Pancreatic neuroendocrine tumours localized to the pancreas and amenable to complete surgical resection are rarely reported. In West Africa, such patients present too late for surgery to be considered. In the reported case, a patient with persistent epigastric pain underwent a computed tomographic examination which led to the discovery of a large (6cm x 5cm) localized tumour in the body and tail of the pancreas. Complete resection of the tumour was performed. Histological examination showed a pancreatic neuroendocrine tumour without capsular invasion. Adjuvant chemotherapy was deemed unnecessary. The patient remains symptom free 2 years after the procedure with no evidence on subsequent imaging of tumour recurrence. Although extremely rare, large pancreatic neuroendocrine tumours may still be amenable to complete excision. Resectable tumours are rarely encountered in the West African sub-region. Even more uncommon is the neuroendocrine neoplasm of pancreatic origin presenting early enough for surgical exploration. We recently managed a middle-aged woman who presented to a peripheral facility with persistent epigastric pain of recent onset. Her insistence on complete understanding of the source of the pain led to a computed tomographic examination and discovery of a large tumour in the body and tail of the pancreas. She underwent exploratory laparotomy and complete resection of the tumour which proved on histological examination to be a neuroendocrine neoplasm. Her postoperative recovery was uneventful and she remains disease-free 2 years after the procedure.A 57 year old lady presented to a peripheral hospital with complaints of penetrating epigastric pain of a week’s duration. There was no vomiting or weight loss. Bowel movements were normal. Clinical examination at the time was unrevealing. An abdominal ultrasound examination was reported as normal. The patient’s insistence on full investigation of the persistent epigastric pain led to a computed tomographic examination and discovery of a pancreatic tumour subsequent to which she was referred to our institution. The CT scan  showed aHistological examination of the specimen  showed aPancreatic neuroendocrine tumors (PNETs) are uncommon neoplasms. In Europe and Asia, the reported incidence is < 1 per 100,000 persons per year [In West Africa, PNETs that are localized to the pancreas and amenable to complete surgical resection are rarely reported. Indeed we found no such report in the English language literature. Ostensibly, many patients present with advanced disease and are not given the benefit of surgical exploration. In the reported case, the patient’s insistence on complete investigation of persistent epigastric pain led to the discovery of the tumour. The pain most likely resulted from stretching of the pancreatic capsule and not from tumour invasion. Because the histological examination indicated complete resection of the tumour, it was judged there was no need for chemotherapy. The patient remains symptom free 2 years after the procedure with no evidence on subsequent imaging of tumour recurrence . The 201Surgical resection with regional lymph node dissection is the only curative treatment option and is recommended to all patients with early-stage well-differentiated pNENs . DependiResectable pancreatic neuroendocrine tumours are rarely encountered in Africa. Thorough investigation of unexplained abdominal pain may lead to early diagnosis which improves the potential for resectability and a good prognosis.The authors declare no competing interests.


Ultra-short bowel syndrome (USBS) refers to a clinical condition characterized mainly by severe diarrhea and nutritional disorders caused by the residual small intestine length of <30 cm . After R Since the jejunum was characterized by its ease of dissociation, its ability for anastomosis with other organs, and the forward peristalsis of the Y-shaped jejunum loop, Cesar Roux first used it in 1893 to reconstruct the digestive tract. In the early 1940s, the American surgeon Allen Whipple applied the Roux-en-Y anastomosis method to choledochojejunostomy. Today, the Roux-en-Y anastomosis of the bile duct to the jejunum remains one of the main methods of biliary reconstruction. Due to the maturity of this technology, its ease of operation, and good drainage effect, it has been widely employed in clinical practice, although cases of torsional necrosis of the output loop internal hernia are rarely reported. The twisting of the intestine easily forms a closed fistula, accompanied by a blood circulation disorder, causing a strangulated intestinal obstruction. Patients with a twisted intestine often show severe abdominal pain and persistent aggravation, but this symptom lacks specificity, meaning it is easily misdiagnosed. Torsional intestinal obstruction is a serious acute abdominal issue, and timely diagnosis is the key to treatment. Previous studies  have shoA 72-year-old woman was admitted to the hospital due to “persistent severe abdominal pain for one day.” In 2005, a Roux-en Y choledochojejunostomy had been performed for choledocholithiasis. After the operation, the patient successfully recovered and was discharged. After discharge, the patient did not have any discomfort. On December 13 2017, the patient, without obvious inducement, presented with persistent severe abdominal pain, nausea and vomiting, but no radiating pain, no fever, and no jaundice. She went to the local hospital for an abdominal CT examination, which suggested an intestinal obstruction, and intrahepatic bile duct stones. Treatment with antispasmodic, analgesic, anti-infection, and intravenous hydration did not significantly improve the symptoms. She was transferred to our hospital for treatment.The blood pressure was 80/50 mmHg, the heart rate was 118 beats/min, the respiratory rate was 26 breaths /min and no yellow staining was found on the skin or sclera. The abdomen was protuberant and the right abdomen had a surgical scar ~10 cm long. The abdominal muscle was tense, and there was obvious right upper abdominal tenderness and rebound pain. Percussion gave a drum sound with shifting dullness. The bowel sounds were absent in auscultation. An abdominal puncture yielded a bloody fluid. Urgent examination of the chest and abdomen by a CT scan showed that the output loop was twisted and necrotic due to internal hernia; there was also ascites and a common bile duct stone.9/L, hemoglobin was 68 g/L, neutrophil percentage was 82.1%, and platelet count was 149 × 109/L; the renal function test showed that creatinine was 140.22 μmol/L, and the urea was 8.89 mmol/L; Ascites amylase was 236.22 U/L; electrolyte and coagulation function were normal. According to the results of the CT image, combined with the clinical manifestations, past history, physical examination and auxiliary examination, the initial diagnosis was volvulus with necrosis, acute diffuse peritonitis, a common bile duct stone, and diffuse ascites. We gave rapid rehydration and expansion, and actively improved preoperative preparation. After the vital signs were stabilized, an emergency laparotomy was performed.By examining the CT image, we could see the original choledochojejunostomy , the “whDuring the operation, ~2,000 mL of odorous dark red effusion was observed in the abdominal cavity. The ileal loop was herniated from the back of the anti-adverse peristaltic loop of the original choledochojejunostomy, and the mesentery was twisted counterclockwise. Near the root of the rotated mesentery, there was an annular adhesive cord band that compressed the twisted mesentery and the intestine. After separating the adhesive cord band, we reduced the torsion of the intestinal tube, which revealed that the output intestinal loop above the ileocecal junction 5 cm and below the choledochojejunostomy 25 cm was necrotic, blackened, not peristaltic, had edema, and there was exudation of the intestinal wall , over a After reconstruction, the small intestine was ~60 cm. Preoperative examination suggested the presence of a common bile duct stone, and intraoperative exploration of the ampullary calculus of the common bile duct was dilated. To reduce the impact of surgical trauma on the body, we decided to perform side-to-side anastomosis of the bile duct and duodenum . We dissA volvulus is a closed loop intestinal obstruction caused by the compression of both ends of the intestinal loops after the intestinal loop rotates along the long axis of the mesentery, and the mesenteric vessels are blocked. A volvulus obstructs mesenteric blood circulation, potentially leading to necrosis and toxic shock in the short term; it is a common severe acute complication of surgery in the abdomen. The condition is dangerous, requires urgent attention and has a high mortality rate. Therefore, clear diagnosis, accurate positioning, and timely treatment are crucial for the prognosis of patients. Due to non-specific clinical manifestations, CT and multiplanar recombination play an important role in identifying signs of volvulus, such as vascular torsion and transition points . With thThe “whirl sign” was first discovered by a foreign scholar, Fisher , on the Intestinal necrosis on the CT scan is characterized by different degrees of dilatation, hydrops, pneumatosis of the intestinal lumen and pneumoconiosis between the intestines, intestinal wall, and vascularization. Its pathological basis is that insufficient blood supply of the small intestine leads to a series of changes. In the early stage of intestinal ischemia, intestinal peristalsis decreases, and intestinal wall exudation increases. Therefore, the intestinal lumen dilates and accumulates gas, leading to damage to the nerves in the intestinal wall, loss of tension, which result in intestinal lumen dilatation and pneumatosis, excessive proliferation of intestinal bacteria, and pneumatogenic bacteria invading the intestinal wall submucosa and veins. Increased pressure in the intestine lumen and mucosal ulcers allow gas to enter the intestinal wall and veins . WiesnerStudies have shown that the annual incidence of SBV is 1.7–5.7 per 100,000 adults in Western countries and 24–60 per 100,000 adults in Africa, Middle East, and Asia , 13, 14.CT is of great value in the analysis of the etiology and obstruction point of intestinal obstructions. Mastering its key diagnostic signs and rigorously analyzing patient symptoms can lead to correct diagnoses and guide the formulation of treatment protocols. Strangulated intestinal obstruction should be diagnosed as soon as possible and surgery should be performed in time. Flexible use of an active intestinal tube during the operation can avoid the occurrence of USBS, thus improving the success of the operation.The case report was conducted in accordance with the ethical standards set out in the Helsinki Declaration of 1964. The informed consent was obtained from the patient's family. The patient's son gave the consent to include the data in the present case study.All the authors were involved in patient management. ZZ conceived the study. ZZ and CH did the clinical exam and performed the surgery. ZN and CH collected the clinical data and images. CH drafted the manuscript and it has been read and approved by all the authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Malignant endometriosis in an episiotomy scar is rare; only seven cases have been reported previously. Here, we compare two cases of benign endometriosis and clear cell carcinoma.The first case was a 54-year-old woman who presented with a large perineal lesion in her episiotomy scar with high 18F-fluorodeoxyglucose uptake. This location had a history of endometriosis many years ago. She underwent radical excision of the mass and bilateral inguinal lymph node dissection. Histological and immunohistochemical analysis confirmed the presence of clear cell carcinoma arising from endometriosis. Assisted radiotherapy was performed after surgery due to a positive lymph node. No recurrence was detected over a 1-year follow-up period. The second case deals with a 3 × 2 cm mass in the episiotomy scar of a 33-year-old woman. Part of the anal sphincter was resected because of the close proximity of the lesion. Because the disease lay very close to the anus, she received anal sphincter reconstruction combined with mass excision. Pathology result showed typical endometrial glands and interstitial tissues.Deleterious change only happens in patients experiencing perineal endometriosis. Complete excision is crucial for this form of disease; sometimes impairment of the anal sphincter is also necessary. Patients with malignancy required a combination of treatments in order to improve their prognosis. Endometriosis is a common disease in women and is characterized by the presence of ectopic functional endometrial tissue as an inflammatory condition . EndometA 54-year-old female patient presented with a perineal lump which had gradually enlarged over a period of 4 years. Her obstetric history included a vaginal delivery with a left episiotomy 30 years ago. After that, she remained well for 3 years before she felt a small mass in the incision site. She then underwent resection of the mass and was diagnosed with endometriosis. However, this disease relapsed after a few months, and the patient suffered, and underwent the same operation again. After the second operation, she still felt incisional pain during menstruation. Danazol had been prescribed for 1 year, which relieved the pain. Following drug therapy, 18 years passed and the patient underwent radical mastectomy and chemotherapy due to breast carcinoma in 2012.Four years ago, she found a slow-growing perineal mass in the same region. She went to our hospital and physical examination revealed a soft mass, 6 × 5 cm in size, which was closely related to the anterior episiotomy scar Fig. a. Color We performed a radical excision of the tumor and bilateral inguinal lymph node dissection. During the surgery, we found the tumor was firm and tan or red-tan in color. The tumor had extended into the deep part of her pelvis, and the interface between it and the surrounding tissue was not well demarcated. Pathological analysis indicated clear cell carcinoma of the perineum incision, possibly arising from an endometrial implant Fig. a-c. A trA 33-year-old Asian woman presented with a painful mass in her perineal incision, which she had noticed several months before. There was no particular medical history except that she had a vaginal delivery with episiotomy 12 years previously. Subsequently, she felt occasional incisional pain. Four years ago, she had another natural labor and the pain became worse. Over the last few months, the patient could feel a subcutaneous mass in the perineal incision. An ultrasound scan showed a hypoechoic nodule measuring 3.1 × 1.6 × 1.2 cm  adequate and wide excision is the principle of management to prevent recurrence and future malignancy; and (2) we must be very careful not to rupture tumors during surgery as this can cause remnants to remain and subsequent re-implantation to occur. The effect of assisted drug therapy after surgery is not very clear. Adjunctive chemotherapy and radiotherapy are recommended as the prognosis may be improved in malignant patients. Finally, it is very important to follow-up these patients with care.


