Partial cystectomy with wide local excision may be considered a suitable option for selective cases of locally advanced bladder leiomyosarcoma without evidence of distant metastasis; thereby preserving the functional outcome and quality of life. A negative margin, complete tumor resection, and frequent follow‐up in such patients are mandatory. Nonepithelial tumors of the urinary bladder are rare and account for <5% of all bladder malignancies. Leiomyosarcoma is even sparse being 0.1% of overall bladder cancers A 54‐year‐old woman presented with a history of painful hematuria for 2 weeks associated with lower abdominal pain. There were no other associated lower urinary tract symptoms. The rest of the history was unremarkable. The basic biochemistry was within normal limits. A CT scan (computed tomography) of the abdomen was performed, which showed a 5.0 cm (anteroposterior) × 7.0 cm (transverse) × 7.0 cm  space‐occupying lesion in the anterior wall of the bladder and the anterior abdominal wall. The mass had soft tissue and fat densities. Bladder wall adjacent to the mass was irregularly thickened and showed contrast enhancement. Both kidneys and upper tracts appeared normal, and no evidence lymph node involvement or distant metastasis was noted Fig. .Cystoscopy showed a 2.5 cm solid exophytic bosselated bladder tumor with a smaller base on the right anterolateral wall of the bladder. A transurethral resection of bladder tumor (TURBT) was done. Histopathological analysis revealed polypoidal pieces of tissue resembling a spindle cell tumor, lined by normal urothelium Fig. . An immuBased on the above findings, partial cystectomy and wide excision of the tumor were planned. A muscle dividing Pfannenstiel incision was made. A solid mass lesion was noted in the surface of the anterior bladder extending to the rectus muscle. The entire solid mass was excised after opening into the bladder with a large segment of the anterior wall of the bladder. Exploration of the peritoneal cavity did not reveal any pelvic lymph node involvement or evidence of metastasis. The recovery following surgery was uneventful.She was followed up for 3.5 years with regular check cystoscopies and ultrasonography every 3 months in the first year and every 6 months thereafter, with no evidence of recurrence, and currently, she is well and asymptomatic.The spectrum of bladder cancer is diverse, and the majority of cancers are urothelial in origin (90–95%) Two retrospective reviews of mesenchymal genitourinary tumors revealed that sarcoma is the commonest mesenchymal malignancy of the bladder with leiomyosarcoma as the most common histological type n = 192), leiomyosarcomas were the commonest (50%) and 20% were rhabdomyosarcomas and others were carcinosarcomas, angiosarcomas, and osteosarcomas Of the total number of cases reported in the literature n = 92, leiomommonest 0% and 20The review of the literature revealed that the overall prognosis is variable but generally poor Because of the rarity of the disease, there is limited data on leiomyosarcomas and thus, there is no consensus on the management protocols. For patients with small lesions, minimally invasive procedures like transurethral resection or laser fulguration with or without chemoradiation have been utilized. Studies comparing a more radical approach compared to minimally invasive procedures are lacking In large tumors with an advanced stage at diagnosis, the treatment consists of radical cystectomy combined with chemoradiation. This procedure should include wide resection margins with at least a 2–3 cm depth free from tumor invasion. However, the procedure is associated with considerable morbidity and subsequent poor quality of life Partial cystectomy is currently being considered as a reliable option for management of various tumors including bladder sarcomas due to the functional preservation. A case report by Xu et al. n = 35) managed by radical cystectomy and pelvic lymph node dissection at MD Anderson Cancer Center, only five patients (14.3%) were found to have microscopic disease in the regional lymph nodes at surgery In the largest series to date of high‐grade bladder leiomyosarcoma (A close surveillance especially in the first year, with imaging and cystoscopy, is mandatory for early detection of local recurrence or metastasis This case study described a locally advanced moderately differentiated leiomyosarcoma of the bladder without evidence of lymph node involvement of metastasis in CT scan, which was successfully treated with preservation of bladder function. Although bladder leiomyosarcoma has been regarded as an aggressive tumor with poor prognosis in the past, partial cystectomy and wide local excision may be considered a viable option for appropriate lesions without evidence of metastasis. This preserves the functional outcome and quality of life of an individual in comparison to radical cystectomy. However, in such cases, a good tumor‐free resection is extremely important, and meticulous follow‐up with imaging and endoscopy is mandatory to detect the recurrences early.UJ, DMHF and KBH: contributed to collection of information and writing of the manuscript. MVCS and SASG: contributed to writing and final approval of the manuscript.The authors declare that there is no conflict of interest.Informed written consent was obtained from the patient for publication.


Rhabdomyosarcoma is a rare, soft tissue malignancy, diagnosed particularly in adults. It commonly metastasizes to the bone marrow. We present a rare case of an adult rhabdomyosarcoma which illustrates the importance of magnetic resonance imaging in identifying early changes in the internal bone structure.A 50-year-old male presented with acute urinary retention. The patient initially had a CT scan of the lumbar spine which only revealed a protrusion of the L5–S1 intervertebral disc and no apparent cause for the patient’s symptoms. One week later, an MRI was performed which showed extensive bone marrow metastases throughout the lumbar spine and a soft tissue mass in the lower sacral region. The bony metastases were not evident on the CT scan and the soft tissue mass was out of the coverage area of the CT. Subsequent biopsy of the soft tissue mass was performed and histopathology concluded the tissue to be a rhabdomyosarcoma. Unfortunately, the patient died one week after diagnosis.Although adult rhabdomyosarcomas are very rare, this case highlights the advantage of MRI over CT in identifying early changes in the internal bone structure. Therefore, CT should not be relied upon to exclude bony metastases, particularly in the setting of primary cancer with a known tendency to metastasize to the bone marrow. Rhabdomyosarcoma (RMS) is a rare, soft tissue malignancy. The aetiopathogenesis of RMS is uncertain, although it is thought to develop from immature cells of the skeletal muscle lineage . RMS is A 50-year-old male presented to the emergency department of a regional hospital with acute urinary retention. Two weeks earlier, he had been commenced on paracetamol and codeine for back pain and left leg sciatica which were troublesome since moving a refrigerator 3 weeks earlier. The patient’s medical history was notable for a renal transplant at 20 years of age, performed for end-stage renal failure secondary to childhood glomerulonephritis. He was also positive for factor V Leiden mutation and suffered from deep vein thrombosis 18 months earlier. Neurological examination was non-contributory. His urinary retention was initially attributed to opiate overuse and constipation and was relieved by temporary catheter drainage. Opiates were ceased and the patient was discharged from the emergency department.in situ.The patient returned the following day with further urinary retention. An indwelling urinary catheter was placed and the patient was discharged and asked to return to perform a trial-of-void 3 days later. The trial-of-void was subsequently unsuccessful and given his ongoing back pain, CT of the lumbar spine was performed, demonstrating a protrusion of the L5–S1 intervertebral disc; however, it did not provide a conclusive cause for the patient’s urinary retention. He was observed overnight in the emergency department and again discharged the following day with a urinary catheter MRI of the lumbar spine was arranged the following week. It revealed extensive bony metastatic disease throughout the lumbar spine with associated soft tissue masses at the level of the lower sacrum extending into the sciatic notch. The bony metastases were not evident on the initial lumbar spine CT and the soft tissue masses were not within the coverage of the CT. On MRI, the vertebral lesions demonstrated low T1 and T2 signals, and a high STIR signal.The patient was admitted to hospital and CT-guided biopsy of the low sacral soft tissue mass was performed. Histopathology concluded that the tissue was RMS with pleomorphic histology, the most common histological subtype encountered in adult RMS . StagingThe patient had previously had an MRI of a longstanding, right anterior leg mass performed several weeks prior to his initial presentation to hospital. The mass had been present for approximately 12 months. MRI findings were at that time thought to suggest a nerve sheath tumour. No tissue diagnosis was available on this mass but it was hypothesised to represent another RMS focus. The patient started palliative radiotherapy to the sacral mass and one of the pulmonary masses. Systemic chemotherapy was planned; however, the patient’s symptoms rapidly progressed and he died only one week after diagnosis , 2.RMS is a rare, soft tissue malignancy of a mesenchymal origin, suspected to arise from cells of the skeletal muscle lineage . RMS is Following arrival at a histological diagnosis, staging involves a full history, physical examination and routine laboratory tests. Evaluation at and around the primary site is typically made with CT and/or MRI and abdominal ultrasound . HoweverOn contrast-enhanced CT, pleomorphic RMS appears isodense-to-hyperdense compared to skeletal muscles. On T1-weighted MRI, pleomorphic RMS tends to appear isointense-to-hyperintense compared to the skeletal muscle with variable contrast. Pleomorphic RMS typically has high signals on T2-weighted/Short Tau Inversion Recovery (STIR) imaging with extensive heterogeneity . These fIt has been shown that MRI reveals early bone marrow metastases before any changes in the internal bone structure become evident on CT . This ha


