Schwannomas are slow-growing mesenchymal neoplasms that arise from Schwann cells with low malignant potential. These uncommon neoplasms are nerve sheath tumors that arise at almost any anatomical site. The majority of schwannomas are benign, and few are malignant. The current study presents the rare case of an anal schwannoma that was successfully treated by surgery; there are few such cases previously reported in the literature. The patient was admitted to hospital following the identification of a mass incidentally. The tumor was so large that it compressed the tissue around it, although no symptoms were caused. The pre-operative clinical diagnosis was inconclusive in this case, and a final diagnosis was established based on radiographic and histopathological examination. The current study aimed to provide a possible differential diagnosis for such anally-located masses. Schwannomas are derived from Schwann cells . More thA 66-year-old female was admitted to the Third People’s Hospital of Dalian  due to a right anal mass that had been present for several weeks. The patient experienced no pain, difficulty in defecation or other symptoms. A physical examination revealed no unusual findings, with the exception of 10×7-cm, tenacious, mobile and smooth mass that could be palpated when in the knee-chest decubitus position. Computed tomography (CT) scans showed that the tumor, which had uniform density and a clear tunica, was located under a fat layer and inside of the gluteus maximus . The resSchwannomas are nerve sheath tumors that arise from almost any anatomical site, but particularly in the peripheral, cranial or visceral nerves . SchwannThe majority of schwannomas are benign, and few are malignant. Malignant schwannomas are usually large, infiltrating and characterized histologically by perineural and intraneural spread; in the present study, mainly benign schwannomas are discussed. Schwannomas have the characteristics of a slow growth rate, no invasion and a low rate of transformation or recurrence following resection .The site of the schwannoma may vary, however, the tumors mostly occur in the neck, head and tendon sheaths of the limbs. There has also been a study reporting schwannoma of the abdomen .Unusual locations, such as the anus, are rarely reported . In the CT and magnetic resonance imaging (MRI) were more beneficial for the identification of characteristics of the mass, although obviously distinct in clinical features and histological appearance; the pre-operative diagnosis of a schwannoma is not easy owing to a lack of distinguishing features. It is possible to distinguish between benign and malignant schwannomas by imaging techniques, such as CT, ultrasound or MRI. Additionally, it is possible to distinguish between schwannomas and other tumors, for example, fibrosarcomas or liposarcomas , via imaIn the present case, CT was used to find the exact location of the mass beside the rectum, which was compressed as a result, although there were no symptoms of this. A clear tunica could also be observed, therefore the surgical risk and procedural design could be determined.During the surgery, incisions were made in the skin and subcutaneous tissue. The mass was confirmed to be in the subcutaneous tissue, as previously shown by CT. Due to the pre-operative examination and assessment, the mass could be completely resected, and the duration of the surgery was not excessive.Histologically, schwannomas consist of compact cellular lesions. Antoni A (interlacing and cellular fascicles) and Antoni B (less cellular and myxoid) areas, combined with positive uniform S-100 staining characterize the histological appearance of typical schwannomas . TherefoIn conclusion, surgical excision, which can be diagnostic and curative, is the optimal treatment for schwannomas, whether they are benign or malignant. In the present case, a large mass developed, however, there were no resultant symptoms. This was unexpected, as changes, such as altered defecation habits, were anticipated with the development of the tumor. This was just one of the reasons that the nature of the tumor could not be precisely determined prior to the surgery.


Ganglioneuroblastoma (GBN) is a malignant neoplasm of the autonomic nervous system. Adult onset of ganglioneuroblastoma is extremely rare. Only 16 cases have been reported in English literature, to date. Surgery represents the first-line therapy for the treatment of ganglioneuroblastoma. Radiation therapy is indicated in patients with localized unresectable disease. Chemotherapy is reserved for metastatic disease.We present the case of a 63-year-old man affected by ganglioneuroblastoma of the adrenal gland. The diagnosis was made incidentally. The tumor, measuring 5 × 3 cm, was successfully surgically removed. Ganglioneuroblastoma (GBN) is a malignant neoplasm of the autonomic nervous system; it originates from primitive neuroectodermal cells of the neural crest that migrate during embryonic life giving rise to the sympathetic ganglia and the adrenal medulla. Ganglioneuroblastoma represents a subgroup of neuroblastoma tumors with a prominent, mature ganglion cell differentiation, usually located in the adrenal gland (the most frequent site) but also in the posterior mediastinum, the retroperitoneum, and the brain . Adult oIn November 2013, a 63-year-old Caucasian man underwent a CT scan for recurrent renal stones. A mass of the left adrenal gland measuring 5 × 3 cm was incidentally found. The mass was irregular and hypodense and had inhomogeneous contrast uptake, especially in the arterial phase. Magnetic resonance imaging (MRI) confirmed the mass: the signal was highly inhomogeneous and the central area was partially fluid see Fig. . The radThe patient was in good clinical condition and asymptomatic. The complete physical examination was negative. Blood pressure and pulse were normal. Results of the complete blood count, plasma levels of electrolytes, tests of coagulation, kidney and liver function, and urinalysis were normal. For the history of nephrolithiasis, phosphocalcic profile was analyzed and primary hyperparathyroidism as a cause of kidney stones was excluded. Testing for adrenal gland function were all normal: in particular, urinary metanephrines and urinary free cortisol were normal, DHEAS = 1.7 mcg , 17-OH-Pg = 1.1 ng/ml , aldosterone = 291 pg/ml , renin = 13.2 MCU/ml , aldosterone-renin ratio = 2.2 . All the tests were made in order to rule out the possibility of a functioning lesion. In particular, blood tests excluded hypercortisolism, so the patient could undergo surgery without risks.A radical adrenalectomy with complete excision of the lesion was performed. The surgery was radical and without postoperative complication.The surgical sample sent for pathological examination was composed of the adrenal gland and of a nodular mass of 4.5 cm in its greater diameter, with a hemorrhagic and partially necrotic cut surface. The histopathological report described an encapsulated proliferation, which consisted of atypical ganglion cells, in many of which neuro-melaninic pigment was evident, interspersed in a fibrillary matrix Fig. . In addiAs guidelines suggest, the patient underwent total body CT scan and mIBG scintigraphy after the surgery and both were negative. The patients will continue follow-up schedule every 3 months.. [Neuroblastic tumors arise from sympathetic nervous system and are divided into three major categories according to Shimada et al. : neuroblThe International Neuroblastoma Pathology Classification (INPC), established in 1999 and revised in 2003, re-defined the histological features and proposed 4 tumor categories: NB (neuroblastoma), GNB-intermixed, GN (ganglioneuroma), GNB-nodular . The four categories are divided in two distinct prognostic groups: Favorable Histology (FH) and Unfavorable Histology (UH) [The tumor type of the current case was GBN-nodular , unfavorable histology.The International Classification INSS (revised in 1993) is currently used for the staging of the disease  and deletion of the short arm of chromosome 1 that are related to poor prognosis , 8.Ganglioneuroblastoma is a pediatric tumor and adult onset is extremely rare. In the literature, less than 50 cases of adult patients are reported ; the mosTreatment guidelines were derived from pediatric experience. The therapeutic strategy includes surgery, radiotherapy, and chemotherapy. Patients with N-MYC amplification or deletion of the short arm of chromosome 1 have aggressive disease, regardless of age and stage of disease. If the tumor is considered radically resectable, surgery represents the treatment of choice. Because of the high possibility of infiltration of regional lymph nodes, local lymph node dissection is recommended , 25.If the tumor is considered unresectable (stage 3), a diagnostic biopsy should be performed and treatment options are radiotherapy or cytoreductive chemotherapy. Chemotherapy is the treatment of choice in metastatic disease (stage 4) .Active drugs in pediatric population are cyclophosphamide vincristine, adriamycin, and combinations with platinum and etoposide . In highRecurrence of disease occurs mostly in the first 2 years after surgery. Attention to the symptoms and careful physical examination are fundamental. The patient should be examined every 3 months in the first and second year, then every 6 months. Complete blood count, urinary catecholamine analysis, and imaging of the site of the primary tumor (ultrasound or RX scan) should be performed at every examination.It is recommended to perform MIBG scintigraphy every 6 months during the first and second year .Few data are available regarding treatment of adults affected by GBN. In fact, it is not clear if chemotherapy schedules of pediatric studies are suitable and effective for metastatic disease in adults. Prognosis of GBN of the adult also remains uncertain because of the poorness of long-term data.Ganglioneuroblastoma is typically a pediatric disease. Few cases of GBN of the adult are described from the literature. Surgery is the treatment of choice in stage 1 and 2 (children and adult), radiotherapy as a role in stage 3 disease, and chemotherapy is reserved for metastatic disease. Few data are available regarding the efficacy of chemotherapy in stage 4 in the adults. Because of the rarity of the pathology, all cases should be included in the rare cancer network.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.


