Gastric pneumatosis is the presence of air within the wall of the stomach. It represents a spectrum of conditions ranging from benign disease to septic shock and death. Etiopathologically, it can be classified into emphysematous gastritis or gastric emphysema (GE). Along with hepatoportal venous gas (HPVG), it was considered as an ominous radiological sign and warranted an emergent surgical exploration; however, with widespread use of computerized tomographic (CT) scan, an increasing number of benign causes of GE and HPVG have been reported in the literature, where patients can be managed by noninvasive and conservative measures. We hereby describe a case where recurrent episodes of vomiting led to development of GE and HPVG and the patient was managed successfully by conservative measures. Gastric pneumatosis refers to the presence of air within the wall of the stomach. It can be classified into two types: gastric emphysema (GE) and emphysematous gastritis. GE is essentially non-life threatening and can be caused by a variety of iatrogenic and noniatrogenic events –6. PulmoIn rare instances, air within the stomach wall can dissect through the tissue planes and reach the portal veins, leading to hepatoportal venous gas (HPVG). Now from a radiological stand point HPVG denotes a catastrophic abdominal event like intestinal necrosis or bowel obstruction mandating urgent surgical intervention. However with growing use of CT scans in recent times, several benign cases of HPVG are described in the literature where invasive surgical approach is often not required and patients can be managed conservatively. CT scan plays an important role in such cases of acute abdomen to identify the underlying etiological process and help the clinician choose conservative over surgical treatment option –8. We heA 58-year-old male presented to the emergency room with complaints of abdominal pain, nausea, and multiple episodes of vomiting for last twenty-four hours. Patient described a sharp epigastric pain with 8–10 episodes of bilious vomiting and retching. He denied eating unusual food or taking over the counter pain medications. Patient had regular bowel movements and denied any blood in the stool. His past medical history included end stage renal disease requiring hemodialysis and peripheral vascular disease.On physical examination, pulse was 90 beats per minute, blood pressure was 150/90 mm of Hg, and temperature was 98.6° F. Mild tenderness was present in the epigastric region, but abdomen was otherwise soft and without guarding or rigidity. Fecal occult blood test was negative. The remainder of the physical exam was unremarkable.3 . Lactic acid level was elevated to 2.7 mmol/L . Serum amylase, serum lipase, and rest of the comprehensive metabolic panel were within normal limits. Subsequently, a computerized tomography (CT) scan of the abdomen was obtained which revealed air in the wall of the stomach along with large amount of air in the liver, spleen, portal vein, superior mesenteric vein, and splenic vein (Patient had an elevated white blood cell (WBC) count to 13.4 k/mmnic vein . HoweverIn spite of the worrisome findings on the CT scan, patient was hemodynamically stable and abdominal examination was completely benign. Therefore, he was treated conservatively with bowel rest, gastric decompression, intravenous fluids, and antibiotics. He improved significantly over the next 2 days. A repeat CT scan of the abdomen (obtained after 48 hours from presentation) showed complete resolution of gastric pneumatosis and portal venous air . The pro Clostridium perfringens, Escherichia coli, Pseudomonas aeruginosa, Streptococci, Staphylococci, and Enterobacter species are the most frequent causative agents [There are two types of gastric pneumatosis, emphysematous gastritis and gastric emphysema . Emphysee agents . Immunose agents , 10.Unlike emphysematous gastritis, GE is noninfectious in origin and occurs primarily due to entry of intraluminal air into the wall of the stomach. It may be divided into three etiological categories: traumatic, obstructive, and pulmonary .Traumatic GE is caused by transmural diffusion of air after a mucosal injury, which can occur during esophagogastroduodenoscopy (EGD), severe vomiting, cardiopulmonary resuscitation (CPR), or acute gastric dilatation caused by eating disorders –4, 6, 11Clinical manifestations in GE are usually nonspecific. Patients may present with nausea, vomiting, epigastric discomfort, or abdominal pain. Importantly, patients are almost always hemodynamically stable and do not show signs of acute abdomen. In general, it has a benign clinical course and resolves spontaneously without any clinical sequel –4, 6.HPVG was frequently seen with bowel necrosis, small bowel obstruction, peptic ulcer disease, and intra-abdominal abscess . Hence pHussain et al. have classified patients into three broad groups to simplify the treatment approach. First, patients with HPVG and signs of acute abdomen are best treated with emergent surgery. Second, patients with HPVG who lack clinical signs and demonstrate stable hemodynamic parameters should receive conservative management. Finally, patients with HPVG and uncertain clinical features should undergo endoscopy and/or diagnostic laparoscopy to rule out underlying bowel ischemia .We believe that, in our case, repeated episodes of vomiting and retching caused damage to the gastric mucosa and sudden increase in the intragastric pressure. This led to dissection and leaking of air into the intramural layer of the stomach wall and subsequent spread to the portal veins, superior mesenteric vein, and splenic vein . BecauseThe presence of air in the wall of stomach may be due to GE, which is often self-resolving, or due to emphysematous gastritis, which heralds worse prognosis. Superimposed occurrence of air in the portal venous system often causes a dilemma when considering surgical options. Historically, presence of gas in the portal venous system was considered as an acute abdominal emergency and warranted urgent surgical intervention but recently many benign causes of GE and HPVG have been described in the literature. These new cases were not associated with serious abdominal pathology and did not require surgical intervention. Therefore, HPVG by itself should no longer be an indication for emergent surgical intervention.


In the present case, a 49-year-old white female presented to the clinic with a 2-month history of nausea, vomiting, and right upper quadrant pain. On examination a 3-cm mass on the right anterior scalene muscle was noted. A computed tomography scan was performed revealing a 8.7 × 7.7 × 6.1 cm retroperitoneal mass with possible invasion of the inferior vena cava and right renal and left common iliac veins. An excisional biopsy was performed with pathology compatible with spindle cell sarcoma. The patient was then sent for follow-up at the sarcoma clinic as an outpatient. However, before chemotherapy was to be started the patient would be admitted to the hospital with progressively worse nausea and vomiting. At that time the patient’s lab work showed lactic acidosis, acute renal failure, hyperuricemia, hyperphosphatemia, and hypocalcemia, which met the Cairo–Bishop criteria for tumor lysis syndrome (TLS). The patient was admitted to the intensive care unit and kidney dialysis initiated. The patient would become progressively obtunded at which time the family opted for hospice care. The patient eventually succumbed peacefully 3 days after her last admission. In this case report, we briefly review the literature on TLS in solid tumors, and we present a rare case of spontaneous TLS in a retroperitoneal sarcoma. This can cause numerous different electrolyte abnormalities, including hyperuricemia, hyperkalemia, and hyperphosphatemia, which result in deposition of calcium phosphate crystals in renal tubules. This deposition leads to the consumption of calcium and can cause obstructive nephropathy.b values , within 4 Indeed, in a literature review done by Baeksgaard and Sørensen,5 a total of 45 cases of TLS in solid tumors were found from 1977 to 2002. Another literature review done by Vodopivec et al6 reported a total of 100 cases of TLS in solid tumors between 1977 and 2011, with 2 cases of spontaneous sarcoma reported in Poland.7 In this report, we present a case of spontaneous TLS in retroperitoneal sarcoma.TLS occurs more frequently in hematologic malignancies such as Burkett’s lymphoma, especially after starting cytotoxic medications. However, spontaneous TLS has been reported in solid tumors like breast or small cell lung cancer.The patient was a 49-year-old white female who presented with a 2-month history of intermittent upper right quadrant pain (RUQ), nausea, and vomiting. The patient had a past medical history of hypertension but was otherwise healthy. On physical examination, the patient had mild RUQ abdominal tenderness with no palpable organomegaly. However, there was a 3-cm mass that was seen on the right anterior scalene muscle. After admission, initial lab work was within normal limits. An abdominal computed tomography scan showed a 8.7 × 7.7 × 6.1 cm retroperitoneal mass with possible invasion of the inferior vena cava and right renal and left common iliac veins, as seen in An excisional biopsy was performed that revealed an undifferentiated tumor suggestive of a spindle cell sarcoma. The tumor showed positive immunostaining for vimentin and caldesmon, with focal minimal positivity for desmin, as seen in Her lab work at this time revealed a uric acid of 14.3 g/dL, phosphorus of 6.9 mmol/L, potassium of 5.1 mmol/L, creatinine of 2.98 mg/dL, and a lactic acid of 7.2 mmol/L, at which time the patient was considered to be in spontaneous acute TLS . The pat9Management of TLS includes aggressive hydration, treatment of the electrolyte imbalances, and correction of the acid–base disturbances. Commonly used pharmacological agents are allopurinol and rasburicase, which control the excess uric acid levels commonly present. Allopurinol, a competitive xanthine oxidase inhibitor, blocks the metabolism of hypoxanthine, xanthine to uric acid. Allopurinol decreases the new uric acid concentration, which further reduces the obstructive uropathy in patients who are at high risk for TLS. Allopurinol increases the serum xanthine and hypoxanthine levels in the serum, which could lead to acute renal failure by forming xanthine crystals in the renal tubules.11An alternative option for treatment of TLS is lowering uric acid levels by facilitating conversion of uric acid to allantoin, which is more soluble in water. Rasburicase is recombinant urate oxidase, and the indications for use of rasburicase for adult population were expanded in 2009. Rasburicase contraindicated in pregnancy, lactating women, and glucose-6-phosphate deficiency. In comparison to allopurinol, it can be safely given in patients with renal insufficiency, and dosage adjustment is not needed. Uric acid concentration should be measured every 3 to 4 days after the final dose of treatment. If not followed closely, assay concentration may falsely appear low, which leads to early termination of rasburicase.4 Health care providers should be aware of this especially when there are risk factors. This includes but is not limited to a high tumor proliferation rate and high tumor burden . When criteria for TLS are met by the Cairo–Bishop scale, aggressive efforts should be made to resolve these electrolyte imbalances promptly in order to avoid the multiple complications that may arise as a result. Of particular concern are the complications of renal failure that can be immediately life threatening. Moreover, when taken together TLS is a syndrome that can present in tumor of varying types, including solid tumors. Early recognition and aggressive treatment of TLS is pivotal for optimal patient outcomes.Although more common with hematologic malignancies, spontaneous TLS has been reported in solid tumors.


