The aim of this study was to analyze chest CT scans of patients with thoracictextiloma.  This was a retrospective study of 16 patients (11 men and 5 women) withsurgically confirmed thoracic textiloma. The chest CT scans of those patients wereevaluated by two independent observers, and discordant results were resolved byconsensus.  The majority (62.5%) of the textilomas were caused by previous heart surgery. Themost common symptoms were chest pain (in 68.75%) and cough (in 56.25%). In allcases, the main tomographic finding was a mass with regular contours and bordersthat were well-defined or partially defined. Half of the textilomas occurred inthe right hemithorax and half occurred in the left. The majority (56.25%) werelocated in the lower third of the lung. The diameter of the mass was ≤ 10 cm in 10cases (62.5%) and > 10 cm in the remaining 6 cases (37.5%). Most (81.25%) ofthe textilomas were heterogeneous in density, with signs of calcification, gas,radiopaque marker, or sponge-like material. Peripheral expansion of the mass wasobserved in 12 (92.3%) of the 13 patients in whom a contrast agent was used.Intraoperatively, pleural involvement was observed in 14 cases (87.5%) andpericardial involvement was observed in 2 (12.5%).  It is important to recognize the main tomographic aspects of thoracic textilomasin order to include this possibility in the differential diagnosis of chest painand cough in patients with a history of heart or thoracic surgery, thus promotingthe early identification and treatment of this postoperative complication. It can occur in any part of the body and after any type of surgery, butmost cases reported in the literature are linked to abdominal surgery. Few cases are related to thoracic surgery. Because it is a relatively uncommon condition, with serious medical-legalconsequences and nonspecific clinical manifestations that can, however, be accompaniedby severe complications , which aresometimes fatal,(-) it is necessary that clinicians, surgeons, and radiologists always considerthis diagnostic possibility and its radiological presentations so that early diagnosisand correct definitive treatment can be established in a timely manner.Textiloma  is a term used to describe the presence of a masswithin a patient's body consisting of a cotton matrix, which usually corresponds toretained surgical gauze or sponge, surrounded by foreign body reaction.-3 A tgn body. It can surgery. Few cassurgery.,7 Becs fatal,-10 it In cases of a textiloma in the pericardial cavity, magnetic resonanceimaging allows a more appropriate and reliable assessment of the relationship betweenthe mass under study and the heart wall, facilitating surgical planning.(-)In general, performing an X-ray is the first step, since X-ray is the cheapest and mostreadily available method and, in the presence of a visible radiopaque marker, it can beconclusive. Transthoracic or transesophageal ultrasound can be important in theassessment of a textiloma and its relationship with adjacent structures. Usually, CT isthe most effective method to establish the diagnosis and to analyze possible associatedcomplications. In caselanning.-14 given that most patients have a frequent history of cough, chest pain, andhemoptysis. These complications generally resolve completely after resection of thelesion.Since this is a benign condition, it is important that the correct diagnosis beestablished in the preoperative phase, because it allows surgical planning to beconducted more carefully, unlike what occurs in cases of acute lesions. It also allowssurgeons to be more aware of possible associated complications that should be resolvedduring the same operation. In addition, because it behaves as a mass and mimics aneoplasm, patient anxiety and stress caused by an incorrect or inconclusive diagnosisshould be taken into consideration. Although some cases of textiloma are clinicallysilent and are only discovered on routine radiological examination, surgical treatmentis indicated in almost all cases, given tThe objective of the present study was to investigate the main morphologicalcharacteristics and the most common CT findings of textilomas, as well as to analyzesome epidemiological aspects of textilomas, such as clinical manifestations, gender andage distribution, and causal procedure.This was a retrospective, descriptive observational study of CT scans of 16 patientswith a confirmed diagnosis of textiloma. The CT scans were randomly obtained fromradiologists and thoracic surgeons at various medical institutions in six Brazilianstates, between January of 2005 and October of 2013. In addition, we collected clinicaland epidemiological data about those patients, including age, gender, signs andsymptoms, causal procedure, and surgical location of the lesion.We included patients (n = 16) in whom the diagnosis of textiloma was confirmed bysurgical excision of the mass, the analysis of which revealed fragments of surgicalsponge. Two of the patients had previously undergone transthoracic biopsy, but in onlyone of them were small filaments, described as foreign bodies, identified byhistopathology. The study was approved by the Research Ethics Committee of the AntonioPedro University Hospital of the Fluminense Federal University. Because this was aretrospective study, using existing clinical data with no change in patient monitoringor treatment, written informed consent from patients was not required.No standardization existed in the CT studies because multiple institutions were involvedand multiple CT scanners were used. However, all scans were acquired with slicethicknesses ranging from 1 to 10 mm, at 5- to 10-min intervals, from the apices to thehemidiaphragms or until the entire mass was included, for masses extending to theabdomen, with the patient in the supine position, and at end-inhalation. The images wereacquired and reconstructed in a 512 × 512 matrix and photographed, for assessment of thelung fields, at a window width of 1,200 to 2,000 HU and a level of −300 to −700 UH. Forassessment of the mediastinum, the images were photographed at a window width of 350 to500 HU and a center of 10 to 50 HU. The scans were evaluated by two independentradiologists. Discordant results were resolved by consensus. A mass was defined as any expansive pulmonary, pleural, mediastinal, orchest wall lesion with soft tissue, adipose tissue, or bony tissue density, greater than3 cm in diameter, with at least partially defined contours, outside the fissural area,regardless of the characteristics of its contours or the heterogeneity of its content.Consolidation was defined as increased lung parenchymal attenuation that precludes thevisualization of the vessels and outer contours of the bronchial walls. Atelectasis wasdefined as decreased lung volume due to lower aeration of part or all of the lung.The masses on each of the scans were analyzed for the following characteristics:contour; borders; diameter; homogeneity; content; contrast enhancement; location ; origin ; and presence or absence of associated findings . The criteria used todefine the CT findings were those reported in a Brazilian consensus. A mass The clinical manifestations of the 16 patients included chest pain, in 11 patients(68.75%); cough, in 9 (56.25%); dyspnea, in 4 (25.00%); pain in the right shoulder,in 2 (12.50%); and low-grade fever, in 2 (12.50%). One patient (6.25%) wasasymptomatic. The patient group consisted of 11 men (68.75%) and 5 women (31.25%).Patient ages ranged from 29 to 85 years, with a mean of 52 years and 2 months.Regarding the original surgery, 10 patients (62.50%) had undergone heart surgery, 3(18.75%) had undergone lung surgery, and 3 (18.75%) had undergone other procedures.The interval between the original surgery and the diagnosis of textiloma ranged from1 to 120 months, with a mean of 30.6 months (2.5 years).All 16 patients underwent CT. Iodinated contrast material was used in 13 patients(81.25%). The contrast material was not used in 3 patients (18.75%), because they hada history of allergy to iodine.All cases presented as a (round or ovoid) mass with regular contours and borders thatwere well-defined or partially defined. In 7 cases (43.76%), the mass measured nomore than 5 cm in diameter; in 4 (25.00%), it measured 10-15 cm; in 3 (18.75%), itmeasured 5-10 cm; in 1 (6.25%), it measured 15-20 cm; and in 1 (6.25%), it measured20-25 cm. Three (18.75%) of the 16 masses were homogeneous, and 13 (81.2%) wereheterogeneous. It was possible to identify images consistent with sponge-likematerial in 6 46.1%; ; radiopaHalf (50.0%) of the textilomas occurred in the right hemithorax and half (50.0%)occurred in the left. The textilomas were located in the lower third of the chest in9 patients (56.3%), in the middle third in 5 (31.2%), and in the upper third in 2(12.5%). In addition to the mass, 13 patients (81.2%) had other CT findings, whichincluded pleural thickening, in 6 patients (46.15%); atelectasis, in 5 (38.50%);pleural effusion, in 3 (23.10%); and parenchymal consolidation, in 1 (7.70%). Nopatients were identified with fistula.CT-guided transthoracic fine needle aspiration biopsy was performed in only 2patients (12.5%). No neoplastic cells were identified in either of the biopsysamples. For only 1 of those 2 patients did the pathologist detect the presence ofsmall filaments on the slide, described as foreign bodies. The 16 patients underwentsurgery, and, in all of them, the presence of a foreign body containing cotton fiberswas confirmed.Sponge fragments, fibrous wall, and giant cell foreign body reaction were observed inall masses. In addition, areas of necrosis and calcification were identified in someof them. Regarding the space  withinwhich the mass was found intraoperatively, there was a significant predominance ofthe pleural space, in 14 (87.5%) of the 16 patients, followed by the pericardialspace, in only 2 (12.5%). referring to textilomas in general, there is a slight predominance infemales (63%), which is related to the fact that pelvic surgery is more common in thisgroup than in males. However, in the case of thoracic textilomas, we found no reports ofprevalence by gender in the literature.In the present study, which deals with thoracic textilomas exclusively, we found apredominance of males, which corresponded to 68.75% of the cases. Because the vastmajority of published papers on thoracic textilomas consist of isolated case reports,few describe the incidence of textilomas by gender. According to one group ofauthors, referri to 87 years. In the vast majority of cases, age at diagnosis does not correspond to ageat onset of the mass, because although the diagnosis in some cases is established in ayoung patient, the surgery that caused the textiloma often was performed many yearsearlier, whereas in an elderly patient, the original surgery often was performedrecently. In fact, in the above two references, we found that, despite being muchyounger, the 22-year-old patient had undergone the original surgery at 3 years of age,i.e., 19 years earlier, to treat a penetrating wound to the left hemithorax, whereas thepatient who was diagnosed at 87 years of age had undergone the original surgery  only 7 days prior. In addition, on the basis of these two cases, wenote that the age range is very similar to that found in our study, as well as to thatreported in most studies.As to prevalence by age, in our sample, the age group affected was the 29- to 85-yearage group. We found no reports of prevalence by age in the literature. This is probablydue to the fact that, unlike many diseases, textilomas can affect any age group, beingnot directly related to age, but rather directly related to the surgical proceduresundergone by patients, which can occur at any age. An analysis of literature casereports involving adult patients showed that age at diagnosis of gossypiboma ranged from22 years to 87 y7 years. In the  Regarding the surgery that caused the textiloma, heart surgerypredominated, having been performed in 10 patients (62.5%), followed by lung surgery, in3 (18.75%), and by other procedures , also in 3 (18.75%). In almost all published studiesfocused specifically on thoracic textilomas that we consulted, heart surgery predominated as the original surgery, followed by lungsurgery.The most common complaints in our sample were chest pain, cough, and dyspnea. Accordingto