We are presenting a unique case of an 11-year-old girl admitted for investigation of progressive abdominal distention of more than one-year duration. Due to the complete cystic nature of the mass and its enormous size, it was not visualized by the ultrasound and was reported as massive ascites. MRI and postoperative histopathology confirmed a diagnosis of giant serous cystadenoma of the right ovary. She underwent a right ovarian cystectomy with complete preservation of both ovaries and fallopian tubes and is doing well on outpatient follow-up. Although an ovarian cyst detected in an adolescent girl is most likely a physiological or functional cyst , it stilOur case is an 11-year-old Sudanese girl, residing in Qatar, who presented to the pediatric outpatient department with an 18-month history of progressive abdominal distention. The parents had been attributing the abdominal distention to weight gain, especially as the child remained otherwise asymptomatic. They had in fact been encouraging the girl to lose weight. The parents sought medical advice at a local health center, due to flu-like symptoms. The examination at the health center was impressive for signs of massive abdominal distention and she was admitted to our tertiary care hospital promptly for further investigations with a preliminary diagnosis of ascites. Apart from the progressive abdominal distention, there was no other contributory history suggestive of any underlying malignancy, liver disease, heart failure, or undiagnosed renal problems. The girl did not complain of any abdominal pain, constipation, urinary retention, or respiratory distress secondary to her abdominal distention. Our patient had achieved menarche 1 year ago with infrequent menstrual cycles; her first day of the last menstrual period was two weeks prior to her admission. There was no history of menorrhagia or dysmenorrhea.Upon examination, the child was noted to be in good general condition with normal vital signs for age and in no apparent pain or distress. Her weight was 64.5 kg, which was above the 95th centile for her age. Apart from the massive abdominal distention, she was thin built. Her general examination did not reveal any clubbing, pallor, icterus, peripheral edema, or lymphadenopathy. There were no stigmata of chronic liver disease. Abdominal examination revealed a huge uniformly distended abdomen (maximum diameter was 105 cm), extending from the pelvis to the xiphisternum with full flanks. There were no visible dilated veins on the abdomen. Palpation did not reveal any tenderness or masses; fluid thrill was positive. She had normal female genitalia. Her respiratory, cardiovascular, and nervous system examinations were unremarkable. A bedside urine dipstick did not reveal any proteinuria.As the physical findings detected a fluid thrill, her preliminary investigations were directed towards finding a likely explanation for what seemed like a massive ascites. Her preliminary laboratory work-up which included a complete blood count, peripheral smear, serum electrolytes, renal and liver functions tests were within normal. As our patient did not show any signs of chronic liver or renal disease, there was a strong concern among the treating physicians that the presumed ascites could be secondary to an underlying abdominal malignancy. At this stage, the pediatric oncology team was consulted and tumor markers which included Ca125 (6 U/mL), CEA 0.7 microgram/L, alpha-fetoprotein (<1.7 IU/mL) and beta-hCG (<5 IU/L) along with Uric acid 297 micromol/L, and LDH (174 U/L) were ordered, all of which were within normal limits.An urgent transabdominal ultrasonogram of the abdomen confirmed the suspicion of massive ascites . The posThe MRI of the abdomen and the pelvis  revealedA lower abdominal midline incision was made revealing the peritoneum. An elliptical incision is carefully made through the ovarian cortex to the cyst wall.When the cyst wall was reached, blunt and sharp dissection using surgical scissors was used to separate the cyst wall from the surface of the ovary. Intraoperative visualization did not reveal any abnormality of the left adnexal structures. The cyst was aspirated prior to its delivery and gave 13000 milliliters of fluid. The patient underwent right ovarian cystectomy with complete preservation of both ovaries and fallopian tubes. It weighed 13 kg and contained 13 liters of fluid.  HistopatOur patient did well after surgery and was discharged on the fourth postoperative day. Her discharge weight was 48 kg. Upon follow-up a week after her surgery she showed an excellent recovery and will continue to have regular follow-up in our outpatient clinic with an ultrasound examination every three months for early detection of any recurrence.An ovarian mass in pediatrics may represent the commoner physiological functional ovarian cyst or be a benign or rarely malignant tumor . The mosAs general pediatricians, we need to acknowledge that ovarian masses in general in our patient population are by no means uncommon  and can Giant ovarian tumors can be present as asymptomatically increasing abdominal girth  or be acOur patient is unique not only in terms of her age, but also as she posed a diagnostic challenge in many aspects. Firstly, she presented with a huge asymptomatic abdominal distention, which upon initial clinical assessment was presumed to be massive ascites. Moreover, ultrasound of the pelvis and abdomen, in our case, confirmed this clinical diagnosis of massive ascites without delineating a possible cause, necessitating an urgent MRI, which led to the final diagnosis of a giant ovarian mass. If management was undertaken in our patient on the basis of ultrasound diagnosis alone , it may have led to erroneous transabdominal aspiration of the undiagnosed ovarian cyst. If paracentesis was undertaken in this patient it could lead to infection, bleeding, and increased peritoneal adhesion, thus making surgical cystectomy more challenging . UltrasoGiant ovarian tumors have become rare in current medical practice, as most cases are discovered early during routine check-ups. In our case, the patient's family did not seek medical advice for 1.5 years, as they assumed that the increased abdominal girth was due to weight gain and put her on an intense diet and exercise regime. The patient's weight at admission was 67 Kg and at one week postsurgery was 55 Kg. Teaching families and raising awareness are extremely important aspects in such cases.As pediatricians are often the first physicians who encounter such cases, they should be aware of asymptomatic ovarian tumors as a differential diagnosis for massive abdominal distension, given that they are the largest tumors found in the human body .If the pure cystic mass reaches an enormous size and the tumor markers are within normal limits, as in our patient, serous or mucinous cyst adenomas should be considered in the differential diagnosis in adolescent patient . ManagemAccording to literature review by Patel et al. , 7 casesAs rare as giant ovarian tumors are, pediatricians should be aware of its presentation and should include ovarian masses in their differential diagnosis of abdominal distention. Pediatricians should raise families' awareness for seeking medical advice early in case of persistent abdominal distension. Ultrasound should not be the only imaging modality especially in case of massive ovarian cysts as it may mimic ascites. This case report emphasizes the paramount importance of considering ovarian masses in the differential diagnosis of a patient who has abdominal distention without symptoms or signs of liver, renal, or cardiac diseases. It is also vital to raise awareness among the population to seek medical advice as early as possible to avoid complications such as ovarian torsion, rupture, and eventually infertility in such young age group. Fertility-conserving treatments, as in our patient, need careful follow-up because of the possibility of recurrence in the remaining ovary or malignancy transformation.


In our case, a 45-year-old male patient had multiple fractures accompanied by hypophosphatemia. FGF-23 levels were significantly increased, and total body magnetic resonance imaging (MRI) revealed a tumor mass located at the distal tibia leading to the diagnosis of tumor-induced osteomalacia (TIO). After resection of the tumor, hypophosphatemia and the increased levels of FGF-23 normalized within a few days. Subsequent microscopic examination and immunohistochemical analysis revealed a phosphaturic mesenchymal tumor mixed connective tissue variant (PMTMCT) showing a positive expression of somatostatin receptor 2A (SSTR2A), CD68, and Periostin. Electron microscopy demonstrated a poorly differentiated mesenchymal tumor with a multifocal giant cell component and evidence of neurosecretory-granules. However, the resected margins showed no tumor-free tissue, and therefore a subsequent postoperative radiotherapy was performed. The patient is still in complete remission after 34 months. Tumor resection of PMTMCTs is the therapy of choice. Subsequent radiotherapy in case of incompletely resected tumors can be an important option to avoid recurrence or metastasis even though this occurs rarely. The prognostic value of expression of Periostin has to be evaluated more precisely in a larger series of patients with TIO. The typical biochemical pattern of TIO includes normal circulating levels of calcium and parathormone (PTH), normal or low levels of 1.25-dihydroxyvitamin D (1.25-(OH)sphatase . The rensphatase –10.In TIO most tumors overexpress the protein fibroblast growth factor-23 (FGF-23) inhibiting renal phosphate reabsorption in the proximal tubules and acting as a phosphaturic factor , 3, 11. Diagnosis of TIO is often extremely difficult since tumors can be too small for detection by conventional radiological methods. High-resolution magnetic resonance imaging (MRI) of the whole body is the currently proposed method of choice to confirm the location of the tumor. F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is a very sensitive method , 10, 13 In rare cases, a venous sampling of FGF-23 is necessary to detect the tumor , 17. ForIf the responsible neoplasm is surgically removed, the abnormalities in phosphate wasting and in vitamin D metabolism typically dissolve in a few days.The described patient has given written consent for publication of the data and the photographs of the histopathology of the tumor. The following antibodies were used for the immunohistochemical analysis performed at the Institute for Surgical Pathology in Zurich: somatostatin receptor 2A (SSTR2A), polyclonal antibody, dilution 1 : 100, Zytomed Systems; OSF-2/Periostin, monoclonal antibody, dilution 1 : 1000, R&D Systems; CD 68, monoclonal antibody, dilution 1 : 50, DAKO A/S. Human FGF-23 c-terminal was measured in the laboratories of Synlab Weiden, Germany. An ELISA kit of the Company, Immutopics, Inc., was