Herein we report the management of a giant, high-grade and vascular carotid body tumor in a young woman. She presented with slowly progressive neck swelling. Vascular imaging revealed a left-sided, high-grade giant carotid body tumor (> 8cm).  The tumor was completely excised by caudocranial subadventitial dissection. Histology of the tumor revealed a characteristic Zellballen pattern of the lesion, suggestive of a paraganglioma. The patient made an uneventful recovery. We also discuss newer insights regarding the management of such highly vascular lesions. Management of such highly vascular lesions, which completely encase the major carotid artery along with its branches, is even more challenging. We report the management strategy for a similar case, where caudocranial subadventitial dissection completely excised this tumor, one of the largest reported in the literatureA 22-year-old woman presented to the Neurosurgery clinic in Nobel Teaching Hospital with a history of slow progressive but painless swelling over her left neck, ongoing for the last 6 months. She was also experiencing some difficulty while swallowing. She denied history of trauma, any episodes suggestive of transient ischemic attacks or paroxysmal episodes of severe headache, flushing or chest pain. She did not have major surgery or medical illnesses in the past, or any significant family history.Local examination revealed a pulsatile swelling on her left neck. There was no audible bruit over the swelling. The patient then underwent a CT angiography, which revealed a well-defined large (> 8 cm) heterogeneous and hyperdense soft tissue lesion; showing intense arterial enhancement at the level of carotid bifurcation . It was Ultrasound imaging of the abdomen to assess adrenal glands was normal. 24-hour urine vanillylmandelic acid (VMA) and plasma metanephrines were within normal range.The patient was thoroughly counseled regarding her condition and the need for operative management. The risks associated with the surgery, including intra-operative uncontrolled bleeding, lower cranial nerve palsy, ischemic stroke and even death, were detailed. Anaesthetic precautionary measures were implemented to reduce the risk of hypertensive crisis (during tumor manipulation) and hypotensive episodes , by administering antihypertensive drugs and fluid support, respectively. After ensuring temporary carotid control with vascular loops, sub-adventitial dissection of the lesion was carried out starting from the common carotid caudally and then progressing cranially towards the bifurcation and its branches . The maj3. They are the most common tumors of this origin to occur in the head and neck region4. Since the majority of cases seem to occur in people residing at high altitudes, chronic hypoxemia has been postulated to be a cause for such tumors5. Most patients present with features owing to compression of the lower cranial nerves by the lesion6 In few cases, paroxysmal symptoms resulting from excessive circulating catecholamine may be evident8.Carotid body tumors, first described by Von Haller in 1743, are of neuro-ectodermal origin9.Examination should begin by assessing the pulsatility of the tumor. It has a characteristic mobility in the horizontal direction whereas it has restricted mobility in the vertical direction. This aspect is also referred to as the ‘Fontaine sign’10. It helps diagnose the lesion, determine its extent and the involvement of the major vessels. It also aids in simultaneous assessment of both the carotid vessels, to rule out bilateral involvement and carotid artery disease, especially in aged patient groups. In high-risk patients with positive family history or in active catecholamine secreting lesions, this type of imaging can help rule out multiple infections by evaluating the adrenal glands. Shamblinet al classified these highly vascular lesions depending on how they are placed in relation to the carotid vessel, which helps plan their management strategy11. Most high-grade lesions require an adjuvant protocol, either in the form of preoperative embolisation or intra-operative temporary or permanent interposition vascular grafts.Needle biopsy is contraindicated due to the risk of haemorrhage, thrombosis or pseudo-aneurysm12. It is also advisable to rule out synchronous neural crest lesions by imaging the tympanic cavity and the adrenal glands, especially in patients with positive family history13. Although rare, active lesions (seen in around 5% of cases) should be ruled out by assessing the plasma catecholamine or the urinary VMA levels14.Duplex ultrasound study of the carotid vessels is the first line diagnostic imaging modality15. However, there is an inadvertent risk of stroke and increased difficulty in excising the tumor, when it is glued with embolized particles intra-operatively16.The risk of intra-operative and post-operative neurological and the vascular complications increases with the grade of the lesions. The size, vascularity and thereby intra-operative blood loss is minimized with the use of embolisation17. Surgical excision is the management modality of choice, with embolisation and radiotherapy used as adjuncts in a few selected cases10. Cerebral protection from hypotensive insults during vascular clamping or bypass and management of arrhythmias  during tumor manipulation are some of the challenges faced during the intra-operative period19. Surgery may be carried out under local, regional or general anesthesia. Local or cervical plexus block offers the advantage of a continuous neurological assessment to rule out cerebral hypo-perfusion21. Blood loss can be minimized with meticulous sub-adventitial dissection of the lesion from the vessel walls. Intra-operative vascular control can be achieved by temporary carotid ligation, use of temporary arterial bypass or by use of vascular inter-position graft in cases of inadvertent tear within the vessels22. Hypotensive anesthesia is another valid option to maintain a bloodless field23. A temporary clamp of less than 10 minutes is considered safe13. The IJV, vagus nerve and hypoglossal nerve should always be isolated and well protected throughout the procedure. The higher the grade of the lesion and the need for repair or reconstruction, the higher the risk of stroke25.The first successful excision of a carotid body tumor was performed by Albert J Van Der Kogel in 188926, including peri-operative stroke and persistent nerve palsy27.Huge carotid body paragangliomas continue to cause a high incidence of pre- and postoperative complications28. The hypoglossal nerve is the most common nerve to be affected in the post-operative period, thereby undue stretching should be avoided. Mortality has been seen in 3% of cases, with tumors greater than 5 cm29. In cases of transmural involvement of the vessel by the tumor, excision of the main vessel along with the tumor is justified. Internal carotid artery ligation with reconstruction requirements as well as permanent cranial nerve deficits have been observed in 23% of cases, all belonging to Shambling grade 3 tumors30.Cranial nerve palsy is seen in as high as 40% of cases31.A characteristic Zellballen pattern in the histology and positive staining with neuron-specific enolase (NSE) for Paraganglioma and S100 for sustentacular cells is definitive in diagnosing the tumor32.There are no defined pathological criteria to differentiate benign tumors from their malignant counterpart. Distant metastasis and the involvement of the lymph nodes are the only definitive markers to determine its malignant behavior33. Follow-up with doppler and duplex ultrasound of the carotid vessels is currently advocated17.Malignant transformation and local or distant metastasis is estimated to affect around 10% of cases34. Succinate dehydrogenase (SDH) mutations are commonly seen in young patients, and testing for these may provide us with clues when assessing patients at high risk35. Lifelong follow-ups are required36. With judicious anesthetic care and meticulous subadventitial dissection, such lesions can be managed even in a rural setup37.Large and complicated vascular tumors can be managed with proper planning and executionWritten informed consent for publication of clinical data and clinical images was obtained from the patient. Paragangliomas are neoplasms arising from extra-adrenal chromaffin tissue. It frequently cause symptoms by overproduction of catecholamines and carry risk of hypertension during surgery and post –excision, patient may develop hemodynamic insatiability [1]. Carotid body tumor is a slow-growing neoplasm, usually localized at the bifurcation of the common carotid artery represent most commonly encountered are head and neck paragangliomas, accounting for 60–78% [2]. It is usually benign and rarely malignant and accounts for about 0.5% of all head and neck tumors [2].et al. classified carotid body tumor into three classes: in Class I tumor is small and surgically resectable, Class II includes adherent tumor, which surrounding the carotid vessels partially, resection is considered as technically more difficult, and class III, the  size of  the tumor is large ie more than 5 cm and usually completely encases the carotid vessels, resection is considered very difficult, and always carry risk of the cerebral circulation interruption always [3]. In 1971,  Shamblin DSA is considered as important imaging modality of choice for diagnosis as clearly defines, epicentre of tumor, location, size and encasement of vessel branches in tumor and aid in aiding transarterial embolization therapy which reduces intraoperative blood loss. However, it carry limitation poor visualization of adherence of the tumor mass to the peripheral tissues, cerebral embolism causing ischemic stroke and vascular injury are also reported and even risk cardiac asystole with carotid body hypersensitivity. However DSA of cerebral vessels including cross circulation is essential if needed of cerebral vessel revascularization surgery is required [4]. So, currently, computed tomography scan, CT angiography and MRI are preffered routinely .  et al observed microneurosurgical technique is said in dissection. And prevent vascular and cranial nerve injury [1]. Radiotherapy is an alternative management option for patients with co-morbid illness or who may not tolerate the surgery, presence of  metastasis subsequent to surgery complications include otitis externa, otitis media, osteoradionecrosis, cranial nerve lesion and brain injury [5].  Munakomi  and neuroanesthesia team should be commended for successful  surgery, perioperative hemodynamic adequate control  with good outcome. Surgery is preferred treatment modality and chief concern s include highly vascular mass, dense adherence to the vagus nerve. HuaI have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Paragangliomas are a type of infrequent head and neck tumor originating in the paraganglionic brachymeric tissue involved in the development of the branchial arches. Five families of paragangliomas have been described: Brachymeric, intravagal, sympathetic, viscero-autonomic and adrenal. At the histopathological level, this type of tumors has an identical configuration regardless of its origin. Sporadic cases of this class of tumors are more frequent in females. A high frequency of this class of tumors has been established in patients who live at high altitudes and those suffering from the chronic obstructive disease. It has been suggested that chronic hypoxemia plays a role in the genesis of this class of tumorset al. presented a very well documented case and with successful resolution managed in a resource-limited setting. Munakomiet al. testifies that the preparation and expertise of the surgeon are fundamental for the successful resolution of this class of injuries. The therapeutic choice depends fundamentally on the location of this kind of tumors, the size of the lesion, age, health status of the patient plus the experience of the surgeons. The use of various resources as angiography and preoperative embolization suggests that this type of tumors should be ideally managed in third-level care centers. The case managed by Munakomi Finally, it is important to mention that this type of tumors has a significant risk of urinary complications and several postoperative complications have been described, including cranial nerve lesions, cerebral infarction, hemorrhages among others.We have read this submission. We believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is a well-written case report about how to manage a Shamblin Grade 3 carotid body tumor (CBT). Though surgery is first-line treatment of CBT, it remains a challenge because it’s highly vascular and adherent to the vagus nerve in high-grade CBT. The authors discussed the diagnosis and treatment of CBT in detail. In large tumors like this case, cerebral collateral circulation should be evaluated in case of vessel transplantation or ligation performed. HyperForm might be used for intra-operative distal vascular control if tumor is very large to reach the skull base. However, in a resource-limited setting it is difficult for detailed pre-operative evaluation and intra-operative vascular control.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. It is a very beautifully written case report, however I would like to clarify from the authors how a giant carotid body tumour is to be addressed in a normal setting, resource limitation does not change the management in a big chunk of cases like that. It needs a change in headline.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.


