DDIT3 locus.Myxoid liposarcoma is a mesenchymal malignancy most commonly presenting in young adults. This tumor is known for its characteristic chromosomal rearrangement at the DDIT3 and FUS loci demonstrate the pathognomonic chromosomal alteration in the setting of predominantly round cell histology on biopsy, confirmed by RT-PCR.We report a case of myxoid liposarcoma in a 91-year-old, the oldest known patient with this disease-entity. FISH analysis of the Myxoid liposarcoma affects mostly young adults but can be seen in the elderly population. Molecular and cytogenetic assays are helpful auxiliaries to histology in the setting of unusual histology and clinical presentation. Myxoid liposarcoma, the second-most common subtype of liposarcoma, accounts for 10% of soft tissue sarcomas . This diTypical myxoid liposarcoma histology shows nonpleomorphic ovoid mesenchymal cells and rare lipoblasts amidst a prominent myxoid stroma, with an intricately plexiform vasculature. Round-cell liposarcoma, a high-grade form of myxoid liposarcoma, lacks myxoid matrix leaving closely packed, round mesenchymal cells. Regions of myxoid and round-cell liposarcoma morphologies often coexist (MLS/RCLS).t can be identified in the majority of cases [FUS and DDIT3 that is specific for MLS/RCLS [t EWS-DDIT3 rearrangement [DDIT3 locus is an effective diagnostic tool for MLS/RCLS [in situ hybridization (FISH) probes commercially available.Both morphologies share identical cytogenetic aberrations and are thus considered as a single pathologic entity . A recipof cases  creatingMLS/RCLS . A smallt12;1 can be iMLS/RCLS , with brThe most powerful prognostic marker in MLS/RCLS is the presence of a round cell component comprising greater than 5% of the tumor. These high grade round cell liposarcaromas have been shown to behave more aggressively with decreased overall survival and metastasis free survival .Compared with other soft tissue sarcomas, MLS/RCLS is particularly sensitive to radiation therapy . AccordiThe following report depicts a case of MLS/RCLS in a rare elderly age demographic while highlighting the salient diagnostic features of this disease, and the value of molecular testing in the context of unusual clinical features and histology.A 91-year-old male presented to a local emergency department complaining of a large mass in the medial thigh that had grown in size over the preceding several weeks. The mass was otherwise asymptomatic.The patient’s past medical history included atrial fibrillation and hypertension, prostate cancer treated by resection with local recurrence treated by radiotherapy 20 years previously, laryngeal cancer treated by radiotherapy 14 years previously, and finally, separate histories of both colon and anal cancer treated with an abdominal-perineal resection 6 years previously. The patient reported a family history of ovarian cancer and multiple prostate cancers.CT scan of the pelvis demonstrated a 19 cm lobulated mass with complex septations and central necrosis in the adductor compartment of the left thigh (Figure DDIT3, FUS¸ and EWSR1. Break-apart probes for DDIT3 and FUS demonstrated chromosomal rearrangements at both of these loci (Figures EWSR1 was intact. RT-PCR confirmed expression of a type 1 FUSexon7-DDIT3exon2 fusion transcript. The RT-PCR was performed according to previously established protocols [Core needle biopsy of the mass under ultrasound guidance showed high-grade spindled, ovoid and round cell morphology. Although a small amount of myxoid matrix and complex vasculature were noted, no unequivocal lipoblasts were evident and the tumor was considered to lack differentiation towards any specific lineage Figure a. Immuno Figures b, c, whirotocols , using oBased on the pathognomonic molecular findings, a diagnosis of MLS/RCLS was made. The patient was discussed at multidisciplinary tumor board, and offered neoadjuvant radiation treatment followed by surgical excision. Both radiation and surgery were well-tolerated. Final pathology showed a 19 cm lobulated heterogenous yellow and hemorrhagic mass Figure a. Microset al.[A search of the medical literature was performed for reports of myxoid and/or round cell liposarcoma in the elderly. Moreau et al. recentlySeveral facets of myxoid liposarcoma diagnosis and treatment are highlighted in this case. The diagnosis of myxoid liposarcoma in an elderly patient is uncommon, but does occur. Thus an advanced age should not exclude myxoid liposarcoma when other clinical, radiologic, histologic, or molecular findings support this diagnosis.Myxoid liposarcoma can show a wide variation of histologic patterns, at times within the same tumor . This caThe accurate preoperative diagnosis of myxoid liposarcoma prioritized neoadjuvant radiotherapy as the next step in management. This treatment modality has particular benefit in myxoid liposarcoma . AccuratMyxoid/round cell liposarcoma is a relatively common sarcoma among younger adults presenting with a large, deep-seated malignant primary soft tissue mass. However, this tumor can affect older individuals. Molecular cytogenetic studies can greatly assist diagnosis in cases with unusual clinical and histologic features.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.BSS Assisted in interpreting the diagnostic biopsy, compiled the case report, and wrote the manuscript. TON Issued pathological diagnosis of the biopsy and resection specimens, performed cytogenetic and molecular workup, edited the manuscript, and supervised the project. Both authors read and approved the final manuscript.


Purpose. Pseudoepitheliomatous hyperplasia at the limbus can mimic an ocular surface squamous neoplasia. It is an uncommon manifestation of vernal keratoconjunctivitis and has been reported previously in limbal VKC. It, however, has not been reported as a manifestation in the palpebral form of the disease and needs to be kept in the differential diagnosis of a limbal mass lesion in vernal keratoconjunctivitis. Case Report. We report the case of a 24 year old male patient having palpebral VKC and presenting with a papillomatous limbal mass with focal areas of keratinization mimicking an ocular surface squamous neoplasia. An excision biopsy was performed, and the specimen sent for histopathologywhich revealed features of pseudoepitheliomatous hyperplasia with no evidence of dysplasia or malignant transformation. The subepithelium revealed a dense plasma-rich inflammation. Discussion. We report this relatively uncommon presentation of limbal pseudoepitheliomatous hyperplasia mimicking an ocular surface squamous neoplasia in palpebral vernal keratoconjunctivitis. Wide excision as is required for an ocular surface neoplasia may thus be avoided if this entity is recognized in vernal keratoconjunctivitis. Vernal keratoconjunctivitis (VKC) is a chronic, bilateral conjunctival inflammatory condition with two distinct subtypes, palpebral and limbal. The palpebral form is associated with a hypertrophic tarsal response in the form of papillae, giving it the characteristic “cobblestone appearance” while the limbal form consists of diffuse thickening of the limbal tissue  and Horner Trantas spots. Localized involvement of the limbus in the form of a limbal mass is relatively uncommon. A hypertrophic limbal mass lesion in a case of limbal VKC has been reported previously . We repoA 24 year old male was examined in the cornea services of our institute in January 2013 with the chief complaint of noticing a mass in the left eye for the last 6 months which was increasing slowly in size. He also complained of severe itching in both eyes for many years for which he had been prescribed various topical medications. He underwent a complete ophthalmic examination bilaterally. Ocular examination revealed an unaided visual acuity of 20/20 OU and intraocular pressures of 16 and 18 mm of Hg in OD and OS, respectively, by Goldman applanation tonometry. Anterior and posterior segment ocular examination OD was unremarkable except for the presence of papillae on the upper palpebral conjunctiva. There was no limbal involvement in the right eye. On eversion of the left upper lid, an intense papillary reaction was seen diffusely associated with several large “cobblestone” papillae measuring 1.5–2 mm in the centre and lateral side of the lid . These wInvolvement of the limbus in VKC usually occurs at the superior limbus in the form of conjunctival thickening which often may have a gelatinous appearance. Schwab et al.  have preIn the present case, VKC was predominantly of the palpebral type, with no other limbal involvement except for the localized limbal mass present temporally in the left eye. Clinically, the differential diagnoses of PEH and OSSN were entertained. PEH is a benign proliferation of the conjunctival or corneal epithelium which often occurs in response to some preexisting inflammation. It usually presents as a white elevated mass with a hyperkeratotic surface . When arIn our case, the associated intense inflammation because of VKC and the location of the limbal mass at the area in contact with the cobblestone papillae on the upper lid  favoured the possibility of PEH. However, the presence of vascular fronds on the surface of the mass, the associated dilated conjunctival vessels on the lateral edge, and the staining with rose bengal raised the suspicion of OSSN. Histopathology was consistent with a diagnosis of PEH with no features suggestive of malignancy. We hypothesize that the localized epithelial hyperplasia could have occurred in our case because of the combination of chronic underlying inflammation aggravated by mechanical microtrauma to the limbal epithelium caused by rubbing of the large cobblestone papillae present on the upper lid. However, the opposite may also be true; that is, a limbal lesion may have been induced initially by irritation from superior existing papillae, followed by secondary mechanical giant papillary conjunctivitis (GPC) of the upper lid as the limbal lesion grew. This could be supported by the unusual focal nature of the larger papillae on the upper lid. GPC has been previously reported to occur because of mechanical and irritative etiologies . PossiblThis case represents a secondary limbal involvement in a case of palpebral VKC. Awareness of this association of PEH presenting as a limbal mass in predominantly palpebral VKC and clinically mimicking an OSSN is important for ophthalmologists as PEH is a benign condition and does not require excision with large margins as is the case for OSSN .