used.A 45-year-old man was admitted to our tertiary Rheumatology center due to acute aggravation of systemic bone pain. The symptoms  worsened gradually during the last weeks but had developed one year previously. The patient had a medical history of hypertension and denied any family history of metabolic bone disease.2), only painful knees and heels without swelling were conspicuous. Laboratory data are shown in Upon physical examination  scan showed a low mineral density . A bone biopsy of the proximal tibia revealed no signs for fibrosis, osteomalacia, a neoplasm, or a Morbus Paget.Based on the differential diagnosis of a TIO, an MRI of the whole body was performed revealing a tumor, measuring 5.2 × 2.2 × 1.5 cm in size, located at the right dorsal distal tibia. On T1-weighted images the tumor showed isointensity with the muscle tissue, on T2-weighted images hyperintensity . Complem2D was decreased to 2.5 pg/mL despite substitution. The patient still showed hypophosphatemia with a level of 1.83 mg/dL despite oral substitution.The diagnosis of primary TIO was confirmed without evidence of a secondary TIO . Consequently, a tumor excision was performed in the Department of Trauma Surgery, University of Regensburg. Before the operation the level of human FGF-23 c-terminal was 0.545 RU/mL . The level of 1.25-(OH)The histopathology of the resected tissue revealed a PMTMCT, measuring 5 × 2 × 1.5 cm in size. The tumor consisted of monomorphic cells with round cell nuclei without increased mitotic activity (MIB 1 < 2%) and scattered giant cells in small groups without signs of malignancy Figures . The tumSince the tumor was not resected totally, radiotherapy of the right lower extremity has subsequently been performed, as a relapse of a benign giant cell tumor, or PMTMCT has been described , 18, 19.Two days after resection of the tumor, the level of FGF-23 c-terminal was within the normal range  and treatment with phosphate was stopped. The level of alkaline phosphatase was still elevated at 276 U/L. The patient reported a significant improvement of his pain in the knees and heels allowing almost complete reduction of analgesics.Two months later, laboratory data showed normal levels for phosphate, calcium, and FGF-23 c-terminal (0.054 RU/mL). The alkaline phosphatase was still elevated at 178 U/L; the level of 25-(OH)-D was decreased with 17.3 ng/mL; the level of 1.25-(OH)-D was normal. An MRI performed on the tibia showed no relapse of the giant cell tumor.There was a follow-up visit 26, 29, and 34 months after establishment of diagnosis. The follow-up data including laboratory results and DXA has been performed again and showed normal levels of FGF-23 c-terminal and vitamin D see  and a noThis case report presents a patient with a PMTMCT leading to the rare disease TIO.The histopathology of tumors leading to TIO reveals in 70–80% of cases PMTMCTs  which arFolpe and colleagues  performeTo our knowledge a positive staining of Periostin of PMTs of patients with TIO has so far not been described in the literature. Periostin is a newly identified mediator of the inflammatory process and seems to play a role in collagen fibrogenesis and tumor development. It is an extracellular matrix protein expressed by fibroblasts and has been observed in a variety of human malignancies predicting a poor prognosis –25. SeveIn terms of ultrastructural features, neurosecretory granules were found similar to a neuroendocrine tumor , 29–31. In our case report, the electron microscopy investigation showed ultrastructural features of spindle shaped stromal cells with organelle-poor cytoplasm and a few dense granules resembling neurosecretory granules. These findings are consistent with the majority of the literature –31. HoweLate recurrence due to metastatic disease is rare but possible, occurring in less than 5% of the patients with TIO , 19, 33.Caudell and colleagues  performeIn conclusion, TIO is a paraneoplastic syndrome caused by the phosphaturic hormone FGF-23 that can be cured by removing the responsible neoplasm. Subsequent radiotherapy in case of incompletely resected tumors can be an important option to avoid recurrence or metastasis even though this occurs rarely. Especially if a recurrence with the need of re-resection would lead to distinct function of a limb an additive radiotherapy in case of incompletely resected tumors can be recommended. The prognostic value of expression of Periostin has to be evaluated more precisely in a larger series of patients with TIO.


We presented abdominal liposarcoma cases diagnosed and managed in a tertiary care center and also conducted a literature review on main features of this tumor.Chart reviews of eight cases were conducted, and clinical, surgical, histopathological, and follow-up data were recorded.Overall, complete surgical resection was performed with adjacent organ resection in 25% of cases, and radiotherapy was not administered. Recurrence was developed in only one case and died after 2 years and 3 months, and other cases are under follow-up without recurrence. Histopatological examinations revealed findings of well-differentiated liposarcoma.According to our surgical experience, the surgical margin positivity may not be a determining factor for the survival of patients with well-differentiated liposarcoma, and in the absence of macroscopic invasion, adjacent organ resection may not be required. Radiotherapy may not be preferred when complete resection of abdominal mass was achieved. Liposarcoma of abdomen is a rare lesion consisted of malign fat cells and accounts for approximately 20% of all mesenchymal malignancies in adults. These lesions may be found in different organs, typically occurs in either the retroperitoneum or the extremities . AbdominChart reviews of eight cases managed with liposarcoma at the General Surgery Service of our tertiary care university hospital were conducted between December 2011 and January 2014. This study was approved by the Human Ethics Committee of our university. Clinical information regarding the age, gender, clinical findings, imaging findings, surgical procedure, histopathology of the tumor, follow-up findings, overall survival were recorded. Any imaging studies that had been obtained preoperatively were also reviewed. Computerized tomography was used for imaging of abdomen in all patients Figure  was perfAll the patients were followed up at 1, 3, 6, and 12 months and 6-month period in second year. Physical and ultrasonographic examinations with laboratory tests were performed in the third month, and a computerized tomography was performed in the sixth month after surgery. The median follow-up of 21 months  with the shortest follow-up of 15 months and longest follow-up of 24 months.Table In almost all cases, histopatological examinations revealed findings of well-differentiated and grade 1 liposarcoma. Surgical margins were defined as positive in 75% of cases and necrosis was detected in 25% of cases.Recurrence has occurred in only one case and died due to renal failure. Intraoperatively, in case 2, vena cava inferior injury was developed and repaired. Four patients had minor complication according to Clavien-Dindo classification .Eight patients with abdominal liposarcoma were presented in this case series. Overall, complete surgical resection was achieved with adjacent organ resection in 25% of cases. We observed recurrence in only one case who died within 2 years and 3 months, and other cases are under follow-up without recurrence. After median follow-up of 21 months , all cases were alive without recurrence except case 2 who survived 2 years and 3 months after first surgery. Although radiotherapy was not administered to our cases, there was no recurrence except case 2.Liposarcoma is the most common mesenchymal tumor of the retroperitoneal space but continues to pose a challenge with regard to diagnosis, prediction of clinical behavior, and treatment of disease recurrence within the abdominal/retroperitoneal space . The majThe most commonly encountered histologic subtypes of retroperitoneal sarcoma are liposarcoma (41%), leiomyosarcoma (28%), malignant fibrous histiocytoma (7%), fibrosarcoma (6%), and malignant peripheral nerve sheath tumor (3%) . LiposarCHOP gene is inserted adjacent to a novel gene called FUS or TLS (translocated in liposarcoma). While no specific chromosomal translocations have been identified in well differentiated/dedifferentiated liposarcomas, amplification of MDM2 and CDK4 is very frequent in these subtypes, and their identification may be useful diagnostically. Furthermore, overexpression of MDM2 and CDK4 is also being exploited for therapeutic gain [Well-differentiated (low-grade) liposarcomas are the most common types of liposarcomas, followed by dedifferentiated liposarcomas. The amount of lipid inside the cells, the mucoid lipid, and the degree of cell differentiation are the essential of the classification. Myxoid, round cell, and pleomorphic liposarcomas are rare in the retroperitoneum. Myxoid and round cell liposarcomas share the same reciprocal translocation t12,16)q13; p11), in which the ,16, adjuvant RT, preoperative RT, preoperative intensity-modulated RT (IMRT), preoperative chemoradiotherapy, preoperative chemotherapy, and adjuvant chemotherapy. Many studies have shown that a significant number of patients experience prolonged disease-free survival when all grossly evident recurrent disease can be resected. Chemotherapy or radiotherapy administration is still controversial in the treatment of locally recurrent disease . A phaseBecause of the huge sizes of most retroperitoneal sarcomas, the size of the tumor is not a predictor for survival of the disease. Tumor grade has been reported as a significant factor in some studies, with the weight of evidence supporting shorter recurrence-free and overall survival for patients with high-grade tumors ,18. MetaOverall, 5-year survival for well-differentiated subtypes is 90%, while 5-year survival for pleomorphic subtypes is only 30% to 50%. Dedifferentiated and myxoid/round cell subtypes have 5-year survival rates of 75% and 60% to 90%, respectively . Well-diIn summary, abdominal liposarcomas are low-grade tumors in general and surgical excision with wide margin is decreasing the effectiveness of the radiotherapy, increasing the adverse effects especially on intestines. In our cases, although surgical margin was reported as positive in 75% of patients, because of the absence of macroscopic invasion, adjacent organ resection was not performed. According to our surgical experience, in patients with retroperitoneal liposarcoma, surgical resection can be completed considerably easy than expected although its size can be huge. In almost all cases, absence of invasion to adjacent tissues and organs is another advantage during surgical management, adjacent organ resection should not be necessary because of the low invasion potential of these tumors.