Taenia solium, with humans acting as an intermediate host instead of a definitive host. Head and neck involvement including maxillofacial and oral involvement of cysticercosis is quite rare.Cysticercosis is a disease which is caused by the infestation of the larvae We report a series of rare cases of cysticercosis of the head and neck region encountered in a tertiary hospital in Northern India with a brief review of literature and its diagnosis and management. The patients had undergone ultrasonography, FNAC and CT scan. All the cases were treated by Oral Albendazole tablets. The period of study was from August 2014 to August 2015. FNAC proved to be a highly effective way of diagnosis corroborated by imaging evidence. Treatment with albendazole was curative in all the cases.Cytopathology has emerged as an excellent diagnostic modality for cysticercosis. Medical treatment with antihelminthics produces excellent results, as illustrated in our case, and can eliminate the need of surgery. Taenia solium. It is the pork tapeworm belonging to the phylum Platyhelminthes which is a cyclophyllid cestode in the family Taeniidae. Cysticercosis is an infestation of the larva Cysticercus cellulosae, of Platyhelminthes have a two staged life cycle; first as a larva which develops from egg and then as an adult worm. Each of these phases requires a different host. Humans usually acts as the definitive host and harbor the adult stage, intestinal Taenia solium. The parasitic infestation by the pork tapeworm larval stage, cysticercosis, is caused by the ingestion of tapeworm eggs through contaminated food, water or dirty hands. In this case man acts as the intermediate host . Cysticercosis, being a rare entity is seldom suspected for an isolated swelling over the head and neck region thus leading to a diagnostic dilemma for clinicians. The patients who attended the otolaryngology outpatient department of our hospital from August 2014 to August 2015 were included. Four cases of isolated head and neck cysticercosis were reported. Case 1: A 27-year-old woman presented with the chief complaint of a painless nodule on the dorsum of her tongue for the past six months, with gradual increase in size to approximately 4x4 cm. Examination revealed a tense cystic, nontender nodule that was covered with normal mucosa without any fixity . Fine needle aspiration cytology from the swelling pointed towards the diagnosis of cysticercosis. A CT scan of the oral cavity demonstrated a cystic lesion of the tongue. It did not show any calcification or definite scolex. The patient was recommended for surgery; but a trial of Albendazole tablets was given in an attempt to reduce the vascularity and size. Surprisingly the lesion subsided completely after the course of Albendazole thereby eliminating the need of surgery. The patient is under regular follow up with no recurrence of the swelling. Case 2: A 33-year-old man presented with a painless progressive swelling over the left anterior neck for a duration of four months. During examination a non-tender, tense, cystic swelling was palpable deep in the sternocleidomastoid muscle. Ultrasonography of the neck showed the features of a definite cystic lesion with a scolex within it . CT scanCase 3 A 28-year-old woman presented with a painless swelling below the chin for 8 months. She was treated with ATT empirically in another institution for 7 months without resolution. Upon examination a firm globular, non-tender lump was palpated in the submental region. We did an ultrasonography of the neck and FNAC from the lump and finally reached to the diagnosis of cysticercosis of the floor of the mouth. Albendazole tablets were given as the treatment.Case 4 A 35-year-old male presented with a gradually progressive hard, mildly painful swelling over the right temporal bone for a period of 1 year. Upon examination a non-tender bony hard swelling over the right temporal bone was palpated. The patient underwent a CT scan of the temporal bone which showed unifocal calcification within the temporalis muscle . FNAC initially yielded bloody tap. A repeat FNAC performed a week later; however, supported the diagnosis of cysticercosis. The patient was treated with Albendazole and the swelling went down. All the patients were given a standard course of Tablet Albendazole with a dosage of 15mg/kg per day or standard adult dose of 400mg per day for 28 days. CT scan of the brain was performed prior to starting the Albendazole therapy to rule out neurocysticercosis.Smears from the straw colored clear fluid obtained by fine needle aspiration from the swellings showed fibrillary fragments, bluish in color, which were interspersed with small nuclei. Areas of honeycomb appearance were also seen. The background demonstrated mixed inflammatory cells comprising of neutrophils, eosinophils, histiocytes and lymphocytes with occasional granulomas . Giemsa The patients are under regular follow up with no recurrence of the swelling. Cranial CT scan and indirect ophthalmoscopy was performed in all cases with none of the cases showing any abnormalities.. solium when viable eggs of the parasite are ingested. The eggs of the parasite are often present in unwashed and undercooked vegetables and salads. The eggs hatch in the digestive tract and the larvae are transported through the bloodstream to their destination, which is generally the central nervous system, muscles and subcutaneous tissues  and Albendazole (15mg/kg per day for 8-28 days) are potent antihelminthics used in the treatment of cysticercosis . CT scanAlbendazole causes degenerative alterations in the intestinal cells of the worm by binding to the colchicine-sensitive site of tubulin, thus inhibiting its polymerization or assembly into microtubules. The loss of the cytoplasmic microtubules leads to impaired uptake of glucose by the larval and adult stages of the susceptible parasites and depletes their glycogen stores. Degenerative changes occur in the endoplasmic reticulum, the mitochondria of the germinal layer, and the subsequent release of lysosome .Cysticercosis still remains one of the elusive diseases for clinicians to diagnose. Medical treatment with antihelminthics produces excellent results, as illustrated in our case, and can eliminates the need of surgery.


Ectopic pancreas (EP) is a rare congenital anomaly defined as the presence of pancreatic tissue in topographic anomaly. It is usually silent but it may become clinically evident when complicated by acute conditions. The development of laparoscopic surgery has changed the way to manage such conditions, especially in the setting of emergency surgery, thanks to its diagnostic and therapeutic role with excellent results. We decided to perform an emergency diagnostic exploratory laparoscopy in a 29-year-old man with an acute abdomen and nonspecific radiological images for intestinal occlusion. A jejunojejunal intussusception was found, caused by a mass. We decided to carry out minilaparotomy to perform a resection of the affected jejunum. Histological examination confirmed the presence of a jejunal ectopic pancreas. Adult intussusception caused by EP represents 5% of all cases of intussusception. As CT scan, especially when performed in emergency setting for small bowel obstruction diagnosis, can usually demonstrate nondiagnostic findings suggestive of intussusception of unknown origin, laparoscopic exploration could help surgeons in order to perform a resolute diagnosis and treat the pathology. Ectopic pancreas (EP) is defined as an anatomical abnormality in which pancreatic tissue has grown outside its normal location with no anatomical, neural, or vascular connection to the normal pancreas . The EP The development of laparoscopic surgery has changed the way to manage such conditions, especially in some setting of emergency surgery. In particular, laparoscopy may have three different roles: to validate the pathophysiologic diagnosis (diagnostic laparoscopy), to facilitate and guide a subsequent laparotomy (laparoscopic assisted open approach) or, finally, to entirely treat the disease (fully laparoscopic approach). Actually, in such condition, the results of laparoscopy approach are reported to be excellent in terms of reduction of hospital stay, incidence of surgical site infection, postoperative pain, and recovery of bowel function , 8.While EP and intussusception are not unusual conditions, the intussusception caused by EP is rare . We repoA 29-year-old man (BMI: 32 kg/m2) was admitted to our Emergency Department for nausea and intermittent abdominal pain. The pain had increased for the last 2 days in severity and was associated with episodes of emesis. The patient had a story of undetermined colitis, treated with medical therapy, actually in phase of remission.At clinical examination, the abdomen appeared flat, with a generalized tenderness, painful to palpation, in particular in the left upper quadrant. Lab tests showed a white blood cell count of 15,400/mm3. Chest and abdomen X-Rays were normal and abdominal ultrasound was normal too. On the contrary, the CT scan with intravenous contrast medium revealed an aspecific thickening of a tract of small bowel with partial contrastographic enhancement near the left colon, with a modest dilatation of the lumen of small bowel upstream of the injury, as reported in Therefore, in order to perform a resolute diagnosis, in presence of an inconclusive and nondiagnostic CT scan, we decided to perform an emergency exploratory diagnostic laparoscopy. In the operating theater, after the first laparoscopic entry in the abdomen according to the open Hasson technique, an exploratory laparoscopy was performed. All the abdominal cavity was explored and all the bowel was inspected: at 35 cm from the Ligament of Treitz, a jejunojejunal intussusception was found. We decided to reduce the jejunal intussusception in order to define the pathologic cause, suspecting the presence of a mass. In fact, a mass of 4 cm in diameter was discovered on the intestinal serosal surface of the antimesenteric side and the mesentery presented multiple lymph nodes. The wall of the bowel was normal and no signs of ischemia were present.In order to treat the cause of jejunal intussusception and to perform a histological diagnosis too, we decided to carry out an 8 cm laparotomy in the left upper abdominal quadrant and perform a resection of the affected jejunum (including the mass) and subsequently a jejunojejunal anastomosis.The postoperative course was uneventful and the patient was discharged on the 5th postoperative day. Histological examination showed that the mass was a jejunal ectopic pancreas and that dissected lymph nodes simply share a lymphoid hyperplasia. According to the Heinrich classification system, this was a type 2 EP containing acini and ducts but no islets.The first case of EP was reported by Schultz in 1729 and Klob provided its histological confirmation in 1859 –5.Usually EP is localized in the stomach (25–38%), duodenum (17–36%), and jejunum (15–22%), but it has been reported very rarely in other locations such as ileum, Meckel's diverticulum, colon, gallbladder, umbilicus, fallopian tube, mediastinum, spleen, and liver .The etiology of EP is actually unknown even if multiple theories had been implicated on the embryological origin of this rare condition. One theory supposes the persistence of a duodenal evagination involved in the normal development of pancreas, so the remnant part might migrate with the developing of the gastrointestinal tract accounting for its various locations, while another theory suggests the existence of a pancreatic metaplasia of the endodermal tissue .EP usually presents in the form of small yellowish nodules, ranging from 1 mm to 5 cm, covered by intact mucosa with rudimentary pancreatic duct and is frequently classified according to the Heinrich classification system .Most patients with EP are asymptomatic and diagnosis is usually performed during radiology or digestive endoscopy tract examination or surgical exploration for other diseases. When symptomatic, about 30% of cases present with abdominal pain due to pancreatitis, nausea, vomiting, anorexia, and bleeding. Conversely, intestinal obstruction with intussusception is rare . Adult iThe diagnosis of EP still remains challenging and the preoperative imaging studies  are not very specific .Contrast-enhanced computed tomography, especially when performed in emergency setting for small bowel obstruction diagnosis, can usually demonstrate nondiagnostic findings such as exophytic bowel wall lesions or mural wall thickening suggestive of intussusception of unknown origin, like what happened in the case of our patient . TherefoIn As the use of diagnostic and therapeutic laparoscopy improves postoperative outcome of the patient if compared to patients submitted directly to laparotomy, also in our case the patient was discharged on the fifth postoperative day with a rapid recovery of bowel function. Besides the reduction of postoperative hospital stay, laparoscopy generally is associated with significant reduction of postoperative analgesia, incidence of surgical site infections, postoperative cardiac and respiratory complications including pneumonia, and significant reduction of postoperative mortality rates –33.EP is a rare congenital lesion often incidentally diagnosed on pathological examination and should be considered in the differential diagnosis of intestinal mass lesions, especially in case of acute complication such as intussusception. The treatment of intussusception in adults consists of resection of the intussuscepted mass. The laparoscopy has been demonstrated to be a safe and feasible alternative to directly open surgery since, along with its usual advantages, its diagnostic role is making it an attractive option, especially in emergency setting, in hemodynamically stable patient with nonconclusive imaging.