the literature, the most common clinical manifestations are cough, expectoration,chest pain, hemoptysis, and dyspnea.,,20 Re in which the interval was 7 days. In other patients, the diagnosis was madelong after the original surgery, as in the report by Madan et al., in which the interval between the original surgery and the diagnosis was 46years. Even considering these details, it is not always possible to determine exactlyhow long the surgical sponge has been in the patient's body. Some patients cannotaccurately tell the date of the original surgery or how old they were at the time. Otherpatients underwent more than one surgical procedure, which makes it difficult todetermine the exact time of the onset of the condition. One group of authors reported the case of a female patient who had undergone at least twothoracic procedures, making it impossible to determine which intervention had caused thetextiloma.In the present study, the interval between the original surgery and the diagnosis oftextiloma ranged from 1 to 120 months, with a mean of 30.6 months. Because the conditioncan occur after any surgical procedure and because some patients are asymptomatic, wededuce that this interval can vary greatly. Therefore, on the basis once again ofpublished research focusing exclusively on thoracic textilomas, by means of areport-by-report analysis, we could confirm this variability. There are patients in whomthe diagnosis was established shortly after the original surgery, as in the report byWhang et al., in whic et al., in whic textilomas were described as masses, and no other morphological aspectswere identified. In addition, it is of note that the lesions are almost always regularand well defined.CT scan analysis showed that, in all of our 16 cases, the mass had a similar shape, aswell as regular contours and borders that were mostly well defined. In most of thepapers consulted,,,,23 tened.,,,25 have emphasized several radiological characteristics of the lesion in their papers,but without mentioning its diameter. In the studies in which the diameter of the masswas reported, the vast majority of the masses measured 4 to 9 cm, although one wasreported to measure 14 cm. These data are very similar to our findings.In most cases in our sample 87.5%), the mass measured 4 to 15 cm in diameter. As wasthe case with gender and age, we found no statistically significant values for meandiameter of thoracic textilomas in the literature. Analysis was made even more difficultby the fact that many authors,,23 ha.5%, the ,,,-,24 thSignificant CT characteristics in our sample included heterogeneity, in 13 (81.2%) ofthe 16 cases, and peripheral enhancement, in 12 (92.3%) of the 13 cases in whichintravenous contrast material was used. There is a consensus among authors, especiallyamong those who have published papers highlighting CT findings of thoracic textilomas,that chief among the predominant characteristics of these lesions are heterogeneity andperipheral enhancement.,,27 A surgical sponge left in the pleural space, which corresponded to 87.5% ofthe cases in our sample, does not typically result in images of gas because of thereabsorption of air by the pleura, which usually occurs within the first 30 days after surgery. Therefore, bubbles may not be a prominent finding in retained intrathoracicsurgical sponges, as is the case of those in the abdominal cavity. In the consultedliterature, there were no specifications as to the frequency at which sponge-likematerial, gas, calcifications, or radiopaque markers are identified withintextilomas.The lesions that were heterogeneous in density showed findings consistent withsponge-like material, gas, calcification, or radiopaque marker. Of those aspects, theone most commonly found in the cases of the present study was sponge-like material,which was seen in 6 of the 16 masses. Gas bubbles were found within 2 lesions only. Someauthors have shown that, despite being typical, the finding of air bubbles trapped inthe fibers of the surgical sponge can be absent. ,,29 A leura,,,13 wh was not seen in any of the cases in our sample. There also have been noreports in the literature of the frequency of spongiform or folded patterns. A folded pattern was identified in 3 of the 16 cases in our sample, and a spongiformpattern was identified in 2. The air crescent sign, described on rareoccasions, was notIt is important to note that some authors, in a retrospective analysis, found thatcertain characteristics of the mass changed over the years, while the diagnosis was notconfirmed. This refers not only to characteristics such as homogeneity, given that aninitially homogeneous textiloma can become heterogeneous after calcifications or gasdevelop within it, but also to others, since there may be changes in size and evenlocation when it comes to pleural masses.,21Neither hemithorax was predominantly affected, but the lower third was involved in mostcases (56.25%). No frequency rates for these data were available in the articlesstudied. Associated findings were present in 13 patients (81.2%). Pleural thickening,atelectasis, and pleural effusion were found in 6 (37.5%), 5 (31.2%), and 3 (18.8%) ofthe patients, respectively. This finding is in agreement with ours, since in only 1 of the 16 patientsstudied was the diagnosis confirmed by transthoracic biopsy before resection.It was possible to establish that, on the basis of case reports in the literature, inthe vast majority of cases, the diagnosis of thoracic textiloma is confirmed only aftersurgical resection.,,21 Th Even in studies in which the initiating surgical procedure was heartsurgery, the pleural space was the most commonly affected site. When the pericardial space is involved, the mass tends to be locatedposteriorly, which also occurred in our sample.The most common site of occurrence of textilomas was the pleural space . The pericardial space was involved in only 2 cases 12.5%), with thelesion being located posteriorly. These data corroborate those reported in theliterature. Some authors have shown that the thoracic site where retained surgicalsponges are most commonly found is the pleural space, followed by the pericardialspace..5%, withed site. When theriorly,,23 whIn conclusion, in this study, the cases of thoracic textiloma presented as masses,mostly heterogeneous, with peripheral contrast enhancement, and neither hemithorax waspredominantly affected. The most common clinical manifestations were chest pain andcough. In the majority of the cases, the initiating surgical procedure was heartsurgery, and most textilomas were found intraoperatively in the pleural space. (-) Textiloma é o corpo estranho cirúrgico retido mais comum. Pode ocorrer em qualquer parte do corpo e após qualquer tipo decirurgia, mas a maioria dos casos relatados na literatura está ligada à cirurgiaabdominal. Poucos casos são relacionados à cirurgia torácica. Por tratar-se de uma afecção relativamente incomum, com sériasimplicações médico-legais e manifestações clínicas inespecíficas que, entretanto,podem-se acompanhar de graves complicações ,algumas vezes fatais,(-) faz-se necessário que o clínico, o cirurgião e o radiologista tenhamsempre em mente essa hipótese diagnóstica e suas formas de apresentação radiológicapara que um diagnóstico precoce e um tratamento correto e definitivo sejam feitos emtempo hábil.Textiloma (também chamado de gossipiboma ou tecidoma) é um termo usado para descrevera presença de uma massa dentro do corpo composta de uma matriz de algodão, queusualmente corresponde a uma gaze ou compressa cirúrgica retida, circundada por umareação de corpo estranho.-3 Texs comum. Pode ocdominal. Poucos orácica.,7 Por fatais,-10 fa No caso de um textiloma na cavidade pericárdica, a ressonância magnéticapermite uma avaliação mais adequada e confiável da relação da massa em estudo com aparede cardíaca, facilitando o planejamento cirúrgico.(-)A radiografia, por ser o método mais barato e mais facilmente acessível, em geral é oprimeiro exame realizado e, na presença de um marcador radiopaco visível, poderá serconclusiva. A ultrassonografia transtorácica e/ou transesofágica pode ser importantena avaliação do textiloma e de sua relação com as estruturas adjacentes. A TC costumaser o método mais eficaz na realização do diagnóstico e na análise de possíveiscomplicações associadas. No casorúrgico.-14 já que os pacientes, em sua maioria, apresentam história frequente detosse, dor torácica e hemoptise. Tais complicações são, em geral, completamentesanadas após a ressecção da lesão.É importante que o diagnóstico correto seja feito ainda na fase pré-operatória, pois,por tratar-se de uma condição benigna, permite que o planejamento cirúrgico sejaelaborado com mais cuidado, diferentemente do que ocorre quando as intervenções sãorealizadas em lesões agudas. Permite também que o cirurgião tenha uma noção maisadequada de possíveis complicações associadas que devam ser resolvidas no mesmo atocirúrgico. Além disso, por comportar-se como uma massa e simular neoplasia, aansiedade e o estresse do paciente ante um diagnóstico incorreto ou inconclusivodevem ser levados em consideração. Embora alguns casos de textiloma sejamclinicamente silenciosos e somente descobertos em exames radiológicos de rotina, otratamento cirúrgico está indicado na quase totalidade dos casos, já que O objetivo do presente estudo foi avaliar as principais características morfológicasdos textilomas e os seus achados tomográficos mais frequentes, além de analisaralguns de seus aspectos epidemiológicos, como manifestações clínicas, distribuiçãopor sexo e idade e cirurgia causal.Foi realizado um estudo observacional descritivo retrospectivo das TCs de 16pacientes com diagnóstico confirmado de textiloma. Esses exames foram reunidosaleatoriamente com radiologistas e cirurgiões torácicos de várias instituiçõesmédicas em seis estados brasileiros, no período compreendido entre janeiro de 2005 eoutubro de 2013. Foi realizado também um levantamento dos dados clínicos eepidemiológicos desses pacientes, que incluiu o registro da idade, gênero, sinais esintomas, cirurgia causal e localização cirúrgica das lesões.Foram incluídos no estudo pacientes com o diagnóstico de textiloma confirmado atravésde excisão cirúrgica (n = 16) da massa, cuja análise revelou fragmentos de compressa.Dois dos pacientes foram antes submetidos à biópsia transtorácica, mas somente em umdeles foram identificados na histopatologia pequenos filamentos descritos como corposestranhos. O estudo foi aprovado pelo Comitê de Ética em Pesquisa do HospitalUniversitário Antonio Pedro da Universidade Federal Fluminense. Como o estudo foiretrospectivo, usando os dados clínicos existentes sem nenhuma mudança noacompanhamento e/ou tratamento dos pacientes, não foi necessário o consentimentoinformado por parte dos mesmos.Não houve padronização nas rotinas dos estudos tomográficos devido às múltiplasinstituições e tomógrafos envolvidos. Contudo, todos os exames foram realizados comcortes variando de 1 a 10 mm de espessura, com intervalos de 5 a 10 mm, dos ápices àscúpulas diafragmáticas ou até incluir toda a massa, no caso das que se estendiam aoabdome, com o paciente em decúbito dorsal e em fase final de inspiração. As imagensforam obtidas e reconstruídas em matriz de 512 × 512 e fotografadas para a avaliaçãodos campos pulmonares com aberturas de janela variando de 1.200 a 2.000 UH e nívelvariando entre −300 e −700 UH. Para o estudo do mediastino, a variação das janelasfoi de 350 a 500 UH, e a de centro, entre 10 e 50 UH. Os exames foram avaliados, deforma independente, por dois radiologistas. Nos casos discordantes o resultado finalfoi obtido por consenso. A massa foi definida como qualquer lesão expansiva pulmonar, pleural,mediastinal ou da parede torácica, com densidade de partes moles, de gordura ouóssea, maior que 3 cm, com contornos pelo menos parcialmente definidos, fora detopografia cissural, independentemente das características de seus contornos ou daheterogeneidade de seu conteúdo. A consolidação foi definida como um aumento daatenuação do parênquima pulmonar que impede a visualização dos vasos e dos contornosexternos das paredes brônquicas. A atelectasia foi definida como uma reduçãovolumétrica do pulmão decorrente de uma menor aeração de uma parte ou de todo opulmão.Em cada um dos exames foram analisadas as características das massas quanto aocontorno, limites, tamanho, homogeneidade, conteúdo, impregnação pelo meio decontraste, localização em relação ao hemitórax e o respectivo terço comprometido,origem , e presença ou não de achados associados. Os critériosutilizados para definir os achados tomográficos foram aqueles relatados em umconsenso brasileiro.  