A 29-year-old female patient presented with a painless mass on her upper eyelid medially. She noticed the mass 4 years earlier and it had increased in size over time. She had no diplopia, eyelid swelling, skin lesion overlying the mass, or visual disturbances. On ocular examination, eye movements and funduscopy were normal. The mass was movable and painless with palpation. Magnetic resonance imaging with contrast showed a 12x8x7 mm well-circumscribed cystic lesion with no contrast dye appearance. Surgical removal was performed delicately and no capsular rupture occured. Pathological examination revealed an eccrine hidrocystoma. Our aim is to underline that eccrine hidrocystoma should be included in differential diagnosis of orbital masses. Hidrocystoma is a rare benign cutaneous cystic lesion originating from sweat glands (eccrine or apocrine). Hidrocystoma occurs predominantly in the head and neck region. Solitary lesions occur with equal frequency in both genders, while multiple lesions are more common in women.1 Lesions in the head/neck region are most often located in the periorbital/malar area.2 Apocrine hidrocystomas are usually solitary and 3-15 mm in size.1 In this case report we aimed to highlight that orbital eccrine hidrocystoma, though rare, should be included in the differential diagnosis of orbital lesions.Eccrine hidrocystomas may manifest as single or multiple small (1-6 mm in diameter), thin-walled cysts.A 29-year-old female patient presented to our clinic with complaints of a mass located medially on her left upper eyelid which had increased in size over the previous 4 years . The masThe patient first noticed the mass 4 years earlier and since then its growth was documented by annual follow-up with orbital magnetic resonance imaging (MRI) with contrast  or Smith (solitary) type. Eccrine hidrocystomas generally expand in summer and spontaneously regress in cooler weather.1Eccrine hidrocystoma was first described by Robinson1 Our patient had a mass with a maximum diameter of 15 mm; it was likely able to reach this size because it developed over 4 years within the orbit.Hidrocystomas do not recur if total excision is achieved. Because eccrine hidrocystomas are usually subcutaneous, they are obvious and can be diagnosed even at very small sizes (1-6 mm).Other cystic lesions included in the differential diagnosis of eccrine hidrocystomas are follicular cysts, epidermal inclusion cysts, hemangioma, lymphangioma, apocrine hidrocystoma and eccrine acrospiroma.6, Ssi-Yan-Kai and Pearson7, Vignes et al.8 and Mehta et al.9Cases of ‘orbital apocrine hidrocystoma’ have been reported in the literature by Valenzuela and Heathcote6 described a 47-year-old male patient with a 3-month history of a painless mass in the superomedial aspect of his left upper eyelid which was impinging on his peripheral visual field. Orbital computed tomography (CT) imaging revealed a 13x8 mm extraconal cystic mass in close proximity to the globe. Mass excision by anterior orbitotomy was planned, but due to the attachments of the mass to the superomedial orbit, the brown contents of the cyst were first removed, then the excised cyst wall was sent for histopathologic examination. The inner walls of the cyst were lined with columnar epithelium and the cells contained PAS (Periodic Acid Schiff)-positive material in the apical cytoplasm. The mass was determined to be consistent with orbital apocrine hidrocystoma.Valenzuela and Heathcote7 a 46-year-old woman had soft mass growing on the medial aspect of her right lower eyelid for several months. The mass had displaced the globe superolaterally, but the patient’s eye movements appeared normal. Orbital CT revealed an 18 mm mass. However, the cyst ruptured during surgical excision and was determined insufficient for histopathological examination. Two years later, orbital MRI performed due to recurrence revealed another 17.5 mm cystic mass, also located in the inferomedial aspect of the orbit, which was surgically excised with cyst capsule intact. On histopathological examination, the mass was reported as ‘benign apocrine hidrocystoma’.In a case reported by Ssi-Yan-Kai and Pearson8 reported the case of a 33-year-old male with an 18-month history of progressive swelling of his right eyelid. There was no pathology apparent in the eyelid other than edema. Visual acuity and eye movements were normal. An intraorbital extraconal cystic lesion was detected on orbital MRI. The mass was surgically excised and diagnosed as ‘apocrine hidrocystoma’ based on histopathological examination.Vignes et al.9 described a 65-year-old woman who presented complaining of ptosis starting 10 days earlier and a mass in her left upper eyelid. The patient had undergone eyelid repair 7 years earlier due to traumatic ptosis, but no ptosis or mass had been reported in an ocular examination 2 months earlier. Eye movements were restricted on upward gaze and levator function was 14 mm on the right and 5 mm on the left. A soft mass 1.5 mm in diameter could be palpated at the medial aspect of the left supraorbital margin. Orbital CT and ultrasonography were performed and the cystic mass was completely excised after dissecting its adhesions to the levator aponeurosis. Histopathologic examination was consistent ‘apocrine hidrocystoma (sudoriferous cyst)’. The authors attributed cyst development in this patient to one of two mechanisms: either superficial sweat gland cells were implanted in deeper tissues at the time of the injury, or some epithelial cells were implanted into deeper tissues during the eyelid surgery following the trauma, where they gradually proliferated to form a cyst.Mehta et al.10 That case involved a 3-month history of a painless mass in the right upper eyelid. The patient presented with diplopia, proptosis and ptosis. Orbital CT revealed a 1.5x1 cm oval mass in the superomedial aspect displacing the right globe inferolaterally. Total excision was performed by cutaneous incision. The mass was a giant eccrine hidrocystoma, 1x1x2.5 cm in size, encapsulated in fibrous connective tissue.To our knowledge, there are no reports of orbital eccrine hidrocystoma in the literature other than the case of a 14-year-old patient with giant eccrine hidrocystoma reported by Eslami et al.Our aim in this study was to emphasize that eccrine hidrocystomas, although rare, should be considered during differential diagnosis of orbital masses.Informed Consent: It was taken.Peer-review: Externally peer-reviewed.


Lipomas are the most common mesenchymal tumors. Laryngeal lipomas represent 1% of all lipomas but unlike other locations may cause life-threatening symptoms by obstruction of the respiratory tract. In this study, the case of a 32-year old woman with laryngeal lipoma is discussed. The lesion was detected on the left aryepiglottic fold, presented as a stalked and dynamic mass of 2 centimeters diameter. The imaging aspects of laryngeal lipoma cases, clinical evaluation, and approaches to treatment will be discussed. Lipomas are the most common subcutaneous tumors. They may appear at any age, sex or body location. Lipomatous tumors in adults are frequent in the upper trunk, abdomen and shoulders. Rare in the first two decades, they manifest in the age where fat cells starts to accumulate in the body . Their aA 32-year-old female patient came to our hospital complaining of changes in her voice, which had started several months earlier. She had not any complain of dysphagia or dyspnea. The physical examination was normal. Upon admission to ENT Department, the patient was submitted to Mirror examination of larynx which revealed a large submucosal swelling obliterating the left side of the supraglottic larynx and obscuring the airway. Mobility of left vocal cord was limited due to mass effect. A later Endoscopy showed the same findings: a large, smooth, pseudocystic mass, arising from the left aryepiglottic fold. This lesion was about 1.5 x 2 cm in size, of a translucent appearance and covered by normal, non-hemorrhagic mucosa. A computed tomography (CT) scan of the neck revealed a well-defined mass of a very low-density without enhancement, highly suggestive of lipoma . This leThe upper aero-digestive tract is a very rare location for Lipomas  which deThese tumors do not metastasize; however, they have high rates of local recurrence and well-documented potential for delayed dedifferentiation into higher grade sarcomas . The sarLipomas usually present as solitary lesions, but multiple site involvement may be seen in alcoholics, diabetes mellitus and syndromes such as Madelung's disease and Kobberling-Dunningan syndrome . LaryngeLaryngeal lipomas may be pedunculated or submucosal . PeduncuThe treatment of lipomas in head and neck is mainly by surgical excision in order to minimize the recurrence chance. Depending on size and extent of the tumor, it can be removed by endoscopic surgery or open surgery . RecurreLipomas are rare ENT tumors. They cause few non specific symptoms and should be taken into consideration in the differential diagnosis of all benign head and neck masses.


The patient underwent four cycles of cisplatin and vinorelbine chemotherapy as standard adjuvant chemotherapy for pStage III NSCLC. The ALK fusion gene status of NSCLC with atypical CT features should also be investigated.A 68-year-old female patient with a history of gynecological treatment was found to have a cavitary mass in the right lower lobe on an annual chest roentgenogram. The tumor was located in the peripheral area with a pleural tail showing no pleural effusion. In addition, two pure ground-glass-opacity nodules (p-GGNs) in the right upper lobe of the lung were detected on consecutive chest CT scans. The patient underwent right lower lobectomy, partial resection of the right upper lobe, and hilar mediastinal lymph node dissection for complete resection of each tumor. The pathological diagnosis was invasive mucinous adenocarcinoma with signet-ring cells for the cavitary mass in the right lower lobe and invasive adenocarcinoma for the rest of the p-GGNs; subcarinal lymph node metastasis was also detected. The  Certain features of a tumor on chest CT, such as convergence, notch, and a pleural tail, have been reported to have a significant association with an EGFR or ALK fusion gene mutation [ALK fusion gene, the combination of certain tumor features on chest CT, such as a central tumor location, large pleural effusion, and the absence of a pleural tail, and a younger patient age (<60 years old), were shown to have a significant relationship with ALK rearrangement in patients with NSCLC [Several radiological features delineated by chest computed tomography (CT) of non-small cell lung cancer (NSCLC) have been reported to be associated with some utility in detecting the gene mutation status, such as mutation –5. With th NSCLC .ALK fusion with rare radiological features.We herein report a case of surgically resected lung adenocarcinoma that presented as a cavitary mass harboring A 68-year-old female was found to have a cavitary mass on annual chest roentgenography in December 2015. She had a history of treatment for cervical cancer in the uterus in 2001 and had been followed up at our hospital without recurrence. She was a never-smoker and had no significant abnormalities on a physical examination except for an abdominal scar related to the treatment for her cervical cancer.Chest CT revealed a cavitary mass, approximately 4.3 cm in its maximum dimension, in the basal segment of the right lower lobe of the lung Fig. a. In addALK rearrangement was detected by FISH from the specimen obtained from the cavitary mass on the right lower lobe. The postoperative course was uneventful, and the patient is currently disease-free at 5 months post operation.A pathological examination revealed the cavitary mass in the right lower lobe to be invasive mucinous adenocarcinoma  with signet-ring cells (Fig. ALK fusion gene [ALK fusion gene in cases of NSCLC [ALK fusion gene using those three CT features and the age of patients and revealed a sensitivity and specificity of 89.4 and 100.0%, respectively, for the presence of the ALK fusion gene in certain cohorts of patients. However, the equation failed to demonstrate the presence of the ALK fusion gene in our patient in the present report. Retrospectively, a tiny nodule was occasionally found in the basal segment adjacent to the visceral pleura (the peripheral area of the right lung on an abdominal CT taken 8 years prior as a follow-up of cervical cancer of the uterus; Fig. ALK gene fusion in the cavity formation in the tumor, an initial tumor location in a peripheral site without pleural tail formation, and a patient age over 60 years old.Previous reports have shown that some CT features are significantly associated with the ion gene –5. Yamamof NSCLC . In addiALK+ lung cancer [ALK status of the patient was positive, these findings were consistent with those of previous reports.With regard to the pathological features of this case, the permanent specimen showed invasive mucinous adenocarcinoma with signet-ring cells Fig. c. Signetg cancer . Given tALK rearrangement with uncommon radiological features. The ALK gene status of NSCLC with atypical CT features should also be investigated.We report a case of NSCLC harboring