The peroneus tertius (PT) muscle is a variably present muscle, uncommonly found in humans. Injury to the PT tendon is rare with virtually no cases reported in the literature. As a consequence of the rarity of this injury, there is little clinical information regarding injury or rupture of the PT muscle and tendon. We present a case of injury involving this rare anatomical variant. Magnetic resonance (MR) imaging demonstrates a short segment longitudinal split tear adjacent to the tendinous insertion of the peroneus tertius muscle. Knowledge of this rare anatomic variant and the potential for associated pathology is critical in the management of the patient. Directing the orthopedic surgeon, or podiatrist, to this finding is critical for directing intervention.  The peroneus tertius (PT) muscle, also referred to as the fibularis tertius muscle, is a small muscle of the lower extremity whose principal action is weak dorsiflexion and eversion of the foot . AdditioA 39-year-old female presented with pain, burning sensation, and swelling of the left ankle requiring evaluation for a suspected anterior talofibular ligament tear and an osteochondral defect. MRI examination revealed the patient to have a peroneus tertius and quartus, both uncommon anatomic variants. Moreover, a rare high-grade tear injury of the peroneus tertius tendon was identified, which has not been previously reported in the literature.Increased signal on T2-weighted images was demonstrated in the peroneus tertius tendon sheath with a short segment longitudinal split tear immediately adjacent to its insertion. Additionally there was a high-grade, longitudinal split tear of the peroneus longus tendon and a complex longitudinal split tear of the peroneus brevis tendon Figure .T2 sequences also demonstrated elevated signal around the common peroneal tendon sheath, consistent with tenosynovitis Figure .The PT muscle originates at the anterior distal third of the fibula and courses beneath the superior extensor retinaculum before entering the tendinous sheath of the tibialis anterior. The peroneus tertius tendon subsequently passes beneath the inferior extensor retinaculum and inserts on the dorsal base of the fifth metatarsal. Several reports in the literature support morphological variation of the peroneus tertius, including variation in size, site, number of origins, and multiple points of insertion -6. The pInjury to the peroneus tertius tendon is rare, with no known cases reported in the literature. Therefore, there is little information pertaining to the clinical significance, diagnostic maneuvers, and therapeutic options for patients presenting with PT injury or rupture. In this case report, MRI sequences demonstrated a short segment, longitudinal split tear near the insertion of the peroneus tertius tendon, as well as tenosynovitis Figure . There wThe peroneus quartus muscle was also present in our case Figure . The perInjury to the peroneus tertius tendon is rare, with no previously reported cases in the literature. Therefore, there is little information pertaining to the clinical significance, diagnostic maneuvers, and therapeutic options for patients presenting with PT injury or rupture. Knowledge of this rare anatomic variant and the potential for associated pathology is critical in the management of patients who present with injury involving this uncommon variant.


Choristoma is defined as the presence of cells in abnormal locations due to defects during embryological development. The word choristoma implies a neoplasm; whereas heterotopia refers to a displaced tissue without necessarily being a swelling or a neoplasm. Literature contains reports of cartilaginous choristoma in the cervix, endometrium, breast tissue, and oral region. Three cases of cartilaginous choristoma, which were accidentally found during microscopic examination of excised tonsil tissues, are presented.Choristomas may cause difficulty in the differential diagnosis of true neoplasms, since they are rare and may grow. Therefore pathologists should be considered in the differential diagnosis of cartilaginous lesions, because cartilaginous choristomas of the tonsil are a rare entity.  Choristomas are benign lesions, rarely seen in head and neck region. They were also reported in the pharynx, hypopharynx, oral mucosa, and middle ear. Osseous and cartilaginous choristomas occur more commonly in the dorsum of the tongue . The oraThe first patient was a 50-year-old male, who displayed recurrent tonsillitis, and hypertrophy of the right tonsil . The excised tonsil was a 4 x 2 x 1.8 cm wide, hard, solid lesion. The second patient was a 4-year-old male, who displayed snoring, sleeping with the mouth open, and recurrent tonsillitis. Physical examination showed adenoid vegetation obstructing 75% of the choana and tonsillar hypertrophy (+3/+3). During adenotonsillectomy, right (2.5 x 2x 1 cm) and left (2.5 x 1.8 x 1 cm) tonsils were excised. They were soft and solid tissues.The third patient was a 28-year-old male, who displayed recurrent tonsillitis. Tonsils were hypertrophic (+3/+3). Following bilateral tonsillectomy, right (3.2 x 2 x 1.5 cm) and left (3 x 1.8 x 1.5 cm) tonsils were excised. They were soft and solid tissues.In all cases, the tonsils’ surface was greyish brown and the inner part was light brown. Conventional light microscopic examination of tissues showed signs of chronic tonsillitis characterized by reactive lenfoid hyperplasia with distinct germinal centers under multi-columnar stratified squamous epithelium and mature hyaline cartilage islands within the soft tissue around lenfoid follicules -3.Also, epidermal inclusion cysts in the superficial mucosa and actinomyces colonies were present in the tonsil tissue .Embryological anomalies are common in the neck region due to its complexity. Cartilaginous choristoma may be a developmental anomaly due to its common occurrence in the head and neck region. It was first defined by Berry in 1890. The age of the diagnosis for these patients varied greatly, ranging from 10 to 80 years ,4. CartiCartilaginous choristomas should be differentiated from cartilaginous metaplasia. In the oral cavity, cartilaginous metaplasia is usually seen in soft tissue under poorly fixed dentures. It is histopathologically character- rized by diffuse dystrophic calcification zones and single or clustered cartilage cells at different stages .There are several hypotheses for the pathogenesis of choristoma. Haemal et al. suggested differentiation of multi-lineage mesenchymal progenitor cells .Lindholm et al. suggested formation of osteogenic materials due to chronic inflammation , inducedPartihiban et al. suggested that choristomas of the tonsil are related to a developmental anomaly of the second pharyngeal arch and may cause recurrent tonsillitis . TonsilsProper treatment is simple excision of the lesion with the surrounding tissues. No recurrence of cartilaginous choristoma was reported in the head and neck region. However, in other regions, the perichondrium should be excised too, due to risk of new cartilage formation and hence recurrence. These lesions are benign as in any other cartilaginous tissue .Choristomas may cause difficulty in the differential diagnosis of true neoplasms, since they are rare and may grow. Therefore the pathologist should be aware of the properties of such lesions to avoid false diagnosis.


