Cancer patients may harbor micrometastases that remain dormant, clinically undetectable during a variable period of time. A traumatic event or surgery may trigger the balance towards tumor growth as a result of associated angiogenesis, cytokine and growth factors release.We describe a patient with non-small lung cancer who had a rapid tumor growth and recurrence at a minor trauma site of his skull bone.This case is an illustration of the phenomenon of tumor growth after trauma or surgery and its associated cellular mechanisms. This phenomenon deserves further investigation and study. Cancer patients may harbor micrometastases which are responsible for recurrent disease. Micrometastases remain dormant as a result of a balance between tumor cell proliferation and an equivalent rate of cell death ,2. SurgiA 43 year-old smoker was diagnosed with a non small-cell lung cancer (NSCLC) in December 2001. He had a left upper lobe mass with adenopathy in the aorto-pulmonary window. CT-guided FNA of the lung lesion revealed a poorly differentiated NSCLC. Metastatic work-up showed only a suspicious 4 × 2 cm right supra-acetabular lesion of which a core biopsy was negative for malignancy. His total body bone scan showed no abnormal uptake in the skull and CT of brain was negative for metastatic disease.He was given chemotherapy and radiotherapy and had a very good response. In April 2003, the patient reported that he suffered a minor trauma to the right lateral side of his head when he was in the passenger front seat of his car that rolled over a road bump. He reported a new small swelling that grew rapidly over a one month period. On physical examination, the mass was rubbery and not freely mobile measuring 7 cm in largest dimension Figure . Plain sWe report the case of a patient with NSCLC who had an unusual recurrence in his skull after a direct minor trauma. The traumatic event was followed by the development of a small swelling that grew rapidly and manifested itself as an unusual metastatic lesion in the parietal skull bone as demonstrated in the accompanying figures. This event may be explained by the presence of dormant cancer cells might have been stimulated by a new environment of stimulatory factors. Several authors have investigated similar issues and incriminated growth factors, cytokines and angiogenic mechanisms . It is nEstablishment and growth of metastases are thought to be influenced by endogenous inhibitors of angiogenesis which keep metastases in a non-proliferating quiescent state characterized by normal proliferation, increased apoptosis, and insufficient neovascularization ,4. FolkmCytokines and chemokines may act to promote tumors by several mechanisms that include: DNA damage, bypass of p53, angiogenesis, growth stimulation, enhanced survival, subversion of immunity and enhanced invasion . Some chA traumatic event triggers several mechanisms of soft tissue and bone repair of which angiogenesis is part. Dormant cancer cells at the site of tissue trauma and thereby exposed to pro-inflammatory mediators, may be sufficiently stimulated to overcome dormancy. Lee et al.  studied Another mechanism whereby trauma may alter subsequent tumor growth is that cytokine genes are highly polymorphic and since polymorphisms are frequently in regions of DNA that regulate transcription or post-transcriptional events, the cytokines may be cancer-modified genes .Baum suggested that the act of surgery can provoke the outgrowth of dormant micrometatstasis ,13. CoffMost traumatic and surgical events in cancer patients do not lead to tumor growth nor metastases, and swellings occurring after trauma do not require biopsy to prove their nature. However, we suggest that the phenomenon of tumor growth after trauma or surgery deserves further investigation and study. Antiangiogenic drugs might have a potential role for investigation in some circumstances of cancer patients in remission who require surgery, or are subject to a traumatic event.The author(s) declare that they have no competing interests.NSES, the corresponding author, was the main operator in charge of the case, the idea and the manuscript. IIEH assisted in the literature search and manuscript. FBG was involved in the patient's management and radiation therapy. MHH was involved in imaging and preparation of figures. All authors contributed to the preparation of the manuscript. All authors read and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:


Leiomyosarcoma is a malignant mesenchymal tumor originating from smooth muscle cells, which most frequently develops in the myometrium and in the gastro-intestinal tract. Reviewing the international literature, radiation-induced sarcoma arise in 0.035 to 0.2 % of all irradiated patients. Especially in the head and neck region, radiation-induced leiomyosarcoma is an extremely rare lesion. The authors report a case of a radiation-induced leiomyosarcoma of the tonsillar region of the oropharynx in a 51-year-old male patient, who had undergone radiation therapy of this region 38 years before. The lesion was treated by radical surgery. Diagnostic steps, histological presentation and therapy are described in detail and the literature concerning radiation induced malignancies in general as well as radiation induced leiomyosarcoma in particular is reviewed. The highlights of this case are an extremely uncommon location and a rare pathological entity of radiation induced malignancies. Leiomyosarcoma is a malignant mesenchymal tumor which originates from smooth muscle cells and accounts for about 7 to 9 % of all soft tissue sarcomas -3. LeiomRadiation-associated sarcomas are uncommon, constituting less than 5 % of all sarcomas, and generally associated with a poor prognosis . ReviewiIn March 2004 a 51-year-old male patient was referred to our outpatient's department because of oropharyngeal pain of the right tonsillar region. The complaints had started one year before with a right sided feeling of pressure in the oral cavity and the neck. In 1966, 38 years before the patient presented to our department, he had been treated for a squamous cell carcinoma of the left tonsil in the territory of the former Soviet Union. At that time, the then 13-year-old boy underwent radical surgery followed by adjuvant radiotherapy with a cumulative radiation dose of 101 Gray. Although the patient was only 13 years old at the time when the diagnosis of a squamous cell carcinoma of the left tonsil was made, the presented documents left no doubt about the initial histological diagnosis. When the 51-year-old patient presented to our department in 2004, the otorhinolaryngological examination showed a smooth bounded neoformation in the region of the right-sided tonsillar fossa and soft palate with a diameter of about 2.5 cm (Fig. An endoscopic examination of the larynx and hypopharynx was performed in general anesthesia and revealed these regions to be without pathological findings. Tumor-resection was then carried out by a transoral approach in combination with a mapping of the oropharyngeal mucous membrane. Histological examination of the tumor revealed spindle cells with marked polymorphism implicating a storiform growthpattern Fig. . Via immth century, only a short time after Roentgen first discovered x-rays. The first cases of radiation-induced skin cancers were reported by Frieben et al. in 1908 [Radiation therapy is a well accepted modality of treatment in the therapeutical scheme of head and neck cancer. It is of significance as an adjuvant method of treatment after surgery and in some cases a valuable alternative to surgery in cases where tumor-resection can not be performed or would lead to limited quality of life from mutilation and loss of function. Radiation-induced malignancy is a long-term complication of radiation therapy. The potential of ionizing radiation to induce malignant neoformations was already observed in the early 20 in 1908 . Criteri in 1908 . These c in 1908 ,6-8,12.  in 1908 . Further in 1908 . With th in 1908 ,13. Murr in 1908 . As the  in 1908 ,13. Data in 1908 . Surveyi in 1908 .With an estimated incidence of 0.4 to 1.0 % radiation induced malignancy is a rare entitiy . RadiatiWithin the head and neck region, practically all types of cancer have been reported after radiation therapy, but the skin and the thyroid are the most commonly involved tissues . SquamouLeiomyosarcoma is a malignant spindle-cell mesenchymal tumor originating from smooth muscle cells and constituting about 7 to 9 % of all soft tissue sarcomas -3,10,20.In contrast to sarcomas of other histological subtypes, leiomyosarcomas are very rarely induced by radiotherapy ,5,7. EspWe present here an additional case of radiation-induced leiomyosarcoma of the head and neck. The presented case fulfils all criteria for diagnosing the malignancy as radiation induced, that were formulated by Cahan et al. in 1948 and that are described above . The neoThe presented case demonstrates, that clinicians managing cancer patients as well as pathologists have to be aware of radiation-induced sarcomas as a long-term complication of treatment, especially as this pathological entity is today expected to be seen more frequently due to an increased life expectancy combined with improved survival of cancer patients resulting from an increased effectiveness of cancer therapy. As the prognosis of radiation-induced malignancies in general is poor and the treatment options are limited, early diagnosis and a correspondingly better chance of complete surgical excision assume great importance. Nevertheless it has to be emphasized, that the incidence of radiation-induced malignancies is small enough that the risk of its occurrence is vastly outweighed by the benefits obtained from radiation therapy by most patients.


