Pilocytic astrocytomas and meningiomas are benign, primary brain tumors that may involve the optic tract. Classically, the presence of a dural “tail” sign may differentiate a meningioma from other intracranial lesions. In this report, we describe a mass with the typical appearance of a clinoidal meningioma on magnetic resonance imaging (MRI) but postoperatively diagnosed as a pilocytic astrocytoma. This case illustrates the rare occurrence of a pilocytic astrocytoma mimicking a meningioma on MRI. Pilocytic astrocytomas are benign, World Health Organization (WHO) grade I gliomas that most frequently arise in adolescents and young adults and usually involve the cerebellum, hypothalamus, and optic pathways. Radiographically, they are relatively well demarcated and strongly enhance on MRI as they are well vascularized and often exhibit glomeruloid vascular proliferation. Although rare, pilocytic astrocytomas can originate from the optic pathway, anterior or posterior to the optic chiasm. These lesions have a strong association with neurofibromatosis type 1 (NF1) and are estimated to occur in 15% of all patients with this inherited syndrome [In contrast, meningiomas are benign growths of arachnoid cap cells, usually found at sites of dural reflections within the skull, and classically exhibit a homogenously enhancing thickening of the dural margin with peripheral tapering on MRI, known as the “tail” sign . BecauseIn this case report, we describe a young patient whose clinical and radiographic presentation strongly supported a diagnosis of a meningioma but upon neurosurgical intervention was found to have a pilocytic astrocytoma. We describe the clinical course of our patient and highlight the unusual features that were subsequently found.An 18-year-old female, 36 weeks into pregnancy, presented to ophthalmology with poor right-sided vision evolving over few years. Her exam was notable for right optic nerve pallor and atrophy. A brain MRI without contrast due to her pregnancy showed a right supraclinoid mass measuring 2.5 × 2.2 × 2.5 cm, for which she was referred for neurosurgical evaluation. No other neurological deficits were present on examination. Considering the stability of the visual deficit and the late gestational age, a contrast study was postponed until after her delivery. The subsequent MRI confirmed an extra-axial mass in the right clinoid region with homogenous enhancement and interval growth of the lesion to 2.9 × 3.0 × 2.0 cm . There wThe patient subsequently underwent surgical resection via a right frontotemporal craniotomy. Intraoperatively, the frontal excursion of the tumor had a well-defined arachnoid plane, but further opening of the dura revealed tumor infiltration of the optic nerve, which was unexpected for a meningioma. A biopsy was taken from the superior truncal aspect of the tumor and sent to pathology for intraoperative diagnosis, which returned a diagnosis of pilocytic astrocytoma. The final pathology report described a proliferation of piloid glial cells of low to moderate cellularity associated with abundant Rosenthal fibers, rare eosinophilic granular bodies, and microvascular proliferation mostly located at the periphery of the tumor . A few pPostoperatively, the patient recovered without significant complications and reported improved overall vision at her one-month follow-up visit. The 6-month postoperative MRI showed no interval growth of the residual tumor, and the patient is currently receiving regular surveillance imaging.Numerous factors led us to initially believe that our patient's lesion was dural based. Radiographically, the MRI showed a uniformly enhancing lesion that seemed to communicate with the dural surface overlying the right clinoidal area. While there seemed to be extension into the optic canal, preoperative imaging did not suggest optic nerve infiltration. Clinically, our patient had no features of NF1 to support a tumor originating from the optic nerve. Furthermore, the accelerated interval growth of her lesion during pregnancy was consistent with known effects of gestational hormones on meningioma proliferation . IntraopA thorough review of the literature revealed only one other report of an optic pathway glioma mimicking a meningioma on preoperative imaging. Edwards et al. recently discussed a case of an 11-year-old child who presented with complaints of right-sided vision loss. On preoperative imaging, there were an enlarged right optic nerve and a homogenously enhancing, dural-based lesion that extended into the right temporal lobe . During Pilomyxoid astrocytomas were first described in 1999 and subsequently were recognized by the WHO in 2007 as a more aggressive, histological variant of pilocytic astrocytomas. On MRI, these tumors usually enhance homogenously within the chiasmatic-hypothalamic region. Unlike pilocytic astrocytomas, they exhibit T2 signal extension into surrounding deep white and grey matter, in contrast to our patient's radiographic presentation. Interestingly however, the pathology of our biopsy sample did report limited pilomyxoid features. Generally, less than 5% of pilocytic astrocytomas progress towards malignancy [In this case report, we describe the clinical course of a patient who presented with clinical and radiographic signs, all suggestive of clinoidal meningioma. However, the gross appearance and histology of the lesion demonstrated a pilocytic astrocytoma. Therefore, physicians should consider a pilocytic astrocytoma in their differential diagnosis of any dural-based, enhancing lesion within the periclinoidal region.


While acute appendicitis and acute cholecystitis are both common, they are only rarely seen simultaneously. The clinical presentation and hospital course of a 45-year-old female with concurrent acute appendicitis and acute cholecystitis is presented. The laparoscopic approach is ideal for dealing with multiple, simultaenous abdominal pathologies. Acute appendicitis and acute cholecystitis are among the most common diagnoses that general surgeons operate on. However, they are only rarely described simultaneously.A 45-year-old female presented to the emergency department with a 1-day history of new onset abdominal pain. The abdominal pain was described as severe and sharp. It localized to the epigastric, right upper, and right lower quadrants as well as radiated posteriorly. She had nausea, as well as multiple episodes of nonbilious vomiting. The past medical history was significant for breast cancer, and the past surgical history was significant for a c-section, bilateral mastectomy, and bilateral tubal ligation.μL with a hematocrit of 37.8%. Her admission chemistry was normal, but her hepatic profile revealed an elevated total bilirubin of 1.4 mg/dL, a direct bilirubin of 0.5 mg/dL, and normal transaminases and alkaline phosphatase. The urinalysis revealed 3+ occult blood.On admission, her temperature was 97.8°F and hemodynamically stable. Her exam was significant for epigastric tenderness, as well as a positive Murphy's sign, and tenderness over McBurney's point. She had no peritoneal signs, and a negative psoas, obturator, and Rovsing's sign. Clinically, her general appearance was not consistent with sepsis or bacteremia. Her white blood cell count was 8 K/CT abdomen and pelvis with contrast revealed cholelithiasis with the possibility of cholecystitis, as well as a dilated (9 mm) fluid filled appendix suggesting the possibility of early appendicitis . An abdoThe patient was brought to the operating room where a laparoscopic cholecystectomy and appendectomy was performed. The appendix intraoperatively appeared to be an early appendicitis, nonperforated. The abdomen was accessed via a single 12 mm port and five additional 5 mm ports . The surAn important principle of medical diagnosis is for an acute onset of symptoms, the constellation of data should fit into a single best diagnosis. However, in this patient, with her abdominal pain prominent in several areas without diffuse peritonitis, clinical suspicion was raised early of the possibility of more than one pathological process. The laparoscopic approach was ideal for this patient as it allowed access to both the appendix and the gallbladder, avoiding multiple open incisions or the morbidity of a full exploratory laparotomy.Simultaneous appendicitis and cholecystitis in a single patient has only been rarely reported previously. It has been described with an acalculous cholecystitis and appendicitis,  as well While the overwhelming majority of patients with abdominal pain have a single diagnosis, clinicians need to be aware that multiple diagnoses can rarely coexist. In such cases, a laparoscopic approach can be an ideal approach, allowing surgical access to the entire abdomen.


Ileal adenomas associated with familial adenomatous polyposis are a common finding. Many recent studies following panproctocolectomy for familial adenomatous polyposis have confirmed the presence of multiple ileal adenomas and an increase in ileal mucosal proliferation. In this study, we present a case of invasive adenocarcinoma arising in a severely dysplastic tubulovillous adenoma in the ileostomy of a patient with familial adenomatous polyposis; also, we present a literature review. To the best of our knowledge, only very few cases have been reported in the literature.A 59-year-old Caucasian woman developed a primary adenocarcinoma in her ileostomy, complicating the stoma 31 years after its formation.Primary adenocarcinoma following panproctocolectomy for familial adenomatous polyposis is a very rare clinical entity. The risk of developing adenocarcinoma in those patients increases with time. Patient education and medical examination of the stoma are of paramount importance and should be implemented early with the need of designing a surveillance protocol for early detection and management of ileal adenomas, especially in longstanding stomas. Ileal adenomas associated with familial adenomatous polyposis (FAP) are a common finding. Many recent studies following panproctocolectomy for FAP have confirmed the presence of multiple ileal adenomas and an increase in ileal mucosal proliferation. The management protocol for FAP is prophylactic colectomy with either restorative proctocolectomy with formation of ileal pouch reservoir or ileorectostomy. Panproctocolectomy and terminal ileostomy were the first-line management option in 1950s. Currently, this procedure is performed only for cases with recurrent rectal or ileal pouch adenocarcinoma. In this study, we present a case of adenocarcinoma in the ileostomy of a patient with FAP; in this case, invasive adenocarcinoma arising in a severely dysplastic tubulovillous adenoma was found. Also, we present a literature review. To the best of our knowledge, only 11 cases in English and one in German [A 59-year-old Caucasian woman with a previously diagnosed FAP had total colectomy with ileorectal anastomosis 34 years ago followed three years later by resection of the rectal stump and fashioning of an end ileostomy in her left iliac fossa; neither the operative details nor the pathology reports were available. Her medical history shows that she has multiple medical comorbidities, including severe sero-negative rheumatoid arthritis, lumbar disc herniation, total abdominal hysterectomy and bilateral salpingo-oophorectomy., osteoarthritis in both hips, eczema, chronic obstructive pulmonary disease, renal calculi, and chronic renal disease stage 3.Three years ago, she was referred to the colorectal clinic because of abnormal fungating growth at the stoma Figure . She wasen bloc small bowel resection with the ileostomy and safety margin of the skin around the stoma. About 45 cm of adherent small bowel was removed alone with the ileostomy specimen. The rest of the small bowel was examined and did not show any gross pathology. A new stoma was created in her right iliac fossa. She went home seven days after a smooth recovery from the operation.A computed tomography scan of her chest, abdomen, and pelvis after oral and intravenous contrast showed no evidence of metastatic disease. Carcinoembryonic antigen was within normal range. After a discussion in the colorectal multi-disciplinary team meeting, a decision was made to keep the duodenal polyps under surveillance and to carry out a barium meal and follow through study. The results of the contrast study were clear; therefore, our patient underwent a laparotomy with Pathology showed an invasive, moderately differentiated adenocarcinoma arising in a severely dysplastic tubulovillous adenoma with foci of high-grade dysplasia at the mucocutaneous border Figure . The tumAs discovered at a follow-up one year ago, she had developed a polypoid mass at the ileostomy site Figure . The resFAP is an autosomal dominant inherited disease characterized by the presence of hundreds of adenomatous polyps in the colon and rectum. The annual reported incidence ranges from one in 5000 to one in 17,000 live births . The incMany factors have been implicated in the malignant transformation of the ileostomy mucosa: colonic metaplasia and dysplasia of ileal mucosa, chronic irritation due to either physical or chemical trauma, ileitis, and development of chronic inflammatory polyps and malignant transformation in a pre-existing benign adenoma. In this case, we believe that the invasive adenocarcinoma was secondary to malignant transformation in a pre-existing adenoma as evident by the pathology report.en bloc resection of the terminal ileum with its mesentery, surrounding stoma skin, and relocation of a new ileostomy. Our patient was followed up to 18 months without evidence of malignant recurrence. However, she developed a benign adenomatous polyp, which was locally excised with refashioning of the stoma.Table en bloc resection of the ileum with a generous margin of the surrounding skin and relocation of the stoma.The number of reported cases for primary adenocarcinoma following panproctocolectomy for FAP is small. Nevertheless, it is expected that the numbers will increase in longstanding ileostomies in parallel with the duration of the stoma. Patient education and medical examination of the stoma should be implemented early with the need of designing a surveillance protocol for early detection and management of ileal adenomas, especially in longstanding stomas. Surgery should include an EGD: esophagogastroduodenoscopy; FAP: familial adenomatous polyposis.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AH performed literature searches, wrote the paper, and assisted in the operation. RT contributed in writing the amendments and in revising the manuscript. PJM and SG performed the operation and supervised the final revision of the paper. All authors read and approved the final manuscript.