Penile paraffinoma is a well-known delayed complication of paraffin oil injection into the penis for penile girth augmentation but its MRI features have not been previously described.A 35-year-old Ukraine man presented with erectile dysfunction, voiding difficulty and an irregular, hard and painful penile mass that had progressively grown over the last year. He reported having received, seven years before, several penile injections of paraffin oil for penile girth augmentation. On physical examination, the mass was tender, poorly delimited, and involved the whole penile shaft and the cranial part of the scrotum. Preoperative MRI, performed to determine the extent of tissue to be removed and the possibilities of penile reconstruction, showed a newly-formed homogeneous tissue, compressing but not infiltrating Buck’s fascia, iso-hypointense relative to muscle on T1-weighted sequences, and with a low signal intensity at T2-weighted sequences. On T1-weighted fat suppressed sequences, it did not enhance with contrast administration. MRI data were confirmed by surgical findings, as the newly-formed scar tissue did not infiltrate Buck’s fascia. Pathology confirmed the diagnosis of penile paraffinoma.MRI seems to provide an adequate imaging of the histological events occurring after injection of paraffin oil in the subcutaneous tissues. Penile paraffinoma remains a clinical diagnosis, but MRI features may be helpful in planning an adequate surgical strategy and, in selected cases, establishing the differential diagnosis with other penile diseases, including cancer. In the first half of the 20th century, subcutaneous injection of liquid paraffin has widely been used worldwide  for cosm. Reasons for this unreasonable practice include, on one hand, the fact that it is easily available and easily performed by non-medical personnel or the patient himself, on the other hand, lack of standardized medical or surgical techniques for penile girth enhancement.Penile paraffinoma may present with penile scarring and deformity, abscess formation, ulceration, erectile dysfunction, painful intercourse, and voiding problems  up to acMost reported cases of penile paraffinoma focused on disease clinical presentation or on techniques for surgical excision and penile reconstruction , 9. To oA 35-year-old man emigrated from Ukraine presented to our Emergency Department with an irregular penile mass associated with erectile dysfunction and voiding difficulty. The patient reported that the penile mass had progressively grown over the last year up to become, in the last month, hard and painful. Physical examination revealed a tender, poorly delimited, subcutaneous indurated mass that extended on the whole surface of the penile shaft, from the coronal sulcus to the cranial part of the scrotum whereby the granulation tissue was palpable under the skin. The mass had no adherence to the overlying planes and was painful on palpation. There was no ulceration or inguinal lymphadenopathy.There were no relevant findings in patient’s medical history and he reluctantly admitted that 7 years before he had received 6 injections of paraffin oil into the penis, performed by an untrained person, for penile enlargement purposes; therefore, penile paraffinoma was diagnosed. He was scheduled for definite surgical treatment involving complete removal of the newly-formed penile mass and penile shaft reconstruction. In view of the extent of tissue to be removed and the risk of scrotal tissue as well being involved by scarring, thus leading to its removal rather than its use for reconstruction, the patient underwent preoperative penile MRI to properly plan surgery.Penile MRI was performed with a 1.5 T whole body MR unit (Philips Achieva) with the patient supine. The penis was flexed dorsally against the lower abdomen and taped in position to reduce motion of the organ during the examination. A SENSE Torso coil (8 elements) was positioned on the pelvis. First, axial T2-weighted TSE (Turbo Spin Echo) images  and axial T1-weighted TSE images (889/12) were acquired. Then, coronal FFE T2-weighted images 500/13), sagittal and coronal TSE T2-weighted (6009/120) were acquired. Finally, axial T1-weighted GRE images  were acquired with fat suppression before and after a bolus injection of gadopentate dimegluine . During all pulse sequences we used the following common parameters: a field of view of 260 mm, a slice thickness of 4 mm, and a matrix of 320 × 224. MRI showed a 18 mm thick lesion in the subcutaneous tissues of the penile shaft, surrounding the cavernous bodies up to spraining them in some points, causing a minimal distortion of the glans and a moderate narrowing of the bulbar urethra (Figure , sagittaOn the basis of these findings the patient was scheduled for surgical removal of the lesion, taking care to preserve Buck’s fascia and the underlying dorsal penile neurovascular bundle and to reconstruct with vital tissue the penile shaft. Postoperative course was uneventful; the urethral catheter was removed on the following morning and the patient discharged. At six weeks follow-up, he reported to be very satisfied with the cosmetic result as well as with his sexual function. Histological examination of the removed tissue confirmed the diagnosis of paraffinoma, showing optical empty spaces indicative of the presence of large fat globules dissolved during the staining process, along with a heavy inflammation mainly consisting of lymphocytes and histiocytes, throughout the whole specimen Figure .Figure 4There is clinical and histological evidence , 11 thatAn interesting finding of our report is that, in case of paraffinoma, the newly-formed fibrotic tissue does not jeopardizes the ability of MR imaging to evaluate the normal penile structures, particularly Buck’s fascia and neurovascular bundle. As a matter of fact, surgical exploration confirmed our MRI findings of paraffinoma fibrotic tissue attached but not infiltrating Buck’s fascia, which was visible as a thin line hypointense in all pulse sequences. This information is of great clinical relevance in planning the surgical strategy and in counseling patient’s about cosmetic and functional results of surgery.Another interesting point is that, although penile paraffinoma remains a clinical diagnosis based on patient’s admittance of such practice, diseases such as thrombosis of dorsal penile vein, syphilis, herpes genitalis, Behcet and, last but not least, tumors  may occuFinally, our MRI findings of penile paraffinoma were consistent with MRI findings of paraffinomas in the cervico-facial area  as well In conclusion, though penile paraffinoma remains a clinical diagnosis, the MRI features described herein may be helpful in planning an adequate surgical strategy and, in selected cases, establishing the differential diagnosis with other penile diseases, including cancer.Written informed consent was obtained from the patient for publication of this report and any accompanying images. A copy of the written consents is available for review by the Editor-in-Chief of this journal.


Adult, malignant brainstem gliomas are rare entities that often cause treatment conundrums due to the difficulty of surgical resection and, therefore, the absence of pathological diagnosis. This leads to a reliance on radiological imaging for diagnosis, which can often be unreliable. These shortcomings have made the treatment of brainstem gliomas challenging with unpredictable outcomes. The mainstay of treatment consists of chemotherapy and radiation; however, recurrence is inevitable. Predicting outcomes has been the major difficulty in treating these patients as adult malignant brainstem gliomas Grade II have a median survival between five to seven years while Grades III and IV are between 10-17 months . Here, we present the case of a patient with the pathologic diagnosis of a right brachium pontis glioblastoma who had a remarkable survival of 73 months, whereas the expected median survival for these patients is 10-17 months. Adult brainstem gliomas are a very different disease entity when compared to pediatric brainstem gliomas and present significant management challenges due to their rarity and absence of clear diagnostic classifications. While gliomas represent 40-60% of all primary brain tumors, brainstem gliomas only represent about 1-2% with malignant high-grade brainstem gliomas (WHO Grade III and IV) representing only a minority . Even wiFour typical delineations are used for classification of brainstem gliomas based on MRI: diffuse intrinsic low-grade gliomas, enhancing malignant gliomas, focal tectal gliomas, and exophytic gliomas . The enhHere, we discuss a case of a man with a clinical, radiographic, and histological diagnosis of a brainstem glioblastoma who underwent surgical resection, chemotherapy, and radiation with an overall survival of 73 months. This case aims to illustrate the difficulties of predicting brainstem glioma outcomes and alludes to the necessity for better biomarkers.We present a case of a 55-year-old, right-handed male who initially presented to his primary care physician 6 years prior with a 2-week history of double vision, progressive headaches, neck stiffness, toothaches, and subsequently right facial numbness. Given his unremarkable dental workup, he underwent an MRI of the brain that showed a right 2.9 cm (anterior-posterior) by 2.5 cm (transverse) by 2.0 cm (superior-inferior) brachium pontis heterogeneously ring-enhancing mass with associated edema Figure . He was The patient proceeded with a right retrosigmoid craniotomy for resection of his tumor. Intra-operatively, the lesion was noticed to be cystic with hypervascularity. To prevent a postoperative neurological deficit, a subtotal resection was performed, although postoperative imaging revealed a significant resection Figure . PostopePathological specimens were microscopically reviewed by way of histology, immunohistochemistry , and fluorescence in-situ hybridization (EGFR). Histologically, the tumor displayed hypercellularity, microvascular proliferation, and areas of pseudopalisading necrosis, leading to the diagnosis of glioblastoma multiforme, WHO Grade IV Figure . Other s2 for a six-week duration, along with radiation, totaling of 60 Gy. Over this timeframe, he continued on low-dose dexamethasone to reduce the edema associated with radiation. After completing his initial chemotherapy and radiation course, a repeat MRI of the brain was done that showed no change in the size of the enhancing portion of his residual tumor with some associated edema (Figure After a multispecialty discussion, it was determined that he would start adjuvant chemotherapy and radiation. Two weeks postoperatively, he started a six-week course of concurrent temozolomide and radiation. Temozolomide was started at a daily dose of 75 mg/m2 daily for five days for a total of 23 cycles and had MRIs every two to three months to track progression. By 36 months, the residual enhancing portion in the right brachium pontis had regressed significantly (Figure Over the subsequent two years, he continued monthly cycles of temozolomide of 200 mg/mStaphylococcus aureus and he was changed to oxacillin for a total of four weeks followed by two weeks of oral amoxicillin.Regrettably, 69 months after his initial diagnosis, new enhancement was seen along the resection tract in the right cerebellum Figure . After a2 daily, and a stereotactic radiosurgery re-irradiation to the resection cavity over five days.After completing his antibiotics therapy, he underwent a temozolomide re-challenge with 2 cycles of 125 mg/mTwo months later, he was admitted to the hospital for confusion and a lumbar puncture showed mildly elevated WBC concerning for recurrent meningitis. He was placed on ceftriaxone IV and no cultures grew bacteria; however, antibiotics were started 48 hours prior to lumbar puncture. Repeat MRI of the brain showed new strokes and slight ependymal enhancement in the right temporal horn which may have signified leptomeningeal carcinomatosis Figure . Given hIn this case report, we describe a middle-aged man diagnosed with a brainstem glioblastoma who, with standard therapy of surgical resection, chemotherapy, and radiation, survived for 73 months. This is one of the longest survivals documented in the literature. This case is a perfect illustration of the limitations associated with current diagnosis and treatment of adult brainstem gliomas. Based on radiographic appearance and histological grade, the patient should have had a median survival of 10-17 months, and yet, he survived for 73 months, similar to a low-grade brainstem glioma [The current radiology classification may be helpful to guide treatment, but it should not be thought of as a replacement for histological grading and molecular characterization. As more targeted therapies are developed, the need for tissue diagnostics becomes increasingly important. Correlation between MRI imaging characteristics and histological grade has been estimated as low as 67% [The patient’s overall survival could be explained by the fact that he had aggressive surgical resection, whereas many of these tumors have only a biopsy followed by adjuvant therapy. Also, given his low expression of MGMT, it would be expected that he would have a favorable response to temozolomide.In this case, we exemplify the essential need for tissue diagnosis in brainstem gliomas without which adequate treatment will be difficult. However, despite adequate tissue diagnosis, prognostication may still be challenging due to the ambiguous outcomes related to tumor grade and other current diagnostic tools. Ultimately, future biomarker identification that correlates with treatment effect and survival is necessary to improve diagnosis and prognosis associated with brainstem gliomas.


