Solid pseudopapillary tumor of the pancreas, otherwise known as solid and cystic tumor or Frantz tumor, is an unusual form of pancreatic carcinoma, with unknown etiopathogenesis, that accounts for 0.2 to 2.7% of all pancreatic tumors. It is defined as an exocrine pancreatic neoplasia that mainly affects women between the second and third decade of life, and its management is not well defined. Endoscopic ultrasound offers a key anatomical advantage in accessing the pancreas and endoscopic ultrasound fine-needle aspiration has become the gold standard method for the diagnosis of pancreatic lesions.Case 1: A 31-year-old white Hispanic woman presented with epigastric pain for 5 months. An abdominal ultrasound revealed a single 2 cm nodule in the uncinate process of her pancreas. Endoscopic ultrasound showed a regular, well-defined solid lesion with alternating cystic areas at the uncinate process of her pancreas, measuring 1.7 × 1.4 cm; endoscopic ultrasound fine-needle aspiration was then performed with cytopathological analysis compatible with solid pseudopapillary tumor.Body computed tomography confirmed the absence of metastases and she underwent conventional duodenopancreatectomy. However, she died 4 days after surgery due to postoperative surgical complications.Case 2: A 35-year-old Hispanic woman presented with left upper quadrant abdominal pain for 3 months, associated with a palpable mass at this region. A computed tomography scan showed a solitary nodule in the pancreatic body. Endoscopic ultrasound showed a regular, well-defined, homogeneous lesion with small anechoic (cystic) areas, measuring 2 × 2 cm, in between the pancreatic body and neck. Endoscopic ultrasound fine-needle aspiration was performed and cytopathological analysis was suggestive of a pseudopapillary solid tumor. She underwent a body-tail laparoscopic pancreatectomy with splenectomy. Nine months after the diagnosis, she remains asymptomatic, continuing regular follow-up in the oncology out-patient clinic.Solid pseudopapillary tumor is a rare pancreatic malignancy. Endoscopic ultrasound fine-needle aspiration is the gold standard method to characterize and diagnose this type of pancreatic lesion, making this an invaluable tool to help guide clinical management and improve the preoperative diagnostic yield. Solid pseudopapillary tumor (SPT) of the pancreas, otherwise known as solid and cystic tumor or Frantz tumor, is a rare but characteristic neoplasm, with unknown etiopathogenesis, accounting for 0.2 to 2.7% of all pancreatic tumors and less than 5% of pancreatic cystic tumors –3. It isSymptoms of SPT depend on the location and size of the tumor but usually are nonspecific, with abdominal pain being the most common in approximately one-third of patients . SeveralThe treatment of choice is a complete curative surgical resection of the lesion. The long-term prognosis is excellent, since it has a generally indolent behavior and a low degree of malignancy .Here we report two cases of SPT diagnosed by preoperative EUS-FNA, presenting distinct clinical outcomes after a proper surgical approach.A 31-year-old white Hispanic woman, who did not smoke tobacco or consume alcohol, presented with a 5-month history of epigastric pain. She did not present with any other symptoms. An abdominal US revealed a 2 cm, single nodule in the uncinate process of her pancreas. EUS showed a well-defined hypoechoic solid lesion with regular, clear, and precise margins with alternating cystic areas measuring 1.7 × 1.4 cm, located in the uncinate process of her pancreas; the lesion had no communication with her main pancreatic duct Fig. . EUS-FNAA body CT scan was performed, excluding metastatic disease. She underwent conventional duodenopancreatectomy (Whipple procedure). However, she evolved with postoperative sepsis and died on the fourth day after surgery.A 35-year-old Hispanic woman presented with left upper quadrant abdominal pain for 3 months, associated with a palpable mass at this region. An abdominal CT scan showed a solitary nodule in the pancreas body. EUS showed a regular, well-defined, homogeneous lesion with small anechoic (cystic) areas, measuring 2 × 2 cm, localized between the body and the neck of the pancreas Fig. . EUS-FNASPT of the pancreas was first described by Frantz in 1959 . Under 2The symptoms of SPT are usually nonspecific, with abdominal pain being the most common, accounting for approximately 37.6% of the cases. Other signs and symptoms such as jaundice, abdominal fullness, anorexia, nausea, vomiting, and weight loss may also be present. Approximately one-third of the patients are asymptomatic . The senIn our two cases, EUS showed solid hypoechoic lesion with cystic components with regular contours but it was not heterogeneous. Since EUS-FNA is considered the gold standard for pancreatic lesions, EUS-FNA was performed with histopathological diagnostic confirmation of SPT.The diagnosis of SPT with EUS-FNA has been increasing in popularity as shown in a case series of 34 patients , where EComplications related to EUS-FNA are only reported in approximately 1% of patients. The most common complication is acute pancreatitis; other reported complications are abdominal pain, fever, vomiting, and bleeding . Both ofAn anatomopathological study revealed pseudopapillary areas with fibrovascular stems or rosette-like structures secondary to the low cohesion of neoplastic cells . An immuSurgical treatment of SPT offers an excellent overall survival rate, greater than 95% . The surNeither of our patients had neoplastic metastases, although it is known that despite the low malignant potential, up to 15% of cases of SPT develop distant metastases . The mosIn this context, EUS-FNA is a very important method that presents excellent diagnostic rates and provides material for cytological and histological evaluation of SPT.SPT is a rare pancreatic neoplasia. Anatomopathological study is necessary for treatment and prognosis evaluation. EUS-FNA is the gold standard method to characterize and diagnose these type of pancreatic lesions, making this an invaluable tool to help guide clinical management, decide a patient’s surgical candidacy, and improve the preoperative diagnostic yield.


Dear Editor,A 75-year-old White male presented with a three-month history of pain in the lefthypochondrium. The patient also reported experiencing an episode of gross hematuria sixmonths prior. He had quit smoking 20 years prior, having previously smoked 30cigarettes/day for 30 years. He had also undergone surgery for a gastric ulcer 20 yearsprior. He reported no other comorbidities.Computed tomography of the abdomen showed a solid, irregular, concentric mass, which wasexpansive and stenotic, in the middle third of the descending colon  and 1B. Colonoscopy with biopsy of the intestinal mass led to a histological diagnosis ofmoderately differentiated adenocarcinoma of the colon, and the patient was thereforesubmitted to segmental colectomy with colostomy. The anatomopathological study revealeda hard, annular tumor, which was ulcerative and vegetative, infiltrating the intestinalwall and surrounding fat, thus confirming the result of the microscopy study of thebiopsy. Subsequently, ultrasound of the urinary tract confirmed bladder nodulation, with no.Colon cancer is the fourth most common malignancy in men, accounting for 90% of the casesthat occur after the fifth decade of life, adenocarcinoma being the most commontype. It is related toobesity, a sedentary lifestyle, a diet low in fiber, and inflammatory boweldiseases-4. Smoking and alcoholism can also play roles-4.In 5-10% of cases, adenocarcinoma is associated with hereditary syndromes , especially inyoung adults,6. Urothelial carcinoma can bemultifocal/multicentric, can occur in the upper or lower urinary tract, and is oftenrecurrent. Smoking isimplicated in 50-65% of all cases in men and in 20-30% of all cases in women. Other, less common causes includechemotherapy, exposure to aromatic or heterocyclic amines, radiotherapy, and chronicinfection,4-6.Bladder cancer, which is the most common type of malignant neoplasia of the urinarytract, affects individuals 55-60 years of age, 75-80% of whom are men, urothelialcarcinoma being the predominant form. They areclassified as synchronous if they are identified within the first six months after theappearance of the first lesion or as metachronous if they are identifiedthereafter.Multiple primary malignancies are defined as those that are confirmed, independent, andof non-metastatic origin,3,7,8. It is estimated that 75% of casesoccur in individuals over 50 years of age. These values are on the rise due to the effectiveness oftreatments, the variety of therapeutic techniques now available, the improvement ofdiagnostic methods, the increased longevity of the population, and contemporarylifestyles,7. Hayat et al. reported a probability of developing a second malignancy,depending on the primary tumors diagnosed, ranging from 1% (history of hepaticneoplasia) to 16% (previous bladder tumors). Braisch et al.observed that 1.2-2.5% of cancer patients who were smokers developed another distinctmalignant lesion within the first year of follow-up.The overall prevalence of multiple primary malignancies is 0.7-11.7%, increasingproportionally with patient age,6,8.In smokers, multiple primary malignancies can affect several organs, notably the lungs,upper aerodigestive tract, and kidneys, as well as the upper and lower urinary tract.Other potential sites include the thyroid gland, stomach, colon, rectum, andpancreas