The medical literature has reported an increase in myomectomy during caesarean section in the past decade. However, myomectomy performed during pregnancy remains a rarity. The management of uterine fibroids during pregnancy is usually expectant and surgical removal is generally delayed until after delivery. We present a case of a large, symptomatic uterine fibroid diagnosed during pregnancy which was successfully managed by antepartum myomectomy.A 30 year old woman presented with a one year history of abdominal swelling, amenorrhea and severe epigastric discomfort of 19 weeks duration. The abdomen was grossly distended and tense. A sonographic diagnosis of ovarian tumor in pregnancy was made. Laparotomy revealed a 32 cm degenerating subserosal uterine fibroid co-existing with an intrauterine pregnancy. Myomectomy was successfully performed. The subsequent antenatal period was uneventful with a spontaneous vaginal delivery of a female baby at 38 weeks.This report supports other studies and case series that have demonstrated the safety of myomectomy during pregnancy in selected circumstances. The prevalence of leiomyoma during pregnancy is reported as 2% . During We present a case of a large symptomatic fibroid diagnosed during pregnancy which was successfully managed by antepartum myomectomy.A 30-year old primigravida presented to our center on 17 October 2003 with a one year history of abdominal swelling and amenorrhea of 19 weeks duration. The abdominal swelling started as a small lump but markedly increased in size in the preceding 3 months. It was associated with pain, severe epigastric discomfort, constipation, weakness and swelling of the legs.The patient was ill-looking, clinically pale and had bilateral pitting pedal edema. The pulse rate was 80 beats per minute and the blood pressure was 120/80 mmHg. The respiratory rate was 24 cycles per minute. The abdomen was grossly distended and tense. There was a massive central abdomino-pelvic mass which was firm and irregular, measuring 40 cm from the symphysis pubis.Abdominal sonography showed an intra-uterine viable singleton fetus of 20 weeks gestation. It also showed a 30 cm multi-loculated cystic tumor with a thick capsule located at the right posterior-superior aspect of the uterus and free fluid in the peritoneal cavity. A sonographic diagnosis of ovarian tumor in pregnancy was made.Blood tests showed a hematocrit of 22%, and normal electrolytes, urea and creatinin levels. The woman's blood group was 0 Rhesus positive and the hemoglobin genotype was AA. Malaria treatment was started following a positive smear test and two units of sedimented cells were administered to correct the anaemia. Because of the severity of the symptoms and the sonographic findings being suspicious of malignancy, surgery was proposed and discussed with the patient. Laparotomy was performed under general anaesthesia with endotracheal intubation. Operative findings included ascites, normal liver, spleen, kidneys, diaphragm, ovaries and fallopian tubes. The uterus was soft and the size was adequate for 20 weeks of gestation. Fetal movements were visible. A cystic subserosal fibroid measuring 32 cm in diameter was situated at the right posterior superior aspect of the uterus. Fig The subserosal fibroid was adherent to the omentum and the anterior abdominal wall. It was removed and the myoma bed was quickly closed with 2-0 polyglactin suture and hemostasis was easily achieved. The estimated blood loss was 600 mls and 2 units of whole blood were transfused intra-operatively. The tumor weighing 7.7 kg was sent for histology.Intravenous magnesium sulphate was administered to prevent uterine contractions and the woman had an uneventful post-operative follow up. The post-operative hematocrit was 30% and the woman was discharged from the hospital 10 days after the operation. The histology report showed sections of interlacing bundles of smooth muscles with areas of hyaline degeneration with no evidence of malignancy. Repeat sonography during antenatal care visits showed a normally growing fetus and the remainder of the antenatal period was uneventful. The woman went into spontaneous labor at 38 weeks gestation and delivered vaginally a female baby weighing 3.5 kg with Apgar scores of 8 and 10 at one and five minutes, respectively. Two days post partum the maternal hematocrit was 30% and mother and baby were discharged from the hospital. The 6 weeks post-natal visit was unremarkable.To the best of our knowledge this is the first report of antepartum myomectomy from Nigeria. The decision to remove the fibroid was justified by its size and the patient's symptoms. The benefit was the relief of symptoms and a tissue diagnosis of a very large, suspicious abdominal mass. Its subserosal location may have contributed to easy enucleation and closure of the myoma bed. Hypercoagulability in pregnancy might have contributed to the ease in achieving hemostasis. The ease with which the fibroid was removed and the minimal measures used to obtain hemostasis contributed to the safety of the procedure. This case illustrates that myomectomy during pregnancy can be safely performed in carefully selected cases.Antepartum myomectomy associated with reversal of fetal complications such as oligohydramnios, fetal postural deformity and intrauterine growth restriction has been reported .This case also illustrates that cystic degeneration of a subserosal uterine fibroid is a differential diagnosis of ovarian tumor in pregnancy . SonograA degenerating uterine fibroid may mimic an ovarian tumor in pregnancy and obstetricians should be aware of the differential diagnosis. Although most cases of uterine fibroids in pregnancy can be managed conservatively, antepartum myomectomy may be necessary in selected cases.The author(s) declare that they have no competing interest.CU performed the surgery and conceived of the study. PFW did the literature search. Both authors collaborated in the preparation of the manuscript, read and approved the final manuscript.


Rectal squamous cell carcinoma (SCC) is a rare tumor. The incidence of this malignancy has been reported to be 0.25 to 1 per 1000 colorectal carcinomas. From a review of the English literature 55 cases of SCC of the rectum have been published. In this study we report a rectal metastatic SCC to the liver, discussing the efficacy of aggressive adjuvant and neo-adjuvant therapies on survival and prognosis.A 39-year-old female patient with a pure SCC of the rectum diagnosed endoscopically is presented. The patient underwent initially neoadjuvant chemo-radiotherapy and then abdominoperineal resection with concomitant bilateral oophorectomy and hysterectomy, followed by adjuvant chemo-radiotherapy. Five months after the initial operation liver metastasis was demonstrated and a liver resection was carried out, followed by adjuvant chemotherapy. Eighteen months after the initial operation the patient is alive.Although prognosis of rectal SCC is worse than that of adenocarcinoma, an aggressive therapeutic approach with surgery as the primary treatment, followed by combined neo- and adjuvant chemo-radiotherapy, may be necessary in order to improve survival and prognosis. The squamous cell carcinoma (SCC) of the rectum is a rare tumor with a not yet clarified pathogenesis mechanism and a rather aggressive clinical behavior. It has a slight female predominance and prognosis worse than that of adenocarcinoma. Radical surgery is the cornerstone of treatment. However, the role of chemotherapy and radiation in the pre- and postoperative period remains to be elucidated. In the present study a case of a metastatic pure SCC of the rectum to the liver is presented. Aggressive surgical treatment as well as combined neoadjuvant and adjuvant chemotherapy and radiation is described, suggesting a possible positive survival and prognostic effect.2/d) plus Mitomycin and 5 sessions of radiotherapy . Two days after the last session of radiotherapy a laparotomy was performed. Intraoperative findings included invasion of the posterior vaginal wall from the tumor and an abdominoperineal resection and a concomitant total hysterectomy-oophorectomy were carried out. Histology reported the presence of two ulcerated lesions (1 × 2 cm and 2 × 4 cm) in middle and lower rectum both squamous cell carcinoma of the rectum, invading the bowel wall and the adjacent vaginal wall. The surgical specimen contained 15 lymph nodes, all negative for metastatic disease  and the resected margins were free of tumor. Postoperatively, adjuvant chemotherapy (1 session of 5-FU plus Mitomycin) and 23 sessions of radiotherapy  were administered.A 39-year-old female patient was admitted to our Medical Center's surgical department with a 2 month history of altered bowel habits, perianal pain and rectal bleeding. Colonoscopy demonstrated a circumferentially developing ulcerated tumor 8 cm above the dentate line, extending 4 cm proximally. The colonoscope was advanced past the tumor, performing a total colonoscopy, while biopsies from the lesion were obtained and examined histologically, revealing a non-keratinized squamous cell carcinoma of the rectum. Abdominal computed tomography and chest radiograph were negative for metastatic disease. However, a transanal endoscopic ultrasound demonstrated the spread of the tumor beyond bowel's wall in the perirectal space, necessitating institution of neoadjuvant therapy. The patient underwent 1 session of neoadjuvant chemotherapy with 5-Fluorouracil (1000 mg/m2/d) was applied. Fortunately, the patient had an uneventful postoperative course and is alive 18 months after.Five months after tumor resection, liver metastasis was demonstrated in a follow-up abdominal computed tomography and a central hepatectomy was performed. Histology confirmed the presence of a metastatic rectal squamous cell carcinoma to the liver Figure , 2. AdjuSince the first report of rectal SCC by Raiford in 1933 .et al. [Rectal SCC is a rare tumor. The incidence of this malignancy has been reported to be 0.25 to 1 per 1000 colorectal carcinomas ,5,7,21. It seems that the pathogenesis of this malignancy is not yet clear and many theories exist -20: the Clinical manifestations of SCC of the rectum are similar to those of adenocarcinoma: change in bowel habits, pain, tenesmus and rectal bleeding, anorexia and weight loss. The natural history of this malignancy is not clearly defined due to the rarity of the disease. From data presented in Table Immunochemistry is helpful in diagnosing SCC using several markers  in order to differentiate it from other small cell undifferentiated tumors .et al. [The definite therapy is surgical resection of the affected rectum, either by low anterior resection (LAR) or by abdominoperineal resection (APR), depending on the location of the tumor and the patient's preference. An informed consent and a detailed discussion of complications, adjuvant therapy, recurrence and survival-death statistics are definite prerequisites before any operation. Copur et al.  propose et al [The role of neoadjuvant radiotherapy  or adjuvant chemo and/or radiotherapy remains to be elucidated together with understanding the natural history of the disease. It seems that adjuvant therapy can be used in patients with nodal involvement, poorly differentiated cancers and metastatic disease without any proven effectiveness in outcome. Juturi et al  report tSCC of the rectum is a rare and aggressive malignancy with a similar clinical presentation pattern, but a worse prognosis than that of adenocarcinoma, especially if positive nodes are involved or poor histological features are reported. Surgical resection is the treatment of choice, although radiation and chemotherapy can be useful in treating node-positive patients and advanced disease. It is possible and remains to be studied that aggressive combined chemo-radiotherapy is required pre- and postoperatively in order to control this aggressive malignancy.The author(s) declare that they have no competing interests.TT, LS and ND carried out the surgical procedures and contributed to the design of the study; TT and AM gathered the data, drafted the manuscript and critically revised it; EC performed the histological analysis of all surgical specimens and provided histological sections as figures for the manuscript; JV and VS revised and finally approved the manuscript for been published.All authors read and approved the manuscript.


