In this paper, we present the successful therapeutic approach of unresectable liver metastases in a patient with rectal cancer.A 63-year-old male underwent endoscopic polypectomy followed by rectosigmoid resection for an adenocarcinoma of the rectum diagnosed in pT2N0 stage. The angio-computed tomography (CT) revealed four metastatic hepatic nodules ranging from 12 to 130 mm in diameter. After one cure of trans-arterial chemoembolization (TACE) with lipiodol and 5-fluorouracil, combined with FOLFOX4 + capecitabine systemic chemotherapy, the diameter of all hepatic nodules decreased to half size, at 6 months after TACE. Further curative surgical hepatic metastasectomy was done and complete pathologic response was obtained. The patient is free of recurrences and metastases after 26 months of follow-up.This representative case shows that an efficient trans-disciplinary approach could lead to successful therapeutic management even in patients with advanced-staged colorectal carcinomas. Signed informed consent was preoperatively obtained to perform surgery and publish the case details. This is a case report and institutional review board approval was not necessary.A 63-year-old male was hospitalized with long-time history of fecal occult bleeding. The flexible sigmoidoscopy showed a polypoid lesion in the proximal rectum that was endoscopically resected. The tumor was diagnosed as a moderately differentiated adenocarcinoma developed on the background of an adenomatous polyp, with tumor infiltration of the pedicle Fig. , and no Rectosigmoid resection was done and the intraoperative exploration confirmed the multifocal unresectable hepatic metastases. Metastatic biopsy form the VIth segment of the liver was performed. Histological examination of the rectosigmoid showed no remnant tumor cells in the surgical specimen and absence of lymph node metastases. Based on the endoscopic specimen aspect, and keratin 20 positivity within the glandular structures from the liver nodule Fig. , the tum2/day) were performed, according to the international guidelines.7One month after surgery, the oncologic protocol started with 1 session of TACE, which was trans-femorally performed and consisted of infusion of 10 mL of lipiodol and 5-fluorouracil (1000 mg/24 hours) in the right branch of the hepatic artery , using the same therapeutic protocol, were repeated. The patient is alive at 26 months after first surgical intervention, with no signs of tumor recurrence or other metastases at control-CT .12 In other trials, significant TACE-related shrinkage of the metastatic nodules was reported in 42% to 62% of the patients, compared with 9% to 21% of the cases in which only systemic chemotherapy was used.14Currently in the literature, there is only 1 randomized trial that evaluated the usefulness of TACE compared to systemic chemotherapy in patients with liver metastases after CRC, which shows no significant increased survival in the patients.5 the authors presenting the first case of complete pathologic response (CPR) obtained in a patient with a pT3N0 stage sigmoid carcinoma, with 6 unresectable hepatic metastases, similar to our case. In Pernot et al's patient, concomitant systemic FOLFOX4 combined with two sessions of drug-eluting beads loaded with irinotecan (DEBIRI) was performed,5 whereas 5-fluorouracil and systemic FOLFOX4 + capecitabine was the therapeutic regimen used in our case. After 2 sessions of embolization, they obtained CPR and proved under the microscope that no tumor cells were present in the hepatic parenchyma.5 In our case, significant shrinkage (from 130 to 55 mm) was obtained at 6 months after 1 session of embolization but the tumor cells did not disappear.The most recent report in the field was published by Pernot et al,5It is worth noticing that the CPR was microscopically appreciated by Pernot et al based on the presence of fibrosis and acellular mucoid lakes in the liver specimens, without mentioning the immunoprofile of these lakes (CEA and keratins). Moreover, they did not mention data about the CEA and CA 19-9 serum levels in the patient, before and after TACE.15 According to these criteria, the presence of fibrotic areas with acellular mucin pools, in the specimens examined postradiochemotherapy, should be considered as a CPR, independent of the histological aspect of the primary tumor (mucinous carcinomas vs. adenocarcinomas without mucinous component).15 However, this aspect is controversial because the acellular pools can show CEA positivity correlated with a high serum CEA level.16 Moreover, in some rectal specimens with postchemoradiotherapy mucin lakes, tumor cells can be seen after multisliced section. Based on this fact, it was previously suggested by our team that “the presence of acellular mucin pools in surgical specimens of rectal cancers cannot be interpreted as an indicator of complete response at radiotherapy if at least 10 multilevel sections are performed in at least 3 tumor blocks per case, and CEA negativity is not proved.”16The same histological criteria were proposed by the College of American Pathologists to evaluate the CPR to preoperative chemoradiation in resected specimens of rectal cancer patients.This case is the first one reporting CPR based on the metastases’ complete resectability, without recurrences, and constant low serum levels of CEA and CA 19-9, at 24 months after TACE. The case confirms the promising TACE-related results, combined with neoadjuvant systemic chemotherapy, in patients with unresectable liver metastases after CRC, especially in cases without lymph node metastases.Limitations of the paper: This paper was based on only 1 case with a follow-up time of 26 months. To prove the efficacy of TACE combined with neoadjuvant systemic chemotherapy, in patients with multifocal unresectable liver metastases after CRC, a longer follow-up in several cases would be necessary.


Esophageal atresia is the commonest cause of obstruction to esophageal lumen in neonates. Foreign bodies in newborns are extremely rare. We report a rare case of esophageal obstruction closely mimicking atresia due to foreign bodies inserted in a female neonate with homicidal intension. Foreign body (FB) ingestion is a common and serious problem in pediatric population between 6 months to 3 years of age. Coins are the most common foreign body ingested by children. Various other FB like stone, ornament, ring, button and safety pin have also been reported. Esophageal FB are extremely rare in neonates and can be life-threatening. We report a neonate where unusual non-metallic FB led to a presentation akin to that of an esophageal atresia. A 6-day-old full term female baby, delivered at a peripheral hospital, was brought with continuous frothing of saliva from the mouth, refusal of feeds and a progressive respiratory distress since birth. No records were available regarding the initial resuscitation of the baby and whether a nasogastric tube was passed at birth to assess esophageal patency. She was seen at three different hospitals where a diagnosis of esophageal atresia was made before she reached our center for further management.On examination, the baby was a sick-looking full-term female neonate having severe tachypnea with persistent white froth in mouth. No chest wall retractions or central cyanosis was noted. Heart rate was 162 beats per minute and respiratory rate was 54 per minute. Auscultation of the chest revealed equal air entry on both sides with coarse crepitations. Insertion of a red rubber tube through the mouth revealed obstruction at 10cms from the mouth was noted. Chest roentgenogram with the red rubber tube in situ demonstrated the tube lying at the level of the third thoracic vertebrae with presence of air in the stomach. Echocardiographic examination was normal. A clinical diagnosis of esophageal atresia with distal tracheo-esophageal fistula (Vogt type III) was made. She was stabilized by low-pressure continuous upper pouch suction, oxygen, antibiotics and chest physiotherapy.The patient was taken up for a right postero-lateral thoracotomy. On exploration, the esophagus was found to be in continuity with no evidence of esophageal atresia. Careful palpation of the esophagus revealed a hard mass in the upper esophagus. Longitudinal esophagotomy over the mass showed multiple foreign bodies (beetle nuts pieces) and they were meticulously removed . After removal of beetle nut pieces, a nasogastric tube could easily be passed into the stomach from the mouth. Esophagus was repaired over the nasogastric tube and chest was closed after putting an intercostal drain. Post-operative period was uneventful.On retrospective enquiry to understand the motive, we found that the baby was born on a supposedly inauspicious birth star and was believed to be a harbinger of bad luck due to a misguided belief in an astrologer. The grandfather of the baby had forcefully pushed small pieces of beetle nut down the child’s throat. Occurrence of FB ingestion in neonates is rare with only a few reported cases in literature.  Small ornaments and button batteries have been described in neonates, which have been inserted playfully by an elder sibling or due to a homicidal attempt on an unwelcome female baby.  Aggarwal and Gupta reported a case of retained cotton swab in the esophagus probably retained during finger sweep during resuscitation. [5] Respiratory distress is the most common manifestation of an FB in esophagus in neonates. Respiratory distress along with failure to pass a stiff catheter poses a problem in ruling out esophageal atresia, as in our case.  Availability of proper history and visualization on radiograph of the chest should help in clinching the diagnosis. However, nonavailability of proper history and a radiolucent FB poses problems in diagnosis and management, as in our case. Non-visualization of fistula on preoperative bronchoscopy may also point towards an alternate diagnosis especially when radiographs demonstrate the presence of ample gas in the stomach. Computerized tomography has also been used in diagnosing esophageal foreign bodies in neonates. [5]Primary Endoscopic removal is recommended if the pre-op diagnosis is available.  Intraoperative removal by rigid esophagoscopy can also be utilized whenever available and would avoid the need for an esophagotomy. [5] Cervical esophagotomy and thoracotomy have been performed in undiagnosed or impacted cases. [4]To conclude, neonatal esophageal FB may mimic esophageal atresia and a high index of suspicion is required for a proper diagnosis and treatment. Source of Support: NilConflict of Interest: None