Although the effectiveness of perioperative adjuvant therapy in the treatment of hepatocellular carcinoma (HCC) has been investigated, the efficacy of preoperative therapy is unclear. Herein, we report a case of pathological complete response after percutaneous isolated hepatic perfusion (PIHP) for HCC involving portal vein tumor thrombosis (PVTT).A 77-year-old woman was referred to our institute with a liver mass detected on a routine health screening. Computed tomography revealed a 28 × 25 mm HCC in the left lobe of the liver and a tumor thrombus in the left and right portal branches . The patient received a single dose of preoperative PIHP with doxorubicin plus mitomycin C, without severe toxicity. After the chemotherapy, she underwent extended left hepatic lobectomy and thrombectomy of the PVTT. No cancer cells were detected during histopathological analysis, indicating pathological complete response. She remained relapse-free 12 months after the surgery.We experienced a case of pathological complete response after preoperative PIHP with doxorubicin plus mitomycin C for HCC involving PVTT. Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related deaths worldwide . Surgica2 doxorubicin plus 30 mg/m2 mitomycin C for 30 min  176 U/L, alanine aminotransferase (ALT) 157 U/L, albumin 4.2 g/dL, prothrombin time 90.6 %, indocyanine green 15-min retention test (ICG R15) 19.7 %, α-fetoprotein (AFP) 16 ng/mL, protein induced by vitamin K absence or antagonist II (PIVKA-II) 2873 mAU/mL, hepatitis C virus (HCV) Ab positive, HCV RNA 6.54 logIU/mL. The liver damage was grade A and Child-Pugh classification was class A. Contrast-enhanced computed tomography (CT) showed a 28 × 25 mm tumor in segment 4, with a tumor thrombus in the left portal branch reaching the right portal branch, both of which were enhanced in the arterial phase and washed out in the equilibrium phase (Fig. Histological examination of the resected specimen revealed complete necrosis without any viable cancer cells in the primary tumor and PVTT Fig.  and we fThe optimal treatment method for patients with HCC involving PVTT in the portal bifurcation or the main trunk remains controversial . PVTT reSince 1989, our center has been using PIHP for the treatment of advanced multiple HCC . In our Recently, the efficacy of preoperative HAI chemotherapy has been shown in patients with HCC and PVTT , 28. BecThe clinical question of whether preoperative or postoperative PIHP is better should be addressed. Preoperative PIHP might not only reduce post-curative therapy recurrence but also downstage tumors from an unresectable to a resectable stage.In conclusion, further investigation into surgery following neoadjuvant chemotherapy as a possible therapeutic option for HCC involving PVTT is warranted. PIHP with doxorubicin plus mitomycin C is a feasible and promising preoperative chemotherapy for HCC involving PVTT.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.AFP, alpha-fetoprotein; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BCLC, the Barcelona Clinic Liver Cancer; CT, computed tomography; HAI, hepatic arterial infusion; HCC, hepatocellular carcinoma; ICG R15, indocyanine green 15-min retention test; OS, overall survival; PIHP, percutaneous isolated hepatic perfusion; PIVKA-II, protein induced by vitamin K absence or antagonist II; PVTT, portal vein tumor thrombosis; TE, treatment efficacy


The presentation of an acute bowel obstruction caused by endometriosis in an emergency department setting is rare, as it usually presents through years of complaints in the absence of a distinct acute onset. In this report, we present a case of a patient who was familiar with abdominal complaints and eventually required emergency surgery to treat an acute bowel obstruction caused by endometriosis. Endometrioses present infrequently in the acute phase, and only a few cases in which emergency surgery was required have been described in the literature.A 31-year-old Caucasian woman presented to the emergency room of our hospital with a distended abdomen, pain and nausea accompanied by a history of 14 years of chronic abdominal pain and constipation. An abdominal X-ray and subsequent computed tomographic scan showed a severely distended cecum of 9cm with stenosis in the sigmoid. Cecal blow-out was considered highly likely, and, during an emergency laparotomy, an obstructing process was found in the sigmoid. An oncologic resection of the sigmoid was performed with a primary anastomosis and loop ileostomy. A pathological examination revealed a tumor of 4cm in the sigmoid, which contained a tubelike structure with cytogenic stroma and the remains of focal bleeding. These are typical aspects of endometriosis.Infiltrating endometriosis is an invalidating disease that can be misdiagnosed for a wide range of other diseases. Emergency room physicians and surgeons should be aware that it can present as an acute obstruction and should be considered in diagnosing women of childbearing age. After initial colonoscopy, emergency surgery is the best therapeutic approach if there is a complete obstruction. In this case report, we describe a patient who had a long history of abdominal complaints. She came to our emergency department (ED) with a rare case of acute bowel obstruction caused by endometriosis. The diagnosis of endometriosis is usually made after years of complaints with the absence of a distinct acute onset ,2.A 31-year-old Caucasian woman with increasing abdominal distension, pain and nausea was referred to our department by gastroenterologists at the ED. She had had abdominal pain and chronic constipation symptoms since the age of 17 years. These complaints had been extensively analyzed several years earlier by the gastroenterology department, when no abnormalities were identified in blood tests or a colonoscopy. One month prior to her presentation at the ED, she had been admitted to the surgical department with complaints of decreased intake, nausea and a 10-day absence of defecation. Blood tests did not show abnormalities. An abdominal X-ray showed signs of constipation. After conservative treatment with enemas and oral debulking agents, her complaints decreased and she was dismissed from hospital.During the intake at the ED, she was found to have no history of weight loss, and, with the use of bisacodyl and close monitoring of her diet, she had managed to regulate her bowel movements, with the exception of her recent admission. For the preceding 1 year, the patient had desired to become pregnant. Therefore, she had stopped using oral contraceptives, after which she had a regular cycle without intermediate bleeding or abnormal vaginal discharge.4 leukocytes  and a C-reactive protein level of 8.0 . An abdominal X-ray , without any signs of an infection with 6.8×10Given the threat of cecal blow-out, it was decided to perform a laparotomy. During the surgical procedure, a solitary stenosis was found in the sigmoid colon that appeared as a malignancy. Therefore, an oncological sigmoid resection with primary anastomosis was performed. Because of the distension of the cecum, a temporary loop ileostomy was constructed. Upon further inspection of the abdomen, no abnormalities were found in the liver, peritoneum or pelvis. The patient recovered quickly after the procedure and could be discharged after 1 week, with the intention to perform a loop ileostomy reversal after 3 months.A macroscopic pathological examination of the resected sigmoid showed extensive fibrotic foci with induration in the intestinal wall without mucosal abnormalities Figures  and 3. IEndometriosis is defined as the implantation of endometrium outside the uterus [e uterus ,4. In 19e uterus . These ee uterus ,7.Endometriosis affects 10% to 12% of fertile women, with the number of cases diagnosed peaking between the ages of 29 to 39 years. First onset can be as early as adolescence, making it prone to being missed as a diagnosis ,9. EndomSymptoms of deep infiltrating endometriosis of the rectosigmoid include dysmenorrhea, constipation, diarrhea, pain during defecation, dyspareunia and periodic rectal bleeding during menstruation ,10,12,13Deep infiltrating endometriosis often presents at a late stage with extensive complaints due to extensive fibrosis caused by chronic inflammation of the endometriosis. Anti-inflammatory and hormonal therapies have little to no effect on the symptoms and therefore provide no added value in this stage of the disease . SurgicaThis case illustrates that infiltrating endometriosis is a disabling disease. Emergency room physicians and surgeons should be aware that it can present as an acute obstruction and should be considered in diagnosing women of childbearing age. In our patient, a CT scan, rather than an abdominal X-ray, might have revealed the pending obstruction in an earlier phase. In exceptional cases, colon obstruction by infiltrating endometriosis can require an emergency laparotomy with resection of the affected bowel segment. In less urgent cases, more planning is recommended, along with discussion of the case, including medical images, among a multidisciplinary endometriosis team.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.


Foreign bodies are a rare cause of appendicitis. In most instances, ingested foreign bodies pass through the alimentary tract asymptomatically. However, those that enter the lumen of the vermiform appendix may not be able to re-enter the colon and may initiate an inflammatory process. We report a case of acute appendicitis induced by an unusual foreign body.A 26-year-old Sub-Saharan woman presented with right iliac fossa pain and tenderness. She underwent an open appendectomy which revealed a condom fragment within the appendiceal lumen. A detailed retrospective history confirmed accidental ingestion of the condom 2 weeks prior to onset of symptoms.Although a rare finding, a variety of foreign bodies can be lodged in the appendix and may instigate an inflammatory process. There is a need to increase awareness of the potential dangers of ingested foreign bodies. Worldwide, appendicectomy for acute appendicitis is the most common emergency surgical procedure , 2. The A 26-year-old Sub-Saharan woman presented to our unit with a 1-week history of vague colicky lower abdominal pains occasionally radiating to her right iliac fossa (RIF), which progressively increased in intensity over the last 4 days and localized to her RIF. She also developed nausea and anorexia but reported no episodes of vomiting. She took self-prescribed doses of ibuprofen with no relief, prompting a consult at our health unit.3 with a neutrophilic predominance of 10,500cells/mm3. A working diagnosis of acute appendicitis was suggested based on an Alvarado score of 9/10. An abdominal ultrasound scan was requested which revealed a thickened appendiceal wall and fluid collection around her RIF. No FB was identified. She was prepared for emergency surgery. Via a gridiron incision, her appendix was found to be inflamed and an appendectomy was performed. No intraoperative complication occurred and her abdomen was closed in layers. Due to an unusual feel, we blindly dissected the resected appendix and found an incomplete piece of a rubbery material which was consistent with a condom (Fig. On examination, she had a temperature of 38.2 °C, respiratory rate of 14 breaths per minute, pulse of 78 beats per minute, and her blood pressure was 110/82 mmHg. There was tenderness and guarding on palpation of her RIF and a positive Rovsing’s sign. There was no palpable mass and her bowel sounds were normal. A vaginal examination revealed right adnexal tenderness. The rest of the examination was unremarkable. A white blood cell count showed a leucocytosis of 12,500cells/mmThe year 1735 saw the first appendicectomy, which was performed on an 11-year-old boy at St. George’s Hospital in London by Claudius Amyand during which a sewing pin was found to have perforated the appendix . FBs in Various objects acting as FBs have been reported in the literature to be the cause of acute appendicitis, including bird shot, bullets, fishing lines, screws, coins, stones, toothbrush bristle, pins, needles, teeth, bone fragments, dog hair, fruit seeds and pits, toothpicks, drill bits, tongue studs, crown post, keys and intrauterine contraceptive devices , 4, 7–11et al. [In our case, there was no history suggestive of FB ingestion during clinical evaluation. However, following retrieval of the condom fragment from the patient’s appendix and its presentation to the patient postoperatively, she could recall having performed oral sex on her boyfriend 2 weeks prior to the onset of symptoms. She reported that the condom had loosened during the act and she accidentally ingested it. She however did not find it necessary to inform us as she did not think it was the cause of her symptoms because she had passed out fragments of the ingested condom in her feces 5 days after ingestion. It is likely that during its migration in the GIT the condom was torn into fragments and a piece was trapped within the vermiform appendix and the rest expelled in fecal matter. Arya et al.  had repoApart from accidental ingestion of a condom during oral sex, it is important to note that the act is also associated with several other complications including a significant risk of transmission of human immunodeficiency virus, syphilis, herpes, chlamydia, hepatitis viruses, gonorrhea, and human papilloma virus infections .There is a need to increase awareness of the potential dangers of ingested FBs. Each time such incidents occur, it is advisable patients report promptly for proper evaluation and follow-up until the FB is properly traced as it may account for significant morbidity and mortality.Foreign bodies are rare causes of appendicitis. A wide variety of objects can be trapped in the appendix. Our case demonstrates a rare clinical scenario in which an unusual FB became lodged in the appendix and eventually initiated an inflammatory process which resulted in acute appendicitis.


