment is currently recommended due to the tumor's slow growth pattern and low metastatic potential.IVC: inferior vena cava; PFO: patent foramen ovale; PET: positron emission tomography; TTE: transthoracic echocardiogram; US: ultrasound.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.VPR, PJV, RWD, and DGM drafted the manuscript and prepared the figures. GFM, JPB, SKW, and LK reviewed and amended the manuscript. All authors read and approved the final manuscript.