Magnetic resonance imaging using gadoxetic acid, a hepatocyte-specific contrast agent, is one of the most useful MRI techniques used to diagnose liver tumours in humans. During the hepato-biliary phase, there is uptake of gadoxetic acid by normal hepatocytes, leading to hepatic parenchymal enhancement. This feature is used in human medicine to diagnose hepatic parenchymal metastatic disease, to differentiate primary liver tumours, to diagnose liver cirrhosis and focal nodular hyperplasia. This study presents the preliminary results of magnetic resonance imaging of focal lesions localised in the liver parenchyma in dogs following the administration of gadoxetic acid.lesion) in the tumour metastasis was 0.05; the liver enhancement ratio (ERliver) – 0.49 and the post-contrast lesion-to-liver contrast ratio (CR) was 0.17. In dogs with hepatocellular hyperplasia, these values were 0.54; 0.51; and 1.18, respectively. In two dogs with a hepatic adenoma, the ERlesion was 0.26 and 0.17, respectively; the ERliver was 0.47 and 0.47, respectively and the CR was 0.33 and 0.31, respectively. In the dog with a neuroendocrine tumour, the ERlesion was 0.03; the ERliver amounted to 0.58 and the CR was 0.35. In the case of a hepatocellular carcinoma, these coefficients were 0.2, 0.6 and 0.3, respectively.The lesion enhancement ratio (ERBased on the results, it may be assumed that the MR images of the proliferative hepatic parenchymal lesions in dogs using gadoxetic acid are similar to those obtained in humans. This suggests that the contrast enhancement patterns used in human medicine may be useful in differentiating hepatic parenchymal lesions in dogs. Proliferative hepatic lesions may be benign or malignant. Malignant lesions include primary tumours and hepatic parenchymal metastasis . PrimaryDue to the variety of lesions present in the liver parenchyma, new methods enabling their fast and non-invasive differentiation are currently sought. Presently, the most common methods used to diagnose proliferative hepatic parenchymal lesions include the ultrasound and computed tomography, which have low specificity , 5. In hGadoxetic acid  is a paramagnetic, hydrophilic, ionic contrast agent . FollowiThis study presents the preliminary results of MRI in dogs in the hepatobiliary phase following the administration of Gd-EOB-DTPA, a hepatocyte-specific contrast agent, using a high-filed MRI scanner to diagnose various types of focal lesions located in the liver parenchyma.All the dogs qualified for general anaesthesia essential for MR imaging based on the results of the clinical and blood examination. Coagulation disorders, which are contraindications to core-needle biopsies and surgical tumour resection, were excluded in all the dogs. The abdominal ultrasound examination in all the dogs confirmed the presence of a proliferative lesion in the liver parenchyma. MRI was carried out in all the dogs, and the results of subjective assessment are presented in Table In the first dog, the abdominal ultrasound examination revealed the presence of a one small well defined, homogeneous space occupying lesion in the liver parenchyma, while MR imaging indicated the presence of two tumours. The first of these was oval with an irregular margin located in the lateral left hepatic lobe and measured 1.46 × 1.11 cm. The second lesion measured 2.28 × 1.43 cm and was visualised in the right lateral hepatic lobe as seen in the MRI. Both lesions were well demarcated and their signal intensity was similar in all sequences 2). In thThe third patient was diagnosed with a large lesion in the left hepatic lobe. The MRI confirmed a proliferative lesion measuring 9.38 × 6.33 cm, located in the left lateral hepatic lobe. The lesion was oval, well-demarcated with smooth margins Table  The ultrasound examination in the fourth dog revealed the presence of a lesion in the left lateral hepatic lobe. MR imaging confirmed the presence of a clearly visible 3.81 × 3.04 cm lesion with irregular margins in the left lateral lobe In the sixth dog, a multiple large and small space occupying lesions were seen in the abdominal ultrasound; the lesions in the hepatic parenchyma were extensive and their exact localisation in a specific liver lobes was possible only based on MR imaging. The proliferative lesions were 0.5 to 10 cm large and were present in all the hepatic lobes Table  except fAn analysis of the signal enhancement was carried out to confirm the subjective assessment of the MR images in all six dogs Table .Table 2lesion, ER liver and CR for all the lesions are presented in Table The ER The presented study, which was carried out on a high-field MR scanner, enabled a preliminary comparison of various types of proliferative hepatic parenchymal lesions in dogs in the post-contrast examination. The data were recorded approximately 26 min after contrast administration. This is in accordance with own observations  and the lesion was 0.05, which indicated that there was no signal enhancement in the post-contrast sequence. The CR in that dog was low and amounted to 0.17, consistent with a large difference in the signal intensity between the normal liver tissue and the parenchymal lesions. That is also in accordance with the findings in humans [The MRI appearance of the metastatic lesions observed in the first patient were similar to those observed in humans. In humans, liver metastases are typically multifocal and appear in the form of irregularly marginated parenchymal lesions with low signal intensity on T1 weighted images and are hyperintense on T2-weighted images in comparison to normal hepatic parenchyma. These lesions do not show contrast enhancement in the hepatobiliary phase , 17. In n humans .lesion and ERliver in this dog.In the second dog, focal nodular hyperplasia (FNH) was diagnosed in the quadrate lobe based on a histopathologic examination of a biopsy section of the liver. The compromised lobe was homogenous with rounded margins, which corresponds to the description of this type of lesion in humans . In humaThe third and fourth dog were diagnosed with a hepatocellular adenoma based on the histopathologic assessment of biopsy section. In both cases, there was a single tumour in the liver parenchyma, which was significantly different in size. In the third dog, the tumour was well delineated from the surrounding liver parenchyma, while in the fourth dog it was ill defined in pre-contrast sequences. Both lesions were mildly hypointense compared to the surrounding liver parenchyma on pre-contrast T1-W images and mildly hyperintense on T2-W images. In humans, similarly to the presented dog, hepatocellular adenomas are usually single lesions. However, they are usually hyperintense to isointense on pre-contrast T1-W images compared to the surrounding organ parenchyma , 19. Anolesion measuring 0.03 confirmed that there was no contrast enhancement within the lesion, while the CR was 0.35 and was similar to the CR of the dog with the liver adenoma.A neuroendocrine hepatic tumour (carcinoid) was diagnosed in the fifth case based on a histopathologic analysis of the biopsy sections. This tumour is rarely described in humans and animals –23. Therlesion was 0.2 indicating that there was moderate contrast enhancement, while the CR was similar to that obtained in the case of the hepatic adenoma and neuroendocrine tumour.In the sixth dog, a hepatocellular carcinoma was diagnosed based on the histopathologic examination of the liver biopsy sections. This is the most common primary hepatic tumour in dogs , 2, 14. The magnetic resonance imaging findings of proliferative lesions in the liver parenchyma in dogs using Gd-EOB-DTPA, a hepatocyte-specific contrast agent, are similar to those reported in humans with the same types of lesions. This finding warrants further investigation on a larger population of dogs.One limitation of the study was a small and heterogenous study group; hence only preliminary conclusions regarding the post-contrast imaging findings of proliferative hepatic lesions could be drawn. Another limitation was the lack of an assessment of the early  contrast phase, which may have enabled a more detailed differential diagnosis of the lesions. The authors plan to study post-contrast imaging findings of hepatic lesions on a larger group of dogs. They also plan to research all the contrast enhancement stages in liver disease.In accordance with Art. 1 point 2.1 to the Act from January 15th 2015 on the Protection of Animals Used for Scientific or Educational Purposes, the study and all associated procedures do not require the approval of the local ethics committee.The study was carried out on six dogs of different breeds  of both sexes , who were from 10 to 13 years old . All the dogs were patients of the outpatient clinic of the Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats of the Faculty of Veterinary Medicine at the Wroclaw