A 46-year-old female patient with complaints of pain and swelling on right submandibular region and limitation on mouth opening was reported. She had undergone an unsuccessful surgical procedure under local anesthesia performed by a general practitioner for removal of impacted mandibuler right third molar 1 week earlier. On clinical examination floor of the mouth was tender to palpation. Panoramic and the periapical radiographs showed presence of a radiopaque mass similar to that of a tooth root. Computed tomography scans were obtained for detailed radiographic examination, thereby the presence of a high density area in the submandibular region was detected. Under general anesthesia the displaced root was removed and the postoperative course was uneventful. The frequency of complications can be expected to increase as the number of surgical extraction operations of impacted mandibuler third molars increases . DisplacA 46-year-old Turkish female patient was referred to Ankara University, Faculty of Dentistry, Oral Diagnosis and Radiology Department with complaints of pain, slight swelling on the right side of mouth floor and discomfort during swallowing and limitation in mouth opening. Patient history revealed that a week earlier she had undergone an unsuccessful surgical procedure under local anesthesia performed by a general practitioner for removal of an impacted mandibular third molar. The tooth broke during extraction. The procedure was described by the patient as being difficult and complicated.A hard mass was palpated on the posterior region of the mouth floor on clinical examination. Radiographic examination was performed by use of intraoral periapical radiography, panoramic radiography and computed tomography (CT). Figure . PeriapiUnder general anesthesia an incision starting from buccal sulcus towards distobuccal angle of the second molar at gingival margin was extended to the coronoid process directly in line with the anterior surface of ramus. The dislodged root was found by means of blunt dissection and grasped with a pair of artery forceps and removed Figure. . PatientIt is possible that any tooth fragment lost in the submandibular region could prove difficult to retrieve but it would seem that this is a very rare complication of extraction and can not easily be anticipated. We speculate that in the current case tooth crown broke during extraction and tooth root pushed through the submandibular space by the elevator. Besides, efforts made to retrieve the tooth after its initial dislodgement and blind probing appear to be the possible reasons for further displacement from the submandibular space.Some authors prefer to postpone surgery for several weeks to allow fibrosis to occur and stabilize the tooth in a firm position. However delayed intervention may increase the risk of infection and result in a foreign body reaction or migration of the tooth -7. ThereIn this case computed tomography was utilized in terms of locating the tooth, assessing the adjacent structures and perforations of the bone and guiding the surgical procedure. It is our belief that obtaining computed tomography scans before retrieval surgery of displaced tooth fragments would be useful.Adequate clinical and radiographic examination should be performed before third molar removal. The frequency of accidental tooth displacement may be reduced if advanced imaging techniques are often used before surgery.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SK and BO analyzed and interpreted the patient data. KK wrote the manuscript. All authors read and approved the final manuscript.


Isolated cases of epicarditis are rare. Thus far, all have occurred with constrictive physiology as most cases involve both parietal and visceral pericardium. We report the first case of asymptomatic epicarditis that involved only the visceral pericardium presenting without constrictive physiology.A 71-year-old male with a history of atrial fibrillation, coronary artery disease, pericardial effusion, type-2 diabetes and hypothyroidism presented with 5 weeks of fatigue and 1 day of dizziness. Physical examination was significant for pallor and tachycardia. Laboratory analysis revealed a hemoglobin count of 7.2 g/dl and iron deficiency anemia. The patient was transfused and evaluated by endoscopic ultrasound. A polypoid mass in the gastric cardia was found and later diagnosed as gastric adenocarcinoma (staged as T1N0M0). The pericardial effusion was evaluated with transthoracic echocardiography which showed a 2.0 × 2.7 cm mass associated with the right atrium. Transesophageal echocardiography confirmed the mass but did not reveal constrictive physiology. Whole-body contrast computed tomography failed to demonstrate metastatic disease. Biopsy of the cardiac mass revealed epicarditis without parietal pericardium involvement. Partial gastrectomy was performed to remove the gastric adenocarcinoma.This is the first reported case of asymptomatic epicarditis. Our case was especially unusual because the epicarditis presented as an incidental cardiac mass. The clinical picture was complicated due to the concomitant presence of gastric adenocarcinoma and chronic pericardial effusion. This case demonstrates that epicarditis should be considered in the differential diagnosis of cardiac masses. Epicarditis, inflammation of the visceral epicardium, occurs very rarely. Most often, cases of epicarditis occur concurrently with both parietal pericardium involvement and constrictive physiology. In these reports, epicarditis was most often diagnosed after pericardiectomy failed to alleviate the patient's symptoms. However, isolated cases of exclusive epicarditis without involvement of the parietal pericardium or myocardium have been reported.We report the first case of asymptomatic effusive epicarditis without involvement of the parietal pericardium. In our patient, epicarditis presented as a cardiac mass occurring synchronously with newly diagnosed gastric adenocarcinoma. To our knowledge, prior cases of epicarditis have not occurred in the setting of a malignancy and only one prior patient presented with a cardiac mass. The uniqueness of our case is illustrated by contrasting our patient with prior reports of epicarditis with the emphasis on patient presentation, presence of constrictive physiology, method of diagnosis and suspected etiology. We do not include cases of epicarditis that occurred as a consequence of traumatic injury, thoracic surgery or neonatal cases.A 71-year-old Caucasian man with a past medical history significant for type-2 diabetes, coronary artery disease, atrial fibrillation, chronic pericardial effusion and hypothyroidism presented with 5 weeks of increasing fatigue and 1 day of dizziness.Physical examination revealed that the patient was afebrile, had a blood pressure of 140/90 mmHg, an irregularly irregular heart rate of 102 beats per minute and a respiratory rate of 16 breaths per minute. There was no pulsus parodoxus. Examination of the head and neck showed pale conjunctiva, no palpable lymphadenopathy, jugular venous distension or bruits. Auscultation of the chest revealed scattered rhonchi. The patient was mildly tachycardic with no S3 or S4 heart sounds, murmurs or rubs appreciated. There was no hepatosplenomegaly, clubbing, cyanosis or edema and stools were guaiac negative.An electrocardiogram (EKG) on admission demonstrated atrial fibrillation with a rapid ventricular response with low voltage QRS complexes; electrical alternans were not present. The chest radiograph showed a very minimal pleural effusion with no cardiomegaly, infiltrates or masses.Laboratory analysis revealed a white blood-cell count of 12,900/L, with a normal differential, and a hemoglobin and hematocrit of 7.2 g/dl and 23.4%, respectively. The platelet count was 387 thousand/L. The red cell indices were microcytic and iron studies revealed an iron deficiency anemia. Liver function tests were normal. The lactate dehydrogenase (LDH) was 167 U/L . The thyroid-stimulating hormone (TSH) was 16.49 mcIU/ml and the free T3 was 57 mcg/ml.Helicobacter pylori-negative.The patient was admitted for anemia and worked up for a gastrointestinal bleed. Three units packed red blood cells were transfused. Upper endoscopy revealed a mass just below the gastroesophageal junction and three nonbleeding gastric ulcers. To further evaluate the gastric mass, an endoscopic ultrasound (EUS) was performed demonstrating a 30 × 17 mm polypoid mass visualized in the gastric cardia limited to the mucosa/submucosa. The biopsy revealed gastric adenocarcinoma, staged as T1N0M0 by EUS, and was 2 shaped echodensity within the wall of the RA and a second, 16 cm2 echodensity, that extended across the atrioventricular groove . To better define the mass and its anatomic relationship within the RA, several imaging procedures were performed: 1) transesophageal echocardiogram (TEE) showing a 5.7 cmAt this point, our differential diagnosis included a primary gastric adenocarcinoma with metastasis to the heart as well as two separate primary neoplastic processes (one involving the heart and one involving the stomach).To determine the etiology of the cardiac mass, a biopsy was accomplished via a pericardial window through an anterolateral thoracotomy. At thoracotomy, the parietal pericardium appeared normal. Visual inspection revealed several nodular areas over the body of the right atrium, superior vena cava (SVC) and inferior vena cava (IVC). There was no evidence of a thickened, constrictive layer surrounding the heart. Two hundred milliliters of straw-colored fluid was recovered from the pericardial cavity. The fluid was negative for malignant cells and consisted of a few benign and reactive mesothelial cells mixed with inflammatory cells and proteinaceous debris. Viral, bacterial and mycobacterial cultures of the pericardial fluid were negative. Biopsy revealed a normal parietal pericardium and myocardium. However, the visceral pericardium showed a lymphoplasmocytic infiltrate diagnostic of epicarditis Figure . After tOur case presents several significant and rare findings: 1) epicarditis without involvement of the parietal pericardium; 2) epicarditis occurring without constrictive physiology; 3) epicarditis mimicking a cardiac tumor; and 4) epicarditis occurring with gastric adenocarcinoma.The co-existence of a pericardial effusion and constrictive epicarditis was first described by Burchell  and EdwaOur case highlights the importance of cardiac biopsy in the differential diagnosis of cardiac masses. Despite the absence of metastasis on radiographic imaging, the possibility that the cardiac mass represented a metastatic adenocarcinoma, or a second malignant process, necessitated the need for biopsy. Cardiac biopsy with immunohistochemical staining was instrumental in determining the diagnosis of epicarditis.Prior case reports have suggested the etiology of epicarditis to be infectious in origin, including reports citing viral, bacterial and mycobacterial causes. However, in many of the case reports, no cause was reported. Although there have been no reports of epicarditis occurring as a paraneoplastic phenomenon associated with any type of malignancy, there are few reports of gastric carcinoma occurring with paraneoplastic syndromes. We raise the possibility that our patient's gastric adenocarcinoma created an inflammatory milieu resulting in a localized, focal inflammatory response in the epicardium mimicking a cardiac mass. The biological basis for this paraneoplastic phenomenon may be similar to other paraneoplastic processes in which there is the elaboration of interleukin-6 (IL-6) as well as growth factors produced by the tumor . While gOur case highlights several important points: 1) epicarditis can be asymptomatic and can occur without involvement of the parietal pericardium; 2) it can mimic a cardiac mass; 3) cardiac biopsy is essential for diagnosis; and 4) although most reports have suggested infection as the etiology, we raise the possibility of a paraneoplastic syndrome creating the epicarditis. To that end, further studies should investigate this hypothesis.Once the diagnosis is established, epicarditis should be treated on a case-by-case basis based on patient symptomatology and expectant morbidity. If constrictive physiology develops, one must distinguish whether it is the result of parietal and/or visceral pericardial involvement. Treatment should then be directed at removal of the involved layer.EKG: electrocardiogram; LDH: lactate dehydrogenase; TSH: thyroid-stimulating hormone; TEE: transesophageal echocardiogram; CT: computed tomography; EUS: endoscopic ultrasound; RA: right atrium; PET: positron emission tomography; MRI: magnetic resonance imaging; SVC: superior vena cava; IVC: inferior vena cavaWritten informed consent was obtained from the next of kin of the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AM, AE, and SC were all involved in the conception of the case report, data collection, review of literature and writing the manuscript. MR participated in data collection and in rendering a pathological diagnosis. All authors read and approved the final manuscript.