A massaAs manifestações clínicas dos 16 pacientes incluíram dor torácica, em 11 pacientes; tosse, em 9 ; dispneia, em 4 ; dor no ombro direito, em2 ; e febre baixa, em 2 . Um paciente  era assintomático.Em relação ao sexo, o grupo de pacientes foi composto por 11 homens  e 5mulheres . A idade dos pacientes variou de 29 a 85 anos, com uma média de52 anos e 2 meses. Quanto à cirurgia de origem, 10 pacientes  haviam sidosubmetidos à cirurgia cardíaca, 3  à cirurgia pulmonar e 3  aoutros procedimentos . O intervalo de tempo entre a cirurgia de origem e odiagnóstico do textiloma variou de 1 a 120 meses, com uma média de 30,6 meses .Todos os 16 pacientes foram submetidos à TC. O meio de contraste iodado foiadministrado em 13 pacientes . Por apresentarem história de alergia aoiodo, o meio de contraste não foi administrado em 3 pacientes .Todos os casos apresentaram-se como massa , de contornosregulares, com limites bem definidos ou parcialmente definidos. Em 7 casos a massa media, no máximo, 5 cm de diâmetro; em 4 , essa mediaentre 10-15 cm; em 3 , entre 5-10 cm; em 1 , entre 15-20 cm; e, em1 , entre 20-25 cm. Três  das 16 massas eram homogêneas, e 13 eram heterogêneas. Foi possível identificar imagens compatíveis commaterial com aspecto de algodão de compressa em 6 46,1%; ; marcadoQuanto ao hemitórax comprometido, metade das lesões  localizava-se àdireita, e a outra metade, à esquerda . As lesões localizavam-se no terçoinferior do tórax em 9 pacientes ; no terço médio, em 5 ; e no terçosuperior, em 2 . Em 13 pacientes  havia, além da massa, outrosachados à TC, que incluíram espessamento pleural, em 6 pacientes ;atelectasia, em 5 ; derrame pleural, em 3 ; e consolidação doparênquima, em 1 . Em nenhum caso foi identificado trajeto fistuloso.Foi realizada biópsia transtorácica com agulha fina guiada por TC em apenas 2pacientes . Nenhuma delas identificou células neoplásicas. Somente em 1desses 2 pacientes o patologista notou a presença de pequenos filamentos nalâmina, descritos como corpos estranhos. Os 16 pacientes foram submetidos àcirurgia, e em todos foi confirmada a presença de corpo estranho com material dealgodão.Foram observados fragmentos de compressa, parede fibrosa e reação de corpoestranho com células gigantes em todas as massas. Em algumas foram identificadas,ainda, áreas de necrose e calcificação. Quanto ao espaço  em que foi encontrada a massa no ato cirúrgico, notou-se umimportante predomínio do espaço pleural, observado em 14  dos 16 pacientes,estando as 2  restantes no espaço pericárdico. referindo-se aos textilomas em geral, há um leve predomínio no sexofeminino (63%), relacionado ao fato de esse grupo ser submetido a cirurgias pélvicascom mais frequência que o masculino. Entretanto, no caso dos textilomas torácicos,não foram encontrados relatos de prevalência segundo o sexo na literaturaconsultada.No presente estudo, que trata exclusivamente dos textilomas torácicos, notou-se umpredomínio do sexo masculino, que correspondeu a 68,75% dos casos. Como a grandemaioria dos artigos publicados sobre textilomas torácicos restringe-se a relatos decasos isolados, poucos descrevem a incidência dos textilomas segundo o sexo. Deacordo com um grupo de autores, referin e 87 anos. Na imensa maioria das vezes, a idade ao diagnóstico não corresponde àidade da ocorrência do textiloma, pois embora o diagnóstico, em alguns casos, sejafeito num paciente jovem, muitas vezes a cirurgia que originou o textiloma foirealizada muitos anos antes, enquanto que num paciente idoso, muitas vezes, acirurgia original aconteceu recentemente. Desse modo, tomando os dois casossupracitados como exemplos, observamos nos relatos que na paciente de 22 anos, emborabem mais jovem, a cirurgia original foi realizada aos 3 anos de idade, ou seja, 19anos antes, para o tratamento de uma ferida penetrante no hemitórax esquerdo,enquanto, no segundo exemplo (paciente diagnosticado aos 87 anos), a cirurgiaoriginal, para substituição de válvula aórtica, havia sido realizada há apenas 7dias. Usando ainda esses dois casos como referência, nota-se que a amplitude dessafaixa etária é muito semelhante à nossa, assim como à maioria dos casos relatados naliteratura.Quanto à prevalência por idade, na nossa casuística a faixa etária acometida variouentre 29 e 85 anos. Nenhum relato de prevalência por idade foi encontrado naliteratura. Isso se deve, provavelmente, ao fato de que a ocorrência dos textilomas,diferentemente de muitas doenças, não apresenta uma predileção por faixa etária, nãoestando diretamente relacionada à idade, mas sim aos procedimentos cirúrgicos a quesão submetidos os pacientes, o que pode ocorrer em qualquer faixa etária. A análisedos relatos de casos em pacientes adultos encontrados na literatura demonstra que aidade de diagnóstico do gossipiboma variou entre 22 anos e 87 an87 anos. Na imen Quanto à cirurgia que levou à ocorrência do textiloma, houve umpredomínio de cirurgias cardíacas, que foi a cirurgia realizada em 10 pacientes; seguida pela pulmonar, em 3 ; e por outros procedimentos  também em 3 . Emquase todos os trabalhos publicados e consultados especificamente sobre textilomastorácicos, a cirurgia original predominante também foi a cardíaca, seguida pelapulmonar.As queixas mais comuns dos nossos pacientes foram dor torácica, tosse e dispneia. Deacordo com os dados da literatura, as manifestações clínicas mais comuns são tosse,expectoração, dor torácica, hemoptise e dispneia.,,20 Qu cujo período foi de 7 dias. Em outros pacientes, o diagnóstico foirealizado muito tempo depois da cirurgia original, como no relato de Madan etal., cujo intervalo entre a cirurgia original e o diagnóstico foi de 46 anos.Mesmo considerando esses detalhes, nem sempre é possível definir exatamente há quantotempo a compressa estava no corpo do paciente. Alguns pacientes não sabem dizer comprecisão a data ou a idade que tinham na época da cirurgia original. Outros pacientesforam submetidos a mais de um procedimento cirúrgico, dificultando a identificação doexato momento da ocorrência dessa afecção. Um grupo de autores relatou o caso de uma paciente submetida há pelo menos doisprocedimentos torácicos, não sendo possível determinar qual intervenção levou àocorrência do textiloma.No estudo atual, o intervalo de tempo entre a cirurgia original e o diagnóstico dotextiloma variou de 1 a 120 meses, com uma média de 30,6 meses. Como a afecção podesurgir após qualquer procedimento cirúrgico e como alguns pacientes sãoassintomáticos, deduzimos que esse intervalo pode ser muito variável. Assim, tomandopor base, mais uma vez, as publicações exclusivas sobre textilomas torácicos eanalisando relato por relato, pudemos confirmar essa variabilidade. Há pacientes cujodiagnóstico foi feito pouco tempo depois da cirurgia original, como no relato deWhang et al., cujo pe etal., cujo in os autores descreveram o textiloma sob a forma de massa, não tendo sidoidentificado nenhum outro aspecto morfológico. Ressaltaram, ainda, que a lesão quasesempre é regular e bem definida.Ao estudo tomográfico, a forma de massa foi comum em todos os nossos 16 casos, assimcomo o contorno regular e limites, em sua maioria, bem definidos. Na maior parte dosartigos consultados,,,,23 osida.,,,25 deram ênfase, em seus relatos, a várias características radiológicas dalesão ,mas sem citar seu tamanho. Nos estudos nos quais foi descrito o tamanho damassa, a imensa maioria media de 4 a 9 cm, havendo entretanto um relato demassa que media 14 cm. Esses dados são muito similares aos que encontramos.Na maior parte dos nossos casos 87,5%), a massa mediu de 4 a 15 cm. Assim como emrelação ao gênero e à idade, não se encontrou na literatura nenhum valorestatisticamente válido quanto ao tamanho médio dos textilomas torácicos. Dificultouainda mais essa análise o fato de que muitos autores,,23 de,5%, a ma,,,-,24 a As características tomográficas marcantes nos nossos casos foram a heterogeneidade,presente em 13  das 16 massas, e a impregnação periférica, observada em 12 dos 13 pacientes nos quais se administrou o meio de contraste intravenoso. Háconcordância entre os autores, especialmente entre aqueles que publicaram trabalhosdestacando os achados tomográficos dos textilomas torácicos, que, entre ascaracterísticas predominantes dessas lesões, destacam-se sua heterogeneidade e suaimpregnação periférica.,,27 Uma compressa deixada no espaço pleural, o que correspondeu a 87,5% dosnossos casos, geralmente não mostra imagens de gás devido à reabsorção do ar pelapleura, o que costuma ocorrer nos primeiros 30 dias depois dacirurgia. Portanto, as bolhas podem não ser um achado proeminente nas compressasintratorácicas retidas, como ocorre com aquelas na cavidade abdominal. Na literaturaconsultada, não havia especificação da frequência com que se podem identificar omaterial da compressa, gás, calcificações ou marcador radiopaco no interior dostextilomas.No interior das lesões heterogêneas foram identificadas imagens que correspondiam aomaterial da compressa, gás, calcificações ou marcador radiopaco. Dentre essesaspectos, o mais observado nos casos do presente estudo foi o do material dacompressa, presente em 6 das 16 massas. Bolhas de gás foram encontradas no interiorde somente 2 lesões. Alguns autores demonstraram que, embora típica, a presença debolhas de ar aprisionadas entre as fibras da compressa pode estarausente.,,29 Umleura,,,13 o  não foi visto em nenhum dos nossos casos. Os padrões espongiforme epregueado também não tiveram relatos de frequência na literatura.O padrão pregueado foi observado em 3 dos nossos 16 pacientes, e o espongiforme, em2. O sinal do crescente aéreo, descrito em raríssimas ocasiões, não foiÉ importante registrar que alguns autores, numa análise retrospectiva, observaram quecertas características da massa mudaram ao longo dos anos, enquanto seu diagnósticonão era confirmado. Isso se refere não somente a características, tais comohomogeneidade, já que um textiloma inicialmente homogêneo pode passar a serheterogêneo após o surgimento, em seu interior, de calcificações ou de gás, mastambém a outras, uma vez que pode haver mudanças de tamanho e até de localização noque se refere às massas pleurais.,21Não houve predileção da lesão por hemitórax, mas o terço inferior foi acometido namaioria dos casos . Nenhum índice de frequência quanto a esses dados estavadisponível nos artigos estudados. Achados associados estavam presentes em 13pacientes . Espessamento pleural, atelectasia e derrame pleural foramencontrados em 6 , 5  e 3  dos pacientes, respectivamente. Esse dado foi comum aos nossos casos, uma vez que, dos 16 pacientesestudados, somente 1 teve o diagnóstico confirmado, através de biópsia transtorácica,antes da ressecção.Foi possível constatar, pelos relatos de casos da literatura, que a grande maioriados textilomas torácicos tem seu diagnóstico confirmado somente após a ressecçãocirúrgica.,,21 Es Até mesmo em estudos cujas cirurgias de origem foram as cardíacas, oespaço pleural foi o mais afetado. Quando o espaço pericárdico é o comprometido, a localização da massatende a ser posterior, o que também ocorreu em nossa casuística.Quanto à localização mais comum da ocorrência dos textilomas, o espaço pleural foicomprometido na maior parte dos casos . O espaço pericárdicofoi comprometido somente em 2 casos 12,5%) e, nesses, em localização posterior.Esses dados corroboram os descritos na literatura. Alguns autores demonstraram que osítio torácico mais comum de se encontrar uma compressa cirúrgica retida é o espaçopleural, seguido pelo pericárdico. ,5% e, neafetado. Quando sterior,,23 o Em conclusão, os casos de textilomas torácicos no presente estudo apresentaram-se soba forma de massas, em sua maioria heterogêneas, com impregnação periférica pelo meiode contraste e sem predomínio quanto ao hemitórax. As manifestações clínicas maisfrequentes foram dor torácica e tosse. A cirurgia original que mais comumente levou àocorrência dos textilomas foi a cardíaca, e a maior parte dos textilomas foicirurgicamente encontrada no espaço pleural.