The need for surveillance of rare late recurrence of rectal cancer has not yet been established. Local control of unresectable skeletal metastasis is important for palliation of symptoms and support for systemic chemotherapy.18F]-fluoro-2-deoxy-d-glucose accumulation in the sacrum. A CT-guided needle biopsy confirmed the diagnosis of metastatic adenocarcinoma from the previous rectal cancer. The sacral metastasis reached the S1/S2 level and was considered inoperable. Conventional radiotherapy was also excluded due to the previous history of pelvic irradiation. Finally, heavy ion radiotherapy with carbon ions was performed as radical local therapy (70.4 GyE/16 Fr). The patient did not consent to systemic chemotherapy immediately after the irradiation. Five months after radiotherapy, multiple lung metastases were noted on CT, followed by mediastinal and hilar lymph node metastases. Systemic chemotherapy was started 9 months after the irradiation. During this time, the patient experienced some degree of pain and loss in muscle strength of the left lower limb, and a second heavy ion irradiation (60.0 GyE/12 Fr) was performed 11 months after the previous irradiation. After that, the sacral lesion has been stable and his symptoms have not worsened. Two years after the heavy ion therapy, the patient steadily continues outpatient chemotherapy and his quality of life is relatively maintained.A Japanese man underwent preoperative pelvic irradiation (50.4 Gy/28 Fr) and low anterior resection at the age of 57 years. The pathological stage was II (T3N0M0). Nine years after the surgery, his carcinoembryonic antigen (CEA) level showed rapid elevation, although he had no symptoms. A computed tomography (CT) scan showed no evidence of recurrent lesions, but positron emission tomography (PET)-CT revealed abnormally high 2-[In case the risk of late recurrence is relatively high after rectal cancer surgery, clinicians should consider individual follow-up evaluations, including CEA measurements to allow for timely diagnosis and intervention. Heavy ion radiotherapy is effective for local control of sacral metastasis. Most recurrences of colorectal cancer occur within 5 years after curative resection, and the guidelines recommend a 5-year postoperative follow-up , 2; howeA 57-year-old man was referred to our hospital because of blood in the stool, and he was diagnosed with clinical stage II (T3N0M0) rectal cancer in 2004. The preoperative carcinoembryonic antigen (CEA) level (8.1 ng/ml) was slightly above the normal range (0–5.0 ng/ml). Preoperative pelvic irradiation with 50.4 Gy/28 Fr was performed, and the tumor decreased in size. Low anterior resection was performed.The resected specimen contained a 2.0-cm × 2.0-cm moderately differentiated adenocarcinoma with slight venous invasion and partial effect of irradiation and was diagnosed as stage II (T3N0M0) according to the Union for International Cancer Control TNM staging system. The surgical margin was negative. The blood CEA level dropped to the normal value soon after the operation. Adjuvant 5′-deoxy-5-fluorouridine was orally administered for 2 years after the operation. The follow-up examinations showed no sign of recurrence, and 5 years after the surgery, the follow-up was continued with annual computed tomography (CT) scans and biannual blood tests, including CEA measurements.18F]-fluoro-2-deoxy-d-glucose (FDG) accumulation only in the sacrum . The irradiation was performed as one of the “advanced medical treatments,” stipulated by the Ministry of Health, Labour and Welfare in Japan, after approval by the hospital case review committee. Written and informed consent was obtained from the patient. The dose was calculated for the target volume and any nearby critical structures and expressed in gray equivalent  × relative biologic effectiveness (RBE)). The CEA level reached a maximum of 55.6 ng/ml immediately after the heavy ion therapy and then gradually decreased to a minimum of 7.0 ng/ml 3 months after the irradiation.Considering the possibility of distant metastasis, the option of adjuvant systemic chemotherapy was presented but rejected by the patient. Four months after the heavy ion therapy, the CEA level was elevated again to 11.0 ng/ml and continued to increase thereafter. Multiple small lung metastases were noted on CT scans 5 months after the radiotherapy Fig. , but theSystemic chemotherapy (mFOLFOX6 + bevacizumab) was started 9 months after the heavy ion radiotherapy. After three courses of the regimen, the patient developed acute hemorrhagic cholecystitis and was treated conservatively. Around the same time, he developed a decrease in left lower limb muscle strength and needed a wheelchair or walking brace when going out. Furthermore, left limb pain increased and pain control was started with oral administration of tapentadol, pregabalin, and oxycodone. Around the same time, a follow-up CT scan revealed asymptomatic pulmonary arterial and left lower limb deep vein thrombosis, and an oral anticoagulant was started. These bleeding and thrombosis events were thought to be side effects of bevacizumab, which was stopped thereafter.Eleven months after the irradiation, the sacral lesion showed slight progression with worsening of pain, and the second course of heavy ion irradiation (60.0 GyE/12 Fr) was administered. After the irradiation, the sacral lesion remained stable Fig.  and therMost recurrences of colorectal cancer occur within 5 years after curative surgery, and the guidelines in America and Japan recommend a 5-year postoperative follow-up , 2. HoweIn the case we report here, the patient had received preoperative radiotherapy and therefore had a potential risk of late recurrence. Under such a condition, a rapid elevation of the CEA level led to further investigations to identify metastatic lesions. If the follow-up had been terminated at the 5-year limit, the sacral metastasis would not have been diagnosed until the patient developed symptoms due to the metastatic lesion. Although CEA measurement is widely performed in the postoperative follow-up of colorectal cancer for the detection of asymptomatic recurrence, there is no established recommendation about how often or until when CEA levels should be monitored –16. For FDG-PET has been reported to be useful in the diagnosis of recurrent cancer, including colorectal cancer –19. FlanAs there are no definitive or routine follow-up schedules for late recurrence, we should consider tailoring them based on each individual case. For relatively young and healthy patients who may be candidates for radical therapy for metastatic lesions, annual or biannual CEA measurements/digital examination/(PET-) CT may be appropriate choices for the detection of late recurrence. CEA measurement and digital examination may be ideal since they are easy to perform with relatively low cost and low invasiveness. In terms of ceasing follow-up, 7–10 years may be sufficient, although there is no supporting evidence. Merkel et al. recommend at least 7–8 years of follow-up after long-term neoadjuvant radiotherapy or chemoradiotherapy [Skeletal metastasis is relatively rare in colorectal cancer compared with the more common liver, peritoneal, and lung metastases. In previous case series, the rate of skeletal metastasis has been reported to be approximately 6 % , 4. In rThere is no established treatment for skeletal metastases from colorectal cancer. Conventional radiotherapy alone can hardly be considered a radical treatment but is still effective for the prevention and palliative treatment of symptoms from bone metastases, such as pain, paralysis, and pathological fracture. Surgical resection is considered when the metastasis is limited to a single bone site and is curable, if the associated risk of surgery is acceptable. For sacral metastasis, surgery is usually not indicated for S1/S2 lesions because of the high risk of neurological complications. Moriya et al. reported that, in 57 patients with locally recurrent rectal cancer who underwent total pelvic exenteration with distal sacrectomy, the most frequent complication was sacral wound dehiscence (51 % of patients), followed by pelvic sepsis (39 %), but serious complications such as walking impairment and spinal fluid leak did not occur since their guidelines included preservation of the S2 sacral nerves bilaterally . FourneyIn the current case, a sacrectomy was decided against because the metastatic lesion reached the S1/S2 level and the risk of nerve injury was high. Conventional radiotherapy was also not indicated because of the history of preoperative pelvic irradiation. On the other hand, heavy ion radiotherapy using carbon ions has been reported to produce good clinical results for local recurrence of rectal cancer –9. YamadTo avoid the complication of bowel perforation from heavy ion therapy, the recurrent lesion must be separated from the intestinal wall by a space of at least 5 mm; our case met this criterion. If the spacing is not adequate, heavy ion radiotherapy can be performed safely by surgically inserting a spacer between the target lesion and the intestinal wall.In the current case, pain and palsy occurred 1 year after the first course of heavy ion radiotherapy. At first, the nerve disorder may have been an adverse event as a result of the heavy ion radiotherapy. It generally occurs 6–12 months after irradiation, in a small number of people. Since this patient had undergone conventional neoadjuvant radiotherapy during the primary treatment, the accumulative dose to the nerve was high, which may be one of the causes of the nerve disorder. However, as for the worsening of pain prior to the second course of heavy ion radiotherapy, we do not think it was merely an adverse event; in fact, we think it was a symptom of sacral lesion progression. In fact, after the second heavy ion irradiation, further worsening of the nerve disorder ceased and we thought the irradiation was effective. If we had not intervened at the time of diagnosis, far more severe destruction of the sacrum and refractory pain might have occurred.We performed a PubMed search of the literature using the keywords “heavy ion,” “carbon ion,” and “colorectal cancer” and found no reported case of heavy ion radiotherapy for bone metastasis from colorectal cancer. In our case, the heavy ion radiotherapy, which was potentially radical at the time of the irradiation, was unfortunately soon followed by the development of systemic metastases. Nevertheless, the sacral metastasis has been stable after the second heavy ion irradiation, and the patient’s quality of life has been relatively maintained until now. The patient steadily continues outpatient chemotherapy and enjoys his everyday life, including occasional foreign trips with his family. Quality of life is very important in cancer patients, especially those with advanced-stage disease. Heavy ion irradiation to the sacral lesion was considered effective for local control, continuation of systemic therapy, and eventually for maintenance of the quality of life.We encountered a rare case of late asymptomatic sacral recurrence of rectal cancer diagnosed by a rapid CEA level elevation 9 years after the primary surgery. Heavy ion irradiation to the sacral lesion was effective for local control. We conclude that, if the risk of late recurrence is expected to be relatively high, clinicians should consider individual follow-up evaluations, including CEA measurement, even beyond the 5-year limit, to allow timely diagnosis and intervention.