Germ cell tumours are uncommon in aged man. We present a rare case of metastatic seminoma of the testis associated with liver and renal insufficiencies in a 78-years-old man managed successfully with carboplatin based chemotherapy.A 78 years old man admitted with signs and symptoms suggestive of a testicular cancer with alteration of health. Computed tomography of the pelvis and abdomen showed a large retroperitoneal tumour. The diagnosis of seminoma was established from the histological study of the left orchidectomy. At admission, the liver and renal check-up showed liver and renal insufficiencies.The patient received 4 of carboplatin based chemotherapy with significant improvement in symptoms, and complete radiological response. Germ cell tumour is the most common solid tumour in the young adult man but this disease is rare in aged man,2. Pure 2 at days 1 to 5). After the treatment completed the symptoms disappeared (PS = 0 and the abdomen mass shrunk), the serum markers returned to normal, with complete response of the retroperitoneal tumour in CT scan. The patient is still alive without disease, 5 months after the end of chemotherapy.A 78 years old man was admitted to our hospital with 4 years history of swollen left testicle. This man suffered from pain in scrotum and abdomen with alteration of health. The performance status at admission was equal to 3 (PS = 3). A physical examination revealed a fixed abdominal mass. The Computed tomography scan of the pelvis, abdomen and lung showed a large retroperitoneal tumour, measuring 18 × 16 cm  with significant improvement in symptoms complete response of the retroperitoneal tumour.Germ cell tumour is the most common solid tumour in the man aged between 15 and 34 years but this disease is uncommon in aged man. Less than 4% of patients with germ cell tumors are aged 65 years or older . Pure se1. The seminoma can arise in the men above the age of 70.2. Carboplatin in monotherapy or in combination with etoposide can be used to treat elderly patients.3. Single agent carboplatin AUC 7 can be used to treat advanced seminoma in elderly patients with severe alteration of health, renal and liver insufficiencies.A fully informed written consent was obtained from the patient family for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors have made significant contributions by making diagnosis and intellectual input in the case and writing the manuscript.


Primitive neuroectodermal tumor of the uterus is extremely rare. They occur as either pure primitive neuroectodermal tumors or admixed with neoplasms of mullerian origin.A case of uterine primitive neuroectodermal tumor with adenosarcoma in a 50-year-old Asian Indian woman is presented. Histologically, the neoplasm displayed perivascular pseudorosettes and occasional Homer-Wright rosettes. A strong positivity for neuronspecific enolase and synaptophysin was noted, while chromogranin and CD99 were negative. Merging imperceptibly with the neuroectodermal components were the areas of adenosarcoma.To the best of our knowledge, this report represents the second case of a uterine primitive neuroectodermal tumor with an admixed adenosarcoma. The term "primitive neuroectodermal tumor" (PNET) was first coined in 1973 by Hart and Earle to describe a group of tumors thought to be derived from fetal neuroectodermal cells. These tumors were noted to have morphological features of small round cell tumors with variable degrees of neural, glial, and ependymal differentiation [There are two main categories of PNETs according to the cell of origin and location: central and peripheral. Central PNETs are derived from the neural tube and involve mainly the brain and the spinal cord. On the other hand, peripheral PNETs are derived from the neural crest and occur outside the central nervous system, often involving the sympathetic nervous system or soft tissues and bones . PeripheBased on similar clinical, immunohistochemical and cytogenetic profile, Ewing's sarcoma and PNET are regarded as two extremes of a morphological spectrum of the same tumor entity . The occA 50-year-old Asian Indian woman, who had been menopausal for two years, presented with complaints of post-menopausal bleeding for three to four months. A per speculum examination of our patient showed a 10×8 cm vascular congested mass abutting the introitus. A polypoidal mass with a thick pedicle was felt coming out of her endocervix on per vaginum examination.Cervical polypectomy was done on our patient and a histopathological diagnosis of small round cell tumor was arrived at. Following polypectomy our patient continued to have vaginal bleeding. Ultrasonography (USG) and magnetic resonance imaging (MRI) of the whole abdomen and pelvis of our patient revealed an irregular infiltrative mass lesion in her uterine corpus and cervix. No parametrial invasion or significant lymphadenopathy, however, was noted. Subsequently, a total abdominal hysterectomy with bilateral salpingo-oophorectomy with pelvic omentectomy and pelvic lymph node sampling was done on our patient. Her uterus and the cervix grossly measured 8×4×3 cm. On cut surface a polypoidal, soft, tan tumor, was seen filling her entire endometrial cavity and extending to her endocervix.Histology revealed a tumor with majority of the areas displaying primitive neuroectodermal differentiation and a minor component of adenosarcoma constituting around 20% of the tumor volume. The former was composed of sheets of undifferentiated, small round to oval cells with hyperchromatic nuclei and numerous mitotic figures. Micronodular pale islands with fibrillary matrix, perivascular pseudorosettes and occasional Homer-Wright rosettes were seen Figure . Areas oOn immunohistochemistry (IHC), both spindle cell component of the adenosarcoma and small cell component were positive for vimentin. The small cell component also showed strong positivity for neuronspecific enolase (NSE), and synaptophysin Figure . ChromogTwo months post-operatively, our patient again presented with bleeding per vaginum and a nodule at the vaginal vault. Her whole abdomen computed tomography (CT) scan showed normal upper abdomen with a 2×2-cm mass at the vaginal vault. She was then started on radiotherapy and chemotherapy. Until her last follow-up examination at six months after her surgery, our patient has received a total of three cycles of radiotherapy and six cycles of chemotherapy. Her vault nodule has been completely regressed and she is now disease-free.PNETs in the woman's genital tract are extremely rare .The mostUterine PNETs most commonly occur as pure PNETs. An admixture with neoplasms of unquestionable mullerian origin suggests a mullerian derivation for at least some of these tumors . Of the The glands within an adenosarcoma appear to be an integral part of the neoplasm but dissimilar histological appearances can result if non-neoplastic endometrial glands become entrapped within a stromal sarcoma. When entrapment of this type does occur, the glands are commonly hyperplastic. It will usually also be apparent that some are set in a non-neoplastic stroma that is being encroached upon by a malignant stromal component. Also, the presence of glandular structure away from any residual endometrium and its absence from the pedicle of the neoplasm helps to differentiate it from benign entrapped glands . Other cet al., CD99 was positive in seven out of nine cases tested for the marker. Also in their series none of the 12 cases tested for typical EWSR1 rearrangement were positive [Uterine PNETs occur most commonly in patients older than 50 years, and vaginal bleeding is the most common presentation . Histolopositive . Howeverpositive ,4.The differential diagnosis of uterine PNETs include other uterine tumors or tumor-like lesions containing neuroectodermal elements of the type found in the central nervous system. These include mature glial tissue in the endocervix or endometrium, immature teratoma with glial tissue, pure uterine gliomas, MMMT with neuroectodermal differentiation, and retinal anlage tumor. Another group of differential diagnosis includes uterine tumors with small malignant cell population. This group includes rare endometrial carcinomas resembling small cell carcinoma of the lung, endometrial stromal sarcoma, malignant lymphoma, and leukemia. The diagnosis of uterine PNET is based on light microscopic and immunohistochemical evidence of neuroectodermal differentiation .Uterine PNET, occurring as pure or in combination with other histological subtype, is associated with advanced-stage disease and follows a potentially aggressive clinical course . MultimoAwareness of the occurrence of PNET in the uterus and its recognition is important to distinguish it from other tumors that may possess a different behavior and treatmentWritten informed consent was obtained from our patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MBH made the pathological diagnosis and was responsible for conception and final approval of the manuscript. MB carried out the literature search and drafted the manuscript. IC carried out the surgical procedure and reviewed the manuscript. RM carried out the surgical procedure, provided clinical details, followed up our patient and obtained her consent to publish this case report. All authors read and approved the final manuscript.


