Background. Extraosseous Ewing's sarcoma in the spinal epidural space is a rare malignancy, especially in adults. Case Presentation. A 40-year-old male presented with back pain and urinary hesitancy. MRI revealed a thoracic extradural mass with no osseous involvement. He underwent surgery for gross total resection of the mass, which was diagnosed as Ewing's sarcoma. He was subsequently treated with chemoradiotherapy. He remains disease-free 1 year after surgery. Review of the literature indicated only 45 previously reported cases of spinal epidural extraosseous Ewing's sarcoma in adults. Conclusions. Extraosseous Ewing's sarcoma in the spinal epidural space is a rare clinical entity that should be included in the differential for spinal epidural masses. Its treatment is multidisciplinary but frequently requires surgical intervention due to compressive neurologic symptoms. Gross total resection appears to correlate with improved outcomes. Ewing's sarcoma (ES) is a malignant bone tumor of childhood and adolescence that occurs primarily in the diaphysis of long bones, such as femur, tibia, fibula, and humerus, but may also occur in other bony structures and cartilage tissue. This tumor was named after James Ewing, who in the 1920s described this small round blue cell tumor as being a separate entity from other histologically similar malignancies, such as lymphoma or neuroblastoma. It is the second most common malignant bone tumor after osteosarcoma, with the highest incidence in the second decade of life [ES is the main member of a group of tumors known as Ewing's Sarcoma Family Tumors (ESFTs), which also contains peripheral primitive neuroectodermal tumors (pPNET). ES and pPNET are small round blue cell tumors; they were originally described as different entities; however, they are now recognized to represent ends of the morphologic spectrum of the ESFTs due to their close molecular relationship –7. Some Ewing's sarcoma has two forms: the more common osseous Ewing's sarcoma (OES) and the relatively rare extraosseous Ewing's sarcoma (EES). EES has been reported in various tissues, including the chest wall, larynx, kidney, and esophagus. EES was first described by Tefft et al. in 1969, when they reported four patients with paravertebral soft tissue tumors histologically resembling ES . AngervaSpinal epidural EES in adults is a rare presentation among those locations where EES may occur. Here, we present an adult patient we recently treated, who represents only the 46th case of adult spinal epidural EES in the literature. Neurosurgeons should be aware of this rare clinical entity, which often presents with myelopathic and radicular symptoms associated with an epidural mass on imaging studies. Our review sheds light on the diagnosis, management, and prognosis of these cases.The patient is a 40-year-old male, previously healthy, who presented to the emergency department with several weeks of back pain and some urinary hesitancy lasting a few days. MRI of the thoracic spine indicated a heterogeneously enhancing extradural mass within the spinal canal at T10–T12, causing severe cord compression . The masThe patient underwent a T10–12 laminectomy for gross total resection of the tumor , with prPathologic examination indicated a small round blue cell neoplasm  composedPostoperative MRI and PET scan did not reveal residual or metastatic tumor . The preSpinal epidural EES in adults represents a very small fraction of spinal epidural masses and a rare presentation among those locations where EES may occur. We performed literature searches on PubMed to identify reports of spinal EES. We identified 119 cases of spinal EES in the literature from 1969 to 2015. In 43 of these cases the tumor was intradural, while it was localized to the epidural space in 76 cases. Of the epidural EES cases, 31 cases were pediatric patients and 45 were adults . TreatmeThe review of the literature on combined pediatric and adult spinal EES/pPNET showed that the lumbar region is the most common site, followed by the thoracic and cervical spine, with the sacral region being the least common (5% of cases) , 12. HowSpinal EES in adults shows a predilection for males (61% of the cases), with a male : female ratio of 1.6 : 1, similar to that of OES , 14. TheThe mean diagnostic delay calculated from the previous cases is 4.5 months , which iEwing's sarcoma shows vague lobular proliferation of uniform small round blue cells with clear to lightly eosinophilic cytoplasm, evenly dispersed chromatin, and indistinct nucleoli. Peripheral PNET may specifically contain neuroblastic pseudorosettes termed Homer-Wright rosettes , 15, 17.Immunohistochemical studies show that EES/PNETs strongly express cell surface glycoprotein CD99 (MIC2). This biomarker is considered one of the most accurate diagnostic tools and is positive in more than 90% of EES/pPNET cases. However, it is not exclusively specific for these tumors .Approximately 25% of EES/pPNETs demonstrate aberrant expression of keratins, typically considered an epithelial marker. Expression of at least two different neuroglial antigens, such as neuron-specific enolase (NSE), protein S100, chromogranin, or synaptophysin, is required to distinguish pPNET from ES, with the former typically showing more neuronal differentiation , 17, 19.At the genetic level, more than 90% of ES/pPNETs contain the same t translocation. Other translocations occur in 5–10% of cases . The t correlates with a much better outcome and decrease in recurrence rate than subtotal  resection. Of the reported 46 cases in this paper, 45% had a subtotal resection (STR), while 55% of the cases had a GTR. Although partial resection has an increased risk of recurrence, complete resection is often precluded by tumor infiltration to the surrounding neural and paraspinal tissues.Evidence from the literature strongly supports the use of local RT and systemic chemotherapy for treatment of EES/pPNET. Chemotherapy regimens for OES are often followed in adults with EES/pPNET. In the past, a traditional regimen was VACA . The addition of ifosfamide and/or etoposide to that regimen was the subject of many studies. In 1998, Ferrari et al. reported that ifosfamide/etoposide added to the induction, and maintenance phase of chemotherapy along with VACA resulted in a significantly better outcome in terms of histologic response and overall survival (OS) . Other sCurrently, the guidelines for treatment of ESFTs consider VAC/IE as the preferred first-line regimen for localized disease, concurrently with radiotherapy (45 Gy in 25 fractions). Regimens such as VAdriaC  are used to treat metastatic disease . Most ofPatients who underwent combined chemoradiotherapy after GTR or STR had better 1-year survival rates than patients treated with surgery, chemotherapy, or radiotherapy alone  [The prognosis of adult spinal epidural EES/pPNET is poor compared to OES. A study at Dana-Farber Cancer Center concluded that age plays an important prognostic factor, as survival rates are reduced in older adults. Also, primary extraosseous tumor and metastatic disease at diagnosis were adverse prognostic factors, even though both chemotherapy and radiotherapy were administered to patients with those three risk factors . AnotherAlthough primary spinal epidural EES/pPNET in adults is extremely rare, it should be considered in the differential diagnosis of patients with a history of nonspecific back pain and/or radicular pain, especially if accompanied by abnormal neurological examination and an epidural mass on MRI. The disease has an aggressive course, as evidenced by a high incidence of metastases and low survival rates reported in the literature. Early recognition of the disease entity and definitive management is essential. A multidisciplinary approach is the best strategy to manage epidural EES/pPNET, with surgical excision often being the initial intervention, due to neurological symptoms arising from spinal cord compression. Surgical resection should be followed by a combination of adjuvant chemotherapy and radiotherapy to improve overall outcome.


Adenomatoid tumor is one of the most common histological subtypes of paratesticular cancer arising from the epididymis. In very rare cases, these tumors appear as intratesticular lesions originating in the tunica albuginea, representing a diagnostic challenge.We present a case of a 51-year-old man with a small (0.9 cm) hyperechoic lesion of the left testicle mimicking testicular cancer on multiparametric ultrasound. The lesion was localized in the peripheral zone, confirming vascularization and increased stiffness on contrast-enhanced ultrasound and real-time elastography. Preoperative tumor markers and hormone levels were within normal ranges. Staging computed tomography was negative. Organ-sparing surgery with tumor enucleation and frozen section analysis was performed, confirming testicular adenomatoid tumor.Currently, no typical ultrasound features can definitively distinguish intratesticular adenomatoid tumors from malignant testicular masses. Thus, a surgical approach is almost always considered in such a case for both diagnostic and therapeutic purposes. Adenomatoid tumors in the male urogenital tract are benign mesenchymal tumors mostly located in the lower or upper pole of the epididymis , being rWe present the case of a patient with adenomatoid tumor of the left testicle mimicking imaging characteristics of a malignant testicular cancer on multiparametric ultrasound.A 51-year-old man was referred at the urological department due to the primary suspicion of a left testicular cancer. Staging computed tomography of the thorax, abdomen, and pelvis was negative for lymphatic or hematogeneous metastatic tumor spread. Moreover, testicular tumor markers such as α-fetoprotein (AFP) and beta-human chorionic gonadotropin (β-hCG), and preoperative hormone levels  were within normal ranges.Testicular ultrasound confirmed a 0.9 × 0.9 × 1.0 cm rounded, peripheral, and hyperechoic lesion of the lower pole of the left testicle . Final pathology report confirmed a completely removed adenomatoid tumor of the left testicle arising from the tunica albuginea.Adenomatoid tumors that arise very rarely in the testicles in contrast to the epididymis are a difficult diagnostic challenge in the clinical practice that may lead to unnecessary orchiectomy . These tIn conclusion, no typical ultrasound features can definitively distinguish intratesticular adenomatoid tumors from malignant testicular masses. Thus, a surgical approach is almost always considered in such a case for both diagnostic and therapeutic purposes.