University of Environmental and Life Sciences. Focal lesions in the liver parenchyma were identified during routine abdominal ultrasound examinations in all cases. A clinical examination and laboratory blood tests  were carried out prior to MRI to determine whether the animals qualified for further imaging and a core needle biopsy. The animals were premedicated with medetomidine administered at 0.005 mg/kg i.m.  and butorphanol at 0.005 mg/kg i.m. . General anaesthesia was induced with propofol administered at 1 mg/kg i.v. . Anaesthesia was maintained with isoflurane . The respiratory rate, heart rate, oxygen saturation, carbon dioxide concentrations in the respired gases and the inspiratory and expiratory concentration of the anaesthetic mixture were monitored during the MRI examination. MRI was performed on a 1.5-T MRI system  using a 32-channel torso phased array coil. All sequences were carried out with respiratory-triggering. Dogs were positioned in dorsal recumbence. The MRI protocol included the T1-W TFE and T2-W TSE sequences in the transverse plane. Subsequently, Gd-EOB-DTPA (Primovist®), a hepatocyte-specific contrast agent was administered intravenously at 0.1 ml/kg (0.025 mmol/kg), followed by 15 ml of a 0.9% saline solution. The post-contrast T1-W TFE sequence was acquired 26 min after contrast administration, in the transverse plane  software. The T1 and T1 post contrast signal intensity of the tumour was compared to the unchanged liver parenchyma, the homogeneity of the lesion, its size, extent and localisation were also analysed. In the T1 pre and post contrast studies the oval regions of interest (ROI) were set manually in chosen areas to assess the signal enhancement of the liver parenchyma and the tumour. Three ROIs were localised within the unchanged liver parenchyma, and three were placed within the tumour. Where possible, the ROIs were localised away from large blood vessels.liverpre-contrast) and after (SI liverpost-contrast) contrast administration as well as the tumour signal intensity before (SI tumor pre-contrast) and after (SI tumor post-contrast) contrast injection were calculated. Based on those mean values, the enhancement ratios (ER) and the post-contrast lesion-to-liver contrast ratio (CR) were calculated using the following formulae [Based on the obtained results of the signal intensity in the liver parenchyma for each ROI, an arithmetic mean of the signal intensity of the liver parenchyma before (SI formulae , 27:\do


The case is of a 35-year-old right-hand-dominant man who worked in an office. He was a nonsmoker and had no significant medical comorbidities. He was referred with a lump on his left index finger several months following a simple laceration to the area from broken glass. The lump had been progressively enlarging, associated with tenderness and reduced finger flexion secondary to its size. The radiograph  showed sAt follow-up 6 months later, a recurrent mass was noted. The radiograph  showed rHe then presented with a second recurrence approximately 1 year later. On this occasion, magnetic resonance imaging (MRI) was performed in an attempt to delineate the lesion. The MRI revealed a nonspecific appearance of the lesion  but favoWhat is Nora's lesion ?How is it diagnosed?What is the cause?How is it treated?-1,2,4,7,First described by Nora et al1,8Nora's lesion can arise from bone or within soft tissue, and diagnosis is made by a combination of radiology and, most importantly, histological findings. Diagnosis can be difficult due to the varied appearances of the lesion at different stages of the disease. In addition, it can be easily confused with other lesions as there is some overlap in appearances with osteochondroma, periosteal chondroma, parosteal osteosarcoma, and chondrosarcoma and its high recurrence rate may lead to a mistaken diagnosis of malignancy. In this case, consecutive radiographs were available, showing the natural evolution of the lesion in keeping with other case reports.2The cause of Nora's lesion remains unclear, but it is suggested that it may be due to reparative effects after trauma,,2,1,Recommended treatment is complete surgical excision, with en bloc negative margins. The pseudocapsule overlying the lesion and any periosteal tissue beneath the lesion should be excised, as well as decortication of any area in the underlying host bone that appears abnormal.1This case highlights the spectrum of Nora's lesion. Radiologically and histologically, it appears consistent with a reparative process, progressing from cartilaginous proliferation resembling a benign chondroma, then developing a minor osseous component resembling Nora's lesion, and finally a more mature central osseous component and a peripheral cartilaginous component reminiscent of an acquired osteochondroma. Treatment is complete excision of the lesion and the surrounding periosteum, and recurrences are common, with long-term follow-up essential.


Hepatic herniation through an abdominal incisional hernia is a rare phenomenon that has been seldom reported in the medical literature. When present, this may cause patients significant distress and is associated with complications such as hepatic encephalopathy and Budd-Chiari syndrome. Most cases can be managed conservatively through observation, but many cases require surgical intervention to preserve hepatic function. Our case consists of a 54-year-old man who presented with asymptomatic herniation of the left hepatic lobe through an abdominal incisional hernia. Ventral hernia is a bulge through an opening in the abdominal wall, allowing internal organs such as bowel to be dislocated from its original position. When herniation occurs through a prior scar, it is called an incisional hernia. These events are not uncommon, most of them presenting with bowel in the hernial sac . HoweverA 54-year-old Hispanic male with a medical history significant for chronic obstructive pulmonary disease (COPD), diabetes mellitus, alcohol abuse, heroin abuse (on methadone), hepatitis C, latent tuberculosis, and ventral hernia repair presented to our institution’s emergency department complaining of progressive shortness of breath for one month duration. The patient also complained of increased abdominal girth within the same period of time, which he stated worsened his shortness of breath. Initial workup included a chest X-ray showing left lower lobe atelectasis. Notable laboratory findings included hemoglobin: 12.6 g/dL, white blood cell count: 11.5 103/uL, platelet count: 208 103/uL, creatinine: 1.4 mg/dL, blood urea nitrogen: 24 mg/dL, alanine aminotransferase (ALT): 37 IU/L, aspartate aminotransferase (AST): 52 IU/L, total bilirubin: 0.5 mg/dL, and alkaline phosphatase: 72 IU/L. The patient was then admitted to the medical floor under the impression of COPD exacerbation. On admission, surgery was consulted to evaluate the patient’s increasing abdominal girth given his medical history of ventral hernia. An abdominal CT scan was done, which showed the anterior portion of the left hepatic lobe partially herniating through the ventral hernia accompanied by hepatic steatosis (Figures Herniation of the liver or its parts through the abdominal wall is a rare phenomenon that was first described by Adeonigbagbe et al. in the year 2000 . Since tRisk factors associated with the development of hepatic herniation through the abdominal wall include obesity, old age, poor nutrition, increased intra-abdominal pressure, smoking, weak abdominal wall, and postsurgical site infection . In addiPresenting symptoms of abdominal hepatic herniation include abdominal pain, nausea, vomiting, jaundice, dyspnea, confusion, and epigastric swelling . It is oHepatic hernias should be suspected when a patient presents with epigastric bulging, but adequate diagnosis requires imaging studies such as CT scan. In our patient, CT scan was sufficient in demonstrating hepatic herniation through a previous abdominal incisional hernia. Once diagnosed, treatment of hepatic hernias can be a challenge. Currently there are no guidelines that dictate treatment and most cases can be managed conservatively. If any of the aforementioned complications occur, surgical correction should be pursued given the favorable outcomes. One caveat to surgical treatment, however, is the presence of cirrhosis. In these patients, studies have shown that surgical correction of abdominal hernias results in increased morbidity and mortality .In conclusion, hepatic herniation through the abdominal wall is a rare phenomenon that has been seldom reported in the literature. Present day epidemiologic data is lacking, but risk factors have been well established. Clinical consequences include hepatic incarceration and Budd-Chiari syndrome. These can be avoided by promptly identifying liver herniation by imaging such as CT scan, and early surgical correction on a case-by-case basis.