Mature teratoma is a benign germ cell tumor rarely located in the temporal bone. We are reporting a case of a mature teratoma of the temporal bone in a healthy borne 3.5-month-old baby girl with a 2-day suggestive history of otitis media and polypoidal mass expulsing from the external auditory canal of the left ear. A definitive diagnosis is made after complete excision and histological examination of the tissue. Total surgical excision of the tumor is the treatment of choice. Teratomas are germ cell tumors that presented in childhood. Although there are rarely presented in the temporal bone, teratoma should be considered in differential diagnosis of any mass lesion in the temporal bone. Early diagnosis and treatment through complete excision of the tumor are recommended to prevent transformation into immature cell and prevent recurrence. Imaging is obligatory not only for evaluation of the temporal bone structures but also for excluding intracranial erosions. According to our knowledge there are only few cases reported about temporal bone teratomas that were successfully treated surgically with no evidence of recurrence.A 3.5-month-old baby girl with normal prenatal, natal, and postnatal history was presented to our emergency room with a 2-day history of otorrhea and 1-day history of a protruded mass from the external auditory canal. There was no fever or changes in feeding habits.Examination revealed a vitally stabile, well-fed baby girl. The external auditory meatus of the left ear was filled out by a nonhemorrhagic polypoidal mass, which was firm in consistency and nontender on palpation . There wRadiological evaluation was made which includes CT scan  which reThe fourth ventricle was formally configured, being basal cisterns-free with normal shape and configuration of basal ganglia and cortical and subcortical structures unremarkable.There is no evidence of calcification or fatty component seen in CT and MRI.There is no diffusion restriction and ADC is in the normal limit.Decision was made to take the patient to operating room for exploration and excision. Intraoperatively retroauricular incision was made. The tumor was encountered after drilling the outer cortex of the mastoid and removed by tympanomastoidectomy. The ossicles were dislocated. Facial canal, internal carotid artery canal, and the bulb of the internal jugular canal were intact. There was no skull base defect. The remaining ossicles were removed and tympanoplasty type 3 was performed. Then the incision was closed in 2 layers.The histopathological study showed a keratinized squamous epithelium tissue with skin appendages, in the form of hair follicles and sebaceous glands, connective tissue, fat cells, and sweat glands. In addition, there are an elastic cartilage and smooth muscle portion. So based on the result, the diagnosis of temporal bone teratoma was concluded.Teratomas are germ cell tumors that are composed of multiple cell types derived from one or more of the 3 germ layers  . In 1863Abnormal differentiation of fetal germ cells that arise from the fetal yolk sac is believed to be the origin of teratomas. Normal migration of these germ cells may cause gonadal tumors, whereas abnormal migration produces extragonadal tumors .They are most commonly found in sacrococcygeal region (57%) and gonadal regions 29%). Mediastinal teratomas represent only 7% of the tumor whereas head and neck teratoma represents 5% , 2. The 9%. MediaHistologically, they are classified into mature and immature teratomas. This classification depends on the presence of immature neuroectodermal elements within the tumor . As in oClinically, the patient presents at birth or in early childhood with no sexual predominance . They arAs shown in the literature the most common presenting symptoms are hearing loss –8 and otKhan et al. have reported a case in 2013 of a 11-year-old girl with a left side facial palsy due to invasion of the teratoma from the temporal bone into cerebellopontine angle, which was successfully removed through a transtemporal approach .Radiological studies including temporal bone CT scan and MRI are well-established technique to evaluate the temporal bone structures. CT scan is the method of choice in evaluating the temporal bone pathology, skull base erosion, whereas MRI is important in internal auditory canal, inner ear, cerebellopontine angle, and brainstem lesions , 10. RadThe differential diagnosis of a temporal bone mass should include cholesterol granulomas, petrous apex cephalocele, meningioma, cholesteatoma, rhabdomyosarcoma, chondroma, mucocele, and metastatic neuroblastoma. Cholesterol granulomas are cysts filled with viscous fluid, granulation tissue crystals, and cholesterol and enclosed with a thick fibrous capsule. In MRI, they are hyperintense on T1 and T2 and are not enhanced with contrast material .As shown in previous case studies the only curative treatment is a complete surgical excision of the tumor –8. EarlyCholesteatoma appears in CT as a nonenhancing, expansile lesion with variable degree of bone destruction; otherwise in MRI, they have an intermediate to low signal intensity on T1, and in T2 they have a high signal intensity with no enhancement with a contract material.In CT rhabdomyosarcomas show an aggressive soft tissue mass that causes osseous destruction. They have an intermediate signal intensity on T1, variable signal intensity on T2, and variable enhancement . ChondroAs shown in previous case studies the only curative treatment is a complete surgical excision of the tumor –8. EarlyIn our case, clinical examination and radiological imaging have led to the diagnosis of a mature teratoma of the temporal bone. This was confirmed after histological examination of the specimen after the complete successful surgical removal by canal wall down technique.


Context. Primary leiomyoma of the liver is a rare tumour with uncertain pathogenesis with similar presentation with other tumours of the liver. Little is known about its clinical course. Objectives. To review the literature for case reports of primary leiomyoma of the liver. Methods. Extensive literature search was carried out for case reports of primary leiomyoma of the liver. Results. A total of 36 cases of primary leiomyoma of the liver were reviewed. The mean age of presentation is 43 years with slight female sex affectation; females accounted for 55.6% of the cases reported in the literature. The average size of the tumour is 8.7 cm. 34.4% of the cases reviewed were incidental finding with the mean follow-up time of 33 months with most cases reporting no evidence of disease. Conclusions. Primary leiomyoma of the liver is very rare tumour with complex pathogenesis which remains largely unknown. Imaging of the tumour does not allow for a tissue specific diagnosis; hence histological review of the tissue specimen and immunohistochemical stains are imperative for diagnosis. Surgical resection is both diagnostic and curative. The diagnosis of primary leiomyoma of the liver should be considered as a differential in the management of liver tumours. Leiomyoma is a benign smooth muscle neoplasm of mesenchymal origin which commonly occurs in the genitourinary system and the gastrointestinal tract of the body but which rarely occurs in the liver , 2. The This paper seeks to review primary leiomyoma of the liver in the literature because of its rarity, unclear pathogenesis, and the diagnostic challenges it poses in clinical practice.Case reports and case series of primary leiomyoma of the liver were retrieved by extensive literature search of PubMed, Ovid SP, Cochrane database of systematic reviews, Embase, and Clinical Evidence Online. Further search of the literature was carried out by manually searching the relevant references of the studies retrieved. The inclusive criteria include relevant publications of primary leiomyoma of the liver and hence studies with coexisting leiomyoma in other parts of the body were excluded.Epidemiologic, pathologic, clinical, imaging, and prognostic data were retrieved and assessed for all studies. The search keywords include primary hepatic leiomyoma, primary leiomyoma of the liver, primary benign lesions of the liver, and primary tumours of the liver.The clinical and pathologic characteristics of the 35 cases reviewed with the treatment and the clinical outcome are outlined in Primary leiomyomas of the liver are very rare tumours. Eighty-seven years after the first case of primary leiomyoma of the liver was reported, to the best knowledge of the author, 36 cases of primary leiomyoma of the liver have so far been reported in the literature.Hawkins et al.  in 1980 Primary leiomyomas of the liver have been reported in both paediatric and adult populations. There are reports in the literature to suggest the incidence of the tumour in both immunocompetent and immunosuppressed patients. The mean age of presentation is 43 years (range 4.6–87). Primary leiomyomas of the liver have been reported to have female sex predilection , 5–7. LuThis review of 36 cases however demonstrates slight female sex affectation with females accounting for 55.6% of the cases. Familial predispositions have not been reported. The distribution of the lesion is equal in both right and left lobes of the liver with two cases involving the caudate lobe of the liver , 9.The pathogenesis of primary leiomyoma of the liver is not clear and largely unknown. Some theories have emerged as to the possible pathogenesis of these tumours. Proliferations of smooth muscle of the hepatic vessels or the biliary tree have been suggested as a possible origin , 10–13. Immunosuppressive states which include either posttransplant patients on immunosuppressive therapy or patients with human immunodeficiency virus (HIV) have been suggested as a possible causal factor in primary leiomyoma of the liver. Increased risks of de novo neoplasia after transplantation are well documented in the literature –17.Possible explanations for the susceptibility of immunocompromised patients to neoplasms include the disruption of the immunosurveillance ability of the host with the subsequent development of the tumours that would otherwise have been suppressed by a normal immune system . The incThe theory of the possible role of viral induced oncogenesis has been suggested. This is because of the evidence that implicates some DNA viruses in the aetiology of some neoplasms particularly Epstein-Barr virus in smooth muscle tumours , 18. ThiA possible explanation is a multistep theory of viral oncogenesis which suggests that virus infected cells undergo an uncontrolled polyclonal proliferation in the setting of the reduced immune surveillance of the viral transformed cells. Further cytogenetic events alter the growth regulation of a subset of cells, leading to a monoclonal expansion of tumour cells . In suppThe clinical presentation of primary leiomyoma of the liver is similar to the presentation of other liver neoplasms. The most common clinical symptom in this review is abdominal, epigastric, or right upper quadrant pain which accounts for 42.4% of cases reported , 31–33. Primary leiomyoma of the liver may rarely present as a composite tumour. Yanase et al. reported the case of a 59-year-old lady with 13 × 10 × 9 cm firm tumour with mainly a solid tissue portion and interconnected multilocular cystic lesions. Histologic diagnosis of primary leiomyoma of the liver encasing hepatobiliary cystadenoma was made .Screening for tumour markers alpha fetoprotein, carbohydrate antigen 19-9 and carcinoembryonic antigen are usually negative , 12, 19.Imaging alone does not show tissue specific diagnosis and cannot reliably differentiate between primary leiomyoma and other differential diagnosis like leiomyosarcoma, hepatocellular adenoma, hepatocellular carcinoma, angiomyolipoma, and hypervascular metastatic lesions , 37. TheCT findings in leiomyoma of the liver have been variously reported in the cases reviewed as hypodense lesions with strong enhancement in both arterial and portal phase , 36, 38 Ultrasound findings in primary leiomyoma of the liver in the literature have been described as hypoechoic lesions with varying degrees of heterogeneity , 36, 37.MRI findings from several studies suggest hypointense lesions on T1-weighted MRI images with hyperintense lesions on T2-weighted sequences with inhomogeneous contrast uptake , 20, 37.The development of liver specific MR contrast agents which includes reticuloendothelial system specific contrast agents and hepatocytes specific contrast agents have been shown to potentially improve the detection and characterization of liver lesions by providing functional and morphologic information of the liver simultaneously –41. GadoIt has also been suggested that liver specific MR contrast agents may be misleading in the diagnosis of primary leiomyoma of the liver. The absence of contrast retention during the liver specific contrast enhanced MRI, in the case report, led them to suspect a malignant lesion of the liver but it turned out to be a primary leiomyoma on histology after surgical resection . This fiAngiography has been reported to demonstrate irregular , marginaAttempts have been made to make a preoperative diagnosis of this tumour so as to prevent unwarranted diagnostic surgical procedures. CT guided fine needle biopsy had reportedly failed to determine the nature of the mass despite the fact that the primary leiomyoma of the liver in this case was the largest ever reported in the literature with a size of 30 cm. The patient underwent extended right hepatectomy. No extra-hepatic lesions were seen at surgery and the uterus was normal . PercutaSousa et al. initially performed a US-guided fine needle aspiration (FNA) which was inconclusive because of because of insufficient sample which included only a small group of normal looking hepatocytes . The hisThe inconclusive FNA report from the case reported by Sousa et al. is consistent with the series reported by Guy et al. who further reiterated the difficulty of getting adequate sample in 10% of cases where FNA was used in the diagnosis of spindle cell lesions of the liver . Hence FThe average size of the tumour in this review is 8.7 cm (range 2–30). The largest size of this tumour in the literature, 30 cm, was reported by Belli et al. in a 67-year-old woman who presented with abdominal mass . PrimaryHistological review of tissue sections and specimens is absolutely important because the distinction between benign and malignant smooth muscle tumours of the gastrointestinal tract on imaging is not very clear .The cellular architecture has been variably described as multiple interlacing bundles of uniform spindle cells  homogeneCentral , 25 and Primary leiomyomas of the liver have been largely reported without evidence of mitotic changes except for few case reports which variously reported scarce, low, and rare mitoses , 21, 24.Mitotic index as defined by the number of mitoses per specified high power field was not documented for some of the case reports , 12, 21.The cells in the case reports reviewed have been reported to be positive to alpha smooth muscle actin . Some ofPrimary leiomyoma of the liver is amenable to surgery. Surgical resection of the tumour appears to be both diagnostic and curative in this review of the literature. The prognosis of this tumour appears to be excellent without evidence of disease during the follow-up of the cases. The average follow-up of the cases in this review is 33 months (range 4–108).This paper to the best of the knowledge of the author is the largest review of case reports of primary leiomyoma of the liver in the literature. Primary leiomyoma of the liver is a very rare tumour with a complex pathogenesis which remains largely unknown. The diagnosis of the primary leiomyoma of the liver must meet a set of diagnostic criteria proposed by Hawkins et al. which ensures the cells are leiomyocytes and the exclusion of coexisting leiomyoma from other sites of the body. Metastatic workup to exclude occult leiomyoma elsewhere should be undertaken. This should include investigations like oesophagogastroduodenoscopy, colonoscopy, imaging techniques like CT scans and MRI, and a thorough exploration during surgery.Primary leiomyoma of the liver should be considered as a differential diagnosis of liver lesions with or without immunosuppression. Multiple imaging techniques do not allow for a tissue specific diagnosis; hence histological review of the tissue specimen and immunohistochemical stains are imperative for diagnosis. Surgical resection is both diagnostic and curative.