Retinoblastoma is considered the most common intraocular malignancy in childhood, comprising 4% of all pediatric cancers. Management of retinoblastoma has evolved over the past two decades and intra-ophthalmic artery chemotherapy has emerged as a new modality of globe-conserving treatment with excellent results. This treatment achieves effective tumor reduction by delivering localized chemotherapy, decreases enucleation rate, and minimizes systemic and local side effects.We report the case of an 8-year-old girl with a late presentation of an advanced unilateral retinoblastoma associated to diffuse exudative retinal detachment in the right eye, classified as group E by the International Classification of Retinoblastoma. The initial therapeutic proposal for the patient was five sessions of intra-ophthalmic artery chemotherapy (IAC) associated to large spot diode laser therapy. After undergoing four sessions of IAC, the fundus exam revealed a giant retinal tear associated to a total retinal detachment in the affected eye. The IAC treatment was concluded and enucleation was considered the best treatment option at that moment, since IAC was unable to control the tumor’s activity and the patient’s eye presented with a complex rhegmatogenous retinal detachment (RRD). However, family left for a second opinion and never returned.The usage of IAC for retinoblastoma management may lead to important local complications. Despite rare, RRD secondary to IAC may occur. We postulate that the giant tear observed in this case was caused by the rapid tumor necrosis using this route of treatment. Retinoblastoma (RB), a neuroectodermal tumor originated from the inner layer of the optic cup, was first described as a specific entity by James Wardrop in 1809 . HeritabThe survival rate of retinoblastoma is still low, with rates ranging from 50 to 70%. However, in developed countries the survival rate has improved to almost 100%, and so have the visual outcomes , 3. ThisNowadays, there are various routes of administration of chemotherapy treatment including intravenous, intra-arterial, periocular, and intravitreal. The choice for a route of administration depends upon the tumor laterality and tumor staging . ChemothThe systemic side effects caused by IAC are not significant since it offers minimum systemic absorption of drugs. However, its protection against systemic metastasis, pinealoblastoma, and secondary cancers remains a controversy of this treatment . Severe The most common types of RD associated to RB are tractional and rhegmatogenous. Generally, rhegmatogenous retinal detachments (RRD) are caused by breaks adjacent to cryotherapy scars or ablative therapies applied locally , 10, 12.An 8-year-old girl was urgently referred for leukocoria. The patient reported central vision loss and floaters in her right eye for a month. Her family history and past medical history were noncontributory. At presentation, her best-corrected visual acuity was 20/250 and 20/20 in the right and left eye, respectively. The diagnosis of retinoblastoma (RB) was confirmed after slit-lamp, fundus, and ultrasound examination and classified as group E by the International Classification of Retinoblastoma (ICRB). She was taken to the operating room after being submitted to brain and orbital MRI that revealed no central nervous system involvement.In the operating room, a dense multilobulated advanced RB with an extensive exudative retinal detachment (ERD) and vitreous seeding was observed Fig. a, b. TheAfter completing four cycles of IAC treatment with adjacent transpupillary thermal large spot size diode laser ablation, a massive reduction of the tumor’s volume was noticed; however, the ERD persisted. Three weeks later, an inferior giant retinal tear was observed in the right eye Fig. c, d. AftWith therapeutic advancement, IAC has become the preferred route of chemotherapy administration for unilateral RB cases . HoweverPrevious studies have reported tractional and RRD as possible complications of IAC treatment. Most of these retinal breaks associated with RB treatment are caused by the local ablative therapy that mechanically causes the retinal holes that leads to a RD , 10, 12.Despite the slightly increase of post-treatment RRD using IAC, this complication is still considered rare with an estimated incidence of 6% . AccordiIt is important to highlight that none of the eyes reported by Shields et al. presented with such an extensive retinal tear. Managing the RRD in eyes with RB tumors after being treated primarily with IAC can be quite challenging. The first concern is to maintain complete tumor control before repairing the RRD and consequently, analyze its potential to be repaired . Since tIn conclusion, IAC can provoke retinal tears as tractional forces are created during the tumor’s contraction, precluding globe salvage. Thus, RB patients undergoing IAC treatment should be closely monitored for early detection of complications and better management of the disease.


Retroclival hematomas are a rare entity. The pathology can be categorized into epidural hematoma or subdural hematoma based on the anatomy of the tectorial membrane. Frequently, the etiology is related to accidental trauma, though other mechanisms have been observed, including coagulopathy, non-accidental trauma, and pituitary apoplexy. There have been only 2 prior cases where both epidural and subdural hematoma co-present.An 8-year-old male was involved in a high-speed motor vehicle accident. He presented with a Glasgow Coma Score (GCS) of 14 with bilateral abducens nerve palsies. Computed tomography (CT) revealed a hemorrhage along the dorsum sella, clivus, and dens. Magnetic resonance imaging (MRI) demonstrated the retroclival hematoma in both the subdural and epidural space. At discharge, 19 days after the accident, the abducens nerve palsies had resolved without medical or operative intervention.Retroclival hematoma may present after trauma. Although most cases exhibit a benign clinical course with conservative management, significant and profound morbidity and mortality have been reported. Prompt diagnosis with close observation is prudent. Surgical management is indicated in the presence of hydrocephalus, symptomatic brainstem compression, and occipito-cervical instability. Retroclival hematomas are rare and only represent a small subset of posterior fossa extra-axial hematomas, which as a whole constitute approximately 0.3 % of acute extra-axial hematomas , 2. The An 8-year-old male was involved in a motor vehicle crash. He was sitting on the back seat along the driver side; his seat belt status was unknown. The vehicle was “T-boned” by another vehicle traveling 60 miles per hour. At the scene, patient exhibited a GCS 14. On presentation, his eyes were crossed, but he did not complain of diplopia until the following day. Because he was lethargic and confused, he was admitted to the ICU for close monitoring. He denied significant headaches, blurred vision, eye pain, or light sensitivity. Physical examination was significant for bilateral 6th nerve palsies.CT of the head revealed a hemorrhage along the dorsum sella, clivus, and dens Fig. , 1b. MRIRetroclival subdural hematoma (rcSDH) has been reported less often than epidural hematoma (rcEDH). However, both can co-present, particularly in violent injuries . Tables The most common etiology is a traumatic event that induces hypermobility of the neck. Either hyperflexion or hyperextension can lead to soft tissue injury or fractures, causing a retroclival hematoma. The preponderance of reported pediatric cases relative to adult cases may be attributed to the anatomical differences at the craniocervical junction. Compared to adults, children possess certain features  that increase the mobility of the spine and augment the risk for injury , 13. DisThere are a variety of non-traumatic causes of retroclival hematoma. A common etiology is pituitary apoplexy. Hemorrhage can spread through the diaphragm sella into the subdural space, constrained by the posterior arachnoid membrane of the prepontine cistern , 23; on Clinical presentation can be variable. Neurological impairment may be related to stretching, direct compression, or contusion of surrounding nerves and brain parenchyma. The most frequently injured cranial nerve is the sixth cranial nerve (unilateral , 30 or bThese hematomas may be overlooked on axial CT due to beam hardening artifacts in the posterior fossa , requiriExcept for the rare cases that lead to death , 37, 39,Retroclival hematoma may present after trauma. Most cases exhibit a benign clinical course with conservative management, but significant and profound morbidity and mortality have been reported. Prompt diagnosis with close observation is prudent. Surgical management is dictated based on the presence of hydrocephalus, brainstem compression, and occipito-cervical instability.