Cerebral amyloidoma is an infrequently recognized condition that can be confused with a more malignant etiology. Few cases have been reported. We present a case report and a review of the literature.Our patient was a 64-year-old Caucasian man who was incidentally discovered to have a brain mass. He was found to have a cerebral amyloidoma.After discovery of the true etiology of his brain abnormality, it was determined that our patient had a more benign disease than was initially feared. Cases such as this demonstrate why consideration of this disorder is important. Cerebral amyloidomas are rare entities infrequently described in the medical literature. Most commonly, they are noticed incidentally on brain scans. Frequently, they are confused with primary brain neoplasms. The clinical course tends to be benign, although long-term data is lacking.Our patient was a 64-year-old Caucasian man with a medical history of chronic obstructive pulmonary disease, coronary artery disease, and hyperlipidemia. He had been traveling, and experienced a transient loss of consciousness lasting a few seconds while in an airport abroad. He sought medical attention, and an initial computed tomography (CT) study of his head, without contrast, revealed a lobular hyperdensity in the right posterior periventricular distribution tracking to the adjacent parietal subcortical white matter. A follow-up magnetic resonance imaging (MRI) study revealed an infiltrating lesion extending from the right peritrigonal area across the corona radiata and into the subcortical white matter. The lesion showed increased T2-weighted and low T1-weighted signal intensity with post-gadolinium enhancement. Subcortical plaques were noted on fluid-attenuated inversion recovery (FLAIR) imaging (Figure The surgically removed tissue consisted of abnormal and gliotic brain parenchyma containing large confluent masses of pale eosinophilic deposits Figures  and 3 thA staging evaluation was performed, including a CT scan of the chest, abdomen and pelvis, and an MRI scan of the spine to investigate for systemic findings of amyloidosis. The results of these tests were negative. To date, our patient remains well with no further episodes of seizure or neurological dysfunction. Follow-up MRI results have been negative to date. There are currently no plans for a repeat surgical procedure or repeat brain biopsies.Amyloidosis is a heterogeneous group of diseases with complex pathogenesis and may take on many forms and manifest in various organ systems. The pathophysiology invariably results in extracellular deposition of insoluble proteins with β-pleated sheet as their secondary structure. It is the β-pleated sheet of amyloidogenic proteins that allows histochemical identification under light microscopy ,2.Amyloid deposition within the brain parenchyma can take on many forms, of which isolated amyloidomas are the least common ,4. More A review of the literature reveals fewer than 30 reported cases ,8. Of thThe clinical course is thought to be benign, with no cases that were resected recurring. However, lesions that were biopsied without resection have shown growth . Little Although rarely encountered, primary cerebral amyloidomas need to remain in the differential diagnosis of patients presenting with a solitary cerebral mass. While little is known regarding the long-term outcomes, after resection the disease does not appear to progress. With increased recognition, more data may become available on overall prognosis, but at this time it appears to represent a favorable clinical course.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief.The authors declare that they have no competing interests.NA provided information on interpretation of scans and on patient outcomes. JM provided pathologic review of the brain biopsies. DL provided research into cerebral amyloidoma. All authors contributed equally to the writing of this report and agree with the final manuscript.


A fourteen years-old boy was treated post-operatively with proton therapy for a recurrent low-grade oligodendroglioma located in the tectal region. Six months after the end of irradiation (RT), a new enhancing lesion appeared within the radiation fields. To differentiate disease progression from radiation-induced changes, dynamic susceptibility contrast-enhanced (DSCE) MRI was used with a T2* sequence to study perfusion and permeability characteristics simultaneously. Typically, the lesion showed hypoperfusion and hyperpermeability compared to the controlateral normal brain. Without additional treatment but a short course of steroids, the image disappeared over a six months period allowing us to conclude for a pseudo-progression. The patient is alive in complete remission more than 2 years post-RT. The occurrence of new contrast enhancing lesions on routine MRI follow-up after radiation therapy (RT) for brain gliomas was observed more than ten years ago but remains problematic because standard MR imaging techniques do not allow a clear distinction between recurrent tumour and radiation-induced lesions ,2. RecenWe report here a clinical case showing a new contrast-enhancing lesion discovered on a systematic MRI proposed to a fourteen years-old boy treated six months before for a recurrent low-grade glioma by surgery and proton-therapy. Dynamic Susceptibility Contrast (DSC) MR imaging and planned follow-up lead to the diagnosis of pseudo-progression. This phenomenon has rarely been described in children with supra-tentorial low-grade gliomas after proton beam RT, particularly with this type of advanced MR technique.A healthy ten year-old boy with tinnitus and bilateral papillary oedema underwent a brain MRI showing a small tumour of the tectal plate. The lesion presented a signal of low intensity on T1-weighted and a high signal on T2-weighted sequences. No contrast enhancement was visible. The process was responsible for triventricular hydrocephalus by aqueduct compression. The first treatment was a ventriculocysternostomy followed, fifteen months later, by a partial resection when the lesion increased in size. Histopathological diagnosis was a grade II oligodendroglioma (WHO classification), with a proliferation index (MIB 1) of 5%. Three years after the first surgery, a systematic follow-up MRI revealed a recurrence localized on the quadrigeminal plate, close to the left thalami and the third ventricle, again without gadolinium enhancement. A second surgery was attempted, showing the same histology, but a tumour residue was left on the left thalamus Figure . RadioloIn order to more accurately differentiate tumour recurrence from radiation-induced changes, a DSC-MRI was performed as described previously ,9. The TSubacute radiation-induced modifications have been described previously in childhood gliomas, with or without concomitant or sequential use of chemotherapy ,12-14. I18FDG-PET, FDG uptake is not specific of tumour tissue and false positive can be observed in non malignant inflammatory processes. The use of aminoacid tracers as 11C-methionine better discriminates post-RT necrosis from tumour recurrence [This DSC-MR technique evaluates tissue changes, close to the physiopathology of PsP, whereas metabolic tools as FDG-PET or MR spectroscopy (MRS) analyse level of glucose uptake or distribution of metabolites peaks. MRS can distinguish recurrent true necrosis from active tumour -18 but icurrence  but it icurrence ,21 as ancurrence .The lack of typical clinical symptoms and the limits of anatomical MRI techniques imply that any subacute change suggesting disease progression may be considered as possible PsP. Post-RT therapy should not be interrupted too early  and DSC-Written informed consent was obtained from the parents and the patient for publication of this case report and accompagnying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.CM collected the data and wrote the manuscript. FD analysed the imaging studies and contributed to the legend of figures and correction of the manuscript. DD created and developed the software used to treat T2* acquisition and produce the images. JLH supervised the irradiation of the patient. PV analysed the histology of the tumour. CSR operated the patient. CD was the treating physician of the patient. JG supervised the manuscript. All authors read and approved the final manuscript.