Introduction. Follicular variant (FV) papillary thyroid carcinoma (PTC) has aggressive biologic behavior as compared to classic variant (CV) of PTC and frequently metastasizes to the lungs and bones. However, metastasis to the pancreas is extremely rare manifestation of FV-PTC. To date, only 9 cases of PTC have been reported in the literature. Pancreatic metastases from PTC usually remain asymptomatic or manifest as repeated abdominal aches. Associated obstructive jaundice is rare. Prognosis is variable with reported median survival from 16 to 46 months. Case Presentation. Herein we present a 67-year-old Saudi woman, who developed pancreatic metastases seven years after total thyroidectomy and neck dissection followed by radioactive iodine ablation (RAI) for FV-PTC. Metastasectomy was performed by pancreaticoduodenectomy followed by sorafenib as genetic testing revealed a BRAF V600E mutation. She survived 32 months after the pancreatic metastasis diagnosis. Conclusion. Pancreatic metastases are rare manifestation of FV-PTC and are usually sign of extensive disease and conventional diagnostic tools may remain to reach the diagnosis. Thyroid cancer is the commonest endocrine malignancy, presenting with 23 500 new cases per year in the United States and European Union, respectively , 2. DiffPapillary thyroid carcinoma (PTC) is the most frequent form of DTC and the follicular variant of PTC (FV-PTC) is more aggressive than the classic variant of PTC. It differs from classical PTC in being follicular growth pattern, higher prevalence of tumor encapsulation, angiovascular invasion, and poorly differentiated areas and a lower rate of lymph node metastases . Pancreas is an extremely rare site of metastasis of PTC. To date, only 9 cases of pancreatic metastasis secondary to PTC have been reported in the literature. Herein we present a 67-year-old Saudi woman, who developed pancreatic metastasis seven years after total thyroidectomy and neck dissection followed by sorafenib for FV-PTC.In November 2009, a 67-year-old Saudi woman presented in our clinic for her routine visit with the complaints of abdominal pain and indigestion. She had noticed these complaints for 2 months and these have been occurring frequently over 2 weeks, for which she was taking antispasmodics and nonsteroidal anti-inflammatory drugs (NSAIDs), but with minimal improvement. Her previous medical history revealed hypertension and diabetes since last 20 years which were controlled on medications. She had no history of smoking and her weight was stable. Her past surgical history showed that she underwent total thyroidectomy and lymph node dissection for follicular variant papillary thyroid carcinoma pT2N1cM0  in MarchOn physical examination, she was in good general condition and her vitals were stable. Per abdomen examination revealed deep tenderness in epigastrium; however, there was no palpable mass or visceromegaly. There was no other palpable cervical lymphadenopathy and examination of chest, heart, nervous system, and pelvic was normal. Clinical differential diagnosis was chronic pancreatitis, primary pancreatic adenocarcinoma, or metastasis. Her hematological, renal, and liver function tests, tuberculin, serum electrolytes, and thyroid stimulating hormone (TSH) and thyroxin (T4) were found within normal limits. Serum tumor markers, carcinoembryonic antigen (CEA), and cancer antigen 19-9 were also normal; however, serum TG levels were raised, that is, 672.8 ng/mL . Computed tomography (CT) of abdomen showed decreased enhancement of the neck, body, and tail of the pancreas; while enhancement of the pancreatic head appeared normal and there were bilateral multiple pulmonary metastases. Whole body iodine scintigraphy was noniodine avid. Magnetic Resonance Cholangiopancreatography (MRCP) revealed a small hypovascular lesion in the pancreatic neck measuring 1.8 × 1.5 cm. It showed low signal intensity in both T1 and T2 with no enhancement in the arterial phase and faint enhancement in delayed sequences. Mass was abutting the superior mesenteric vein (SMV) and caused narrowing to its caliber below the confluence with splenic vein; however, superior mesenteric artery (SMA) was found normal in caliber with no sign of invasion . CT guidPancreas is rare site metastasis. Common malignancies which metastasize to pancreas are renal cell carcinoma, lung, medullary carcinoma of the thyroid, lymphomas, alveolar rhabdomyosarcoma, and esophagus . MetastaPancreatic metastases remain asymptomatic for long period before diagnosis or manifest as symptoms like chronic pancreatitis as seen in our patient. At time of presentation, pancreatic metastases are usually sign of extensive disease seen in our patient. Conventional diagnostic tools  may remain fail to reach the diagnosis. However, positron emission tomography-computed tomography (PET-CT) and endoscopic ultrasound (EUS) have shown the sensitivity or detecting pancreatic lesions up to 94–100%, though not performed in our case due to unavailability in institute . Surgical treatment in the form of pylorus sparing pancreaticoduodenectomy relieves the symptoms and may increase the disease free survival (DFS) for isolated pancreatic metastasis. However, adjunct and multikinase inhibitors (sorafenib or sunitinib) may slow the disease progression especially in patients with BRAF V600E mutation in tumor cell lines . In conclusion, pancreatic metastases are rare in FV-PTC and they remain asymptomatic or are associated with nonspecific complaints. Improved diagnostic tools  and immunohistochemistry can be helpful for prompt diagnosis and treatment by means of pancreaticoduodenectomy followed by sorafenib which is associated with increased DFS.


This case reports the usage of human amniotic membrane combined with a costochondral graft as an interpositional material in temporomandibular joint reconstruction for the first time in humans. Because of the favorable outcome 20 months postoperatively, it has to be considered as an approach bringing to light the antiadhesive potential of amniotic membrane. This case report must be regarded as initial spadework and should motivate other institutions to intensify their clinical research in this field. Because of the fact that currently used interpositional materials do not prevent the recurrence of temporomandibular joint ankylosis sufficiently, it is of great interest to establish a proper therapeutic intervention fulfilling these demands. Furthermore, the demonstrated antiadhesive properties of amniotic membrane highlight its multifaceted field of application. Nevertheless, further studies have to prove the findings reported in our case. The major complication of both interventions is the recurrence of ankylosis. To date, no surgical or nonsurgical procedure can guarantee nonrecurrence; therefore, its effective therapy posts a clinical challenge. On the basis of the unsatisfactory results experienced with the current treatment options, our aim is to find an adequate new way to deal with TMJ ankylosis.1A 53-year-old, otherwise healthy woman presented herself because of pain in the left TMJ region and an insufficient mouth opening, which exhibited itself in the preceding weeks. Clinical examination revealed a maximum interincisal opening of 15 mm. In preliminary investigations, radiographic, computed tomographic, and magnet tomographic analyses were performed and a neoplasm at the left condylar process, involving the whole joint cavity, was detected. To clarify the finding, a biopsy of the suspicious mass was performed and a giant cell tumor was diagnosed. After careful evaluation of the diagnosis, risks, and benefits of all possible treatment options, the woman was assessed to undergo radical excision of the tumor, including total resection of the condylar process plus the articular disk. On the basis of the positive outcome of the previously performed animal experiments and the informed consent of the patient, a costochondral graft combined with an allogeneic human amniotic membrane (HAM), was chosen to reconstruct the joint head. For this intention, ethical approval of the independent ethics committee was obtained.Starting the operation, the occlusion was fixed with wire splints. In the next step, the costochondral graft was harvested without any complication from the right ninth rib and kept in a moist bandage during excision of the neoplasm. Through a submandibular and a preauricular approach, the tumor and the condylar process were totally resected. The margins of all frozen sections were clear. The harvested autologous costochondral rib graft was prepared and shaped before transplantation . OsteosyThe postoperative treatment included intensive physiotherapy and regular follow-up appointments. Wound healing, mouth opening, and her general condition were evaluated on the 1st, 3rd, 5th, 7th, 14th, and 30th day and then every month postoperatively. A 20-month follow-up of the patient showed uneventful wound healing without complication. Ankylosis of the TMJ was avoided by long-term observation and the patient presented a maximum interincisal opening of 32 mm 8 months postoperatively . The cor,3,2,1,6,10,12,15,18,10,20,19,22,Temporomandibular joint ankylosis is classified into true and false ankylosis. False ankylosis is the restricted movement of the joint due to extra-articular factors such as muscles, nerves, or the coronoid process. True or intra-articular TMJ ankylosis is the obliteration of the TMJ by fibrous tissue, mainly resulting from trauma, surgical intervention, infection, rheumatoid arthritis, or neoplasm, causing pain, insufficient mouth opening, and difficulty in mastication and speech.2


