There are several techniques for creation of a neovagina in male-to-female reassignment surgery. Although vaginoplasty with the sigmoid colon is not a common procedure, it is becoming more common. Perforation of the recto-sigmoid neovagina after sex reassignment surgery is very rare. We hereby report a case of perforation of the neovagina that presented as acute peritonitis, with a massive abscess in the intra-abdominal cavity.This case report describes a 33-year-old Asian woman presenting with mild persistent abdominal pain, nausea, and vomiting who had undergone male-to-female sex reassignment surgery four years prior. Physical examination revealed mild abdominal pain without rebound tenderness. An abdominal computed tomography scan showed a massive abscess that occupied a significant portion of the intra-abdominal cavity. Perforation of the neovagina was confirmed by exploratory laparotomy and surgical drainage with primary closure was performed without any complications.This is a rare case involving perforation of the neovagina that was successfully treated with surgical intervention. This case emphasizes the importance of taking a detailed medical history and to make physicians and patients aware that bowel vaginoplasty can result in a weak vagina. Vaginal reconstruction is indicated in several conditions including vaginal agenesis, gender dysphoria in biological males, and genital trauma. There are several techniques for construction of the neovagina in male-to-female reassignment surgery. The penile-scrotal skin flap technique is considered the standard in vaginoplasty, however, use of the sigmoid colon for reconstruction is becoming more common because of good sexual and psychosocial outcomes –6. AlthoA 33-year-old Japanese female who underwent male-to-female sex reassignment surgery four years prior presented to our clinic with persistent abdominal pain that had gradually worsened over seven days. She also complained of nausea and vomiting, but otherwise claimed to be healthy. She had visited her primary care physician five days earlier, but no definite diagnosis was made.Upon presentation, the patient was alert and vital signs were unremarkable except for a fever of 38°C. Physical examination revealed mild abdominal tenderness without rebound tenderness. There were no other remarkable findings. A blood test revealed an increased white blood cell count 12,600/μL) and C-reactive protein level (26.64mg/dL), and liver and kidney function tests were normal. An abdominal X-ray showed signs of bowel obstruction with bowel distention and multiple gas-fluid levels. An abdominal computed tomography scan revealed partial bowel obstruction and a massive abscess, which occupied a significant portion of the intra-abdominal cavity (Figure 2,600/μL Although free air was not observed in radiographic images, bowel perforation was suspected. However, considering the discrepancy between the mild clinical manifestations and the abdominal imaging, we suspected a perforation of the neovagina rather than of the intestinal tract. Intravenous antibiotics were immediately administered, and surgical intraperitoneal drainage was conducted five hours after initial presentation to our hospital. During the procedure, 10L of saline was used, and the perforation was confirmed at the top of the neovagina Figure . Primaryet al.[et al.[Perforation of the neovagina after sex reassignment surgery is very rare. In 2001, Liguori et al. reportedl.[et al. in 2011,Spontaneous rupture of the neovagina with introitus occlusion has been reported, however, perforation without introital stenosis has not been described. In contrast to previous literature that emphasizes the importance of regular sexual intercourse and vaginal dilation to avoid complete introital stenosis , we specWe report a case involving perforation of the neovagina that was successfully treated with surgical intervention. Rupture of the neovagina is a very rare origin of an acute abdominal syndrome, and this case emphasizes the importance of taking a detailed medical history and making physicians and patients aware that bowel vaginoplasty can result in a weak vagina.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.


Spindle cell oncocytoma (SCO) of the adenohy-pophysis is a rare tumor in the sellar region. Due to its rarity, little information is available regarding SCO. It is often misdiagnosed as another type of sellar tumor. In the present study, two cases of SCO were reported. One patient was a 35-year-old female presenting with decreased visual acuity, amenorrhea and lactation. The other patient was a 62-year-old female with no clear symptoms or signs. Cranial magnetic resonance imaging (MRI) revealed a suprasellar mass with marked homogeneous enhancement in the two cases. A craniotomy was performed to completely resect the tumors. The tumors were immunopositive for vimentin, epithelial membrane antigen (EMA), S-100 and thyroid transcription factor-1 (TTF-1). The tumors were pathologically diagnosed as SCO. No recurrence occurred during the follow-up period of 15–21 months. In the present study, the literature was reviewed and the clinical data, imaging features, intraoperative findings and recurrence of 24 cases were analyzed in the literature as well as the present two cases. The average age of the SCO patients was 58.5 years and no gender preference was observed for the disease. The tumor exhibited homogeneous enhancement on the MRI. The intraoperative assessment revealed that the tumor had a rich blood supply and the SCO tumors were immunopositive for vimentin, S-100, EMA and TTF-1. These findings provided valuable clinical data for the preoperative diagnosis and surgical removal of SCO tumors. Spindle cell oncocytoma (SCO) of the adenohypophysis is a rare benign tumor in the sellar region, accounting for 0.1–0.4% of all sellar tumors . SCO wasA 35-year-old female was admitted to the First Hospital of Jilin University , who had been presenting with amenorrhea and lactation for two years. On examination, her visual acuity was 0.8 in the left eye and 0.5 in the right eye. Dark spots were observed in the left inferior temporal quadrant and decreased light sensitivity was observed in the right nasal quadrant. Cranial magnetic resonance imaging  revealed a suprasellar round mass of 2.5×3.0×1.0 cm, with equal T1 and T2 signals. This mass exhibited marked homogeneous enhancement . LaboratThe patient was diagnosed as having a pituitary prolactin adenoma. The tumor was resected through the second gap using a right expanded frontotemporal craniotomy. The tumor was gray with blood vessels on the surface, was firm without clear encapsulation and had an appearance similar to that of normal brain tissue with a rich blood supply. The pituitary stalk was adherent to the tumor and was pushed inferiorly by the tumor. The stalk was partially preserved following careful dissection. The tumor was removed section by section until complete removal of the tumor was achieved by visualization under a microscope. Persistent diabetes insipidus occurred following surgery and it was gradually relieved following oral administration of desmopressin acetate for 2.5 months. An enhanced MRI performed at seven days after surgery confirmed the complete removal of the tumor. No recurrence had occurred by the time-point of the 21-month follow-up examination .Postoperative hematoxylin and eosin (H&E)-stained sections revealed that the tumor was composed of spindled and epithelioid cells arranged in nests and sheets. The cells had an abundant eosinophilic cytoplasm. Mild to moderate nuclear atypia was identified; however, mitosis was not observed. Nuclear pleomorphism was observed in certain cells and a double nucleus was occasionally present. Infiltration of scattered mature lymphocytes was observed in the extracellular matrix . The tumA 62-year-old female was admitted to the First Hospital of Jilin University due to a sellar mass identified during a routine physical examination. She presented no clear symptoms or signs. Cranial MRI revealed a suprasellar mass of 2.3×1.7×2.0 cm, with long T1 and short T2 signals . This maThe patient was diagnosed as having a nonfunctional adenoma. The tumor was resected between the first and second gap using a right transpterional craniotomy. The tumor was light yellow and slightly soft, and it had a brain stem-like appearance with a rich blood supply. The tumor was removed section by section. Care was taken to preserve the membrane-like pituitary stalk dorsolateral to the tumor until the tumor was completely removed. Transient diabetes insipidus occurred immediately following surgery; however, it was effectively treated following two weeks of oral administration of desmopressin acetate. An enhanced MRI performed at three days after surgery confirmed the complete removal of the tumor. No recurrence had occurred by the time-point of the 15-month follow-up examination .Post-operative H&E-stained sections demonstrated that the tumor was composed of spindled and epithelioid cells arranged in intersecting fascicles. The cells had an abundant eosinophilic cytoplasm with round or oval nuclei and inconspicuous nucleoli. Mild to moderate nuclear atypia was identified; however; mitosis was not observed. Nuclear pleomorphism was observed in certain cells. Infiltration of a few mature lymphocytes and local interstitial mucoid degeneration was observed . The tumet al (http://www.ncbi.nlm.nih.gov/pubmed) for studies published between 2002 and 2013. The clinical characteristics, intraoperative findings as well as the imaging and immunohistochemical features of the 24 published cases, and the two cases reported in the present study were assessed. SCO commonly occurred in middle-aged and elderly males or females. Of the 24 cases published in the literature, 10 patients were male and 14 were female. No gender preference for SCO is therefore present. The average age of the SCO patients was 56.4 years . In the present two cases, the patients were females aged 35 and 62 years old, respectively.SCO was first reported by Roncaroli et al  in 2002 et al . Histoloet al ,2. In a Similar to nonfunctional pituitary adenoma, the most common clinical manifestations of SCO are visual impairment and panhypopituitarism. Of the 24 cases in the literature, 14 cases presented with decreased or impaired visual acuity and 12 cases presented with panhypopituitarism. In addition, intermittent epistaxis was reported in one patient with a large SCO  and one SCO is often misdiagnosed preoperatively. Of the 24 cases of SCO in the literature, 14 cases were misdiagnosed as being nonfunctional adenomas. Due to its spindle-like shape, four cases were misdiagnosed as being schwannomas. In addition, one case was misdiagnosed as being a craniopharyngioma due to recurrent intratumoral bleeding . Furtheret al . The mean MIB-1 labeling index was 3%. A total of two cases with a high MIB-1 labeling index (10–20%) exhibited recurrence. The other six cases with a low MIB-1 labeling index also exhibited recurrence. Of the six cases treated with radiotherapy (doses of 50–55 Gy), recurrence occurred in four cases. No intra- or extracranial metastases were identified. However, the longest follow-up period was 16 years . These fet al  found thIn conclusion, SCO was identified as a novel type of tumor in the WHO classification of tumors of the CNS in 2007 . However