A 4-year-old entire female 25 kg Golden Retriever was referred because of 1-month history of an insidious onset and progressive course of hind limb gait abnormalities. The general physical examination was unremarkable. Neurological examination showed mild proprioceptive ataxia of the hind limbs and marked monoparesis of the right hind limb. Postural reactions were reduced in the left hind limb and absent in the right. Segmental spinal reflexes were normal. The clinical findings were consistent with a thoracolumbar (T3-L3) neuroanatomical localization of the lesion.The main differential diagnoses included degenerative , congenital , inflammatory/infective , and neoplastic  etiologies. The complete blood cell count and serum biochemical analyses were within normal limits.Magnetic resonance imaging (MRI) of the thoracolumbar vertebral column and spinal cord was performed using a 0.17 T Magnet . Sequences included T1-weighted (T1-W) and T2-weighted (T2-W) images in transverse and sagittal planes. In addition, T1-W images in sagittal, transverse, and dorsal planes were obtained after intravenous administration of paramagnetic contrast media gadoversetamide  at 0.1 mmol/kg bodyweight (BW).MRI showed, at the level of the 13th thoracic vertebra, a lesion lateralized on the right side hyperintense on T2-W, iso- to slightly hypointense on T1-W images, with a mild peripheral contrast enhancement. The abnormal findings were consistent with a roundish, well-demarcated intradural-extramedullary spinal cord space-occupying lesion of 7 mm in diameter. MRI also showed mild dilatation of the central canal cranial to this mass consistent with mild syringohydromyelia, as illustrated in Based on the MRI findings, the main differential diagnoses included an inflammatory space-occupying lesion, epidermoid cyst, and, less likely, juvenile neoplasia such as nephroblastoma or primary neuroectodermal tumor.The dog underwent decompressive surgery under general anesthesia. Premedication was performed using acepromazine (0.02 mg/kg BW IM) and methadone (0.3 mg/kg BW IV), followed by induction with propofol (2 mg/kg BW IV). General anesthesia was maintained with isoflurane and oxygen. Intraoperative analgesia was provided by a constant rate infusion of fentanyl (0.005 mg/kg BW/h IV).in toto and submitted for histopathological examination.A T13-L1 right hemilaminectomy was performed. Bulging of the dura mater was observed immediately following hemilaminectomy. After durotomy, the lesion appeared as a fluid-filled mass . The masAll excised tissue was fixed in 10% neutral buffered formalin, embedded in paraffin, and sectioned. The sections were stained with hematoxylin and eosin, alcian blue, and periodic acid–Schiff (PAS).Histology showed non-encapsulated, partially cystic mass, consisting of moderately cellular epithelial proliferation. The cells were organized in ducts and occasionally branching tubules of cuboidal to columnar, mono-, or bilayered epithelium with intercalating goblet cells and occasional cilia on the luminal surface . The strImmunohistochemistry for cytokeratin was positive throughout the epithelial cells, while GFAP and S100 did not produce significant immunopositivity. Giving its similarities with the respiratory epithelium, a spinal neurenteric cyst (NC) was diagnosed.Postoperative (PO) analgesia consisted of methadone (0.2 mg/kg BW/4 h IV) for the first day and buprenorphine (0.01 mg/kg BW/6 h IV) for the following 2 days. In addition, antibiotic medication  was administered for 5 days. The dog was discharged 4 days after surgery with the following medication: tramadol , omeprazole (0.75 mg/kg BW/24 h PO), and firocoxib (5 mg/kg BW/24 h PO) for 5 days. Postoperatively, the dog was mildly ataxic in the hind limbs and showed a worsening of the monoparesis in the right hind limb, which improved over the following 2 months.Seven months postoperatively, on neurological examination, the dog showed only a mild right hind limb monoparesis. MRI was performed at that time and revealed right dorsolateral localized meningeal contrast enhancement at the level of T13-L1 and an adjacent focal flattening of the spinal cord. A surgical scar tissue was suspected . The dogA 1-year-old entire male 27.8 kg mix-breed dog was presented with a history of acute onset of ataxia and paresis of the left hind limb, worsening over the following 10 days. At the first neurological examination, the dog was paraplegic, postural reactions were absent in the hind limbs, and segmental spinal reflexes were normal. Nociception was absent in the left hind limb and markedly reduced in the right hind limb. Neuroanatomical localization was T3-L3 myelopathy. The main differential diagnoses included inflammatory/infective , vascular (ischemic and hemorrhagic myelopathy) and, less likely, intervertebral disc extrusion or neoplastic (for example lymphoma and nephroblastoma) diseases.MRI of the thoracolumbar vertebral column was performed using a 0.3 T Magnet . Sequences acquired included T1-W and T2-W images in transverse and sagittal planes, T1-W images in transverse planes after intravenous administration of paramagnetic contrast media gadodiamide  at 0.1 mmol/kg BW, fluid attenuated inversion recovery (FLAIR) in sagittal planes and short tau inversion recovery (STIR) in dorsal planes.MRI showed an apparently intradural-intramedullary spinal cord abnormality at the level of the first lumbar vertebra which was hyperintense on T2-W and STIR images, hypointense on T1-W  and FLAIBased on MRI findings, the main differential diagnoses included inflammatory disease such as an abscess, congenital anomaly (epidermoid cyst) or juvenile cystic neoplasia. At this time, the owner declined surgical intervention and the dog was treated with prednisolone (1 mg/kg BW/24 h PO). Three days after the first presentation, a subsequent examination showed worsening of the neurological signs with loss of nociception in both hind limbs and a surgical exploration of the lesion was planned. The dog was premedicated with fentanyl (0.002 mg/kg BW IV) and induced with propofol (5.5 mg/kg BW IV). General anesthesia was maintained with a total intravenous anesthesia by target-controlled infusion of propofol (20 mg/kg BW/h). During the surgery, analgesia was provided by a constant rate infusion of fentanyl (0.01 mg/kg BW/h IV).A left-sided hemilaminectomy was performed. The exposed dura appeared swollen. A durotomy was performed revealing a reddish, well encapsulated mass attached to the spinal cord.The mass was adherent to the spinal cord and, after pia mater resection, was isolated with the aid of microbipolar coagulation and dissected with microsurgical instruments and a surgical microscope . All the visible mass was removed, fixed in formalin, and submitted for histopathological examination. The specimen was processed and stained as the case 1.Histology showed an encapsulated, cystic, and multiloculate tissue with moderately cellular epithelial proliferation embedded in moderate amount of stroma and surrounded by adipocytes. Cells were organized in a stratified cuboidal epithelium with cavities filled by mucoid material. In the same areas, there were ducts and tubules characterized by a ciliated respiratory epithelium. Distributed within the stroma were multiple microhemorrhages. Immunohistochemistry was negative for GFAP and positive for cytokeratin and epithelial cells showed PAS positive intracellular material . Post-opThe dog regained nociception in the hind limbs within 2 days after the surgery. One week postoperatively, the patient was presented with an increased tone in the left hind limb, was able to ambulate unassisted showing proprioceptive ataxia and paraparesis with knuckling on the dorsum of the paw in the left hind limb. Two months after surgery, the hind limbs ataxia was less severe, and the dog did not show any more knuckling of the paw in the left hind limb.Follow-up was obtained by telephone calls to the owner, who reported a slowly progressive continuous improvement. Two years after surgery, the owner sent a video, which showed the dog to be well ambulatory with very mild proprioceptive ataxia in the hind limbs.In human medicine, NCs are rare congenital lesions of the central nervous system commonly found in the spinal cord or, more rarely intracranially in the caudal fossa  and two spinal NCs have been described . An intradural-intramedullary location of an NC has not been previously described.In people, NCs can occur at any level of the spinal cord and are most commonly found in the lower cervical and upper thoracic spinal cord segments . MRI findings cannot distinguish spinal NCs from other pathologies, including neoplasms, which have a poorer prognosis. For this reason, surgical exploration should be considered in spinal patients with evidence of a suspected intradural lesion.


We report a case of the pisiform and hamate coalition in 13-years-old male. Interoperative findings revealed that the ulnar nerve runs over the hook of the hamate which is the nonanatomic site. Surgical resection of pisiform relieved the pain. Fusions of the carpal bones are rare anomalies which occur in 1% of the population . Fusion A 13-year-old boy was referred to the clinic because of the left wrist joint pain without apparent trauma. Physical examination revealed tenderness over the pisiform, and the pain worsened when the patient flexed the wrist joint. He had neither the limited range of motion of wrist nor the unstable distal radioulnar joint. There were no signs of ulnar nerve neuropathy. The radiography and computed tomography (CT) of the wrist joint showed an unusual shape of the pisiform as well as an incomplete coalition between the pisiform and hamate . InjectiThe geographical variation of carpal bone coalitions has been reported, indicating that genetic factors may play a role in coalition . The abset al. also demonstrated two cases of the pisiform–hamate fusion which caused ulnar neuropathy. Excision of the pisiform, combined with the decompression of the Guyon canal has been previously reported [Excision of the pisiform has been reported to treat pisotriquetral complaints . Berkowireported . On the reported . In the


Prostatic ductal adenocarcinoma, is an uncommon entity in the spectrum of prostatic carcinoma. Clinically it is different from common prostatic acinar adenocarcinoma. It is usually more aggressive than prostatic acinar adenocarcinoma. We are presenting a case report on prostatic ductal adenocarcinoma, a cystic variant of prostatic carcinoma in a 55-year-old man who complained of obstructive urinary symptoms with mildly raised prostate-specific antigen (PSA). On further evaluation in our radiology department a cystic lesion with enhancing polypoidal soft tissue component was noted in prostatic parenchyma. Histopathology confirmed the diagnosis of ductal adenocarcinoma. As hair becomes white in men, the risk of prostatic malignancy increases. Prostatic cancer is the second most common cause of death in men usually having an indolent course. World Health Organization (WHO) in 2016 classified epithelial tumor of the prostate in various subcategories like acinar and ductal adenocarcinoma and almost all prostatic malignancies develop from glands as acinar adenocarcinoma. Pure ductal adenocarcinoma, formerly known as “endometriod adenocarcinoma”, is a clinical and histological variant that arises from ducts and represents only 0.2%-0.4% of all prostatic malignancies. The incidence of ductal adenocarcinoma has been increasing over each decade at approximately the same rate as acinar carcinoma .Cystic prostatic carcinoma is a rare entity with few cases reported in the literature . MalicowIn our case report, we represented a 55-year-old man who came to our hospital with abdomen-pelvic complaints such as pain in abdomen and obstruction in urine with few episodes of hematuria and he was further clinically investigated and radiopathologically diagnosed as prostatic ductal adenocarcinoma: a cystic variant of prostatic carcinoma.A 55-year-old man came to our hospital with complaints of vague abdominal pain, burning micturition, hematuria, increased frequency and urgency of urine, more during night and pain during defecation since four months. He was referred to the urology department where the clinical examination was done including digital rectal examination which revealed an enlarged prostate. Further, more hematological investigations were done with no abnormal findings aside from prostate-specific antigen (PSA) which was mildly raised with a value of 12.4 ng/ml. He had no remarkable medical history.The patient was further investigated in our radiology department where an abdominal ultrasonography and intravenous pyelography (IVP) was done. On ultrasonography, he was diagnosed with moderate hydroureteronephrosis with chronic cystitis with significant post void urine and increased volume of the prostate which measured approximately (75)cc with grade-III prostatomegaly and a large cystic swelling within prostatic parenchyma. On IVP it was diagnosed as moderate hydroureteronephrosis with significant residual post void urine.Contrast-enhanced computed tomography (CECT) was done with axial images of delayed phase which showed well defined large cystic lesion measuring approximately 7.8 x 7.1 cm in the mid and left pelvis likely arising from the prostate. Lesion demonstrated multiple enhancing polypoid soft tissue components along the wall. The lesion abutted urinary bladder anteriorly, rectum medially and levator ani muscle posteroinferiorly with loss of fat planes as shown in Figure There was also mid circumferential wall thickening of the urinary bladder with few internal iliac lymph nodes as shown in Figure Bone scan and computed tomography (CT) of chest, abdomen, and pelvis were negative for metastasis.Histological sections from the specimen, as seen in Figures The patient underwent combination treatment open radical retropubic prostatectomy along with androgen blockade drugs, bicalutamide, and goserelin for six months. An 8-10 cm incision was made (well below the belt-line) in the skin between the umbilicus and the top of the pubic bone. The pelvis was then explored and the important structures such as the urinary bladder, prostate, urethra, blood vessels, and nerves were identified.The prostate along with cyst was removed from the urethra below and the bladder above, and the bladder and urethra were reconnected. The yellowish color fluid was found in the cyst. The blood vessels leading to and from the prostate were divided and tied off. A catheter running through the penis into the bladder was typically required for at least a week after surgery. A surgical drain was left in the pelvis to allow drainage of blood and other fluid. Additional components of the operation include:- Lymphadenectomy: Left sided internal iliac lymph nodes were removed. Prostate cancer often spreads to nearby lymph nodes in the early stages, especially the sentinel lymph node.- Nerve-sparing surgery was attempted to protect the cavernous nerves of the penis, which control erection. These nerves are very thin and fragile and run next to the prostate and may be destroyed during surgery, leading to impotence.- Bone scan and CT chest, abdomen, and pelvis were negative for metastasis; radiotherapy was not given to the patient. Serum PSA level was within normal range of 4 ng/ml and under follow up.Carcinoma of the prostate is the most common form of cancer in men and is the second most common cause of death . Ductal Tumor represents pathologically by tall columnar, pseudostratified epithelium with papillary architecture and macroscopically, it appears to be exophytic with villous growth and can involve the surrounding pelvic structure. Men with prostatic ductal adenocarcinoma are likely to present with locally advanced disease, although lymph nodes appear to be comparable between ductal and acinar pathology .It is suggested that in prostatic ductal adenocarcinoma presenting with normal or slightly raised serum PSA level except in metastatic disease due to growth in pre-existing ducts or urethra which provide a route of egress of cellular secretions . Thus, tHistological differential diagnosis includes prostatic intraepithelial neoplasia and intraductal carcinoma  .Prostatic ductal adenocarcinoma tends to metastasize to some unusual locations like dural metastasis to falx and visceral which may be due to the propensity of prostatic ductal adenocarcinoma to disseminate via hematogenous route rather than lymphatics .Purely cystic prostatic ductal adenocarcinoma is a rare entity. In our case report, we diagnosed our patient with prostatic ductal adenocarcinoma on radiological basis and was further proved by histopathological examination. Our patient was diagnosed having ductal adenocarcinoma of the prostate with Gleason score 5+4=9, grade group V (WHO 2016 Classification). Our patient underwent a combination of surgical resection and androgen deprivation therapy and is under follow-up. More efforts are being made from our behalf to contribute knowledge regarding tumor biology, to understand normal to slightly raised serum PSA levels, and to assess its response to therapy.