A 15-year-old boy presented with swelling in the submandibular region. X-ray of the swollen part showed faint radio opaque shadow. A provisional diagnosis of sialadenitis with sialolithiasis was made. Excised mass was reported histopathologically as plexiform neurofibroma of submandibular salivary gland.Plexiform neurofibroma of the salivary gland is a rare benign tumor often present in the parotid gland. It is very rare in submandibular salivary gland. It is a slow growing, locally infiltrating tumor. Neurofibromas constitute only 0.4% of all salivary neoplasms. Plexiform neurofibromas of the salivary glands are rare, often presenting in the parotid gland. They are very rare in submandibular salivary gland.2 They arA 15-year-old boy was admitted with a swelling in the submandibular region, which rapidly progressed in size. There was no history of pain or increase in size of swelling while taking meal. On examination, a firm swelling in the submandibular region of size 8 × 5 cm, with ovoid shape and well-defined borders was present. It was bidigitally palpable. No café-au-lait spots were present over the body. A faint radio-opaque shadow, suggestive of calculus was noticed in the region of the gland. Provisional diagnosis was chronic sialadenitis with sialolithiasis. Fine needle aspiration cytology (FNAC) was reported as chronic sialadenitis.Intraoperatively, mass was arising from submandibular salivary gland. A tubular growth was extending from the mass into the adjacent tissue .Gross specimen was gelatinous and vaguely nodular, showing greyish white to grey yellow areas. No calculus was found in the specimen. Microscopic picture showed cellular and nodular area of tumor tissue. Central nerve fiber bundles surrounded by neurofibroma tissue were seen in an abundant mucoid matrix and collagen background. Adjacent salivary gland also showed thickened nodular nerve bundles between salivary lobules. No atypia was present. Features were suggestive of plexiform neurofibroma of the submandibular salivary gland Figures  and 3.Neurofibromas are benign nerve sheath tumors which present in the following three forms: local discrete, generalized neurofibromatosis, and plexiform neurofibromas. Common sites of occurrence of plexiform neurofibroma are fifth cranial nerve and extremities. Neurofibromas constitute only 0.4% of all salivary neoplasms. Plexiform neurofibromas of the salivary glands are rare, usually presenting in the parotid gland. They are very rare in submandibular salivary gland.Plexiform neurofibromas are diffuse enlargements of multiple fascicles of the nerves and its branches, leading to thickening of nerves. They grow along nerves extending into the surrounding tissue. They are slow growing and locally infiltrating benign tumors. When located deeply, they may have greater chance of malignancy. Large plexiform neurofibromas of submandibular salivary gland may be associated with pressure symptoms on trachea and pharynx. Sometimes they may extend into spinal canal and compress the spinal cord. They grow rapidly in children, during puberty, and in pregnancy.Plexiform neurofibromas are frequently seen in patients with Type I neurofibromatosis and undergo malignant changes in 2% of the cases. Patient with plexiform neurofibroma without family history or without features of Type I neurofibromatosis require genetic work up. In such cases, tumor may present as a result of local somatic mutation and patient may not transmit the disease to their offspring.Neurofibromas have been reported in parotid glands.6 Of 300 12A search in the literature revealed only five cases of plexiform neurofibromas of submandibular salivary gland .Of five cases, three were females and four of the above five cases presented with Type I neurofibromatosis. However in our case, there was no Type I stigma present.If we consider FNAC to diagnose plexiform neurofibroma, its diagnostic yield appears to be low. A plexiform neurofibroma may be suspected in the appropriate setting with the help of cross sectional imaging. Computed tomography (CT) imaging may show conglomerate multilobulated masses that may appear as a ’bag of worms.’ There is hypoattenuation with heterogenous contrast enhancement. A characteristic ’branching’ hypoattenuated mass on CT, with branching tubular masses extending into adjacent tissue, could virtually be diagnostic. In our cHistopathologically, there is diffuse cylindrical enlargement of multiple fascicles of the nerve and its branches. There is a myxoid matrix containing Schwann cells, nerve fibers, mast cells and perineurial, endoneurial fibroblasts.Surgical excision is the treatment of choice. Recurrence may occur. It is reported in 20% of the patients with plexiform neurofibroma after complete resection and increases to 44% with incomplete resection .Plexiform neurofibroma is an extremely rare tumor. It is a slow growing tumor in the submandibular region. It is more common in children. CT is somewhat diagnostic. FNAC may be helpful. Final diagnosis can be achieved by excision biopsy. Frequently, patient desires excision for cosmetic reason. Recurrence is common in case of incomplete removal.


Fallopian tube carcinoma is a rare gynecological malignancy with low accuracy detection preoperatively. The symptoms are unspecific and imaging can be misleading. Since it was first described in 1847, there have been only a little over 2000 case reports.This case report describes a 66-year-old Caucasian woman who presented with progressive diffuse abdominal pain, without other symptoms. After abdominopelvic magnetic resonance imaging, she was sent to the Portuguese Oncology Institute of Oporto with the suspicion of peritoneal carcinomatosis of unknown primary tumor. Due to a pelvic palpable mass  she was directed to the Gynecology team. Surgery was performed and a large mass in her upper abdomen was identified. The extemporary examination revealed a high-grade adenocarcinoma. During surgery a small change of color and consistency of her left fallopian tube was noted and unilateral adnexectomy was performed. After pathologic and immunohistochemistry tests, the diagnosis of fallopian tube carcinoma with peritoneal dissemination was made.This case is very unique in the way that a small primary fallopian tube carcinoma was able to disseminate to the upper abdominal quadrant with little pelvic dissemination. The symptoms and imaging were unspecific. Although a rare occurrence, we should not forget fallopian tube carcinoma in the differential diagnosis of peritoneal carcinomatosis, even in the absence of Latzke’s triad. BRCA genetic mutation confers an augmented risk of developing PFTC. Some suggest that in all PFTC cases encountered in their series 16% have BRCA mutations [Primary fallopian tube carcinoma (PFTC) is a rare gynecological malignancy that accounts for 0.14 to 1.8% of all gynecological cancers  because utations . Latzke’utations . Dependiutations . Tumor dutations . Stagingutations ,12. Progutations , tubal mThis case report presents a 66-year-old Caucasian female housekeeper. Her background includes squamous carcinoma of the nose treated with surgery (14 years ago), hypertension and appendectomy (at a young age). She was nulliparous and had no previous known gynecological problems . Her only symptom was diffuse abdominal pain, more intense on the flanks, progressing for 3 months and with increasing intensity. The family doctor requested a computed tomography scan that suggested peritoneal carcinomatosis, moderate ascites, with no reference to the primary tumor site. When further examined, a complete and thorough examination showed:1. No vaginal discharge, endocervical polyp (no dysplasia) and normal cervical-vaginal cytology.2. Blood work: elevation of CA-125 (515UI/mL), CA-19.9 and carcinoembryonic antigen within normal range, hepatic enzymes slightly elevated.3. Diagnostic paracentesis: no malignant cells.4. Gastrointestinal tract study: normal upper and lower endoscopy.5. Abdominopelvic magnetic resonance imaging (MRI): moderate ascites, peritoneal thickening around transverse mesocolon and omental involvement  Figure  and a laThe patient’s case was reviewed by the Gynecology team at the Portuguese Institute of Oncology of Oporto and an exploratory laparotomy was decided. The intra-operatory findings showed diffuse parietal peritoneal implants  with a voluminous mass involving her epiploon, from the hepatic hilum to the splenic hilum, invading the great gastric curvature. An anterior abdominal wall implant was removed and sent for extemporary examination which revealed high-grade adenocarcinoma. Ascitic fluid was collected; atypical gastrectomy, omentectomy and myomectomy were performed. When reviewing the adnexial area, a small dilation and purple color were noticed on her left fallopian tube. The surgery was completed with left adnexectomy. Macroscopic residual disease >2cm) was present at the end of surgery. During the postoperatory period, a positron emission tomography scan revealed multiple ganglion metastases with several small implants on her pelvic and abdominal cavities .Pelvic MRI is not totally specific for adnexal evaluation  and pelvThe higher tubal neoplasia differentiation, the invasion only of her stomach’s outer layers, the presence of intraepithelial tubal neoplastic areas and the complete response to chemotherapy (imaging and the CA-125 descent), favors the diagnosis of PTFC with secondary peritoneal involvement. Extensive metastasis in the upper abdomen without PTFC muscle and serous coats breach is possible due to the exfoliation of malignant cells into the peritoneal fluid, followed by the natural flow of peritoneal fluid in the peritoneal cavity, which can take the metastasis to the upper abdomen.et al.[BRCA status.PFTC is a rare entity that poses diagnostic challenges. Symptoms, imaging and even pathological findings are not straight forward. In this case report we found a small PFTC (9mm) with extensive upper abdominal dissemination. This kind of presentation is unusual, although it presented at a late stage  as do most PFTCs. The staging and adjuvant therapy in PFTC is similar to that of epithelial ovarian cancer and primary peritoneal cancer . The appet al. for the Other recent studies from several cancer institutes have identified a number of promising biomarkers including HE4, mesothelin, and kallikreins. It would be possible to look for membrane and secreted proteins that distinguish the normal fallopian tube epithelium from its malignant counterpart. This is an essential step in the development of diagnostic and prognostic biomarkers for this disease.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.CO reviewed the literature, analyzed the clinical case information and the imaging data and was a major contributor in writing the manuscript. DF contributed with surgical description, literature review and interpretation of patient data. HD provided the description of MRI slides and reviewed the final text. CB performed the histological examination and provided the description of the histological images. All authors read and approved the final manuscript.Epiploon and gastric curvature. Hematoxylin and eosin stain showing infiltrative serous adenocarcinoma with papillary pattern (A). Severe nuclear atypia (B).Click here for fileImmunohistochemical analysis. Immunohistochemistry stains showing intense and diffuse p53 signature on the affected mucosa  and high proliferative Ki67 index .Click here for file


Dear SirThis is in reference to our article published before [1]. On 1 year follow up, the patient had local recurrence measuring 8 cm X 5 cm infero-laterally to the previous scar. MRI of the local region showed a large well defined heterogeneously enhancing soft tissue mass in subcutaneous layers involving ilio-tabial tract with areas of deep multiple recurrences . There was no evidence of metastasis. Local excision was done. Histopathology was identical as before- the desmoid tumor. The surgical margins were free; the mass was surrounded with fibrocollagenous tissue. Keeping in view the unresectable deep recurrences, he was administered radiotherapy locally. MRI done after 6 weeks of radiotherapy did not show any residual disease. The child is under close follow up.Even after multiple recurrences, successful salvage is achievable, particularly when high-dose focal radiotherapy is incorporated [2]. It would also be imperative to mention role of intra-operative electron radiotherapy (IOERT), followed by moderate doses of external beam radiotherapy (EBRT) after organ-sparing surgery, in patients with primary or recurrent aggressive fibromatosis. Introduction of IOERT into a multimodal treatment approach in patients with aggressive fibromatosis is feasible with low toxicity and is known to yield good local control rates even in patients with microscopical or gross residual disease [3]. Such facility is however unavailable in our setup.In our case, the hip joint was not involved. A case of aggressive pediatric hip fibromatosis with severe joint destruction has been reported recently [4], and we would like to prepare ourselves for such an eventuality. Source of Support: NilConflict of Interest: None declared