Intrathoracic gossypiboma, a retained surgical sponge in the thoracic cavity, is a rare but serious complication of thoracic surgeries. A 70-year-old man presented with an eight-month history of cough. He had undergone coronary artery bypass surgery eight years ago. The posteroanterior chest X-ray revealed a well-marginated homogeneous opacity at the left hemithorax with striped appearance in the center. Thoracic CT revealed a pleural-based mass at the left lower lobe with a hyperdense rim. After the diagnosis of gossypiboma, it was removed surgically. Although rare after thoracic surgery, gossypibomas need to be considered in the differential diagnosis in case of respiratory symptoms. A gossypiboma or a textiloma is a non-absorbable surgical material with a cotton matrix, around which a foreign body reaction occurs . The terGossypibomas are generally reported after abdominal laparotomy; however, it can occur following any surgical procedure. An intrathoracic gossypiboma is extremely rare, most of which are associated with pulmonary surgeries , 6. AlthA 70-year-old, normotensive, nondiabetic, non-smoking male patient came to our hospital with an eight-month history of chronic recurrent cough without sputum, hemoptysis, dyspnea or fever. The symptoms were relatively resistant to inhaled corticosteroids. He had undergone coronary artery bypass surgery eight years ago. General physical examination revealed a thin male with a sternotomy scar. Physical examination of the chest revealed diminished breath sounds and fine crepitation at the left lower lung zone. Routine hematological, biochemical investigations and pulmonary function test were within normal limits. Routine chest radiographs were taken initially. The posteroanterior and lateral projection  revealedThorax computed tomography (CT) scan  revealedAn exploratory surgery of the left hemithorax was performed. On opening the thorax, dense adhesions were found. Thickening of the parietal pleura was also observed in the lower left pleural cavity. The mass contained strong-smelling purulent material and fragments of a disintegrated surgical sponge. The mass was dissected and removed . AdditioThe word “gossypiboma” refers to sponges, towels or other instruments  that are inadvertently forgotten within the human body during surgical procedures . It is aGossypibomas have most commonly been found in the abdomen (56%), pelvis 18%) and thorax (11%) with an average discovery time of 6 to 9 years after the procedure  or endogenous  . The mosIntrathoracic gossypibomas are rarely seen following thoracic surgeries. Patients are usually asymptomatic for a long period after the operation. The diagnosis of intrathoracic gossypiboma can easily be missed because of its rare occurrence, low index of suspicion and lack of familiarity with imaging findings. Thoracic CT is the best method for diagnosis and evaluating complications. An awareness of this condition in individuals with prior thoracic surgery and persistent respiratory symptoms should alert the physician.


Urethral prolapse in a premenopausal adult female is exceedingly rare. This paper describes a case of strangulated urethral prolapse presenting as a urethral mass in an unusual demographic and reviews the literature on etiology and management. Only a few cases have occurred in women of reproductive age. The etiology is likely multifactorial. Treatment with surgical excision provides good results in the majority of cases. Urethral prolapse is defined as eversion of the urethral mucosa through the external urethral meatus . The vasIn contrast to the pediatric population, urethral prolapse in adults is extremely rare and occurs almost exclusively in white and postmenopausal females. Vaginal bleeding, hematuria, dysuria, frequency, urgency, and nocturia are all potential presenting symptoms . Herein,A 46-year-old female presented to the emergency room with a bulging mass from her urethra. The patient reported progressing groin discomfort over the previous week that she had attributed at first to the onset of menstruation. The patient then felt a “bump” while wiping and discovered with a mirror a large mass bulging from her urethra. She subsequently went to a rural emergency room for evaluation, where the treating physician placed a Foley catheter. She was subsequently transferred to our tertiary institution for urologic evaluation.Subjectively the patient complained of some pain with palpation of the mass. She denied any urinary complaints, even prior to this event, including hematuria, dysuria, frequency, or difficulty voiding. She denied any trauma. Her medical history was remarkable for hypothyroidism and untreated but mild stress urinary incontinence that had been present since her last vaginal birth 14 years prior. The patient reported a total of 2 prior vaginal deliveries. Her past surgical history was remarkable for an endometrial ablation procedure and breast augmentation. She had also recently undergone laser hair removal of her genital pubic hair.Her vitals were within normal limits. On exam, the patient was a well-developed, nonobese female (BMI 22.3) in no acute distress. Her genitourinary exam was remarkable for prolapsed, congested, and necrotic urethral mucosa surrounding the Foley catheter . There wThe patient was brought to the operating room. The catheter was removed. However, attempts at manual reduction when anesthesia was induced were not successful. Cystourethroscopy was performed revealing excess urethral mucosa. The bladder was otherwise unremarkable. A new catheter was placed. Using electrocautery, the prolapsed urethral mucosa was circumferentially excised around the catheter. At intervals, the healthy urethral mucosal margin was sutured to the vestibule using absorbable suture. The final result yielded all prolapsed tissue excised from healthy urethral margins that were sutured to the vestibule . At the The etiology of urethral prolapse is controversial and multiple theories have been proposed. One popular theory is that it occurs from weak attachments between the inner and outer smooth muscle layers of the urethra . Other cDiagnosis of urethral prolapse is made by history and clinical findings of a circumferentially prolapsed meatus, often described as a “doughnut” shaped mass protruding from the urethra. It may be confirmed by placement of a catheter or cystoscopy. The prolapsed urethra may be congested, necrotic, bleeding, and tender to palpation. The differential diagnosis includes malignancy, condylomas, and urethral caruncle, the latter can be differentiated by the lack of circumferential urethral involvement. Extensive imaging, lab work, and other testing for workup is almost always unnecessary.For nonstrangulated prolapse, medical therapy consists of topical estrogens and good hygeine. Sitz baths may also be attempted with mostly good success reported in children . RecurreTo our knowledge, only four cases of urethral prolapse in adult premenopausal females have been described to date , 8, 9. T


Dear Sir,Congenital pyloric atresia is a rare anomaly accounting for less than 1% of upper GI atresias. It may occur in isolation or in association with other congenital anomalies, epidermolysis bullosa being the most frequent. It presents with upper abdominal distension, non-bilious vomiting or rarely with complications as aspiration pneumonia, electrolyte imbalance or gastric perforation. Though iatrogenic gastric perforations secondary to aggressive resuscitation with bag-mask ventilation and nasogastric intubation are the most frequent in newborns, neonatal gastric perforation due to congenital outlet obstruction have rarely been reported [1-5]. The clinical course of a newborn is worth sharing who presented with gastric perforation and had an underlying pyloric atresia that was missed.A two days old pre-term (weight 1.6 kg) male newborn was referred to our institute from a remote area. According to his parents, he was delivered by caesarean section and admitted in NICU for respiratory distress. There was no history of aggressive resuscitation and/or mechanical ventilation. Ante-natal ultrasound had shown polyhydramnios. He had passed meconium in small amount few hours after birth and on the 2nd of life, developed gross abdominal distension.On arrival, the baby was sick, lethargic and hypothermic with poor peripheral perfusion. He was in respiratory distress, chest was clear and had oxygen saturation of 74% at room air. Abdomen was grossly distended, and tense. Anal orifice was normal. X-ray abdomen revealed massive pneumoperitoneum. As a resuscitative measure, 16G I.V cannula was inserted in the epigastrium to relieve tension pneumoperitoneum, followed by tube laparostomy which drained only small amount of hemorrhagic fluid. After optimization of his general condition, laparotomy was performed. A 3×3 cm perforation was found at the fundus of stomach; distally small bowel was collapsed and peritoneal cavity was clean. Gastrorrhaphy was performed and abdomen was closed at that stage.Post operatively, he developed septicemia but recovered ultimately. NG feed was allowed on the 8th post operative day which was not tolerated. There was upper abdominal fullness with continuous non-bilious NG aspirate and X-ray abdomen showed paucity of gases beyond stomach. Upper GI contrast study was done, which revealed contrast filled, distended stomach and failure of passage of contrast beyond, suggestive of gastric outlet obstruction . He was re-explored and type I pyloric atresia was found which was excised and Heineke Mikulicz pyloroplasty was performed. Post operative course was then uneventful. He was allowed oral feed on 6th post op day (of 2nd surgery), which was tolerated well. It was gradually increased and he was discharged to home.Though uncommon, congenital causes of gastric outlet obstruction such as a type I pyloric atresia must not be forgotten and missed while operating upon a newborn with gastric perforation. Had it been in mind, the baby wouldn’t have undergone re-exploration. Distending the stomach with normal saline after repair of perforation would be sufficient to confirm distal patency. An ante-natal ultrasound shouldn’t be underestimated as it may give clue to the diagnosis.Source of Support: NilConflict of Interest: None declared