This report presents a case of primary anorectal melanoma. A 63-year–old male presented with blood in stool. Rectal digital examination and proctoscopy revealed a mass in the anorectal junction. Transanal polypectomy was performed. Histopathology and immunohistochemistry with Melan A showed a malignant anorectal melanoma with positive resection margins. Abdomino-perineal rectum resection was performed after excluding distant metastasis. Four month later, the patient was readmitted with metastases to the liver and to the gastric mucosa. Best supportive care was initiated. This case report demonstrates the aggressive nature of this rare tumor and appeals for a less aggressive management while maintaining the quality of life. Primary anorectal malignant melanoma is an extremely rare malignancy that is thought to arise from melanocytes in the mucosa around the anorectal junction. AMM is associated with a relatively poor prognosis, and surgical resection is the only curative treatment option. This case demonstrates the aggressive nature of this rare entity.A 63-year-old man presented with a history of blood in the stool. Rectal examination revealed a mass in the lower rectum. A broad-based rectal polyp about 6 cm from the anal verge was seen on proctoscopy, and biopsies were taken Figure . HistopaFirst reported by Moore DW in 1857 ,3. The rAMM is mostly seen in the sixth decade, with a female predominance ,5, and rA mass is usually palpated on digital rectal examination. Proctoscopy usually reveals a hemorrhoid-like pigmented lesion near the anorectal junction, on which a biopsy must be performed. The histopathologic findings are similar to those of melanomas of other origins , as well as ruling out primary sites (skin and retina), are mandatory.Each patient with AMM should be discussed in an interdisciplinary board, and treatment should be individualized based on the tumor size, age, comorbidities, and absence or presence of metastases.Surgical resection is the mainstay of treatment ,7-9. APRThe prognosis is poor, with overall survival rate <20% in 5 years. Age >60 years and lesions >1 cm in diameter have been identified as prognostic factors ,4,8,9.In the case presented, AMM was diagnosed after transanal polypectomy with positive margins; thus APR was performed. Despite aggressive surgical management, disease progression was very rapid; with the development of hepatic and gastric metastases within 4 months. This case demonstrates the aggressive nature of AMM and questions the role of aggressive surgery  in the management of AMM. Therefore, until more evidence becomes available, the quality of life must be kept in focus when managing AMM, as is the case with WLE.A written informed consent was obtained from the patient for the publication of this case report with the accompanying images. A copy of the consent is available for review from the Editor-in-Chief of this journal.


Bone metastases can present in a wide variety of appearances across all imaging modalities. We present a unique appearance of a distal femoral metastasis in a patient who initially complained of knee pain. The radiographic and CT findings were initially suspicious for calcium pyrophosphate deposition (CPPD) arthropathy; however, an MRI demonstrated multiple lesions with a lamellated appearance confirmed on biopsy to be metastatic disease. This unusual lamellated appearance has not been previously described. We present this case to help distinguish this entity radiographically and better classify this finding as a manifestation of metastatic disease. We present a patient with knee pain whose CT and radiography were suspicious for calcium pyrophosphate deposition CPPD arthropathy. However, further MR imaging revealed multiple bony lesions with a lamellated appearance, which has not been previously described in the literature for metastatic foci. Metastasis can present with a wide variety of findings depending on the primary neoplasm. However, the current finding of a lamellated appearance on MRI secondary to metastasis appears to be novel. We would like to emphasize this rare appearance of bone metastases and to distinguish it as a manifestation of metastatic disease.A 71-year-old male with a past medical history of hypertension, hyperlipidemia, diabetes mellitus, lumbar degenerative disc disease, and multiple cerebral vascular accidents presented with left knee pain. He believed that the knee pain first started after he syncopized from a hypoglycemic episode. He was hospitalized for the hypoglycemic episode and complained of knee pain during that admission. Knee radiographs were obtained but were interpreted as normal. Approximately one month later, the patient presented to his primary care provider with continuing symptoms of significant left knee pain. Physical examination of his knee revealed a joint effusion and tenderness to palpation. Informed patient consent was obtained prior to treatment.Radiography demonstrated joint space narrowing, subchondral sclerosis, subchondral lucency, and chondrocalcinosis, which raised suspicion for CPPD arthropathy Figure .A CT scan revealed a lesion in the medial femoral condyle with a faint target appearance of alternating lucency and sclerosis. There was also soft tissue fullness adjacent to the medial femoral condyle inseparable from the medial gastrocnemius muscle with linear calcification Figure .MRI revealed two peripheral intramedullary focal mass-like lesions seen within the superior portion of the medial femoral condyle demonstrating a lamellated or “target” like appearance with extensive marrow and surrounding soft tissue edema Figure -3B.A technetium-99mm bone scan demonstrated numerous foci of increased radiotracer uptake, including the left medial femoral condyle, left humerus, right iliac crest, right acetabulum, sternum, vertebrae, and ribs Figure .The decision was then made to perform an image-guided bone biopsy. Pathology revealed metastatic, moderately to well-differentiated adenocarcinoma. The immunoprofile supported metastatic origin from an upper gastrointestinal or pancreatobiliary tract primary tumor. Thetumor marker, CA 19-9 was highly elevated to 289 U/mL . CEA was also elevated to 223.85 ng/ml . The histological findings demonstrated a concentric pattern, which shared similarity with the lamellated appearance on MRI  is the third most common site for metastasis after the liver and lung. Approximately 80% of the primary tumors are adenocarcinomas arising from the prostate, breast, lung, kidney, thyroid, gastrointestinal tract, and bladder -7. The mWe would like to highlight the unusual MRI appearance which demonstrated multiple concentric rings that can be described as a lamellated or target appearance. This was seen on both T2 fat-suppressed sequences and proton density sequences. These findings are not be confused with the Halo sign, which is a high-signal intensity ring surrounding a relatively low signal intensity on fluid-weighted (T2) images. It is thought to result from the destruction of trabeculae with a resultant fluid-filled gap, which is demonstrated as a retraction space on histology. A compliment to the Halo sign is the Bull’s Eye sign, which is a low signal intensity on T1 surrounding high-signal intensity. The Bull’s eye sign is thought to represent islands of developing bone marrow that contain yellow marrow centrally, which excludes malignancy .Our histological images demonstrated concentric layers of necrotic bone, lamellar bone, and woven bone surrounded by tumor. The cause of the lamellated appearance on MRI may have been caused by waves of bone lysis followed by reparative “creeping” substitution. These histological findings are often seen in bone metastases. It is unknown why this MRI appearance is not encountered more often; but when it is seen, it should raise suspicion for metastatic disease.Metastatic disease is the most common neoplasm found in bones, but it can mimic a variety of entities on imaging. We present a unique MRI appearance of a bone metastasis. When encountered on MRI, this lamellated appearance should raise suspicion for metastatic disease.


A temporary protective loop ileostomy is a routine procedure to protect the anastomosis in patients who undergo low anterior resection for rectal cancer. The aim of this case report is to present a rare complication caused by Meckel’s diverticulum.We describe a case of a 71-year-old white man with dysfunctional ileostomy after low anterior resection for rectal cancer due to adhesions and pressing effects of Meckel’s diverticulum near the ileostomy site, which led to volvulus of his small intestine and obstruction. As a result he underwent a supplementary operation to resolve this complication by Meckel’s diverticulum resection.During a low anterior resection for rectal cancer and a protective ileostomy procedure the presence of Meckel’s diverticulum should not be ignored. Our proposal is the primary resection of Meckel’s diverticulum as the best surgical choice; according to the limited international literature on such cases we report a possible alternative to a protective ileostomy by creating a conduit using Meckel’s diverticulum as a stoma. A temporary protective ileostomy is a routine procedure for patients who undergo a low anterior resection for rectal cancer with anastomosis less than 5cm from the anal verge. We present a rare case of dysfunctional temporary loop ileostomy due to adhesions and volvulus caused by Meckel’s diverticulum (MD) which was primarily ignored.A 71-year-old white man was diagnosed with rectal adenocarcinoma 5cm from the anal verge. Computed tomography (CT) and magnetic resonance imaging (MRI) highlighted circumferential thickened rectal mucosa. The tumor was considered to be resectable and he underwent a low anterior resection with an end-to-end anastomosis 2cm from the rectal verge in which circular staplers EEA™ 28mm were used. A protective ileostomy was created. A Meckel’s diverticulum was encountered near the site of the ileostomy, 7cm away from the afferent limb of the protective ileostomy, without any further action.During the early postoperative period his progress was satisfactory and the loop ileostomy was functional, but on postoperative day (POD) 4 the ileostomy appeared dysfunctional and he presented symptoms of incomplete ileus.During POD 5 a Foley catheter was inserted in the ileostomy and remained there for 2 days. The ileostomy started to be more functional, but after the catheter was removed, obstruction symptoms reappeared. An endoscopy in the ileostomy revealed mechanical obstruction of the ileostomy by adjacent bowel loop and possible volvulus of the ileostomy loop.In consequence, the patient underwent a supplementary operation, in which we found volvulus of loop ileostomy as a result of adhesions and pressing effects of MD, which was encountered close to the ileostomy. Adhesiolysis and a resection of the MD Fig.  were perColorectal cancer represents 9% of all cancers around the globe. It is the third most common cause of death in the USA . In 2008MD was first described in 1803 as a vestigial remnant of the omphalomesenteric duct. It is often encountered incidentally during appendectomy and it is associated with serious complications such as obstruction, intussusception, perforation, diverticulitis and gastrointestinal bleeding .In low anterior resection for rectal cancer, protective ileostomy is strongly suggested when anastomosis is performed less than 5cm from the anal verge .Our case report is about a rare case of dysfunctional ileostomy in which the MD caused volvulus of the small intestine near the ileostomy and this in combination with its adhesions led to bowel obstruction and, as a result, dysfunction of the protective ileostomy.et al. that used MD as an alternative conduit to a defunctioning ileostomy, which reported satisfactory results [Research of the limited international literature on cases similar to this case report revealed a report of the use of MD as a urinary conduit . We foun results .In conclusion, during a low anterior resection for rectal cancer and a protective ileostomy procedure, the presence of MD should never be ignored. Our proposal is the primary resection of MD as the best surgical choice for avoiding the complication we have described in our case report.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.


