Solitary fibrous tumor is a rare type of mesenchymal, spindle-cell tumor reported mostly in the pleura. Retroperitoneal occurrence is rare and histopathological diagnosis is challenging. A 55-year-old woman with nonspecific abdominal pain was found to have a retroperitoneal/pelvic mass adjacent to the upper rectum. The patient underwent surgical resection in clear margins of this pelvic tumor, entering the total mesenteric excision surgical plane. Final histopathology revealed a solitary fibrous tumor and the case is presented herein. Solitary fibrous tumor in the retroperitoneum is rarely found in the literature and to the best of our knowledge less than a hundred cases are described so far. Histopathological diagnosis is mostly based on a “patternless pattern” on microscopic examination, which is a storiform arrangement of spindle cells combined with a “hemangiopericytoma-like appearance” and increased vascularity of the lesion. Surgery is the mainstay of treatment and recurrence rates are generally low. Solitary fibrous tumor (SFT) is a rare type of mesenchymal, spindle-cell tumor and includes heterogenous variety of neoplasms, both benign and malignant. They are mostly reported arising in the pleura, and about 30% develop in extrapleural tissues, including the retroperitoneal space . SurgicaA 55-year-old woman was investigated for nonspecific lower abdominal and back pain. The patient's past medical and surgical history was clear and physical examination as well as routine haematological and biochemical laboratory investigations were unremarkable. Computed tomography (CT) of the abdomen and pelvis revealed an approximately 10 × 10 cm tumor in the retroperitoneal space, immediately anterior to the aortic bifurcation, high in the pelvis, and posteriorly to the upper third of the rectum . MagnetiAfter multidisciplinary team (MDT) meeting discussion, surgical exploration was decided and performed via midline laparotomy. Bilateral ureter guidewires were inserted intraoperatively, to facilitate identification of the ureters. The left colon was mobilized and the total mesorectal excision (TME) surgical plane was entered; the tumor was mobilized and excised in clear margins macroscopically without any intraoperative adverse events Figures . There wHistopathological examination showed a neoplasm composed of bland and uniform oval to spindle cells with minimal cytoplasm, small elongated nuclei, and indistinct nucleoli . The tumNo adjuvant treatment was decided on the MDT and the patient remains asymptomatic and tumor free on follow-up visits one year later.SFTs are soft tissue spindle-cell neoplasms, first described by Klemperer and Rabin in 1931 . These nSFT in the retroperitoneum, as in the case reported above, is rarely found in the literature and to the best of our knowledge less than 100 cases are described so far . The maiHistopathological diagnosis is challenging and mostly based on a “patternless pattern” on microscopic examination. This pattern is a storiform arrangement of spindle cells combined with a “hemangiopericytoma-like appearance” and increased vascularity of the lesion . DiffereSFTs are considered malignant when histopathological examination shows high cellularity, high mitotic activity (more than 4 mitoses per 10 HPF), pleomorphism, necrosis, and hemorrhagic changes .Moreover, SFTs can cause paraneoplastic syndromes and mainly hypoglycemia, which is thought to arise due to the production of Insulin like Growth Factor-2 (IGF-2) from the tumor. Such a condition may be the presenting symptom for these cases . When coTomographic imaging cannot differentiate retroperitoneal SFT from other solid retroperitoneal sarcomas , 12; howDue to the rarity of SFTs, especially in the retroperitoneum, studies to define the best management approach are lacking and adjuvant treatment options are based on case reports and observational studies. Interestingly, antiangiogenic drugs, as bevacizumab, based on the high vascularity of the lesion are used initially and conventional chemotherapy to keep the disease stable is a strategy proposed in an important study on the matter, treating advanced disease . Even beIn conclusion, SFT in the retroperitoneum should be managed aggressively with primary surgery and has a good prognosis. Histopathological diagnosis is stepwise and immunohistochemistry can guide towards the right direction in equivocal cases. Uncertain clinical behavior and lack of management guidelines confuse clinicians and multidisciplinary team approach is of paramount importance.


Lipomas originated from fingers are rare and the dissection is necessary when the lipomas limit the finger movement or cause pain.A 57-year-old male was admitted to our department due to a painless swelling on the volar side of the middle finger of the right hand. The flexion movement of the distal interphalangeal joint was limited.: Imaging studies and open biopsy confirmed that it was a finger lipoma.: An excisional biopsy was performed.: The patient recovered completely after two weeks.: Based on this case and literature we reviewed, ultrasound and MRI should be used to diagnose the finger lipoma and excision was the main treatment option. Clinically, most lipomas are asymptomatic mass with clear margin and moderate mobility. However, tumors that compress nearby nerves will cause pain. Here, we report a rare case of lipoma of the middle finger of the right hand, with no prior traumatic history.Lipomas are benign tumors occurring in regions of abundant adipose tissues. Previous study reported that hand lipomas were mainly found in the thenar and hypothenar regions.2The private information and medical records were obtained from patient with informed consent and with approval of the institutional ethics committee .3A 57-year-old man arrived at our Hand Surgery Department, with a complaint of a painless swelling on the volar side of the middle finger of the right hand. The mass had been found for more than 7 years and was growing slowly.Physical examination showed a soft, mobile subcutaneous mass of size 35 mm × 15 mm localized at the middle and distal phalanxes and the overlying skin was normal. The flexion movement of the distal interphalangeal joint was limited now due to the swelling. The patient denied fingertip paresthesia, palpable pulse, fluctuation, thrill, or bruit  was a better option to support the diagnosis of lipoma. In fact, researchers had found that MRI can provide a highly accurate diagnosis in more than 80% of the cases. Differential diagnosis based on imaging characteristics includes neoplastic and non-neoplastic lesions, such as giant cell tumor, implantation cyst, and spindle cell lipoma.,10 Lipomas usually don’t require treatment. However, if the lipomas cause pain or restrict joint movement, surgical resection is recommended.Etiology and pathogenesis of this disease are still unclear. Genetic, traumatic, and metabolic factors have been investigated and the conclusions were still inconsistent.In our case, the finger lipoma was mainly detected by ultrasound. At last, the tumor was removed surgically and the patient recovered completely after 2 weeks.


The conventional operative intervention for leaks following coloanal anastomoses has been proximal fecal diversion with or without take-down of anastomosis. A few of these cases are also amenable to percutaneous drainage. Ostomies created in this situation are often permanent, specifically in cases where coloanal anastomoses are taken down at the time of reoperation. We present two patients who developed perianastomotic pelvic abscesses that were treated with transanal large bore catheter drainage resulting in successful salvage of coloanal anastomoses without the need for a laparotomy or ostomy creation. We propose this to be an effective therapeutic approach to leaks involving low coloanal anastomoses in the absence of generalized peritonitis. Anastomotic leaks carry a reported mortality of 6 to 39% . MajoritWe present two patients managed with a transanal drainage following coloanal anastomotic dehiscence.An 86-year-old female underwent uncomplicated Altemeier procedure for rectal prolapse and was discharged on postoperative day (POD) 5. She presented to the emergency department two days after her discharge with fevers up to 102.6°F, pelvic pain, fatigue, and anorexia.On exam, she was febrile to 101.6°F, pulse was 79, and blood pressure was 117/58. Her abdominal exam did not reveal any evidence of generalized peritonitis, and lower abdominal tenderness was present. Her WBC count was 13.1. Imaging demonstrated a large fluid collection and gas within the pelvis that tracked cephalad in the retroperitoneum.She was admitted, made NPO, and started on antibiotics. Interventional radiology deemed the abscess not amenable to percutaneous drainage. Thus, we proceeded with an anorectal examination under anesthesia for surgical drainage of the area and stoma creation, if needed. She was noted to have a grossly intact anastomosis. A vaginal exam demonstrated fluctuant swelling in the posterior vaginal vault, and a 18-gauge needle was used to aspirate 30 mL of clear straw-colored fluid and air. A diagnostic laparoscopy was then performed demonstrating normal-appearing bowel and pelvis without evidence of fecal matter. We felt that the collection represented a post-op seroma, and operation was concluded at this time.The patient was maintained on empiric IV antibiotics, and her diet was resumed. She remained hemodynamically stable however continued to experience ongoing fevers. A CT scan was repeated on hospital day 6 , demonstOnce again, interventional radiology determined that the collection was not suitable for percutaneous approach, and she was taken back to the operating room. We were unsuccessful in accessing the abscess cavity via a skin incision on the right lateral aspect of coccyx. An anorectal exam under anesthesia revealed anastomotic defect extending about 1.5 proximally. The abscess cavity was suctioned out via this defect, and a 26-French Malecot drain was placed in the cavity transanally. The drain was then secured to perianal skin via two nylon sutures.Repeat CT scans done on 7 and 15 days after the drainage demonstrated resolving fluid collections Figures  and 3. TThe patient presented again two weeks later after spontaneous removal of Malecot drain. An exam under anesthesia was performed revealing involution of abscess cavity into fibrotic sinus tract. This tract was incorporated into the bowel lumen by dividing the septum with LigaSure device precluding the possibility of recurrent abscess caused by the presence of a narrow sinus tract.The patient was seen in follow-up in the office two months after her last procedure. She reported minimal residual rectal discomfort, was continent without recurrent prolapse, and endorsed normal bowel function.A 61-year-old male underwent low anterior resection for rectal cancer. He was discharged on postoperative day 11 after recovering from post-op ileus. Six days later, he presented to the emergency department with acute onset of abdominal pain. He was afebrile, had normal heart rate, and was mildly hypertensive on presentation. Although diffuse abdominal tenderness was present, there were no signs of peritonitis on exam. WBC count was 11.8K. CT scan demonstrated possible dehiscence at the anastomotic site and presence of enteric contrast in a pelvic collection measuring 4 × 5.1 cm without gross contamination of peritoneal cavity.He was taken to the operating room as the abscess was determined inaccessible via percutaneous route. The exam revealed a small posterior disruption of coloanal anastomosis. The cavity was suctioned out, and a transanal 26-French Malecot drain was placed.Diet was resumed a week after drainage, and drain was removed prior to his discharge on day 10. Follow-up CT scan demonstrated near resolution of the previously visualized fluid collection and a smaller cavity that communicated with the rectum . The patAbdominal wash out with stoma creation is the treatment of choice for an anastomotic dehiscence in presence of peritonitis. Many of these patients also require a complete take-down of anastomosis . The repRestoration of bowel continuity may not be possible after take-down of coloanal anastomosis; however, these leaks carry the benefit of accessibility via transanal route, which in select cases may allow for preservation of the anastomosis.It is imperative to note that both of our cases were hemodynamically stable and did not exhibit any signs of generalized peritonitis. Furthermore, anastomotic failures encompassed a small portion of anastomotic circumference. We strongly caution against employment of this technique in patients with frank peritonitis, hemodynamic instability, or major anastomotic disruption which, in our opinion, are best managed with fecal diversion and anastomotic take-down.Several previous publications have addressed the issue of anastomotic preservation with or without proximal diversion. Out of the techniques described, perhaps the most similar to our proposed method is the vacuum-assisted closure anastomotic leaks. Weidenhagen et al.  reportedPossible complications of proposed approach include anal pain, poor bowel function, and compromised fecal continence. Many patients go on to develop a chronic sinus that could lead to fistula formation  as witneOur case report demonstrates that transanal drainage is a viable option that allows anastomotic preservation while avoiding fecal diversion in selected patients with low anastomotic leaks.