Little attention has been paid to the toxicity of silver amalgam fillings, which havebeen used over the centuries in Dentistry. Amalgam particles may accidentally and/ortraumatically be embedded into the submucosal tissue during placement of arestoration and perpetuate in such area. This article presents a case of amalgamtattoo and investigates whether it is related to the patient's repeated episodes ofsinusitis. The patient was a 46-year-old woman with a 2 mm diameter radiopaque lesionin the right oral mucosa detected on a panoramic radiograph and presented as a blackmacula clinically. A complete surgical resection was carried out. Thehistopathological examination revealed deposits of dark-brownish pigments lining thesubmucosal tissue with adjacent lymphocytic inflammatory infiltrate andmultinucleated giant cells phagocyting pigments. There was a negative staining forboth iron and melanin. One year after lesion removal, the patient reported that thesinusitis crises had ceased after repeated episodes for years. It may be speculatedthat the inflammatory process related to amalgam tattoo seems to lead to a localimmune response that causes sinusitis because it enhances the human leukocyte antigenDR (HLA-DR) tissue expression. Gingiva andalveolar mucosa are the most common locations, and the mandibular region is morefrequently affected than the maxillary region13.Amalgam pigmentation, generally called amalgam tattoo, is a relatively common finding inthe oral mucosa1.Tissue reaction to amalgam can vary considerably and arise as a macrophage or chronicinflammatory response, usually in the form of foreign body reaction, or even not developany responseThis article presents a case of amalgam tattoo and investigates whether it is related tothe patient's repeated episodes of sinusitis.A 46-year-old female patient presented with a 2 mm black macule on the oral mucosa ofthe posterior fornix on the right. The patient reported that a tooth with an amalgamfilling had been extracted from that region 15 years before. Differential clinicaldiagnosis suggested were melanoma, melanocytic nevus, hematoma, hemangioma and amalgamtattoo.A panoramic radiograph revealed a 2 mm radiopaque lesion on the right oral mucosa  in the sA complete surgical excision was carried out. Histopathological examination revealedepithelial acanthosis and brownish-black pigment deposits in the submucosa surrounded bya lymphocyte inflammatory infiltrate ,and mulThe patient had been suffering from repeated episodes of sinusitis for years, which hadbeen diagnosed and treated by a physician. After excision of the lesion, the attacksceased without any specific treatment. One year after surgery, no recurrence ofsinusitis was observed.8 and is a common findingin the dental practice13. Clinically, it presents as an asymptomatic, ill-defined black maculaor plaque whose main location is along the gingival margin and the alveolar mucosa, asin the present case8. Amalgam mayaccidentally and/or traumatically embed into the submucosa during a fitting ofprosthetic crowns, removal of old amalgam fillings, extraction of restored teeth,endodontic treatment, and flossing shortly after a restorative dentistryprocedure8. Also, amalgam might release some level of metals due tothe galvanism between different alloys in the mouth (e.g.: a tooth restored with gold),and mercury may diffuse through soft tissue developing the amalgam tattoo10.Amalgam tattoo is characterized by the deposit of restorative debris material composedof a mixture of silver, mercury, zinc, tin and copper in subepithelial connectivetissue8. Buchner, etal.1 (2004) observed no reactionin 45% of the cases of amalgam tattoo, while 17% have a macrophage reaction, and in 38%a foreign body chronic inflammation was noted. In the present case, we observed thepresence of a foreign body type chronic inflammation with pigment phagocytosis bymultinucleated giant cells. While copper and zinc are rapidly lost from the region ofthe tattoo, mercury and tin are lost more slowly and, finally, only silver remainspermanently in the tissues7.Connective tissue response to amalgam varies greatly and depends on the particle sizeand composition4 (1998) reported thatthe inflammatory reaction to amalgam tattoo becomes more severe as mercury content inthe tissue increases, and the delayed reaction has also been associated with thepresence of silver. Probably, the immune response of the amalgam tattoo related-cases isthe type IV hypersensitivity (delayed or cell-mediated hypersensitivity particularlywith respect to CD4+ T-lymphocytes), which is similar to the contact allergy,and seems to be related to mercury in most cases5.Forsell, et al.12 (1996) found anincreased expression of class II major histocompatibility complex (MHC) molecules inmonocytes, resident macrophages and mononuclear cell related to the mercuryaccumulation, which, thereby, promotes a persistent chronic inflammation and shifts inmononuclear cell subpopulations on the tattoo amalgam zone.Nadarajah, et al.15. Amalgam tattoo should only be removedif no radiopaque particles are revealed radiographically because, in these cases, allother causes of oral pigmented lesions, especially melanomas, should be ruled out.However, Leite, et al.8 (2004) showedan increase in the level of human leukocyte antigen DR (HLA-DR) expression andmetallothioneins  in inflammatory cells,blood vessel walls and connective tissue fibers impregnated with amalgam debris. Thesefindings demonstrate that residual elements of amalgam tattoo still have noxious localeffects over tissues, and systemic effects could not be neglected.Several studies have shown that amalgam tattoos require no treatment intervention asthey are a safe and innocuous restorative material and have not been reported to causesystemic health effects16 (1987) reported acase of a patient who had had an amalgam tattoo for 2 years and complained of swellingand local soreness, sinusitis, headache, fatigue, and weight loss. Following completeremoval of lesion, clinical symptoms ceased drastically, which may be suggestive of adirect relation to the amalgam tattoo. The patient of this case had a difficult clinicalmanagement of sinusitis for years that disappeared after removing the amalgam tattoo. Webelieve that the relationship between sinusitis and amalgam tattoo is that amalgamtattoo cause an increase in tissue-specific expression of the HLA-DR. Also, systemicallyfree mercury in the amalgam may give rise to a type IV hypersensitivityreaction11, which can contributeto sinusitis attack.Weaver, et al.+ T lymphocytes (helper T cells) expressed on macrophages,dendritic cells, B cells as well as in endothelial and fibroblast cell lines6. MHC molecules play a central role inregulating T cell-mediated immune response in two forms: 1. Since different antigenicpeptides are bind to different class II gene products, an individual will mount avigorous immune response against an antigen only if this individual inherits the gene(s)for those class II molecule(s) that can bind the nominal antigen and present it tohelper T cells6. This could be thecause concerning the relation of different tissue reactions to the amalgam tattoo,justifying the absence of a reaction. 2. During intrathymic differentiation, only the Tcells that can recognize self-MHC molecules are selected for export to the periphery.Thus, the type of MHC molecules that T cells encounter during their differentiationinfluences the functional capacity of mature peripheral T-cells6.Class II MHC antigens are coded for in a region called HLA-D, which has threesub-regions: HLA-DR, HLA-DP and HLA-DQ. In general, class II molecules present exogenousantigens to CD4+ T lymphocyte. Irritants are able to induce HLA-DR internalization byantigen-presenting cells8. There aredendritic cells located just beneath the epithelia, which express high levels of classII MHC molecules and are able to capture and respond against exogenous antigens. Inresponse to these antigens, dendritic cells express chemokine receptor levels similar tothe naive T cells. Therefore, dendritic cells are recruited into the T-cell zones oflymphoid tissues, the ideal site for antigen presentation to the recirculating Tcells6. Inside the granulomas,macrophages are presented in two forms: some express lysozymes with a capacity forphagocytosis, while others represent antigen-presenting cells and CD4+ Tcell-stimulating6. Amalgamtattoo attracts to its location many cells that express class II MHC molecules,enhancing HLA-DR molecule expression, which has previously been cited in thisarticle.HLA-DR is an antigen, part of class II MHC, which molecules are abundantly expressed indendritic cells, monocytes and macrophages, and are responsible for antigen presentationto CD414. Some studies have shown an increase of the HLA-DRexpression in the nasal mucosa of patients with chronic sinusitis7, and an increase in CD4+ Tlymphocytes expression9, thus contributing to the maintenance ofthe inflammatory process.While the presence of mucosa-associated lymphoid tissue (MALT) in the human upperrespiratory mucosa is still being debated, it is known that lymphoid follicles arepresent in the mucosa of patients with chronic sinusitis, and they play an importantrole in mucosal immunity and persistent local inflammation+ T lymphocytes,and, associated with new stimuli , leads to aprofuse chronic inflammatory process causing a sinusitis crisis. Therefore, the removalof amalgam tattoo reduces the number of dendritic cells sensitized in these lymphoidfollicles, since the migration from the oral cavity to these follicles ceases,minimizing or ending such sinusitis attacks, as occurred in the present case and in thecase described by Weaver, et al.16(1987).We believe that dendritic cells in the oral mucosa sensitized to amalgam tattoocompounds and with an increased HLA-DR expression migrate into lymphoid folliclespresent in the nasal mucosa of patients predisposed to chronic sinusitis. In this area,dendritic cells effectively stimulate the activation of CD4The amalgam tattoo seems to have a crucial relationship with chronic sinusitis inpredisposed individuals. However, due to the rare cases described in the literature, thedefinitive establishment of this relationship can only be made by investigating theclinical profile in a large number of patients with amalgam tattoo.