Lumbar intervertebral disc herniation and spinal tumor are major pathologies that may cause back pain and radiculopathy. Neurological symptoms resulting from disc herniation and intradural spinal tumor together, however, are very rare.We report a case of lumbar disc herniation which coexists with intradural schwannoma at the same spinal level in a 67-year-old man. The patient presented with persistent low back pain, sciatica, and weakness of the lower limbs. Contrast lumbar spine magnetic resonance (MR) imaging clearly delineated an intradural lesion and an extradural herniated disc at L3/4 level. Using a single posterior approach, both pathologies were addressed. Pathological studies confirmed the intradural lesion was schwannoma. The case report highlights a rare concomitance of two symptomatic pathologies in a lumbar spine, which deserves clinical attention. Complete history, careful physical examination, and investigative measures, such as contrast MR imaging, are helpful to establish throughout diagnoses.  Lumbar intervertebral disc herniation is one of the most common spinal disorders that cause back pain and radiating leg pain . Spinal A 67-year-old man presented with low back pain, sciatica, and weakness of the lower limbs for 2 years. His back and leg pain exacerbated after standing or walking and relieved by lying supine with the knees and hips flexed. Overall, his pain was tolerable. He can walk well, though he felt his legs were weaker than usual. He sought treatment at a local hospital, and magnetic resonance (MR) imaging revealed a herniation disc at L3/4 level. Two months ago, however, his back pain worsened considerably and he started to have intermittent claudication. His symptoms failed to respond to conservative treatments, and his walking distance decreased to approximately 100 m. He was referred to us for further treatment. His bowel and bladder functions were normal since he was sick.2) at the left side of the dural sac and a herniated disc of moderate size at the right lateral recess of the L3/4 spinal canal . His knee and ankle reflexes at the right leg disappeared, and sensation at the medial side of his left calf diminished. Pathological reflexes were negative at both legs. Lumbar spine MR imaging revealed an intradural lesion 14 × 8 mm4 × 8 mm2The patient underwent laminectomy and intrathecal tumor resection. Intraoperatively, the lesion was found to be encapsulated and stuck to a nerve root. After tumor removal, discectomy and posterior lumbar intervertebral fusion were performed. Histological studies revealed a herniated disc and a schwannoma. At the 6-month postoperative follow-up, the patient did not have back and leg pain. Neurological deficits at the extremities fully recovered, and he returned to normal life.The current case highlights a rare situation that symptomatic disc herniation and spinal tumor present simultaneously in a spinal segment. To our knowledge, there are only four similar cases of lumbar disc herniation coexisting with intradural tumor reported in English literatures –6. AlberSpinal schwannoma is a benign nerve sheath tumor, which comprises approximately 15 % of all spinal tumors . The vasIn general, posterior epidural migration of a herniated lumbar disc fragment, a rare situation of disc herniation, should also be included in the differential diagnosis for extradural and intradural tumors –12. ExtrWhen clinical symptoms cannot be fully explained by an identified pathology, the coexistence of another spinal pathology should be considered. It is easy to establish the diagnoses when a spinal tumor and a herniated disc present in the same spinal region, as both pathologies are displayed on a MR study. It is noteworthy, however, that spinal tumor and lumbar disc herniation may present at different spinal regions and a single MR study may not be able to reveal both. Knafa reported a patient who presented rapidly progressive spinal cord compression following discectomy . Her symWe reported a rare case with disc herniation and spinal tumor present at the same spinal level. Due to the similarities of clinical presentations and image findings for spinal tumor and disc herniation, and at an early stage, a diagnosis of spinal tumor was missed in our case. We highlighted the possibilities of concomitant dual or epidural pathologies in some cases. Complete history, careful physical examination, and investigative measures, such as contrast MR imaging, are helpful to establish throughout diagnoses.Written informed consent was obtained from the patient for the publication of this case presentation and accompanying images. A copy of the written consent is available for the review by the Editor-in-Chief of this journal.


A traumatic neuroma is not a true neoplasm but a reactive proliferation of neural tissue that commonly occurs after the transection or damage of a nerve bundle. Traumatic neuromas are rare in the oral region and usually occur as a solitary nodule of the mental foramen, lower lip, or tongue. This is the first report of a diffuse traumatic neuroma of the palate.A 30-year-old Japanese man was referred to our clinic complaining of painful swelling of the left side of his palate. The swelling was diffuse and his pain increased with palpation of his palate. He had no noteworthy medical or family history, and was not aware of any history of trauma or inflammation in his head or neck area. We administered antibiotics and non-steroidal anti-inflammatory drugs because we suspected that his symptoms were the result of inflammation caused by an infection. However, his symptoms did not change. An incisional biopsy was performed, and histopathologic examination indicated that the lesion was a traumatic neuroma. Under general anesthesia the lesion was resected with a 5-mm margin using an electric scalpel because of the diffuse expansion and indistinct borders of the mass. Some tumor cells were observed within the surgical margins of the resected specimen, but there has been no recurrence of either the pain or mass in the 3 years since the surgery.The location and diffuse nature of this traumatic neuroma are both very rare. While we were initially unsure about the diagnosis and treatment of this mass, the treatment outcome has been good. However, a postoperative recurrence can occur at any time following the excision of a traumatic neuroma, and close long-term follow-up will continue. A traumatic neuroma is a hyperplastic lesion caused by trauma or surgery that involves the peripheral nerves and is not considered to be a true neoplasm . It may A 30-year-old Japanese man was referred to our clinic complaining of pain, tenderness, and swelling on the left side of his palate for the past several months. Our initial clinical examination found that his left palatine mucosa was significantly swollen compared with his right side. The swelling was diffuse, and its borders were unclear Fig. . The sweBased on his clinical and radiographic examinations, our initial diagnosis was a soft tissue tumor. An incisional biopsy was performed and histopathologic examination of the lesion revealed haphazard nodes and inflammatory cells in a fibrous stroma Fig. . ImmunohTraumatic neuromas, also called amputation neuromas, are not true neoplasms but reactive proliferations of neural tissue that occur after transection or damage to a nerve bundle. Jones and Franklin  reportedet al. [The history of trauma or surgery is very important in the diagnosis of a traumatic neuroma. Our patient was not aware of any history of trauma or surgery. We therefore ruled out other neurogenic tumors Table . The hiset al.  noted thet al. , 3. ThesThe palatine mucosa is composed of a keratinized stratified squamous epithelium, lamina propria, and a submucosal layer. The submucosal layer is composed of glandular and adipose tissues that surround the palatine neurovascular bundle that runs under the lamina propria . The palCausal factors for oral traumatic neuromas include tooth extraction, orthognathic surgery, ill-fitting dentures and intra-oral incisions , 3, 14. et al. [It is a possibility that our surgical treatment did not result in the complete excision of the lesion. However, the tumor has not recurred in the 3 years since the surgery. Tay et al.  reportedet al. . Simple et al. .The borders of diffuse traumatic neuromas are often unclear, and the extent of the actual tumor may be such that a complete excision would result in severe neurologic damage, such as an area of hypoesthesia or complete nerve palsy. In these cases, simple excision of the tumor using an electrical scalpel is an effective method of treatment, and reduces the likelihood that the residual traumatic neuroma tissue would cause repeat symptoms or a full recurrence of the tumor.We report an extremely rare traumatic neuroma in an uncommon location and without a defined cause.Written informed consent was obtained from the patient for the 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.


Lipoid proteinosis is a sporadic congenital metabolic disorder which is characterized by deposition of hyaline material in dermis, submucosal connective tissue, and various internal organs. It has an extremely low prevalence rate with less than 300 cases reported so far. This progressive disease has a vast spectrum of manifestations ranging from asymptomatic lesions to fatal seizures and respiratory obstruction making timely diagnosis of this rare disorder an imperative task for oral health care practitioners. We report a case of characteristic oral manifestations of lipoid proteinosis in a 28-year-old male patient along with a review of relevant prevailing literature. Lipoid proteinosis is a rare autosomal recessive congenital disorder having a vast continuum of ophthalmic, cutaneous, neurologic, and oral manifestations characterized by deposition of hyaline material in various organs. A review of the prevailing literature revealed that less than 300 cases have been reported so far and very few cases have been accounted from the Indian subcontinent . Lack ofHere we report a case of lipoid proteinosis in a 28-year-old male patient with accentuated oral manifestations along with its scrupulous diagnostic work up.A 28-year-old male patient, a single child from a consanguineous marriage, reported to us for a routine dental checkup. He presented with hoarseness of voice since childhood. He gave history of occasional recurrent self-limiting oral ulcerations since 2 years. He gave no history of seizure episodes, visual disturbances, or any other systemic symptoms. Patient's family and medical history were noncontributory.On general physical examination he was found to be moderately built and nourished. There was presence of waxy beaded papules on the margins of both eyelids  and areaOn intraoral examination, macroglossia was evident with crenations along the margins and there was absence of papillae on the dorsum surface. On palpation the tongue and the sublingual frenum were found to be stiff and limited mobility of the tongue was noted Figures  and 3.There was presence of diffuse yellowish waxy papular lesions throughout the oral mucous membrane which appeared nodular and rough on palpation .A lateral skull view and posterioanterior view did not delineate the presence of any calcifications. On the basis of history and clinical appearance differential diagnoses considered were amyloidosis, lipoid proteinosis, myxoedema, and erythropoietic protoporphyria.Complete hemogram and thyroid profile values were found to be within the normal range. An incisional biopsy from the buccal mucosa and ventral surface of the tongue was performed. Similar histological findings and staining patterns were observed in the sections from both sites. Hematoxylin and eosin stained sections revealed stratified squamous parakeratinized epithelium and it was hyperplastic in nature. The tongue specimen showed spongiosis of epithelial cells in few areas. The connective tissue showed hyalinized fibrous stroma with fibers, fibroblasts, blood vessels, and proliferating endothelial cells. Numerous eosinophilic amorphous aggregates were seen in the connective tissue . SimilarAfter clinicopathologic correlation a final diagnosis of lipoid proteinosis was rendered. Patient was educated and made sentient about his condition; however patient was lost to followup.Lipoid proteinosis also known as Urbach–Wiethe syndrome or Hyalinosis cutis et mucosae is a sporadic autosomal recessive metabolic disorder which was first described by Viennese E. Urbach and C. Wiethe in 1929 [Exact etiology of this disorder still remains an enigma; however some researchers believe that frame shift and nonsense mutation in the gene encoding for extracellular protein 1 (ECM 1) gene on band 1q21 are liable. ECM is a glycoprotein expressed in several tissues, including those of the skin. This glycoprotein is composed of two alternatively spliced isoforms, ECM1a and ECM1b, the latter lacking exon 7 of the 10-exon gene. Exons 6 and 7 are the most common sites for ECM1 mutations in LP . Exact rThe earliest and most unswerving clinical sign of this disorder is hoarseness of voice due to hyaline deposition in laryngeal mucosa which may manifest at birth or later in life. Hoarseness of our patient's voice was the first manifestation which caught our attention. Oral health care practitioners who are not well aware of this feature may erroneously diagnose it as chronic laryngitis and overlook this vital clue .Cutaneous lesions manifest as yellowish waxy areas commonly affecting face, lips, and margins of the eyelids . Beaded Areas like palms, axillae, knee, and elbows which are subjected to constant mechanical trauma may develop a hyperkeratotic, verrucous surface .Intraoral manifestations include macroglossia, macrocheilia with fissuring, and nodular thickened mucosa due to infiltration of waxy yellowish white plaques and nodules. Loss of papillae of the tongue along with its restricted mobility has been reported in literature . These cIntracranial calcifications have been reported with epilepsy, mental dysfunction, and neuropsychiatric abnormalities .Clinical diagnosis is confirmed by histopathological examination. Histologic H and E stained sections divulge the presence of amorphous, extracellular, and eosinophilic hyaline material. They are PAS positive and diastase resistant .In the present case complete haemogram and thyroid profile values were found within the normal range which ruled out the possibility of myxoedema. Congo red staining was found to be negative, which ruled out amyloidosis. Erythropoietic protoporphyria exhibits similar cutaneous clinical manifestations but absence of similar oral presentation ruled out the possibility of this disease. All in all, the clinical and histologic features of the present case favored a diagnosis of lipoid proteinosis.2 laser therapy have also been suggested by a few authors [No specific treatment is available for this uncommon disorder. Oral steroids, dimethylsuphoxide, intralesional heparin, etretinate, and penicillamine have been used in therapeutic management. Dermabrasion, chemical skin peeling, blepharoplasty, and Co authors , 12.Even though it is a progressive disease, prognosis is good with a normal life expectancy . HoweverIn a country like India where certain communities still have frequent consanguineous marriages, the probability of offsprings to be affected by this genetic disorder is high. Vast spectrum of manifestations of this sporadic genetic disorder may result in diagnostic ambiguity. Hence, it is imperative for oral health care practitioners to have profound knowledge to thwart erroneous diagnosis and render appropriate counseling and treatment to such patients.