Adenocarcinoma of the cervical esophagus is a rare tumor, in comparison to adenocarcinoma of the distal esophagus which is on the rise and is often associated with Barrett's esophagus. We present a case of aggressive cervical esophageal adenocarcinoma in a 46-year-old female with no endoscopic or histopathologic evidence of Barrett's esophagus. We discuss the possible etiology of this tumor and review the treatment options, highlighting the importance of a multidisciplinary approach to the management of this rare disease. Esophageal adenocarcinomas typically arise in the lower third of the esophagus with a pathogenesis linked to gastroesophageal reflux disease and subsequent development of Barrett's epithelium. However, primary adenocarcinomas in the cervical esophagus are believed to result from mucosal “cardiac” glands, submucosal glands, or heterotopic gastric mucosa. Adenocarcinoma in the cervical esophagus is a rare tumor with little known about its typical prognosis or optimal therapy, including ideal surgical management and use of neoadjuvant or adjuvant chemotherapy and/or radiotherapy. A 46-year-old Caucasian woman with no significant past medical or family history presented to her primary care provider with a one-year history of sore throat and dysphagia to solid foods. She reported a remote smoking history in her teens and rare alcohol consumption. Workup included a barium swallow study with a persistent filling defect in the upper esophagus measuring 5 cm × 1.8 cm originating from the posterior right wall of the esophagus. Differential diagnosis included both benign and malignant lesions of the upper esophagus. Upper endoscopy with endoscopic ultrasound revealed an ulcerated, friable mass extending from 15 to 19 cm from the incisors with evidence of invasion into the muscularis propria and suspicion for regional node involvement Figures . Biopsie2 and irinotecan 65 mg/m2 on weeks 1, 2, 4, and 5 of radiation). Radiotherapy consisted of a total of 64.8 Gy to the primary esophageal tumor and adjacent nodes plus 39.6 Gy to superior mediastinal nodes. Follow-up PET/CT 14 weeks after completion of definitive chemoradiation therapy revealed continued hypermetabolic activity in the proximal esophagus and repeat upper endoscopy revealed residual tumor. Otolaryngology performed a cervical esophagectomy, lymph node dissection, and left radial forearm microvascular free tissue transfer reconstruction of the cervical esophagus. The pathologic specimen contained moderately differentiated adenocarcinoma of the esophagus undermining the squamous epithelium, with metastasis to two of six paratracheal lymph nodes, but no evidence of Barrett's esophagus or identifiable vestiges of heterotopic gastric mucosa. The patient was staged as T3N1M0 after a PET/CT of the neck demonstrated a hypermetabolic esophageal mass with adjacent right paratracheal and superior mediastinal lymphadenopathy. CT scan of the chest, abdomen, and pelvis were negative for distant metastases. Six weeks of definitive/neoadjuvant chemoradiotherapy were delivered according to the Ilsen regimen . A third recurrence five months later in a right subclavicular node was treated with resection and concurrent capecitabine/limited field radiation. Most recently, she had evidence of multifocal recurrence nearly two years after the initial chemoradiation. She is currently participating in a phase II clinical trial with an oral Aurora kinase inhibitor and has stable disease based on radiographic imaging after six treatment cycles. Squamous cell carcinoma predominates in the cervical esophagus; adenocarcinoma in the cervical esophagus is extremely rare with, to our knowledge, less than 30 cases reported in the literature. Adenocarcinoma of the distal esophagus, in contrast, is common and the relative prevalence has been increasing from 1.7% to 10% historically to upwards of 50% of all malignant tumors of the esophagus in more recent studies . ReasonsNo standard therapy exists for primary cervical esophageal adenocarcinoma. Treatment strategies published in the few case reports range from endoscopic mucosal resection to laryngo-pharyngo-esophagectomy with lymph node dissection with or without neoadjuvant or adjuvant chemoradiotherapy. However, the number of cases reported in the current literature is too small and the details of their staging and treatment too inconsistent to postulate whether these tumors have a different prognosis than the more common distal esophageal adenocarcinomas . Our pat


Introduction. Inflammatory pseudo-tumors (IPT) of the liver are rare and difficult to diagnose, because mimicking malignant tumors. Aim. We report a case of IPT of the liver wich diagnosis was made on clinical, radiological and evolutif features. Observation. A 15-year-old man had a 4-month history of abdominal pain in the right upper quadrant with fever and cought. Two successives ultrasonographies revealed a hypoechoic lesion occuping the segment VIII with 8 cm of diametre. Physical examination was normal. Laboratory investigation showed normal blood counts, liver function test and tumoral markers. Another ultrasonography was interpretated as normal. Tomodensitometry had showon a 3-cm lesion wich enhanced later after contrast injection. A second tomodensitometry done one mounth later described a 2-cm sub capsular heaptic lesion. Discussion. On routine activiy, pre operative diagnosis of IPT of the liver is difficut, and rarely made with certitude because mimicking a malignant tumor. In our cae report here, the analysis of previous history, of clinical, biological and radiological presentation, had permittes us to pose the diagnosis of PTI of the liver and this despite the absence of histological confirmation by percutaneous biopsy. The inflammatory pseudotumors of the liver (IPLs) are fibroblastic proliferations more or less fibrous, infiltrated by polymorphic inflammatory cells . They arHereby we present another case of spontaneous regression of IPL in which we recall diagnostic and evolutionary modalities.We report a case of 15-year-old young man otherwise healthy who complains for 4 months of right upper quadrant pain accompanied with high fever and productive cough. Chest X-ray revealed an elevation of the right diaphragmatic dome . AbdominAbdominal tomography revealed a subcapsular lesion occupying segments VII and VIII and measuring 4 cm in diameter spontaneously hypodense and having slight peripheral enhancement at delayed stage .A second tomography done one month later described the same lesion with the same characteristics but with a dramatic decrease in size which is evaluated to be 2 cm in diameter . This spThe pathogenesis of IPL remains uncertain. It would be in relation with an exaggerated or inadequate inflammatory response of an existing microorganism in the portal circulation . Abbey-TSince the IPL are known as benign lesions  and thatIn terms of radiologic analysis, the diagnosis of IPL should be evoked every time that we are faced with partially fibrous hepatic mass with late uptake of contrast material and in absence of signs for specific hepatic tumor . In thisIt has not been established whether steroid administration accelerates resolution of IPL but it may reduce the systemic symptoms of the inflammatory syndrome . Most ofThe IPL are benign lesions which show spontaneous regression. The preoperative diagnosis is difficult since the radiological presentation is taken for a malignant tumor. Attention should always be paid in case of partially fibrous hepatic mass with late contrast uptake and without any specific sign in order to avoid any unnecessary surgery.