Intraductal papillary mucinous neoplasm (IPMN) accounts for 20-50% of all cystic neoplasms of the pancreas. Rarely, IPMN, whether benign or malignant, can fistulize into adjacent organs like duodenum, stomach or common bile duct. IPMN can be associated with other diseases like Peutz-Jeghers syndrome and familial adenomatous polyposis. Association with adult polycystic kidney disease (ADPKD) is extremely rare. We report a case of a 60-year-old male with a large IPMN in the head of the pancreas diagnosed by magnetic resonance imaging, endoscopic ultrasound and cyst fluid analysis. It was complicated by fistula formation into the second part of the duodenum. Patient was simultaneously having adult polycystic kidney disease. There is only one case report of uncomplicated IPMN with ADPKD in the literature so far. And even rarer, there is no any case report of fistulizing IPMN with ADPKD reported so far, to the best of our knowledge. Cystic neoplasms of the pancreas are rarely encountered, diagnosed in 10% of pancreatic cysts detected on imaging. They consist of intraductal papillary mucinous neoplasm (IPMN) of the pancreas, mucinous cystic neoplasm, serous cystadenoma, papillary cystic tumors and cystic islet cell tumors .Though rare, IPMN, whether benign or malignant, can fistulize into adjacent organs like duodenum or stomach. Moreover, IPMN can be associated with many other conditions like Peutz-Jeghers syndrome and familial adenomatous polyposis but association with adult polycystic kidney disease (ADPKD) is extremely rare and is almost unheard of. Only one case of IPMN (non-complicated) with ADPKD has been reported in the literature .We report a case of a 60-year-old male diagnosed to have an IPMN complicated by a fistula formation into second part of the duodenum associated with ADPKD. There is not a single case report of similar combined presentation in an individual patient reported in the literature so far, to the best of our knowledge.A 60-year-old male, chronic smoker, non-alcoholic, presented with 3 months history of pain in upper abdomen which was epigastric, dull aching, continuous, mild to moderate intensity and radiating to back. He had significant anorexia and weight loss of 8 kg. He did not have similar pain in the past. On physical examination, the patient was pale, malnourished, afebrile, with a blood pressure of 150/90 mm Hg, pulse rate of 90 beats per minute and a respiratory rate of 22 breaths per minute. Abdominal examination revealed soft and non-tender abdomen with non-palpable liver and spleen. There was an approximately 8 × 8 cm ballotable non-tender cystic lump with ill defined margins noted in left lumber region which did not move with respiration.3, and platelet count of 3.3 lakh/mm3. Renal function tests showed serum creatinine of 3.3 mg/dL and blood urea nitrogen of 54 mg/dL. Liver function tests were normal. Serum amylase and lipase were 90 IU/L and 80 IU/L, respectively. Serum CA 19-9 was 20 IU/mL.Laboratory examination showed hemoglobin of 9.2 g/dL, total leukocyte count 8,800/mmUltrasonography of the abdomen was suggestive of dilated pancreatic duct (7 mm in head) and a 6 × 5 × 5 cm well defined cystic collection with wall thickness of 4 mm with multiple mobile internal echoes seen in the head and body of pancreas which was communicating with pancreatic duct. It also showed bilateral innumerable renal cortical cysts, largest measuring 10 × 10 cm in left kidney. Magnetic resonance cholangiopancreatography (MRCP) with magnetic resonance imaging (MRI) abdomen showed large 8 × 5 × 5 cm cystic irregular collection with septations involving head and body of the pancreas, almost replacing them with 7.5 mm pancreatic duct. MRI also suggested bilateral polycystic kidney disease . EndoscoIPMN is defined as an intraductal epithelial tumor composed of mucin-producing columnar cells showing papillary proliferation, cyst formation, and variable degrees of cellular atypia, even within an individual neoplasm.IPMN, whether benign or malignant, can become complicated in 6.6% cases forming a fistula into adjacent organs . The fisThe most common organ fistulized is the duodenum 64%), followed by the common bile duct 56%) and the stomach (17%) [6% and th4%, folloAssociation of IPMN with ADPKD is very rare. Only one case has been reported in 2009 by Yasunori Sato from Japan. Simple pancreatic cysts can be found in as many as 7-10% patients with ADPKD, but rarely a cyst in the pancreas can turn out to be a cystic neoplasm of the pancreas. Other diseases that are associated with IPMN are Peutz-Jeghers syndrome and familial adenomatous polyposis [In case of fistulizing IPMN, a biopsy specimen should be taken from the fistula endoscopically which would reveal whether the tumor has invaded an organ adjacent to the pancreas and enable determination of extent of surgery and prognosis. There are no clear guidelines to manage IPMN complicated by a fistula formation. However, pancreaticoduodenectomy is the standard of care for an IPMN fistulizing into duodenum in most of the centers.Our patient had a large IPMN involving the head of the pancreas diagnosed on MRI, EUS and cyst fluid analysis with unusual feature of fistula formation into second part of duodenum and simultaneous association with ADPKD. This is the first case, to the best of our knowledge, of a large IPMN with ADPKD and a fistula formation into duodenum.