Meningioangiomatosis is a rare hamartomatous lesion or meningiovascular malformation in brain. In extremely rare condition, meningioma may occur together with meningioangiomatosis, and only 19 cases have been described in English literature until now. We now report a case of meningioangiomatosis-associated meningioma with atypical and clear cell variant. A 34-year-old man presented a 3-month history of progressive numbness and weakness of his left lower extremity. He had no stigmata of neurofibromatosis type 2. Magnetic resonance imaging (MRI) revealed multifocal lesions in the right frontoparietal lobe. The lesions were totally removed. Microscopically, parts of lesions were atypical and clear cell meningioma corresponding to WHO grade II. The adjacent brain parenchyma showed the histological features of meningioangiomatosis. Neoplastic cells in atypical meningioma area were immunoreactive to epithelial membrane antigen (EMA) with high MIB-1 index of up to 20%. However, the spindle cells in meningioangiomatosis area were negative for EMA with low MIB-1 index of up to 1%. The diagnosis of atypical meningioma associated with sporadic meningioangiomatosis was made. To our knowledge, this is the first case of a meningioangiomatosis-associated meningioma with atypical and clear cell variant component to be described. The patient had been followed-up for 11 months without adjuvant radiotherapy or chemotherapy. No tumor recurrence was found during this period. Meningioangiomatosis-associated meningioma is more likely to occur in younger patients and histologically to mimic parenchymal invasion of brain. We suggest that postoperative radiotherapy or chemotherapy should be given careful consideration to avoid over-treatment due to erroneously interpret as malignant meningioma. Meningioangiomatosis is a rare meningiovascular malformation in the central nervous system, which is characterized by a plaque-like or nodular mass within the cerebral cortex and overlying leptomeninges in the patients with intractable seizures. Meningioangiomatosis may occur either sporadically or occur in patients with neurofibromatosis type 2 (NF2). Sporadic meningioangiomatosis usually presents seizures and persistent headaches. NF2-associated meningioangiomatosis is often asymptomatic and diagnosed only at autopsy . HistoloA 34-year-old Chinese man presented a 3-month history of progressive numbness and weakness of his left lower extremity, and which had increased in severity over the past 2 weeks. Epileptic fits or neurological deficits were not recorded. On physical examination, the patient had mild weakness on his left lower extremity. Sensory examination revealed that hypoalgesia could be detected in the area below the left knee. Neurological examinations showed no abnormality in cranial nerves, and no defect was disclosed by the visual field test. The patient had no family history of neurofibromatosis, and no stigmata of NF2 including acoustic schwannomas or masses of the spinal cord was found by neuroimaging examination. Magnetic resonance imaging (MRI) revealed multiple hypointense lesions in the right frontoparietal lobe with heterogeneous contrast enhancement after Gd-diethylenetriamine pentaacetic acid administration Figure . Fluid aIt was found the removed whitish mass was composed of collagen bundles and spindle tumor cells forming small whorls and syncytial structures when examined under the light microscope. Focal hypercellularity and higher mitotic activity were noted. Necrosis and haemorrhage were not observed, but up to 6 mitotic figures of tumor cells per 10 high power fields were detected in these areas Figure . These hDuring postoperative course, the patient developed a transient mild left hemiparesis within 2 weeks after surgery. When he was recovered from this condition, the patient reported an improvement of his sensorimotor problems, but slight numbness remained in his left lower extremity. The patient was discharged home without adjuvant radiotherapy or chemotherapy, and 11-month follow-up was performed till the patient was lost to be contacted. Follow-up MRI did not show any residual lesion 3 months after surgery, and neither tumor recurrence nor seizure was found during this period of postoperative follow-up.Meningioangiomatosis is a rare malformative or hamartomatous lesion involved in meninges and cortex. It was first described in 1915 by Bassoe and Nuzum as an incidental autopsy finding in a boy with NF-2 . AlthougThe pathogenesis of meningioangiomatosis remains unclear, it has been debated whether the biological nature is a hamartoma or a neoplasm. For a long time, meningioangiomatosis was considered as a harmartomatous lesion with degenerative change . Other mMeningioangiomatosis has rarely been reported to coexist with meningiomas. To our knowledge, only 19 cases of meningioma together with meningioangiomatosis have been reported in English literature to date -14. AmonThe main differential diagnosis of meningioangiomatosis-associated meningioma to be considered on histopathology is malignant meningioma with invasion of brain parenchyma because infiltration of cortex by the perivascular proliferating spindle cells and reactive gliosis sometimes may be erroneously interpreted as invasion of brain. However, true parenchymal invasion is present when neoplastic cells break through the pia mater to involve the underlying cortex and encircle islands of heavily gliotic tissue. In our case, meningioma components of the lesion mixed atypical cells and clear cells with hypercellularity, higher mitotic activity and higher MIB-1 index which corresponded to WHO grade II; however, the fibroblast-like spindle cells disposed around the blood vessels were bland appearance with lower proliferation index and lacking EMA expression. Therefore, we did not regard the meningioangiomatosis component of the lesion as the brain invasion by atypical or clear cell meningioma because high level of MIB-1 index is known to be detected in meningiomas of brain invasion . These fWe reported a rare case of meningioangiomatosis-associated meningioma with atypical and clear cell meningioma variants occurring in frontoparietal lobe of a middle-aged man. In contrast to conventional meningiomas, meningioangiomatosis-associated meningioma is more likely to occur in younger males, and any variants of meningioma might present in this lesion with either sole pattern or composite pattern. Although meningioangiomatosis is a benign hamartomatous or malformative lesion, it may be erroneously interpreted as brain invasion when it uncommonly co-existed with meningioma. The relationship between the prognosis and meningioangiomatosis-associated aggressive meningioma remains unclear. The investigations of a longer follow-up period and more cases would help to better clarify the biological characteristics and clinical outcome of this rare but distinct lesion.The authors declare that they have no competing interests.YYC made contributions to acquisition of clinical data, and analysis the histological features of case by H&E staining. TXY drafted the manuscript. ZL revised manuscript critically for important intellectual content and has given final approval of the version to be published. BNL participated in the design of the study and performed the neurological image analysis. QH carried out the immunoassays. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Its a dilemma to attempt a palliative procedure to debulk the tumour and/or prevent future obstructive complications in a locally advanced intra abdominal malignancy.A 38 year old Vietnamese man presented with a carcinoma of the colon which had invaded the gallbladder and duodenum with a sealed perforation of the second part of the duodenum. Following surgical exploration, it was evident that primary closure of the perforated duodenum was not possible due to the presence of unresectable residual tumour.We describe a novel technique using a covered duodenal stent deployed at open surgery to aid closure of a malignant duodenal perforation. With locally advanced intra-abdominal malignancy the surgeon is faced with the dilemma of attempting a palliative procedure to debulk the tumour and/or prevent future obstructive complications against limiting the impact of any surgical procedure on remaining quality of life. Unfortunately it remains extremely difficult to assess tumours which are adherent to local structures and the decision must be made whether to continue anatomical dissection or to leave the main tumour bulk in-situ and perform a simple bypass procedure.A 38 year old Vietnamese man was admitted with a 10 month history of epigastric pain, fatigue, 10 kg weight loss and recent onset jaundice. He had no other significant medical history. Clinical examination demonstrated anaemia and a tender mass in the right upper quadrant of the abdomen. A computerised tomography (CT) scan of the abdomen revealed a 7 × 5 cm thick-walled, complex mass adjacent to the second part of the duodenum, which contained fluid and air and abutted the hepatic flexure of the colon. The working diagnosis was a collection secondary to a colonic perforation and he was treated with intravenous antibiotics. He improved with conservative management and was discharged a month later for outpatient colonoscopy. The colonoscopy revealed a lesion in the transverse colon, histology of which showed a mucinous adenocarcinoma.He subsequently returned to the Accident and Emergency Department following an upper gastrointestinal bleed. On his second admission, a repeat CT scan again suggested localised colonic perforation with formation of an abscess adjacent to the duodenum, along with thickening of the ascending colon, predominantly centred around the hepatic flexure. Given the clinical presentation and diagnostic uncertainty a diagnostic laparoscopy was performed which revealed a large perforated tumour at the hepatic flexure with ascites and peritoneal tumour nodules. A laparotomy was performed via a transverse incision and following mobilisation of the hepatic flexure, a colonic tumour was found to have invaded the gallbladder and duodenum with an abscess cavity anterior to the second part of the duodenum. At the base of the abscess cavity a large hole was apparent in the second part of the duodenum with malignant tumour invading the duodenum. Given the size of the defect (5 cm × 2 cm) and the presence of tumour it was not possible to resect and form a primary closure of the duodenum. The presence of metastatic spread precluded a curative resection by pancreatoduodenectomy.A right hemicolectomy was performed to debulk the tumour and an ileotransverse anastamosis formed. Due to the extent of the disease and associated abscess the anterior wall of the duodenum came away with the colon during this manoeuvre. A retrograde cholecystectomy was carried out to resect the residual tumour invading the gall bladder. The ampulla was identified with the aid of a transcystic catheter. An 82 mm expandable covered duodenal stent with a diameter of 18 mm  was manually inserted through the duodenal perforation into the proximal duodenum with the distal end of the stent inserted into D2. A small opening into the side wall of the stent was made prior to the positioning of the stent to accommodate the ampulla and thus facilitate drainage of bile within the stent. A per-operative cholangiogram confirmed free flow of contrast in the duodenum. The residual duodenal wall was closed over the stent and following antrectomy a gastrojejunostomy was formed to bypass the duodenum (Bilroth II reconstruction).The patient was discharged 7 weeks later following a prolonged, but otherwise uncomplicated recovery. He subsequently underwent a palliative course of chemotherapy survived for a further 18 months without gastrointestinal symptoms, before succumbing to his disease.The major risk with attempting palliative resection is the feasibility of reconstructing anatomy that has been altered by the malignant process. In the case described separation of the main tumour bulk from the duodenum left a perforation involving most of the anterior surface of the second part of the duodenum. Significantly sized malignant perforations of the duodenum are unlikely to heal following simple primary closure and are at risk of resulting in high output fistulas or high level GI tract obstruction due to disease progression. Simple duodenal closure and duodenal bypass in this case would not have been sufficient to safely defunction the perforation.Several techniques have been described for closure of large duodenal perforations, such as duodenojejunostomy, serosal and mucosal pedical patching -3 withouCovered self-expanding metallic stents have been used to treat oesophageal leaks and fistulas with clinical success ranging from 67-100%, with recurrent fistulas or leaks in 8-20% of patients -7. PlaceWe believe that in this case, the novel deployment of a covered duodenal stent during an open operation negated the requirement for a major pancreatobiliary resection and permitted safe primary closure of the malignant perforation. This allowed the early use of palliative chemotherapy and, in conjunction with tumour debulking, may have resulted in a significant gain in symptom free survival.The authors declare that they have no competing interests.PFL helped in preparation of the manuscript and literature search. ABC helped in preparation of the manuscript and literature search. JP helped in preparation of the manuscript, literature search and editing the manuscript for its final content. AGP helped in preparation of the manuscript, literature search and editing the manuscript for its final content. All authors read and approved the final manuscript.The publication of this case was approved by the National Research Ethics Service, King College Hospital Research Ethics committee, as the consent from the patient and next of kin was not possible. The copy of ethical committee approval is available with chief editor.