Accurate diagnosis of spine lesions is important for its successful management. Imaging–guided percutaneous biopsy is gaining increasing acceptance as a means for obtaining tissue for diagnosis. Most biopsies can be rapidly performed under local anaesthesia, with little patient discomfort and improved safety. Spinal anatomy is, however, complex with many adjacent vital structures. Good knowledge of anatomy and precise needling technique is, therefore, important. Today, biopsy of spinal lesions is best performed under computed tomography (CT) fluoroscopic guidance. Indications for imaging-guided biopsy include confirming metastasis in a patient with a known primary tumour, determining the nature of a solitary bone lesion, excluding malignancy in vertebral body compression, and investigating for infection. Among the various issues to be considered are site of lesion, location of adjacent vital structures, approach, and type and size of needle. Complications are rare, particularly when a meticulous technique is applied. In summary, CT-guided percutaneous biopsy is a safe and an effective technique for the evaluation of spinal lesions and useful in planning therapy. Biopsy entails the removal of tissue from a living body with the aim of establishing a precise diagnosis, usually by microscopic examination or culture. It can be performed during surgery (open biopsy) or percutaneously (closed biopsy). Percutaneous biopsy of bony lesions may be performed under the guidance of a variety of imaging modalities, such as, fluoroscopy -4, compuImaging- guided biopsy of bony lesions is a safe procedure, with development of major complications being rare. Reported accuracy ranges from 68% to 97% ,29,32-38Although the use of fluoroscopy ,4, ultraA well-planned and executed biopsy is essential for accurate diagnosis and enables appropriate treatment. For a suspected primary tumour, biopsy should be performed at centres that specialise in the treatment of bone tumours. At these centres, joint management decisions are taken by a multidisciplinary team that includes surgeons, oncologists, pathologists, and radiologists. All imaging, particularly MR imaging, should be completed prior to biopsy. The radiologist should review the clinical data and all imaging studies to ensure that a biopsy is indicated and to determine the most appropriate biopsy site. Radiographs provide an overview of the lesion and its characteristics, and they are probably the best single modality for providing a diagnosis or short list of differential diagnoses. In complex-shaped bones, such as, the spine, CT aids in showing lesion details and the presence of associated calcification. Bone scintigraphy helps determine the extent and distribution of the disease. MR imaging is best for defining the local extent of the disease, particularly for radiographically-occult or subtle lesions, marrow involvement, and associated soft tissue components .The biopsy route should be planned such that it does not compromise the neurovascular bundles, and uninvolved tissue compartments should not be crossed. The biopsy should be done in consultation with the surgeon who will be performing the definitive surgery and ideally also with the pathologist who will be examining the specimen. The radiologist should aim to obtain at least three specimens during biopsy, particularly if a cytotechnologist is not present during the procedure to confirm adequacy of the biopsy specimen. Anticoagulants should be discontinued prior to biopsy, and for assessment of infection antibiotics should be stopped at least 48 hours before the biopsy. Other factors to be considered prior to biopsy are blood tests for coagulopathy , platelet counts, need for sedation or anti-anxiety premedication, and written informed consent .Indications for biopsy of spinal lesions include ,40-43:Confirm or exclude metastasis in a patient with a known primary tumour.Determine the nature of a solitary bone lesion with non-specific imaging findings.Exclude malignancy in vertebral body compression, especially metastases or myeloma .Evaluation for tumour recurrence.Investigation for infection to confirm diagnosis and to obtain sample of organism, e.g., discitis or osteomyelitis .Contraindications include -43:Bleeding diathesis.3).Decreased platelet count (<50,000/mmSuspected vascular lesion in the thoracic vertebra. Haemorrhage leading to cord compression may occur.Infected soft tissues surrounding bony lesion to be biopsied, particularly when a non-infective lesion is suspected.Inaccessible sites, e.g., C1 and odontoid lesions.Uncooperative patient. General anaesthesia may be required.During CT fluoroscopy the patient is positioned to facilitate needle access to the lesion and, ideally, also to ensure as much comfort as possible. For biopsy of thoracic and lumbosacral spine lesions, the patient usually lies in a prone position. For the cervical spine, patients may be placed prone for lesions located in the pedicles and posterior elements. For anteriorly-located cervical spine lesions, the patient lies in a supine position. Sometimes, the patient may have to be placed in a lateral decubitus, semi-prone or semi-supine position, to ensure patient comfort and to minimise patient movement. Although the radiation dosage in CT fluoroscopy is relatively small, compared with conventional diagnostic CT , care shThe patient’s vital signs should be continuously monitored during the procedure. Following preliminary axial CT scanning, the most appropriate slice is selected to plan the most ideal route for directing the needle into the lesion . GeneralThe lesion depth, entry point, and angle of the chosen needle route should be estimated or measured on the most appropriate CT image. The point of entry at the patient’s skin is estimated or, alternatively, a grid of radio-opaque skin markers may be placed to help determine the entry point . The selIn biopsy of anteriorly-located lesions in the C3-C7 vertebrae, an anterolateral approach is usually adopted. As in the cervical discographic technique, the radiologists’ fingers are used to guard the carotid artery, together with the internal jugular vein and adjacent nerves, while the needle is directed towards the vertebral lesion. The needle should be inserted towards the vertebral body during the first pass, preferably from the patient’s right side, taking care to avoid puncturing the oesophagus and the trachea . AnterioFor posteriorly-located cervical spine lesions  and lesiThe type of needle used depends on the nature of the lesion and the operator’s personal preference. A large variety of needles are available commercially . They caIdeally, the needle should be placed into different parts of the lesion to ensure representative sampling . In tumoThe radiologist should be familiar with smear preparation on glass slides  and the After biopsy, the puncture site should be dressed and checked for possible complications. Prophylactic pain medication should be given to the patient. The length of the post- biopsy observation period depends on whether or not sedation was given. If the pleura is inadvertently punctured, further imaging to exclude a pneumothorax is indicated. The patient is sent home with instructions for pain medication, warned about possible complications, and told what to do if any occur.The types and incidence of complications depends on the type of needle used and on the anatomical location of the lesion. Reported incidence rates are 0 to 10%, with serious complication rates being less than 1% -18,21,28Bleeding requiring transfusion. Excessive local bleeding may be controlled by gelfoam insertion.Needle breakage.Infection.Neurological injury, including paresis or paralysis. Cord compression may rarely occur after biopsy of hypervascular spinal lesions, e.g., metastatic renal cell carcinoma or haemangioma.Pneumothorax. Rates of 4 to 11% after thoracic spine biopsy have been reported.Tumour seeding along the needle track.Infection spread along the needle track, with resultant formation of a draining sinus.CT-guided percutaneous biopsy has a useful role in the diagnosis and the management of patients with spinal lesions. Most biopsies can be safely and rapidly performed under local anaesthesia. Meticulous technique, knowledge of the spinal anatomy and of indications and contraindications, and awareness of possible complications are essential for success.


We report a case of a patient with multiple, intracranial superficial calcified tumorous lesions with focal amyloid deposition. On the basis of the first neuronavigated needle biopsy, the tumors were originally assessed as amyloidomas. Additional data was obtained from a second biopsy and supplementary neuroimaging information and the tumors were diagnosed as of vascular origin, probably cavernomas. The report exemplifies how only one diagnostic tool may sometimes be misleading in establishing a final diagnosis. The additional imaging may thoroughly enhance, supplement and improve the diagnostic process.  The brain can be affected by a varity of disorders associated with amyloid deposition . Rarely,A 46-year-old female patient with unremarkable medical history was admitted to the neurology department in 2005 due to a first grand-mal epileptic seizure, which was successfully treated by intravenous application of diazepam. No abnormalities were found during the neurological examination, with the exception of a partial lower right quadrantanopia on confrontational visual field testing. A native CT scan of the brain revealed multiple calcified tumors in both cerebral hemispheres, without surrounding edema A. On a cA small needle biopsy of the largest occipital tumor revealed hypocellular connective tissue with focal tinctorial and optical characteristics of amyloid deposits A, B, C. The most common form of amyloid deposits in the brain is cerebral amyloid angiopathy (CAA), with or without Alzheimer’s neurodegenerative changes, preferentially affecting the cortical and leptomeningial blood vessels. CAAs do not usually show any changes on neuroimaging but rare pseudotumors in association with CAAs have been reported , 5. In cThe second small biopsy of the stony-hard tumor in the right occipital lobe revealed the vascular nature of the lesions. Calcified cavernomas are the most likely possibility, on the basis of the negative three-dimensional CT angiography and T2* MRI , 9. SincDespite the presence of multiple intracranial masses, the patient was asymptomatic, except for an epileptic seizure and visual field defects. This suggests that the tumors were longstanding, with little or no mass effect on surrounding structures. Supratentorial cavernomas may be associated with chronic epilepsy, which is generally the most frequent manifestation of the disease. The most common complication of cavernomas is bleeding, resulting from rupture of ectatic blood vessels , 11. In The present report illustrates how only one diagnostic tool may sometimes be misleading in establishing a final diagnosis and how imaging may thoroughly enhance, supplement and improve the diagnostic process. In our case, only a small needle biopsy of the focal amyloid deposits in multiple intracranial vascular tumors, which were probably cavernomas, was misleading. Additional biopsy and T2-weighted gradient-echo MRI were needed for accurate final diagnosis.


Retroperitoneal teratomas are usually asymptomatic, though there have been isolated reports of retroperitoneal teratomas presenting as intra-abdominal abscesses and peritonitis in adults. A 7-year-old girl who had presented with acute abdomen due to ruptured retroperitoneal teratoma is reported. Retroperitoneal teratomas (RPTs) are uncommon tumors representing about 5% of all teratomas [1]. Majority of them are benign. They are typically asymptomatic; but when symptoms do occur due to enormity of their size, patients will present with only abdominal distension or a palpable mass on physical examination [2]. RPTs resulting in chemical peritonitis or localized abscess and presenting as acute abdomen have rarely been described in adults [3-6]. RPT presenting as acute abdomen has been even rarer in pediatric patients. An extensive literature search could reveal only 2 cases hitherto . We report here another case of ruptured retroperitoneal teratoma that resulted in chemical peritonitis. A 7-year-old girl presented with abdominal mass that was noted at birth. She had abdominal pain and recurrent febrile episodes for the last 6 months that had worsened a week before presentation. On examination, she was febrile with generalized abdominal tenderness. A large well-defined, firm, fixed, tender mass, having bosselated surface and measuring 15 cms in diameter occupied entire left half of her abdomen. The fingers could be insinuated between the mass and left costal margin above and the mass and the pelvic brim below. Leukocyte count was 14,000/ mm3. Biochemical parameters were normal. Abdominal roentgenogram showed a soft tissue shadow occupying the left half of the abdomen displacing the stomach up and the bowel loops to the right. There were extensive areas of calcification . Chest x ray was normal. Abdominal ultrasound revealed a large heterogeneous retroperitoneal mass pushing the left kidney and the ureter with mild to moderate left hydronephrosis. CT scan abdomen showed a well-defined retroperitoneal mass measuring 14cm x 10cm x 9cm in the left half of the abdomen having mixed density, septations, calcifications and teeth-like structures . The mass displaced the left kidney posteriorly and cranially, the sigmoid colon anteriorly, and aorta and inferior vena cava to the right. The serum alpha fetoprotein levels were within normal range. The diagnosis of infected retroperitoneal benign teratoma was made.At operation a small amount of thick turbid came out. There were inter-loop pockets. The thick capsule of the tumor was found breached at 2 places. The overlying sigmoid colon was firmly adherent to the tumor capsule. The aorta, inferior vena cava and the mesenteric vessels were pushed to the right and did not pose any risk to the dissection. Both ovaries were normal.Excision of the large tumor necessitated resection and anastomosis of the sigmoid colon. Though the tumor could be removed in toto, there was gross spillage intra-operatively. Few para-aortic lymph nodes were sampled. The resected specimen had variegated appearance and there was evidence of cartilage, teeth, and hairs .The patient did well post-operatively and was discharged on 15th postoperative day. The biopsy was reported as mature cystic teratoma (dermoid cyst) with evidence of extensive xanthogranulomatous reaction to keratin. The para-aortic lymph nodes had only reactive changes. She has been on close follow up since last 6 months and has been doing well. Retroperitoneal teratomas are rare, representing only 1% to 11% of primary retroperitoneal neoplasms [8]. They typically present as asymptomatic abdominal mass but can grow to enormous size. There are only 2 children reported hitherto who had presented with acute abdomen. Pontinen et al almost half century ago, had reported a retroperitoneal teratoma in a three year old girl that simulated an acute appendicitis [7]. Nguyen et al had recently described a 9-year-old girl who presented with an acute abdomen because of an abdominal abscess that was treated with surgical drainage and antibiotics [8]. Fifteen years later, she had a recurrence of symptoms and the abscess was ultimately recognized to be an infected retroperitoneal teratoma. Though the diagnosis of infected retroperitoneal teratoma was made at the age of 24 years, this teratoma must have been present since birth and got missed at the earlier presentation in the childhood.Most of the retroperitoneal tumors in childhood are cystic and benign [2]. Spontaneous rupture of cystic retroperitoneal teratomas is a rare occurrence probably because of the thick encasing capsule. Taking analogy from cystic ovarian teratomas, two clinical presentations could be associated with such intraperitoneal rupture of benign cystic teratomas [9]. The first is acute peritonitis caused by the sudden rupture of tumor contents, which may occur spontaneously or more commonly in association with torsion, trauma, infection, or labour. The second presentation is chronic granulomatous peritonitis resulting from a chronically leaking dermoid, which can be characterized by multiple small white peritoneal implants, dense adhesions, and variable ascitis that simulate carcinomatosis or tuberculous peritonitis. The latter is the more common presentation in case of cystic ovarian teratomas [9].vCT scan is considered as better radiological investigation than ultrasonography for the diagnosis of RPTs [10]. MRI has been also used recently. At CT, a mature RPT manifests as a complex mass containing a well-circumscribed fluid component, adipose tissue, and calcification [10]. The presence of hypoattenuating fat within the cyst and the presence of calcifications in the cyst wall are considered highly suggestive of cystic RPT [10]. At CT, the presence of fat-fluid levels in the peritoneum has been quoted as a reliable sign of intraperitoneal rupture of abdominal teratoma and subsequent chemical peritonitis [3]. However, the diagnosis of rupture of RPT is usually made at operation.The operative management of RPTs, especially those with rupture, may be complex and challenging. Despite their benign nature, the lesions can attenuate and surround major vessels, making resection difficult. Preoperative imaging has been known to be offer limited help in demonstrating the position of the major vessels [11]. In particular, the veins may be effaced. Excision of ruptured RPT in our case was also a formidable surgical exercise.In conclusion, rupture of RPT is an extremely rare phenomenon. It may be difficult to make a preoperative diagnosis and the surgical excision could be a challenging task.Source of Support: NilConflict of Interest: None declared