Intraoperatively we discovered a dusky gallbladder withgangrenous patches and gallbladder torsion with 270 degrees clockwiserotation along the longitudinal axis. Gallbladder torsion is a rare cause ofacute cholecystitis with less than 500 cases published in the literature. Gallbladder torsion should be included in the list of differential diagnoses inpatients suspected of having acute cholecystitis especially when there areinconsistencies between clinical features and imaging. It is worth notingthat 3-dimensional reconstructed CT may be useful in preoperative diagnosis ofgallbladder torsion. Gallbladder torsion is a rare presentation of gallbladder pathology. Features are generally consistent with acute cholecystitis and the diagnosis is usually made intraoperatively. Further research is needed to assess the benefits of imaging modalities preoperatively, specifically 3-dimensional CT reconstruction in gallbladder pathology. If gallbladder torsion is suspected or diagnosed, prompt surgical intervention is required.9/L and a C-reactive protein of 81 before a decision was made to proceed to emergency laparoscopic cholecystectomy the following day. Intra-operatively we discovered a dusky gallbladder with gangrenous patches and torsion of the gallbladder with 270 degrees clockwise rotation along the longitudinal axis (Figures An 80 year old female presented with clinical findings suggestive of acute cholecystitis. Her pain was unusual such that it was constant in nature, rated as 8/10 in her right upper quadrant and there was no clinical improvement over 24 hours. An abdominal ultrasound scan was performed, which reported small mobile gallstones, a distended thick walled gallbladder with surrounding pericholecystic fluid and a dilated common bile duct. There was no impacted stone seen in the cystic duct or Hartmann's pouch. Hence a request for CT was made and again it confirmed no calculous obstruction. The patient was managed with intravenous antibiotics initially but had worsening pain, fever to 38.6°C, white cell count of 14 × 10Pathophysiology of acute calculous cholecystitis is mostly due to impacted stone in the Hartmann's pouch or cystic duct with gallbladder outflow obstruction, biliary stasis and bacterial overgrowth. In contrast, acalculous cholecystitis is related to poor perfusion of the gallbladder, acute inflammation with necrosis, bile stasis, bacterial overgrowth and secondary infection. This case demonstrated that gallbladder torsion is another possible mechanism for acute gangrenous cholecystitis which is rarely suspected pre-operatively, yet may require immediate surgery and if not treated promptly could potentially lead to septic or fatal complications.The history and physical examination findings on presentation were suggestive of acute cholecystitis. At no stage could we differentiate between torsion and gallstone cholecystitis from the history and examination findings alone. CT abdomen is not commonly requested to make the diagnosis of acute cholecystitis except in selected cases with obstructive jaundice where choledocholithiasis, head of pancreas malignancy or cholangiocarcinoma are suspected. In this case we did not suspect torsion but the severity of the pain was atypical, not consistent with and could not be explained by the ultrasound findings, hence further imaging was requested.Torsion of the gallbladder, also known as “floating gallbladder” was first reported by Wendel in 1898 . It has To make the diagnosis of gallbladder torsion is difficult, with less than 10% of cases reported pre-operatively in the literature . KitagawThis case demonstrates the importance of understanding the patho-physiology of acute cholecystitis. Having a high index of suspicion for other causes of acute cholecystitis in the absence of simple gall stone obstruction, or when investigation results do not correlate with the clinical presentation, gallbladder torsion should still be considered even if it is an extremely rare entity.


Hodgkin’s lymphoma (HL) is a rare malignancy which often presents with lymphadenopathy and classic “B symptoms” of weight loss, fever, and night sweats. Additional masses or nodes could easily be presumed to be a result of the initial diagnosis. On the other hand, adult rhabdomyosarcoma is a rare malignancy presenting with a new mass in a patient with previous diagnosis of Hodgkin’s lymphoma. In both cases, a tissue diagnosis should be obtained to appropriately confirm the diagnosis.We present a case of a 64-year-old male who presents with right axillary lymphadenopathy, diagnosed as Hodgkin’s lymphoma. He subsequently developed left inguinal lymphadenopathy without the classic B symptoms of HL. Excisional biopsy revealed rhabdomyosarcoma. Stage III Hodgkin’s lymphoma (lymph node involvement on both sides of the diaphragm) is not commonly seen without typical B symptoms. Once the diagnosis of two primary malignancies is made, the dilemma becomes determining the treatment course. In the case of Hodgkin’s lymphoma and rhabdomyosarcoma, there is some overlap in the chemotherapeutic regimen and use of radiation.This case illustrates the importance of careful examination of Hodgkin’s lymphoma patients and consideration of additional tissue diagnoses in atypical presentations of new masses or lymphadenopathy on the opposite side of the diaphragm. Hodgkin’s lymphoma (HL) is an uncommon malignancy of the lymphatic system, with an incidence of 2.5 per 100,000 [Rhabdomyosarcoma (RMS) is a malignant tumor of striated muscle similar to other high-grade soft tissue sarcomas. It is the most common soft tissue sarcoma in children  but a rare diagnosis in adults, with only an approximated 400 new cases in the USA each year –5. OveraA 64-year-old Hispanic male presented to an outpatient surgical setting at an inner-city community hospital complaining of a newly discovered right axillary mass. The patient had no past medical or surgical history other than a left inguinal hernia repair performed 6 years prior for a reducible, asymptomatic, left inguinal hernia. On physical examination, the patient was noted to have a large, firm, irregular, fixed, non tender mass in the right axilla, consistent with a pathologic lymph node. He denied any constitutional or B symptoms. He also denied any weight loss, sick contacts, or recent travel. The patient was offered a short course of oral antibiotic therapy and was asked to return to the office in 2 weeks. When the patient returned, the mass had slightly increased in size. The decision was made to perform a right axillary lymph node excisional biopsy. Microscopic examination revealed scattered Reed-Sternberg (RS) or mummified cells mixed with reactive inflammatory cells within fibrous nodular background Fig. . ImmunohHe was immediately referred to a hematologist/oncologist, and the patient was prepared to initiate chemotherapy. Various tumor markers, hepatitis panel, and HIV testing were all negative. During this time, the patient developed right epitrochlear lymphadenopathy discovered by the oncologist. When seen again by the surgeon during a postoperative visit, the patient complained of left scrotal pain with an associated left inguinal mass, which he attributed to a recurrence of his previously repaired left inguinal hernia. Upon close examination, it was determined that the patient had left inguinal lymphadenopathy, with characteristics similar to the right axillary contents that were previously excised. The oncologist, once notified of this finding, requested a PET/CT scan. The scan revealed multiple enlarged right subclavian, right axillary, and left inguinal lymph nodes with moderate to significant FDG uptake. Based on the nature of Hodgkin’s lymphoma, the recommendation was made for an excisional biopsy of the left inguinal lymph node due to the low likelihood of the mass having the same HL origin (as would be more likely with non-Hodgkin’s lymphoma).A left inguinal lymph node excisional biopsy was performed concurrently with placement of a left subclavian Mediport. Grossly, the excised mass had a similar appearance to the right axillary lymph nodes removed 2 months earlier. It was an encapsulated, flesh colored structure. Unexpectedly, the microscopic examination revealed thin fibrous septae surrounded by small round blue cells with an alveolar growth pattern. Immunohistochemical and molecular studies confirmed the diagnosis of rhabdomyosarcoma, alveolar type Fig. . The patHodgkin’s lymphoma typically presents as painless lymphadenopathy. The so called B symptoms, which include weight loss, fever, and night sweats, may be present and implicate a poorer prognosis. Due to mediastinal involvement, the nodular sclerosing type may present with chest pain, cough, and shortness of breath. Often, a plethora of diagnostic modalities aid in the diagnosis of Hodgkin’s lymphoma, but ultimately, a tissue diagnosis is needed. This is usually obtained surgically with an excisional lymph node biopsy, as intact morphology is required for an accurate diagnosis. The one exception to this is in head and neck masses, where a fine needle aspiration (FNA) may be pursued in order to rule out squamous cell carcinoma, which is very common in this anatomic location. Once the diagnosis is made, a clinical stage is deciphered, in order to orchestrate the treatment plan.Hodgkin’s lymphoma can be described in four stages as follows: stage I , stage II (two or more lymph node areas on the same side of the diaphragm), stage III (lymph node areas on both sides of the diaphragm), and stage IV . Four treatments options are available depending on the nature of the disease: radiation therapy, induction chemotherapy, salvage chemotherapy, and hematopoietic stem cell transplantation. An example of an induction chemotherapeutic regimen is cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) . When inRhabdomyosarcoma typically presents as a mass or area of localized swelling, and less than half of these patients present with pain. However, symptoms can be specific to the anatomic location of the lesion . Diagnosis is made with a surgical biopsy . CT and MRI are helpful for planning surgical resection, as well as planning routes and doses for potential radiation therapy post operatively. Locoregional and metastatic disease can be investigated with a bone marrow biopsy, chest CT scan, technetium diphosphonate bone scan, and even a lumbar puncture . Mainstay therapy for rhabdomyosarcoma is surgical resection. High-risk histology and advanced stage may warrant chemotherapy with or without radiation. For example, non-metastatic alveolar rhabdomyosarcoma is usually treated with the vincristine, dactinomycin, and cyclophosphamide (VAC) protocol with the addition of radiation therapy .Specifically relevant to this case, our patient initially presented with two groups of enlarged lymph nodes on the same side of the diaphragm and did not present with B symptoms. He subsequently developed involvement of a new group of lymph nodes on the other side of the diaphragm  without development of B symptoms. This was a rare presentation which raised the suspicion of the oncologist, prompting a second excisional biopsy. Specific to this case of Hodgkin’s lymphoma with synchronous rhabdomyosarcoma , overlapping treatment is available, thus making treatment options less cumbersome. Margin negative (R0) resection is the goal for the rhabdomyosarcoma. Given its aggressive histology and the possibility of incomplete resection, chemoradiation will likely be pursued. The CHOP induction chemotherapeutic regimen for Hodgkin’s lymphoma has some degree of overlap with the VAC protocol for rhabdomyosarcoma (vincristine being used for both). The challenge for the chemotherapist is the dose frequencies and potential toxicities that these patients may experience.Patients with Hodgkin’s lymphoma that present with a second primary tumor usually do so as a complication of chemoradiation. Cancer screening is conducted regularly in HL patients receiving treatment. However, presenting with Hodgkin’s lymphoma and a second primary tumor simultaneously is exceedingly rare and poorly described in the literature. This can be a challenging diagnosis to make, and clinicians must be aware that such entities exist. When synchronous masses are present, or a new mass is discovered in a patient with Hodgkin’s lymphoma prior to treatment, one must be careful not to assume that they are the same entity. When in doubt, a tissue diagnosis should be pursued.Not applicable.Consent was obtained from the patient for publication of relevant medical information.Not applicable.