With the rapid strides in the perfection of surgical techniques and with the advances in the pre and postoperative care of the patient, it is almost imperative to obtain an early and accurate pre-operative diagnosis of emergencies in the new born infant. It is a well documented fact that next to birth traumas, the commonest cause of death in the newborn is the complication of developmental anomalies. Roentgenological examination is of enormous importance in the early diagnosis of these emergencies of the alimentary tract as reliable objective evidence can be obtained at the time when the diagnosis is a matter of conjecture on the basis of clinical evidence alone. In the newborn there occur not infrequently, congenital anomalies, that if left untreated, result in death. Prompt recognition and adequate surgical correction of the anomaly will result in a gratifying low morality rate. Not only is the mortality in a given case directly related to the promptness of diagnosis and proper surgical treatment but also to the period of recovery and convalescence in the hospital which is uneventful and minimised to a considerable extent. It has been a common opinion among the medical profession that the newborn infant cannot withstand surgical procedures and that operations should be delayed on this ground whenever possible. But Ladd has poinWith the first breath of life air enters the pharynx, esophagus and then passes on into the stomach and intestines. As the baby goes on swallowing air, large amounts are visible in the small and large bowels within 12 hours after birth, depending upon the active crying of the baby. About 80% of the gas that is seen in the alimentary tract is due to swallowed atmospheric air. Experience tells us that, whenever the baby does not cry actively due to some reason or other, the amount of gas seen in the alimentary tract is slight in the first 12 hours. This presence of gas and its distribution in the small and large bowels serves as a contrast medium and helps in identifying the various anatomical segments of the alimentary tract and locate the site of obstruction when present.One of the gravest congenital anomalies is esophageal atresia with or without tracheoesophageal fistula. This anomaly is more common than is usually considered to be the case. There are several morphological types, the commonest being the one with atresia of the proximal end forming a blind pouch, the distal segment being in communication with the trachea or one of the main bronchi. According to Caffey more thaThe roentgenoligical diagnosis is confirmed by passing a soft rubber catheter into the esophagus and finding an obstruction at about the level of the second or third dorsal vertebrae. This procedure as well as the injection of one or two c.c. of lipiodol through the catheter to outline the upper esophageal segment and its blind pouch should be performed under fluoroscopic control. Such an examination with the help of a spot film demonstrates the level of the upper esophageal pouch as seen in This is a congenital anomaly of indeterminate origin and as a rule the upper descending portion of the duodenum is involved but any portion may be encircled. The circle may not be complete always. It is a rather rare extrinsic cause of congenital duodenal obstruction. Slight degrees of obstruction go undetected throughout life. One of Poppel's cases waAcute intestinal obstruction in the new born, is sometimes produced by atresia or stenosis of a segment of the small bowel. This is the commonest cause of intrinsic intestinal obstruction resulting from failure of complete re-canalization of the epithelial tube in embryonic life. Atresia results from an imperforated intestinal diaphragm or a solid occluding epithelial plug, whereas stenosis results when small channels exist through these diaphragms or plugs. Attention is directed to these patients because of persisting vomiting of bile-stained material, which starts soon after birth. The site of obstruction usually determines the abdominal distention.Roentgenological examination should be limited to scout films of the abdomen in various views wherever it is possible. From the scout films alone, the point of obstruction could be located as no gas is found beyond the stenotic segment. In case of complete intestinal obstruction, barium should never be administered by mouth. As has been mentioned before, the child might aspirate the barium into the lungs during the act of vomiting or the barium might form a concretion in the bowel, which becomes a hazard to the patient post-operatively after an anastomosis circumventing the atresia has been made. When the atresia or stenosis is in the terminal loops of the ileum and when there is enormous gaseous distension proximally, at times it is difficult to distinguish it from a large bowel distension. As a rule, in all doubtful cases to make out whether it is small or large bowel obstruction, it is always safer to do a barium enema. This helps in ruling out a large bowel obstruction This pathological entity owes its recognition mainly to Farber and NeuhThe roentgenological findings are basically similar to any type of small bowel obstruction. In cases of complete obstruction, the scout films reveal pronounced distension of the small bowel with air-fluid levels demonstrable in the erect or lateral recumbent postures. However, in some cases, a small amount of gas is forced into the tenacious and mucilaginous meconium and is seen as small bubbles of gas scattered in the small bowel. Neuhauser has poinThe rarer complication of volvulus of the segment of bowel occluded with meconium should be borne in mind when it becomes a real surgical emergency. This disorder is a nonbacterial chemical peritonitis, which results from the extrusion of meconium through the intestinal wall into the peritoneal cavity. Whether this process goes on in late fetal life or immediately after birth is not definitely know. Variable amounts of lime are usually deposited in the extruded meconium in the form of incrustations on the clusters of cornified epithelial cells. When the calcified masses are large enough they can be visualised on the scout films of the abdomen. These calcifications are usually circular or curvilinear, irregularly distributed in the abdomen. These calcifications associated with small intestinal obstruction, are fairly characteristic of meconium peritonitis. Imperforate anus is one of the most frequent emergencies in the newborn and is promptly recognised without an X-Ray examination. The complexity is not appreciated however, since this anomaly is commonly associated with atresia of the rectum and some type of a fistula; rectovaginal, rectoperineal, rectourethral or rectovesical. In some cases, the rectum and the rest of the colon are normal except for a cutaneous septum in the region of the anus. An infant with this type of imperforate anus will rapidly develop marked gaseous distension of the intestines within a few hours of birth. It is of prime importance to determine how low the rectal pouch is in the pelvis to help in determining the type of operation that is going to be employed.Using Wangensteen's technique of inverting the baby and placing a metallic marker on the perineal dimple, it is possible to determine how near the pouch is to the perineum by taking a lateral view of the pelvis . This mePartial or complete absence of a hemidiaphragm is not so common as is thought to be. Unless it is recognized early and treated radically, the morality rate approaches 80-90%. Of all varieties of anomalies of the diaphragm, the commonest is the defect in the pleuroperitoneal membrane region, especially on the left side. This results in massive herniation of the abdominal contents into the thoracic cavity. The newborn presents with characteristics attacks of cyanosis associated with dyspnea particularly during or shortly after feedings. Roentgenological examination of the chest and abdomen presents the true picture of the herniation. The chest reveals the heart and mediastinum to be pushed to the opposite side of the hernia. The presence of gas distended gastro-intestinal tract in the thoracic cavity cannot be mistaken for any other condition. One may administer lipidiol by mouth for identification and location of various portions of the gastrointestinal tract, and thus confirm the diagnosis as well This anomaly of developmental origin is such a striking abnormality in the newborn that it usually receives prompt attention by the clinician. This condition consists of herniation of the abdominal contents into an abnormal sac-like umbilical cord, which consists of a translucent membrane composed of peritoneum and amniotic membrane. In rare cases, the infant may be born with an omphalocele in which the sac is absent. Roentgenological examination is imperative whenever there is clinical evidence of intestinal obstruction or strangulation. Anteroposterior and lateral views of the abdomen reveal the typical obstruction pattern of the bowel as previously described. In addition, the gas distended loops of bowel can be traced lying outside the anterior abdominal wall. However, occasionally associated abnormalities such as sacrococcygeal dermoid can also be detected as in one of our cases which is shown in Malrotations of the gastrointestinal tract and faulty mesenteric attachment may rarely lead to volvulus of the mid or hind-gut. In these cases, scout films of the abdomen suggest a picture of intestinal obstruction but do not help usually in making an etiological diagnosis. In cases of non-rotation of the hind-gut, a barium enema of the colon reveals the abnormal position of the cecum, which will be situated on the left side of the abdomen.The much rarer anomalies such as pericardiodiaphragmatic herniation and reduplications of the alimentary tract with complications of obstruction and strangulation of the intestines deserve mention and roentgenological examination with contrast media plays a very important role in the postulation of a diagnosis preoperatively.An attempt has been made to stress the importance of roentgenological examination in establishing definite preobservation diagnosis in some of the alimentary tract emergencies in the newborn. A brief account of the roentgenological criteria has been given with illustrations of surgically proved cases whereever possible. A short list of pertinent references is appended.


Desmoplastic infantile ganglioglioma (DIG) is a rare supratentorial brain tumor occurring mostly before the age of 2 years. It has a good prognosis and total excision of the tumor is curative, necessitating no further treatment. An accurate pathologic diagnosis is crucial. Until now, <60 cases of this tumor type have been reported. Herein, we report a 3-month-old boy with intractable seizure who was found to have DIG after surgery. Desmoplastic infantile ganglioglioma (DIG) was first described by Vanderberg in 1987.Now, this tumor is recognized as a distinct entity and is included in the World Health Organization (WHO) classification under the category of neural and mixed glio-neuronal tumors, and is in the grade I of the WHO classification. Until noWe present a case in a 3-month-old male infant presenting with intractable seizure and a large mass in the right temporal lobe, which showed classic histological features of DIG. Hence, the current case extends the reported spectrum of this rare tumor and helps pathologists in considering the diagnosis especially in young patients.A 3-month-old infant was admitted with the chief complaint of seizure. He was the first child of the family, born during an uncomplicated full-term pregnancy and a normal vaginal delivery. The family history was unremarkable. Physical examination revealed no abnormality, with a normal neurological examination. Magnetic resonance imaging (MRI) scan showed a hypodense area in the right temporal region, with marked enhancement in the medial parts and severe surrounding brain edema .A right temporal craniotomy accompanied by peripheral temporal lobectomy was performed and more than 90% of the tumor was excised. The postoperative period was uneventful, with no seizure after surgery.The specimen, which was received in the pathology department, showed multiple fragments of grayish and firm tissue, altogether measuring about 3 cm × 3 cm × 2 cm. The hematoxylin and eosin (H and E) stain revealed a markedly desmoplastic tumor, showing deposition of dense collagen fibers. The neoplastic cell population was heterogenous, composed of spindle-shaped astrocytes with a fascicular arrangement in the abundant collagenous reticulin-rich stroma . ScatterImmunohistochemistry (IHC) was performed to confirm the diagnosis. There was diffuse reactivity with glial fibrillary acidic protein (GFAP) in addition to focal isolated ganglion cells being positive with synaptophysin Figure  and BFollow-up of the patient after 6 months is unremarkable, with no seizure or any evidence of recurrence.DIGs are rare intracranial tumors, most likely diagnosed in the first 24 months of life.Boys are affected more commonly than girls. SymptomsThey are massive, firmly attached to the dura, extensively infiltrate the subarachnoid space but do not involve the ventricular system. Most comPathologic features of the tumor have been clearly described in several previous reports. Histologically, the most prominent feature of DIG is desmoplasia and spindle cells with a storiform pattern of arrangement. There isThe first component can be shown to be GFAP positive, but the latter component is of neuroepithelial origin and reactive with markers such as synaptophysin.9] Age of the patient and lack of desmoplasia in the ganglioglioma can differentiate this tumor from DIG.[The main histologic differential diagnoses are reticulin-rich desmoplastic tumors such as pleomorphic xanthoastrocytoma, which can be differentiated by age of the patient, prominent lipidization of the cells and absence of neural component. Another from DIG.Our case was a 3-month-old baby with intractable seizure of undetermined cause. CT showed a large superficial tumor in the temporal lobe, which is the third most common site of brain involvement. Pathology of the tumor revealed typical histologic and IHC features.Complete resection is usually curative with no further additional therapy. Our case