Isolated mycobacterial infection of gall bladder is an extremely rare entity. Only anecdotal reports are evident in the literature. A preoperative diagnosis of mycobacterial infection of gallbladder is therefore very difficult. The case of a 72-year-old male who underwent surgery for suspected gallbladder cancer is presented. The diagnosis of cancer was based on radiological findings and an abnormal uptake of fluorine-18-fluoro-2-deoxy-D-glucose (FDG) on positron emission tomography (PET) scan whilst being followed up for colorectal cancer. He underwent cholecystectomy and gallbladder bed resection. Histopathology was consistent with mycobacterial infection of the gallbladder. Primary mycobacterial infection of the gallbladder is rare and very few cases have been reported in the literature. The first case was reported in 1870 by Gaucher [Gallbladder tuberculosis (GT) can mimic gallbladder carcinoma in a patient presenting with gallbladder mass , 3. Due A 72-year-old Vietnamese man living in Australia for 30 years was found to have a gallbladder mass on imaging whilst on followup for Dukes B rectal cancer. He had undergone a low anterior resection in 2004. He did not have past history of tuberculosis.Ultrasound (US) abdomen revealed an abnormal gallbladder with thickened wall and solid mass at the fundus raising the possibility of neoplasia . This waColonoscopy did not reveal any intraluminal abnormality. PET scan revealed a focus of prominent FDG accumulation in the vicinity of the gall bladder mass lesion raising a suspicion for malignancy .These findings were discussed in a multidisciplinary meeting. The consensus opinion was to perform an open cholecystectomy and gallbladder bed resection in view of the likelihood of malignancy. Intraoperative findings revealed a 50 × 35 × 35 mm gallbladder with a hard nodular mass in the fundus. This was firmly attached to the hepatic flexure. Cholecystectomy with resection of gallbladder bed was performed. The specimen was sent for frozen section which revealed necrotising granuloma suggestive of mycobacterial infection with no evidence of malignancy. This was confirmed on paraffin section.The postoperative course was uneventful. The tissue was sent for polymerase chain reaction (PCR) test which confirmed the diagnosis. Infectious diseases consultation was obtained. The patient was commenced on a course of antitubercular therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol for six months. He has recovered well from the surgery and is making good progress on antitubercular treatment.Isolated mycobacterial infection of gallbladder is an extremely rare entity especially in the western world. Most cases of GT have been reported in the Asian literature –5.The gallbladder is highly resistant to tubercular infection possibly due to the inhibitory function of bile , 3. The The presence of a mass that fills the gallbladder associated with cholelithiasis is indistinguishable from carcinoma of the gallbladder . MoreoveUltrasound and CT scan may show an enlarged gallbladder, irregularly thickened gallbladder wall, or a soft tissue mass with necrosis or calcification, or nodular lesions, although neither ultrasound nor CT lesions are highly specific .A preoperative diagnosis is difficult to obtain due to the lack of pathognomic features on radiology. GT is therefore mostly diagnosed only after histopathology of the resected specimen .Positron-emission tomography (PET) is a noninvasive method to assess metabolism in vivo by means of positron-emitting radiolabeled tracers. Fluorine-18-fluoro-2-deoxy-D-glucose (FDG) is a glucose analogue that is phosphorylated in the cells but not further metabolized.Most malignant tumors show increased uptake of FDG. Malignant transformation and growth of tumor cells is associated with overexpression of glucose transporters and increased hexokinase activity .PET scans have sensitivity of 0.80 and specificity of 0.82 in the diagnosis of gallbladder cancer  corroborTo our knowledge this is only the second paper documenting an FDG avid mass in the gallbladder being a mycobacterial infection . Most prIn a culturally diverse country such as Australia, many patients from Asian and south east Asian backgrounds are treated. Mycobacterial infections are endemic in these regions. One should consider a differential diagnosis of gallbladder mycobacterial infection when treating a patient with gallbladder mass in this scenario.


Case Presentation. A 59-year-old woman presented with vaginal bleeding and visited a local clinic. She had a uterine tumor pointed out and was referred to our hospital. Ultrasound scans revealed a large heterogeneous mass occupying the whole uterine cavity. Cytological test of endometrium was performed but the result was negative. A fractional endometrial curettage revealed no malignancy. Magnetic resonance imaging (MRI) revealed a heterogeneous solid tumor of 77 × 76 mm. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy was performed. On gross examination, the tumor was arising from the uterine body and occupied the whole uterine cavity. Histopathological examination revealed phyllodes-like architecture on low magnificationandperiglandular cuffing of tumor cells. The lesion was confined to the uterus. Histopathological final diagnosis was adenosarcoma. Her postoperative course was uneventful and she was discharged without postoperative treatment and remains alive without disease 6 months after the surgery.Adenosarcoma is a rare tumor which consists of benign glandular epithelium and malignant mesenchymal component. Here we report a case of adenosarcoma of the uterine corpus.  Adenosarcoma is a rare tumor which consists of benign glandular epithelium and malignant mesenchymal component. This entity was originally described by Clement and Scully  in 1974 A 59-year-old postmenopausal woman, gravida 2, para 2, presented with vaginal bleeding and visited a local clinic. Cytological tests of uterine cervix and endometrium were both negative. She had a uterine tumor pointed out and was referred to our hospital. Vaginal examination revealed enlarged uterus and ultrasound scans revealed a large heterogeneous mass occupying the whole uterine cavity .Cytological test of endometrium was performed again but the result was negative. A fractional endometrial curettage revealed only fibrous tissue with epithelial-like cells. Magnetic resonance imaging (MRI) revealed a heterogeneous solid tumor of 77 × 76 mm .Degenerated myoma, leiomyosarcoma, or endometrial stromal sarcoma was suspected. Serum levels of CA125 were slightly elevated to 41.4 U/mL, whereas CA19-9 and CEA were within normal limits. The patient was admitted and total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy was carried out .At laparotomy, the uterus was fist size and no serosal invasion was observed. Both ovaries were intact. The tumor was arising from the uterine body and occupied the whole uterine cavity. Glandular epithelium with little atypia and proliferation of atypical mesenchymal cells were seen. Mitosis exceeded 2 per 10 high power fields. No myometrial invasion or lymph node metastasis was seen. The lesion was confined to the uterus. Peritoneal cytology revealed no malignant cells. Histopathological final diagnosis was adenosarcoma .Her postoperative course was uneventful. She was discharged without postoperative treatment and remains alive without disease 6 months after the surgery.Mixed epithelial-mesenchymal tumors of the uterus include adenofibroma, adenosarcoma, and carcinosarcoma. Adenofibroma has benign glandular epithelial element and benign mesenchymal stroma, whereas carcinosarcoma has both malignant epithelial and mesenchymal stroma. Adenosarcoma is one of the rare diseases consisting of benign glandular epithelial element and malignant mesenchymal component. It may be classified as an intermediate state between the two formerly stated entities. It accounts for 8% of all uterine sarcomas. This entity was originally described by Clement and Scully  in 1974 Adenosarcoma is a typically low grade tumor and behave like low grade sarcoma. Adenosarcoma with sarcomatous overgrowth was first used by Clement in 1989 for those tumors that contain more than 25% of sarcomatous component . This is1-weighted images and high intensity on T2-weighted images compared to the myometrium and areas of small cysts [2-weighted imaging, reflecting glandular epithelial components, and relatively low signal intensity on high b value diffusion-weighted imaging, reflecting its low grade nature, may be characteristic findings [Common symptom is genital bleeding. As for MRI findings, Yoshizakoet al. reported a case of uterine adenosarcoma demonstrated on magnetic resonance (MR) imaging. Imaging revealed a markedly enlarged uterus with thin myometrium occupied by a large polypoid mass. The mass contained solid components with low intensity on Tll cysts . Takeuchfindings .Unfavourable prognostic factors are sarcomatous overgrowth, deep myometrial invasion, presence of heterologous elements and extrauterine spread . Tanner As for lymphadenectomy, Kaku et al. reported a lymph node metastasis rate of 6.5% and para-aortic lymph node metastasis rate of 0% in 31 patients with adenosarcoma. Two patients with lymph node metastasis had myometrial invasion, heterologous elements, and sarcomatous overgrowth . Tanner There is no optimal adjuvant or systemic treatment strategy but standard sarcoma chemotherapy regimens appear to have efficacy in both adenosarcoma and adenosarcoma with sarcomatous overgrowth . Tanner Adenosarcoma of the uterus should be a differential diagnosis when a large polypoid mass is occupying the endometrial cavity and protruding into the vaginal cavity. A biopsy specimen often fails to diagnose this entity, and pathological diagnosis should be made on surgical specimen.