Background. Spontaneous rupture of an ovarian artery aneurysm is a rare but usually life-threatening event. It is most often associated with pregnancy or fibroids. Our case followed a normal vaginal delivery and then a delayed presentation with features similar to other less life-threatening postpartum conditions. The diagnosis could have been missed but for the meticulous and timely interventions which avoided catastrophic outcome. Case. This is a case of a multiparous woman with rupture of a left ovarian artery aneurysm, causing massive retroperitoneal hemorrhage and hematoma that required a combination of arterial embolization, percutaneous CT scan guided drainage, and surgical evacuation of the hematoma. Conclusion. Spontaneous rupture of ovarian artery should be considered as one of the differential diagnoses in the immediate postpartum period especially when the clinical symptoms do not correlate with the amount of blood loss. A high index of suspicion, prompt diagnosis, intervention, and a multidisciplinary approach in the management were the elements of a successful outcome in this case. Spontaneous rupture of an ovarian artery aneurysm is a rare and usually life-threatening event, most often associated with pregnancy or fibroids , 2. PregHere we report a postpartum patient with prompt diagnosis of rupture of an ovarian artery aneurysm that was complicated with retroperitoneal hemorrhage and hematoma. Ovarian and uterine artery embolization, minimally invasive drainage, and laparotomy and evacuation of retroperitoneal blood clots are shown to be effective in the management of this case.A 38-year-old P4145 with preterm delivery at 34 weeks for her fifth baby was readmitted four days postpartum with complaints of weakness, dizziness, and abdominal pain. On admission, she was anemic, hypotensive, and tachycardic. She also had a palpable abdominal mass in the left flank, which was expanding. The index pregnancy was complicated by hyperthyroidism that was well controlled with Methimazole, chronic left leg varicosity that worsened during pregnancy, multiparity with a cystocele, and depression that was diagnosed during the pregnancy. The patient had an uncomplicated preterm vaginal delivery, a normal immediate postpartum course, and she was discharged home two days postpartum.At readmission, her hemoglobin/hematocrit were 8.1/24.0 as compared to 11.1/32.7 at discharge two days priorly. A CT scan of the abdomen and pelvis with contrast demonstrates a large retroperitoneal hemorrhage due to a ruptured left ovarian artery aneurysm Figures . She subThe patient has resumed normal activities and she has remained asymptomatic since discharge.Ovarian aneurysmal rupture causing severe abdominal pain is a rare event with only a few documented cases in literature. When evaluating a patient with abdominal pain, it should be considered in the differential diagnosis. Previous cases of ovarian aneurysm have mostly been treated with embolization or surgery , 8. HowePrompt diagnosis and effective supportive therapy are required for the management of rupture ovarian artery aneurysm. As in previous cases, adequate embolization in addition to percutaneous drainage and surgical evacuation played important role in the treatment for this patient.


Myxoid liposarcoma is the most common soft-tissue sarcoma that metastasizes to the peritoneal cavity. Recently, an advanced intensity-modulated radiotherapy, known as helical tomotherapy, has been introduced to improve target coverage, while reducing normal tissue radiation. Here, we report a case of myxoid liposarcoma with multiple peritoneal seeding that was chemotherapy-refractory, but was successfully salvaged by helical tomotherapy-based intraperitoneal radiotherapy.A 71-year-old East-Asian male was initially diagnosed with myxoid liposarcoma in his left thigh by excision. Six years later, the patient underwent a left pneumonectomy for metastatic myxoid liposarcoma in the left lung. Since then, the patient was treated with two segmental resections, and multiple lines of chemotherapy, for repeated recurrences in the peritoneal cavity. The patient underwent intraperitoneal radiotherapy followed by tumor boost radiotherapy, as salvage treatment for chemotherapy-resistant metastatic peritoneal myxoid liposarcoma. The prescribed dose was 24 Gy delivered in 15 fractions of 1.6 Gy over 3 weeks, followed by a 16 Gy boost dose administered in eight fractions of 2 Gy, to multifocal peritoneal lesions. A positron emission tomography scan obtained 8 weeks after completion of radiotherapy, showed a complete metabolic response of metastatic peritoneal lesions. Radiotherapy was well tolerated, without any side effects. In a computed tomography scan obtained 20 weeks after completion of radiotherapy, most of the peritoneal metastatic lesions had disappeared, except for two small residual nodules.This case suggests that low fraction-sized intraperitoneal radiotherapy (1.6 Gy administered once daily), followed by a focal boost using helical tomotherapy, is a feasible treatment without side effects. It produced an excellent tumor response, and durable intraperitoneal control for metastatic peritoneal myxoid liposarcoma. Liposarcomas are malignant tumors of mesenchymal origin that arise from adipose tissue, and are the second most frequent type (comprising 15–20%) of all soft tissue sarcomas (STS), with incidence peaks in the fourth to sixth decades of life . The WorThe excellent tumor control from whole abdominal radiotherapy (WART) has been reported in ovarian cancer patients with peritoneal seeding or carcinomatosis -11. HoweIn September 2013, a 71-year-old East-Asian male visited our institution with a 5-month history of abdominal pain, nausea, and constipation. Physical examination revealed a distended abdomen due to multiple, non-tender masses, with no signs of peritonitis or abdominal wall hernias. The Eastern Cooperative Oncology Group (ECOG) performance status of the patient was “1”. His medical history included a huge, non-tender, deep, rubbery MLS , with a maximum size of 20 cm at the medial side of the left thigh. The tumor had been treated by excision . For second treatment planning, the GTVboost was equal to the CTVboost. The planning target volume (PTVboost) was made by three-dimensional expansion of the CTVboost with 0.5 cm axial, and 1 cm superior/inferior margins. A RT boost dose distribution in the coronal plane is illustrated in Figure However, follow-up abdominal CT in September 2013, showed multifocal peritoneal nodules with fatty components within the mesentery of the jejunum, ileum, and ascending colon Figures  a. The pet al. . The folClinical symptoms and treatment-related side effects were monitored weekly during treatment, at the end of treatment, and monthly thereafter. RT was well tolerated, without any side effects, such as bone marrow suppression, nausea, diarrhea, or abdominal cramps. The patient did not experience tumor lysis syndrome. Surveillance by positron emission tomography (PET) scan in December 2013 showed a complete metabolic response of the peritoneal metastatic lesions Figure  b. FurthUsing the case presented here, we report on the effective salvage of recurrent chemotherapy-resistant peritoneal lesions after segmental resection for a metastatic peritoneal MLS, by IPRT using HT. Although some studies have suggested that MLS tends to be relatively more radiosensitive than other types of STS, with high rates of regression and even complete clinical response ,13, RT, Limited data are available on the treatment for metastatic peritoneal relapse from MLS. Surgery may be the treatment of choice for those patients with complications, such as incomplete intestinal obstruction, abdominal pain, abdominal distension, gastrointestinal bleeding, urinary obstruction, and anorexia ,17. HoweConventional WART has been effective in intraperitoneal tumor control to some degree. However, it would not have sufficiently covered the whole intraperitoneal cavity, as we wished to spare the liver and kidneys using the basic technique of anterior to posterior (AP) and posterior to anterior (PA) direction beam delivery. Modern advances in RT techniques, such as IMRT, have allowed us to overcome the shortcomings of conventional WART ,24. A reNo consensus currently exists regarding the optimum IPRT dose and fractionation schedule for metastatic peritoneal lesions from MLS. Future research should focus on obtaining the lowest radiation dose that induces symptomatic relief without significant toxicity. Perhaps a more modest dose might obtain the same palliation as reported in the present study. In our case, the low fraction-sized IPRT schedule (1.6 Gy given once daily) appears to be associated with the lack of any side effects experienced by the patient, such as bone marrow suppression, nausea, diarrhea, or abdominal cramps. Although there is an understanding of the mechanism of cell death by radiation at conventional fraction size (1.8–3.0 Gy per fraction), the effect and safety of IPRT at a lower fraction size (<1.8 Gy) on patients with a peritoneal metastatic MLS is still unknown, and should be further investigated with clinical observation and preclinical studies.Generally, patients with MLS have a good prognosis, and they have the potential for gaining maximum benefit from techniques that minimize the side effects of RT . MLS priThe present case report shows that low fraction-sized IPRT (1.6 Gy given once daily), followed by tumor boost RT using HT, provided excellent tumor control and symptom relief for a patient with bulky multifocal abdominal tumors, identified as a metastatic peritoneal MLS. Our findings, taken together with reports from the literature, emphasize that radiosensitivity in other types of cancer could translate into excellent tumor control when IPRT using HT is appropriately applied.This study was performed in accordance with the Helsinki Declaration and the written consent by the patient.Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Primary hyperparathyroidism is an endocrinopathic condition characterized by hypersecretion of parathyroid hormone. Excess parathyroid hormone results in an altered state of osseous metabolism involving bone resorption and tissue change known as osteitis fibrosa cystica, which is the end stage of primary hyperparathyroidism. Osteitis fibrosa cystica is associated with the development of brown tumors, which are rare because hyperparathyroidism is now usually diagnosed and treated before symptoms develop. Brown tumors are rarely the first symptom of hyperparathyroidism and can occasionally be mistaken for malignancy.We herein report three cases of primary hyperparathyroidism with an unusual presentation of brown tumors. All three patients were Asian. In the first case, a 42-year-old man was admitted with a mass mimicking a malignant bone neoplasm in the right mandible as the first manifestation of primary hyperparathyroidism. The second case involved a 25-year-old man admitted with a fracture of his right femur. The third case involved a 43-year-old man with multiple brown tumors in both lower limbs. All three patients underwent successful parathyroidectomy for parathyroid adenomas; one case was complicated by a papillary thyroid carcinoma.Complete evaluation of the medical history and biochemical and radiographic findings is necessary to achieve a correct diagnosis and avoid unnecessary bone resections in patients with primary hyperparathyroidism. The parathyroid glands secrete parathyroid hormone (PTH), which is involved in regulating the metabolism of calcium and phosphorus. PTH plays an important role in tooth development and bone mineralization and increases bone resorption. Excessive secretion of PTH is termed hyperparathyroidism (HPT), which is an endocrine condition categorized as primary, secondary, or tertiary. Primary HPT (PHPT) is an endocrinopathic condition characterized by hypersecretion of PTH, which may be caused by an adenoma (solitary or multiple), idiopathic hyperplasia, or a parathyroid carcinoma. Secondary HPT is caused by hypocalcaemia or vitamin D deficiency acting as a stimulus of excessive PTH production. Chronic renal failure is the main cause of secondary HPT. Tertiary HPT is caused by the development of autonomous parathyroid hyperplasia after long-standing secondary HPT, most often in patients with renal failure . Most caSkeletal involvement in classic PHPT is characterized by a strikingly high rate of osteoclastic bone resorption and is accompanied by a cellular repair process that results in the accumulation of fibrous stroma and connective tissue cells along with multinucleated giant cells. Thus, brown tumors have been described as resulting from an imbalance between osteoclastic and osteoblastic activity, resultant resorption with fibrous replacement of the bone, and eventual osteitis fibrosa cystica (OFC).Brown tumors are reactive lesions and do not represent true neoplasms. They may be difficult to diagnose because they present clinically and radiologically as other diseases such as giant cell tumors, multiple bone metastases, or multiple myeloma , 6. MoreBrown tumors involving the jaw bones as the first manifestation of PHPT and pathological fractures that lead to a diagnosis of PHPT are not commonly described –11. We hm99Tc bone scintigraphy revealed multiple hypermetabolic foci in the right acromion, left maxilla, and bilateral mandibular bone. Urinary tract ultrasonography revealed multiple nephroliths on the left side and mild hydronephrosis caused by lower ureteral calculi on the right side. Biopsy of the right mandibular mass revealed spindle-shaped mesenchymal cells with a large number of multinucleated giant cells throughout the lesion. The benign lesion was identified as a giant cell granuloma. The mandibular lesion was removed before performing magnetic resonance imaging (MRI) of the thyroid gland and neck.A 42-year-old man with no known disease history noticed a mass on the right side of his face, which gradually generalized. One month later, he presented to our hospital for an examination. He had no other associated complaints or any significant family history. Intraoral examination revealed a reddish, nontender, hard, ill-defined sessile swelling in the right side of the mandible. Panoramic radiography revealed a well-defined, osteolytic lesion measuring 40 × 30 mm in the right mandible Fig. , b. CompLaboratory data are shown in Table These findings suggested that PHPT initially manifested as a brown tumor of the jaw. Contrast MRI of the neck confirmed the existence of a 2.5-cm nodular mass on the lower right parathyroid Fig. . Mini-inThe patient recovered well postoperatively, and his serum calcium 2.13 mmol/L) and PTH (66.40 pg/ml) levels normalized within 1 week. Detailed biochemical data observed before and after parathyroidectomy are shown in Table 3 mmol/L A 25-year-old man developed swelling and pain of the right shoulder after tripping on a step and falling onto his right side. Two weeks later, he was hospitalized with swelling and deformity of the right thigh when crossing the legs. Radiography confirmed a comminuted fracture of the femur secondary to a lytic bone lesion Fig. . Chest rParathyroidectomy was performed, and the lesion was histologically confirmed to be a benign parathyroid adenoma. The patient recovered well postoperatively, and his serum calcium (2.08 mmol/L) and PTH (65.40 pg/ml) levels normalized within 2 weeks. The patient’s biochemical data before and after parathyroidectomy are shown in Table A 43-year-old man presented with a 1-month history of left foot swelling with no other associated complaints or significant medical history. The swelling was mildly tender in the left fifth metatarsal bone with no reddish color or throbbing sensation. Radiography revealed multiple mild but expansive lytic bone lesions in the bilateral distal tibia and left fifth metatarsal bone Fig. –c. BiopsPHPT was suspected. Enhancement CT of the neck revealed a round mass measuring 2.7 × 1.4 cm behind and below the left thyroid lobe and a round lesion measuring 1.5 × 1.0 cm located in the left thyroid lobe Fig. . ParathyThe incidence of PHPT is difficult to assess and may vary widely from 0.4 to 21.6 cases per 100,000 person-years , 13. AddAlthough many systems are affected in patients with PHPT, the most pronounced alternations are observed in the bone. Classic skeletal lesions are bone resorption, OFC, and brown tumors. With the recent development of imaging and laboratory screening methods, however, hypercalcemia due to primary or secondary HPT can often be detected early, with a decrease in frequency of OFC and brown tumors. A brown tumor is the localized form of OFC . It is mThe term “brown tumor” is derived from the characteristic appearance of a brown-colored material within the cystic lesion, which is caused by high vascularity, hemorrhage, and hemosiderin deposits . Brown tOn radiography and CT, brown tumors are seen as lytic lesions or sclerotic lesions with regular borders and no cortical disruption, periosteal reaction, or inflammatory signs . MRI shoSome large bone defects increase the risk of spontaneous fracture, a rare complication of PHPT. The reported crude fracture rate in patients with PHPT has been documented as 15 per 1000 person-years (compared with 8 per 1000 in controls) . HoweverBrown tumors exhibit no pathognomonic histological changes and are characterized by numerous giant cells, diffused or arranged in clusters, in a background of mononuclear oval-to-spindle stromal cells . These gThe treatment of choice for PHPT is parathyroidectomy, and the best treatment of brown tumors is cure of the underlying PHPT , 17, 18.In summary, PHPT is now usually detected in the early and asymptomatic phase because of recent improvements in analytical techniques. A brown tumor is a benign clinical entity appearing as an extremely rare manifestation of HPT and an uncommon cause of pathological fractures, which can be difficult to distinguish from other tumors, tumor-like lesions, and metastatic disease. When a patient, especially a middle-aged patient, presents with unexplained lytic bone lesions or pathological fractures, surgeons, endocrinologists, and especially radiologists should be reminded of this unusual presentation of PHPT to avoid unnecessary surgical removal. Our cases highlight the importance of a thorough diagnostic work-up for PHPT. A definitive diagnosis is only possible upon completion of clinical, radiological, and biochemical analysis.Written informed consent was obtained from the patients for publication of these case reports and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. This study was approved by the ethics committee of the First Affiliated Hospital of Shantou University Medical College.