Carcinoid tumour is a well-known primary endobronchial lung neoplasm. Although calcifications may be seen in up to 30% of pulmonary carcinoid tumours, near complete ossification of these tumours is an unusual finding. Such lesions can prove diagnostically challenging at the time of intraoperative frozen section as the latter technique requires thin sectioning of the lesion for microscopic assessment. We present an unusual case of endobronchial carcinoid tumour with extensive ossification in a 45-year-old male. Preliminary intraoperative diagnosis was achieved through the alternative use of cytology scrape smears. The final diagnosis was confirmed after decalcification of the tumour. The prognostic implications of heavily ossified carcinoid tumours remain elusive. Long-term clinical follow-up of these patients is recommended. A 45-year-old male presented to the Emergency Department with two episodes of hemoptysis and progressive exertional wheezing over a 9-month period. The patient's past medical history was unremarkable apart from a previous 20 pack-year smoking history. He reported a single episode of hemoptysis 8 years priorly and was lost to follow-up after initial radiologic investigations identified a 3.1 cm mass. He denied any interim respiratory symptoms.On physical exam, the patient had normal vital signs and was in no apparent distress. His chest exam was normal and there were no stigmata of chronic lung disease. There was no palpable lymphadenopathy. Chest CT imaging revealed a calcified 4.2 cm hilar mass with associated right middle lobe collapse . The radIntraoperative gross specimen assessment revealed a hard, well-circumscribed, ossified 5.0 cm mass  encasingMicroscopic examination of the formalin-fixed, decalcified mass revealed mature, anastomosing trabecular bone, with intervening nests of uniform tumour cells. The cells were occasionally arranged in trabecular structures and vague rosettes Figures . DespiteThe WHO classification recognizes 4 histologic types of pulmonary neuroendocrine tumours: typical carcinoids, atypical carcinoids, small cell carcinomas, and large cell neuroendocrine carcinomas . The typClinically, pulmonary carcinoids occur more frequently in males and typically manifest in the 5th decade of life . In sympAs many as 30% of typical carcinoids may be accompanied by intralesional dystrophic calcifications . OssificIn summary, although extensive ossification is an unusual presentation for pulmonary carcinoid tumours, the implication of this phenotype remains elusive. Long-term follow-up of these patients is required to better characterize this phenomenon in disease progression. Finally, this case highlights the utility of cytology scrape preparations in making a diagnosis at the time of intraoperative consultation when specimens may not be suitable for usual frozen section technique. Recognize the rare presentation of ossification in pulmonary carcinoids. Realize the limits of intraoperative consultation in extensively ossified lung tumours.Medical Expert is considered.


Primary cutaneous actinomycosis is a rare clinical form with variable presentation. The tumoral presentation of actinomycosis as pseudocarcinomatous or sarcomatous masses is completely rare. The management of cutaneous actinomycosis needs proper antibiotic treatment and surgical resection would not be adequate alone. Herein, we report a case of primary cutaneous actinomycosis on the dorsal surface of the hand as draining and infiltrated lesions along with the scar of previous tumor excision that had not received proper antibiotics after the surgery. Actinomyces, and normally colonizes the mouth, colon, and urogenital tract. It has no predilection for age, race, season, or occupation and is seen commonly in tropical countries. The previous male preponderance is now surpassed by an increasing number of females being infected, as it is associated with long-term use of intrauterine devices [Actinomycosis is a slowly progressive infection caused by anaerobic or microaerophilic bacteria, primarily of the genus devices , 2.Actinomycosis is characterized by chronic and progressive suppurative inflammation, commonly seen on the neck, thorax, and abdomen. Five main clinical types are cervicofacial (60%), thoracic 20%), abdominal (15%), pelvic, and primary cutaneous, the last being rare and having a variable manifestation 0%, abdom. Herein,A 35-year-old man has been referred to our Dermatology Clinic with the complaint of painful firm immobile nodules along with a surgical scar on the dorsum of his hand. There were also pus drainage and ulceration in some part of the scar. He claimed that there was a tumoral swelling at the dorsum of his left hand in the second metacarpal area for 12 months. It had been gradually increased in size and led to the restriction of the movement of the index finger. Therefore, he came to an orthopedic surgeon and underwent a tumor excision operation about six months ago. He completely improved after this surgery and did not follow up any further treatment. Four months after the surgery, some painful immobile ulcerated nodules with low discharge appeared on the way of the surgical scar. He works as an electrical technician but there was no obvious history of trauma or significant medical problem. Physical examination showed swollen areas at the dorsum of the left hand and palpable tender immobile nodules on the surgical scar with low discharge. Some nodules showed ulcerated crusted surface .The hematological and biochemical laboratory tests were normal. The hand radiography was done and reported as normal. Therefore, he underwent an incisional biopsy of the nodules. Microscopic examination reveals an ulcerated epidermis with underlying neutrophilic microabscesses surrounded by granulation tissues consisting of plasma cell, macrophage, and fibroblast infiltration. Sulfur granules were found at the center of these inflammatory reactions as filamentous basophilic radiating fungal-like structures in the dermis Figures  and 3.Regarding these clinical and histopathological data, the diagnosis of actinomycosis was made. Moreover, we asked the patient to bring us any histopathology report of the tumor excised on his hand about one year before his admission. Surprisingly, the diagnosis of actinomycosis had also been mentioned in that report. But he had not come to his surgeon for any further treatment and the recurrence of the lesions occurred on the surgical scar. The patient was treated with intravenous penicillin G for four weeks and then oral penicillin. Resolution of symptoms and sings occurred but the patient did not come back for further follow-up. Actinomyces spp.Actinomycosis is believed to be acquired by endogenous implantation into deep tissues where anaerobic environments exist. Perforating wounds, dental surgery, or compound fractures are some of the routes of infection. Primary actinomycosis of the extremity is rare because of the endogenous habitat of the etiologic organism. Cutaneous localization of actinomycosis generally occurs by contiguity of primary centers by direct inoculation or by extent through the bloodstream. In the latter case, there are often several lesions. Posttraumatic actinomycosis and cases associated with insect bites have also been reported , 5. Ther Nocardia can usually be differentiated from Actinomyces by acid-fast staining, as Nocardia characteristically display varying degrees of acid fastness on Ziehl-Neelsen staining due to the mycolic acid content of the cell wall. Another valuable clue is that Nocardia grow under aerobic environments, whereas Actinomyces grow under anaerobic settings [Cutaneous actinomycosis needs to be differentiated from other chronic skin diseases, such as cutaneous tuberculosis, sporotrichosis, nocardiosis, and skin and soft tissue tumors or malignancy. Diagnosis is based on identification of sulfur granules in histological examination and also by a positive culture. The histological picture consist of suppurative inflammation with abscesses and pus filled sinus tracts in which bacteria form typical granular colonies (sulfur granules) composed of radiating Gram-positive filaments , 6. The settings . We coulThe management of cutaneous actinomycosis is high dose intravenous antibiotics for 4–6 weeks followed by oral antibiotics for 6–12 months. Beta-lactams including penicillin G are the treatment of choice. In penicillin resistant cases, we could use the other antibiotics such as clindamycin, erythromycin, tetracycline, and chloramphenicol , 11. AmoIn conclusion, our reported case seems to be a bit distinctive due to its location on the hand as a rare location of primary cutaneous actinomycosis  and espe


Osteochondroma is the most commonly-found benign bone tumour. It is a benign, cartilaginous-capped bony projection. They are usually present on the bony surfaces of the long bones in adolescents and young adults. The risk of malignant transformation is <1% with solitary osteochondroma. We present a rare case of an osteochondroma in a patient with advanced age and an unusual location. Osteochondromas make up 20% to 50% of benign tumours and account for approximately 10% of all bone tumours . It has Osteochondromas usually present as painless, palpable, slow-growing masses. They rarely cause numbness, weakness or changes in the colour of the skin. An osteochondroma can be investigated using x-rays, computed tomography, and magnetic resonance imaging (MRI). MRI is a safe and elaborate method of investigation for a detailed evaluation of the osteochondroma and its adjacent structures.A 66-year-old woman presented to our clinic with complaints of pain on the plantar surface of the medial aspect of her left foot for the past one year. She felt a palpable mass which has been gradually and slowly increasing in size and causing pain, especially when she walks. She said the pain was bearable at the start but for the past few months, the pain has made walking increasingly difficult.On physical examination, she had a palpable mass over the head of the first metatarsal on the plantar aspect. It was hard, non-mobile, mildly tender, and covered in the callused skin but without ulceration. The results of the neurovascular examination of the foot were normal. The x-ray showed a bony growth on the plantar surface of the first metatarsal Figure .We discussed with her the treatment options, including the surgical option, with its risks and complications. Given her general health and willingness to proceed, we planned for surgical exploration and excision of the mass under general anaesthesia.She was given general anaesthesia and placed in the supine position. We made a medial 5 cm incision over the left first metatarsal to gain access to the underlying structures. Once the underlying tissue was dissected, the lesion was revealed as a sessile mass over the head and neck of the plantar surface of the first metatarsal Figure . We exciOsteochondromas usually present during the patients' first three decades of life with no predilection for sex . SymptomOur case had two distinctive features. First, our patient was 66 years old, which is a very unusual age of presentation for osteochondroma. Secondly, the osteochondroma was located at the base of the first metatarsal bone rather than the classical long bone location.Osteochondroma is the most common benign tumour in patients in their second or third decades of life, but we should always be aware of its capability for an unusual presentation, as this case illustrates.


Collision tumors are uncommon but well described clinical entities composed of distinct tumor histologies occurring within the same anatomic site. Optimal management of patients with collision tumors remains highly variable and depends on clinical characteristics such as the involved tumor types, predominant histology, as well as the extent of disease. Comprehensive genomic profiling is a means of identifying genomic alterations to suggest benefit from targeted therapy.TSC1 partial loss. The patient was subsequently initiated on temsirolimus 15 mg intravenously weekly for 4 months. Restaging imaging demonstrated a partial response to therapy by RECIST 1.1 criteria and clinical benefit for 6 months until the patient passed away secondary to unrelated causes.A 78-year-old woman presented to medical oncology with liver metastases occurring within the background of a 1-year history of uveal melanoma. Biopsy of the liver metastases revealed presence of adenocarcinoma along with nests of malignant melanoma consistent with a collision tumor. The disease was refractory to several lines of conventional cytotoxic chemotherapy, and the patient later developed pulmonary metastases while on chemotherapy. The patient’s tumor tissue was assayed by comprehensive genomic profiling which revealed presence of a TSC1 mutation that objectively and durably responded to mTOR inhibition.We report the first case of a collision tumor composed of adenocarcinoma and melanoma with a  TSC1-TSC2 complex has emerged as an integral signal involved in the inhibition of mTORC1. Inactivating alterations of tumor suppressor genes TSC1 and TSC2 have been implicated in tuberous sclerosis and a wide variety of malignancies in which mTORC1 was found to be highly activated [TSC1 mutations respond to mTOR inhibitors and the clinical significance of such a mutation is highlighted in the present case [Cancer therapy continues to move towards the targeting of molecular signaling pathways; mTOR inhibitors have been well studied since the early 1990s with increasing recognition immunosuppressive and anticancer properties. In particular, the TSC1 mutation. This case highlights two unique facets in both the phenomenon of collision tumors and the significance of targeted signaling pathway agents where traditional chemotherapy has failed.We present a patient with a prior diagnosis of uveal melanoma with new metastatic hepatic disease for whom biopsy unexpectedly demonstrated a collision tumor of melanoma and adenocarcinoma of unknown primary. Although collision tumors have been described in literature, primarily between two cutaneous malignancies, a combination of melanoma and adenocarcinoma is extremely rare with only a few reported cases –5. The pA 78-year-old woman presented to our institution for further management of newly diagnosed metastatic liver disease.The patient initially presented with symptoms of decreased visual acuity of the right eye 1 year prior. Comprehensive physical examination was unrevealing. The patient was referred to ophthalmology and was diagnosed with choroidal melanoma. The tumor initially measured 19.5 x 13.6 mm and involved 50% of the optic nerve head as well as the macula. The patient was treated with radiotherapy along with transpupillary thermotherapy.As part of routine surveillance for the diagnosis of uveal melanoma, the patient was followed with serial CT scans of the abdomen and pelvis every 3 months. Nine months after the initial diagnosis repeat CT scan revealed multiple liver masses suggestive of metastatic disease involving the lateral segment of the left hepatic lobe. A dominant mass was identified measuring 6.9 x 5.8 cm and the patient was referred for core needle biopsy. Pathology revealed abundant involvement by adenocarcinoma, which stained positive for pankeratin AE1/AE3), CK7, CK20 . This was discontinued secondary to grade 2–3 gastrointestinal toxicity . The patient subsequently received 8 cycles of gemcitabine  combined with protein-bound nab-paclitaxel . Restaging imaging revealed progressive disease in the liver as well as the interval development of metastatic lung nodules.The patient’s tissue was submitted as a formalin-fixed, paraffin-embedded block to a CLIA-certified, CAP-accredited laboratory  for CGP. DNA was extracted from the tumor specimen. Hybrid-capture-based CGP using next-generation sequencing was performed of the entire coding sequence. This included 236 genes and 47 introns of 19 genes involved in fusions at a depth of X500. Alterations were identified as point mutations, deletions, amplifications, duplications, insertions, rearrangements, and splice variants. These were characterized as known or likely pathogenic changes as reported by the FoundationOne assay.TSC1 loss (homozygous deletion) of exons 20-23, CDKN2A/B loss, BAP1 (E20fs*52), PBRM1 (R1095fs*39). CGP is a validated approach in detecting base substitutions, short insertions, deletions, copy number alterations and selected fusion products. The technique has been directly compared to established assays including PCR. Test sensitivity approximately 95–99% across various alteration types with high specificity . Because CGP is a validated technique to identify genetic abnormalities, no additional testing on the tumor sample was clinically indicated [DNA extracted from the biopsy of the collision tumor submitted for NGS contained both melanoma and adenocarcinoma. Several genomic alterations were identified as follows ndicated .TSC1) is a tumor suppressor gene found on the long arm of chromosome 9. TSC1 encodes the protein gene product hamartin composed of one transmembrane domain and two coiled-coil domains. The first coiled-coil domain modulates interaction between hamartin and tuberin. A second coiled-coil domain is encoded by exons 17 to 23 which stabilizes the tuberin-hamartin complex [Tuberous sclerosis gene 1  15 mg intravenously weekly. The patient was followed with clinical examinations monthly and restaging imaging every 2 months while on therapy. After 4 months of treatment, a restaging CT scan of the chest, abdomen, and pelvis demonstrated a significant partial response to therapy by RECIST 1.1 criteria  histological classification guidelines, a collision tumor should comprise at least two different malignant components with no mixed or transitional area between , 11. SevAlthough cases of synchronous adenocarcinoma and melanoma have been reported, the presentation remains exceedingly rare –5. The cTSC1 and TSC2 have been reported in a variety of neoplasms and benign tumors including pulmonary lymphangioleiomyomatosis (LAM), perivascular epitheloid cell tumors (PEComa), urothelial carcinomas, renal cell carcinoma and hepatocellular carcinomas [PTEN loss and PIK3CA amplification, which are also targets for mTOR/P13K inhibitors, have been implicated in 7% and 9% respectively, in carcinomas of unknown primary [TSC1 or TSC2 may predict a response to downstream inhibition of the mTOR pathway [Mutations in rcinomas . Mutatiorcinomas , 14. Alt primary . Of greaBAP1) gene, which is frequently inactivated in metastatic uveal melanomas [BAP1 encodes a nuclear ubiquitin carboxyterminal hydrolase, which is a class of deubiquitinating enzymes, and contains binding domains for BRCA1 and BARD1 to form a tumor suppressor complex among other functions [BAP1 have been highly associated with onset of metastatic behavior thus suggesting a potential novel target for therapy [This patient’s disease had been highly refractory to conventional chemotherapeutic agents, but did demonstrate sensitivity to temsirolimus. In addition, the patient’s CGP demonstrated mutation of BRCA1-associated protein 1 (elanomas . BAP1 enunctions . In uvea therapy .Additionally, noted on NGS were alterations in CDKN2A/2B as well as PBRM1. CDKN2A/2B encode tumor suppressor gene products cyclin-dependent kinase 4 inhibitor A/B. This gene encodes a cycle-dependent kinase inhibitor that prevents activation of the CDK kinases thereby inhibiting cell cycle G1 progression , 18. IntIn our patient, disease progression on multiple lines of cytotoxic chemotherapy suggests that targeted inhibition of mTOR pathway was critical in inducing tumor response. Because tissue composed of both adenocarcinoma and melanoma was submitted for NGS, it is unknown whether the genetic alterations observed were unique to either tumor histology. Given the radiographic response to therapy with mTOR inhibitor, no repeat biopsy was clinically indicated. Nonetheless, the potential of detecting significant therapeutic targets implies that patients with refractory collision tumors would benefit from genomic profiling.TSC1 gene locus. The objective clinical response achieved with targeted inhibition of the mTOR pathway further highlights the clinical significance of the genetic alteration identified by NGS. As a result, NGS may have a potential utility in identifying actionable targets in collision tumors failing to response to traditional cytotoxic chemotherapy. Further investigation into the identification of driver genetic mutations in collision tumors and potential therapeutic targets is warranted.To our knowledge, this is the first case of a collision tumor composed of adenocarcinoma and melanoma with a mutation of the


Gastrointestinal stromal tumors (GISTs) rarely present with predominantly cystic changes. Here, we report a case of giant GIST of the stomach with predominantly cystic changes in a 74-year-old female patient.H-caldesmon, and DOG-1. Complete surgical resection was performed without regional lymphadenectomy. The patient recovered uneventfully and no recurrence occurred.The tumor was 10 cm × 15 cm in size and positive for CD117, The case illustrates that GIST with cystic changes should be considered in the diagnoses of hepatic and pancreatic lesions. Furthermore, immunohistochemistry with CD117, DOG1, and other molecular markers is critical for diagnosis of GIST of the stomach and facilitates optimization of treatments for GIST. Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the digestive tract. Although GISTs only occur in less than 5% of all gastrointestinal tract tumors, they account for 60% of all gastric stromal tumors . GISTs aA 74-year-old female patient was hospitalized because of worsening abdominal pain for 2 days. The patient had distending upper abdominal pain for 3 months. The pain was intermittent and dull and did not radiate. She had no nausea or vomiting. Two days before admission, the pain worsened without apparent causes. The patient had no fever, and urine and stool were normal. She had no respiratory symptoms except occasional cough and whitish sputum. The patient had a history of hypertension for 5 years; the blood pressure was as high as 190/90 mmHg, and the patient took oral nifedipine .Treponema pallidum, HIV (human immunodeficiency virus), and HCV (hepatitis C virus) were negative. Abdominal ultrasonography revealed a hypoechoic intraperitoneal mass in the upper left quadrant, 13.3 cm × 12.5 cm in size, with punctate hyperechoic deposits. The wall of the cyst was rough, with many irregular hyperechoic protuberances. Abdominal CT showed a cystic hypointense shadow with septations, approximately 15.6 cm × 14.7 cm × 13.6 cm in size (Fig. Physical examination at admission showed tenderness in the mid and upper left abdomen, but no rebound tenderness was elicited. A mass was palpated in the upper left abdomen. The mass was approximately 10 cm in diameter and had an indistinct boundary and was poorly mobile. The findings were otherwise unremarkable. Laboratory findings including blood chemistries, routine blood tests, coagulation profile, and tumor markers were normal. Immunological tests for antigens or antibodies related to infections with Exploratory laparotomy showed a cystic mass in the left upper quadrant, 10 cm × 15 cm in size, starting from the posterior wall of the gastric fundus and had intimate relations with the spleen and the greater curvature of the gastric fundus. Rapid pathological examination indicated gastric stromal tumors. The tumor, the proximal stomach, and the spleen were excised. The tumor had a maximal diameter of 15 cm, with necrosis and cystic degeneration Fig. . No invaGISTs are the most common mesenchymal tumors and account for 0.1 to 3% of all gastrointestinal tumors . The tumOne noticeable feature of our case is the presence of predominantly cystic changes in the tumor. GISTs often form solid tumors and are rarely predominantly cystic. GISTs with cystic changes are more frequently seen in high-grade malignancies. Because of aggressive tumor growth, necrosis, hemorrhage, liquefaction, and cystic degeneration occur from lack of adequate blood supply, leading to formation of large cystic spaces . NecrosiGISTs possess malignant potential and are highly invasive and tend to metastasize to remote organs . MetastaGISTs of the stomach with cystic changes are rare and may defy diagnosis preoperatively. Our case illustrates that GIST with cystic changes should be considered in the diagnoses of hepatic and pancreatic lesions. Furthermore, immunohistochemistry with CD117, DOG1, and other molecular markers is critical for diagnosis of GIST of the stomach and facilitates optimization of treatments for GIST.


The etiology of ectopic third molars located in the sigmoid notch of the mandible is unclear. Only a few cases have been reported. The aim of this article is to discuss the etiology as well as treatment options and diagnostic imaging techniques.A PubMed and Medline search of the literature from 1965 to 2015 to ectopic third molars in the mandibular notch was performed. Furthermore, a clinical case provided by the authors is reported.Among the eight reviewed cases, two male and six female patients were affected that ranged from 25 to 62 years of age (mean 48.4). Pain and swelling in the preauricular region or trismus but also the absence of symptoms was reported. Only in two of the summarized articles an extra-oral access for the removal of the tooth was used. The etiology seems to be individually different, however dentigerous cysts and chronic inflammation seem to play an important role in their appearance. While previous diagnostic reports described two-dimensional diagnostic imaging, currently the three-dimensional imaging is common for preoperative surgical planning with respect to removing ectopic molars.Ectopic third molars in the mandible are a rare condition. The etiology seems to be individually different. Nowadays, three-dimensional imaging is common for preoperative surgical planning. Ectopic molars in the mandible are rare cases and the etiology of this condition is still unclear . EctopicA clinical case provided by the authors is reported. Furthermore, a literature search in PubMed and Medline databases was achieved by using the following MeSH terms: “sigmoid notch” OR “mandibular notch” AND “ectopic tooth” OR “third molar”. Inclusion criteria were international cases of ectopic third molars in the sigmoid notch, which have been reported in English or native language from 1965 to 2015.From 1965 to 2015 only eight cases with ectopic third molars that occurred in the sigmoid notch of the mandible have been reported. In addition to six case reports which were written in English language , two casSix female patients and two male patients were diagnosed with ectopic molars in the sigmoid notch. The age ranged from 25 to 62, with an average age of 48.4 years.As clinical symptoms the eight reported cases describes pain , swellinTreatment was described in all cases except one . GraniteCystic lesions were described in four cases , 9, 12. Diagnostic imaging techniques reports from 1992 to 1965 described lateral oblique radiographs , 11, 12,A 51 year-old male was referred to our Clinic of Cranio-Maxillofacial Surgery by his dentist. The patient described pain in the preauricular region for a few days. The panoramic radiograph revealed lower right third molar being dislocated in the sigmoid notch associated with a radioluscent lesion Fig. , 3, 4. AUp to now, only a few reports of ectopic third molars located in the mandible were recorded in the literature. The etiology of this condition is still unclear but several causes were discussed. Capelli described a correlation between the lack of space between second molar and the ramus mandibulae leading to an ectopic position of the impacted third molar . Also a In symptomatic patients surgical removal, after a careful preoperative planning, is the recommended treatment . In the Ectopic third molars in the sigmoid notch of the mandible are a rare condition with higher prevalence in women. The etiology seems to be individually different, however dentigerous cysts and chronic inflammation seem to play an important role in their appearance. For planning the surgical entryway, which is mostly selected from intraoral as well as the assessment of operative-risks, three-dimensional diagnostic imaging techniques should be a preoperative standard in diagnostics.


Benign laryngeal lesions, especially laryngeal polyps are very common and they usually only cause hoarseness and rarely develop into dyspnea. This condition is generally attributed to smoking. Cardiorespiratory failure and sudden death due to large laryngeal polyp was reported in the literature. The preferred treatment of large polyps is surgical excision using suspension microlaryngoscopy. We present a case of a 60-year-old man presented to the emergency department with stridor and severe dyspnea. He had a 4-month history of a neglected inspiratory dyspnea and dysphonia. Fiberoptic laryngoscopy revealed a large laryngeal mass causing airway obstruction. Administration of oxygen, inhalation and intravenous administration of corticosteroid did not relieved his symptoms. As intubation was judged impossible, an emergency tracheostomy was performed to salvage the patient. After tracheostomy, the dyspnea ceased. Computed tomography scan showed a homogeneous regular formation of 2.5×1.5 cm obstructing the glottis and the subglottis lumen. Direct laryngoscopy under general anesthesia identified a valve-like large polyp attached to the anterior wall of the subglottic region. The polyp was totally excised with no complication. Decannulation was carried out on the second postoperative day. The mass was histologically diagnosed as normal vocal cord polyp.


Non-Hodgkin's lymphomas (NHL) with intracranial origin are very rare and constitutes about 1-2% of primary central nervous system lymphomas (PCNSL). Diffuse large B cell lymphoma (DLBCL) is the most common subtype of NHL and mostly seen in immunocompromised patients. Therefore, the occurrence of giant solitary DLBCL in an immunocompetent patient is puzzling. We present a case of 68-year-old man who was admitted at our facility with a history of “hypomnesia of two (2) months” duration. Magnetic resonance imaging (MRI) revealed a space occupying lesion in the bilateral frontal lobe and corpus callosum measuring about 5.4cm * 4.6cm * 3.8cm with mixed signal intensities and vasogenic edema around the mass. Radiological, this mass was mistaken for meningioma until histopathological studies revealed DLBCL. Giant solitary primary intracranial lymphomas are very rare and can be mistake for meningioma even with very experience radiologist or neurosurgeon since the radiological features of PCNSL can be very unspecific. We achieved to total resection because of the giant and solitary nature of our case. The prognosis of PCNSL is general very poor when the patient is immunocompromised. In immunocompetent patients, who are well managed with surgery and chemotherapy, the overall survival and quality of life can very encouraging. Primary central nervous system lymphoma (PCNSL) constitutes about 1-2% of all Non-Hodgkin's lymphomas (NHL) . Also, NWe present a case of 68-year-old man who was admitted at our facility with a history of “hypomnesia of two (2) months” duration. He denied headaches, vomiting, visual loss and palpitations. He however has associated urine and stool incontinence which started two (2) weeks prior to his illness. He was diagnosed hypertensive 10 years ago and has been on antihypensives ever since the diagnosis was made. General physical examination was unremarkable with no palpable lymph nodes and no signs of chronic anemia. All systems were grossly normal. Neurological examination did not yield much. Cranial nerves were normal. Ophthalogical examination was unremarkable. Digital rectal examination revealed a weak sphincter tone. Preoperative laboratory investigations revealed grossly normal complete blood count (CBC) with slightly increase in the percentage of neutrophilic segmented granulocyte in the peripheral blood as well as a decrease in the percentage of lymphocytes. Liver enzymes where markedly deranged. All other routine laboratory investigations were normal. MRI revealed a space occupying lesion in the bilateral frontal lobe and corpus callosum measuring about 5.4cm * 4.6cm * 3.8cm with mixed signal intensities . The lesWe use the left frontal craniotomy via the anterior skull base to access this giant lesion. Intraoperatively, we observed that the scalp and skull were normal. After drilling and removing the bone flat, the dura was opened. We observed that the ICP was high and CSF was decompressed to decrease the ICP. The lesion was seen occupying the left frontal lobe and extending down to the anterior skull base as well as the anterior portion of the corpus callosum. There was marked edema around the lesion as well as shifting of falx toward the right frontal lobe. The lesion had a slightly tough texture with general blood supply coming from the anterior cerebral artery and its branches. There was significate adhering of the lesion to the brain tissue or matter. We attained total resection of the lesion. Postoperative CT-Scan done on day one (1) and day six (6) after surgery confirmed total resection of lesion . PatholoPCNSL constitutes about 1-2% of all NHL . Our patGadolinium enhancement often show lesions with varying intensities and homogeneous patterns , 14, 15.Additional rare radiological differentials are; dural metastasis, solitary fibrous tumour, leiomyosarcoma, plasmacytoma, inflammatory pseudotumour, neurosarcoidosis, Castelman's disease and rheumatoid nodule ,11. The Although the gold standard treatment is surgical excision of the lesions, total resection is usually not achievable because of multifariousness of the masses or their infiltrative nature . On the Giant solitary primary intracranial lymphomas are very rare and can be mistake for meningioma even with very experience radiologist or neurosurgeon since the radiological features of PCNSL can be very unspecific. The gold standard treatment is surgical excision of the lesions, although total resection is usually not achievable because of multifariousness of the masses or their infiltrative nature. We achieved to total resection because of the giant and solitary nature of our case. The prognosis of PCNSL is general very poor when the patient is immunocompromised. In immunocompetent patients, who are well managed with surgery and chemotherapy, the overall survival and quality of life can very encouraging.The authors declare no competing interest.