Splenogonadal fusion is a rare developmental anomaly in which an abnormal connection between splenic tissue and gonads or mesonephric derivatives is present. Here we present a case of young man with the complaint of primary infertility for 3 years. On evaluation (USG and MRI abdomen and pelvis), his right scrotal testis was atrophied and left intra-abdominal undescended testis. On laparoscopic assessment, a mass was seen on the left side due to continuous type of splenogonadal fusion for which excision and left orchidectomy were done. Postoperative period was uneventful and he was discharged under satisfactory condition. Splenogonadal fusion is a rare entity and it is commonly mistaken for testicular tumour. It should be considered in the differential diagnosis of testicular masses especially when there are associated congenital anomalies and preoperative laparoscopic assessment, should be done to avoid unnecessary radical surgery. Splenogonadal fusion is a very uncommon developmental anomaly arising due to abnormal connection between developing splenic tissue from dorsal mesogastrium and gonadal or mesonephric derivatives. Such rare anomaly usually takes place during the 5th to 8th week of gestation, that is, before gonadal descent starts and presents as mass. The product fusion commonly diagnosed as a testicular mass of unknown origin in association with other congenital deformities .A 25-year-old male patient presented in urology clinic with chief complaint of primary infertility of a 3-year duration. General physical examination was normal. On local examination, patient's right atrophic testis was situated in scrotum and of size 1.5 cm × 1.5 cm. On the other hand, there was empty scrotum on left side which was suggestive of undescended testes. There were no associated congenital anomalies seen. Routine blood investigations, renal function test, and liver function tests were normal. The levels of tumor markers as AFP and beta-hCG were 5 kIU/L and 2.5 kIU/L which were within normal limits. Semen analysis revealed azoospermia. Hormonal study revealed primary testicular failure with elevated gonadotropin levels. Ultrasonography (USG) revealed absence of left sided testis and epididymis in the scrotum and inguinal canal. MRI reported two oblong masses each 2.5 × 1 cm in the left retroperitoneal region anterior and lateral to psoas muscle at L3 to S1 level with atrophied left seminal vesicles . PatientThe first description of splenogonadal fusion was made by Bostroem in 1883, and a detailed report by Pommer followed in 1889. There are few other names existing for this disorder in literature as ectopic scrotal spleen or testicular splenic fusion. In a review of 30 cases,  Putschar and Manion categorised splenogonadal fusion into continuous and discontinuous types depending on the anatomical continuity between the principal spleen and the gonad . The conContinuous type of splenogonadal fusion has been associated with many anomalies, including cryptorchidism, which has been found in approximately 33% of the cases of splenogonadal fusion. Other associated anomalies include cardiac defects, limb bud abnormalities also called peromelia , micrognathia, hypoglossia, craniosynostosis, spina bifida, palatine, and anorectal and rare syndromic anomalies. Discontinuous type is usually not related to any congenital anomaly though few cases of associated cardiac defects are reported in the literature. Although the case we presented here was of continuous type of splenogonadal fusion, there was no other associated congenital anomaly, except cryptorchidism and infertility .Techniques of diagnostic imaging are available if there is a clinical suspicion of splenogonadal fusion. The most reliable investigation to confirm its diagnosis is preoperative imaging through 99 m Tc-sulfur colloid liver spleen scan, which detects accessory spleen. Recently, Doppler ultrasonography of the scrotum of patients with a palpable testicular mass has been used to diagnose preoperatively few cases of splenogonadal fusion by visualizing a hypervascular mass on the upper pole of testis and comparing it with patient's own normally located spleen , 8. SuchSplenogonadal fusion is a very uncommon disorder and due to its presentation as an asymptomatic testicular mass it can easily be misdiagnosed as malignancy though involved structure is of normal characteristics which suggests its benign nature. It must be considered as an important differential diagnosis of testicular masses, more so if it is associated with congenital anomalies. Preoperative laparoscopic assessment may prevent unnecessary radical orchidectomy but, in cases in which salvage is done for cryptorchidism, surveillance for detection of any future occurrence of malignancy is recommended.


Central ossifying fibroma is a benign slow-growing tumor of mesenchymal origin and it tends to occur in the second and third decades of life, with predilection for women and for the mandibular premolar and molar areas. Clinically, it is a large asymptomatic tumor of aggressive appearance, with possible tooth displacement. Occasionally treated by curettage enucleation, this conservative surgical excision is showing a recurrence rate extremely low. The objective of this study was to report a case of a 44-year-old woman, presenting a very large ossifying fibroma in the mandible, which was successfully treated with curettage, and to conduct a brief literature review of this lesion, focusing on the histology, clinical behavior, and management of these uncommon lesions. Central ossifying fibroma (COF) is the most common benign fibroosseous neoplasm of the oral and maxillofacial region. It was described by Menzel in 1872 but was appointed by Montgomery in 1927 [Central ossifying fibroma usually presents clinically as a painless and expansive spherical or ovoid jawbone mass that may displace the roots of adjacent teeth and cause root resorption , 10. COFThe aims of this report are to present a case of COF in the mandible and to provide a critical review of the current literature regarding lesions of this type.A 44-year-old black woman was referred to the maxillofacial surgery clinic of the Vale do Rio Verde University for evaluation of an asymptomatic swelling in the vestibular region of the left mandible canine . The exaCOF is more frequent in female patients in the second to fourth decades of life , 16–18. Most cases of COFs are asymptomatic, with the first clinical manifestation being a swelling of the mandibular cortical layer, which produces a marked extraoral facial asymmetry , 10. TheWhen the lesion occurs in patients between 5 years and 15 years of age, it is called a juvenile ossifying fibroma , which dThe differential diagnosis of COF is based on radiographic features. As a completely radiolucent lesion, COF can be misdiagnosed as a lesion with a radiographically similar appearance, such as focal cementoosseous dysplasia, odontogenic cyst, periapical granuloma, traumatic bone cyst, unilocular ameloblastoma, and central giant cell granuloma. The imaging features in the present case were similar to those of most reported cases, showing a circumscribed radiolucent lesion with well-defined margins and intralesional calcification , 9.Histologically, COFs contain ossicles that connect to form bone trabeculae that are usually surrounded by osteoblasts and occasionally by osteoclasts. Cementum-like rounded calcifications are also frequently observed, and a mixture of these two types of calcifications is commonly observed inside a single lesion  1, 2, 2, 21.Enucleation by curettage has been reported as a method for the treatment of COF . In someThe clinical management of COF remains uncertain. To avoid or minimize the chance of recurrence, a partial or en bloc resection of the jaw is preferred for larger lesions , 22. AltOur findings showed that the conservative surgical excision of COF appears to be a versatile, secure, and satisfactory treatment option Figures  and 4. A


Concurrence of duodenal atresia and gastric duplication cyst is extremely rare entity. We report a 6-day-old female neonate who presented with neonatal intestinal obstruction. X-ray abdomen showed double bubble sign. At laparotomy, a huge cystic structure attached to greater curvature of the stomach along with duodenal atresia of second part of duodenum was found. The cystic structure was excised and duodeno-duodenostomy performed. Histopathology report confirmed it gastric duplication cyst. A 6-day-old female neonate developed signs of neonatal intestinal obstruction. She was a product of twin pregnancy with gestational age of 35 weeks. At birth, she underwent CPR in delivery room, and after intubation received one dose of surfactant. The other twin was normal. On the 4th day she was extubated but very next day developed bilious vomiting and was referred to our center. Thoraco-abdominal x-ray revealed double bubble sign in favor of duodenal obstruction . Cardiology consultation revealed multiple cardiac anomalies. She underwent CT angiography later in the course of management which confirmed coarctation of the aorta. At laparotomy a distended stomach and huge cystic structure (communicating) attached to the greater curvature of stomach was found . Further exploration revealed duodenal atresia type I with annular pancreas at 2nd part of the duodenum. The cyst excised and gastric wall repaired. Duodeno-duodenostomy was then carried out. Postoperative recovery was uneventful. The infant is doing well at six months follow-up.Gastric duplications (GD) are the rare alimentary tract duplications.[1] GDs mostly present with vague abdominal pain, vomiting, and occasionally a palpable abdominal mass. These may remain asymptomatic or present with complications.[2] GDs have occasionally been reported with intestinal atresia. Few case reports of GIT duplications and atresia of the adjacent part of normal alimentary tract are available on literature search.[3-5] In our case gastric duplication was associated with duodenal atresia and annular pancreas. Presence of cyst may have some role in vascular accidents which might have resulted in atresia of the adjacent part. Surgery is the mainstay of treatment.[2] In our case, the cyst was huge in size and communicating with stomach. Histopathology confirmed gastric mucosa in our case.In conclusion, concurrence of gastric duplication cyst with duodenal atresia is a rare event. Presence of duplication cyst may have some role in genesis of duodenal atresia in the index case.Source of Support: NilConflict of Interest: None declared


Skull and intracranial metastases from hepatocellular carcinoma (HCC) have seldom been reported. A skull metastasis of HCC with a tumor bleeding resulting in spontaneous subdural hematoma (SDH) is extremely unusual. We report the first case of acute spontaneous SDH in a 69-year-old woman who presented with acute onset of headache, because of tumor bleeding caused by skull metastasis of HCC.A 69-year-old woman was referred to our hospital because of progressive headache, nausea, and vomiting for 3 days. Brain computed tomography (CT) performed in the emergency department (ED) revealed a left temporal SDH with a slight mass effect and a small left temporal bone erosion. Tri-phasic abdominal CT demonstrated a large right lobe liver tumor compatible with HCC. She experienced progressive deterioration of consciousness in the intensive care unit. Follow-up CT showed an enlargement of the SDH. An emergency craniotomy for hematoma evacuation and removal of skull tumor was performed. She regained consciousness and had no neurological deficits during the postoperative course. Pathological examination of the skull specimen indicated metastasis of a HCC.Patients with acute SDH without a history of head injury are rarely encountered in the ED. Metastatic carcinoma with bleeding should be included as a differential diagnosis for acute spontaneous SDH. Before an operation for SDH, the possibility of metastatic lesion of the skull should be considered in the surgical planning and the origin of malignancy should be sought. Acute subdural hemorrhage (SDH) commonly results from closed head injury. The linear translation of acceleration along the skull can cause injury to the veins, arteries, or brain parenchyma, resulting in SDHs, epidural hematomas, or contusion hematomas . Skull aA 69-year-old woman was referred to our hospital because of progressive headache, nausea, and vomiting for 3 days. In addition, she complained of dizziness and a decrease in appetite. She had neither systemic disease nor history of recent trauma or injury to the head. Her Glasgow Coma Scale (GCS) was 13 (E3V4M6) at the emergency department (ED) without notable focal neurological signs. Routine laboratory examination demonstrated normal liver function with no evidence of coagulopathy and thrombocytopenia. Chest radiography showed no remarkable findings. However, emergency computed tomography (CT) of her head revealed a left temporal SDH with slight mass effect and small left temporal bone erosion Fig. . ExaminaDuring her second day in the ICU, her consciousness deteriorated significantly. Her GCS dropped from 13 to 8 and her pupils were anisocoric. Emergency brain CT showed an enlargement of the left temporal SDH with significant mass effect (Fig. Skull metastasis from HCC occurred infrequently, in about 0.4–1.6% of patients with HCC . HCC comTo our best knowledge, there is no report of acute SDH from a metastatic skull lesion of HCC. Hsieh et al. reviewed 68 patients with HCC and skull metastases . They reAnatomically, the dura mater is a thick, dense and fibrous membrane. It can be devided to outer endosteal layer and inner meningeal layer. Microscopically, the dura was found to consist predominantly of collagen fibers, although the thickness of the dura varied between sites. Dura was significantly thinner in relation to the ethmoid sinus, tegmen and sigmoid sinus, indicating its greater susceptibility to possible injury at these sites during surgery and head trauma ,10. The Our patient presented with a sudden onset of headache that resulted from spontaneous SDH presumably due to the bleeding of the metastatic tumor that passed through the dural perforation into the subdural space. We emphasize that if an acute SDH is found in a patient without a history of trauma, then skull metastasis with tumor bleeding should be considered. The possibility of malignancy with skull metastases can guide an appropriate surgical strategy. Surgical planning of metastatic tumor bleeding is different from traumatic SDH. Total removal of metastatic tumor and evacuation of SDH are equally the top priority of surgical planning.Acute spontaneous SDH in patients without a history of head injury is rarely encountered. Metastatic carcinoma with a tumor bleeding should be included in the differential diagnosis for patients presenting with spontaneous SDH.Written informed consent was obtained from the patient’s son for publication of this case report and any accompanying imagines. A copy of the written consent is available for review by the Editor of this journal.