Fungal sellar abscess is rare. A 42-year-old man was admitted with 2-month headache characterized by right peri-orbital pain. An intrasellar mass was found to be simulated a pituitary neoplasm after magnetic resonance imaging examination, and operated on via an endoscopic trans-sphenoidal approach. Milk-like pus and a mass of ash black mixed and necrotic material were found and removed. Histopathology revealed numerous aspergillus hyphae. Itraconazole was given on a dosage of 200 mg twice a day orally for 6 weeks. No recurrence was observed during follow-up. Complete surgical resection through endoscopic trans-sphenoidal approach combined with systemic anti-fungal therapy, should be considered as the optimal treatment. Fungal sellar abscess is rare and only 18 cases have been reported. In this report, we state a case of invasive aspergillosis involving the sellar area, which was revealed by clinical features suggesting a pituitary neoplasm.A 42-year-old man was admitted with headache and diplopia of 2 days duration in December 2014. The feature of headache was persistent and electric shock-like peri-orbital pain on the right side, without nausea and vomit. He was engaged in fungus mushroom cultivation for 3 years. His medical history was insignificant. Neurological examination showed the right abducens nerve palsy. T2-weighted MRI revealed an heterogenous intrasellar mass . Itraconazole was given on a dosage of 200 mg twice a day orally for 6 weeks.With a preoperative diagnosis of pituitary neoplasm, endoscopic trans-sphenoidal surgery was planned. After the diminished sphenoidal sinus was entered, some milk-like pus and thickened mucosa were excised. When the paper-thin sellar floor bone and dura were opened, more milk-like pus and a mass of ash black mixed and necrotic material were found and removed. The pituitary gland and the diaphragma sellae were found to be intact after the removal of the lesion. The specimens were negative for aerobic and anaerobic bacterial cultures. Histopathological examination of the necrotic material consisted of numerous hyphae, according with characteristic of aspergillus species Fig. . Plasma Postoperatively he get a transient diabetes insipidus for 5 days. He had relief from headache and improvement in function of the right abducens nerve. No recurrence was observed on contrast enhanced MRI scans during 6-month follow-up.The major pathogen of fungal sellar abscess is aspergillus species. Aspergillus are ubiquitous fungi found in soil and organic materials and can establish saprophytic growth within the respiratory tract after inhalation. The organism can become pathogenic under anaerobic conditions. In our case, the patient had been engaging in fungus mushroom cultivation for 3 years, which may be a cause of sellar aspergillosis, since there was no significant medical history.Preoperative diagnosis of fungal sellar abscess is difficult .The controversy is that patients with fungal sellar abscess should be treated with anti-fungal drug when the diagnosis was ascertained. Some reports consider postoperative systemic anti-fungal therapy as superfluous in case of total macroscopic extirpation of an invasive aspergillosis without subdural involvement (Boutarbouch et al. Long-term cultivation of fungus mushroom may be a cause of sellar aspergillosis. If people who long-time working in damp and dark environment, is attacked by acute and persistent headache, diagnosis of fungal sellar abscess should be taken into consideration. Although the diagnosis is difficult, MRI showing a hypo-intense zone into the hyper-intense process and rim enhancement, may help to preoperative diagnosis. Complete surgical resection through endoscopic trans-sphenoidal approach is extremely crucial. Systemic anti-fungal drug should be taken immediately after diagnosis was ascertained.The patient has consented to the submission of the case report for submission to the journal.


Cavernous hemangioma is not a neoplasm, but rather a congenital venous malformation with the potential to develop in all parts of the body, though it is very rarely seen in the thymus. We report a case of cavernous hemangioma in the thymus partially resected. A 71-year-old woman presented with pericardial discomfort, and chest computed tomography (CT) showed a left lateral mediastinal mass which was 2.0 × 1.2 × 1.8 cm in size, with border regularity and without calcification. Its interior was partially enhanced. Three-dimensional chest computed tomography image showed a tortuous vessel connecting to the tumor. Surgical resection was performed for the purpose of providing a definitive diagnosis and treatment because a mediastinal tumor such as thymoma or teratoma was suspected. Partial resection of the thymus including the mass was done by utilizing a three-port, left-sided video-assisted thoracic surgery (VATS) approach with hoisting of the third rib with the patient in a spinal position. A wine-colored mass bulging from the surface of the left lobe of the thymus was identified along with the communicating vessel which could only be cut with an energy device. It is considered that thymic partial resection using VATS is a better option for small and non-infiltrative lesions. Cavernous hemangioma (CH) is not a neoplasm, but rather a congenital venous malformation with the potential to develop in all parts of the body, though it is very rarely seen in the thymus. Here, we report a case of cavernous hemangioma in the thymus that was partially resected using a video-assisted thoracic surgery (VATS) procedure.A 71-year-old woman presented with pericardial discomfort while coughing, and chest computed tomography (CT) showed a left lateral mediastinal mass. Although the mass remained unchanged in CT findings 3 months later, surgical resection was recommended because a mediastinal tumor such as thymoma or teratoma was suspected. The anterior mediastinal mass was 2.0 × 1.2 × 1.8 cm in size, with border regularity and without calcification. Its interior was partially enhanced Fig. , and a tSurgical resection was performed for the purpose of providing a definitive diagnosis and treatment. With the patient in a spinal position, partial resection of the thymus including the mass was done by utilizing a three-port, left-sided VATS approach with hoisting of the third rib. A wine-colored mass bulging from the surface of the left lobe of the thymus was identified Fig.  along wiThe size of the excised mass was 2.3 × 1.3 × 1.8 cm, and there was no infiltration of the adjacent thymus Fig. . A histoCH is not a vascular tumor, but rather a congenital vascular anomaly classified as a venous malformation in the low-flow lesion category by the International Society for the Study of Vascular Anomalies (ISSVA) , 2. ThisCH occurs with greater frequency in the liver, accounting for approximately 30 % of known cases, as well as in the brain and skin, whereas there are several reports of mediastinal cases in Japan . Since iWhen occurring in the thymus, a CH may require resection for diagnosis and treatment, as it is otherwise difficult to distinguish from another type of mediastinal tumor such as a thymoma. Even though it does not generally invade the neighboring tissue, complete resection is desirable, as previously described. Cohen et al. reported that subtotal excision should be chosen if complete resection carries serious risk because there was no rapid growth noted in a case of incomplete resection and re-resection can be considered at the time of recurrence . ExtirpaFor accurate diagnosis of CH, magnetic resonance (MR) imaging or ultrasound sonogram are often used to examine the brain, liver, and other organs. The typical imaging manifestation of CH is popcorn-like lesion with a peripheral hypointense rim so-called hemosiderin rim on T2-weighted MR images. As for mediastinal or lung vascular anomalies, enhanced CT may be very effective, as it can reveal a phlebolith in some cases of venous malformation. No phlebolith was seen in our patient, while the center of the mass was enhanced and a communicating vessel running through the thymus was detected. In addition, findings obtained with a three-dimensional image analysis system  showed the positional relationship of the tortuous vessel and the mass on the side wall (Fig. The mass was resected completely but we intend to follow the present patient to note vessel changes.We experienced a rare case of CH in the thymus. Our experience indicated that enhanced CT and a three-dimensional image analysis system would be helpful for diagnosis of vessel malformation and thymic partial resection using VATS would be a better option for small and non-infiltrative lesions.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.