Isolated tubal torsion is a rare event. The clinical presentation is often nonspecific and the diagnosis is difficult, especially in the gravida abdomen. If left untreated, torsion can result in premature labour and foetal loss, as well as maternal morbidity. Here we present a case of isolated tubal torsion in a primigravida occurring in her third trimester and subsequent successful laparoscopic salpingectomy, rather than laparotomy. We discuss some of the diagnostic difficulties faced and approached to surgery as well as a brief review of the literature. In our case the women went on to successfully complete her pregnancy with no further complications. Isolated tubal torsion is a rare event. The clinical presentation is often nonspecific and the diagnosis, difficult, especially in the gravida abdomen. If left untreated, torsion can result in premature labour and foetal loss, as well as maternal morbidity. Here we present a case of isolated tubal torsion in a primigravida occurring in her third trimester and subsequent successful laparoscopic salpingectomy, rather than laparotomy.+3/40 gestation presented with sudden onset severe right-sided abdominal pain described as an intermittent sharp stabbing pain radiating to her right flank. Her pain was associated with three episodes of vomiting but no diarrhoea, constipation, or fevers. On examination her vital signs were unremarkable; temperature of 37.2°C, pulse 80, blood pressure 134/70, respiratory rate 14 and saturating at 100% onroom air. Her abdomen was diffusely tender in all quadrants with increased tenderness of the right flank and epigastric region. Systems review and examination were otherwise unremarkable. CTG was normal and reactive with good foetal movements. On admission she had a white cell count of 11.9 × 109/L  H, lipase 179 U/L, and a raised CRP of 9.3 mg/L H. Serum electrolytes, liver function tests, and full blood count were otherwise normal. Her urine dipstick showed trace protein and leukocytes and subsequently grew no bacteria.A 28-year-old female, G1P0 30+3/40 gestation a right adnexal cyst of uncertain origin, measuring 35 mm × 34 mm × 35 mm, was noted. The patient had conceived naturally and her antenatal history was largely unremarkable aside from an increased risk of trisomy 13 and 18 at her nuchal scan which was later confirmed to be normal via chorionic villus sampling. She was not on any regular medications aside from the pregnancy multivitamin Elevit.The patient had no history of gallstones, renal calculi, or previous UTI's and was otherwise well with no medical issues of note. On her dating scan at 7As an inpatient an ultrasound was performed which revealed a single live intrauterine pregnancy consistent with 30-week gestation. Kidneys and renal tract were normal. The appendix was not visualised but a 47 mm oblong cyst was seen in the right adnexa. The left adnexa and ovary were reported as normal. Her pain began to settle with 15 mg of morphine and 10 mg of Buscopan. She was given two doses of 11.4 mg Celestone IM 12 hours apart and kept nil by mouth overnight.The following day her symptoms remained unresolved. The patient continued to have intermittent severe pain and her CRP and neutrophilia were increasing. The decision was made to proceed to surgery. The risk of premature labour secondary to intra-abdominal infection was a deciding factor. At this point her primary differential diagnosis was that the previously identified adnexal mass was undergoing torsion with subsequent necrosis and infection. Other differentials included tuboovarian torsion, atypical appendicitis, gall bladder, and hepatic pathologies. The patient was consented for an exploratory laparoscopy for confirmation of the diagnosis and subsequent laparotomy.Intraoperatively, atrochar was inserted into the epigastrium, pneumoperitoneum achieved, and camera inserted to view the mass. A torted right hydrosalpinx was seen with an associated fimbrial cyst. The left ovary and tube appeared grossly normal. The cyst was approximately 50 mm and haemorrhagic but was otherwise simple in appearance. The mass was deemed removable by laparoscopy and two further ports were inserted as per traditional laparoscopic cholecystectomy positioning, to accommodate the gravid uterus. The torted hydrosalpinx was detorted; however, the fallopian tube had been compromised and it was necessary to proceed with removal. A right salpingectomy was performed. The tube was ligated adjacent to the uterus using 2xPDS and divided. It was placed in an endocatch bag, drained, and removed. The port sites were closed with subcuticular sutures. Prophylactic tocolysis was not used and uterine irritability did not develop postoperatively. Anatomical Pathology confirmed the diagnosis of a simple, uniloculated fimbrial cyst (44 × 22 × 10 mm) and ischemic fallopian tube which was otherwise histologically normal.+3/40 gestation with spontaneous rupture of membranes and went on to have an emergency caesarean section, unrelated to her previous operation, for foetal distress. Postpartum recovery was unremarkable.The patient had an uncomplicated postoperative recovery and continued the pregnancy with no further issues. She presented at 38The occurrence of isolated tubal torsion is a rare event, especially in pregnancy . Diagnos3 at the time of her dating ultrasound. Given her history and subsequent ultrasound showing a new oblong mass in the adnexa, the diagnosis of a tubal torsion secondary to a pre-existing cyst was strongly suspected prior to surgery. Adnexal masses are well known to cause torsions during pregnancy. A previous study of adnexal masses in pregnancy found that masses between 60–80 mm were most likely to cause torsion and 94% of torsions occurred before 20-week gestation [In this case our patient had a known likely tuboovarian cyst identified prior to pregnancy which measured 35 mmWith the increased availability of more advanced imaging methods, there is a trend towards the use of Magnetic Resonance Imaging (MRI) in helping with diagnosis prior to surgery in pregnancy. In our case ultrasound was the only imaging modality used, as the patient's pain was quite severe and warranted immediate surgical intervention. However, in cases where the pain experienced is milder, and time to surgery is not as critical further investigation can be performed. MRI is emerging as an alternative option to diagnostic surgery and is becoming more widely used in larger centres where access to this modality is more readily available for acute presentations .Unless imaging is able to conclusively exclude the need, early surgical intervention is recommended for pregnant women presenting with an acute abdomen irrespective of their gestation. This is due to the dire complications that can result from a conservative “wait and see approach”. Premature labour is far more likely, and the risk of maternal morbidity and mortality higher, if infection of the abdominal cavity is allowed to occur . A torteThe technical approach in surgical intervention is also an important consideration with the gravid abdomen. Depending on the pathology suspected and the skill of the operator, either laparoscopic or open approach  can be used with similar overall outcomes for maternal and foetal wellbeing . In caseThis paper has described a case of isolated tubal torsion in the third trimester of pregnancy successfully treated by laparoscopic surgery alone with subsequent completion of the pregnancy. Aggressive management including early surgical invention is indicated in such cases to prevent foetal and maternal morbidity and mortality.