The authors report a case of pseudomyxoma peritonei with gelatinous peritoneum in a 47-year-old-woman. The main symptom for discovery was a chronic pelvic abdominal pain. This disease is particularly rare. The gelatinous substance is often associated with a malignant ovarian tumor or appendicitis perforated. Currently, on the whole, an exploratory laparoscopy allows diagnosis, biopsies, and appendectomy. The treatment is essentially surgical. The prognosis depends on grade (1/3) and response to chemotherapy. This case was presented to the tumor board. A 47-year-old woman without comorbidities presented to a gynecologist for a chronic pelvic abdominal pain for 4 months. There were no other signs. The patient is not at a menopausal stage and had the last period date before a week of admission. Also she is homosexual. She agreed to undergo eventual hysterectomy. Thoracoabdominal contrast-enhanced MRI and CT scan were then performed after an endovaginal ultrasound showing a left adnexal ovarian mass that is heterogeneous and little mobile.The MRI shows a fluid mass of 10 × 7 × 8 cm encompassing the uterus and ovaries. It presents a fine peripheral enhancement onto which enhanced tissular nodules are grafted, and there are also septa behind the left ovary and a curvilinear calcification.T2 sequences confirm a dilated appendix at 11 mm of diameter with thickened walls, containing liquid, and hypo signal T2, calcifications and especially an enhancement on the appendicular tail.This examination shows a peritoneal pseudomyxoma with a partitioned mass encompassing the uterus and adnexa, nodular vesicular and tissue implants, and small mucoid implants scattered in the peritoneal cavity.An appendicular mucocele and a gelatinous disease of the peritoneum are possible complications.Radiologists requested an abdominal scan to visualize an ovarian malignant pathology. The results of this review are in contradiction with the MRI. The differential diagnosis revealed a stage III c ovarian cancer.An exploratory laparoscopy is performed showing a gelatinous disease of the peritoneum. Both ovaries are ovulatory, with a normal wall. The appendix is retro cecal and dilated at its base with an infiltrated meso. Appendectomy is performed systematically. Its base is particularly dilated. A double suture by Endoloop is necessary.The peritoneal lavage is then carried out. Mucus is sent to anatomical pathology department for the evaluation of the histological grade. Ovarian and peritoneal biopsies are performed. All results will be presented to the tumor board to decide on further treatment. No other abnormalities are found in the abdominal cavity.First, a gelatinous disease of the peritoneum indicates the presence of a gelatinous ascites, due to mucin-producing tumor cells implanted on the peritoneal surfaces. Mucin is essential for the diagnosis.In 1842, first Rokitansky and then Cruveilhier described gelatinous degeneration in the peritoneum and believed that the disease originated in the ovaries , ovarian , and peritoneal causes. Other causes are described in the literature : malignaThe mucocele is due to the chronic nature of luminal distension. Most frequently, a rupture of a mucinous tumor or a mucocele of the appendix in the peritoneal cavity leads to the gelatinous disease of the peritoneum . This isDissemination initially is locoregional. But, it is frequent to see multiple sites of localization. Fairise et al.  describeFor a long time, it was believed that the origin could be mixed (ovarian and appendicular). Moreover, there are often voluminous ovarian tumors in this disease, which are mistaken for primitives. Immunohistochemistry and genetics history were to be expected to affect the appendicular mucocele as the main cause of the disease. Appendix is distended by hypersecretion of mucin: it is the mucocele appendicular .Actually, research seems to show that the disease progression is related to microbial agents  , 7. MultIf the appendix is the most frequent origin of the disease, other tumors may be concerned for the etiology: mature teratoma, digestive tumors, etc.The three reasons for appendicitis are obstruction, distension, and rupture with intraperitoneal dissemination of the mucus. Each implant is an epithelial cell proliferation producing mucus . DissemiThere are no specific signs. The main sign is abdominal ascites: from a simple effusion to an important ascites, in fact, the clinical aspect is rich .But the absence of pathognomonic signs explains the difficulty of clinical diagnosis. In our case, only the pelvic abdominal pain was present. In published literature, it is always imagery and laparoscopic findings that offer the macroscopic diagnosis.Biology is not useful for diagnosis, but tumor markers  are used for the detection of early recurrences. So we need of a starting rate. They are high in most of the patients and useful to survey the chemotherapy efficiency.Imaging  are very useful to see the lesions.Ultrasounds allow seeing an eventual ovarian cystic mass associated with peritoneal implants or effusion, evaluate septa, and calcifications.They allow seeing the implants, the associated tumors (ovaries), the effusion, the extension of the disease on mesentery, and in deciding the surgical strategy.They will show the “scalloping of the liver” , the parBut, laparoscopy is the best indication to explore the peritoneal cavity. During the procedure, it is possible to evacuate the mucus and wash the cavity, to perform the biopsies of the peritoneum, and to carry out a diagnostic adnexectomy, a systematic appendectomy.The aim is to obtain an anatomopathological analysis, to evaluate the appendix, and to define the grade and the stage of the disease because the therapeutics depends on it and to define a therapeutic strategy.In the case of our patient, washing and aspiration were performed to remove the maximum of the gelatinous effusion, and staging was completed by performing biopsies of the peritoneum and the macroscopically normal ovaries. On the other hand, the appendix appeared abnormal, and we confirmed an appendectomy. (Its base showed a mucocele of 1.1 mm diameter.) The mesentery was normal and there were no lesions on the liver and stomach and omentum was normal macroscopically. The diaphragmatic domes are not yet reached Figures .Appendix, appendectomy: low-grade mucinous tumor limited to the mucosa extending over 2.4 cm in length, without submucosal infiltration (LAMN), without vascular invasion, complete excision, healthy section of the appendix without tumor, and small defect of the wall near the sectional section without associated inflammatory reaction.Douglas, biopsies: low-grade appendicular mucinous tumor (LAMN).Peritoneum: deposit of mucus without visible tumor epithelial cells.Peritoneal washing: rare atypical cells compatible with mucinous adenocarcinoma.TNM classification for mucinous peritoneal tumor is as follows: pT4a, pNx, L0, V0, pPnO, and G1.In Figure The ovaries show no macroscopic abnormalities but are covered with mucus. After washing, a bilateral biopsy is carried out for diagnostic purposes.Exploratory laparoscopy was used for diagnosis and to perform peritoneal staging, appendectomy, and ovarian biopsies.The final pathological result allows to determine the TNM classification and the stage of the disease.The different sections show that there is no invasion of the appendix but the presence of adenocarcinomatous cells in the effusion Figure .TNM classification for mucinous peritoneal tumor: pT4a, pNx, L0, V0, pPnO, and G1.The general classification into four grades has been previously described Figure .It is a mucinous neoplasia of low grade, with or without cysts, characterized by a proliferation of cylindrical epithelial cells, planar or villous architecture without mucus, neoplastic cells, and invasive extraappendicular focus.It is an appendicular lesion of mucinous neoplasia of low grade, with or without cysts, characterized by a proliferation of cylindrical epithelial cells, flat or villous architecture with the presence of extraappendicular mucus, absence of neoplastic cells, and invasive extra-appendicular focus.Group 3 consists of lesions of mucinous neoplasia of low grade, with or without cysts, characterized by a proliferation of cylindrical epithelial cells, flat or villous architecture with the presence of mucus, extraappendicular neoplastic cells, and absence of invasive extraappendicular focus.Group 4 consists of appendicular lesions of high grade, mucinous neoplasia, or invasive neoplasia invading the wall—appendicular beyond the mucous muscle.There is possible presence of mucus, neoplastic cells, and extraappendicular invasive foci.Appendectomy: The material examined in total and over several depths shows multiple depressions of mucus and epithelial flaps bordered by a layer of mucus-secreting cylindrocellular epithelial cells with mild cytotoxic atypia. No high-grade dysplasia component is seen. The submucosa is thinned and atrophic. Epithelium in low-grade dysplasia is limited in the appendix, 0.3 cm from the surgical section and 0.8 cm from the tip. The tip is obstructed by a fibrous reshaping. At 0.3 cm from the surgical section, there is an area of defect of the appendicular wall, with no associated inflammatory reaction.About Douglas and peritoneum: fragments of low-grade appendicular mucinous tumor and fragments of peritoneum in the presence of mucus deposits mixed with chronic and acute inflammatory elements, without tumor epithelial cells.The results of the patient are as follows:The peritoneal lavage shows rare atypical cells compatible with a mucinous adenocarcinoma ++.WHO histological classification of the tumors of appendix.Abdominal radiographs are rarely helpful for diagnosis . UltrasoThe MRI shows a fluid mass of 10 × 7 × 8 cm encompassing the uterus and ovaries. It presents a fine peripheral enhancement onto which enhanced tissular nodules are grafted, and there are also septa behind the left ovary and a curvilinear calcification.The masses do not show a hyper signal in diffusion and there is no decrease in the diffusion coefficient.A complementary ultrasound is performed, which shows heterogeneous fluid mass that do not move around the left ovary, without mobilization to the right during the right lateral decubitus.The coronal sequence in abdominal T2 shows small nodular fluid implants scattered in the peritoneum under the mesocolic zone, at the tip of the right liver (no visible lesions) without “scalloping” Figures  and 5.But this sequence shows a cecal appendix dilated to 11 mm in diameter and 37 mm in length, containing liquid with thickened walls, in hyposignal T2 with calcifications, and an elevation in relation to the appendicular tail with tissue thickening.The MRI is compatible with peritoneal pseudomyxoma, but appendicular mucocele and gelatinous disease of the peritoneum remain possible Figures , 3–5.It is a probable appendicular mucocele at the origin of this pseudomyxoma.The mainstay of the treatment is surgery and chemotherapy. Radiotherapy is not efficient because the tumor is not differentiated.In our case, washing and aspiration removed the maximum of the mucous effusion, and laparoscopy allowed us to visualize normal ovaries, but a bilateral biopsy was performed, and the systematic appendectomy (diameter of the base of 1.1 cm) must allow the diagnosis of pseudomyxoma, define the grade, and decide on the surgical and chemotherapeutic strategy. Surgery must remove all lesions to eradicate the lesional process. In case of malignant mesothelium, all peritoneal lesions should be removed: but the surgical time and the postoperative complications make this surgery extremely difficult .A good washing of the peritoneal cavity is useful, but the recurrence is very frequent. The approach depends on the size of the lesions and damage. But laparotomy remains a good method. The surgery must obligatorily remove the appendix, sometimes even a right hemicolectomy and hysterectomy with bilateral adnexectomy.In fact, intraoperative chemotherapy –11 and pTaking advantage of the barrier between plasma and peritoneum, higher concentrations of chemotherapeutics penetrate peritoneal nodules with a low rate of systemic absorption. It is a real minimal invasive chemotherapy and repetitive (one application per month for 3 months). The procedure is performed for 90 min under general anesthesia. The chemotherapy is vaporized in the form of an aerosol, which is therefore homogeneous in the peritoneal cavity benefiting from laparoscopy under a pressure of 12 mm Hg . In liteThe problem of peritoneal disease is that it remains microscopic, and surgical redux would require removal of the entire peritoneum, but this long and dangerous surgery can result in large complications or even vital prognosis. It will remain incomplete since it is not possible to remove all mesos. Moreover, no current imaging can visualize peritoneal lesions in preoperative and postoperative surgery. Tumor blood markers are ineffective and do not evaluate response to treatment.Finally, in three studies, the prognosis depends on complete cytoreductive surgery and association with hyperthermic intraperitoneal chemotherapy. Surgery should be continued if possible. The recurrence rate remains high, and preoperative and postoperative morbidity remains high at 24%. Mortality is estimated at 2% –17.All authors participated in this article.The authors declare no conflict of interest and not any ethical problems. A written informed consent was obtained from the patient for the publication of this case report. The reviewer, BH, and handling editor declared their shared affiliation, and the handling editor states that the process nevertheless met the standards of a fair and objective review.


Breast metastasis arising from non mammary malignancy is very rare and occurs in malignant melanomas, sarcomas, lung cancers, ovarian tumors, renal and thyroid carcinomas. Few cases of breast metastasis from myxoid liposarcoma have been reported in the worldwide literature. We report herein a case of a 51-year-old woman with 2-year history of a slowly growing, painless mass of the right proximal thigh. Imaging investigations showed an intermuscular mass with low-attenuation areas on the CT scan (A) and high signal intensity on T2-weighted MR images (B). Material obtained by biopsy revealed a myxoid liposarcoma. A bone scan performed as part of the initial staging process showed multiple hot spots suggestive of skeletal metastasis in addition to increased soft tissue tracer uptake projected over the right proximal thigh and the left mammary gland corresponding respectively to the primitive tumour and a breast metastasis (C). Chest CT scan showed a left breast mass with similar attenuation feature to the primitive tumour (D). The patient was treated by six chemotherapy cycles  with good control of her disease on tree years follow up (E). Myxoid Liposarcoma is a rare soft-tissue tumour with a possible aggressive evolution leading to intensive chemotherapy protocols. Soft tissue uptake on bone scan is exceptional, but can occur in a large spectrum of disease. In this case, necrosis and high-water content of myxoid tissue, reflected as marked high signal intensity on T2-weighted MR images, may contribute to the soft tissue uptake mechanism of the bone seeking radiopharmaceutical.