Askin tumor is a malignant small round cell tumor that originates from the thoracopulmonary region, usually observed in young subjects. We report a case of askin tumor in a 11 year-old men, who had in his past history a surgery for hydatid cyst of the liver, actually hospitalised for right pulmonary upper lobe mass of the lung. After resection of the mass, the pathological exam confirmed the diagnosis of primitive neuroectodermal tumor (PNET). An adjuvant treatment (radiotherapy and chemotherapy) was done; the patient died 11 months after surgery. Askin tumor is an exclusion diagnosis not always readily made. In 1979, Askin and al first identified a PNET of the thoracopulmonary region in children and young adults as a specific pathological entity [A 11 year-old child was referred to our department with a 1 month history of pain in the right chest. In his past history, he had a surgery of hydatid cyst of the liver three years ago. A physical examination revealed a diminution of the breath sound in the upper right lobe without other clinical sign, and the patient was in excellent condition. The chest X-ray realised in our patient showed right upper lobe opacity  and the Askin's tumor or primitive neuroectodermal tumor (PNET), is an extremely malignant small cell tumor of the thoracopulmonary region. Originating from the neuroepithelial cells of the intercostals nerves, these tumors may involve the ribs, the soft tissue of the chest wall, and the lung. An indistinguishable t 11,22) translocation has been demonstrated in Askin's and Ewing's tumour, perhaps indicating a common origin for these tumours 1,22 tran, 4. HistMarina et al  felt theMultimodality therapy has improved local control and overall survival for patients with PNET of the chest wall, but uniform treatment regimens remains underteminated. Actually, standard treatment of askin's tumor comprises surgery after chemotherapy . The proAskin tumors are rare but highly malignant and must treated by aggressive interdisciplinary management including radical surgery and chemotherapy.


Primary vitreoretinal lymphoma (PVRL) is a rare and fatal ocular malignancy that is mostly classified as diffuse large B cell lymphoma (DLBCL). PVRL is often fatal because of its association with the central nervous system (CNS). PVRL frequently masquerades as uveitis and sometimes recurs in clinical findings as keratic precipitates (KPs) and subretinal lesions. Pseudohypopyon is one of the clinical findings of the local recurrence of PVRL and is treated with radiotherapy; however, the effectiveness of local control with an intravitreal injection of methotrexate (MTX) has not yet been determined. We herein present a case of recurrent vitreoretinal lymphoma that repeatedly developed pseudohypopyon and treated with intravitreal MTX.A 64-year-old woman was diagnosed with PVRL involving primary central nervous system lymphoma (PCNSL). She received radiotherapy to the whole brain and a local ocular treatment, which resulted in temporary remission of the disease. Pseudohypopyon was detected during the follow-up. It was 2-mm high, viscous, and swollen in the center. Anterior chamber biopsy revealed the presence of atypical lymphocytes, indicating the recurrence of DLBCL. Pseudohypopyon was treated with intravitreal methotrexate and completely disappeared. Pseudohypopyon has since repeatedly appeared and been treated with intravitreal MTX each time. The recurrence of PVRL with KPs and subretinal invasion was treated with intravitreal MTX each time. Recurrence with pseudohypopyon was not simultaneous with KPs or subretinal invasion. No CNS involvement was detected during the observation period.Pseudohypopyon is one of the signs of recurrent vitreoretinal lymphoma. Although pseudohypopyon was temporarily controlled with intravitreal MTX, this treatment did not completely induce its remission. Primary vitreoretinal lymphoma (PVRL) is a subset of primary central nervous system lymphoma (PCNSL), mostly diffuse large B-cell lymphoma (DLBCL). PVRL is often fatal because of its association with the CNS . ApproxiPVRL often recurs even though it is treated systemically. In recurrent cases, the same ocular findings, such as KPs, vitreous cells, and subretinal invasion, are observed . PseudohIn the present study, we reported the rare complication of recurrent pseudohypopyon in a patient with PVRL treated with intravitreal MTX. We also monitored treatment-associated changes in the lesion by serial examinations.2) and radiotherapy to the right eye of 40Gy. Brain recurrence has not been observed since then.A 64-year-old woman presented to a local doctor in 2000 with blurred vision in her right eye. She was diagnosed with chronic iridocyclitis and treated with topical corticosteroids with limited improvements. More detailed examinations were not performed at that time. In 2003, she consulted a neurologist for depression, and thereafter was diagnosed with CNS lymphoma by brain MRI. On presentation, best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/20 in the left eye, and intraocular pressure was normal. A slit-lamp examination showed KPs and inflammatory cells (2+) in the anterior chamber of the right eye. A fundus examination of the right eye revealed vitreous opacities (3+). Slit-lamp and fundus examinations of the left eye showed no abnormalities. Since the identification of lymphoma cells in the vitreous is required for a diagnosis of PVRL, we performed diagnostic vitrectomy. A vitreous biopsy sample indicated increased IL-10 levels (379 ng/mL) and an elevated IL-10 to IL-6 (12.6 pg/mL) ratio. A cytological analysis also showed large atypical lymphoid cells, resulting in DLBCL. She was diagnosed with PVRL with CNS involvement and started treatment. She underwent one course of intravenous HD MTX chemotherapy , and flare (2+) Fig. . KPs werThe recurrence of PVRL with pseudohypopyon appeared 14, 15, and 18 months after the first appearance of pseudohypopyon Fig. . An intrPVRL typically responds well to initial treatments; however, relapse rates are high and repeated treatments are sometimes needed. There are various types of clinical features for the recurrence of PVRL. Pseudohypopyon is relatively rare and its pathogenesis is not fully understood. Previous studies reported that pseudohypopyon was treated by a combination of systemic chemotherapy and radiation , 7; howeSeveral studies have reported pseudohypopyon with the recurrence of PVRL. Lobo A et al. described a patient with a rare and unusual presentation of hypopyon uveitis who was eventually diagnosed with DLBCL . PapalioAn optimal treatment has not yet been established for recurrent PVRL. However, the general treatment for PVRL is a combination of systemic chemotherapy and radiation. An intravitreal injection of MTX and rituximab was recently shown to be effective for intraocular lesions, and has also been used in the treatment of PVRL local recurrence; however, its application to recurrent pseudohypopyon has not yet been described. In our case, we temporarily controlled the local lesion with an intravitreal injection of MTX at the time of each recurrence; however it did not completely go into remission. Comparing the effectiveness of intravitreal MTX with local radiation therapy, the severe side effects such as radiation retinopathy and keratopathy were observed . In contRegarding the pathogenesis of pseudohypopyon, previous studies reported that retinal lesions of PVRL emerge from the retinal pigment epithelium and Bruch membrane , 9, howeIn conclusion, we herein report a case of pseudohypopyon as a clinical manifestation of PVRL recurrence. The pathogenesis of pseudohypopyon remains to be addressed. Although pseudohypopyon was temporarily controlled by intravitreal MTX, it did not completely induce its remission.CNS, central nervous system; DLBCL, diffuse large B cell lymphoma; HD, high-dose; KPs, keratic precipitates; MTX, methotrexate; PCNSL, primary central nervous system lymphoma; PVRL, primary vitreoretinal lymphoma