Intracranial lipoma is an uncommon entity. A rare type of tumor in the internal auditory canal (IAC) and the cerebellopontine angle (CPA) is lipoma. There are a few case reports in the literature related to intravestibular lipoma. Herein, we report a case of lipomas within the cerebellopontine angle and vestibule of the inner ear in a patient with tinnitus and dizziness. The patient was evaluated with a 1.5 T magnetic resonance imaging (MRI) system. MRI and CT showed the masses in the left CPA and the left IAC. These lesions were hyperintense on both T1- and T2 weighted images and showed no enhancement after gadolinium administration. Conservative management was suggested. Histopathological diagnosis is rarely necessary with the widespread use of magnetic resonance imaging. Considering significant morbidity during resection, conservative follow-up is the best approach for CPA and IAC lipoma. Lipomas are asserted as ectopic fat that are formed secondary to lipomatous involution of the residue of meninx primitiva, the mesenchymal derivative of the embryonic neural crest, which envelops the developing embryo. Intracranial lipomas are most commonly observed at the midline, often with concomitant callosal or other midline anomalies, but can also occur in the suprasellar and pineal regions and rarely in the cerebellopontine angle (CPA) . LipomasIn 2011, a 26-year-old woman referred to our department complaining of a profound hearing loss in the left ear. Episodes of tinnitus and dizziness were reported in her history. Although the patient described dizziness, she did not have spontaneous nystagmus in physical examination and the Romberg test was negative, so advanced vestibular tests were not performed. Tonal audiometry revealed a 37-dB hearing loss in the left ear, with 70% speech discrimination. Right ear pure tone audiometry was within the normal range.The patient was subjected to radiological examination and computed tomography revealed a homogeneously hypoattenuated CPA mass . MRI shoThe largest proportion of CPA tumors are vestibular schwannomas and meningiomas, composing approximately 85-90% of the tumors seen in this location . Other lCurrent theories on the pathogenesis consider lipomas as congenital malformations with one or two possible origins. A dysraphic disorder may cause mesodermal inclusions to remain trapped within the closing neural tube, or dysgenesis of indigenous tissue may cause the meninx primitiva to differentiate abnormally into adipose tissue , 8. SomeThese tumors can cause symptoms related to the VIII nerve involvement, such as hearing loss, tinnitus, vertigo and nausea. Mukherjee et al. reported a study with 10 cases. Nine patients had hearing loss, five patients had unilateral and one patient had bilateral tinnitus, and two patients had vertigo . MukherjClinical and radiologic follow-up was recommended for the other patients .White et al. studied 15 cases; eight lesions were confined to the IAC, while seven involved the CPA. The median tumor size at diagnosis was 7.2 mm. One patient underwent subtotal resection . Our patIn these three series, the lesion was located in IAC in 18 out of 32 patients, in CPA in 12 out of 32 patients and in only two patients, the lesion was in CPA and IAC together similar to our case. Two of the 32 patients were operated and the others were followed up clinically and radiologically as in our cases. Due to their specific imaging findings, the diagnosis of intracranial lipomas is highly suggestive. The CT scan shows a marked hypodense nonenhancing lesion in the CPA, which has similar densities with adipose tissue (-40 to -100 HU). MR imaging demonstrates characteristic hyperintense lesions on T1-weighted MR and hypointense on T2-weighted MR images compared with the brain tissue. As in our case, they did not enhance after the administration of contrast agent. The use of MR imaging with fat suppression was extremely helpful to clearly demonstrate the lipomas.As a result, lipomas must be kept in mind in the differential diagnosis. Careful radiologic evaluation is critical for correct diagnosis in order to prevent unnecessary intervention.


Pancreatitis and sinusitis as presentations of Burkitt lymphoma are uncommon and rarely described in children. We describe here the case of a child who presented with symptoms suggestive of sinusitis unresponsive to antibiotics, with subsequent development of abdominal symptoms due to pancreatitis. He was eventually diagnosed with Burkitt lymphoma. Burkitt lymphoma is a highly aggressive B-cell non-Hodgkin lymphoma. The sporadic form commonly affects the ileocecal region of the bowel and presents as an abdominal mass. Involvement of the pancreas is rare and few cases have been reported in children. Burkitt lymphoma of the head and neck primarily presents as lymphadenopathy but presentation as sinusitis is uncommon.We describe the case of an 8-year-old male who presented with symptoms suggestive of sinusitis and also abdominal symptoms suggestive of pancreatitis. On further imaging, he was found to have nasopharyngeal and abdominal masses due to Burkitt lymphoma.An eight-year-old male was referred to us for complaints of abdominal pain, emesis, and pancreatic mass noted on CT (computerized tomography) scan. His symptoms had started 7 days prior to admission with diffuse mid epigastric pain and postprandial emesis. He did not have any associated symptoms such as fever, diarrhea, abdominal distention, or weight loss. Previous history was significant for a 3-month course of progressively worsening nasal congestion, snoring, and anosmia. He was diagnosed with sinusitis and was initially treated with Clindamycin followed by trimethoprim-sulfamethoxazole and subsequently with a 10-day course of PO Prednisone (0.25 mg/kg daily) without any improvement of symptoms. On admission, he was afebrile, was hydrated, and was not in acute pain. Physical examination was significant for hyponasal voice, nasal congestion, mouth breathing, and bilateral nontender submandibular and anterior cervical lymphadenopathy. His abdomen was soft, was nondistended, and had no palpable masses or organomegaly but epigastric pain was present on palpation. Initial laboratory tests included an elevated lipase (7500 U/L) and amylase (306 U/L) consistent with acute pancreatitis. He was managed with bowel rest and intravenous fluid hydration. Other initial labs included a complete blood count, liver, and renal function tests which were within normal limits. Peripheral smear showed normocytic, normochromic RBC with normal number and morphology of the neutrophils, lymphocytes, and platelets.Given his upper airway symptoms, MRI (magnetic resonance image) of the orbit and face was done which revealed a 3.1 cm × 5.8 cm × 3 cm nasopharyngeal mass extending into the sphenoid ethmoidal recess causing airway obstruction . DiffuseAn MRCP (magnetic resonance cholangiopancreatography) was obtained to better characterize the pancreatic mass seen on CT scan. T1 and T2 weighted images revealed a 1.8 cm × 2.1 cm × 1.9 cm well-circumscribed, isointense solid mass over the head and neck of the pancreas . There wAfter resolution of pancreatitis, patient was taken to the operating room for exploratory laparotomy. A single palpable mass was appreciated at the neck of the pancreas. Intraoperative ultrasound was performed and did not show invasion to the mesenteric vessels. Further examination of the abdomen did not reveal evidence of metastatic disease and hence the mass was deemed resectable. A pancreaticoduodenectomy with classic antrectomy and gastrojejunostomy, pancreaticojejunostomy, and hepaticojejunostomy (Whipple Procedure) was performed. During the creation of the gastrojejunostomy, 2 nodules located on the anterior abdominal wall were palpated. Biopsy of the lesions was submitted to pathology for frozen section and appeared to be “small and blue” in nature; however it could not be further characterized. Wedge resection was performed for cytology evaluation. On gross examination of pancreatic specimen, a smooth, tan, firm lesion measuring 2.1 cm × 2 cm × 2 cm was noted. The pancreatic duct was stenosed, but patent. Margins were negative of disease.The specimen, as sent for pathology, consisted of a pancreatic head (5 × 3.2 × 2.5 cm), gastric segment (2.5 × 1.8 × 1.5 cm), duodenal segment (30 × 3.2 cm), and gallbladder (7.8 × 5 cm) with common bile duct (5 × 0.2 cm). The pancreatic duct was found stenosed, but patent. Dissection of the specimen revealed a smooth, tan, firm lesion measuring 2.1 × 2 × 2 cm, located 5 cm from the gallbladder neck, bordering the inferior, superior, anterior, and posterior pancreatic margins and extending into the gastric mucosa.On histologic examination, the majority of the pancreas had been effaced and replaced with sheets of lymphoid infiltrate. The medium-sized cells had a high nucleus : cytoplasm ratio and the round, monomorphic nuclei contained at least one basophilic nucleoli . No tangFurther tests for spread and staging of the lymphoma were done. Bone scan was negative for metastasis. Bilateral bone marrow aspiration showed no increase in blast population and no involvement of bone marrow with lymphoma. Storage iron was absent. c-MYC rearrangement was positive in the tumor tissue but negative for the bone marrow. CSF was positive for malignant lymphoid cells. The patient was stratified under Group C due to his CNS positivity and started on treatment as per standard arm Group C1 under Protocol CCG 5961/FAB LMB 96 protocol [He had resolution of clinical symptoms after the first cycle of chemotherapy and a repeat MRI showed a significant reduction in the size of the nasopharyngeal mass. This implied that the adenoid enlargement is most likely due to Burkitt lymphoma since there was a remarkable improvement of symptoms immediately after the start of chemotherapy. He is planned to receive maintenance cycles with Methotrexate and Cytarabine.Acute pancreatitis in children is most commonly secondary to medications like steroids and L-asparaginase, trauma, or anatomical abnormalities in the pancreatic-biliary system . LymphomBurkitt's lymphoma is an aggressive tumor with a doubling time of 24–48 hours . It is cPresentation with bilateral involvement of the maxillary, ethmoid, and sphenoid sinuses, as seen in our patient, is rare. Given its rapid growth, severe facial deformity can result and immediate intervention is mandated. Nasopharyngeal involvement can present with hyponasal speech and otitis media and is frequently misdiagnosed as sinusitis and/or nasal polyposis  as was iUltrasound as the initial imaging modality is acceptable for evaluation of the abdominal mass but the extent of the disease, vessel, and lymph node involvement is better delineated with MRI or CT . PositroDue to the high incidence of extranodal disease, the Murphy staging system is used to stage the pediatric lymphomas as compared to the Ann Arbor staging used for adults. Stage IV NHL is defined as tumors involving bone marrow and/or CNS, regardless of other sites of involvement. A patient is considered to have CNS disease if any malignant cell is present in the CSF regardless of cell count. CNS involvement is seen only in 8.8% of the patients with Burkitt lymphoma. The response to first-line therapy is one of the most important prognostic markers for NHL.Burkitt lymphoma rarely presents as pancreatitis or sinusitis. Since it is an aggressive tumor with an excellent response to chemotherapy, a high suspicion of Burkitt should be maintained in all children unresponsive to antibiotics and steroids to avoid misdiagnosis and complications.