Dear Editor,café-au-lait spots were noted, together withbilateral axillary freckles (A healthy, nonsmoking, 27-year-old male patient was referred to our institution forinvestigation of a three-month history of progressive dyspnea. He reported that hisdyspnea worsened on physical exertion and significantly limited his daily activities. Hereported no cough, fever, night sweats, or weight loss; nor did he report any new lumpsor masses during the last three months. Upon skin examination, multiple subcutaneousnodules and freckles .Collectfreckles -d. Becau. Overall,these tumors are associated with high local invasion, rapid growth, and early distantmetastasis unless they are excised in a timely manner. The most common locations for MPNST inneurofibromatosis patients are the extremities, head, and neck. Thoracic involvement,however, is remarkably rare, few cases having been reported. According to the size and location of theintrathoracic tumor, compressive manifestations such as pain, dyspnea, dysphagia, andsuperior vena cava syndrome may be the presenting manifestations, as seen in ourpatient, who reported dyspnea as the sole symptom related to his MPNST,4.MPNSTs are exceedingly rare sarcomas in the general population, with a lifetime risk ofless than 0.01%. Conversely, in association with neurofibromatosis, these tumors arisein higher frequency because of malignant transformation from preexisting plexiformneurofibromas-6. Therefore, any suspicious lesions should generally prompt histologicalsampling.The identification of MPNST in neurofibromatosis patients may be troublesome for severalreasons. First, the existence of multiple benign neurofibromas may delay theidentification of changes in plexiform neurofibromas. In addition, because superficialcutaneous neurofibromas do not undergo malignant transformation, MPNSTs often remainundetected until they reach a moderate size or cause compressive symptoms. Furthermore,CT and magnetic resonance imaging might not be accurate enough to differentiate benignfrom malignant lesions with any degree of reliability in the very early stages, althoughadvances have been made in the area of positron emission tomography.Although the mainstay of successful treatment of an MPNST is surgical excision afterdisease staging, neoadjuvant chemotherapy may be employed in order to reduce itsdimensions beforehand, especially in patients with lesions surrounding vital organs.Radiotherapy might also delay recurrence, although it has not been shown to improvesurvival in MPNST patients


Uterine leiomyomas are common and can affect up to 30% of women older than 35 years. Despite this, leiomyomas of the vulva are rare, masquerading, and usually misdiagnosed as Bartholin cyst preoperatively. These smooth muscle tumors are typically painless, solitary, and well circumscribed and can affect female of any age group. We present a case of a 46-year-old female that presented to the clinic with 2-year history of right labial mass and was diagnosed as Bartholin cyst initially. The patient underwent elective excision under spinal anaesthesia and the mass was removed. The final diagnosis after microscopy result showed benign vulvar leiomyoma. Leiomyoma of vulva is a rare, benign mass that is present on the vulva. Uterine leiomyomas are common and can affect up to 30% of women older than 35 years . DespiteA 46-year-old female P4 +0 presented to the clinic with 2-year history of right labial mass. The mass showed mild progression over that period and was associated with pain. There was no history of discharge, fever, or weight loss. General examination was unremarkable except for a soft mass that measured 4 × 3 cm in the right labial area. The mass was medial to the right labia minora. The patient had a history of four spontaneous vaginal deliveries without induction. The family history was unremarkable.The mass was diagnosed initially as a Bartholin cyst. She was counseled for the management options and agreed to undergo surgical intervention. She was booked for day care surgery. An elective excision under spinal anaesthesia was performed. The incision at the mucocutaneous junction showed soft, fleshy, and well defined mass measuring 3 × 4 cm. The mass was enucleated in fragments and sent to the histopathology lab. The patient had a good recovery postoperatively with no complications.On histopathological examination, the gross specimen consisted of two soft pieces of tissue measuring 4.1 × 2.3 × 1.8 cm. Slicing of the specimen revealed fleshy solid cut surface and no cyst was seen. Microscopy revealed benign tumor composed of sheets and fascicles of oval to spindle shaped cells with abundant dense cytoplasm and areas of hyalinization Figures . The finLeiomyomas are benign tumors that arise from smooth muscle cells in possibly any anatomical site within the body . Vulvar A common mistaken initial diagnosis for vulvar leiomyoma is Bartholin's cyst, since both share some of the presenting symptoms such as painless lump, redness, and swelling of the area. Some features that support the diagnosis of Bartholin's cyst are everted labia minora and cystic consistency of the swelling; however, finding inverted labia minora and firm consistency of the swelling support the diagnosis of vulvar leiomyoma .In cases with vulvar leiomyoma, differentiating between benign and malignant lesions is somewhat challenging. Nielsen et al. proposed a criterion to distinguish between the two lesions based on 4 features: more than 5 cm in widest dimension, infiltrative margins, more than 5 mitotic figures per 10 hpf, and moderate to severe cytologic atypia. If 3 or all features were found, then the neoplasm is considered to be a sarcoma. Benign but atypical leiomyomas fulfill only 2 characteristics, and benign leiomyomas are the ones that exhibit 1 or none of the traits . In refeExcision of the tumor with some of the surrounding normal tissue is the treatment of choice, for it decreases the rate of recurrence and increases the 5-year survival rate . RadiothVulvar leiomyoma is a rare tumor that is commonly misdiagnosed as Bartholin's cyst. Distinguishing between benign and malignant forms is also confusing, which makes vulvar leiomyoma a great diagnostic challenge. As there are a few techniques used to differentiate between the natures of the tumor, excisional biopsy seems to be the best current method used in addition to being the treatment of choice for such tumors. Continuing follow-up after treatment is highly recommended.


Sclerosing mesenteritis is a non-neoplastic inflammatory disease that occurs in the bowel mesentery. Distinguishing sclerosing mesenteritis from neoplasms may be difficult because of the clinical and radiographic similarities between the two disease entities.We report a case of sclerosing mesenteritis mimicking peritoneal metastases of colorectal carcinoma. A 73-year-old man with stage II descending colon adenocarcinoma with poor prognostic features was found to have developed left lower abdominal quadrant masses on computed tomography (CT) 9 months after undergoing radical surgery. These masses were diagnosed as peritoneal metastases because they grew in size and displayed fluorodeoxyglucose (FDG) uptake 3 months later; thus, a laparotomy was performed. The masses, which were localized in the jejunal mesentery, were excised completely via segmental jejunal resection. Histopathological analysis confirmed that the masses were sclerosing mesenteritis. The patient showed no signs of sclerosing mesenteritis or colorectal carcinoma recurrence during follow-up.In patients suspected of having localized peritoneal metastasis from malignancies, any masses must be sampled by surgical excisional biopsy and subsequently examined to rule out alternative diagnoses, such as sclerosing mesenteritis. Sclerosing mesenteritis is non-specific inflammatory mass-forming lesion in the mesenteric connective tissue that is characterized by variable degrees of fibrosis, chronic inflammation, and fat necrosis –5 and maHere, we report the case of a patient who underwent surgery for presumed metachronous localized peritoneal metastases from descending colon cancer and was ultimately diagnosed with sclerosing mesenteritis and thus avoided receiving unnecessary chemotherapy.A 73-year-old man with advanced descending colon carcinoma was referred to our hospital for surgery. The patient had previously undergone a hemithyroidectomy for papillary thyroid carcinoma and an appendectomy for acute appendicitis. He was also receiving medications for the treatment of type 2 diabetes mellitus and the prevention of cerebral infarction. His carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels were 4.0 μg/L and 4.7 kU/L, respectively, and were thus each within their normal ranges. Computed tomography (CT) was negative for metastatic lesions. The patient underwent a laparoscopic partial colectomy and regional lymph node dissection. The pathological diagnosis was moderately differentiated tubular adenocarcinoma that had invaded the subserosa (T3) and was without lymph node metastasis (N0) (Fig. Nine months after the primary surgery, the patient underwent CT, which revealed soft tissue attenuating masses in the left lower abdominal quadrant Fig. . The patThe patient suffered from postoperative ileus but recovered with conservative treatment and showed no signs of sclerosing mesenteritis or descending colon cancer recurrence after 6 and 18 months of follow-up, respectively.Sclerosing mesenteritis is an inflammatory process within the mesentery and can be categorized into the following three subgroups, depending on the predominant tissue component: mesenteric panniculitis, which is characterized by chronic inflammation; mesenteric lipodystrophy, which is characterized by fat necrosis; and retractile mesenteritis, which is characterized by fibrosis , 8, 10. The CT findings of sclerosing mesenteritis will vary depending on the predominant features of the disease . MesenteThe prognosis of sclerosing mesenteritis is generally regarded as favorable with supportive treatment , 7, 12. In conclusion, it is necessary to excise and examine mesenteric nodules in patients with a history of malignancy to distinguish tumor recurrence from alternative diagnoses, such as sclerosing mesenteritis.Sclerosing mesenteritis can mimic peritoneal metastasis from malignancies, and it is necessary to excise and examine a mesenteric nodule developing in patients with a history of malignancy to distinguish recurrence and differential diagnosis such as sclerosing mesenteritis.