Primary gallbladder lymphoma, although rare, usually presents in females with symptoms mimicking cholecystitis. We present a rare case of primary gallbladder in an 81-year-old male with no risk factors whose only symptom was weight loss. Routine blood tests including liver function tests were unremarkable. A CT colonography was carried out to exclude colonic malignancy. Unilateral gallbladder wall thickening and lymphadenopathy were incidentally detected and confirmed by ultrasound and a decision for the patient to undergo laparoscopic cholecystectomy and intraoperative cholangiogram was made. Histology confirmed extranodal marginal zone lymphoma with follow-up staging and biopsy of the bone marrow not demonstrating spread. Cholecystectomy was therefore deemed curative and no adjuvant therapy was necessary. Thickening of the gallbladder wall on any imaging with or without symptoms should not be ignored or assumed to be cholecystitis, even in males with no risk factors. In these patients urgent cholecystectomy with intraoperative cholangiogram is indicated with histology and haematology follow-up. Malignant lymphomas are considered tumours of lymph nodes although 40% occur in extranodal tissues, usually from the gastrointestinal tract. As an organ normally devoid of lymphoid tissue primary lymphoma of the gallbladder is exceptionally rare. Usually gallbladder lymphoma is secondary to infiltration from widespread lymphoproliferative disease.Primary gallbladder cancer is of adenocarcinoma type in 96% of cases with primary lymphoma accounting for only 0.1%–0.2% of cases, the majority of which are diffuse large B cell lymphomas or extranodal marginal zone lymphomas (EMZL) [In this report we present a rare case of a primary gallbladder lymphoma in a male patient whose only symptom was weight loss and present the incidental radiological findings correlated with the histology and intraoperative findings.An 81-year-old gentleman with early stage Alzheimer's dementia who is otherwise well presented with gradual ongoing weight loss as his only symptom. The patient's full blood count and liver function tests were unremarkable. He underwent virtual CT colonography to investigate the weight loss. Whilst no colonic pathology was found, the imaging detected a distended gallbladder with a thickened medial wall of 1 cm and small volume porta hepatis lymphadenopathy .This raised the suspicion of gallbladder cancer reaffirmed by an ultrasound scan which demonstrated the gallbladder to be markedly distended containing sludge, with a thickened posterior wall of 8 mm but no gallstones .The decision was made to proceed to urgent laparoscopic cholecystectomy with on-table cholangiogram. Intraoperative laparoscopy revealed a grossly enlarged, thick-walled gallbladder. To aid dissection percutaneous aspiration was carried out draining over 250 ml of pus. Extensive adhesiolysis to free the gallbladder from the duodenum and colon was required prior to identification of Calot's triangle. An intraoperative cholangiogram was performed demonstrating normal ductal anatomy with no obvious obstruction. The cystic duct and artery were then ligated. Dissection of the gallbladder off the liver bed was exceptionally difficult as it was firmly attached, with complete obliteration of the plane. Once the gallbladder was freed, diathermy to the liver bed was carried out in case any posterior wall remained adherent. Thorough washout was performed and a large drain placed on the liver bed before removing the gallbladder via the umbilical port in a bag. Postoperative recovery was uncomplicated and the patient was discharged with analgesia 72 hours later following drain removal.Urgent histology revealed replacement of the entire gallbladder by a lymphoid lesion with ulceration of the mucosal surface and transmural infiltration with extension beyond the serosal surface into surrounding adipose tissue. Lymphoid cells were positive for CD 20 and BCL 2 immunostains and negative for CD 3, CD 5, CD 23, CD 10, BCL 6, and cyclin D1 immunostains. CD 21 highlighted expanded follicular dendritic cell MeshWorks. Lymphoid cells showed expression of IgM and were negative for IgD. Overall appearances were those of an extranodal marginal zone lymphoma of the gallbladder .The patient was referred promptly to haematology, where staging via contrast CT of the neck, chest, abdomen, and pelvis as well as bone marrow studies showed no metastatic disease. The laparoscopic cholecystectomy was considered curative with only routine surveillance required.Whilst the pathogenesis of EMZL is unclear, various theories have arisen. Tomori et al. studied bile bacteriology and reported that EMZL may develop in 11% of gallbladders in association with positive bile cultures and gallstones . Mani etIn this case our male patient had no evidence of gallstones and lacked any symptoms resembling cholecystitis. Gallbladder lymphoma should not, therefore, be excluded if the patient lacks these findings, since presentations of this condition can vary. Our patient presented indolently with weight loss and the diagnosis was picked up incidentally. Similarly a recent report demonstrated a gallbladder lymphoma which grew to 4 cm with relatively little clinical signs and normal serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 . DespiteAs with gallbladder carcinoma, ultrasonography is sufficient for identification of wall thickening, polyps, or masses prior to surgery. More specifically, CT or magnetic resonance imaging (MRI) findings of homogeneous submucosal thickening of the gallbladder wall with a preserved mucosal surface are described as being suggestive of lymphoma . Fine nePrimary extranodal marginal zone lymphoma of the gallbladder, whilst rare, has an excellent prognosis if detected early and resected via laparoscopic cholecystectomy. Whilst presentation is most commonly in females with gallstones and symptoms mimicking cholecystitis we present a case in a male with no such findings. Thickening of the gallbladder wall on any imaging with or without symptoms should not be ignored or assumed to be cholecystitis, particularly in the elderly, even when no risk factors are present. With these findings, patients should instead undergo urgent cholecystectomy, with or without stones and even with normal blood results. Moreover, intraoperative cholangiogram is beneficial in excluding bile duct lymphoma and urgent histology should always be requested so that postoperative referral to haematology can be expedited.


Cervical cancer is the third most common female cancer worldwide and the use of routine screening resulted in earlier stage and younger age at diagnosis. Fertility preservation via radical trachelectomy comes up as an option in such patients. Recent literature reviews confirm the safety of this operation with excellent oncologic outcomes in appropriately chosen patients. However, recurrent disease is likely and a strict follow-up is recommended to detect recurrences at an early stage following radical trachelectomy. In this report, a case who underwent radical trachelectomy and developed widespread recurrences 7 years after initial surgery possibly due to the lack of oncologic follow-up is discussed. Cervical cancer is the third most common female cancer worldwide with more than half a million new cases diagnosed and 274,000 deaths occurred annually . NeverthHere, a case who developed widespread recurrence 7 years after radical abdominal trachelectomy possibly due to the lack of oncologic follow-up is reported. Fertility-sparing surgery in cervical cancer was discussed as well with special emphasis on eligibility criteria, indications for completion surgery and/or adjuvant radiotherapy, oncological safety, pregnancy outcomes, and postoperative follow-up recommendations.A 35-year-old nulliparous woman was referred to our hospital from an in vitro fertilization center for pelvic mass and adenocarcinoma on Pap test. The review of her past medical history revealed that she had been diagnosed to have stage 1B1 cervical adenocarcinoma 6 years ago when she had presented with complaints of postcoital bleeding and bloody vaginal discharge. On her examination, she had been found to have an exophytic lesion involving the central part of the cervix and protruding into the vagina. The outer parts of the exocervix and vaginal fornices had looked normal. A punch biopsy of the lesion had shown invasive adenocarcinoma and the patient had been subjected to a radical abdominal trachelectomy with pelvic and para-aortic lymphadenectomy without any further diagnostic evaluation. On her permanent pathology, the disease was a grade 2 adenocarcinoma which was 1.5 cm in diameter with no vaginal or parametrial involvement. Excised vagina was 2.5 cm in length while the excised parametria was 3.0 and 2.8 cm in width at the left and right sides, respectively. Also, 29 lymph nodes were negative for metastasis and all surgical margins were free of disease. However, there was diffuse lymphovascular space invasion and the disease invaded the cervical stroma deeply with 75% of stromal invasion detected in some areas. The patient and her husband had rejected adjuvant pelvic radiation treatment which had been recommended due to those two intermediate pathological risk factors. Despite strict follow-up recommendations, she had been lost to follow-up thereafter. During the subsequent period, she failed spontaneous conception for the first postoperative year. Then, 6 cycles of controlled ovarian hyperstimulation with intrauterine insemination (COH + IUI) were done but failed. Lastly, four in vitro fertilization cycles were performed without any success. Her conception attempts lasted for 5 years in total and during that period the patient was not subjected to any investigations for her cervical cancer and she did not meet with any gynecologic oncologist.On her admission, the patient had abnormal vaginal bleeding lasting for more than 1 year with severe pelvic pain, gross hematuria, right lower extremity pain, and swelling. On pelvic examination, the residual cervix was completely infiltrated with tumor. In addition, the upper anterior vagina and lateral fornices were involved. The right parametrium was infiltrated with tumor extending to the pelvic sidewall and a right adnexal mass was palpated. Under general anesthesia, a cervical biopsy was done which revealed recurrent adenocarcinoma. Cystoscopy was done for gross hematuria during the same operative session which showed neoplastic invasion causing a mass within the bladder. Cystoscopic biopsy from the bladder mass confirmed adenocarcinoma infiltration. After assuring that cervical adenocarcinoma has recurred, imaging studies were performed to document the extent of recurrence. Computerized tomography of abdomen and thorax and magnetic resonance imaging of pelvis showed recurrent cervical mass invading upper vagina and bladder with right parametrial infiltration up to pelvic sidewall . A rightMore than 40% of all patients diagnosed with invasive cervical cancer are of childbearing age and a significant proportion of these young women are candidates for fertility-sparing surgery , 9. For On the other hand, although all the above-mentioned eligibility criteria are met, the pathological assessment of the radical trachelectomy specimen will identify that fertility preservation is not appropriate in 30% of patients to be able to ensure oncologic outcomes . During Following radical trachelectomy, 40% of recurrences occur in the parametrium or pelvic sidewall whereas 25% occur in the pelvic, para-aortic, and/or supraclavicular lymph nodes . Hence, As a result, she was diagnosed to have local, regional, and distant recurrences 7 years after initial diagnosis. Due to multiple sites of unresectable recurrent disease surgery was not an option and combination chemotherapy was initiated which resulted in considerable symptomatic improvement.In conclusion, fertility preservation may be considered in well-selected young women with invasive cervical carcinoma. However, a careful and detailed discussion before surgery with the patient and her family is of vital importance. This discussion should include the possibilities of completion surgery and adjuvant radiation therapy which conflict with future fertility. Also, the family should be informed about the risk and pattern of recurrent disease and the gynecologist should make sure that the patient will comply with the predetermined strict follow-up schedule. Otherwise, attempts to preserve fertility may lead to catastrophic, life-threatening consequences as seen in the current case.