A 21-year-old female patient admitted to the emergency department complaining of left side pain. Hypovolemic shock, which was probably caused by retroperitoneal bleeding from left sided renal angiomyolipoma, was developed. Abdominal computed tomography showed multiple fat containing lesions in different, regions including right bladder wall, lower pole of left kidney, and right kidney. Some lesions compatible with tuberous sclerosis such as angiofibromas, Shagreen patches, myocardial, and brain hamartomas were also detected. Bladder wall mass showing intra- and extravesical extensions was seen at exploration. We removed the tumor completely preserving bladder trigone. Angiomyolipoma located at lower pole of left kidney was also removed. Diagnosis of bladder angiomyolipoma was confirmed by the immunohistochemical examination. Recurrent or residual mass was not detected at the three-months-follow-up. We report the first case of bladder angiomyolipoma confirmed by histopathologically as a tuberous sclerosis. Tuberous sclerosis (TS) is a genetic multisystem disorder characterised by prevalent hamartomas in several organs, including skin, brain, eyes, heart, kidney, lung, and liver . The expAngiomyolipomas are rare tumors and associated with tuberous sclerosis in 20–30% of cases. The kidney is the most commonly affected organ and liver, mediastinum, colon, uterus, and lung are also be affected [A limited number of previous bladder angiomyolipomas have been reported in the literature. But bladder angiomyolipoma associated with tuberous sclerosis has not been seen in the literature. We report the first case of bladder angiomyolipoma in a 21-year-old woman with TS.A 21-year-old female patient was admitted to the emergency department complaining of left side pain. Hypovolemic shock, which was probably caused by retroperitoneal bleeding from left sided renal angiomyolipoma, was developed. Abdominal computed tomography showed multiple fat containing mass lesion in different regions including right bladder wall and lower pole of left kidney and right kidney. Furthermore, there was prominent hemorrhagic fluid in left retroperitoneal space. After stabilization of hemodynamic condition, selective arterial embolization was performed for the angiomyolipoma that was the cause of the bleeding. Dermatologic, cardiac, and neurologic examinations were done. Some skin lesions compatible with TS such as angiofibromas on and around the nose were observed on the face and Shagreen patches in the inguinal and gluteal regions. Cardiac lesions, which were located in myocardium suggesting hamartomas, were detected by echocardiography. In addition, subcortically located abnormal signal intensities compatible with hamartomas were detected at brain magnetic resonance imaging (MRI). But the patient had no history of cardiac complaints, epilepsy, and mental retardation symptom. The main complaint of the patient was dysuria and recurrent urinary tract infection without macroscopic hematuria.Abdominal MRI was performed just before the surgical intervention. MRI revealed that a left sided angiomyolipoma embolised before is found to be same size, a fat containing mass lesion showing intravesical and extravesical extensions is located at right bladder wall, and a fat containing mass lesions is at the right kidney.We made intraperitoneal exploration through lower midline incision. Bladder wall mass 10 cm in size showing intra-vesical and extravesical extensions was also seen at exploration. We made a frozen section and pathologic exam result was reported as a benign lesion. Thereafter, we established the surgical treatment strategies regarding the pathologic exam result; consequently, partial cystectomy was carried out. We removed the bladder wall tumor completely preserving bladder trigone. Angiomyolipoma, 12 cm in size, located at lower pole of left kidney, was also removed through upper midline incision in the same session. After the surgery, the patient was uneventful and no residual mass lesion on bladder wall was detected at the three-month-follow-up abdominal MRI.A multilobulated mass lesion, 10 × 6 × 7 cm in size, arising from the right and superior walls of the bladder, largely extended in right half of the pelvis is observed . The masIn An 8 cm tumoral tissue, which is rich in fatty tissue, with bleeding areas, surrounded by a smooth contoured is monitored.Smooth contoured tumoral tissue containing fatty tissue, 10 × 8 × 8 cm in size, extending into the bladder lumen at the upper portion of the bladder is observed.Morphology is similar in the samples taken from both regions. Wide, normochromatic, and eccentrically located lipoma areas with a clear cytoplasm and nucleus consisting of lipocytes and scattered smooth muscle fibrils and thick wall structures are observed on the sections. In the trichrom staining, muscle fibrils are observed to show activation with dark red. Mitotic activity is not prominent. Pleomorphism and atypia are not observed. In the immunohistochemical examination, positive staining is observed in the epithelial area and vascular endothelia with cytokeratin, while positive staining is observed in the smooth muscle fibrils with actine and negative staining is monitored in connective and fatty tissues with vimentine, whereas negative staining is observed with S100 . TS is an inherited neurocutaneous disorder that is characterized by pleomorphic features involving many organ systems, including multiple benign hamartomas of the brain, eyes, heart, lung, liver, kidney, and skin . AngiomyWe could not find in the literature reported bladder mass lesions in TS. A few number of angiomyolipoma cases originated from the bladder wall have been reported, although these were not related with TS .Most of the patients with TS have one or more skin lesions, as seen in our patient. Other lesions suggesting TS are cerebral and cardiac hamartomas and renal angiomyolipomas, also seen in our patient.  There are some reported cases which have isolated bladder angiomyolipoma. One of the angiomyolipomas was established with cystoscopy, which was 1 cm in size and detected with sonography . SimilarTwo types of renal angiomyolipoma are recognized: (1) the sporadic type, usually a unilateral neoplasm typically seen in middle-aged women, (2) the multifocal neoplasm, usually small and bilateral, diagnosed in young men in association with TS . There wWe present a rare case of angiomyolipoma of the bladder in the patient with tuberous sclerosis. Diagnosis was confirmed by the histologic and immunohistochemical findings.


Tuberculosis (TB) can present both in its pulmonary or extra-pulmonary forms. Cardiac tuberculoma previously described only after autopsy is continuously seen with the advent of more advanced imaging modalities.A 23-year-old male with a four month history of a progressively increasing left anterior thoracic wall mass of 5 cm in diameter was referred from oncology for clinical re-evaluation and for echocardiography. Systemic examination was essentially normal. Transthoracic and trans-oesophageal echocardiography showed the presence of a pericardial mass around the right atrioventricular junction. Thoracic CT scan showed an anterior mass in left chest wall extending to the pericardium and also the presence of mediastinal lymphadenopathy. Mantoux test was positive and histological examination of tissue biopsy confirmed the presence of TB. However, blood tests and culture of aspirated purulent fluid were unyielding. A diagnosis of pericardial tuberculoma with mediastinal and parietal extension was made and patient was successfully treated with standard anti-TB chemotherapy.The possible differential diagnoses for chest wall tumors are varied and a high degree of suspicion is needed to diagnose cardiac tuberculoma especially in endemic regions. Imaging though helpful in morphological description cannot make precise diagnosis. The diagnosis depends on histological and culture studies. There is usually a good evolution with anti-TB treatment.In an era of an increasing number of acquired immune-compromised patients, and with increasing number of diagnoses of tuberculosis, a diagnosis of cardiac tuberculoma should be considered in patients presenting with a thoracic wall mass. Tuberculosis (TB) is a global health concern despite the widespread attention that it has received over the years. Pulmonary tuberculosis is the most commonly recognized form, however, extra-pulmonary manifestations of tuberculosis account for about 15-20% of cases . It is tA 23-year-old male with an irrelevant past history presented with a four month history of a progressively increasing left anterior thoracic wall mass of 5 cm in diameter. With this, he initially had a cardiology consultation and after clinical evaluation was referred for an oncology review and management for a suspicion of a malignancy. Before any intervention at the latter department, he was again referred to cardiology for re-evaluation and for echocardiography. Systemic examination was essentially normal. Transthoracic and trans-oesophageal echocardiography Figure  were donCardiac tuberculosis was first reported by Maurocordat in 1664 and by Morgagni in 1761 [The differential diagnosis of masses of the anterior and mid-mediastinum  includesComplete regression of tuberculoma treated with standard anti-TB chemotherapy has been reported  as in ouWe presented in this case a rare form of extra pulmonary TB. To our knowledge this is the first reported case in the literature in an immunocompetent patient with TB presenting as an anterior chest wall mass. A high index of suspicion is needed for its diagnosis especially in highly endemic regions as patients can be successfully treated with standard anti-TB chemotherapy. In an era of increasing number of acquired immuno-deficiency syndrome patients, and with increasing number of diagnoses of tuberculosis, a diagnosis of cardiac tuberculoma after a thorough clinical evaluation should be considered in patients presenting with a thoracic wall mass.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interest.ML and MJ conducted the literature search, drafted the first manuscript, performed language correction, and participated in article design and coordination. ML and MBN conducted the echocardiography and participated in manuscript draft. GNCD, SD, FA and DMZ critically revised the manuscript for important intellectual content. AA, PST and MMD participated in investigation studies and critically evaluated the article. All authors read and approved the final manuscript.