Testicular tumors are very common among man under the age of 45 years. The case of bilateral synchronous testicular seminoma is very rare. We present a case of bilateral synchronous testicular seminoma stage-I in a 42-year old Indian male who came to our hospital with chief complaints of dull ache in the abdomen and groin, bilateral scrotal swelling and heaviness, left-sided scrotal swelling since last four years, and right-sided since last two years. He underwent bilateral orchidectomy followed by radiotherapy. In this case we throw light on this rare condition and discuss the management. Germ cell tumors of testis, in man under the age of 45 years, is the most common malignancy . HoweverPatient 42 year Indian male father of two came to surgery outpatient department of our hospital with chief complaints of dull ache in the abdomen and groin, bilateral scrotal swelling and heaviness, left sided scrotal swelling since last four years and right sided since two years. There was no relevant past, family or personal history that could have been of importance to establish the provisional diagnosis of testicular malignancy. On examination his vitals were stable and there was no cardiovascular, respiratory or neurological disorder. On local examination swelling was present over bilateral hemiscrotum left more than right. On left side swelling was 11X8X6 cm3 (approx.), non-tender, firm to hard in consistency, surface was regular and it was associated with restricted mobility and it was possible to get over the swelling, transillumination was negative. On right side swelling was 8X6X5 cm3 (approx.), non-tender, firm to hard in consistency, surface was regular and it was associated with restricted mobility, it was possible to get over the swelling, transillumination was negative. Testicular sensations on the left side were absent and on the right side were altered (reduced). Also, the inguinal lymph nodes were bilaterally swollen, non-tender and palpable. Patient was admitted to the male surgery ward with a provisional diagnosis of the bilateral testicular malignancy.Patient was admitted and routine and diagnostic investigations were performed, hemoglobin was 14.6 gm%, Total leukocyte count, differential leukocyte count and platelet count were within their normal range. Serum urea and electrolyte levels were normal. Liver and kidney function tests were within normal limits. Chest radiograph did not reveal any abnormality. Urine routine and microscopic examinations were normal; blood group and cross matching were also done. Special investigations included the assessment of serum tumour markers Beta HCG was elevated 12 mIU/ml, Alpha-fetoprotein and lactate dehydrogenase (LDH) were normal.Ultrasonography of the abdomen and pelvis  revealedCT scan of the abdomen and pelvis revealed left testis was enlarged measuring about 11X8.8X7.8cm and appears heterogeneously hypodense with a CT attenuation value of 20-30HU on post contrast CT scan there was mild heterogeneous enlargement of the testis with CT attenuation of 30-40HU with few enhancing areas. Right testis was enlarged measuring about 8X6.9X5.5cm and appear heterogeneously hypodense with CT attenuation value of 20-30HU on post contrast CT scan there was mild heterogenous enlargement of the testis with CT attenuation of 30-40HU with few enhancing areas. Both epididymis were not seen separately from the enlarged testis bilaterally. There was moderately non enhancing collection seen within the left extra testicular compartment. There were no internal septations suggestive of left hydrocele. The overlying scrotal wall was thin and stretched.Intraoperatively biopsy of the left testis was done from the suspicious area and frozen sections were sent for the histopathological examination. Frozen sections were suggestive of malignancy. Histopathological findings, revealed spermatocytic seminoma stage-IA. The patient underwent Left sided orchidectomy  under geHistopathological studies revealed that both testes were atrophic and multilobulated. The microscopic evaluation also revealed atrophic seminiferous tubules with reduced spermatogenesis, and dysplastic cells. The seminiferous tubules were surrounded by numerous infiltrates composed of lymphocytes, neutrophils, and macrophages. Neoplastic cells and inflammatory infiltrates were present in both testes .The patient was given prophylactic radiotherapy for next 15 days and the total dose given was 20Gy to prevent any relapse. He was advised to follow up every 6 months, presently he was asymptomatic, follow-up CECT abdomen and pelvis are normal, tumor markers are well within the limits and there is no evidence of disease.Germ cell tumors of testis occurring bilaterally is a very rare entity, and its incidence ranges from 1% to 5% as published previously in the large series  . The impManagement of the bilateral synchronous testicular tumors is a comparatively not easy mainly due to the rarity of the condition and the paucity of the literature. An institutional study carried at Memorial Sloan Kettering Cancer Centre over 50 years, showed 10 patients with synchronous out of 58 reported cases of bilateral testicular germ tumors. The histopathological findings in this study showed seminoma to be the predominant tumor with only 7 cases of nonseminomatous tumor. Treatment as mentioned in this series was mostly based on the histological findings and the stage of the tumor. The patients with both seminomatous and nonseminomatous tumors with stage-I, the method of treatment was retroperitoneal lymph node dissection. Chemotherapy was used in higher stages of tumor. However, stage-I bilateral seminoma were treated with postoperative radiotherapy and in higher stages chemotherapy was the treatment of choice [Over the last 50 years, the main management of testicular stage-I seminoma has been the orchidectomy followed by adjuvant radiotherapy as done in this case. However, many studies mentioned the deadly effects of radiotherapy, which might not even be essential in many cases. The use of surveillance and chemotherapy instead of postoperative radiotherapy, in case of recurrence will be a better option. Radiotherapy has many side effects like nausea, fatigue, oligospermia, increased risk of development of second cancers, peptic ulceration. Besides, there has been lots of questions raised on cardiac toxicity as a side effect of radiations in cancer survivors.As mentioned by Agrawal et al (2010) due to the presence of lots of studies mentioning about various ways of management only a generalization can be made about the treatment of testicular cancers . Stage oTesticular cancer is very common among males but it has very high cure rate in excess of 90%. While most types have a tendency to spread, if not noticed and can spread to the other testicle, and metastasize to the lymph nodes or other body organs, such as the lungs. Early diagnosis and treatment is very important for a favorable outcome. However, in cases where patient failed to come to surgeons, as in this case, there was involvement of both the testes and as the patient had two children i.e. his reproductive life was successful, thus removal of the testes was the best option. It was followed up with a regular radiation therapy and follow up monitoring for any metastasis.Testicular malignancies are rare and bilateral synchronous spermatocytic seminoma is the rarest of all the testicular malignancies. It should be considered, especially while evaluating germ cell tumor in both young as well older men. It is distinct in its histologic appearance and can be easily differentiated from other tumors histopathologically. Since, it rarely metastasizes, correct histologic diagnosis and treatment i.e. involving the prophylactic radiotherapy to the lymph nodes involved, followed by orchidectomy for stage I seminoma can have great impact on prognosis. This treatment modality is the most cost-effective and is associated with the lowest risk of tumor recurrence (1% to 3%) , 5.