Schwannomas are uncommon benign tumors of the external auditory canal. The clinical features, the differential diagnosis, and the surgical treatment of these lesions are discussed.A 51-year-old patient presented with a mass obliterating the external auditory meatus. Excisional biopsy was performed. Diagnosis was reported to be schwannoma by histopathologic examination.Schwannoma, rarely seen in the external auditory canal, can be managed by a precise excision of the tumor via transmeatal approach. Schwannomas are slow-growing benign tumors originating from the Schwann cells surrounding the peripheral, cranial or autonomic nerves. In head and neck region, schwannomas most commonly appear as acoustic neuroma 25–45%) . These t5–45% . TA 51-year-old female patient presented with a mass originating from the posterior wall of the right external auditory meatus. She had a history of progressive right sided hearing loss and recurrent external otitis over a period of 12 months. Physical examination revealed an ovoid mass covered with normal skin without any pigmentation or ulceration. The mass completely obliterated the lateral half of the right external auditory meatus hindering the visualization of underlying tympanic membrane. Pure tone audiometry revealed a mild conductive hearing loss on the lesion side. Computer tomography (CT) scan of the temporal bone demonstrated a well-circumscribed soft tissue mass, 16 × 17 mm in size in the lateral part of the external auditory canal posterior wall  and lesser occipital nerves  respectively.The clinical presentation of these tumors is usually with recurrent external otitis, pain and drainage with poor odour. Because of the enlarging mass, a mild conductive hearing loss is commonly encountered during the progression. Neurogenic symptoms such as pain or paresthesia are uncommon.Schwannomas also can originate from the tympanic membrane . In caseSchwannomas consist of a true capsule facilitating the surgical dissection. They have a hard parenchymatous consistency with a non-infiltrating nature and exhibiting a smooth surface under a normal skin. Considering these morphological findings, the differential diagnosis should be made with respect to a number of other soft tissue neoplasms such as fibroma, chondroma, and leiomyoma. Definitive diagnosis should be based on the histological and immunohistochemical findings. Histologically, the tumor is characterized by streams of elongated spindle cells, with the elongated nuclei often arrayed in a palisade pattern. Areas consisting of thick concentration of cells are called Antoni type A (Verocay Body), whereas those in which the cells are loose and irregularly arranged are called as Antoni type B. A positive S-100 protein is the indicative of Schwann cell origin.Neurofibroma also originates from Schwann cells and must be considered in histopathologic examination. Neurofibroma does not have a true capsule; have a dense cellular consistency and increased mitosis. Histologic sections show local invasion areas . There iTreatment of choice in these tumors is excisional biopsy. Provided that the complete excision is performed, local recurrence is extremely rare. Transmeatal approach was performed in the present case while the good cleavage plane provided an en bloc resection with preservation of surrounding structures.The author(s) declare that they have no competing interests.O.T. drafted and prepared the manuscript. S.S.E. reviewed the patient's medical record in order to collect all the available information. S.E. was involved in revising the article for intellectual content details. All authors read and approved the final manuscript.


Bowel reconstruction after subtotal esophagectomy represents a problem when a previous distal gastrectomy was performed: usually the colon or jejunum is used.In a 10 year period 126 patients with primary esophageal cancer underwent esophageal resection in our Department. Surgical procedures were 57% two-phase subtotal oesophagectomy, 23% transhiatal, 9% stripping, 10 three-phase total esophagectomy and 2 endoscopic resections.In 112 patients alimentary tract reconstruction was achieved by means of esophago-gastric anastomosis. Reconstruction was performed using colon in 10 cases and jejunum in 2. We describe the technical aspects of esophagectomy and gastric reconstruction in a patient with previous antrectomy and Billroth II reconstruction. The procedure was performed via a combined laparotomy and thoracotomy with anastomosis at the level of the azygous vein using the remnant stomach.Few technical reports have been reported in literature about the use of remnant stomach in reconstruction for subtotal esophagectomy subsequent to distal gastrectomy. Several hypotheses are made to explain the maintenance of the gastric vascular integrity as its intramural network without micro-vascular anastomosis. In a 10° year period between 1994 and 2004, 126 patients with primary esophageal cancer underwent esophageal resection in our Department of Surgery. Surgical procedures were: 74 (57%) two-phase subtotal oesophagectomy, 30 (23%) transhiatal, 10 (9%) stripping, 10 three-phase subtotal esophagectomy and 2 other procedures (endoscopic resections). After esophageal resection for carcinoma reconstruction of the alimentary tract can be achieved using stomach, colon or jejunum. When technically possible the stomach is the organ of choice, since esophago-gastric anastomosis has been demonstrated to present a lower incidence of complications (i.e. leakages). Colon or jejunum may be used in patients previously undergone to partial gastric resection or total gastrectomy. This is confirmed by our experience: in 112 patients (90%) with primary esophageal cancer, alimentary tract reconstruction was achieved by means of esophago-gastric anastomosis. Reconstruction was performed using colon in 10 (8%) cases and jejunum in 2 (2%). One patient had previously undergone partial gastrectomy and manifested a lower thoracic esophageal carcinoma. Two-phase subtotal esophagectomy was carried out and reconstruction was achieved using the remnant stomach without micro-vascular anastomosis. We wander why gastric remnant in patients who previously received partial gastric resection has not been widely used and if this is a surgical axiom or it is unquestionably demonstrated that it is not technically possible [A 60-year-old white male was admitted to our Department in January 2003 because of dysphagia and odinophagia. The patient's medical history included perforated benign gastric ulcer treated in 1965 by means of distal gastrectomy and ante colic end to side gastrojejejunostomy (Polya anastomosis). An esophagoscopy confirmed an ulcerated tumour of the lower third esophagus with the upper margin located at 35 cm from dental arcade; a squamous cell carcinoma was identified on biopsies. The interval between previous distal gastrectomy and esophagectomy was 38 years. Barium meal showed a capacious residual stomach with efficient emptying function through a wide gastrojejunostomy. The size of the residual stomach was measured before operation with contrast barium meal x-ray: 8 cm in length at the lesser curvature and 11 cm at the transection of the body  associated with 5th right thoracotomy with two field lymph node dissection was carried out. In the right upper abdomen the duodenum stump, transverse colon, and lower surface of the liver were tightly adherent. Exploration of the thorax and abdomen excluded presence of distant metastases and confirmed wide gastrojejunal anastomosis. The right gastroepiploic arcade was divided at the time of previous gastrectomy. The residual stomach, afferent and efferent loops of jejunum were fully mobilized from peripheral cohesions. Short gastric vessels were not preserved and the left gastric artery was divided; no jejunal vessel was sacrified. The afferent loop was transected very close to the gastrojejunal anastomosis and the gastric end was closed. The other end was covered with gauze and closed. The prepared stomach roll was pulled up in continuity with the efferent loop through the posterior mediastinal route into the right emithorax. The upper end of the oesophagus was resected 5 cm above the tumour. The specimen was removed after careful sleeve resection of the lesser curve. Proximal and distal resection margins were tested by frozen-section histology assessment. The remnant stomach appeared rosy with adequate bloody supply probably by the efferent jejunal flap with its wide gastrojejunal anastomosis (this was checked by transilluminating the mesenteric vessels). The esophagus was anastomosed mechanically with a circular stapler by an anterior gastrotomy to the high point of the remnant stomach (fundus) at the level of the azygos arcade. No micro vascular anastomosis was performed. At the end there was absence of tension in the anastomosis Figure . The affPathological examination revealed a squamous cell tumour of 23 mm in diameter pT3, pN0, M0, R0, G2 (Stage IIA). None coexisting neoplastic lesion was found in the resected esophagus. Evidence of areas of mild dysplasia and esophagitis of the noncancerous esophageal mucosa surrounding the cancer lesion and at the esophagogastric junction was randomly observed. None of the 15 lymph nodes dissected were involved. Postoperative course was uneventful. On follow-up, two years after operation, the patient was alive without evidence of recurrence. The patient had an improved intake of food, mainly managing a semi-solid diet with an average intake per meal was 400–500 mL. Endoscopy findings, barium meal contrast exam and angio-CT scan confirmed good vascularity of the jejunal flap and stomach.The relationship between previous gastrectomy and subsequent occurrence of primary malignant esophageal tumour remains controversial. Maeta reported that of 129 patients surgically treated for esophageal cancer 12 (9%) had previously undergone partial gastrectomy ,4. We prhypothesis can be made: the reconstituted microvascular supply from the anastomosed efferent jejunal loop with its wide gastrojejunal anastomosis contributed to the maintenance of the gastric vascular integrity as its intramural network. Vascular adaptation is a more likely hypothesis for the adequate blood supply than jejunal vessels: Reavis demonstrated that the delay effect is associated with both vasodilation and angiogenesis and results in increased blood flow to the gastric fundus prior to esophagogastric anastomosis in animals: delayed operations have less anastomotic collagen deposition and ischemic injury than those undergoing immediate resection [Several esection . ClinicaAt the third post-operative month, an angio-CT scan, demonstrated good vascularity of the jejunal flap and residual stomach without any vascular congenital abnormality of the aorta and its branches. The prepared stomach roll was pulled up in continuity with the efferent loop with posterior mediastinal route as it provides the shortest distance between abdomen and the thorax. A sufficient long jejunal flap must be needed. Pre-operative and intra-operative assessments revealed the stomach had an adequate length. Previous gastrectomy often causes strict adhesions between the mesocolon and the adjacent organs, making difficult the use of colon for reconstruction. The reduction in number of surgical manoeuvres beneath the transverse colon and few bowel anastomosies represent a real advantage. Chen and Lu proposed the resection of the tumour through left thoracotomy, preserving the left short gastric artery and transporting the residual stomach, the spleen and tail of the pancreas into the left thoracic cavity, and using the residual stomach to reconstruct the alimentary tract and preserve vascular integrity of the stomach . MatsubaFinally, in the authors' experience, this technique proved to be efficient with no postoperative complication and long follow-up. The technique must be performed in Institutions with well-trained surgeons and high volume UGI procedures. We recommend further reports to verify the usefulness of the proposed technique.UGI: upper gastrointestinalCT: computer tomographyThe author(s) declare that they have no competing interests.GD participated in acquisition of dataFR participated in study conception and designLB conceived the analysis and interpretation of dataGD and GC carried out drafting of manuscriptRD conceived the critical revision and supervisionAll authors read and approved the final manuscript