Internal inflammatory root resorption (IIRR) is a rare condition of the root canal and if it is left untreated it may lead to destruction of the surrounding dental hard tissues. Odontoclasts are responsible for this situation which can potentially perforate the root. Many initiating factors have been mentioned for IIRR, almost all causing chronic inflammation in the vital pulp. IIRR is usually symptom free, but in cases of root perforation, a sinus tract usually forms. The prognosis of treatment depends on the size of lesion with small lesions being managed with good prognosis. However, in case of notable destruction of the tooth, the prognosis is poor and tooth extraction may become inevitable. This report represents the management of an extensive perforative IIRR that was successfully sealed with calcium-enriched mixture (CEM) cement. After 12 months the tooth was still symptomless and in function. Internal inflammatory root resorption (IIRR) is a well-known disease that ultimately perforates the root and destroys the surrounding dental hard tissues . HoweverUnlike root resorptions initiating from the surrounding root tissues, IIRR tends to be self-limiting after the whole root canal pulp tissue becomes necrotic due to advancing root canal infection . When coaka. dentinoclasts) from the dentin inside the root canal [From etiologic point of view, under normal conditions predentin layer and odontoblast cells covering the mineralized dentine, act as a barrier that separates pulpal cells with resorbing potential  because of its antimicrobial properties, profound seal and being very well tolerated by the tissues .Calcium-enriched mixture (CEM) cement is a tooth-colored cement with clinical applications similar to MTA. It offers proper sealing ability, antimicrobial properties, hard tissue induction properties and shorter setting time, greater flowability and lower film thickness than MTA .The present report reviews the diagnosis (using CBCT), and nonsurgical treatment (using CEM cement) of a perforative IIRR that had developed a sinus tract and represents the one-year outcome of treatment.An elderly lady in her seventies asked for a dental visit, with her chief complain being dull pain and swelling in the upper-lip area. On a regular assessment she was healthy and used to take 1 mg cortisol daily for her rheumatoid arthritis. Intra oral examination revealed a normal oral hygiene. The upper lip was swelled and dense on palpation. The vestibule was filled with swelling and a sinus tract was evident in periradicular area of the maxillary left central incisor. The orthograde periapical radiography showed a large lucency within the limitations of the canal. Also CBCT was indicated for evaluation of the extents of the intracanal lesion and also the periradicular lucency , the latLa-Chaux-de Fonds, Switzerland) up to 50/0.04 as the master apical file. To dissolve the hyperemic resorptive tissue in the non-accessible areas, CH powder  was mixed with normal saline to prepare a creamy paste that was transferred to the canal with a lentulo spiral . The tooth was temporarily restored and two weeks later along with healing of the sinus tract, the patient’s symptoms faded away. During the second appointment the canal was rinsed with saline and dried. Then, the whole canal space was filled with CEM cement  mixed according to user’s instruction. Confirmation radiography was taken . After mouth rinse with 0.2% chlorhexidine gluconate , a classic access cavity was prepared. The canal was negotiated with a # 15 K-file  and an excessive bleeding was observed. After determination of an estimated working length (WL) , the canas taken  and afteas taken  and 12 mas taken , the patThe present report revealed the successful nonsurgical management of a perforative IIRR lesion in upper left central incisor using CEM cement. After one year, the tooth was symptomless and functional.IIRR is characterized by the resorption of the internal aspect of the root by multinucleated giant cells (dentinoclasts/odontoclasts) . IIRR isOnce the diagnosis of IIRR is made and the tooth is deemed restorable with a reasonable prognosis, conventional root canal treatment is the treatment of choice , 14. WhiIn the next stage, treatment procedure is followed by obturation of the canal with an appropriate root-filling material to prevent it from reinfection. IIRR defects can be difficult to obturate due to intra canal irregularity . Thus th3), phosphorous pentoxide (P2O5), and silicon dioxide (SiO2) [CEM is an endodontic filling material with its major components being calcium oxide (CaO), sulfur trioxide (SOe (SiO2) . The floe (SiO2) . The seae (SiO2) . It has e (SiO2) . Moreovee (SiO2) . The folAlso using CBCT for diagnosis and determining the extent of the IIRR lesion in this case cannot be overlooked. The advent of CBCT has improved the clinicians’ diagnostic capability for IIRR . NeverthInternal inflammatory root resorption can be successfully treated provided it is diagnosed in time and treated using proper strategy and biomaterials. CEM cement is a good candidate for sealing and filling the internally resorbed teeth.


Dear Editor,A previously healthy, 28-year-old woman presenting a palpable mass in the righthypochondrium for 3 years, evolving with local discomfort over the last 20 days.Ultrasonography (US) demonstrated an expansile mass best characterized by computedtomography (CT) and magnetic resonance imaging (MRI) which showed a well defined solidmass in continuity with the liver by a thin pedicle originating from the segment V andcaudally extending towards the pelvis, measuring 18.0 × 9.4 × 5.2 cm, withfeatures and pattern of enhancement suggestive of hemangioma  and 1B. -8, with a prevalence of0.4-20% in necropsies,5-8. In most cases,hemangiomas are small, asymptomatic and incidentally found at imaging studies,2,5,6.Hemangioma is the most common benign liver tumor-3,5,6. The first casewas reported by Ellis et al. in 1985; and up to 2013, only 24 cases were described inthe literature,4.In spite of the lack of consensus about the dimensions to define a giant hemangioma,ranging from 4 to 10 cm according to the literature, it is known that the exophyticpresentation, particularly those pedunculated, are very rare  and, likely anygiant lesion, may determine compression of the intrahepatic biliary ducts, vascularstructures or adjacent organs, manifesting with pain, early satiety, hemorrhage,jaundice, nausea and vomiting,2,5,6,8. Main complications include torsion due to a long and mobile pedicle,infarction,6, spontaneous or traumatic rupture, congestive heartfailure, and Kasabach-Merritt syndrome,6,7.In almost 50% of cases, pedunculated hemangiomas are symptomatic at thediagnosis,4,5.A correct diagnosis of the pedunculated lesion may be difficult, despite the typicalradiological presentation, because of the limitation in define the origin of the mass,since a thin pedicle may be almost undetectable at images-4,6,8. At US, the image is typically hyperechoic, homogeneous, with welldefined margins; and, in cases of giant lesions, central heterogeneity may bepresent. At CT, with acertain frequency, giant hemangiomas do not present with the typical pattern ofhypoattenuating lesion with centripetal enhancement and homogenization at delayedsections, due to the presence of avascular areas of necrosis, fibrosis orhemorrhage,8. MRI is the most sensitive and specific (> 90%)diagnostic method,6. The lesions are well defined, homogeneous, with lowsignal intensity at T1-weighted sequences, and high signal intensity at T2-weightedsequences.The most used modalities of imaging in diagnosis include US, CT and MRI.Biopsy is not recommended in such cases, due to the risk of hemorrhage,4, retroperitoneal mass, other pedunculated liver tumors such as hepatocellularcarcinoma, mesenchymal hamartoma, focal nodular hyperplasia or adenoma.There are reports in the literature describing pedunculated hemangiomas as gastric,adrenal tumor,2,4-7, and for cases of pedunculatedhemangiomas due to their tendency to torsion,6.Surgical treatment is reserved for cases of giant or symptomatic lesions, uncertaindiagnosis, lesions with complications