Primary CNS lymphoma (PCNSL) is a rare non-Hodgkin's lymphoma confined to the CNS. Local relapse of this disease is common, but extracranial or subcutaneous metastasis is rare with only a few cases being reported in literature. We report a 63-year-old male patient, who responded well to treatment for PCNSL but relapsed two and half years later with a lumbosacral nodule at the site of a previous lumbar puncture due to microscopic tumor seeding. Clinicians treating patients with PCNSL must remain alert to the possibility of extracranial solitary relapse even after the resolution of initial disease because prompt treatment can result in a good outcome. Primary CNS lymphoma (PCNSL) is an aggressive uncommon form of extranodal non-Hodgkin's lymphoma confined to the CNS, but its incidence has increased in both immunocompromised and immunocompetent hosts. Around 1900 new cases are diagnosed in the USA each year. It affects the brain parenchyma, intraocular compartment, cranial nerves, and rarely the spinal cord [+ diffuse large B cell lymphoma [Stereotactic biopsy is the diagnostic procedure of choice revealing CD20lymphoma . Nationalymphoma . 10–15% Data on the relapse of PCNSL is limited and prognosis is poor, with a 2–4-month survival  Relapse In patients with late relapses ≥5 years, intracranial sites remained most frequent with only one systemic relapse occurring in the kidney among 230 patients, as reported by Nayak et al. .We report a patient with well documented PCNSL, who relapsed in a site of previous lumbar puncture, without CNS involvement.A 63-year-old man presented, in October 2009, with complaints of right sided hemiparesis. An MRI of the brain showed a large mass in the left frontal area  and a stHe stayed in remission until August 2012, when he presented with a palpable 1.5 cm nodule, in the lumbosacral region, the site of a previous lumbar puncture. A biopsy of the lesion showed a diffuse large B cell lymphoma, consistent with recurrence of the original CNS lymphoma. He underwent local excision followed by chemotherapy, in the form of 4 cycles of the R-CHOP  regimen, to treat the recurrent nature of his disease. Postchemotherapy consolidation radiotherapy of 3000 Gy in 250 cGy was directed at the lumbosacral spine region and the patient acquired complete remission, with the area showing no palpable mass, hypopigmentation, or wound dehiscence. At the last visit (on 17th of September 2013), the patient continued to be in remission.Extracranial skin or subcutaneous recurrence of PCNSL is rare with few reported cases in the literature. Al Bahrani et al.  reportedOur patient, who presented with PCNSL and responded well to treatment with high dose methotrexate and radiation, remained in remission for almost two and a half years. He then presented with an extracranial relapse; however, according to the literature, PCNSL only rarely relapses or metastasizes to extracranial regions. The 1.5 cm solitary subcutaneous nodule discovered in our patient at the site of lumbar puncture responded well to treatment with the monoclonal antibody Rituximab and CHOP, which represent the backbone for treating patients with DLBCL . After rIn our review of the existing literature, a previous case on relapse of PCNSL in the lumbosacral region, especially in a site of previous lumbar puncture, could not be found. We speculate that the reason for development of the rare lesion at the site of the lumbar puncture was due to microscopic tumor seeding.Clinicians treating patients with PCNSL must remain alert to the possibility of extracranial solitary relapse even after the resolution of initial disease because prompt treatment can result in a good outcome.


Mature cystic teratoma is the most frequent benign ovarian neoplastic lesion in adolescents and is generally composed of fully differentiated tissue arising from multipotential three germinal layers. It accounts for approximately 50% of benign ovarian tumors in childhood. Rarely, a bilateral, synchronous, or metachronous presentation can be observed, supporting a conservative approach as the first surgical approach. We report a case of an ovarian mature cystic incarcerated in indirect inguinal hernia in a 15-year-old girl undergoing ovary-sparing surgery. To our knowledge this is the first case of such lesion incarcerated in an inguinal hernia reported in literature. Mature cystic teratoma (MCT), the most common benign ovarian neoplastic lesion in adolescents, arises from the totipotential primitive germ cells . MCT accHistologically, MCT is characterized by external lining composed of squamous epithelium with an underlying fibroconnective tissue containing hair follicles, sebaceous, eccrine, and apocrine glands. The presence of all the skin appendages in these cysts distinguishes them from epidermoid and sebaceous cysts.MCT occur most commonly in the ovary, but cases of extragonadal origin have also been described, especially in the omentum, the most common extragonadal site of these parasitic MCT .We report an undescribed case of 15-year-old girl with an ovarian MCT incarcerated in an indirect inguinal hernia, treated with ovary-sparing approach. A dermoid cystic lesion, probably the result of an ovarian autoamputation due to ovarian torsion, was previously described in an indirect inguinal hernia that occurred in a 66-year-old woman . Other rAlthough classic treatment of ovarian teratomas was oophorectomy, “ovary-sparing tumor surgery” has become a popular procedure in order to avoid fertility impairment secondary to decreased ovarian tissue reserve and remarkable possibility of contralateral metachronous teratoma development.A 15-year-old female presented at our institution with a slowly growing mass in left groin, noted for 2 years, in menarcheal period. On abdominal examination, the lesion appeared as a smooth, nontender, irreducible mass measuring about 6 × 2,5 cm, fixed in the left inguinal region, and had well-defined margins.The patient reported a previous failed surgical excision in local anesthesia, attempted in an adult surgery department of another hospital; the first attempt failed because of the unexpected intraoperative detection of the left ovary in inguinal region.The patient was, then, admitted to our institution 2 months later; the first surgical approach and a further US described a multicystic left ovary  in inguinal region with a hyperechogenous 3,3 cm nodule containing calcific inclusions .Magnetic resonance imaging (MRI) showed a hernia sac extending into the left inguinal region and containing ovarian tissue with an inner cystic-solid mass; there were fat-fluid levels within the mass and a dissection plane between the mass and ovary was evident on MRI Figures  and 3.Because of the suspected diagnosis of ovarian MCT incarcerated in an inguinal hernia, serum levels of alpha-fetoprotein (AFP), beta-human chorionic gonadotropin (BHCG), and lactate-dehydrogenase (LDH) were investigated, revealing normal serum values.Surgical excision of the mass and reconstruction of the inguinal region were performed.During surgery the mass was detected at external inguinal ring and isolated from ovarian tissue ; the ovaThe postoperative period was uneventful. Drain was removed on the third postoperative day and the patient was discharged on the third day postoperatively.At macroscopic pathology, the cystic mass revealed a sebum-like material containing hair. Histopathologic examination of the cyst wall showed keratin composed flooring epithelium with underlying connective tissue including skin adnexa and cylindrical ciliated epithelium. These morphological features were compatible with a MCT.So, the girl was enrolled in a clinical and imaging follow-up in order to detect any eventual relapse or involvement of the residual ovarian tissue. Pelvic US performed 24 months after surgery showed normal ovaries. Actually, she remains clinically well after a 30-month follow-up .MCT occur most commonly in the ovary, but extragonadal lesions have also been described. There have been three proposed theories concerning the etiology of those extragonadal sites: (1) primary teratomas originating from displaced germ cells; (2) teratomas developing in a supernumerary ovary, and (3) autoamputation of an ovarian teratoma and reimplantation into an extragonadal site .In our case MCT was found within left ovary inside hernia sac in the left inguinal region. Incarceration of the ovary in the inguinal hernia was probably due to the excessive growth of both ovary and mass under pubertal hormonal stimulation. Adhesion between the tumor and the adjacent structures was probably due to subacute torsion.Although it is unclear which signal allows the growth of these lesions, it has been suggested that increasing estrogen and progesterone levels stimulate the sebaceous component of these tumors, partially explaining the increase in size seen in MCT after puberty and the arrested growth after menopause , 9.A differential diagnosis of masses in the inguinal region and radiological features includes not only hernias, but also gynecologic, vascular lesions such as lymphangiomas and benign and malignant tumors of the various structures within the inguinal canal. Adnexa or hemorrhagic ovarian cyst in an incarcerated inguinal hernia and primary neuroblastoma of the inguinal canal or neuroblastoma metastasis are some of the lesions reported .Appropriate imaging investigations could avoid unexpected intraoperative features, improving the prognosis by identifying potentially life-threatening lesions.Pelvic US, which allows good evaluations of localization, size, and structure of the lesion, should be the first approach imaging investigation; computed tomography (CT) scan or MRI can be used in selected case. MCT are mostly in cystic-solid composition with calcifications in 40% of cases . FrequenSerum markers are useful in differentiating benign from malignant ovarian lesion . ElevateThe recommended management of MCT is generally surgical excision due to risk of ovarian torsion, spontaneous rupture, and malignancy occurrence. Nevertheless, malignant transformation of a mature teratoma is a very rare complication, with a reported incidence of 0,17–2% . AutoimmMature teratomas are classically treated with oophorectomy, either in open or laparoscopic approach. However ovary-sparing surgery has gained an increasing success and consent in recent years. MRI investigation should be performed for proper identification of tumor margins in order to indicate and plan ovary-sparing dissection .Since there is a low recurrence rate (0–4%)  for ovarHowever, long-term follow-up with clinical evaluation, serum markers, and imaging studies should be performed in order to detect early relapse or contralateral ovarian involvement.