Schwannomas grow slowly, originating from the Schwann cells of the nerve sheath. Schwannomas of cranial origin have the highest incidence, followed by intraspinal schwannomas. However, paravertebral schwannoma is rare, and to our knowledge, giant paravertebral schwannomas near the lumbar nerve roots with bone destruction are extremely rare.A 47-year-old Chinese woman complained of lower back soreness and a sensation of a bulging lumbar disc with no obvious cause for the past 3 years.Lumbar magnetic resonance imaging showed a large mass with uneven density, 17 × 12 × 15 cm in size, located to the right of the 4th lumbar with obvious bony destruction. Histopathology and immunohistochemistry confirmed that this mass was a benign schwannoma.Complete resection of the tumor (measuring about 17 × 12 × 15 cm in size) and vertebral reconstruction using internal fixation were performed.The patient was discharged without complications after surgery. The 3-year follow-up revealed that the patient recovered well with no evidence of recurrence.Here, we emphasize the importance of careful radiological examination and reflect on the difficulty of tumor resection. Furthermore, understanding the treatment and diagnosis of lumbar paravertebral schwannoma is critical for plastic surgeons and radiologists when encountering similar cases. Extraspinal schwannomas occur in the head, neck, upper and lower limbs, and posterior mediastinum. They typically present as single tumors, but occasionally present as multiple tumors. They rarely occur in the retroperitoneal spinal nerve roots; however, retroperitoneal tumors are the most common neurogenic tumors. The diagnosis and treatment of schwannomas in the lumbar spinal canal has been reported in a large number of studies, while giant paravertebral schwannomas near the lumbar nerve roots with bone destruction are reported less frequently and can be easily misdiagnosed or missed entirely.Schwannoma originating from the lumbar nerve is a rare and slowly growing tumor, which arises most commonly in the peripheral nervous system. Most patients are diagnosed when they develop a faint pain in the lower back or on physical examination. When the tumor compresses the nerve, it can manifest as lower back pain in the area of the diseased nerve root and radiation pain or soreness in the lower extremities. The symptoms gradually increase and the pain is not relieved after rest. Initially, there are no sensory disturbances or only regional hyperalgesia. When the spinal nerve root is compressed or strained, it can produce pain, further causing weakening of muscle strength and abnormal tendon reflex. In the current case study, the patient was diagnosed with a benign paravertebral schwannoma using the results of a magnetic resonance imaging (MRI) scan and a pathological examination rather than by the characteristic symptoms. Schwannomas can cause bone destruction, which is mainly caused by the compression of adjacent vertebral bodies and the expansion of intervertebral foramen. However, bone destruction caused by schwannomas is rarely reported.The clinical symptoms of lumbar paravertebral schwannoma are usually nonspecific and generally develop late in the progression of the disease.In this study, we describe a rare case of giant paravertebral schwannoma near the lumbar nerve roots with bone destruction in a 47-year-old woman.2A 47-year-old woman presented with only lower back pain and symptoms of bulging lumbar disc for 3 years, accompanied by limited movement and numbness. Referred for further investigation by the orthopedics department, a large spinal tumor was detected by MRI scan. She did not have any history of medical conditions, familial genetic conditions, food or drug allergies, or tuberculosis. In addition, the patient lost about 3 kg in body weight over the previous month. A further physical examination revealed no palpable head, neck, supraclavicular, axillary, or epitrochlear lymph nodes. A specialist examination revealed that the patient had a physiological curvature of the spine, and the activity was normal. There was no tenderness or searing pain in the lumbar spine or paravertebral spine, and there was no significant limitation on lumbar motion. Muscle strength and muscle tension were normal, muscles did not atrophy, physiological reflexes existed, and pathological reflexes were not elicited.Routine laboratory testing revealed normal levels of tumor markers such as carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), carbohydrate antigen 19-9, carbohydrate antigen 12-5, and carbohydrate antigen 153, but an elevated level of neuron-specific enolase . X-ray and 3-dimensional computed tomography scans showed a large mass on the right side of the lumbar 4 vertebral body, the lumbar intervertebral foramen 4 to 5 was dilated significantly, and the adjacent vertebral bodies and zygopophysis of the lumbar 4 were resorbed due to compression of the tumor. In addition, MRI showed a large mass with uneven density, 17 × 12 × 15 cm in size, located to the right of the 4th lumbar with obvious bony destruction ; and tumor growth is slow, asymptomatic during the early phase, the retroperitoneal space of the tumor growth site is large, and the location is deep, so it is difficult to detect by physical examination. In this case, the schwannoma was detected late in the progression of the disease, with only the symptoms caused by lower disc bulge. There are case reports where schwannomas have been misdiagnosed as psoas abscesses and ovarian dermoid cysts at all ages. Tumor markers including AFP and CA125 contributed to the differential diagnosis of gynecological tumors versus schwannomas. However, our patient's tumor marker test  was negative. Therefore, a schwannoma should be considered when a patient tests negative for these markers. It is reported that 7.5% of gynecological tumors were positive for expression of AFP and 22.6% were positive for CA125. Hence, AFP and CA125 should not be the specific criteria for diagnosing gynecological tumors. Kim et al reported that strong immunohistochemical S100 protein staining was associated with schwannomas. Our patient's pathological examination of S100 was strongly positive in this study presentation and was also reported in the literature.Schwannomas are benign neoplasms arising from the nerve sheath. Occasionally, they are reported in locations such as the head, neck, peripheral nervous system, liver, pancreas, esophagus, stomach, and peritoneum. Currently, complete surgical resection of the tumor tissue is the best method of treatment. Schwannomas have a complete envelope, which is not tightly adhered to surrounding tissues such as soft tissues, spinal cords, and nerve roots. Therefore, they are easy to separate and can be completely removed. After complete resection of schwannomas, recurrence is rare, and only patients treated with partial resection have recurrence. However, we should note that the spine is rich with blood vessels, which favors hemorrhage during the operation. Tang et al reported that 39.88% of patients undergoing sacral tumor resection had blood loss greater than 3000 mL. Their data indicated that blood volume loss was influenced mainly by location, volume, and the blood supply of the tumor. Hemorrhage is a serious intraoperative risk in cases where major vessels are situated near the tumor, and there are currently several reports of unsuccessful tumor excisions and intraoperative mortalities. In this patient, the anterior and posterior combined laminectomy fully protected the facet joints. The advantage was that it could be exposed to decompression and had little effect on the stability of the spine. Due to the large schwannoma, after complete removal of the tumor and surrounding structures, the patient underwent bone fusion and internal fixation to achieve stable reconstruction of the spine and achieve proper healing. In short, to determine the best treatment for giant lumbar paravertebral schwannomas the following should be taken into account to reduce the incidence of surgical complications: the actual growth shape and size of the tumor, extent of invasion, relationship of the tumor with the dura mater, if the patient is a candidate for blood transfusions, surgical consultations, and classification to determine the best operation methods and protocols. The purpose of an operation is to remove the tumor as completely as possible, relieve pressure, and restore the function of the nerve and the spinal cord to the greatest extent, so as to maximize the success rate and prognosis of the operation.On the treatment side of schwannoma, radiotherapy and chemotherapy are not effective for this common and benign tumor.In summary, we described a rare case of a giant paravertebral schwannoma near the 4th lumbar nerve roots with bone destruction. The most interesting finding is that the only clinical manifestation was a sensation of a bulging disc in the lower back. Although MRI cannot accurately provide a preoperative diagnosis, it can intuitively reflect the location and size of the tumor and the relationship with the surrounding organs and blood vessels. As for the tissue source of the tumor and distinguishing between benign and malignant, the diagnosis depends on surgical and pathological examinations. Moreover, we believe that extensive resection is useful for treating giant schwannomas and minimizing the risk of local recurrence, as our patient was free from disease at the 3-year follow-up.Data curation: Dai Min, Bin Zhang.Funding acquisition: Dai Min, Bin Zhang.Methodology: Ping Zhan, Yuan Liu.Project administration: Hangjun Chen.Resources: Ping Zhan, Yuan Liu.Supervision: Bin Zhang.Writing – original draft: Hangjun Chen.Writing – review & editing: Qiang Xu.