We aimed to characterize specific MRI findings seen in immune competent patients with intracranial primary CNS lymphoma (PCNSL) and to determine their value in the management of such patients. Pre-treatment MRI examinations of 21 immunocompetent patients with biopsy-proven PCNSL were retrospectively evaluated. T1 and T2 signal characteristics as well as contrast enhancement features are described in all patients. Diffusion, perfusion and proton-MR-spectroscopy features are described in a subset of these patients. In the proper clinical and radiologic setting, suggesting the diagnosis of PCNSL can help institute proper treatment in a timely fashion and avoid unnecessary attempts at surgical resection and the associated morbidity. Involvement of the central nervous system by lymphoma can occur in the presence of systemic lymphoma involvement (secondary) or in isolation as a primary CNS neoplasm.Primary central nervous system lymphoma (PCNSL), the focus of this article, originates in the brain, leptomeninges, spinal cord, or eyes and typically remains confined to the CNS; with only rare spread outside the nervous system. It was initially described by Bailey as perivascular sarcoma  and is aPCNSL in the vast majority of patients is a subtype of non-Hodgkin’s lymphoma (NHL), and is usually large cell or immunoblastic type, and is by definition restricted to the CNS (stage IE) ,3.PCNSL is encountered in the immunocompetent and in the immunocompromised patients, but the cause and behavior of PCNSL differ based on the affected population. Immunocompromised patients are at particular risk for developing PCNSL which is typically secondary to HIV, organ transplantation, or congenital immunodeficiency syndromes. In this setting, PCNSL arises from Epstein-Barr virus (EBV) infection of B-lymphocytes. In contrast, there is no well-established cause for PCNSL in immunocompetent patient. No correlation has been found between the disease and EBV or the human herpes viruses in this immune competent population . AdditioThere are no pathognomonic imaging features for PCNSL. However, the clinical presentation and imaging features can be quite specific Table . AlthougPCNSL typically involves the supratentorial brain and the lesions are most typically in contact with ventricular or meningeal surfaces. The lesions can also be deeply seated in the parenchyma. The most commonly involved sites include periventricular white-matter, deep gray nuclei, corpus callosum and superficially adjacent to CSF spaces . AtypicaHemorrhage or internal calcifications within the tumor are quite rare. This fact contributes to the relatively homogeneous appearance of PCNSL on imaging. When present, hemorrhage and calcification can alter the signal intensity, depending on the age of the hemorrhage and the composition of the calcification .PCNSL usually appears hyperdense on non-contrast enhanced CT scan which reflects hypercellularity of the tumor and the high nuclear/cytoplasmic ratio. This gives on MR imaging the classical iso-to-hypointense signal (relative to grey-matter) on both T1- and T2-weighted images -6. FolloIn this article, we review the specific MR imaging features of PCNSL in immunocompetent individuals which can help radiologists reach the correct diagnosis and start treatment without delay or unnecessary surgical intervention.Most of our patients complained from non specific symptoms like headache, seizure and change in mental status. On the other hand, few of them complained from focal neurological deficient typical of a mass effect. Cranial nerve symptoms and vertigo were also noticed in few patients. The systemic symptoms like fever, night sweet and weight loss were very rare.We reviewed the clinical data and imaging features at presentation of 14 male and 7 female immune competent patients with ages ranging from 28 years to 71 years who were diagnosed histopathologically with intracranial PCNSL over a period of 8 years (from January 2004 to August 2012) in King Hussein Cancer Center, Amman, Jordan.Two experienced radiologists independently reviewed and analyzed the images retrospectively. All scans were reviewed noting lesion location in the brain, size, margin, and the signal characteristics. The presence of calcifications, hemorrhage, perilesional edema, meningeal enhancement and the characteristics of enhancement were also examined. Disagreements were resolved with consensus.All patients had FLAIR, T2- and T1-weighted images. Post-contrast T1-weighted images were also obtained in all patients. Diffusion-weighted MRI (DW-MRI) was available in 18 patients, while proton-MR-spectroscopy (1H-MRS) was available in 6 patients. Perfusion MR imaging was performed also in 6 patients. Most of the studies were obtained on a 1.5 Tesla Siemens Magnetom Avanto machine. On this machine, the acquired T1 and T2 images were fast spin-echo sequences with TR 500 ms and TE 7.8 ms for T1 and TR 3630 ms and TE 93 ms for T2. For FLAIR, TR 8700 ms and TE 84 ms values were used. Slice thickness was 6 mm for all sequences. T1 sequences were obtained along the three orthogonal planes pre- and post-contrast. The T2 and FLAIR sequences were obtained axially. The DWI was obtained using B-values of 0, 500 and 1000 s/mm2. Two of the later cases were imaged on a 3 Tesla Philips Ingenia machine. The pre- and post-contrast T1 sequences were isotropic, ultrafast spoiled gradient echo sequences (TR 8.3 ms and TE 3.8 ms). For T2, a 5 mm axial fast spin echo sequence with TR 4000 ms and TE 110 ms was obtained. For FLAIR, the TR and TE values were 11000 ms and 125 ms, respectively. MR spectroscopy was performed with a long echo time (135 ms) as a multivoxel 2D exam encompassing the lesion and normal-appearing white-matter.The contrast used in all these MR exams was OptiMark™  which was administered intravenously at a dose of 0.2 mL per kg body weight.T1, T2 and FLAIR sequences were examined qualitatively. Both the DWI images and the ADC maps were examined qualitatively and quantitatively. The mean ADC values in the lesions and in the contralateral normal-appearing white-matter were measured and a ratio was calculated. The MR perfusion maps were also studied in the same way, qualitatively and quantitatively. The cerebral blood volume (CBV) values were determined in the lesions and in the contralateral normal-appearing white-matter and the ratio (rCBV) was calculated. For proton MR Spectroscopy, the ratios of the major metabolites  were determined. Also, the presence of lipid peaks was determined.The exams were reviewed on Brilliance Workspace Portal (by Philips). The diffusion and perfusion values were obtained on Syngo Via workstation (by Siemens).The 21 patients exhibited 36 lesions. Fourteen of twenty one patients (66.7%) were males. Thirteen patients have a solitary lesion (62%) and the other eight patients have multiple lesions .Most of the lesions (30 lesions) were located supratentorially (83.3%) and the most common site supratentorially was the hemispheric white-matter (17 lesions (56.7%)). Representative T2WI, precontrast T1WI and postcontrast T1WI, ADC and DWI maps are shown in Figure On T1 sequences, 24 lesions (66.7%) were isointense, 10 lesions (27.8%) were hypointense and only 2 lesions (5.5%) were hyperintense relative to gray-matter Figure . On the Perilesional edema or signal abnormality was present in 31 lesions ranging from mild in two lesions, moderate in thirteen lesions and marked in 16 lesions. The degree of edema was judged and reported as follows: a mean diameter of peritumoral edema of less than 10 mm was graded as mild, a mean diameter of 11–20 mm of peritumoral edema was graded as moderate, while marked was used when the mean diameter of peritumoral edema was more than 20 mm. The degree of mass-effect was judged subjectively depending on the degree of displacement and/or compression of the adjacent structures.The degree of enhancement was variable. Most of the lesions (30 lesions out of 36) were intensely enhancing (83.3%), three lesions showed minimal enhancement and the remaining three lesions showed moderate enhancement. All lesions were diffusely and homogeneously contrast-enhancing (no necrosis). None of the lesions showed no enhancement. However, some of the lesions showed a slit-like center Figure .Only two lesions out of 36 showed hemorrhagic changes (6%) and two out of 21 patients showed meningeal enhancement (10%). None of the lesions showed calcification.lym/ADCwm for all lesions measured (including the non-diffusion-restricted ones) was 1.4. The ADC ratio range was between 0.91 and 3.00.Diffusion-weighted MRI b = 1000 s/mm2) was available in 18 patients. By visual inspection, areas of restricted diffusion were present in 72.4% (n = 21/29) of the lesions in the form of increased signal on DWI and iso to low signal on ADC maps relative to cerebral white-matter  and marked reduction in N-acetylaspartate (NAA) peaks Figure . The avePerfusion-weighted MR imaging was performed in 6 patients . PWI shows marked reduction in rCBV  in 5 lesions .We observed contrast enhancement in all our lesions. It was intense in 30 of the 36 lesions. The contrast enhancement was diffuse and homogeneous in all cases (no ring-like enhancement or necrosis). This is compatible with what has been reported . In the We also noticed that when the PCNSL lesion occurs in subcortical location, it respects the cortex and its morphology (the lesion wraps around the cortex giving the appearance of a crescent) Figure . We obseWe didn’t encounter any cysts  in our patients. A recent article about brain tumors manifesting as cyst with a mural nodule did cite only one case of PCNSL in which the cysts was related to an adjacent synchronous epidermoid cyst ,12.Leptomeningeal enhancement was present in 2 of our 21 patients. The rate of such involvement in our population is slightly higher than what has been reported (1%) .Edema is a common feature of PCNSL. Some published data reports the edema in 77% of the lesions, though usually less prominent than that in malignant gliomas or metastases . We obseDWI measures the diffusion of water molecules in biologic tissues. It is a surrogate marker of tumor cellularity. Highly cellular tumors, like CNS lymphoma, would demonstrate a relative decrease in apparent diffusion coefficient (ADC) values .lym/ADCwm) for all lesions measured (including the non-diffusion-restricted ones) was 1.4. The ADC ratio range was between 0.91 and 3.00.We observed subjective diffusion restriction (hyperintensity on DWI and iso- to hypointensity on ADC maps) in 21 of 29 lesions. Mean normalized ADC values  . It alsoWhile contrast enhancement reflects leakiness of the vessels (disruption of the blood–brain barrier), perfusion assesses tumor vascularity. The documented importance of revascularization through angiogenesis for tumor growth has led to a growing interest in such imaging techniques. Perfusion MR and CT imaging visualize nutritive delivery of arterial blood to the capillary bed in the biologic tissue . Postprocessing of the acquired data allows for calculation of physiologic parameters, such as cerebral blood volume, cerebral blood flow, mean transit time, and time to peak .In our patient cohort, the average rCBV was 0.84 with a range from 0.23 to 1.9. It was calculated as a ratio of the signal in the lesion relative to the contralateral, normal–appearing white-matter. This is consistent with what has been described in the literature. The low rCBV in lymphoma might be attributed to the characteristic angiocentric growth pattern. This perivascular infiltration also leads to massive leakage of contrast media in the interstitial space which accounts for a characteristic intensity time curve. This low CBV coupled with the characteristic intensity time curve may play an important role in differentiating PCNSL from the other frequently encountered differential diagnosis including glioblastoma multiforme and metastases both of which show significantly higher rCBV values [MRS allows for noninvasive acquisition of biochemical information from biologic tissues. Within a defined volume of interest, signals are registered from chemical nuclei; the most commonly used nuclei are protons (hydrogen).In our PCNSL patients, MRS (at TE 135 ms) consistently showed increased choline and decreased NAA along with the presence of lipid peak. This is consistent with what has been described in literature -19 and wWe also noticed a transition zone of abnormal spectra outside the enhancing area reflecting the infiltrative pattern of lymphoma which extends beyond the contrast-enhancing region. This might aid in differentiating PCNSL from metastasis but not from high grade glioma.PCNSL is a highly malignant tumor which requires different approach in diagnosis and management compared to other high-grade malignant brain tumors. Suggesting the correct diagnosis prior to steroid administration or unnecessary surgical procedures is frequently achievable based on characteristic imaging features. PCNSL typically present as a homogenous mass with T1 and T2 signal intensity that reflects high-cellularity characteristics. The mass typically shows diffuse, homogeneous contrast-enhancement. The lesions typically have less mass-effect than a comparable size metastasis or high-grade glioma. In a subcortical location, the mass may respect the overlying cortex resulting in a crescent-shaped morphology. Necrosis, hemorrhage and calcifications are atypical features and are rare in these tumors.New imaging techniques  play important role in the diagnosis of PCNSL and differentiating it from other primary and secondary brain tumors (high-grade gliomas and metastases). This is especially important when the characteristic imaging features on traditional imaging are absent.Comparing what we have found in our population and what has been described in the literature for PCNSL and other brain tumors, we find that PWI can be very helpful in differentiating PCNSL from other high-grade brain tumors which is consistent with the results from other studies. In addition, rCBV ratio is significantly lower in PCNSL compared to what has been described for high-grade glial brain tumors and metastasis. ADC on DWI is also lower in PCNSL compared to the high-grade glial tumors and metastasis, but may not be as accurate as the rCBV in differentiating PCNSL from high-grade glioma (glioblastoma multiforme and anaplastic astrocytoma) and metastases. The lipid peak on MR spectroscopy seems to be a consistent finding as well.Written informed consent was obtained from each patient for the publication of this report and any accompanying images.The authors declare that they have no competing interests.AM and HA-A collect patients with PCNSL, review the MRI findings and perform the radiological and statistical analysis.MQ drafts the manuscript and perform the radiological and statistical analysis for the DWI part. HA-R follows patients clinically and perform some statistical analysis. All authors read and approved the final manuscript.