Ebiino, also known as false tooth extraction, is a traditional practice done mainly in the remote areas of African countries, including Uganda. It involves the extraction of tooth buds in babies with common childhood illnesses such as fever, cough, and diarrhea. It is thought that the tooth buds are responsible for the ailments seen in these infants. The practice is performed by traditional healers using unsterile instruments. The complications associated with this dangerous practice have been mentioned in the literature and include anemia and septicemia, among others. This case report describes a baby with noma, an orofacial gangrenous infection.A 16-month-old girl from western Uganda belonging to the Banyankole ethnic group was admitted to Mbarara University Teaching Hospital with a 5-day history of a dark lesion on the left cheek. The lesion had started from the left upper gum at the site where a tooth bud had been extracted 1 week prior to admission. The child had experienced occasional cough and fever and also had erupting tooth buds. These tooth buds had been seen as the cause of the cough and fever by the traditional herbalist; hence, they were extracted. An unsterile instrument had been used for the procedure. At the hospital, a local examination showed necrotic tissue involving the left cheek and extending into the left upper gingival area of the girl’s mouth. A clinical diagnosis of orofacial gangrene (noma) was then made.Ebiino, or false tooth extraction, is still practiced in some remote areas of Uganda. Noma has been mentioned as a possible complication of this traditional practice; however, case reports in the literature are scant. Public awareness of the dangers of this practice is therefore still required to prevent this dangerous complication. This prThe complications attributed to false teeth extraction are numerous and can be either local or systemic. They include anemia, pneumonia, meningitis, and septicemia, among others . A studyA 16-month-old girl from Ankole in Western Uganda was admitted to the surgical ward of Mbarara University Teaching Hospital in Western Uganda with a dark lesion on the left cheek. This lesion had been present for 5 days prior to admission. It had started as a small red lesion on the left side of the upper gum and had quickly spread to the inner cheek. The child had been subjected to a tooth bud extraction on that side of the gums by a traditional herbalist 1 week prior to admission. The procedure had been done to cure Ebiino, a diagnosis that was reached by the traditional herbalist after the parents reported that the child was experiencing cough and flu and that they had spotted erupting tooth buds.Associated with this dark lesion was a high-grade intermittent fever and pain. The girl’s feeding was also described as difficult, owing to her pain, but manageable. The child is the first born of the family and was up-to-date with her growth milestones and immunizations. Her mother has never attended any formal education and is a small-scale subsistence farmer together with the father of the child. The family hails from a village in Bushenyi district, which is located in Western Uganda.A physical examination revealed that the child was in fair general condition. She had features of malnutrition that included brown, sparse hair, and she weighed 7.3 kg, which is below the fifth percentile on the weight-for-age chart adopted from the National Centre for Health Statistics. This showed failure to thrive. The child also had moderate pallor of the mucous membranes and was afebrile with a temperature of 36.6 °C.Locally, she had a dark necrotic patch on the left cheek that involved most of the upper lip and nose and extended into the left upper gingival area. The lesion was generally oval in shape and measured about 8 cm × 5 cm. It was tender to touch. The rest of the local examination was unremarkable.The history and findings pointed to the diagnosis of noma. The child was admitted to our hospital and started on intravenous ceftriaxone 400 mg once daily as well as rectal paracetamol for pain. A blood sample was also taken for a complete blood count, which showed mild leukocytosis and an estimated hemoglobin level of 10 g/dl. Radiology services were not available at the hospital at the time, and the parents could not afford to have it done outside the hospital. Surgical debridement was also done Fig. . A nasogFalse teeth (Ebiino) refers to gingival swelling that occurs during eruption of the primary canine teeth in infants and consists of extraction of deciduous canine tooth buds . This faIn Uganda, the regions in which this practice has been described include Northern, Eastern, and Western Uganda . In someLow level of education was found to favor the occurrence of these false teeth . The lacThe complications arising from this practice have been thought to be due to the use of unsterile instruments. Some of the complications described include septicemia, anemia, osteomyelitis of the maxilla and mandible, tetanus, and hemorrhage , 7. A stNoma (cancrum oris) is a devastating gangrenous disease that leads to severe destruction of tissue in the face and is associated with high morbidity and mortality . The disFusobacterium necrophorum and Prevotella intermedia as the suspected key players [Noma begins with ulceration of the gingivae in a wide variety of forms. If the condition is detected at the gingival stage, progression can be prevented by local disinfection, common antibiotics, and immediate nutritional rehabilitation . Acute n players .If left untreated, the gingival condition can progress to noma proper through transmission of the soft tissues in contact with gingival lesions . In thisIn the acute stage, the role of surgery is a minor one, with wound care and very occasionally treatment of hemorrhage . For thoThe only truly effective approach to the problem of noma throughout the world is prevention . Noma caIn our patient, addressing the traditional practice of Ebiino would have gone a long way in preventing the development of noma as a complication of the practice. A study done in a Western Ugandan community, where our patient is from, led to a number of conclusions regarding Ebiino, including the following, among others: that the concept and beliefs of false teeth (Ebiino) were still widespread in that community; that children younger than 2 years of age were still more vulnerable to those beliefs; that there was still a strong association of false teeth as a cause of diarrhea, acute respiratory infection, fever, loss of appetite, and malnutrition in children in that community; that traditional pediatric oral surgery was still widespread in that community; and that community knowledge on preventive methods of false teeth was still scanty .We have described a case of a patient with noma as a possible deadly complication of the traditional practice regarding false teeth (Ebiino) that is still prevalent in some rural communities in Uganda. More therefore needs to be done to address this common practice of false teeth extraction to prevent this terrible complication of noma.


Background: Gastrointestinal tract (GIT) duplications are one of the rare congenital anomalies and can occur in any portion of the gastrointestinal tract but are more commonly encountered in small intestine. The duplication cysts cause symptoms like abdominal mass and intestinal obstruction requiring surgery or may remain asymptomatic. We are reporting our 15 years’ experience duplication cysts presenting in neonates.Methods: It is a retrospective study undertaken in the department of pediatric surgery between 2001 and 2015 for GIT duplications in neonates. Patients were analyzed for their antenatal diagnosis, age, sex, clinical diagnosis, investigatory approach, operative management and surgical outcomes. Results: Total number of neonates, diagnosed with gastrointestinal duplication in the last 15 years, was 17. Male to female ratio was 3.3:1. The most common location was found to be the ileum occurring in 71% of cases. Apart from ileum, 2 cases of duodenal and 1 case each of gastric, colonic and cecal duplication cyst were encountered. Majority cases presented with sub-acute intestinal obstruction and were managed successfully by resection and end to end anastomosis. Associated gut atresia was found in 4 cases while 1 case was found to be associated with perforation of gut.Conclusion: Gastrointestinal tract duplications often present with typical symptoms of gastrointestinal tract obstruction. Early diagnosis and management is required to prevent postoperative morbidity and mortality. The incidence of gastrointestinal duplication is about 1 in 4500 live births and is found in 0.2% of the children. They can occur along the entire length of the gastrointestinal system. They can present at any age but 80% of cases present within first two years and majority within first three months of life with antenatal diagnosis made in significant number of cases. Preoperative diagnosis of neonatal DC is quite challenging as to rare cause of intestinal obstruction. The objective of this study is to report our experience of 15 years in diagnosis and management of neonatal gastrointestinal duplication with focus on location, clinical presentation and associated malformations.This study is a retrospective analysis of the neonates who were brought to the department of Pediatric Surgery from 2001-2015 and was diagnosed with gastrointestinal tract duplication. Data was retrieved from the patients' medical records to review for antenatal diagnosis, age, sex, clinical presentation, location, diagnostic work-up, surgical approach, associated gut malformations and post-operative course.Demography: Total number of neonates admitted with gastrointestinal duplication in the last fifteen years was 17. Amongst them, 13 were males and 4 were females accounting for male to female ratio of 3.3:1. Presentation: All cases except one presented with abdominal lump and sub-acute intestinal obstruction. One case, however, presented with features of perforation peritonitis. Preoperative workup: Antenatal diagnosis was made in 10 cases. A thorough investigative work up was undertaken. X ray abdomen showed multiple air fluid levels suggestive of intestinal obstruction in all patients. Ultrasonography abdomen revealed cystic lesion with dilated gut in all 17 cases. CT scan was also performed in four cases for the possibility of duplication cysts. Management: The patients were kept nothing per oral. Nasogastric tube was placed for suction; intravenous fluids and antibiotics were given. The dehydration and electrolyte imbalance was corrected. After adequate resuscitation, the patients were operated. All the cases had solitary duplication cysts except in one case where two cysts were found. The cysts were non-communicating in all cases and their size varied greatly from smallest being 3×3cms to largest being 10×10cms in size. However, one case of giant ileal duplication cyst was encountered where the cyst measured approximately 15×12cms. One case had associated perforation of gut leading to peritonitis. Associated atresia of gut was observed in 4 cases . The most common site for duplication was found to be ileum present in 12 neonates, thus, accounting for 71% of cases. Two of the neonates had duodenal duplication cyst while three other neonates had gastric, colonic and cecal duplication cyst, respectively. Ileal, cecal, and colonic duplication cysts were excised along with intimately adherent part of normal GIT and end to end anastomosis was performed . However, gastric and duodenal duplications were managed by cyst excision and mucosal stripping. The resected specimen on histopathological examination confirmed the diagnosis of gastrointestinal duplication . Follow-up: All patients had uneventful postoperative period and doing well on follow up except one patient with perforated gut which could not be saved postoperatively.Gastrointestinal duplications are the result of one or more congenital anomalies of uncertain etiology. They are generally saccular or tubular masses with presence of an intimate attachment to the GI tract, a layer of smooth muscle in the wall and an epithelial lining resembling some part of the GI tract. The cysts become incorporated into the bowel wall and share a common blood supply with the parent bowel.  Almost all duplications in our series were saccular except colonic duplication which was tubular.Previous studies report duplications to be more common in males.[3-6] In our study also, 13 neonates were males accounting for majority of cases. The most common location reported in the literature is terminal ileum representing more than 70% of small GI duplications. Stern et al reported the incidence of duplication to be 30% in the ileum, 30% in the ileocecal calve, 8% in the stomach, 10% in the duodenum, 8% in the jejunum, 7% in the colon and 5% in the rectum. [7] In our series, maximum number of cases i.e. 13 (71%) were of ileal duplication cyst. But the site most commonly involved in our series was mid ileum rather than terminal ileum. Apart from ileum, 2 cases of duodenal duplication and 1 case each of gastric, colonic and cecal duplication cyst were encountered.The clinical presentation of duplication cysts vary greatly from asymptomatic to acute abdomen. However, in recent days, with the increasing use of prenatal ultrasound scan, many cases are being identified in utero. Our series report 10 cases which were diagnosed antenatally. The mode of presentation usually depends on the anatomic level of the duplication, size, mass effect of lesion, presence of heterotopic gastric mucosa within the duplication and communication with the adjacent bowel and inflammation. Often they mimic other intra-abdominal conditions posing great diagnostic difficulty. Duplications can sometimes lead to complications which include perforation, intussusception, volvulus, and associated malignancy. [9] But malignancy arising from duplication cysts particularly in children is quite rare. Our majority patients presented with features of subacute intestinal obstruction. 1 case, however, was complicated by perforation of gut. Various congenital anomalies have been found to be associated with GI duplications in particular vertebral and genitourinary malformations. Although no such anomalies were found in our patients, but four cases were associated with atresia of gut. This atresia may be probably attributed to intrauterine volvulus which might have occurred as a result of duplication.The imaging modalities commonly used to investigate duplication cysts are X-ray abdomen, ultrasonography (USG), barium studies, CT scan and magnetic resonance imaging (MRI) as they are helpful in defining the anatomic borders of a duplication. [10] USG of duplication cysts demonstrate an echogenic inner mucosal layer and a hypoechoic outer muscular layer - “double-wall” sign which is highly indicative of enteric duplications and thus USG is considered to be the first choice imaging modality. [11] A contrast study demonstrates a submucosal mass with mass effect extending into the lumen of the gastrointestinal tract. CT scan and MRI are not used routinely but are quite helpful in difﬁcult cases. Radionuclide scanning with technetium-99m sodium pertechnetate can be used in cases with suspicion of presence of heterotopic gastric mucosa. The treatment of choice for GIT duplication remains surgical excision taking into account the location, size and benign nature of lesion. The aim of the intervention when possible should be total resection as partial excision is associated with high risk of recurrence. [12] We treated all our cases with surgical resection and end to end anastomosis except gastric and duodenal duplication where cyst excision was performed with mucosal stripping. In the last two decades, minimally invasive surgery has gained much importance in the field of pediatric abdominal surgery. But literature review reveals only few controlled studies of the outcome in laparoscopic surgery in alimentary tract duplications. Shehi et al attempted laparoscopic excision of gastric duplication cyst in a neonate but they had to convert it to open laparotomy owing to the difficulty to separate the cyst from the stomach. [13] However, few cases are reported in the literature which were successfully treated laparoscopically. [14]GIT duplications, albeit rare, are still not uncommon in the pediatric population. The clinical presentation is quite diverse and often mimics other intra-abdominal conditions thus posing a great challenge to pediatric surgeons to arrive at clinical diagnosis preoperatively. Therefore high index of suspicion should be kept in mind when dealing with neonates presenting with features of intestinal obstruction. Overall, open surgery is safe with good tolerance rates but minimally invasive surgery should be considered in centers with adequate expertise.Source of Support: NoneConflict of Interest: None


Introduction. Tympanosclerosis is a commonly encountered entity within ENT clinics and primary care settings. Recognizing ear pathology is essential for correct management. Oftentimes the diagnosis is clear; however in certain cases further workup to rule out other more insidious disease processes is warranted. Case Report. We present a case of tympanosclerosis which presented as an ear mass without classic appearance of tympanosclerosis. Through imaging and biopsy the diagnosis of tympanosclerosis was made. The patient was treated surgically with good outcome. Discussion. Various ear pathologies, with different treatment algorithms, may present as clinically similar to one another. Differential diagnosis for this case included tympanosclerosis, cholesteatoma, or other middle ear masses. We review these entities and discuss their pathophysiology and implications on management.  Tympanosclerosis is a commonly encountered physical exam finding within ENT clinics. At times, findings are not “classic” as they appear in textbooks. Knowledge of various tympanic membrane and middle ear pathologies is essential for correct diagnosis and treatment when necessary. We present a case of tympanosclerosis, which because the diagnosis was not clear on physical examination provides opportunity to review several different pathologies that may be encountered in practice.An 81-year-old male presented to the ENT clinic with bilateral hearing loss, progressively worsening over the past three years. He denied otorrhea, otalgia, tinnitus, vertigo, and headaches; he had no history of ear surgery, ear trauma, or significant noise exposure. On physical exam, both auricles were normally developed, and both external auditory canals were patent with intact skin. Otoscopy revealed a diffusely thickened right tympanic membrane and a white, spherical mass involving the pars flaccida and most proximal portions of the malleus manubrium . PalpatiAn audiogram was obtained and revealed mixed hearing loss bilaterally, slightly worse on the right. A high-resolution temporal bone CT scan was then obtained and confirmed the presence of a 3-4 mm lesion involving the upper eardrum and proximal malleus . The midTympanosclerosis, stiffening of the tympanic membrane due to calcification, typically presents as white plaque-like lesions, involving discrete regions of the tympanic membrane and/or middle ear  Figure . These pThis patient's presentation was not typical, in that the lesion appeared to be a spherical mass rather than the plaque-like lesions seen typically in tympanosclerosis. For this reason, there was concern for cholesteatoma, a keratin-containing cyst , which oTypically, a diagnosis of tympanosclerosis is easily made with the combination of history and physical exam, frequently appearing as white plaques within the substance of the tympanic membrane. When associated with hearing loss, an audiogram will reveal abnormalities involving sound conduction. In the absence of an audiogram, a tuning fork examination (512 Hz tuning fork) can be extremely helpful. The Weber exam (vibrating tuning fork placed in the midline) is lateralized to the affected ear and Rinne exam  finds bone conduction to be greater than air conduction. In this patient, the spherical appearance of this lesion prompted workup with high-resolution temporal bone CT scan  and subsequent surgery to resect and confirm the lesion histologically. Without tissue for microscopic examination, the differential for this mass included not only tympanosclerosis, but also cholesteatoma or other insidious processes such as a tumor, which made surgical excision the preferred option in this patient. Surgery was uneventful and three months after procedure the patient reported improved hearing. There was no evidence of recurrent disease on physical exam.


Gliosarcoma is an uncommon variant of glioblastoma, which commonly demonstrates dural attachment. However, skull base invasion is rarely seen with this entity. Herein, we report a 44-year-old female patient diagnosed with primary intracranial gliosarcoma extensively invading the skull base and muscles of mastication. She presented to our institution with a three-month history of difficult right jaw opening and retro-orbital pressure and one week of severe right-sided postauricular headache. Head CT demonstrated a 6 cm mass with marked bony erosion. Brain MRI at a one-week interval more clearly characterized tumor extension through the right orbit and muscles of mastication, with overall growth to 7 cm and worsening midline shift. The patient underwent a right frontotemporal craniotomy for gross total resection. Pathology confirmed the diagnosis of gliosarcoma, IDH-wildtype (WHO grade IV). Her postoperative course was uneventful and she was discharged at preoperative neurologic baseline. To our knowledge, this is the third reported case of a primary intracranial gliosarcoma with direct invasion of skull base, brain parenchyma, and extracranial compartment. However, this is the first report case of primary GS invading the surrounding musculature and orbit. This case report highlights the rapid aggressiveness of gliosarcomas and further a prior undescribed radiographic and anatomic finding of skull base invasion with this entity. Gliosarcoma (GS) is a rare variant of glioblastoma (GB), characterized by a biphasic tissue pattern, with alternating areas of glial and mesenchymal differentiation . GS compA 44-year-old woman presented with difficulty opening her right jaw, swelling in the right cheek and temple region, and right retro-orbital pressure. She had no history of radiation therapy or tobacco use. Family history was significant for multiple malignancies, including second- and third-degree relations with leukemia, prostate cancer, breast cancer, and ovarian cancer. She denied any family history of neurologic disease—including central nervous system neoplasms.A presumed diagnosis of sinusitis was made, and a short course of steroids and antibiotics was initiated. Three months later, the patient's symptoms had not improved but rather had expanded to include severe headache and retroauricular pain with cervical radiation, as well as V2 distribution paresthesia. She presented to an outside emergency department, where head CT identified a 6 cm right temporal lobe mass growing through and destroying the greater wing of the sphenoid bone and invading into the infratemporal fossa. She was subsequently referred to our institution for further work-up and treatment.On examination, the patient was noted to have a firm right temporal mass, mild right proptosis, and right V2 paresthesias, but no other appreciable neurologic deficits. Brain MRI demonstrated marked growth, approximately 1 cm, over the one-week interval, with increased midline shift, mass effect, and vasogenic edema. The extracranial extension was better delineated with clear extension into the orbit, maxillary sinus, and invasion of the right pterygoid, masseter, and temporalis muscles . CT-guidThe patient was taken to the operating room for a right frontotemporal craniotomy, subtemporal exploration, tumor resection, and temporal lobectomy. During exposure, a firm and encapsulated tumor invasive through the temporal bone was encountered below the temporalis muscle , which wThe procedure was well tolerated and the patient recovered without complaints of jaw motion difficulties or new facial numbness. Routine MRI performed on postoperative day one revealed no evidence of residual enhancing tumor , and the IDH1 or IDH2 mutation detectable by pyrosequencing. Methylguanine-DNA methyltransferase (MGMT) promoter methylation was not detected by a methylation-specific PCR-based assay.Pathology revealed a malignant neoplasm with variable morphology and extensive infiltration of adjacent fibroadipose and muscle tissue. Gliofibrillary cytoplasmic processes and cerebral parenchymal investment consistent with infiltrative glioma were widely observed, with foci of necrosis surrounded by vaguely pseudopalisading tumor cells . The infPrimary GS is an uncommon tumor and in its prototypical form rarely extends beyond the dura in the absence of preceding radiation or craniotomy. Specific invasion of the skull base is exquisitely rare for primary GS, with three prior cases appearing in the literature –9, two on = 6, 86%); proptosis was not previously observed, whereas cranial neuropathies, papilledema, and mass effect were inconsistently reported.Literature review for case reports was completed by searching PubMed using keywords “gliosarcoma” together with “extracranial” or “skull base.” Initial search, primary review, and secondary bibliographic review identified 29 publications from 1985 to 2013. Six of these were confirmed cases of GS with involvement of the skull base –12. Fourn = 5, 71%). In the setting of primary GB, progression to GS after radiation occurred within 2–6 months. Mortality was high with only one patient surviving beyond 12 months; death is most frequently attributed to metastatic disease, including spread to the lungs and spine [Although the number of studies available for comparison is small, MRI characteristics of GS invading skull base appear to be consistent. They typically demonstrate heterogeneous, peripheral enhancement attributable to frequent tumor hemorrhage and internal necrosis, with a corresponding predominance of peritumoral cytotoxic edema that may obscure clear radiographic differentiation at the tumor-parenchyma interface. Involvement of the infratemporal fossa or sphenoid sinus is common, with each occurring in roughly two-thirds of patients (nd spine .The mechanism of extradural and extracranial extension by GS remains unclear, although the most important barrier to tumor dissemination is thought to be the dura, which plays a role in the containment of glial and other related CNS malignancies . SeveralAlthough GS treatment falls within the broader paradigm of GB management, several studies have reported that temozolomide does not significantly impact overall survival , 17. OneSequencing and comparative genomic hybridization studies have helped elucidate differences between GB and GS, although their results are limited by the lack of randomized studies or molecular data, both of which are attributable to the rarity of GS . NotwithTo our knowledge, this is the first reported case of a primary intracranial GS with direct invasion of the skull base, brain parenchyma, extracranial compartment, and orbit. This case report illustrates how rapid and aggressive the natural history of GS can be. Further this case report adds to the radiographic differential of a mass involving the soft tissues, bone, and intra-axial compartments beyond aggressive meningioma, metastasis, primary bone neoplasm, or sarcoma. Although GS is rare and similar to GB, the higher mortality of GS and notable molecular differences between GS and GB urge the need for specialized treatment modalities beyond mild alterations of standard GB treatment.


We report a rare case of advanced metastatic renal cell carcinoma which initially presented to the clinic with back and forehead lumps. Ultrasound imaging of the lumps and later of the abdomen picked up a right renal tumour which led to further computed tomography and bone scans. The bone scan confirmed that the forehead lump was a calvarial metastasis and such a presentation for metastatic RCC is very rare which bears a significantly poorer prognosis. Renal cell carcinoma (RCC) is often picked up incidentally on imaging  and may A 55-year-old man first presented with lumps on his mid-lower back and right forehead to his general practitioner who referred him to the General Surgery Department. On further history taking, it was noted to be associated with intermittent constipation, early satiety, and loss of weight of 4 kg over the duration of one month. There were no complains of gross haematuria or abdominal pain. He had no past medical history but had a 40-pack-year history of smoking. The lumps were approximately 4 cm in diameter, mobile, and painless with no surrounding erythema.Gastroscopy and colonoscopy were performed, to evaluate the cause of the early satiety and constipation in a male aged above 50, which revealed polyps of tubular adenoma histology. Blood tests revealed normal renal function and electrolytes with elevated alanine transaminase and alkaline phosphatase. Ultrasound of the forehead lump was reported as a heterogeneous soft tissue lesion with skull vault destruction, highly vascular and separate from underlying brain parenchyma. The mid-lower back lump was reported as a solid vascular lesion. The radiologist decided to also perform a targeted ultrasound abdomen which located a right renal neoplasm with extension of the likely tumour thrombus into the right main renal vein and to the inferior vena cava. The patient was subsequently referred to the Urology Department which ordered further imaging to stage the tumour.A computed tomography showed a 6.4 cm endophytic hypervascular right renal tumour  at the iBased on the abovementioned imaging, the tumour was staged at T4N0M1, clinical stage IV. Consolidation cytoreductive nephrectomy was initially entertained with presurgical course of tyrosine-kinase inhibitors but at the multidisciplinary meeting it was decided that the patient was unlikely to benefit from cytoreductive nephrectomy due to the extensive metastatic burden with poor overall prognosis and the surgical risk was high in view of the bilateral pulmonary arterial thrombi. These options were still conveyed to the patient including the stage of his disease as well as the prognosis. Histological confirmation was also encouraged in the form of a fine-needle aspiration of the forehead or back lump. The patient refused to go ahead with any of the suggested procedures or any form of chemotherapy. He opted for Traditional Chinese Medicine and was subsequently referred for palliative services. The patient passed on 6 months later.More than 70% of renal cancers are picked up incidentally  and comm3–7% of patients with RCC have cutaneous metastases , 8, 9. CThe cutaneous, head, and neck metastases usually represent a very poor prognosis with a reported survival period of less than 6 months , 14, 15.Many large retrospective studies have reported the incidence of RCC with cutaneous metastasis and the different sites of cutaneous involvement and if there were other organs involved –22. No dHowever, there are 2 case reports in literature where patients with solitary skin lesions have been reported to be stable for more than 6 months after targeted chemotherapy was delivered , 31. AnoIn conclusion, RCC can present with atypical sites of metastasis. Metastasis at the time of diagnosis of RCC frequently occurs, with the skin not infrequently involved. Solitary cutaneous metastases are uncommon but one should have a high index of suspicion for primary visceral malignancies upon detecting them. Prompt diagnosis and treatment may improve outcomes.


The term fibro-osseous lesion encompasses a spectrum of disorders ranging from inflammatory to neoplastic that microscopically exhibit a connective tissue matrix containing formless trabeculae of compact bone. Characteristically, they are located over healthy bone, from which they are abruptly differentiated. The majority of the lesions arise from the maxillofacial region; the occurrence of a lesion in the external auditory canal (EAC) being extremely rare as is in our case. The lesions present with a range of symptoms ranging from conductive hearing loss, Eustachian tube obstruction to bone erosion that develop due to the mass effect. We report a case of a 35-year-old male patient who presented with insidious onset left aural fullness, decreased hearing followed by intermittent mucopurulent discharge from the ear, who was eventually diagnosed with a benign fibro-osseous lesion of the external auditory canal. An erosive benign fibro-osseous lesion of the external auditory canal (EAC) is rarely seen. We found only four cases during our review of literature spanning the last 15 years [A 35-year-old Indian male presented with insidious onset left ear fullness and decreased hearing since six months followed by intermittent mucopurulent discharge from the left ear. The discharge later turned mucopurulent with foul odour. No associated vertigo, imbalance, tinnitus, facial asymmetry, altered sensorium, nausea, or vomiting was reported. There was no history of aural trauma, ear procedure, or surgery.Otoscopy showed an opalescent lesion at the bony-cartilaginous junction of the left external auditory canal. The lesion was completely occluding the left EAC and obscuring the view of the tympanic membrane. On gentle probing, the lesion was firm, non tender, and non-bleeding. Tuning fork test showed a negative Rinne test on the left side and Weber lateralized towards the left ear. A pure tone audiogram showed a flat curve with moderate conductive hearing loss (50-55 dB) in frequencies ranging from 250 Hz through 8000 Hz on the left side.High-resolution computed tomography (HRCT) of the temporal bone revealed ill-defined, mildly hyperintense soft tissue opacification of the left middle ear cavity with bulging into the cartilaginous portion of the left EAC. Bony septae within the roof of the left temporomandibular joint were absorbed, associated with severe cortical erosion of the anterior bony wall of the left EAC. The lesion was noted abutting the incus and the malleus. Erosion of mastoid air cells septae and opacification of the mastoid antrum were noted. The sinodural plate appeared intact Figure .Canal wall down modified radical mastoidectomy with meatoplasty was undertaken under general anaesthesia. The lesion along with granulation tissue was removed from the external auditory canal, mastoid cavity, and middle ear in a piecemeal fashion Figure  and was Histopathological findings revealed bony trabeculae with extensive calcification enmeshed in a fibrocollagenous stroma Figure . These fBenign fibro-osseous lesions of the external auditory canal are often confused with osteomas and exostosis, and hence we must know about each of the above conditions in detail to arrive at a proper diagnosis. Osteomas of the external auditory canal usually arise from the tympanosquamous or tympanomastoid suture as solitary bony growths that are pedunculated . ExostosBenign fibro-osseous lesions have an unknown etiology. However, Macarenco et al. postulate that they result from chronic inflammation secondary to local trauma or chronic minor local injury . They arHistopathologically, an encapsulated fibrous tissue or connective tissue with interwoven bony trabeculae is seen frequently; there is also a presence of small blood vessels. Cartilaginous tissue is not seen and hence local ossifying phenomenon can be ruled out . CalcifiClinically, the patients present with progressive ear pain and hearing loss, which can later result in ear discharge if the mass gets infected. The ear pain is of variable intensity. Hearing loss is most often conductive in nature and is dependent upon the size of the mass, involvement of the middle ear ossicles, and obstruction of the external auditory canal.There is no gold standard treatment or specific protocol in the treatment of benign fibro-osseous lesion. As these lesions are slow growing in the majority of cases, observation is sufficient for asymptomatic cases. In symptomatic cases, multiple biopsies may be required for a definitive diagnosis. Surgical exploration and curettage are required in these cases to prevent further complications such as meningitis or encephalitis that can result from localized erosion .Benign fibro-osseous lesion of the external auditory canal is extremely rare and its erosive variant remains under-recognized worldwide. HRCT of the temporal bone provides valuable insight regarding the biological activity of the tumor and the extent of lesion for preoperative planning. A histological picture aids in ruling out malignancy and reaching a most probable diagnosis.


We describe a case of a giant conjunctival nevus presented in a 12-year-old girl with suspicious clinicomorphological appearance. The lesion was noticed by the parents at the age of 3 years as a “fleshy spot” on the bulbar conjunctiva. The lesion remained unchanged until approx. 6 months before recent admission. On slit-lamp examination, a large conjunctival lesion with variegate pigmentation and indistinct margins was detected on the superonasal part of the bulbar conjunctiva of the left eye. Intralesional cysts and vessels were detected with AS-OCT examination. Wide excision and cryotherapy to the scleral bed were performed and amniotic membrane graft was used to restore the ocular surface. Histopathological examination revealed compound type conjunctival nevus and disclosed any sign of malignancy. Although giant conjunctival nevus is a rare entity, precise diagnosis and adequate management are very important as it can be confused with malignant melanoma. Conjunctival nevi are the most frequently diagnosed benign melanocytic tumors of the ocular surface. Considering the great variability of the clinical appearance, the diagnosis can be challenging. Large conjunctival nevi can cause further diagnostic and differential-diagnostic difficulties as they can be confused with malignant melanoma or—in amelanotic cases—with lymphangioma , 2. GianA 12-year-old girl was referred to our department with a pigmented conjunctival lesion suspicious for malignant melanoma by another ophthalmic hospital. The lesion was noticed by the parents when the child was 3 years old as a “fleshy spot” on the conjunctiva. The lesion remained unchanged until approximately 6 months before recent admission. During these months, considerable increase in the size of the alteration was noticed by the parents. Parts of the lesion became pigmented and elevated causing foreign body sensation.Detailed ophthalmological examination was performed. The visual acuity was 6/6 in both eyes without correction, and intraocular pressure was 12 Hgmm in the right and 13 Hgmm in the left eye. On slit-lamp examination, a large conjunctival lesion with variegate pigmentation and indistinct margins was detected on the superonasal part of the bulbar conjunctiva of the left eye . EnlargeAnterior segment optical coherence tomography (AS-OCT) was performed with Topcon 3D 2000 OCT using three-dimensional (3D) volume scans. Variegate severity of posterior shadowing and multiple intralesional cysts were detected on B scans, whereas C scans revealed the presence of intralesional cysts and intratumoral vascularity .Written informed consent was obtained from the parents prior to surgery and also for the use of amniotic membrane. Excision of the tumor and cryotherapy for the scleral bed was performed under local anesthesia. Amniotic membrane graft was used for the reconstruction of the ocular surface. The resected tissue was admitted to histopathological examination. Histological examination revealed nevus cell nests with vertical maturation tendency and junctional activity in the epithelial-stromal border of the conjunctiva. Multiple cysts could also be detected. Neither pagetoid spread nor mitotic activity could be observed. The found histopathological signs were characteristic for compound type conjunctival nevus .Giant nevi represent a rare subgroup of melanocytic conjunctival alterations. Considering the extended conjunctival involvement and variegated clinicomorphological appearance, these lesions can cause differential-diagnostic difficulties as they can be confused with malignant melanoma. Although the potential of conjunctival nevi for malignant transformation is low (less than 1%), giant conjunctival nevi require careful management .In our case, an enlarging conjunctival lesion with indistinct border and variegate pigmentation was detected on the bulbar conjunctiva in a 12-year-old girl. Rapid growth and profound change in pigmentation were noticed by the parents. These changes could be initiated by hormonal influences since melanocytic lesions of the conjunctiva tend to modify during puberty. The lesion raised the suspicion of malignant transformation, as (1) rapid enlargement was reported by the parents; (2) variegate pigmentation and indistinct margin of the lesion could be observed; (3) large feeding vessels were presented . AlthougIn conclusion, giant conjunctival nevi represent a rare subgroup of primary melanocytic lesions of the conjunctiva. AS-OCT can detect intralesional cysts and vessels within the nevi; therefore AS-OCT is a useful examination method in the management of conjunctival nevi. In suspicious cases, surgical excision must be performed to exclude malignancy.


The introduction of ultrasound contrast agents has rendered contrast-enhanced ultrasound (CEUS) a valuable complementary technique to address clinically significant problems. This pictorial review describes the use of CEUS guidance in abdominal intervention and illustrates such application for a range of clinical indications. Clinical application of CEUS discussed include commonly performed abdominal interventional procedures, such as biopsy, drainage, nephrostomy, biliary intervention, abdominal tumor ablation and its subsequent monitoring, and imaging of vascular complications following abdominal intervention. The purpose of this article is to further familiarize readers with the application of CEUS, particularly its specific strength over alternative imaging modalities, in abdominal intervention. Image guidance improves the safety and effectiveness of abdominal intervention and creates opportunities for minimal invasive therapies –5. UltraWith the introduction of microbubble ultrasound contrast agents (UCAs), the issue of lack of enhancement with conventional US was addressed. UCA have been available in most parts of the world for more than 20 years. More recently, Lumason  has been granted FDA approval in the United States for abdominal applications for investigation of focal hepatic lesions in both the adult and pediatric populations . There iPerformance with contrast-enhanced ultrasound (CEUS)-guided abdominal intervention, as in other image-guided procedures, depends not only on the operator’s technical skill, but also on the knowledge embedded in the imaging technology, available tools, and existing protocols . The purMicrobubbles in the UCAs consist of an inert filling gas, such as sulfur hexafluoride, encapsulated by phospholipid shells . MicrobuMicrobubbles in UCA remain exclusively intravascular when administered intravenously, making them ideal for assessment of both micro- and macro vasculatures. Visualization of the vascularity of an abnormality offered by CEUS conveys its use to image-guided intervention through improved localization of a focal abnormality. Conversely, lack of perfusion can be established conclusively in avascular abnormalities such as abscesses.CEUS should be performed after an unenhanced conventional US examination is fully evaluated. This allows the operator to identify the area of interest, and establish suitability of a subsequent CEUS examination. UCA are most commonly manually injected as a bolus through an intravenous line, usually via an antecubital vein, followed by 10 mL of 0.9% normal saline flush. It is generally best to insert the intravenous line after the baseline conventional US examination to avoid unnecessary cannulation in case a CEUS examination is not deemed worthwhile. However, due to logistical reasons, patients who are likely to benefit from intravenous UCA administration may need placement of an intravenous line prior to conventional US study at many facilities. The volume of UCA administered varies depending on the structure investigated, sensitivity of ultrasound machines and the UCA used. Conventionally, intravenous use of UCA requires 1.2–4.8 mL depending on the site examined. A dose of 2.4 mL of Lumason per injection is considered adequate for the liver and other abdominal procedures. After administration by intravenous injection, UCA lasts for about 4–5 min in the circulation. A second dose of equal volume can be administered if required.Endocavitary CEUS is a developing technique , 18. ManEndocavitary CEUS differs from intravenous CEUS, in that the volume of the solvent is much smaller than the full blood circulation volume, so a much smaller dose of UCA is required. Endocavitary CEUS can be performed by first diluting UCA in 0.9% normal saline, and the resulting solution is then injected into tubes or cavities. Adequate dilution of UCA is essential to avoid posterior acoustic shadow artifacts secondary to a high concentration of microbubbles. In our experience, this could be achieved with a dilution of 0.1 mL Lumason in approximately 40–50 mL of 0.9% saline. The administered volume of the solution with diluted UCA varies on a case-by-case basis dependent on the estimated volume of the cavity. The lack of circulation of UCA in a confined cavity means microbubbles remains stable within a collection for up to 20–30 min . DestrucUS and CT-guided percutaneous drainage is routinely used as the treatment for a variety of intra-abdominal collections. While sterile fluid collections can be easily identified on gray-scale US, complex collections such as hepatic abscesses, pancreatitis-associated fluid collections, retroperitoneal, and bowel-related abscesses, may appear almost solid and mass-like. The variation in sonographic appearances of complex intra-abdominal collections may make accurate diagnosis difficult due to the resemblance in their sonographic features to those of other pathology . CEUS faEndocavitary CEUS with injection of UCA through a drainage catheter can be performed either immediately after drainage catheter insertion or in the subsequent follow-up period. Tubes and drains are easily detected on gray-scale US but their tip positions are sometimes difficult to locate. Endocavitary CEUS through a drainage catheter primarily facilitates confirmation of the catheter position within the collections. It also provides additional assessment of effectiveness of drainage, particularly in a collection with multiple loculations  Fig. 3)3). FurthOne of the main issue to be confronted in image-guided percutaneous biopsy procedures is the lack of imaging differentiation between the target and adjacent structures . Poor diUS-guided percutaneous nephrostomy (PCN) is routinely used in patients with clinical necessity of urinary drainage or urinary diversion. Frequent technical difficulties contributing to a failed PCN include lack of visibility of a target calyx  in casesFollowing a successful PCN, it is frequently deemed necessary to assess the renal collecting system and ureter for free passage of urine prior to nephrostomy removal. The existing experience in CEUS voiding urosonography has showed safety of administration of endocavitary UCA within the urinary tract without side effects . UCA canPercutaneous trans-hepatic biliary drainage is commonly performed for the treatment of biliary obstruction. It is critical to determine whether the biliary drainage catheter is positioned adequately to ensure the effectiveness of the drainage. The position of the tip of a biliary drain is often difficult to visualize on conventional US due to bowel gas. A fluoroscopic cholangiography is often required following percutaneous biliary drain insertion or a biliary stent placement. In patients with contraindication to iodinated contrast material or in children in whom ionizing radiation exposure is undesirable, CEUS cholangiography has the potential to offer a practical alternative. CEUS percutaneous trans-hepatic cholangiography was first described in 2009 . PercutaWith the advent of thermal ablation technologies, percutaneous ablation has emerged as a viable treatment option as an alternative to surgery in the management of solid abdominal tumors. Frequently utilized ablative mechanisms include radiofrequency ablation (RFA), microwave ablation (MV), cryoablation, particularly for hepatocellular carcinoma , 47, hepPercutaneous ablation of solid abdominal tumors involves the placement of ablation probes into the tumor masses under image guidance. Accurate intra-procedure delineation of tumors and post-ablation evaluation of the ablation zone are fundamental to the effectiveness of treatment. Conventionally, procedural guidance can be achieved with CT or US. US allows multiple planes to perform the procedure in real time. However, even in the most experienced hands, some lesions are poorly visualized on gray-scale US and there can be difficulty in differentiating viable tumors from areas of normal parenchyma or necrosis . CEUS faPercutaneous thermal ablation therapy is a widely used method for liver tumors, which has been a curative method for small liver cancer treatment . SonograRecent advances in nephron-sparing procedures have evolved the management of renal tumors. Ablative technologies offer an alternative nephron-sparing treatment to surgery for small renal tumors . InvisibDuring surveillance following ablation therapy, the ablation scar may be of a similar texture to the surrounding normal tissue on grayscale US. The clarity in assessment of tissue vascularity achieved with CEUS could be used for monitoring effectiveness of ablation therapy and detecting local disease recurrence Fig. . It compEndocavitary CEUS offers potential in detecting complications relating to abdominal intervention such as radiologically inserted gastrostomy tubes . UCA canExtravasation of intravenous contrast medium is a well-known angiographic and CT finding of active bleeding. Conventional US imaging is able to recognize clots and hematoma but cannot determine whether intra-abdominal bleeding has spontaneously stopped or is still ongoing . Active US is routinely used as the imaging modality of choice for interventions in the pediatric population because of concern over medical ionizing radiation exposure of children. CEUS is a safe and potentially cost-effective imaging modality for pediatric population . PediatrCEUS-guided abdominal intervention shares with conventional US-guided procedures some common causes for potential failure. First, when performing an interventional procedure, the acoustic window often needs to be larger than the window for a diagnostic US exam. Poor acoustic windows, resulting from rib shadows, respiratory movement, limited patient mobility and intervening bowel gas, may all increase procedural difficulty. Second, CEUS and US lack the panoramic properties of CT, and deep positions of abdominal organs or some retroperitoneal areas are not always adequately visualized. Moreover, as a prerequisite, CEUS-guided intervention requires adequate operator experience and expertise in interpreting diagnostic CEUS findings in addition to skills in conventional US-guided intervention. Finally, despite growing experience in the literature on CEUS-guided intervention , furtherContrast-enhanced US, as a natural progression from conventional US, lends itself well to abdominal interventions as it combines traditional advantages of ultrasound guidance with real-time enhancement information without significant side effects. The current state of knowledge suggests CEUS offers a valuable armamentarium for abdominal intervention, not only as a credible alternative to other imaging modalities such as CT, but has the potential to even surpass conventional alternatives and offer solutions for complex logistical or clinical challenges encountered in image-guided abdominal intervention.


Vesicouterine fistula is a rare type of urogenital fistulas. It is most commonly observed after cesarean section (C/S) due to iatrogenic reasons. In this article, a case of a vesicouterine fistula which developed after C/S operation is presented. This was the patient's second C/S and this time placenta previa totalis was the primary pathology. Since it is a rare complication, we found it interesting, and, in this article, this clinical problem was discussed with details about diagnosis and treatment in light of the literature. The VUFs, which are observed after caesarean delivery, are not accompanied by urinary incontinence, are characterized by amenorrhea and cyclic haematuria, and are called Youssef's syndrome [Vesicouterine fistulas (VUFs) are classified in the group of urogenital fistulas (UGFs). These rare fistulas make up 1–4% of all UGFs [syndrome . In thisA 28-year-old and 4-year married woman was admitted to the gynaecology outpatient clinic. She had two caesarean sections two years apart. The second caesarean section was performed due to placenta previa totalis and was uneventful. The main complaints of the patient were pelvic pain, haematuria, and intermittent vaginal discharge started a week after caesarean delivery. The external genitalia were assessed as normal. The speculum examination showed minimal fluid in the posterior fornix after valsalva manoeuvre. Uterine and adnexial movements were painful by bimanual examination. Transvaginal ultrasound was within normal limits. In the pelvic magnetic resonance imaging (MRI), a fistula tract was observed between anterior uterine wall which was at the same segment of the caesarean section and the posterior bladder wall. The filling of the liquid to the uterine cavity and vagina from the fistula tract was observed in the images taken after filling the bladder retrogradely with the liquid containing gadolinium .In the cystoscopic examination, a 1 cm fistula orifice was observed 2.5 cm above the trigone in the posterior bladder wall . FollowiThe World Health Organization (WHO) reports that 130.000 new urogenital fistula cases develop each year as a result of difficult deliveries [VUFs, which are a rare type of urogenital fistulas, are also defined as Youssef's syndrome . It was VUFs may appear in different clinical presentations like amenorrhea, cyclic haematuria, pelvic pain, secondary infertility, and recurrent pregnancy losses, with or without involuntary urinary incontinence , 5.While the constant urinary incontinence is imminent in the vesicovaginal fistula, this is subject to the level of the fistula tract in the VUFs. There may be menouria without urinary incontinence depending on the acting of a healthy cervix as a sphincter. While classic Youssef triad  is observed in the fistulas above the uterine isthmic level, menstruation is accompanied by urinary incontinence in the fistulas below it (incompetent cervix). That there is urinary incontinence from time to time in some cases is subject to the exceeding of the intrauterine pressure by the intravesical pressure and the drainage of the urine flow into the uterus from an incompetent cervix , 5–7.There are three subtypes of Youssef's syndrome. Type 1 presented with menouria, Type 2 presented with urine flow into uterus and vagina, and Type 3 presented with normal menstrual cycles . Our casThe diagnosis can be made using cystoscopy and radiological methods like ultrasonography, cystography, intravenous pyelography, cystoscopy, saline infusion sonohysterography, hysterosalpingography, helical computed tomography, and MRI , 10. RadThe double echogenic line between the uterus anterior wall and the posterior wall of the bladder in the ultrasound may suggest a VUF . DiffereIn our case, the pelvic ultrasound was nondiagnostic. The diagnosis and the surgical treatment plan were made upon cystoscopy and MRI findings. The definitive treatment in VUF is surgery, besides conservative and expectant treatment approaches. Surgical treatment may be carried out via vaginal, transvesical, transperitoneal, laparoscopic, and robotic route , 13.The expectant treatment method can be preferred in small fistulas. In this approach, the bladder is catheterized for 4–8 weeks, and amenorrhea is provided with oral contraceptives, progesterone, or gonadotropin hormone analogues , 3, 8. IExpectant or surgical treatment can be preferred in cases that are symptomatic in the early postpartum period. Surgery should be planned in the first 48 hours for the cases with intensive haematuria and postpartum pain . HoweverWe performed the surgical treatment with suprapubic, transabdominal, and transperitoneal approach in the postpartum third month. The bladder was catheterized for three weeks. Laparoscopic and robotic surgery approaches have similar success rates to open surgery in the surgical treatment of VUF. Minimally invasive techniques are superior to open surgery in terms of postoperative patient comfort and returning home early –20.Vesicouterine fistulas known as Youssef's syndrome among genitourinary fistulas are rare fistulas. The number of increasing caesarean deliveries is the main cause of VUFs. As this syndrome may present in different clinical scenarios, suspicion, awareness, and further examination are important factors in the diagnosis. Cystoscopy is basic for diagnosis and exclusion of other possible lesions where MRI is basic for both the diagnosis and the planning of the treatment method. Laparoscopic and robotic surgeries should be preferred in the treatment of VUFs according to the surgeon's experience.


A 42 years old male patient went to our observation for a white lesion in the left cheek presented 5 months ago. He reported general good health, a previous diagnosis of genital lichen planus. During the clinical examination we observed a white not scrapable lesion of 3 cm in the left cheek and 2 small esophitic lesions in the gingival tissue near the retromolar trigone, with cauliflower shape. The lesions is not linked with a traumatic event and we decided to make an incisional biopsy and 2 excisional biopsies for esophitic lesions on the gingiva, with a temporary diagnosis of leukoplakia and HPV squamous papilloma. The histological examination confirms instead the presence of an oral plaque lichen planus, without signs of dysplasia and the presence of 2 squamous papillomas on the tissue removed in the gingival. It is the first documented case in literature of an oral lichen planus which occurs many years after genital lesions, rare in a male subject. In addition, the simultaneous presence of HPV lesions in the same oral anatomic region is particular. Treatment includes topical therapy with podophyllin for HPV lesions or surgical excision and medical treatment of lichen planus with topical cortisones, immunosuppressants or aloe vera-based gels.


Supernumerary testis, also known as polyorchidism, is a condition characterized by the presence of more than two testes. Another condition of the testes is seminoma, a common cause of testicular germ cell tumor. A 35-year-old male was transferred to our hospital with a diagnosis of abdominal mass causing abdominal pain. On physical exam, he had a palpable undescended left testicle in the left inguinal canal, which was determined to be seminoma. The mass was surgically removed, and the patient underwent chemotherapy. The report discusses his workup, treatment, and outcome. This case illustrates an unusual presentation of supernumerary testis with the extra testis harboring a seminoma. When presented with a case of testicular cancer with no tumor noted in the palpable testes, malignancy in an extranumerary testicle should be considered in the differential. Patient is a 35-year-old male who was transferred to our hospital with a diagnosis of abdominal mass after presenting to an outside hospital (OSH) for abdominal pain. Patient reports a three-month history of abnormal bowel movements and a 3-week history of an enlarging, palpable abdominal mass. A CT scan obtained at the OSH revealed a 14 × 18 × 20 cm abdominopelvic mass causing ureteral obstruction and bilateral hydronephrosis, with no retroperitoneal lymphadenopathy . PhysicaTesticular germ cell tumors are the most prevalent malignancy in males between the ages of 15 and 35 years  with an


Omental torsion is a rare and very unusual cause of acute abdominal pain. If often mimics other acute pathologies and it is very difficult to diagnose preoperatively, which can lead to deterioration of the patient. It is seldom reported in the literature.We report a well-documented case of a 67-year-old white woman who complained about abdominal pain, which was slowly increasing in severity. She had no previous abdominal interventions. An abdominal ultrasound showed multiple gallstones. At laparoscopy, free hemorrhagic fluid was seen and further exploration showed torsion of the right part of her omentum. A partial omentectomy was performed. Her postoperative course was uneventful.Omental torsion is a rare cause of abdominal pain. Primary omental torsion is seldom reported in the literature. Blood examinations are frequently normal. Abdominal ultrasound and computed tomography can exclude other pathologies. Exploration remains the preferred diagnostic and therapeutic modality. Surgeons should include the diagnosis of omental torsion in their differential diagnosis of acute abdominal pain. Omental torsion and infarction are rare and unusual causes of acute abdominal pain. Omental torsion and infarction is caused by the twisting of the omentum along its long axis compromising its vascularity. It often mimics other acute pathologies and is very difficult to diagnose preoperatively, which can lead to the deterioration of the patient. We report a case of primary omental torsion with infarction of the right part of a bifid greater omentum.A 67-year-old obese white woman consulted the gastroenterologist in our hospital with a 2-day history of abdominal pain located in her right hypochonder, which was slowly increasing in severity. She did not complain of symptoms such as nausea, vomiting, or diarrhea. She had no history of abdominal problems.3), normal liver function test, and an elevated C-reactive proteine (CRP) (43.4 mg/L). An abdominal ultrasound showed multiple gallstones with a normal choledochal duct, lacking significant signs of acute cholecystitis. Because of the presumption of symptomatic cholecystolithiasis, our patient underwent a laparoscopic exploration. Inspection of her peritoneal cavity revealed free intra-abdominal hemorrhagic fluid. Further exploration showed torsion of the right part of her omentum, which can be visualized in Fig. A clinical examination revealed a tender right hemiabdomen with percussion pain. Laboratory tests demonstrated leukocytosis (10.2 × 1000/mmHer bifid omentum was twisted around its vascular axis several times, as demonstrated in Figs. Omental torsion is a rare cause of acute abdominal pain, which can present in two ways. Eitel first described primary omental torsion in 1899 , 3. The Omental torsion mainly affects adults; it affects males twice as frequently as females, with the majority being overweight . ReportsThe primary symptom associated with omental torsion is pain, which is frequently localized in the right part of the abdomen . The paiBlood examinations are frequently found to be normal. Because of the clinical context of an acute abdomen, ultrasound and computed tomography are useful to assist the diagnosis. Classical signs of omental torsion on computed tomography are the whirl sign of a fatty mass with concentric linear strands . ComputeExploration remains the preferred diagnostic and therapeutic modality , 10. SurOmental torsion is an unusual cause of acute abdominal pain with nonspecific symptoms and signs of acute abdomen, making diagnosis very difficult. Surgeons should include it in their differential diagnosis of acute abdomen. Computed tomography can be useful to reveal the diagnosis or to exclude other pathologies. Surgical resection of the infarcted omentum remains the treatment of choice.


Ingestion of foreign bodies is common and conservative treatment can eliminated most particlesfrom the gastrointestinal tractunless peritoneal signs appear. A 22-year-old man presented to emergency department who had ingested glass particles of a crushed beveragebottle.Hecomplained ofepigastric and periumbilical pain. Physical examination did not revealany peritoneal signs. Abdominal X-ray showed stomach full of small glass particles. Conservative treatment, without any surgical intervention,resulted insafely eliminating glass particlesin this patient. Foreign bodies may be ingested, inserted into a body cavity, or deposited into the body by a traumatic or iatrogenic injury. Most ingested foreign bodies pass throughthe gastrointestinal tract without any problem. HoweverA 22-year-old male was brought to emergency department with chief complaint of periumbilical and epigastric pain since 4 hours before. He explained that he had ingested crushed glasses of a beverage bottleafter a family argument. About 30 minutes after swallowing glass particles,the patient had developed irritation and pain in epigastric and periumbilical area without any other associated symptom.Hedenied history of other diseases including psychiatric problems.On physical examination normal vital signs were detected, no oral lesion or laceration or bleeding was seen. He had normal breathing sounds. Abdomen had normal bowel sounds with mild epigastric tenderness without rebound tenderness or guarding.Chest X-ray and abdominal X-ray were performed. Chest X-ray was normal with no air under diaphragm or pneumomediastinum. Abdominal X ray  showed aThe patient was monitored continuously and carefully; surgical consultation was done, laparotomy was planned but patient didnot agree to undergo surgical intervention.Thereafter, he was monitored closely and observed in emergency department with serial physical exam. Serial abdominal radiography was done every other day to evaluate the removal of the particles . All glaCases of intentional glass ingestionare rare, so there is no special guideline to approach them. In these cases, it is expected to see oral cavity laceration, drooling, inability to swallow, neck pain or chest pain. If the objects could pass the esophagus, mild abdominal pain or even signs of acute abdomen may appear. Based on the routine approach, in order to identify the location, number and size of the ingested particles, and also evaluate the presence of any kind of complications, radiography could be suggested as an initial screening method. AlthougEmergency esophagogastroduodenoscopy is suggestedin cases of sharp or pointed foreign bodies. They can result in complications such as gastrointestinal bleeding, abscess formation,mediastinitis or peritonitis due to perforation of the gastrointestinal tract, 10. Sur


Gallstone spillage is a common intraoperative event during laparoscopic cholecystectomy (LC). Patients present months to years with nonspecific symptoms after the original procedure. The complications of retained peritoneal gallstones are infrequent. Having a high index of suspicion is the key to early diagnosis. Every effort should be made to remove spilled gallstones at the index operation to prevent future complications, however, conversion from laparoscopy to laparotomy for retrieval of spilt gallstone is not recommended. Here we present a case of retained gallstone presenting as a large intra-abdominal mass four years after laparoscopic cholecystectomy in a middle age bariatric patient. Laparoscopic cholecystectomy (LC) is the treatment of choice for acute cholecystitis as well as for symptomatic cholelithiasis. Gallstone spillage is a common intraoperative event during LC. Woodfield, et al. report an incidence of gallbladder perforation of 18.3%, with complication of peritoneal gallstones occurring in approximately 1.7 per 1,000 LCs, in approximately 2.3% of cases in which stones were spilt, and in 7% of cases in which stones were knowingly left unretrieved in the peritoneal cavity . Here we2. Blood tests revealed vitamin B1 (thiamine) and Vitamin D  deficiency, the rest of the laboratory results were within normal limits.A 52-year-old female presented in our bariatric clinic for routine follow-up for history of laparoscopic sleeve gastrectomy about five years ago for morbid obesity who reported having occasional postprandial epigastric pain that had been ongoing for about three months. There was no associated nausea or vomiting. She was not on antacid or proton pump inhibitor. History was significant for laparoscopic cholecystectomy four years ago for biliary colic with iatrogenic perforation of the gallbladder due to dense adhesion, all visible gallstones were aspirated at that time and her recovery was uneventful. She had also had diagnostic laparoscopy, laparoscopic-assisted hysterectomy and bilateral salpingo-oophorectomy, cesarean-section. She was on multivitamins at home. Physical examination was unremarkable – she weighed 106 kg, height 1.72 m with a body mass index (BMI) of 35.8 kg/mOn this occasion, upper endoscopy was done which showed small amount of bile gastritis, otherwise, it was unremarkable. Subsequent computed tomography (CT) scan revealed a densely calcified lesion within the omentum without surrounding inflammation Figure . The patPathology reported an 8.7 x 7.5 x 2.8 cm irregular segment of serosal covered, lobulated, yellow-pink adipose tissue consistent with lipoma and a 3.9 x 2.7 x 2.3 cm dark brown, ovoid apparent calculus embedded within membranous tissue associated with foreign body reaction and chronic inflammation , gallstone size greater than 1.5 cm, elderly patients, male sex, and subphrenic/subhepatic location of retained gallstone .Retained peritoneal gallstones are not without complications. The effort to minimize iatrogenic gallbladder perforation is important including using the surgical technique that minimizes the risk of gallbladder perforation. This includes establishing the correct plane in dissecting the gallbladder from the liver, minimizing diathermy injury, and having a low threshold for using hydrodissection in Calot’s triangle . If a peIntraoperative management of spillage gallstones in the abdominal cavity involves immediate judicious removal of as many stones as possible. Thorough irrigation and suction should be performed after collecting the visible stones in order to minimize the number of lost stone. Clear documentation of the intraoperative gallstone spillage in the operative report is recommended for alerting clinician in the future to the possibility of retained stone causing any subsequent problems that might lead to a prompt diagnosis ,3.The complications of retained peritoneal gallstones are usually associated with delayed presentation of unexpected clinical problem. There is often a mean time of 4.8 months between onset of symptoms and the diagnosis of retained gallstone being made . CT scanIn our case, pathology was consistent with a large 4 cm gallstone encased in the omentum. The patient had a gallstone dropped into the abdomen at the time of her cholecystectomy years ago, and this became encased in omentum and developed a calcified rim around it. No malignant pathology was noted.The complications of retained peritoneal gallstones are infrequent. Having a high index of suspicion is the key to early diagnosis. Every effort should be made to remove spilled gallstones at the index operation to prevent future complications, however, conversion from laparoscopy to laparotomy for retrieval of spilt gallstone is not recommended.


Leiomyosarcomas of the penis are rare, with only 29 reported cases to date. We record the case of a patient who presented with a 2-year history of a seemingly indolent penile skin lesion. On histopathology of the local resection, a diagnosis of subcutaneous leiomyosarcoma was made. Specifically, leiomyosarcoma of the penile frenulum has not been clearly reported previously. The patient underwent a further excision to ensure an adequate resection margin and has had no disease recurrence at subsequent follow-up. Our case was of a lesion that, although clinically benign, was malignant and this possibility should be borne in mind when assessing patients.


The authors describe a 48-year-old woman suffering from bilateral upper-extremity numbness and axial radiating pain. Magnetic resonance imaging revealed soft-tissue edema and enhancement surrounding the dorsal tip of the C7 spinous process. Excisional biopsy of the lesion revealed a mildly inflamed bursa, with no evidence of an active infection. Removal of the inflamed bursa resulted in complete resolution of the upper-extremity numbness and improvement in her neck pain. Although similar cases have been reported to be associated with rheumatologic conditions, most notably polymyalgia rheumatica (PMR), the current report underlines the presentation of radicular-like complaints associated with interspinous bursitis in the absence of other conditions affecting the musculoskeleton. The spinal column harbors a variable number of bursae, usually located between each of the spinous processes of the cervical and lumbar segments . InflammHistory and examinationA 48-year-old woman presented to the emergency department (ED) with complaints of neck pain, right-sided facial and hand pain, hand numbness, intermittent fever, and a bulge at the posterior aspect of her neck. The patient’s past history was found to be positive for removal of a pituitary macro-adenoma, chronic headaches, neck and back pain as well as occasional upper-extremity numbness. Physical examination revealed a reduced cervical range of motion and spinous process tenderness. No neurologic deficits were found. Workup to rule out infection including white blood cell count, C-reactive protein, and repeated lumbar punctures was negative. Initial diagnostic imaging which consisted of cervical spine magnetic resonance imaging (MRI) without contrast demonstrated mild-to-moderate degenerative changes of the cervical spine without findings suggestive of neural or soft tissue infection Figure . FollowiSurgical treatment and post-operative courseFollowing evaluation, the patient underwent excisional biopsy of the C7 peri-spinous process soft tissue. Exploration revealed mildly inflamed bursa with no evidence of infection or involvement of other soft or osseous elements. Following excision, the patient reported significant improvement in neck pain and hand numbness. The bursa specimens sent for cultures, including acid-fast bacilli and fungi, yielded no growth.In an anatomic study performed in 27 cadavers by Bywaters et al. , the incIn conclusion, this case, albeit consisting of merely a “minor” nuisance, may provide important lessons in a broader context. First, we suggest that interspinous bursitis should be considered as one of the more common pain generators during evaluation of patients complaining of either simple or “radicular-like” neck pain. Simple palpation of the spinous processes during physical exams, and looking for signs of increased contrast uptake may assist in the diagnosis. Second, the high association previously reported between interspinous bursitis and multi-system rheumatologic pathologies, such as PMR, may serve to both prompt further rheumatologic evaluation as well as assist in avoiding unnecessary surgical interventions for other non-surgical pathologies.