Non traumatic gastrointestinal emergencies in the children and neonatal patient is a dilemma for the radiologist in the emergencies room and they presenting characteristics ultrasound features on the longitudinal and axial axis. The most frequent emergencies are : appendicitis, intussusceptions, hypertrophic pyloric stenosis, volvulus due to intestinal malrotation. The aim of this article is to familiarize the reader with the US features.A retrospective analysis of 200 ultrasound examinations performed in neonatal and children patients with fever, abdominal pain, leukocytosis, vomiting and diarrhea were evaluated.Of 200 exame 50 cases of intussusceptions, 100 cases of appendicitis, 20 cases associated with abscess;10 gangrenous appendicitis with absence a color Doppler , and 10 cases of perforated appendicitis at tomography computer integration and 10 cases of volvulus was found.Ultrasonography (US) is therefore rapidly becoming an important imaging modality for the evaluation of acute abdominal pain, particularly in pediatric patients, where satisfactory examination is often not achievable for the attending clinicians. US provides excellent anatomic detail on the longitudinally and axial axis . Non traumatic gastrointestinal emergencies in the children and neonatal patient is a dilemma for the radiologist in the emergencies room, they presenting characteristics ultrasound features on the longitudinal and axial axis .The abdominal pain in children is one of the most common presentations at the emergency room. Inability to give reliable history, atypical clinical presentations, numerous extra-abdominal causes and the painful abdomen in children often causes difficulty in arriving at the correct diagnosis and causing diagnostic dilemma. Early diagnosis is the first step towards proper management of a patient presenting with acute abdomen and pain. The radiologist, therefore, plays a key role in the initial care of these emergencies pathology in infants and the appropriate surgical referral. It is important that the radiologist understand the anatomic changes in affected infants as reflected by imaging techniques.The objective of this article is to familiarize the reader with the US features of the most common and some of the least common non traumatic gastrointestinal emergencies. This is a retrospective analysis of 200 ultrasound examinations performed in neonatal and the children patient arriving in the emergency room with fever, abdominal pain, leukocytosis, vomiting and diarrhea. B-mode and Color Doppler ultrasonography has become the imaging modality of choice for evaluating non traumatic gastrointestinal emergencies. In the present study, we have discussed the diagnostic efficacy of ultrasonography in the evaluation of acute abdominal conditions in pediatric age group, and we have presented the tipical features on the longitudinal and axial axisWe evaluated retrospectively 200 ultrasound exams effectuated between January 2009 and December 2011, in 200 patients aged few day to 14 years old arrived in emergency room for abdominal pain, vomiting, leukocytosis, fever and diarrhea. Ultrasonography (US) was done using 3.5 MHz and 7.5 MHz transducers and the image are examinated effectuated on the longitudinally axis and cross axis combined with colour Doppler ultrasonography (CDUS). At the start of the examination, the patient is asked to point to the site of maximal tenderness.We found 50 cases of intussusception. On the axial scans we evaluated “crescent in doughnut sign” and “concentric ring sign”, a sign of the donut. On the longitudinal scan the “ sandwich sign”, and “hairfork sign”. We found 100 cases of appendicitis, 20 cases associated with abscess;10 gangrenous appendicitis with absence a color Doppler , and 10 cases of perforated appendicitis at computer tomography integration.The ultrasonographic sign in axial scans is “target sign”, in longitudinal scans: a fluid-filled uncompressible, blind-ending tubular structure; parietal diameter> or = 6mm. We found 20 cases of hypertrophic pyloric stenosis. The sonographic features on the axial scans the is “donut sign”. On the longitudinal scans is “double track sign”We found 10 cases of volvulus. On the axial scan we found “whirlpool sign” formed by the mesenteric vein is on the left side of the artery, and the arterio-venous dilatation of the loop upstream; hyper-echoic thickening of the bowel wall edema; course spiral loop.In our study we found 50 cases of intussusception. Intussusception is one the most common causes of the acute abdomen in infancy . IntussuIn our experience the mean age is 1 year, and the tract of the intussusception are ileum-colic in all patient. 30 patient had a classic clinical triad :currant-jelly stools, hematochezia and a palpable mass, 5 patients had a convulsion after vomiting and 15 patient had a vomiting.Ultrasound is a highly accurate in the diagnosis with a sensitivity of 98%-100% and a specificity of 88%-100% [The component of intussusception produced characteristics sign on the ultrasonography scan. This sign are on the longitudinally axis “sandwich sign” and “hair-fork sign” and on the axial axis are “crescent in donught sign” and “concentric ring sign”.In US modality the intussusceptions had a large mass, usually greater than 5x2.5cm, that often displaces adjacent bowel loops. In our On the US image the intussusceptions is a complex structure. The intussusceptions (the receiving loop) contains the folded intussuscepted (the donor loop), which has two components: the entering limb and returning limbs. On axial intussusception has a variable appearance, which is primarily due to the amount of mesentery. Us obtaOn the longitudinal scan obtained at the centre of the mass show the sandwich sign formed by three parallel hypo-echoic bands separated by two nearly parallel hyper-echoic bands. Fig.  The outeWe found 100 cases of acute appendicitis.Acute appendicitis is one of the major causes of hospitalization in children. Acute appendicitis is the most common condition requiring emergency abdominal surgery in the pediatric population, with 60,000–80,000 cases annually in the UnitedStates .The condAlthough knowledge of the classic findings is important, the clinical diagnosis of acute appendicitis in children is not always straightforward. Us is a highly accurate in the diagnosis with a sensitivity of 44%-94% and a specificity of 47%-95% .We performed the graded-compression technique of US with linear array transducer. Gentle, gradual pressure we used to compress the anterior abdominal wall, resulting in displacement and compression of normal bowel loops. Adequate compression has been achieved if the iliac vessels and psoas muscle are visualized, since the appendix will be anterior to these structures. Scanning is performed in both longitudinal and transverse planes, and the examination begins with identification of the ascending colon, which appears as a non peristaltic structure containing gas and fluid. The transducer is then moved inferiorly to identify the terminal ileum, which is easily compressible and displays active peristalsis. This is useful to expedite the examination and to aid in locating a retro-caecum appendix. On longitudinal images, the inflamed, non perforated appendix appears as a fluid-filled, uncompressible, blind-ending tubular structure. The maximal appendix diameter, from outside wall to outside wall, is greater than 6 mm. Fig.  In earlyOther findings of appendicitis include on the longitudinal axis and on the axial axis an appendicolith, which appears as an echogenic foci with acoustic shadowing ; peri-cecal or periappendicular fluid; increased periappendicular echogenicity representing fat infiltration ; and enlarged mesenteric lymph nodes. Fig. US features of perforation include loss of the echogenic sub-mucosal layer and presence of a loculated periappendicular or pelvic fluid collection or abscess In the our experience we found 20 cases of abscess;10 gangrenous appendicitis with absence a color Doppler , and 10 cases of perforated appendicitis at computer tomography integration -13. We uWe found 20 cases of hypertrophic pyloric stenosis (HPS), mean age seven week of life. Infantile hypertrophic pyloric stenosis is a common condition affecting young infants in the fourth-seven week of life; despite its frequency, it has been recognized only for a little over a century, and its etiology remains unknown. The male-to-female ratio is approximately 4:1, with reported ratios ranging from 2.5:1 to 5.5:1 .The lesion is characterized by gastric outlet obstruction and multiple anatomic abnormalities of the pyloric antrum. Typically, infants with HPS are clinically normal at birth; during the first few weeks of postnatal life, they develop non bilious forceful vomiting described as “projectile.” The clinical diagnosis hinges on palpation of the thickened pylorus, or “olive” . In our Ultrasonography exam of the antrum-pyloric region were obtained in all patient: first, with the infant in supine position; and then, with the patient in the lateral decubitus position, right side down . In the supine position, we effectuated axial scanning . In the decubitus position on the right side, we effectuated a longitudinal scanning . If suff. In the normal anatomy of pylorus the transverse diameter is 0.7-1.1 cm , the length of pyloric canal is 1.0-1.3 cm and the thickness of circular muscle is too thin to measure [In the normal pylor when the canal is viewed in cross section we evaluated the “bulls-eye” sign performed by outer anechoic rim, which is almost too thin to measure, represents the normal circular (Torgensen’s) muscle, and he inner echogenic layer represents the mucosa and submucosa. The innermost anechoic center represents fluid in the pyloric canal measure .In the hypertrophic stenosis on the cross scanning with the infant in the supine position is visualized the “donut sign” consists of a prominent anechoic rim of thickened muscle, and an echogenic center of mucosa and submucosa  Fig. 7)7).On thi, and can visualize peristalsis; and can evaluate the thickness of the muscle and the overall length of the pyloric canal. On this view hypertrophic muscle remains closed, and no fluid passes into the duodenum. On the longitudinally view we evaluate the “nipple sign”, characterized of the muscle hypertrophic to a variable degree, mucosa crowded, thickened to a variable degree, and protrusion into the distended portion of the antrum [In the longitudinal plane with the patient in the lateral decubitus position, right side down we observed the continuity between anechoic rim of hypertrophied circular muscle and the normal muscle of the gastric antrum . In this plane, by changing the degree of obliquity of the patient, can demonstrate the same anatomic features of the canal in the longitudinal plane e antrum -25.On this view, we evaluate the “double track sign” characterized by double layer of redundant mucosa hiper-echoic separated by several linear tracts of contrast material, that occludes the lumen of the stomach protrudes into the liquid and antral . Fig.  On this In the our experience we evaluate 10 cases of mid-gut volvulus due a mal-rotation but we haven’t image with a whirlpool sign because the patient arrive in our emergencies room with a intestinal necrosis with the arteriovenous dilatation of the loop upstream; hyper-echoic thickening of the bowel wall edema and fluid in the intestinal tract with “tanga sign” and on the Color Doppler absence of the flow. Mal-rotation is a congenital abnormal position of the bowel within the peritoneal cavity and usually involves both the small and the large bowel -28. Mal-The diagnosis of midgut volvulus in infants is facilitated by direct sonographic visualization of the twisted bowel loop. Normally, the SMV is on the right side of the artery. In mal-rotation, we evaluated the “whirlpool sign” on the axial scan. The whirlpool sign is formed by the mesenteric vein is on the left side of the artery ,36.B -mode and Color Doppler ultrasonography has become the imaging modality of choice for evaluating non traumatic gastrointestinal emergencies. Ultrasound, through the research for these characteristic signs, is a valid method for the study and for the immediate diagnosis in the emergency room of these pathologies -39.The authors declare that they have no competing interests.AR wrote the manuscript. AD and AR edited early versions of the manuscript. RG also edited the final version of the manuscript, and AR adapted and revised the figures and figure legends. All authors read and approved the final manuscript.


Inflammatory myofibroblastic tumor (IMT) of the stomach is extremely rare and its prognosis is unpredictable. We present a 37-year-old woman with a gastric IMT. She presented epigastric pain since 2 months, anemia and weight loss associated. Physical examination showed cutaneous pallor and mild abdominal tenderness in the epigastrium. Abdominal ultrasonography showed a tumor near the pancreas and the CT scan revealed that the lesion was arising from the stomach. Upper endoscopy showed a submucosal lesion of approximately 7.5 cm located in the posterior wall of the gastric body such as a gastrointestinal stromal tumor (GIST). The patient underwent a subtotal gastrectomy and Billroth I reconstruction. The histopathological and immunohistochemical analysis revealed an IMT that originated from the gastric wall. Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm that occurs preferentially in children and young adults . This diIMT grows as a result of a reactive inflammatory or postsurgery process and commonly occurs in the lung, mesentery, omentum, and retroperitoneum, but it can also be seen in the extremities, head and neck, genitourinary tract, and other organs , 3. NeveClinically, the majority of IMTs are benign but they require adequate surgical treatment because it has a tendency for local recurrence , 10, 11.We report a case of gastric IMT in an adult woman and a review of the literature.A 37-year-old woman presented with epigastric pain since 2 months with weight loss associated (45 pounds). She denied other gastrointestinal symptoms and signs such as nausea, vomiting, abnormal bowel habits, melena, or hematemesis. She had no medical or familial history. Physical examination showed cutaneous pallor and mild abdominal tenderness in the epigastrium but no palpable abnormal abdominal tumor.The laboratory findings, including tumor markers, were normals, except for a normocytic, normochromic anemia (hemoglobin: 7.7 g/dL). Abdominal ultrasound showed cholelithiasis and a lesion (6.8 × 4.8 × 7.3 cm) near the pancreas. There was no evidence of internal calcifications, connection to the pancreatic duct, or flow in the color doppler ultrasonography. However, the CT scan  revealedUpper digestive endoscopy revealed a submucosal, broad-based, and protruding tumor of approximately 7.5 cm, located in the posterior wall of lower gastric body such as a gastrointestinal stromal tumor (GIST) .The patient underwent subtotal gastrectomy and Billroth I reconstruction. Macroscopically, the tumor measured 9.0 cm × 7.0 cm × 6.0 cm. The external surface of a well-encapsulated lump of soft solid tumor was smooth and glistening but without gastric mucosal lesion. On serial sectioning, the cut surface was characterized by several amorphous fragments of fibrous tissue. Histologically, the tumor was composed of round and spindle-shaped myofibroblastic cells, diffusely scattered inflammatory cells, and many vascular structures Figures  and 4. TThe final diagnosis was consistent with IMT that originated from the gastric wall.The patient had an uneventful postoperative period and has been followed up without any recurrence.The primary inflammatory myofibroblastic tumor (IMT) is a very rare neoplasm in adults and the exact nature of the disease is not yet completely understood . It was The histological appearance of a gastric IMTs is similar to that of soft tissue IMTs. It has been debated whether IMT is a tumor or inflammation, and also whether it is benign or malignant. However, studies on cytogenetic abnormalities, such as rearrangements of the ALK gene on chromosome 2p23, clonal chromosome abnormalities, and DNA aneuploidy, and the role of oncogenic viruses in the pathogenesis of IMT suggest that it is a real neoplasm , 15, 16.This entity is characterized by a myofibroblastic proliferation, a lymphoplasmacytic infiltrate distributed among the tumor cells and a myxoid background stroma. Three architectural patterns have been described in IMT: myxoid hypocellular pattern, a cellular fascicular or nested pattern with variable amounts of myxoid stroma, and a sclerotic, hyalinized pattern with minimal myxoid stroma , 17–21. As far as the differential diagnosis is concerned, there are a few tumors or lesions in the stomach that must be distinguished from IMT. They include gastrointestinal stromal tumor (GIST), inflammatory fibroid polyp, smooth muscle neoplasm, peripheral nerve sheath tumor, solitary fibrous tumor, fibromatosis, and, rarely, the follicular dendritic cell sarcoma . GIST maClinically, IMT presents with an abdominal mass or cystic lesion with related compressive symptoms, such as abdominal pain and vomiting. It was described a case that bled spontaneously into the peritoneal cavity and developed a hemoperitoneum . Kim et Most IMTs require surgery to obtain definite diagnosis and treatment. Nevertheless, local excision is an option in selected cases . CompletRecently, ALK reactivity was found to be associated with local recurrence, but not distant metastasis, which was confined to ALK-negative lesions, suggesting that reactivity may be a favorable prognostic indicator in IMTs . HoweverConcluding, the main difficulty in the management of IMT lies in the unpredictable postoperative course. There are no definitive clinical, histopathological, or genetic features to predict recurrence or metastasis.


Adrenal pseudocysts are rare cystic masses that arise from the adrenal gland and which are usually non-functional and asymptomatic. Adrenal pseudocysts consist of a fibrous wall without an epithelial or endothelial lining. We report the case of a patient with a giant adrenal pseudocyst presenting with right hypochondralgia and high fever.A 52-year-old Japanese man was admitted with right hypochondralgia and a chill. Abdominal computed tomography revealed a well-defined cystic mass measuring 19 cm which was located in the right adrenal region and the contents of which were not enhanced with contrast medium. Abdominal ultrasonography revealed a heterogeneously hypo-echoic lesion with a peripheral high-echoic rim. Serum hormonal levels were almost normal. Despite treatment with antibiotics, the high fever persisted. Based on these findings, we made a preoperative diagnosis of a right adrenal cyst with infection. However, the possibility of malignancy still remained. The patient underwent laparotomy and right adrenal cyst excision with partial hepatectomy in order to relieve the symptoms and to confirm an accurate diagnosis. Histological examination revealed an adrenal pseudocyst with infection. His condition improved soon after the operation.We report a case of a giant adrenal pseudocyst with infection. Surgery is required for symptomatic cases in order to relieve the symptoms and in cases of uncertain diagnosis. The pau50 cases .Cystic lesions of the adrenal gland are uncommon and demonstrate a spectrum of histological changes and may vary from pseudocysts to malignant cystic neoplasms. An adrenal pseudocyst is a fibrous-surrounded cyst within the adrenal gland devoid of a recognizable layer of lining cells. The incidence of adrenal pseudocyst with infection is very rare. Only a few cases have been found in the MEDLINE database search with 'adrenal pseudocyst' and 'infection' so far. We report a case of giant adrenal pseudocyst presenting with a right hypochondralgia and high fever, which was diagnosed as an adrenal pseudocyst with infection measuring about 19 cm in largest diameter.3; C-reactive protein of 23.7 mg/dL; alkaline phosphatase of 634 U/L; and gamma glutamyl transpeptidase of 183 U/L. The hormonal examination, serum catecholamines, cortisol and aldosterone were all within normal limits. Fasting blood sugar, renal functions and liver function were within normal limits. Tumor marker  levels were within normal limits; urine and stool examination, chest X-ray, gastrointestinal endoscopy and colonoscopy did not reveal any abnormalities. He underwent several imaging investigations. An abdominal US revealed an 18 × 18 cm heterogeneously hypoechoic lesion in the right adrenal area with a peripheral highechoic rim  which was performed seven years ago, revealed a unilobulated cyst, measuring 14 cm in diameter, adjacent to the liver. The internal structure of the cyst was homogeneous and there was no septation. Upon this finding his lesion was misdiagnosed as a liver cyst and it was suggested that it be monitored. He was admitted to our hospital with a two-month history of right hypochondralgia and high fever. On clinical examination, he was febrile with temperature of 38.0°C. His blood pressure was 116/76 mm Hg without orthostatic changes or tachycardia. A clearly defined mass occupied the right hypochondrium and was tender. Laboratory investigation showed: a total leukocyte count of 12,200/mmm Figure . The conm Figure . Clear mm Figure  but hetem Figure . Based oStaphylococcus captis. The histological examination showed that the cystic wall was 0.6 cm to 1.1 cm thick and consisted of dense fibrous tissue, without an epithelial lining  was started. Despite treatment with antibiotics, the high fever persisted. He had blood culture taken three times during a fever episode and all of the results were negative. Percutaneous aspiration was not performed because of the possibility of its malignancy due to the large size of the mass. The patient underwent reverse-L-type laparotomy and excision of the right adrenal cyst. At laparotomy, the cyst was found to be densely adhered to the posterior abdominal wall, the liver, the inferior vena cava and the right kidney. It was resected concomitant with partial hepatectomy. The cyst was unilocular, measured 19 × 18 × 19 cm and weighed 1525 g. It contained a reddish brown fluid and a culture of the fluid showed g Figure . There wAdrenal cysts are rare and the documented incidence varies between 0.064% and 0.18% in autopsy series . HoweverHistologically, cystic formations of the adrenals are divided into four groups: parasitic; epithelial (true cysts); endothelial ; and pseudocysts . There aThe true origin of adrenal pseudocyst remains a mystery. One theory suggests that these lesions result from an intra-adrenal hemorrhage caused by trauma, a sepsis event or some other form of shock . The iniMost adrenal cysts are asymptomatic because of their small size . In the Due to the wide use of the diagnostic imaging modalities, the detection rate of adrenal cystic lesions is increasing. However, a preoperative confirmatory diagnosis of a large adrenal cyst can be very difficult because of the indistinct boundary with surrounding organs and adhesion to neighboring organs. Furthermore, even with integrated fluorine-18 fluorodeoxyglucose positron emission tomography (PET), adrenal lesions may be identified as false-positive at PET, including adrenal adenomas, adrenal endothelial cysts and inflammatory and infectious lesions .The differential diagnosis of adrenal pseudocysts includes splenic, hepatic and renal cysts, as well as mesenteric or retroperitoneal cysts, urachal cysts and solid adrenal tumors. An exact diagnosis is clinically important in large lesion because adrenal incidentalomas larger than 5 cm  carry anOn CT, most pseudocysts demonstrate well-demarcated round or oval masses with fluid density but the CT features of pseudocysts are more complicated than simple cysts due to the complicated components such as septa, blood and soft-tissue components. The cysts wall shows occasional calcification. MRI is the best modality for visualizing the complicated intracystic components. Moreover, MRI is particularly sensitive for detecting intracystic hemorrhage, which shows hyperintense on both T1- and T2-weighted images.Treatment of adrenal cysts is determined by size and the symptoms related to the mass. Surgical excision is indicated by the presence of symptoms, a suspicion of malignancy and an increase in size, or the detection of, a functioning adrenal cyst. Surgical treatment may not be necessary for small asymptomatic lesions as most cysts are benign . If the An adrenal pseudocyst is an uncommon clinical finding and is even rarer when it is giant-sized and infected. Surgery is required for symptomatic cases in order to relieve the symptoms and in cases of uncertain diagnosis. Radiological and clinical features of the tumor are nonspecific, thus, histopathological examination is essential in order to establish a definitive diagnosis.CT: computed tomography; MRI: magnetic resonance imaging; PET: positron emission tomography; US: ultrasound.The authors declare that they have no competing interests.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.MM, KM and KY were involved in drafting the manuscript. KT, HA, SY and IE revised the manuscript. All authors have read and approved the final manuscript.