The incidence of invasive cancer within a mucinous cystic neoplasm of the pancreas varies between 6 and 36%. Polycystic ovarian syndrome is a disorder characterized by hyperandrogenism and anovulatory infertility. One surgical treatment that can restore endocrine balance and ovulation in polycystic ovarian syndrome is partial ovarian destruction. Successful pregnancies following preconception pancreaticoduodenectomies (Whipple procedures) and chemoradiation to treat pancreatic neoplasms have been reported rarely but none were diagnosed with pre-cancer polycystic ovarian syndrome-associated infertility. Gemcitabine is an antimetabolite drug used for the treatment of pancreatic cancer that can have profound detrimental effects on oogenesis and ovarian function. Whether the ovarian destructive property of gemcitabine could act as a method to restore ovulation potential in polycystic ovarian syndrome is unknown.A 40-year-old white American woman with a history of pancreatic cancer treatment with a Whipple procedure and chemoradiation with gemcitabine had a successful pregnancy after years of pre-cancerous anovulatory infertility and polycystic ovarian syndrome. She received no fertility agents and delivered full term via a spontaneous vaginal delivery with no pregnancy complications.Gemcitabine treatment for pancreatic cancer may result in resumption of ovulation in women with polycystic ovarian syndrome and these women should be counseled accordingly. Mucinous cystic neoplasms (MCNs) of the pancreas comprise up to 25% of all resected cystic neoplasms , 2. TheyThe usual surgical procedure performed for primary pancreatic malignancy is the Whipple procedure or pancreaticoduodenectomy . RadiatiPolycystic ovarian syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women and typically presents with insulin-resistance, hirsutism, and anovulatory infertility . The incGemcitabine is a fluorinated nucleoside antimetabolite drug used for treatment of cancer of the pancreas and can have profound detrimental adverse effects on oogenesis . A recenWhether the ovarian disruption associated with gemcitabine can have effects on restoring ovulation similar to partial surgical destruction in PCOS is unknown.We present a case of a woman with a history of 14 years of PCOS-induced anovulatory infertility and MCN-associated pancreatic cancer treated with a Whipple procedure, radiation, chemotherapy, and gemcitabine who had a successful conception and full-term delivery.A 35-year-old gravida 0 white American woman with a 14-year history of unprotected intercourse without conception secondary to PCOS and 8 pack years of smoking presented to an emergency room with a lump in her left abdomen and sharp, left-sided, intermittent pain of 2 months’ duration. She was admitted and a computed tomography (CT) scan and magnetic resonance imaging (MRI) scan of her abdomen and pelvis showed an 18×19 cm left retroperitoneal mass  scan displayed hypermetabolic activity at the periphery of the mass. Four weeks after her initial presentation, she underwent an exploratory laparotomy and decompression of the pancreatic mass yielding 2 liters of fluid. An attempt was made to resect the body of the pancreas but significant adhesions were noted and surgery was abandoned. The final pathology report was MCN and low grade dysplasia. A postoperative CT scan 2 weeks after her surgery showed the mass had increased in size to 20.3×15.1 cm with multiple septations. On a follow-up visit with her surgical oncologist her BMI was 29.1. At this point she was transferred to a centralized oncology center for surgical evaluation and management of the pancreatic mass with at least low grade dysplasia. Fourteen weeks after her initial presentation she underwent a Whipple procedure and splenectomy, removal of a retroperitoneal mass yielding 1.5 liters of mucinous material and an omental flap. Ovarian transposition was not performed. An 18 cm multiloculated cystic mass was present at the distal tip of the tail of her pancreas. Her final pathology revealed stage 1B invasive adenocarcinoma arising in the MCN with extensive high grade dysplasia (PTX N0 M0). All 37 lymph nodes were negative with negative venous or lymphatic invasion and the closest margin of 6 cm.She returned to the regional cancer center and started single-agent gemcitabine 8 weeks postoperation. After four cycles, her post-chemotherapy CT scan showed no evidence of metastatic disease. She was started on concurrent fluorouracil (5FU) and targeted pancreatic radiation therapy 24 weeks after her definitive surgery and finished 25 fractions with minimal side effects and standard shielding. When she started her radiation her BMI was 32.4. Fifteen months after her initial presentation a quantitative beta-human chorionic gonadotropin (hCG) was obtained and returned 5783 mIU/ml. She had not changed sexual partners. An ultrasound revealed an intrauterine pregnancy with no embryonic pole or heartbeat. She had a spontaneous abortion at 6 weeks. There was no note of ovarian morphological abnormality. Her repeat CT scan 1 year later showed no evidence of pancreatic disease and she entered cancer surveillance at that time.in vitro fertilization. Her targeted fetal ultrasound was normal as were serial obstetric scans. Her pregnancy was uneventful and standard prenatal testing was normal. She maintained normoglycemia on orally administered hypoglycemic agents. At 38 weeks, she had labor induced and delivered vaginally a healthy baby with Apgar score of 8/9 and birth weight of 2865 grams. She was discharged with her baby 2 days after her delivery.She first presented to our service 50 months after her initial presentation as a 40-year-old gravida 2-0-0-1-0 at 19 weeks’ gestation. She gave a history of an extensive infertility workup in the past prior to her cancer treatment which was consistent with PCOS-induced anovulation. Male factor workup was negative and she had attempted conception with the standard PCOS methods including timed intercourse after attempted medically induced ovulation without success. Weight loss did not result in conception. She did not attempt more invasive assisted reproductive techniques such as This is the first report of a conception without the use of assisted reproductive technology and a successful term delivery in a woman with PCOS-induced anovulatory infertility after treatment with a Whipple procedure and chemoradiation. We performed a MEDLINE search of the English language literature and found two cases reporting preconception Whipple procedure , 14. In One of the suggested treatments of PCOS-induced anovulatory infertility is weight loss. However, our patient had no significant BMI changes and she had not even started an exercise program during her entire post-cancer preconception treatment so it is unlikely that any modification of lifestyle was operative in her sudden ovulation. In addition, she never took metformin which is an off-label but commonly used form of treatment for PCOS infertility. She conceived twice after taking four cycles of gemcitabine which is the only chemical she ingested that is known to be consistently toxic to gonads. It is unlikely that radiation was involved in her sudden resumption of ovulation since pelvic irradiation is known to result in diminished fertility potential .et al. [There has been one report investigating molecular markers of human fertility related to chemotherapy involving gemcitabine indirectly. Chatzidarellis et al.  reportedet al. . Whetheret al. . Our patIn summary, women with PCOS-induced anovulatory infertility who are post-Whipple procedure and chemoradiation using gemcitabine should be counseled to use contraception if they do not desire pregnancy. Another option is a bilateral salpingectomy at the time of the Whipple procedure if they desire permanent sterilization.This is a case of a pregnancy and term delivery following a Whipple procedure for IB adenocarcinoma of the pancreas discovered in a MCN in a 40-year-old woman. This case is very unusual because this patient had polycystic ovarian disease and anovulatory infertility for 14 years prior to her cancer. Her cancer was treated with surgery and chemoradiation. One of the chemotherapeutic agents used was gemcitabine which is known to have toxicity to ovaries. One of the treatments for PCOS infertility is partial ovarian destruction. Our patient resumed ovulation after her treatment. She had the same sexual partner, did not lose weight, and did not change her lifestyle. The important element to this case, in our opinion, is that women with PCOS who do not desire pregnancy and are scheduled for gemcitabine should be counseled about the possibility of resumption of ovulation.


A 6-year-old male Pit bull mix dog presented for bleeding from the mouth persisting for five days. A clinical evaluation revealed a 2 × 3 cm soft tissue mandibular mass at the crown of the first premolar, as well as a non-regenerative anemia and hyperproteinemia. Cytologic and histopathologic evaluations of the mass were compatible with an oral plasmacytoma. Plasma cell tumours are derived from cells of the B lymphocyte plasma cell lineage. Solitary collections of these neoplastic cells which originate in soft tissues or organs are referred to as extramedullary plasmacytomas (EMPs) ,2. EMPs EMPs can develop from cutaneous or mucocutaneous tissues . The mosThis report describes a case of an oral plasmacytoma in a Pit bull mix dog in Trinidad and Tobago.A 6-year-old male Pit bull mix dog was presented to the Veterinary Teaching Hospital at the School of Veterinary Medicine, University of the West Indies, Trinidad and Tobago, for a bleeding mass in the mouth which the owner noticed 5 days prior to presentation. Temperature, pulse, and respiratory rates were within normal limits, and there was no enlargement of the submandibular lymph nodes. In the oral cavity, there was a pink, round mass measuring 2 × 3 cm at the crown of the first premolar on the right lower jaw, and dental plaque was noted on all teeth. Radiographs of the thorax and skull were taken, and a fine needle aspirate of the mass was performed for cytological examination. Blood was also taken for a complete blood count (CBC). The cytology smears and blood smears were stained with Wright-Giemsa stain and examined. Eight days later, the owners decided to euthanize the dog, electing not to seek further treatment. At this time, samples of the oral mass were collected, placed in 10% buffered formalin, and sent for histopathological examination.The radiological findings demonstrated osteolytic changes in the mandibular bone in the region underlying the mass. There was a well-circumscribed, irregular soft tissue opacity measuring approximately 2 × 3 cm at the rostral aspect of the right mandible. Premolar 1 on the right side of the jaw was also displaced, but it was not associated directly with the bone lysis. Thoracic views showed that there was no evidence of metastases to the lungs and no pathologic lung pattern. Osteophyte formation was found on the cranioventral border of the 4th thoracic vertebra (T4).The complete blood count revealed a normocytic, normochromic, non-regenerative anemia  0.37–0.55 L/L; MCV 65 fL, RI 60–77; MCHC 334; RI 320–360 g/L; reticulocyte count <1%) and hyperproteinemia  due to a hyperglobulinemia . Serum immunoelectrophoresis was not done to determine if the hyperproteinemia was due to a monoclonal gammopathy.The individual slides were of low to high cellularity, and consisted of nucleated cells present in a background containing high numbers of red blood cells . The nucThe sections examined consisted of sheets and packets of moderately densely packed round cells on a thin fibrovascular stroma that extended to the deep border . The rouIn a study of oral tumours in dogs over a 10-year period 1996–2006), the most common oral cancers were melanoma (30.7%), squamous cell carcinoma (18.2%), osteosarcoma (8.9%), and fibrosarcoma (8.9%). Epulides accounted for 18% of the oral masses, while oral EMP represented 5.2% of all oral tumours. Oral EMPs were found on the tongue, originating from the rostral aspect of the mandible, on the maxilla, hard palate, and on the buccal surface of the upper lip [–2006, thApproximately 50% of all human cases of EMP have hyperglobulinemia, and one in three will progress to multiple myeloma . Serum eIn dogs, repeated studies have shown no obvious correlation between EMPs and the development of multiple myeloma. Unlike multiple myeloma, EMPs have a more favourable prognosis, tend to be locally invasive often causing osteolysis, which was seen in this case, but have a low rate of metastasis . MultiplDogs with a mucocutaneous EMP usually present with a single, visibly smooth, raised, red mass, which may be ulcerated or bleeding. There is evidence that suggests that a canine oral EMP may develop at sites of chronic inflammation such as gingivitis and periodontal disease ,9. This The diagnosis of plasmacytoma can be made by cytology or histopathology. Typical cytologic features are discrete round cells, eccentrically located nuclei, bi- and multinucleation, and variable amounts of basophilic cytoplasm with a perinuclear clear Golgi zone. The morphology of the cells in this case was similar to this typical morphology. Amorphous eosinophilic material, representative of amyloid, is seen in less than 10% of plasmacytomas ,11.Immunohistochemistry can be used for confirmation or for the identification of undifferentiated plasmacytomas, as other round cell tumours may have a similar morphological appearance . The immComplete surgical excision is the primary treatment for oral and cutaneous EMPs and is often curative provided that there are no metastases ,5. LocalThis paper describes a case of an oral plasmacytoma in a dog. This report also highlights the utility of cytology and histopathology in the diagnosis of neoplasms in situations where more advanced diagnostic tests such as immunohistochemistry are not available for further characterisation.There are no case reports about this type of tumour in the Caribbean. This report represents the first from Trinidad. As more papers are published about the occurrence of round cell tumours such as plasmacytomas and lymphomas within the Caribbean, further studies can be done to see if there are geographical differences in the incidence between the tropical island countries, such as Trinidad, and other regions in the world, as well as the potential reasons for these differences.