Myositis ossificans is a benign, self-limiting condition that usually affects young, athletically active men. To the best of our knowledge, this case report describes the oldest recorded patient with myositis ossificans.Our patient was an 83-year-old Japanese woman who presented with a one week history of a palpable mass in the left thigh. She had a history of surgery for transverse colon cancer and lung cancer at the ages of 73 and 80, respectively. Clinical and radiological examinations suggested a malignant neoplasm such as metastatic carcinoma or extraskeletal osteosarcoma. A diagnosis of myositis ossificans was made by core needle biopsy. Our patient was asymptomatic and had no recurrence at one year follow-up.Clinicians should consider myositis ossificans as a possible diagnosis for a soft tissue mass in the limb of an older patient, thereby avoiding unnecessarily aggressive therapy. Myositis ossificans (MO) is a benign lesion of heterotopic ossification that chiefly affects active adolescents and young adults, with a slight male predominance. Any part of the body may be involved, but the anterior thigh is the most common site. This lesion is clearly related to trauma in 60% to 75% of cases . DespiteAn 83-year-old Japanese woman was referred to our hospital with a one week history of a palpable mass in the anteriomedial aspect of the left thigh. There was no history of antecedent trauma, but our patient had a history of surgery for transverse colon cancer and lung cancer at the ages of 73 and 80, respectively. Physical examination revealed a tender, firm, and non-mobile mass that was 7 × 6 cm in size. Laboratory data were within the normal limits, including erythrocyte sedimentation rate, C-reactive protein and white blood cell counts.A plain radiograph did not show any alteration. A magnetic resonance imaging (MRI) scan revealed a 6 × 5 cm poorly defined mass in the left vastus medialis muscle Figure . On T1-wThe possibility of a malignant neoplasm was proposed, and a core needle biopsy was performed. Microscopically, the lesion was composed of a proliferation of fibroblasts admixed with foci of bone trabeculae lined by plump osteoblasts Figure . AbnormaMO, a benign condition, is commonly defined as a heterotopic ossification of soft tissues. MO can be seen at any age, but rarely occurs in babies or older patients . To the The pathogenesis of MO is still uncertain. In cases with an apparent history of traumatic injury, it can be assumed that the process commences with tissue necrosis or hemorrhage followed by exuberant reparative fibroblastic and vascular proliferation with eventual ossification. In a small number of cases, etiologies may include burns, infections or drug abuse. However, non-traumatic cases have been documented in the literature ,5. In moThe zoning phenomenon of peripheral maturation is the most important diagnostic feature. Various radiological techniques have been applied for the detection and follow-up of MO . Plain rDifferential diagnostic problems may arise in both early and late stages. In the earlier stages, the differential diagnoses should include extraskeletal osteosarcoma and synovial sarcoma when peripheral ossification is incomplete. In later stages, MO must be distinguished from parosteal or extraskeletal osteosarcoma and chondrosarcoma ,7. HowevThe differential diagnosis may also include metastatic carcinoma in our case. Skeletal muscle metastasis is relatively rare. The most frequent affected sites include the abdominal wall, back, thigh, chest wall, and shoulder. The most common primary tumor is located in the lung and the most common histological diagnosis is adenocarcinoma -10. Not The treatment of MO is usually conservative because of its self-limiting character and spontaneous regression. However, surgical excision is advised when joint function is impaired, neurovascular impingement is encountered, or the lesion is unusually large or painful. Surgery should only be undertaken on mature lesions.Although rare, MO should be considered in the differential diagnosis of older patients with a soft tissue mass. Without the characteristic radiological features, a biopsy is necessary to elucidate a diagnosis.The authors declare that they have no competing interests.JN managed our patient and drafted the manuscript. KN performed the histological examination of the specimen. KN, HI and MN participated in the design of the study and helped to draft the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Agenesis of the gallbladder is a rare congenital anomaly occurring in 13 to 65 people of a population of 100,000. The rarity of the condition, combined with clinical and radiologic features that are indistinguishable from those of more common biliary conditions, means that it is rarely diagnosed preoperatively, and patients undergo unnecessary operative intervention.This case report describes the case of a 79-year-old symptomatic Caucasian man who underwent laparoscopic cholecystectomy for suspected choledocholithiasis despite imaging studies raising suspicion of gallbladder agenesis. Intra-operatively, the diagnosis of gallbladder agenesis and associated common bile duct stones was made.The preoperative diagnosis of this rare condition is difficult to make. However, with advances in biliary tract imaging and with heightened awareness of this anomaly, fewer patients will need to undergo unnecessary operative intervention. The authors review the different imaging modalities available to help diagnose this condition and highlight the importance of being aware of this rare anomaly to avoid an operation that carries a high risk of iatrogenic injury. Since its first description by Lemery in 1701, a number of cases have been published, with a reported incidence of 0.01% to 0.06% [Isolated agenesis of the gallbladder is a rare congenital anomaly that results from failure of the cystic bud to develop to 0.06% . It is eto 0.06% ,4. Symptto 0.06% .Despite recent advances in biliary tract imaging, the pre-operative diagnosis of gallbladder agenesis remains elusive. Here this case report describes a case of symptomatic gallbladder agenesis with common duct stones diagnosed at laparotomy and discuss the utility of the various imaging modalities that are currently available to attempt to diagnose this condition.A 79-year-old Caucasian man presented to the clinic with reduced appetite, unintentional weight loss of approximately 6 kg, and a history of fatty food intolerance. He denied any abdominal pain or febrile episodes, and physical examination was unremarkable. Biochemical investigations, however, revealed deranged liver-function tests with total bilirubin, 66 μmol/L; ALT, 122IU/L; ALP, 274IU/L; and gamma GT, 864IU/L.An abdominal ultrasound showed a dilated common bile duct (CBD) with stones inside it. The gallbladder was not visualized, but strong echoes with acoustic shadowing were seen, suggesting a contracted gallbladder. A computed tomography (CT) scan revealed stenosis of the proximal CBD and dilated intra- and extra-hepatic bile ducts. Furthermore, it showed a small pseudocystic structure that was assumed to be a shrunken gallbladder.The patient proceeded to endoscopic retrograde cholangiopancreatography (ERCP), which showed multiple stones (the largest measuring 1.5 cm) in the CBD, which could not be removed, and so a stent was inserted  asySymptomatic patients commonly present with right upper quadrant pain, dyspepsia, jaundice, fatty food intolerance, or nausea, but these symptoms are indistinguishable from those of other common biliary tract conditions, making diagnosis difficult. It has previously been suggested that the pathophysiology of symptoms in gallbladder agenesis is similar to that of the post-cholecystectomy syndrome, and it is thought that the causes of pain include biliary dyskinesia and choledocholithiasis .Management options for this symptomatic group include smooth muscle relaxants, and if this fails, sphincterotomy . ImportaIn the 1960s, Frey  suggesteThe usual initial investigation for patients presenting with right upper quadrant pain is an abdominal ultrasound. It has been suggested that the absence of the ultrasonographic features of the WES triad  and the double-arc shadow should raise suspicion of gallbladder agenesis as the diagnosis . However99mTc-HIDA) are promising in the diagnosis of various gallbladder anomalies, including agenesis. However, nonvisualization of the gallbladder also typifies cystic duct obstruction secondary to acute cholecystitis, and so symptoms are more often attributed to this condition [Hepatobiliary scintigraphy scans (such as ondition .Computed tomography (CT) scanning and ERCP are further techniques that can be used to diagnose agenesis of the gallbladder. In combination with ultrasound, ERCP increases the likelihood of successful diagnosis. However, non-visualization of the gallbladder is commonly attributed to an obstructed cystic duct, anatomic variations, or technical errors (as in our case), and agenesis of the gallbladder is considered the least likely explanation. Recent literature suggests that CT and ERCP are useful postoperative modalities, if gallbladder agenesis is suspected at laparoscopy . In thisIf gallbladder agenesis is suspected pre-operatively, endoscopic or laparoscopic ultrasound has been shown to be effective in confirming the suspicion . HoweverA lack of awareness of this condition among surgical, gastroenterologic, and radiologic staff was the main reason for operative intervention in this case, and the subsequent conversion to an open procedure. Despite a suggestive ultrasound, CT, and ERCP, the diagnosis was still not made, and the patient underwent cholecystectomy for presumed gallstones. This highlights the need for greater appreciation of agenesis of the gallbladder as a cause of biliary symptoms, especially when initial radiologic tests suggest an absent gallbladder. A suggested decisional tree for the investigation of suspected gallbladder agenesis has been devised (see Figure In conclusion, agenesis of the gallbladder is a rare but well-recognized congenital anomaly, the management of which is conservative. However, clinical and radiologic features mimic those of more common biliary conditions, and so patients frequently undergo unnecessary operative procedures. With the newer minimally invasive radiologic techniques, this situation can largely be avoided if awareness of this condition is improved. Pre-operative MRCP should be considered in cases in which ultrasound suggests nonvisualization of the gallbladder, and surgeons should maintain a low threshold for further investigation before any decision to operate. A conservative approach with follow-up imaging is advocated in cases of doubt to avoid unnecessary operations. In cases that are diagnosed at laparoscopy, the author agrees with the other authors that further procedures should be abandoned, and the patient should undergo post-operative investigation with the radiologic modalities already described, to prevent the morbidity of conversion to an open procedure.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review from the journal's Editor-in-Chief.The author declares that they have no competing interests.