Ortner’s syndrome is defined as left recurrent laryngeal nerve palsy caused by a cardiovascular pathology. Here we report the case of a 68-year-old man who presented to our hospital with hoarseness, whose initial chest imaging mimicked a thoracic neoplastic process with left pleural effusion. The final diagnosis was Ortner’s syndrome due to the silent rupture of a thoracoabdominal aortic aneurysm. Diagnostic thoracentesis, before computed tomography, in resource-poor settings, may have resulted in an adverse outcome in our case.A 68-year-old Sri Lankan man was referred to us by an otolaryngologist for further evaluation of a suspected thoracic malignancy. His presenting symptom was hoarseness of three months duration. He had essential hypertension for the last four years and had a history of 25 pack-years of cigarettes smoking. His chest X-ray showed a left-sided mediastinal mass with mild to moderate pleural effusion. An ultrasound appeared to show an encysted pleural fluid collection. However, we proceeded with computed tomography before diagnostic thoracentesis. The diagnosis of Ortner’s syndrome was made after the computed tomography due to the silent rupture of his thoracoabdominal aortic aneurysm.Hoarseness due to left recurrent laryngeal nerve palsy can be the presenting symptom of cardiovascular pathologies, Ortner’s syndrome. Silent rupture of thoracic aortic aneurysms can mimic that of thoracic malignancy, which is reported in literature. We illustrate the importance of a high degree of suspicion of cardiovascular pathology in order to avoid an adverse outcome following diagnostic thoracentesis. Ortner’s syndrome, or cardiovocal syndrome, is defined as left recurrent laryngeal nerve palsy caused by a cardiovascular pathology, such as left atrial enlargement, dilatation of the left pulmonary artery, or a thoracic aortic archaneurysm (TAA) . AlthougA 68-year-old Sri Lankan man was referred by an otolaryngologist in a general hospital to a pulmonologist at our hospital for further evaluation of suspected thoracic malignancy. He had transient episodes of syncope during the last year, although his main presenting symptom was hoarseness. He was known to have had essential hypertension during the last four years and had a history of 25 pack-years of cigarettes smoking. There was no family history of malignancy or connective tissue disorders. His general examination did not reveal any clubbing of his fingers or lymphadenopathy. There was a stony dull percussion note with absent breath sounds in the left lower zone of his chest. His blood pressure was 130/100mmHg in both arms, and his cardiovascular examination was otherwise unremarkable.An indirect laryngoscopic examination was performed by the otolaryngologist, who noted left vocal cord palsy. His chest X-ray showed a homogeneous, soft tissue, dense, well-defined lesion in his left lung, extending from the aortic knuckle to the left hemidiaphragm Fig. . Its medHis contrast-enhanced computed tomography (CT) scan with aortography showed a thoracoabdominal aortic aneurysm with peripheral thrombosis Fig. . The lefThe final diagnosis of Ortner’s syndrome due to the silent rupture of his thoracoabdominal aortic aneurysm was made on the basis of clinical presentation and CT aortographic appearance. The cardiothoracic surgical team attended to him and decided to manage medically without surgical intervention. Nifedipine SR 20mg was replaced by metoprolol MR 100mg daily and atorvastatin 10mg daily was added to the medical management. He is now under the care of a cardiologist for the optimum control of his atherosclerotic risk factors, and his symptoms had not progressed on his follow-up visits up to now.Aortic aneurysm is defined as a permanent localized dilation of the aorta, having at least a 50 % increase in diameter compared with the expected normal diameter . AbdominThoracic malignancies, mainly bronchogenic cancers, present with hoarseness in higher frequencies  than TAA . The cheAn ultrasound scan of our patient’s chest showed what appeared to be encysted pleural fluid collection. Diagnostic thoracentesis with pleural fluid analysis gives the most accurate diagnosis in the majority of cases. As our main differential diagnoses of this patient were thoracic malignancy and silent rupture of a TAA, we preceded with a contrast-enhanced CT chest scan before diagnostic thoracentesis or bronchoscopy. His CT chest scan with aortography confirmed the diagnosis of leaking aneurysm of the thoracoabdominal aorta. A thoracentesis in this instance would have caused an adverse or fatal outcome.Cystic medial degeneration that weakens the aortic wall results in TAA. It is normal with aging, but can be aggravated by hypertension. The risk factors that are involved in the aneurysm formation are same as those for atherosclerosis: hypertension, hyperlipidemia, and smoking . ConnectThe treatment options include surgical and medical therapy. Our patient’s advanced age, symptomatic aneurysm, and Crawford type II aneurysm increase the morbidity and mortality risk following open TAA repair . As suchThe silent rupture of a TAA can mimic that of thoracic malignancy. A CT scan is not available prior to a diagnostic thoracentesis in resource-poor settings though it is not an absolute prerequisite for thoracentesis. We illustrate the importance of the careful interpretation of chest X-rays and the clinical picture to avoid adverse outcome from diagnostic thoracentesis or intercostal tube insertion, in cases of cardiovascular pathology causing massive effusion.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Cytomegalovirus (CMV) enteritis post coronary artery bypass grafting (CABG) has been previously reported but never in an immunocompetent patient not on steroid therapy preoperatively.CMV enteritis must be considered and actively sought in immunocompetent patients who develop GI complications post CABGA MEDLINE literature search and manual review of the bibliographies of relevant papers failed to identify any other histologically proven case of post CABG CMV enteritis  in a patient who was immunocompetent, not on steroid therapy preoperatively and whose revascularization was done on a beating heartA 65 year old immunocompetent gentleman presented with signs/symptoms of crescendo angina and an elevated troponin (297ng/L). Angiography showed triple vessel disease and severe left ventricular dysfunction. Cardiac Magnetic Resonance Imaging demonstrated some reversibility but a low ejection fraction of 20%. He underwent urgent CABG, and as per protocol was admitted to the cardiac intensive care unit (CICU).Postoperatively, he developed multiple complications including lower and upper gastrointestinal (GI) bleeding, acute abdomen and dialysis resistant lactate acidosis. Due to his abdominal symptoms/signs, he underwent a laparotomy, resection of 82 cm of necrotic perforated small bowel and fashioning of an end ileostomy.Histology proved the aetiology of his abdominal symptoms/signs was CMV enteritis.1. Consider CMV enteritis in immunocompetent patients who have complicated cardiac ICU stay and signs and symptoms such as abdominal pain, watery or bloody diarrhoea, bleeding, obstruction, toxic megacolon, perforation and fistula formation.2. Have a high index of suspicion for CMV enteritis in patients on steroids pre-operatively who have complicated ICU recovery and shows the above signs and symptoms.3. As mortality for CMV enteritis can be as high as 80%, early diagnosis and treatment are crucial.Written informed consent was obtained from the patient for publication of this abstract and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Gossypiboma is rare and mostly asymptomatic in chronic cases. It can be confused with other soft tissue masses.Our patient was an 87-year-old Japanese man with a history of surgery for a lumbar lesion causing lumbar canal stenosis 19 years earlier. Computed tomography showed a soft tissue mass with osteolysis and periosteal thickening of the vertebral lamina. On magnetic resonance imaging, the mass showed heterogeneous signal intensity on T2-weighted imaging, suggesting a malignancy. At the time of biopsy, small pieces of retained surgical sponge were collected. Surgical treatment was performed to excise the soft tissue tumour.Gossypiboma should be included in the differential diagnosis of soft tissue masses in the paraspinal region in patients with a history of previous spinal surgery. Surgical sponges with radiopaque markers are easily recognized on plain radiographs, but retained foreign bodies without such markers present a difficult diagnostic problem. This intraoperative complication has rarely been reported in the paraspinal area-10. GossAn 87-year-old Japanese man was admitted to our hospital because on an earlier visit to another hospital for his lumbago he was found to have a paraspinal mass on magnetic resonance imaging (MRI). He had undergone surgery for lumbar canal stenosis 19 years earlier at another hospital. At our out-patient clinic, his temperature was 37.1°C, blood examinations showed leucocytosis  and increased C-reactive protein . The neurological examination was normal. MRI revealed a soft tissue mass at the L3 to 4 level. The mass lesion was hypointense compared with the spinal cord on T1-weighted imaging, with heterogeneous signal intensity on T2-weighted imaging (Figure et al. reported that, of the 9729 closed claims reviewed, 40 patients had retained surgical sponges, and two of 40 patients were post-laminectomy[Gossypiboma after spinal surgery has been rarely reported and occurs much less commonly than after operations in the abdominal cavity. Kaiser inectomy.Gossypiboma can remain asymptomatic for many years and is mostly detected incidentally by radiologic investigations. Since cotton sponges are inert, they do not stimulate specific biochemical reactions without granuloma formation-10.Various imaging techniques are used to diagnose gossypiboma. If the sponge has a radiopaque marker, the diagnosis can be made easily by X-ray examination. On CT, these lesions appear as well-circumscribed masses that contain hyperdense material and show capsular enhancement in the abdomen,13. In tThe diagnosis of gossypiboma is sometimes very difficult. Although chronic gossypiboma may be inert, sponges with radiopaque markers should be used to identify retained surgical sponges as soon as possible.Retained surgical sponges do not show specific clinical and radiological signs. They should be included in the differential diagnosis of soft tissue masses in the paraspinal region in patients with a history of previous spinal surgery.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: Computed tomography; MRI: Magnetic resonance imaging.The authors declare that they have no competing interests.Surgery was performed by TK, TS, and TA. TK, NM, EA, and MT were the major contributors in writing the manuscript. EA and YS supervised the whole work. All authors read and approved the final manuscript.


Rhabdomyoblastic differentiation in a malignant peripheral nerve sheath tumor (MPNST) is termed malignant triton tumor (MTT), a rare neoplasm that poses a diagnostic dilemma in the differential diagnosis of neck masses and portends poor prognosis. We report a sporadic case of MTT of the neck in a 23-year-old female. We present the pathological findings. Immunohistochemistry confirmed the neurogenic origin with S-100 expression and the rhabdomyoblastic differentiation with desmin and vimentin positivity. Radical surgical excision was done. After 4 years there were no signs of recurrence or distant metastasis. The clinical, microscopic, and long-term follow-up of this case are consistent with those of a low-grade malignancy. Malignant peripheral nerve sheath tumor (MPNST) is a rare soft tissue neoplasm with a poor prognosis. It can occur in association with neurofibromatosis type 1 (NF-1) or sporadically accounting for 5–10% of soft tissue sarcomas . MPNST oIn the majority of reported cases, triton tumors are located across peripheral nerves, usually close to the spine, in the head and neck region, or in the upper and lower extremities . HoweverTwo theories were proposed as an explanation to the development of this tumor . The firTo further elucidate the natural history and prognosis of this rare neoplasm in the head and neck, we present a case of sporadic MTT arising in the neck with an unusual prognosis.A 23-year-old female patient presented to the craniomaxillofacial and plastic surgery department at our institution with a 10-month left neck swelling. Her medical and family histories were unremarkable and negative for prior radiation exposure and NF-1, respectively. Physical examination revealed a slightly tender, firm mass, fixed to the underlying structures, with a normal overlying skin and no palpable lymphadenopathy.Conventional computed tomography (CT)  and CT aMacroscopically, the tumor was oval in shape, partially encapsulated with a smooth yellowish-white surface. The cut surface showed microcysts, hemorrhage, and necrosis with brownish areas . On micrThe annual follow-up CT scans revealed no evidence of recurrence or metastases. Our patient is alive and still free of recurrences four years after initial diagnosis.A so-called mosaic tumor with both muscular and neurogenic components. In spite of being a rare tumor, the head and neck region is one of the most frequent sites of involvement of MTT. For this reason, head and neck surgeons and pathologists should be familiar with the nature, the treatment modalities, and prognosis of this rare tumor , 22.Our reported case in the neck was sporadic. It seems that the head and neck neoplasms are infrequently associated with NF-1 compared to those located in other sites . Our patIn the present case, the IHS was essential to reach the proper diagnosis. Tumor morphology of a malignant schwannoma with potentially overlooking the neoplastic rhabdomyoblasts makes IHS essential in the diagnosis of MTT. However, Weiss and Enzinger  mentioneOnce the diagnosis was done, complete tumor resection with negative margins should be the goal of surgery, as in the present case. Therefore, it would certainly make sense to consider the use of such treatment without delay. This is consistent with other researchers , 30, 31.The visibility of the neck mass in our reported case made its timely diagnosis possible. Reports of tumors in noticeable sites aid in the it's early diagnosis and excision while the tumor is still small leading to a better prognosis. Such areas include the extremities  and the The size of the tumor is also an important prognostic factor affecting survival. In the current case, the tumor size was smaller than 10 cm. It was mentioned that patients with tumors less than 10 cm had better survival than those with larger tumors , 18, 32.Victoria et al.  reviewedFurthermore, our case was sporadic and of low-grade malignancy. This is in accordance with Brooks et al.  who repoThe clinical, microscopic, and long-term follow-up of the present case showed that our case was a low-grade malignancy. Finally, we would like to emphasize that early diagnosis and wide surgical treatment are important for the prognosis of MTT.