Chondroblastic osteosarcoma, representing about 25% of osteosarcoma, is a fatal primary malignancy of the skeleton if not diagnosed and treated appropriately. It most commonly occurs in the long bones of the extremities near the metaphyseal growth plates. In this report, we describe the occurrence of chondroblastic osteosarcoma involving the left distal tibia in a 14-year-old male. The diagnosis was confirmed by the histological examination of a surgical biopsy. The patient was treated by both surgery and neoadjuvant chemotherapy. No recurrence was noted at 3 years of follow-up. To our knowledge, only two cases describing chondroblastic osteosarcoma of the distal tibia had been reported through English medical literature. Therefore, the aim of our article is to make the clinician aware of this rare clinical presentation and also to provide a comprehensive review of the literature related to this uncommon malignant tumour. Chondroblastic osteosarcoma (CO) is a variant of osteosarcoma which are the most common malignant tumours of the skeleton , 2. It rA 14-year-old boy, with no medical history, consulted our out-patient department for pain in his left leg evolving 3 months ago. There was no history of trauma. He hadn't fever, nor weight loss. On examination, we noted a painful swelling in the distal end of the tibia. There was no abnormal mobility in the distal end of left tibia. The plain radiographs showed a metaphyseal osteolytic lesion of the distal left tibia . A MagneWe reported an uncommon location of CO. In fact, this type of malignant tumor, like other conventional osteosarcomas, has a distinct predilection for the metaphysis of long bones and most commonly affects the knee region, especially the distal femur and proximal tibia –5. LocatHowever, in the case described by VandenBussche et al, the patient suffered from pathologic fracture . The radIn summary, we report a case of CO of the distal tibia, which is a rare condition. The diagnosis was confirmed by the gold standard biopsy. The multi-centric approach, which included the neo-adjuvant chemotherapy, meticulous surgical resection of the tumour and postoperative chemotherapy, improved the prognosis and prevented the limb loss.The authors declare no competing interests.


Colonic angiosarcoma is a rare malignancy representing only 0.0012% of all colorectal malignancies. Due to its non-specific symptoms, diagnosis is often delayed. However, because of the aggressive nature of this malignancy, it is important to keep it in the differential diagnosis of rectal bleeding, pelvic discomfort, chronic diarrhea, and weight loss in patients with risk factors. We present a case of angiosarcoma of the colon in a 74-year-old female with a remote history of chemo-radiation for anal squamous cell carcinoma (ASCC).  Angiosarcomas are rare malignant tumors accounting for less than one percent of the malignant sarcomas . They arA 74-year-old female with a history of anal squamous cell carcinoma (ASCC)  and past tobacco use was evaluated for chronic diarrhea of two months' duration. She also complained of rectal bleeding, pelvic cramps, and an unintentional 15-pound weight loss. She denied any nausea or vomiting. She did not report any new medications, sick contacts, changes in diet or recent travel. Her family history was non-contributory. On examination, her vital signs were stable. The abdomen was soft, non-tender, with no lymphadenopathy and a small umbilical hernia. Rectal examination was normal. There were mild external skin changes consistent with prior radiation therapy. Laboratory tests showed mild anemia with a hemoglobin of 11.2 g/dL (reference range 12.0-16.0 g/dL). She underwent a colonoscopy that revealed a stricture of the sigmoid colon, concerning for malignancy versus extrinsic compression. A computerized tomography (CT) of the chest, abdomen, and pelvis showed a thickened area of the sigmoid colon. Two hypodense areas were noted in the right and left lobes of the liver, in addition to infiltrates in the right middle and left lower lung lobes concerning for metastases. An omental implant concerning for metastatic spread was seen adjacent to the cecum. On positron emission tomography (PET) scan, the sigmoid colonic thickening was markedly hypermetabolic. Carcinoembryonic antigen was 0.4 ng/ml (reference range 0.0-3.0 ng/ml) and cancer antigen 125 (CA 125) was also within normal limits at 18 U/ml (reference range 0-21 U/ml). A laparoscopic sigmoid resection with primary anastomosis was performed. On histologic examination, the sigmoid colonic tumor was composed of infiltrative, pleomorphic cells forming vascular channels  reported in 2013 [Colonic angiosarcoma commonly metastasizes to the liver, lungs, and bones . MetastaDue to the rarity of the condition, there are no specific guidelines for the diagnosis or the management of colonic angiosarcoma . SurgicaColonic angiosarcoma is a rare but possible cause of chronic diarrhea, rectal bleeding, and pelvic discomfort in patients with a history of chemo-radiation. Recognition of the angiosarcoma and experience with more cases may help establish management guidelines for patients with this rare but aggressive colonic malignancy.


Odontogenic cysts have a high prevalence in the dental clinic population, with dentigerous cyst being one of the most frequent ones and whose aetiology involves accumulation of fluid between the reduced enamel epithelium and the crown of an unerupted tooth. In the diagnostic process of these lesions, one should consider complementary imaging exams such as conventional radiography and computed tomography, which are commonly used for providing anatomical information on the tissues compromised by the lesion, but not on the nature of it. Magnetic resonance imaging (MRI) scans are noninvasive modalities which, due to their unique acquisition characteristics, can provide distinct information on the nature of the lesion. This study reports on a case of dentigerous cyst in the mandible of a 9-year-old patient, documented by means of different imaging modalities. MRI played an important role in both diagnosis of the lesion and differential diagnosis between neoplastic lesions presenting similar imagenological behaviour under other techniques of radiography. A considerable number of lesions can compromise the dentomaxillofacial complex. Among these, one can highlight tumours and cysts of odontogenic origin as they are highly prevalent in the dental clinic population. The majority of the gnathic cysts are lined by odontogenic epithelium—the reason by which they are termed odontogenic cysts , 2.Dentigerous cyst is the most common odontogenic cyst originating from the separation of the pericoronal follicle from the unerupted tooth, with prevalence of about 20 percent among all cysts lined with epithelium in the maxillae .In the diagnostic process of these lesions, one should consider imaging exams, such as the complementary modalities due to mainly their easiness of access, acquisition, and use of relevant information for conducting the diagnostic process . ImagingIn addition to the conventional radiographic techniques, the cone beam computed tomography (CBCT) is a remarkable modality as it provides accurate information regarding location, delimitation, and effects of lesions on the surrounding structures, since the resulting images are shown with no overlapping and distortion, which allows us to characterise the structures three-dimensionally. Nevertheless, despite the actual contributions, these exams have significant limitations compared to MRI, with exposure to X-ray radiation being the main one .Recent research has shown that MRI provides information which are beyond the image quality, not exposing the patient to the harmful effect of ionising radiation and thus helping determining a precise diagnosis both spatially and anatomically for conducting the treatment. The determination of the content of the lesions is another advantage consistent with MRI compared to other imaging modalities , 9.The aim of this study is to discuss on several diagnostic imaging modalities by means of a case report of a dentigerous cyst, emphasising the singular role of MRI in the analysis and treatment planning for such a lesion.A 9-year-old male patient was referred to our clinics for evaluation of the presence of asymptomatic tumefaction, hard on palpation, in the right posterior region of the mandible, resulting in a facial asymmetry. Intraoral examination showed evidence of lingual displacement of tooth #45 as well as presence of root remnants of tooth #46, including a solid mass lined by mucosa of normal appearance in the region corresponding to the entire alveolar crest extending occlusally .Panoramic radiograph was performed and showed a radiolucid, unilocular image of precisely corticalised limits involving tooth #47, which was in horizontal position and projecting towards the ipsilateral region of the mandibular ramus, with the crown medially positioned. This lesion extended from the apical region of tooth #45 to the corresponding mandibular ramus, with a very thin mandibular base encompassing the root remnants of tooth #46 . The radCone beam computed tomography  was used to evaluate the lesion three-dimensionally, operating with field of view (FOV) of 16 × 6.0 and voxel size of 0.2 mm. The resulting images enabled us to identify a homogeneous hypodensity of the lesion internally as well as its expansive aspect lingually, buccally, and inferiorly. An advanced thinning of bone cortices and complete basal displacement of the right mandibular canal were also observed. No region suggesting bone in continuity at the borderline areas of the lesion was observed either, which characterised its expansive nature .The CBCT images were consistent with the diagnostic hypotheses suggested by the panoramic radiograph, which enabled us to conduct a more precise investigation of the lesion in terms of damage to the surrounding osseous structures. However, the clinical, radiographic, and tomographic characteristics were not enough to clarify the real nature of the lesion, thus making the decision-making process difficult for an initial surgical approach.In order to conduct the differential diagnostic process and evaluate the internal content of the lesion, MRI was also performed by using a Sigma Tesla machine  with head coil at axial, sagittal, and coronal anatomical planes for T1- and T2-weighted images, which were obtained by using an 8-channel phased array head coil with T1 sequence  and T2 sequence . These images have evidenced the previously viewed expansive characteristics. The T1-weighted images showed the internal intermediate signal of the lesion, which are homogeneous characteristics demonstrating the absence of calcification process and fat content. On the other hand, the T2-weighted images showed hypersignal content delimited by areas of signal ranging from intermediate to hyposignal intensity, indicating presence of liquid content  with consequent differentiation from a solid tumour .After evaluation of the MR images and aspiration punction characterising the cystic content of the lesion, an incisional biopsy was performed and a decompression device was installed. The biopsy material was sent for histopathological exam. We have observed on the laminas fragments of cystic capsule partially lined by non-keratinised stratified epithelium. In the focal area, one could note an eosinophilic staining in the epithelium as well as columnar cells in the periphery and cuboidal cells in the basal region. The capsule consisted of dense conjunctive tissue and exhibited multiple cordon-nest-like structures typical of odontogenic epithelium. In some areas, there was a tissue with myxoid appearance and in others it was possible to identify inflammatory infiltrate which was predominantly lymphoplasmocitary, ranging from discrete to moderate. Adipose tissue and hemorrhagic areas completed the histological picture, characterising the final diagnosis of dentigerous cyst as hypothesised after MRI examination .After four months of the installation of decompression device, a new panoramic radiography was performed to evaluate the periphery of the lesion, where an area of bone sclerosis (compatible with bone neoformation) was observed, thus evidencing a tissue-repair process. With regard to the radiographic evolution of the case by comparing the images, it was observed that there was a significant decrease in the cystic volume and discrete reorientation of the eruption axes of the displaced teeth .The radiographic and tomographic aspects, including the clinical characteristics, were found to be relevant as they allowed us to determine the differential diagnosis of the present case, namely, dentigerous cyst, unicystic ameloblastoma, or KOT. This happened because these lesions are clinically and radiographically similar –7, 9, 10In general, these lesions are considered diagnostic hypotheses when one observes a single lesion located in the posterior region of the mandible close to the third molar, with enhanced density at the centre, and well-delimited –7, 9, 10For this reason, MRI has played a key role in the diagnostic process by providing new information which enabled us to determine a consistent presumptive diagnosis and consequently a more coherent surgical approach , 7, 11.The T1-weighted image of the lesion showed an intermediate signal, thus not being useful for determination of the content of the lesion. Nevertheless, T2-weighted image enabled us to observe an intense brightness inside the lesion, which contributed significantly to the interpretation of a probable cystic lesion rather than tumoural. These MRI data were important for us to consider the dentigerous cyst as the most probable lesion among the options raised in the differential diagnosis , 11.Such information had notable repercussions on both diagnosis and initial therapeutic approach. In fact, the dentist-surgeon who performed the biopsy had considered the presumptive diagnosis of dentigerous cyst but then considered decompression as the most plausible option of treatment .Regardless whether the case involves a tumoural or cystic lesion, the biopsy would be indicated anyway because the final diagnosis was based on histopathological examination as recommended in the clinical practice. The histopathological results confirmed the presumptive diagnosis of dentigerous cyst, showing that the MRI data should be considered relevant in the diagnostic process as it allows for differentiation between cystic and tumoural lesions in terms of content –15.Although other lesions have a similar image pattern of dentigerous cyst on MRI, this technique helps limit substantially the broad differential diagnosis . Histopathology is the key element in preparing the final diagnosis , but MRIConsidering the real contribution of MRI to the diagnosis and treatment of the present case as well as to other cases reported in the literature, it is clear that the dentist-surgeon should consider it as an essential modern tool for optimisation of the patient treatment , 9, 16.In conclusion, the benefits of MRI in the diagnostic process were found to be obvious in the present case report. The use of this complementary examination enabled the practitioner to have a safer and more efficient performance, thus optimising the treatment for the patient.