Osteochondroma is the most common benign bone tumor in the scapula. This condition might lead to snapping scapula syndrome, which is characterized by painful, audible, and/or palpable abnormal scapulothoracic motion. In the present case, this syndrome was successfully treated by use of endoscopically assisted resection of the osteochondroma.A 41-year-old man had a tolerable pain in his scapular region over a 10 years' period. The pain developed gradually with shoulder motion, in particular with golf swing since he was aiming a professional golf player career. On physical examination, "clunking" was noted once from 90 degrees of abduction to 180 degrees of shoulder motion. A trans-scapular roentgenogram and computed tomography images revealed an osteochondroma located at the anterior and inferior aspect of the scapula. Removal of the tumor was performed by the use of endoscopically assisted resection. One portal was made at the lateral border of the scapula to introduce a 2.7-mm-diameter, 30 degrees Hopkins telescope. The tumor was resected in a piece-by-piece manner by the use of graspers through the same portal. Immediately after the operation pain relief was obtained, and the "clunking" disappeared. CT images showed complete tumor resection. The patient could start playing golf one week after the surgery.Endoscopically assisted resection of osteochondroma of the scapula provides a feasible technique to treat snapping scapula syndrome and obtain early functional recovery with a short hospital stay and cosmetic advantage. Osteochondromas are the most common benign bone tumors of the scapula ,2. OsteoRegarding removal of the osteochondroma, conventional open excision has slow functional recovery and cosmetic disadvantage due to a large operative incision -7. RecenHere, we present a case with a scapular osteochondroma causing snapping scapula syndrome and treated with endoscopically assisted resection, and we discuss the practicality of the technique.A 41-year-old man had tolerable pain in his shoulder, which developed gradually over a 10 years' period. The pain occurred with shoulder motion, particularly in relation to his golf swing, since he was aiming at a professional career as a golfer. On physical examination of the scapula, "clunking" was noted once from 90 degrees of abduction to 180 degrees. However, active range of motion (ROM) was normal. There was no winging of the scapula. The upper extremity and shoulder girdle muscle strength was normal.A trans-scapular roentgenogram showed a pedunculated type of a bony projection, which was continuous with the scapula Figure . ComputeUnder general anesthesia, the patient was placed in a prone position, with the right arm draped free to allow a full range of motion. The lesion was approached through a 2-cm incision along the lower lateral aspect of the scapula. The teres major muscle was dissected on the same line. Then scapula was elevated by a retractor and then the 2.7-mm-diameter, 30 degrees Hopkins telescope  was introduced into this portal. Since the tumor was covered by the subscapularis muscle, a part of the muscle was removed to access the tumor by use of graspers. Consequently, the tumor was visualized and resected in a piece-by-piece manner by the use of graspers of different sizes  had solitary lesions. The scapula was involved in 33 cases, approximately 3.8% of the Mayo clinic series ,2. With A scapular osteochondroma might cause the snapping scapula syndrome in adolescence or early adulthood . In the et al., [The snapping scapula syndrome was first described by Boinet in 1867. The subject was fully reviewed by Milch and Burman in 1933 . The cauet al.,  reviewedBoth conservative and surgical approaches have been applied to treat this condition. The conservative treatment including immobilization of the scapula, physiotherapy, or local anesthetic injection might be effective in cases where only the soft tissues are involved. In contrast, when the cause of the snapping scapular syndrome is a bony abnormality, the involved area must be resected. Recently, endoscopic resection has been introduced as treatment of painful snapping scapula caused by bone abnormalities ,6.Historically, the extra-articular endoscopic resection of the bone tumors was first introduced and applied in the case of a chondroblastoma of the femoral head in 1995 ,13. Of oet al., [et al., [In order to safely achieve complete tumor resection through a small incision, the most important factors are the location and the number of the portals. Ruland et al.,  describe[et al.,  applied [et al.,  to treat[et al., , the porA case with snapping scapula syndrome due to an osteochondroma was successfully treated with an endoscopically assisted resection by the use of one lateral portal. This is a feasible technique to obtain early functional recovery with short hospital stay and cosmetic advantage.The author(s) declare that they have no competing interests.SF collected the data and has written up the manuscript, HF had the idea and granted permission to use his patient data for preparing the manuscript, and finalized writing of the manuscript. SY helped in scrutiny of the paper.All authors read and approved the final manuscript.


A carcinoma within a hernia in the groin is uncommon, with an incidence of less than 0.5 percent of all excised sacs. This article describes a case of synchronous colonic carcinomas, one of which presented as an inguinoscrotal mass.A 69-year old man presented with a large, irreducible left inguinoscrotal hernia and symptoms of obstruction. On examination, there was an 8 cm palpable mass within the hernia sac. CT scan revealed small and proximal large bowel obstruction secondary to a large ingunoscrotal sac and synchronous colonic tumours of the transverse colon and the ascending colon. The former presented as an inguinoscrotal mass. Laparotomy revealed a large tumour mass arising from the transverse colon in the hernia sac. The procedure was followed by an extended right hemicolectomy, during which the second tumour in the ascending colon was also resected.This case demonstrates a rare but interesting occurrence of primary transverse colon carcinoma presenting in a hernia sac, in conjunction with a synchronous tumour of the ascending colon. Prognosis is comparable to patients with a solitary tumour of similar pathological staging when the resection is curative. The presence of an inguinal hernia itself does not signify an increased risk of colorectal malignancy. However, in the presence of obstruction, incarceration, and weight loss, malignancy should be suspected. Thorough clinical examination, flexible sigmoidoscopy or radiographic evaluation is necessary preoperatively in such patients. Surgical resection, with or without adjuvant oncological treatment, should be performed as soon as possible, using established techniques with modifications according to involvement of local structures. Carcinomas in hernias in the groin are divided into saccular, intrasaccular and extrasaccular , based oA 69-year old man with a long-standing irreducible left inguinoscrotal hernia presented with 6–8 weeks history of constant dull ache in the paraumbilical region and associated vomiting. He also reported having loose stools and weight loss of 2 stone over the last 6–8 weeks. On examination, there was a large irreducible left inguinoscrotal hernia with a palpable mass measuring approximately 8 cm within the hernia sac. Plain abdominal film revealed evidence of subacute small bowel obstruction. A subsequent CT revealed small and proximal large bowel obstruction with a large left-sided inguinoscrotal hernia. In addition, there was a loop of transverse colon, with significant circumferential wall thickening, within the hernia sac  of the ascending colon with one focus of extramural vascular invasion. The second tumour was again a moderately differentiated adenocarcinoma of the transverse colon with one focus of extramural vascular invasion . All 14 lymph nodes showed no evidence of nodal metastases.Convalescence was initially complicated by reduced urine output which was managed with fluid balance and use of furosemide. He made a slow but good recovery and was discharged on day 37. The case was discussed in a multidisciplinary meeting. In view of the vascular invasion, a post-discharge oncology outpatient appointment was arranged to discuss the option of adjuvant chemotherapy. He will also be offered left sided colon imaging, either colonoscopy or flexible sigmoidoscopy, to assess the remainder of the colon.The incidence of synchronous malignancies of the colon and rectum varies from 2 to 11 percent. We need to detect synchronous malignancies, if any, during resection of the index lesions in order to avoid repeated surgery in the future, at which time the tumours are more likely to be of advanced stage and thus bear a less favourable prognosis. We can do this by performing preoperative total colonoscopy, palpating the entire colon intraoperatively, and carefully inspecting the resected segment macroscopically and microscopically after the operation .Most synchronous tumours arise as independent neoplasms. They are generally similar to single lesions in clinical characteristics and pathological findings . HoweverThere is limited literature on the management of patients with malignancies in hernia sacs and we found no clear evidence on the best approach in treating these patients. The previously reported cases were mainly of sigmoid tumours  and to oInvasion of the contiguous structures within a hernial sac in not unheard of . LymphatThe reported increased incidence of colonic malignancies in inguinal hernia patients that exceeds the age-related expected incidence has led some to advocate screening . GravityThe present case demonstrates a rare but interesting occurrence of primary transverse colon carcinoma presenting in a hernia sac, in conjunction with a synchronous tumour of the ascending colon. The presence of an inguinal hernia itself does not signify an increased risk of colorectal malignancy. Further, inguinal hernia alone is a relatively rare cause of colonic obstruction. In the present case, the presence of symptoms of obstruction, incarceration, weight loss and a palpable mass within the hernia sac immediately raised the suspicion of malignancy. Thorough clinical examination, endoscopic (e.g colonoscopy) and radiological evaluations  are necessary preoperatively in such patients. Surgical resection, with or without adjuvant oncological treatment, should be performed as soon as possible, using established techniques with modifications according to involvement of local structures. Prognosis is comparable to patients with a solitary tumour of similar pathological staging when the resection is curative.The author(s) declare that they have no competing interests.SPT drafted the article, prepared the illustration and performed the literature search. SSL assisted in performing the surgery, conceived this report, and supervised drafting and revision of the article. SMH helped to acquire the radiological images, prepared the cover letter and performed the literature search. DOR performed the surgery, supervised the drafting and overall structure of the article. All authors have read and approved the final manuscript.