Herein, we report on a rare case of craniopharyngioma arising in the left temporal lobe with no prior history of head trauma or surgery. There was a solid-cystic mass in the left temporal lobe on MR images. To the best of our knowledge, this is the second case of a craniopharyngioma occurring in the temporal lobe.  Craniopharyngiomas are rare benign epithelial tumors, arising from the pituitary stalk or gland and developing in the sellar and parasellar region of the central nervous system and constitute approximately 3% of all intracranial tumors , 2. ThesAn 18-year-old woman presented with headache, dizziness, and blurred vision in August 2011, with no previous history of head trauma or surgical operation. General physical examination was normal and neurological examination revealed right homonymous hemianopia. All laboratory blood tests were unremarkable.The magnetic resonance imaging of the brain revealed a large heterogeneous solid-cystic mass in the left temporal lobe with no connection to the craniopharyngeal duct, the suprasellar, or intrasellar regions, although there was no significant edema or mass effect . ContrasA few days later, the patient underwent complete surgical resection of the mass. She received 5040 cGy adjuvant radiation therapy in 28 fractions. There was no macroscopic residue in posttreatment contrast enhanced MRI nor local recurrence in follow-up MRI. The histopathologic examination revealed neoplastic tissue composed of solid, pseudopapillary structures lined by several layers of tumoral cells which were cytokeratin and EMA positive in immunohistochemistry study. These data revealed the histologic diagnosis of papillary craniopharyngioma .There are two histological subtypes of craniopharyngioma: the adamantinous and papillary types . The adaA primary ectopic craniopharyngioma is a rare tumor that diagnoses for the first time without any Rathke's pouch within the vestigial craniopharyngeal duct. Secondary ectopic craniopharyngiomas are rare event. Suspected recurrence of a previously operated cancer arises from tumor cell spillage along the resection corridor or via cerebrospinal fluid dissemination .Our preoperative diagnosis was of low grade glioma because of the enhancing well-defined solid-cystic appearance of the mass with no significant edema or mass effect. Craniopharyngiomas are not usually included in the differential diagnosis of such a mass at left temporal lobe; however, the histopathologic findings showed papillary craniopharyngioma.There are two theories that may explain the origin of these tumors according to the different histological subtypes, together with the characteristic location of these tumors in the sellar and parasellar region. According to the embryogenetic theory, the adamantinomatous subtype arises from epithelial remnants of the craniopharyngeal duct, which connects the stomodeal ectoderm with the evaginated Rathke's pouch, which in turn forms the adenohypophysis. Rathke's pouch and the craniopharyngeal duct are derived from the stomadeum, which in turn forms teeth primordia. Thus, craniopharyngiomas can potentially arise anywhere along the migration of Rathke's pouch, such as the nasopharynx, paranasal sinuses, third ventricle, and posterior fossa. According to the metaplastic theory, the squamous papillary subtype is a result of metaplasia of squamous epithelial cell rests that are remnants of the part of the stomadeum that contributed to the buccal mucosa . There iIn conclusion, clinical (age of our case and MR imaging characteristics other than location) and histopathologic findings all were compatible with primary papillary craniopharyngioma, and to the best of our knowledge, this is the second case of a craniopharyngioma originating in the temporal lobe. It is likely to be derived as a result of metaplasia of squamous epithelial cell rests that are remnants of the part of the stomadeum.


A 24-year-old man underwent left ear tympanoplasty for chronic otitis media and 3 months later started developing asymptomatic, tumor-like, cutaneous lesion over the incision site. There was no pain or itching. The lesion gradually progressed in the subsequent years protruding behind the ear to cause apparent cosmetic deformity. A clinical diagnosis of incisonal keloid was made. Keloids typically occur in response to dermal injuries such as surgical wounds, lacerations, burns, or inflammatory skin conditions. Because recurrence is common, surgical removal is generally not recommended; treatments with glucocorticoid injections, laser therapy, or radiotherapy may be tried but are usually associated with a poor response. Given the large size of the lesion in this patient, a complete surgical excision was performed and a diagnosis of keloid was confirmed histopathologically. The patient also received eight weeks infiltration of glucocorticoids postoperatively. There was no recurrence six months after surgery and the patient was lost to further follow-up.


Primary osseous leiomyosarcoma of the spine is a very unusual condition, with only few cases being reported in the literature. In fact, this type of tumors arises from the smooth muscle cells and occurs usually in the uterus and the gastrointestinal tracts. If the spine should be involved, it occurs generally as a metastatic location. Location to the spine as a primary site is exceedingly rare. We present the case of a 37 years old female patient, with multiple spine levels involvement - to vertebral body and to posterior aspects of Vertebra, causing spinal cord compression syndrome. A secondary location to the skull was diagnosed one month later. Through a literature review, we analyze various aspects in the diagnosis and management of this rare entity. Primary osseous leiomyosarcoma of the spine is a very rare condition. This type of tumors arises from the smooth muscle cells and occurs usually in the uterus and the gastrointestinal tracts. The spine may then be involved as a metastatic location . PrimaryA 37 years old female was admitted to our department for a 2 months history of lombosacral radiculopathy - especially to the right leg - and low back pain, which was treated with NSAID (non steroid anti-inflammatory drug) with only partial remission. Two weeks before admission, the patient experienced rapidly progressive paraparesis with urinary dysfunction. Her past medical history was unremarkable. On admission, the patient was in moderate general condition (Karnovsky 50%) with a predominant right paraparesis (3/5), a sensory level below the umbilicus and genitor-urinary sphincter dysfunction. Reflexes were exaggerated on lower limbs. Local examination of the spine could find tenderness in the right paravertebral area on T12-L1 level, related to a subcutaneous fixed mass. Computed tomography and magnetic resonance imaging of the spine were performed. Findings were compatible with multiple metastases, and involved:  the postTaking advantage of the patient’s position, and given the history of lombosacral radiculopathy, an S1 right hemilaminectomy with curettage of the sacral body and radicular decompression were also performed. Operative findings were compatible with the upper level. Histology specimens were analyzed for both localizations, with an identical result: a malignant spindle cell proliferation with large necrotic areas. Tumor cells were arranged into short fascicles and interlacing bundles . The nucLeiomyosarcoma is a malignant neoplasm originating from the smooth muscle cells. It occurs predominantly in the retroperitoneum, the intrabdominal space and the subcutaneous tissue of the extremities . PrimaryWe performed a careful analysis of the existing literature through a Pubmed research of Medline’s database . To date, 17 cases of primary spine locations have been reported . These lAlthough no consensus about treatment is available, management of these tumors, given their malignancy, should include total radical excision whenever possible . AdjuvanThe diagnosis of a primary spine location of leiomyosarcoma is an unusual condition. It should only be made after careful screening for a primitive tumor, and on immunohistochemical basis. Surgical treatment, as for other spine malignancies, should be as radical as possible. We report herein another unusual aspect of this tumor.


A 44-year-old patient presented with two-year history of (R) lumbar pain. There was a strong history of childhood animals' contact, including dogs. A brother had multiple hydatid cysts requiring surgery. Initial ultrasound showed a large (R) adrenal mass measuring 10 × 9 × 8 cm. Subsequent CT scan confirmed a heavily calcified cyst in the (R) adrenal gland. Hormonal studies were normal. He had an uneventful course following a total adrenalectomy. Isolated adrenal hydatid is extremely rare with an incidence of less than 0.5%; however, the diagnosis should always be suspected in all patients from an endemic area presenting with an adrenal cystic mass.  Echinococcus granulosus. Dogs are the principal definitive host while sheep are the most common intermediate one. Individuals get accidentally infected by ingesting the worm's eggs in contaminated food and water, or through close association with domestic dogs. Larvae producing cysts commonly involve the liver, the lungs, and the kidneys. The liver is involved in almost 70% of the cases. Larvae that escape filtration by the liver involve the lungs in 25% of the patients [Hydatid disease is a zoonotic infection caused by the parasitepatients . The dispatients . For thipatients . Hydatidμmol/L successively. He was labeled as a nonfunctioning (R) adrenal mass. He later admitted to a strong history of childhood contact with animals including dogs. His elder brother was operated for multiple hydatid cysts in the abdomen. There were no urinary or other systemic symptoms. General examination including the blood pressure was normal apart from mild tenderness in the (R) renal angle. CT scan abdomen in July 2015 showed a large well-defined oval shaped heavily calcified cystic mass at the right adrenal gland, measuring 8.5 × 6.6 cm on transverse and AP diameter, respectively  flank pain of 2-year duration. Ultrasound and subsequent CT scan performed 2 years ago showed a (R) suprarenal mass. He denied a history of hypertension, palpitations, or syncopal attacks. Serum cortisol, ACTH, metanephrine, and normetanephrine were normal at 201 nmol/L, 2.8 pmol/L NR 1.6–13.90), 29 ng/L (NR < 90), and 92.0 ng/L (NR < 129), sequentially. Similarly, aldosterone and renin levels were normal with aldosterone/renin ratio of 3.6. Serum testosterone and dehydroepiandrosterone sulphate were also normal, at 5.94 nmol/L and 3.61 .90, 29 n Figures  with foc Figures , and 8. Hydatid cyst involving the adrenals is rare and is usually a part of a generalized Echinococcosis. It is frequently discovered incidentally. Furthermore and similar to our patient, abdominal pain resulting from organ compression can be a presenting feature . In very E. granulosus antigens to inhibit B cell activity and proliferation [Although serology is useful in the diagnosis of hydatid disease, a number of patients may have a negative test. In some series 30–40% of patients with hepatic cystic echinococcosis are antibody negative. This could be due to the capacity offeration . In geneferation . The indferation . ConsequP < 0.01). The recurrence rate without adjuvant albendazole was 16.66% while no recurrence was seen in patients who received albendazole [Hydatid cyst can be asymptomatic and need not any intervention except for doubt in the diagnosis and in large cyst causing mass effect. Treatment of adrenal hydatid, when indicated, is mainly surgical and by total cyst excision. Small asymptomatic nonfunctioning cts are treated conservatively. Total adrenalectomy may be considered when the cyst has completely destroyed the gland. Both laparoscopic resection of an adrenal hydatid and laparotomy are accepted surgical intervention . Laparotendazole . It may endazole .This patient's history of childhood contact with animals and the slowly progressive nature of his adrenal mass together with a history of hydatid in his brother are highly suggestive of hydatid disease. The radiological findings are characteristic though not pathognomonic. Both macroscopic and microscopic features are consistent with adrenal hydatid cyst. A caveat to the diagnosis is the absence of the scolices and/or hooks in the histopathology sections, albeit could be focally present within the specimen but not sampled in the tissue sections or on the glass slides.Overall, isolated hydatid disease of the adrenals is rare. The diagnosis should be suspected in all patients from or who lived in endemic areas. Surgical excision with either laparotomy or laparoscopic approach remains the intervention of choice in such cases. Adjunctive medical treatment improves the outcome and decreases the recurrence rate.