Background. Duplication of the alimentary tract is a rare congenital anomaly. Gastric duplication cysts (GDCs) represent 4% of all alimentary tract duplications, and approximately 67% manifest within the first year of life. Duplication cysts in adults are generally encountered as incidental findings at endoscopy or laparotomy. Herein, we report two rare cases of symptomatic GDC presenting in adults. Case 1. A 27-year-old male presented with a five-month history of back pain. Exam revealed mild epigastric tenderness with a vague palpable mass in left upper abdomen. CT scan showed 8 × 7.4 × 6 cm homogenous, nonseptated cystic mass posterosuperior to pancreatic tail. On laparotomy, a cystic mass measuring 11 × 8 cm was found, which was densely adherent to posterior wall of stomach suggestive of GDC. Case 2. A 28-year-old woman presented with epigastric pain associated with vomiting for 2 months. Exam revealed mild epigastric tenderness. CT scan showed four cystic lesions in the medial wall of distal stomach measuring approximately one cm each suggestive of duplication cysts. Exploratory laparotomy with antrectomy and truncal vagotomy with Billroth II reconstruction were performed. Pathology in both patients was diagnostic of GDC. Conclusion. GDC is a rare anomaly, and its presentation in adults is even rarer. Duplication of the alimentary tract is a relatively rare congenital anomaly. It can affect any part of the gastrointestinal tract with ileum being the most common site , 2. ThesA 27-year-old male presented with a five-month history of progressively increasing back pain associated with mild epigastric discomfort and loss of appetite. Review of systems revealed weight loss of approximately 25 pounds with occasional nausea. He denied vomiting and alteration of bowel habits. Family history was significant for the fact that his mother had been previously treated for benign cystic neoplasm of pancreas. Past medical history was not significant. Physical examination revealed mild epigastric tenderness with a vague palpable mass in the epigastric and left subcostal regions measuring approximately 7 × 5 cm.MRI and CT scans of the abdomen demonstrated 8 × 7.4 × 6 cm homogenous, nonseptated cystic mass posterosuperior to pancreatic tail . Left ad Since it was not clear whether the mass was arising from adrenal or pancreas, a complete adrenal workup was done including 24-hour urinary cortisol, urinary VMA, metanephrine level, serum aldosterone, and renin, which did not reveal any evidence of functional adrenal tumor.  On exploratory laparotomy pancreas and left adrenal appeared normal; however there was a soft cystic mass measuring approximately 11 × 8 cm, which was densely adherent to posterior wall of stomach close to the greater curvature. Excision of cystic mass along with resection of adjoining stomach was performed for a presumed gastric duplication cyst. Surgical specimen measured 10 × 7 cm. Cut surface of specimen revealed a light yellowish gelatinous material. The inner surface was smooth and white-pink in color with 1.5 × 1.2 cm rough area . There w Patient's postoperative course was uneventful. He was discharged on postoperative day 4 and has been asymptomatic since then. On microscopy, cyst wall was composed of mucosa, submucosa, and muscularis propria with myenteric plexus. The mucosa was predominantly gastric body type consisting of parietal, chief, and mucus cells with patchy intervening areas of simple columnar epithelium containing apical mucus and cilia seen in embryonic intestinal epithelium .A 28-year-old woman was transferred from community hospital for evaluation of recurrent, nonradiating epigastric pain associated with nausea and occasional nonbilious vomiting for two months. She denied any change in bowel habits and weight loss. Her medical history was significant for lumbar herniated disc and recurrent shoulder dislocation. Physical exam was unremarkable except for mild epigastric tenderness.  Diagnostic work up included abdominal CT scan, which demonstrated four cystic lesions in the medial wall of distal antrum and pylorus measuring approximately one cm each, suggestive of duplication cysts .  Upper GI endoscopy showed bulging of the gastric antrum and pylorus by an external compression without any mucosal abnormality. Endoscopic ultrasound showed multiple intramural cystic lesions measuring 3.5 × 2.5 cm in total dimension. The cysts appeared to be lined by mucosal layer with surrounding muscularis propria suggestive of duplication cysts. Fine needle aspiration was attempted but failed.  An exploratory laparotomy with antrectomy and truncal vagotomy with billroth II reconstruction were performed.  Patient's postoperative course was uneventful. She was discharged on postoperative day 10 and has been asymptomatic since then. Cut surface of specimen revealed two cysts filled with clear mucinous fluid measuring 2 cm and 1.3 cm in the greatest dimension. The inner surface of cysts was lined by pink-tan epithelium, and wall thickness was approximately 0.6 cm. There was no communication between the cysts and gastric segment. On microscopy, cyst wall was composed of mucosa, submucosa, and muscularis propria. Mucosa was predominantly of gastric type with small islands of pancreatic acini . Gastrointestinal duplication is a relatively rare anomaly that may occur at any level from oral cavity to rectum with ileum being the most common site. Duplication cysts of the stomach are quite rare, and most of them have been reported in children , 5, 6. D The essential criteria for diagnosis of a gastric duplication cyst are (a) the wall of the cyst is contiguous with the stomach wall; (b) the cyst is surrounded by smooth muscle, which is continuous with the muscle of the stomach; and (c) the cyst wall is lined by epithelium of gastric or any other type of gut mucosa , 4, 9. Our present cases fulfilled these criteria excluding other diagnoses. Gastric duplication cysts comprise 4% of all gastrointestinal duplications. Various other congenital anomalies such as alimentary tract duplications, esophageal diverticulum, or spinal cord abnormalities are encountered in up to 50% patients .  These malformations are believed to be congenital, formed before the differentiation of epithelial lining, and therefore named for the organ with which they are associated , 10. Dup Greater than 80% of gastric duplications are cystic and do not communicate with lumen of the stomach. The remainders are tubular with some communication . The str Gastric duplications typically become symptomatic during childhood. 67% are diagnosed within the first year of life, and less than 25% are discovered after age 12 . The dup The clinical presentation of gastric duplication cysts can be highly variable and nonspecific ranging from vague abdominal pain to nausea, vomiting, epigastric fullness, weight loss, anemia, dysphagia, dyspepsia with abdominal tenderness and epigastric mass on physical examination , 10. Bec Because of the rarity of adult gastric duplications, it is difficult to outline their natural history with certainty. As with the native gastric mucosa, the cyst lining may undergo erosions, ulceration, and regenerative changes. In noncommunicating cysts, increased fluid production may result in pressure-induced necrosis of the mucosa. These changes may lead to bleeding into the cyst or perforation into the peritoneal cavity.  Duplication cysts have the potential for neoplastic transformation. The production of oncofetal antigens raises the problem of a precancerous condition in long standing intestinal duplications . Out of  Although it is difficult to diagnose GDC preoperatively, recent imaging modalities have provided some informative findings. CT scan and endoscopic ultrasound (EUS) are the best ways to identify GDC . Classic Complete removal is the treatment choice to avoid the risk of possible complications such as obstruction, torsion, perforation, hemorrhage, and malignancy , 10. A nIn summary, this unusual developmental anomaly should be included in the differential diagnosis of cystic masses of the gastrointestinal tract, and the possibility of malignancy should also be considered. While the diagnosis of gastrointestinal tract duplications may be suggested by imaging studies, more often the correct diagnosis is not established prior to surgery. Due to the risk of malignant transformation and other complications, GDCs should be treated surgically by complete resection.


Several complications have been reported with inguinal hernias. Although hematuria and flank pain, either as the presentation or as a complication of inguinal hernia, are infrequent, this condition may lead to the development of obstructive uropathy, which can have diverse manifestations.A 71-year-old Iranian man with Persian ethnicity presented with new onset episodes of gross hematuria and left-sided flank pain. A physical examination revealed a large and non-tender inguinal hernia on his left side. An initial workup included an abdominal ultrasound, an intravenous pyelogram and cystoscopy, which showed left hydronephrosis and a bulging on the left-side of his bladder wall. On further evaluation, computed tomography confirmed that his sigmoid colon was the source of the pressure effect on his bladder, resulting in hydroureteronephrosis and hematuria. No tumoral lesion was evident. Herniorrhaphy led to the resolution of his signs and symptoms.Our case illustrates a rare presentation of inguinal hernia responsible for gross hematuria and unilateral hydronephrosis. Urologic signs and symptoms can be caused by the content of inguinal hernias. They can also present as complications of inguinal hernias. Hematuria may reflect either significant nephrological or urological disease. Hematuria of nephrological origin is frequently associated with casts in the urine and almost always associated with significant proteinuria . IsolateA 71-year-old Iranian man with Persian ethnicity presented to our urology clinic complaining of recurrent episodes of gross hematuria and left-sided flank pain of one week's duration. He mentioned no history of trauma, prior disease, medication usage or significant family disorder. On physical examination, he was fully conscious with a blood pressure of 110/70 mmHg, pulse rate of 120 beats/min and temperature of 37°C. His bowel sounds were normoactive on auscultation. There were no remarkable findings on abdominal palpation, except for a non-tender, large left inguinal hernia with extension to his scrotum. Other related examinations, including a digital rectal examination, were normal. A urine analysis showed pH 5, with 10 to 15 RBCs per HPF, 10 white blood cells per HPF, with rare bacteria and yeast. A urine culture was negative.Genitourinary ultrasonography reported a grade 2 hydroureteronephrosis on his left side. An intravenous pyelogram also revealed left hydroureteronephrosis associated with an ill-defined filling defect on the left side of his urinary bladder Figure . In ordeA diagnosis was made of a large inguinal hernia with pressure effects on the urinary system, resulting in hematuria and obstructive hydroureteronephrosis;the abdominal wall was thus opened with a classic inguinal incision. The contents of his hernial sac, including his sigmoid colon and its mesentery, were adhered to the surrounding tissues. An attempt to reduce the content of his hernial sac was unsuccessful, so a low midline incision was made for better exposure and reduction. There was no intra-abdominal mass. A redundant sigmoid colon was found fixed at the internal ring due to severe and chronic adhesion. His proximal sigmoid colon had compressed his bladder and distal ureter at the vesicoureteral junction. After reduction of his hernial sac content, our patient underwent a successful hernia repair with mesh, leading to a quick and uneventful postoperative recovery.Our patient's signs and symptoms subsided following surgery. On a postoperative cystogram, all signs had disappeared Figure . Our patAlthough hematuria presents with many urologic diseases, the acute onset of gross hematuria is almost always indicative of a postrenal pathology. This includes stones, infection, trauma and tumor.Inguinal hernias present along a spectrum of scenarios. These range from incidental findings to surgical emergencies such as incarceration and strangulation of the hernia sac contents. Asymptomatic inguinal hernias are frequently diagnosed incidentally on physical examination or may be brought to the patient's attention as an abnormal pain-free bulge. In addition, these hernias can be identified intra-abdominally during laparoscopy . PatientThe presence of urological symptoms and signs such as hematuria, flank pain and hydroureteronephrosis may be seen with an inguinal hernia, but they generally occur when there is associated bladder herniation -6. A broMoreover, although urological symptoms and signs are often the predominant clinical symptoms when herniation of urinary organs occurs, our case revealed that urological features could be present even in the absence of urinary organ herniation. We think that, given the resultant urinary retention, high intraluminal pressure and consequent urothelial injury in the ureter and upper urinary system, the hematuria occurred as a rare presentation of an inguinal hernia. So, in this clinical pattern, care must be taken to prevent probable morbidities through either diagnostic or therapeutic procedures.Ruling out urinary organ herniation during preoperative work-up is helpful to avoid surgical complications, the most common being ureteral injury. Ultrasound may be helpful in diagnosis, with its ability to demonstrate hydronephrosis and, occasionally, the herniated urethra in the inguinoscrotal region, but it has limited value in showing the herniated ureter and a high index of suspicion is required. Nevertheless, in this case, ultrasound could be the first step in diagnostic imaging since urinary symptoms were present. Intravenous pyelography may aid the diagnosis by showing an intact non-herniated ureter. Computed tomography is the preferred imaging modality with high spatial resolution, not only to detect herniation, but also to show associated pathologies.Our case illustrates a rare presentation of inguinal hernia, responsible for gross hematuria and unilateral hydroureteronephrosis. Urologic signs and symptoms can be induced by the contents of an inguinal hernia. They can also be present as complications of an inguinal hernia.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.Authors were all involved in the drafting and re-editing of the manuscript. The final manuscript was read and approved by all six authors.