Sarcoidosis of the genital tract is a rare condition. Ovarian manifestation of this disease is rarer still.The case presented here represents ovarian manifestation of sarcoidosis. At the point of referral to our hospital, based on computerised tomography (CT) ovarian carcinoma was a differential diagnosis. Further magnetic resonance imaging along with CT guided biopsy aided by laboratory study supported a diagnosis of sarcoidosis. Patient responded to medical management by a multidisciplinary team.The case shows the importance of FNAC and biopsy in case or ovarian masses and multi disciplinary team approach to management. Sarcoidosis of the genital tract is a rare condition. Ovarian manifestation of this disease is rarer still. In previously reported cases of genital tract sarcoidosis, the diagnosis was made on surgical specimen. We report the first case of non-surgical management of ovarian sarcoidosis. The successful management of this patient is principally due to the expertise offered by the multi disciplinary team (MDT). Our report highlights the importance of managing complex cases within a MDT environment.A 40-year-old para four obese Caucasian woman with two-year history of lower abdominal pain was referred from a peripheral hospital for the further management of bilateral adnexal masses. The computerised tomography (CT) scan of abdomen and pelvis revealed a complex cystic lesion of 7–8 cm in the right adnexum and bilateral ureteric obstruction. All baseline blood tests including haematology and tumour markers (CA 125 -26 IU/ml) were normal. The serum tests showed normal liver function and moderately impaired renal function .in situ for the past three years. Given her body habitus (BMI 42), abdominal and pelvic examination was difficult and non-specific. The only finding of relevance was bilateral adnexal fullness.She had a complex medical history including obstructive sleep apnoea, asthma, glaucoma, hypothyroidism, hypertensive cardiomyopathy and bipolar disorder; registered disabled. She also had a copper intra uterine contraceptive device She was managed within the gynaecological oncology multi disciplinary framework (MDT). On reviewing the CT films the features noted include bilateral basal pleural thickening, bilateral hydronephrosis, retroperitoneal lymphadenopathy associated with retroperitoneal fibrosis and bilateral adnexal cystic masses. There was a small volume of ascites.Magnetic resonance imaging (MRI) was performed for further characterisation of the adnexal masses. The right adnexal complex cystic lesion measured 8 × 7 × 7 cm in diameter and had a thick wall (up to 2 cm), which was irregular. There were several septations, some of which measured 3 – 4 mm. There were no enhancing papillary formations, although the wall and septa enhanced. The appearance suggested an ovarian lesion with possible involvement of the Fallopian tube. The left adnexal cyst measured 5 × 6 × 4 cm, had a smooth wall and contained a single thin septation, consistent with a benign ovarian cyst. Both cysts contained fluid, which was low on T1 and high on T2, with no evidence of fat or blood. Surrounding the cysts posteriorly, the fat was streaky in appearance and there was marked thickening of the adjacent fascial planes, with thickening of the mesorectal fascia up to 1 cm. The fascial thickening extended up the pre-sacral space and along the posterior aspect of the pelvic sidewalls, resulting in the obstruction of the ureters. Enlarged lymph nodes (up to 1.8 cm in short axis) were present along both pelvic sidewalls, which were striking due to the very high T2 signal intensity  course of prednisolone. Symptomatic improvement was observed but the renal function did not change. Repeat imaging demonstrated resolution of hydronephrosis.The woman was reviewed again clinically after the course of steroids. During this interval the physicians ordered an autoantibody screen as autoimmune disease can co-exist with sarcoidosis; the screen was negative . On examination there was no evidence of any palpable lymphadenopathy. An ultra sonographic examination six months later demonstrated a bulky uterus and reduction in the size of the right adnexal cyst. Repeat imaging  a further two months later demonstrated resolution of the left adnexal cyst. There was a small residual cyst on the right and marked decrease in the thickening of the mesorectal fascia. The lymph nodes appeared normal . The UK prevalence rate is 20 per 100 000, and the incidence increases from north to south . Both thOnly a few cases of sarcoidosis of the female genital tract have been reported, and Winslow et al  feel thiIn the reported cases to date, the age of the patients ranged between 32 years and 72 years. The gynaecological problems in these women were postmenopausal bleeding, menorrhaegia, cervical carcinoma in situ, abdominal pain and abdominal distension. Three of the seven patients had prior history of documented sarcoidosis and it was an incidental finding in the remaining cases. In our case report, the main complaint was abdominal pain with adnexal masses leading to cancer referral.Preoperatively in one case, the CT scan of the abdomen revealed enlarged lymph nodes in para aortic and mesenteric region and in the second case the mediastinal nodes were enlarged ,5 ClinicIn three reported cases, women underwent exploratory laparotomy with a provisional diagnosis of ovarian malignancy but the histological diagnosis was sarcoidosis. The CA-125 was between 248–477 IU/ml ,5,6. PosMore obscure causes of the genital tract granulomas include coccidiomycosis, lymphogranuloma inguinale, foreign body reaction and leprosy. Bacteriological proof is essential to differentiate these from sarcoidosis. These can be differentiated by appropriate history, special staining of tissues and microscopic findings. ,9There are no specific radiological findings in the literature to describe ovarian sarcoidosis. In the opinion of the radiologists, an intra abdominal (and thoracic) inflammatory process rather than malignancy was more likely to explain the findings. The striking feature on the MRI of this woman was the presence of marked thickening of fascial planes, which is not typical of ovarian cancer. The serum CA 125 level is raised in 80% of epithelial ovarian cancer. Given the normal level of CA 125 and unusual radiological findings it reassured us that this was not obviously an ovarian malignancy.Following a CT guided lymph node biopsy an empirical diagnosis of sarcoidosis was made on the basis of clinical and laboratory findings with histological support. This woman was managed conservatively, given the woman's poor anaesthetic profile. A percutaneous biopsy of the lymph node facilitated arrival at the diagnosis with minimal morbidity.et al [Although White et al  describeSubsequent clinical review and repeat imaging after steroid therapy demonstrated resolution of the left adnexal cyst. The lymph node biopsy together with follow-up imaging post treatment offered evidence to suggest that the process was likely to be sarcoidosis. Given the clinical and radiological improvement of the patient, following MDT discussion the woman was satisfactorily discharged from our care to be monitored by physicians.The case in point not only illustrates a rare manifestation of sarcoidosis affecting the ovary but also highlights the importance of managing such complex women in a MDT environment to optimise care. MDT approach can function as an ideal conduit for the management of complex patients with complex adnexal masses. The presence of an expert diagnostic radiologist in this setting is vital in determining the subsequent modality of care. Although preoperative imaging of adnexal masses is routine but where doubt exists regarding the diagnosis, a simple preoperative imaging guided biopsy of suitable tissue can help avoid major surgery and the attending risks. The resources of the MDT have ensured appropriate care and optimum outcome for this woman.We describe a case of ovarian sarcoidosis, which is a rare clinical entity. The presentation can mimic that of carcinoma. Therefore optimum management of such patients should be delivered within a MDT environment.The author(s) declare that they have no competing interests.RW and RB – Primary co-authors in producing and revising the manuscript.AR – interpreted and correlated imaging data with text narrative. Contributed to concept development and revised manuscript.AJ – Concept development and authority over final draftAll authors have read and approved the final manuscript.