Endometriosis is a common, hormone-dependent gynecologic disease. Undiagnosed in large proportion of women, managing therapies depend on the impact of quality of life and includes hormonal treatment and pelvic surgery. Less likely endometriosis can occur in post-menopausal women. Malignant transformation of endometriosis is a rare but well-described process, most of time occurring in the ovary, and justifies the practitioner not to underestimate this pathology. We present a case of a 61 year old woman with a symptomatic endometriotic pelvic mass, status post hysterectomy, with no history of endometriosis diagnosed beforehand. Endometriosis is a benign, hormone-dependent and inflammatory disease. Described for the first time in 1925, it is characterized by the presence of endometrial tissue outside of the uterine cavity, occurring most commonly in fertile women . EndometAlthough endometriosis is a benign proliferative disease; it does share common characteristics with neoplastic processes . MalignSarcomas are a rare and heterogeneous group of malignant tumors of mesenchymal origin, affecting principally soft tissues (80%) but also bones (20%) . The hetThis paper presents the case of a 61 year old woman, status post hysterectomy, presenting a pelvic mass with vaginal bleeding and diagnosed with deep pelvic endometriosis.A post-menopausal 61 year-old 2G1P woman presented to the Gynecology Obstetric Hospital in Freiburg, Switzerland, in January 2018 for severe metrorrhagia without abdominal pain. Medical history included high blood pressure and moderate dyslipidemia. The patient was under hormone replacement therapy (HRT). In her past medical history, the patient had a cesarean and a total hysterectomy by laparotomy in 2000, without ovariectomy, for menometrorrhagia (no morcellation needed). The pathological report of the hysterectomy specimen showed a focal hyperplasia of the endometrium without atypia and a submucosal leimoyoma.During her visit, the medical examination showed a normal abdominal status and the vaginal palpation done by the junior doctor seemed normal. Nevertheless, the speculum examination revealed a budding mass of the vaginal dome. A vaginal ultrasound showed a heterogeneous highly vascularized lesion above the vaginal dome measuring 53 × 66 mm. The ultrasound showed a normal right ovary, the left ovary was not seen. There was no free liquid in the peritoneal cavity. We partially stopped the bleeding by dabbing with silver nitrate but as the bleeding was not totally stopped, we performed an embolization of the right and left vaginal arteries with coils .Further anamnesis revealed that this mass had been known since 2013 and discovered after a CT scan exam and ultrasound performed because of vaginal bleeding. At that time, it measured 45 mm in its greatest dimension. The patient had decided not to pursue further investigations as tumor markers  were normal and for personal reasons.A first vaginal biopsy under local anesthesia produced two small fragments of endometrial tissue with no atypia or malignancy . The bioThe abdominal CT scan and MRI found a hypodense mass adjoining the vaginal dome possibly infiltrating the posterior bladder wall and the rectum . The recHowever, multidisciplinary discussions between gynecologists and pathologists, attempting to correlate a mass of unclear location  with histological findings, lead to the potential hypothesis of a mullerian adenofibroma, a rare low grade neoplasm of the gynecological tract. It associates benign epithelial mullerian glands with a stromal component with few atypia  and would be difficult to distinguish on small samples from its counterpart the low grade mullerian adenosarcoma. The results of immunohistochemical techniques, using antibodies against CD10, estrogen receptors, and epithelial markers, though not specific, were consistent with the mullerian adenofibroma hypothesis. Endometriosis was discussed but not retained because of the notion of hysterectomy in this patient.Surgery was decided after multidisciplinary discussion. Before the surgery, a double J probe was inserted in ureters. Initially, a diagnostic laparoscopy was done, in conjunction with the visceral surgeons, showing a diffuse adherential status resolved by adhesiolysis. Bilateral adnexectomy by laparoscopy followed by a laparotomy conversion in order to extract the whole tumor. The coagulation and removal of the mass pedicle resulted in a bloc resection of the infiltrated recto-sigmoid with a small part of the vagina. A discharge ileostomy was performed. The operation lasted 8 h and the bleeding amounted to about 850 cc.There were no immediate postoperative complication. Two weeks after the surgery, the patient developed a febrile state with a painful renal percussion and inflammatory syndrome with acute renal failure. After introducing antibiotic for pyelonephritis, the patient underwent a CT scan that showed a displaced right JJ probe that was removed the following day. The renal insufficiency was probably multifactorial and due to a context of infection, ileostomy liquid loss, toxicity of the antihypertensive drug, and acute tubular necrosis.The evolution was favorable. The vaginal bleeding stopped after surgery. The ileostomy was closed 3 months later.muscularis propria concluded to endometriosis. Both ovaries harbored serous cystadenofibromas . No malignant neoplasm was found. No vaginal mucosa/wall was identified within the surgical specimen.The pathological analysis of the 75 mm large, highly vascularized, rectosigmoid mass that had developed in the sigmoid meso and the After phone call with the patient February 2019, she does not report any abdominal pain of vaginal bleeding. The last imagery and clinical control in Mai 2018 was normal.Because of the complex symptomatology and the invasive manner of diagnosis, in the form of laparoscopy with visual findings of the endometriosis lesions , the exade novo development , and other estrogen secretors such as adipose tissue or the adrenal glands. Studies show that the endometriotic tissue could secrete its own estrogen, confirmed by the possible presence of aromatase expression in these ectopic lesions , 12. Reselopment .Although the physiological ovarian estrogenic secretion is over after menopause, this patient had several risk factors for maintaining a hyper estrogenic state, favorable to endometriosis, such as obesity and HRT . Retrospective anamnesis, the patient did not report any pain or fertility issues and the diagnosis of endometriosis was never assumed beforehand.The first choice of treatment of postmenopausal endometriosis is a surgical procedure with optimal cytoreduction, by carbon dioxide ablation, laser, or bipolar diathermy , due to The association of endometriosis with an increased risk of malignancies has been described  but is dAge is a risk factor for many malignancies, from which we may hypothesize a higher malignant transformation potential risk for postmenopausal women with endometriosis .For the moment, there are no recommendation for “prophylactic surgery” in women with endometriosis because of the malignant risk . PublishAssuming a low-grade malignant tumor by viewing this mass, and the bleeding symptomatology, we performed surgery, but advanced endometriosis can be the cause of error or incorrect intraoperative evaluation by infiltrating the parametrium or lymphatic nodes or invasive procedures with complications .Histological findings of the CT scan biopsy suggest a consistent with adenofibroma/sarcoma of low-grade diagnosis. But we know that the diagnosis of sarcoma is very difficult because of the histological and molecular heterogeneity and the rareness of this disease . AdvanceEstrogenic dependency of endometriosis lesions explain the therapeutic potential of aromatase inhibitors that block the conversion from androgen to estrogen. This medication showed value in patients who are not eligible for surgery , 29 but It should be kept in mind that endometriosis is still an evocable diagnosis even after menopause and even after hysterectomy. The exact prevalence of endometriosis is still unknown because of the pauci-symptomatic nature and the invasiveness of the diagnostic procedure. Endometriotic lesions can mimic malignant lesions by their infiltrative character and produce a large panel of symptoms dependent on the site of the damage. Endometriosis is associated with cancer types such as endometrioid carcinoma of the ovary, but without proof of a causal link. The main procedure for treatment is surgery but should be balanced with the complication risks of a surgical procedure.Consent was obtained from the patient for the publication of this case report.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Odontogenic keratocyst (OKC) has a special mention in the field of oral and maxillofacial surgery due to its varied presentation and high recurrence rate. The presence of Bcl-2 and cytokeratin 10 along with interleukins in the basal and suprabasal layers led to the inhibition of apoptosis of the surface epithelium and hence the high rate of recurrence. We discuss six cases diagnosed as odontogenic keratocyst on biopsy that underwent surgical removal. At the time of biopsy, the contents of the cyst were drained to allow decompression, then enucleation with Carnoy’s solution was performed as a secondary procedure. Based on our findings, we suggest a modification to Pogrel’s protocol of decompression with a drain in place followed by enucleation. Treatment of odontogenic keratocyst (OKC) is one of the highly controversial protocols among oral and maxillofacial surgeons. Treatment modalities range from simple enucleation in the case of lesions that are less than 1 cm to extensive resection in the case of cysts that extend into the skeletal base. We discuss cystic cases that were diagnosed by biopsy with decompression followed by enucleation with the application of the Carnoy’s solution and/or electrochemical cauterization.It was Broca who brought about the classification of odontogenic tumors in 1869, which was in use until 1914. Until the end of 1914, Broca’s classification of odontoma was maintained . In 1971The aggressive nature of the cyst with its parakeratinized epithelium is dealt using decompression followed by enucleation along with the involved overlying mucosa ,9; this Herein six cases of odontogenic keratocyst are presented. Each had extensive lesions due to their anterior-posterior expansion but were treated conservatively. A biopsy was done to confirm the diagnosis and to decompress the lesion, allowing the thickening of the lining epithelium to take place. Following this, the lesion was enucleated, and the lining epithelial fragments were meticulously removed from the cystic cavity along with the overlying mucosa. These areas were then subjected to cauterization with either Carnoy’s solution or electronically.A 19-year-old woman presented with a concern of continuous mild gnawing pain over the left angle of the mandible for the past two weeks, with progressive trismus limiting her to a 26-mm mouth opening as well as signs of inferior alveolar nerve paresthesia. An orthopantomogram (OPG) followed by a computerized tomography (CT) scan confirmed the extent of the lesion.The aspirate was a cheese-like creamy material. A biopsy with decompression was performed. Odontogenic keratocyst was the histopathological diagnosis, and the patient was advised to have the cyst enucleated under general anesthesia. Henceforth, under general anesthesia, the cystic cavity was completely enucleated, the inferior alveolar nerve was lateralized Figure , and theThe second patient was a 39-year-old with a concern of mild pain and swelling that seemed to