A 60-year-old woman presented with synchronous adrenal metastasis and an inferior vena cava tumor thrombus in the adrenal vein that developed from an ovarian carcinoma. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and right adrenalectomy with caval tumor thrombectomy for treatment. Microscopic examination revealed a clear cell ovarian carcinoma and a metastatic adrenal tumor. The patient is clinically free of disease after 6 years of follow-up. There have been no reports of synchronous adrenal metastasis with an inferior vena cava thrombus that developed from an ovarian carcinoma. As several reports have described the long-term survival after adrenalectomy for the treatment of isolated adrenal metastasis, clinicians should be aware of this potential occurrence so that patients can be appropriately treated. Adrenal metastases from visceral carcinoma are uncommon; they most commonly arise from primary lung, breast, and kidney tumors . AdrenalA 60-year-old woman—with no history of tumors—was admitted to the hospital because of abdominal distension. Abdominal ultrasonography and magnetic resonance imaging (MRI) revealed a pelvic mass with solid components and a 20-cm left ovarian tumor, respectively Figure . ComputeOvarian cancer can spread via peritoneal implantation, lymphatic invasion, or hematogenous dissemination. Although intraperitoneal implantation is the primary mode of ovarian cancer dissemination, hematogenous metastases are uncommon. However, autopsy and cross-sectional imaging studies have determined that the prevalence of metastases in advanced disease is higher than the prevalence that was previously recognized. The reported prevalence of adrenal and pancreatic metastases in patients with ovarian cancer at autopsy is 15% and 21%, respectively . HematogWhile the abdominal cavity is routinely surveyed using CT before the treatment of ovarian cancer, incidental discovery of an adrenal mass is rare, even in patients with advanced disease. Table There are potentially a number of routes for the development of adrenal metastases from an ovarian carcinoma, including the systemic venous, arterial, and lymphatic routes of dissemination. Some reports suggested that the incidence of contralateral lymph node metastasis from the primary site of the ovarian cancer was 11–30% ,13. AlthThe management of patients with adrenal metastases poses a therapeutic challenge. Although adrenal metastases were considered incurable, surgery is now recommended for isolated adrenal metastasis. Adrenalectomy for metastatic cancer was rarely performed because the survival benefit for patients undergoing such resections was not clear; however, it is now advised in patients with a good performance status where there is unilateral adrenal metastasis with no residual primary or other distant metastases ,14.In the case of this patient, the metastases were localized to the adrenal gland and tumor thrombus. Macroscopically complete resection with subsequent chemotherapy contributed to the improved prognosis.To the best of our knowledge, we present the first case of synchronous adrenal metastasis with an IVC tumor thrombus through the adrenal vein from an ovarian carcinoma. This is an uncommon case; however, clinicians should be aware of this occurrence so that patients can be treated appropriately. We believe that patients with macroscopically complete tumor resection may benefit from surgical intervention.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.The authors declare that they have no competing interests.HT, AT, YT, All authors read and approved the final manuscript.


Schwannomas of the colon are rare and are difficult to diagnose preoperatively, since they often defy endoscopic and radiographic detection. Immunohistochemical stains are useful postoperatively to confirm this tumor, but more reliable diagnostic techniques (such as colonoscopic biopsy with immunohistochemistry) have emerged to enhance preoperative diagnostic accuracy. Here we report an instance of schwannoma arising in the ascending colon, where immunohistochemical staining of a preoperative biopsy facilitated diagnosis. After laparoscopic resection, histologic examination was confirmatory. Schwannomas of the gastrointestinal tract are relatively uncommon and rarely involve the large intestine -3. AlthoWhile accurate diagnosis prior to surgical intervention can aid in therapeutic planning, limitations of conventional imaging and lack of sufficient biopsy material usually make this difficult. Recent improvements in colonoscopic techniques have led to use of endoscopic biopsy and immunohistochemistry in combination as a more reliable method for accurate preoperative assessment. We report here an instance of schwannoma of the ascending colon, confirmed by immunohistochemistry, for which laparoscopic right hemicolectomy was performed.A 61-year-old male was referred to his local hospital for a routine health examination. On screening colonoscopy, a polypoid lesion of the ascending colon was discovered  indicated that the lesion of the ascending colon protruded intraluminally, exhibiting homogenous enhancement Figure . A well-Schwannomas are uncommon neoplasms arising from Schwann cells of the neural sheath ,6. They et al. [Preoperative diagnosis of schwannoma is difficult due to its tissue density and the tendency for ulceration . Biopsieet al.  describeet al. ,16. Moreet al. -20.Schwannoma of the colon usually is not diagnosable solely by routine histology. A newer, more reliable approach incorporates immunohistochemistry ,7. Charaet al. [Because the prognosis for schwannoma differs from other gastrointestinal stromal tumors, a correct diagnosis is critical. Schwannomas overall are considered benign, but they may recur locally if excision is incomplete and in rare instances are capable of malignant transformation ,5. TozbiStandard treatment for schwannomas is complete surgical resection ,24. The In conclusion, schwannomas of the ascending colon are rare tumors dependent upon immunohistochemistry for definitive classification. Accurate preoperative diagnosis is essential for appropriate surgical management. While radical resection affords optimal outcomes, a laparoscopic approach may be used.Written informed consent was obtained from the patient for publication of this report and any accompanying images.The authors declare that they have no competing interests.HJK wrote the main manuscript and HRK performed the operation, revised, the manuscript for important intellectual content, and gave the final, approval for the version to be submitted for publication. All authors read and approve the final manuscript.


Asymptomatic pituitary abnormalities occur in about 10% of cranial magnetic resonance imaging scans, but metastatic carcinoma of the pituitary gland is rare: 133 cases have been reported. Two thirds secreted either prolactin or adrenocorticotropic hormone, and another 24% were non-secreting.A 42-year-old Caucasian man lived for 30 years after the diagnosis of a pituitary tumor whose clinical and biochemical features were those of acromegaly and hypogonadism. Radiotherapy, totaling 7300 rad, was administered to the sella over two courses. Growth hormone levels normalized, but he developed both thyroid and adrenal insufficiency, and replacement therapy was commenced. Fourteen years later, growth hormone levels again became elevated, and bromocriptine was commenced but led to side effects that could not be tolerated. An attempted surgical intervention failed, and octreotide and pergolide were used in succession. Twenty-seven years after the diagnosis, a mass from an excisional biopsy of below the angle of the mandible proved to be metastatic pituitary carcinoma. Immunohistochemical staining was positive for synaptophysin, growth hormone, and prolactin. One year later, an octreotide scan showed uptake at the sella, neck, and spleen. Our patient declined further active oncology treatment.Metastatic pituitary carcinoma associated with acromegaly is particularly rare. To the best of our knowledge, this is the eighth such case and is the first report of growth hormone and prolactin present in the metastatic mass. Magnetic resonance imaging scans show that about 10% of the healthy adult population have pituitary abnormalities, which are likely asymptomatic pituitary adenomas  showed tA 42-year-old Caucasian man complained of headache, vomiting, and blurred vision. A pituitary tumor was diagnosed after a skull X-ray, and he received 3300 rad to his sella. Two years later, he presented with impotence, joint pains, and perspiration. His serum GH level was 16.2μg/L (reference range is 0.45 to 2.2) and was not suppressed by the administration of oral glucose. His serum testosterone level was subnormal at 423nmol/L (reference range is 797 to 3470). His visual fields were normal, but a skull X-ray demonstrated an enlarged sella. Acromegaly with partial hypopituitarism was diagnosed. Further radiation therapy (4000 rad) was administered, and he received testosterone replacement. His GH levels were normalized, but 3 years later hypothyroidism and hypoadrenalism were diagnosed, and appropriate replacement therapies were begun.Fourteen years after the initial diagnosis, his GH levels again became elevated (25μg/L). A computed tomography scan revealed a partially empty sella but no tumor. He received therapy with up to 5mg of bromocriptine twice daily for 1 year and then the drug was discontinued because of intolerable side effects . Surgical exploration was deemed inappropriate because of previous irradiation, especially in the absence of radiologic evidence of a pituitary mass. After 18 years, a computed tomography scan, which was performed because of progressive enlargement of the hands, feet, and nose and an elevation of the GH level (104.5μg/L), revealed a sellar mass. Attempted transsphenoidal exploration was abandoned as a result of failed intubation.Therapy with octreotide by subcutaneous injection was initiated. The dose was gradually increased to the maximum approved level of 500mg three times daily and was administered by continuous subcutaneous infusion. GH levels were reduced to 14.5μg/L but not normalized. After four more years, octreotide was discontinued and therapy with pergolide commenced. However, GH levels continued to increase.Twenty-seven years into the disease course, the patient developed a soft, painless, 4cm mass below the angle of his right mandible. Fine-needle aspiration was suspicious for lymphoma, and an excisional biopsy was performed.Histopathology revealed tumor cells with abundant pink cytoplasm. Electron microscopy demonstrated cells containing membrane-bound dense core granules indicative of a neuroendocrine tumor. Some cells contained globular fibrous bodies of intermediate filaments suggestive of a GH-secreting tumor Figure . ImmunohThe GH level decreased from 363μg/L before surgery to 101μg/L but on subsequent follow-up began to rise again. One year later, a radionuclide scan with indium-labeled octreotide showed continued uptake in the region of the sella, neck, and spleen. The patient declined further investigation or active treatment for acromegaly and was treated symptomatically before he died, at the age of 72, 30 years after initial presentation.Pituitary carcinomas may be non-functioning or hormone-secreting. In the review series on 132 pituitary carcinomas [®, linear accelerator, and proton beam used. The relative value of stereotactic radiosurgery in malignant cases awaits investigation. The role of treatments with dopamine agonists cabergoline or bromocriptine and somatostatin analogs such as lanreotide and octreotide is case-dependent, but follow-up should continue for life. Drugs that block GH receptors, such as pegvisomant, may relieve symptoms but do not reduce the tumor size and should not be used in malignant cases.Treatment of malignant pituitary tumors includes surgery to remove the primary and metastatic tumor augmented by conventional and stereotactic radiotherapy. The mode of radiation depends on the availability of technology with Gamma KnifeGH production by the cervical metastasis was not unequivocally demonstrated, but reduction in GH following surgical removal of the neck mass suggests that the continued GH production was originating, at least in part, from the extracranial metastasis. Prolactin levels were not measured for many years prior to the removal of the metastasis and were subsequently undetectable. However, the positive immunostaining for prolactin in addition to GH in an extracranial metastasis from a GH-producing tumor is a unique feature of the case .The etiology of pituitary carcinoma is poorly understood. It has been suggested that radiation may induce mutations in tumor cells, making them more likely to metastasize. A number of cases of sarcomas arising many years after cranial irradiation in tissues previously exposed to radiation have been reported ,11. HighMetastatic pituitary carcinoma associated with acromegaly is rare. To the best of our knowledge, this is the eighth case and the first report of GH and prolactin present in the metastatic mass.Despite all reasonable attempts, written informed consent for publication from the patient’s next of kin could not be obtained. The case is important to public health, and every effort has been made to protect the identity of our patient. There is no reason to believe that our patient’s next of kin would object to publication.GH: Growth Hormone; LH: Luteinizing Hormone; TSH: Thyroid-Stimulating Hormone.The authors declare that they have no competing interests.SS and RL managed the patient clinically, ES reported the histology and WT wrote the text. All authors read and approved the final manuscript.