Maxillary lateral incisors are widely known to be single rooted with one root canal. Although rare cases with root canal variations are being reported in many populations, the reports regarding Iranian population is extremely limited. In this report, we are presenting the endodontic treatment of a double rooted maxillary lateral incisor. These rare root-canal variations should be considered in pretreatment evaluations by clinicians who perform endodontic treatments.  Failure to eliminate the biological irritants from infected root canals with a careful preparation and obturation of canal space will eventually lead to an unsuccessful treatment. Furthermore, to access to success in endodontic treatments, a clinician must be aware of all root canal morphologies and their anatomical variations.Although the latest editions of endodontic textbooks assert that the maxillary lateral incisors have a single root in 100% of the cases, -3 reportIn this report, the endodontic treatment and follow-up examination of an uncommon case of maxillary lateral incisor with two roots is presented. HistoryA 16-year-old female patient was referred to the endodontic department at Shiraz dental school with a chief complaint of slight pain in her maxillary right lateral incisor when biting. The patient also reported a history of swelling in her upper right anterior buccal mucosa during the past month.The patient had no abnormal medical history, complicating illnesses or history of trauma.Clinical ExaminationThe extra oral examination revealed no abnormal findings . The intPeriodontal examination showed the presence of a periodontal pocket with the probing depth of 4mm. The crown of the affected tooth was intact; however it displayed a lingual pit above the cingulum. The result of the thermal tests was negative which confirmed a nonvital pulp. Radiographic ExaminationOn the radiographic examination, two roots were detected in her maxillary right lateral incisor with an oval-shaped radiolucency around the roots a. It is DiagnosisThe final diagnosis was made based on both clinical and radiographic examinations. The involved tooth had a primary endodontic lesion with necrotic pulp and acute apical periodontitis.Treatment optionsAs a first treatment option, root canal therapy with several follow-up examinations was recommended to the patient. Consequently, in case of treatment failure, apicectomy will be performed. Tooth extraction and implant placement was another possible treatment option. The patient preferred to undergo root canal therapy.TreatmentThe tooth was isolated with a rubber dam. An access cavity was made from the lingual pit using high speed turbine and diamond fissure bur  under cooling water spray. Since the teeth had a large orifice, the access cavity was prepared with an extra extension toward the palatal surface. This was done to make a straight access to the narrower root canal which was located palatally.The absence of any vital pulp tissue or bleeding re-confirmed our initial diagnosis. Working length was then determined radiographically with a k-file # 35  for the buccal canal and a k-file # 15 for the palatal root canal a. The wo2 to the working length and tooth was coronally sealed with the temporary filling material . A week later the patient was recalled. During reexamination, the tooth was completely in a normal condition with no tenderness to percussion.2.5% sodium hypochlorite was used as an irrigant during preparation. The root canals were dried with sterile paper points . Calcium hydroxide powder  was mixed with sterile saline  in a 6:4 powder/saline ratio to obtain a paste-like consistency. Then, the root canal was filled with Ca (OH)The root canals were irrigated again, dried and obturated by lateral condensation technique using gutta-percha  and AH26 sealer .A final radiograph was taken after completing the treatment b. PatienThe 6-month follow-up examination of the patient revealed no clinical abnormalities. The tooth was completely asymptomatic and did not show any sign of mobility. The recall radiograph showed moderate bone formation in the periapical region c.Disturbances in the normal development of Hertwig's epithelial root sheath can lead to some dental anomalies like grooves formation, dens in dente, gemination and fusion. These conditions may exhibit an appearance confused with double rooted teeth.In the present case, the pre-treatment clinical and radiological evaluations did not indicate the presence of any grooves or invaginations in enamel or dentin. Furthermore, the clinical examination apparently ruled out the conditions such as gemination or fusion. It is notable that gemination is where the double crown with a single root is present and the fusion is where a bifid crown with two root canals in a single root is evident. ThereforAlthough the main etiology of this variation is unknown, a disturbance in the development of Hertwig’s epithelial root sheath and consequent formation of a horizontal flap is construed. This hypothesis is a main reason for creation of an extra root.Although,Considering the 6-month follow-up period, moderate bone formation was seen in the periapical region of the involved tooth. Moreover, the tooth had no abnormal clinical findings at the follow-up examination.It is notable that the surveys evaluating the outcome should be based on both clinical and radiological appraisal. Besides,To properly diagnose and handle the treatment of such cases, thorough radiological evaluations with Clark’s rule and taking parallel angle radiographs before and during the endodontic treatments are crucial and strongly recommended. Furthermore, using the new radiographic techniques such as cone beam computed tomography (CBCT) can also be very helpful in identification of anatomical features and variations of the root canal system., 23 It iVariation in the root canal is a possible finding during dental practice. A skillful clinician should have a comprehensive knowledge about any possible complexity or variation in root canal systems to be able to perform a sound treatment and achieve more predictable endodontic results.


Ciliated hepatic foregut cyst (CHFC) is a rare cystic lesion most commonly identified in segment 4 of the liver that arises from the embryonic foregut. The classic histologic pattern is comprised of 4 distinct layers . Although rare, cases of metaplastic and malignant epithelial lining have been described in CHFC.We report 6 additional cases of CHFC, one of which had gastric metaplasia of the cyst lining, and review all reported cases of CHFC in the English literature. We describe the clinicopathologic analysis of 6 cases, with selective immunohistochemical analysis on 1 case with gastric metaplasia.Cases occurred in 4 women and 2 men . Cysts ranged in size from 0.7 to 17 cm (average 7.2 cm) and were grossly tan-pink to white with blood-filled contents. The majority were located in segment 4 of the liver, however 2 were located in the porta hepatis. Tumor serologies (CA19-9 and/or CEA) were performed in 3 cases; 1 case demonstrated elevated CA19-9, and 2 cases had laboratory values within normal limits. All cases showed the classic histologic findings, however one case additionally had extensive gastric metaplasia.In conclusion, CHFC is a rare diagnostic entity that should be considered in the differential diagnosis for cystic hepatic lesions, particularly those located in segment 4 of the liver. Metaplasia and squamous carcinoma can occur, therefore complete surgical excision is the recommended treatment.The online version of this article (doi:10.1186/s13000-015-0321-1) contains supplementary material, which is available to authorized users. Ciliated hepatic foregut cysts (CHFC) are rare cystic lesions of embryological origin that have been increasingly diagnosed in the last few decades . WheelerThe esophagus and trachea form from the dorsal foregut, while the liver forms from the ventral foregut; the similar features of CHFC compared to bronchial and esophageal cysts are presumably due to this common derivation of the liver, esophagus, and tracheobronchial tree from the embryological foregut . There aOver one hundred cases of CHFC have been reported to date in the world literature . Among tSix cases of CHFC have been identified at our institution over a 24 year time period. One of these cases showed extensive gastric metaplasia. In this report we aim to describe these six cases, as well as to provide a detailed review of the English literature regarding this rare diagnostic entity with a focus on metaplasia of the ciliated epithelial lining. A search of the pathology database at our institution from 1989 to 2013 identified six cases of CHFC. Hematoxylin and eosin-stained slides and immunohistochemical stains (if performed) were reviewed for each case. The patient demographics, clinical presentation, imaging studies, and follow-up were obtained through available clinical records. This study received approval from the Human Resources and Protection (HRPO) Office and Institutional Review Board (IRB) Committee at Washington University.Clinicopathologic characteristics of the patients are summarized in Table Grossly, the cysts were tan-pink in color, with one cyst having green-brown plaques on the inner surface. They contained white to bloody contents; specifically, one contained thick, tan, mucoid material, one contained white material, and one had a small amount of attached thrombus. The cysts ranged in size from 0.7 to 17 cm in greatest dimension (average 7.2 cm). All six cysts were unilocular. Five cysts had smooth walls, and one had numerous “irregular fibrous trabeculae” in the wall.Histologic examination showed that five of the six cysts were entirely lined with simple, ciliated, cuboidal to columnar epithelium, surrounded by loose connective tissue, smooth muscle, and a poorly defined fibrous pseudocapsule Fig. . Goblet CHFC are increasingly reported hepatic lesions thought to be derived from the embryonic foregut that most frequently are identified in segment 4 of the liver, although a minority occur in the right lobe . Over onThe differential diagnosis for these lesions includes biliary cyst, simple cyst, parasitic cyst, mucinous cystic neoplasm (biliary cystadenoma), and various cystic metastases, such as cystic neuroendocrine tumor or necrotic metastases. Rarely, endometrial cysts may present as cystic lesions in women. In a child, an epidermoid cyst or a mesenchymal hamartoma are common possibilities . When idThe classic histologic appearance of these lesions consists of 4 layers: a ciliated inner epithelial lining, loose connective tissue, smooth muscle, and a fibrous capsule . ElectroA review of the English literature showed 83 cases published to date, which are summarized in Additional file Twelve cases  had histologic evidence of metaplastic epithelium lining the inner cyst wall –19, 33. In conclusion, CHFC is a rare entity with 89 cases reported to date in the English literature, including the 6 cases from the current study. All cases from this series demonstrated the classical histologic features, with the cyst wall comprised of 4 distinct layers. While the inner epithelial lining is most commonly ciliated and pseudostratified, rare cases with squamous metaplasia, squamous carcinoma, and/or gastric metaplasia have been reported. Interestingly, tumor serologies were elevated in a minority of benign cases and showed no correlation with metaplasia or malignant transformation. This rare diagnostic entity should be included in the differential diagnosis of cystic liver lesions, and complete surgical excision should be recommended given the potential for metaplastic or malignant squamous carcinoma and the inability to monitor disease progression.A waiver of informed consent was granted from the HRPO Office and IRB Committee at Washington University due to the fact that this is a retrospective case series and no changes were made to patient management as a result of this study. The Washington University HRPO/IRB Committee is willing to provide written documentation confirming their decision for review by the Editor-in-Chief of this journal.


Spontaneous splenic rupture is always neglected when consulting acute abdominal pains in gynecological emergencies. It constitutes about 1% of all splenic ruptures and can be managed by abstention, surgery or embolization. We present the case of a young lady who was diagnosed of spontaneous rupture during surgery that was mistaken for ruptured hemorrhagic ovarian cyst and finally treated by total splenectomy. The pre-operative work up was absolute for a rupturred hemorrhagic cyst and secondariy for a ruptured ectopic gestation. Abdominal pain is one of the most common reasons for emergency department visits. Splenic rupture, which is a life-threatening abdominal emergency, constitutes a group among causes of abdominal pain, and is often seen as secondary to abdominal trauma. It requires rapid diagnosis and treatment. Spontaneous rupture of the spleen is a rare condition and constitutes up to 1% of all splenic ruptures [Mrs XY. is 23 year old, nulliparous woman who was wheeled to the emergency service of the gynaeco-obstetrical unit of the hospital for severe abdominal pains of sudden unset followed by dizziness and loss of stability leading to a fall and collapsed. She has no amenorrhea and her hemoglobin electrophoresis is AA. She has no particular medical or surgical past history. Interrogation reveals her last coitus some minutes before onset of symptoms after 2years of forced abstinence (fiancé abroad), no accident or fall, and no fight. Physical examination reveals conserved general state, unstable hemodynamic parameters . Her conjunctivae were coloured with a distended abdomen especially in the pelvic region of hemoperitoneum confirmed by an abdominal tap (7milliliters of unclotted blood). Vaginal exams  reveal no bleeding, no pelvic mass but tender with bulging pouch of Douglas.A presumptive working diagnosis of a ruptured hemorrhagic ovarian cyst was considered. An emergency pre-operative work-up  was performed as routine and she was prepared for exploratory laparotomy under general anesthesia. Two units (500 milliliters /unit) of Blood were also reserved. During surgery, we found hemoperitoneum of about 2500 milliliters of fresh blood, a clean pelvis with neither adhesions nor a pathologic tube or ovary. Extension of the incision anteriorly for abdominal exploration reveals a macroscopically healthy liver but the spleen presents lacerations at 3 points posteriorly (2-4cm) that were actively bleeding (grade 3). Total splenectomy was done  with theThe first published case of spontaneous rupture of the spleen was by Rokitansky in 1861 . It was Typically, patients present with hypovolemic shock and signs of peritonitis. Two other signs that are suggestive of splenic rupture are Kehr's sign (left diaphragmatic irritation resulting in referred pain to the left shoulder) and Balance's sign  . None ofOur case had no trauma history. CT scan was not done because we did not think about rupture of the spleen before surgery. Pre and postoperative hematological and infectious causes were surveyed, and no positive findings were detected except for some viral markers that weren't looked for. Microscopic and macroscopic examinations of the spleen were normal. Therefore, the case was accepted as spontaneous rupture of the spleen. We however had a worry whether it could be post coital according to the history of onset of the pain although she didn't accept a traumatic intercourse. Many theories have been proposed to explain spontaneous rupture of the spleen. Existence of a mall area of localized disease with no traces left on the spleen is an accepted theory. Other theories are quietly chronic passive congestion causes, degenerative changes of the splenic artery or rapid dissection into the splenic parenchyma that triggers the rupture. Cases of spontaneous rupture of the spleen have been described after vomiting  and afteHistorically the treatment of choice for all kinds of splenic rupture used to be splenectomy. Nowadays it remains subject to debate. Splenectomy remains the treatment of choice in patients with a hemoperitoneum and severe hypovolemic shock. During laparotomy repair of the spleen or tamponade by the use of an absorbable mesh (splenorraphy) should be considered to preserve splenic tissue . The thiWith this case, we emphasize that spontaneous rupture of the spleen must be considered in the evaluation of abdominal pain in both traumatic and non-traumatic patients. A negative pregnancy test in the context of severe abrupt abdominal pain and hemoperitoneum should initiate thoughts of a ruptured spleen since early recognition and treatment can prevent serious morbidity and mortality.


Mucoceles arising from the Blandin Nuhn glands are uncommon benign lesions of the oral cavity, which by their clinical presentation may be confused with more serious diseases such as vascular lesions, pyogenic granulomas, polyps, or squamous papillomas; thereby, it is convenient to be aware of the characteristics of this entity to guide the accurate and timely diagnosis and treatment. Herein, we present a case of a 10-year-old patient with a recurrent lesion of this type, which required surgical excision and marsupialization of the same, with no evidence of recurrence during follow-up. Mucoceles are benign cystic lesions of the oral cavity, which are developed from the extravasation or retention of mucin produced by the minor salivary glands, which are found throughout the surface of the oral cavity, except in the gingival sulcus; in spite of their great distribution, prevalence depends on their location. Mucoceles of the lower lip are the most common (77.9%), followed by lingual mucoceles and mucoceles of the floor of the mouth (15.6%). Mucoceles on the ventral surface of the tongue derived from the Blandin Nuhn glands are considered quite unusualHerein, we present a female 10-year-old patient who consulted for a condition with three weeks of evolution of a midline lesion of the tongue ventral surface, characterized as a cystic, sessile, reddish mass, of progressive growth, associated to occasional pain The minor salivary glands are a set of three types of glands found throughout the oral cavity, except in the gingival sulcuset al.,et al.,et al.,The cystic formations or mucoceles of the Blandin Nuhn glands have been reported as unusual; according to HarrisonHarrisonThe diagnosis of mucoceles of the Blandin Nuhn glands stems from their clinical characteristics, although they may resemble a vascular lesion, a pyogenic granulomas, polyps, or squamous papillomas; for this reason, it is important to raise awareness amongst the medical population of this pathology.Given their location, these types of lesions are exposed to repeated trauma with subsequent irritation and discomfort for the patient.This is why in spite their benign characteristics, their treatment is complete surgical excision, which may or may not include marsupialization of the lesion according to its size. According to Baurmash


Pilocytic astrocytomas are histologically benign tumors, generally found in the pediatric population. Onset of symptoms is generally insidious, predominantly stemming from mass effect upon nearby structures. Patients harboring a pilocytic astrocytoma may present with gait disturbance, headaches, cranial nerve deficits, as well as hydrocephalus, depending on the exact location. Although cases of adult pilocytic astrocytomas in the adult population are described, they are quite uncommon. We present a case of an adult female presenting with acute neurological compromise resulting from an acutely hemorrhagic posterior fossa pilocytic astrocytoma. Her initial neurological assessment was consistent with a Glasgow coma scale of 4T, as the patient was experiencing decerebrate posturing. An emergent external ventricular drain was placed in the emergency department for acute hydrocephalus as a temporizing measure, prior to evacuation of the associated subdural and intratumoral hemorrhages, as well as resection of the mass. After a long hospital course and extensive rehabilitation, the patient made a remarkable recovery and eventually gave birth to a child via Caesarean section three years after her initial presentation. Pilocytic astrocytomas are pathologically benign tumors typically seen in the pediatric population. Their clinical presentation is rather insidious from the onset and rarely acute. Depending on their location within the brain, and whether they are supratentorial or infratentorial, their symptomatology varies. Patients with supratentorial pilocytic astrocytomas may present with headaches and symptoms of a mass effect upon nearby structures, potentially leading to hydrocephalus or sensorimotor disturbances. Infratentorial pilocytic astrocytomas can also be a cause of hydrocephalus but may also cause compression of the cranial nerves with subsequent palsies.In this paper, we aim to present an unusual case of an adult harboring a cerebellar pilocytic astrocytoma presenting in an acute fashion with a rapid neurological decline after spontaneous intratumoral hemorrhage. Reports in the literature of hemorrhagic presentation of these tumors exist, although they are quite rare -11. The A 30-year-old otherwise healthy female presented with the sudden onset of headache and subsequent obtundation. Upon arrival to our emergency department, her airway was secured with endotracheal intubation. Initial vital signs revealed bradycardia. The Glasgow coma scale score on admission was a 4T, as the patient had decerebrate posturing. Her eyes deviated downward with non-reactive, pinpoint pupils. Informed consent was waived due to the patient's neurological presentation. A CT scan of the head revealed a calcified lesion in the right cerebellar cortex with an acute intralesional hemorrhage and adjacent subdural hematoma. Effacement of the fourth ventricle with associated obstructive hydrocephalus was also noted Figure .An emergent right frontal external ventricular drain was placed in the emergency department as a temporizing measure. The opening pressure was over 30 cm H2O (Figure A CT angiogram of the head and neck to rule out underlying vascular lesions was unremarkable. The patient was then taken to the operating room for surgical decompression. A paramedian suboccipital craniotomy was performed on the right side. The dura was opened and a subdural hematoma was quickly encountered and evacuated. An intra-axial cerebellar tumor rapidly presented as the dissection proceeded and a significant amount of intratumoral hemorrhage was noted. A gross total resection was undertaken Figure .A very small amount of tumor was purposefully left on the brainstem in an effort to avoid significant morbidity from an injury to the lower cranial nerves and the vertebral artery branches that were involved within the tumor. Final pathology of the tumor revealed a pilocytic astrocytoma Figures -6.The patient was following commands on the first postoperative day and was extubated a few days later. Postoperative neurological assessment revealed bilateral sixth cranial nerve palsies, right sensorineural hearing loss, and gait ataxia. The external ventricular drain was weaned and removed without any need for permanent CSF diversion. She was transferred for acute rehabilitation and was eventually discharged home with significant clinical improvement. At her one-year follow-up, she had minimal residual brainstem and cerebellar deficits. Adjuvant radiation therapy was considered, but the radiation oncologist felt that the risks of radiation therapy were not justified. She was able to walk independently and eventually return to work. Three years after her initial presentation, the patient got married and had a child via Caesarean section. During the postoperative period and during her pregnancy, her residual tumor has remained stable and no further episodes of hemorrhage or growth have been noted. Some of her symptoms, such as ataxia, got worse when she was pregnant but improved after delivery of the child.Few reports exist describing adult pilocytic astrocytomas presenting in such an acute fashion with a cerebellar intratumoral hemorrhage, subdural hematoma, and acute obstructive hydrocephalus. Cases of hemorrhagic pilocytic astrocytomas have been reported in the literature, albeit on rare occasion. Golash, et al. reported on a case of a spontaneous intracerebral hemorrhage in a 13-year-old girl later found to be a pilocytic astrocytoma . Lones aThe pathophysiology leading to intratumoral hemorrhage of a pilocytic astrocytoma remains unclear. Higher grade astrocytomas present with hemorrhage more commonly as a result of vessel necrosis, rapidity of tumor cell proliferation, or secondary to neovascularization. Some contributing factors that are speculated in the literature to the etiology of hemorrhagic pilocytic astrocytomas include preexisting hypertension, abundant neovascularization of the tumor, structural abnormalities from tumor cell invasion of the vasculature, coagulation defects, endothelial proliferation, rupture of encased aneurysms, and dysplastic capillary beds , 12. AnoThe tumor itself can also grow into the subdural space, causing traction on communicating veins. This traction can cause the vessels to become more susceptible to rupture, even from an otherwise minor trauma . This maOur patient presented with several features, making this a unique case. The patient described in this paper made remarkable improvements during her rehabilitation. Three years after her surgery, she delivered a child via Caesarean section and had no increase in the size of the small amount of residual tumor during her pregnancy. She has not had any more hemorrhage into the tumor. Underlying pilocytic astrocytomas should be considered in the differential diagnosis of adults presenting with an unexplained cerebellar hemorrhage.


Synovial sarcomas (SS) are classified as subgroup of soft tissue sarcomas affecting mainly extremities of young adults. Primary SS of kidney are very rare tumours with poor prognosis. Though they have characteristic histology and immunohistochemistry (IHC) due to rarity of incidence it is difficult to diagnose them. Sometimes chromosomal rearrangement studies are required to confirm the diagnosis. We are presenting a case of 41-year-old male who was referred to our cancer centre for evaluation of left renal mass. CT scan of abdomen revealed a large left renal mass encasing the aorta. Biopsy of renal mass revealed poorly differentiated sarcoma and IHC was positive for vimentin, CD99, and BCL2 and negative for AE1, epithelial membrane antigen, and leukocyte common antigen. The patient was clinically inoperable as renal mass was encasing the aorta. So he was subsequently offered palliative chemotherapy in form of ifosfamide and adriamycin. CT abdomen shows partial response after 3 cycles of chemotherapy according to RECIST criteria. Synovial sarcomas (SS) are a group of soft tissue sarcomas (STS) affecting mainly young adults. The most common site of occurrence is in extremities. The term “synovial” is misnomer as tumour morphology and immunohistochemistry (IHC) do not correlate with normal synovium of joint . Due to Synovial sarcomas primarily originating in the kidney are very rare. Fewer than 50 cases of primary renal synovial sarcoma are reported till date . Both prForty-one-year-old male patient presented with pain in left lumbar region and macroscopic hematuria for 1 month. His past and family history is unremarkable. He is chronic tobacco chewer for 10 years and nonalcoholic. The patient was referred to our cancer centre based on abdominal ultrasonography findings of left renal mass. On examination the patient has normal height, weight, and body mass index for his age. His vitals were normal and performance score by ECOG (eastern cooperative oncology group) was 1.Clinically nontender palpable mass was felt over left lumber fossa of around 5 × 5 cm with smooth surface and hard consistency. Pallor was present in the sclera and no lymphadenopathy or icterus was found. CT scan findings show enlarged left kidney and it is almost completely replaced with heterogeneously hypodense material. There is hypodense filling defect noted in left renal vein extending up to inferior vena cava suggestive of tumour thrombosis . Lab invHistopathological examination of the biopsy specimen from the left renal mass shows round to spindle cells with hemangiopericytoma pattern and area of hyalinization . High poThe patient was clinically inoperable upfront according to urooncology surgeon. So he was subsequently offered palliative chemotherapy in form of ifosfamide and adriamycin. CT abdomen shows partial response after 3 cycles of chemotherapy according to RECIST criteria.Various STS primarily arising from kidney according to histology are leiomyosarcoma, liposarcoma, rhabdomyosarcoma, fibrosarcoma, and malignant fibrous histiocytoma , 3. The Three histologic subtypes of synovial sarcoma are noted: monophasic, biphasic, and poorly differentiated. There is a clinical challenge to diagnose it. As spindle cell morphology its differential diagnosis would be sarcomatoid renal cell sarcoma, primary Ewing sarcoma of kidney, adult Wilms tumour, and undifferentiated carcinoma. The presence of both mesenchymal and epithelial markers is suggestive of synovial sarcoma at any site , 10. WhePrimary renal SS have highly aggressive course and prognosis is poor. As tumor is very rare, no definite standard treatment guidelines are available at present. Treatment is usually based on the occurrence of scattered cases published in the world literature. Management of the patient by data is extrapolated from treatment of STS. Frontline surgery is advisable and there is no role of chemotherapy as curative intent. Chemotherapy can be given as palliative intent when upfront surgery is not possible for inoperable lesions or medically unfit patients or recurrence of the disease after upfront surgery. Still there are scattered case reports of adjuvant chemotherapy that is used in soft tissue sarcoma like doxorubicin, ifosfamide, and etoposide .In our case the patient was inoperable so we started combination palliative chemotherapy in form of adriamycin and ifosfamide.Primary renal SS are very rare type of STS with aggressive behaviour and poor prognosis. Surgery is the mainstay of treatment and adjuvant chemotherapy has some role. If not resectable role of chemotherapy is palliative.


Spinal subdural haematoma is rare and may be associated with blood dyscrasia, anticoagulant therapy, lumbar puncture, rupture of arteriovenous malformation, tumour bleeding and spinal trauma. We present a 65-year-old female with history of hypertension and atrial fibrillation. She was on anticoagulant. She presented to the emergency department with an acute lumbar back pain, severe paraparesis and urinary retention. Examination on admission, revealed lower limb paralysis (grade 1/5), cauda equina syndrom and difficulty in self-voiding. A lumbar spine magnetic resonance imaging (MRI) scan was arranged urgently. No coagulation abnormality was detected. MRI demonstrated an epidural haematoma at T12-L1 with spinal cord compression. Decompression was recommended but the patient refused surgery. A complete resolution of the haematoma and neurological recovery ensued without surgical intervention. Neurological recovery was observed within 24 h after Spinal subdural haematoma onset. MRI one month later showed total absorption of haematoma. One year later, the patient always has urinary retention, and she is under intermittent catheterization. Surgical decompression is still the main treatment option of Spinal subdural haematoma, however, a conservative therapeutic approach with careful observation may be considered as a treatment of choice in some cases where surgery is refused (high risk or other reasons) and neurologic recovery is early and sustained.


Haemangiopericytoma (HPC) is a rare vascular tumor with borderline malignancy, considerable histological variability, and unpredictable clinical and biological behavior. HPC can present a diagnostic challenge because of its indeterminate clinical, radiological, and pathological features. HPC generally presents in adulthood and is equally frequent in both sexes. HPC can arise in any site in the body as a slowly growing and painless mass. The precise cell type origin of HPC is uncertain. One third of HPCs occur in the head and neck areas. Exceptional cases of hemangioblastoma arising outside the head and neck areas have been reported, but little is known about their clinicopathologic and immunohistochemical features. This study reports on a case of a large sacro-anterior HPC in a 65-year-old male. HPC originates from the pericytes of blood vessels, which is a specific cell type that surrounds the capillary vessels. Therefore, HPC can occur in areas where capillaries are found. HPC was first named and described in 1942 by Stout and MurrayA 65-year-old male underwent a computerized tomography (CT) scan because of abdominal pain. The non-contrast-enhanced CT scan revealed a space-occupying lesion approximately 10.7 cm × 8.1 cm in the sacro-anterior. The tumor was asymmetrical and its boundary was clear. The surrounding fat gap of the tumor was clear and no enlarged lymph gland was found  for CNS neoplasms considers SFT and HPC as distinct entities with different prognostic implications-HPC is a rare vascular tumor that originates from the pericytes of blood vessels that are also called Zimmurman cells,,-HPC has no pathognomonic clinical or radiological signs. Therefore, diagnosis can only be made after careful histopathological examination. The diagnosis of HPC is often made after excluding other tumors that demonstrate HPC-like features. The histologic characteristics of HPC are the tumors that have rich capillary networks and closely arranged tumor cells in the peripheral blood vessels. Tumor cells are intensive skin cells that may be round, oval, or fusiform with unclear boundaries-The histopathology of HPCs has been well-documented, but the fine-needle aspiration biopsy (FNAB) results are rarely describedGiven the unexpected and potentially aggressive behavior of HPCs, complete excision is the recommended treatment. The common problem with HPC is local recurrence after incomplete excision, with rates varying from 13% to 40%. In cases of local recurrence, adjuvant radiotherapy and chemotherapy can be offered.Although the results of adjuvant radiotherapy and chemotherapy vary, adjuvant radiotherapy and chemotherapy are still used as supplementary treatment for HPCs. HPCs are not sensitive to radiotherapy. Radiotherapy is reserved only as adjuvant therapy for cases of incompletely excised tumors, recurrent tumors, and tumors with high-grade histopathologic features. Chemotherapy may have a role in the treatment of distant metastatic disease, but its role in the primary treatment of HPC remains unclear. Vincristine, Adriamycin, and Cyclophosphamide have been used in cases of aggressive HPCs with variable successHPC is a rare soft tissue tumor with high histological variability and unpredictable clinical and biological behavior. One third of HPCs occur in the head and neck and only a few cases have been reported regarding tumor localization in the sacro-anterior. Pre-operative evaluation must include a thorough imaging evaluation (CT and MRI scan), including the results that may not be specific for HPCs. The treatment of choice is radical excision. HPCs are potentially malignant, regardless of the benign pathology. Given the possibility of recurrence and metastasis in HPC cases, surgical excision may not be sufficient