A case of congenital transmesenteric hernia leading to intestinal obstruction is being reported here.  Internal hernia is the protrusion of a viscus, within the peritoneal cavity, through an opening  in the peritoneum or the mesentery [1]. The incidence of internal hernias is less than 1%  and they represent 5.8% of small bowel obstruction . The hernial opening can be acquired or congenital particularly in the case of transmesenteric and transmesocolic hernias which represent 8% of all internal hernias [3]. Congenital transmesenteric hernias, when strangulated, can cause acute bowel obstruction with potentially fatal consequences.A 5-week-old female infant, weighing 3.5 kg, born from a full-term twin pregnancy with no prenatal or perinatal risk factors, was admitted in emergency with progressive abdominal distension, bilious vomiting, fever and failure to pass faeces for 3 days. She had pallor and signs of dehydration. Vital signs were normal. The abdomen was distended with generalized tenderness and guarding. Bowel sounds were absent; no mass was palpable. The rectal examination was normal. The plain abdominal X-ray showed features of small bowel obstruction and poor aeration of the distal gut without any sign of pneumoperitoneum. The ultrasound scan showed significant gaseous distension of proximal bowel loops with a minimal intra-abdominal fluid effusion. However, there was no obvious evidence of bowel invagination. A differential diagnosis of midgut volvulus secondary to malrotation and intussusception were considered. Blood results revealed hyponatremia, hyperkaliemia and hypochloridemia with microcytic normochromic anaemia (haemoglobin concentration: 5 Gr/dl). After correction of hydration, electrolyte disorders and blood transfusion, a laparotomy was performed by a supra umbilical transverse approach. A 25 cm long necrosed jejunal loop, starting from 30cm of ligament of Trietz, was found incarcerated in a trans-mesenteric opening of 3 cm diameter; resulting in a strangulated trans-mesenteric internal hernia . Intestinal resection was performed removing the segment of sphacelus loop along with the mesenteric defect, with an immediate end-to-end anastomosis.The post-operative period was marked by the occurrence of disseminated intravascular coagulation disorder and dyselectrolytemia, which required management in the intensive care unit. These complications worsened causing death of the infant on the fourth post-operative day.Internal hernias are rare diseases [1]. They can be acquired following a Roux-en Y- anastomosis which can be post traumatic or post inflammatory [2]. Their origin can be congenital causing transmesenteric hernias in 6.60% of cases, paraduodenal hernias in 2.20% of cases and pericaecal hernias in 2.20% of cases [4]. Congenital transmesenteric hernia is a rare disease which remains the most common aetiology of congenital internal hernias constituting 35% of cases .Patients of any age can be affected by this pathology . The diagnosis is usually made during a laparotomy for acute bowel obstruction due to strangulation . The preoperative diagnosis of a complicated internal hernia is difficult to make, however, in some cases a computed tomography scan can contribute . According to Fujita [10], a series of plain abdominal X-Rays can be useful in the diagnosis of this condition by showing a constant image indicating the presence of air in the bowel accompanied by a circular or oval lacuna of the image of gas in the middle of the abdomen.The size of the mesenteric defect varies from 2 or 3 cm to 15 cm [5]. This defect is either near the ileocaecal region or Treitz’s ligament [1]. According to Capito [6], this defect could be the first step of the formation of a bowel atresia. Its occurrence could be explained by a thrombosis with limited necrosis of the mesentery [6]. Other theories mention the occurrence of intra- peritoneal inflammation, traumatism, partial regression of the development and the induction of a mesenteric opening by the colon during its migration through the umbilical opening . There was only one mesenteric defect in our case, but in certain cases there have been two defects as described by Lin [7]. Bowel resection with end-to-end anastomosis and closure of the mesenteric opening should be performed .The delay in surgical management led to strangulation and necrosis of bowel in our case. Bowel necrosis is known to contribute to mortality in 40-80% of the cases .Source of Support: NilConflict of Interest: None


A 60-year-old African American woman presented with a 5-year history of a large, left-sided abdominal mass originating in a remote burn scar. Resection was coordinated with the Sarcoma team, and reconstruction was performed with extensive mobilization and skin grafting. Pathology confirmed myxoid dermatofibrosarcoma protuberans (DFSP) with focal fibrosarcomatous changes, an extremely rare and malignant variant.What are the classic etiological presentation features of DFSP?What is the clinical course of DFSP?What are accepted treatment options?What are potential reconstructive options for this lesion?,DFSP is a rare dermal malignancy that accounts for less than 1% of soft-tissue sarcomas. It typically arises between the ages of 20 to 50 years, is slightly more common among men and African Americans, and usually appears as a dermal or subcutaneous multinodular tumor with surrounding violaceous skin changes on the trunk, head and neck, or extremities.1-2,1,DFSP is typically slow growing, which often delays the diagnosis. Dermal and subcutaneous finger-like projections often grow asymmetrically and well beyond the obvious clinical tumor.1,In considering treatment options, a multidisciplinary team approach is mandatory. Surgical excision has been the gold standard. Mohs surgery permits tissue preservation and is preferable for smaller tumors but often impractical for larger tumors. Historically, recommended margins ranged from 3 to 5 cm. Recent evidence suggests that in-depth pathological analysis of all margins may be more important and margins of 1 to 2 cm are adequate.2DFSP in the head and neck is problematic, and preoperative comorbidities may drive the reconstruction toward less invasive options. Given the usual recommendation for a clear margin of underlying fascia, it is important to plan for these defects. Preoperative discussions with the patient about cosmetic deformity and recurrence are imperative to manage expectations. In our case, the tumor was excised with minimal sacrifice of the anterior rectus fascia with a total defect size of 36 × 33 cm  and 2. O-DFSP is a rare and slow and asymmetrically growing tumor of the dermis and subcutaneous tissue.1


Paragangliomas (PGs) are neuroendocrine tumors derived embryonically from the neural crest cells of the autonomic nervous system. Approximately 3 % of all paragangliomas occur in the head and neck area. Head and neck paragangliomas (HNPGs) are rare and highly vascularized tumors, the majority of which are benign. Multiple HNPGs with hepatic paraganglioma are exceedingly rare.We report a 59-year-old male patient with a 40-year history of an enlarged mass at the right side of the neck and two months of epigastric discomfort. Neck physical examination revealed a 6 × 6 cm, ovoid, firm mass on the right side of the neck. A pre-contrast computed tomography (CT) scan of the head and neck revealed bilateral heterogeneous soft tissue masses at the bifurcation of the carotid artery with indistinct border, the size of which was 2.4 cm × 2.6 cm on the left and 5.4 cm × 4.3 cm on the right. The lesions were intensely and heterogeneously enhanced with the internal and external carotid arteries surrounded and pushed anteriorly after contrast administration. Magnetic resonance imaging (MRI) showed a hyperintense signal on T2 weighted images compared to the surrounding muscle tissue and an intense contrast enhancement on T1 weighted images. Digital subtraction angiography (DSA) exhibited a highly vascularized masses that occupied and deformed both sides of the carotid bifurcation. As for the hepatic mass, non-contrasted CT imaging of the upper abdomen showed a 6.1 cm × 5.5 cm × 5.8 cm low density mass in the liver with indistinct border. On late arterial phase, the mass showed slight enhancement with an enlarged hepatic artery pushed around the lesion. MR imaging of the lesion in the liver demonstrated low signal intensity on T1 weighted images but heterogeneous high signal intensity on T2 weighted images. On diffusion weighted images, the mass showed high signal intensity whereas low signal intensity was seen on the image of apparent diffusion coefficient (ADC). Moreover, the contrast-enhanced MRI showed that the lesion was intensely but heterogeneously enhanced.123I-metaiodobenzylguanidine (123I-MIBG) are helpful in the evaluation of the patients with PGs. Increased awareness of their concomitant occurrence and familiarity with their characteristic features are critical for clinicians and radiologists to avoid diagnostic and therapeutic pitfalls and to facilitate the early diagnosis.Multiple HNPGs with hepatic paraganglioma are exceedingly rare. Advanced medical imaging modalities such as ultrasound (US), CT, MR, DSA and  Paragangliomas (PGs), representing 0.012 % of all tumors, are rare and mostly benign neoplasms that originate from the neuroendocrine tissue along the paravertebral axis and thus may develop at various body sites . PGs in 123I-metaiodobenzylguanidine (123I-MIBG) may be useful in the evaluation of the patients with PGs. To date, there are very few literatures describing the radiologic features of hepatic PGs. Here we report a case of multiple HNPGs with hepatic PGs and make a short review of the literature related to the radiologic features and therapeutic strategies of the rarely occurring multiple tumors.Although Stoeckli et al.  had repoA 59-year-old man presented with a 40-year history of an enlarged mass at the right side of the neck and two months of epigastric discomfort. He denied fatigue, flushing, heat or cold intolerance, headaches. There was no abnormality of his familial history related to cancer or inherited diseases. Neck physical examination revealed a 6 × 6 cm, ovoid, firm mass on the right side of the neck. Laboratory evaluation revealed γ-glutamyltransferase 135 , lactate dehydrogenase 104 , creatine kinase 14 , C-reactive protein 147 , D-dimer 12.23 (upper reference limit: 0.55 mg/L). The plasma levels of tumor markers alpha fetal protein (AFP) and CA199 were within normal limits.A pre-contrast CT scan of the head and neck revealed bilateral heterogeneous soft tissue density masses at the bifurcation of the carotid artery with indistinct border, the size of which was 2.4 cm × 2.6 cm on the left and 5.4 cm × 4.3 cm on the right. After contrast administration, the lesions were intensely and heterogeneously enhanced with the internal and external carotid arteries surrounded and pushed anteriorly Fig. . MRI shoNon-contrasted CT imaging of the upper abdomen showed a 6.1 cm × 5.5 cm × 5.8 cm low density mass in the liver with indistinct border. On late arterial phase, the mass showed slightly enhanced with an enlarged hepatic artery pushed around the lesion Fig. . MR imagThe patient recovered with uneventful course after surgical removal of the tumors and was followed annually for 8 years without clinical and radiological signs of recurrence.Paragangliomas are considered to be benign tumors that arise from paraganglia , 15. The123I-MIBG are also necessary to establish the diagnosis [Due to the highly vascular nature of most HNPGs, an open or closed biopsy should not be attempted , 18. Theiagnosis , 18, 19.iagnosis . Moreoveiagnosis . With reThe current treatment options for HNPGs include surgical resection, radiation therapy, permanent embolization or a combination of those modalities . Surgica123I-MIBG are helpful in the evaluation of the patients with PGs. Increased awareness of their concomitant occurrence and familiarity with their characteristic features are critical for clinicians and radiologists to avoid diagnostic and therapeutic pitfalls and to facilitate the early diagnosis.In conclusion, multiple HNPGs with hepatic paraganglioma are exceedingly rare. Advanced medical imaging modalities such as US, CT, MR, DSA and Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consents is available for review by the Editor of this journal.