This paper is a retrospective study on 8 patients admitted and treated in Paediatric Surgery and Orthopaedics Clinic of “M. S. Curie” Hospital Bucharest between 1997 and 2007. The patients with malignant bone tumors (table 1.) were studied by sex, tumor type, location, age at the moment of diagnosis, age at the moment of the last evaluation, type of surgery, external fixator implanted, complications, results and survival period. We also considered for each patient the extent of the tumor to diaphysis, soft tissue involvement, involvement of physis and epiphyseal invasion, articular extent, vessels and nerves invasion, presence of metastases and local skin invasion. The certain diagnosis was based on pathological anatomy exam, because clinical and imagistic data were not decisive in each case.There were studied only those patients who received external fixators, the only method to achieve oncological safe resection and osteoarticular recontruction. We used monoplanar or circular fixators, in adjustable or mixed mountings.The postoperative complications were not fatal. The survival period has been between 6 months and 18 years. Only two patients, who have survived 6 months and respectively 18 months, were not able to return to prior activities. The other six were reinserted in social activities.Nowadays, there is made a great effort to save the affected limbs. The conservative treatment is preferred to the amputation, which is being used in very few cases. The development of reconstructive bone surgery is sustained by the possibility to delineate the tumor by diagnosis based on imaging and by the possibility to use modern preoperative and postoperative chemotherapy and radiotherapy.Limb conservation was possible only in aggressive benign tumors up to 1970. Since then the same treatment was preferred also in malignant bone tumors, because the relapse appeared as frequent as in cases with amputation but the physical and psychological comfort made the patients to accept it readily.The goal of malignant bone tumors treatment is to save the life of the patient, to preserve the affected limb, to maintain the length and function of the limb.Oncologic surgery consists of “en bloc” tumor resection followed by bone reconstruction or modular prosthetic replacement. Modular prosthetic replacement leads to the loss of at least one growing cartilage. The use of radiotherapy in some cases may also affect other growing cartilages, leading to limb length discrepancies. Case 1Fig. 1.a). Surgical treatment consisted in oncological “en bloc” tumoral resection and bone reconstruction using two autogenous fibular grafts.Patient U.L., male, now aged 34 years, has been diagnosed with left femoral diaphysis juxtacortical  osteosarcoma and the diagnosis has been confirmed by pathological anatomy exam , by lab tests, elevated alkaline phosphatase serum levels, and by immunological tests, low anti-sarcoma antibodies serum levels.After 3 years, local relapse occurred, confirmed by radiological examination .On surgery, we practiced tumor relaps resection, grafts resection and a modular diaphyseal prosthesis made out of a hidroxiapatite implant on a gamma nail splint . Immunohistochemistry study showed elevated Fe, Mg and C levels in the bioelectrolysis liquid.On reintervention we practiced prosthesis and gamma nail ablation. We also practiced sample prelevation from the ends of the remaining fragments in order to perform pathological anatomy and immunohistochemitry exams. We used an external fixator, implanted “in abeyance”, in order to decide whether a femoral endoprosthetic reconstruction or a bone reconstruction was needed. The pathological anatomy exam did not show neoplastic elements, so we decided to practice on external fixator a massive autogenous tibial graft, representing 1/3 of homolateral tibial volume.Fig. 1.d.), which may favour fractures. The use of bone grafts  longer than 5 centimeters leads to pseudoarthrosis or late consolidation  shortening occurred, but it has been well tolerated: there are 14 years after the first surgery and the patient could walk after only 4 months postoperative. We applied as a treatment controlled electromagnetic field for 6 months. After 14 days, since the intervention, we alternatively applied a 0.02 T electromagnetic field, half an hour proximal and half an hour distal, twice a day (in the morning and in the evening). Postoperative, at two months and four months, respectively, the control radiographs, after applying of the electromagnetic field, showed signs of bone reorganization in the proximal fragment and no relapse.Fig. 1.e.).In 2004, at the time of the last evaluation, 14 years after the first surgery, we ascertained very good statics and locomotion and complete social integration of the patient. , bone washing-out and the presence of disorganized trabeculae that determined tumor septation.The early arterial phase of the angiography showed neovascularity in the diaphysis and also in the surrounding soft tissue. The late venous phase shows tumor extension and its limits.During surgery, the extemporaneous histological examination confirmed the diagnosis of an aggressive giant cell tumor, of fourth stage. We practiced tumor resection, with the excision of eight centimeters of the femoral distal end, of the knee and of five centimeters of the tibial proximal end. We implanted a complex adjustable Ilizarov external fixator. We also made a double corticotomy, femoral and tibial, respectively.After tumor resection, a total bone deficit of thirteen centimeters resulted, which could have been replaced by modular knee prosthesis, costing about 12.000 euro. For financial reasons, we used bone transport, with the disadvantage of a complex fixator implant for 202 days. The healing index was 15.6. The long fixator maintaining time led to infection around two of the wires, which have been removed and replaced by transosseous osteosynthesis at different points. For three months, we used a fixed knee orthesis. After one year, the patient could walk again, with the knee in fixed extension. On her revisit, three years after surgery, we ascertained the consolidation of the arthrodesis and the distraction points.Case 5Patient G.G, female, aged 16, has been admitted with the diagnosis of a tumor in the distal third of the left femur. The diagnosis of chondrosarcoma has been established by anamnesis, clinical examination, imaging data, angiography and immunohistochemistry. The surgery consisted in oncological “en bloc” tumoral resection, allograft implant and plate and screws osteosynthesis. After 45 days, allograft infection occurred and we proceeded to an Ortofix external fixator implant, allograft resection and the remaining cavity was filled with gentamicin pearls.After draining the infectious process, in 1999, on request of the patient and family members, we implanted modular knee prosthesis, because there was no contraindication of this treatment. The patient could walk ten days after surgery. One year postoperative the statics and locomotion were normal and the patient was rapidly integrated to school.Six years after the first surgery, the patient required a new evaluation because she noticed the swelling of the knee. We ascertained local relapse and lung metastases. She refused amputation and lung metastases excision. The patient died at the age of 22, after six years of survival.Case 6Patient S.T., female, aged 16, has been admitted with the diagnosis of a tumor in the proximal metaphysis of the right tibia. After performing the radiological protocol of investigation, we established the diagnosis of osteolytic osteosarcoma, without lung metastases. The MRI examination did not show invasion of the physis or the epiphysis.We proceeded to slow and progressive epiphysiolysis on Monoplanar Triaxial external fixator. After epiphyseal lift up, we proceeded to tumor resection on an external fixator, allograft, plate and screws osteosynthesis. While maintaining the external fixator, we ascertained infection on a diaphyseal pin. We extracted the infected pin and replaced it downwards with other pin. On the last evaluation, at the age of 18 (two years after surgery), the patient was integrated to school. The radiograph showed the complete integration of the allograft. Nowadays the clinical evolution is favourable.Case 7Fig. 2.a.) on an Ortofix external fixator .Patient N.G., male, aged 14, has been admitted with the diagnosis of a tumor in the distal half of the left humeral diaphysis. After performing standardized investigations, we established the diagnosis of Ewing sarcoma. After six weeks of chemotherapy and ten cobaltotherapy sessions (400 rad/session), we performed surgery with oncological “en bloc” tumor resection and bone reconstruction with autogenous fibular graft .On periodic check performed after one, two and three years respectively, we noticed the progressive graft integration . In each case the survival was above 7 years. The survival below five years was registered in 25% of all cases (2 patients), the survival between 5 and 10 years - in 12.5% of all cases (1 patient) and the survival above 10 years - in 62.5% of all cases (5 patients). One of the patients who survived more than 5 years, died 6 years postoperative, because of the neoplastic impregnation syndrome, with bone tumor relapse and lung metastases.complications are very serious, imposing laborious surgical interventions or a conservative attitude and supportive treatment to maintain vital functions by the time of death. In our patients we registered the following postoperative complications: pathological fracture (one case), bone infection (three cases), limb shortening (one case), tumor extension (one case), relapse (one case), and metastases (two cases):Generally, bone tumors Shortening of the affected limb – 10 centimeters. This complication occurred because of the many surgical interventions, necessary in a case of juxtacortical osteosarcoma with local relapse, osteitis, due to bioelectrolisis, followed by an autogenous tibial graft implant.- Tumor extension from the distal femoral metaphysis to the epiphysis and transarticular to the tibia is a rare complication, which occurred in a case of fourth stage giant cell tumor.- Local relapse – occurred in two cases. The first case was a chondrosarcoma and the tumor relapse was accompanied by another complication – lung metastases. Shortly after relapse, the patient died, six years postoperative. The second case, a patient with juxtacortical osteosarcoma, local relapse occurred on the two autogenous fibular grafts of 30 centimeters. After relapse we excised the grafts and implanted a modular diaphyseal prosthesis made of hidroxiapatite on a gamma nail splint.- Infection – has been noticed in three cases. In two of these cases it was a minor complication, infection of the transosseous fixing wires. In the first case we removed the infected wire and replaced it with another wire to maintain the stability of the mounting. In the second case we simply removed the infected wire. In both cases, the infection was healed. In the third case, it was a major infection of the allograft. We proceeded to allograft resection and the remaining cavity was filled with gentamicin pearls. After one year, the infection was healed and we implanted a modular knee prosthesis. The patient died five years after modular prosthesis implant, because of local relapse and lung metastases.