This is the first report of a primary glioblastoma (GBM) that evolved into secondary or post-treatment gliosarcoma without evidence of a second  Gliosarcomas are characterized by a typical biphasic tissue pattern composed of gliomatosis and sarcomatous components. Primary gliosarcomas account for approximately 2% of glioblastomas (GBM) , but onlde novo tumor and with extension into the left pterygomaxillary fossa. To the best of our knowledge, this is the first report of primary GBM that evolved into secondary or post-treatment gliosarcoma without evidence of a second Although due to the prevalence of mesenchymal component, dural invasion and metastasis are more common in gliosarcoma than GBM; only a few cases of post-treatment gliosarcomas with extracranial metastases were reported. Those were predominantly multiple systemic metastases spreading via hematogenous dissemination to the chest, abdomen, and pelvis -6 or werDirect extracranial infiltrations and skull base extensions of either GBMs or gliosarcomas remain a poorly understood and extremely rare phenomenon. This is because tumor invasion may be hindered by the dura mater and tight junctions between the blood vessel endothelial cells, which act as a barrier to malignant cell spread. It was previously believed that the lack of the lymphatic system in the brain may also prevent cancer cell spread , but sinExtracranial GBM extensions to the neck, ethmoidal, maxillary and sphenoid sinuses, orbit, pterygomaxillar and nasal fossa -15, paroA 56-year-old male initially presented with gradually worsening and localized, left sided headaches that became so severe he presented to the emergency department. He was found to be mildly aphasic with memory loss symptoms that had been ongoing for a couple of months. The rest of his clinical examination was normal. Brain magnetic resonance imaging (MRI) with  and chemotherapy, i.e., daily temozolomide and weekly irinotecan. Subsequently, he received courses of chemotherapy consisting of temozolomide and either carmustine or irinotecan and Taxol. The patient was doing very well with no evidence of progressive disease for 2 years and 8 months after the initial diagnosis when he presented with worsening headaches. Brain MRI was performed  Figure . The patThere is limited clinical experience with post-treatment gliosarcomas presented in the literature. The largest series was reported by Han et al.,  and inclAccording to the Han et al.’s definition , the casGliosarcomas have a similar cytogenetic profile to primary GBM with the exception of epidermal growth factor receptor (EGFR) amplification , which iIt has been reported that post-treatment gliosarcomas have a greater potential to metastasize compared to primary gliosarcomas , but thede novo tumor and with extension into the left pterygomaxillary fossa. There are a few cases of primary gliosarcomas with extracranial extension, but this was not reported among post-treatment gliosarcomas. Due to the rarity of gliosarcomas, unclear mechanisms of pathogenesis, and limited clinical experience; clinical management of these tumors is challenging. In the case presented here, the survival time was 32 and 2 months from GBM and gliosarcoma diagnoses, respectively. This is the first report of primary GBM that evolved into secondary or post-treatment gliosarcoma without evidence of a second


Cervicocephalic artery dissections, once considered a rare disease, have become increasingly recognized as a cause of stroke in young and middle-aged individuals. Early diagnosis is mandatory because anticoagulation or antithrombotic therapy can help prevent primary or secondary ischemic events. However, the diagnosis is still a crucial challenge for radiologists and neurologists.We reported a rare case of 33-year-old patient with progressive ischemic stroke due to dissection from an intimal tear in the right proximal internal carotid artery to distal middle cerebral artery.3D fat-saturated T1 VISTA imaging, owing to its comprehensive neck and head coverage, high spatial resolution, enables the reader to have several sections with good contrast covering the dissected arterial segment, even in the rare dissection involving extra- and intra-cranial arteries referred in this article.Clopidogrel 75mg daily was prescribed, also the patient was given rehabilitation training.His symptoms improved gradually.We describe that 3D fat-saturated T1 VISTA was helpful for the diagnosis and follow-up in our case of cervicocephalic artery dissection complicated with progressive ischemic stroke. However, for totally acute occlusion of the artery without typical features of dissection, the unequivocal distinction between intramural haematoma and intraluminal thrombus may still be difficult with 3D fat-saturated T1 VISTA alone. Future studies should investigate whether an optimal VISTA technique would be useful for making a definite diagnosis. They are among the most common causes of stroke in young and middle-aged adults.2A 33-year-old man presented to the neurology department with right-side headache and left-side hemiparesis. On examination, no murmurs were appreciated on cardiac auscultation, and pulses were symmetric. Neurological examination demonstrated a central left-sided hemiparesis . Brain diffusion-weighted imaging Fig. A at admi3,4 while IADs were estimated to represent <10% of all spontaneous cervicocephalic artery dissections in the adults.CADs and IADs are among the most common causes of stroke in young and middle-aged adults without vascular risk factors who are less likely to have cerebrovascular atherosclerosis. CADs accounted for 8% to 25% of stroke in patients under 45 years, and approximately 2% of ischemic strokes overall,,3,5,6 The patient referred in the text had no history of trauma, but reported coughing and sneezing caused by cold previously.Trauma, infections, and connective tissue disorders are well-known predisposing factors, but the majority of cases are spontaneous or related to trauma, in a healthy artery, with no identifiable etiological factor. as the rare case mentioned in the text manifested.Most common type of CADs have been reported to occur in the internal carotid artery, more than 2 cm after the bifurcation in the majority, and may extend in height to the sub- and intrapetrous segments, but rarely as far as the intracranial segments,,6 The typical patient with CADs presents with pain on one side of head or neck accompanied by partial Horner syndrome and followed by cerebral ischemia hours or days later. This classic triad is found in less than one third of patients, but the presence of any 2 elements of this triad should strongly suggest the diagnosis.,4 Apart from right-side headache, the patient described manifested as progressive ischemic stroke for the extension of dissection from an intimal tear in the proximal RICA to distal middle cerebral artery, which resulted in severe arterial stenosis and secondary ischemia.Early and reliable diagnosis is of great importance to start a timely appropriate management to prevent primary or secondary ischemic events.,6Digital subtraction angiography is traditionally considered the golden standard for dissection diagnosis due to the precise delineation of the luminal abnormalities, but its use is limited by its invasiveness and cost. This technique does not enable the detection of the mural hematoma either, angiography may be considered normal in the event of CAD and IAD, especially if the dissection does not cause any alteration in the arterial lumen.,8 using variable refocusing flip-angle turbo-spin-echo imaging, with large and complete coverage of the head and neck area and acceptable scan duration for clinical practice. The parameters of the imaging sequences were as follows: an oblique coronal plane acquisition, spectral adiabatic inversion recovery fat saturation mode, repetition time (TR)/echo time (TE) = 350/19 ms, field of view = 280 × 199 × 120 cm3, 400 × 284 matrix, variable refocusing flip angle, slice interval = 0; voxel size = 0.7 × 0.7 × 0.7 cm3, oversample factor = 1.5, and number of excitations = 2. The contrast between the hyper-T1 signal of the hematoma and the surrounding tissues, associated with a high spatial resolution, enables the reader to have several sections with good contrast covering the dissected arterial segment, even in the rare dissection extending from extra- to intracranial arteries referred in the text. Many studies have investigated the value of 3D T1 VISTA for the diagnosis of cervicocephalic artery dissections, and all of them showed that 3D T1 VISTA is more useful than conventional imaging tools. Takemoto et al first reported the value of 3D T1 VISTA sequence in the diagnosis of CAD. They concluded that a 3D black blood T1-weighted imaging yielded better distinction of intramural hematoma in intracranial vertebral artery dissection compared to 2D spin echo T1-weighted images and time-of-flight MRA. Another study showed that 3D T1 VISTA is useful for diagnosing vertebrobasilar artery dissections at subacute stages, as it can reveal vessel wall and lumen abnormalities, including not only intramural hematomas, but also intimal flaps, dilatation, and abnormal vessel enhancement, with no or minimum flow artifacts due to sequence-endogenous flow void enhancement. Also 3D fat-saturated T1 VISTA imaging can be used as follow-up imaging examination according to the signal intensity changes. The intramural hematoma showed a wide variety of signal intensities from mild to moderate and very bright hyperintensities, depending on the age of the hematoma; however, it differed from that of cerebral hematomas. These differences in the speed of hematoma decomposition might be explained by recurrent microbleeds into the intramural hematomas which are caused by leaky neovessels. As the follow-up imaging examination 7 months later of the patient referred in the text revealed, the intramural hematoma signal intensity of RICA decreased notably, while that of RMCA became brighter than before, suggesting that the speed of intramural hematoma decomposition might differed at different segments of the artery.Recent magnetic resonance technologic innovations allow the acquisition of 3D fat-saturated T1 VISTA imaging,Although there were many advantages mentioned above for 3D T1 VISTA in the diagnosis of CAD, we also found the limitations of 3D T1 VISTA in the clinical practice. First, for totally acute occlusion of the artery without typical imaging features of dissection, the unequivocal distinction between intramural hematoma and intraluminal thrombus may still be difficult with 3D T1 VISTA alone. Just like the patient mentioned in this article, comprehensively considering the successional lesions starting from the proximal RICA to RMCA and typical crescent-like hyperintensity of the RICA, we deduced the probable diagnosis of subacute dissection extending from the origin of RICA to distal RMCA. However, we could not completely rule out the possibility of thrombus formation adjacent to the dissected RICA resulting in the occlusion of the RMCA. Second, spin-echo metrics are time consuming and this may be paramount in critical care scenarios, echo-planar imaging would offer faster acquisition in this condition.,10 From 40% to 80%, and usually happens within the first 2 to 3 months, while others may leave sequelae on the vascular wall and arterial lumen, with varying degrees of residual stenosis, or even occlusion, as the follow-up 3D fat-saturated T1 VISTA imaging showed in the text.,11It is reported that recanalization rate of CADs varies among studies.There were also several limitations in our study. First, this was a case report and the contrast-enhanced imaging was not performed. Contrast-enhanced 3D T1 VISTA might be useful in manifesting subtle structure abnormalities, assessing vessel inflammatory reaction, and distinguishing intramural hematoma from intraluminal thrombus. Second, as previous studies already showed that a 3D T1 VISTA can provide similar information and may be a substitute for 2D sequence, the 2D T1 black blood sequence was not performed for the patient.In conclusion, we describe that 3D T1-VISTA was helpful for the diagnosis and follow-up in our case of cervicocephalic artery dissection complicated with progressive ischemic stroke. However, for totally acute occlusion of the artery without typical features of dissection, the unequivocal distinction between intramural hematoma and intraluminal thrombus may still be difficult with 3D T1 VISTA alone. Future studies should investigate whether an optimal VISTA technique would be useful for making a definite diagnosis.


Introduction. Intramuscular myxoma is a rare benign primitive tumor of the mesenchyme founded at the skeletal muscle level; it presents itself like an unpainful, slow-growing mass. Myxomas with bone lysis are even more rare; only 7 cases have been reported in the English literature, but never at the shoulder level. Case Presentation. We describe an 83-year-old patient with a growing mass in the deltoid muscle with unique scapular lysis, without any symptom. Magnetic resonance imaging (MRI) and a biopsy were performed and the diagnosis of intramuscular myxoma has been retained. In front of this diagnosis of nonmalignant lesion, the decision of a simple follow-up was taken. One year after this decision, the patient was still asymptomatic. Conclusion. In the presence of an intramuscular growing mass with associated bone lysis, intramuscular myxoma as well as malignant tumor should be evoked. MRI has to be part of the initial radiologic appraisal but biopsy is essential to confirm the diagnosis. By consensus, the standard treatment is surgical excision but conservative treatment with simple follow-up can be an option. Myxoma is a rare benign primitive tumor of the mesenchyme ; it presAn 83-year-old woman presented with a slow-growing, palpable, painless mass in her left shoulder. She was known for auricular fibrillation, a type of hypothyroidism. The patient had no symptom; she just noticed the apparition of this mass two years earlier. At examination, no limitation in shoulder range motion was found and a mass of about 6 cm diameter was palpable.Conventional X-rays were normal. CT scan and magnetic resonance imaging (MRI) were performed and showed an important prescapular necrotic cystic-like mass measuring 9.5 × 6.0 cm Figures –3 with s5Intramuscular myxomas are localized in skeletal muscles; they represent a distinct subtype of myxomas and have been described for the first time in 1965 by Enzinger .In terms of localization, extracardiac myxomas are rare, and they occur most commonly in the head and skin tissue . RegardiHistologically, myxoma is a primitive tumor of the mesenchyme composed of undifferentiated stellate cells in a loose mucoid stroma with reticulin fibers; vascularization is poor but focal hypervascularity may be seen and an abundant myxoid matrix is present . The tum5Under MRI examination, the myxoma presented a cystic-like aspect partly solid with thick rim enhancement Figures –3 16]. . 16]. UsThe differential diagnosis of intramuscular myxomas includes also aggressive angiomyxoma, myxoid neurofibroma, myxoid liposarcoma, cellular or juxta-articular myxoma, and nodular fasciitis , 19. BecClinically intramuscular myxomas usually present as a painless slow-growing mass; symptoms are due to the compression of surrounding structures . In caseBy consensus, the recommended treatment of intramuscular myxomas is surgical excision. However, the recurrence of intramuscular myxomas is rare, restricted to isolated cases, and more commonly associated with syndromes –26. In oIn the presence of an intramuscular growing mass with associated bone lysis, myxoma as well as malignant neoplasm must be evoked. MRI with gadolinium injection and biopsy should be part of the initial appraisal to obtain a clear diagnosis. Surgical excision is the recommended treatment but every case should be discussed, and conservative treatment with simple follow-up can be an option for this benign tumor.


Management of benign liver tumours (BLT) is still object of discussion. Uncertainty still exists about patient selection, details of management, indications for surgical intervention and potential surgery-related complications. The up-to-date strategies for management of the most common benign solid tumours are recapitulated in this article. In addition, recommendations concerning practical issues are presented.Available data from peer-reviewed publications associated with the major controversies concerning treatment strategies of solid BLT were selected through a PubMed literature search.Non-randomized controlled trials, retrospective series and case reports dominate the literature. Conservative management in BLT is associated with low overall morbidity and mortality when applied in an appropriate patient population. Surgical intervention is indicated solely in the presence of progressive symptoms and suspicion of a malignant change. Linking abdominal symptoms to BLT should be interpreted with caution. No evidence is recorded for malignant transformation in haemangiomas and focal nodular hyperplasia (FNH), while a subgroup of hepatocellular adenoma (HCA) is associated with malignancy. Follow-up controls of BLT at 3 and 6 months should be sufficient to prove the stability of the lesion and its benign nature, after which no long-term follow-up is required routinely. However, many questions regarding this topic remain without definitive answers in the literature.Conservative management of solid BLT is a worldwide trend, but the available literature does not provide high-grade evidence for this strategy. Consequently, further prospective investigations on the unclear aspects are required. Hence, this article summarises practical highlights of therapeutic strategies. This manuscript summarises current state of the art and practical management recommendations of haemangiomas, FNH and HCA.The finding of benign liver tumours (BLT) has markedly increased because of recent technical advances in abdominal imaging modalities . AutopsyAvailable data from peer-reviewed publications associated with this topic were selected through a PubMed literature search. Articles were selected using the indexing terms “benign liver tumours”, “liver neoplasm surgery”, “focal nodular hyperplasia”, “liver haemangioma”, “hepatocellular adenoma”. Only larger series with more than 30 patients with benign lesions were included. Due to lack of data, meta-analysis including descriptive statistics was not possible. The current literature concerning this topic was summarised.Liver haemangiomas are common incidental findings, reflecting a high prevalence within the common population ranging from 1 to 20% . OriginaLinking abdominal symptoms to liver haemangiomas should be interpreted with caution. Eventual symptoms unrelated to an incidentally detected haemangioma should be clarified and alternative causes excluded . Patients with large lesions may present abdominal pain, due to tension of Glisson’s capsule, compression of local structures, intra-lesional thrombosis and infarction or haemorrhage. The risk of haemorrhage seems to be less than 1%  and for Considering a benign and uncomplicated natural history for the majority of haemangiomas, non-operative management might be the right approach for the majority of patients. The risk of potential complications should be carefully weighed against operative risks. Surgery should therefore be reserved as salvage treatment after exclusion of other causes and open discussion with the patient . AlternaFNH is a non-malignant hepatic tumour without vascular origin, often diagnosed incidentally on radiologic imaging. Autopsy series reported that 8% of non-haemangiomatous lesions were FNH, representing 66% of all benign non-haemangiomatous lesions . FNH occAs shown in Fig. The natural history of FNH is uneventful, lacking complications and changes over time. However, enlargement in the setting of OCPs and during pregnancy have been reported . To dateHCA is a rare, solid and benign liver tumour of presumable epithelial origin. The estimated prevalence is about 0.004%. These lesions occur mostly in women of childbearing age and seem strongly associated with the use of OCPs and oestrogens . Women oHistorically, HCAs were treated with a watch and wait policy and the unselective recommendation to avoid OCPs. Surgical intervention was preferred for larger lesions—the “5 cm rule”—due to an expected higher risk of malignant transformation. However, current management options may also include minimally invasive techniques like radiofrenquency ablation (RFA) and transcatheter arterial embolisation (TAE). New molecular insights have shown that b‑HCA and I‑HCA are prone to malignant degeneration especially if the size reaches >5 cm. In these instances, invasive treatment is recommended . AccordiOne of the major discussions involves the clinical application of the molecular subclassification in the diagnosis and treatment of adenomas, balancing the risk of an invasive liver biopsy with benefits of an individualised therapy. When a lesion is >5 cm, OCPs should be stopped and MRI performed after 6 months. If the lesion has decreased to <5 cm, definitive signs of an H‑HCA should be ruled out. If H‑HCA is subsequently identified, therapy can be less aggressive because the risk of malignant progression is very low. Follow-up should be performed, initially every 6 months, and if the lesion shows no further alteration, follow-up can be stopped or repeated yearly until menopause . For smaMost patients with a BLT can be observed with a low risk of misdiagnosis, complications or malignant transformation. In the past years, a trend towards conservative management could be observed . PatientThe risk of potential complications and the severity of symptoms need to be weighed against surgical risk. Minor liver resection for the treatment of a wide range of BLT is associated with low morbidity (9%) and virtually no mortality in centres with a high volume of patients. The presence of comorbidity, prolonged surgical time and incomplete resections are associated with major morbidity. Besides parenchymal-sparing approaches with close margins, laparoscopic resections provide a benefit in terms of pain reduction and comfort, especially in the long term . For all


Almost all hepatoblastomas are isolated to the liver. Hepatoblastoma arising from and limited to extrahepatic tissue is an extremely rare clinical entity.Here we present a case of a 7-year-old Chinese boy of Han ethnicity with hepatoblastoma originating from the hepatogastric ligament. A complete resection was performed and the entire course was uneventful. He received six cycles of postoperative chemotherapy and had no signs of recurrence for 3 years after surgery.Hepatoblastoma arising from extrahepatic tissue is extremely rare. A pedunculated hepatoblastoma is prone to hemorrhage and tumor metastasis. The best treatment for a long-term cure is complete resection of the primary tumor combined with chemotherapy. Primary pediatric hepatic malignancies occupy 1 to 2% of all pediatric tumors. Arguably, the most common histological subtype of primary malignant hepatic tumors in children is hepatoblastoma, which comprises the plurality of liver malignancies at a 79% incidence [A 7-year-old Chinese boy of Han ethnicity presented to our Department of General Surgery, Children’s Hospital of Nanjing Medical University with an abdominal mass that was revealed on ultrasound examination after a tumble. His serum alpha-fetoprotein (AFP) was elevated to 163.1 ng/ml . An abdominal computed tomography (CT) showed that there was an inhomogeneous low density mass in the hepatic portal area, the size of which was approximately 3.2 × 4.3 cm, and it slightly adhered to the surrounding tissue. Contrast-enhanced CT showed that the mass was not uniformly enhanced, the center of the tumor had obvious enhancement, and there was no significant invasion of his liver Fig. . An abdoMost hepatoblastomas occur before the age of 3 years, with a median age of approximately 18 months, and they account for 58% of the malignancies diagnosed in children with extremely low birthweight . HepatobWe could better understand a pedunculated hepatoblastoma through our learning of pedunculated hepatocellular carcinoma , 11. PedThis is to the best of our knowledge a rare case of isolated hepatoblastoma arising from extrahepatic tissue. Extrahepatic hepatoblastoma is prone to hemorrhage and tumor metastasis. The best treatment for a long-term cure is complete resection of the primary tumor combined with chemotherapy.