Kaposi's sarcoma was originally described by Moritz Kaposi in 1872 as a rare form of multiple hemorrhagic skin lesions. Today it is well documented as a systemic, multifocal, steadily progressive reticuloendothelial system tumor with a predilection for skin and visceral involvement. It occasionally presents as a visceral disease without skin manifestations. We report a case of Kaposi's sarcoma of the small bowel in a seropositive patient who presented with acute right lower quadrant pain and was diagnosed with intestinal obstruction with perforation on contrast-enhanced multidetector computed tomography (MDCT). The diagnosis was confirmed as Kaposi's sarcoma on postoperative histopathological analysis.  Over one hundred years ago Moritz Kaposi described an unusual hemorrhagic cutaneous lesion, which has been known since as Kaposi's sarcoma . VisceraA 59-year-old man infected with the human immunodeficiency virus (HIV) presented to the emergency department with severe abdominal pain localized to the right lower quadrant of approximately 12-hour duration. This was accompanied by two episodes of vomiting and decreased appetite. The patient was also getting treatment for pulmonary tuberculosis.Clinical examination showed pain in the right lower quadrant. He was found to be febrile with a temperature of 38.1°C (100.6°F) and laboratory findings showed a normal white blood cell (WBC) count. A MDCT was performed using oral and intravenous contrast.The MDCT showed an abnormally dilated small bowel loop (up to 4.5 cm) in the right mid to lower abdomen with small bowel fecalization. There was an abrupt transition point in the right lower quadrant with wall irregularity and thickening at the level of the transition and a possible small intraluminal mass. There were also multiple locules of intraperitoneal free air, concerning for perforation; however no definite site was identified. Inferior to the transition point within the small bowel mesentery there were multiple enhancing soft tissue masses (largest measuring 2.6 × 2.2 cm) in keeping with abnormal lymphadenopathy .A preoperative diagnosis of acute mechanical small bowel obstruction was made. The differential diagnoses under consideration were small bowel lymphoma, tuberculosis, fungal infection, small bowel carcinoid, and Kaposi's sarcoma. The imaging findings were conveyed to the referring clinician and surgeon.An open surgical laparotomy showed proximal ileal small bowel microperforation along the antimesenteric border. Distal to the perforation there was an obstructing rubbery soft tissue intraluminal mass with associated varying size mesenteric lymphadenopathy. The diseased segment of small bowel was resected followed by a side to side anastomosis.The intraoperative findings were concerning for small bowel lymphoma. The bowel specimen and lymph nodes were sent for histopathological diagnosis. The postoperative course was uneventful.Pathologic analysis was performed at our institute on the resected 20.5 cm long segment of small bowel. The segment measured 4 cm in circumference distally and was dilated proximally to 6.5 cm in circumference. Four centimeters from the distal end was a stricture with the adjacent mucosa displaying congestion and effacement of the plicae semilunares. Superficial to this region, the bowel serosa displayed a 4 cm wide area of congestion. Finally, adjacent to the stricture was a well-demarcated, submucosal nodule measuring 0.4 cm in greatest dimension.Histology revealed this nodule to be a spindle-cell lesion involving the mucosa and submucosa and demonstrating characteristic slit-like spaces and extravasated red blood cells. Mitotic figures were easily identified. Immunohistochemical staining for HHV-8 demonstrated strong nuclear staining within the lesion . These fA final diagnosis of Kaposi's sarcoma presenting as acute small bowel obstruction with perforation was made with histopathological correlation.Kaposi's sarcoma of the small bowel is an uncommon entity seen mostly affecting HIV positive patients. It has been described to occur mostly in young homosexual males and differ from its classical form in virulence and preponderance of systemic manifestations . Most gaKaposi's sarcoma is the most common AIDS related tumor in homosexual men and in populations in parts of Africa . The gasThe diagnosis of gastrointestinal Kaposi's sarcoma is made on endoscopic visualization of a submucosal mass or masses of a red-purple colour, which is typical of Kaposi's sarcoma; confirmation is made histologically with biopsy specimen .On the basis of previous reports, the small bowel and stomach were common sites while the colon and particularly the esophagus were rarely affected. Very few cases of isolated gastrointestinal lesions without any other stigmata of systemic or skin manifestation have been reported .The clinical presentation of Kaposi's sarcoma of the gastrointestinal system varies from constitutional symptoms to epigastric pain, generalized abdominal discomfort, and loss of weight and appetite , 4, 5. MThe most common radiological finding in the gastrointestinal tract is of multiple submucosal masses with or without central ulceration (“target” or “bull's-eye” lesions). Plaques-like lesions or small nodules are less common radiological manifestations. Intussusception and bowel obstruction are an uncommon manifestation of Kaposi's sarcoma but do occur .MDCT was beneficial in the diagnosis of the acute small bowel obstruction in our patient and differentiating from other causes of right lower quadrant pain such as appendicitis, cecal diverticulitis, omental infarct, infectious ileitis, Meckel's diverticulitis, and inflammatory bowel disease of the distal small bowel.As shown in this case the multiplanar reformatted 2D images with coronal and sagittal reconstructions clearly depicted the dilated small bowel loop, right lower quadrant transition, and intraperitoneal free air.Kaposi's sarcoma is a tumour of spindle cells and vascular clefts with extravasated red blood cells. The spindle cells of Kaposi's sarcoma are generally believed to originate from lymphatic or blood vessel endothelial cells, which would explain the multicentric nature of the tumour . The HIVThe specimen underwent gross, histologic, and immunohistochemical assessment, revealing a spindle-cell lesion involving the mucosa and submucosa with slit-like spaces and extravasated red blood cells. Mitotic figures were readily identified. The tumour cells showed strong nuclear positivity for HHV-8 by immunohistochemistry. The features were diagnostic of Kaposi's sarcoma.In closing, this case report documents the preoperative imaging diagnosis of acute mechanical small bowel obstruction with perforation in an HIV positive male. The appearances on MDCT suggest an obstructing intraluminal mass as the cause and Kaposi's sarcoma was confirmed on postoperative histopathological analysis.


Syringocystadenoma papilliferum is a rare benign hamartomatous adnexal tumorof the apocrine or eccrine sweat glands. Most patients present a solitarylesion in the head and neck region. Presentation outside the head and neckregion is even more uncommon. We present a case of Syringocystadenomapapilliferum with papulonodular lesion located on the vulva of an infantgirl. This case illustrates the atypical location of this rare disease andadds to the differential diagnosis of lesions on the vulva. Histopathology is fundamental to excludeother dermatoses and define therapeutic approach.Syringocystadenoma papilliferum (SCAP) is a rare benign adnexial neoplasm, ofcontroversial origin, derived from apocrine and eccrine glands.Female child, 8 years old, whose mother reported the onset of a nodule in thegenital region since birth, with occasional pruritus, of slow and gradualgrowth. She underwent antibiotic therapy, corticosteroids and topicalantifungals, with no improvement.At the dermatological examination, she presented a erythematous nodule with smoothsurface, fibroelastic consistency, measuring about 3cm, on the left labium majus.The anatomopathological examination of biopsy of the lesion showed papillomatousepidermis associated with invaginations and papillary projections. Glandularepithelium presented as an external layer of cuboid cells, with round nuclei andscarce cytoplasm, and an internal layer of cylindrical cells with decapitationsecretion. The dermis revealed a plasmocyte-rich inflammatory infiltrate. Thesefindings are compatible with SCAP . The pat3 It is accepted that differentiation is predominantlyapocrine1. It is achildhood or adolescence neoplasm, observed since birth in 50% of cases, as inthe present case.SCAP is a hamartomatous adnexal tumor which arises from pluripotent cells. Derivedfrom apocrine and eccrine glands, its histogenesis is stillcontroversial.4It has a tendency to increasein size during adolescence, becoming more verrucous and papillomatous.3 Its most frequent sites are the scalp, neck and face(75%), with already reported uncommon sites: eyelids, arms, buttocks, auricularpavilion, scrotum, vulva, back and abdomen which are very rare locations, suchas the one presented in this case.5Its clinical presentation is a papule, plaque or a single or grouped nodule, withno hairs, asymptomatic, but that may become exsudative and with a linear aspectarrangement.4Histopathologically, itspresentation is a dermal endophytic tumor with irregular papillary projectionsof scaly epithelium, forming ductile structures which connect with the surface,aligned by glandular epithelium constituted by an external layer of cuboidcells, with round nuclei and scarce cytoplasm, and an internal layer ofcylindrical cells with decapitation secretion and plasmocyte-rich inflammatoryinfiltrate.2Association with other benign neoplasms of adnexal origin may occur, such asapocrine adenoma, hidradenomapapilliferum, trichoblastoma, eccrine poroma,sebaceous nevus of Jadassohn and others.2 laser in locationsunfavorable for surgery.4Tumor cells show a reaction of positive staining with carcinoembryonic antigen. Itis rarely associated with malignant progression, but basal-cell carcinomadevelopment was described in 10% of the cases, mainly when associated withsebaceous nevus of Jadassohn. Squamous cell carcinoma andsyringocystadenocarcinoma papilliferum were also reported as a progression ofSCAP, but are extremely rare. Healing treatment is surgical excision, but thereare cases in which removal was effective with CO6 SCAP is a rare benign adnexal neoplasm which presentfew reports of uncommon location described in the literature. This illustratesan additional case of atypical location of this rare disease and contributes tothe differential diagnosis of vulvar lesions.The patient in the present case was referred to pediatric surgery, becauseexcision is recommended to prevent infections, hemorrhages, exacerbated growthand malignant degeneration.


It evolves in a disorganized fashion and the cerebellum loses its normal architecture with no clear plane from normally structured cerebellar tissue.2-5 We report a case of a young woman with hydrocephalus and cerebellar symptoms caused by a rare occurrence of dysplastic Gangliocytoma arising within the left cerebellar hemisphere and vermis.Lhermitte-Duclos disease (LDD) is a rare pathologic condition, which was first described in 1920 by Giorgianni et al.A 19-year-old woman with uneventful medical history was admitted in March 2012 with a 6 months history of vertigo and the posterior headache and 2 months history of nausea, vomiting, and visual disturbance. On admission, the neurologic examination revealed edema in fundoscopy and an unsteady tandem gait with a tendency to fall to the left side. Other neurologic exams were normal. Computed tomography (CT) scan showed a hypodense area in the left cerebellar hemisphere and vermis with no calcification, reduced fourth ventricle, and obstructive hydrocephalus. Magnetic resonance imaging (MRI) with and without contrast revealed an irregular lesion, hypo signal on T1-weighted image and high signal on T2-weighted image with no enhancement . The pat4 Around 220 LDD cases, have been reported in the literature.1,5 This is a slowly evolving lesion that forms a mass. It is composed of granule, Purkinje and glia cell. LDD was found associated with phakomatosis, Cowden syndrome, systemic hamartomas and malignant neoplastic lesions of the breast, thyroid and genito urinary tract.2,3 Imaging plays an important role. Hypo attenuated on unenhanced CT scan. No appreciable enhancement is seen on contrast-enhanced CT image.1LDD is a rare condition, usually affecting patients aged 30-50 years. There is no sex preference.2The appearance on MRI imaging is highly characteristic, showing tiger stripe appearance. LDD should be excised if symptomatic.In this case report, we presented a patient with dysplastic gangliocytoma of the cerebellum both as hemisphere and vermis with symptoms of cerebellum and raised intracranial pressure. The diagnosis of this rare entity should be considered in any young, and middle age adult presenting with signs of intracranial hypertension and cerebellar combined with characteristic radiologic features; however MRI cannot replace the histopathologic diagnosis. Surgery appears to be the only efficient treatment if symptomatic. Long-term follow up is advisable in order to reduce the probability of occasional symptomatic recurrence and to identify the possible sign of Cowden syndrome, which carries a risk of developing malignancy.