increase in size along the lower left posterior teeth region extending up to the mental foramen. As the latter was involved, the patient exhibited left mental nerve paresthesia.An OPG revealed a huge cystic lesion extending from the first premolar on the right to the distal aspect of the second molar on the left side with impactions of both the canines at the symphyseal region Figure . A cone-An incisional biopsy was performed at the apical region of 34, where the cortical bone was soft in consistency and fluctuant which came back as orthokeratinized OKC. Under general anesthesia (GA), the cystic lesion was enucleated and the bony defect was filled with alloplastic bone.The third patient was a 35-year-old woman with a concern of mild pain and sensitivity of the teeth in the maxillary anterior region. A CT was taken following the OPG to determine the involvement of teeth. An expansile lesion with bone loss extended from the first premolar on the left to that on the right. Mild infraorbital paresthesia of the left side was noted. Aspiration revealed a thin, straw-colored fluid, with a creamy, cheese-like material. Enucleation was performed under general anesthesia and the cavity was cauterized with electrotherapy. The bony defect was then grafted with autogenous bone from the iliac crest.The fourth patient was a 29-year-old with a concern of halitosis and fluid leaking intraorally from the right body of the mandible. He had a horizontal impaction surgically removed by a local dentist. OPG revealed a well-scalloped radiolucent lesion extending from the mesial aspect of the first molar to the mandibular foramen that had become secondarily infected. Biopsy revealed parakeratinized odontogenic keratocyst that was planned for enucleation with chemical cauterization under general anesthesia with open dressing and debridement carried out meticulously as an outpatient. He was given upper and lower arch bars for elastics and intermaxillary fixation (IMF) during the first week of the post-operative period as the lesion had extended to the lower border, undermining it.The fifth patient was a 35-year-old with an ongoing concern of pain in the 48 region for the past two weeks. On examination, she had an impacted tooth with a cystic lesion extending from the distal aspect of the first molar to the angle of the mandible involving the inferior third of the ramus. The biopsy specimen came back as orthokeratinized odontogenic keratocyst. Therefore, at that time in 2005, meticulous precaution was taken to ensure the cystic lining was not left behind, and the enucleation was carried out in totality along with the involved overlying mucosa (Figure The sixth patient was referred to the department for a concern of a mandibular symphyseal fracture and was found to have a cystic lesion in the anterior mandible. The lesion was curetted along with the fracture reduction Figure . Test reThe cases discussed are provided in a tabulated format Table .All six cases involved the mandible except for the one case that involved the upper anterior premaxilla region. The lesions had generally obliterated the vestibule expanding both the buccal and the lingual cortical plates.The OPGs revealed well-defined radiolucent lesions with a scalloped margin in two cases. CTs with 3D reconstruction were taken to study the relations of the involved roots with the cyst Figure . PerforaAll the lesions when aspirated contained a creamy cheese-like material except for the one in the premaxilla region that instead contained a straw-colored fluid. The biopsy, however, confirmed that it was an odontogenic keratocyst. Four patients presented with the cyst having a sinus opening, and three were discharging fluid. The intraoral sinus seemed always to be present to the most mesial region of the lesion, leaving the ramus and the angle of the mandible intact. The biopsy was normally performed close to the sinus opening allowing the drainage of the lesion and was closed primarily after enucleation with alloplastic or autogenous bone graft with plasma rich fibrin Figure .The biopsy reports of most cases came back as orthokeratinized Figure , except Under general anesthesia, a complete mucoperiosteal flap was elevated in the respective regions. The point of entry was always close to the biopsied site. Different surgeons were involved in the surgical procedures but all followed the same protocol of meticulous enucleation of the cystic lining along with the involved overlying mucosa, with lateralization of the inferior alveolar nerve when essential, along with Carnoy’s solution , 13. TheIn cases where the lower mandibular border was thinned out, precautionary measures were taken to protect against pathological fractures. One patient had an arch bar and the other an eyelet with IMF for three weeks. In the other, a lateral bony window was created Figure  to help The treatment modality varies from region to region. Huge lesions, especially the parakeratotic types, are dealt aggressively with enucleation and resection. The aggressive nature of OKC has been attributed not only to the presence of matrix metalloproteins as well as interleukin-1 alpha and parathyroid hormone-related protein but also to the presence of Bcl-2 and cytokeratin 10, leading to the high rate of recurrence .The increase in morbidity associated with the resection and the compromise in the quality of life in dealing with large lesions has led surgeons to consider decompression followed by enucleation as an alternative treatment option. Pogrel reported a review of 10 cases of OKC that were treated conservatively with decompression and enucleation with no recurrence . In his The complete decompression of the cystic cavity by using a drain tube fixed to the first molar for eight to nine months, followed by a cystectomy done as a second stage procedure, was investigated by Brøndum and Jensen in 1991 . Over anProtocols should be in place that require dentists to perform a diagnostic OPG for patients on their first visit followed by imaging being done once every three years for a given individual so that these lesions could be discovered at an early stage. As for treatment options, a biopsy should be performed with the complete aspiration of the fluid contents that allows the thickening of the epithelium. The final treatment would be a conservative enucleation instead of an aggressive resection that mutilates patients, as most of these patients belong to the younger generation. None of these suggestions take away the fact that long-term follow-ups are essential with periodic radiographic examination.


BRCA1 or BRCA2 genes, which are tumor suppressor genes. Hundreds of different types of mutations in these genes have been identified, some of which have been determined to be harmful, whereas others have no proven impact. BRCA mutations are well known to be associated with breast, uterine, and ovarian cancers along with some nongynecological malignancies involving the peritoneum, prostate, pancreas, skin, stomach, and rectum. However, there are no reported cases to date of an association between carcinoid tumors and a BRCA mutation.A BRCA mutation is a mutation in either of the Our patient was a 33-year-old White woman with BRCA2 mutation who presented to her primary care physician for evaluation of abdominal pain. She underwent computed tomography of her abdomen and pelvis, which showed an incidental finding of infrahilar mass along with renal stones. Further workup with bronchoscopy and biopsy of the mass confirmed it to be a carcinoid tumor of the lung.No literature thus far exists describing a connection between BRCA mutations and carcinoid tumors. Early diagnosis and prompt treatment of carcinoid tumors are proven to have impact on survival and prognosis of these patients. Carcinoid tumors, also known as neuroendocrine tumors (NETs), are an uncommon group of pulmonary neoplasms accounting for 1–2% of all lung cancers in adults and around 20–30% of all NETs . These tBRCA2 gene mutation status. She presented to her primary care doctor for abdominal and back pain after bilateral prophylactic mastectomy. She had a strong family history of BRCA2-positive breast cancer in two of her aunts and one cousin. Her physical examination revealed that her vital signs were normal, and her abdominal examination was unremarkable except for mild nonspecific lower abdominal tenderness. For evaluation of lower abdominal pain and back pain, she underwent computed tomography (CT) of the abdomen and pelvis, which showed nonobstructing bilateral renal calculi and incidentally showed right infrahilar adenopathy. She underwent further CT of the chest with contrast enhancement, which revealed a right hilar mass measuring 3 × 2.2 cm and suspicious for malignancy  with right thoracotomy, right middle and lower lobectomy, and lymph node resection.The pathology report of the lung nodule confirmed it to be a typical carcinoid tumor with metastasis to one subcarinal lymph node Fig. . A histoAs per discussion with the patient and according to National Comprehensive Cancer Network (NCCN) guidelines, the patient would not receive any chemotherapy currently and would be closely followed by an oncologist.The patient has had two follow-up appointments with her oncologist since the VATS procedure. After discussion with the patient and according to NCCN guidelines, the patient did not receive any adjuvant chemotherapy. The plan moving forward would be close surveillance with serial CT scans  and chromogranin A measurements.Carcinoid syndrome represents a constellation of symptoms that are seen in patients with NETs. The symptoms are exhibited because of release of chemical mediators, and as many as 40 such mediators have been identified in the pathophysiology of carcinoid syndrome . The mosBRCA2 gene mutation. Carcinoid tumors have been well studied from the early 19th century. There have been multiple case reports and studies about carcinoid tumors of the lung; however, to the best of our knowledge, there is no literature thus far describing a connection between BRCA mutations and carcinoid tumors. A BRCA mutation is a mutation in either of the BRCA1 or BRCA2 genes, which are tumor suppressor genes [BRCA2 gene mutation. Our patient had heterozygous germline BRCA2 mutation c.4884_4885del. This observation can be incidental and unrelated; however, further studies and vigilant case reporting can solidify this association.The most significant and important finding in our patient is the history of positive or genes . HundredCarcinoid tumors are commonly seen in the gastrointestinal tract with frequent metastasis to liver. The first description of carcinoid tumors was in the late 18th century by Lubarsch, followed by Oberndofer in 1907 . In the The definitive treatment for lung carcinoid depends on the extent of disease, pulmonary reserve, and distant metastasis . For patThe role of adjuvant chemotherapy after complete resection of the lung NET is not recommended, owing to total lack of prospective randomized controlled trials. However, there are a number of retrospective studies to study the role of adjuvant chemotherapy, but most of those studies have not found a benefit from adjuvant chemotherapy –18. MostNo literature exists showing a connection between BRCA mutations and carcinoid tumors; thus, further studies and vigilant case reports are needed to solidify the association between them. Patients with BRCA mutation should be examined with a careful workup for carcinoid tumor in appropriate clinical scenarios. Delay in diagnosis may possibly result in unfavorable prognosis, which may ultimately lead to death. Early diagnosis and prompt treatment with complete surgical resection have been proven to prolong survival.