A primary intraparenchymal meningioma located in the subcortical region of the brain without a dural attachment is extremely rare. To the best of our knowledge, this is the first report showing that meningioma can mimic cavernous malformations.We present the case of a 42-year-old German man who presented to our institution with seizure. Both computed tomography and magnetic resonance imaging scans showed characters of an intra-axial subcortical lesion with a ‘popcorn’ appearance and hemosiderin deposits in the right parietal lobe. The initial diagnosis was cavernous malformation. Intraoperatively, the lesion presented as a subcortical mass that had no connection to the dura or the ventricle. The histological diagnosis showed a WHO Grade 1 ‘raddled’ psammomatous meningioma with extensive metaplastic ossification. A literature review of 29 cases of intraparenchymal meningiomas regarding their clinical presentations, location and management was performed.Meningiomas can be found in any region of the brain with and without dural attachment. Intraparenchymal meningiomas can have multiple entities mimicking their presentation. Caution must be used regarding the preoperative differential diagnosis. Meningiomas account for approximately 15% of all intracranial neoplasms –6. The mWe present a rare case of primary intraparenchymal meningioma that, preoperatively, was not typical for meningioma and showed characteristics of cavernous malformation. We reviewed all cases of intraparenchymal meningiomas in the literature to gather information regarding their sites, clinical presentations, pathological features, management, and outcome.A right-handed 42-year-old German man presented to our institution with convulsive seizures. There were no other neurological symptoms or signs and no neurological deficits. The initial computed tomography (CT) scan of his brain revealed a hyperdense lesion with calcification in the right parietal area. His cranial MRI scan Figures , 2 and 3A right parietal craniotomy was performed under MRI-guided navigational assistance. Grossly, no mass or any other pathologic tissue was observed below the dura or on the cortex. Using a sulcal approach, the mass reached about 2cm into the cortex, showing a good cleavage. The mass was completely calcified (like a stone) and measured about 1.5×1.5cm in diameter. A gross total resection could be achieved. Postoperatively, he had no neurological deficits.A histological examination of the specimen showed (at low magnification (5× objectives)) a tightly packed and parallel laminated mass of fibrous tissue Figure . There wFurthermore, the lesion contained areas of transition into mature lamellar bone and was partly bordered by brain tissue with piloid gliosis. There was no periodic acid-Schiff-positive inclusions, nor hemosiderin deposits. An immunohistochemistry analysis revealed focal positivity for epithelial membrane antigen and Vimentin Figure . StaininIn the literature review, we identified 36 cases of intraparenchymal meningiomas, including our case report. Case reports with insufficient information and meningiomas secondary to underlying meningioangiomatosis were excluded; 29 cases were included in total. There were 18 male (62.1%) and 11 female (37.9%) subjects, with the age ranging between 0.4 and 60 years (mean: 21.2 years). Of the 29 intraparenchymal meningioma cases, 26 were located in the supratentorial region (89.7%) and three were located in the infratentorial region of the brain (10.3%). The frontal location was dominant, being reported in 12 cases (41.4%). The most frequently reported clinical presentation was seizure, being reported in 20 cases (69.0%). In almost all of the cases, the radiological appearance was a solid mass showing contrast enhancement.Preoperatively, three cases mimicked a glioma, one case mimicked metastasis und one case mimicked a cavernoma. Total surgical resection was the standard treatment approach and was achieved in all the cases, except in three cases involving the brainstem, in which only a subtotal resection was performed. Radiotherapy following the surgery was done in four cases und one subject additionally underwent adjuvant chemotherapy. Regarding the histopathology, the fibrous type proved to be dominant, being reported in 11 cases (37.9%). The majority of the patients had no postoperative deficits. The location, clinical presentation, radiological finding, and outcomes are summarized in Table Intraparenchymal meningiomas are meningiomas that arise within the brain tissue without dural attachment and have also been used to characterize meningiomas that are not dural based . The etiOur case report shows several factors which pointed to the diagnosis of cavernous malformation: the subcortical location, clinical presentation, radiological findings like the characteristic popcorn appearance on the MRI scan, and hemosiderin deposition. Other findings, such as peritumoral edema, calcifications, hypointense appearance to gray matter on T1-weighted MRI scans, and mixed signal intensity on T2-weighted MRI scans, are also reported in cavernous malformations in different stages after hemorrhage. It has been reported that cavernoma malformations may mimic meningioma , 44–46. Our case report highlights the fact that preoperative diagnosis of atypical meningioma is challenging and classical MRI features may not be sufficient to distinguish the different pathologic entities, moreover, they can be misleading. Therefore, caution must be used in the preoperative differential diagnosis. In our case report, an angiography could have helped to distinguish the meningioma from a cavernous malformation, but this is not guaranteed due to the possibility of showing the same radiological features .The literature review shows that intraparenchymal meningiomas occur in all regions of the brain, including supratentorial and infratentorial areas. Intraparenchymal meningiomas were, in most cases, not considered and misdiagnosed as other lesions. The clinical presentation was site dependent; seizures were the most common symptom. Unlike the usual meningioma, where the meningothelial variant of meningioma is the most common, the fibrous variant of meningioma is dominant in intraparenchymal meningiomas . It seemThe meningioma in our patient had two unusual features: the subcortical location and the radiological appearance mimicking cavernous malformation. This case report highlights the fact that the typical radiological appearance of one lesion may sometimes be misleading. Intraparenchymal meningiomas can have multiple entities mimicking their presentation. Caution must be used in the preoperative differential diagnosis.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.


Retroperitoneal lipomas are an extremely rare condition with only 17 cases described in the literature since 1980. They can reach enormous size and cause significant abdominal symptoms. The most important differential diagnosis is the well-differentiated liposarcoma, which preoperatively often may not definitely be ruled out.We present the case of a 73 year-old Caucasian patient with a giant retroperitoneal lipoma of 9 kg measuring 55 cm in diameter. The patient presented with abdominal pain and swelling that had been slowly progressive for the last 15 years. On computerized tomography an immense retroperitoneal tumor was revealed. Intraoperatively, the tumor did not show any signs of infiltrative growth, therefore sole tumor extirpation was performed.Retroperitoneal lipomas are not clearly distinguishable from well-differentiated liposarcomas on imaging and even biopsies may be misleading. Moreover, abdominal symptoms, i.e. pain, obstipation and dysphagia may occur due to mechanical displacement. Therefore, surgical exploration with complete oncological resection is the therapy of choice if malignity cannot be ruled out.The online version of this article (doi:10.1186/s13104-015-1038-7) contains supplementary material, which is available to authorized users. Lipomas are benign tumors of mature adipocytes  which arA 73 year-old, Caucasian female was referred to our center with a giant retroperitoneal mass. The patient complained about significant abdominal swelling and recurrent episodes of abdominal pain and obstipation. The tumor had been slowly progressive over the past 15 years. On physical examination the patient’s abdomen was greatly distended and non-tender on palpation. Blood tests showed no significant pathologies. A computerized tomography (CT) scan showed the giant retroperitoneal mass (Figure Intraoperatively a giant, clearly demarcated fatty tumor adherent to the right retroperitoneal fatty tissue measuring 55 x 40 x 10 cm was evident Figure . AlthougGiant retroperitoneal lipomas in adults are scarce, with a total number of 17 cases described in the literature since 1980 -20 (TablRetroperitoneal lipomas are a rare condition. The presented case points out that abdominal lipomas can grow to enormous size and cause clinically significant symptoms and, even if massively enlarged, are resectable with good clinical outcome. Further research is required to fully understand the underlying etiology and genetic mechanisms. The most important differential diagnosis is the more frequent well-differentiated liposarcoma, therefore oncological resection should always be considered.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.