Ewing's sarcoma is a highly malignant tumor of bone and is more common in children in the age group of 10 to 20 years. Sometimes the classic clinical and radiological presentation of Ewing's sarcoma may not be the norm and patient may have an atypical presentation leading to diagnostic confusion. This situation is especially true for Ewing's sarcoma involving iliac bone. We report a case of Ewing's sarcoma involving the right ilium in a patient presenting with right lower quadrant pain and nonspecific radiological changes. To the best of our knowledge, this scenario has not been reported in literature. We recommend early magnetic resonance imaging and computed tomography to diagnose the disease early when there is slightest suspicion of the disease. Ewing's sarcoma is known for being highly malignant. Named after James Ewing , it is tA girl, 13 years of age, Saudi in origin, presented to us with a history of pain in the right lower quadrant of 6-month duration. She had visited many clinics for her pain with no relief to her symptoms. In the initial stages of her disease, she had undergone multiple ultrasound examinations with no clue of the diagnosis. The patient already had undergone appendectomy 2 years back, so appendicitis was not kept as a differential diagnosis. In one of the latest ultrasound examinations of the abdomen, the sonologist picked up a mass in her right iliac fossa arising from pelvis suspecting an abscess or a tumor. The patient was referred to our clinic for further evaluation and treatment. On our examination, there was no tenderness in the right iliac fossa nor could any swelling be palpated. ESR, CBC, and CRP were normal. X-ray of the pelvis (AP) was done and did not show any significant bony changes . MRI of Early diagnosis of Ewing's sarcoma of ilium remains challenging partly because of the subtle difficult to detect changes in the radiographs and the nonspecific clinical symptoms that patients have. After reviewing the literature by searching Pubmed with terms such as “Ewing's sarcoma of ilium,” “Diagnosis of Ewing's sarcoma of ilium,” and “clinical presentations of Ewing's sarcoma,” we could find few case reports regarding the atypical presentation of Ewing's sarcoma. The delay in diagnosis can partly be due to the radiologic appearance of inflammatory and tumorous lesions in the iliac bone which is characterized by destructive alterations and consolidations simultaneously. This pattern is nonspecific. The value of plain films of this area is compromised by the anatomy of the iliac bone and by overlying structures . There hPatients of Ewing's sarcoma need a multidisciplinary approach to treatment which include involvement of oncologists, radiation oncologists, surgeons, and radiologists. While surgery is effective and appropriate for patients who can undergo complete resection with acceptable morbidity, children who have unresectable tumors or who would suffer loss of function are treated with chemotherapy and radiation therapy alone. We were fortunate enough to have clear margins at the time of surgery in our patient without causing any functional disability to the patient. Prognosis depends on extent of the disease, size, and location of the tumor, presence or absence of the tumor metastasis, tumor response to therapy, age, and disease relapse. Most centers today report long-term survival of 60% to 70%. The worst prognostic factor is the presence of distant metastasis. Even with aggressive treatment, patients with metastasis have only a chance of 20% long-term survival. Histological grades are of no prognostic significance.We believe that Ewing's sarcoma should be kept as one of the rare differential diagnoses for lower quadrant pain. Ultrasonography should not be relied on much and X-rays may not add more to the knowledge. Lower threshold should be kept for investigations such as CT and MRI to detect the disease early and start the appropriate treatment.


A 24-year-old woman was referred to our department because of melena. These symptoms combined with severe anemia prompted us to perform an emergency upper endoscopy, which showed bleeding from an ulcerated 30 mm submucosal tumor in the gastric antrum. A computed tomography scan revealed a homogeneously enhanced mass, and endoscopic ultrasonography identified a well-demarcated mass in the third and fourth layers of the gastric wall. Because analysis of the possible medical causes remained inconclusive and the risk of rebleeding, laparoscopy-assisted gastric wedge resection was performed after administration of 10 units of red cell concentrate. Histological and immunohistological analysis revealed the tumor to be a gastric glomus tumor. Gastric submucosal tumors remain challenging to diagnose preoperatively as they show a variety of radiologic and clinicopathologic features and are associated with the risk of bleeding upon biopsy, as is indicated in the guidelines for gastric submucosal tumors. Gastric glomus tumors characteristically present with exsanguinating gastrointestinal hemorrhaging that often requires blood transfusion. Additionally, gastric submucosal tumors typically occur in elderly patients; however, this case involved a young patient who was 24 years old. Here, we describe this case in order to identify features that may aid in early differentiation of gastric submucosal tumors. Glomus tumors (GTs) are benign lesions originating from modified cells of the glomus body that are responsible for regulation of arteriolar blood flow. Although these tumors usually occur in peripheral soft tissue , in the A 24-year-old woman with no previous history of illness presented with vomiting andmelena to her local primary clinic. Tachycardia was noted as a characteristic physical abnormality, and her hemoglobin level was extremely low (6.3 g/dL). The patient was transferred to our hospital and was subjected to further testing along with transfusion of 10 units of red cell concentrate. An emergency upper gastrointestinal endoscopy revealed active bleeding from an ulcer on the surface of an elevated lesion located in the lower portion of the stomach, along the greater curvature. The bleeding was successfully controlled using local sclerosis therapy.Two days later, the patient underwent another upper gastrointestinal endoscopy, which revealed a 30 mm, well-circumscribed, soft SMT . The gasDuring the operation, a tumor, approximately 30 mm in diameter, was found in the antral wall of the stomach. The tumor had not invaded the adjacent organs and was successfully removed via gastric wedge resection. The patient had an uneventful postoperative course and was discharged six days after surgery.Histologically, the tumor was composed of atypical glomus cell nests surrounding capillaries . ImmunohThe tumor was completely resected and was determined not to be severely malignant based on the detection of few cells undergoing mitosis and the observation of few atypical cells. We therefore chose not to provide adjuvant therapy while continuing to monitor the patient through follow-up. Ten months after the operation, the postoperative course remains uneventful without signs of relapse.GTs are rare benign mesenchymal tumors arising from the glomus body. This type of tumor was first reported by De Busscher in 1948 , and lesGastric SMTs vary in malignant potential from benign to highly malignant and vary in size from a small nodule to a large mass, such as gastrointestinal stromal tumors (GISTs), heterotopic pancreas, hemangiomas, carcinoid tumors, and neurilemmomas. Additionally, GTs may present as a solitary, hypervascular SMT, as in our case. Among these tumor types, GISTs are the most common ones and are often malignant, so the main diagnostic strategy when examining such a gastric SMT is to differentiate it from GISTs. An ideal course of action would be to perform a preoperative biopsy, but this is often difficult owing to the potential for rebleeding, and guidelines for gastric SMTs recommend operation without a biopsy when patients have symptoms . RadioloPatients with gastric SMTs usually present with epigastric pain and distress, having been reported in over 50% of patients. Gastrointestinal bleeding and ulcer-like symptoms are occasionally observed and have been reported in 5% of patients with gastric SMTs. However, exsanguinating gastrointestinal hemorrhage from a SMT is very rare. Gastric GTs are thought to be highly vascularized because this tumor arises from cells of the arteriovenous anastomosis plexus and, in several reports, gastric GTs have led to exsanguinating gastrointestinal hemorrhaging requiring a blood transfusion –11.Additionally, gastric SMTs such as GISTs generally occur in elderly patients, especially in patients above the age of 60; by comparison, this case involved a 24-year-old patient. Although the scarcity of reports may preclude a predictive conclusion, gastric GTs have been reported to occur at younger ages than GISTs, with a median age of 45 years  . Gastricα-smooth muscle actin and vimentin but negative for CD34 and KIT. These immunohistological features may help to distinguish GTs from other histologically similar tumors.We confirmed that gastrointestinal GTs are histologically and immunophenotypically comparable with the GTs found in peripheral soft tissues, as previously reported , 14. HisIn general, gastric GTs have a good prognosis; however, several authors have reported that gastric GTs can metastasize hematogenously to the liver, lungs, and brain –17, and


Primitive neuroectodermal tumor (PNET) is usually an aggressive, rapidly progressing and metastasizing tumor. Occurrence of this type of tumor in the kidney is considered as unusual and few cases have been reported so far. We present a metastatic PNET arising probably from the kidney in a 17-year-old female patient with local invasion and metastasis to the stomach. PNET should be considered as a differential diagnosis of a large heterogeneous soft tissue mass in the abdomen, especially in those with widely local invasion and metastases. Primitive neuroectodermal tumors (PNET) are a group of small round cell malignancies with neural crest origin. These tA 17-year-old girl was admitted with abdominal pain and distension for the past 6 months. She also had nausea, vomiting and a weight loss of about 10 kg. Physical examination revealed multiple abdominal masses on the left side of the abdomen, pallor, ascites and pleural effusion without any peripheral lymphadenopathy. The patient’s remarkable laboratory findings were severe anemia (hemoglobin: 7.4 g/dL) and a significantly increased ESR (85 mm/h) and serum LDH (835 U/L).Abdominal ultrasonography revealed mass lesions adherent to each other in the upper portion of the retroperitoneal space. There was free fluid in the peritoneal and both pleural cavities  and 2. PAbdominal CT scan confirmed several adherent mass lesions in the retroperitoneum with heterogeneous solid and cystic components (mostly solid) and several curvilinear calcifications . The lefHistological examination revealed a small rounded cell tumor with hyperchromatic nucleus and scant cytoplasm in a fibrotic stroma. Foci of necrosis were remarkable . ImmunohPeripheral primitive neuroectodermal tumors  are a group of small round cell malignancies with neural crest origin that arise outside the central and sympathetic nervous system . They bePeripheral PNETs are rare in the abdomen . This tuReview of radiologic findings showed that most cases of retroperitoneal PNETs in the literature, similar to our case, presented as a large mass with areas of necrosis and heterogeneous enhancement in contrast imaging. Some cases had areas of hemorrhage, but in our case, there was no hemorrhage. Our case had several foci of curvilinear calcification compared to other case reports, in which calcification was a rare finding (one of ten cases in a case series) . There wAlthough vascular encasement of abdominal aorta and visceral vessels was seen in our case, like some other cases of retroperitoneal PNETs, there was no clinical or imaging evidence of venous thrombosis in the inferior vena cava (IVC), while venous thrombosis has been detected in other patients , 9. Appr