Calcinosis is frequently associated with systemic sclerosis (SSc) and can be located at various sites, although it is most commonly seen in the hands. When it presents around the synovial joints and is associated with a mass-like appearance, it is classically called tumoral calcinosis. Few cases of tumoral calcinosis have been reported in the paraspinal region. They are usually located in the cervical segment and rarely in the lumbar region. Occasionally, they have been associated with nerve root compression and intraspinal extension. We report the case of a 47-year-old female with advanced SSc who presented to our hospital’s radiology department with chronic low back pain and right L5 radiculopathy due to tumoral calcinosis. An initial lumbar spine MRI showed multifocal, low signal, mass-like lesions involving the right paraspinal soft tissues. At the L5–S1 level, one lesion compressed the right L5 exiting nerve root. A CT scan of the lumbar spine performed later demonstrated the calcified nature of the lesions depicted by MRI and evidenced signs of pulmonary fibrosis at the base of the lungs. Further clinical work-up also showed that the patient had Raynaud's phenomenon, oesophageal dysmotility, sclerodactyly, dyspnoea, facial telangiectasias, generalized weakness and arthralgia. The diagnosis of a subtype of SSc, called limited cutaneous SSc, was made. Our case describes the CT and MRI findings of tumoral calcinosis in an unusual location secondary to limited cutaneous SSc. Knowledge of the imaging features of this uncommon manifestation of SSc could potentially increase its prospective diagnosis and hence improve patient management. Middle-aged females are affected more frequently than males. It is characterized by excessive collagen deposition (fibrosis) in the skin and microvasculature, and autoimmune abnormalities. Two overlapping forms of the disease are seen: diffuse SSc and limited cutaneous SSc (lcSSc). The latter is classically associated with calcinosis, Raynaud’s phenomenon, oesophageal dysfunction, sclerodactyly and telangiectasias.2 It is less commonly seen in the paraspinal soft tissues, particularly in the cervical spine.3 Even less frequently, calcinosis can involve the thoracic or the lumbar spine and cause neurological manifestations owing to foraminal and/or intraspinal extension.5 When calcinosis presents as lobulated periarticular soft tissue masses, usually at the extensor surface of the joints, it is classically known as tumoral calcinosis.6 Here, we present a rare case of tumoral calcinosis in the lumbar spine secondary to lcSSc, and highlight its typical imaging findings on both CT and MRI.Calcinosis is defined as deposition of calcium salts in tissues. Calcinosis is frequently associated with SSc, especially in the hands and in advanced stages of the disease. It has also been reported to occur in the wrists, forearms, elbows, shoulders, knees, around the iliac crests, over the gluteal regions and the thighs.A 47-year-old female presented to an outside institution with chronic low back pain and right L5 radiculopathy, and an MRI of the lumbar spine was performed (not shown). It showed a mass-like lesion at the right L5–S1 foramen and a diagnosis of hernia or tumour was considered. Over a 1-month period, the patient was managed clinically with analgesics with partial resolution of symptoms.T1 and T2 weighted sequences) was obtained . It occurs in either a localized or generalized distribution and is found in patients with normal serum chemistry levels. On the other hand, metabolic calcification usually results in generalized mineral deposition owing to a disorder of calcium/phosphate metabolism .6Despite this pathology-based classification, some authors believe that the term “tumoral calcinosis” should follow the historical definition. Hence, this term should be strictly used to suggest diseases caused by a hereditary metabolic dysfunction of phosphate regulation associated with massive periarticular calcinosis. In addition, the “secondary” causes of tumoral calcinosis would be better categorized as dystrophic and metabolic (metastatic) calcifications, according to serum chemistry levels . Dystrophic calcification results from underlying damaged tissues and includes a wide range of pathologies , which may be important in patient management.7On MRI, lesions typically show low intensity on 15 It has been described in both the primary and secondary forms of tumoral calcinosis.16 On ultrasound examination, tumoral calcinosis lesions may show cystic spaces that contain fluid sedimentation levels, with increased echogenicity of the dependently layering debris.16 Similarly, on radiography and CT imaging, a radiodense component within the dependent components of the lesion is seen, while on MRI, the fluid sedimentation level appears as a high signal layered over a low signal on T2 weighted sequence.16 To the best of our knowledge, our case is the first MRI description of sedimentation sign in a patient with SSc.Occasionally, tumoral calcinosis lesions may show fluid sedimentation level on ultrasound, radiography, CT or MRI. This characteristic finding occurs owing to calcium crystal sedimentation within the dependent portion of the lesion and is recognized as the “sedimentation” sign.6Several pathologies can present with calcified masses in the soft tissue and involve the paraspinal region, as previously mentioned. Although most tumoral calcinosis aetiologies show similar characteristics on imaging, careful evaluation could potentially raise suspicion for particular entities in the differential diagnosis.i.e. synovial sarcoma, extraskeletal osteosarcoma, etc.) or secondary (metastasis), should be the first consideration in the differential diagnosis. On imaging evaluation of the spine, multiple lytic or blastic bone lesions, which may or may not be associated with soft tissue components and contrast enhancement, would be helpful findings in favour of a secondary neoplasm aetiology, particularly in a patient with a history of malignant neoplasm and over 40 years of age. In fact, calcified lesions associated with non-calcified soft tissue component and/or contrast enhancement on CT and MRI should promptly raise suspicion for neoplasms over tumoral calcinosis.6 On MRI, soft tissue neoplasms may also demonstrate poorly defined and infiltrative margins with mixed signal intensity on T1 and T2 weighted sequences owing to the presence of haemorrhage, calcification as well as solid and cystic components. Moreover, a neoplasm may also show bone involvement manifesting as periosteal reaction, superficial erosions or bone destruction, features that are not typical of tumoral calcinosis.6 In addition, the sedimentation sign, although non-specific for SSc diagnosis,13 may be particularly helpful to distinguish tumoral calcinosis from neoplasm, as in our case.Soft tissue neoplasms, either primary  for publication of this case report, including accompanying images.


Chronic expanding hematoma is a rare entity resulting from trauma or surgery. This condition usually occurs in soft tissue, such as the trunk or extremities, while chronic expanding hematoma arising from bone has not been reported previously. We describe an unusual case of a huge intraosseous chronic expanding hematoma arising from the ilium, which had grown over a 40-year period following hip surgeries.A 57-year-old Japanese woman presented with a 1.5-year history of right hip pain. She had a history of bilateral developmental dysplasia of the hip and had undergone bilateral arthroplasties in childhood. A physical examination revealed a large, firm, immobile mass at her right ilium. Based on radiographic findings, a type of slow-growing bone tumor was suspected, and an incisional biopsy was performed. A histopathologic examination revealed large amounts of old clotted blood within the lesion, and the capsule of the lesion was composed of dense, fibrous, connective tissue. There was no evidence of neoplasia, and chronic expanding hematoma was suspected. The lesion was resistant to conservative treatment, and so we performed an internal hemipelvectomy (including the capsule of the mass) and a reconstruction by hip transposition 2.5 years after the incisional biopsy. There was no recurrence of chronic expanding hematoma at the most recent follow-up of 1 year and 8 months postoperatively.A chronic expanding hematoma is characterized by its persistence and increasing size more than 1 month after the trauma or surgical event suspected of causing hemorrhage. To the best of our knowledge, this is the first report of chronic expanding hematoma arising from bone. We performed internal hemipelvectomy and hip transposition, and there has so far been no recurrence. This disease may be considered a differential diagnosis for bone tumor when the patient has a history of surgery or trauma, regardless of how many years have passed since the index event. Chronic expanding hematoma (CEH) is a rare entity resulting from trauma, surgery, and/or bleeding disorders. Previous reports have described the location of CEHs as the thoracic cavity or the soft tissue of the extremities, while intraosseous CEH has not been reported previously. We describe an unusual case of a huge intraosseous CEH arising from the ilium, which had grown over a 40-year period following hip surgeries. The patient was successfully treated by surgical excision and hip transposition.A 57-year-old Japanese woman presented with a 1.5-year history of right hip pain when she walked long distances. She had a history of bilateral developmental dysplasia of the hip and had undergone bilateral acetabular osteotomies in childhood. There was no history of trauma, anticoagulant use, or a collagen vascular disorder. She is a housewife. She has no medical history and family history.4/μL, C-reactive protein (CRP) 0.12 mg/dL, aspartate aminotransferase (AST) 15 U/L, alanine aminotransferase (ALT) 11 U/L, blood urea nitrogen (BUN) 11 mg/dL, creatinine 0.50 mg/dL, activated partial thromboplastin time (APTT) 27.8 seconds, and prothrombin time-international normalized ratio (PT-INR) 0.97 INR).A physical examination revealed a firm, immobile mass measuring 18 cm × 12 cm located on the right side of her ilium. An operation scar measuring 14 cm was found in the front of her hip joint. There was no redness of the skin or swelling of the inguinal lymph nodes. There were no neurological signs of motor or sensory disturbances in her limbs. She could walk with one axillary crutch on one arm and could stand on her right leg. The joint motions of her right hip joint were − 20° extension, 30° flexion, 20° abduction, and 10° adduction. There were no differences in the circumferences of her lower limbs. All laboratory data were within normal limits including coagulation studies: white blood cells (WBC) 7300/uL, hemoglobin 12.8, platelet 22.6 × 10A plain radiograph revealed expanded deformity of her right ilium with marginal sclerosis and calcification inside the bone Fig. . ComputeBased on these findings, our differential diagnoses were giant cell tumor of the bone, aneurysmal bone cyst, or low-grade malignant tumor such as telangiectatic osteosarcoma. Therefore, an incisional biopsy of the lesion was performed. An intraoperative examination revealed that the lesion had a thick capsule; when the capsule was incised, abundant blood was drained from inside. The intraoperative hemorrhage from the incisional biopsy was 500 ml; then, our patient needed a blood transfusion because her hemoglobin level decreased to 6.7 mg/dl from the preoperative level of 12.8 mg/dl. A histopathologic examination revealed large amounts of old clotted blood within the lesion. The capsule of the lesion was composed of dense, fibrous, connective tissue Fig. . There wWe discussed the treatment options of the current case because there was no previous example of a huge CEH of bone. Surgical treatment was not recommended due to inaccessibility based on our experience of the intraoperative massive hemorrhage at the previous biopsy. We selected non-operative management for the current case. A consecutive selective arterial embolization program was started and performed five times Fig. . In addiAt the operation, the mass was completely covered in a capsule, with no evidence of invasion of the neighboring muscle. On macroscopic examination, the lesion was encased in a thick capsule Fig. . After tExternal fixation of her pelvis and her right femur was applied for 6 weeks postoperatively. After removing the external fixation, partial weight-bearing was permitted for 4 weeks, and full weight-bearing with one crutch was allowed 14 weeks postoperatively.There was no recurrence of CEH at the most recent follow-up of 1 year and 8 months postoperatively. She can ambulate with the assistance of one crutch and a heel lift of 5 cm Fig. .We described an unusual case of a huge intraosseous CEH arising from the ilium, which had grown over a 40-year period following acetabular osteotomies. Intraosseous CEH has not been reported previously.et al. as a rare clinicopathological entity characterized by its persistence and increasing size more than 1 month after the trauma or surgical event suspected of causing the hemorrhage [CEH was first described by Reid morrhage –4. HowevThe detailed mechanism underlying CEH has not yet been clarified. It is thought that the expansion is related to the inflammation stimulated by blood breakdown . These cCEH can occur at any location in the trunk or extremities, and symptoms differ according to location. Postoperative cases have been reported, most of which have involved the thoracic cavity after surgery of the lung, coronary arteries, or aorta , 9, and It is very difficult to differentiate CEH from a malignant tumor, as in both cases the mass slowly expands and occasionally erodes the bone . MagnetiCEH should be managed by complete surgical excision, as incomplete removal may lead to recurrence . In ordeWe have presented an extremely rare case of CEH arising from bone a long period after hip joint surgeries. To the best of our knowledge, this is the first report of CEH arising from bone. We performed internal hemipelvectomy and hip transposition, and there has so far been no recurrence. This disease may be considered a differential diagnosis for bone tumor when the patient has a history of surgery or trauma, regardless of how many years have passed since the index event.