Peripheral Ameloblastoma (PA) is the rarest variant of ameloblastoma. It differs from the other subtypes of ameloblastoma in its localization: it arises in the soft tissues of the oral cavity coating the tooth bearing bones. Generally, it manifests nonaggressive behavior and it can be treated with complete removal by local conservative excision. In this study we report a case of PA of the maxilla in a 78-year-old female patient and we describe the four different histopathological patterns revealed by histological examination. After local excision and diagnosis, we planned a long term follow-up: in one year no recurrence had been reported. The choice of treatment is illustrated in Discussion. Ameloblastoma is a benign odontogenic tumour which originates from ameloblasts. It commonly arises between the third and the fourth decade of life –3 and itA 78-year-old female patient was referred to the Dental Clinic of the University of Padua in order to evaluate a painless swelling on the palatal mucosa located near the superior left canine. The lesion, as described by the patient, was first noticed 10 years before. The patient was a nonsmoker and was under treatment for hypertension . Oral examination revealed two adjacent lesions, covered with normal coloured mucosa, measuring 7 × 5 × 5 mm and 4 × 3 × 3 mm . The maiExcisional biopsy of the two lesions was performed under local anaesthesia, and the tissues were submitted to histopathological examination. Microscopic examination of the main lesion showed a mucosal mass covered by stratified squamous epithelium . The lamAccording to the clinical, radiographic, and histopathological exams, a PA was diagnosed. Four months after the excisional biopsy the surgical wound appeared healed by secondary intention. Further surgical approach  was deemed unnecessary and a two-month follow-up was planned. After two months the lesion area was clinically unchanged. A second CT performed 10 months later did not show the superficial bone resorption, confirming the tumour was not infiltrating the bone . After oTreatment of the subtypes of ameloblastoma is still controversial and it is based on recurrence potential and aggressivity of each subtype. In addition, the choice of treatment depends not only on the apparent microscopic pattern on biopsy, but also on the tumour location, size of the lesion, age of the patient, and reliance of the patient for good long term follow-up.Whereas radiotherapy and chemotherapy are not recommended techniques, surgical intervention, radical or conservative resection, is the preferred management for ameloblastomas .Radical resection can be marginal or segmental and it is associated with a recurrence rate ranging from 0% to 10% , 4. SuchSolid and multicystic ameloblastoma can be treated with a surgical approach extended up to 1–1.5 cm around radiographic or histologic margins of the lesion since, because of its capacity of infiltrating the bone, it is regarded as a locally aggressive tumour , 4; consUnicystic ameloblastoma, which is thought to be less aggressive than solid or multicystic ameloblastoma, often can be treated with enucleation and peripheral ostectomy sometimes supplemented by physicochemical treatment  . However3/month, resp.) [PA, per contra, manifests a benign behaviour with an average growth rate lower than other subtypes of ameloblastoma  , 21. Mor, resp.) , 8, 9. T, resp.) .In the reported case the tumour appeared as an exophytic sessile lesion and the patient had no symptoms. Intraoral examination as well as the radiographs gave no useful indication in order to formulate the correct diagnosis. The lesion was treated with local excision and, after the response of the histopathologic laboratory, further surgical approaches were judged as unnecessary overtreatments. Nevertheless, considering the recurrence rate of the PA (from 16% to 19%) , 22, 23


To present a case of conjunctival lymphoma in a young woman complicated by pregnancy.A 38-year-old previously healthy woman presented with a 2-year history of progressive right blepharoptosis. Giant papillomatous sessile masses were identified in the upper and lower fornix bilaterally and involved the tarsus of the right upper lid. The remaining ophthalmic examination was unremarkable. Histopathology and immunohistochemistry showed mucosa-associated lymphoid tissue (MALT) lymphoma with immunoglobulin kappa monotype. Further workup showed no evidence of systemic lymphoma or orbital involvement.Partial regrowth of conjunctival lymphoma occurred 6 months after excision and the MALT lymphoma remained indolent during the course of her pregnancy without radiotherapy. Lymphomas that occur outside of lymph nodes or the spleen are defined as extranodal and account for about 24% to 48% of lymphomas. Mucosa-associated lymphoid tissue (MALT) lymphoma  is the predominant histopathological type of malignant lymphoma of the conjunctiva. It presents primarily in female patients in their late 60s and is often localized and of indolent clinical behavior –8. It doThe study protocol adheres to the tenets of the Declaration of Helsinki, and was approved by the Human Research Ethics Committee at Chang Gung Memorial hospital, Taiwan No. 100-2022B). A 38-year-old woman visited the Chang Gung Memorial Hospital in March 2010 complaining of progressive painless right blepharoptosis over a 2-year period. She had no relevant medical history. The initial ocular examination showed that her best-corrected visual acuity was 20/20 in each eye, and her eye movements were full in both eyes. The anterior and posterior segments of both eyes were normal. A giant papillomatous mass was identified in the entire superior tarsal conjunctiva of the right eye  with immunoglobulin kappa monotype Fig. . The Ki-Extranodal lymphomas can occur in a variety of organs, including the conjunctiva, orbit, salivary glands, skin, thyroid, lungs, stomach, and intestines. Ocular adnexal involvement occurs in <10% of extranodal lymphomas . ConjuncConjunctival lymphomas can masquerade as chronic conjunctivitis that does not respond to various treatments . StraussHere we report a case of tarsal conjunctival lymphoma for which blepharoptosis was the sole manifestation. MALT lymphomas occur in patients of all ages but are most common in patients aged 50–70 years. The differential diagnosis includes the following: Conjunctival papilloma typically presents with a pink sessile or pedunculated configuration; conjunctival amyloidosis can appear as a yellow to pink diffuse mass; and chronic papillomatous or follicular conjunctivitis and metastatic tumors can appear as multiple elevated fleshy pink vascularized tumors that may resemble conjunctival lymphoma clinically. Tumor biopsy is critical to differentiate conjunctival tumors.The most common ocular site for lymphoma involvement is the orbit. McKelvie et al. reported a series of 73 patients with lymphoproliferative lesions of the ocular adnexa, disease of the orbit and lacrimal gland comprised 74.3%, and conjunctival disease was noted in 17% in their series . There mOur patient was relatively young at the onset of lymphoma, and systematic workup showed no other organ involvement. Immunohistochemical study showed positivity for CD20 with the absence of staining for CD3 lymphocytes, along with a monotypic expression of kappa light chains. In patients with stage IE ocular adnexal lymphomas, localized radiotherapy is the treatment of choice, and surgery alone is not recommended because of the high recurrence rate , 18–20. Conjunctival MALT lymphoma during pregnancy is uncommon. When making treatment decisions for cancer during pregnancy, it is important to consider the best treatment options for the pregnant woman balanced against the possible risks to the growing baby. Surgery poses little risk to the growing baby and is considered the safest cancer treatment during pregnancy. Radiation therapy can harm the fetus in all trimesters; physicians generally avoid using this treatment during pregnancy. The risks to the baby depend on the dose of radiation and the area of body being treated. In our case, the conjunctival lymphoma remained latent during her pregnancy; there was no systemic metastasis in 5 years with excision therapy alone. More information is needed for the effect of pregnancy on the clinical course of conjunctival lymphoma.