Giant condylomata are not usually seen nowadays in developed nations, but such cases are still seen in the under-resourced countries. Condylomata acuminata are commonly transmitted through sexual intercourse. Generally diagnosed based on their appearance. Giant condyloma acuminata also named Buschke- Löwenstein tumour (BLT) is a slow growing cauliflower-like tumor, locally aggressive and destructive, with possible malignant transformation. Common clinical treatment of anogenital warts is conservative, however, in extreme cases conservative therapy is insufficient and surgical excision is required. A case of common presentation of giant condylomata in a 50 years old, divorced, multiparous woman is presented and the literature is reviewed. She presented with 15 years history of slowly progressive vulval lesion and associated itching, contact bleeding, malodorous vaginal discharge and difficulty in walking. She had previously been treated with podophyllin and cryosurgery without success. The growth measured 30×10 cm in each side and was successfully excised with no evidence of malignancy concomitant and reconstruction also done.  The immune system effectively repels the majority of HPV infections and is associated with marked localized cell mediated immune responses. However, approximately 10% of individuals develop a persistent infection, with risk of developing benign proliferative lesions, high-grade precursors and eventually invasive carcinomas.9 HPVs are classified into high- or low-risk types depending on oncogenic potential. Low-risk types 6 and 11 are isolated in approximately 90% of genital wart cases.3 The most common clinical treatment is conservative, with local chemical or physical destruction and immunological therapy.10 In more extreme cases conservative therapy is insufficient and surgical excision is required.Anogenital warts  are a common sexually transmitted disease among females and males.11,12 A complex histological pattern may exist with areas of benign condyloma intermixed with foci of atypical epithelial cells or well differentiated squamous cell carcinoma. GCA is mainly localized to the genital region, however, in rare cases the tumor is localized to distinct histological zones of the anorectal region. Due to infiltration of the underlying tissue, fistulae and abscesses may be observed. GCA is resistant to chemotherapy or radiotherapy and usually requires local radical resection for curative treatment. We report a case of 50-year-old lady with GCA of vulva who was successfully treated by simple vulvectomy and reconstruction of the defect by ‘‘two-advanment flap technique’’.Giant condyloma acuminata  is an extremely rare clinical form of genital warts, characterized by aggressive down growth into underlying dermal structures.A 50-year-old female presented with cauliflower-like growth over the uvula region. The growth had been diagnosed previously as condyloma acuminatum which was resistant to conservative therapy . The patOn examination, there was a huge friable, foul smelling growth on her vulva involving both labia majora, extending anteriorly to mons pubis and posteriorly to perianal region . There wA simple vulvectomy, achieving wide margins, was performed. Small lesions in perianal area and labia minora were also excised. Reconstruction of vulva was performed using ‘two flap advancement technique’. In this technique, two random pattern flaps in the dimension of 1:1 or 1:2 were raised adjacent to the defect and advanced medially to resurface the defect. This resulted in defect being transferred laterally, but this defect was smaller than the original defect and could be closed primarily  and 3.Final histopathology report confirmed the diagnosis of condyloma acuminatum with mild degree of dysplasia . Functio10 In rare cases, anogenital warts develop into extremely large tumor masses leading to deterioration of patient quality of life. An identified underlying histopathology of specific cases of giant condyloma is superficial planocellular carcinoma. Anogenital warts are the most common outcome of HPV genital infection. Therapeutics against this sexually transmitted disease are currently associated with low efficacy, due to a 30-70% recurrence rate identified six months following therapy administration.Patients with high susceptibility to local development and fast progression  and the highest rate of recurrence often exhibit various types of immunodeficiency. In addition, immunodeficiency leads to difficulties in evaluation of optimal therapeutic management. However, patients with no marked immunodeficiency and treatment-resistant genital warts have been identified. Furthermore, condyloma lesions occasionally form large exophytic masses, interfering with intercourse, normal urination, defecation or vaginal delivery.13 The method selected for reconstruction is crucial, particularly in neglected cases similar to the present case study. Local tissue availability and the patient’s condition and attitude towards the development of the disease are major factors for reconstruction with local fascio-cutaneous flaps. Five years following surgery, the present patient is disease-free with no recurrence.Commonly, GCA develops as cauliflower-like masses and the tumors exhibit histological features of pseudo-epitheliomatous proliferation and local invasion. In the absence of metastases, they are termed Buschke-Löwenstein tumors. Due to the aggressive local development of these masses, they belong to the verrucous carcinoma group, although a malignant histological alteration in the form of micro-invasive carcinoma or well-differentiated epidermoid keratinizing carcinoma has been reported. Due to the high frequency of local recurrence, radical surgical excision is the current treatment of choice as topical preparations and chemotherapy are generally considered ineffective.1,3 Other modalities include combined radiotherapy and chemotherapy, topical agents  and intralesional injections of interferons.4-7Many treatment strategies have been documented in the literature for management of GCA, but mainly in the form of case reports. Complete surgical excision with histologically clear margins, with or without adjuvants, is the mainstay of the treatment for GCA, including that of vulva.1,8-10 Flaps have been shown to give better results for reconstruction of vulva.9,8 To conclude, surgical treatment using wide local excision of the lesion with clear margins and reconstruction of the resultant skin defects by two transpose flap technique gives excellent cosmetic and functional results.The skin defects created after excision of GCA in the peri-anal region can be managed with mesh skin grafting, flaps and even healing by secondary intention.The authors declare no conflict of interest.


Endobronchial tumors represent the rarest cause of airway obstruction in pediatric population. Due to rarity of the condition, a high index of suspicion is required for early diagnosis. We report a patient in whom diagnostic bronchoscopic biopsy was reported as leiomyoma while post resection histopathology showed an atypical carcinoid. Bronchial carcinoids are rare tumors and characterized as low grade malignant tumors with metastatic and invasion potential. They arise from neuroendocrine Kulschitzky cells found in basal layer of bronchial epithelium. Based on presence/absence of necrosis and normal/raised mitotic index; carcinoid tumors are classified in to typical (10%) or atypical (90%) subgroups. An elevated mitotic index (2 mitoses/ 10 HPF) associated with necrosis is consistent with an atypical carcinoid tumor and with a worse prognosis as compared to typical tumors. [1] Herein one such case is reported.A 13-year-old girl referred from other city with the complaints of choking and hemoptysis for last five months. In her native city she was initially managed as a case of pulmonary tuberculosis and took anti-tuberculous therapy but symptoms did not subside. She underwent bronchoscopy and found to have an obstructing mass in left main stem bronchus. Due to some technical issues related to biopsy sampling, she was referred to our institute.On examination, there was no sign of respiratory distress. Percussion note was dull on left side with no air entry on auscultation. Chest x-ray showed collapsed left lung. CT scan chest showed a 2.5 cm x 2 cm mass in left upper lobe bronchus causing complete collapse of left lung . Bronchoscopy showed an obstructing lesion in left main bronchus . A biopsy was taken which revealed spindle shaped lesion without any atypia favoring leiomyoma. The girl underwent a left thoracotomy and pneumonectomy in collaboration with a cardiothoracic surgeon. The tumor was completely excised. Upper lobe was found completely involved by tumor while lower lobe cannot be salvaged due to extension into main stem bronchus . Histopathology showed infiltrating carcinoid tumor staining positive for chromogranin. Ki-67 showed increased proliferative index. Postoperatively, the patient had an uneventful course. Her chest drain was removed on first postoperative day. She was discharged on 5th postoperative day and is doing fine on follow-up.The most common presentation of bronchial carcinoid in children is hemoptysis, cough, dyspnea, chest pain and pneumonia.[2-4] Our patient had an unusual presentation of choking with hemoptysis which may be related to large amount of bleeding from lesion. These are often diagnosed late. Our case had a delay of five months before diagnosis. The CT scan/MRI can give a clue about mass. Bronchoscopic biopsy though useful could be non-representative or insufficient sampling could result in different histopathological diagnosis as happened in the index case.The accepted treatment modality is complete surgical excision with sparing of all normal tissue. There are reports of endobronchial laser ablation of pedunculated lesions but it may be incomplete due to invasion of bronchial wall by tumor.[1]We planned for lobectomy but owing to extensive disease involving lower lobe as well, pneumonectomy was done.Source of Support: NilConflict of Interest: None declared


The appropriate surgical approach for a large mediastinal tumor is controversial. Median sternotomy is the standard approach for thymomas. We herein report the case of a giant thymoma, 13 cm in diameter, surgically resected via anterolateral incision. Subsequent thymectomy was performed via thoracoscopy. The resected specimen was a WHO type AB thymoma, Masaoka stage I, without capsular invasion. The anterolateral incision was less invasive and more versatile in the present case, as the incision could be extended to a hemiclamshell or posterolateral incision depending on exposure and relationship to adjacent organs and vascular structures. Thymomas are rare neoplasms with an indolent growth pattern and present with various clinical symptoms . They arA 45-year-old man was referred to our hospital due to a routine chest x-ray showing an abnormal shadow in the right lower lung field Fig. . He had Thoracoscopic examination through the eighth intercostal space revealed no adhesions or pleural disease. An anterolateral incision, 20 cm in length, was made in the fifth intercostal space. The tumor was excised from the anterior mediastinal fat tissue and thymus. Dense adhesions of the tumor to the pericardium were sharply peeled off, and the tumor was resected without involvement of the superior vena cava or inferior pulmonary vein. Intraoperative frozen section diagnosed the tumor as a thymoma; thymectomy was thus performed through the same incision via thoracoscopy. The adherent portion of the pericardium was excised and reconstructed with the use of a Gore-Tex pericardial patch.The resected specimen was 13 × 11.8 × 8 cm, showing a well encapsulated tumor with a lobulated appearance separated by fibrous bands. Microscopic examination revealed the tumor to be composed of a lymphocyte-associated area and a spindle cell-dominant area Fig. , which wThe optimal surgical approach for giant thymomas is a point of controversy Table . Two casWhile median sternotomy is the standard approach for thymomas, only three cases of giant thymomas resected via median sternotomy have been reported –6. MediaWhile the size of the thymoma has been reported to be a significant prognostic factor from experienced single centers , 11, spoIn the present case, surgical resection for a giant thymoma and additional thymectomy were successfully performed via an anterolateral approach, which is relatively less invasive and more versatile due to the ability to extend the incision posteriorly or to add a median sternotomy.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.