- Pathological fracture– occurred in a case of Ewing sarcoma presenting in an advanced stage. For patient comfort and in order to perform cobaltotherapy we proceeded to an external fixator implant.- Lung metastases – occurred in two cases.- Malignant bone tumors have a great extent tendency. First, invasion tends to destroy the metaphyseal marrow and to extend to the medullary cavity. As a rule, the diaphyseal medullar cavity invasion corresponds to the appearance of metaphyseal osteolysis areas and to the distruction of the cortical bone limiting the eccentric tumor.Table 2). If the tumor extends beyond it, it is compulsory to perform oncological “en bloc” tumoral resection and modular prosthesis implant (Table 2). Tumor extension to the soft tissues must be evaluated for each case, so the oncological resection should preserve certain parts of the extensor and flexor muscle, making possible the mobilization of the joint.Physeal invasion occurs after one or both cortical bones of the metaphysis are destroyed. The physis represents a relative obstacle against tumor extension. Tumor extension beyond physis represents epiphyseal invasion. Defining the epiphyseal invasion is very important for oncologic surgery. If the tumor does not cross beyond thephysis, it is possible to save the epiphysis and perform bone reconstruction  and anti-sarcoma antibodies serum levels. Imagistic evaluation consists, beyond customary radiographs, computed tomography, magnetic resonance imaging, bone scintigraphy and angiography.Usually, these investigations are performed before open biopsy. The therapeutic strategy consists of 4-6 weeks of preoperative chemotherapy for the majority of bone tumors. The treatment scheme varies with the tumor histological type. For each patient with malignant bone tumor the preoperative diagnostic evaluation consisted of every laboratory and imagistic examinations mentioned above.The preoperative evaluation after chemotherapy is selective, being reserved only for tumors with great extension, that could excessively invade the soft tissues and also for metaphysis tumors, extended to the growing cartilage limit. For the first case it is important to establish whether the remaining muscle after oncological resection would ensure joint mobility. For the second case it is important to decide whether the epiphysis can be saved, so bone reconstruction is possible, or the epiphysis must be excised, so modular prosthesis is needed. In order to establish the therapeutic strategy, a computer tomography scan or a magnetic resonance imaging study must be performed.Thoracal pleuralpulmonary radiograph is a usual preoperative investigation, meant to ascertain whether lung metastases are present or not. If there are radiopaque processes in the pulmonary hila, that are difficult to diagnose, it is necessary to perform a pulmonary computer tomography scan. If there are lung metastases, the therapeutic strategy needs to be changed.The angiography performed during the diagnostic evaluation, or, if necessary, after chemotherapy, is very important in ascertaining tumoral extension to the soft tissues and in establishing the relationship between the tumor and adjacent neovascular structures. The early arterial phase shows active neovascularity around the tumor, extended to the soft tissues. The late venous phase shows the intrinsic blood vessels of the tumor, createing the aspect of “red tumor”. The “red tumor” image delineates the area of the sarcomatous tumor that must be radically excised, in order to save the affected limb. Postoperative evaluation of the eight patients in our study consisted in radiologic and laboratory tests. Radiographs were performed in order to ascertain graft integration, the stability of the prosthesis and possibly the occurrence of local relapse or metastases. Laboratory tests were performed in order to monitorize tumor evolution. We determined: red blood cells sedimentation rate, alkaline phosphatase, creatin kinase, lactic dehydrogenase and anti-sarcoma antibodies serum levels. The high alkaline phosphatase serum levels show osteogenesis of the malignant tissue. The high levels of this enzyme correlate with the degree of neoplastic osteoblasts activity and with the size of the tumor, too. Dynamic enzyme evaluation is useful for osteosarcoma evolution monitoring. The serum level of this enzyme decreases almost to normal after tumor excision and increases in case of metastases or relapse.Anti-sarcoma antibodies serum levels increase after tumor resection and decrease when relapse or metastases occur.The patients with malignant bone tumors have been continuously monitorized, every 3-4 months during the first year and twice a year in the following period. Lung metastases occurrence imposes patient reevaluation in order to establish the indication of bone or lung metastases excision. If osseous metastases considerably weakened the bone or pathological fractures occurred, bone reconstruction for patients comfort is performed. The orthopaedic treatment of malignant bone tumors implies complex mountings, difficult to be configured before surgery is performed. These mountings are adapted to each particular case and usually bone transport is needed, in order to compensate the remaining osseous defect after oncological en bloc resection. Only one of our patients needed a complex mounting. This mounting has been used for a fourth stage giant cell tumor with transarticular extension. It involved two fragments transport . Complex mountings are usually made on Ilizarov or Monticelli external fixator.Of all 16 mounting types, the most frequent were adjustable (used in 8 cases), less frequent used mounting types were mixed (4 cases), rigid (3 cases) and complex mounting was used only for one case.These mountings were made on different types of external fixators: Ortofix – 6, Monoplanar Triaxial – 3, Ilizarov – 2, Fixano – 2, Shearer – 2 and Monticelli – 2.Monoplanar external fixator, all-round or circular, can be used in different situations:Preoperative – before oncological “en bloc” resection- This indication has been useful for a patient with Ewing sarcoma in an advanced stage, complicated with a pathological fracture. The external fixator conferred comfort because to the patient, he could walk and it permitted preoperative radiotherapy, too. Using this fixator we avoided patient immobilization in bed and we excluded the risk of metastases implied by other interventions.Intraoperative – for extemporaneous epiphysiolysis- Intraoperative epiphysiolysis is performed before bone reconstruction. We used this strategy for a Ewing sarcoma. In this case after epiphysiolysis we implanted an autogenous graft that had been sterilized by boiling and then we performed plate and screws osteosinthesis.Postoperative- We used external fixators for the following situations: External fixator to sustain autogenous grafta) This indication has been very useful for the patient with juxtacortical osteosarcoma. In this case we implanted a 30 centimeters autogenous homolateral tibial graft, sustained by an Ortofix fixator. A 14 years old patient with Ewing sarcoma had the same indication. In this case, after humeral diaphysis oncological resection we implanted an embedded autogenous fibular graft.External fixator as a separate technique for slow and progressive epiphysiolysisb) After studying 24 bone samples from patients with metaphysis or diaphysis osteosarcoma, Canadell noticed that in half of these cases the tumor was not extended to the growing cartilage or to the epiphysis. In order to determine tumor extension to the growing cartilage, we used radiographs, computed tomography and angiography. MRI is the perfect method to determine the extension to the growing cartilage.In one case, after growing cartilage was decollated using a distraction regimen of 1-2 milimeters every day, we excised the tumor and then we implanted an autogenous graft sterilized by boiling, which has been stabilized by the same external fixator. In another case, after epiphysiolysis we excised the tumor and then we implanted a graft stabilized by plate and screws. Osteoarticular allografts are useful for tumors with certain anatomical localization. The size of these grafts must correspond with the size of the excised bone. When using allografts, the recovery period is long. Severe complications may occur during the first three years after surgery. Mankin et al. report 14% of these complications as infections, 10% as fractures, 9% as pseudoarthroses and 3% as joint instability. The implant failure is estimated to 33% after 60 months follow up .Bone transport used to compensate the remaining osseous defectc) For a 19 years old patient with a fourth stage giant cell tumor extended transarticulary, we performed tumor resection leading to an osseous defect of 13 centimeters that had been reconstructed by double  bone transport. External fixator used for local bone compacting in case of graft fracture or pseudoarthrosisd) In the patient with embedded autogenous fibular graft, graft fracture occurred after 8 months. The adjustable mounting on Ortofix fixator allowed bone compacting at the fracture site, leeding to the healing of this complication.External fixator used to sustain allograft infection treatment and prosthesise) Limb reconstruction refers to every technique used to rehabilitate bone continuity and also joint mobility. In case of allograft infection, such as in our patient with osteosarcoma, we excised the allograft and filled the remaining cavity with gentamicin pearls in order to preserve the length of the limb and maintain it by external fixator implant. After the infection was healed, a modular knee prosthesis was implanted.For malignant bone tumors, external fixators are used in the following circumstances:After studying the 8 malignant bone tumors for which external fixators were used, we came to the following conclusions. Preoperative – in case of secondary fracture, for patient comfort and in order to perform radiotherapy, before oncological en bloc resection;a) Intraoperative – for extemporaneous epiphysiolysis, followed by tumor resection and bone reconstruction;b) Postoperativec) to sustain autogenous graft; external fixator supports bone reconstruction. Charging the affected lower limb (static and dynamic loading) facilitates osteogenesis and grafts integration, allows compacting in case of late consolidation between graft and bone extremities and also avoids fractures in high risk bone resorption areas (with extensive osteoporosis);• to perform slow and progressive epiphysiolysis;• for remaining defect reconstruction by bone transport;• for local compacting in case of graft fracture or pseudoarthrosis;• to sustain allograft infection treatment; in order to maintain limb length and to perform prosthesis implant after infection healing.• Mixed or complex adjustable mountings are used for malignant bone tumors.