A granuloma is a collection of epithelioid histiocytes that is often associated with multinucleated giant cells, and is considered widely to be a non-neoplastic lesion, although some lesions demonstrate aggressive behavior similar to that of a neoplasm. The diagnosis of giant cell granulomas  is confirmed by histopathologic examination. Early detection and excision are important to minimize potential dentoalveolar complications. The following article consists of case reports of central and peripheral giant cell granuloma (PGCG), and discussion about the diagnosis and management of such lesions.How to cite this article: Mukherjee CG, Mukherjee U, Bansal A, Mukhopadhyay M. Giant Cell Granuloma: Two Expressions in Pediatric Population. Int J Clin Pediatr Dent 2018;11(1):46-49. In some cases, these undergo progressive growth and reach a considerable size, which compromises oral function. Peripheral exophytic lesion occurring on the gingival/ alveolar crest. Centrally located lesion within the jaw, facial bones, or skull.2 Both lesions are characterized by the presence of several multinucleated giant cells and mononuclear stromal cells in a fibrous connective tissue matrix.3 The most common treatment is surgical, which may range from curettage to en bloc resection.4 This article reports two cases of giant cell granuloma, central and peripheral, and describes the presentation, investigation, diagnosis, and treatment.These are benign reactive lesions, which are of unknown etiology and pathogenesis.An 8-year-old boy reported with a swelling in the right upper front region of the jaw for the past 6 months. History revealed that initially, the swelling was small in size, and increased gradually, and did not respond to antibiotics prescribed by the physician. Intraoral clinical examination revealed a single, sessile, firm, localized, nontender swelling in the edentulous region, extending from distal margin of 52 till the mesial margin of 55 (approximately 3 cm × 4 cm). The mucosa over the swelling was erythematous with a purple hue, with indentations on the surface due to contact with teeth of the opposing arch . CalculuOrthopantomogram revealed a poorly circumscribed radiolucency extending from region of 52 to 55 .Written consent from the parents was obtained, followed by incisional biopsy. The histopathological sections stained with hematoxylin and eosin revealed superficial ulcerated stratified squamous epithelium. The lamina propria revealed profuse multinucleated giant cells in highly cellular and vascular connective tissue stroma. The stromal tissue also showed extravasated red blood cells and hemosiderin pigment  and 4.Thus, the diagnosis of PGCG was confirmed. Excision of the entire growth was carried out after a week, under local anesthesia, followed by placement of sutures.A 4-year-old girl reported with slowly enlarging bony hard swelling in the lower right back region of face, causing gross facial deformity. Orthopantomogram revealed multilocular radiolucent shadow extending from mandibular right first deciduous molar till anterior border of ramus of the mandible .Written consent from the parents was obtained, followed by incisional biopsy. Photomicrograph of the section stained with hematoxylin and eosin revealed multiple multinucleated giant cells in highly cellular and vascular connective tissue stroma. The stromal tissue showed bony trabeculae, osteoids, and hemosiderin pigments. The case was finally diagnosed as central giant cell granuloma (CGCG) .Surgical management involved meticulous removal of the lesion intraorally along with additional curettage.Postoperative panoramic radiograph showed evidence of satisfactory healing .5 clinically manifesting as a firm sessile or pedunculated nodule.6 It arises usually in response to local irritation, mainly from the gingival connective tissue, periodontal membrane, or periosteum of the alveolar ridge.7The PGCG of the oral cavity is more commonly seen in the mandibular arch,8Radiographic features are usually nonspecific. Sometimes, the crest of the interdental bone or the alveolar margin exhibits signs of superficial destruction when the granuloma occurs associated with the teeth. Superficial erosion with peripheral “cuffing” of the underlying bone is seen in cases where the granuloma arises from the edentulous ridge.9 It is characterized by a nonencapsulated mass of tissue, which consists of a reticular and fibrillar connective tissue stroma with plump, ovoid, and fusiform fibroblasts and multinucleated giant cells.10 Management includes eliminating the entire base of the growth along with any local irritating factors.The differential diagnosis of PGCG includes pyo-genic granuloma, fibrous epulis, inflammatory fibrous hyperplasia, peripheral ossifying fibroma, peripheral odontogenic fibroma, and papilloma. Histopathological examination confirms the diagnosis.1In children, reactive oral lesions like PGCG may exhibit a rapid growth rate and, within several months of initial diagnosis, reach significant size. These soft tissue nodules may sometimes be quite aggressive and cause bone resorption, interfere with eruption of teeth and its movement of varying degrees. Radiographs aid in confirming that PGCG does not represent a central bone lesion with cortical perforation along with soft tissue extension, but from the oral mucosa. Early detection results in decreased risk of tooth and bone loss.10Central giant cell granuloma, a relatively uncommon benign bony lesion, exhibits a variably aggressive nature, occurring predominantly in children and young adults. It is usually asymptomatic, discovered during routine radiographic examinations, or when the painless bony expansion is noted by the patient or the parents.10Serum parathyroid hormone levels should be analyzed in such cases, in order to rule out the diagnosis of Brown’s tumor, as seen in cases of hyperparathyroidism.Some reports have divided the lesions of CGCG into two categories: Nonaggressive lesions with a slow growth rate, without cortical perforation, and may show new bone formation;10 Aggressive lesions grow quickly and are associated with pain, cortical perforation, and root resorption. Paresthesia of the lip is an occasional finding.11Establishment of a definitive diagnosis relies on a combination of the clinical and radiological findings with biochemistry and histopathology. Conventional management is by curettage or resection, which may result in loss of teeth, or developing tooth germs. Non-surgical treatment includes systemic calcitonin therapy and intralesional injections with corticosteroids, which may be considered in case of children, since it does not involve immediate loss of teeth or bone structure but may require eventual future surgical treatment.The choice of treatment is influenced by clinical behavior of the lesion. The patient’s age, site, and extension of the growth are also contributing factors. Early detection in children enables conservative management, resulting in decreased undesirable loss of oral structures.


Bezoars are an uncommon cause of mechanical intestinal occlusion. There are four different kinds of bezoars: phytobezoars, made of vegetables and fibers; trichobezoars, resulting from the ingestion of hair and frequently an expression of psychiatric disorders; lactobezoars, which are formed of milk curd; and pharmacobezoars, caused by drugs and medications. Symptoms are classically indistinguishable from one another and from more common causes of intestinal occlusion, so it can be difficult to establish a correct diagnosis in order to apply the correct treatment. We present a rare case of two different phytobezoars causing intestinal occlusion . We also describe the correct techniques for making a correct and fast diagnosis of occlusion caused by phytobezoars, and the possible conservative and operative treatments.We present the case of a double phytobezoar that was surgically treated with a double enterotomy. Our patient was a 68-year-old Caucasian man with a medical history of hypertension, a previous open appendectomy, and open repair of a perforated gastric ulcer. He was admitted with a 5-day history of abdominal pain located in his upper quadrants along with vomiting. After a preoperative examination, he was taken to the operating room. He was discharged in a good clinical condition 11 days after surgical intervention. A physical examination at 6 months demonstrated our patient was in good health.Diagnosing bezoars is difficult because of their rarity. However, they must be taken into consideration in a differential diagnosis because their treatment is not always surgical. In fact, it may be conservative in many cases and a correct diagnosis will guide towards the correct therapy. Small bowel obstruction (SBO) is a common surgical presentation, with different possible etiologies that include postoperative adhesions 60–80%), volvulus, intussusceptions, hernias, and tumors. In all these cases symptoms are similar and include abdominal pain, nausea and vomiting, inability to pass gas or bowel movements, and sometimes fever , so a co0–80%, voTrichobezoars occur especially in psychiatric disorders, such as trichotillomania and trichophagia. They are more frequent in young women and frequently located in the stomach, with a possible extension up to the ileocecal junction , 11, 12.Symptoms such as abdominal pain and distension, nausea and vomiting, dysphagia, weight loss, fever, and constipation , 17, 18 3; normal, 19,900/mm3) with signs of hemoconcentration . His liver and renal function were normal, with a creatinine concentration of 0.99 mg/dL. An abdominal X-ray revealed signs of bowel obstruction with jejunal air-fluid levels. An abdominal computed tomography (CT) scan with contrast medium showed massive distension of his stomach, duodenum, and jejunum with an abrupt stop at that point: the remaining loops of his intestine appeared to have collapsed. Particularly, his stomach and the lower third of his esophagus were distended by abundant fluid material and there was no evidence of free air in his abdomen and no peritoneal fluid (Fig. A 68-year-old Caucasian man was admitted to our emergency surgery with a 5-day history of abdominal pain located to his upper quadrants along with vomiting. Our patient’s history included hypertension, a previous open appendectomy, and open repair of a perforated gastric ulcer. He described the pain as a worsening continuous ache lasting several hours, relieved by taking prokinetic agents and anti-emetics. A physical examination revealed a slightly distended abdomen. Deep palpation caused pain in his left quadrants but there were no signs of peritoneal or gallbladder inflammation; both Murphy and Blumberg signs were negative. Auscultation revealed active peristalsis. His laboratory test results were significant for neutrophilic leukocytosis (21,900/mmTaking into account his clinical symptoms, laboratory test results, and the instrumental evaluation, urgent explorative laparotomy was performed. This revealed abnormal distension of his stomach and jejunum, with two foreign bodies of diameter 4 cm, one in the gastric body Fig.  and one Phytobezoars are an uncommon etiology of SBO. They can be suspected in patients with co-morbidities or psychiatric diseases but diagnosis in healthy patients can be difficult, in particular if diagnosis is based solely on a physical examination and anamnesis . In the The treatment of bezoars can be conservative, especially in the case of phytobezoars. Mechanical disintegration can be tried, using mechanical lithotripsy, a Dormia basket, or an electrosurgical knife . ChemicaBezoars must be taken into consideration in cases of SBO even though they are infrequent. Their presentation classically is indistinguishable from other causes of occlusion. In cases in which the nature of the occlusion is known, the treatment could be nonsurgical. The case presented in this article is interesting because bezoars were not suspected. However, in our particular case, the choice of treatment would have been the same, even if starting with the correct diagnosis. It must be noted that surgery may not always be the best course of treatment. Therefore, it is important to make an accurate diagnosis in order to adopt the most effective strategy and consider every possible solution.


