Hemobilia is a rare cause of upper GI bleeding and the reasons for the majority of the cases are iatrogenic. It is also one of the rarest vascular complication following laparoscopic cholecystectomy but acute pancreatitis due to postcholecystectomic hemobilia as a late complication of cholecystectomy is not yet described.We presented the case of a 32-year-old female, admitted to our emergency surgery clinic with hematemesis, jaundice and abdominal pain who had a history of laparoscopic cholecystectomy 4 months ago. Patient was diagnosed as acute pancreatitis and obstructive jaundice caused by postcholecystectomic hemobilia. Afterwards she is successfully treated by ERCP, angiographic identification and embolization of right hepatic artery pseudoaneurysm.We presented that postcholecystectomic hemobilia may cause acute pancreatitis and acute pancreatitis caused by postcholecystectomic hemobilia should also be included to the rare complications which may occur following cholecystectomy. Hemobilia is a rare cause of upper GI bleeding and the reasons for the majority of the cases are iatrogenic. It is also one of the rarest vascular complication following laparoscopic cholecystectomy but acute pancreatitis due to postcholecystectomic hemobilia as a late complication of cholecystectomy is not yet described.We report a case presented with acute pancreatitis caused by the hemobilia as a complication of cholecystectomy.A 32-year-old female presented with complaints of abdominal pain and hematemesis. History revealed that she has been suffering severe right upper quadrant pain for one year which resolved 4 months ago following elective laparoscopic cholecystectomy. Cystic artery and cystic duct was explored during operation and cholecystectomy was completed without any difficulty. Her physical examination revealed jaundice, abdominal tenderness, and melena. Her heart rate was 98/min., blood pressure 100/60 mm/hg and body temperature 36.7 C. Her abnormal blood analysis results were as following; hemoglobin: 6.4 g/dl, hematocrite: 21%, MCV: 70 fl, AST: 435 IU/L, ALT: 220 IU/L, GGT: 256 IU/L, LDH: 400 IU/L, amylase: 2046 IU/L, lipase: 7339 IU/L, total bilirubine: 8.0 mg/dl and direct bilirubine: 6.2 mg/dl.Nasogastric intubation and irrigation confirmed the presence of upper GI bleeding. Ten hours after admission source of the bleeding was identified as duodenal papilla by the emergency upper GI endoscopy where esophagus, stomach and bulbus were found to be normal (Figure Abdominal ultrasonography did not demonstrate any pathological finding except confirming that patient was cholecystectomised. Abdominal computerized tomography demonstrated a dimensions were 2 × 1.8 cm at portal hilus and it was connected to the right portal vein with a fenestration in diameter of 5 mm. (Figure th hour after the admission. Ongoing blood leak through papilla was visualized. Contrast serial graphies after canulation of the papilla revealed a dilated common bile duct with a diameter of 18 mm and mobile filling defects with labile shapes suggesting a thrombus. We supposed that the dilatation in the common bile duct was a chronic process. A sphincterotomy, 10 mm in length was made. Thrombus was removed with balloon catheter. The amount of ongoing hemorrhage after ERCP was not much to cause an alarm, patient was rapidly referred to angiography unit for further diagnose and treatment.ERCP was performed with the diagnose of acute pancreatitis caused by hemobilia at the 16Selective angiography revealed a pseudoaneurysm of right hepatic artery connected to remaining cystic duct and angioembolization was made during the same intervention (Figure After ERCP and angioembolization, patient's abnormal amylase, lipase and liver function test results begun to decrease rapidly to the normal values. No additional blood transfusion was required. Oral feeding was allowed on the second day and the patient was discharged on the fourth day of the intervention.The term hemobilia was first used by Sandblom to describe bleeding into the biliary system after a subcapsular liver injury but this therm now covers all reasons which causes bleeding in to the biliary three . It is aClinical presentation of hemobilia can be variable and intermittent . HemobilFor the diagnosis and evaluation of hemobilia sonography and computed tomography are helpful in assessing the possibility of tumor or stone disease .Magnetic resonance imaging can distinguish blood from stones and sludge and may be helpful when the diagnosis is uncertain . The diaHemobilia from a hepatic artery source frequently requires transcatheter embolization via a right femoral artery approach or even hepatic artery ligation, which can result in liver failure in patients with underlying hepatic insufficiency . AngiogrVascular injuries during laparoscopic cholecystectomy may occur in 0.2%-0.5% cases and these injuries are also reported that they may cause hemobilia with pseudoaneurysmatic dilatation . PostchoPostcholecystectomic hemobilia usually occurs 4 weeks after operation . In caseHemobilia after cholecystectomy and acute pancreatitis after hemobilia which resulted from liver trauma are previously and separately described conditions in the literature. But hemobilia rising from a pseudoaneurysm after cholecystectomy and causing acute pancreatitis was not yet described. Our patient had a hemobilia which caused obstructive jaundice and acute pancreatitis 4 months after cholecystectomy.We treated her as it is suggested in the literature with ERCP and angiographical embolization having a successful outcome. The special point which we would like to underline is that we defined a new late complication of cholecystectomy; postcholecystectomic pseudoaneurysmatic hemobilia causing acute pancreatitis.The authors declare that they have no competing interests.EA, HA and MAB undertook the management of our patient from the time of his initial presentation to ERCP and follow up examination. OZO and ANT performed the endoscopy, KD and EA performed the ERCP. AU and EI achieved the angiography and CT. All authors read and approved the final manuscript.Written informed consent was obtained from our patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/10/75/prepub