This report describes a clinical case with an atypical intraoral sinus tract formation from diagnosis and treatment to short-term outcome and definitive prosthetic rehabilitation. In detail, the patient underwent conservative nonsurgical root canal treatment followed by guided bone augmentation of the regions involved in periapical inflammation and sinus tract formation. The removal of the inflammatory source of the lesion as well as the affected tissue clearly led to a healing of the surrounding bone tissues. Subsequently, the tooth was reconstructed using a fibreglass post and a metal-ceramic crown; an implant was successfully placed in the previously inflamed bone region. Infections of the dental pulp may be caused by caries, operative dental procedures, and traumata; they are always initiated by a mixed, predominantly gram-negative, anaerobic bacterial flora . InitialDepending on their cellular composition and structural organization, these lesions can be referred to as abscesses, granulomas, or apical cysts. The periapical abscess is a suppurative process, leading to spontaneous pus drainage and, consequently, to the formation of a drainage duct, called fistula or sinus tract , 3–5. UsAfter the formation of the sinus tract, typical symptoms of acute periapical inflammation, such as exactly locatable intensive pain, continuously subside and the drainage can persist until the tooth is treated or removed –5. In thA 58-year-old male patient came for regular dental examination at the Department of Operative Dentistry and Periodontology, University School of Dental Medicine, CharitéCentrum 3, Charité - Universitätsmedizin Berlin. Subjectively, the patient was without any dental complaints. His medical history showed no significant findings. However, his dental history revealed a complicated extraction of the mandibular right first molar performed two years earlier, which had led to a free-end situation (without a definitive rehabilitation up to the first appointment).Upon examination of the mandibular right second premolar, a carious lesion was detected on the occlusal surface. Pulp sensitivity to cold  was negative, and the tooth was not sensitive to percussion. At a first glance, there was no evidence to suggest a sinus tract; naked-eye inspection of the typical predilection sites for the sinus tract formation on the buccal and vestibular sides of the alveolar ridge revealed no pathological findings. Therefore, an immanent implantation and prosthetic rehabilitation were discussed and scheduled with the patient. However, a radiographically visible periapical lesion, involving the distal region of the mandible .The endodontic treatment was carried out without any anaesthetics, thus confirming the existence of necrotic pulp tissue. A rubber dam  was placed and, after caries removal, an access cavity was prepared . On the The root canal was prepared with rotary files and reamers  using a combined crown-down and step-back technique under irrigation with 5% sodium hypochlorite  and 0.2% chlorhexidine digluconate solution . The preparation of the root canal was performed to ISO size 35 master point, up to a working length of 15.5 mm  as intraSix weeks later the endodontically treated premolar was reconstructed with a fibreglass post and a composite restoration . Rubber One year later, the patient returned for the follow-up examination. The mandibular right second premolar still was completely asymptomatic. Radiographically, the periapical area showed a partial bony recovery, comparable to the situation several weeks after endodontical treatment . HoweverImmediately before the procedure, the patient rinsed for 2 minutes with a 0.2% chlorhexidine digluconate solution . The treatment was initiated by establishing local anesthesia (Ultracain D-S), followed by full thickness mucoperiosteal flap elevation and removal of the compromised elements. The granulation tissue was thoroughly curetted and removed using a surgical curette . After removal of the granulation tissue, a defined 5-wall bony defect remained, which was cleaned manually and by means of sonic instrumentation , followed by copious irrigation with saline. Subsequently, the defect was filled with an alloplastic bone grafting material . A porcine collagen membrane  was sized and placed over the defect. The soft tissue was repositioned over the augmented region and sutured with 4.0 silk sutures . Examination one week later showed uneventful healing without any exposure of the membrane.The postoperative appointment six months after augmentation showed no remaining evidence of the sinus tract; radiographically, the periapical area showed a complete healing Figures . SubsequSinus tracts developing periapically from chronic low grade inflammations are considered a common clinical observation . HoweverThe localization of any sinus tract's aperture buccally or vestibularly of the alveolar ridge can be explained by the preferential flow of exudate through less resistant areas, spread through bone marrow, periosteum, and connective tissue and between the fascias and will drain onto the epithelial surface on the buccal or vestibular side of the alveolar ridge –5. In raSinus tracts of dental origin may be misdiagnosed as periodontal abscesses, osteomyelitis, neoplasms, tuberculosis, or actinomycosis . As dent Enterococcus faecalis in the root canal [ Enterococcus faecalis seems to be the most prominent microbe in endodontic failures; indeed, this is a bacterium that is very difficult to eliminate using conventional methods. Regarding the elimination of Enterococcus faecalis, the root canal rinsing has been shown to be most efficient when sodium hypochlorite is combined with chlorhexidine digluconate [The root canal treatment was performed by means of rotary files and reamers using a combined crown-down and step-back technique under irrigation with 5% sodium hypochlorite and 0.2% chlorhexidine digluconate solution. In spite of any strong antibacterial effects of sodium hypochlorite, this rinsing solution will not lead to total absence of bacteria. Even the use of calcium hydroxide as an interim dressing does not exert sufficient antibacterial action againstot canal . Enterocluconate .The present case demonstrates a delayed regeneration of the sinus tract in spite of successful endodontic treatment. Previous investigations showed that sinus tracts are usually lined with granulomatous tissue, although, in more advanced stages, an epithelial lining might also be present , 15. MorBecause of the unilateral free-end situation, a restoration, such as a fixed cantilever bridge, or a solitary dental implant was clearly indicated. Cantilever bridges are considered to be a compromise but are preferred to a removable partial denture, especially for unilateral edentulous dentitions. Technical failures are more commonly observed if nonvital teeth are used as abutments for cantilever bridges . In consIn the presented case report the healing of the atypical sinus tract associated with periapical lesion of endodontic origin was observed. However, due to urgency of prosthetic rehabilitation of the patient, guided bone augmentation, implantation, and definitive reconstruction had to be accelerated. In many instances, like with the present case, accurate radiographic and intraoral examinations are of great importance. Precise radiographic examination can alert clinicians to the presence of variations, leading to successful treatment.


Solid hemangioblastomas are rarely found in this particular area of the brain. To the best of our knowledge, the case of only one patient harboring a hemangioblastoma not associated with Von Hippel-Lindau disease has been previously reported in the literature in this anatomic region. Regarding age presentation, it is rare for sporadic hemangioblastoma in any part of the brain to occur in older patients; only two cases have previously been reported, and neither were in this anatomical space. A solid hemangioblastoma represents a surgical challenge because of its high vascularization, very similar to an arteriovenous malformation, and it should be removed en bloc via an infratentorial supracerebellar approach with an excellent outcome.We report here the case of a 63-year-old white male patient with a sporadic hemangioblastoma located in the posterior incisural space mimicking a tentorial meningioma. It was completely removed A hemangioblastoma should be considered among the differential diagnosis of hypervascularized masses in the posterior incisural space, even in cases of solid tumors, in older patients, or in the absence of Von Hippel-Lindau disease. These tumors located in the posterior incisural space represent a challenge, and the infratentorial supracerebellar approach provides panoramic exposure to allow safe resection. In older patients, hypervascularized tumors of the posterior incisural space associated with the tentorium are commonly tentorial meningiomas. Hemangioblastomas (HBL) are rarely found in this location, not even in older patients –4. We reThe potential risk of significant intraoperative bleeding exists in cases in which the diagnosis has not been suspected preoperatively or not recognized intraoperatively. Because the presumptive diagnosis of HBL has a large impact on the surgical technique, the objective of this report is to emphasize that HBL should be considered among the differential diagnosis of hypervascularized tumors in the posterior incisural space even in cases of a solid mass, in older patients, or in the absence of VHL disease.A 63-year-old white male patient of Polish descent had a 3-month history of headaches, vomiting, and episodes of blurring vision, compatible with intracranial hypertension syndrome. On admission, he had papilledema, nystagmus, and lethargy. A T1-weighted magnetic resonance imaging (MRI) scan showed a low signal intensity lesion in the anterosuperior part of the posterior fossa in contact with the falcotentorial dura junction, displacing inferiorly the cerebellar vermis and compressing the aqueduct of Sylvius, producing obstructive hydrocephalus. The mass enhanced homogeneously with gadolinium-based contrast. Flow voids compatible with vessels were observed around the tumor. Fig  and b. Men bloc resection to be performed  was performed to treat the hydrocephalus. After the ETV, our patient did well. Five days later, he was operated on for tumor removal. The surgery was performed in a semi-sitting position via an infratentorial supracerebellar approach. The tumor was a highly vascularized and well-circumscribed mass. The lesion was meticulously dissected from the surrounding tissue. The tumor was found to be separated from the superior aspect of the cerebellar vermis by a thick arachnoidal layer. Several small vessels feeding the tumor and coming from the tentorium were coagulated. The mass dramatically reduced its size, allowing rmed Fig .Fig. 2PoA pathological examination demonstrated a tumor characterized by a double component, vascular and cellular, with a network of small and delicate vessels that separated groups of large polygonal cells, with clear and vacuolated cytoplasm and small, oval hyperchromatic nuclei. A reticulin stain and CD34 immunostain readily delineated the complex capillary networks of the HBL  (Fig There were no complications, and our patient had a complete recovery of his preoperative symptomatology. Postoperative screening using clinical, laboratory, ultrasound, and body imaging scans for the detection of VHL disease were negative. A long-term follow-up until 5 years post surgery was uneventful.HBL is a histologically benign tumor that is associated with VHL disease in 20 % of cases but sporadic in 80 % of cases , 5. DeveThe gene may also be mutated in 4–14 % of cases of sporadic HBL . For spoHBL usually occurs in young adults, with a mean age at diagnosis of 32 years for VHL-associated HBL and 40 years for sporadic HBL , 5. We fHBLs are more frequently found in the cerebellum or in the brain stem; other localizations such as supratentorial, spinal cord, orbit or sellar sites are less common . To the en bloc removal is then possible. Preoperative embolization is not recommended because of poor results [HBL characteristically presents as a cystic mass with a solid mural enhancing nodule; however, presentation as a highly vascular solid mass is not infrequent. Calcifications and edema are rare , 14. Sol results . HBL is  results .Although uncommon, HBL is a tumor that should be considered when dealing with vascularized tumors in the posterior incisural space, even in relation to the dura, and at any age. This consideration may help in planning surgical approaches that address the inherent risks of this entity.