Hepatocellular cancer is one of the most common and fatal cancer tumor worldwide. However, the obtained results are questionable in terms of medical treatment of hepatocellular cancer. The muscle, soft tissue and cutaneous metastases of hepatocellular cancer, for instance, are rare and may result from interventional procedures. Seeding of tumor along the biopsy needle upon percutaneous biopsy is a very rare phenomenon. We report a very rare case of a 79 -year- old man, known to be hepatitis C virus carrier with a metastatic tumor in abdominal wall caused by seeding of tumor after three years following a percutaneous biopsy procedure. Even years later, after a biopsy procedure for diagnostic purposes and may be soft tissue metastases. This complication is a very rare condition that should not be ignored but can be observed. The biopsy requirement should be questioned closely and avoided unnecessary biopsy procedures. Both biopsies were considered inadequate. It was found to be positive for anti-HCV, he had normal results for liver function tests and tumor marker investigations, and he was observed without any medical treatment. He had no complaint in follow-up.In 2014, the patient came to our hospital with a palpable, painless mass in the right upper quadrant; liver function tests and level of alpha fetoprotein were normal, and abdominal tomography showed a highly vascularized mass of 10x7x12 cm with irregular contours located in thoracic-abdominal wall at the left lobe of liver, segment 4, with multiple lesions of 2 cm in size adjacent to this lesion in the intra-abdominal and sub-hepatic regions on the right side . It was The patient known to be a Hepatitis C carrier exhibited no clear results upon inadequate biopsy sampling performed three years ago, had normal results in liver function tests, and he was observed without any medical treatment. For the last three months, patient who had right flank pain and the mass on the right side, levels of AFP and liver function tests the patient’ s were normal marked. Biopsy was performed to explain the etiology of the patient’s right hand side of the painless mass. We realized that the tumoral seeding had occurred due to inconclusive biopsy sampling performed three years ago according to pathologist’s report. Seeding of tumor after interventional procedure is rather rare.Seeding of tumor may occur at a rate of 2.29% biopsy with percutaneous ethanol injection, 1.4% alone liver biopsy, 0.95% radiofrequency ablation with biopsy, and 0.61% radiofrequency ablation without biopsy.8Another trial has also shown that the risk of seeding within 3 months and 4 years following biopsy was between 0% and 5.1%. In the report of studies that the patients should be monitored for a minimum of 4 years for the presence of such a risk.The most of time radiological imaging may be sufficient for diagnosis of HCC and biopsy procedure shouldn’t be administered except in very exceptional circumstances. If a biopsy is performed, it would be remembered that there is a risk of seeding and this situation may occur years even after the procedure. If the biopsy is done, the procedure should be performed by qualified professionals, by using appropriate technique and needles in unique expedition. While seeding of tumor following biopsy is an extremely rare phenomenon, it should not be overlooked.


Introduction:The necessity for complex and multidisciplinary approach of “border” surgical pathology has unanimously been agreed upon for such a long period of time, its advantages becoming even more obvious in rare, particular cases.Patients and methods:We report the case of a 39 year-old man diagnosed with lymphangiomatosis back in his childhood. He is admitted with a giant pseudotumoral scrotal mass presenting an important scrotal enlargement (40/35 cm).Physical examination, blood tests, ultrasound, IVP, abdominal and chest CT, psychiatric and plastic surgery evaluation established the diagnosis: peno-scrotal lymphedema with gigantic hydrocele and depressive disorder. Taking into account the important enlargement of the scrotum associated with the alteration of the local skin, we decided to form a mixed surgical team: urology - plastic and reconstructive surgery.We performed bilateral surgical therapy of hydrocele with partial excision and eversion of sac edges, excision of peno-scrotal skin and subcutaneous tissue surplus. At the end we made a reconstruction by using a partial-thickness graft from the normal skin of the left thigh.Results:Spinal anaesthesia was sufficient in order to perform a qualitative complex surgery. Intra and postoperative course was uneventful with minimal blood loss.Conclusion:Rare cases like this one clearly reveal the advantages of a multidisciplinary surgical team by combining usual surgical procedures from different specialities that could lead to spectacular results. Lymphedema is an abnormal collection of protein-rich fluid in the interstitium and, regardless of etiology, is caused by inadequate lymphatic drainage leading to a chronic inflammatory process of hypertrophy and hyperplasia of connective tissue.Peno-scrotal lymphedema is a condition which leads to the progressive enlargement of the scrotum and penis causing significant psychical discomfort for patients, making both sexual intercourse and urination act difficult or even impossible, impairing movement and proper hygiene of the perineal region.The lymphedema is classified into primary, idiopathic - when it is caused by lymphatic malformation and could be congenital (Milroy disease), lymphedema praecox , and lymphedema tarda (after 35 years old).Wuchereria bancrofti warm (that causes filariosis) transmitted by mosquito bites migrate to the lymphatic tissue of the scrotal region causing lymphedema [1].Secondary lymphedema is due to an acquired obstruction and most frequently is the result of a parasite spreading disease – filariosis. The larvae of But the second type of lymphedema can result out of inflammatory or infectious diseases such as lymphogranulomatosis, tuberculosis or bacterial cellulitis.The most common etiologic malignancy is the prostate cancer with metastases inguinal lymph nodes.1], [2], [4].Surgical procedures, especially inguinal lymphadenectomy and radiation therapy in the pelvic region, can also be important causes. Literature mentions only one case of peno-scrotal lymphedema after complicated circumcision .The peno-scrotal lymphedema secondary to silicon subcutaneous or intradermic penian self injection is also described .Surgical treatment based on the restoration of lymphatic drainage with different anastomoses is not used anymore due to poor results [5].The excision of all the affected penile skin and subcutaneous tissue is a fundamental principle for an uneventful postoperative evolution and good plastic results ,[8].The coverage of the penile shaft with split-thickness skin graft is the optimal choice due to its very impressive cosmetic results. In the same time, the use of flaps could affect tactile sensitivity and erection, so, this technique has lost its supporters over time [The plastic surgery result is impressive when it is seen through the eyes of a patient with better mental status and recovered self-esteem.


The paranasal sinuses mucoceles are benign expansive cystic lesions that occur rarely in the sphenoid sinus and contain mucous material enclosed by cylindrical pseudostratified epithelium. To report one case of sphenoid sinus mucocele that occurred with headache and was submitted to surgical treatment through endonasal endoscopy approach. 59-year-old male patient with history of increasing frontoorbital, bilateral, fluctuating headache and exophthalmos. There was no other associated clinical abnormality. Computed Tomography (CT) and Magnetic Resonance Image (MRI) scans confirmed an expansive mass of sphenoid sinus, suggesting mucocele. The patient was submitted to endonasal endoscopic surgery with posterior ethmoidotomy, large sphenoidotomy, and marsupialization of the lesion. Mucoceles of the sphenoid sinus are a very rare condition with variable clinical and radiological presentation. Surgical treatment is absolutely indicated and early treatment avoids visual damage that can be permanent. Endonasal endoscopic approach with drainage and marsupialization of sphenoid sinus, using a transnasal corridor, is a safe and effective treatment modality. The paranasal sinuses mucoceles are benign expansive cystic lesions that occur rarely in the sphenoid sinus and contain mucous material, enclosed by cylindrical pseudostratified epithelium . The treA 59-years-old male patient, with a 2-year history of increasing frontoorbital bilateral and fluctuating headache, is presented. There was no other associated clinical abnormality, loss of vision, or nasal obstruction. On admission, there was no sign of meningeal irritation. Clinical exam showed bilateral exophthalmos. Ophthalmological review and fundoscopy were normal. Eyes movements were normal and painless, and neurological examination was negative. He has no history of local radiation or surgery. Rhinoscopy was negative.Initially, head and paranasal sinuses CT scan was performed and revealed a large, isodense, well-defined, expansive space-occupying lesion in a midline location, centered in the body of the sphenoid bone and extended to posterior ethmoid cells. The lesion was causing marked thinning of the sphenoid sinus bony wall with bony erosion areas. There were no calcifications. MRI shows a hyperintense lesion on T1 and a hyperintense lesion on T2 weighted images. There was no suppressed fat on STIR sequence . In sagiThe patient was submitted to endonasal endoscopic approach with large sphenoidotomy, marsupialization, and bilateral posterior ethmoidectomy. During nasal step right inferior and middle turbinates were lateralized and bilateral superior turbinates were removed. The anterior wall of sphenoid sinus was protruded forward between both middle turbinate and nasal septum. In order to make a large sphenoidotomy the posterior septum was removed. During this maneuver draining was carried out and the mucocele was empty. The sphenoidotomy showed a little solid mass, occupying clival recess that was removed. It was very thick and adherent to the walls of sphenoidal mucosa, covering an osseous erosion area, especially in opticocarotid recess region . Sphenoi revision surgeries monthly during the first 6 months before surgery without nasal synechiae or other complications. He presented a complete improvement of the algic picture and postoperative CT scans showed an air-filled cavity replacing the lesion in the sphenoid body with no residual soft-tissue lesion  and there is no sex prevalence. The interval between the first symptoms and diagnosis varied from 3 days to 38 years, with an average of 3.7 years . SymptomMucoceles may have variable densities on CT (most of them being hypodense) and variable signal intensities on MRI, according to their water and protein content, density, and possible infection (most of them being isointense on T1 and hyperintense on T2 weight images) and do not show contrast enhancement except some cases with thick encapsulation . The difDifferential diagnoses include necrotic primary adenoma with significant intrasellar extension, craniopharyngioma, chordoma, plasmacytoma, osteoma, osteoblastoma, basal cell and squamous cell carcinoma, rhinolitis, polyps, and fibrous dysplasia . The RMIStaphylococcus aureus, Staphylococcus epidermidis, and streptococci). In such cases, antibacterial therapy should be based on the organisms most likely to be encountered. In case of sterile contents high spectrum of antimicrobial drugs is recommended [The contents of mucoceles are usually sterile, although there may be infected, named mucopyoceles. In those cases, the most frequently isolated germs are Gram-positive organisms (ommended .Surgical treatment is absolutely indicated in mucoceles . The purMoryiama et al.  did not Sphenoidal mucoceles unusually contain calcifications within their wall . In thisMucoceles of the sphenoid sinus are very rare condition with variable clinical and radiological presentation. Surgical treatment is absolutely indicated and early treatment avoids visual damage that can be permanent. Endonasal endoscopic approach with drainage and marsupialization of sphenoid sinus, using a transnasal corridor, is a safe and effective treatment modality.


Portal vein aneurysms are extremely rare, less than 200 cases have been reported until late 2015. They are defined as a portal vein diameter exceeding 19 mm for cirrhotic patients and 15 mm in normal livers. Most patients are asymptomatic, but complications may occur. We report a case of a 68-year-old female admitted for etiological assessment of a portal hypertension revealed by an upper gastro intestinal bleeding, who was incidentally diagnosed with a portal vein aneurysm. Venous aneurysms are uncommon, and have been reported to occur in most major veins. Portal localisation accounts for around 3% of all venous aneurysms . It is dWe report the case of a 68-year-old female with no past medical history, presented with an upper gastrointestinal bleeding and pain in left upper abdomen. Physical examination found a splenomegaly and signs of portosystemic collateral formation including abdominal wall dilated veins and rectal haemorrhoids. No biological abnormalities were noted besides those due to hypersplenism (anaemia and thrombocytopenia). The patient underwent upper gastrointestinal endoscopy that showed stage III oesophageal varices with portal hypertensive gastropathy and red signs. Ultrasonography revealed a fusiform dilatation of the portal bifurcation measuring 40 mm in diameter with dilated branches; no signs of portal thrombosis were detected . The porAneurysms in the visceral veins are uncommon, but they have been described in most major veins . Portal Portal vein aneurysm and portal calcifications are both rare entities that are associated to portal hypertension, they may both be incidentally found in an ultrasonography or an angio-CT scan of a patient suffering from a portal hypertension, regardless of underlying etiology.


Sciatica is a common clinical presentation with a number of etiological factors. Many of them are innocuous like prolapsed intervertebral disc or peripheral compression in the sciatic nerve. Occasionally the cause could be of a more serious nature like a nerve sheath tumor or more infrequently, lymphomatosis. We describe recurrent lymphoma in a patient who had been in remission presented with sciatica as result of the involvement of the nerve with metastatic tumor. Neurolymphomatosis (NL) is an uncommon presentation of lymphoma in which there is an infiltration of cranial nerves, spinal roots, or peripheral nerves by lymphoma cells in the setting of a known or unknown hematologic malignancy . It is iA 23-year-old female was diagnosed with DLBCL in October 2010. PET scan had shown that her disease was based in the mediastinum and was characterized by bulky lymphadenopathy. The patient had experienced back pain secondary to the mediastinal disease. She immediately began chemotherapy with the CHOP-R protocol. Completion of the protocol in February 2011 resulted in full resolution of her symptoms. Follow-up PET imaging demonstrated no evidence of lymphoma.In June 2011, a surveillance PET/CT scan revealed a tubular-shaped density within the left thigh . MRI evaIt has been shown that up to 40% of DLBCLs present with extranodal disease, and that the vast majority of NL cases are B-cell lymphomas . HoweverCommon presentations of NL include painful peripheral neuropathy, painful radiculopathy, cranial neuropathy or a painless polyneuropathy . PresentDue to NL having associations with a history of non-Hodgkin’s lymphoma or leukemia, patients presenting with a mono- or poly-neuropathy should be worked up for in intraneural tumor.


To report the clinical evolution and handling of a Spitz nevus, from its initialflat feature to becoming an irregular, nodular, reddish lesion. Female child, phototype II, with a small congenital nevus on the left lower limband other sustained small nevi. The patient went through annual clinical anddermoscopic evaluations between the ages of three and seven, period during whichthe nevi located on the left thigh grew rapidly. The clinical hypothesis was Spitznevus, with indication of surgical removal with a safety margin andanatomopathological study. Considering patient’s age and clinical/histologicalaspects, the diagnosis of Spitz nevus was confirmed.  Initial globular pattern and size under 5 mm upon dermoscopy allowed clinicalfollow-up. However, onset of hyperchromia and rapid growing of the lesion, alongwith aesthetic concerns, possibility of trauma in the region, and risk ofmalignancy at puberty guided the decision of total resection and follow-up forrecurrence. Nevi, also referred to as moles, are either congenital or acquired hamartomas that maypresent brownish or pinkish pigmentation that blackens by the activity of melanocyticcells, responsible for lesion onset. There being no consensus yet, the hypothesis isthat genetic factors and sun radiation can alter the characteristics of suchlesions.Spitz nevus predominates in children and young people. It is named after Sophie Spitz,who first described it in 1948 as juvenile melanoma. When present in adulthood, nevuscan be confused with melanoma, so a thorough evaluation by dermoscopy and histologicalstudies are required to rule out the hypothesis of an aggressive lesion.This clinical case aims to demonstrate the clinical evolution of a Spitz nevus in achild.Female child, phototype II, presenting a small congenital nevus on the left lower limband other small acquired nevi, underwent annual clinical and dermoscopic examinationsbetween the ages of three and seven for monitoring.At three years and seven months of age, during summer, onset of new lesion on the leftthigh, close to the groin. Lesion was flat, measuring roughly 1 mm  and clasUnder gas sedation and local infiltration anesthesia, a spindle-shaped incision was madewithin a 2-mm safety margin, both around the lesion and at depth. The surgery wasfinished with mononylon suture 7.0. The piece was then fixed in a 10% formalin solutionand referred to histological analysis. At macroscopy, the nevus removed from the leftthigh measured 0.5 x 0.4 x 0.2 cm and had dome-shaped center, grey-brownish color andslightly bosselated surface, being submitted to histological examination. Uponmicroscopy, a skin fragment with a slight central bulging was analyzed because ofintradermal proliferation. At dermal-epidermal junction, nests of nevus cells with asmall amount of melanin pigment in cytoplasm were found. Their nuclei were rounded, withslight volume variation and no atypia, but with some binucleations or multinucleations.Junctional nests of epithelioid pattern were predominant. No fusocellular component wereidentified, but several Kamino bodies and matured dermal components were present. Theoverlying epidermis had intense papillomatosis with mild hyperkeratosis, and thesurgical margins were free of lesion. There were no signs of malignancy, so thehistological findings along with macroscopic study and clinical report suggested Spitznevus .Spitz nevus is nowadays treated as a single entity and, given its difficult diagnosiseven by histological analysis, it may be classified by its structural characteristics asjunctional, intradermal or, more commonly, compound nevus.2.,Many lesions are indistinguishable from melanoma in adults,The most important and peculiar dermoscopic pattern in this lesion is starburst, in 53%of cases, followed by globular (22%) and atypical patterns (25%), the latter beingconsidered a confusing factor for melanoma diagnosis.Criteria to define the biological behavior of this lesion are still unclear. Someclinical features suggest greater potential for malignancy, such as size larger than 1cm, tumor extension to subcutaneous tissues, ulcerations, and high mitosis index uponhistology.,Spitz nevus occurs more commonly on the face and lower limbs of children andadolescents.Pediatric patients less than 12 years old and presenting with clinical and dermoscopiclesions suggestive of Spitz nevus were followed up in regular consultations for twoyears, and it showed that some lesions may involute, stop growing or evolve, increasingin size at the same cellular pattern or becoming malignant.,Just like other authors,


Trichobezoar is a rare gastrointestinal pathology, but should be considered in patients with abdominal mass and previous history of trichophagia. In physical examination, it is important to verify signs of alopecia. Minimally invasive surgery is a secure method to remove the specimen from the stomach. Question: What does this surgical specimen represent?Answer: This is a gastric trichobezoar surgically removed from a 14‐year‐old‐patient with previous history of trichophagia. The patient presented in the emergency room with a previous story of epigastric pain and abdominal distension for the last 6 weeks. Abdominal computed tomography was performed and suggested trichobezoar, confirmed by upper endoscopy, which was unable to remove the specimen. As the patient was symptomatic, surgical intervention was indicated. A laparoscopic gastrostomy was performed, and the specimen was removed from the abdominal cavity toward a Pfannenstiel incision (Fig. DJS: prepared the manuscript, member of surgical team. ARD: reviewed the article, member of surgical team.None declared.


Laparoscopic cholecystectomy (LC) is preferred in the treatment of symptomatic cholecystolithiasis. Gallstone spillage is not uncommon, and there have been reports of associated complications. We report a case of a free intraperitoneal gallstone, left inadvertently during LC, which developed an inflammatory phlegmon with abscess containing gallstone, causing extraluminal compression on the distal ileum, resulting in small bowel obstruction. This complication in particular is almost unheard of. The patient underwent laparoscopic drainage of abscess and retrieval of gallstone, which relieved the obstruction. Clinicians, therefore, need to keep an open mind in the workup for bowel obstruction. During LC, gallstone spillage should be prevented and retrieved whenever possible to minimize early and late complications associated with it. Laparoscopic cholecystectomy (LC) is the gold standard for treating symptomatic gallstones, with large studies and systematic reviews reporting reduced hospital stay and pain , 2. Compµmol/L, respectively; ALP, GGT, ALT, and AST were 333, 557, 194, and 158 U/L, respectively. His white cell count was 13.9 × 109/L, and CRP was 105 mg/L. A computed tomography (CT) scan was performed due to his atypical presentation to the emergency department, which showed cholecystitis with a distended gallbladder containing a 21 mm solitary lamellated calcified calculus. This was then confirmed on abdominal ultrasound, which, in addition to the above findings, showed that there was no evidence of choledocholithiasis or biliary duct dilatation.An 83-year-old man presented to the emergency department (ED) with upper abdominal chest pain with newly deranged liver function tests (LFTs) and raised inflammatory markers. On examination, he was found to be tender in the right upper quadrant as well as in the epigastrium. His LFTs were as follows: unconjugated and conjugated bilirubin were both 26 and 14 The patient underwent LC, performed by a senior surgical trainee with an intraoperative cholangiogram showing no filling defects in the biliary ducts and free flow of contrast into the duodenum. During the operation, the gallbladder was inadvertently opened whilst dissecting it from the liver bed, resulting in spillage of the large calculus. While retrieving the gallbladder specimen in an endoscopic bag, the spilled calculus was left inadvertently in the peritoneal cavity. The operator did not realize that the spilled stone was unretrieved. The patient made an uneventful, gradual recovery and was discharged on postoperative day 1. Macroscopic histopathology report revealed a partially opened gallbladder with no gallstone within the lumen, suggesting that the spilled large calculus was not retrieved from the peritoneal cavity. Microscopically, it was consistent with acute and chronic cholecystitis with muscle hypertrophy and fibrosis of the wall.The patient re-presented to the emergency department 3 weeks after discharge with central abdominal pain, anorexia, and vomiting. He had been experiencing these symptoms since day 3 of discharge, and they had been getting worse until the time he re-presented. In spite of these symptoms, he was systemically well. Examination of the abdomen revealed minimally distended abdomen with tenderness in the periumbilical region. These symptoms and signs suggested that he had small bowel obstruction. However, in the setting of recent cholecystectomy, we wanted to rule out the possibility of a biliary injury. His LFTs and inflammatory markers were normal. His symptoms were further evaluated with a CT scan, which showed evidence of SBO with transition point in the right iliac fossa. The obstruction was from a laminated calcified structure applying extrinsic compression on a loop of small bowel. With the knowledge of the index operation and the pathology report of the retrieved specimen, it was suspected that this structure was the unretrieved gallstone. This calculus was associated with a surrounding phlegmon, evidenced by intense inflammatory change on the CT scan .The patient underwent laparoscopy in view of the CT scan findings. Laparoscopy identified a large phlegmon compressing on the distal ileum causing obstruction with distended proximal and collapsed distal small bowel loops . DissectLaparoscopic cholecystectomy has now become the gold standard in treating symptomatic gallstones since its introduction in 1987. Spillage of gallstones during LC is not uncommon –7. It caThe adverse events, in general, from unretrieved gallstones following LC are uncommon as reported by Manukyan et al. . This waJabbari Nooghabi et al. recently reviewed 10 large case series reporting on postoperative complications from spilled gallstones during LC , 24. MosThe management of spilled gallstones is varied. Known literature suggests that every attempt should be made to retrieve the spilled gallstones irrespective of low rates of complications from them , 39, 40.Complications from unretrieved gallstones are rare. Small bowel obstruction from extrinsic compression from gallstones is extremely rare. The presentation of such complications is often vague and needs definitive diagnosis before considering operative intervention. Our case report emphasizes the need for detailed investigative modalities such as CT scan to accurately diagnose the nature of complication and the required surgical intervention. Although rare, unretrieved gallstones can cause significant complications as witnessed in our case. Operating surgeons should be vigilant in recognizing the spillage of large gallstones. We henceforth recommend laparoscopic retrieval of all spilled gallstones to the best possible attempt to prevent such complications.


BML) is a very rare condition and is characterized by the presence of benign smooth muscle tumours in organs distant from the uterus, most commonly the lung. It generally affects women of reproductive age and prognostic is usually excellent. However, the course of the disease is unpredictable. We report here the case of a 76‐year‐old woman with a previous medical history of uterine benign leiomyomas in whom BML was acutely revealed by a respiratory distress due to voluminous pulmonary and pleural leiomyomas requiring surgical extraction. Clinical evolution was remarkable by resistance to medical treatment and development of rare bone localization.Benign metastasizing leiomyoma (BML is a contradictory entity characterized by benign histological features but with metastatic potential. Pulmonologists as well as oncologists in charge of patients with multiple pulmonary nodules and a history of uterine leiomyoma should be aware of this potential diagnosis in order to implement appropriate diagnostic procedures for this benign tumour. Benign metastasizing leiomyoma (BML), characterized by the presence of benign smooth muscle tumours in organs distant from the uterus, most commonly the lung, is a very rare condition (<200 cases reported in the literature). It generally affects women of reproductive age with a history of benign uterine leiomyoma resection We report here the case of a 76‐year‐old woman in whom BML was acutely revealed by a respiratory distress and whose evolutive pattern was remarkable by resistance to medical treatment and development of a rare bone BML localization.A 76‐year‐old woman was admitted in intensive care for acute respiratory distress. She complained of an increasing and isolated dyspnoea developed over the previous months. Her medical history included heavy smoking habits , ischaemic coronaropathy, and a total hysterectomy 4 years previously for postmenopausal metrorrhagia. It had revealed multiple subserosal uterine benign leiomyomas with no evidence of extrauterine involvement at that time.On admission, she was severely hypoxemic with a saturation of 91% when breathing 6 L/mn of oxygen. Chest X‐ray showed a right, unilateral massive pleural effusion associated with bilateral parenchymal nodules. Biology was unremarkable. A pleural chest tube was rapidly inserted disclosing an exudate (49 g/L of proteins) with 80% lymphocytes. Clinical improvement was dramatic and chest high‐resolution computed tomography (HRCT) confirmed the presence of bilateral, well‐defined lung nodules with one of them reaching 15 cm in diameter . Surgical biopsy is therefore the most frequent approach to histopathological confirmation of BML. Various immunohistochemical markers such as desmin, muscle‐specific actin, and caldesmon confirm smooth muscle differentiation. Presence of oestrogen and progesterone receptors suggests a female genital tract origin and a hormone‐dependent growth. The usually low expression of Ki 67 and absence of cytological atypia argues for their benign nature In several other aspects, our patient was quite atypical. First, her age was higher than usually reported in the literature. Second, clinical presentation was unusually acute due to a massive pleural effusion and large pleural and pulmonary nodules mimicking a metastatic lung cancer in this ex‐heavy smoker. Third, bone localization with lytic femoral BML lesion has to the best of our knowledge not been reported before.Treatment options for BML include surgical removal in the first place, potentially iterative in case of recurring symptomatic lung nodules BML is a contradictory entity characterized by benign histological features but a highly metastatic potential. Pneumologists as well as oncologists in charge of patients with multiple pulmonary nodules and a history of uterine leiomyoma should be aware of this potential diagnosis in order to implement appropriate diagnostic procedures for this benign tumour.No conflict of interest declared.Appropriate written informed consent was obtained for publication of this case report and accompanying images.


Myasthenia gravis is an autoimmune disorder affecting the neuromuscular junction. Ocular myasthenia gravis presents as ptosis with extraocular motility restriction and is prone to be misdiagnosed as third nerve palsy or congenital or aponeurotic ptosis. Juvenile ocular myasthenia gravis in very young children is difficult to diagnose and can be easily labeled as a case of congenital ptosis, the more so when the condition is bilateral. We present a case of a two-year-old child who presented with bilateral ptosis and was diagnosed as a case of simple congenital ptosis elsewhere with the advice to undergo tarsofrontalis sling surgery. The child was diagnosed with juvenile myasthenia gravis on thorough history, examination, and systemic evaluation and was started on anti-myasthenic treatment.  Myasthenia gravis is the most common disorder of neuromuscular junction with an estimated prevalence of 20 cases per 100,000 population . ChildhoWe herewith report a rare case of bilateral juvenile myasthenia gravis in a 2-year-old child who was misdiagnosed with simple congenital ptosis and was also advised surgery for the same.A 2-year-old male child presented to us with complaints of drooping of both upper lids for the past 5 months. The parents reported improvement of drooping after sleep. They also complained that the motility of the eye balls was limited and the child turned the head to fixate on objects. The child had fallen from height 5 months back and the parents were correlating the complaints to the trauma. The patient had already been examined at some other centre where he was diagnosed to have congenital ptosis and was advised to undergo tarsofrontalis sling surgery to clear the visual axis and prevent amblyopia. On examination, visual acuity by fixation method was central, steady and maintained (CSM) in both the eyes. There was not any evident amblyopia on the basis of fixation preference. The child was orthophoric on Hirschberg examination. Marginal reflex distance (MRD-1) was around 1 mm and was found to be variable. Extraocular movements were difficult to examine but were found to be limited to varying extents in all direction of gazes. Ice pack test was performed with much difficulty and mild improvement (around 1 mm) was noted. The rest of the anterior and posterior segment examination was within normal limits. Based on history and examination, a differential diagnosis of mitochondrial myopathy and juvenile myasthenia gravis was considered. Blood investigations revealed a highly raised serum acetyl choline receptor antibody level. The opinion of a neurologist was sought and the patient was started on pyridostigmine tablets. There was marked improvement in ptosis and extraocular movements following the initiation of therapy Figure 1 . The patMyasthenia gravis is termed ocular myasthenia gravis (OMG) when weakness is limited exclusively to the eyelids and extraocular muscles . There aMyasthenia gravis presenting before 19 years of age is termed juvenile myasthenia gravis . Up to 5In a study by VanderPluym et al. on clinical characteristics of pediatric myasthenia, almost 36% of the patients had ocular myasthenia and the age for the same ranged from 18 months to 11 years . 8 out oIn their report of 3 cases of juvenile myasthenia gravis, Gradient et al. found only a single case to be under 3 years of age and the case was not exclusively ocular .In their article on juvenile myasthenia gravis with prepubertal onset, Evoli et al. found the age range to be between 1.5 and 9.2 years and only 5 patients had ocular myasthenia .Myasthenia gravis is a great mimicker and resembles various neurological and muscular disorders. Early onset ocular juvenile myasthenia is prone to be misdiagnosed because the clinical features have quite a resemblance with congenital ptosis. The chance of misdiagnosis increases in bilateral cases as presented in the current case report.The key to a correct diagnosis lies in thorough history and meticulous examination. Various bedside tests including ice test and Cogan lid twitch help in arriving at a correct diagnosis. Acetyl choline receptor (AchR) antibodies are present only in 55% of cases of ocular myasthenia . Anti-Muth or 5th stimulation. Electrophysiological testing is invaluable in diagnosis of suspected juvenile myasthenia gravis. Repetitive nerve stimulation test shows a decremental response of >10% in the compound motor action potential by the 4Management of juvenile myasthenia gravis is based on similar principles as of adult myasthenia  . Since oTo conclude, the present case report highlights the importance of including myasthenia gravis in the differential diagnosis of any child presenting with ptosis with or without diplopia. A proper history and meticulous examination are the key to the diagnosis and better management in all such cases.The authors declare that they have no competing interests.


Rectal leiomyosarcoma (LMS) is an extremely rare disease. Previously, LMS was not properly distinguishable from gastrointestinal stromal tumor (GIST) until c-kit, a characteristic marker of GIST, was discovered in 1998. No standard therapeutic strategy for gastrointestinal LMS has been established except for surgical resection because of its rarity. Rectal LMS is often accompanied by symptoms, which can enable detection at a small size. However, when a large LMS is detected at the lower rectum, it is difficult to excise due to the narrow pelvic space.We present the case of an 86-year-old man with a large LMS. The LMS was asymptomatic and incidentally found at the lower rectum when he visited another hospital for management of benign prostatic hypertrophy. An abdominoperineal resection of the rectum was performed with combined resection of both seminal vesicles and a part of the prostate because tumor invasion was suspected. We used the hybrid method of laparoscopic and transanal total mesorectal excision (TaTME) approaches to achieve negative surgical margins. Late-onset urethral injury occurred in the postoperative course, which was successfully treated with a urethral catheter. The patient was discharged and received no adjuvant therapy. Local recurrence did not occur, but multiple lung metastases were detected 4 months later and the patient died 12 months after the surgery.This is the first report of the hybrid method of laparoscopic and TaTME approaches to remove a large LMS at the lower rectum. Gastrointestinal leiomyosarcoma (LMS) is a rare entity that could not be accurately diagnosed until c-kit, a characteristic marker of gastrointestinal stromal tumor (GIST), was discovered in 1998 . HoweverThe patient was an 87-year-old man who had regularly visited another hospital for management of benign prostatic hyperplasia. His medical history included hypertension. In November 2013, a rectal mass was incidentally identified. Colonoscopy showed a large submucosal tumor at the lower rectum  showed that the size of the tumor was 7.5 cm in diameter and that there were no signs of distant metastasis Fig. . The tumWe made a diagnosis of a rectal LMS with suspected invasion of the left seminal vesicle and prostate. In March 2014, we performed an abdominoperineal resection of the rectum combined with both seminal vesicles and part of the prostate. We used the hybrid method of laparoscopic and TaTME approaches for better surgical view because it was apparently difficult to achieve negative surgical margins due to the large tumor located within a narrow pelvic space Fig. . Tumor nIt had been difficult to distinguish gastrointestinal LMS from GIST until c-kit was discovered in 1998 . AccordiTo our knowledge, there are only 10 cases, including our case, in the English-language literature since 1998 in which immunohistochemical findings have been reported , 5, 7 . There have been some reports on the effectiveness of radiotherapy against local recurrence , 13, 14,We reported a case of LMS in the lower rectum. It was successfully removed by the hybrid method of laparoscopic and TaTME approaches. This method can be useful to achieve negative surgical margins in the resection of large pelvic tumors.


Pituitary macroadenomas are the most common suprasellar lesions in adults and are typically managed surgically through transsphenoidal resection when symptomatic. Due to their close proximity to the optic chiasm, pituitary macroadenomas often present with signs of bitemporal hemianopsia. Alternatively, these tumors can cause mass effect, thus presenting with signs of elevated intracranial pressure or can present with signs and symptoms of endocrine dysfunction. Here, we discuss a 55-year-old male diagnosed with a non-functioning pituitary macroadenoma (NFPA) based on cranial imaging, ophthalmologic exam, and endocrine evaluation. Following diagnosis, the patient was scheduled for transsphenoidal hypophysectomy. On magnetic resonance imaging (MRI) done three and half months later for surgical planning, the tumor had almost completely regressed and only residual pituitary tissue was noted. We describe the presentation and clinical course of the patient, summarize chief differential diagnoses, and discuss potential managements of these conditions. Pituitary adenomas are common intracranial lesions believed to be present in as many as one in six individuals in recent postmortem radiologic series . Adenoma3 sellar/suprasellar mass . His free T4 was 0.56 ng/dL , prolactin was 1.9 ng/mL , testosterone was 27 ng/dL , FSH 6.2 IU/L , and LH 1.7 mlU/L . The patient was referred to our institution for outpatient evaluation of his sellar/suprasellar lesion. On neurologic examination, he was found to have a bitemporal hemianopsia; however, the remainder of his neurologic examination was nonfocal. Based on his outside laboratory values, MRI findings, and physical examination we believe the patient harbored a non-functioning pituitary macroadenoma. Given the degree of chiasmal compression and subjective visual field deficit, we felt that surgical resection via an endoscopic endonasal transsphenoidal approach was indicated. As is our protocol, a planning MRI and computed tomography (CT) scan of the brain and skull base were ordered and performed. The repeat imaging was done three and a half months after his initial MRI. The new MRI Figures -5 showedThe infundibulum was now visible and normal in appearance. The optic chiasm had also normalized in position. There was no sign of acute or chronic blood products within the sella, and on further interview the patient denied any episodes of sudden onset of headache or change in vision.We present a patient with an incidentally discovered NFPA, which spontaneously regressed over the course of approximately three and a half months. The patient had an MRI with imaging characteristics classic for a NFPA and documented visual field defects. A routine preoperative planning MRI demonstrated complete disappearance of the NFPA.The differential for sellar and suprasellar lesions is broad and includes not only neoplastic entities such as pituitary adenoma, metastases, Rathke’s cleft cyst, craniopharyngioma, and meningioma but also vascular lesions and inflammatory lesions such as sarcoid and autoimmune hypophysitis. One must certainly consider this broad differential when evaluating this case. While the clinical, endocrinologic, and imaging characteristics supported a diagnosis of NFPA for our patient, there are a few specific alternative diagnoses that warrant discussion. The first of which is autoimmune hypophysitis. Autoimmune hypophysitis is a disorder with a strong temporal relationship to pregnancy where there is lymphocytic infiltration of the pituitary gland and infundibulum frequently leading to hypopituitarism, diabetes insipidus or hyperprolactinemia. Our patient did not match the classical clinical picture of autoimmune hypophysitis , although there are case reports in the literature of males and elderly patients presenting with autoimmune hypophysitis . Additio Interestingly, it has been described by Armstrong, et al. [Another possible diagnosis is pituitary apoplexy with interval resolution. Pituitary apoplexy is a clinical syndrome caused by sudden hemorrhage and/or pituitary infarction. It is rare, affecting only 2-12% of pituitary adenomas and is generally considered to be a neurologic emergency. The signs and symptoms can vary; however, headaches are present in greater than 80% of cases, visual disturbances and oculomotor palsies accompany greater than 50% of cases and resultant endocrine dysfunction is well documented . InteresThe natural history of non-functioning pituitary adenomas is not well studied because the majority of pituitary macroadenomas with chiasmal compression are treated surgically to prevent further vision loss. Research conducted by Igarashi, et al.  in JapanFurther research into the natural history of NFPA could shed great insight into indications for and timing of surgical intervention for these non-secretory macroadenomas. Cases such as these suggest that imaging should be obtained as near the planned operative intervention as possible in order to minimize unnecessary operations and intraoperative complications.


The patient received four courses of bleomycin, etoposide, and cisplatin (BEP) as adjuvant chemotherapy. Follow-up PET scan revealed no uptake in the right mesenteric lymph node. To date, no recurrence or metastasis has been identified for 16 months.An asymptomatic 26-year-old man received an annual medical check-up, and chest X-ray showed a protrusion of the aortopulmonary window. Chest computed tomography (CT) revealed an anterior mediastinal tumor and cysts with thin wall and septum enhancement. The preoperative diagnosis was cystic thymoma or malignant lymphoma. We performed total resection of the tumor through a median sternotomy. The pathological findings revealed seminoma, positive for c-kit stain, and multilocular thymic cysts. Cysts were lined by normal squamous epithelium and no seminoma cells were located on their surface. So, cysts were probably secondary changes caused by seminoma cells themselves or inflammatory stimulations. No invasion to adjacent structures was seen. After the surgery, testicular ultrasound imaging and abdominal, pelvic, and cerebral CT showed no apparent tumor or enlarged lymph nodes; however, an abnormal uptake in the right mesenteric lymph node was pointed out by  Prominent cystic change of mediastinal seminomas in patients is uncommon and rarely reported, and those cases that are reported show only unilocular cystic changes. Here, we present a patient with a mediastinal seminoma with multilocular thymic cysts. It is probable that primary seminoma caused the cyst formation of the thymus.2 cisplatin on days 1–5, 100 mg/m2 etoposide on days 1–5, and 30kU bleomycin on days 1, 8, and 15, repeated 21 days) as adjuvant chemotherapy. Follow-up PET scan revealed no uptake in the right mesenteric lymph node (Fig. A 26-year-old man underwent a chest X-ray for an annual check-up, which showed a protrusion of the aortopulmonary window Fig. . Seven mode Fig. . To dateMediastinal germ cell tumors account for only 1 to 5% of all germ cell tumors . SeminomPrimary mediastinal seminoma should be listed as one of the differential diagnoses, when anterior mediastinal tumor with unilocular cyst is confirmed, especially the patient is young male.


Large multinodular goiters, obvious to the naked eye, are rarely confronted by clinicians nowadays; yet they do have a place in the differential diagnosis of the neck masses. Due to the fact that 80% of the neck masses in adults are related to malignancy, the later should be ruled out. A 69‐year‐old woman living in a village in Thessaly, Greece, was hospitalized for acute lower respiratory infection. She was found with a hard, painless, nodular yet asymptomatic neck mass. The trachea was midline and there was no intrathoracic extension of the mass. She reported that the mass had been gradually increasing for the last years, but she denied any compression symptoms and had not sought any medical advice. The patient was clinically and biochemically euthyroid. An ultrasound was ordered and revealed a grossly enlarged thyroid with multiple nodules >10 mm, the largest of which was 36 × 28 mm with a peripheral halo and absence of microcalcifications. No cervical lymphadenopathy was detected. The patient underwent a total thyroidectomy and the diagnosis of nontoxic multinodular goiter (NMG) was histopathologically confirmed. Given that the patient had never been exposed to any goitrogens, could you justify the origin of the NMG?The incidence of either diffuse or nodular goiter is very much dependent on the iodine intake; in areas where iodine intake is insufficient, long‐standing and multinodular goiters are more frequently confronted. In the 1960s, several Greek areas were iodine deficient None declared.SSP, SM, CZ, and VG: equally contributed to the conception of the work. SSP: wrote the first draft of the manuscript and all authors revised it critically and approved the final version to be published.


Juvenile psammomatoid ossifying fibroma (JPOF) is a rare fibro-osseous lesion that usually occurs in the facial bones. The pathognomonic histopathologic feature is the presence of spherical ossicles, which are similar to psammoma bodies. It is considered to be a unique lesion because of its reported tendency to occur in children and adolescents and its tendency for locally aggressive growth. Because this lesion is aggressive in nature with high recurrence rate, early detection and complete surgical excision are essential.Herein, we present a case of 11 year old girl, who presented to our clinic with history of gradual onset pain around right elbow associated with limitation of right forearm rotation for 3 months. After getting informed consent, we performed needle biopsy and histopathologically it was diagnosed as Psammomatoid type juvenile ossifying fibroma (JPOF) of proximal radius. We performed extensive debridement, curettage of entire cystic lesion involving the proximal radius and filled the cavity with allograft bone granules and intramedullary titanium elastic nail through fibular strut graft, bridging the cystic lesion.As far as our knowledge there is no reported case of psammomatoid type of juvenile ossifying fibroma of proximal radius. We believe that such tumors in long bones are aggressive and have tendency for recurrence. Definitive diagnosis is utmost important for proper planning, surgical excision and reconstruction of long bones and need regular follow up to look for any recurrence or malignant transformation. El-Mofty (2002) described two variants of Juvenile ossifying fibroma (JOF), namely Juvenile psammomatoid ossifying fibroma (JPOF) and Juvenile trabecular ossifying fibroma (JTOF) -6 Radiog1) and CT scan images showed markedly expansile lytic lesion measuring 4.5 cm X 3.8 cm in transverse diameter at proximal radial shaft with thinning of cortex, short trasitional zone, without periosteal reaction or surrounding soft tissue involvement .Herein, we present a case of 11 year old girl, who presented to our clinic with history of gradual onset pain around right elbow associated with limitation of right forearm rotation for last 3 months. Initially she was treated at her native place with some analgesic medications. Since pain and limitation of her activities in school was increasing, she approached our hospital for further investigation and treatment. She didn’t give any history of weight loss or any other constitutional symptoms. On detailed examination, we found that there was diffused swelling around dorsofeatures were suggestive oradial aspect of proximal right forearm with local tenderness over proximal radius. Active and passive flexion was 0-100* and rotation was from 30* supination to 20* pronation. Plain radiograph showed huge cystic bony lesion with multiple septae . The overall clinical, imaging and histopathological features were suggestive of non-aggressive type of JPOF. Considering this diagnosis, we considered extensive curettage and fibular strut graft interposition rather than enbloc excision of the tumor. Through Kaplan’s dorsal approach, we performed extensive debridement and curettage of entire cystic lesion involving the proximal radius. We broke the tumor cortex, removing the mechanical block involving the proximal radioulanr joint. We later filled the cavity with allograft bone granules and intramedullary titanium elastic nail through autologous fibular strut graft, bridging the cystic lesion . On table there was significant increase in range of rotational movement of forearm. She was put on above elbow back slab for 4 weeks and followed by gradual range of motion and strengthening exercises. She was on regular follow up thereafter. At 18 months follow up, she was symptom free with almost full range of active elbow motion, without any functional limitation  and follow up radiograph shows incorporation of allograft and fibular strut graft without any signs of recurrence .After getting informed consent, we performed needle biopsy and histopathologically it was reported as Psammomatoid type juvenile ossifying fibroma (JPOF) of proximal radius , Osteogenic sarcoma and Osteoblastoma -9. JPOF Histopathological differential diagnoses of JPOF include cementum-forming neoplasms, which include cementifying fibromas, cementoblastoma, and familial gigantiform cementoma . CementiThe larger and more aggressive lesions require resection with 5 mm margins. Close clinical and radiological follow up is required for JPOF. Recurrence after surgical management of JPOF is common and is reported to range from 30% to 56% . LongstaAccording to our knowledge, there is no reported case of psammomatoid type of juvenile ossifying fibroma of proximal radius. There are several case reports of such tumor involving maxilla-fascial bones. But in our opinion, the behavior of such tumors is similar and so the diagnosis and treatment principles remain to be same. We believe that management of JPOF should be based on location, type, variant, aggressiveness, duration of presentation, and involvement of surrounding soft tissue. In our opinion, non-aggressive JPOF based on clinical, imaging, histopathological features can be treated by extensive intra-lesional curettage and local excision, but aggressive types should be treated by en-bloc or radical excision to prevent recurrences. At the same time, we also understand that we need to follow up this case on long term basis to make final conclusion regarding our mode of treatment for such tumor. Our main aim was to report this rare tumor involving the upper limb bone rather than to give surgical management protocol.


Hepatic angiomyolipomas are a rare, benign group of mesenchymal tumors in the liver. Hepatic angiomyolipoma is sometimes misdiagnosed as hepatocellular carcinoma, and there is the possibility of a malignant transformation. Hence, the accurate diagnosis of this disorder is necessary.A 64-year-old Japanese man was observed to have a space-occupying lesion of 15-mm diameter in the liver during a follow-up examination for a previously resected cecal carcinoma. He underwent lateral segmentectomy of the liver with a provisional diagnosis of hepatic metastatic recurrence of the carcinoma based on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging and diffusion-weighted imaging.We have explored the combination of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging and histological examination to confirm our diagnosis of hepatic angiomyolipoma comprising an intimate mixture of numerous abnormal blood vessels, adipocytes, and epithelioid spindle cells of various sizes. Immunohistochemical examination revealed characteristic pathological findings associated with positive qualitative immunoreactions for human melanoma black 45 and desmin. Electron microscopic findings revealed the presence of melanosomes in the epithelioid cells. Diffusion-weighted imaging provides a more accurate diagnostic image with the characteristic macroscopic appearance of hepatic angiomyolipoma. Through immunohistochemistry and electron microscopy, we also show that this benign tumor comprises tissue elements. PEComas [Angiomyolipoma (AML) is a rare, benign mesenchymal neoplasm most often arising in the kidney. Hepatic angiomyolipoma (HAML) is a rare, benign mesenchymal liver tumor first described by Ishak in 1976 [PEComas . HAML maPEComas , which aPEComas .Recently, HAML lesions identified by focusing on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (Gd-EOB-DTPA MRI), immunohistochemistry, and both clinical and pathological characteristics of the tumors were reported . HoweverA 64-year-old Japanese man with no evidence of tuberous sclerosis was discovered to have a space-occupying lesion in the liver during a follow-up examination for cecal cancer. After ileocecal cancer surgery, no signs of metastasis were detected on imaging examinations, and tumor markers were not detected. No infectious diseases, such as schistosomiasis, were detected, and the patient did not use oral hormonal agents. Physical examination of the patient’s abdomen revealed normal active bowel sounds, no tenderness or rebound tenderness of the epigastrium, and no hepatomegaly or splenomegaly. Results of tests for antibodies against hepatitis B surface antigen and hepatitis C virus were negative. Tumor marker levels, such as α-fetoprotein, protein induced by vitamin K absence or antagonist II, carcinoembryonic antigen, and carbohydrate antigen 19-9, were within the normal ranges. Abdominal ultrasonography revealed a 25-mm low-density tumor with a high-density area in segment 2 (S2) of the liver. Gd-EOB-DTPA MRI also showed a slight T2 hyperintensity Fig.  and T1 hWith a clinical diagnosis of hepatocellular carcinoma (HCC) and hepatic adenoma, a partial hepatectomy of S2 was performed. The resected specimen showed a tumor of 25 mm in diameter. The cut surface of the resected liver showed a relatively firm, whitish-gray nodule, which was well circumscribed from the surrounding hepatic parenchyma. Some very small, yellowish areas were embedded at the periphery. No distinct necrotic areas were noted Fig. . A hematMost of the patients with HAML have no symptoms and their lesions are detected incidentally during routine medical examination . The typHAML comprises three tissue elements: blood vessels, epithelia or spindle-shaped smooth muscle cells, and mature adipose tissue. Immunohistochemical staining showed absence of hepatocytes, but smooth muscle cells were strongly positive for a melanocytic cell-specific monoclonal antibody. The final histopathological diagnosis (HMB-45-positive) is consistent with HAML. Moreover, formalin-fixed tissue sections examined under an electron microscope showed moderate amounts of stacked, rough endoplasmic reticulum; mitochondria; lysosomes; and oval, cytoplasmic, melanosome-like, electron-dense granules.According to the differential diagnosis, we first investigated HAML using Gd-EOB-DTPA MRI, immunohistochemical analyses, and electron microscopy. Type I hybrid-type lesions were enhanced in the arterial phase but were followed by rapid washout in the PVP and delayed phases.Because the radiological features of HAML depend on the relative proportion of adipose cells in the tumor, HAML was not readily distinguishable from HCC –8. LiverThe imaging characteristics of HAML correlated with its histological components, and detection of fat content was typical of HAML. MRI is more sensitive than computed tomography in detecting fatty tissue, which appears hypointense on fat saturation pulses or chemical shift imaging. However, it is occasionally difficult to differentiate between HAML and other hepatic tumors that contain fatty tissue, such as fatty metamorphosis of HCC, hepatocellular adenoma with fat content, lipoma, and liposarcoma , 9.The MRI findings reported by Sakamoto were of a low-signal-intensity mass with some tiny, high-signal-intensity foci on T1-weighted images. The tiny, high-signal-intensity foci were thought to be due to abundant adipose tissues, as indicated by the results of immunohistochemical examination .Moreover, according to a recent study in which researchers compared Gd-EOB-MRI features of lipid-poor HAMLs and HCCs, both lesions showed similar dynamic enhancement patterns during the arterial phase, followed by hypointensity on PVP or transitional phase (late dynamic phase) . HoweverConsidering the developmental site of HAML, in our patient, because immunohistochemical analyses and electron microscopy revealed all three components of an AML  and because three differentiated epithelioid cells contained a so-called secondary hit mutation, they were believed to have derived from a common progenitor cell . Earlieret al. showed that CD117 is positive in all cases of benign renal AML and HAML [HAML is generally managed as a benign tumor in clinical settings; however, since 2000, several reports have revealed its potential for malignant transformation with evidence of recurrence , 20. Makand HAML . In our and HAML .According to the future plan, no signs of tumor recurrence or metastasis were observed during the follow-up period. Therefore, HAML should not be considered as an entirely benign tumor; at least, there is a possibility of its malignant transformation. We will continue with periodic imaging examinations for our patient.We have explored the combination of Gd-EOB-DTPA MRI and DWI, which provides a more accurate diagnostic picture with the characteristic macroscopic appearance of HAML. Moreover, HAML is sometimes misdiagnosed as HCC. This may lead to its malignant transformation. Hence, its accurate diagnosis is necessary. Through immunohistochemistry and electron microscopy, we have also shown that this benign tumor comprises tissue elements.


Adrenal cortical carcinoma (ACC) is a rare neoplasm often associated with an aggressive biological behavior. Complete surgical resection is the mainstay of therapy for ACC and offers the best chance for prolonged disease-free survival. We present an unusual case of a long-standing adrenal mass, well documented over a period of at least 18 years, without the development of metastatic disease, and ultimately proven to represent ACC after successful surgical resection. Physicians should be aware that ACC can present with a wide spectrum of biological behavior, from very aggressive to more indolent disease. Adrenal cortical carcinoma (ACC) is a rare neoplasm often associated with an aggressive natural history. As the second most aggressive endocrine malignancy after anaplastic carcinoma of thyroid, ACC accounts for approximately 0.2% of all cancer deaths in the United States annually, with an incidence of approximately 1 to 2 cases per million people per year . We presA 47-year-old woman was referred by her primary physician for a surgical opinion concerning an asymptomatic, 14 cm, right adrenal mass described on recent magnetic resonance imaging (MRI). The right adrenal mass had been previously radiographically identified at least as far back as 1992. Surgical resection had been recommended to the patient back in 1992 at another institution, but she had declined, reportedly because of a fear of the major surgery at the time. Therefore, the mass was simply followed intermittently over the ensuing 18 years at irregular intervals without a definitive diagnosis or any treatment. Her past medical history included attention deficit disorder, asthma, benign cystic breast disease, breast reduction surgery and a recently identified 9 x 4.6 cm left adnexal mass. On careful questioning, she denied any symptoms from the large adrenal mass, including any pain, fullness, nausea, vomiting, dyspepsia or increasing abdominal girth. Abdominal examination was also normal, without any palpable mass or other related findings.Laboratory studies revealed a serum cortisol level of 10.7 mcg/dL , serum aldosterone of 2 ng/dL , plasma renin of 1.46 ng/mL/h  and serum metanephrines of 131 pg/mL  indicating that the tumor was non-functioning. MRI of the abdomen revealed a 14 cm, irregular, right adrenal mass with heterogeneous density and attenuation characteristics concerning for malignancy. Comparison with a previous MRI examination provided by the patient from 1992 revealed that the mass had slowly increased in size (from 6 cm to 14 cm) and changed in appearance over the period of 18 years . There wSurgical resection of the large, and enlarging, right adrenal mass was recommended both for diagnosis and for treatment. However, the patient first underwent a laparoscopic left salpingo-oophorectomy to exclude malignancy in the large, complex, left adnexal mass. Final pathology from the adnexal mass was a benign luteal cyst, hydrosalpinx, and endometriosis. After successful recovery from the salpingo-oophorectomy, elective right adrenalectomy was undertaken using an open, trans-abdominal approach through a generous right subcostal incision.At laparotomy, the large adrenal mass was found adherent to the capsule of the liver posteriorly and inseparable from the right diaphragm. It did not involve the right kidney. A separate small mass was also palpable in the fundus of the gallbladder, distant from the adrenal mass. An en-bloc resection of the entire adrenal mass, along with a portion of the right diaphragm and a portion of the capsule of the right lobe of the liver was performed. The diaphragm was closed primarily with permanent sutures without a chest tube. Simple cholecystectomy was also performed, with a benign intraoperative frozen section of the gallbladder mass. The estimated blood loss was 100 cc, and she received 2 units of packed red blood cell transfusion intraoperatively.The postoperative course was initially unremarkable. The patient was discharged home on postoperative day 4. She was however readmitted 2 weeks postoperatively with shortness of breath secondary to a large, right-sided, pleural effusion. The pleural effusion required drainage using a temporary pigtail catheter. She was again discharged, and then fully recovered.The final pathology revealed the adrenal tumor to be 14 cm in maximum diameter, with a weight of 566 gm. Extensive necrosis was present, along with gross calcifications. The tumor was densely adherent and fibrosed to the diaphragm, but not actually invading microscopically. Sections showed a neoplastic process consisting of large polygonal cells with abundant granular eosinophilic cytoplasm. Nuclei were markedly variable in size, with some showing large intra-nuclear inclusions. Extensive zonal necrosis was present. Invasion into, but not through, the capsule was present. The nuclear grade was high (Fuhrmann grade IV). The tumor was oncocytic with less than 25% of clear cells. There was a diffuse growth pattern . Based oNo adjuvant therapy was recommended. The patient continues to do well and no evidence of disease 7 months after the surgical resection.ACCs are frequently large, and size has been reported to be a prognostic factor . A very Although ACCs can develop at any age, there is a bimodal age distribution, with disease peaks before the age of 5 years and in the fourth to fifth decade of life. In general, the level of aggressiveness and pace of disease progression are more rapid in adults than in children [Nearly half of ACCs are functional, frequently resulting in symptoms that lead to recognition and diagnosis. Many of the nonfunctional tumors will remain without signs or symptoms of the disease until the tumor either becomes large enough to cause symptoms from compression of nearby structures, or the patient develops symptoms from the metastatic disease. The remainder is identified incidentally on radiographic imaging done for other reasons. The patient reported was symptom-free and the mass was non-functional. Her tumor was identified incidentally on radiographic imaging.Computerized tomography (CT) is useful in distinguishing benign adrenal adenomas from ACC. MRI is a complementary diagnostic modality to CT, in that local invasion and involvement of the vena cava are more readily identifiable. Imaging phenotype consistent with ACC include the following: irregular shape; large size (> 4 cm in diameter); intralesional calcification; tumor heterogeneity on both plain films and contrast enhancement, which may indicate intralesional hemorrhage, necrosis, or both; unilateral location; high CT attenuation values  and evidence of tumor invasion of local structures or extension into major vessels . ImagingDespite multiple improvements in the diagnosis and treatment of other types of solid malignancies over the past 2 decades, ACC continues to be a highly lethal malignancy with poor overall survival and few effective treatment options . CompletWeiss proposed a scoring system which consists of nine criteria to aid in the diagnosis of adrenal cancer . The preAdjuvant treatment with mitotane has been shown to be beneficial in patients with ACC . Given tThe existence of this malignant tumor for at least 18 years prior to resection is extremely unusual. To the best of our knowledge, this is the first case of ACC to be reported with a well-documented 18-year untreated interval prior to successful surgical resection.


We present a case of left upper extremity paresis secondary to acute brachial artery occlusion in an elderly female with active non-ST segment elevation myocardial ischemia (NSTEMI) in the setting of paroxysmal atrial fibrillation. The patient was initially suspected to have a cerebrovascular attack (CVA); however, computed tomography (CT) head was negative for acute stroke. The diagnosis was confirmed by computed tomographic angiography (CTA) of the upper extremity, confirming the diagnosis of acute left brachial artery occlusion. In evaluating a patient with concern for acute stroke with atypical presentation, it is essential to obtain a complete history and perform a rapid and thorough examination. Acute limb ischemia (ALI) should be considered in the differential diagnosis of CVA with atypical presentation. The clinical burden of peripheral arterial events is substantial, with high case fatality, poor functional outcome, and a high rate of emergency and subsequent vascular intervention to prevent death and limb loss . We presThe patient is an 83-year-old female who presented to an outside rural hospital emergency department with a complaint of nausea and chest discomfort of one-day duration. Her medical history included hypertension, hyperlipidemia, carotid artery stenosis, traumatic subarachnoid hemorrhage, transient ischemic attack, and paroxysmal atrial fibrillation. She is a nonsmoker. On exam, she was normocardic with a regular rhythm. The rest of her vital signs were normal. Laboratory investigation revealed white blood cell count 6.9 K/uL, hemoglobin 14.6 g/dL, platelet count 170 K/uL, lipase 21, and an abnormal troponin level 0.180 ng/mL. An electrocardiogram (ECG) obtained reveal normal sinus rhythm, pulse rate 60. The emergency department physician diagnosed non-ST elevation myocardial ischemia (NSTEMI). Her chest discomfort improved with administration of nitroglycerin and morphine; anticoagulation with heparin drip was initiated and she was transferred to our facility. Her home medications include baby aspirin, metoprolol, and ramipril.On arrival, she complained of acute onset left upper extremity weakness. A stroke alert was initiated. The patient’s systolic blood pressure was 180 mmHg and the ECG demonstrated atrial fibrillation at 90 beats per minute. On neurologic examination, the left upper extremity strength revealed no effort against gravity with some preserved strength in wrist and finger extension. Diminished sensation to gross touch on the left forearm compared to the right. Findings from the remainder of the neurological examination, including speech and language, cranial nerves, coordination, and left lower extremity strength and sensation, were normal. A computed tomography scan of the brain showed no gross evidence of intracranial hemorrhage. There was hypodensity representing age-indeterminate infarct within the left occipital lobe and age-indeterminate periventricular and subcortical small vessel ischemic changes.Given that weakness and mottling were prominent, palpation of the left upper extremity for pulses was done. The left brachial, radial, and ulnar pulses were not palpable, and the left upper extremity was colder than the right upper extremity. There were also no appreciable Doppler signals. A CTA of the left upper extremity was performed, which revealed left distal brachial artery occlusion Figure . VasculaPostoperatively, a transthoracic echocardiogram obtained was negative for an intracardiac thrombus. The patient recovered well  and was discharged home on postoperative Day 5 on aspirin and coumadin with a goal international normalization ratio (INR) of two to three.The clinical burden of peripheral arterial events is substantial, with high case fatality, poor functional outcome, and a high rate of emergency and subsequent vascular intervention to prevent death and limb loss . We presVascular disease is the leading cause of death and disability worldwide . Acute lPatients with upper extremity ALI are more likely to have atrial fibrillation (50%) as compared to the 29.8% of patients with lower extremity acute limb ischemia , while pUpper extremity arterial occlusions can have a variety of presenting factors. Two of the most commonly described features are coldness and pain in the affected extremity, often occurring distally first and moving proximally. The pain is often a rest pain in acute occlusion but could also be claudication. Other presenting findings include paresthesia, paralysis, cyanosis, or pallor, decreased or absent radial or ulnar pulse, and gangrene of the digits . If any Clinical evaluation of patients with suspected arterial occlusion will demonstrate a change in temperature (coolness to touch) along the extremity affected as compared to the unaffected extremity. Furthermore, the bilateral pulse exam will demonstrate a diminished or absent palpable or Dopplerable pulse distal to the site of occlusion in the affected extremity. A CTA can be used to confirm the occlusion, while an urgent vascular surgery or an interventional radiology consult is necessary .The three main treatments for acute limb ischemia include open surgical revascularization, endovascular revascularization, and anticoagulation with observation. Fluid resuscitation, pain control, and unfractionated heparin can be utilized to temporize the patient until definitive management can occur . In patiIn evaluating a patient with concern for acute stroke with atypical presentation, it is essential to obtain a complete history and perform a rapid and thorough examination. Acute limb ischemia should be considered in the differential diagnosis of CVA with atypical presentation.


Buschke–Löwenstein tumor of anorectal and perianal area is a rare but highly aggressive tumor, frequently associated with human papillomavirus (HPV) types 6 and 11. It often grows over years in immunocompetent patients and can be highly destructive to local tissue. We present a case of a 61-year-old male with HIV infection who presented with worsening pain and swelling in the anorectal area for one-year duration. Exam revealed a 15 × 10 cm mass in the anorectal area with multiple sinuses and fistulas. MRI revealed extension of the mass through pelvic structures. Biopsy showed squamous epithelium with koilocytes and histochemistry positive for P16, suggestive of HPV infection. Biopsy was negative for malignant transformation. He was not a candidate for surgery or radiation due to extensive infiltration of deeper structures and multiple fistulas. He refused interferon therapy, and diverting colostomy was placed for palliation. He presented two months later with overwhelming sepsis and died despite maximal medical therapy. Buschke–Löwenstein tumor, often called giant condyloma accuminatum, is considered by some authors as intermediate between condyloma and squamous cell carcinoma . Histolo3 with high neutrophils of 9800 cells/mm3. His HIV viral load was <20 copies/ml, and his CD4 count was 480 cells/μL. His HIV treatment regimen included lopinavir-ritonavir, raltegravir, and saquinavir which he was tolerating well. Physical examination revealed an approximately 15 cm × 10 cm fungating mass with multiple sinuses and fistulas involving entire right buttock and perineum along with a very foul-smelling purulent discharge . BiopsyWe presented a case of rapidly growing gigantic perianal condyloma in a controlled HIV-infected patient that was deemed unresectable at the time of presentation and ultimately led to the patient's demise secondary to septic shock.Typically, this tumor presents as a slow-growing cauliflower-like mass in genital or anorectal region with slow infiltration into deeper tissues , 4. It oGold standard for treatment is surgical resection with wide tumor-free surgical margins. It is essential as it has high rate of recurrence 66%) and malignant transformation 56%) [6% [5]. P6% and maPrognosis depends on the size of tumor on presentation and factors like immunosuppression and secondary infection. Immunosuppressed patients are at higher risk for malignant transformation with 40–60% patients having invasive squamous cell carcinoma . AlthougProphylactic vaccination against HPV has been shown to reduce the incidence of HPV-associated HPV infections including HPV6/11 and thus is expected to also prevent Buschke–Löwenstein tumors.


We describe an unusual case (a 79-year-old woman) of secondary extramedullary plasmacytoma (EMP) involving the duodenum. While all the previously reported cases of duodenal involvement by EMP (namely 20 cases) were characterized by the presence of ulcerative masses or ischemic necrotic lesions, in our case EMP led to the unusual finding of several non-polypoid lesions with a depressed central area. The final diagnosis was multiple myeloma IgA lambda, stage II A, with secondary duodenal EMP. To our knowledge this is the first report showing duodenal involvement by EMP with the aspect of multiple non-polypoid lesions. Extramedullary plasmacytoma (EMP) is a rare entity accounting for less than 4% of all plasma cell tumors and occurs mainly in the upper aero-digestive tract. In the GI tract most EMP occur in the stomach and only 20-30% arise in the small intestine . Twenty H. pylori infection at rapid urease test and histology. From the second to the fourth portion of the duodenum we found several grossly round non-polypoid lesions with a reddish central depressed area, II c + II a type, according to the Paris classification. The largest of these lesions had a diameter of about 1 cm (A 79-year-old woman was referred to our Gastroenterology Unit because of severe normocytic normochromic anemia (haemoglobin 6.8 g/dL) and positive fecal occult blood on three separate samples. Colonoscopy was negative. An upper gastrointestinal endoscopy was performed and showed antral erosive gastropathy without out 1 cm . Multiplout 1 cm . Immunohout 1 cm . Immunosout 1 cm , while iTo our knowledge this is the first report showing duodenal involvement by EMP with the aspect of multiple non-polypoid lesions. Moreover, in our case, it was the histology performed on duodenal biopsy specimens which led to the suspicion of multiple myeloma which was then confirmed at the subsequent histological evaluation of bone marrow. Our case report also points out the concept that the diagnosis of EMP should prompt a subsequent workup including quantitative and qualitative serum and urine protein analyses, a radiographic evaluation of the axial skeleton, and bone marrow biopsy. This is clinically relevant because therapy for primary or secondary EMP is quite different. Primary EMP often requires only radiotherapy or surgery, while secondary EMP requires systemic therapy.


Hibernoma is a rare soft tissue tumor stem from persistent fetal brown fat tissue. This benign tumor may occasionally occur in head and neck area and, in most cases, is characterized by an asymptomatic slow growth.We presented an uncommon case of hibernoma of the posterior cervical triangle occurring in a 30-year-old man referred to the department of otolaryngology. The patient suffered from a right, very painful, and rapidly growing mass since 3 months. MRI examination reported both an infiltrating mass and a homogenous enhancement of an underlying vascularization after the injection of intravenous contrast. According to the risk of sarcoma, a surgical procedure was made to completely excise the mass that was a hibernoma.Hibernoma may occur with an uncommon clinical presentation imitating malignancy. MRI plays a key role in the differential diagnosis and surgery remains the better therapeutic approach. Hibernoma is a rare benign tumor originating from persistent fetal brown fat tissue . The broA 30-year-old man was referred to the Department of Otolaryngology and Head and Neck Surgery for mass located in the right posterior cervical triangle of the neck. The patient had this mass since several months but it recently started to grow in a context of substantial neck pain. The patient had no difficulty to breathe and swallow. Clinical examination exhibited a relatively mobile, soft mass located in the supraclavicular area. No cervical node was found. Both clinical and ultrasound examinations led to suspect a soft tissue mass, and the magnetic resonance imaging (MRI) revealed a 38 mm along the axis tumor Fig.  between Since the first case described in 1906 , approxiClinically, most patients with neck hibernoma are usually asymptomatic over time even if the slow growth of the tumor may, at some point, compress the adjacent structures , 8. In oIn our patient, the MRI examination showed a 38 mm along the axis, relatively well circumscribed tumor with intermediate signal intensity between subcutaneous fat and muscle. Moreover, the observed tumor was homogenous, relatively well circumscribed, with septa > 2 mm and some nodular areas. All of these features led us to exclude lipoma but the critical point concerned the differential diagnosis with liposarcoma. Indeed, the high vascularization, the large septa, and the fast arteriovenous contrast enhancement may mislead to liposarcoma diagnosis. Thus, as reported in the current literature, even with imaging, the characteristics of this tumor remain difficult to differentiate from malignant fat tumors and some very rare tumors such as angiolipoma and malignant fibrous histocytoma , 13, 14.The final diagnosis is made after a fine needle aspiration procedure or after the surgical excision . As showHibernoma is a rare benign tumor that can mimic malignant lesion of the soft tissue such as liposarcoma. In this paper, we report an unusual presentation of hibernoma of the posterior cervical triangle characterized by both severe pain and rapid growth. MRI plays a key role in the differential diagnosis, especially with other benign tumors but still remains limited for the differential diagnosis with malignancy. The biopsy and the surgery procedure correspond to the gold standard approaches for the final diagnosis, the exclusion of liposarcoma, and to select the appropriate treatment. To date, there is no described case of recurrence or malignant transformation.


Ventricular involvement in central nervous system tuberculosis can be in the form of tuberculous ependymitis, intraventricular tuberculoma, intraventricular tuberculous abscess, choroid plexitis and choroid plexus tuberculoma. Only a few cases of choroid plexus tuberculomas have been described and even more rare is the description of the role of endoscopy in management of intraventricular tuberculomas. We report a 33-year-old patient while on treatment for tubercular meningitis who developed a left side choroid plexus lesion with loculated temporal horn. To confirm the diagnosis, endoscopic biopsy of the lesion was carried out. The final histopathology was tuberculoma. Intraventricular tuberculomas are usually associated with recalcitrant lesions, probably due to the poor drug levels within the CSF or as an indirect effect of immune resistance and biopsy becomes important to rule out other possibilities. Ventricular involvement in cases of neurotuberculosis is rare. Only few cases with intraventricular tuberculomas are reported in the literature.Figure 1A). He became unconscious one week back, and was referred to our hospital. On arrival to casualty he was in altered sensorium, he was drowsy, obeying simple commands, and disoriented. The MRI showed multiple intracranial enhancing lesions suggestive of tuberculomas with a lesion in the left atrial region causing loculation of temporal horn and hydrocephalus (D) with mass effect on brain stem. A test to diagnose human immunodeficiency virus infection was negative. He initially underwent tapping of the temporal horn in emergency basis. As he was taking antitubercular drug therapy, and new lesions appeared, the possibility of drug resistant tuberculosis or alternate diagnosis was considered. A procedure that can be diagnostic and therapeutic was desirable, hence he underwent left temporal burr hole and through loculated temporal horn endoscopic biopsy of the lesion and thereby unblocking the loculated temporal horn. The lesion was white and firm in consistency diffusely involving the choroid plexus. The ventricular walls were looking normal. A biopsy was taken from the choroid plexus lesion and fenestration of loculated temporal was carried out connecting it to the lateral ventricles. Histopathological examination showed necrotizing granulomatous inflammation in the choroid plexus consistent with tuberculoma . Post operatively, he was continued on daily antitubercular treatment. About 40 days later, he lapsed into altered sensorium and was localizing to painful stimuli. Head CT scan showed re-loculation of temporal horn for which he underwent temporal horn-peritoneal shunt after which he improved. After about 4 months, he developed speech difficulty with righthemiparesis and ataxia. He had severe lower back pain with difficulty in walking. An MRI showed increase in size of caseating tuberculoma in left frontal opercular region  along with some resolution of choroid plexus lesion. There was D12-L1 vertebral osteomyelitis with paravertebral abscess . As patient was not willing to undergo surgery for spinal stabilization, he underwent CT guided biopsy and aspiration of para-spinal abscess. The microbiological examination of pus showed acid fast bacilli morphologically resembling mycobacterium tuberculosis complex on Ziehl-Neelsen (ZN) staining. He was asked to continue antitubercular drug therapy. At 16 months of follow-up from initial diagnosis and treatment he has arrest of progression of disease.A 33-year-old male had a history of headaches and intermittent fever. He was evaluated at a local hospital and diagnosed to have tubercular meningitis and started on anti-tubercular treatment (ATT) comprising Isoniazid 10mg/kg, Rifampicin 15mg/kg, Pyrazinamide 35mg/kg and Ethambutol 20mg/kg, 2 months prior. A head CT scan carried out at that time had not shown any mass lesion  is rare. It manifests in the form of tuberculous ependymitis, intraventricular tuberculoma, intraventricular tuberculous abscess, choroid plexitis, and choroid plexus tuberculoma.1Although various authors have identified the presence of small tubercles in the choroid plexus, ependymal scarring, and thickened membrane as features observed within the ventricle following tuberculous infection,Effective management protocol for intraventricular tuberculomas is unclear.Our patient initially had meningitis for which he was started on ATT and, a few months later, had developed multiple intracranial tuberculomas with one in choroid plexus of leftlateral ventricle. Inspite of strict adherence to ATT, appearance of new lesion was an indication of biopsy. As endoscopy can solve dual purpose, biopsy and CSF diversion, it was chosen.In conclusion, neurotuberculosis associated with ventricular lesions are associated with poor response to treatment and may need longer duration of treatment or other modes of effective drug delivery.