Peritoneal cysts are rare benign intra-abdominal lesions most commonly found attached to the mesentery of the ileum. They may be asymptomatic, present with abdominal pain, bloating or discovered incidentally. We describe the case of a peritoneal cyst located in an unusual position in a female patient; attached to the falciform ligament. We present a case of a 61 year old lady who presented with abdominal pain and bloating of 12 months duration. Her past medical history was unremarkable. Examination revealed mild abdominal distension with a sense of fullness in the right flank. There was mild tenderness to deep palpation. Her full blood count, renal and liver function tests were normal. CT scanning confirmed a large cystic structure in the right side of her abdomen (Figure At laparotomy, a 16 × 10 cm thin walled cyst was found attached to the falciform ligament Figure . It contPeritoneal cysts are rare, usually benign tumours that are cystic in nature. They can be located anywhere in the mesentery between the duodenum to the rectum although most are found in the ileal mesentery. The estimated incidence of these lesions is 1:100,000 and 1:20,000 in adults and children respectively . They apPeritoneal cysts were first described by Benevenni, an Italian anatomist during a post mortem examination in 1507. In 1880 Tillaux performed the first successful surgical excision of a peritoneal cyst.Most peritoneal cysts are asymptomatic. Symptoms arise due to the pressure effects exerted by these lesions onto surrounding structures. Commonly these include abdominal pain, distension, constipation and vomiting. Common complications include, rupture, obstruction, infection, torsion or haemorrhage within the cyst -8The diagnosis of such lesions requires a thorough history, clinical examination and a high index of suspicion coupled with radiographic imaging. The most useful imaging modalities are abdominal ultrasound and computed tomography .Treatment of cysts should be considered in patients who develop symptoms or when cysts cause complications. Treatment options include percutaneous drainage, complete excision or marsupialisation. If bowel is involved, a segmental resection of the affected bowel may need to be performed. Complete excision should be considered the preferred treatment as it prevents recurrence. Partial excision or marsupialisation can result in infection and sinuses and therefore should be reserved for patients whose cysts involve a large proportion of the bowel mesentery. Simple drainage usually results in recurrence of the cyst and should not be performed.Laparoscopic complete excision has been shown to have the added advantage of a shorter post operative course and fewer complications  and shouWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AP and VL co wrote and edited the manuscript. BSR performed the surgical excision.


Sir,Tuberculosis of the gall bladder is extremely rare, and hence, not adequately documented. CholelitA 58-year-old male patient presented with a year-long complaint of chronic upper abdominal pain along with fever since the last 5 days. There was no prior history of tuberculosis or of contact with such patients. Clinically, he was febrile and the abdomen showed epigastric and right hypochondriac tenderness. Murphy's sign was positive. Hematological examination revealed leucocytosis and neutrophilia. ESR was 67 mm in the first hour. Liver enzymes and chest X-ray were normal. Abdominal ultrasound revealed thickened wall with distended gall bladder and a calculus in the neck of the gall bladder suggestive of chronic calculous cholecystitis.Mycobacterium tuberculosis was highly positive (H: 1359); whereas, IgM was negative. Sputum was negative for acid-fast bacilli. In view of the positive serological test for tuberculosis, a complete course of antitubercular treatment was administered for 7 months . He remained asymptomatic after 1 year of follow-up.After 3 days of failed conservative treatment, laparotomy through Kocher's incision revealed thickened, distended, and densely adherent gall bladder with omental adhesions. Pus was aspirated from the tense gall bladder. Following adhesiolysis, cholecystectomy was performed by the fundus-first method. Histopathological examination of the specimen revealed features suggestive of acute on chronic cholecystitis with chronic granulomatous reaction and foreign body giant cells. Serum IgG for In English literature, >50 cases of tuberculosis of the gall bladder have been reported. Rarity oet al.[Schistosomal cholecystitis is a rare variety of granulomatous infection and must be distinguished from the tuberculous form. In the medical literature, >10 cases of schistosomal cholecystitis are described. Sharara et al. describeet al.[et al.[As tuberculous cholecystitis is difficult to diagnose preoperatively, all resected cholecystectomy specimens should be sent for confirmatory histopathological examination, especially in endemic areas where the diagnosis is suspected. In our case, there were dense adhesions around the gall bladder with signs of acute inflammation suggestive of acute on chronic cholecystitis. Moreover, intraoperatively, the gall bladder was found to contain pus and stones at the neck. Surgery was justified in our case since there was co-existent empyema of the gall bladder. A study by Raja et al. showed tl.[et al. reportedAlthough tuberculosis of the gall bladder is a rare entity, we recommend subjecting all resected gall bladder specimens for histopathological examination in endemic areas to rule out tuberculosis.


The recognition of neonatal intestinal perforation relies on identification of free gas in the peritoneum on plain abdominal radiographs and the associated clinical signs. The neonatal bowel takes several hours to fill with gas, potentially obscuring one of the radiological signs of bowel perforation in the neonate.+2 weeks of gestation, who was suspected before birth to be at risk of intestinal perforation, based on antenatal ultrasound signs of bowel obstruction. However, the diagnosis of intestinal perforation after birth was initially delayed because the first abdominal radiograph, requested by the neonatal team, was taken too early in the clinical progression of the neonate's condition. As a consequence, this delayed referral to the paediatric surgical team and definitive management.We describe the case of a male, Caucasian neonate, born prematurely at 35This case illustrates how consideration of the timing of abdominal radiographs in suspected intestinal perforation in the neonate may avoid misinterpretation of radiographic signs, thereby avoiding delays in referral and treatment in the crucial first few hours of life. Abdominal distension with bile-stained vomiting in a neonate can potentially represent bowel obstruction. Neonatal bowel obstruction can be complicated by intestinal perforation, hence the necessity for early surgical referral in cases of neonatal bowel obstruction. Intestinal perforation may occur before birth. The preliminary imaging modality of choice to diagnose suspected bowel obstruction and intestinal perforation in a neonate is a plain supine abdominal radiograph. Accurate diagnosis often relies on recognition of abnormal gas patterns within the abdomen. However, the passage of gas through the neonatal intestine takes a number of hours after birth.in utero bowel perforation, which can be associated with postnatal meconium peritonitis. Meconium peritonitis can be treated operatively or non-operatively, since in utero bowel perforations may heal spontaneously. A recent meta-analysis of the literature has helped to clarify the features of meconium peritonitis that are associated with a need for operative management [Peritoneal calcification is indicative of nagement . Cases onagement .+2 week) Caucasian neonate with suspected antenatal bowel obstruction presented to the neonatal unit with mild abdominal distension and bile stained aspirates. The infant was otherwise well at birth. No other abnormal features were detected on examination. Prenatal test for cystic fibrosis was negative.A premature (35An abdominal radiograph was taken by the neonatal team within 1 hour of birth. No dilated loops were demonstrated. A calcified rim was present in the centre of the abdomen, with some irregular calcification in the right upper quadrant. There was no evidence of free gas within the peritoneal cavity (Figure A second radiograph was performed approximately 4 hours after birth because of increasing abdominal distension in the neonate. On this second radiograph, free gas was visible in the peritoneal cavity Figure . The surAt laparotomy, a large perforation was found in the ascending colon. Meconium and calcified material were drained from the peritoneal cavity. A drain was inserted and a stoma formed from the proximal ascending colon. The neonate made a good recovery postoperatively. Hirschprung's disease and cystic fibrosis were excluded as causes of the perforation.The relevance of this case study to the management of neonates with suspected antenatal bowel obstruction is that the first abdominal radiograph placed our neonate in the lowest risk category, suggesting the neonate could be safely managed non-operatively. Conversely, the second abdominal radiograph, demonstrating perforation, placed our neonate in a category that generally requires surgical management ,2.British Medical Journal highlighted the potential dangers of iatrogenic radiation, stressing the imperative for doctors to protect patients from unnecessary exposure [A second issue highlighted in this patient is that this neonate was exposed to an extra dose of radiation that ultimately proved to obscure the diagnosis, therefore it was of no benefit to the patient. A recent article in the exposure .This study illustrates a potential pitfall in the use and interpretation of plain abdominal radiographs in the first few hours of life that may negatively impact on management of neonatal patients.The authors declare that they have no competing interests.MJG wrote the case study, researched and wrote the literature review. MMC critically revised the literature review and advised on radiological aspects of the case. KL was lead consultant who managed the case, instigated the conception of the case study, gave advice on the intellectual content of the case study in relation to clinical practice and obtained consent from the parents. All authors read and approved the final manuscript.Written informed consent was obtained from the parents of 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.