Pheochromocytoma is a rare tumor, accounting for <0.1% of the hypertensive population. Extra-adrenal pheochromocytomas (EAPs) are rarer still, accounting for 10% of all pheochromocytomas. Pheochromocytomas are functional catecholamine-secreting tumors of the paraganglionic chromaffin cells found in the adrenal medulla and the extra-adrenal paraganglia cells. EAPs are readily detected by computed tomography (CT) as soft tissue masses closely associated with the entire length of the abdominal aorta. Here, we present a rare case of EAP in a 45-year-old male hypertensive patient diagnosed by CT-guided fine needle aspiration cytology. The smears showed loosely cohesive tumor cells with prominent anisokaryosis and abundant eosinophilic, granular cytoplasm. The diagnosis was later confirmed by histopathology. The present case also highlights the fact that fine needle aspiration of pheochromocytoma is not necessarily contraindicated. Extra-adrenal pheochromocytomas (EAPs) are uncommon neuroendocrine cell neoplasms arising from the paraganglia, which are widely dispersed throughout the body in small nests, from the upper cervical region to the floor of the pelvis, adjacent to the autonomic nervous system and their ganglia.Fine needle aspiration cytology (FNAC) of EAPs has been reported to have a variety of morphologic patterns that can result in a misdiagnosis because these lesions can mimic a wide spectrum of epithelial and mesenchymal tumors.Fine needle aspiration of clinically suspected pheochromocytoma is generally regarded as a contraindication in view of the risk of precipitating a hypertensive crisis. However, this complication occurs only rarely as per the literature.A 45-year-old male presented with an asymptomatic abdominal mass since one year. The patient was a known hypertensive since six months. Both ultrasonography and computed tomography (CT) revealed a 12 cm × 10 cm retroperitoneal soft-tissue tumor situated anteromedial to the lower part of the left kidney .FNA was performed under CT guidance using a 22-gauge needle. The aspirated material was spread on glass slides. Air-dried and 95% ethyl alcohol-fixed slides were stained by may-grünwald giemsa, hematoxylin and eosin and Papanicolaou stains. The remaining material from the needle hub was fixed in 65% alcohol and sent for cell block.FNA smears showed loosely cohesive clusters and scattered tumor cells with prominent anisokaryosis, abundant eosinophilic granular cytoplasm and indistinct cell borders. Occasional binucleate cells were seen Figure  and 2b. After adequate pre-operative precautions, the patient was taken for surgery. At surgery, a retroperitoneal, solitary, well-encapsulated tumor of size 15 cm × 12 cm was seen in front of the left kidney and was encasing the left renal vessels. The left kidney and adrenals were normal. The tumor was excised completely.Histologically, it was a well-encapsulated tumor with cells arranged in a Zellballen pattern. Individual cells were large, polygonal to spindle-shaped, having abundant granular, eosinophilic cytoplasm and vesicular nuclei with prominent nucleoli. Areas of hemorrhage were noted. The histology was compatible with pheochromocytoma . PostopePheochromocytomas are uncommon neoplasms composed of chromaffin cells that synthesize and release catecholamines and, in some instances, peptide hormones. These tumors are important because they give rise to surgically correctable forms of hypertension.EAPs have been reported to occur in a wide variety of sites and generally parallel the course of the sympathetic nervous system. They occApproximately 10% of EAPs, especially retroperitoneal ones, can behave in a malignant fashion, as proven by the presence of metastatic lesions. Accurate localization in a metastatic lesion may not be as helpful diagnostically as that for a primary EAP. The common locations reported for metastases are liver, bone, lymph node and lung.[FNA has proven to be a valuable tool in the diagnosis of mass lesions. However, its use in the diagnosis of EAPs is controversial due primarily to the potential risk of hemorrhage within the lesion, which can be life-threatening. Consequently, there have been relatively few reports discussing the cytologic features of EAP. Nevertheless, when EAP is clinically unsuspected due to the lack of a typical presentation, FNA is often the modality used for the initial work-up.Although FNA cytology is helpful in the diagnosis of these tumors, there is a significant cytomorphologic overlap with other tumors. Unusual cytologic features of EAP should be kept in mind. Cells with prominent nucleoli may simulate malignant glandular cells and suggest adenocarcinoma. Dense, often eosinophilic cytoplasm may be observed in EAP, suggesting squamous differentiation. Neuroendocrine tumors tend to display prominent nuclear atypia and pleomorphism. In fact, this feature has been used as a soft criterion to distinguish paraganglioma from adenocarcinoma since adenocarcinoma rarely shows such tremendous cellular pleomorphism within the same tumor. The exact anatomic location of the tumor is crucial to an accurate cytologic diagnosis on a FNA specimen.131 - or I123 - labeled meta-iodobenzylguanidine scan is indicated in extra-adrenal tumors to rule out multicentricity and metastases.[The presence of hypertension with symptoms of adrenergic excess should alert the clinician to the tumors of adrenal medulla as well as the extra-adrenal paraganglion system. Urinary tastases.Surgery after adequate pre-operative preparation remains the treatment of choice. A life-long follow-up is indicated as the EAPs are more likely to recur and to metastasize. Annual determination of urinary catecholamines and their metabolites is recommended. Persistent hypertension after successful removal of pheochromocytoma occurs in approximately 25% of the cases.[In conclusion, the cytologic features of EAP, although suggestive, are not specific. A high index of suspicion and knowledge of clinical information, exact anatomic location and cytologic morphology combined with appropriate ancillary studies are the key to an accurate diagnosis. FNA of p


Myxofibrosarcoma is common in the extremities of elderly people and is characterized by a high frequency of local recurrence.We report a 37 year old female who presented with a 4-month history of facial pain and a 3-month history of painful progressive swelling in the preauricular area. She underwent a total parotidectomy. The tumor was histopathologically and immunohistochemically diagnosed as a low-grade myxofibrosarcoma. The patient was free of disease 9 months after surgery with uneventful post-operative clinical course.Parotid area swelling should always alert doctors. To our knowledge, this is the first case of parotid myxofibrosarcoma. It should be added to the differential diagnosis of diseases of the parotid. We have to recognize this disease and seek adequate treatment for it. Myxofibrosarcoma is a fibroblast-derived sarcoma with character of myxoid areas in association with varying proportions of cellular areas showing a pleomorphic storiform pattern. It grows commonly in the subcutaneous of the extremities of elderly people, with rare occurrences in the head and neck (2.7%) .Here we report a case of low-grade myxofibrosarcoma, arising in the parotid, and review the clinical, radiological and histopathological characteristics of this neoplasm. To our knowledge, such a presentation of parotid myxofibrosarcoma has not been reported before.A 37-year-old woman presented with a 4-month history of right facial pain and a 3-month history of progressive painful swelling beneath the right ear lobe. Examination revealed a soft swelling in the anteroinferior auricular area. The mass was smooth, elastic, mobile and painful on pressure, not fluctuant. The facial nerve function was normal. The cervical lymph node was not palpable. There were no systemic symptoms. The patient was screened for metastases, and no lung or abdomen lesion was detected. Sonography revealed solid echo in right parotid gland and cervical lymph node swelling. A contrast enhanced CT scan revealed a well defined soft tissue mass in right deep parotid lobe Figure .The standard parotidectomy was performed. A 10 mm × 10 mm superior deep lateral cervical lymph node was resected simultaneously. The rapid intraoperative pathological diagnosis showed the samples from the mass low-grade malignancy and no metastases in the lymph node. Therefore the mass was removed with surgical margin of 1 cm radius around it and preservation of the facial nerve. The surgical margin was microscopically free of tumor. A closed vacuum drainage system was used.Macroscopically, the tumor was a grayish-red collagenous mass intermingled with myxoid. Main stem of the facial nerve and the sternocleidomastoid muscle were involved Figure . The excMicroscopically, the tumor was fairly well circumscribed but not encapsulated perfectly. It consisted of hypocellular to moderately cellular myxoid or fibromyxoid areas. Curvilinear capillaries with perivascular cell condensation were found. Fusiform tumor cells vary from small and bland to enlarged, bizarre, pleomorphic and multinucleated. The cytoplasm of the cells was scant and slightly eosinophilic, and mitoses were infrequent Figure .Immunohistochemical studies showed that the tumor cells expressed strong immunoreactivity for vimentin (VIM) and alpha1-antichymotrypsin (α1-ACT). Labeling index of Ki-67 (the number of Ki67 positive tumor cells divided by the sum of Ki67 positive and negative tumor cells) was 35% Figure . Desmin Pathology revealed a T3N0M0 (AJCC 2002) parotid myxofibrosarcoma of low histological grade.The patient's post-operative clinical course was uneventful. She was discharged on the six post-operative days. The right parotid received the full dose of radiation (68.4 Gy). The patient was free of disease 8 months after surgery.Myxofibrosarcoma (MFS), one of soft tissue sarcomas with complex genomic profiles, shows gains and losses of numerous chromosomes or chromosome regions . MFS wasAccording to the study of Antonescu CR and Baren A, basing on microscopic analysis, immunohistostaining by S100 and ultrastructural analysis will help us with the differential diagnosis between myxofibrosarcoma and fibromyxoid sarcoma . UnfortuBasing on the degree of cellularity, pleomorphism of the nucleus and mitotic activity, myxofibrosarcoma has been divided into three ,8 or fouMyxofibrosarcoma is one of the commonest sarcomas of the elder's extremities. It often grows slowly and painlessly with almost equal incidence of men and women. In our case, the patient was just 37-year old, which makes it special. What's more, majority of the tumors are located in the subcutaneous tissue and form multiple gelatinous nodules, which tend to spread in a longitudinal manner. In the head and neck region, myxofibrosarcoma is uncommon. We found some case reports of myxofibrosarcoma in this region, such as in sphenoid sinus, maxillary sinus, hypopharynx, mandible and neck -18. TherParotid area swelling should always alert doctors. A unilateral swelling of the parotid implicates a possibility of a rare malignant myxofibrosarcoma. To our knowledge, this is the first case of parotid myxofibrosarcoma. It should be added to the differential diagnosis of diseases of the parotid. We have to recognize this disease and seek adequate treatment for it.The authors declare that they have no competing interests.XL, XC, YC, JHQ, LQ and ZHS were the clinicians who planned the evaluation and procedure. JY was the pathologist who evaluated the specimen. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/10/246/prepub


Adnexal torsion in advanced pregnancy is an uncommon emergency. Torsion usually occurs in ovaries with functional cysts or tumors. It is uncommon for a normal-sized ovary to undergo torsion in advanced gestation. We report torsion of a normal-sized ovary in the third trimester of pregnancy, most probably the first case report of its kind in the English-language literature.A 32-year-old Omani woman at 32-weeks gestation (gravida 2 para 1) was admitted with right iliac fossa pain, nausea and vomiting of 2 days duration, as well as a history of a similar episode one month earlier. On examination, a provisional diagnosis of appendicitis was made. Laparotomy revealed, however, that the right ovary was gangrenous and had undergone torsion.Adnexal torsion, though rare, should be kept in mind in the differential diagnosis of lower abdominal pain in advanced gestation. Although in our patient, the affected ovary could not be saved, an early diagnosis using imaging like Doppler of the adnexae will enable early intervention to save the ovaries of the patient, especially in young women. Adnexal torsion is the fifth most common gynecological emergency with a reported incidence of 2.7% . The incWe report a case of torsion of a normal ovary during the third trimester of pregnancy.A 32-year-old Omani woman at 32-weeks gestation  was admitted with a history of right iliac fossa pain, nausea and vomiting of 2 days duration. She had no fever or urinary symptoms. She reported similar symptoms had occurred one month earlier, when she had presented at a different hospital and was given analgesics which relieved her of the symptoms until the time of the present admission.3. The results of urine microscopy were normal.On examination, the patient was afebrile and her vital signs were stable. Abdominal examination revealed a gravid uterus corresponding to 32 weeks with tenderness in the right lower quadrant. There was no uterine activity. An abdominal ultrasound scan revealed the fetal parameters corresponded to gestation with normal amniotic fluid and fetal activity. The non-stress test was reactive. An adnexal mass of 3.2 × 2.5 cm was discovered with internal echoes and irregular walls. Her hemoglobin was 11 g/dl and the white cell count was 10,500/mmThe opinion of a general surgical team was sought and a provisional diagnosis of appendicitis was made. Laparotomy was conducted through a grid-iron incision. The appendix was normal in appearance. Minimal blood-stained peritoneal fluid was noted on opening the abdomen. The right ovary was gangrenous and had undergone torsion three times on its pedicle. Since there was no evidence of vascular supply on untwisting the ovary, it was unsalvageable and a salpingo-ovariectomy was performed. Histopathology confirmed a gangrenous ovary and fallopian tube.The patient experienced an uneventful postoperative period. Pregnancy continued until 39 weeks and the patient vaginally delivered a healthy baby weighing 3200 g.Adnexal torsion is rare in the second trimester of pregnancy and exceptional in the third trimester. Diagnosis is hampered by non-specific symptoms common in pregnancy. Early diagnosis is essential as it facilitates a conservative approach. When diagnosis is made early and the adnexa is hemorrhagic, simple detorsion is possible with good functional health . The useLaparoscopic management of a non-obstetric emergency in the third trimester of pregnancy has been reported to be feasible and safe by Upadhyay et al. . LaparosAn early diagnosis might have helped conserve our patient's ovary. Though rare, adnexal torsion should be considered in the differential diagnosis of acute abdominal pain in the third trimester of pregnancy.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AS was involved in the management of the case and wrote the manuscript draft. VG conducted the literature research and revised the manuscript.


Echinococcus granulosus is an endemic parasitic zoonosis characterized by worldwide distribution particularly in Mediterranean countries. The most commonly involved anatomical locations are the liver and lung. Occasionally the cyst may progressively increase in size, mimicking gross ascites or intrabdominal tumor. Herein, are reported a case of a 40-year-old patient with a giant exophytically expanded hepatic echinococcus cyst, misdiagnosed as an abdominal malignancy during formal investigation. The patient was admitted to the hospital complaining for mild diffuse abdominal tenderness, moderate abdominal pain, nausea, diarrhoea, and vomiting. A CT scan revealed the presence of a giant abdominal mass 25 × 21 × 14 cm, resembling a tumor, adherent to the liver edges and parietal peritoneum, displacing intestinal loops. During the ensuing days the patient's clinical condition worsened, and he became febrile. Exploratory laparotomy was performed, and an exophytically grown giant liver hydatid cyst was removed, despite the radiological findings and the preoperative clinical suspicion.Hydatidosis due to  Echinoccocus granulosus is an endemic parasitic zoonosis characterized by worldwide distribution with prevalence in the Middle East and the Mediterranean countries [Hydatidosis due to ountries . Liver iountries , 2. HoweA 40-year-old man was admitted to our hospital with pain in the right upper quadrant and epigastric region beginning 20 days before, after weightlifting and loss of appetite associated with nausea. The patient had no history of liver disease, jaundice, or changing in bowel habits. Fever appeared the last day before the admission probably because of partial rupture of the cyst as a result of abrupt increase in intraabdominal pressure and spillage of the content into the peritoneal cavity.other lesions were seen. Results of laboratory tests except of a mild leucocytosis otherwise were normal. Abdominal computed tomography (CT scan) revealed the presence of a 25 cm × 21 cm × 14 cm cystic mass strongly adherent to the right hepatic lobe. The cyst filled the entire right and median side of the abdominal cavity, displacing the intestinal loops to the left, and was extended down into the pelvis. The patient was taken into operation with the diagnosis of a large cystic with solid features tumoral mass  for two months. There was not recurrence of hydatid cyst at nine months follow up of the patient.Differential diagnosis of a hydatid cyst, from other abdominal cystic lesions, is sometimes difficult. The challenge in this case laid in its clinical presentation. The clinical presentation of hydatid disease is largely asymptomatic until complications occur . When syStructurally, a hydatid cyst is composed by an innermost cellular membrane, the germinal layer, or endocyst which gives rise to scolices and daughter cysts and an external acellular cuticule, the ectocyst or laminated membrane, which is secreted by the parasite. In our case the ectocyst was adherent strictly to the parietal peritoneum, and meticulous dissection was needed. Daughter cysts can often simulate the appearance of cystic tumors  and can Echinococcal cysts are mostly found in the liver (60%–70% of cases), lungs 10%–25%), and less frequently involved anatomical locations such as brain %, and le. The tre


Transitional carcinomas are extremely rare in the fallopian tube. A 41-year-old premenopausal lady presented with colicky abdominal pain and was found to have a left-sided pelvic mass on examination. In view of the elevated CA-125 and imaging findings suggestive of ovarian mass, she underwent staging laparotomy. Pathological examination confirmed a primary transitional cell carcinoma of the left fallopian tube. Review of available literature suggested that the primary transitional cell carcinoma is probably less aggressive compared to classical adenocarcinoma of the fallopian tube, and it has to be distinguished from the recently recognized entity, parafallopian tube transitional cell carcinoma. Primary fallopian tube carcinoma (PFTC), first described by Renaud in 1847, is the least common gynecological malignancy encountered in practice. Though histologically and clinically, fallopian tube carcinoma resembles epithelial ovarian cancer (EOC), transitional cell carcinoma of the fallopian tube is a very rare histological variant, with only around 20 cases having been reported worldwide so far.[1A 41-year-old lady presented with intermittent colicky lower abdominal pain of 1-month duration. Her menstrual cycles were regular, 2-3/28 days. She had two vaginal deliveries in the past. There was no history of breast or ovarian cancer in her family. Her bladder and bowel habits were normal.On examination, she was of average build with good performance status. Her vitals were stable, with no pallor, edema or lymphadenopathy. Abdominal palpation showed a supra-pubic mass of 12 cm diameter, arising from the pelvis, towards the left side. The mass was of variable consistency, with restricted mobility. On vaginal examination, a left adnexal mass of about 14 cm diameter, adherent to the uterus, was felt. However, per rectal examination did not reveal any mass in the Pouch of Douglas (POD).Patient was evaluated with routine blood investigations, tumor markers and imaging, including ultrasound and a CT scan of the abdomen and pelvis. The invThus, with a provisional diagnosis of ovarian malignancy, the patient underwent a staging laparotomy. Per-operatively she had about 750 mL of hemorrhagic ascitic fluid. There was an irregular mass arising from the left fallopian tube, of size 14 × 8 cm, with predominant solid areas along with cystic areas, protruding from the fimbrial opening, consisting of multiple thin-walled cysts of size 0.5 to 2 cm. Many of the cysts were already ruptured, and their serosanguineous contents were leaking into the peritoneal cavity. Both the ovaries, on gross examination, appeared apparently normal. No obviIntraoperative frozen section from the tumor was reported as malignant epithelial tumor. In view of this, a total abdominal hysterectomy, bilateral salpingo-oophorectomy, infra-colic omentectomy, appendicectomy, bilateral pelvic and para-aortic lymphadenectomy, along with multiple peritoneal biopsies, were performed. Final histopathologic examination showed transitional cell carcinoma of the left fallopian tube with marked desmoplastic reaction, papillary fronds and areas of necrosis and invasion of the muscular wallFigures  and 4. B2) and Carboplatin (AUC – 6). At the time of completion of treatment, her CA-125 was 13.3 IU/L. She was disease-free after 1 year and remains to be so and is on regular follow-up since then. The latest CA-125 at the time of last follow-up was normal, and a CT scan of the abdomen and pelvis showed no evidence of disease.Postoperatively she received 6 cycles of adjuvant chemotherapy with paclitaxel . About 50% to 60% of patients present with vaginal bleeding or spotting, abdominal and/or pelvic mass; and 30% to 40% of patients present with colicky or dull abdominal pain.[Between 0% and 23% of cases of PFTC may have abnormal cervical cytology suggestive of adenocarcinoma. Pap smeaet al., have reported a preoperative diagnosis rate of 2%.[The reported rate of preoperative diagnosis in fallopian tube carcinoma is low. Baekelandt te of 2%. Both theIn this case, a color Doppler was not done; but the CT scan finding of tortuous enlarged vessels, noted in the periphery of the mass with ascites, and the markedly elevated CA-125 level were strongly suggestive of malignancy.The pretreatment CA-125 level is an independent prognostic factor of disease-free survival and overall survival (OS) in patients with PFTC. CA-125 is also found to be a good marker for post-treatment follow-up, similar to ovarian carcinoma. Primary adenocarcinoma constitutes more than 90% of the malignant tumors of the fallopian tube. Other less common histological types include clear cell carcinoma, squamous cell carcinoma, endometrioid carcinoma, transitional cell carcinoma, mixed carcinoma and sarcoma. Transitional cell carcinoma of the fallopian tube is a very rare histological pattern of fallopian tube carcinoma. The morphology of transitional carcinoma is similar to that of tumors of the urothelium. There is a newly recognized entity known as parafallopian tube carcinoma, where the tumor is closely attached to the extraluminal portion of the tube. It is presumed to arise from Walthard's rest, paratubal cyst or directly from the tubal serosa. Hence itSurgery is the treatment of choice, as in cases of ovarian tumors. A staging laparotomy through a generous midline vertical incision is recommended, as in cases of ovarian cancer. Studies suggest that patients with PFTC have higher rates of retroperitoneal and distant nodal metastases than those with epithelial ovarian cancer. Hence a Patients with stage I disease without risk factors like involvement of the muscularis layer were reported to have 100% 5-year survival and need not be treated with adjuvant chemotherapy. In contrast, stage I with invasion of the muscularis layer or tumor in the fimbria and higher stages should receive adjuvant chemotherapy.8 Adjuvanet al., in a study comparing transitional cell (TC)–predominant PFTC with non–TC-predominant PFTC found that TC-predominant tumors tended to relapse later  than non–TC-predominant tumors , resulting in a significant difference in the 2-year disease-free survival rate. Hence he concluded that TC pattern and non-TC pattern are considered to be worthy of distinction in PFTC.[Uehira  in PFTC. Most of our experience regarding PFTC is either extrapolation from the more common ovarian carcinoma or from isolated case series and retrospective studies over a long period of time. It appears that it tends to present earlier than EOC and has a higher incidence of lymphatic spread, necessitating routine evaluation of lymph nodes. But our knowledge of rare histological types like transitional cell carcinoma is still limited.


Primary lymphoma of the bladder represents 0.2% of all bladder malignancies. Secondary involvement of the bladder by malignant lymphoma occurs in 10% to 50% of cases. Most lymphomas of the bladder are non-Hodgkin's lymphomas of the B-cell type, with preponderance among women. The impact of positron emission tomography (PET) on tumor staging has recently become very important due to its use in the study of diagnosis extension and individual therapy design.We report the case of a 79-year-old Caucasian man with intermittent haematuria as the presenting symptom of non-Hodgkin's lymphoma of the bladder. He was first diagnosed with primary lymphoma of the bladder using the current staging method, but a positron emission tomography study subsequently revealed that he instead had a secondary involvement of the bladder.The staging of non-Hodgkin's lymphomas, which is useful in order to plan accurate therapy, has been changing since the introduction of positron emission tomography scanning. Primary lymphomas of the bladder, although very rare, may be even more uncommon when this imaging technique is used to assess the extension of the disease. Although the interpretation of this technique has some limitations that should be taken into account, the extensive use of positron emission tomography should nonetheless help improve the diagnosis of this disease. Most tumors of the bladder are derived from the epithelium. Non-epithelial tumors are extremely rare. Among these, leiomyosarcomas are the most common in adults and rhabdomyosarcomas are the most common in children . MetastaMeanwhile, primary lymphomas of the bladder are very rare and were first described by Eve in 1885 . They reThe most frequent symptoms of bladder lymphomas are gross haematuria followed by concomitant urinary tract infection, dysuria and increased urinary frequency . Other cUsually, the diagnosis of primary lymphoma of the bladder is one of exclusion. It is made in the absence of any other nodal or extranodal involvement after biopsy with immunohistochemical study, and after a negative study of disease extension, which includes bone marrow biopsy and computed tomography (CT) . This apA 79-year-old Caucasian, Spanish man was admitted to our hospital because of intermittent painful gross haematuria lasting for seven days. He smoked 20 cigarettes per day and reported having an appendectomy 40 years prior to presentation. He had worked as a seaman in his youth and was currently retired. He took no medications.Results of his general examination were normal. His rectal examination revealed an enlarged prostate, grade I/IV, with no masses or nodules. Results of his analytical studies including serum chemistry, prostate specific antigen (PSA), and coagulation studies were normal. A mild anaemia (hemoglobin = 11.3 g/L) with a normal mean corpuscular volume was reported. His erythrocyte sedimentation rate (ESR) was 67 mm per hour. An ultrasonographic study of his abdomen had normal results, except for an irregular border of the right lateral wall of his bladder.Meanwhile, his intermittent gross haematuria continued, sometimes with associated blood clots. A cystoscopy procedure was performed and an irregular mass affecting his right antero-lateral wall was found. Biopsy revealed a diffuse, large B-cell lymphoma with the following immunohistochemical findings: CD20-, BCL6-, and DC10-positive. Meanwhile, his MIB1 had a high proliferation level. CT scans of his chest, abdomen and pelvis were performed and showed neither enlarged nodes nor liver or spleen involvement. No metastatic lesions were likewise found. His peripheral blood smear test was normal, as were his direct and indirect Coombs tests, serum protein counts, and plasma serum immunoglobulins. His β2-microglobulin was 2.79 mg/dL .Results of a whole body PET study of our patient Figures  and 2 reOur patient was started on a treatment with CNOP  and monoclonal antibodies anti-CD20. He showed good tolerance and initial response to this treatment.Our patient showed no abnormalities on the CT study. Nevertheless, significant nodal and extranodal  extension of his disease was discovered upon performing a PET study.PET with 2- [fluorine 18] fluoro-2-deoxy-D-glucose (FDG) is increasingly being used in combination with CT to evaluate thoracic and abdominopelvic malignancies . A commoA number of studies have shown FDG-PET to be useful and in fact superior to CT for primary staging and assessment of disease extension in both Hodgkin's disease and NHL. The technique is reported to have sensitivities of 82% to 99% and specificities of 99% to 100% . AlthougIn assessing a patient's response to therapy, FDG-PET at the end of treatment seems to aid considerably in differentiating between residual masses with and without residual lymphoma. Concerning treatment planning, meanwhile, in the context of a combined-modality therapy, radiotherapy for lymphomas is moving towards more conformal techniques to reduce the irradiated volume and to include only the macroscopic lymphoma. In this context, accurate imaging is essential, and FDG-PET in combination with CT scan is increasingly being used. The availability of PET and CT scanners suited for virtual simulation has aided in this process .The limitations of FDG-PET in detecting lymphomas have included variable FDG uptake in low-grade lymphomas; physiologic activity in muscles, bone marrow, bowels, and the urinary system; and FDG uptake in inflammatory or infectious processes, any of which may mask or mimic tumor signals . AnotherThis case suggests the need for extensive lymphoma staging, and especially the need for PET implementation, in order to make an accurate diagnosis of the extension of the disease and to properly design a course of treatment.The authors declare that they have no competing interests.JADP, JTR and PPF analyzed patient data on aematological disease and PET interpretation. SMC, MCGF and JPS reviewed the literature related to the clinical case. JADP, JTR and PPF were major contributors in writing the manuscript. JPS provided help in translating the manuscript into English. All authors read and approved the final manuscript.Written informed consent was obtained from our patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Paraganglioma-like dermal melanocytic tumor is a rare subtype of benign dermal melanocytic tumors. Its histopathologic features resemble those of paraganglioma, but the immunostaining characteristics are those of melanocytic lesions.We report a case of a 60-year-old male with a paraganglioma-like dermal melanocytic tumor of his left cheek and briefly review the English literature. A 60-year-old male presented with a skin-colored slightly raised soft 0.8 cm papule on his left cheek present for an unknown period of time. The clinical impression was a "skin tag". The patient's past medical history was unremarkable. An excisional biopsy of the lesion showed a well demarcated cellular nodule in the dermis Fig.  with norThe neoplasm was immunoreactive for Melan-A, MITF, and S-100 protein Fig.  indicatiThe excisional biopsy margin was clear. Clinical follow-up was planned.The term of primary paraganglioma-like dermal melanocytic tumor (PDMT) was coined by Deyrup, et al  in 2004.The purpose of this report is to familiarize clinicians and pathologists with such a rare type of benign dermal melanocytic tumor.Written consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DPS conceived, drafted and submitted the manuscript. BW reviewed the literature and prepared the photomicrographs. BT revised and proof-read the manuscript. All authors have read and approved the final manuscript.


Gnathostoma spinigerum basing on the typical morphology of its cephalic end. The patient responded completely to oral albendazole therapy.Live intraocular nematode is a rare occurrence that is mostly reported in South East Asian countries. Herewith we report such a case from Nayagarh district of Odisha. A 28 year old female presented with swelling, redness, lacrimation, pain & diminished vision of left eye since 2 1/2 years. Slit lamp examination revealed a worm piercing iris muscle. The worm was removed by paracentesis of anterior chamber and sent to the Department of Microbiology. It was identified to be  Gnathostomiasis is a rare zoonotic infection of human beings where man is the paratenic host. Human Gnathostomiasis, caused by ingestion of third stage larva (L3) of the nematode (infective form) which may be found in raw or poorly cooked meat  or in contaminated water. It can involve any organ system but the most common manifestation of infection is localized, intermittent, migratory swelling in the skin and subcutaneous tissue. As human is not a suitable host for the parasite, ingestion of infected fish causes migration of the infective form from stomach via intestine to dermal, subcutaneous tissue and often associated with localized pain, pruritus and erythema. Ocular involvement may occur years after initial infection. A total of 12 cases of intraocular gnathostomiasis have been reported in literature until1994 [A 28 year old female belonging to a slum area of Nayagarh district of Odisha, came to ophthalmology outpatient department with chief complain of swelling, redness, lacrimation, pain and diminished vision of left eye since 2 1/2 years. The symptoms were insidious in onset and progressive in nature. The patient was a house-wife, non-vegetarian, and had no pet animals. On general examination there was no oedema, pallor, organomegally and lymphadenopathy. Examination of the left eye revealed congestion, redness, lacrimation, & swelling but the right eye was normal. Slit lamp examination of the left eye revealed a live worm piercing the iris muscle whose movement was recorded in video. The conjunctival fornices and the cornea were normal. Ocular movement and fundoscopy of both the eye were normal. The worm was removed by paracentesis of anterior chamber and sent in normal saline to the department of Microbiology.Under low & high power magnification morphology of the parasite was studied. The worm was found to be approximately 1.5 to 2.0 cm in length, having a typical head bulb with five circumferential rows of hooklets and fine cuticular spine on body surface Figure .Gnathostoma spinigerum. The patient was treated with oral albendazole 400 mg daily for 21 days along with tapering dose of oral corticosteroids and responded completely.Routine examination of the blood revealed normal laboratory parameters except slightly raised eosinophil count (6%). Both thick & thin peripheral blood smear were negative for Microfilaria, Loa-loa, Ascaris, Dirofilaria, Onchocerca etc. No ova, cyst or egg were found in the stool microscopy for three consecutive days. A pair of salivary gland and esophagus was distinctively visible. Basing on the above findings the worm was diagnosed to be a male larva (L3) of Gnathostoma larva into the eye is not clearly known.Live intraocular nematode is a rare occurrence and mostly reported from Southeast Asian countries, particularly Thailand & Japan . The firGnathostomes is one of the causes of larva migrans and may produce fatal eosinophilic myeloencephalitis [phalitis . If the phalitis .CNS: ; L3: (third stage of larva).Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of the journal.The authors declare that they have no competing interests.ST participated in preparation of the manuscript and review of the patients' medical records. NC conducted the literature review and participated in preparation of the manuscript. BDR participated in preparation of the manuscript. All authors read and approved the final manuscript.


Hemolymphangioma of the pancreas is a very rare benign tumor. There were only six reports of this disease until December 2008. Herein, we report a case of giant hemolymphangioma of the pancreas in a 20-year-old girl.We describe a 20-year-old girl who presented with a mass in abdominal cavity and epigastric discomfort about a week. Physical examination showed a great abdominal mass. Abdominal computed tomography showed extrinsic duodenal compression due to a large retroperitoneal tumor possibly arising from pancreas. The tumor enucleation was performed and a diagnosis of hemolymphangioma of the pancreas was made. The patient had a complication of chylous leakage, which was successfully managed. The patient is alive and well, after 26 months of follow-up, with no complaints or recurrence.From this case and literature, we can conclude that hemolymphangioma of the pancreas in adult is a rare benign tumor, and accurate diagnosis can not be preoperatively established. Tumor resection should be performed whenever possible. The risk of recurrence seems very low. Hemolymphangioma of the pancreas is a rare disease and basically benign cystic tumor. There were only six reports of this tumor of the pancreas until December 2008 (PubMed) -6. CystiThe patient was a 20-year-old girl who complained of a mass in abdominal cavity and epigastric discomfort about a week. She was a college student. On admission she was well, not vomit, stomachache and icteric. Physical examination showed a large abdominal mass. Abdominal computed tomography showed extrinsic duodenal compression due to a large retroperitoneal tumor possibly arising from pancreas, which had polycystic structure and partial blood flow Figure . No abnoMacroscopically, the mass measured 18 × 16 × 12.5 cm. It was nodular, and soft in consistency. The tumors were multiloculated cystic masses full of bloody fluid. Microscopically till December 2008 (Pubmed), we found only 6 case reports -6. TheirHemolymphangioma of pancreas are usually large lesions with a diameter of larger than 10 cm, and the commonest site is the head of pancreas. Generally, they are large masses with thin wall having multiple thin septa with varying size cystic cavities containing fluid similar to hemorrhagic and rarely of clear lymphatic nature. Microscopically, the tumor consists of abnormal lymphatic and blood vessels with polycystic spaces. These cysts have connective septa covered by endothelium.This tumor may be asymptomatic for a long time. Abdominal pain and awareness of abdominal mass are the most common symptoms. Other infrequent symptoms such as vomiting and nausea are caused by occupied tumor. This tumor is commonly a benign disease and has no invasion ability. But in the 6th case reported by a Japanese group[The clinical diagnosis of hemolymphangioma of pancreas is not often due to its rarity and the absence of clinical expression. Laboratory tests are frequently normal although the case reported by Banchini  had a slSurgery including local resection of this tumor is a definitive modality. Two operative attitudes are possible: the tumoral enucleation and the partial pancreatectomies. Hemolymphangioma of the pancreas is commonly a benign disease and has no invasion ability. Local resection is necessary. But in the Japanese case, pancreatoduodenectomy was performed because the tumor invaded to the duodenum to cause the duodenal bleeding. In addition, pancreatoduodenoctomy is performed for suspicion of malignancy. All cases in the literature had good prognosis as did our case. The risk of recurrence or metastasis seems very low, but careful follow-up is necessary.Herein, we reported a case of hemolymphangioma of the pancreas head with a large size in a 20-year-old girl. The wide infiltration and adherence of adjacent organs and tissues was an important feature of the present case.From this case and literature, we can conclude that hemolymphangioma of the pancreas in adult is a rare benign tumor, and accurate diagnosis can not be preoperatively established. Tumor resection should be performed whenever possible. The risk of recurrence seems very low. Despite its low frequency, this disease should be considered when a multiloculated cystic masses in abdominal cavity is seen.Written consent was obtained from the patient or their relative for publication of study.The authors declare that they have no competing interests.LFS and HLY designed the study, performed picture acquisition and drafted part of the manuscript. PLQ and KFD performed the surgery, carried out data acquisition and drafted part of the manuscript. All authors participated in the editing and have read and approved the final manuscript.


The case of adenocarcinoma with human chorionic gonadtropin (HCG), primary in the male gallbladder, is extremely rare. A Medline search has shown only a few similar cases reported.We herein describe a case of primary gallbladder adenocarcinoma associated by ectopic HCG positive tumor cells in a 79-year-old male.Pathological examination showed a mixture of moderately and poorly differentiated adenocarcinoma with ectopic HCG and placental alkaline phosphatase (PlAP) in tumor cells, though the increase of serum or urinary HCG secretion was not confirmed. The literatures were also reviewed.A case of gallbladder cancer with ectopic HCG production is quite rare in the literature, though many similar cases in other site, especially in GI tract, are reported. Embryological consideration suggests the increased frequency of similar cases more than being thought now. In gallbladder, human chorionic gonadotropin (HCG) related carcinoma is exceedingly rare in the literature. One case of adenocarcinoma with choriocarcinomatous element though negative by immunostain , two adeHere we report a case of adenocarcinoma with ectopic HCG of the gallbladder. The literatures are also reviewed.A 79-y-old Japanese male was admitted to the Samukawa Hospital  because of jaundice in June 2009. Computer tomography (CT) scan and magnetic resonance imaging (MRI) of the abdominal organs showed a mass lesion in the gallbladder, and the obstructive jaundice due to malignancy was suspected. He had no significant past history. Then he was admitted to the Tokai University Oiso Hospital  for further examination and surgical treatment. After the additional examinations, clinical diagnosis of gallbladder cancer was made and cholecystectomy was performed at July 7, 2009. No tumorous lesion, suggestive of primary site, was identified in other organ including testis, mediastinum or gastrointestinal tract by CT scan, MRI or other examination.For light microscopy, the specimen was fixed in 10% buffered formalin, and 4 mm-thick tissue slices were embedded in paraffin. Paraffin sections were stained with HE. Immunohistochemical detection of various markers in tumor was performed by the indirect immunoperoxidase method using antibodies ; Dako, placental alkaline phosphatase (PlAP); Dako, chromogranin-A (CGA); Dako, CD56; Leika, Insulin; Dako, Glucagon; Dako, Gastrin; Dako, Prolactin; Dako, alfa-fetoprotein(AFP); Dako, Japan) ,28.Pathological examination of the resected gallbladder revealed a large, ulcerative tumor mass measuring 4.5 cm × 3.5 × 2.5 cm occupying more than two thirds of the gallbladder wall with necrosis Fig. . MicroscImmunohistochemistry revealed positive staining for cytokeratin AE1/AE3 in all tumor cells, HCG and βHCG in the highly atypical tumor cells of poorly differentiated adenocarcinoma Fig. . Other aLater than one month after the operation, serum HCG titer was measured for the first time and was normal, less than 1 mU/ml. Because of an old male patient with gallbladder tumor, preoperative evaluation of HCG was not performed.Postoperative chemotheraty with anti-metabolic drug, Gemcitabine hydrochloride, was done and no apparent clinical evidence of recurrence has been obtained yet, more than 11 months after the operation.Although quite rare, some cases of gallbladder carcinoma with HCG have been described in the literatures Table . The hisMany cases of non-gestational choriocarcinoma have been reported in gastrointestinal tract or other organs -18, thouAbu-Farsakh and Fraire represented a second case of coexisting adenocarcinoma and choriocarcinoma of the gallbladder . This maFukuda and Ohnishi reported a case of gallbladder adenosquamous cell carcinoma with immunostain positive HCG accompanied by the remarkably increased serum and urinary HCG . The priAs in these cases of gallbladder carcinoma, most of the reported cases of non-gestational choriocarcinoma in GI tract or other sites also revealed a coexistent adenocarcinoma component -17. The Gastrointestinal tract tumors with ectopic production of HCG have been reported by many authors -26. FukaIn our case, although neither apparent increase of serum or urinary HCG nor histologically typical choriocarcinoma element was confirmed, immunoreactive βHCG in adenocarcinoma cells was clearly identified especially in rather poorly differentiated lesion. These findings are consistent with the category, "adenocarcinoma with ectopic production of HCG" and the origin of HCG positive tumor cells in our case might represent a metaplastic differentiation or dedifferentiation.Guo and coworkers described 21 cases of undifferentiated carcinoma of the gallbladder and βHCG positive tumor cells were observed in 9 cases, though serum or urinary level of βHCG was not described . Cases wOnly one case of ETT in the gallbladder with markedly elevated HCG levels in urine and serum was reported in the literature . ETT is As previously mentioned, the gastrointestinal tract tumors with ectopic production of HCG have been reported by many authors -26 and gA case of gallbladder cancer with ectopic HCG production is quite rare in the literature, though many similar cases in other site, especially in GI tract, are reported. Embryological consideration suggests the increased frequency of similar cases more than being thought now.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SS drafted the manuscript and described the pathology component and took photographs, participated in writing the discussion, coordinated and edited the manuscript. MI edited the clinical part of the manuscript. MI, TF, EI and YO provided the clinical data and edited the clinical case presentation. SS reviewed the entire manuscript, participated in writing the discussion and the pathology component and edited the manuscript. All authors read and approved the final manuscript.