Positron Emission Tomography with 2-deoxy-[F-18]-fluoro-D-glucose (FDG-PET) has become a reliable diagnostic tool in clinical practice similar to Magnetic Resonance (MR) imaging and Computed Tomography (CT). FDG-PET has especially been used to differentiate malignant from benign lesions, and for staging and follow- up malignant tumors. However, FDG-PET has some pitfalls in cancer screening and FDG tracer accumulates at sites of infection and inflammation. Bone tuberculosis may be confused with malignant tumors of bone and its metastases, and can accumulate focally increased FDG in active period. We present a 60-year-old woman with lytic bone lesions and mediastinal hypermetabolic foci, initially suspected to be malignant by means of FDG-PET and the other imaging modalities; however, bone biopsy confirmed the diagnosis of bone tuberculosis. Conflict of interest:None declared. Tuberculosis (TB) is a chronic infectious disease caused by the tubercle bacilli. Although TB has been a well-known disease, it has not yet been completely eradicated throughout the world. New technologies and drugs may help the physicians fight against the resistant tubercle bacillus; however, TB remains to be major problem in developing countries . Its incPositron Emission Tomography with 2-deoxy-[F-18]-fluoro-D-glucose (FDG-PET) plays an important role in differentiating benign from malignant tumors, staging and follow- up. However, FDG-PET is not a specific technique for cancer screening and FDG tracer accumulates at sites of infection and inflammation and it can also render some false positive results in differentiating tuberculosis from malignancy .A 60-year-old woman presented to our hospital with a four- month history of increasing pain in the right knee. No difference was noted in pain character with motion and at rest. Pain was localized in medial tibial metaphysis. Local tenderness and painful arch of knee motion were observed without any tumoral tissue clinical inflammatory findings. She had no history of fatigue, cough, weight loss, diabetes, night sweats or of a malignancy. The blood count and CRP were within normal range. Sedimentation rate was elevated. A plain radiogram revealed a lytic lesion in proximal metaphysic of tibia. Computed tomography showed a lytic and exocentric lesion starting intramedullary and destructing the cortex with soft tissue extension, whereas MR delineated a 3x2 cm hypointense mass in T1 sequences and heterogenic hyperintense lytic mass with contrast enhancement in STIR sequences . RadiogrFDG-PET imaging with I.V. administration of 370 MBq FDG was performed following six hours of fasting while the patient had a serum glucose level of 92 mg/dl. We waited one hour for distribution of FDG in the body then the patient was imaged using PHILIPS Gemini Dual GS  integrated PET/CT scanner with 2 slice CT. Whole body PET/CT showed increased FDG uptake at the left side of the anterior arch of the first cervical vertebra and at the interarticular region and at the proximal metaphysis of right tibia . Also inBased on the results of imaging studies, oncology and chest diseases consultations were requestedt. The clinical manifestations, physical examination and blood tests were not in line with the imaging results. The patient underwent thoracic lymph node biopsy with mediastinoscopy and percutaneous bone biopsy from tibia under fluoroscopy. The pathologic examination confirmed the diagnosis of bone tuberculosis and lymph node involvement. The patient received chemotherapy with ethambutol, rifampicin and isoniacid for 6 months and recovered totally without needing any surgery. The musculoskeletal system is involved in only 1%-3% of cases with tuberculosis . The disBone tuberculosis usually appears at least 2 years after pulmonary or visceral TB. In the light of chest X-ray and consultation with an expert in chest diseases, neither any mass nor any findings of physical examination did suggest pulmonary TB. The only positive result was broadening of the mediastinum on PA thorax x-ray. Only 33% of the patients with bone TB also have active pulmonary TB . Our patFDG-PET has become a powerful diagnostic tool in the clinical practice similar to MR and CT. Nuclear medicine has began to take an important part in daily practice of orthopedics, thanks to the developments of medical technology. Not only does it inform us about malignancies using FDG-PET but it also provides valuable preoperative knowledge to traumatology, arhtroplasty and spine surgery . Unlike Taking late images generally facilitates differentiation of infection from malignancies. In infections, late images should indicate FDG washout from the tissue. However, washout was not observed in our case, even an increased FDG accumulation was noted.In conclusion, any involvement of particularly the tibia by TB is rarely confronted and its symptoms may be similar to malignant tumors. Malignancy could be confused with TB by imaging studies including FDG-PET. FDG tracer accumulates at sites of infection and inflammation and it can render false positive results in infection and inflammation differentiating malignancy ,5. Becau


Jejunogastric intussusception is a rare complication of gastric surgery. It usually presents with severe epigastric pain, vomiting, and hematemesis. A history of gastric surgery can help in making an accurate and early diagnosis which calls forth an urgent surgical intervention. Only reduction or resection with revision of the previously performed anastomosis is the choice which is decided according to the operative findings. We present a case of JGI in a patient with a history of Billroth II operation diagnosed by computed tomography. At emergent laparotomy, an efferent loop type JGI was found. Due to necrosis, resection of the intussuscepted bowel with Roux-en-Y anastomosis was performed. Postoperative recovery was uneventful. Jejunogastric intussusception (JGI) is a rare complication of gastrectomy with an incidence of 0.1% –4. A morIn this paper, we aim to report a case of JGI with regard to its presentation, diagnosis, and surgical treatment.A 63-year-old male patient was admitted to the hospital with severe colicky epigastric pain followed by hematemesis. There was a past history of gastric surgery (Billroth II operation), which had been performed 23 years previously for peptic ulcer disease. On physical examination, there was a mildly distended abdomen, epigastric tenderness, and a vague feeling of an epigastric mass on deep palpation. The usual laboratory investigation was unremarkable. A computed tomography showed a distended stomach containing a nonhomogeneous mass . The diaThe term retrograde intussusception (invagination) was first introduced by John Hunter to define an invagination of the intussusceptum in an antiperistaltic or proximal direction as opposed to the usual peristaltic or distal direction . IntussuTwo different forms of JGI have been described according to its clinical presentation . In the Early diagnosis of the acute form is of paramount importance. The first specific diagnostic study should be an emergent endoscopy which is carried out by endoscopists aware of JGI and its endoscopic picture. Computed tomography allows the differentiation of the distinct stages of the disease. It shows a dilated stomach with intragastric filling by the bowel loops. In spite of the endoscopic and imaging findings, most reported cases of JGI were diagnosed at surgery . Surgical options include only reduction or resection of the compromised bowel with revision of the anastomosis depending on the conditions found during the operation . It coulJGI is a rare life-threatening complication of gastric surgery which is often diagnosed at surgery. Although endoscopy and computed tomography may be helpful during preoperative evaluation, laparotomy is usually required for the correct diagnosis. Early surgical intervention is the most important factor for prevention of morbidity and mortality.


Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign lesion, primarily occurring in the head and neck. ALHE arising from the ocular adnexa is rare, and the bilateral presentation is especially rare in the eyelids.A 64-year-old Japanese man presented with tearing. Multiple nodules, approximately 5 mm in size, were observed in bilateral upper and lower eyelids. Surgical excisions of the both eyelids masses were performed. Histopathological examination of the excised masses demonstrated proliferated blood vessels lined by plump endothelial cells together with a lymphoid and eosinopilic infiltrate, compatible with a diagnosis of ALHE. Flow cytometry studies showed that the mass consisted of mostly CD3-positive cells. During two-year follow-up, no recurrence of the mass was observed and the patient had no subjective symptom of tearingALHE may occur in the bilateral eyelids. The cause of ALHE remains uncertain, but our results of flow cytemetry suggest that T cells are related to the pathogenesis of this disease. Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon, poorly understood, benign slow-growing lesion . The mosWe report a case of ALHE occurring in bilateral eyelids and discuss the clinical, histopathological and flow cytemetric features.3 with 0.2% eosinophils. Serum concentration of immunoglobulin E was slightly elevated at 278.7 mg/dL, and immunoglobulin G4 was 59.3 mg/dL . Magnetic resonance imaging demonstrated bilateral multiple masses localized in the eyelids. The lesions were isointense to cerebral parenchyma on T1-weighted images, and hyperintense on T2-weighted images. After gadolinium infusion, the masses demonstrated moderate enhancement.A 64-year-old Japanese man consulted a local clinic because of tearing. Multiple nodules each approximately 5 mm in size were observed in bilateral upper and lower eyelids. He was referred to our hospital for further examination and treatment. He had an unremarkable medical history and no history of trauma. The corrected visual acuity was 0.8 in each eye. Well defined hard lesions in both upper and lower eyelids were present, without inflammatory signs such as redness Figure . OphthalFor diagnosis purpose, biopsy of the right upper eyelid mass was performed via the skin and conjunctiva. Since a pathological examination during surgery showed eosinophilic infiltration and an allergic disease was suspected, local injection of triamcinolone acetonide was performed at the end of procedures. Histopathological examination showed proliferated blood vessels lined by plump endothelial cells with an epithelioid appearance, surrounded by a collagenous stroma containing a lymphoid and eosinophilic infiltration, and no evidence of lymphoid follicles Figure . These hSubsequently the right eyelid mass was surgically excised. Residual lesions were removed piece by piece. At the end of surgery, triamcinolone acetonide was injected again into the eyelid. Although the patient refused additional surgery at first, one year after the initial operation, excision of left upper eyelid masses was performed in the same manner as the right eyelid mass. Histopathological and flow cytometric findings were the same as the right mass. During follow-up of two years, although some lesions remained unexcised, no recurrence of the excised masses was observed and the patient had no subjective symptom of tearing.ALHE arising from the ocular adnexa is rare. ALHE occurring in eyelids which presented as bilateral multiple nodules has never been reported. The diagnosis of Kimura’s disease should be kept in mind in patients with a subcutaneous mass in the periocular region . ALHE anThe cause of ALHE remains uncertain. Our flow cytemetric study demonstrated that the mass was consisted of CD3-positive cells, but there was no TCR rearrangement. These findings suggest that the pathogenesis of ALHE might be a T cell reactive process. In some previous reports, a history of trauma or evidence of associated damage or rupture of blood vessels was present in many cases. Therefore, some authors considered ALHE as a reactive process. Moreover, the bilateral presentation in our case also suggests that there is a reactive process. On the other hand, others considered these lesions as neoplastic . PreviouComplete surgical excision seems to be the most effective treatment . HoweverALHE may occur in the bilateral eyelids, albeit rarely. It is necessary to include ALHE in the differential diagnosis of an eyelid 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 Series Editor of this journal.The authors have declared that no competing interests exist.SU: patient interaction and diagnosis, drafting of manuscript. HG: patient interaction and diagnosis, performed surgery. YU: patient interaction and diagnosis. TN: pathological diagnosis. TN: pathological diagnosis. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2415/13/38/prepub


Pigmented villonodular synovitis (PVNS) arising from the elbow joint is extremely rare; only 24 cases have been reported. It is extremely difficult to differentiate PVNS from other soft tissue tumors on the basis of imaging findings alone. Therefore, a biopsy is required for definitive diagnosis. A 20-year-old female reported a mass on her right elbow. Physical examination revealed a tumor measuring 3.0x3.0 cm. Magnetic resonance imaging (MRI) revealed that the signal intensity of the tumor was isointense to muscle on T1-weighted images; however, it was hyper- or isointense to muscle on T2-weighted images. In images obtained by gadolinium-enhanced MRI, the margin of the tumor was well-contrasted. Thallium (Tl)-201 scintigrams revealed an abnormal accumulation in the area of the mass in the early and delayed phases. On the basis of clinical findings, imaging characteristics and incision biopsy results, localized PVNS was diagnosed and marginal excision was performed. We thus identified an extremely rare case of PVNS arising from the elbow joint. When interpreting Tl-201 images for the assessment of bone and soft tissue lesions, it is important to recognize PVNS as a condition that simulates malignant tumors. Furthermore, PVNS should be considered in the differential diagnosis when increased Tl-201 activity is closely related to the joint. MRI aids in the differentiation by demonstrating features of hemosiderin degradation products. These findings are likely to be extremely helpful in the differential diagnosis of bone and soft tissue tumors. Pigmented villonodular synovitis (PVNS) is a rare, idiopathic, proliferative disorder of the synovium  with twoA 20-year-old, right-handed female reported a mass on the right elbow; this mass had caused progressive pain over the last 2 years. Although the patient had not suffered a previous trauma involving her right elbow joint, the patient recognized pain and a mass on the flexion side. Physical examination revealed an elastic and soft tumor measuring 3.0x3.0 cm. It demonstrated no adhesion to the skin and its margin was well-defined. The active range of motion of the affected elbow was −15° extension, 80° flexion, 90° supination and 90° pronation.A roentgenogram of the right elbow revealed a soft tissue mass around this joint, with no apparent bone erosion or cystic changes . MRI revOn the basis of clinical findings and imaging characteristics, the tumor was diagnosed as a primary soft tissue tumor and an incisional biopsy was performed. Microscopic examination revealed a nodular growth covered by synovial lining cells. Mitotic figures were observed in parts, as were a large number of multinucleated giant and inflammatory cells. The stroma presented fibrosis and hemosiderin deposition was observed in areas of the surface . HistoloOne month later, marginal excision with anterior capsulectomy was performed since the tumor demonstrated adhesion to the anterior lesion of the joint capsule. There was no apparent bone erosion and the capsule was brownish-yellow. The tumor was dumbbell shaped since a dull groove was created by the tendons of the brachioradialis and brachialis and its surface was smooth. Complete excision, including the anterior capsule was performed to reduce the risk of local recurrence. Following surgical treatment, the active range of motion of the operated joint was recovered fully to 0° extension and 140° flexion with physical training. The pain and mass were fully resolved following treatment and there was no recurrence 5 years after surgery.et al in 1941, based on clinical and pathological experience (The term PVNS was introduced by Jaffe perience . PVNS isperience . LPVNS iperience ,7,11. Prperience . It is cet al(et al(et al(A literature review identified only 24 documented cases of PVNS involving the elbow joint; of these, 15 were case reports and nine were included in seven large retrospective PVNS series of all sites: one case from Scott , one froet al, one fro al(et al and two  al(et al. In the  al(et al,19 and 1 al(et al.PVNS shows the same radiodensity as that of soft tissue. The disease causes contour erosion of the underlying bone or round lytic areas with well-demarcated borders, which are observed particularly at points of capsular insertion . MRI strIt has been reported that PVNS demonstrates high isotope accumulation , althougIn conclusion, we identified an extremely rare case of PVNS arising from the elbow joint. When interpreting Tl-201 images for the assessment of bone and soft tissue lesions, it is important to recognize PVNS as a condition that simulates malignant tumors. Furthermore, PVNS should be considered in the differential diagnosis when increased Tl-201 activity is closely related to the joint. MRI also aids in the differentiation by demonstrating features of hemosiderin degradation products. These findings are likely to be extremely helpful in the differential diagnosis of bone and soft tissue tumors.


We describe a case of multiple peritoneal nodules with cysts at the free border of the omento and other locations of the peritoneal surfaces. A total abdominal hysterectomy and bilateral salpingooophorectomy were performed for a myomatous uterus and bilateral ovarian cysts. The omentum and several fragments of the abdominal peritoneum were also removed. Microscopic diagnosis was Disseminated Peritoneal Endosalpingiosis-Leiomyomatosis. Endosalpingiosis is a nonneoplastic lesion of the Mullerian system, similar to but less frequent than the homologous lesions of endometriosis and endocervicosis . They haflorid cystic endosalpingiosis [Peritoneal endosalpingiosis, also known as ingiosis , is charThis paper shows multiple peritoneal nodules with solid and cystic areas in the same specimen. It is a rare entity: Disseminated Peritoneal Endosalpingiosis-Leiomyomatosis.A 44-year-old woman  presented pelvic pain, uterine leiomyomas, and bilateral ovarian tumors. In 1991 an endometriosis cyst was removed. Also myomectomy by hysteroscopy was done in 1999. A total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Omento was also removed and multiple biopsies of the abdominal peritoneum were taken. The correct diagnosis was made under microscopic examination. The patient is asymptomatic at the moment, one year after the intervention.Multiple white mesenteric nodules were found accidentally. Three of the solid ones were submitted as intraoperative biopsy and were informed as benign leiomyomatosis.The surgical specimen consisted of a uterus with multiple leiomyomas and double adnexae with Mature Cystic Teratomas (Dermoid Cyst) in both ovaries. The omento and several biopsies of the abdominal peritoneum were also received. Multiple nodules between 0.2 and 3 cm were found in the free border of the omento. The smaller ones were solid while the others had cystic areas with smooth wall and clear liquid . MicroscEndosalpingiosis is a benign condition of the Mullerian system characterized by the presence of glands lined by ciliated tubal-type epithelium and involves the peritoneum, subperitoneal tissues, omentum, retroperitoneal nodes, and so forth. It was first described by Sampson in 1930 [The morphological appearance of our case resembles a florid cystic endosalpingiosis. Clement and Young described four cases of florid cystic endosalpingiosis presenting as a tumor-like mass . It is cThe symptomatology is not specific. The most common symptoms are pelvic pain, hyper or dysmenorrhea, and infertility but sometimes they have no complaints at all , 7. It sIn summary, in this paper we describe a case of Omental Endosalpingiosis associated with Disseminated Peritoneal Leiomyomatosis. The importance of our case is to underline the differential diagnosis between these lesions and diffuse peritoneal carcinomatosis or disseminated abdominal malignancy. It represents the crucial diagnostic challenge that can only be made by microscopic exam . Also, s


Primary intraosseous cavernous hemangioma is a rare bony tumor. To date, only 9 cases of multiple lesions and 2 cases with a dural tail sign have been reported.Here, we present a case of multiple cavernous hemangiomas of the skull with dural tail sign in a 24-year-old man. No abnormalities were observed in the right orbit by craniography, but frontal bone destruction was unintentionally discovered. Computed tomography and magnetic resonance imaging demonstrated multiple intraosseous lesions that destroyed the surrounding bone and intracranial extension. Total resection of the two lesions and cranioplasty were performed. Histological examination confirmed the lesions as a cavernous hemangioma.Cavernous hemangioma is a rare bony tumor that should be considered in the differential diagnosis of skull tumors. Resection of all lesions should be performed on patients with multiple cavernous hemangiomas, and these patients should have regular follow-up examinations. Based on this case, and our literature review, we found that outcomes are usually very good. Primary intraosseous cavernous hemangioma (PICH) is a benign vascular lesion. More than 50 percent of PICHs are observed in the spine, whereas these lesions seldom occur in the skull. PICHs account for 0.2 percent of bone tumors and 7 percent of skull tumors . Skull PA 24-year-old man presented with progressive right eye exophthalmous for one year, without any other ocular or nervous symptoms. There were no obvious abnormalities in the right orbit; however, left frontal bone destruction was found on plain radiographs of the skull. To obtain more information, orbital computed tomography (CT) scanning was conducted, and a lesion was observed in the right orbital roof Figure . The lesDuring the operation, a grid-like boney tissue was observed within these red-colored tumors, which adhered themselves to bloody meninges. The two lesions were completely removed along with the normal bone tissue around them. After the operation, the diagnosis of skull cavernous hemangioma was made by histopathological review Figure . The immIn 1845, Toynbee first reported a case of cavernous hemangioma of the skull, and this condition was defined by Rowbotham from the histological point of view until 1924 . Skull PRadiography of the skull is the most useful method to identify PICHs, whose typical features are a “honeycomb” or “sunray” pattern . HoweverThere are two histological classifications of PICH: sinus and capillary. Most PICHs of the spinal canal are classified as sinus, and many PICHs of the skull are classified as capillary . Madge eThe present case should be distinguished from multiple tumors that penetrate into the internal skull. Because approximately 70 percent of meningiomas have the dural tail sign and because the other MRI features of this case were similar to those of meningiomas, we considered this to be the disease before the operation . In thisa priori.Total surgical resection is the major treatment of skull PICH. This surgical procedure has the benefits of low blood loss during the operation and a low recurrence rate after the operation . ResectiOther reported treatments include curettage and radiotherapy. Curettage may lead to serious bleeding during the operation and recurrence after the operation . RadiothWritten informed consent was obtained from the patient and his parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the series editor of this journal.PICH: Primary intraosseous cavernous hemangioma; MRI: Magnetic resonance imaging; CT: Computed tomography.We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. None of the authors have any competing interests to disclose.All authors fulfill the authorship criteria because of their substantial contributions to the conception, design, analysis, and interpretation of the data. XP analyzed the data and drafted the manuscript. LSY and LYM participated in data acquisition. XQ conceived the study, and participated in its design and in data acquisition. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/13/155/prepub


Acute mesenteric ischemia due to an embolism of the superior mesenteric artery is associated with a high mortality rate. Over 20 percent of acute mesenteric embolism cases consist of multiple emboli, and the long-term prognosis depends on the incidence of subsequent embolic events at other sites. The incidence of emboli in the upper extremity associated with a superior mesenteric arterial embolism has rarely been described. The signs and symptoms of ischemic change in the upper limb can be masked by other circumstances, such as postoperative conditions or complications. In these cases, a late presentation or delayed diagnosis and treatment can result in limb loss.We present a rare case of a 67-year-old Japanese woman with atrial fibrillation who developed an embolic occlusion of the brachial artery associated with a superior mesenteric arterial embolism. She developed gangrene in her right hand, which had progressed to the point that amputation was necessary by the time the gastrointestinal surgeon had consulted the Department of Orthopedic Surgery. The brachial arterial embolism diagnosis was delayed by the severe abdominal symptoms and shock conditions that followed the emergency enterectomy, resulting in amputation of the upper limb despite anticoagulation therapy. In this case, multiple infarctions of the spleen were also observed, indicating a shower embolism.When treating a superior mesenteric arterial embolism in a patient with atrial fibrillation, the possibility of recurrent or multiple arterial thromboembolic events should be considered, even after the procedure is completed. Acute mesenteric ischemia due to an embolism of the superior mesenteric artery (SMA) is associated with a high mortality rate . Over 20An embolus in an upper limb is an uncommon event; when diagnosed promptly, however, it can be successfully treated with prompt surgery, such as an embolectomy . TherefoWe report a rare case of brachial arterial embolism associated with an SMA embolism. Because of the severe abdominal symptoms and the shock conditions that followed an emergency enterectomy, the brachial arterial embolism diagnosis was delayed, resulting in amputation of the upper limb.A 67-year-old Japanese woman complained of acute-onset abdominal pain and vomiting . Her vital signs were largely stable, apart from tachycardia with atrial fibrillation (Af) that had never been treated. The laboratory data revealed acidosis, inflammation, and elevated lactate and creatine phosphokinase (CPK) levels. The contrast-enhanced computed tomography (CT) imaging revealed that the SMA was occluded by a thromboembolism. Because of her pre-existing Af, she was diagnosed with embolic occlusion of the SMA and intestinal necrosis. She was treated with an emergency enterectomy  colitis and sepsis. Due to her respiratory insufficiency and shock conditions, she was treated with ventilator support. Although antibiotics resolved her MRSA colitis within 3 weeks of the laparotomy, she began to gradually develop gangrene in her right hand.Post-operatively, she developed methicillin-resistant The three-dimensional CT images showed that her right brachial artery was occluded 5 cm proximal to the elbow joint Figure B; howeveAn abdominal CT scan revealed multiple infarctions of the spleen, indicating a shower embolism. Anticoagulation therapy was re-started after the amputation to prevent recurrent or new emboli. She was able to ambulate independently 2 months after the amputation. She used a prosthetic upper limb for 12 months after the amputation, at which time she died of malnutrition resulting from the enterectomy.Acute mesenteric ischemia refers to the acute onset of intestinal hypoperfusion, which can be caused by occlusive or non-occlusive obstruction of arterial or venous blood flow. SMA emboli are a major cause (up to 50 percent) of acute mesenteric ischemia . The SMAThe most frequent causes of upper limb amputation are trauma and cancer, followed by vascular complications. Amputating an arm following an embolism is rare because emboli are the cause of only 1 percent of upper limb amputations . In mostThe signs of ischemic change in an upper limb can be masked by the patient’s post-operative condition or by complications, which can lead to a delayed diagnosis. The limb remains threatened once the ischemic cascade has been initiated, even after successful revascularization . In the Upper limb emboli may be attributed to a variety of sources. Two-thirds of the cases are of cardiac origin, and Af is the usual etiology. Obstructions have been found in the subclavian artery in 7–8 percent of patients, at the axillary level in 26–36 percent of patients, at the brachial level in 48–52 percent of patients, and distal to the elbow in 9–15 percent of patients -13. In oWhen treating an SMA embolism in a patient with Af, the possibility of recurrent or multiple thromboembolic events should be considered, even after the procedure. Rapid diagnosis is essential for preventing the catastrophic events associated with intestinal infarction and the subsequent development of shower emboli.Written informed consent was obtained from the patient’s next of kin to publish this case report and any accompanying images. A copy of the written consent is available for review by the editors of this journal.SMA, Superior mesenteric artery; Af, Atrial fibrillation; CPK, Creatine phosphokinase; CT, Computed tomography; MRSA, Methicillin-resistant Staphylococcus aureus.The authors declare that they have no competing interests.TY1 was the major contributor to studying the case and writing the manuscript. TY1, HY and KS were involved in the patient’s medical care. TY2 and KS were responsible for drafting the manuscript. TY2 edited and submitted the manuscripts. TY2 and AO critically revised the manuscript and provided the final approval of the version to be published. All of the authors read and approved the final manuscript.


Intestinal ischemia is a rare complication of laparoscopic surgery. Its prognosis depends on a high index of suspicion and effective early treatment.In the present report, we describe three cases where intestinal ischemia developed following laparoscopic surgery. Case 1 concerns a 52-year-old Caucasian man who developed large bowel ischemia following laparoscopic adjustable gastric band surgery. Case 2 concerns an 82-year-old Caucasian woman who developed fatal intestinal ischemia following laparoscopic cholecystectomy. Case 3 concerns a 58-year old Caucasian woman who developed right-sided lower intestinal ischemia following open cholecystectomy.Intestinal ischemia is a rare complication of laparoscopic surgery. The identification of high-risk patients is an essential primary preventive measure. A high index of suspicion is required to make an early diagnosis, which may help improve outcomes. Intestinal ischemia is a rare complication of laparoscopic surgery. Its prognosis depends on a high index of suspicion and effective early treatment. However, the early signs and symptoms are entirely non-specific or even absent. Mesenteric ischemia has previously been reported after various laparoscopic procedures -14. In t2). He had a medical history of diabetes mellitus, hypertension and obstructive sleep apnea. The procedure was performed according to the standard technique with maintenance of the intra-abdominal pressure at 15mmHg with a pneumoperitoneum time of 70 minutes. A calf muscle pump was applied during the procedure and our patient received low molecular weight heparin (LMWH) post-operatively. He had an uneventful post-operative recovery and he was discharged home within 24 hours. On the seventh post-operative day, he was readmitted with a two-day history of increasing abdominal pain and distension with multi-organ failure. He had leukocytosis (13 × 109 cells/L) and a raised lactate level of 5.5mmol/dL. An abdominal computed tomography (CT) scan showed intra-mural gas in the cecum and ascending colon, in keeping with ischemic bowel. On laparotomy, an ischemic right colon was identified with normal superior mesenteric artery (SMA) pulsation; therefore a right hemicolectomy was performed with an end ileostomy and removal of the gastric band. Post-operatively our patient required intensive care unit support for three weeks and renal replacement therapy. Post-operative histological examination demonstrated ischemic changes with no identifiable cause. He was discharged five weeks later.A 52-year-old Caucasian man underwent LAGB for morbid obesity (body mass index (BMI) 49.7kg/mAn 82-year-old Caucasian woman underwent LC for symptomatic gallstones. Her medical history included hypertension and a previous transient ischemic attack on aspirin. LC was performed according to the standard technique with maintenance of intra-abdominal pressure at 12mmHg with a pneumoperitoneum time of 45 minutes. A calf muscle pump was applied during the procedure and our patient received LMWH post-operatively. Our patient was discharged on the first post-operative day. On the fifth post-operative day, she was readmitted with a history of severe generalized pain associated with vomiting and diarrhea. She had generalized abdominal distension and tenderness. Blood test results showed a raised C-reactive protein level of 300mg/L, and a raised lactate level of 6mmol/dL. An abdominal CT scan showed markedly dilated small and large bowel loops with a heavily calcified aorta and SMA. No intravenous contrast could be seen within the SMA  -3,5-9,13 -3,5-9,12) is absorbed into the circulation, resulting in hypercapnia, respiratory acidosis, and increasing the systemic vascular resistance secondary to the hemodynamic stress response  [Normal intra-abdominal pressure (IAP) is 5 to 7mmHg and at an IAP of 12mmHg, renal functional impairment develops . The prolamines) ,24-26. Alamines) . AlthougRisk factors such as atherosclerosis and hepatic or renal impairment can predispose to ischemia . Nearly 2 pneumoperitoneum that may occur in standard laparoscopy. This technique may be an alternative option in high-risk patients with cardiorespiratory diseases [Diagnosis of acute intestinal ischemia requires a high index of suspicion. Patients commonly present with early non-specific symptoms of abdominal pain, nausea, vomiting with either diarrhea or delayed bowel action . Preventdiseases .Intestinal ischemia is a rare complication of laparoscopic surgery. It tends to occur mainly in high-risk patients with significant cardiopulmonary diseases or atherosclerosis. Proper pre-operative assessment to identify those patients at risk may help to prevent the development of this serious complication. A high index of suspicion is required to make an early diagnosis, which may help improve outcomes.Written informed consent was obtained from the patients (cases 1 and 3) or the patient’s next-of-kin (case 2) for publication of this manuscript and 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.WAK, DJH, and JDT prepared the manuscript. DNL outlined the manuscript’s layout and supervised the work. All authors read and approved the final manuscript.