Primary natural killer (NK)/T cell lymphoma of adrenal glands is an extremely rare tumor with aggressive clinical behavior. There have only been a few cases reported worldwide and the highest reported survival was 90 days. We report the first case of primary unilateral adrenal NK/T cell lymphoma in China with good outcome.This is a 28-year-old man who presented with abdominal pain and was found to have a large mass on the left adrenal and the top of the renal region. The patient underwent surgical resection and the pathology revealed primary adrenal NK/T cell lymphoma. He received adjuvant sandwich therapy encompassing sequential chemotherapy, radiotherapy and chemotherapy. The patient remains clinically and symptomatically disease-free with over two years follow up.Given the rarity of this disease, there is limited experience with regard to its diagnosis and treatment. This case report will add to the scant literature on this tumor and will be useful for the differential diagnosis and treatment of adrenal disease. There have been seven reported cases of NK/T cell lymphoma involving adrenal masses worldwide –7. AmongA 28-year-old male experienced abdominal pain and a mass on the left side of the abdomen. Color duplex ultrasonogram and subsequent computed tomography (CT) scan revealed a 10 × 9 cm adrenal mass invading the top of left renal and partial of retroperitoneal region Fig. . These aAfter the surgery, the patient was without any systemic symptoms. He did have a 10 kg weight loss secondary to the removal of the majority of the large mass and the poor postoperative nutrition support. The postoperative physical examination was unremarkable. A postoperative CT scan of the abdomen showed a residual tumor, measuring 2.7 × 5.3 cm at the left side of retroperitoneum with the absence of left adrenal gland and kidney  is a standard chemotherapy regimen for NK/T lymphoma patients in the western countries. However, there was a shortage of L-asparaginase in our province in the end of 2013, when this patient was first treated. Therefore, this patient was treated with CHOP according to the previous case reports , 7. As aOur patient remains disease-free with a follow up of over two years. We list three possible reasons for the longer disease-free survival for our patient: (1) the NK/T cell lymphoma only involved one adrenal gland; (2) the NK/T cell lymphoma did not involve other organs, except for the adjacent kidney; and (3) the utilization of trimodality therapy.In conclusion, primary adrenal NK/T cell lymphoma is an exceedingly uncommon neoplasm and the outcomes for it are generally poor. We present the first case of a primary adrenal NK/T cell lymphoma in China with over 2-year disease-free survival treated with trimodality therapy. NK/T cell lymphoma should be considered in the differential diagnosis of a rapidly enlarging adrenal mass. As reports of such cases increase and our understanding of the disease improves, we anticipate more effective treatment for these patients.


Emphysematous cholecystitis (EC) is a distinct clinical disease that carries a high rate of morbidity and mortality. Maintaining a high index of suspicion, especially in the right patient population, combined with emergency bedside ultrasound can lead to rapid diagnosis and initiation of treatment for this life threatening condition. Abdominal pain and biliary diseases are common complaints and findings in emergency departments. Emphysematous cholecystitis (EC) is a rare but clinically important form of acute gallbladder inflammation separate from acute cholecystitis -3. This We report a case where emergency medicine bedside ultrasound (EMBU) played a key role in the prompt diagnosis and initiation of appropriate treatment which led to further imaging and surgical consultation for this unique disease. Informed consent was obtained from the patient for this study.A 65-year-old male with a significant past medical history, including insulin dependent diabetes mellitus and nonischemic cardiomyopathy (status post left ventricular assist device placement) presented with a two-three days history of crampy abdominal pain, nausea, anorexia, and fever. The temperature on presentation was 103°F. A physical exam revealed an acute on chronically ill appearing male with mild right upper quadrant tenderness to palpation. Laboratory testing showed normal white blood cell count of 7.7 (thousand/mL), elevated alanine transaminase 91 (U/L), aspartate aminotransferase 199 (U/L), alkaline phosphatase 280 (U/L), total bilirubin 4.7 (mg/dL) and lactic acid 2.5 (mmol/L).EMBU of the right upper quadrant demonstrated a distended gallbladder with small layering gall stones, biliary sludge, a thickened gallbladder wall, small amounts of pericholecystic fluid, and most interestingly echogenic foci rising from the dependent part of the gallbladder towards the nondependent wall (gas). Refer below for sonographic findings Figure -2.Given the concern for EC from the above findings, computed tomography (CT) of the abdomen and a comprehensive radiology were performed and the right upper quadrant ultrasound was obtained. Abdominal CT showed gallbladder distension and wall thickening with a small amount of nondependent gas in the region of the gallbladder wall Figure . The comDuring surgery, the gallbladder was noted to be thickened and edematous. The patient had an unremarkable intraoperative cholangiogram. Pathologic examination of the gallbladder revealed multiple flat black calculi, tan-red mucosa, and adherent yellow-brown material. The gallbladder wall ranged from 0.5-0.7 cm in thickness.Blood cultures (obtained prior to administration of antibiotics) grew Enterobacter aerogenes and Clostridium perfringens. The patient was transitioned to oral levofloxacin and metronidazole and discharged from the hospital six days after surgery.As stated above, the EC is a rare but distinct clinical disease. It occurs more commonly in males and diabetics and has high morbidity and mortality 15%) rates compared to acute cholecystitis despite its often deceptively mild clinical findings 5% rates . EC ofteClassic sonographic findings of EC include highly echogenic collections of gas, with or without shadowing and reverberations, which originate from the gallbladder wall or lumen. These are often described as “powder snow like” speckled echoes. Another finding is termed the “effervescent gallbladder” in which gas bubbles are seen rising from the dependent portion of the gallbladder towards the nondependent portion. This has been described as similar to champagne bubbles rising in a glass -3.It is important to consider other potential sources or causes of gas in the gallbladder/biliary tree in addition to gas forming infections. These include enterobiliary fistula or anastomosis, incompetent sphincter of Oddi, spontaneous internal biliary fistula, recent instrumentation such as endoscopic retrograde cholangiopancreatography (ERCP), medication side effects  and cholangitis .Establishing the diagnosis of EC requires clinical suspicion and visualization of gas in the gallbladder lumen and/or wall. It is especially important to maintain a high index of suspicion when the gallbladder is poorly visualized, especially in patients with a history of diabetes. Treatment includes prompt cholecystectomy or if a patient is a poor surgical candidate, an alternative therapeutic option includes broad spectrum antibiotics in conjunction with percutaneous cholecystostomy , 4.This case report emphasizes the role of EMBU in the rapid diagnosis of this concerning disease. Bedside images were obtained and interpreted within 20 minutes of the patient arriving at his emergency department room. Comparatively, the comprehensive right upper quadrant ultrasound by Radiology took 95 minutes from arrival time to obtain and 155 minutes from arrival for preliminary radiographic interpretation. CT images took 228 minutes from arrival to obtain and 351 minutes from arrival for preliminary radiographic interpretation.Given the high morbidity and mortality associated with emphysematous cholecystitis (EC), prompt diagnosis and appropriate management are crucial. An understanding of the sonographic findings of EC and use of emergency medicine bedside ultrasound (EMBU) can aid in the rapid identification of this distinct clinical entity.


Postprandial symptoms of neuroglycopenia after bariatric surgery may result as a consequence of endogenous hyperinsulinemic hypoglycemia (nesidioblastosis) not dumping syndrome. Pancreatectomy is an acceptable treatment for this condition. We present the The online version of this article (doi:10.1007/s11695-016-2318-6) contains supplementary material, which is available to authorized users. In 2005, Service et al.  called a2). Episodes of hypoglycemia erroneously attributed to dumping syndrome started 5 months after the operation. The Roux-en-Y gastric bypass was converted to a sleeve gastrectomy (body mass index 23 Kg/m2) after 4 years. The new operation was not successful in controlling the episodes of hypoglycemia. A full workup excluded an insulinoma and the diagnosis of nesidioblastosis was made. A robotic subtotal pancreatectomy was performed. Operative time was 7 h. A self-limited pancreatic fistula was the only complication associated to the procedure. No intervention was necessary to treat the fistula. The patient was discharged at postoperative day 5. Pathologic examination of the pancreas confirmed the diagnosis of nesidioblastosis. No episode of hypoglycemia or pancreatic insufficiency was observed with a follow-up of 2 months.A 34-year-old obese female patient underwent a laparoscopic Roux-en-Y gastric bypass (body mass index 41 Kg/mHypoglycemia is a rare event after restrictive bariatric operations but it has an incidence of 0.2 % after Roux-en-Y gastric bypass . DiffereESM 1(MP4 1.14 GB)


Because of its high rate of early recurrence and its poor prognosis, long-term survival after cholangiocarcinoma is rare; therefore, only limited information on patients surviving more than 5 years after surgical therapy is available.We report the case of a 57-year-old white man who developed a distal bile duct carcinoma 9 years after curative surgical therapy of intrahepatic cholangiocarcinoma. He had undergone a right lobe hemihepatectomy 11 years ago. Nine years later, he was diagnosed with a distal bile duct carcinoma and a duodenopancreatectomy was performed. On histologic examination both carcinomas revealed a tubular and papillary growth pattern with cancer-free resection margins and for both carcinomas there were no signs of lymphatic infiltration or metastatic spreading. Targeted next-generation sequencing showed an identical activating mutation pattern in both carcinomas.Late recurrence of cholangiocarcinoma, even anatomically distant to the primary, in long-time survivors is possible and could be caused by a distinct tumor biology. A better understanding of the individual tumor biology could help hepatologists as well as hepatobiliary and pancreatic surgeons in their daily treatment of these patients. Cholangiocarcinomas (CCA) account for 3 % of all gastrointestinal tumors , with anAccording to their anatomical localization they are classified as intrahepatic (iCCA), perihilar (pCCA), and distal (dCCA) carcinomas . In a laIn Western countries, common risk factors for CCA are primary sclerosing cholangitis (PSC), inflammatory bowel disease, alcohol, tobacco smoking, fatty liver disease, diabetes, cholelithiasis, and choledocholithiasis; the common risk factor for iCCAs is viral hepatitis. Furthermore, there are gene variations, which might have the potential to enhance carcinoma development , 6, 7.The only available curative treatment option is surgical resection with negative margins. Depending on the localization, there are also options for neoadjuvant, adjuvant, and palliative chemotherapy, radiation, ablative treatment, and even liver transplant . The ratDue to the reported low survival rates there are only a few patients who develop a secondary CCA. If recurrence occurs, it needs to be differentiated between recurrence as metastatic disease, a locoregional relapse, probably due to residual cells after the first operation or a second primary in other parts of the biliary system due to field change or genetic predisposition .2 at the time of presentation. His mother had colorectal cancer otherwise there was no family history.Eleven years ago, a 46-year-old white man presented with painless jaundice. He showed no other symptoms and had no risk factors such as high alcohol consumption or tobacco smoking. With a bodyweight of 73 kg and a height of 175 cm his body mass index (BMI) was 24.49 kg/mAn endosonography showed an intraluminal polypoid tumor with disintegration of all wall layers at the bifurcation of his bile duct system. The finding was confirmed by endoscopic retrograde cholangiopancreatography (ERCP). Biopsies were taken with the pathologic results coming back inconclusive.Computed tomography showed an intrahepatic cholestasis and two hypodense lesions in segment VIII of his liver. It showed no signs of metastasis or other unknown pathologies. The analysis of serum tumor marker carcinoembryonic antigen (CEA) was negative and cancer antigen (CA) 19-9 was found to be elevated at 75 kU/l (<37 kU/l).He was treated with right liver lobectomy with resection of the bile duct directly distal of his pancreatic head, resection of the bile duct of his left liver lobe up to the first intersection, and with a regional lymphadenectomy. The reconstruction was performed by biliodigestive anastomosis with Roux-en-Y hepaticojejunostomy. A bile duct drain was inserted in the dorsal bile duct of his left lobe and closed on day 10 after contrast imaging of the anastomosis. Postoperatively, he recovered well. On the planned day of discharge he developed an aphasia leading to further diagnostics, which showed a transitoric ischemic attack of his left-brain hemisphere. He was transferred to neurology and fully recovered.A gross examination showed a right hemihepatectomy with a 4×2×2 cm polypoid tumor in his right hepatic bile duct extending into the bile duct junction . The liver parenchyma was non-cirrhotic and prominent portal tracts were seen. Resection margins were free of tumor.Histologic examination revealed an intraductal tumor with tubular and papillary and solid growth pattern. There was a stromal invasion into the ductus hepaticus dexter. In the portal tracts intraductal tumor growth without stromal invasion was found Fig. . AccordiThe same patient presented 2 years ago at the age of 55 with a mass of 1.8×2.4 cm at the papilla of Vater. The mass was detected via magnetic resonance imaging (MRI) during a regular cancer follow-up. In the meantime he had developed an arterial hypertension that was well controlled with ramipril 5 mg once daily. On admission he reported no weight loss, no fever, no sweating, and no signs of icterus or pruritus. His clinical examination was without any pathological finding.Contrast sonography showed a hypertrophia of his left liver lobe with status post-right hemihepatectomy and no pathological findings. Computed tomography showed a dilatation of the residual common bile duct and normal size pancreatic duct and a contrast enhancement next to the papilla of Vater leading to the suspicion of an intraductal tumor. There were no signs of metastasis Fig. .Fig. 2aOn macroscopic examination, an ERCP supported the suspicion of an adenocarcinoma in his distal residual common bile duct. The pathology of the biopsy came back positive for an adenocarcinoma. An analysis of serum tumor markers  showed no elevation.He was treated with a pylorus-preserving resection of his pancreas head and his duodenum. Postoperatively, he recovered well. Oral nutrition with low amounts of fluids were started on day 1 and escalated up to solid food on day 5. He was discharged on day 14. A 6 French pancreatic drain that was placed intraoperatively was removed on day 30 during an ambulatory visit.2 at day 1, 8, and 15 every 4 weeks) as monotherapy. Chemotherapy was planned for 6 months but discontinued after 3 months due to head aches and weight loss. As of April 2016, there are no signs of tumor recurrence during follow-up.In addition, he received adjuvant chemotherapy with gemcitabine  was performed on formalin-fixed paraffin-embedded (FFPE) samples of both cases as described before . Isolateet al. [A literature research revealed only a few cases comparable to our case. Nakahira et al.  reportedet al. , indicatThere are several case reports showing that intramucosal tumor residuals after resection might lead to recurrences of the tumor especially at the side of anastomosis –17. A caet al. [Jang et al.  evaluateKRAS mutation nor a TP53 mutation was detected, which are both linked to a worse outcome [The case presented here shows an example of a patient developing a secondary tumor in the same environment but anatomically distant 9 years after the primary diagnosis of pCCA. The identical mutation pattern and the absence of the most frequent gene alterations  in both  outcome .PIK3CA gene as in our case, further treatment options might be available in the future [With the ongoing development of phosphoinositide 3-kinase (PI3Kinase)-specific inhibitors as targeted therapy for tumors with activating mutations in the e future .Late and far distant recurrence of CCA in long-time survivors is possible and could be caused by a special tumor biology.


Primary non-Hodgkin’s lymphoma’s of the tongue is very rare and accounts for 1% of all malignant tumor of the oral cavity. Clinical features are non-specific ulcerative lesions that do not heal. In the literature, the majority of cases are diffuse large B cell type however, T cell phenotype also may occur. We describe a 77 years old man, who presented with an ulcerative mass in the left margin of the tongue the diagnosis diffuse large B cell lymphoma was confirmed. The patient is actually on treatment R-mini CEOP and has favorable evolution. Non Hodgkin lymphoma represent the third most common group of malignant lesions of the oral cavity following squamous cell carcinomas and salivary gland neoplasms. Further only 1% of all lymphomas are primary oral cavity lymphoma. Non Hodgkin’s lymphoma’s of the tongue is extremely rare. It can arise from Waldeyer’s ring including the tonsils, nasopharyngeal lymphoid tissue, soft palate and base of tongue [A 77 years old man presented with a history of odynophagia (dysphagia) and left sided pain of the tongue. Weight loss; night sweats and fever was reported. Local examination revealed an ulcerative lesion involving the left margin of the tongue and measured 2cm in diameter. The lesion was extensive to the right tonsil. Two cervical lymphadenopathy (jugular carotid) of 5 and 1 cm in diameter . SystemaPrimary malignant lymphoma of the tongue is very rare . ElderlyA localized non-Hodgkin’s lymphoma of the tongue base rarely occurs, and should be considered in the differential diagnosis of tongue base lesions. A proper clinical evaluation, histopathologic as well as immunohistochemical evaluation of biopsy specimen, are indeed essential to improve the management and the prognosis of this disease.


Cardiac tumors are a very rare entity. Leiomyosarcoma represents less than 1% of cases.a 51-year-old woman diagnosed with primary left atrium leiomyosarcoma. She was treated by optimal surgery and adjuvant chemotherapy. She is still alive after a follow-up of 24 months without evidence of local or distant recurrence.Cardiac leiomyosarcoma is a rare tumor with a dismal prognosis. Surgery is the mainstay of treatment. Adjuvant treatment is still controversial. Cardiac tumors are a very rare entity with an incidence of 0.02%. Only 25% are malignant with a prevalence ranging from 0.001% to 0.28 . In spitThis case aimed to describe the clinical, histological, therapeutic and prognostic features of this rare pathology.We present the case of a 51-year-old woman, with past medical history of hypertension, who consulted in September 2014 for bilateral lower limb pain and lower extremity edema since 6 months. The diagnosis of hypertrophic osteoarthropathy was suspected. In this context, a CT scan revealed a 6 cm defect, involving the right atrium and the right inferior pulmonary vein, which appears markedly enlarged. This aspect evoked a large intracavitary thrombus. A transesophageal cardiac ultrasound showed a 30 × 26 mm, with little mobility, lobed tumor, in the left atrium, connected to the atrial septum. The tumor wasn’t obstructive. Cardiac chambers dimensions and pulmonary pressure were normal. There was no systolic or diastolic left ventricular dysfunction. The patient was referred to a cardiovascular surgeon with a suspected diagnosis of left atrium myxoma. Surgery was performed through median sternotomy. The patient had a cardiopulmonary bypass (CPB) with aortic and bi-caval cannulation. The left atrium was dissected, revealing a voluminous, septal based tumor involving the right inferior pulmonary vein and the posterior wall of the left atrium, suggestive of malignancy. We did a wide en bloc excision of the tumor, extended from the posterior wall of the left atrium Fig. Microscopic examination revealed the presence of conjunctival tumoral proliferation made of spindle cells with a fascicular organization infiltrating myocardial fibers. A high mitotic activity was noticed. Surgical margins were clear. Immunohistochemical staining showed an intense and diffuse positivity of alpha-smooth-muscle actin and caldesmon and the negativity of PS100, desmine and myogenin. Based on these findings, diagnosis of primary cardiac leiomyosarcoma grade 3 according to FNNCLCC was confirmed.Post-operative CT scan revealed no metastases. According to a multidisciplinary staff, an adjuvant chemotherapy consisting on six cycles of Doxorubicin and Ifosfamide was prescribed.The patient is regularly followed. After a follow-up of 24 months, she still has no clinical or radiological evidence of recurrence.We presented a rare case of cardiac leiomyosarcoma treated by surgery followed by an adjuvant chemotherapy. The patient is still alive after a follow-up of 24 months.Until December 2015, we found only 32 cases of primary cardiac leiomyosarcoma with available data. In most studies, it was defined as tumors originating only from cardiac chambers, excluding those located in the pericardium and great vessels . EpidemiMedian age at diagnosis was 48 with a female predominance [This tumor has a poor prognosis due essentially to advanced stages at presentation. It usually remains asymptomatic until advanced stages. Even when it becomes symptomatic, presentation is atypical and non specific. Symptoms of obstruction especially dyspnea is found in 78.1% of cases . PhysicaEchocardiography, especially the trans-esophageal route, is habitually the initial imaging modality. It may show the tumor, its extent and its hemodynamic consequences Fig. . CT scanCardiac leiomyosarcomas have a high rate of local and distant recurrence, occurring even after an optimal resection of the primary tumor.The left atrium is the most frequent location of cardiac leiomyosarcomas (51%). That joins operative and radiological findings, in our case.Biopsy is the gold standard for histological confirmation but this step can sometimes be overtaken and the diagnosis is then made on the examination of resected mass.Complete surgical resection, when it’s possible, is the mainstay of treatment.Since soft tissue sarcoma is a heterogeneous group, benefits of adjuvant chemotherapy isn’t clearly established. Several studies defined subgroups associated with a high risk of local and distant relapse. Risk varies depending on factors like size >5 cm, high grade, depth and chemosensitive histologies with a metastatic potential. Leiomyosarcoma belongs to the high risk group. Major drugs used are Doxorubicin, Ifosfamide and Dacarbazine . It’s whIndications of radiation therapy are mostly restrained to palliative setting. It’s proposed when margins of resection are positive or for aggressive localized disease or for recurrences. Since the lack of evidence concerning the efficacy of radiotherapy in management of cardiac leiomyosarcomas and the poor tolerance, its use stills equivocal and unusual.According to the reported cases of leiomyosarcomas with cardiac involvement, the mean survival time of patients who underwent surgery and chemotherapy was about 12 months . SeveralIn the case above, our patient had a grade 3 tumor with a high mitotic activity. She underwent a carcinologic surgery and adjuvant chemotherapy. Currently, she is still alive and there is no evidence of local recurrence or metastasis, after a follow-up of 24 months.Cardiac leiomyosarcoma is a rare tumor with a dismal prognosis. Wide margin resection is the mainstay of treatment. For soft tissue sarcoma, adjuvant chemotherapy is still controversial. Nevertheless, leiomyosarcoma belongs to the high risk group of soft tissue sarcoma associated with a metastatic potential. In this group, there is a trend to outcomes improvement with adjuvant chemotherapy. Drugs used in this context are Doxorubicin, Ifosfamide and Dacarbazine.Regarding the scarcity of this disease, it’s important to report all cases with a longer follow-up to refine indications and modalities of adjuvant treatment and prognostic factors.


Osteochondroma is a benign tumor that tends to develop in mandibular condyle and coronoid process in the craniofacial region. If tumor mass has grown from condyle into the infratemporal space with zygomatic arch obstructing the access, there are risks associated with surgical exposure and local resection of these masses.This study reports on a case of osteochondroma on mandibular condylar head where we treated with surgical excision via preauricular approach with 3D analysis. After the local resection, there were no surgical and post-operative complications until 8-month follow-up period.In local excision of osteochondroma, our method is a minimally invasive method. It is a good example of osteochondroma treatment. Osteochondroma is characterized by cartilage-capped osseous protrusion from the external surface of the affected bone . It can If tumor mass has grown into the infratemporal space with zygomatic arch obstructing the access, there are risks associated with surgical exposure and local resection of these masses . To reduCondylar osteochondroma can be treated with total condylectomy, subtotal condylectomy, conservative condylectomy, or local excision –7. TradiThis study reports a case of osteochondroma on mandibular condylar head which was treated with local excision via preauricular approach and zygomatic arch osteotomy.A 46-year-old man was referred to our clinic due to chief complaints of chin deviation to the right side. There were right posterior cross bite and dental midline deviation to the right side by 5 mm Fig. . In panoReconstruction and differentiation of tumor mass and surrounding structures were done using Mimics . In a mandible only view, tumor mass could be observed at all directions. Resection line of tumor mass was identified Fig. . We coulUnder general anesthesia, a preauricular incision was made. Dissection and bleeding control was done until zygomatic arch and temporomandibular joint capsule appeared. Two osteotomy lines were made. A posterior one was made at the foremost point of articular eminence while an anterior one was made at 15 mm in front of the posterior line. Zygomatic arch osteotomies were completed, and the fragment was displaced downward with the masseter muscle still attached. The joint capsule was incised, and the lateral pterygoid muscle was dissected to expose the tumor mass. Tumor mass was resected with saw. The surface of condyle was smoothed with round bur. Tumor mass was sent to the Department of Pathology. The zygomatic arch fragment was repositioned and fixed with a four-hole straight shape miniplate Fig. .Fig. 5aAfter the operation, intermaxillary fixation was done for 2 weeks with rubber rings. A month later, normal occlusion with proper dental midline was maintained Fig. .CT was taken immediately after the operation. It confirmed that the tumor mass was removed Fig. .Fig. 7PrPathologic diagnosis of the tumor mass was the osteochondroma Fig. .Fig. 8HiThere are many theories about the etiology and pathogenesis of cartilage-capped and exophytic bony growths. They can occur in bones formed by endochondral ossification. They can also develop from displacement of the lateral portion of the growth plate which then proliferates in a direction diagonal to the long axis of the bone and away from the nearby joint . In our Histopathological findings are crucial to the diagnosis of osteochondroma. Histologic examinations include a cartilaginous cap similar to that seen in a normal cartilage, endochondral ossification, cartilaginous islands in the subcortical bone, and a marrow space contiguous with the underlying bone Fig. . It has When considering treatment, the growing state and the type of osteochondroma are crucial. Growth status can be judged by repeated occlusal evaluation or bone scintigraphy. If an active growth is noticed in a child and the asymmetry is large, subtotal condylectomy is usually performed. However, in adult patient with the same symptoms, both side condylectomy and orthognathic surgery should be included. After such condylectomy, lateral open bite on the contralateral side might occur unless some kind of reconstruction is performed. A costochondral graft or a total stock joint prosthesis may be used. However, it has disadvantages such as exploration of the second surgical site, donor site morbidity, and bone resorption. A total joint prosthesis has disadvantages of high cost, material wear and potential failure, and restricted use in the growing patient , 12. An If the condition is inactive and there is no TMJ symptom, the reason for surgical intervention can be cosmetic or associated with dysfunction of mastication. In this situation, treatment can be chosen depending on osteochondroma classification. In type 2 with globular expansion, condylectomy should be performed as described above. In type 1 with protruding expansion, just local excision is sufficient. Some excellent outcomes have been reported for type 1 . In thisAfter 3D reconstruction of the CT images, the tumor mass was growing to anteromedial side of the mandibular condyle; thus, it might be difficult to approach to the mass through only preauricular incision due to the obstruction of zygomatic arch Fig. . To alloThe malignant potential and risk of recurrence are the major drawbacks of conservative procedure. The recurrence rate for solitary osteochondromas in long bone is approximately 2% . Of all Osteochondroma in the facial area is an uncommon disease. However, more cases have been reported and its treatment has been systematized. Its growth state and the type of tumor are important to decide treatments. In the case of inactive type 1 osteochondroma, local excision alone can provide good results. In local excision of osteochondroma, our method is a minimally invasive method. It is a good example of osteochondroma treatment.


Intraluminal migration of a retained surgical sponge causing intestinal obstruction and fistula is extremely rare occurrence.A case of a 35-year-old male, who complaining a diffuse abdominal pain beginning three days earlier. He also complained of occasional vomiting, nonspecific abdominal pain, and an unintentional 15 kg weight loss during the past 2 years. However, there were no clear findings in previous laboratory work. He had received an open appendectomy approximately 4 years earlier.Retained surgical sponge.A contrast-enhanced CT of the abdomen showed a clear invagination of the small intestine. However, intraoperatively, we could not find an intestinal segment with intussusception. After the adhesive intestine was detached, a jejunal−ileal cross-linked fistula was found. More surprisingly, a retained surgical sponge was found inside the ileal fistula when the cross-linked fistula was detached.The patient was discharged 7 days after surgery.This is the first report showing an atypical image of a complete transmural migration of a retained surgical sponge mimicking intussusception. Declaration is not done exactly due to legal-medical issues connected with this problem; a recent study estimated the incidence of retained surgical foreign bodies as 1 in 5500 operations. Patients with RSS can remain with unspecific clinical symptoms both in the early postoperative period and for months or years after the initial operation. Rarely, RSS is able to do intraluminal migration without creating any defect into the gastrointestinal tract. Diagnosis tends to be difficult. Abdominal x-ray, ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and upper-gastrointestinal endoscopy can all be used to assist in diagnosis. In the present case, we aimed to report a case of an RSS, who survived 4 years after an appendix section, causing an intestinal obstruction due to its complete migration into the interior of the ileum and a fistula between jejunum and ileum, without any apparent opening in the intestinal wall.This study was approved by the ethics committee of Clinical Medical College of Yangzhou University , Yangzhou, China. The patient consented to the publication of this study.29 L−1, with 81.5% polymorphonuclear leukocytes. The tumor markers were negative. A contrast-enhanced CT of the abdomen showed a clear invagination of the small intestine (Figs. A 35-year-old Chinese man was admitted to the hospital with a chief complaint of diffuse abdominal pain beginning 3 days earlier. On admission he was febrile, with a temperature of 38.6°C. He denied recent use of antibiotics. The patient also complained of occasional vomiting, nonspecific abdominal pain, and an unintentional 15 kg weight loss during the past 2 years. However, there were no clear findings in previous laboratory work, including a general blood test and a tumor markers test, or abdominal imaging. He had received an open appendectomy approximately 4 years earlier. Physical examination revealed diffuse tenderness in the epigastric region. Laboratory tests conducted on admission showed a white blood cell count of 9.0 × 10A laparotomy was performed. Intraoperatively, we found that the entire peritoneal cavity was very clean. An adhesive mass of the ileum crossing the jejunum was found about 45 cm proximal to the ileocecal valve Fig. . This wa3 However, nonspecific symptoms and inclusive imaging still preclude an accurate diagnosis, especially in cases of complete transmural migration of RSSs. In the present case, calcified reticulate rind sign, an imaging feature typical of cases of complete transmural migration, is not observed. Instead, we identified an atypical image mimicking intussusception. By considering a patient's surgical history and the typical blood phenotype of upregulated polymorphonuclear leukocytes, surgeons may be able to improve their diagnostic accuracy.To our knowledge, this is the first report showing an atypical image of a complete transmural migration of a RSS mimicking intussusception. RSS, usually referred to as GP, is an avoidable complication. Unfortunately, it still occurs. The reported incidence of GP varies from 1/1000 to 1/1500 for intra-abdominal operations. In a report on an animal experiment, Wattanasirichaigoon et al summarized 4 stages in the process of transmural migration of sponges: foreign body reaction, secondary infection, mass formation, and remodeling. Patil and his colleagues described that an increased pressure of the intra-abdominal mass on the bowel loops can lead to necrosis of the intestinal wall partially or entirely. Consequently, this process can lead to fistula or obstruction. The case we presented that an intraluminal surgical sponge was observed, which had completely migrated into the intestine without inducing peritoneal infection.Until now, only 4 cases of complete transmural migration of surgical sponges in humans have been reported. Various hypotheses have been formulated to explain exactly how the presumed transvisceral migration of such a foreign body might occur, and, moreover, without causing any particular parietal alteration. Dhillon and Park suggested that an inflammatory reaction surrounds the foreign body, and an abscess pouch forms and erodes the neighboring tissues.


Resection of primary esophageal cancer following previous pneumonectomy is a challenging procedure and was scarcely reported.Here we report a case in which reduced thoracic space was used in left transthoracic esophagectomy to counter the difficulties caused by previous left pneumonectomy.Retrograde dissection and infra-diaphragmatic esophagogastric anastomosis are examples of using postpneumonectomy changes to facilitate subsequent transthoracic esophagectomy for cancers of the lower esophagus. The occurrence of primary esophageal cancer after preceding pneumonectomy for primary lung cancer is rare. For patients with previous pneumonectomy, transthoracic esophagectomy is always technically challenging given the postpneumonectomy anatomic deviations and a solitary lung as the remaining pulmonary reserve , 2. We hA 72-year-old man came to our department with progressive dysphagia for nearly 2 months. At presentation, he could only take down fluid. The patient used tobacco and alcohol before he underwent left pneumonectomy for a pT2N0M0 primary squamous cell lung cancer 12 years ago, which was followed by 4 cycles of gemcitabine/carboplatin doublet chemotherapy. At postoperative follow-ups, he had been shown to be recurrence free.Barium swallow and esophagogastroduodenoscopy were ordered and a distal esophageal mass was identified which was 36 cm from the incisors with extension to the cardia. Biopsy confirmed poorly differentiated adenocarcinoma. Computed tomography (CT) of the chest and abdomen demonstrated marked anatomic changes as a result of previous pneumonectomy, i.e. hyperexpansion of the right lung, mediastinal shift to the left hemithorax, elevation of the left hemidiaphragm and reduced left intrathoracic space with heterogeneous opacification Fig. . No metaBased on the patient’s will and examination results, a left transthoracic esophagectomy with the ad hoc design of retrograde esophageal dissection and superior diaphragmatic reconstruction was pursuit for curative intent. This procedure was initiated with a regular posterolateral thoracotomy. Thoracic probing identified the imaging-proven anomalies that highly obscured normal anatomy. As such, retrograde dissection starting from the abdomen was justified.This was achieved by the standard abdominal component of a typical left transthoracic esophagectomy Fig. , which iRetrograde dissection of the esophagus was facilitated by the elevated diaphragm, which stretched and widened the esophageal hiatus. It was carried cephalad until 5 cm proximal to the esophageal mass, at which point the esophagus was transected. After the frozen section confirmed negative margin, the gastric conduit was prepared, and an end-to-end esophagogastric anastomosis was performed with an intraluminal circular stapler , reinforced by several 4–0 absorbable sutures. An abdominal drainage tube was placed, and the diaphragmatic was reanastomosed superior to the esophagogastric anastomosis for an intentional precaution of postoperative anastomotic complications Fig. . In the In the postoperative course, ambulation was initiated on postoperative day (POD) 4. Oral feeding was restored on POD 7. Thoracic and abdominal drainage were terminated on POD 11 and POD 12 respectively after confirmation of anastomotic integrity. The patient was discharged on POD 14 with a normal chest CT. Postoperative pathology revealed a stage IIA primary adenosquamous esophageal carcinoma adventitia involvement (pT3N0M0).The patient was followed up for 12 m, and was readmitted once for incision wound infection on POD 30, which required open drainage but no antibiotic use. No relapse was found.Esophagectomy in the setting of prior pneumonectomy is challenging and only few cases have been reported to date –5. A dilThe objectives of this method were three-fold: first, to aid the dissection in the unfamiliar postpneumonectomy area under the guidance of improved vision from the abdominal side; second, to keep the contralateral hemithorax intact so as to minimize impact on the residual pulmonary reserve; third, to establish infra-diaphragmatic anastomosis to allow for improved management improved management for potential anastomotic leak. These are important as they circumvent the technical hurdles arising from the previous pneumonectomy while maintaining safety at a reasonable level. Also, this procedure distinguished itself by taking advantage of the existing anatomic abnormalities without additional use of dedicated devices, thus making it more affordable and less technology demanding.As an alternative, transhiatal esophagectomy could be an approach that avoid thoracic entry. However, this approach was also compromised by postpneumonectomy changes, and risk was further added by previous mediastinal lymph node dissection. Albeit our treatment proved to be useful in this patient, the surgical approach should be optimized on an individual basis, and the procedure presented here is only applicable for tumor of the lower esophagus. The lesson we took from this case is that a mindset of out-of-the-box thinking should always be ready for various real-life clinical scenarios.In summary, transthoracic esophagectomy post ipsilateral pneumonectomy is feasible, and safe dissection and extrathoracic esophagogastric anastomosis can be achieved by even harnessing postpneumonectomy changes. An example is retrograde dissection plus infra-diaphragmatic esophagogastric anastomosis, which facilitates transthoracic esophagectomy for cancers of the lower esophagus.


Lymphoepithelial cyst (LEC) is the most commonly encountered congenital neck pathology in the lateral part of the neck. A 66-year-old woman presented to the ENT clinic due to difficulty in swallowing persisting for approximately 1 year. Magnetic resonance imaging revealed a cystic mass at right tonsil. Surgery was performed due to this unilateral tonsillar mass, which was excised together with the right tonsil. LEC was diagnosed at histopathological examination. LEC in the palatine tonsil is rare, and only a few cases have been reported in the literature. We report a rare case of LEC in the palatine tonsil. Lymphoepithelial cyst (LEC), otherwise known as the branchial cleft cyst, is the most commonly encountered congenital neck pathology in the lateral part of the neck . BranchiBranchial cysts are divided into four types depending on their anatomical location. First branchial cleft cysts occur in the region of the ear. Second branchial cleft cysts are the most common type, at a level of 95%, and occur in the lateral part of the neck anteriorly to the sternocleidomastoideus muscle. Third branchial cleft cysts connected to the pharynx lie deep inside the carotid artery system. Fourth branchial cleft cysts appear in the thyroid region, generally on the left side .In addition to the neck, LECs may rarely be observed in the oral cavity in the tongue, nasogenian sulcus, the floor of the mouth, the soft palate, or the retromolar region , 5. LEC A 66-year-old woman presented to the ENT clinic due to difficulty in swallowing persisting for approximately 1 year. At ENT examination the right tonsil was hypertrophic and the inferior pole was bilobulated. A mass with the density of soft tissue obstructing the oropharyngeal air column at the level of the inferior lobe of the tonsillar palatine was observed at magnetic resonance imaging (MRI) . A cystiLEC is the most common congenital head and neck lesion after thyroglossal cyst. LECs occur due to the incomplete closure of embryological branchial clefts. Second LEC, the most common form (95%), is localized along the anterior margin of the sternocleidomastoid (SCM) muscle. First arch branchial cysts constitute 1–4% of cases, while third and fourth arch clefts are very rare . VariousThey are generally detected in late adulthood but are very rare at advanced age. LEC becomes conspicuous as a painless, fluctuating neck mass. Rapid growth or pain may be present in the branchial cyst in association with upper respiratory tract infection. Differential diagnosis is diverse, and cystic hygroma, hemangioma, and metastasis should be considered .Ultrasonography (USG) is the imaging technique of choice in lesions of a cystic nature. LEC appears with a hypo- or anechoic thin wall with well-determined margins at USG. At CT they are hypodense, thin-walled lesions. At MRI, they appear hypointense on T1 weighted sequences and hyperintense on T2 weighted sequences .In addition to the neck, LECs may rarely be observed in the oral cavity in the tongue, in the floor of the mouth in the soft palate or in the retromolar region. A few case reports have been published of LEC in the tonsillar region. As with cervical branchial cysts, the therapeutic option in oral LECs is total excision. Injection of sclerosing material may be an alternative to surgical excision in the treatment of LECs .Since LECs are more common at pediatric age group, they can be observed at any ages. Our patient was sixty-six years old. Although LECs usually occur in the neck, they can be seen in the oral cavity. While evaluating the tonsillar masses LECs should be kept in mind.