Gastro Intestinal Stromal Tumors (GISTs) are rare stromal neoplasms that represent the most common mesenchymal tumor of the G.I. tract, accounting for 5% of all sarcomas ,2. OrigiWe report the case of a 62-year-old lady who had been diagnosed and being treated unsuccessfully for Irritable bowel syndrome for 11 years and eventually found to have an obstructing small bowel GIST.The symptoms from GIST may mimic those of irritable bowel syndrome. A physiological alteration in gut peristalsis resulting from neoplastic transformation of the interstitial cells of Cajal, is a hypothesis that could explain this presentation. An alternative diagnosis should be considered when treating patients with irritable bowel syndrome who fail to respond for a prolonged period. A 69 year old lady presented 11 years ago with pain of mild to moderate severity on the right side of her abdomen. This pain was intermittent, described as 'no more than a dull ache' and associated with nausea, bloating and flatulence. She also suffered from constipation and experienced partial relief of her symptoms following defeacation. She reported worsening of her symptoms after a heavy meal, and experienced occasional bouts of steatorrhea. Physical examination revealed mild right-sided abdominal tenderness only.Apart from the above she was a healthy lady without any co morbidity and no history of previous abdominal surgery. Initial investigations included an abdominal ultrasound scan (USS), a hepatobiliary iminodiacetic acid (HIDA) scan and an oesophago-gastro-duodenoscopy (OGD), which did not reveal any abnormality. Flexible sigmoidoscopy and colonoscopy were also unremarkable. Her pain was thought to be due to a slow transit colon and she was advised to take laxatives on a regular basis, which resulted in partial and temporary relief of her symptoms. Although her condition did not impact her lifestyle significantly, her symptoms never subsided completely and almost two years following initial presentation she underwent an endoscopic retrograde cholangiopancreatography (ERCP), a cream absorption test, wheat intolerance test and a CT scan of her abdomen. All of these did not reveal any abnormality and thus irritable bowel syndrome was thought to represent best her condition. She was also advised to take antispasmodics together with various combinations of laxatives and a course of Pancrelipase (Creon) tablets for presumed pancreatic insufficiency, which resulted in only temporary relief.An opinion of a gastroenterology consultant physician was sought, resulting in another abdominal USS and OGD, as well as a barium follow through study which were all normal and thus she continued to take symptomatic treatment.Finally, 11 years from presentation, the patient was admitted to hospital with acute small bowel obstruction and underwent a laparotomy within 24 hours of admission after adequate fluid and electrolyte replacement. At the operation a sizable mid-ileum, obstructing tumor was revealed, that was wedge resected with adequate gross margins followed by end to end hand sewn anastomosis. The rest of the laparotomy was unremarkable with no evidence of macroscopic spread of disease.Histopathological analysis revealed a densely crowded spindle and polygonal cell tumour showing moderate nuclear pleomorphism Figures  and 2 . The patient made an uneventful recovery and remarkably, all her previous abdominal symptoms were completely resolved. A CT scan of the chest, abdomen and pelvis performed subsequently did not reveal the presence of metastatic disease. Her case was discussed in our multidisciplinary team meeting and it was decided not to proceed with any adjuvant treatment. At one year follow up our patient was a very happy lady completely free of her abdominal symptoms.Although morphologically similar to other benign and malignant smooth muscle and neural stromal tumors, GIST constitutes a distinct group of rare gastrointestinal tract tumors that originate from the interstitial cells of Cajal . The latGISTs arise from the muscularis mucosa or muscularis propria layers and most exhibit an endophytic growth pattern, growing within the bowel lumen. The overlying mucosa is usually preserved but larger and more aggressive tumors tend to ulcerate through this. In up to one third of patients the tumor invades an adjacent organ. The vast majority of GISTs (up to 70%) arise in the stomach, with 20–30% originating in the small intestine and the remainder 10% occurring in the oesophagus, colon and rectum [The clinical presentation is variable and depends on tumor size and anatomic site. Their submucosal location can produce local obstructive symptoms, particularly when arising in the oesophagus or the small intestine. Vague upper abdominal pain, fullness, GI bleeding, palpable mass are other modes of presentation whereas sometimes they are found incidentally during barium studies, endoscopy or abdominal scans performed for other reasons . AccordiOur patient had a very long course of vague symptoms consisting of abdominal pain, nausea, bloating and constipation, which were initially attributed to impaired gut motility as part of the irritable bowel syndrome. Her symptoms, however, failed to improve sufficiently to any treatment approach.As mentioned above GIST's arise from the interstitial cells of Cajal, which play an important role in the regulation of gut peristalsis. Neoplastic transformation of these cells to a GIST could possibly result in alterations of the normal, local regulation of the gut motility. This hypothesis could, at least in part, explain our patient's symptoms especially at the initial stages of her presentation when the tumor would be too small to cause mechanical obstruction. More research into the physiology of the gut motility in relation to a GIST tumor would be needed to support or reject such a hypothesis.The occurrence of a GIST in the small bowel can present with vague symptoms, in our case symptoms thought to be from IBS for 11 years. We suggest that at least in the initial years our patients' symptoms may have been the result of functional alteration of gut peristalsis due to the increased number of CD117 positive cells in a slow growing GIST. That would suggest that GISTs can alter the motility of the G.I tract, even when the tumor is significantly small and thus difficult to detect on routine investigations. The symptoms may mimic those of irritable bowel syndrome and an alternative diagnosis should be considered when treating patients who fail to respond for a prolonged period. Resection of the tumour resulting in complete resolution of her symptoms strengthens the above suggestion. Although a diagnostic laparoscopy may not have helped detect the tumour when very small, it could have been considered at some stage during the years preceding her final presentation as acute intestinal obstruction.The author(s) declare that they have no competing interests.MSK has contributed towards conception, design, analysis and interpretation of dataVK has contributed towards conception, acquisition of data and preparation of the draft.JMT has contributed towards revising the manuscript critically and has given final approval for the version to be published.


Pectoralis major myocutaneous (PMMC) flap continues to be the workhorse in head and neck reconstruction. Although free tissue transfer has revolutionized the reconstruction in cancers of the oral region, PMMC is still considered a readily accessible source of vascularized soft tissue available to the reconstructive surgeon and especially in most developing nations where due to the cost, time, expertise, or infrastructural constraints free flaps cannot be generally offered. Although commonly used in adults, it has been hardly described for reconstruction in children.We present a 4-year-old child with recurrent fibromatosis of the oropharyngeal region where the PMMC was used for reconstruction of the surgical defect and to the best of our knowledge is the youngest patient undergoing reconstruction with PMMC for neoplastic lesion of the head and neck.The PMMC flap is justifiably a popular flap that continues to command an important place in the head and neck surgeon's reconstructive armamentarium. Initially described by Ariyan in 1979, the PMMC flap has been used to reconstruct oncologic head and neck defects after either primary extirpation or surgical salvage following radiation failure . The ver® biopsy was suggestive of fibromatosis. Computerized tomogram (CT) scan revealed a large soft tissue mass infiltrating the massetter, parotid gland, floor mouth, submandibular gland, the lateral oro-nasopharyngeal wall and the pterygoid muscle. The horizontal ramus of mandible was eroded and the mass extended across the midline. Excision of the mass with segmental mandibulectomy was performed. Reconstruction with a free fibula was deferred for a later stage in view of the young age, large mass and concern of recurrent disease. Since the mucosal defect following excision was not large enough primary closure was performed. Histopathology confirmed juvenile fibromatosis and all cut margins of resection were free of tumour. The patient presented after 13 months with recurrent swelling over the cheek with significant difficulty in swallowing and constant dribbling of saliva due to inadequate mouth closure  declare that they have no competing interests.QSS – lead pediatric oncosurgeon involved in this patient's management, research, acquisition of data, acquisition of consent, writing, drafting and critical review and revision of manuscript.QAG – involved in discussions leading to manuscript preparation and critical review of manuscriptPYS – contributed to manuscript conception, organizing manuscript, critical reviews of manuscript.All authors have read and approved the final manuscript