Background: In this case we describe the rare and not previously documented presentation of cystitis cystica as a large solitary cystic lesion within the bladder wall.Case Presentation: We present a case of a 46-year-old Russian male with a history of lower urinary tract symptoms and suprapubic pain. CT urogram showed a 5.8 cm filling defect/cystic mass related to the base of the bladder and prostate with 8 mm thick wall. The patient underwent cystoscopy and contrast study of bladder lesion with urethral dilatation and transurethral deroofing of bladder wall cyst under general anesthesia. A histologic diagnosis of cystitis cystica was made.Conclusion: This case described the rare presentation of a large solitary bladder cyst arising from the anterior bladder wall, identified histologically as cystitis cystica. Cystitis cystica presenting as a large cystic lesion of the bladder wall is rare; however, a diagnosis of cystitis cystica should be considered in unexplained cystic defects of the bladder wall. A community ultrasound scan of the urinary tract requested by the general practitioner identified a cystic lesion of the bladder.The ultrasound scan identified a 5.9 × 5.4 × 5.9 cm irregularly shaped cystic lesion, with a thickened wall of 8.1 mm thought to be an ureterocele .On probing, he had a history of LUTSs with an international prostate symptom score of 9/35: frequency 2/5, urgency 1/5, nocturia 1/5, intermittency 1/5, straining 1/3, incomplete emptying 3/5 plus suprapubic and perineal pain and intermittent left testicular pain now known to be because of a radiologically identified left varicocele and episodes of prostatitis, likely chronic. Clinical examination was normal except for suprapubic tenderness. There was no history of frank hematuria or fever.Urinalysis identified mild hematuria with small quantities of red blood cells, with no evidence of infection.Prostate-specific antigen was within normal range at 0.423 ng/mL.Initial diagnostic cystoscopy was performed; however, it proved to be inconclusive as the cystic lesion could not be observed and showed no obvious abnormality.A contrast-enhanced CT urinary tract showed a 5.8 cm filling defect/apparent cystic mass related to the base of the bladder and prostate with 8 mm thick wall . Contents measure 48 HU before and after contrast. Contrast was noted to pool around the cystic mass on the delayed phase with the patient supine. Appearance was not typical of an ureterocele or transitional-cell carcinoma. Cystoscopy was recommended to exclude unusual ureterocele or cystic neoplasm.Two stones at the lower groups of collecting system of left kidney 5 mm in size and a 1.3 cm simple left renal cyst were also reported .Local multidisciplinary team discussion recommended cystoscopy under general anesthesia to further examine the bladder lesion.The various imaging modalities used identified this cystic lesion of the anterior wall of the bladder but not of the mucosa.Contrast-enhanced MRI of pelvis and prostate describes a 6 × 5.5 cm intraluminal lesion in the bladder with asymmetric wall thickening, related to the bladder base, appearing separate to the prostate. The content of the lesion is of higher signal than normal bladder contents on T1W and T2W images  and 4.Eleven months after initial presentation to urology, the patient underwent cystoscopy and contrast study of the bladder lesion with urethral dilatation and transurethral deroofing of the bladder wall cyst  under general anesthesia. On observation, the endothelium of the bladder appeared normal and the large cystic lesion arising from the anterior bladder wall was identified.No obvious punctum was seen and within the cyst was an organized clot.The lesion at the time of surgery appeared to be benign.Biopsies were taken and sent for histologic analysis. A histologic diagnosis of cystitis cystica was made, with the overlying urothelium showing mild urothelial hyperplasia and no malignant change. Postoperatively, the patient experienced ongoing dull aching left flank pain and hematuria. However, the patient reports that his episodes of prostatitis had significantly improved. Although the patient's LUTSs were relatively mild (9/35), postoperatively the patient had a noticeable improvement in frequency, urgency, and incomplete emptying. Testicular pain remains an issue secondary to the currently untreated varicocele. Ten months before the initial bladder resection, two 5 mm nonobstructive lower pole stones were identified on CT urogram. Five months after initial resection, a CT urogram carried out identified a residual/recurrent discolored lesion seen in the bladder base along the posterior wall measuring ∼1.5 cm. A few small calcific densities within the bladder likely to represent small bladder calculi were also noted. The small calculus in the lower pole of the left kidney had now formed a staghorn calculus involving the middle and lower calices measuring 3.4 × 2 cm without causing any hydronephrosis or obstructive uropathy, given the low density (340–440 HU), which may represent a uric acid calculus.Repeat flexible ureteroscopy identified discoloration in the region of the prostatic indentation. The patient underwent flexible ureteroscopy laser lithotripsy, Double-J stent insertion, and transurethral resection of residual bladder neck lesion.Recent evaluation of the benign cystic lesion of bladder shows almost complete resolution.The resected lesion from the bladder neck contained superficial fragments of diathermized and crushed detrusor muscle with a focal area of calcification; no surface urothelium or evidence of malignancy was identified.The decision to use endoscopic laser lithotripsy through ureteroscopy was because of patient preference in an attempt to render him stone free in one treatment.During the procedure, it was not possible to render the patient stone free and a considerable proportion of the staghorn calculus remained.Two days post-Double-J stent insertion, the patient reattended with renal colic. Blood results were unremarkable, and an abdominal X-ray confirmed that the stent remained in the correct position. The ongoing pain was stent related and he was discharged with regular analgesia.Postoperatively the patient had a degree of bleeding attributed to the resection of the bladder mucosa, and given that he has an indwelling stent, he may experience further episodes of visible hematuria.As a result of the incomplete laser lithotripsy, a further noncontrast CT KUB 4 weeks after treatment identified that the staghorn calculus within the left kidney was similar to the previous scan. Although the calculus appears less dense compared with the previous CT, it appears almost similar in size and measures ∼3.2 × 2.1 cm. An incidental simple renal cyst in the upper pole of the left kidney remains unchanged. There is a suggestion of subtle irregularity in the bladder that has not been optimally assessed through scan, and correlation with repeat cystoscopy is recommended.The patient's preference for further management would be for flexible ureteroscopy left laser lithotripsy, with the aim of rendering him stone free in that one sitting. Future scheduled intervention of repeat flexible ureteroscopy laser lithotripsy of the significant volume residual stone is planned at the patient's request and the patient will continue to be followed up as an outpatient with CT scans, ureteroscopy, and evaluation of ongoing clinical symptoms.2Cystitis cystica is a benign proliferative lesion of the bladder as a result of a chronic reactive inflammatory disorder thought to be caused by chronic irritation of the urothelium because of infection, calculi, obstruction, or tumor.Cystitis cystica is characterized by hyperplasia of the bladder mucosa and the presence of cystically dilated von Brunn nests within the lamina propria. Cystitis cystica predominantly occurs at the bladder neck and trigone region of the bladder.Minor forms are common and have similar clinical features as cystitis, but its major form may be mistaken for bladder tumor on cystoscopy.CT imaging in cystitis cystica classically shows the appearance of multiple small filling defects of 2 to 5 mm in the bladder wall; however, in this case, cystitis cystica presented as a large solitary cystic lesion within the bladder wall not previously described in the literature.Cystoscopic biopsy is mandatory. Submucosal nests of columnar epithelial cells surrounding a central liquefied region of columnar degeneration are histologically diagnostic.4Hematuria or symptoms of urinary tract infection are the usual presenting feature of cystitis cystic; however, patients can be asymptomatic.2 There is debate among specialists of the precancerous potential of cystitis cystica. Harik and O'Toole 20122 considered cystitis cystica to be a premalignant lesion of the urinary tract, leading to adenocarcinoma of the bladder, although there is limited documentation of the progression of cystitis cystica to carcinoma of the bladder.Cystitis cystica may occur at any age, and there is a slight male predominance.4 suggested that cystitis cystica may be a normal urothelial variant with no precancerous potential.This patient has a positive family history of bladder cancer, with his father previously diagnosed with the condition. However, the prevalence of cystitis cystica has been reported at 60% in normal bladders on autopsy and Wiener et al.This case described the rare presentation of a large solitary bladder cyst arising from the anterior bladder wall, identified histologically as cystitis cystica.Cystitis cystica presenting as a large cystic lesion of the bladder wall is rare; however, a diagnosis of cystitis cystica should be considered in unexplained cystic defects of the bladder wall.


Meconium peritonitis is an infrequent congenital disease usually caused by perforation of the fetal digestive tract. Meconium peritonitis resulting from intrauterine appendiceal perforation has been rarely reported and is often overlooked during pregnancy. We herein report two cases of fetal appendiceal perforation.Two neonates were found to have intestinal distension and gradually increasing ascites antenatally. After birth, diagnostic abdominal punctures revealed meconium peritonitis. Urgent surgery showed both neonates had developed gangrenous appendicitis in utero. Pathological examination supported the diagnosis of fetal appendiceal perforation in both neonates, and one also had deformity of cecal duplication. In the present report, we also review the presentation, diagnosis, pathology, management, and recent literature of fetal appendiceal perforation.Meconium peritonitis due to fetal appendiceal perforation is extremely rare, and preoperative diagnosis is almost impossible. However, clinicians should be aware of abnormal gastrointestinal manifestations in the fetus during the antenatal examination. For neonates with severe meconium peritonitis, an early operation with careful intraoperative exploration is necessary. Meconium peritonitis (MP) is a sterile chemical peritonitis that is caused by intrauterine bowel perforation and has low morbidity 1/30,000). Although the mortality rate was historically high (70–80%), the survival rate for neonates with MP has increased to > 80% because of improvements in fetal diagnostic techniques and proper management, including surgical procedures /30,000. . Local iWe herein describe two newborns diagnosed with MP due to fetal appendiceal perforation, and we share our experience with special reference to the clinical presentation, evaluation , and surgical treatment of this condition.A 3490-g boy was born by cesarean section at 36 5/7 weeks of gestation to a 26-year-old gravida 1, para 1. The Apgar scores at 5 and 10 min were 9 and 10, respectively, with normal oxygen saturation. Prenatal ultrasound (US) examination showed local intestinal expansion and mild polyhydramnios at 26 weeks of gestation Fig. . MagnetiPhysical examination of the neonate revealed normal development and a normal response to external stimulation. His abdomen was slightly distended without palpation of a mass; however, an asymmetric feeling of guarding was noted during abdominal palpation. Laboratory studies showed that the white blood cell count and C-reactive protein (CRP) concentration were normal. A plain abdominal radiograph and US examination revealed intestinal obstruction with ascites. The patient was then admitted to the hospital. Diagnostic abdominocentesis was performed, and yellow turbid liquid was extracted. Thus, the primary diagnosis of MP was made, and an urgent exploratory laparotomy was performed.At surgery, about 300 ml of turbid ascites was aspirated, and all of the abdominal organs were encased within a huge cystic pseudomembranous structure. Dense adhesions were present around the gut with scattered calcifications. After releasing the adhesions, we found gangrenous appendicitis with perforation near the tip as well as a perforated lesion at the terminal ileum. A limited ileocecal resection was then performed with ileo–ascending colon anastomosis Fig. , d.Histological sections from the appendix showed ulceration of the mucosa with increased lympho-mononuclear cells in the lamia propria, hyperemia and edema in the submucosa, and organizing serositis with perforation Fig. , b. Notath week of gestation, he was born by cesarean section.A 3560-g male newborn was smoothly delivered by cesarean section to a 32-year-old gravida 2, para 1. At mid-pregnancy (about 27 weeks of gestation), prenatal US examination showed fetal ascites with a maximum depth of 11 mm, and follow-up US examination indicated that the ascites had been gradually increasing Fig. . At the After birth, physical examination of the neonate revealed a mildly distended abdomen. During abdominal palpation, a hard mass of about 4 × 3 × 3 cm was felt in the right middle abdomen. A plain abdominal radiograph suggested calcification foci in the abdominal cavity Fig. . The whiSimilar to the intraoperative findings in Case 1, after complete suction of the ascites, we found that the intestines were firmly stuck together, especially in the right lower abdomen. We released the adhesions and carefully cleaned up the calcified lesions, then found a gangrenous appendix with perforation near the tip. Intraoperative exploration revealed no other structural anomalies Fig. . A standOnly a few cases of prenatal appendicular perforation have been reported since Martin first described this condition in 1986  , 8, 9. AOnce a patient has clear surgical indications, such as signs of peritonitis, abnormal diagnostic abdominocentesis, or imaging/laboratory examination findings that indicate a severe situation, laparotomy should be performed as soon as possible because MP has a high mortality rate, and early management is needed , 13. In We have herein presented two rare cases of MP caused by fetal appendiceal perforation. Preoperative diagnosis of appendiceal perforation in utero is very difficult; however, clinicians should be aware of any abnormal gastrointestinal symptoms in the fetus and maintain constant attention. For patients with severe MP, an early operation with careful intraoperative exploration is necessary.


A 76-year-old female presented to our hospital with a 2 cm firm, nontender, protuberant umbilical nodule. She received treatment with antibiotics for suspected granuloma, with no improvement after two months. High levels of CA125 as well as an ovarian cyst and intrathoracic and intra-abdominal lesions on imaging studies made us suspect an ovarian cancer with a Sister Mary Joseph nodule (SMJN) and other metastases. A bilateral salpingo-oophorectomy and umbilical and omentum tumor resections were performed and a metastatic ovarian serous adenocarcinoma was diagnosed by histopathology. After surgery, the patient received chemotherapy with paclitaxel, carboplatin, and bevacizumab; however paclitaxel allergy was observed. As a result, chemotherapy continued with carboplatin and bevacizumab every three weeks for a total of 6 courses. Currently, she is still undergoing treatment with bevacizumab and CA125 levels have been progressively decreasing. SMJN is a rare umbilical metastasis which needs to be considered as a differential diagnosis in the presence of an umbilical tumor for prompt treatment initiation.  Sister Mary Joseph nodule (SMJN) is a rare umbilical lesion resulting from an intra-abdominal and/or pelvic malignancy. It was named after Sister Mary Joseph, a surgical assistant to Dr. William J. Mayo, who noted the association between the presence of an umbilical nodule and an intra-abdominal malignancy . Its incHere, we present a case of SMJN as an ovarian cancer metastasis, its diagnosis, treatment and follow-up.A 76-year-old female with a one-month history of a rapidly enlarging and friable umbilical tumor presented to our hospital for a surgery consult. She had a past history of hypertension, hyperlipidemia, and tubal ligation. Her family history was not relevant. Physical examination showed a 2 cm firm, nontender, protuberant umbilical nodule . She wasWith the suspicion of a malignant umbilical tumor, blood tests were performed and revealed high levels of CA125 (over 500 U/mL). Biopsy was proposed for a definitive diagnosis; however it was not pursued per patient's request. An upper and lower gastroenterological endoscopy was performed and showed no major abnormalities. Gynecology was consulted for further evaluation and a 2 cm ovarian cyst was noted on a transvaginal ultrasound. Imaging by CT and MRI confirmed the diagnosis and showed intra-abdominal and right lung metastatic lesions Figures .With the suspected diagnosis of a metastatic ovarian cancer, an exploratory laparotomy was performed. A cystic lesion of approximately 2-3 cm was seen on the right ovary and a small amount of ascites was noted . MoreoveThe postoperative course was uneventful and the patient was discharged 10 days after surgery. Chemotherapy with paclitaxel, carboplatin, and bevacizumab was started one month after hospital discharge; however paclitaxel allergy (skin rash) was observed. As a result, chemotherapy continued with carboplatin and bevacizumab only, every three weeks for a total of 6 courses. Currently, the patient has monthly follow-ups with blood tests (tumor markers) and vaginal ultrasounds. CA-125 levels have been progressively declining, though they are still not under normal limits. The patient will continue with 10 additional chemotherapy courses with bevacizumab.Umbilical tumors are rare and can be classified as benign or malignant. Benign causes include umbilical hernia, granuloma, abscess, mycosis, and eczema. Malignant tumors can be either primary or metastatic , 6. The When an umbilical nodule is found it is necessary to make an accurate histological diagnosis between primary and metastatic lesions. Fine needle aspiration cytology and core biopsy are proposed as simple, fast, accurate, and inexpensive diagnostic tools , 10. AlsPrevious studies showed that, among umbilical malignancies, 88% originated outside the umbilicus and 12% were primary skin tumors. The mean age of diagnosis is approximately 50 years, with a range of 18–87 years. Moreover, women are more likely to have malignant tumors affecting the umbilicus . AlthougSMJN is considered a late manifestation of a malignant process and represents an advanced stage of the disease . Mean liIn conclusion, the presence of SMJN is a rare and often poor prognostic sign of a disseminated malignancy. SMJN needs to be considered as a differential diagnosis of an umbilical nodule in order to make a prompt identification of the primary lesion.


Takotsubo cardiomyopathy (TCM) is a form of stress-induced cardiomyopathy featured by the dilatation of the apex of the left ventricle during systole. Whereas the pathogenesis of this disorder is not well understood, it usually occurs after an emotional or physical stress such as acute asthma, surgery, chemotherapy, and stroke. However, its occurrence in ileus patients is rarely reported. We hereby report probably the first case of TCM after ileus in the literature and discuss its implications.An 85-year-old man was brought to the Emergency Department due to vomiting, abdominal pain, and no stool passages for 2 days. His abdomen was markedly distended, and ileus pattern was observed in the plain film of abdomen. Electrocardiogram showed right axis deviation, poor R-wave progression, and diffuse ST-segment elevation in the anterior leads, and cardiomegaly was observed by roentgenogram. A ventriculography showed an ejection fraction of 33% and confirmed the apical dilation consistent with TCM. He was treated with medication and discharged without remarkable adverse events. A follow-up transthoracic echocardiogram 4 months later showed normalization of his left ventricular systolic functions.The precise mechanisms of the development of TCM are still unknown, but it is widely believed that it is triggered by the catecholamine surge produced in response to stress. This case demonstrated that such a stress can be of various forms, including ileus and other conditions that may lead to severe abdominal pain, and highlight the importance of awareness in diagnosing this rare but potentially lethal condition. Takotsubo cardiomyopathy (TCM) is a form of stress-induced cardiomyopathy, featured by the dilatation of the apex of the left ventricle during systole. It was first described in the English language in 1991 . The patAn 85-year-old man with diabetes, hypertension, and chronic obstructive pulmonary disease was brought by ambulance to the Emergency Department with the chief complaints of vomiting, abdominal pain, and no stool passages for 2 days. Physical examination revealed labored breathing. Patient also demonstrated peritoneal signs, including muscle guarding and rebounding tenderness. Bowel sounds were absent, but cardiac sounds were normal without rub, murmur, or gallop. Upper and lower extremity pulses were intact and symmetric. His initial electrocardiogram (ECG) showed normal sinus rhythm with right axis deviation, poor R-wave progression, and diffuse ST-segment elevation in the anterior leads Fig. . A roentAs laparotomy was suggested by a surgeon who was consulted in the intensive care unit, the patient received pre-anesthesia assessment. On the basis of the recommendation from a cardiologist who performed the assessment, the patient underwent left heart catheterization on the second day of hospitalization, which failed to show a significant obstruction in any coronary distribution Fig. . VentricThe CARE guidelines were followed in this report.Over 90% of TCM cases are observed in postmenopausal women , and cliThe physical stressors that can induce TCM include acute asthma attack, surgery, chemotherapy, stroke, car accident, suicide attempt, etc. , 10, 13.Given the nonspecific symptoms and signs, a high clinical index of suspicion is essential for prompt diagnosis of TCM, a rare but potentially fatal disorder. One of the indices of suspicion is either emotional or physical stimulus that is stressful for the patient. This case suggests that ileus, and probably severe abdominal pain caused by other etiologies, can be added to the list of stress triggers that can cause TCM and alarm clinicians.


Multicystic nephroma is an uncommon, non-familial renal neoplasm that is usually benign. About 200 cases of this lesion have been described in the literature.We report on a Sudanese child who presented at the age of two and a half years with an abdominal mass, clinical and radiological features favored the diagnosis of hydatid cyst which is endemic in this African tropical country, and the diagnosis of multicystic nephroma was only possible after histopathological examination.Multicystic nephroma is a rare benign tumour with an excellent prognosis. Clinical and radiological differentiation of multicystic nephroma from hydatid cyst is difficult. Thus, histopathological examination of the surgical specimens seems to be the only feasible method of making the correct diagnosis. Multicystic nephroma (MCN) is a rare, non-familial renal tumour, that has a benign nature. About 200 cases of this lesion have been reported so far . DiffereThe pathogenesis of MCN remains unclear,  thus itsWe describe a Sudanese child who presented at the age of two and a half years with an abdominal mass, clinical and radiological features favored the diagnosis of hydatid cyst and the diagnosis of multicystic nephroma was only possible after histopathological examination. To our knowledge this is the first case report of multicystic nephroma masquerading as hydatid cyst from a tropical country in Africa.A two and a half year old male child from Darfur province, west of Sudan was brought by his parents because of abdominal distension for 8 months prior to admission. The distension was associated with mild pain and no symptoms related to the urinary or gastrointestinal systems. His past medical history was unremarkable apart from poor socioeconomic status and contact with livestock and sheepdogs. Physical examination revealed a slightly pale child with no jaundice and no lymphadenopathy. Abdomen was grossly distended with bulging of the right flank, there was umbilical hernia. There were cautery marks, striae, and superficial veins Fig. . SuperfiInvestigations performed included a full blood count which showed nutritional anaemia, ESR 57 mm/h. His renal and liver function tests were entirely normal. Urine analysis was also normal. CXR was normal.The first abdominal ultrasound revealed a huge right cystic renal mass, containing small daughter cysts arranged eccentrically as well as few septations with normal left kidney. Findings were compatible with right renal embryonic multi cystic tumor. A repeat ultrasound in a different setup showed the same findings with a strong possibility of hydatid renal disease. Computed tomography (CT) of the chest was normal and CT abdomen showed a large cystic mass arising from the right kidney consistent with hydatid cyst Fig. . The paeThe first case of MCN in the literature was reported by Edmund et al. as cystic nephroma of the kidney in 1892 . In 1956MCN is diagnosed by set of criteria as suggested by Powell et al. in 1951 . The diaOur case was a two and a half year old male child with unilateral MCN, and this is similar to what is reported in the literature , howeverThe background history of our case was poor socioeconomic status, poor sanitation and contact with livestock and sheepdogs, all these, together with the radiological findings, favored the diagnosis of hydatid cyst (Echinococcosis) . Cystic echinococcosis is caused by infection with the larvae of Echinococcus granulosus. Areas of the world with noted prevalence are rural regions of Africa, southern Europe, Asia, the Middle East, Central and South America and is principally maintained in a dog–sheep–dog cycle, . SerologAt present there is no reliable clinical or radiographic means to differentiate cystic nephroma from other cystic renal disease in children . The nonhistopathological examination from a resected specimen seems to be the only feasible method of making the correct diagnosis .Because preoperative diagnosis is difficult to achieve and multicystic renal cell carcinoma is suspected, radical nephrectomy is the standard treatment of choice. Our case had a radical right nephrectomy as the diagnosis was uncertain and the dynamic renal scan showed a nonfunctioning right kidney. In cases of solitary, localized, unilateral lesions less than 4 cm with frozen section proven diagnosis, nephron-sparing surgery is advocated . The proMCN is a rare benign tumour which has a good prognosis. Clinical and radiological differential diagnosis of MCN from hydatid cyst is difficult. Thus, histopathological examination of the surgical specimens seems to be the only feasible method of making the correct diagnosis.


Echinococcus granulosus that can potentially affect any part of the human body. Liver and lungs are the most frequent localizations. Primary musculoskeletal hydatidosis are seldom reported in literature and their incidence is unknown.Hydatid disease (HD) is a cosmopolitan parasitosis caused by We deem interesting to report a case of a primary hydatid cyst in a 25-year-old patient who presented with a painful swelling of the right elbow. Meticulous examination and preoperative imaging did not reveal other localizations. Patient was admitted for surgery where total excision of cyst was done without intraoperative spillage and a cutaneous skin flap was subsequently required to make up for soft tissue loss.Primary hydatid cysts are sometimes difficult to diagnose preoperatively. It should be considered in the differential diagnosis of subcutaneous cystic lesions in regions where hydatid cysts are endemic. Currently, surgical excision is deemed first choice treatment for solitary cysts and antihelminthic treatment should be initiated preoperatively in the case of risk of rupture or in the event of complications. Species mainly involved include d cattle . Humans Echinococcus.Parasite larvae can develop in any part of the human body with the liver (68.8–80%) and lungs 10–22.4%), representing the most frequent localizations. Other rare localizations reported in literature include the spleen, peritoneum, skeleton, kidney, brain, cardiac muscle and even sub cutis 2.4%, rep. SubcutaWe hereby report a case of primary subcutaneous hydatid cyst of the elbow in a 25-year-old patient with a 3-year history of an incipient right elbow swelling.The authors intend to highlight the pitfalls in the diagnosis and management of primary musculoskeletal hydatid cysts through a rare case report and a review of relevant literature.A 25-year-old man, Middle Eastern origin, history of exposure to livestock was admitted to our unit complaining of a painful swelling of the right elbow. The swelling developed over 3 years and was associated with recent pain without fever or rigors, and pruritus. Anamnesis did not reveal any trauma to the elbow or prior medication.He was afebrile on admission with good general conditions, and physical examination revealed a tender right lateral elbow mass with distension of overlying skin. Mass measured 4 cm by 6 cm and there were no signs of excoriations nor fistula Fig. .Fig. 1Ri9 cells/L, eosinophil level of 158 cells/L, and a normal erythrocyte sedimentation rate of 15 mm/h. Liver function tests were unremarkable. Hydatid serology was negative and there was no modification in the appearance of the mass.On day 3, patient became febrile with a temperature of 38.8 °C. Lab test demonstrated a normal total WBC count of 5.0 × 10Plain elbow and chest radiographs were also unremarkable albeit diffuse soft tissue swelling of the elbow: there were no bone erosions nor calcifications. Ultrasound came back for a cystic lesion of the elbow with several floating membranes without color Doppler test. Magnetic resonance Imaging (MRI) depicted a unilocular cyst with multiple septations giving it a multivesicular or rosette appearance, confined to the soft tissues, adjacent to the medial elbow muscles without infiltrating bone nor surrounding neurovascular structures Figs.  and 3.FiPatient was prepared for elective surgery with consent and antihelminthic therapy was initiated preoperatively for 5 days. En block surgical excision of the mass under general anesthesia was undertaken. Care was taken to remove the mass en block without perforating the cyst wall, through meticulous pericystectomy along surrounding muscle fibers Fig. . The cysThe operating field was covered with adequate dressing. Cutaneous skin flap was done subsequently with favorable outcome and no signs of local recurrence 2 years after surgery.Hydatid disease is an anthropozoonosis caused by Echinococcus species; humans represent intermediate hosts in parasite life cycle when they occasionally ingest eggs through contaminated food or water , 3. The Thus primary soft tissue involvement is very rare; causing a diagnostic challenge . It is wCysts may present in several ways, including a slow-growing lump with variable pain or sudden onset of symptoms due to cyst rupture. Rupture of cysts releases antigens into muscles thus causing an inflammatory response that may be complicated by secondary bacterial infection . More so(USG) is a very useful diagnostic imaging tool for hydatid disease. Not only does it detect liver cysts but it also allows the classification and staging of liver hydatid disease [Diagnosis is based on clinical evidence such as anamnestic data pertaining to origin and history of exposure to livestock, presentation as well as radiological backing. Hydatid serology is often negative in 1 out of 2 cases of extra hepatic hydatid disease as was the case in our patient. Ultrasonography  disease , 16. Nev disease . It alsoIt is essential to establish definitive preoperative diagnosis of skeletal muscle hydatid cysts. This contraindicates certain treatment options like marginal excision or incisional biopsy due to the likelihood of dissemination and anaphylactic shock on spillage. Thursky et al.  reportedSupplementary chemotherapy with antihelminthics for skeletal muscle hydatid disease is controversial and currently no evidence provides sufficient backing on the benefit of its association with conservative treatment. Albendazole remains the gold standard drug administered in adjuvant therapy. Combination therapy with praziquantel has been reported in the treatment of inoperable hydatidosis . In caseThis case of primary skeletal muscle hydatidosis illustrates the significant morbidity associated with hydatid disease. Preoperative diagnosis is important in the management of hydatid cyst. Pericystectomy potentially combined with neoadjuvant therapy could help reduce complications and recurrence in large hydatid cysts.


We report a case of a woman with a gastrointestinal bleeding. An esophageal ulcer was detected in the endoscopy, however a histological malignancy could not be found. A computer tomography (CT) scan showed a thickness in the distal esophagus and enlarged lymph nodes, so a malignancy was highly suspected. However, the patient refused to follow the recommended clinical procedure of a surgical intervention. Four years later a carcinoma could be ruled out because of follow-up examinations. A 60 year old lady with a long-time history of alcohol abuse was admitted to the hospital in December 2005. She had complained about increasing weakness for two weeks. Because of increasing dizziness she turned to her general practitioner who found a slight anemia due to iron deficiency and prescripted iron orally. After a collapse at home with a short loss of consciousness she was transferred to the neurological emergency room. After a short while she felt better and discharged herself on her own responsibility but immediately collapsed again in front of the door of the neurological department. She was then transferred to the emergency room of the Internal Hospital, where the laboratory results showed remarkably reduced hemoglobin (2.8 g/dL). Pathological laboratory findings included reduced spontaneous thromboplastin time  and an elevated tumor marker  .She was directly admitted to the gastroenterological intermediate care unit (IMC) and was substituted with red blood packed cells. Although there were no clinical signs of GI- bleeding (melena or hematemesis) a gastroscopy was performed which detected an esophageal ulcer .Computed tomography (CT) scan of the thorax performed on the next day with a special esophageal protocol (water filling) confirmed the finding and showed a circular thickness of the wall in the lower part of the esophagus as well as several augmented lymph nodes in the mediastinum and retroperitoneal. Esophageal perforation or a pneumothorax could not be detected .The patient went on high dose PPI treatment and was stable during 3 days of monitoring in the intermediate care unit. Consecutively, she was transferred to the regular ward. No further event of bleeding was detected for the duration of stay in hospital.Endoscopic ultrasound (EUS) examination described a subtotal stenosis of the distal esophagus with exhaustion of the muscularis and several para-aortal lymphnodes, which was suspicious for a carcinoma .To rule out an esophageal carcinoma several biopsies in the area of the suspected carcinoma were performed, showing no malignancy. The taking of the biopsies turned out to be difficult because the area of the suspected carcinoma was remarkably callous so the caliper glided off easily. All following histological examinations showed no malignancy, but a carcinoma of the esophagus was profoundly assumed and a surgical resection was recommended based on the control CT scan 8 weeks later, which showed an unchanged result. However, the patient refused to underlay this procedure. After discharge from the medical hospital the patient was readmitted three times because of recurrent upper gastrointestinal bleeding and reexamined in the further course: The follow up CT scans in September 2006, September 2007 and December 2009 showed unaltered findings. Consequently, the initial diagnose of an esophageal malignancy turned out to be wrong. The surgical resection would have included a complicated procedure with a high morbidity and mortality , 2.The present case report focuses on the discrepancy between a highly suspected carcinoma by radiological and endoscopic findings on the one and no histopathological proof of malignancy on the other side.Our case shows as well that, if chronically, an upper GI-bleedings may sustain undetected for a long time. In this case a collapse was the first symptom to be admitted to a hospital which is per se not so much suggestive. In general, dysphagia, pain and weight loss are more common reasons for patients to turn to a medical department for this diagnosis . AlthougSince esophageal cancer is a common cause of esophageal ulcer the lesion was biopsied several times to enforce a histopathologic diagnosis of cancer. However, repeated endoscopic examinations did not lead to a final diagnosis of cancer. Literature shows a wider range of sensitivity (69% versus 100%) mainly depending on the experience of the endoscopists . TherefoIn our patient, the CT scan was suspicious of an invasive tumor. In addition CEA was slightly elevated, and an endosonografic examination confirmed this finding.Adenocarcinomas are the most dominant subtype of proven malignancies in the distal esophagus . Rarely Esophageal and gastric cancers are distinct carcinomas of the upper gastrointestinal tract, while the distinction between them was less clear at the gastroesophageal junction at time of first presentation 2005 . MeanwhiAlthough the possible existence of micrometastasis in superficial esophageal cancer is the most important factor in deciding the therapeutic strategy, it is difficult and molecular biomarkers are not a valuable selection at this stage . The mosFurther radiological imaging  was not performed in our case, because the diagnostic value was contradictory discussed at time of first presentation. However, high-resolution MRI has a high diagnostic accuracy for evaluating mural invasion  and esopNon neoplastic esophageal ulcers are a rare cause of recurrent GI-bleedings. CT scan with a special esophageal protocol is an important tool for differential diagnostic considerations. However, its sensitivity is not 100% so it does not reveal all patients with esophageal cancer successfully. Therefore the histopathological proof of neoplasma seems essential because of the high perioperative morbidity and mortality. Our case shows that there might be a risk of confusion because a circular thickness of the wall could be misinterpreted as a malignant lesion. If newer diagnostic tools like PET scan will help to better differentiate between malignant and non malignant lesions has to be shown.


Introduction Pigmented villonodular synovitis (PVNS) is a benign but aggressive lesion arising from sinovia. The temporomandibular joint (TMJ) is hardly ever involved.Methods We describe a case of PVNS arising in the left TMJ involving infratemporal fossa soft tissue and the skull base; we also present the reconstruction.Results A 37-year-old woman had progressive mandibular swelling for 6 months. Computed tomography of the skull revealed an osteolytic lesion in the left TMJ, involving the upper mandible, condyle, and glenoid fossa and extending to the infratemporal fossa and fossa media through a defect in temporal bone. Surgical management included a left pterional craniotomy to reach the temporal skull base and resect the intracranial tumor and a facial approach with partial left mandibulectomy and resection of left condyle, glenoid fossa, and tumor removal in infratemporal fossa. Mandible function was restored with prosthetic reconstruction of the condyle. She progressively started to eat solid foods after 3 months, becoming increasingly functional and asymptomatic. At 30 months' follow-up, she had no sign of tumoral recurrence and showed asymptomatic and normal TMJ function.Conclusion PVNS should be considered in the differential diagnosis of bone neoplasms affecting young patients. In such cases, radical excision is mandatory and TMJ prosthesis for local reconstruction may be used to preserve functionality. Pigmented villonodular synovitis (PVNS) is a benign but aggressive proliferative lesion arising from sinovia, most commonly found in the joints of the long bones. The temporomandibular joint (TMJ) is hardly ever involved.To date, 58 cases of PVNS have been described, and 19 of them presented with intracranial extension. In these cases, the ideal approach to lesion excision and functional reconstruction is not standardized, and several strategies may be applied.We describe a case of PVNS arising in the left TMJ and involving infratemporal fossa soft tissue and the skull base; we also present the reconstruction with a prosthesis.A 37-year-old woman had intermittent mild to moderate headache 7 years previously. Computed tomography (CT) was normal at that time. The main diagnosis was a primary headache, and she started to use analgesics.Six months ago, she presented with dizziness and worsening of headache in the left side, especially in the temporal and mandibular regions. At that time, mandibular swelling was noted, and she presented with pain when masticating. Neurologic examination revealed no alterations. There was no previous history of trauma.CT of the skull revealed an osteolytic lesion in the left TMJ, involving the upper mandible, condyle, and glenoid fossa, compromising and extending to the soft tissue in the infratemporal fossa and invading the fossa media through a defect in the temporal bone. The lesion had slight contrast enhancement . MagnetA CT-guided percutaneous biopsy disclosed a mesenchymal neoplasm with several giant and multinucleated cells, with regular nuclei, similar to stromal cells, and new and old foci of hemorrhage. The pathologic report confirmed a giant cell tumor compatible with PVNS .Treatment included surgical removal with free margin resection. The surgical management involved multidisciplinary principles. A left pterional craniotomy was performed to reach the temporal skull base, resect intracranial tumors, and debride the skull base. The operative field was entirely extradural; the tumor was focused in bone, and no dural involvement was noticed . The tuSimultaneously, a facial approach was used with partial left mandibulectomy; the left condyle, glenoid fossa, and tumor in the infratemporal fossa were excised. The lesion was rigid and had little bleeding. Mandibular function was restored with a prosthetic reconstruction of the condyle.After surgery, the patient was restricted to liquid foods. Neurologic examination revealed House-Brackmann grade III facial nerve paresis and hypesthesia in the left V2 territory. The patient has since reported to regular follow-up. At 20 days' follow-up, there was still grade II facial nerve paresis and V2 hypesthesia. She had progressed to a pasty diet. Three-month follow-up revealed mild TMJ pain, with resolution of facial paresis and hypesthesia. She progressively started to eat solid foods after 3 months, becoming increasingly functional and asymptomatic. At 30 months' follow-up, there was no sign of tumoral recurrence, and the patient had asymptomatic and normal TMJ function . No adjPVNS is a rare and benign neoplasm with excellent outcomes, even with intracranial extension.There are no clinical symptoms specific to PVNS.Few reports of PVNS involve the TMJ, and approximately one-third have invasion of the skull base.Safaee et al described five patients who underwent surgical resection, with 1 recurrence at 61 months.However, when these lesions involved the TMJ, complete resection with free margins becomes technically difficult, and there are issues to be addressed concerning reconstruction of the TMJ.In our case, we diagnosed a PVNS in a young woman with TMJ pain and swelling. Image studies revealed a mass in the TMJ extending to the infratemporal fossa and skull base. A combined multidisciplinary approach was used to resect the lesion and allowed for the reconstruction of the TMJ. The facial nerve lesion was peripheral, especially in the mandibular branch, due to external traction during parotidectomy. The lesion was partial and temporary, with full recovery after 3 months, which was not related to the intracranial approach. Facial nerve dissection during parotidectomy was important to allow surgical reconstruction of the TMJ.We performed a zygomatic osteotomy to allow an anterior approach to the glenoidal cavity and to the skull base. However, a zygomatic osteotomy was unnecessary because parotidectomy was done by an external approach to allow mandibular condyle resection and tumor removal.The prosthesis was applied to reconstruct the glenoidal cavity after resection of the mandible condyle and to keep the height of the ascending mandibular ramus. Without the resected condyle, there would be mandibular asymmetry (static and dynamic) with consequent dental occlusion dysfunction, leading to masticatory and phonatory dysfunction.Reconstruction of the glenoidal cavity was the most important step; there are other alternatives such as bone graft, but bone graft is not usually a long-lasting material. In young patients, the glenoidal cavity must be resistant to support pressure and action, which is why we used a prosthesis instead of bone graft. There was low morbidity and complete functional recovery after 3 months. The patient also returned to singing in the choir. Additionally, the patient was asymptomatic after 2 years, and there have been no signs of tumor recurrence in routine follow-up.We highlight the differential diagnosis of bone neoplasms affecting young patients. In such cases, radical excision is mandatory and TMJ prosthetic for local reconstruction may preserve functionality.


Colitis cystica profunda is a rare nonneoplastic disease defined by the presence of intramural cysts that contain mucus, usually situated in the rectosigmoid area, which can mimic various malignant lesions and polyps. Its etiology still remains not fully elucidated, and several mechanisms such as congenital, post-traumatic, and infectious have been implicated in the development of this rare entity.Herein, we describe a unique case of colitis cystica profunda in the setting of Peutz-Jeghers-type polyp of the sigmoid colon, associated with high-grade dysplasia of the overlying epithelium in a 48-year-old female patient, who presented to the emergency room with signs of intestinal obstruction. To the best of our insight, this is the first manifestation ever reported in the literature regarding the coexistence of solitary Peutz-Jeghers-type polyp, colitis cystica profunda, and high-grade dysplasia of the epithelium of the colon.The purpose of this case report is to highlight colitis cystica profunda and its clinical significance. An uncommon nonneoplastic entity, many times masquerading as malignant lesion of the rectosigmoid area of the colon. Clinicians and pathologists should be aware of this benign condition that is found incidentally postoperatively in patients undergoing colectomies, leading to unnecessary increase of morbidity and mortality in these patients, who otherwise could have been cured with conservative treatment only. Colitis cystica profunda (CCP) is generally an uncommon benign condition of the colon and rectum that can resemble and impersonate different conditions and diseases such as mucinous adenocarcinomas, carcinoid tumors, and pancreatic heterotopias . Less thA previously healthy 48-year-old woman, with no significant past medical history and no family history of colorectal diseases, presented to the emergency room with abdominal distension, colicky pain, and a history of repeated episodes of lower gastrointestinal hemorrhage for as long as couple of months. She also complained of 8 kg weight loss in the last 2 months. She denied taking any prescription or over-the-counter medications. Clinical examination revealed a malnourished woman in severe distress due to diffuse abdominal tenderness. Signs of colonic obstruction were apparent. Digital rectal examination was indicative for rectal bleeding. Her vital signs were temperature 38°C, pulse 118/min, blood pressure 105/60 mmHg, and respiratory rate 20/min. Blood counts showed Hb 7.4 g/dl and a white blood count of 16.000. Serum electrolytes, liver function tests, and urinalysis were unremarkable. A plain abdominal X-ray and abdominal CT scan confirmed the signs of large bowel obstruction, along with a polypoid mass fully occluding the lumen of the terminal sigmoid colon. The patient was taken to the operating room where a standard left hemicolectomy was performed because of the malignant appearance of the mass and the extensive lymph node involvement that was found intraoperatively  is an infrequent syndrome with autosomal dominant inheritance, linked to a germline mutation of serine threonine kinase 11, which was initially identified by Peutz in 1921. It is described by gastrointestinal hamartomatous polyps, usually encountered in the small intestine along with mucocutaneous pigmentation. A Peutz-Jeghers-type polyp in a patient that is not accompanied with mucocutaneous pigmentation and family history of Peutz-Jeghers syndrome is termed solitary Peutz-Jeghers-type polyp . AccordiIn summary, a case of solitary Peutz-Jeghers-type polyp associated with CCP and high-grade dysplastic changes is reported herein. To our knowledge, this is the first case ever reported. The purpose of this case report is to highlight CCP and its clinical significance; an uncommon nonneoplastic entity, many times masquerading as malignant lesion of the rectosigmoid area of the colon. Clinicians and pathologists should be aware of this benign condition that is found incidentally postoperatively in patients undergoing colectomies, leading to unnecessary increase of morbidity and mortality in these patients, who otherwise could have been cured with conservative treatment only.Knowledge of CCP and its clinical presentation are indispensable to differentiate this benign entity from malignancy. However, there are cases in which this uncommon entity overlaps with dysplastic changes of the epithelium of the bowel, a fact that needs extra attention not only from the medical practitioners but also from the pathologists who examine the histology of the disease. Moreover, the association with other rare entities like solitary Peutz-Jeghers-type polyp, as in our case, is of paramount importance in order to avoid overly aggressive treatment decisions. Based on the current medical literature, our reported case is unique, highlighting the potential association of CCP with dysplasia along with the coexistence of solitary hamartomatous polyp; an association that has never been reported in the past.


Hematoma arising within an intrapancreatic accessory spleen (IPAS) is an extremely rare pathological entity.We present the case of a 39-year-old man with acute abdominal pain.The patient was initially diagnosed as pancreatic cystic neoplasm according to CT and MRI imaging.Distal pancreatectomy was conducted because of the possibility of malignancy.Surgical resection showed that the lesion was a hematoma in an IPAS.Our case indicated that the differential diagnosis of hematoma in IPAS should be born in mind for cases with cystic neoplasm in tail of pancreas and an epidermoid cyst arising within an intrapancreatic accessory spleen (ECIAS). To our knowledge, no hematoma in an IPAS has been reported previously in English literature. We herein report a case of a spontaneous hematoma arising in an IPAS that was preoperatively diagnosed as a mucinous cystic neoplasm; and resected using distal pancreatectomy.An intrapancreatic accessory spleen (IPAS) is a relatively rare clinical presentation, with the prevalence of 1.7% in general population.2A 39 years old male presented with a 3-day history of epigastric pain. The patient had no comorbidities and was not on any medications at time of presentation. He had normal vital signs, and abdominal examination, except for mild epigastric tenderness. Consent to conduct of the case report was obtained from the Ethics Committee of the First Affiliated Hospital of Zhejiang University.Laboratory tests showed normal liver and kidney functions. The amylase, lipase, Tumor markers and coagulation levels were all normal. Tumor markers and coagulation levels were all normal. In order to find out the cause of abdominal pain, the patient received abdominal computerized tomography (CT) and magnetic resonance imaging (MRI) scan. The results showed that a well-defined cystic neoplasm without enhancing mural nodes (3.3 cm × 3.1 cm in size), was located in the tail of pancreas and approaching to splenic hilus Figs. . Distal The surgical specimen contained a well-demarcated cyst cavity, that was 3.5 cm × 2.5 cm in size, and surrounded by pancreatic tissue on macroscopic appearance. Microscopically, the capsule wall was surrounded by spleen tissue, containing hemorrhage, hemosiderosis, chronic inflammatory cells, and histiocyte collection  is similar with cystic fluid on unenhanced CT imaging and no high signal intensity on T1-weighted images was found. We guess that the lesion might be a chronic hematoma, although the patient presented the symptom of acute pain. On the imaging, a hematoma in IPAS mimics a cyst neoplasm in the tail of pancreas and an epidermoid cyst arising within an intrapancreatic accessory spleen (ECIAS). ECIAS is very uncommon. There was no more than 40 cases reported previously in English literature.–10 Therefore, the patient was misdiagnosed as pancreatic cystadenoma at first.For the diagnostic modalities of a hemotoma in abdomen, the noninvasive diagnosis primarily depends on CT and MRI features. The signals of the abdominal hematoma on both CT and MRI were changed with the passage of time. The abdominal hematomas on unenhanced CT imaging are typically hyperdense (40–60 HU) in the acute phase and hypodense in the chronic phase, due to time-related changes in hemoglobin levels. reported that 1 case of perigastric hematoma and 1 case of perirectal hematoma were treated successfully with EUS-guided drainage and stent placement. Therefore, it is safe to perform EUS-FNA procedures for a chronic hematoma. In this case, the patient refused to take EUS-FNA procedures and received surgery directly.Endoscopic ultrasound (EUS) is a key modality for the evaluation of suspected pancreatic lesion, as the entire pancreatic gland can be demonstrated with high spatial resolution from the stomach and duodenum. Under EUS, a hematoma and a cyst lesion has the same image which presents as hypoechoic fluid collection with or without internal separations. It is difficult to differentiate a hematoma in IPAS from ECIAS and cyst neoplasm in the tail of pancreas. For a pancreatic cyst lesion, in order to avoid unnecessary surgical intervention, it is necessary to sample the cyst contents for cytologic and fluid analysis by endoscopic ultrasound guided fine needle aspiration (EUS-FNA). For the chronic hemotoma, Ulla-Rocha et alIn conclusion, a hematoma arising in IPAS is a rare entity that can mimic cystic lesions in the tail of pancreas and ECIAS. Our case indicted that the differential diagnosis of hematoma in IPAS should be born in mind for cases with cystic neoplasm in tail of pancreas. In order to avoid unnecessary surgical intervention, cytologic and fluid analysis of lesion by EUS-FNA in chronic hematoma phase is recommended.


Polypropylene material is widely used in gynecological surgery. There are few reports regarding its carcinogenic potential. There is lack of evidence supporting tumor formation directly attributed to the use of polypropylene material. This patient is a 49-year-old woman with a history of stress urinary incontinence which required a MiniArc® Sling who presented with a hard, tender, immobile mass on the anterior vaginal wall. Pathological analysis of the mass revealed a tumor-like reaction to the polypropylene material that resembled a giant cell tumor of soft tissue. The use of polypropylene in surgery is ubiquitous across disciplines; thus consideration for a tumor-like reaction to the material should exist for patients who present with a mass near the surgical site. Giant cell tumor of soft tissue (GCTST) is a rare lesion that has sporadically been reported in the literature as far back as the early 19th century . ExtraosRecently, it was reported that a giant cell granuloma grew around polypropylene suture that had been used in a tendon transfer procedure, and the histopathology was consistent with a foreign-body reaction to the polypropylene material. Similarly, there was a case of a suture granuloma that occurred 12 years after an open appendectomy, and several reports in the literature describe foreign-body reactions caused by suture material that mimic cancer . The posThe presence of foreign bodies is known to induce inflammation, and foreign-body induced inflammation is a recognized factor known to modulate tumor progression . Giant cA 49-year-old woman presented to clinic due to pelvic pressure and dyspareunia. Her medical history was significant for Graves' disease and tricuspid regurgitation. Her surgical history was significant for a MiniArc sling for stress urinary incontinence four years prior to presentation, endometrial ablation for abnormal uterine bleeding two years ago, remote C-section, and a laparoscopic bilateral tubal ligation. During examination, a hard, tender, and immobile mass was palpated on the anterior wall of the vagina. The epithelium covering the mass was intact and there was no discharge or bleeding noted during the examination. Due to her complaints of urinary urgency and frequency, cystourethroscopy was initially performed. No abnormality was found in the urethra by evaluation using a 0-degree cystoscope. The intravesical cavity was without any abnormal findings using a 70-degree cystoscope and with complete evaluation of the entire bladder including all edges. An MRI revealed a lesion measuring 3.1 × 2.4 × 2.2 cm shown along the anterior wall of the vagina, adjacent to the base of the bladder .The patient opted for removal of the vaginal mesh as dyspareunia had occurred after its placement. Vaginal excision of the mesh and surrounding mass was performed by making a vertical incision in the anterior vaginal wall, and cystourethroscopy confirmed the integrity of the bladder and urethra following the procedure. Specimens of the mesh and surrounding mass were sent to pathology for evaluation . It consHistologically, specimens demonstrated a marked fibroblast reaction with large numbers of giant cells . Many ofThe use of polypropylene mesh for treatment of pelvic organ prolapse and urinary incontinence has increased over the past decade. Some controversy exists within the field regarding appropriate concerns that should be discussed with patients when considering the use of mesh in gynecological surgery. In 2011, the FDA issued a public health notification of adverse events that stated “serious complications with surgical mesh for transvaginal repair of POP are not rare.” Shortly thereafter, on behalf of and endorsed by over 600 members of the Pelvic Surgeons Network, a separate review of the literature highlighted their belief that the FDA presented a biased view regarding vaginal mesh use in all repair procedures for pelvic organ prolapse . DespiteHistologically, GCTST is characterized by a mixture of mononuclear cells and osteoclast-like multinucleated giant cells. Metaplastic bone formation at the periphery of the lesion is observed in 40–50% of cases . Cystic In a recent case report, recurrence of colon cancer was suspected after a suspicious lesion appeared on CT and PET scans, requiring exploratory laparotomy; a giant cell granuloma had developed around mesh used for prior abdominal hernia repair, demonstrating the ability of these lesions to mimic cancer and unavoidable surgical intervention .In summary, we describe the first case of a tumor-like reaction resembling a primary GCTST in the vagina. Giant cell tumors are rare and likely underrecognized. The foreign-body reaction can make the clinical picture confusing. Consistent with the histology, the lesion in our patient could have developed as a result of the foreign-body reaction to the polypropylene mesh that had been used in the sling. Despite the benign nature of GCTST, formation of any mass can be very stressful for patients, specifically if they have had a prior diagnosis of cancer and are concerned for recurrence. Further research is warranted to better understand the inflammatory reaction to polypropylene due to its widespread use in gynecological procedures and the increased risk that patients may develop a mass late in life as a result of material used during surgery.