Nasal chondromesenchymal hamartoma (NCMH) is a very rare, benign tumour of the sinonasal tract usually presenting in infants. We present a systematic review of NCMH cases alongside a case report of an adult with asymptomatic NCMH.A systematic review was conducted in accordance with PRISMA guidelines. A PubMed, EMBASE and manual search through references of relevant publications was used to identify all published case-reports of NCMH. Data was collected from each case-report on: patient demographics, laterality, size and location of NCMH, presentation, co-morbidities, investigations, treatment and follow-up.n = 18). Presentations included: nasal congestion (n = 17), nasal mass (n = 15) and eye signs (n = 12). NCMH also involved the paranasal sinuses (n = 26), orbit (n = 16) and skull-base (n = 14). All patients underwent operative resection of NCMH. A small 2014 case-series found DICER1 mutations in 6 NCMH patients, establishing a link to the DICER1 tumour spectrum.The systematic review identified 48 patients (including ours): 33 male, 15 female. Mean age was 9.6 years (range: 1 day–69 years) with the majority aged 1 year or younger at presentation (NCMH is a rare cause of nasal masses in young children and adults. In light of the newly established link between NCMH and DICER1 mutations surgeons should be vigilant for associated DICER1 tumours, as NCMH may be the ‘herald tumour’ of this disease spectrum. Nasal chondromesenchymal hamartoma (NCMH) is a very rare, benign tumour of the sinonasal tract. Forty-seven cases have been reported in the English literature and the vast majority of these presentations are in infants and young children often below the age of one. NCMHs have a mixed morphological structure comprised of predominantly mesenchymal and cartilaginous components. NCMH patients present with symptoms that are dependent on the location of the tumour in the nasal cavity or paranasal sinuses and their compression of local structures. These symptoms range from nasal obstruction to visual impairment and facial and dental pain. To date there have only been 6 cases of adult presentation of NCMH. Here we present the first systematic review of NCMH cases published in the literature to assess the patient demographics, presentation, management and prognosis of NCMH alongside a new and unusual case in an adult.A 49-year-old man was referred to our outpatient clinic presenting with a small mass in his right nasal cavity. The lump, which the patient first noticed 5 years ago, had been growing insidiously over time and by the time of presentation had become visible at the right anterior naris. The patient did not complain of any symptoms but sought consultation as his wife was concerned by the cosmetic appearance of the mass.Examination revealed a large firm mass arising from the right side of the anterior nasal septum with approximately 0.5 cm attachment to the anterior cartilage of the septum. The left and right nasal cavities were otherwise unremarkable. Clinically, the mass had the appearance of a papilloma confined to the nasal cavity with an attachment to the septum only and therefore further imaging was not undertaken. The differential diagnoses considered at the time of presentation were: nasal polyp, squamous papilloma or inverted papilloma.The patient subsequently underwent excisional biopsy of the right nostril mass under general anaesthetic using a circumferential subperichondrial incision with a small margin. Intraoperatively, the mass had the macroscopic appearance of a 0.5 cm × 2 cm × 2 cm calcified nodule. Due to a small 0.5 cm base, subsequent healing was achieved by secondary intention aided by the routine application of topical antibacterial cream. Histopathological analysis showed the nodule to contain cartilage and aneurysmal bone covered in stratified squamous epithelium with keratinisation Figs.  and 2. HThe patient was followed up in clinic and was discharged after 2 years having shown no signs of recurrence. Furthermore, a telephone interview was conducted 4 years post operation and the patient reported no recurrence of the nasal mass. He confirmed that he had no post-operative complications and was happy with the outcome of the operation.A systematic review was undertaken in accordance with PRISMA guidelines . No systn = 18) and only 8 adult patients (including our case) have been described. Site of pathology was limited to the nasal cavity only in 10 patients, and involved the paranasal sinuses  in 26 patients, the orbit in 16 patients, extending to the skull base in 14 patients, had intracranial extension in 8 cases, involved the nasopharynx in 3 patients and the oropharynx in 2 patients (see Table Forty-Eight NCMH patients (including our case) have been reported in the English literature Fig. . Most can = 17), nasal mass (n = 15), eye signs  (n = 12), facial swelling (n = 8), headaches or facial pain (n = 6), stertor or respiratory distress (n = 8), ophthalmoplegia (n = 4), recurrent sinusitis (n = 4), rhinorrhoea (n = 3), otitis media (n = 2), epistaxis (n = 2), toothache (n = 1), hyposmia (n = 1), hydrocephalus (n = 1) and 4 patients were asymptomatic or had no signs and symptoms documented . Eleven patients were found to have persistent disease or disease recurrence on follow up, seven required further surgery, three patients were described as stable, and no further information was given on the other patient. Li et al. described the first and only reported case of malignant transformation of NCMH .Thirty-six patients had no documented past medical problems. One adult patient had a history of multiple vascular aneurysms. Eleven of the patients had been diagnosed with pleuropulmonary blastoma (PPB) prior to NCMH detection. Of these 11 patients, 5 had other co-morbidities including three with Sertoli-Lleydig cell ovarian tumours, two with pulmonary cysts, one jejunal polyps, one papillary thyroid carcinoma, one cystic nephroma and one multinodular goitre.A potential weakness of this systematic review is the possibility of reporting bias through publication bias both within individual case reports and across the review. This reporting bias is three-fold: firstly in the incomplete publication of all the clinical aspects of the case-reports by the original authors, for example not reporting follow-up times or co-morbidities etc. Secondly it is possible that there have been cases of NCMH that have not been reported in the literature and can therefore not be included in the systematic review. Thirdly the exclusion of case-reports of “Mesenchymal chondrosarcoma”  “nasal hNCMHs are predominantly benign lesions that are locally destructive and because of their aggressive appearance can be mistaken for a malignant tumour. However NCMHs can be slow growing and therefore have a delayed presentation. Histopathologically these lesions are analogous to other mesenchymal hamartomas, and consist of islands of chondroid tissue such as hyaline cartilage, areas of calcification, and mesenchymal cellular elements such as spindle cells and myxoid stroma.McDermott et al. were the first to recognise NCMH as a distinct clinic-pathological entity in 1998 when they described a case series of seven patients with a tumefactive process of the nasal passages and contiguous paranasal sinuses with a detectable mass in the nose . In thisIn our case, the NCMH was initially thought to be a papilloma confined to the nasal septal wall and therefore further imaging was not undertaken prior to resection. However pre-operative imaging of these lesions provides valuable information regarding involvement of adjacent structures such as the paranasal sinuses, orbit and intracranial cavity. On computed tomography (CT) imaging, NCMH are typically seen as non-encapsulated, poorly defined masses often with cystic components . MagnetiPatients with NCMH most commonly present with symptoms of nasal obstruction, nasal mass, or eye signs, which reflects the involvement of NCMH in the nasal passages and orbit. Ophthalmic signs include signs of globe displacement such as strabismus, extropia, hypertelorism, proptosis, enophthalmus and ophthlmoplegia, direct results of the intra-ocular extension of NCMH or ocular compression by NCMH –26. TherDICER1 mutations in 6 out of 8 evaluated patients, and somatic DICER1 mutations in 2 out of those 6 patients with germline mutations , juvenile granulosa cell tumour [JGCT] and gynandroblastomas. Less commonly the DICER1 tumour spectrum includes: cystic nephroma (CN), and thyroid gland neoplasia, multinodular goitres [MNG], adenomas, or differentiated thyroid cancers. The rarest observed tumours in this spectrum, alongside NCMHs, are ciliary body medulloepithelioma (CBME), botryoid-type embryonal rhabdomyosarcoma (ERMS) of the cervix or other sites, renal sarcomas, pituitary blastomas, and pineoblastomas [DIECR1 tumours. Surgeons and physicians should therefore be aware of these disease associations and should be vigilant of a diagnosis of NCMH in patients presenting with sino-nasal or orbital symptoms who have a history of any of these tumours. Johnson et al. importantly also point out that due to its location, NCMH is more likely to present early in life than the other DICER1 tumours [DICER1 mutation analysis if available, or ensure long-term follow up of these patients and be vigilant for associated tumours, as NCMH may be the ‘herald tumour’ of this disease spectrum.The aetiology of NCMH is thought to be due to an underlying genetic predisposition therefore accounting for the early presentation in the majority of cases. Priest et al. and Stewart et al. investigated patients with both NCMH and the rare paediatric dysembryonic sarcoma of the lung and pleura: pleuropulmonary blastoma (PPB) , 27. In utations . This relastomas . Eleven  tumours . SurgeonDICER1 mutation, the majority of the 42 reported cases have not had formal DICER1 mutation analysis. Therefore an association or lack thereof in the non-tested cases cannot be inferred.There are also cases in the literature of children, adolescents and adults with NCMH who have had an asymptomatic infancy , 12, 14.Successful management of NCMH entails complete resection in order to prevent recurrence. A complete excision however is not always technically feasible, especially in cases of intracranial extension of NCMH. An incomplete resection poses the risk of recurrence as well as the possibility of continued tumour growth and progressive symptoms. Nine patients in this systematic review were found to have disease recurrence, most likely from incomplete surgical excision.DIECR1 mutation has very recently been established and therefore in light of this any patient with a DICER1-related tumour spectrum and new nasal or orbital symptoms should raise the suspicion of NCMH. Furthermore surgeons should subsequently be vigilant for associated DICER1 related tumours, as due to their location NCMHs may be the ‘herald tumour’ for this disease spectrum. This case and systematic review highlights the fact that NCMH can mimic other benign and malignant lesions and that surgeons and physicians should be aware of rare pathologies accounting for nasal masses.We present an unusual case of NCMH in an adult without nasal obstructive symptoms due to the anatomical location of the NCMH attached to the nasal septum. A systematic review of the literature has highlighted that presentation is mostly related to tumour location, with nasal mass, nasal obstruction and ophthalmic signs being the most common forms of presentation. The majority of patients presenting with NCMH are children and infants below the age of one, but there have now been a few adult cases of presentation. Surgical resection is the treatment of choice with low recurrence rates in the majority of cases. There has only been one reported case of malignant transformation and NCMH is still considered a benign tumour. NCMH’s association with the Written consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editor-in-chief of this journal.


Combined branch retinal artery and central retinal vein occlusion is a rare condition that has been infrequently reported. This case report, aside from reporting the above-mentioned condition, highlights the importance of performing spectral domain optical coherence tomography in establishing a complete diagnosis, especially in uncertain and complicated cases. We also present spectral domain optical coherence tomography findings of a case of combined unilateral simultaneous central retinal vein and branch retinal artery occlusion.We present a single case of an initially missed, unilateral branch retinal artery occlusion combined with central retinal vein occlusion in a 51-year-old female Chinese patient without a significant past medical history, who experienced sudden, painless vision diminution in her right eye eleven days prior to presentation. She eventually recovered visual acuity to 0.60, despite having presented with poor vision.Combined unilateral central retinal vein and branch retinal artery occlusion may occur in patients with no medical history of arterial hypertension and diabetes mellitus and can achieve a relatively good visual outcome. This case reaffirms the significance of performing a spectral domain optical coherence tomography examination in patients suffering from central retinal vein occlusion with suspicion of unilateral simultaneous branch retinal artery occlusion to identify the affected pathological areas. CRVO is a common retinal vascular disorder that arises from a blockage of the central retinal vein. As a consequence of the blockage, stagnant blood gradually leaks out through the vein walls and leads to blurred vision. BRAO refers to an obstruction or blockage of one or multiple branch retinal arteries resulting in a severe loss of vision, the area and degree of which is associated with the distribution of the occluded branch retinal artery. Histopathologically, acute BRAO results in ischemia in the corresponding retinal quadrant marked by inner retinal edema in the initial stages and atrophy in long-standing cases . The comsyndrome , and homsyndrome , which rIn this report, we describe a single case of combined unilateral CRVO and BRAO and emphasize the efficacy of spectral domain optical coherence tomography (SD-OCT) examination in this type of case.A 51-year-old female Chinese patient without arterial hypertension, diabetes mellitus or significant past ophthalmic history presented to our hospital complaining of painless, suddenly impaired vision in her right eye for 11 days. Prior to that, she had been hospitalized at the local county hospital with visual acuity of 0.06 and 0.80 in the right and left eyes, respectively. Based on the results of ophthalmologic, fundus and fluorescein angiography (FA) examinations, clinical diagnosis of CRVO was established and traditional Chinese medicine was prescribed to activate blood circulation and decrease blood stasis. Upon presentation to our hospital, the anterior segment examination under a slit lamp biomicroscope (SLE) was unremarkable in both eyes, and visual acuity of 0.10 and 0.80 was revealed in the right and left eyes, respectively. Intraocular pressure was in the normal range. A dilated fundus evaluation demonstrated an edematous macula, tortuous and dilated retinal veins with radially patterned hemorrhages, blurred and elevated disc margins in her right eye, and retinal paleness in the upper region of the macula Figure A. A retrThe SD-OCT features of combined unilateral CRVO and BRAO in our case were:1. hyperreflectivity and increased thickness of the nerve fiber and inner retinal layers in the superior ischemic retina compared to the inferior unaffected area near the BRAO retina;2. decreased reflectivity of the outer retinal layers in the superior half, probably due to an optical shadowing effect;3. macular edema and serous macular detachment typical for CRVO;4. no cystoid macular edema was observed either on presentation or at follow-up visits;5. a well-defined demarcation line between the affected and unaffected areas near the BRAO retina6. peripapillary retinal detachment Figure Combined unilateral simultaneous CRVO and BRAO is a rare condition, which if incomplete, has been proposed to be deemed as one entity. In patients with a combined concurrent CRVO and BRAO, an embolic compound has not been found, suggestive of the secondary nature of BRAO due to compression of the artery because of the obviously swollen optic nerve and/or central retinal vein resulting from CRVO . This isin-vivo histological changes in the retina [In our case, we performed the assisting diagnostic procedure with SD-OCT in addition to FA, in order to establish the final diagnosis of combined unilateral CRVO and BRAO. This approach is optimal for patients with a questionable diagnosis of combined unilateral CRVO and BRAO. SD-OCT has quite recently been introduced to the medical world and has revolutionized the ocular imaging service. It is a cutting-edge technique using a significantly faster, non-mechanical technology providing non-invasive acquisition of detailed; i.e., up to 5 microns resolution, e retina ,7.These anatomical changes are the result of the denaturation of intracellular proteins, with the accumulation of intracellular fluid and consequent cellular necrosis. We propose that the name ‘retinal edema’ should not be used for this clinical condition, as the extravascular fluid is found in the intracellular space, and we suggest that the term ‘acute ischemic retinopathy’ is more appropriate .Preservation of the integrity of the IS-OS line and the external limiting membrane has been reported to have prognostic value in cystoid macular edema due to vascular occlusions . PresencThroughout the follow-up visits, atrophy of the superior retina was observed.Combined unilateral CRVO and BRAO may occur in patients without a significant past medical history. SD-OCT is an efficient method for establishing a combined unilateral CRVO and BRAO diagnosis. Timely use of SD-OCT facilitates fast and precise diagnosis of the aforementioned condition, ensuring prompt treatment. In our case, although the patient presented with poor visual acuity, we can report the presence of an intact IS-OS line on SD-OCT, thanks to which a good visual outcome was attained.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 of this journal.BRAO: Branch retinal artery occlusion; CRVO: Central retinal vein occlusion; SD-OCT: Spectral domain optical coherence tomography; ILSR: Inner layers of superior retina; IS-OS: Inner segment-outer segment; FA: Fluorescein angiography; ELISA: Enzyme-linked immunosorbent assay; PCR: Polymerase chain reaction.The authors declare that they have no competing interest.TLS critically revised the manuscript and gave final approval of the version to be published, AK designed, drafted the manuscript in English and made the submission, PO drafted the manuscript in Chinese and examined the patient, JZ and LYMD helped to draft and translate the Chinese manuscript, case history and examination reports and were involved in the clinical and scientific discussion of the case. All five authors revised the manuscript and made intellectual contributions. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2415/14/91/prepub


Hydrosalpinx is a rare cause of abdominal pain in paediatric patients, though cases are documented in the literature. Its aetiology differs considerably from traditional hydrosalpinx due to ascending sexually transmitted infection. Hydrosalpinx can resent mimicking an acute abdomen or can be asymptomatic. Management of paediatric hydrosalpinx varies but often involves surgical removal of the affected tube. A 12-year-old girl presented with left-sided acute abdominal pain setting within 24 h. Initial ultrasound scan suggested presence of hydrosalpinx. Post-discharge follow-up appointment with a consultant paediatric gynaecologist demonstrated no symptomology, but repeated scan by another sonographer showed continued presence of possible hydrosalpinx, which had since grown. Later, MRI was performed to confirm site of the lesion. However, MRI revealed no tubal masses, suggesting spontaneously resolved hydrosalpinx. Consultant-administered ultrasound scan confirm no tubal abnormalities. Our case suggests spontaneous resolution in possible paediatric hydrosalpinx. Our recommendation is for conservative management of asymptomatic paediatric and adolescent hydrosalpinges, with emergency surgery offered if symptoms indicative of tubal or adnexal torsion. A 12-year-old nulliparous girl presented to paediatric admissions unit with acute onset abdominal pain centralized to the left iliac fossa over the past 12 h, leading to one episode of sudden collapse. She reported no associated bowel or urinary symptoms. The patient had reached menarche aged 12 and had regular menstrual cycles. She denied any prior sexual activity, and her last menstrual period has occurred 1 week prior. She had no prior surgical or medical history of note. Social and family history was unremarkable.On examination, abdominal tenderness was noted with no associated guarding or peritonism. Midstream urine and beta-hCG levels were tested and recorded, with normal findings. The patient was admitted for observation. However, the pain resolved within 24 h and no further symptoms were reported following resolution. Admission notes suggested initial working diagnosis was of an ovarian cyst. The patient was discharged and scheduled for a follow-up review and ultrasound scan in 2 weeks.On the initial follow-up 2 weeks after discharge, an outpatient ultrasound scan was performed by an experienced gynaecological sonographer Fig. . The sonDue to missed appointments, the next follow-up scan was performed 6.5 months later by a different experienced gynaecological sonographer Fig. . This soWith the continued presence of what appeared to be a possible hydrosalpinx, a laparoscopy and salpingectomy were scheduled. Prior to the operation, a consultant radiologist-administered MRI of the pelvis was performed with the aim of confirming the site of the hydrosalpinx Fig. . HoweverDue to these new imaging findings, a decision was made to review the patient using the original imaging modality: ultrasound. A pelvic ultrasound, using a trans-abdominal approach and performed by a consultant radiologist, demonstrated no evidence of a pelvic cyst or mass or any free fluid.As there were no further troubling symptoms and no abnormalities reported on two separate imaging modalities, no treatment was indicated. The patient was reviewed one final time in follow-up clinic. The patient was discharged from gynaecology outpatient follow-up clinic. There has been no recurrence in symptomology reported as of time of writing.Chlamydia trachomatis [Adult hydrosalpinx is traditionally associated with pelvic inflammatory disease due to an ascending sexually transmitted infection such as chomatis . Howeverchomatis . Pelvic chomatis . Neoplaschomatis . Overallchomatis . In thisWithout clear pre-existing tubal or ovarian pathology, paediatric hydrosalpinx is likely due to increased fallopian tube mobility on the ligamentum latum . As wellNew onset symptomology of previously asymptomatic hydrosalpinx can also be due to abnormal tubal peristalsis activity or inherent congenital tubal abnormalities . These aAmongst paediatric patients, hydrosalpinx appears to be most common in the perimenarcheal phase , possiblClinical onset of fallopian tube disease is highly variable. There is often associated pain, but occasionally, no pain may be noted . Where tImaging is paramount in diagnosing hydrosalpinx. In children with acute or subacute-onset pelvic pain, trans-abdominal ultrasound is the preferred initial imaging modality . UltrasoUltrasonography of hydrosalpinx can easily demonstrate dilatation at the ampulla  or an elMagnetic resonance imaging is also useful to differentiate hydrosalpinx from other similar presentations , 5. FluiImaging is also useful in allowing us to determine whether dilatation is acute or chronic. More acute conditions are demonstrated by the ‘cogwheel sign’, which shows subtle, linear projections protruding into the lumen . ChronicFurthermore, we can review potential complications using imaging. On both ultrasonography and MRI, a characteristic whirlpool sign is classically noted where tubal torsion is present . This isHowever, it is not possible to make a definite diagnosis without diagnostic surgery, thought this is obviously invasive. The benefits of surgical investigation, like laparoscopy, include possibility of simultaneous treatment if an abnormality is detected .There remain some drawbacks of using ultrasonography , includiHydrosalpinx is a known cause of fallopian tubal torsion, which can have an adverse impact on fertility due to possible tubal and ovarian necrosis. Moreover, torsion itself can result in acute abdominal pain, nausea and vomiting. Torsion is three times more frequent on the right tube than left, likely due to the cushioning effect of the sigmoid colon on the left tube . IsolateHydrosalpinx itself can be painful with the enlargement of a mass in the abdomen. This can change with the waxing and waning of hydrosalpinx with reabsorption of hydrosalpinx and subsequent re-accumulation .Fallopian tube pathologies, including both ovarian cysts and hydrosalpinx, indicate surgical intervention when presenting as an acute abdomen . A low tThe types of surgeries offered vary. Salpingectomy refers to the surgical removal of a Fallopian tube, and is often preferred over other surgeries where the tube and ovary are preserved, as those operations have a higher risk of future ectopic pregnancies. While salpingectomy is most often indicated for ectopic pregnancies, it is also used to manage tubal damage, as in hydrosalpinx.Historically, salpingectomies were completed using a laparotomy approach. With technological advances, a laparoscopic approach is increasingly favoured as it avoids the larger laparotomy incision, leading to less post-operative pain and quicker discharge .Bilateral salpingectomy is a cause of female sterility and should be avoided. Hydrosalpinx resection has previously been recommended where there is no functional ipsilateral ovary .Other surgical procedures which may be considered include salpingostomy, salpingopexy and detorsion. Salpingostomy is a tubal corrective surgery and eliminates the need for tubal loss. However, it is also associated with a significantly increased rate of ectopic pregnancy post-operatively . SalpingIn paediatrics, all cases requiring surgery must be considered carefully, with the decision to operate being weighed against the use of an invasive management approach in asymptomatic minors. Furthermore, often, paediatric operations can be inherently more challenging, with variable anatomy and aetiologies. The decision to operate in paediatric hydrosalpinx presents its own unique set of challenges. In managing paediatric hydrosalpinx, there is a fine line between under-treatment and over-treatment. In under-treatment, there is a risk of tubal or ovarian torsion, recurrence, tubal pregnancy and infertility . With ovHydrosalpinx often adversely affects future fertility. The presence of this structure can cause inflammation of the fallopian tubes, and free uterine fluid can impact implantation . The preThere are reports of resolution of hydrosalpinx in adult patients in the literature. The findings from this case presentation are quite novel because a spontaneous resolution of this condition in paediatrics has never been clearly reported in the literature. However, in all cases of paediatric hydrosalpinx, a decision to operate is made quickly after presentation and diagnosis. Perhaps, in prior cases, due to the speed in operating, there was insufficient time for a spontaneous resolution.Utilize a watch-and-wait approach for asymptomatic hydrosalpinx. Ensure that patients and parents/guardians are educated on the condition and all potential risks.Routine ultrasound scanning to assess changes in hydrosalpinx size/shape/location.If the hydrosalpinx is symptomatic and suggestive of possible tubal/ovarian torsion, emergency surgery should be offered, with detorsion or salpingectomy depending on potential for revascularization.Given that this case report suggests potential for spontaneous resolution, our proposed management for conservative management is as follows:We have presented this case report of a 12-year-old girl with what appears to be spontaneous resolution of possible hydrosalpinx not requiring any medical or surgical management. Paediatric hydrosalpinx is often treated with surgery, particularly salpingectomy, in order to prevent future risk of ovarian torsion and thus to preserve fertility. However, salpingectomy can be associated with reduced fertility as well. We hope to propose a case for a watch-and-wait approach without any intervention for asymptomatic possible hydrosalpinx in order to minimize any unnecessary treatment in a paediatric patient.


Interstitial deletions of chromosome 11 long arm are rarely observed and the associated phenotype ranges from normal to severe, depending on the position and size of the deletion and on the presence of unmasked recessive genes on the normal homologous. To our knowledge 32 cases are reported in literature with three family cases. Phenotype-genotype correlation is not very clear and the most common features are characteristic facial dysmorphisms, palate anomalies and developmental delay. Growth retardation is not typical and other major malformations are reported in some cases.We described a child with 11q interstitial deletion diagnosed at birth with hypotonia and minor dysmorphisms using standard cytogenetic techniques; array CGH was subsequently performed to define the deletion at a molecular level.This case gave us the opportunity to attempt a genotype-phenotype correlation reviewing the literature and to describe a rehabilitative program that improved the development perspectives of this child. Only in seven reports the deletion was characterized by cytogenetic molecular techniques [Terminal 11q deletions are reported in literature to be associated with the well-described Jacobsen Syndrome. On the contrary interstitial deletions are very uncommon and heterogeneous in size and location of breakpoints, spanning from bands 11q13 to 11q23. From the first description by Taillemite et al. , case IDchniques . The majchniques . PositioHere we describe a case of de novo interstitial deletion of chromosome 11 long arm identified at birth while investigating mild dysmorphisms and hypotonia. The long term rehabilitative program is described and the good results obtained allow us to be positive in the prognosis of similar cases of 11q interstitial deletions. Finally we attempt a genotype/phenotype correlation reviewing the literature to search candidate genes with a role in the phenotype.The proband is a boy and he is the only child born from a 36 year old father and a 27 year old mother. The parents were healthy and unrelated; paternal family history was negative for genetic diseases, while in the maternal family, eight members were affected by retinitis pigmentosa with an autosomal dominant pattern of transmission. Prenatal ultrasonographic evaluation gave normal results in fetal growth and morphology. No prenatal invasive genetic test was performed.The child was born by natural delivery after a 40 week gestation plus 5 days. Birth weight was 3420 g , length at birth was 52 cm, (between 50°- 75° centile), occipito-frontal circumference (OCF) was 35.5 cm (50°- 75° centile), APGAR score was 9/10. In neonatal period, the child presented hyperpyrexia  and greater than 10% weight loss, which regressed with adequate nutrition. Episodes of bronchospasm and tirage, repeated episodes of cyanosis and desaturation resolved spontaneously shortly before discharge (at one month of age). During childhood his height growth was at the lower limit. He did not show any major malformation, besides submucous cleft palate. Brain MRI scan did not show any structural anomalies.He had mild myopia and his hearing was normal. He did not show any significant medical complications.At the age of 12 years and 1 month his weight was 41.6 kg (25°-50° percentile), his height was 134.2 cm (<3° percentile) and his OFC was 53 cm (50° percentile). His Body Mass Index (BMI) was 23 (75°-90° percentile). Facial dysmorphic features included long face, high nasal bridge, short and smooth philtrum, micrognathia. He had small hands and nasal speech.Endocrinological analysis (IGF-1 dosage and growth hormone stimulation test with arginine) showed results consistent with isolated growth hormone (GH) deficiency. A further brain MRI scan, carried out when he was twelve, revealed a small pituitary gland. GH treatment has been advised and the patient has just started this therapy.Written informed consent was obtained from the parents for publication of this case report and any accompanying images.At birth, karyotype on peripheral blood lymphocytes was requested because of mild hypotonia and minor dysmorphic features.http://genome.ucsc.edu/). Array-CGH was performed according to the manufacturer’s instructions (Agilent Technologies) and allowed the identification of a more distal deletion of 17,2 Mb in size: from 11q14.3 to 11q22.3 . In the same region, 337 SNP probes showed a single allele  and expressive skills: he used gestures associated with vocalization to indicate, to formulate questions, to express disappointment or excitement. Then, speech therapy sessions began twice a week at the age of 4.The proband showed a deficit of phonetic and non-phonetic phonation. Later, rhinolalia and rhinophonia, and a deficit in coordination and in phonological memory were observed. Consequently, a double diagnosis of specific expressive language disorder and of childhood apraxia of speech was formulated.At 5 years, after one year of speech therapy, he achieved a quite complete phonetic repertoire, vocabulary increase with risk threshold for semantic errors, and emerging narrative skills. While he showed an adequate lexical comprehension, morphosyntactic comprehension was delayed of one year and communication was supported by mimics and gestures. At the same time, he developed social skills, showing more relational and playing capacities with peers and adults.At age 6, verbal speech was sufficiently intelligible despite the persistence of hypotonic and uncoordinated glosso-velo-pharyngeal muscles.His cognitive development, as measured by WIPPSI Scale, was in the lower limits of the normal range, with a discrepancy between verbal (VIQ) and performance (PIQ) scores  .At the age of 8, the proband presented an impairment in the ability of naming objects and in lexical retrieval with the help of phonemic cues. On using the Italian version of the Peabody Picture Vocabulary Test , comprehMorphosyntactic comprehension using the Rustioni Metz test  showed aMoreover, learning difficulties in the presence of a cognitive development at the lower limit of the normal range emerged. In particular, reading comprehension, measured using the MT battery of tests , was inaAfterwards, counselling to parents and teachers, together with neuropsychiatric follow up continued until today with longitudinal controls (twelve years). We considered highly important to support parents and teachers in finding a harmonious global development which could take into account not only the educational aspects, but also the emotional and relational sides.We were able to observe a global improvement in cognitive abilities . The CNTN5 gene, coding for contactins which mediate cell surface interactions in the development of the nervous system, is described as been involved in autism spectrum disorders . The GRIIn literature ,12,16,20The phenotype we observed in our case has only been described in one other report  in whichAfter considering all the collected clinical information, we drew the conclusion that it is not possible to define a distinctive phenotype of the 11q partial monosomy due to the heterogeneity in size and position of the deletions and to the absence of a minimal common deleted region. About family cases showing normal phenotype ,4 we couWe found this case particularly interesting because it gave us the opportunity to describe a rehabilitation program that we believe has improved the development perspectives of this child and therefore his quality of life.Written informed consent was obtained from the patient’s parents for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors do not have any competing interest, financial or otherwise, to declare.RN, FB contributed to design the study, collected the literature data and performed the neuropsychiatric evaluation of the patient and the rehabilitation programme and wrote a part of the article MB contributed to design the study, collected the literature data and wrote a part of the article. PS contributed to the neuropsychiatric evaluation of the patient. NV contributed to design the study, performed genetic studies on the patient, collected the literature data and wrote a part of the article. S.R. performed arrayCGH. LD and FN contributed to design the study and critically read the manuscript. AS, AS performed the paediatric evaluation of the patient. All authors read and approved the final manuscript.Literature review of the 11q interstitial deletions from proximal to distal deletion.Click here for file


We report a case of double primary liver cancer comprising hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). A 58-year-old Chinese man without obvious liver cirrhosis was diagnosed with multiple HCC in segment V (SV) and segment VIII (SVIII) of the liver. Preoperative abdominal magnetic resonance imaging revealed two solid masses in SV and SVIII. We performed hepatic resection of both segments. The tumors in SV and SVIII were pathologically diagnosed as HCC and ICC, respectively. Immunohistochemically, the HCC in SV was positive for carcinoembryonic antigen and negative for α-fetoprotein (AFP) and cytokeratin (CK), while the ICC in SVIII was negative for both AFP and CK. These observations confirmed the diagnosis of double primary liver cancer (HCC and ICC). Double primary liver cancer is extremely rare. We herein review previous reports of patients with a histological diagnosis of double primary liver cancer. Based on the findings of this case and the literature review, we speculate that the imaging findings of double primary hepatic cancer conform to the pathologic findings. Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) are the two main primary liver cancers. The occurrence of synchronous double cancers comprising different primary hepatic tumors is very low. Only 33 cases of ICC with HCC have been reported , and a s12/l; hemoglobin, 95 g/l; white blood cell count, 12.7 × 109/l; albumin, 40.1 g/l; globulin, 18.4 g/l; total bilirubin, 13.2 μmol/l; and prothrombin time, 13.8 s. The alanine aminotransferase, aspartate aminotransferase, and lactate dehydrogenase levels were within their normal ranges. Hepatitis B virus-related antigen and antibody were negative with the exception of hepatitis B surface antibody (578.200 IU/l) and hepatitis B core antibody. The carbohydrate antigen 19-9, carbohydrate antigen 242, α-fetoprotein, and carcinoembryonic antigen levels were 331 U/ml, 167.31 U/ml, 9.53 ng/ml, and 3.61 ng/ml, respectively. Abdominal magnetic resonance imaging identified two liver tumors: one in segment V  and one in segment VIII  of the right lobe  is a rare primary liver tumor containing unequivocal elements of both HCC and ICC. In 1949, Allen and Lisa  first clDouble primary hepatic cancer is an unusual hepatic tumor comprising two histologically distinct tumors that exist simultaneously within the liver. The imaging findings of HCC often exhibit an area of hyperenhancement in the early phase and hypoenhancement due to washout of contrast medium in the late phase; otherwise, the ICC shows peripheral enhancement in the early and late phases. In the present patient, because both HCC and ICC occurred in the liver simultaneously, the imaging findings of these two distinct tumors could be compared in the same condition. In our patient, slight contrast enhancement was observed at the centrality of the mass in SVIII on magnetic resonance imaging obtained during the hepatic arterial and portal venous phases; concentric filling was shown on the delayed images Figure a. In conet al. [Surgery remains the only treatment option offering a potential cure for localized disease, especially in noncirrhotic patients, although the risk of recurrence may be higher than that associated with pure HCC or ICC . Lymph net al.  reviewedet al. [Previous studies have reported a poorer prognosis for cHCC-CC than for either HCC or ICC. The prognosis of combined HCC and ICC has generally been recognized to be poorer than that of ordinary HCC because of the ability of the combined type to metastasize to many organs . Cao et et al.  reportedIn summary, we have reported a case of double primary liver cancer (cHCC-CC) confirmed by pathological and immunohistochemical analyses. Although double primary liver cancer is rare, it must be considered as a differential diagnosis of liver tumors. Imaging findings may be helpful to achieve a correct preoperative diagnosis. If in doubt, intraoperative frozen section analysis may be necessary to select the correct surgical approach.Written informed consent was obtained from the patient for the publication of this case presentation and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


We report a case of lung carcinoma metastasizing into a meningioma in a 68-year-old female, who presented with progressively worsening right-sided hemiparesis and multiple episodes of adult onset epilepsy. Magnetic resonance imaging revealed an oval-shaped extra-axial hypointense lesion with a central hyperintense nodule in the left frontal region favoring a most probable diagnosis of a meningioma. Left frontoparietal craniotomy and excision of the tumor were carried out and histopathology with hematoxylin and eosin stain revealed a meningioma with metastatic adenocarcinoma and was confirmed by immunohistochemistry. The origin of metastasis was presumed to be from the lungs. A computed tomography (CT) scan of the chest with contrast showed a 3.1 x 2.9 cm mass with spiculated margins in the left lower lobe. Fine needle aspiration cytology (FNAC) proved it to be adenocarcinoma. Though it is common for more than one tumor to occur in the same patient, metastasis from one tumor into another is very rare (tumor-to-tumor phenomenon). Metastasis can grow into a meningioma, neurilemmomas, and gliomas. It can even grow in the same location from where an intracranial meningioma has been removed . We repoA 68-year-old female presented to our clinic with progressively worsening right-sided hemiparesis and multiple episodes of adult onset epilepsy. The patient had been previously seen by multiple specialty doctors for complaints of recurrent headaches, mood and behavior changes for the past six months. This was associated with decreased appetite and sleep. There was no history of head trauma, and no focal neurological deficits were found during the initial evaluations, general physical and neurological examinations. Four weeks ago the patient experienced a sudden onset of weakness in her right limbs. The patient developed an unsteady gait and her condition deteriorated to a point where she could neither walk nor stand without support. The patient experienced an episode of a severe headache with epilepsy. The episode, which subsided on its own, was witnessed by the patient’s relatives, who reported that the patient was jerking and had lost consciousness for two minutes. No episodes of tongue biting, rolling of eyes or loss of bowel or bladder control were witnessed. At the clinic, neurological examination of the patient revealed no cognitive deficits. Cranial nerve examination was normal. The power had significantly decreased in the right upper and lower extremities. Muscle tone was slightly decreased and reflexes were slightly weaker on the right side. The patient could not stand up or walk.T1-weighted magnetic resonance imaging (MRI) showed an oval-shaped extra-axial hypointense lesion with a central hyperintense nodule in the left frontal region Figure . The mosIntracranial meningioma is a relatively common tumor with an incidence of four per 100,000 and a female predominance of 2.5:1 . InteresHyo Sung Han, et al. suggested a criterion to assess a true tumor-to-tumor metastasis as follows. Firstly, the metastatic focus should be at least partially enclosed by a rim of tumor tissue, and the existence of metastasizing primary tumor must be proven and compatible with metastasis . The preA patient with a meningioma showing areas of abnormal enhancement can have widespread metastatic disease even if a primary is unknown. Tumor-to-tumor metastasis is a rare but important phenomenon, particularly in the case of invasive tumors. Transportation of malignant cells from the lungs can be easily explained by the extensive and high blood flow in the meningioma vessels. The only diagnostic approach towards identifying an intrameningioma metastatic lesion is through biopsy of the tumor. An optimal management approach towards treatment of superimposed malignancies needs to be developed.


Seborrheic pemphigoid (SP), first described in 1969 by Schnyder, is a peculiar variant of BP which clinically resembles pemphigus erythematosus, since it is characterized by ruptured bullae and erosions covered with crusts involving the seborrheic areas. To the best of our knowledge, from the first description only four other cases of SP have been reported, of which two are in the English literature. We report an additional case of SP in a 56-year-old man with cervical spondylogenic myelopathy with very impaired mobility. Bullous pemphigoid (BP) is a chronic, autoimmune, often pruritic, subepidermal, blistering dermatosis occurring mainly in elderly individuals aged 70 years and older. Classically, patients present with large tense bullae on apparently normal or erythematous skin, located at the sides of the neck, axillae, groins, upper inner aspects of the thighs, and abdomen. Not rarely, excoriated, eczematous, papular, or urticarial lesions may precede the onset of the blisters , 2. In aThe latter variant is known as “seborrheic pemphigoid” and is a very rare form of BP, since there are only a few cases reported in the literature. We report an additional case of seborrheic pemphigoid in a patient with cervical spondylogenic myelopathy with very impaired mobility.A 56-year-old man presented to our clinic with a three-month history of recurrent and mild itchy bullae quickly evolving in erosive lesions covered by crusts located on his scalp, forehead, auricular and periauricular regions, and interscapular area (seborrheic sites). The patient had been previously diagnosed as having impetigo and seborrheic dermatitis; however, specific therapies for these disorders were found to be completely ineffective. His medical history included an untreated progressive (during previous 4 years) slight bilateral age-related sensorineural hearing loss (presbycusis); bipolar disorder (since he was 35 years old) controlled from about 5 years with quetiapine, duloxetine, and lorazepam; and cervical spondylogenic myelopathy with very limited mobility (from about 2 years) which had worsened considerably in the last six months. The cervical problem has been treated only with physical therapies . The man denied other drugs intake and health issues. Physical examination revealed very few flaccid blisters, several erosions , and hematic and serous crusts on a slightly erythematous background Figures ; NikolskSeborrheic pemphigoid (SP) is a peculiar variant of BP which clinically resembles pemphigus erythematosus , since it is characterized by ruptured bullae and erosions covered with crusts involving the seborrheic areas . The firWhen a blister is available, its histological examination shows a picture comparable to the classic form of BP, with a subepidermal cleavage . Direct  Malassezia yeast, which is notoriously localized to seborrheic sites, to activate the complement system, via either the alternative pathway or the classical pathway, with the possibility to amplify the complement-mediated inflammation which is characteristic of BP [ Malassezia yeast [The reasons underlying the peculiar location of the lesions in seborrheic areas in SP are not clear. It is well-known that the regional variability in the BP antigens skin expression may play a role in the distribution of the lesions of BP, given that the greatest concentration of BP antigens is in the skin of flexor surfaces of the arm, leg, and thigh, the most common sites involved in BP . On the ic of BP . Consideia yeast , the posia yeast , and theia yeast , 23.Although SP may sometimes be confused with seborrheic dermatitis or impetigo, the main differential diagnosis is pemphigus erythematosus. In our opinion, the negativity of Nikolsky's sign, as described in the present case, may help to suspect a SP rather than pemphigus erythematosus, since in the latter it is almost always present . Anyhow,With regard to the therapy, according to other authors , our cas