Undifferentiated pleomorphic sarcoma (UPS) is the most common sarcoma that appears in older patients, usually in the extremities and the retroperitoneum. Other locations are rare. By definition, in UPS, although the malignant cells tend to appear fibroblastic or myofibroblastic, they should not show differentiation towards a more specific line of differentiation. In this sense, we report the case of an 80-year-old patient with an initial clinical diagnosis of a locally advanced colonic neoplasm that was later confirmed as a primary mesenteric UPS. Primary mesenteric UPS are extremely rare with less than 20 cases reported. We also review the pathologic and radiologic diagnostic criteria and the natural history of these tumours. Undifferentiated pleomorphic sarcoma (UPS), previously known as malignant fibrous histiocytoma, is the most common sarcoma appearing in late adult life. By definition, although the malignant cells tend to appear fibroblastic or myofibroblastic, they should not show differentiation towards a more specific line of differentiation. In this sense, as the pathological and molecular diagnostic techniques have improved in the last few years, in many cases previously classified as malignant fibrous histiocytoma, a more specific diagnosis can be confidently made. In those remaining true cases of UPS, the most frequent localization is the extremities, followed by the retroperitoneum. On the other hand, visceral and intra-abdominal primary involvement is rare. We report the case of an elderly gentleman with the diagnosis of a primary mesenteric UPS, an extremely rare site of involvement by this tumour. We also review the pathologic and radiologic diagnostic criteria and the natural history of these tumours.A 75-year-old male was referred to our hospital in May 2010 with a two-month history of diffuse abdominal pain and intermittent rectal bleeding. He also reported low-grade fever in the evenings. No weight loss or other symptoms were noted. His previous medical history was unremarkable except for hypertension and type 2 diabetes. On physical examination, the patient had a good general status and was not septic. A painful, poorly defined, and nontender mass was noted in the right hypochondrium; there were no signs of peritoneal irritation. Blood counts, renal and hepatic biochemistry tests, LDH levels, and tumour markers values were all within the normal range. Only the fibrinogen level and the C-reactive protein were elevated .A full-body CT scan revealed a heterogeneous, well-circumscribed mass in the right abdominal loin that seemed to originate from the hepatic flexure colon and descended towards the anterosuperior iliac spine . The masAn exploratory laparotomy was performed in May 2010. A right colonic mass was seen that occupied the whole right abdominal flank and infiltrated the distal ileum. There was a small quantity of ascitic fluid. The right kidney was not infiltrated. An extended right hemicolectomy with a distal ileal resection was performed. The postoperative course was uneventful and the patient was quickly discharged.The pathologic analysis showed a poorly delimitated 14 × 13 cm tumoural mass, covered by the colonic mesentery. The lesion was lobulated and heterogeneous, with intertwined gelatinous and solid zones. Cavitated and necrotic areas in the interior and in the outer surface of the tumour were readily seen. The tumour was extrinsic to the colon and originated from the mesentery. However, when the intestinal lumen was inspected, fungating masses were seen in the right colon and in the caecum, secondary to the mesenteric tumour. The surgical margins were free.The microscopic study revealed a poorly differentiated mesenchymal tumour, with ample zones of necrosis and with an extensive mononuclear inflammatory component. Some zones were abscessified. The malignant cells formed different morphological patterns, from highly cellular epithelioid areas to pleomorphic-storiform areas . AlthougThe patient began follow-up in our outpatient clinic. No adjuvant treatment was given. Unfortunately, an unresectable local and peritoneal recurrence was diagnosed in August 2010. Palliative chemotherapy was begun with pegylated doxorubicin, with little effect, and the patient died in October, 2010, six months after the original diagnosis.The mesentery is a frequent avenue of spread for malignant neoplasms through the peritoneal cavity and between the peritoneal spaces and the retroperitoneum. On the other hand, primary tumours arising from the mesentery are rare. Most of these are mesenchymal in origin, and the majority are histologically benign . The mosIn our case, we report a primary mesenteric undifferentiated high-grade pleomorphic sarcoma (UPS). UPS, previously known as a malignant fibrous histiocytoma, is defined as a high-grade pleomorphic neoplasm with no identifiable lines of differentiation using currently available diagnostic techniques  and accoIn our patient, the clinical presentation was a locally advanced primary colonic tumour, due to the presence of fungating tumours in the colonic lumen secondary to the primary tumour invasion, a rare occurrence. The CT appearance was similar to that in other published cases and showed a well-circumscribed soft-tissue mass, with hypodense areas due to necrosis and cystic degeneration , 11. HowHistologically, tumours are composed of a haphazard, storiform, or fascicular arrangement of highly pleomorphic and spindle-shaped cells with numerous typical or atypical mitosis; areas with necrosis and hemorrhage are frequent. In our case, the stroma had an important inflammatory component and the final diagnosis is UPS with prominent inflammation , 13, 14.Although numbers are limited, most reports suggest that intra-abdominal UPS is a rare but aggressive tumour, the prognosis of which is poorer than that seen in tumours in the extremities, due presumably to late detection –10. TumoAdjuvant chemotherapy with the combination of anthracyclines-ifosfamide is also controversial and was not offered in our patient's case due to his advanced age. Unfortunately, although the tumour was completely resected with clear margins, our patient developed local and systemic recurrence with rapid progression after one month of surgery, with little effect of the palliative chemotherapy given. He died six months after the original diagnosis, highlighting the extremely aggressive nature of the tumour.


Testicular cancer is the most common malignancy of men aged 15–40. Metastatic spread classically begins with involvement of the retroperitoneal lymph nodes, with metastases to the liver, lung, bone, and brain representing advancing disease. Treatment is based on pathologic analysis of the excised testicle and presence of elevated tumor markers. We report a case of a 34-year-old male presenting with back pain who was found to have a right renal mass with tumor extension into the inferior vena cava. Subsequent biopsy was consistent with seminoma. We review this rare case and discuss the literature regarding its diagnosis and management. Testicular cancers are the most common malignancy for men aged 15–40 [A 34-year-old Latino man was referred to clinic with a diagnosis of a renal mass with inferior vena caval thrombus. This was initially found after he reported a one-month history of back pain. He denied any hematuria, pain, weight loss, lower extremity edema, and his physical exam was unremarkable. An MRI showed an 8 cm renal mass with tumor thrombus extending into the IVC, below the diaphragm .Additionally, he had bilateral retroperitoneal lymphadenopathy and a left supraclavicular mass. His LDH was elevated at 408 and his AFP and HCG were both within normal limits. Given his age, elevated tumor markers, and extensive adenopathy concerning for testicular cancer, he underwent a scrotal ultrasound, which demonstrated a hypoechoic left testicular lesion .The patient initially underwent a biopsy of the supraclavicular lymph node, but the histology showed only necrosis and was noncontributory. He then underwent a biopsy of the renal mass as well as a subsequent left inguinal orchiectomy. Histologically, the renal biopsy supported the diagnosis of metastatic seminoma, showing homogeneous, medium-sized tumor cells that were loosely organized in nests, surrounded by fibrous stroma with a lymphocytic infiltrate, with no renal cortex or medulla seen. No granulomas were identified. Immunohistochemical staining showed that the tumor cells were positive for SALL4, vimentin, c-Kit, and OCT4 and negative for CD30, desmin, SMA, and cytokeratins AE1/AE3. The orchiectomy specimen grossly showed unremarkable brown spongy parenchyma, with an ill-defined, tan-yellow shiny area 1.3 cm in greatest dimension and confined to the testes. Histologically, the testis excision showed marked fibrosis consistent with regressed seminoma. No viable tumor was found .The patient was subsequently referred to medical oncology for chemotherapy and further treatment. An IVC filter was placed cephalad to the thrombus and he was started on bleomycin, etoposide, and cisplatin (BEP) systemic chemotherapy with side effects of watery diarrhea and fatigue. During treatment with BEP, he was admitted to the hospital due to development of neutropenic fever, severe mouth pain, and genital lesions consistent with HSV infection. After 3 cycles of BEP, he developed pulmonary toxicity and bleomycin was discontinued for the fourth cycle. He underwent a CT scan six months after presentation showing substantial interval decrease in the size of bilateral retroperitoneal, pelvic, and left lower cervical lymphadenopathy. Marked interval decrease in the size of the IVC thrombus was also noted. These changes were thought to be consistent with necrosis secondary to chemotherapeutic effect on the lymphadenopathy. New scattered ground glass airspace opacities in the bilateral mid- and lower lungs were also seen, consistent with his bleomycin induced pulmonary toxicity. The patient received two additional cycles of EP, after which the patient underwent a PET scan (now seven months postpresentation). This PET scan showed mild retroperitoneal enhancement consistent with resolving necrosis. Repeat CT scan obtained eight months after presentation and treatment showed no change in the partially calcified lymph nodes in the retroperitoneum and an unchanged stable eccentric thrombus of the IVC . There wTesticular cancer is the most common cancer in males between the ages of 15 and 40 . 95% of Grossly, intratesticular seminoma presents as a cream or tan-colored nodular mass. Microscopically, confluent sheets of cells are seen with clear or eosinophilic cytoplasm. The sheets are classically divided by fibrous bands containing a prominent lymphocytic infiltrate. In both primary tumors and metastases, granulomas are a classic feature. Syncytiotrophoblast can be seen and should not be overinterpreted as evidence of choriocarcinoma. Seminomas typically stain positively for placental alkaline phosphatase (PLAP), CD117/c-Kit, OCT3/4, SALL4, vimentin, and D2-40. In contrast, they are negative for CD30, desmin, SMA, and pan-cytokeratin. These immunostains are useful in differentiating subtypes of germ cell tumors and identifying minor components, as mixed germ cell tumors are common.Ultrasonography remains the standard imaging modality for testicular malignancy, and CT with oral and intravenous contrast is preferred for diagnosis of retroperitoneal lymphadenopathy. While this study focuses predominately on seminomatous testicular tumors, the NCCN recommends postdiagnostic abdomen and pelvis CT scan, with or without chest imaging, for both seminoma and NSGCT. Additionally, bone scan or brain MRI should be performed as clinically indicated . Tumor mRenal cell carcinoma frequently metastasizes to the lumen of the IVC, but seminoma can also mimic this picture. Case reports exist of IVC involvement on initial presentation, although involvement is more typically found after diagnosis . In a 20Testicular cancer is a common malignancy for males aged 15–40. Initial presentation involving an IVC tumor thrombus is rare, especially in the setting of regressed testicular tumor. Treatment should follow the standard guidelines of testicular and retroperitoneal imaging, orchiectomy, and chemotherapy. Pulmonary embolus precautions should be taken, and patients should be counseled that retroperitoneal lymph node dissection with vascular reconstruction may be necessary.