Non-islet cell tumor induced hypoglycemia (NICTH) is a very rare phenomenon, but even more so in gastrointestinal stromal tumors. It tends to present in large or metastatic tumors, and can appear at any time in the progression of the disease. We present herein a case of NICTH in a GIST tumor and report an exon 9 mutation associated to it.A thirty nine year-old man with a recurrent, metastatic gastrointestinal stromal tumor presented to the hospital with nausea, dizziness, loss of consciousness, and profound hypoglycemia (20 mg/dL). There was no evidence of factitious hypoglycemia. He was stabilized with a continuous glucose infusion and following selective vascular embolization, the patient underwent debulking of a multicentric 40 cm × 25 cm × 10 cm gastrointestinal stromal tumor. After resection, the patient became euglycemic and returned to his normal activities. Tumor analysis confirmed excessive production of insulin-like growth factor II m-RNA and the precursor protein, "big" insulin-like growth factor II. Mutational analysis also identified a rare, 6 bp tandem repeat insert (gcctat) at position 1530 in exon 9 of KIT.Optimal management of gastrointestinal stromal tumor-induced hypoglycemia requires a multidisciplinary approach, and surgical debulking is the treatment of choice to obtain immediate symptom relief. Imatinib or combinations of glucocorticoids and growth hormone are alternative palliative strategies for symptomatic hypoglycemia. In addition, mutations in exon 9 of the tyrosine kinase receptor KIT occur in 11–20% of GIST and are often associated with poor patient outcomes. The association of this KIT mutation with non-islet cell tumor induced hypoglycemia has yet to be established. Gastrointestinal stromal tumors (GIST) are rare mesenchymal tumors most commonly found in the stomach or small intestine of adults. Their incidence ranges from 2.1 to 15 per million people, they are evenly distributed between genders, and 90% are CD-117 positive . They usExpression of CD-117 is the diagnostic marker for GIST and is the transmembrane tyrosine kinase receptor also known as KIT or c-KIT . The ligTo follow is a unique case associating GIST-induced hypoglycemia due to overproduction of "big" insulin-like growth factor II with an exon 9 mutation.A 39 year-old man with a multifocal abdominal recurrence of a small bowel gastrointestinal stromal tumor presented to the hospital following loss of consciousness preceded by weakness, dizziness and nausea. His serum glucose was 20 mg/dL  and required a continuous infusion of high dose (10%) dextrose to maintain a serum glucose concentration above 70 mg/dL. Serologic workup demonstrated no evidence of factitious hypoglycemia and it discarded the diagnosis of islet cell-induced hypoglycemia. The insulin like growth factor (IGF) I and IGF binding protein 3 level were below the normal range, while insulin, pro-insulin, C-peptide and IGF II levels were all in the normal range  in the tumor; confirming GIST histology. Extracted DNA was amplified by polymerase chain reaction for exons 9, 11, 13 and 17 of KIT. No mutations were found in exons 11, 13 or 17; however one allele at position 1530 in exon 9 contained a 6 bp tandem repeat insert (GCCTAT). This led to a duplication of amino acid residues alanine 502 and tyrosine 503  for further analysis. The concentration of II E [68–88] ("big" IGF-II) in plasma was 51.9 ng/mL . The levels of IGF binding protein 6 (IGFBP-6) were reported to be within the normal range. In situ hybridization of the tumor samples demonstrated high expression of IGF II mRNA and elevated pro-IGF II figure .It has been found that specific KIT mutations in GIST may predict a patient's prognosis. Mutations on exon 11 are the most common (79%), while those on exon 9 are only found in about 11% of GIST. Most patients with exon 11 mutations respond to treatment with imatinib, while less than half of those with exon 9 mutations respond and are almost twice as likely to recur -18.The particular mutation we found in our patient has been reported very infrequently, and is thought to induce a ligand-independent gain-of-function with homodimerization and constitutive autophosphorylation ,20. The The incidence of NICTH is thought to be one fourth that of functional insulinomas (1 case of NICTH per million people-years) ,22. NICTHigh concentrations of pre-pro-IGF II genes that are not properly glycosylated result in the high molecular weight "big" IGF II. Compared to physiologic IGF II, it has a significantly higher affinity to the insulin receptor, and a lower affinity to its binding protein ,25. The The management of most patients with NICTH requires prompt intravenous hydration and glucose infusions. Once stable, the ideal treatment is to remove the source of hypoglycemia. In NICTH, the hypoglycemia is not due to a dysfunctional insulin receptor nor abnormal K-ATP channels, therefore diazoxide is unlikely to be effective . AttemptOur experience and review of the literature suggest that a multidisciplinary approach is helpful in the management of NICTH in GIST and that prompt surgical debulking is the treatment of choice.The author(s) declare that they have no competing interests.GAE conceived and drafted the manuscript, obtained references, participated in its design and coordination and edited the figures and legends. WAR directed and obtained the GIST mutational analysis and participated in its design and editing. TLN participated in its drafting, references, editing and design. DCH contributed to the patient's care and contributed to the conception and drafting of the manuscript. GJW Performed the GIST mutational analysis and participated in its design and coordination. LB contributed to the patient's care and coordinated communication with the University Medical Center Utrecht, Utrecht, The Netherlands for obtaining molecular analysis of IGF. RG contributed to the patient's care and participated in its editing, design and coordination. MDM contributed to the patient's care, performed surgical resection, obtained operative photos and participated in its design, editing and coordination. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


We report a new case of small bowel metastases from primary lung cancer. Such metastases are not exceptional, but their clinical manifestations are rare.The case involved a 56-year-old man with a squamous cell carcinoma of the lung (stage IV) that had been treated with chemotherapy. He presented fourteen months after diagnosis with an acute abdominal pain. Abdominal CT-scan demonstrated a perforated jejunum and he underwent emergency surgery. Postoperative pathologic analysis confirmed the diagnosis of metastatic pulmonary carcinoma. The patient was discharged after ten days, but died 8 weeks after surgery at home on tumor progression.We were able to find 58 documented similar cases in the literature. Most cases presented with bowel perforation or obstruction. Squamous cell carcinoma was the most common histological cell type followed by large cell carcinoma. Other metastases are often present, and the prognosis is mostly fatal at short term. Lung cancer is the most common cause of cancer related death in both men and women in Western countries. More than 25% of all cancer deaths are attributable to lung cancer ,2. IntraA 56-year-old man  presented in September 2002 with a five month history of cough, fever, night-sweat and a weight loss of 5 kg in 12 months. A bronchoscopy with biopsy revealed a squamous cell carcinoma of the lung. A FDG-PET/CT scanning showed a disseminated praetracheal, aortoal, supraclavicular and infracarinal lymphadenopathy and a spleen metastasis (stage IV) . The pat3).At New Year's Day 2004, the patient presented again with a three days history of increasing abdominal pain, diffuse abdominal guarding and rebound tenderness. Laboratory evaluation was without pathological findings except a marked leukocytosis  . Out of Mc Neill et al. reported in their autopsy study of 431 cases small/large bowel metastases without oesophageal/stomach metastases in 46 cases (11%) . All patIn an autopsy study of Burbige et al. 18 out of 147 (12%) patients with a diagnosis of primary carcinoma of the lung had metastatic lesions in the gastrointestinal tract [Mc Neill et al. and Antler et al. ,7 reportReviewing the literature between 1961 and 2003 we were able to document 58 clinically manifest metastasis to the small bowel ,9-37. OnOver 80% of patients with metastases to the small bowel were male, with ages ranging from 36 to 78 years with a median of 60 years.Metastases to the small bowel may present as perforation , obstruction , six (10%) patients had haemorrhage, and in one patient (2%) the small bowel metastasis was discovered in a staging CT scan.Of those patients with known location of metastasis (n = 38), 21 (55%) had jejunal metastasis, 12 (32%) ileal, three (8%) duodenal and two (5%) patient had both jejunal and ileal metastasis.In 34 patients we were able to document the histological tumor type. Squamous cell carcinoma was the most common histological cell type  followed by large cell carcinoma  and adenocarcinoma .In 7 (12%) patients the initial diagnose of lung cancer was discovered because of the abdominal symptoms, before any pulmonary disease was considered. Five out of these seven patients presented with abdominal perforation. This fact could retract the statement that particularly chemotherapy induces necrosis of the tumor cells which has replaced a portion of the small bowel wall, thus causing perforation of abdominal metastasis ,23. AccoPhillips et al.  reviewedSmall bowel metastasis typically occurs in the final states of widespread disease .Surgery in this group of patients will have a high morbidity and mortality due to cancer, age and associated medical problems . Of thosReview of the literature indicates that metastases of primary pulmonary carcinoma to small bowel occur late in the course of the disease, are more common than thought and may be associated with serious clinical complications. When symptomatic, patients usually present with a small bowel perforation, obstruction or haemorrhage. Squamous cell carcinoma and large cell carcinoma of the lung are more likely to result in gastrointestinal metastases than the other cell types.Treatment of obstructed or perforated small bowel is similar to any acute surgical abdomen: prompt exploratory laparotomy. When perforation of small bowel lesions is found, the procedure of choice is resection of the involved small intestine with primary enteroenterostomy, obstructions could be treated with bypass procedures.FDG-PET/CT:Fluorodeoxyglucose-Positron Emission Tomography/Computed TomographyCT-scan: Computed TomographyWBC: White blood cell countNo reimbursements, fees, funding or salary from an organization were received. Furthermore I have no other financial or non-finacial competing interests.