A 60-year-old male was referred to Nanjing Drum-Tower Hospital  due to the presence of gastric carcinoma. A biopsy was performed under an electronic gastroscope and the pathological analysis resulted in the diagnosis of gastric small cell carcinoma (GSCC). The mass had invaded the liver and the pancreas according to an enhanced computed tomography scan, thus current surgical methods were considered to be of high risk and highly challenging. Following four cycles of neoadjuvant chemotherapy with irinotecan  and oxaliplatin  the patient underwent a D2 gastrectomy and an esophagojejunal Roux-en-Y anastomosis, followed by adjuvant chemotherapy. The patient experienced survival without progression in the 8-month follow-up. To the best of our knowledge, this is one of few cases of GSCC treated with the combination of neoadjuvant chemotherapy, surgery and adjuvant chemotherapy. Small cell carcinomas (SCC) are a group of neuroendocrine tumors, the majority of which arise from the lung . When coGastric SCC (GSCC), one of the typical SCC arising from the digestive system, is a rare small cell neuroendocrine tumor . HoweverA 60-year-old male presented to the Nanjing Drum-Tower Hospital  with a one-year history of epigastric distress. No other symptoms, including acid regurgitation, eructation, nausea, emesis, diarrhea or melena, were described. The patient had no history of hypertension or diabetes mellitus and suffered from no infectious diseases, such as hepatitis or tuberculosis. The patient had smoked one pack of cigarettes per day for the past 30 years and had consumed alcohol for ~20 years, but had no significant drug use or history of malignancy in first-degree relatives. There was no evident histological abnormality upon physical examination. An electronic endoscopy revealed irregular tumor-like lesions in the cardia, lesser curvature of the stomach and angular notch. A separate, large, ulcerated mass with friable mucosa was observed in the gastric cardia. Multiple biopsy specimens were obtained. The hematoxylin and eosin-stained sections revealed densely-packed sheets of small basophilic cells. Immunostaining was positive for cytokeratin and the tumor was focally positive for synaptophysin and chromogranin A. The immunohistochemical profile supported the histological diagnosis of an SCC. No abnormality was detected on chest radiography. A routine blood examination, liver function test and electrocardiogram were performed. Among all the tumor markers, the level of carbohydrate antigen (CA)-125 was 69.80 U/ml, slightly higher than the normal range of 0–35 U/ml. Computed tomography (CT) revealed a thickening of the gastric wall and a mass , mainly Collectively, the electronic gastroscopy (EG) and CT findings supported a final diagnosis of metastatic GSCC. Following a multi-disciplinary discussion between the Departments of General Surgery and Radiation Oncology, it was decided that current surgical methods would be of high risk and highly challenging. A plan was developed to start the treatment of the patient using neoadjuvant chemotherapy. Therefore, the patient underwent treatment with irinotecan  and oxaliplatin  for a four-cycle period, without an evident adverse reaction. Following two cycles of chemotherapy, the patient achieved a partial response. The CT scan revealed that the lesion had clearly decreased in size . The enhFollowing another multi-disciplinary discussion, the patient underwent a D2 gastrectomy and esophagojejunal Roux-en-Y anastomosis. There was a 5×2×1-cm mass under the cardia of the stomach, in the lesser curvature. The serous membrane layer was complete and there were no metastatic nodules found in the liver, pancreas, spleen, kidneys, abdominal wall or pelvic cavity. The post-surgical pathology revealed that the tumor was 4×4×0.8 cm in size, invading the serosa, nerves and vessels of the stomach. The surgical margin was revealed to be tumor-free. Three metastasis-positive lymph nodes were found in 27 cleaned lymph nodes around the stomach. The pathological tumor-node-metastasis stage was stage IV T4aN2M1; . FollowiThe neuroendocrine tumors of the digestive system are typically classified by their differentiation according to the World Health Organization classification  as folloet al (et al summarized and analyzed the clinical features and prognosis of GSCC (SCC of the stomach is rarely reported. The condition was first reported in 1976 by Matsusaka et al . GSCCs aet al ,18 and tet al  and, not of GSCC . However of GSCC . OxaliplIn the present study, following the pathological diagnosis of GSCC, the enhanced CT scan revealed that the mass had invaded the liver and the pancreas, with a nodular shadow of low density in the liver and mild enhancement. Current surgical methods were concluded to be of high risk and highly challenging following multi-disciplinary discussion. Subsequent to four cycles of neoadjuvant chemotherapy with irinotecan and oxaliplatin, the enhanced CT scan revealed that the lesion was markedly decreased in size and that there was no clear nodule in the liver. The patient then received a D2 gastrectomy and esophagojejunal Roux-en-Y anastomosis, followed by adjuvant chemotherapy. The present case of combined neoadjuvant chemotherapy, surgery and adjuvant chemotherapy highlights the comprehensive treatment of GSCCs, particularly neoadjuvant chemotherapy, which provided the patient with an opportunity to receive surgery. The present patient is currently alive without disease progression and the follow-up of this case continues.


Background: Human hydatid disease is caused by echinococcus granulosus and has a global distribution. It mainly affects the liver, but can involve other organs. In this paper, we present a case of a primary hydatid cyst of the fallopian tube.Case presentation: A 69-year-old  with abdominal pain and urinary frequency was presented to the Gynecology Clinic of Imam Khomeini Hospital Sari, Iran, in September 2011. On physical examination, there was a nontender abdominal mass under umbilicus. The sonography of abdomen and pelvic showed a multiloculated mass with thick septation in right adnexa suggesting mucinous ovarian tumor, while the uterus, left adnex, liver, spleen and kidneys were all normal. The patient’s chest x-ray was normal. Serum tumor markers including CEA, CA125, αFP and βHCG were negative. An exploratory laparotomy was performed. There was a 20 cm firm elastic mass in the anterior surface of uterus originated from the right fallopian tube and was removed. Hydatid cyst was confirmed by pathological examination.Conclusion: Although primary hydatid cyst of genital tract is rare, in high prevalence countries it should be considered. Echinococcsis is an infection caused by larval stage of Echinococcus granulosus, E. multilocularis, or E.vogeli in human. The disease may result from the development of expanding parasite cysts in visceral organs , 2. It dA 69-year old (gravida 16 para 16 woman) with abdominal pain and urinary frequency presented to the Gynecology Clinic of Imam Khomeini Hospital Sari, Iran, in September 2011.She was from a rural area of south Khorasan province. On physical examination, there was a nontender abdominal mass under the umbilicus, although the liver and spleen were within normal size. She was admitted in gynecology ward and workup of abdominal mass was performed. The sonography of abdomen and pelvic showed a multiluculated mass with thick septation in the right adnexa suggesting mucinous ovarian tumor, while the uterus, left adnex, liver, spleen and kidneys were all normal. The patient’s chest x-ray was normal. Serum tumor markers including CEA, CA125, αFP and βHCG were negative. All other lab tests were in normal range except mild anemia.An exploratory laparotomy with midline incision was performed, no ascites was present. There was a 20-cm firm elastic mass in the anterior surface of uterus originated from the right fallopian tube. Two ovaries were atrophic and normal , 2. . She underwent total abdominal hysterectomy and bilateral salpingoophorectomy. Pathologic report confirmed the diagnosis of hydatid cyst (Exploration of entire peritoneal surface and organs were normaltid cyst . The patPrimary hydatid disease in reproductive organs is rare. Reviewing the literature, we found less than ten articles about primary involvement of reproductive organs, among them only in one article, the primary involvement of fallopian tubes was reported . The invIn this paper, we report the second case of primary fallopian tube hydatid cyst worldwide. This suggests that hydatid disease is still a health care problem in Iran, however, the atypical site of the cyst makes it difficult to diagnose.


Rectourethral fistula is one of the complications that can occur after prostatectomy in the urologic discipline. However, a delayed-onset rectourethral fistula after intersphincteric resection (ISR) for low rectal cancer is extremely rare. Here, we report one such case in a 57-year-old man. After ISR for low rectal cancer with a diverting stoma (DS), the DS was closed. After approximately 1 year, frequent pneumaturia and right orchitis were observed. Results of contrast enemas and abdominal computed tomography examinations revealed a rectourethral fistula from an anastomosis to the urethra. The colonoscopic appearance revealed a pinhole fistula on the anastomotic line, with thick pus. We performed a transverse colostomy, and the pneumaturia and right orchitis were no longer observed. Two months later, colonoscopy, contrast enemas, and cystoscopy revealed no rectourethral fistula. To the best of our knowledge, our case is the first report of a delayed-onset rectourethral fistula after ISR. Intersphincteric resection (ISR) is commonly performed for very low rectal cancer . PreviouThe patient was a 57-year-old man who underwent ISR for low rectal cancer with a diverting stoma (DS) in May 2010 in our hospital . Using 32 absorbable sutures, a manual end-to-end anastomosis was created. The primary tumor was located in the right lateral wall of rectum and 3 cm from the anal verge. He was discharged after an uneventful postoperative course. Histopathological examination revealed well-differentiated tubular adenocarcinoma with no lymph node metastasis, and it was classified as pStage II (pT3 N0 M0). Results of contrast enemas performed before the DS was closed revealed no anastomotic leak, so the DS was closed in September 2010. The patient had frequent defecation  without fecal incontinence for a period of time after this procedure. The frequent defecation was gradually declining . After approximately 1 year, frequent pneumaturia and right orchitis were observed. Results of contrast enemas revealed a rectourethral fistula from an anastomosis to the urethra Fig. . We encoOur report has two points of great clinical significance. Firstly, the delayed-onset event occurred after ISR for very low rectal cancer is very rare. Secondly, our case is the first report about rectourethral fistula after ISR.Anastomotic leaks have become troublesome in the surgical treatment of rectal cancer with or without a DS. Recently, in cases of low anterior resection for rectal cancer, Shiomi et al. reported that the frequency of anastomotic leak was 13.2 % in patients with DS versus 12.7 % in cases without DS; no significant differences were found . On the Symptoms associated with anastomotic leaks in previous reports include rectovaginal fistulas and seminal vesicle-rectal fistulas. Rectovaginal fistulas, the first type, have been frequently reported, and their repair has been adequately investigated and developed. Kosugi et al. reported that the gluteal-fold flap was a good technique for the repair of rectovaginal fistulas , but thiThe reports of delayed-onset anastomotic leaks are very few. August et al. reported three cases in association with bevacizumab therapy . The intThe treatment options for rectal fistulas have been classified into two types: conservative measures and aggressive treatments. The former includes interventional radiology (percutaneous drainage) and colostomy, and the latter includes local repair  and re-aIn our case, the patient rejected the closure of his colostomy. Therefore, it remains unclear whether this rectourethral fistula was healed; if the colostomy was closed, it would be clear that the rectourethral fistula made a resurgence.This report describes a very rare case of a delayed-onset rectourethral fistula after ISR as well as the advantages of conservative measures, i.e., colostomy, for the treatment of this complication. The pathogenesis was less pronounced; therefore, the operative manipulation of ISR must be performed cautiously.Written informed consent was obtained from the patient 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.


CT findings in three cases with solitary fibrous tumors (SFTs) confirmed by histopathology and immunohistochemistry were reviewed retrospectively, and compared with pathological results. The three tumors were large, well-defined, and smooth contour masses and SFT consisted of solid components of two different densities. On enhanced CT scans, tumors were strongly enhancing, the multiple vascular shadows were seen within the tumor in the arterial phase. There is progressive enhancement from the arterial to the venous phase, and the tumor capsule can be observed. Histologically, the tumors are composed of spindle cells within a background of collagen stroma, and showed a wide range of growth patterns, alternating hypercellular (tumor cell-rich) and hypocellular (collagen-rich) areas. The diagnosis is confirmed by characteristic positive immunohistochemical staining for CD34. Solitary fibrous tumors (SFTs) are rare spindle-shaped cell tumors originated from dendritic mesenchymal cells. They mostly occur in visceral pleura, but rarely in the retroperitoneum , 2. In tCase one was a 22-year-old female who suffered from intermittent abdominal pain in central right position for 6 years, with paroxysmal pain radiating to the right waist, which relieved after resting. Upon physical examination, a palpable tough-quality mass in central right abdomen was seen, with no tenderness and rebound tenderness. Enhanced abdominal CT showed a lobulated soft tissue mass on the right retroperitoneum, 160 mm × 105 mm × 66 mm in size and with a clear boundary. The solid part of the tumor in the arterial phase showed a moderately heterogeneous enhancement, with a CT value of about 76 HU. A plexiform disordered vascular shadow was visible, together with extensive unenhanced low-density cystic areas (Figure Case two was a 61-year-old female, who developed a huge retroperitoneal placeholder as indicated by examination. The patient had neither chest tightness, shortness of breath, difficulty in breathing, nor abdominal discomfort. Upon physical examination, the abdomen was flat and soft, with no palpable mass. Plain chest and abdominal CT scans showed a huge soft tissue mass shadow fused by multiple nodules of varying sizes on the right retroperitoneum, approximately 164 mm × 150 mm × 116 mm in size. Heterogeneous density and extensive low-density cystic areas were seen, with CT values of 25 to 40 HU, and clear boundaries with the surrounding organs. There was a shift in the heart, and the liver and right kidney were under compression, as well as the aorta and inferior vena cava. Varicose veins in the abdomen were also observed. The solid part of the mass in the arterial phase was moderately and heterogeneously enhanced, with a CT value of about 83 HU, and a plexiform disordered vascular shadow was visible (Figure Case three was a 66-year-old male, who developed a huge retroperitoneal placeholder in the pelvic cavity, as revealed by examination. The patient had no back pain or hematuria, no abdominal distention or abdominal pain, and no sychnuria, urgency, or dysuria. A plain pelvic CT scan showed a huge retroperitoneal soft tissue mass on the right side of the bladder, approximately 78 mm × 63 mm × 58 mm in size, with a heterogeneous density. Multiple cystic areas of low density were seen, with CT values of 25 to 40 HU, and with unclear boundaries with the neighboring bladder (Figure The onset age of SFTs is 19 to 85 years old, and the age of peak incidence is 40 to 60 years old. SFTs are more common in women. In our study, there were two female patients. Visceral pleura is the most common site of SFT occurrence, but there are more than 1/3 of SFTs occurring outside of the thoracic cavity, including in the head and neck, spinal cord, abdominal and pelvic cavity, respiratory tract and surrounding soft tissue, among others , 11, andCT can be used to identify the focus area and clarify the origin. It is also important in revealing the characteristics of tumor growth to some extent, as well as for efficacy and prognosis evaluation. The retroperitoneal SFT was mostly lobulated and large, in round or oval shape, and grew slowly in an expansive way. The surrounding tissues mostly shifted under compression. In the three cases discussed herein, the maximum diameter was above 160 mm, and a significant extrusion occurred to the surrounding organs. The organs were deformed under compression. Most tumors have intact envelopes, which is an important feature of retroperitoneal SFTs . In all MRI can accurately show the histological features of retroperitoneal SFTs, which has great value for tumor diagnosis. However, the three cases discussed herein did not undergo this procedure. According to the literature , 9, 10, Gastrointestinal stromal tumors, neurogenic tumors, and soft tissue sarcoma, among others, need to be distinguished from retroperitoneal SFTs.In short, retroperitoneal SFTs are rare, with no typical clinical manifestations, and therefore it is often difficult to make a correct preoperative diagnosis. CT imaging of retroperitoneal SFTs usually shows the following characteristics: large tumors with clear boundaries, intratumoral solid components in two different densities, cystic degeneration, necrosis, and myxoid degeneration, significant enhancement and a visibly enhanced envelope. These features can be used as the criteria for differential diagnosis for tumors originating from the retroperitoneum. The confirmed diagnosis still depends on histological and immunohistochemical examinations.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.


This case report discusses a 23-year-old male patient who presented with shortness of breath during exercise. Echocardiography revealed an intracardiac mass located on the mitral valve. His medical history included surgical closure of an atrial septal defect type 2 at the age of 2 years. After being discussed within a multidisciplinary heart team, the intracardiac mass was surgically removed. Histopathological examination revealed a blood cyst. This case report emphasises that the presence of an acquired intracardiac cyst is a rare entity and that a pathophysiological association between the formation of a blood cyst and previous cardiac surgery has not been proven yet.The online version of this article (doi:10.1007/s12471-015-0707-4) contains supplementary material, which is available to authorized users. In the majority of cases, intracardiac masses are tumours; 90 % of all tumours in the heart are benign. Of these tumours, myxoma is the most common (70 %). Less frequently, blood cysts are seen. A congenital origin has been described in most of these cases . The exaA 23-year-old male patient presented to the outpatient clinic with shortness of breath during exercise. At the age of 2 years, he underwent surgical closure of an atrial septal defect type 2. At the age of 18 years, a mitral valve prolapse of the anterior mitral valve leaflet was diagnosed, with trivial mitral regurgitation. His history included coloboma of the iris and a surgical correction of phimosis. Physical examination was unremarkable. The electrocardiogram, laboratory testing and chest X-ray showed no abnormalities.Transthoracic and transoesophageal echocardiography exhibited an intracardiac mass attached to the anterior leaflet of the mitral valve, a moderate mitral regurgitation with an eccentric jet as well as normal left ventricular function Fig. , Movie 1Surgery was performed by re-do median sternotomy. After aortic and bi-caval cannulation, cardiopulmonary bypass was established. Myocardial protection was achieved by antegrade cold blood cardioplegia during aortic cross clamping. A trans-septal approach was used to expose the mitral valve and the mass. A yellow, smooth and spherical mass with a diameter of 2.0 cm was found attached to the anterior mitral leaflet adjacent to the posteromedial commissure


Ganglioneuroma are rare, benign neural tumor of sympathetic nervous system originating from neural crest sympathogonia. Pelvic ganglioneuromas may mimic ovarian masses. We present a patient operated with the diagnosis of ovarian tumor which had a pelvic gangliuoneuroma.An eleven-year old female patient complaining of abdominal pain and a mass was seen at our hospital. On examination a 10×10 cm mass was palpable in the pelvis. Laboratory parameters were all normal and the tumor markers such as β-HCG, AFP, CEA, serum catecholamines were negative. Abdominal ultrasonography and computed tomography showed an 11×6×9 cm solid mass containing calcification. The preoperative diagnosis was an adnexal mass of ovary. The patient was operated under general anesthesia and we found a retroperitoneal mass attached to the spine at L5. The tumoral mass was completely excised. Histopathological examination of tumor was reported as ganglioneuroma. The patient was discharged on seventh day of hospitalization with no neurological deficit.Retroperitoneal ganglioneuromas are usually present with local mass a benign tumoral course. The preoperative diagnosis may be difficult in pelvic ganglioneuromas due to close similarity with the ovarian masses. The treatment of the ganglioneuroma is total surgical excision and histology provides a confirmatory diagnosis. Ganglioneuromas (GNs) are well differentiated; benign, central and peripheral autonomic neural system related tumours mostly originated from sympathetic nervous system.1The most common localization of ganglioneuroma is posterior mediastinum and retroperitoneum. Girls are more commonly affected than boys and generally they are diagnosed under the age of 10 years.5Here in, we report a case of a patient who was preoperatively diagnosed as ovarian tumour and uneventfully operated but she had a diagnosis of ganlioneuroma after histopathological evaluation.An 11-year- old female patient complaining with abdominal pain and abdominal mass was admitted to our hospital. The patient had been suffering from these symptoms for three months and before admission she was diagnosed as abdominal hydatid cyst. On physical examination: a 10×10 cm mass was palpable in the pelvis extending up to the umbilicus and was dull on percussion. Biochemical, haematological, hormonal laboratory parameters were all normal and the tumour markers such as β-HCG, AFP, CEA, serum catecholamines were negative. Serology for hydatid disease was also negative. Abdominal computed tomography showed a 110×63×90 mm mass with solid internal structure, which displaced the right common iliac artery and vein anteriorly. Hyper vascular septa with highly resistant arterialize was observed in the mass .The patient was operated under general anaesthesia after preoperative preparations. Although the preoperative diagnosis was an adnexal mass of ovary, intraoperatively it was seen that the mass was retroperitoneally situated. The patient mass was located retroperitoneally at the conjoined with right and left common iliac artery and vein and attached to the L5-S1 vertebrae by posterior capsule. At the posterior of L5 spinal capsule there was a neural connection with the tumour wall. We removed the tumoural mass completely and dissected neural connection which was the main and only connection of spinal cord with the tumour. The excised tumour was well-demarcated, non-cystic and measuring (110×63×90mm .At the histopathological examination; lobular mass with dirty white appearance in cross section was found. Staining with S-100 dye was reported as ganglioneuroma with schwann type stromal mature ganglion cells and immune positive. The patient’s postoperative neurological examination was normal and was discharged on seventh day of hospitalization.Neuroblastic tumours from sympathetogonia are divided in to three groups’ as neuroblastomas, ganglioneuroblastomas and ganglioneuromas according to the degree of cellular & extracellular maturation. Ganglioneuraoma are composed of gangliocytes and mature stroma and are benign in nature. Neuroblastoma are the most immature, poorly differentiated and malignant tumours of all the three.7Ganglioneuroma are mostly seen during infancy and preschool period. The age of diagnosis is generally under 10 years and average age is 7. Girls are three times more affected than boys. The incidence of the tumour is reported to be 1/100.000.2They are clinically asymptomatic and, non-functional. Because of their slow growth pattern, diagnosis is usually made at late adolescence age. The diagnosis is made by tumours mass and pressure affect to surrounding tissues and organs. If the tumour grows retroperitoneally, the main symptoms are abdominal pain and distention.The main differentiation criterion for neurological tumours was histopathological existence of mature ganglion cell. Ganglioneuroma contains; schwans cells, ganglion cell, fibroses tissue and neural fibers. There are no immature cells, atypical, mitotic structure or necrosis in ganglioneuromas as neurobastomas.6The definite diagnosis of ganglioneuroma in our case was made by existence of: both bundle forming, oval nucleated and spindle shape schwans cells with the ganglion cell appearing as granulated eosinophilic cytoplasm. Surgically total resection of the tumour is the main treatment and there is no recurrence reported.In conclusion, the preoperative diagnosis of retroperitoneal ganglioneuromas due to radiological confusion with other tumours are very difficult. We should keep in mind that retroperitoneal masses may be a ganglioneuroma and the diagnosis can be made only by histopathological evaluation postoperatively.


The present case report is of trauma episode of the lower anterior teeth, causing pulpal necrosis with periradicular periodontitis, resulting in the occurrence of cutaneous sinus tracts (fistula). Previous misdiagnosis and inappropriate medical treatment were ineffective. Only when properly referred to dentists, the differential diagnosis was made. The guideline to diagnose cutaneous sinus tracts (fistula) is based mainly on accurate pulp sensitivity tests of the involved traumatized teeth. Intraoral and dental examinations are critical in making the diagnosis. The case presented here shows that cutaneous odontogenic sinus tracts associated in traumatized teeth, even in absence of caries or tooth fracture.How to cite this article: Mishra R, Khan TS. Cutaneous Sinus Tract in Association with Traumatic Injury to the Teeth . Int J Clin Pediatr Dent 2013;6(3):205-207. This report involves a case of cutaneous facial sinus tract of dental origin, its diagnosis and treatment.Although cutaneous sinus tracts of dental origin have been well documented in the medical and dental literature, these lesions continue to be a challenging diagnosis. The discharge of purulent exudates usually is associated with periapical radiolucent area and goes through tissues and structures along the path of least resistance.A 12-year-old boy reported to the Department of Pedodontics and Preventive Dentistry, Babu Banarasi Das College of Dental Sciences, Lucknow with a complaint of episodic drainage from a cutaneous lesion in the mental region of lower jaw. He stated that he had felt an induration about 1 year ago and left it untreated because he had no pain. However, as the lesion started to discharge pus during the following months, he then received several treatments from a dermatologist. Inspite of taking large number of antibiotics and antifungal medications both orally and topically, the lesion did not heal then patient was referred to our college. The patient had also reported a history of trauma to that area 4 years back. Extraoral examination showed a nontender elevated crusty nodule approximately 1 cm in diameter in the mental area  Palpatio4 The discharge of purulent exudates usually is associated with periapical radiolucent area and goes through tissues and structures along the path of least resistance.5 The site of drainage can be located intra- or extraorally, depending on certain circumstances such as: the tooth which is diseased, and the apex position relatively to muscular attachments, bacterial virulence and lower host resistance.6 In a cohort study of 108 odontogenic sinus tracts Slutzky-Goldberg et al.7found just 1case with cutaneous sinus tract. In the report of Gupta and Hasselgren,4 all odontogenic sinus tracts (29 cases) had intraoral openings. Studies revealed that the extraoral sinus tracts is most commonly found on the cheek, chin and angle of the mandibule, and in this way making the diagnosis more difficult to the clinician. These authors have reported how important is the interaction between physicians and dentists is to avoid submitting patients to multiple biopsies, antibiotic regimens and unnecessary surgery, before correct diagnosis and endodontic therapy are in course.489 The cutaneous sinus tracts are a sequel to pathosis and that the clinician should be able to recognize the primary cause. Therefore, taking the patient's history becames crucial in order to avoid misdiagnosing a wide variety of diseases like ingrow hair, osteomyelitis, local skin infection and neoplasm.10 In several cases of teeth traumatism the pulp can be affected, even if the crown-root integrity is not damaged. Odontogenic sinus tracts appear as a papule or nodule with purulent discharge usually in the chin or jaw.11The histology of these tracts is often characterized as fragments of granulation tissue that are focally lined by epithelium.1 Most infections are polymicrobial, and culture often yields growth of anaerobes or facultative anaerobes, such as Streptococcus species. It has been observed that systemic antibiotic therapy will result in a temporary reduction of the drainage and apparent healing. Surgical excision of cutaneous sinus tracts followed by root canal treatment of the affected teeth is the treatment of choice.Cutaneous sinus tract and fistulization of the facial skin have a wide range of etiologies, the most common being odontogenic in origin. Such patients usually seek help from surgeons or dermatologists rather than dentists and often undergo multiple inappropriate treatments. In diagnosis of cutaneous dental fistula, although the examiner usually looks for dental caries or periodontal diseases, he should bear in mind the possibility of dental traumatic injuries.Chronic, draining dental infection is one of the most common causes of fistulae of the face and neck. An understanding of the pathogenesis of cutaneous fistulae arising from dental infections will lead to proper early diagnosis and treatment without unnecessary surgery. The case presented here shows that cutaneous odontogenic sinus tracts associated in traumatized teeth, even in absence of caries or tooth fracture; the clinician must investigate the pulpal health of the teeth in the contiguous area of cutaneous fistula. This case report highlights the need for thorough diagnostic procedures that should always include a dental examination. The clinician should recognize that a cutaneous sinus tract is a sequel to pathosis, while the associated nonvital tooth, with its periradicular periodontitis, is the primary cause.


Prolapse of the fallopian tube after hysterectomy is a rare but known complication. Cases of prolapse of the fallopian tube through the vaginal vault have been reported after abdominal, vaginal or laparoscopic hysterectomies. This is the first case report to the best of our knowledge on the prolapse of a fallopian tube through an abdominal wound after caesarean section.We report a case of the prolapse of the fimbrial end of a fallopian tube through an abdominal scar after caesarean section mimicking scar endometriosis. A 24-year-old primipara South Asian woman of Punjabi ethnicity presented to our institute with a fleshy mass protruding through her abdominal scar and bleeding from the mass during menstruation for the past 5 months. She underwent a caesarean section 6 months earlier for breech presentation. Her history revealed she had wound dehiscence on the sixth postoperative day. The major portion of her wound healed in 1 month leaving a 2 cm area in the middle of her vertical scar. An abdominal examination revealed a 2×2 cm fleshy mass protruding through the middle part of her infraumbilical abdominal scar. At the time of the surgery we found that the fimbrial end of her left fallopian tube was protruding through her abdominal scar.Awareness of this complication may prevent improper management of wound dehiscence and such complication causing prolonged agony to the patient. Prolapse of the fallopian tube after hysterectomy is a rare but known complication. Cases of prolapse of the fallopian tube through the vaginal vault have been reported after abdominal, vaginal or laparoscopic hysterectomies –3. We reA 24-year-old South Asian woman of Punjabi ethnicity presented with fleshy mass protruding through midline vertical abdominal scar and bleeding from the mass during menstruation for the past 5 months. She was primigravida; she underwent a caesarean section 6 months earlier at term gestation for breech presentation in a local hospital. She delivered a normal healthy baby boy and the immediate postpartum period was uneventful. On the sixth postoperative day she noticed serosanguinous discharge from her abdominal wound and wound dehiscence was diagnosed. She was managed conservatively and the wound was left for secondary healing by the attending physician. Her history revealed that she was given antibiotic coverage during this time. The major portion of her wound healed in 1 month leaving a 2 cm area in the middle of her vertical scar. An investigation at the time of her caesarean section revealed that she was anemic (hemoglobin 8 gm %). Peripheral blood film revealed microcytic hypochromic anemia. On admission to our institute she was emaciated, thin built, anemic and her vital signs were normal. An abdominal examination revealed a 2×2 cm fleshy mass protruding through the middle part of her infraumbilical abdominal scar. On per vaginal examination her uterus seemed attached to the anterior abdominal wall at the scar site and with cervical movement the mass was getting retracted into her abdomen. With her history of menstruation through the abdominal wound a provisional diagnosis of scar endometriosis/uterocutaneous fistula was made and ultrasonography (USG) and fistulogram were suggested. USG showed normal uterus and adnexa and fistulogram showed communication with intraperitoneal cavity. A tissue biopsy revealed granuloma. She was planned for excision of the fistula tract and repair. On an operating table methylene blue dye was injected through the wound to mark the fistulous tract and dye was found to be escaping through her vagina confirming communication with uterine cavity. An elliptical incision was made around the fleshy mass and on entering the abdominal cavity, the left side of her uterus was adherent with her anterior abdominal wall at the scar site and the fimbrial end of her left fallopian tube was found to be protruding through the abdominal scar. A probe (dilator) was passed through the tube and diagnosis was confirmed (Fig. et al. [Pozzi in 1902 described the first report of postoperative prolapse of fallopian tube after vaginal hysterectomy . Since tet al.  did a syet al. ; howeverPrevention of tubal prolapse can be achieved by improving the general condition of the patient and treating anemia and infections during the pregnancy, using a proper technique of wound closure at the time of primary surgery and careful inspection in the case of wound dehiscence for burst abdomen. Awareness of this complication may prevent inadequate treatment of wound dehiscence and such complication causing agony in the patient’s life.Written informed consent was obtained from our patient 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.


Cholangiocarcinoma (bile ducts cancer) is a rare and aggressive form of cancer. It metastasizes frequently to liver, peritoneum, and lungs. Colon metastasis is extremely uncommon. We report here a 70-year-old male who was diagnosed with cholangiocarcinoma for which he underwent a Whipple procedure. Fifteen months later, a CT scan revealed mural thickening in the colon; this was supplemented with a PET scan, which confirmed this mass. Histological diagnosis of metastatic cholangiocarcinoma to the colon was made and the patient was treated with chemotherapy. Although rare, cholangiocarcinoma metastasis can be found in the colon. A high index of suspicion is required to diagnose and treat early. More cases need to be reported to find out further about the prognosis of the disease. Cholangiocarcinoma, also known as bile duct cancer, originates from bile ducts, including the intrahepatic, perihilar, or distal (extrahepatic) biliary tree, exclusive of the gall bladder or ampulla of Vater. Cholangiocarcinoma accounts for about 3% of gastrointestinal malignancies. It is a rare form of cancer that usually is locally advanced at the time of diagnosis. Intrahepatic cholangiocarcinoma arises from small intrahepatic ductules  or large intrahepatic ducts proximal to the bifurcation of the right and left hepatic ducts. The extrahepatic bile ducts are divided into perihilar (including the confluence itself) and distal segments, with the transition occurring at the point where the common bile duct lies posterior to the duodenum . The repThe most common sites of metastases are liver, peritoneum, and lungs but cases in unusual sites, such as skin and adrenal gland, have been reported previously -5. ColonInformed patient consent was obtained prior to treatment.2 weekly for three out of four weeks each month for a total of six months. Nine months after the therapy started, the patient developed atrial fibrillation for which he underwent cardioversion and was then put on Coumadin. After being on Coumadin for five months, he noticed blood in his stool. An investigation revealed an elevated INR of 5.2. After correcting the INR, he underwent a CT scan as well as a colonoscopy due to continued bleeding. The CT scan of the abdomen and pelvis showed an area of mural thickening in the middle to distal portion of the ascending colon suspicious for a neoplastic process, bilateral pleural effusion more than the previous studies performed earlier. Colonoscopy confirmed the mass initially noticed on the CT scan as shown in Figure We diagnosed a 70-year-old-male with cholangiocarcinoma for which he underwent a Whipple procedure. The pathology report showed a moderately differentiated adenocarcinoma of the middle and distal bile duct, 0.5 cm in size, which was confined to the bile duct with clear margins; one out of 17 (1/17) lymph nodes tested positive for adenocarcinoma. With that information, we staged the tumor as pT1N1MX (Stage IIB). Subsequently, the patient was placed on adjuvant chemotherapy consisting of gemcitabine, 1,000 mg/mHistology showed adenocarcinoma, and the immunostaining was positive for CK7 and CA19-9 and negative for CEA and CK20. These pathological findings were consistent with a metastatic bile duct adenocarcinoma confirmed by an immunoperoxidase staining pattern identical to the patient’s primary tumor at the time of initial diagnosis about 15 months previously. A PET-CT scan revealed a small focus of tracer uptake within the right supraclavicular area with a standardized uptake value (SUV) of 2.5. A pretracheal lymph node had an SUV of 3.3, a subcarinal lymph node had an SUV of 4.0, and a right hilar lymph node had an SUV of 3.1. Mild tracer uptake was seen in the left lower effusion, but no uptake in the right pleural effusion. In the right lower lobe, a focal mass-like lesion was found with SUV of 2.4. The tracer uptake was insignificant in the liver, but there was significant tracer uptake seen in the bowel adjacent to the gastric anastomosis with an SUV of 3.7, which was possibly due to inflammatory change. The lymph node anterior to the inferior vena cava within the right mid-abdomen had an SUV of 2.7. A soft tissue mass abutting the colon at the level of the hepatic flexure had an SUV of 11.1. A lymph node anterior to the right common iliac vein had an SUV of 3.6. The major conclusion of the PET-CT was that the soft tissue mass near the hepatic flexure was consistent with malignancy. The adenopathy in the abdomen, the chest findings, and the lesion in the right lower lobe of the lung all pointed toward metastasis.The case was thoroughly discussed in different multimodality conferences and finally diagnosed as colon metastasis from his primary cholangiocarcinoma. The patient was treated with systemic chemotherapy consisting gemcitabine and cisplatin based on the diagnosis of cholangiocarcinoma, which resulted in a partial response with a duration of response of four months. He later progressed to peritoneal disease and was treated with oral capecitabine.Only a handful cases have been published to date to verify the spread of cholangiocarcinoma to unusual locations, such as adrenal glands, bones, brain, colon, and skin -5. One pAnother important aspect of this case is that our patient developed atrial fibrillation for which he was placed on Coumadin. Bleeding from the rectum or other sites of bleeding is not an unusual finding in patients receiving anticoagulation therapy, including Coumadin. However, due to our expertise in GI malignancies and experience of reporting similar cases, we did not stop after correcting INR but further investigated the cause of bleeding that led to this diagnosis . This isIn summary, cholangiocarcinoma is a rare but aggressive form of cancer that spreads rapidly unless it is completely resected. It is usually diagnosed at a stage when it is too advanced for surgical resection. The tumor is relatively silent in the start and usually diagnosed when it is in an advanced stage. There is, however, the need for a screening method to detect the tumor at its early stages. Some patients do present with jaundice, and primary care providers refer them for ultrasound and endoscopic retrograde cholangiopancreatography. But the patients presenting with vague abdominal pain delay the initial diagnosis of such patients. Therefore, a high index of suspicion is required for early detection. It is usually late and the tumor is advanced by the time jaundice develops. Last but the least, rapid referral and awareness of unusual sites of metastases of cholangiocarcinoma is the key in the quick diagnosis and the treatment of cholangiocarcinoma.


Angiomyolipomas (AMLs) are benign mesenchymal tumors seen in kidneys in association with tuberous sclerosis. They are uncommon in liver. Angiomyolipomas of liver show great histological diversity and various types and patterns are described. Among them, epithelioid and inflammatory angiomyolipomas are rare. We report a case of epithelioid angiomyolipoma of Liver with an inflammatory component. Angiomyolipomas are benign mesenchymal tumors seen in the kidney either sporadically or in association with tuberous sclerosis . They beA 50-year-old gentleman came to the casualty with a history of fever, vomiting, and abdominal pain. He was a nonsmoker and nonalcoholic with no history of diabetes mellitus or hypertension. The patient did not have any features of tuberous sclerosis complex. An ultrasonogram showed a mass in the liver. CT showed a large mass in the left lobe of liver suggestive of hepatocellular carcinoma or giant angioma . The patWe received segmentectomy specimen of liver which weighed 650 grams and measured 15 × 9 × 8 cms. Surface was bosselated . Cut secMicroscopy showed a neoplasm composed of epithelioid cells, thick-walled blood vessels, and adipocytes. The epithelioid cells had granular pink or vacuolated cytoplasm and vesicular oval/round nuclei, some showing prominent nucleoli. There was pigment in some of the cells. Thick-walled blood vessels were seen dispersed and were prominent near the capsule. Adipocytes were seen in some of the sections focally. Also noted were inflammatory cells comprising of lymphocytes, plasma cells, and histiocytes throughout the lesion Figures  and 5. EAngiomyolipomas are benign mesenchymal tumors classically described in kidney in association with tuberous sclerosis . HepaticHepatic angiomyolipomas have been classified histologically depending on the amount of various components that are vessels, smooth muscle cells, and adipocytes as angiolipomas, myolipomas, and angiomyolipomas . Others This case is reported because of several interesting aspects. Our patient is a 50-year-old male who was thought to have Hepatocellular carcinoma clinically. Radiological differential diagnosis included hepatocellular carcinoma and giant angioma. AMLs are mostly located in the right lobe whereas in our case it was in the left lobe. Grossly the tumour was cystic with necrosis which is unusual in AML. Predominant epithelioid morphology is not common, and the prominent inflammatory component seen in our case has been described only in 11 cases earlier.


Although vascular tumours are one of the most common soft tissue neoplasms, those occurring in the gastrointestinal system are rare and cases involving mesentery are even further rare. Herein, we reported a rare case of giant hemangioma in mesentery of the small bowel.A 5-year-old girl was admitted to the emergency room with abdominal pain and vomit for two days. Ultrasonography and computed tomography showed a giant solid-cystic abdominal mass, preferring diagnosis of teratoma. A large neoplasm in the mesentery of the small bowel was found in the surgical exploration, which was then resected with the partial bowel. A brown honeycomb mass in size 16 cm×8 cm×5 cm was observed to adhere to the small bowel, and diagnosed as hemangioma of cavernous and venous mixed type in final pathology.The mesenteric hemangioma is extremely rare and the variable imaging tests are non-specific, thus the diagnosis is rarely made before surgery and usually established by histopathological investigation after surgery. So the mesenteric hemangioma is supposed to be differentiated in abdominal mass, either in adults or children. Complete surgical resection is the optimal treatment. Vascular tumours are one of the most common soft tissue neoplasms which account for about 7 per cent of all benign tumours . They ocA 5-year-old girl was admitted to the emergency room with abdominal pain and vomit for two days. She had experienced of such symptom about twenty days ago and had naturally remited after fast. She had no history of anaemia and bloody stool. B-mode ultrasonography displayed several echogenic areas in strip or tubal form communicating with each other in the abdomen with the biggest diameter of about 6 cm and internal spotted medium echoes Figure . ComputeGross examination showed a brown honeycomb mass in size 16 cm×8 cm×5 cm, which adhered to the small bowel Figure . HistoloHemangioma is one of the most common benign tumours widely found in many organs, with a high occurrence during infancy and childhood. About 250 cases have been reported in the gastrointestinal system in the English papers since 1839. Hemangioma involving mesentery is extremely rare, and only twenty cases have been reported, among which four cases were in large size. The four cases were all adults, and no such patients of children or adolescents have been reported to our knowledge. Herein we reported a case aged 5 years in which the tumour was limited to the mesentery of the small bowel.In histopathology, hemangioma may be classified into several categories according to vessel size and wall thickness . ActuallHemangiomas of mixed cavernous and venous type are supposed to be one variation of venous type by some pathologists because venous hemangiomas may also have area indistinguishable from cavernous hemangiomas . HoweverThe origin of mesenteric hemangioma is still uncertain. Most reported cases involved both bowel wall and mesentery. Given hemangiomas of mesentery are far rarer than those of bowel, they are always proposed to be originated from the bowel, especially submucosa . But in The symptoms of intestinal and mesenteric hemangiomas were often bleeding or obstruction depending on its location -10. In oThe preoperative diagnosis of mesenteric hemangioma was difficult, sometimes even nearly impossible. The imaging methods including B-mode ultrasonography, CT, and magnetic resonance (MR) and so on, although provide some useful information, only can demonstrate an abdominal mass rather than diagnose accurately -14. The The optimal treatment of intestinal or mesenteric hemangiomas is surgical resection. In our case, operation was adopted successfully. Radiation, cryotherapy and other therapies have been used for some non-resectable cases and more wildly cases named of hemangiomatosis, but the prospect was limited ,15.We reported one rare case of giant mesenteric hemangioma, which was characterized of occurrence in a young child and pathology of cavernous and venous mixed type. The mesenteric hemangioma is extremely rare and the variable imaging tests are non-specific, thus the diagnosis is rarely made before surgery and usually made by histopathological investigation after surgery. The mesenteric hemangioma is supposed to be considered in differentiation in abdominal mass, either in adults or children. Complete surgical resection is the optimal treatment.Written informed consent was obtained from the guardian of 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.SMA: Smooth muscle actin; MR: Magnetic resonance; CT: Computed tomography; cm: Centimetre.The authors declare that they have no competing interests.GZ performed the pathological observation and collected the clinical information. JL made the pathological diagnosis and made up the manuscript. HJ performed the immunohistochemistry and participated in manuscript revision. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/13/50/prepub


Salivary gland cancers are rare and represent approximately 5% of all head and neck cancers and only 0.3% of all malignancies. The majority (75%) of salivary gland tumors occur in the parotid gland, and while benign lesions are more common, mucoepidermoid carcinoma (MEC) makes up 40–50% of malignant parotid gland tumors. No randomized controlled trials exist regarding the role of adjuvant radiation for patients who undergo surgical resection of low-grade MECs. Herein, we report two cases of successful postoperative radiation therapy in low-grade, pT2N0 MEC of the parotid gland. The role of adjuvant radiation therapy for patients with MEC of the parotid gland is based on data from institution reviews and lacks data from randomized controlled trials. Per our review of the literature, the pathological findings of positive surgical margins and/or perineural invasion in two patients with low-grade MEC of the parotid gland warranted adjuvant radiation for improved local control after partial parotidectomy. Both patients tolerated postoperative radiation therapy with only mild side effects and, at last follow-up, five years after completion of therapy, had no clinical or radiographic evidence of either local recurrence or distant metastasis. Salivary gland cancers are rare and represent approximately 5% of all head and neck cancers and only 0.3% of all malignancies . The majPatients with salivary gland tumors commonly present with a mass and/or localized pain. Management of these cancers typically involves surgical resection with postoperative radiation therapy considered in cases where there is concern for local failure based on pathological assessment. Though previously believed to be radioresistant, generally accepted indications for adjuvant radiotherapy in MEC include positive surgical margins, positive nodal involvement, extracapsular extension, perineural invasion, and advanced stage (T3 and T4) . While aHerein, we report two cases of successful postoperative radiation therapy in low-grade, pT2N0 MEC of the parotid gland.The patient is a 27-year-old African American male who presented in October 2008 with a 5-year history of a mass in the area beneath his left ear. It was originally noted to be approximately 1 cm in size but, by the time of presentation, it had grown to almost 2 cm and had become painful. He sought medical attention and a trial of antibiotics was unsuccessful in resolving the mass. A CT of the maxillofacial area in late October 2008 revealed a subtle, mixed isodense nonenhancing mass measuring 2 × 1.6 cm in the left parotid gland with no adenopathy in the neck. MRI in December 2008 again demonstrated a 1.3 cm mass in the superficial aspect of the left parotid gland without adenopathy.Fine needle aspiration (FNA) of the lesion on December 23, 2008, returned inflammatory cells consistent with sialadenitis but could not rule out a low-grade malignancy. Resection of the lesion via a nerve sparing left parotidectomy in January 2009 demonstrated a 2.7 cm low-grade MEC with involved margins and perineural invasion. This tumor was classified as low grade according to the AFIP grading scheme, with a total score of 2/14 . There was no evidence of lymphovascular invasion and four lymph nodes were excised and pathologically negative for carcinoma.On physical exam two weeks after surgery, the patient's House-Brackmann score was rated II/VI. The patient exhibited complete eye closure with maximal effort, symmetric facies at rest, and mild weakness of the marginal mandibular and buccal branches. Four months later, his House-Brackmann score improved to I/VI, though he continued to complain of xerostomia on the left side of his mouth, left side face and neck pain, some discomfort with swallowing, and a left sided headache. He was referred to Radiation Oncology for additional evaluation and management.At his initial consultation appointment in February 2009, physical exam revealed a healing incision in the left auricular area consistent with his recent parotidectomy with no lymphadenopathy. After a careful review of the available literature regarding this rare malignancy, he was offered adjuvant radiation therapy to the left parotid tumor bed based on the findings of positive surgical margins and perineural invasion.The radiation fields included the existing tumor bed with appropriate margin to cover microscopic disease spread, patient motion, and daily set-up error, with daily 200 centigray (cGy) fractions to a total dose of 6,000 cGy. The risks, benefits, and alternatives to adjuvant radiation therapy in this context were discussed in detail with the patient and informed consent was obtained.Intensity modulated radiation therapy (IMRT) was delivered via a TomoTherapy machine , with a 6 MV photon beam. He completed treatment as planned with no breaks required and experienced only mild xerostomia, dysgeusia, and hyperpigmentation in the skin of the treatment field. His physical exam and MR imaging 5 years after completion of therapy demonstrated no evidence of recurrent disease.This patient is a 30-year-old Caucasian male who presented with a 2-year history of a 2 cm, nontender mass below his right ear. FNA of the lesion on December 4, 2007, demonstrated a chronic lymphocytic infiltrate consistent with a Warthin's tumor versus sialadenitis. At this time, resection of the mass was recommended by Otolaryngology but the patient declined. An MRI of the neck on January 29, 2009, demonstrated a 2.9 × 1.6 cm heterogenous mass in the right deep parotid with multiple other smaller lesions adjacent to it without lymphadenopathy. He underwent nerve sparing parotidectomy with a sternocleidomastoid flap on February 3, 2009. Pathology demonstrated a 2 cm low-grade MEC in the deep lobe of the parotid with a positive surgical margin. This tumor was also classified as low grade according to the AFIP grading scheme, with a total score of 2/14 . Nine lymph nodes were excised and were pathologically negative for disease. There was no evidence of lymphovascular invasion.On physical exam, six weeks after surgery, this patient's House-Brackmann score was rated IV/VI due to documented incomplete eye closure. Two months later, his House-Brackmann score improved to II/VI, exhibiting full eye closure and only mild smile asymmetry. By November 2009, the House-Brackmann score was I/VI, and the patient complained only of some areas of numbness in the buccal distribution of V2. He was referred to Radiation Oncology for additional evaluation and management.Based on the finding of positive surgical margins, the patient was offered adjuvant radiation therapy. He was counseled and subsequently treated in the same fashion as the previous patient, with IMRT delivered via TomoTherapy machine , with the same fractionation schedule and total dose. He had no significant difficulty during treatment, with only some mild xerostomia, dysgeusia, and hyperpigmentation in the skin of the treatment field. His physical exam and MR imaging 5 years after completion of therapy demonstrated no evidence of recurrent disease.The mainstay of treatment for salivary gland tumors, in general, and mucoepidermoid carcinomas, specifically, is surgical resection. For intermediate or high-grade MEC, adjuvant radiation therapy appears to aid in local control  in cases of advanced staging, close or positive surgical margins, high-grade histology, perineural invasion, or lymphovascular invasion. In the case of low-grade disease, the indications are less clear; traditionally, low-grade disease has been treated with surgical excision alone . In bothIn a 1997 study from Garden . TerhaarIndications for treatment of the neck, especially for patients with clinically negative lymph nodes (N0), remain unclear. The strongest predictors for occult lymph node metastasis in a clinically N0 patient have traditionally been tumor histology, pathologic grade, tumor size, and site of disease . ArmstroDe Brito Santos et al.  recommenIn conclusion, the role of adjuvant radiation therapy for patients with mucoepidermoid carcinoma of the parotid gland is based on data from institution reviews and lacks data from randomized controlled trials. Per our review of the literature, the pathological findings of positive surgical margins and perineural invasion in two patients with low-grade MEC of the parotid gland warranted adjuvant radiation for improved local control after parotidectomy. For these reported patients with low-grade MEC, direct treatment of the neck was not performed.Both patients tolerated postoperative radiation therapy with only mild side effects and, at last follow-up, five years after completion of therapy, had no clinical or radiographic evidence of either local recurrence or distant metastasis.