Ogilvie's syndrome describes the phenomenon of an acute colonic pseudo-obstruction without a mechanical cause. It is rare but has been reported to occur after Caesarean section. It can lead to bowel perforation or ischaemia.A healthy, 28-year-old Caucasian woman presented 2 weeks past her expected date of delivery for her first pregnancy. She underwent an uncomplicated elective Caesarean section but developed abdominal pain and bloating postoperatively and was subsequently diagnosed with acute colonic pseudo-obstruction, also known as Ogilvie's syndrome.This case report highlights the rare, but potentially dangerous, diagnosis of Ogilvie's syndrome after Caesarean section. It is of particular interest to obstetricians, midwifery staff and general surgeons and shows the importance of accurate diagnosis, regular abdominal reassessment and early senior input to ensure appropriate and rapid treatment. Ogilvie's syndrome (OS) was first described in 1948 [A healthy, 28-year-old Caucasian woman in her first pregnancy  with grade one placenta previa presented 2 weeks past her expected date of delivery (at 39+2/40) for elective Caesarean section. She had had no pre-operative treatment for her condition and Caesarean section was carried out under spinal anaesthesia . There were no operative complications and there was minimal maternal blood loss. The total operating time was 11 minutes and a healthy baby boy weighing 3.1kg was delivered.Postoperatively, the patient initially recovered well, although she required paracetamol (1g 4 × daily), diclofenac (50mg 3 × daily) and dihydrocodeine (60mg 4 × daily) regularly for analgesia. On postoperative day (POD) 1, she reported abdominal distension and absolute constipation but no abdominal pain, and she was treated with lactulose. She developed shoulder-tip pain in the early hours of POD 2 which developed into colicky, central abdominal pain although she had passed flatus and had no vomiting. Physical examination revealed soft, abdominal distension with right-sided abdominal tenderness and no clinical evidence of peritonitis. Plain radiographs revealed widespread colonic dilatation with no free air  imaging showed widespread colonic dilatation and a maximum caecal diameter of 8cm  is rare and has been reported as isolated case reports or small case series. It is described by a clinical and radiological picture of acute large bowel obstruction without a mechanical cause. It has most commonly been reported after pregnancy or Caesarean section, although has also been reported to occur after trauma and severe burns.The pathophysiology of the condition is still unclear although one explanation is that an imbalance between sympathetic and parasympathetic innervation to the colon results in an overall excess in sympathetic activity . This exManagement of OS can be classified into non-surgical and surgical treatment, although arguably diagnosis and recognition are the most important aspects of care. Indeed, significant morbidity and mortality from the condition has been reported when there is a wrong diagnosis, most commonly paralytic ileus, and a delay in the diagnosis of bowel perforation, usually by junior obstetric or general surgical doctors .Progressive abdominal distension is often painless at first. Importantly, bowel sounds are usually present and may be normal. Initial management should include intravenous fluid therapy, nasogastric suction and a plain abdominal X-ray. Most cases do not require surgical intervention and settle with either endoscopic or pharmacological therapy. Colonoscopic decompression is successful in the majority of cases, although recurrence is common. Pharmacological treatment includes naloxone, cholinergic stimulation with neostigmine or erythromycin and cisapride. In our patient, both colonoscopic decompression and neostigmine failed to resolve the pseudo-obstruction, and she developed progressive caecal distension and subsequently caecal perforation and peritonitis. Surgical treatment is indicated when the caecal diameter is greater than 9cm or there is evidence of perforation and comprises either caecostomy or, if ischaemic bowel is present, limited right hemicolectomy with or without primary anastomosis.The authors believe that OS, though uncommon, is a diagnosis to consider when investigating patients who have recently undergone Caesarean section. We advocate early general surgical referral and draw attention to the importance of regular abdominal examination to assess response to treatment and determine when surgical intervention is needed. Furthermore, we urge early escalation to senior obstetric and general surgical opinion if concerns persist.CT: computed tomography; mcg: micrograms; OS: Ogilvie's Syndrome; POD: post-operative day.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AS was a major contributor in writing the manuscript and interpreted the data regarding the operation and outcomes. EN gathered and analysed the data regarding the obstetric history and the non-operative management of the patient; she was also a major contributor in writing the manuscript. MG performed the general surgical operation and provided the data and details of the operation. KH was the consultant surgeon in charge of the patient and provided the intellectual basis for the report; in addition, he was a major contributor to the discussion. All authors read and approved the final manuscript.


Dermoid cysts are one of the most frequently occurring ovarian cysts; parasitic dermoid cysts, however, are extremely rare.We report a case of a 29-year-old Japanese woman with an incidental finding of an adnexal mass on bimanual examination. Sonographic imaging reported an 8 cm mass in the Pouch of Douglas. This was found to be a parasitic dermoid cyst and was removed at laparoscopy.We believe laparoscopy to be a safe and effective means of managing parasitic ovarian dermoid cysts. Dermoid cyst (benign cystic teratoma) of the ovary is one of the most common ovarian neoplasms but parasitic cysts are very rare and their true incidence is unknown. We report a case of a parasitic dermoid cyst in the Pouch of Douglas (POD) managed laparoscopically. To the best of our knowledge, this is the only reported case of laparoscopic removal of a non-omental parasitic ovarian dermoid in the literature.A 29-year-old Japanese woman underwent a bimanual pelvic examination, under anaesthesia, prior to large-loop excision of the transformation zone for large volume high-grade cervical intraepithelial neoplasia. During this examination, a 10 cm right adnexal mass was noted. Outpatient pelvic ultrasonography (USS) and cancer antigen 125 (CA-125) were arranged.On review, the patient was asymptomatic and the USS showed a normal uterus and left ovary. The right ovary was not positively identified. There was a 6 × 8 cm echogenic mass seen on the left and posterior to the fundus of the uterus with no abnormal vascular flow. It was uncertain whether this mass was fibroid, ovarian or bowel in origin. The CA-125 was mildly elevated at 38 . The plan was to review her with magnetic resonance imaging (MRI) of the pelvis and tumour markers; CA-125, CA-19-9, carcino-embyonic antigen (CEA), alpha-feto protein, and human chorionic gonadotropin. The patient failed to attend for the MRI. The tumour markers were all normal except for a slightly elevated CEA of 7 ug/L . She was then booked for an elective laparoscopy.Laparoscopy showed a normal uterus, left ovary and tube, a dilated right tube and a small right ovary. A 6 × 6 cm mass was noted in the POD adherent to the posterior aspect of the uterus on the left side. No ligamentous attachment or vascular pedicle was seen. Adhesiolysis was performed by blunt dissection, and the cyst was decompressed within a bag and removed through a 10 mm suprapubic port. The patient's recovery was uneventful and she was discharged after 24 hours.Histopathology confirmed a mature cystic teratoma containing squamous epithelium and mature skin adnexal structures.Mature cystic teratoma is one of the most common ovarian tumours, accounting for 10% to 20% of all ovarian neoplasms. Teratomas are derived from germ cells and may contain structures from all three embryonic germ layers. They are bilateral in 8% to 15% of cases [Parasitic dermoid cysts are extremely rare entities, and their actual incidence is unknown. Several theories exist to explain their occurrence. The first theory proposes the development within a supernumerary or ectopic ovary, which may occur after implantation of ovarian tissue after surgical procedure or inflammation such as pelvic inflammatory disease. Supernumerary ovaries may also occur as a result of abnormal arrest of germinal cells in the dorsal mesentery during their embryonic migration to the genital ridge . AnotherPre-operative assessment of these adnexal masses using clinical signs and symptoms, tumour markers and pelvic ultrasound is essential to establish risk of malignancy and therefore plan an appropriate surgical approach . ManagemLaparoscopy is a safe and effective method of managing parasitic dermoid cysts, provided preoperative assessments are suggestive of a benign tumour.POD: Pouch of Douglas; USS: ultrasonography; CA-125: cancer antigen 125; MRI: magnetic resonance imaging; CEA: carcino-embyonic antigenWritten informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.CEB conducted the literature review and conceived and drafted the manuscript. AK helped in collecting records and preparing the manuscript. NP critically revised the manuscript for intellectual content and gave final approval of the version for publication. All authors revised and approved the manuscript.


Cystic neoplasms of the pancreas comprise 10%–15% of pancreatic cystic lesions, with the serous cystadenoms being the commonest. The association of exocrine and endocrine tumours of the pancreas unrelated to Von Hipple Lindau disease is very rare. Very few cases have been reported in the literature. We present another case of both these tumours in one patient.A female patient was seen in the surgical clinic for a pain in the right groin. Clinical examination and investigations confirmed a diagnosis of combined endocrine and exocrine tumours of the pancreas. She underwent surgery and is under regular follow-up in the surgical clinic.Biphasic differentiation of pancreatic stem cell during embryological development could happen and may result in combined endocrine and exocrine tumours of the pancreas. Imaging studies are excellent in diagnosing theses lesions. Surgery has a central role and could be curative. To our knowledge, only seven similar cases have been reported in the literature -6. Here,A 73 years-old lady was seen in the clinic in August 2006 for a right inguinal pain which had been present for a few months. She had no significant past medical history. Abdominal examination revealed a mass in the left upper quadrant. There were no other physical findings.Computed tomography (CT) of the abdomen confirmed a 12.3 cm × 8.2 cm mass arising from the body and the tail of the pancreas and extending into the splenic hilum  are excellent tests for cystic lesions of the pancreas, not only for the initial detection of a lesion but also for the characterization of such lesions by visualization of the calcification of the cyst wall, septa, mural nodules, possible showing of communication between a cyst and the pancreatic duct, and findings suggestive of pancreatitis. The presence of a central scar visualized with the use of CT or MRI is a highly diagnostic feature that is found in about 20% of serous cystadenomas .Management of these lesions has not been standardised, is evolving and depends on many factors such as the presence or absence of symptoms, surgical risk of the patient, age, type of the tumour, its location and size. The proper evaluation and subsequent management of this disease in patients without symptoms have not been fully defined ,3. The rCombined endocrine and exocrine tumours of the pancreas are very rare. The potential of pancreatic ductal stem cells for biphasic differentiation along the embryologic developmental line of exocrine and endocrine pancreas could happen. Cystic lesions of the pancreas are asymptomatic and mainly discovered incidentally. Imaging studies such as CT and MRI are excellent tests which help diagnose these lesions. The role of surgery is central in managing these tumours, especially if both endocrine and exocrine tumours coexist, and could be curative if complete resection is performed.The author(s) declare that they have no competing interests.AA Performed literature review, drafted and revised manuscript. VU Evaluated radiological features and contributed to radiological part of manuscript, AE Carried out initial assessment of the patient and helped in draft of manuscript. HM Contributed to the concept of the report AB Operated on the patient and corrected the manuscript for it scientific content. ND Evaluated histopathological features and contributed histological part.All authors read and approved the final manuscript.