MRI showed a large, predominantly solid mass involving the cerebral parenchyma of the left temporal and parieto-occipital lobes with extension across the midline. Histologically, it was a mixture of glial and neuronal components. Architecturally, the tumor was notable for its pseudopapillary pattern with hyalinized vessels. PGNT is considered as a low grade neoplasm and surgical excision has been curative in most of the cases. More cases of PGNT need to be reported as they may add further knowledge about its biologic behavior and allow its recognition and classification.Papillary glioneuronal tumor (PGNT) is a recently described lesion of the brain, which is still not included as a separate entity in WHO classification. To date 32 cases of PGNT have been reported in the world literature. We report the 33 In the The patient was a 41-year-old male who presented with pain in the nape of the neck of one week duration in December 2005. Also there was a history of headache on and off for the past one year and vertigo for two and a half years. Magnetic resonance imaging showed a predominantly solid tumor with ill defined margins. The mass showed a heterogeneous hyper-intense signal on T2 weighted images with no obvious cystic degeneration. It was occupying the cerebral parenchyma of the left temporal and parieto-occipital regions. There was involvement of posterior part of body and splenium of the corpus callosum with extension of the lesion across midline to the right parietal region. The left side of midbrain, thalamus and basal ganglia appeared distorted along with tentorial herniation. The posterior part of the body of the left lateral ventricle was compressed and the third ventricle was displaced to the right side. The tumor was close to but did not reach the cortical surface. Calcification and perilesional edema were absent  ,4. SeizuHistologically this tumor shows a biphasic pattern in the form of pseudopapillae and solid areas. The solid areas are mainly composed of neuronal elements which may be in the form of an admixture of small, intermediate or large cells in a fine fibrillary matrix (neuropil). A detailed review of literature suggests that besides these features, degenerative changes are also common in this neoplasm Table . They maDifferential diagnostic considerations include other neoplasms that may radiologically present as cystic masses with a variably enhancing mural nodule, such as pilocytic astrocytoma and ganglioglioma. The architectural similarities have been noted between PGNT, central neurocytoma and ganglioglioma, however its geographic limitation to the cerebrum suggests a different histogenesis. Other differential diagnoses include ependymoma, extraventricular neurocytic neoplasm and dysembryoplastic neuroepithelial tumor.Treatment offered to these patients is surgical resection and, if necessary, post operative radio- or chemo-radiotherapy. Follow-up data range from 6 months  to 19 yeIn conclusion, we report a rare brain tumor, the PGNT in a 41-year-old male with bilateral involvement without any obvious cystic change. On microscopy there was extensive angiomatous change. To the best of our knowledge these changes have not been reported previously.The author(s) declare that they have no competing interests.BDR has made corrections in the manuscript and given approval for publication.YK has designed, carried out acquisition and analysis of data and drafted the manuscript.AB has given her valuable suggestions and has helped in drafting of the manuscript.SM has provided the relevant clinical information.


Solitary fibrous tumors (SFT) represent a rare entity of soft tissue tumors. Previously considered being of serosal origin and solely limited to the pleural cavity the tumor has been described in other locations, most particularly the head and neck. Extrathoracic SFT in the soft tissues of the trunk and the extremities are very rare. Nine cases of this rare tumor entity are described in the course of this article with respect to clinicopathological data, follow-up and treatment results.Data were obtained from patients' records, phone calls to the patients' general practitioners, and clinical follow-up examination, including chest X-ray, abdominal ultrasound, and MRI or computed tomography.There were 6 females and 3 males, whose age at time of diagnosis ranged from 32 to 92 years (mean: 62.2 years). The documented tumors' size was 4.5 to 10 cm (mean: 7 cm). All tumors were located in deep soft tissues, 3 of them epifascial, 2 subfascial, 4 intramuscular. Four tumors were found at the extremities, one each at the flank, in the neck, at the shoulder, in the gluteal region, and in the deep groin. Two out of 9 cases were diagnosed as atypical or malignant variant of ESFT. Complete resection was performed in all cases. Follow-up time ranged from 1 to 71 months. One of the above.mentioned patients with atypical ESFT suffered from local relapse and metastatic disease; the remaining 8 patients were free of disease.ESFT usually behave as benign soft tissue tumors, although malignant variants with more aggressive local behaviour  and metastasis may occur. The risk of local recurrence and metastasis correlates to tumor size and histological status of surgical resection margins and may reach up to 10% even in so-called "benign" tumors. Tumor specimens should be evaluated by experienced soft tissue pathologists. The treatment of choice is complete resection followed by extended follow-up surveillance. Solitary fibrous tumors (SFT) – previously known as benign fibrous mesotheliomas – were considered being of serosal origin and being exclusively located in the thoracic cavity as pleural fibrous tumors. More recently, however, SFT have been reported in many extrapleural locations such as the head and neck region; in particular, the meninges, the orbita, the nasal and oral cavity, the salivary glands, and the visceral organs, the retroperitoneum, and the pelvic space. Extrapleural solitary fibrous tumors (ESFT), especially those at the extremities, still represent a rare entity of soft tissue tumors. In a previous study extrapleural solitary fibrous tumors (ESFT) counted for 0.6% of all soft tissue tumors, sent in for analysis . In factFrom January 1999 to May 2005, nine patients were diagnosed with extrapleural SFT at our institutions. Data were obtained from patients records and phone calls to the patients and their general practitioners.Preoperative incisional biopsy specimens were obtained in 4 of 9 cases. The resection specimens were examined regarding tumor size, exact location, extension to adjacent soft tissues, and cut surface. A macroscopic photograph of cut surface was obtained in selected cases.Histopathological evaluation was performed by experienced soft tissue pathologists.The criteria for histopathological diagnosis included the widely accepted characteristic features of SFT . Light microscopical analysis was based on H&E stained slides. Immunohistochemical analysis included the following antibodies table : vimentiFollow-up data were available for all patients and consisted of clinical examination, chest X-ray, abdominal ultrasound and computed tomography or MRI of the tumor site. Follow-up time ranged from 1 to 71 months (mean: 26.5 months).The patients included 6 women and 3 men. Their age at time of diagnosis ranged from 32 to 92 years and averaged 62.2 years. Tumors were painless or became symptomatic by their mass effect, causing localized pain, or as in one patient, hypaesthesia. There were no other  symptoms. The tumors existed 5 months to 5 years before being diagnosed. All tumors were located in deep soft tissues, 3 of them epifascial, 2 subfascial, 4 intramuscular. Four tumors were located at the extremities  which should best be regarded as a "waste basket" and be considered a mere diagnosis of exclusion. The lipomatous variant of SFT ("lipomatous hemangiopericytoma") includes a mature fat component intermingling with typical areas of SFT. Rare myxoid SFT may cause considerable problems in differential diagnosis to more aggressive soft tissue neoplasms or soft tissue tumors of another differentiation. Branching and ectatic blood vessels typical for SFT known as hemangiopericytoma-like vessels may be a feature of several other predominantly malignant soft tissue tumors , implicating that a wider range of other soft tissue neoplasias has to be considered in the histopathological differential diagnosis of SFT. The so-called "patternless pattern" or the combination of different histological patterns such as storiform, fascicular, neuraltype, diffuse sclerosing, and heringbone growth pattern may lead to a wrong diagnosis . TherefoExtrathoracic solitary fibrous tumors (ESFT) by now have been reported at almost every anatomic location, but reports of tumors at the extremities or intramuscular tumors as well as tumors with malignant clinical behaviour or atypical histologic features are rare -18.Other series of ESFT's showed almost equal distribution of the incidence for male and female, with patients' ages ranging from the third to the eighth or ninth decade with a maximum in the sixth decade concurring with our data ,7,8.Some studies suggested a very low rate of recurrence and metastasis ,11,23, wVallat-Decouveleare suggested atypical histologic features, such as nuclear atypia, areas of increased cellularity, necrosis and 4 or more mitoses per 10 HPF as being predictive for clinical malignant behaviour of the tumor and found local or distant relapse in those cases in 80%, but also reported a case of clinically malignant behaviour of a histological benign appearing case. Recurrent tumor specimens showed a higher grade of atypia than the primary tumor but usually retained their immunohistochemical profile. Gold's data proposed to add the size of the primary tumor as well as the resection status to the predictive factors of clinical behaviour. Positive surgical resection margins and primary tumor sizes of more than 10 cm were positively correlated with unfavourable clinical outcome.In our series, the only patient with recurrent disease and metastasis was primarily resected incompletely, underlining this suggestion. In the recurrent tumor specimen increased atypia was seen, but if this atypia had already been present in the primary tumor and therefore could be considered as of predictive value cannot be determined. The recurrence occurred 2 years and the metastasis 2 ½ years after primary resection and following radiation. Detailed histopathological information about the primary tumor could not be obtained.Complete surgical resection is commonly accepted as treatment of choice for ESFT. Due to improved techniques in reconstructive surgery, even large lesions can usually be completely resected, preserving the limbs. Amputations should be limited to extended or recurrent tumors. Befitting the rareness of this entity reports of radiation therapy and chemotherapy of ESFT are anecdotal and so far, no significant benefit of adjuvant treatment has been reported. In some cases, especially malignant variants or incomplete resections with no further surgical option, it may although be used ,3. This According to the late recurrence or metastasis, long follow-up periods (at least 15 years) should be maintained with closer follow-up during the first two years. In cooperative patients a life long follow-up may be recommended. Follow-up should include clinical examination as well as abdominal ultrasound and chest x-ray.Soft Tissue sarcoma specimens should be evaluated by experienced soft tissue pathologists for correct diagnosis of SFT and detection of atypia. SFT with atypical histologic features, such as nuclear atypia, areas of increased cellularity, necrosis and 4 or more mitoses per 10 HPF, tumor sizes of more than 10 cm and incomplete resection are positively correlated with local recurrence and metastatic disease. Therefore complete resection at an early stage should be the main purpose of surgical treatment. Follow-up should be maintained for 10 years.The author(s) declare that they have no competing interests.AD designed the study, obtained the patients' data and drafted the manuscript.ML contributed to manuscript preparation and helped designing the studySL contributed to evaluation of the dataLS contributed to obtaining the dataHS revised the manuscript, gave substantial intellectual input concerning evaluation of the data and gave final approval of the version to be publishedTM contributed to manuscript preparation and histopathological evaluationCK participated in the study design, histopathological evaluation, and manuscript preparationAll authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here: