We report the case of a 3-yr-old boy who presented an acute right hydrocele. A rapid scrotal swelling under tension developed the first hours and the child complained for discomfort especially during palpation of the scrotum. Three days later, surgical exploration revealed an incomplete torsion of a communicated and pedunculated peritoneal sac arising from the tunica vaginalis testis.The present case report represents the eleventh report of torsion of processus vaginalis saccular protrusion in the literature, being unique due to painless hematocele. In the patent processus vaginalis the containing fluid or any of the intraabdominal organs is characterized as hydrocele or hernia respectively. Hernia or hydroceles sacs as well as the rare saccular protrusion of processus vaginalis (SPPV) are peritoneal protrusions. Histologically a single layer of mesothelial origin cells, lining the inner cyst surface and loose connective tissue in the parietals may be present. In several cases the parietals of a congenital hernia sac may contain some muscle fibers. In the literature only fourteen similar complicated SPPV cases in children -10 and oOur case refers to a 3-year-old boy who presented to the emergency department, because of an acute sudden swelling of the right scrotum. Because of the swelling the child felt uncomfortable in palpation. The clinical examination revealed a trans-illuminated poorly encysted big hydrocele like a common cyst of spermatic cord in tension. The cyst was afebrile having bilateral cremasteric reflexes. As an infant, he had a big scrotal hydrocele on the right side, which gradually disappeared until the 15th month of his life. Blood and urine laboratory tests, in exception of elevated white blood cells  were normal.The preoperative clinical and ultrasound diagnosis suggested hydrocele in tension and the child was operated three days later. Surgical exploration revealed a hematocele, with bloody fluid accumulation mainly in the tunica vaginalis testis. The SPPV was hanging from a twisted pedicle, arising from the internal parietal layer of tunica vaginalis. Dissection and resection of the hydrocele sac, including the SPPV was performed. The appearance of the twisted SPPV was non-translucent figures , insteadThe SPPVs, which are usually referred as intrahernial hydroceles or intrahydrocelic hernias, are fluid-filled sacs lying entirely within the hernias. Intrahernial or intrahydrocelic sacs are a more accurate term, because these entities containing fluid contents and are free hanging. They seem like simple serous cysts, with a short or long pedunculated stalk, communicating through a small hole, as in our case in the hanging part with the intrahydrocelic space.s a partial distal intussusception of a patent processus vaginalis, in a child, was Dr. Lockwood in 1896 [The first who described a pedunculated cyst within the hernia sac, a in 1896 .In the literature only eight cases referring to "torsion of an inguinal hernia" -7 and thThe SPPV most frequently lie just proximal to the scrotal inlet or close to the testis and it can produce discomfort or acute scrotum in cases that is tearing. For this reason they must be included in the differential diagnosis of suddenly appearing persistent hydroceles or acute scrotum in children. The severity of symptoms depends on the cyst's size and the existence and the pattern of the concomitant torsion. Long pedunculated small cysts are more predisposing in complete torsion. This fact is facilitating from the gravity, since the cyst is hanging from a firm point towards the bottom of the hydrocele sac, exactly as the clapper bell. Eleven out of the thirteen reported cases were presented with painful scrotal swellings, but two were painless enlargements, as in our case -9. This The preoperative clinical and ultrasound diagnosis in our case was difficult. The cyst was occupying almost the entire anatomical space of the tunica vaginalis without acute scrotum, because of partially twisting. In such cases bleeding may occur mainly from the external parietal vessels lying next to the cyst, although it is difficult to cause necrosis of the cyst. In all of the reported cases the patients did not present nausea, vomiting or abdominal pain, symptoms that are very common in children with testicular torsion.In conclusion, the SPPVs are rare inguinal-scrotal pedunculated sacs which containing serous fluid. These are rather types of communicated, coexisting and non-classified hydroceles instead of hernias that lie in a hydrocelic or hernia sac. In very rare cases SPPVs can twist producing either uncomforting like hydroceles in tension or symptoms of acute scrotum.Written consent was obtained from the patient, a copy is available from the editor in chief.CE, FD, FG, CM, AN, PM, RS, and PN contributed equally to the patient's therapy, writing the present case report and approving it.


Hemangioma of the median nerve presenting as acute carpal tunnel syndrome is unusual A-18- year old male presented with severe incapacitating pain of sudden onset of left forearm and hand after manual field work. There was swelling on volar aspect of forearm, with hyperalgesia in the median nerve distribution. The fingers and wrist were inmarked flexion and the patient did not allow wrist and finger extension. X-rays were within normal limits. An emergency volar carpal ligament release revealed, haematoma about 100 ml with numerous vessels encircling the median nerve. Histopathology of lesion turned out to be a cavernous hemangioma. Post operatively patient had full recovery. Chronic carpal tunnel syndrome (CTS) is a unique entity in that it is the most common entrapment neuropathy encountered in neurosurgical practice. A thorough search of the literature has revealed that till now two cases of chronic CTS due to hemangioma involving the neurovascular structures in the wrist and forearm have been reported.We are reporting here a case of hemangioma of the median nerve with a presentation of acute CTS.In May 1996, a young manual laborer of 18 years presented with agonizing pain in his left forearm and hand for the past two days. Patient developed this pain after having exerted during manual fieldwork. Pain was sudden in onset, severe and incapacitating, not responding to analgesics. A diffuse, nonreducible swelling was present on the volar aspect of the forearm . No pulsHistopathology proved it to be a cavernous hemangioma. Postoperatively patient showed full recovery of functions with normal sensations although he had to change his job from a manual worker to a vendor.CTS  described in 1854 by Sir James Paget, is the most common entrapment neuropathy encountered in neurosurgical practice. Most cases are thought to be idiopathic in nature, presumably resulting from cumulative repetitive microtrauma in individuals with congenitally small carpal canals. It occurs in middle-aged obese women. It is usually bilateral and may occur due to increase in canal contents, decreased canal size, neuropathic inflammatory conditions and conditions due to altered fluid balance. Hamartomas involving the peripheral nerves were first described in 1953 by Mason,18Pathophysiology of carpal tunnel is typically demyelination. Tenosynovitis is not a part of the pathophysiological process in chronic idiopathic CTS. Acute CTS may be thought of as a compartment syndrome of carpal canal and decompression should be performed as early as possible. Acute CTS can be diagnosed through history and physical examination alone and electrophysiological studies are not required. Acute CTS differs from chronic CTS in that the presentation is of sudden onset and characteristic features of chronic CTS such as thenar wasting, trophic changes, night pain and paresthesias in median nerve distribution may not be present.et alet alet alin situ as no plane of cleavage could be found. In our ten year follow-up he has had no recurrence of symptoms or thenar wasting till date although he had to change his profession from a manual worker to a vendor to avoid recurrence of symptoms due to traumatic rupture of vessels in the hemangioma.To the best of our knowledge only two cases of chronic CTS due to a hemangioma involving the neurovascular structures in the wrist and forearm have been reported. Although 44 cases of fibrolipomatous hamartomas involving peripheral nerves have been reported, nearly half of them by Silverman and Enzinger,Whenever a patient presents with s/s of acute CTS the possibility of a hemangioma involving the median nerve should be kept in mind in the differential diagnosis. Surgery can be limited to decompression only if a plane of cleavage cannot be found. If symptoms recur or progress later, total resection and grafting may then be carried out, although the results are not satisfactory22


The appearance of the apple-core lesion of the colon can be caused by several diseases.A male patient was referred to the surgical clinic with melaena and weight loss. Clinical examination and investigations confirmed an apple-core lesion of the colon. He underwent surgery, but unfortunately, died of a chest infection two weeks after the operation.This case shows the use of computed tomography in demonstrating the primary cause of iron deficiency anaemia, and at the same time, staging the disease for loco-regional metastasis. An 86-year-old white English man was referred to the surgical clinic in September 2007 for melaena and weight loss. He was anaemic on physical examination with no other clinical findings. He had a history of a left pneumonectomy in 1985 for a squamous cell carcinoma of the lung, Chronic Obstructive Airway Disease, Benign Prostatic Hypertrophy and diverticulosis. His Haemoglobin was 6.0 gm/L.Abdominal CT  showed aThe appearance of the apple-core lesion of the colon can be caused by several diseases. The differential diagnosis includes colonic adenocarcinoma, lymphoma, Crohn’s disease, chronic ulcerative colitis, ischaemic colitis, Chlamydia infection, tuberculosis, Helminthoma, Amoebiasis, Cytomegalovirus, villous adenoma, and radiosurgery such as high doses of Cyberknife used for treating unresectable abdominal malignancies, for example, pancreatic cancer -3.Colonic carcinoma is usually detected on colonoscopy or barium enema for evaluating vague abdominal symptoms ,6. The cIntestinal tuberculosis occurs in the ileocaecal region in 90% of the cases. The stricture involves a longer segment of bowel, and is associated with nodular or ulcerated mucosa . In mostThe ischaemic stricture has gradually tapering margins with concentric narrowing of the bowel lumen and intact mucosa . It usuaIn this case, we have demonstrated the value of CT scan in detecting a typical apple-core stricture as the cause of patient’s iron deficiency anaemia. This test provides a confirmatory radiological diagnosis and helps stage the disease with a single investigation. This may assist in reducing the delay between symptoms and treatment.


Textilomas have been reported in many locations. We report the first case of textiloma located in the maxillary sinus that mimicked a sinus cyst recurrence on computed tomography images.A 60-year-old Caucasian man was referred for persistent infection of the right maxillary sinus. A maxillary sinus benign cyst had been removed three months before. Computed tomography showed a sinus opacity evoking a cyst recurrence. A new operation was planned to remove the cyst by a Caldwell-Luc approach. After excision of very thick fibrous tissue, a compress was discovered in the maxillary sinus. The patient did not present with any sinus infection after the operation.The surgeon should always take into account the possibility of textilomas in a patient with a history of sinus surgery. Textiloma can be defined as a mass within the body composed of cotton matrix, which usually refers to a retained surgical sponge or compress, surrounded by a foreign-body reaction .Most cases of textiloma reported in the literature have been connected to abdominal, orthopaedic and cardiothoracic surgery -3. At thA 60-year-old Caucasian man was referred to us for persistent infection of the right maxillary sinus. He was operated on three months ago for a benign cyst. A Caldwell-Luc operation was performed. Since this operation, the patient complained of having recurrent sinusalgia with purulent rhinorrhea. Computed tomography (CT) showed a sinus opacity evocating a cyst recurrence Figure . A new sThe main complication of a maxillary sinus textiloma is a persistent infection. In this case, the sinusitis was limited .The erroneous diagnosis of a mass provoked by the presence of a textiloma was frequently reported in the literature in other regions -5. In thThe suspicion of textiloma should be raised when a patient with a history of previous maxillary sinus surgery presents with a history of chronic sinus infection associated with a sinus mass on CT images, even though textiloma is unlikely to be found in such a small cavity.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.YP redacted the manuscript. TS supervised the manuscript. Both authors read and approved the final manuscript.The authors are two medical doctors. Yoann Pons is a head and neck surgeon.Thomas Schouman is a maxillofacial surgeon.


We present the case of a 71 year old man with recurrence of a Gastro Intestinal Stromal Tumour (GIST) at the gastrojejunal anastomosis eight years following partial gastrectomy for a very small primary gastric GIST. He presented acutely on both occasions with haemodynamic shock secondary to massive haematemesis. During his initial presentation in 2001, an emergency laparotomy was performed, demonstrating a pre-pyloric ulcerative lesion. The histopathology was in keeping with a diagnosis of a gastric GIST with a < 2 cm tumour, with <5 mitosis per 50/HPF, no signs of necrosis and invasion limited to the mucosa. Eight years later the same patient presented with a similar clinical picture of haemodynamic instability secondary to haematemesis. Emergency endoscopy showed an irregularly shaped elevated lesion on the gastrojejunostomy line suggestive of recurrence. He subsequently underwent completion gastrectomy and the histology revealed a 0.8 cm GIST tumour composed of spindle cells with <5 mitosis per 50/HPF, tumor invasion into the submucosa and positive expression of c-kit and SMA. The patient remains recurrence free 18 months post surgery. The literature suggests that tumour size, mitotic rate and tumour site are the most important predictive factors of recurrence. Additional features such as the presence of necrosis, local tumour invasion and positive resection margins, can also influence recurrence rates. In this case the lesion was a gastric GIST, very small (<2 cm), had low proliferation rate (<5 mitosis/HPF), lacked necrosis and was limited to the mucosa. Recurrence of such a primary GIST at the anastomotic line, eight years after initial resection has never been demonstrated among review of several thousand primary GISTs. This case highlights how even the most innocent GISTs can never be described as truly benign. Gastrointestinal stromal tumours (GISTs) are the most common form of mesenchymal tumours found in the gastrointestinal (GI) tract. GISTs most commonly occur in the stomach and small intestine but can also be found in smaller numbers in the colon, rectum and oesophagus . Many GIPrimary GISTs have uncertain malignant potential and the long term prognosis of GIST has been challenging for clinicians and pathologist alike. Large multi centre studies on primary GISTs have lead to the development of prognostic scoring systems based on tumour histopathology ,7. Withist Department of Surgery, University of Athens Medical School in 2009. Eight years earlier the same patient, who had a known history of gastric ulcers, presented with a similar clinical picture to a different surgical unit. On admission he showed signs of haemorrhagic shock with a haemoglobin level (Hg) of 7 g dL. Emergency upper GI endoscopy was unable to identify the source of bleeding due to large volumes of blood in the stomach. Surgical treatment with a laparotomy was decided and the intraoperative findings demonstrated an acute gastric hemorrhage secondary to a massive propyloric ulcerative lesion. Resection of the lesion was decided and a distal gastrectomy and Billroth II reconstruction performed. The subsequent histology revealed a <2 cm gastrointestinal stromal tumour, with a mitotic rate of < 5 mitosis/50 per HPF, lacking necrosis and localized to the gastric mucosa. The patient made an uneventful recovery and was discharged eleven days post surgery. The patient was reviewed over the following two years and repeat endoscopies failed to reveal any signs of recurrence. The patient subsequently declined further surveillance and follow up.A 71 year old man with signs of syncope and haemorrhagic shock secondary to massive haemetemesis was referred for emergency treatment and investigation to the 1At his readmission in 2009 the patient was primarily treated conservatively due to his hemodynamic instability. After successful resuscitation, an emergency upper GI endoscopy was performed which revealed an irregularly shaped elevated lesion on the gastrojejunostomy line and a thrombus at the center of the lesion. The hemorrhagic lesion was situated along the posterior anastomotic suture line. Multiple biopsies were performed and a definitive endoscopic haemostasis was obtained.Preoperative staging computed tomography (CT) showed no lymphadenopathy or hepatic metastasis and as the patient's performance status was otherwise excellent, the decision for a second operation was deemed favorable. The patient went on to have a successful completion gastrectomy with regional lymphadenectomy and the continuity of the gastrointestinal tract was maintained through the Roux-en-Y method. It is important to note that lymphadenectomy is not routinely performed in GIST as metastatic spread rarely occurs through the lymphatic system. However the unusual presentation of the case created uncertainty over the malignant potential of the tumour and the experienced surgeons deemed lymphadenectomy the most appropriate measure in this instance. Histological review of the specimen showed macroscopically an ulcerative lesion on the suture-line, measuring 0.8 cm in diameter. The cut surface was gray with a rubbery consistency. Microscopically, it was a gastrointestinal stromal tumor figure , composeThe significant majority of mesenchymal tumors of the stomach are believed to derive from the interstitial cells of Cajal, the gut pacemaker cells . Since tPrimary GISTs have the potential for curative treatment, with surgical resection the first line option for all resectable non metastatic tumours. The overall 5 year survival rate for resectable GISTs has been shown to range from 46% to 78.5% ,4. Howevet al reviewed 288 patients with primary GIST and reported no recurrence in the very low risk group and a 1.9% recurrence in the low risk group [et al performed a similar study and also demonstrated no recurrence in the very low risk group [The NIH risk scheme originally developed in 2002 by a consensus conference of experts was based on the tumour size and mitotic rate - subdividing GIST into very low risk , low risk , intermediate risk  and high risk  [sk group ,10. Gastsk group . In the There have been subsequent studies and case reports documenting late GIST recurrence with metastasis from small (>2 cm but < 5 cm) tumours but no reported cases, from our literature review, of local recurrence of a very small (<2 cm), < 5 mitosis/50HPF, gastric GIST . AdditioThere are several plausible hypotheses for tumour recurrence in this instance. Despite the fact that the histopathological specimen resected was R0 there may still have been some local infiltration of the tumour margin. In addition there are several studies which highlight the risk of tumour recurrence with intraoperative tumour rupture or laceration . AlthougAccording to the literature recurrence of GIST is dependent on tumour size, mitotic rate and tumour site, with additional factors such as necrosis, local invasion and tumour free margins influencing recurrence also. In the current case, the mass was very small, located in the stomach, exhibited very low mitotic activity, showed no signs of necrosis and was limited to the mucosa. Recurrence of such a GIST tumour on the suture line eight years after resection presents a previously undocumented case and demonstrates that even the most subtle GISTs can never be considered as truly benign.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.APe and NB wrote the manuscript. KB, EF and EP where the surgical team and reviewed the manuscript. APa reviewed the pathology. All authors read and approved the final manuscript.


To describe various approaches of computed tomography (CT)-guided core biopsy and evaluate its ability to obtain adequate tissue for the assessment of mediastinal masses.Between February 2004 and October 2006, 83 percutaneous CT-guided biopsies of mediastinal lesions were performed on 82 patients under local anesthesia. Coaxial needles were used and minimum of 3-4 cores were obtained. Post-biopsy CT scan was performed and patients observed for any complications. Tissue samples were taken to Pathology Department in formalin solution.From the 83 biopsies, adequate tissue for histological diagnosis was obtained in 80 (96%), and the biopsy was considered diagnostic. Of the 80 diagnostic biopsies, 74 biopsy samples were definitive for neoplastic pathology and 6 biopsy samples revealed no evidence of malignancy. There were no major complications. Minor complications were recorded in 5 patients.Percutaneous image-guided core biopsy of mediastinal lesions is an accurate, safe and cost-effective tool for the initial assessment of patients with mediastinal masses. Image-guided percutaneous needle biopsy is a reliable technique for the diagnosis of thoracic lesions, particularly for assessment of mediastinal lesions.–3 PercutThere are several alternative methods of obtaining tissue samples from mediastinal lesions for histopathological analysis. These include surgical techniques such as thoracoscopy, cervical mediastinoscopy and anterior mediastinotomy; and needle biopsy techniques such as transbronchial needle biopsy and endoscopic ultrasound-guided fine needle aspiration biopsy.–11Percutaneous image-guided transthoracic needle biopsy allows access to virtually all mediastinal compartments, including those that are inaccessible with other alternative techniques.A retrospective analysis of percutaneous CT-guided biopsies of mediastinal lesions done between February 2004 and October 2006 was performed. The data collection was done with respect to demography, size of lesion biopsied, biopsy technique used, number of attempts, histopathological diagnosis and complications if any.This study included 82 patients who underwent 83 percutaneous CT-guided biopsies for the diagnosis of mediastinal lesions. Out of these, 55 were male and 27 females, of age range 1 year to 73 years .Masses from all compartments of mediastinum were sampled and included in the study.The biopsies were performed with GE light-speed multiplanner diagnostic-CT scanner. All patients referred for the procedure had previous imaging done either with CT or fusion positive emission tomography-CT.A full coagulation profile, hemoglobin level, platelet count and serum for cross-matching were available before every biopsy. Platelet counts and international normalized ratio were routinely measured in all patients. A platelet count of at least 50,000 and INR value of less than 1.5 was prerequisite for the procedure. Patients with history of, or laboratory values suggesting, abnormal coagulation were admitted before the procedure. The coagulation profile was corrected before taking the patient for procedure.Procedures were performed under local anesthesia, deep sedation with local anesthesia or general anesthesia. In cooperative adult patients (74), the biopsies were performed under local anesthesia with continuous pulse oximetry and noninvasive blood pressure monitoring.In pediatric patients (8), the procedure was performed under deep sedation with local anesthesia (6) or under general anesthesia (2). General anesthesia was planned when medically indicated or for patients in whom respiratory control was needed for lesion stability.All the pediatric patients were referred to the Department of Anesthesia for pre-anesthetic checkup. Pediatric patients with an American Society of Anesthesiologists status grade II and higher were admitted before the procedure.In view of intravenous contrast administration during the procedure, the adult patients were kept fasting for 4-6 h. For the purpose of sedation or general anesthesia, the pediatric patients were kept fasting for 6-8 h. Informed written consent for biopsy was obtained from all patients. In pediatric patients, consent for anesthesia and biopsy was obtained from parents.In each case, previous imaging studies were reviewed to determine the best approach for percutaneous biopsy. The approach to a biopsy of mediastinal lesion in a given patient depends on multiple factors, including the clinical circumstances, the location and size of the target lesion and the presence of comorbid conditions. Patients were placed supine, prone or in lateral decubitus position, depending on the location of the lesion and safe approach for needle placement.A diagnostic CT scan using thin axial sections was obtained after intravenous contrast administration to delineate vascular structures and differentiate vessels from lymph nodes. Then, the most suitable slice was chosen to reach the lesion and avoid injury to vascular structures and vital organs. This location was marked on skin surface with axial laser beam localizer incorporated in the CT gantry. Radiopaque markers were positioned along this laser light beam. A scan was then repeated at 2.5 mm interval to localize the exact point of entry and depth of the lesion from the skin surface.Radiopaque markers were then removed and a mark placed on skin with an indelible pen. The depth of the lesion was calculated on the scanner in the plane of biopsy trajectory. The skin entry site was prepared in surgical fashion with savalon, povidine iodine and spirit. Local anesthetic, 5-10 ml of 1% xylocaine without adrenaline, was administered at the skin puncture site and along the expected needle tract.A small dermotomy was made at the entry site with no. 11 blade. The coaxial needle was introduced to a predetermined depth as judged on the scan. A repeat localized CT scan was performed for the area of interest to confirm the needle position into the target lesion and for avoidance of vital structures. If inadequate, the needle position was readjusted. Trucut needle assembled in automated firing gun was then advanced through the coaxial needle and core biopsy taken.The biopsies were performed using coaxial trucut biopsy system (Cook's quick core). The needles used were 18 G/20 G of 9 cm/15 cm/18 cm length with 10 mm/15 mm/20 mm throw. The needle selection depended on depth of lesion from skin surface, size of lesion to be biopsied and proximity to vital structures. Smaller needle diameter (20 G) was used in high-risk patients. Patients were considered to be at high risk if they had a history of coagulopathy, an American Society of Anesthesiologists status of >III or a lesion near a vital structure.Coaxial technique helps to avoid number of passes, reducing the risk of inadvertent injury to vital structures and reducing the time of procedure.On an average, 3-4 cores were obtained in all patients. A post-biopsy CT scan was performed after the needle removal to check for complications.Tissue samples were taken fresh to the Histopathology Department in formalin solution. Tissue samples were collected in different tubes if they were to be sent for molecular studies.The patients were observed for 1-3 h after the procedure to ensure their hemodynamic stability and to monitor their respiratory status. The admitted patients were shifted to the wards with continuous monitoring. Expiratory chest radiographs were obtained 3 h after the biopsy in patients in whom the pleural surface had been punctured during the biopsy procedure.Verification of the percutaneous biopsy results was done with surgical pathology findings, bone marrow biopsy, biochemical features, functional imaging, patients′ response to appropriate therapy, correlation with known primary tumour in cases of metastases and clinical follow-up examination for at least 6 months.From the 83 biopsies, adequate tissue for histological diagnosis was obtained in 80 (96.4%), and the biopsy was considered diagnostic. The remaining 3 biopsy samples on histological analysis revealed fibrocollagenous, fibrous and inflammatory tissue and were considered nondiagnostic. A reattempt to biopsy was made in only 1 patient. The size of the lesions sampled ranged from 1.5 cm to 6 cm.Out of these three nondiagnostic biopsies, one was a case of anterior mediastinal mass with signs of superior vena cava obstruction under evaluation. The CT-guided biopsy sample from this mass on histological analysis revealed fibrocollagenous tissue only. A reattempt was made to sample the mass. Histopathological analysis of second biopsy sample revealed classical Hodgkin's disease, mixed cellularity. Another case was of a posterior mediastinal mass operated outside, surgical pathology suggestive of malignant tumor. Postoperative CT scan revealed residual mass in the posterior mediastinum. CT-guided biopsy was performed from this mass, which on histopathological analysis revealed fibrous tissue only. In view of high index of clinical and imaging suspicion, the posterior mediastinal mass was excised with wedge resection of adjacent lung. Surgical pathology analysis revealed high-grade pleomorphic sarcoma. Third case was of an ill-defined anterior mediastinal mass of the pre-vascular compartment, under evaluation. CT-guided biopsy from the mass was performed; histological analysis revealed inflammatory tissue. Surgical excision of the mass was performed; histopathological analysis revealed metastases from squamous carcinoma.Of the 80 diagnostic biopsies, 74 biopsy samples were definitive for neoplastic pathology. Six biopsy samples revealed no evidence of malignancy and were suggestive of non-neoplastic pathology. Out of these 6 non-neoplastic pathologies, 5 were tuberculous in origin and 1 was sarcoidosis which presented as mediastinal adenopathy. One of these patients was a treated case of renal cell carcinoma of right kidney. Follow-up PET-CT scan revealed hypermetabolism in the neck and mediastinal nodes. The mediastinal node was sampled under CT guidance; histopathologic diagnosis was tuberculous lymphadenitis . All theOut of these 74 biopsies, 24 had surgical pathology confirmation. These patients were either primarily operated upon or treated initially with chemotherapy or radiotherapy and later underwent surgery to remove the residual tumor. The biopsy diagnoses in these cases were thymoma (n = 9), neurogenic tumor (n = 5), teratoma (n = 3), malignant round cell tumor (n = 4), neuroblastoma (n = 1), liposarcoma (n = 1) and pleomorphic sarcoma (n = 1). In all these patients, the biopsy diagnoses were confirmed after examination of the excision specimen.In 51 biopsies, surgical confirmation was not possible. In 24 of these cases, biopsy diagnoses were concordant with the clinical, biochemical and radiological features of the tumor; the predicted response to therapy; or clinical behavior of tumor. The biopsy diagnoses in these cases were lymphoma (n = 20), yolk sac tumor (n = 1), residual primitive neuroectodermal tumor (n = 1), malignant germ cell tumor (n = 1), spindle cell sarcoma (n = 1).Out of these 51 biopsies, 26 biopsy results were suggestive of metastases. The biopsy findings were corelated with histopathology of primary malignancy. The biopsy diagnoses in these cases were metastases from adenocarcinoma (n = 8), squamous carcinoma (n = 6), small cell carcinoma of lung (n = 5), non-small cell carcinoma of lung (n = 4), osteogenic sarcoma (n = 1), epithelioid sarcoma (n = 1) and pleomorphic sarcoma (n = 1).There were no major complications that required any kind of intervention. Five minor complications such as small pneumothorax (n = 4) and hematoma (n = 1) were recorded. No active intervention was required in these cases. Patients were observed for hemodynamic stability and respiratory status for at least 3 h and then discharged.In mediastinal lesions, early diagnosis, separation of malignant-benign lesions and early medical treatment are the main goals to decrease mortality. The possibility of severe complications such as respiratory or circulatory compression mandates fast and sometimes urgent diagnosis and treatment of mediastinal masses.There are several methods for obtaining tissue samples for cytologic or histologic diagnosis of mediastinal lesions. These include percutaneous image-guided transthoracic needle biopsy; surgical techniques such as thoracoscopy, cervical mediastinoscopy and anterior mediastinotomy; and needle biopsy techniques include transbronchial needle biopsy and endoscopic ultrasound-guided fine needle aspiration biopsy.–14CT-guided percutaneous transthoracic needle biopsy has several advantages over other alternative biopsy techniques. Image guidance allows precise localization of target lesion and access to virtually all mediastinal compartments, including those that are inaccessible with other alternative methods, such as mediastinoscopy, transbronchial biopsy and endoscopic ultrasound-guided biopsy.Percutaneous transthoracic biopsy is less invasive than mediastinoscopy and requires only local anesthesia. In comparison to other alternative methods, transthoracic biopsies are cost-effective because they shorten the period from admission to diagnosis, decrease the number of surgical procedures and shorten the time of hospital stay, which reduces overall treatment costs. There arVarious approaches for image-guided transthoracic biopsies of mediastinal lesions have been advocated. These include extrapleural or direct mediastinal approaches such as parasternal, paravertebral, trans-sternal and subxiphoid approaches; and the transpulmonary approach14 Figur. The besIn our series, repeat attempt to sample the mediastinal mass was made once. The second biopsy result in this patient was diagnostic of Hodgkin's disease. Out of 83 biopsies, 80 biopsy results were considered diagnostic (96.4%) in whom the results could be confirmed by surgical pathology, clinical follow-up examination or correlation with primary malignancy in cases of metastatic diseases. This is in concordance with other series that have dealt with percutaneous biopsy of mediastinal masses. In all these studies, the percutaneous biopsy results were shown to be correct in 75-90% of patients.14–19Out of 83 biopsies, distribution of results were primary neoplasm (n = 49), secondary neoplastic process (n = 28) and non-neoplastic conditions (n = 6). In our series, diagnostic accuracy for primary mediastinal neoplasm was found to be 93.8%; and secondary neoplastic process, 96.5%. High rate of neoplastic pathologies in our study is due to our being a tertiary referral center for cancer. The diagnostic accuracy for non-neoplastic conditions was 100%. These results are in concordance with other studies.20Lymphoma was the most common neoplastic pathology in our study group. Diagnostic accuracy of lymphoma in our series was 95.2%. There was no major complication; only five minor complications were recorded. No active intervention was required in these cases. Complication rate was 6.02%. Our results have shown percutaneous image-guided biopsy of mediastinal lesions to be accurate and safe.An overall diagnostic accuracy of 93-96% was achieved for percutaneous biopsy of mediastinal lesions in our series. Minor complications were seen in five patients (6.02%), and there were no major complications. Familiarity with cross-sectional imaging facilitates planning of safe access route for biopsy of mediastinal lesions. To conclude, percutaneous image-guided core biopsy of mediastinal lesions is safe, accurate and cost-effective.


Gastric outlet obstruction due to ulceration is extremely rare in childhood. We report a case of gastric outlet obstruction possibly secondary to peptic ulceration and our surgical management. Our approach, without vagotomy or antrectomy, would appear to be a safe and effective. Gastric outlet obstruction (GOO) may be caused by peptic ulceration, caustic ingestion, tumor, chronic granulomatous disease, or eosinophilic gastroenteritis -6, but p2) receptor blockers, proton pump inhibitors (PPI), and treatment for Helicobacter pylori (H pylori) has revolutionized the non-surgical management of peptic ulcer disease, with most patients now being treated conservatively [The introduction of histamine-2 (Hvatively ,9.2 receptor blockers who required surgical intervention.Herein, we present a case of severe GOO possibly secondary to peptic ulceration despite intravenous administration of H2-blockers, PPI and enterokinesis activators were commenced elsewhere. Two weeks later, she was referred to us for intractable vomiting and epigastric pain. There was no family history of peptic ulcer. Abdominal radiology was suggestive of pyloric obstruction but ultrasonography showed a normal pylorus. On barium meal, there was no passage of barium from the stomach to the duodenum and the stomach was distended with increased peristalsis. On endoscopy, the antrum was so narrowed circumferentially that the endoscope could not be passed through, but surprisingly, the mucosa was normal without scarring (Fig. H pylori were negative. Imaging analyses and laparoscopic investigation revealed no obvious compression from surrounding organs. Endoscopic balloon dilatation was performed twice without improvement so surgery was planned. At laparotomy, gastrotomy was performed transversely over the antrum just proximal to the stricture and the lesion delivered through the incision (Fig. A previously healthy 2-year-old girl contracted influenza and developed epigastric pain and tarry stools. Hing Fig. . Serum gion Fig. . An endoion Fig. .GOO is extremely rare in children and its management is not established . There aH pylori was negative. Surprisingly, the mucosa of the antral stricture was normal and no mucosal scar was identified on preoperative endoscopy or intraoperatively, although mucosal scarring is usually present after treatment of peptic ulceration according to other reports in the literature [In the present case, we did not perform vagotomy because serum gastrin was normal and terature ,13-15. OWe believe our procedure is suitable for patients with GOO secondary to peptic ulceration and should be considered as one of the indications for surgical intervention in children with GOO with normal serum gastrin.2: Histamine-2; PPI: Proton Pump Inhibitors; H pylori: Helicobacter PyloriGOO: Gastric outlet obstruction; HWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MO did the literature search and wrote the case report and also obtained written consent. AY conceived the study and helped to draft the manuscript. TO, TT and GJL prepared the manuscript and helped in the literature search. All authors had gone through the final manuscript and approved it.


Polyarteritis nodosa can on rare occasions manifest itself as vasculitis of the gallbladder. Patients typically present with right upper quadrant pain and are initially worked up for cholecystitis. The definitive diagnosis is then usually based on surgical and histopathological findings.In this case a 23-year-old Caucasian female presented with a 3 week history of right upper quadrant pain and fevers.The clinical pathway and imaging findings of a rare case of gallbladder vasculitis as a manifestation of polyarteritis nodosa are demonstrated. We present the clinical pathway of a rare case of gallbladder vasculitis secondary to polyarteritis nodosa. The clinical pathway demonstrates the importance of the clinical presentation and the use of medical imaging in confirming the diagnosis.A 23-year-old Caucasian female presented with a 3 week history of right upper quadrant pain, fevers, bilateral ankle pain and swelling with an accompanying rash. Her past medical history consisted of a previous hospital admission 3 months earlier due to an acute inflammatory polyarthritis associated with fever. During that admission the patient had developed a maculopapular rash over the trunk and limbs. Skin biopsies of the right thigh were taken which showed leukocytoclastic vasculitis. Symptoms improved after commencement of prednisone and the patient was discharged.When the patient represented she had an elevated C-reactive protein 168 mg/L , erythrocyte sedimentation rate 76 mm/hr (0-12) and alkaline phosphatase 162 U/L 30-130). All her other blood results were normal. Rheumatoid Factor, ANCA and HLA B27 were negative as were blood cultures and viral serologies. Hepatobiliary scintigraphy was requested to investigate hepatobiliary function  is an uncommon multisystem, necrotizing vasculitis of small- and medium-sized muscular arteries in which involvement of renal and visceral arteries is characteristic . It was Vasculitis is a clinicopathologic process characterized by inflammation of and damage to blood vessels. Polyarteritis nodosa (PAN) can cause specific complaints related to the vascular involvement within a particular organ system which may dominate the presenting clinical picture as well as the entire course of the illness. Involvement of the gastrointestinal tract has a 44% incidence in patients with classic PAN. Clinical manifestations include abdominal pain, nausea and vomiting, bleeding, bowel infarction and perforation, cholecystitis, as well as hepatic and pancreatic infarction. At autopsy 10% of patients with classic PAN have involvement of the gallbladder.Gallbladder vasculitis of varying aetiology is rare but has been well described in the medical literature -13. AbdoIn this reported case the hepatobiliary scintigraphy findings were consistent with slow filling of the gallbladder most likely due to oedematous swelling of the vasculitic tissue as was subsequently demonstrated by the histopathology. Appropriate knowledge and awareness of gallbladder vasculitis secondary to polyarteritis nodosa will help interpret non-specific yet clearly abnormal hepatobiliary scintigraphy findings.ANCA: anti-neutrophil cytoplasmic antibody; HLA: human leukocyte antigen; PAN: polyarteritis nodosa; IDA: iminodiacetic acid.Written informed consent was obtained from the patient for publication of this case report and all accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.BK, SOT and AW made substantial contributions to conception and design and drafted the manuscript. JC, NM and KCA revised it critically for important intellectual content and gave final approval of the version to be published.


Acute mesenteric ischemia is a serious acute abdominal condition requiring early diagnosis and intervention to improve the outcome. Although transmural acute bowel infarction represents about 1% of all cases of acute abdomen, it has a higher annual mortality rate than colon cancer. It tends to affect the colon in segmental fashion, mostly the splenic flexure and rectosigmoid portions of the colon. Isolated ischemia of the right side of the colon is rarely reported, especially in association with shock. Diagnosis of acute colonics ischemia is challenging as it may easily be confused with other non ischemic conditions both clinically and radiologically. Surgical resection is still the main curative approach. We present a case of segmental terminal ileum, cecum and part of ascending colon infarction due to isolated IleoColic artery thrombosis. A 57-year-old Indian male laborer was admitted to the hospital from the Emergency Department complaining of central abdominal pain. The pain had started on the previous day with severe colicky pain starting around the umbilicus. This pain was non-radiating, was not related to meals. It was associated with anorexia, nausea, one attack of vomiting [coffee ground vomitus], and two attacks of non bloody diarrhea with no mucus. There was no history of urinary symptoms, fever or weight loss. The patient was hypertensive on beta blockers, had no history of surgeries or allergy, and had no special habits. Physical examination revealed no evidence of arrhythmia or heart failure. Physical examination was significant only for marked generalized abdominal distension, tenderness, rebound tenderness, abdominal guarding and rigidity. There were no bowel sounds, no ascites or organomegaly. Rectal examination revealed an empty rectum with mild dark blood in the rectum. Blood workups showed some abnormal limits; white blood cell count of 13.5 thousand/ml, sodium 129 mmol/L, potassium 5 mmol/L and bilirubin 50 umol/L. Urine examinations was positive for ketones, glucose and red blood cells. Chest x-ray revealed no air under the diaphragm or signs of intestinal obstruction. Angio CT of the Abdomen revealed complete thrombosis of the distal IleoColic artery with secondary nonenhancement of the wall of the distal ileum, cecum and part of ascending colon secondary to arterial occlusion (thrombosis). [Figure Acute mesenteric ischemia represents one of the most threatening abdominal conditions in elderly patients . It has Diagnostic criteria of AMI include pneumatosis intestinalis, venous gas, superior mesenteric artery occlusion, celiac and inferior mesenteric artery arterial occlusion with distal superior mesenteric artery disease, or arterial embolism or, alternatively, bowel wall thickening combined with any one finding of focal lack of bowel wall enhancement, solid organ infarction, or venous thrombosis. By combining these criteria, a sensitivity of 96% and a specificity of 94% can be achieved . Other CSome investigators have promoted endovascular treatment as a first-line therapy for mesenteric occlusive disease . SimonetLaparoscopic second-look operation is one of the safest interventions, which proves the technique is really "minimally invasive." It not only prevents unnecessary laparotomies but also saves poor-risk patients from additional surgical trauma. It has become the routine procedure of choice for every patient who is operated on with the diagnosis of mesenteric ischemia .Acute arterial mesenteric ischemia is a serious condition if not recognized and treated early. There is often a delay in diagnosis and treatment of this condition because of its diverse causes and non specific radiological studies. We recommend that whenever mesenteric ischemia is suspected Angio CT should be ordered because the routine CT examinations may miss focal arterial mesenteric ischemia. Decreasing the time to diagnosis remains the only reliable means to decrease the morbidity and mortality associated with this disease.AMI: acute mesenteric ischemia; ANA: antinuclear antibody; ANCA: anti-neutrophilic cytoplasmic antibodies; CA 19-9: cancer antigen 19-9; CEA: carcinoembryonic antigen; CT: computerized tomography; PSA: prostate specific antigen; SIRS: systemic inflammatory response syndrome.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review from the journal's Editor-in-Chief.The authors declare that they have no competing interests.HH, MFA, AEO did the surgery. HH, EMB wrote the article. All authors read and approved the final version of the manuscript.


A rare case of an apocrine tumor in the male perineal region is reported. A dermal cystic lesion developed in the region between the anus and scrotum of a 74-year-old Japanese male. The cystic lesion, measuring 3.5 × 5.0 cm in size, was lined by columnar or flattened epithelium with occasional apocrine features and supported by a basal myoepithelium lining. A mural nodule, measuring 1 × 1.5 cm in size, protruded into the cystic space and consisted of a solid proliferation of tubular glands with prominent apocrine secretion and basal myoepithelial cells. Immunohistochemical examination showed that the luminal cells were partially positive for gross cystic disease fluid protein 15 and human milk fat globulin 1, and the basal myoepithelial cells were positive for alpha-smooth muscle actin and S-100 protein. Estrogen and progesterone hormone receptors were focally and weakly positive for luminal epithelium. Although no mammary-like glands were present in the dermis around the tumor, this unusual apocrine tumor has been suggested to be derived from male anogenital mammary-like glands and mimic a mammary-like gland adenoma in the male perineum. Mammary-like glands (MLGs) are present in the skin of the anogenital region of males as well as females. MLGs are distributed in the periclitoral region, interlabial sulci, fourchette, perineal and perianal regions in females and in the ventral side of the penis, perineal and perianal regions in males . AlthougWe describe a rare apocrine tumor in the anogenital region of a male and suggest that it is derived from male anogenital MLGs.A 74-year-old Japanese male presented with a skin tumor between the anus and scrotum. On physical examination, the lesion was 5 cm in maximal diameter and located in the dermis and covered with normal epidermis. The resected lesion, measuring 3.5 × 5.0 cm in size, was a cystic tumor containing fluid content. A yellowish polypoid intra-cystic tumor, measuring 1 × 1.5 cm in size, was projected into the cystic space Figure .The epidermis showed no remarkable change. The cystic tumor with no connection to the epidermis was located in the dermis and encapsulated by dense collagenous tissue Figure . The innBoth cystic and glandular parts were lined by two rows of epithelial linings: luminal epithelium with apocrine differentiation and basal myoepithelium. Although normal MLGs were absent in the resected specimen, the diagnosis of an apocrine tumor with apocrine cystadenoma-like and intra-cystic tubular adenoma-like features was made.Hidroadenoma papilliferum, an adenoma with apocrine differentiation, usually occurs in females but also in males. Another case of vulvar apocrine tumor has been reported to show combined histological features with hidroadenoma papilliferum and syringocystadenoma papilliferum . In the The hidroadenoma papilliferum occurs at the anatomical area where MLGs are distributed and is recently recognized as the most common clinical manifestation of MLGs-related tumors in vulvar MLG adenomas . The MLGImmunohistochemically, the luminal cells were positive for low molecular weight cytokeratins (CK7 and CAM5.2) and CEA. GCDFP-15 and HMFG-1, markers for apocrine differentiation -12, wereWe have described a rare apocrine tumor in the male anogenital region. Although normal MLGs were absent in the adjacent tissue, the tumor in the present case demonstrated the same histological and immunohistochemical pattern as MLG adenomas.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MR, KH and AT participated in conception of the idea and writing of the manuscript. AT, YU, TY and TK performed the histopathological interpretation of the tumor tissue.All authors have read and approved the final manuscript.


The authors report a pediatric patient who presented with a slow-growing swelling on the scalp. Computed tomography (CT) of the head revealed an osteolytic intradiploic lesion of the cranial vault. The lesion was excised in toto, and histopathological examination revealed benign intradiploic meningioma. The possible etiology, clinical findings, CT appearance, differential diagnosis, and treatment strategy are discussed. Approximately 1% of the meningiomas arise in extradural sites.1 The meniA 13-year-old boy was admitted with the complaint of a swelling on the right side of the head near the temple since 6 months. The parents reported that the swelling had gradually increased in size over 2 months. There was no history of similar swellings on the head or elsewhere in the body. There was no history of pain, fever, headache, vomiting, seizures, or visual disturbances.General examination showed a moderately built and moderately nourished boy. He was not anemic, jaundiced, or cyanosed, and there was no peripheral lymphadenopathy. He had blood pressure of 110/70 mm Hg and a pulse rate of 76/min. No abnormality was detected either in the central nervous system or the cardiovascular system. The patient had an upper respiratory tract infection, which was controlled with antibiotics. Local examination revealed a small swelling of about 2 cm in diameter in the right upper temporal region. The skin over the swelling appeared normal. There was no visible pulsation or audible bruit. The surface of the lesion was smooth and the consistency was hard. The swelling appeared to arise from the bone. Plain CT of the head Figures  showed cth postoperative day with advice to come for periodic follow-up.The postoperative period was uneventful and patient was discharged on the 7It is likely that intradiploic meningiomas originate from arachnoid cells entrapped in the bone.2 Head trThe classification of primary extradural meningiomas was introduced by Lang and colleagues and is as follows:Type I: Tumors that are purely extracalvarialType II: Tumors those are purely calvarialType III: Calvarial tumor with extracalvarial extensionth to 7th decades of life. The present case is a 13-year-old boy who presented with a solitary lesion in the pterional area. Intradiploic meningiomas are usually solitary. Convexity intradiploic meningiomas most commonly present as slow-growing scalp masses, with possible relation to cranial suture. Common locations include the periorbital region and fronto, temporo parietal region.Based on their anatomical location, these types are further divided into convexity or skull-base tumors. Intradiploic meningiomas usually belong to either type 2 or type 3; the present case belongs to type 3. These tumors tend to occur in young patients but there is a second peak between the 5Radiographically, intradiploic meningiomas are typically either osteoblastic or osteolytic.2 Mixed vWide surgical resection of intradiploic meningioma is the treatment of choice and is potentially curative if surgery is possible.4 HoweverThe present case belongs to the osteolytic subtype of intradiploic meningioma. The tumor was excised in toto and histopathological examination showed evidence of a benign type of intradiploic meningioma. The patient was advised to come for periodic follow-up to rule out recurrence of the lesion.


Advanced gastrointestinal stromal tumors (GISTs) can metastasize and recur after a long remission period, resulting in serious morbidity, mortality, and complex management issues.A 67-year-old woman presented with epigastric fullness, mild jaundice and weight loss with a history of a bowel resection 7 years prior for a primary GIST of the small bowel. The finding of a heterogeneous mass 15.5 cm in diameter replacing most of the left lobe of the liver by ultrasonography and CT, followed by positive cytological studies revealed a metastatic GIST. Perioperative optimization of the patient's nutritional status along with biliary drainage, and portal vein embolization were performed. Imatinib was successful in reducing the tumor size and facilitating surgical resection.A well-planned multidisciplinary approach should be part of the standard management of advanced or metastatic GIST. Gastrointestinal stromal tumors (GISTs) are neoplasms of the gastrointestinal tract. Despite their less aggressive pathologic nature, GISTs can metastasize and recur after a long remission period. Such cases may produce serious morbidity, mortality, and complex management issues for the treating physician. We hereby report the case of a patient who presented with an isolated metastatic GIST to the liver that was successfully treated with a multidisciplinary approach including imatinib therapy, portal vein embolization, and hepatic lobectomy.A 67-year-old woman presented with epigastric fullness, mild jaundice and a 12-pound weight loss over a period of 3 months. The patient had a history of a bowel resection 7 years prior to presentation for an unknown malignancy. On physical examination, her abdomen was soft with a palpable and non-tender mass in the mid-epigastrium. Initial work-up including ultrasonography revealed a large liver lesion, follow-up CT confirmed the presence of a heterogeneous mass 17.5 cm in diameter replacing most of the left lobe of the liver Figure  with martotal billirubin: 4, direct billirubin: 3.93, alkaline phosphatase: 942, AST: 124, ALT: 156. The addition laboratory values were within normal limit.The patient was admitted to the hospital for additional work-up. A percutaneous transhepatic cholangiogram was performed, with placement of a right biliary drainage catheter for decompression. The bilirubin and liver function tests at the day before drainage placement were as follow: total billirubin: 4 direct billirubin: 3.93 ALK: 942 AST: 124 ALT: 156. Two days later the labs were as follow: total billirubin: 3.45 direct billirubin: 3.28, alkaline phosphatase: 788 AST: 117 ALT: 123, and 30 days later was: total billirubin: 0.7 direct billirubin: 0.30 alkaline phosphatase: 130 AST: 28 ALT: 25. A core liver biopsy was also done at the time, which demonstrated atypical spindle cells. Immuno-histochemical studies yielded positive CD117, vimentin and actin stains, all consistent with GIST. It was later established that the patient had previously undergone a small bowel resection for a primary GIST. Upper and lower endoscopy as well as small bowel series were subsequently performed. These revealed no tumors of the GI tract, suggesting the liver mass was a late and isolated metastatic manifestation of the prior GIST tumor.A multidisciplinary and staged treatment course was recommended. Side effects and benefits of using Imatinib drug were considered by our tumor board, and the patient was started at a dose of 600 mg per day to reduce tumor size. The patient was followed regularly for the next few months as an outpatient. Her jaundice resolved and the biliary catheter was successfully removed four months after placement. A significant clinical improvement was noted, with resolution of the patient's initial symptoms and a 7-pound increase in body weight. Frequent abdominal CT scans showed a hepatic mass that diminished in size, but stabilized after 6 months of imatinib therapy at a diameter of 11 cm Figure .The patient then underwent portal vein embolization (PVE) in hopes of promoting hypertrophy of the right lobe and further atrophy of the tumor-laden left hepatic lobe, in preparation for surgical resection.Two months following PVE, while still on imatinib, the patient underwent an uncomplicated left hepatic lobectomy with cholecystectomy Figure . IntraopThe patient tolerated the procedure well and was sent home after a 14-day hospitalization. The postoperative course was complicated by the formation of a subhepatic abscess that was successfully treated with drainage catheters and systemic antibiotics. Imatinib was discontinued approximately one month after surgery for a total of one year of therapy. Follow-up CT 6 months after surgery demonstrated no residual neoplastic disease Figure . At fourGastrointestinal stromal tumors are the most common mesenchymal neoplasms of the GI tract. They have an overall incidence of 3000–5000 cases per year in the United States -3. It isGISTs are usually detected by endoscopy, CT or MRI performed for abdominal symptoms. The gold standard for diagnosing GISTs is pathological tissue examination, which normally demonstrates atypical splindle cells. A positive stain for CD117 carries a specificity of 95% for these tumors, and will unequivocally establish a diagnosis [When GISTs originate in the small bowel, they behave in a more aggressive manner . The mos®), a selective inhibitor of tyrosine kinase, has revolutionized the management of this disease in recent years. Imatinib has a significant shrinking effect on GISTs, and can be used when primary GISTs have attained a very large size or are in unfavorable locations, increasing the risk of positive resection margins [®), a multikinase inhibitor has been approved by the Food and Drug Administration for treatment of GISTs that are refractory to imatinib [The only definitive treatment for GISTs is surgical resection. This can be done laparoscopically in some cases, or with the traditional open approach. The mainstay of surgical therapy in primary or metastatic disease is to achieve a complete resection with negative margins . Convent margins . Imatini margins . Imatini margins ,15: naus margins . The dru margins . Our patimatinib .Resection of GIST liver metastases may be curative when the primary disease has been eradicated and negative surgical resection margins are attained. However, a large tumor burden in the hepatic parenchyma may prohibit resection given the risk of insufficient remaining liver tissue and subsequent postoperative liver failure . An optiThis case, to our best knowledge, represents the first in the literature describing a multidisciplinary approach for the successful management of a large metastasic GIST to the liver. We attribute the success of this case to a well thought out management plan set forth by a dedicated tumor board utilizing advanced and evidence-based therapeutic modalities. Timing and resource utilization were key factors in the management of this patient. Perioperative optimization of the patient's nutritional status and state of health with biliary drainage was helpful. The pharmacologic effect of imatinib reduced the tumor size and improved the surgical resectability. Additionally, PVE facilitated the operation and promoted healthy liver tissue hypertrophy. Lastly, careful operative technique and dedicated follow up allowed for a good surgical outcome in this patient. A well-planned multidisciplinary approach should be part of the standard management of advanced or metastatic GISTs.The authors declare that they have no competing interests.TM, JP and MG designed the study. PR carried out the data and bibliographic research and drafted the manuscript. MG carried out the picture acquisition, manuscript revision and editing process. TM and JP did the last manuscript revision and the editing process.


Jejunojejunal intussusceptions are not very common in adults, and unlike in children, a lead point is usually found. The clinical presentations in adults tend to be more chronic or intermittent, and they include obstructive syndrome, abdominal cramps, gastrointestinal bleeding, or palpable abdominal mass at physical examination. These unspecific symptoms often lead to late diagnosis after many investigations or even only after an inappropriately extensive surgery. We report the rare case of a 37-year-old female with intermittent bowel obstruction due to jejunojejunal intussusception secondary to the lipoma. The main clinical signs of this uncommon pathology are presented together with the necessary paraclinical investigations that enable surgical treatment. Jejunal lipoma is a rare cause of adult intussusception, is usually diagnosed during surgery with the presence of mechanical obstructive syndrome. Some patA 37-year-old female with past history of appendicectomy in 1982 and surgery for kidney lithiasis in 1996, suffering from intermittent periumbilical cramping pain with partial obstructive syndrome for nearly 3 years. During the previous 6 months (June 2006), she was operated for left ovary cyst by Pfannenstiel incision. She was admitted to the hospital on November 2006 because of increasing of abdominal pain with partial bowel obstruction. Clinical and physical examinations revealed normal vital findings with sensitive and palpable mass over the left periumbilical region. Rectal examination was normal and hematologic values were normal. There was a dilatation of a proximal small bowel loop on the plain abdominal radiograph. Ultrasonography (US) revealed multilayered small bowel lumen along the periumbilical area. A contrast-enhanced abdominal computed tomography (CT) scan with oral contrast administration demonstrated classic bowel-in-bowel appearance of small intestinal intussusception  and an oIntussusception is defined as the telescoping of a proximal segment of intestine, termed intussusceptum, into the distal intestinal loop, known as intussuscipiens. The majority of intussusceptions occur in infancy and early childhood, rarely in adults , and may be ileocolic, colocolic, enteroenteric, or jejunogastric without anatomic predilection. The unde1Ultrasonography is very appropriate and useful in the diagnosis of intussusception. First, it is a more available and generalized technique than CT, enabling it to be used more often with emergency and acute symptoms, and therefore, it is available at times of abdominal crisis in intermittent processes. It showed the typical multilayered appearance consisting of the alternating hyperechoic and hypoechoic concentric rings that represent alternating layers of mucosa, bowel wall, and mesenteric fat in cross section. Lipoma of the small intestine may appear on US as a highly echoic mass.5 CT scan24Surgery is usually the treatment of choice for symptomatic gastrointestinal lipomas with laparotomy and resection of the affected intestinal segment. Laparoscopic surgery is an excellent alternative approach, and can be a useful method for reducing hospital stay, complications, and return to normal activity.6Jejunojejunal intussusception caused by lipoma is a rare disease. Ultrasonography is a safe, noninvasive and effective tool for early, preoperative diagnosis of patients with intussusception and acute abdominal pain. Computer tomography is sensitive to delineate the nature of lipoma as well as the reluctant intussusception.


Schwannoma is a myelin sheath tumor that can occur almost anywhere in the body. The most common locations are the central nervous system, extremities, neck, mediastinum and retroperitoneum. Benign schwannomas in the porta hepatis are extremely rare and radiologically are diagnosed as either enlarged lymph nodes or bowel masses, such as gastrointestinal stromal tumors. In this location they usually produce symptoms by compressing adjacent structures and often present with obstructive jaundice. The preoperative diagnosis can be extremely difficult. Benign schwannomas, also referred to as neurilemomas and neurinomas, are encapsulated myelin sheath tumors. They are usually benign and their presentation depends on the anatomical location and tumor extent. A benign1A 38-year-old man was admitted to our institute with upper abdominal pain, poor appetite, loss of weight and yellowish discoloration of the eyes for 2 months. His clinical and family histories were noncontributory. There was no history of drug intake. Per abdominal examination revealed a soft abdomen with no evidence of hepatomegaly or splenomegaly. There was no lymphadenopathy. Laboratory investigations revealed elevated values of total bilirubin (7.4 mg/dl), direct bilirubin (4.3 mg/dl) and alkaline phosphatase (567 U/l). Total protein, albumin, ALT  and AST (aspartate aminotransferase) were normal. These findings were consistent with obstructive jaundice. CT scan of the abdomen revealed a heterogeneously enhancing lesion measuring 4.7 × 3.4 × 3.2 cm  in the region of the porta hepatis , 2, exteBenign schwannoma is a tumor arising from Schwann cells, which form the neural sheaths of the peripheral nerves. The most common locations are the cranial nerves  and the peripheral nerves in the region of the neck, mediastinum and extremities. Theoreti5In the present case, CT scan revealed a heterogeneous lesion at the porta hepatis, which was initially suspected to be a lymph nodal mass or an exophytic gastrointestinal stromal tumor (GIST). Gastrointestinal stromal tumors are a distinct group of mesenchymal tumors arising from the muscularis propria layer of the digestive tract; they often project exophytically and/or intraluminally.9 On CT s7On histopathology, the characteristic features include the presence of alternating Antoni A and Antoni B areas. The Antoni A area is composed of spindle-shaped Schwann cells arranged in interlacing fascicles. The Antoni B area consists of a loose meshwork of gelatinous and microcystic tissue. Large, irregularly spaced, thick-walled blood vessels can be seen in Antoni B areas. These may contain intraluminal thrombi.This case illustrates the difficulty in making the diagnosis of a schwannoma in the porta hepatis based on CT imaging features alone. Schwannoma can be mistaken for GIST and polypoid extrahepatic cholangiocarcinoma, and it is not possible to pre-operatively make a diagnosis based on imaging findings alone.In this case, the postoperative course was uneventful and at a follow-up visit after 3 months, the patient was clinically asymptomatic and free of icterus.


We report a case of a 21-year-old man with a popliteal venous aneurysm of the left popliteal fossa, with local symptoms and pain during palpation. Early diagnosis is fundamental in order to prevent the thromboembolic events or other major complications. Duplex scanning, Computed Tomography scanning, and Magnetic Resonance imaging are considered to be important non-invasive diagnostic methods for the diagnosis of PVA. The Angio Computed Tomography acquisition confirmed a 36 mm ×17 mm oval mass in the left popliteal fossa continuous with the popliteal veins. This lesion had presented contrast enhancement only in delayed acquisition (180 sec) and so appeared to be a true venous aneurysm and no arterial. The PVA was repaired surgically via a posterior approach to the popliteal fossa. A 4 × 2aneurysm was identified. In the same time open tangential aneurysmectomy and lateral vein reconstruction were realised. This case is interesting because the Angio Computed Tomography study, in delayed acquisition, has allowed a correct diagnostic assessment of PVA and the surgical treatment.  Popliteal venous aneurysms (PVAs) may cause fatal complications  , 2 if thA 21-year-old male footballer has presented, for a few months after trauma a local discomfort in particular in the left popliteal fossa during palpation and usual daily activities. Physical examination was negative for the presence of a soft mass in the upper part of the popliteal left fossa without local signs of inflammation. Instead was positive for the pain in the front part of the left knee during palpation. There was no evidence of clinical signs of peripheral arterial angiopathy. Chest and abdomen examination, arterial blood pressure, chest X-ray, oxygen saturation, and electrocardiogram were normal. Duplex scanning, Computed Tomography scanning, and Magnetic Resonance imaging (MRI) are considered to be important non-invasive diagnostic methods for the diagnosis of PVA. Magnetic Resonance imaging (MRI) without contrast media demonstrated a 4 × 2 cm oval formation with dishomogeneous hyperintensity on T1-and T2-weighted sequence in the left popliteal fossa adjacent to the vessels suspected for a blood lesion . Then the color-Doppler ultrasonography (US-CD) was performed to identify the true origins of this lesion. This examination demonstrated only a mixed echogenicity mass in the left popliteal fossa with no evidence of arterial or venous nature. Subsequently this mass was evaluated with Angio-Computed Tomography (ACT) using a computed tomography scanner . Images were acquired without and with contrast media intravenously  and a scan was obtained with three phases from the injection of contrast media. Every data acquired were transferred to an Advantage Windows workstation (GE Advantage) and reconstrued using maximal intensity projection (MIP) and volume rendering (VR) technique. The ACT acquisition confirmed a 36 mm × 17 mm oval mass in the left popliteal fossa continuous with the popliteal veins. This lesion had presented contrast enhancement only in delayed acquisition (180 sec) and so appeared to be a true venous aneurysmFigures and 3.The PVA was repaired surgically via a posterior approach to the popliteal fossa. A 4 × 2 cm aneurysm was identified. In the same time open tangential aneurysmectomy and lateral vein reconstruction were realised . A histopathologic examination revealed an aneurysm venous wall with none evidence of inflammatory or degenerative signs. The patient was given warfarin for anticoagulation and was discharged on the 3th postoperative day. Two months postoperatively, the patient's symptoms were improved; the repetition of venous duplex scanning showed patency of the repaired popliteal vein without venous thrombosis. Elastic stockings were suggested for support, and daily aspirin was recommended for prophylaxis against thrombosis. The patient was able to resume normal activities.Popliteal venous aneurysms are uncommon and not clinically important in most cases. However they can lead to severe complications including deep-vein thrombosis, pulmonary embolism, and death , 8. The etiology of venous aneurismal remains unknown but congenital factors, inflammation, trauma, or degenerative changes have been proposed . ProbablAsymptomatic incidental detection, local lower extremity symptoms, or embolic pulmonary episodes may represent different aspects of manifestation of the same condition . Most popliteal venous aneurysms are showed with pulmonary embolism (24%) or chronic venous disease  ; but usuIn this case the ACT study has permitted a correct diagnosis assessment of PVA. This lesion had presented contrast-enhancement only in delayed acquisition (180 seconds) and it had demonstrated that this aneurysm was venous and not arterial. Other differential diagnosis of PVA could be the Baker's cyst and tibiofibular cysts. These lesions are different in site and morphology, but the diagnosis is easy with the Ultrasonography and MRI. Baker's cyst is a persistent joint fluid effusion  that can be localized in the back of the knee. It can be caused, more frequently in adults, by posterior herniation of the knee joint capsule. Cysts in the proximal tibiofibular joint are uncommon, and they have a similar manifestation. Their clinical diagnosis is difficult. In both cases the US examination shows an ipo-echogenicity mass and the MRI demonstrates an oval mass hypointensity on T1-weighted sequence and hyperintensity on T2-weighted sequence. Surgical options in the treatment of symptomatic and asymptomatic cases include tangential aneurysmectomy with lateral venorrhaphy, resection with end-to-end anastomosis, resection with interposition graft, or ligation of the proximal and distal vein. Early patency rates are encouraging, with no reports of recurrent pulmonary embolism following surgical repair, although the long-term results of surgery are unknown .Early diagnosis is fundamental in order to prevent the thromboembolic events or other major complications. This case is interesting because the ACT study, in delayed acquisition, has allowed a correct diagnostic assessment of PVA and the surgical treatment.


A unicornuate uterus with a rudimentary horn is the most uncommon uterine anomaly of the female genital tract. It has an estimated frequency of one in 100,000 among the fertile female population. This anomaly results from the abnormal maturation of one Müllerian duct with the normal development of the contralateral one.We report here the case of a 14-year-old Caucasian girl who came to our hospital with intense dysmenorrhea. Imaging techniques revealed a unicornuate uterus with a rudimentary horn and a large hematosalpinx. We performed a laparoscopic removal of this uterine anomaly without any complication in the postoperative period.In our case report, we demonstrate that laparoscopy is the best approach for the treatment of IIb Müllerian abnormalities. Laparoscopy resulted in anatomical and reproductive results equivalent to those offered by a laparotomic approach, but with the additional advantages of minimally invasive surgery, such as better cosmetic results and postoperative period, which are essential for very young patients. A unicornuate uterus with a rudimentary horn is the most uncommon uterine anomaly of the female genital tract. It has an estimated frequency of one in 100,000 among the fertile female population . We repoA Caucasian 14-year-old girl was admitted to our department with a clinical history of dysmenorrhea for the past two years since her menarche. During her menstruation, she suffered from acute and severe right lower-quadrant pain that caused repeated school absenteeism. The rest of her medical history was unremarkable. Physical examination revealed a uterine mass in the right side of the pelvis with diffuse tenderness of the lower abdomen, but a normal vagina without masses and just one cervix. Three-dimensional ultrasonographic exam revealed the presence of a supposed didelphys uterus with hematometra in the right one, as well as a hematosalpinx measuring 45 × 33 mm on the same side Figure . No renaUterine Müllerian abnormalities occur when the embryo is just 20 mm long. All the anatomical variations are classified by the American Society of Reproductive Medicine. A unicornuate uterus with a noncommunicating rudimentary horn belongs to group II-b, which may be differentiated by a complete uterine septum bicollis with an obstructed longitudinal vaginal septum. This is diagnosed by a physical vaginal exploration as we did in this case. This subtype of anomaly is associated with endometriosis, by means of a retrograde menstruation, and also with renal abnormalities, both of which should be assessed before any treatment ,4. It isThe surgical technique of choice has to be adapted to the type of malformation. In the case of a rudimentary uterine horn firmly joined to a unicornuate uterus, some details need to be kept in mind: First, there is not a well-defined limit between the unicornuate uterus and the rudimentary horn in some cases, which means the surgeon must proceed with extreme caution. Hysteroscopic transillumination can be useful in such a case, since opening the uterine cavity may affect future reproduction . Second,Our report demonstrates the superior performance of laparoscopy for the treatment of IIb Müllerian abnormalies. Laparoscopy resulted in anatomical and reproductive results equivalent to those offered by a laparotomic approach, but with the additional advantages of minimally invasive surgery, that is less scarring and a shorter postoperative period, which are essential for very young patients.The authors declare that they have no competing interests.IZ collected, analyzed, and interpreted data from the patient, and was a major contributor to writing the manuscript. PA and TP contributed to writing the manuscript and performed the surgery. JBA supervised the work and collected the patient's informed consent. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's mother for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Adenomatoid tumors are regarded as distinctive benign mesothelial neoplasms of the paratesticular region, most commonly occuring at the tail of the epididymidis.Because of its rarity, the clinical and histopathological aspects are discussed.We present the case of a 41-year-old patient with an adenomatoid tumour located in the tail of the left epididymis that referred to our department with gradual enlarged intrascrotal mass. The diagnosis was achieved by echography, and was confirmed by surgical excision and histological analysis.Due to its low incidence in intrascrotal pathology, we believe it is important for the physician to be aware of this interesting entity in order to make a differential diagnosis from other inflammatory processes and to adopt the proper surgical approach. A variety of neoplasms derived from mesenchymal elements may arise on the patatesticular tissues. The diagnostic considerations may include carcinoma of rete testis, malignant mesothelioma, ovarian-type epithelial tumors, epididymidal carcinoma and metastatic carcinoma. Adenomatoid tumors were first described in 1945 by Golden et al as a small firm asymptomatic intrascrotal mass, with no pain or tenderness, occurring in third to fifth decades of life. The origin of the adenomatoid tumor is not clear, although the structural and immunohistochemical studies support the mesothelial origin. The histological pattern of the tumor is characterized by tubules, cords, and small nests, formed of cuboidal cells with vacuolated cytoplasm, and we may discriminate three kinds of adenomatoid tumor:plexiform, glandular and angiomatoid. The elected treatment is orchiectomy and epididymectomy, a probably aggressive surgical treatment which in combination with immunohistological confirmation are essential to resolve a formidable diagnostic challenge.A 41 years old man referred to our department for painless enlargement in the left hemiscrotum. Personal and familial history were unremarkable, without epididymitis, torsion or trauma. On physical examination, a hard, painless, firm, intrascrotal mass at the lower pole of the left testis was revealed, apparently distinct from the testis and arising directly from the surface of the left epididymis. Scrotal skin epididymis, spermatic cord, inguinal region and right testis were normal.β-hCG (β-subunit human chronic gonadotropin), α-fetoprotein (AFP), lactic dehydrogenase (LDH) were within normal ranges. The first clinical impression was a probable germ cell neoplasm.Ultrasonography confirmed a solid isoechoic lesion lying on the border between epididymal tail and lower pole of the left testis, without any disruption of the architecture of the testical parenchyma. The testicular parenchyma immediately adjacent to the mass showed slightly degreased echogenity compared with the parenchyma elsewhere. Preoperative laboratory investigation, including hemogram, blood chemistry studies were within normal limits. Plasma levels of The patient subsequently underwent a total left orchiectomy-epididymectomy, which revealed a white, crescent-shaped, well circumscribed tumor, about 1,5 cm, without involvement of the testicular parenchyma.Histological appearance of this paratesticular tumor is represented by cuboidal cells, with vacuolated cytoplasm and with gaping spaces Fig. . The neoImmunohistochemical positivity for mesothelial marker HMBE1  and calretinin confirm the mesothelial origin of the tumor Fig. , 4. ThisParatesticular tumors are uncommon and comprise less than 5% of all intrascrotal tumors. Epididydimal epithelial tumors are a rare subtype of paratesticular tumors with the adenomatoid tumor being most common followed by the papillary cystadenoma and the leiomyoma . These tAdenomatoid tumors present as a relatively small well demarked, without capsule nodule, less than 2 cm in diameter. The largest diameter that has been reported is 12 cm .The tumor has a plethora of microscopic appearances, represented by three basic patterns:tubules, cords, and small nests, formed of cells that are cuboidal with vacuolated cytoplasm also characterized by peripheral eosinophilic and lymphatic infiltration . Gaping The possible histogenesis of adenomatoid tumors has aroused controversy and our data, so far, are contradictory. However, the most recent investigations favor a mesothelial origin ,8 and otIn conclusion adenomatoid tumor of the epididymis is a distinctive clinical identity with much differential diagnosis, hard to distinguish; the cornerstone of accurate characterization of the tumor is still a comprehensive, traditional clinicopathologic approach, clinical history, routine light microscopy and immunohistochemical markers are crucial for the correct diagnosis.β-hCG: β-human chorionic gonadotrophin; AFP: α-fetoprotein; LDH: lactic dehydrogenase; HMBE1: mouse anti-human antigen mesothelial cellThe authors declare that they have no competing interests.All authors have made substantial contribution to concept this case report.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in Chief of this journal.


Primary nerve sheath tumors in an intrascrotal and extratesticular location are extremely rare, with only a few cases reported in the literature. We report a fine needle aspiration cytology (FNAC)-diagnosed and histologically confirmed case of paratesticular schwannoma in a 32-year-old male. The patient had no evidence of neurofibromatosis and there was a pre-operative cytologic suspicion of leiomyoma as well. A palpable left-sided inguinal lymph node showed features of reactive lymphoid hyperplasia. This case is documented to highlight the rarity of paratesticular schwannoma and the role of FNAC in its pre-operative interpretation. Most of them occur during the 3ribution. Cytologiribution.–7 A repribution.7 the diagA 32-year-old male presented with a history of gradually increasing, painless, left-sided scrotal swelling of six months’ duration. No similar swellings were appreciated elsewhere in the body and there was no other significant history or clinical findings. On physical examination, an oblong, firm mass, measuring 4.5 cm × 3.5 cm in size was observed at the root of the scrotum, close to the testis. The patient also had a friction ulcer over the scrotal skin along with an enlarged left-sided inguinal lymph node. A provisional clinical diagnosis of epididymal tumor/lymphoma was considered.Ultrasonographic examination demonstrated the paratesticular location of the scrotal mass with scant amount of fluid collected within the tunica vaginalis, along with an enlarged left-sided inguinal lymph node.FNA of the scrotal mass as well as the lymph node was performed using a 23-gauge needle attached to a 5-mL syringe. Smears were fixed with ether–alcohol (v/v) and stained with hematoxylin and eosin (H and E). Examination of the cytologic smears revealed tightly cohesive tissue fragments with variable cellularity, exhibiting slender spindle cells showing dark, wavy nuclei . Some clSurgical exploration of the scrotal sac revealed a firm, nodular, whitish lesion attached to the sac and not involving the testis. Scrotal mass was excised sparing the testis. The specimen submitted for histopathological examination consisted of a partly skin-covered, oblong, firm mass, which measured 4.5 cm × 3.5 cm × 2 cm. The cut-surface was whitish, lobulated and glistening, with central yellow-brown areas . ImprintSchwannomas arise from the cranial, spinal and the peripheral nerves of the body. Several sites of involvement have been documented, with the rare sites reported being face, neck, scalp, hands, tongue, palate and the larynx. Testicular schwannomas are the rarest.78 FNAC f7et al.[4Domanski et al. studied et al.5 Sparselet al.–49 The dClinically, schwannomas tend to be asymptomatic; however, when they enlarge, they result in symptoms related to compression of the surrounding structures. RecurrenFNA in our case provided an accurate pre-operative diagnosis. Although a differential of leiomyoma was also considered, it could easily be excluded by the cytological features, which well reflected the Antony A and B areas of the histologic sections. Imprints taken from the surgical specimen, although sparsely cellular, showed features consistent with schwannoma.Our case highlights the importance of FNA in the pre-operative tissue diagnosis of unusual paratesticular tumors such as schwannoma.


Small bowel obstruction is a common world-wide condition that has a range of etiological factors. The management is largely dependent on the cause of the obstruction. Small bowel obstruction caused by foreign body ingestion is rare; many items have been reported as responsible, but there are no reports implicating polyurethane foam.We report the case of a 44-year-old Irish male who presented following ingestion of polyurethane foam. He was asymptomatic on presentation but developed a small bowel obstruction shortly thereafter.Patients presenting following ingestion of polyurethane foam should be scheduled for elective laparotomy, gastrotomy, and retrieval of the cast on the next available theatre list - given that they are suitable for surgery. We report the case of a 44-year-old gentleman with a background history of multiple laparotomies for deliberate self harm who presented six weeks following ingesting of polyurethane self-expanding foam. On admission, the patient had no signs or symptoms of small bowel obstruction. A plain film of his abdomen confirmed the presence of an intra-gastric cast of self-expanding foam Figure .A planned elective operation for laparotomy and retrieval of the cast was organized. In the interim, he went on to develop a small bowel obstruction. A CT scan of his abdomen confirmed the small bowel obstruction to be secondary to migration of a fragment of foam Figure .The obstruction settled with conservative management. Thereafter, he underwent a laparotomy, gastrotomy, and removal of the cast on an elective basis Figure . He madeth and early 20th century, a concern of the physician rather than the surgeon. The value of surgical intervention was only recognized after the advent of anaesthesia and antisepsis.Bowel obstruction was, until the late 19In the developed world, intra-abdominal adhesions are recognized as the leading cause of small bowel obstruction, accounting for over 60% of all cases. Small bowel obstruction secondary to foreign bodies remains a rare cause.Small bowel obstruction (SBO) secondary to foreign bodies (FB) is rare; it represents less than 6% of all SBO cases , and cauGenerally, bezoars remain in the stomach; however, they will occasionally pass to the small bowel . Unlike Other reported FB causing SBO include mesh plugs following open hernia repair, retained surgical gauze, magnetic toys, endoscopy capsules, retained PEG tube internal bumpers, gastric bands, and many others.The signs and symptoms of FB SBO are the same as those of SBO secondary to any other cause, however a history of FB ingestion is usually evident; otherwise, a high index of suspicion is necessary, especially in children and patients with psychiatric illnesses.In the management of FB ingestion, there are recommendations that are in place, recommended by a panel of experts . These sPatients presenting following ingestion of self-expanding foam should be scheduled for surgical retrieval on the next available elective list, as they are at risk of developing small bowel obstruction, due to the fragmentation of the lithobezoar.Written informed consent was obtained from the patient for publication of this case report and accompanying images.A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MM collected the patient information, performed the literature review, and was the major contributor in writing the manuscript. EM edited the manuscript and provided critical analysis of the body. BK interpreted the imaging and contributed to the image selection in the manuscript.All authors have read an approved this final manuscript.


Urachal carcinoma is an uncommon neoplasm associated with poor prognosis.A 45-year-old man was admitted with complaints of abdominal pain and pollakisuria. A soft mass was palpable under his navel. TC-scan revealed a 11 × 6 cm tumor, which was composed of a cystic lesion arising from the urachus and a solid mass component at the urinary bladder dome. The tumor was removed surgically. Histological examination detected poor-differentiated adenocarcinoma, which had invaded the urinary bladder. The patient has been followed up without recurrence for 6 months.The urachus is the embryological remnant of urogenital sinus and allantois. Involution usually happens before birth and urachus is present as a median umbilical ligament. The pathogenesis of urachal tumours is not fully understood. Surgery is the treatment of choice and role of adjuvant treatment is not clearly understood. Urachal carcinoma is an uncommon neoplasm associated with poor prognosis. The estimated annual incidence of urachal carcinoma in the general population is one in 5 million, or 0.01% of all cancers in adults. Urachal carcinoma has been estimated to comprise 0.17-0.34% of all bladder cancers [A 45-year-old man was referred to our hospital with complaints of micturition pain of 5 months' duration, and lower abdominal pain and pollakisuria of 1 month's duration. A physical examination revealed a soft tender mass under his navel. Periumbilical discharge was not recognized. Laboratory data: hemoglobin, 15.9 g/dL; erythrocyte count, 4865000/mL; leukocyte count, 11600/mL; platelet count, 259000/mL. CEA: 5.1 ng/ml. Urinalysis: hemoglobin (++). Urine cytology: negative. Cystoscopy detected mucosal edema and erosion at the bladder dome. TC-scan showed a soft-tissue mass along the umbilicus, which extended from the bladder dome to the posterior wall of the bladder and the peritoneum. The size of the tumor was 11 × 6 cm , high tumor grade HR, 3.6), positive local lymph nodes , metastases at diagnosis , advanced tumor stage HR, 4.8), failure to perform umbilectomy , and primary radiation therapy  were all univariately associated with death (P < .05). Only grade and margins were significant in the multivariate analysis. Modern therapeutic regimens have offered minimal benefit, especially when unresectable. No survival benefit was noted for lymphadenectomy or adjuvant therapy. Salvage surgery resulted in a long-term cure for 50% of patients who had local recurrences. No effective treatment was identified for patients with metastatic UrC. The question as to whether partial or radical cystectomy is suitable for localised disease is difficult to answer since urachal tumours are rare. Furthermore, within this group, urachal adenocarcinoma is uncommon in those under 40 years. However, in order to evaluate which surgical approach is correct or whether new chemotherapeutic agents will induce objective responses and improve long-term survival requires co-operation between physicians and centres internationally so that larger studies can be conducted. This approach can only benefit patients [, positiv, failureThe urachus is the embryological remnant of urogenital sinus and allantois. Involution usually happens before birth and urachus is present as a median umbilical ligament. The pathogenesis of urachal tumours is not fully understood. Surgery is the treatment of choice and role of adjuvant treatment is not clearly understood.Written informed consent was obtained from the patient for publication of this case report. A copy of the consent is available with editorial officeThe authors declare that they have no competing interests.SS, ER, ER, RS and VF are surgeons of the Unit of Surgical Oncology (Chief: VF) and have performed the operation. LV is General Psysician of the patient. VG and CF are radiologists of the Department of Radiology. All authors read and approved the final manuscript.


Primary osteosarcomas are one of the most common malignant bone tumors principally affecting the long bones in children and adolescents. An unusual case of a primary osteoblastic osteosarcoma of the rib in a 42-year-old male is presented here. The patient underwent a wide excision of the tumor and chest wall reconstruction. Although clinically unsuspected in this unusual site, the classic microscopic feature of a ramifying osteoid matrix amidst the tumor cells was diagnostic of an osteosarcoma. Osteosarcomas (OS) are the most common primary malignant bone tumors exclusive of multiple myeloma. They principally arise in the metaphyses of the long bones, particularly at the lower end of the femur and upper ends of the tibia and humerus. Short boA 42-year-old man presented with a progressively increasing right-sided chest wall swelling for three years. The swelling was accompanied by pain for the past three months. However, there was no fever, cough, breathlessness or loss of weight. There was no history of receiving radiation or a pre-existing bone lesion. Physical examination revealed a bony hard mass in the right hemithorax measuring 5×5 cm extending from the anterior axillary to the mid axillary line. An X-ray examination revealed an opacity in the right lateral chest wall involving the ribs and soft tissue. A computed tomography (CT) scan showed a lobulated, extra pleural, soft tissue density, with calcification involving the fifth and sixth ribs, which showed sclerosis and destruction . The lunGross examination revealed a partly encapsulated bony hard mass measuring 12×11×4 cm, bearing five ribs. The tumor was seen involving and encasing all the ribs . The cutPrimary osteosarcomas usually originate in the metaphysis of the long bones. Approximately 10% of osteosarcomas are located in the flat bones, with the pelvis being the main site, and a mere 1 – 2% occur in the thoracic bones inclusive of the ribs, sternum, and clavicle.[Cases originating from the ribs are infrequent and have been reported mainly in the pediatric population–5 In a lOS originating from such a rare site poses a diagnostic challenge to the radiologist, pathologist, and the surgeons. The typical ‘sunburst’ radiological pattern observed in the OS of the long bones may not be evident in the OS of the flat bones. Owing toAlthough a CT scan and magnetic resonance imaging (MRI) can evaluate the exact location and extent of involvement of the bone and adjacent structures, they may not be useful in defining the exact nature of the tumor. Some authors opine that osteosarcoma should be suspected if the CT scan reveals a dense calcification within a mass that is centered in a rib. HistopatIn conclusion, this case highlights the fact that OS of the rib, although rare, should be considered in the differential diagnosis of primary malignant neoplasms of the rib.