Metastatic disease to the gallbladder is unusual. The most common malignancy metastatic to the gallbladder is melanoma, followed by renal cell carcinoma (RCC) and breast cancer. Due to the unusual nature of the disease, there are no trials available for review. Thus, the management for these patients has been based on institutional experience and review of case series. The indications for surgical intervention for melanoma are metastatic disease discrete to the gallbladder and biliary symptoms, which are uncommon for melanoma, but might occur due to cystic duct obstruction culminating in cholecystitis. Laparoscopic cholecystectomy without a lymphadenectomy is emerging as the preferred approach for this metastatic deposit. The vast majority of patients with metastases to the gallbladder from RCC carry a good prognosis and a laparoscopic cholecystectomy should be considered. Patients with metastases to the gallbladder from the breast classically present with biliary symptoms and commonly undergo a laparoscopic cholecystectomy, which invariably demonstrates a deposit in the gallbladder from lobular breast cancer. In the present report, we review the indications for surgical intervention from various malignancies metastatic to the gallbladder and the current consensus for the laparoscopic approach from the diverse metastatic deposits to the gallbladder. An autopsy analysis of 1,000 consecutive cases of malignancies revealed an incidence of metastasis to the gallbladder of 5.8% [In a Korean report, 20 cases of metastasis to the gallbladder were discussed [In our review of the literature, because the typical course of metastasis to the gallbladder is via hematogenous spread , the mosIn the present review, we discuss whether surgical intervention has the same recommendations for a metastatic deposit from melanoma compared to breast cancer. We also interrogate the role of laparoscopic cholecystectomy in such approach. A discussion of a case in our own experience is a pertinent good start.A 53 year-old man referred to the surgical oncology clinic after an episode of abdominal pain that revealed an isolated right liver lobe mass Figure , which sHe had a good response to these modalities to the point of complete regression of the liver and lung lesions as assessed by Positron Emission Tomography (PET) scan. During the same examination, a new gallbladder lesion that had high uptake was identified Figure ; panel BThe aggressive nature of melanoma and the potential to metastasize to any organ in the body is demonstrated in a review of the literature reported by Dong , which cWhile primary melanoma to the gallbladder is possible due to the presence of melanocyte migration during development, the need to differentiate primary and metastatic melanoma to the gallbladder (MMGB), is the center of current debate ,7 and isIn the majority of cases, an asymptomatic presentation is the rule for MMGB. However, when symptoms occur, it is the result of cystic duct obstruction leading to cholecystitis . The vasThe largest case series available today originates from the Duke University Medical Center, which documented 19 cases of MMGB in 1999 . The maiWhile survival is important in the management of patients with metastatic disease to the gallbladder, the indications for surgical intervention in this group of patients remain unclear. A group from the Sloan Kettering Cancer Center reported their experience with 13 cases of metastatic melanoma to the gallbladder in 2007 . The goaIn a report of a 58 year-old man with MMGB who presented with acute cholecystitis, the authors' review of the literature indicated that while symptoms are uncommon, when present, acute cholecystitis is most likely clinical presentation, followed by biliary obstruction leading to cholangitis. Fistula formation and hematobilia might also occur , similarIn one case, a 63 year-old woman underwent an oncologic operation for gallbladder cancer and during pathological examination she had metastatic melanoma to the gallbladder . This paIn a separate report, twenty-one months following resection of a melanoma of an upper arm, a 30 year-old woman develop MMGB . This paA 32 year-old woman had a melanoma excised from her shoulder and a year later she began having symptoms of biliary colic. She underwent an open cholecystectomy and pathological examination demonstrated metastatic melanoma. She later developed brain metastases and died from wide spread disease four months following this event . In theiLaparoscopic cholecystectomy (LC) has been described for the management of these lesions. The first report of LC for MMGB was described by Velez during an incidental finding in 1995 . Since tIn one case, a 54 year-old man with MMGB was treated by LC. The authors concluded that LC was a feasible approach when the disease was limited to the gallbladder, but indicated that an exploratory laparotomy might detect other sites of metastasis by palpable inspection not captured by pre-operative imaging modalities . The queIn another case, a 48 year-old man with a melanoma of his flank and axillary metastasis, developed colicky pain, two years after the resection. Diagnostic tests revealed a polypoid lesion and a LC was undertaken. Examination of the GB revealed MM. In their review, the authors indicated that only 60 cases of MM had been reported in the world literature and 81% of patients had symptoms leading to a cholecystectomy . Their aIn a report of a 37 year-old woman with metastatic melanoma to the gallbladder who presented with acute cholecystitis, the authors treated this patient via a LC and lymphadenectomy of the hepatoduodenal ligament . In theiThe short spectrum of clinical presentation was documented in two cases of MMGB . In one In a case of MMGB and metastatic melanoma to the small bowel with an unknown primary, a 58 year-old man presented with abdominal pain and vomiting culminating in a small bowel obstruction . This paThus, for MMGB the clear indications for surgical intervention are disease limited to the gallbladder and biliary symptoms. Other indications need to be considered in a case-to-case basis. While, there are not sufficient cases to comment on the feasibility of performing these cases laparoscopically, several reports have undertaken this approach and with the increasing role of laparoscopic surgery, it is likely that most of these cases are going to be attempted via a laparoscopic approach.The second most common malignancy to metastasize to the gallbladder is renal cell carcinoma (RCC). The largest reported series was documented in 2006 and consisted of 24 non- consecutive cases. In this series, the average age of the patients was 64.5 ± 2.4 year-old and 87.5% were men. 58.3% of the lesions were metachronous deposits presenting with an average of 9.1 ± 1.8 years after the primary diagnosis of RCC. Fifty percent of patients were alive and 37.5% had no evidence of disease at the time of the report with the longest follow up of 6 years [A second large series was reported in 2008 and included 13 cases . In thisSince this series, several case reports have been documented. In one case a 64 year-old woman presented with biliary colic and underwent a successful LC. Pathological examination revealed a metachronous RCC lesion with a median interval of seven years . This maAn earlier and smaller series from Korea reported eight cases of metachronous lesions to the gallbladder from RCC. In this series, the median age was 60.6 ± 5.5, only two patients underwent a laparoscopic cholecystectomy, two were treated via an open cholecystectomy and the rest via a laparotomy .The body of evidence from these series and case reports of RCC metastatic to the gallbladder indicate that the metastatic lesions are typically metachronous. Patient with these lesions carry a good prognosis and a LC is an adequate form of treatment.Even in comparison with the rarity of metastatic lesions to the gallbladder from melanoma and renal cell cancer, breast cancer metastatic to the gallbladder is even more unusual. Autopsy studies indicate that the gallbladder is affected with a frequency of 4-7% . Only a Because, breast cancer is the most common cancer in women, all the gallbladder metastases have been reported uniquely in this cohort. Compared to ductal carcinoma of the breast, lobular breast cancer is more likely to metastasize to the gastrointestinal tract . Thus, tWhile the most common type of cancer to metastasize to the gallbladder is lobular, followed by ductal, a 62 year-old woman with a history of ductal papillary breast cancer was treated via a LC for symptomatic cholelithiasis . PatholoThe first case series of MBGB was publish in 2006 and included only four reported cases at the time . In thisHowever, unusual presentations were common. Two cases of metastatic breast cancer: one to the ileum and one of the gallbladder presented symptomatically, which lead to diagnostic imaging and the unveiling of the diagnosis of MBGB . An 84 yIn our review, lobular carcinoma is the most common type of breast cancer with metastasis to the gallbladder. Most patients in this group present with symptoms and because they were all women, a diagnosis consistent with biliary colic was entertained and a cholecystectomy performed. Most patients in this cohort had a relatively good prognosis in spite of metastatic dissemination. While there are no studies comparing the laparoscopic to open approach, a substantial number of these cases were performed laparoscopically such that it is possible to proceed with such approach in a case-to-case basis.In a Korean review of metastatic lesions to the gallbladder, the most common site of origin for the primary cancer originated from the gastrointestinal tract with the stomach (n = 8) and colon (n = 3) as the most common sites. The authors presented two lesions metastatis to the GB from the HCC, RCC, and melanoma as well as one from the extra hepatic bile ducts, uterus, and appendix. The vast majority of these cases were metachronous lesions and symptomatic. The authors concluded that a complete resection of gross disease was associated with the best chance of survival in this cohort of patients . HoweverA report of a 60 year-old woman with symptomatic cholelithiasis who underwent a laparoscopic cholecystectomy was previously reported. Pathological examination of the gallbladder and oncologic diagnostic workup demonstrated synchronous metastatic gallbladder cancer form a cervical primary site. She succumbed to the progressive nature of this disease 16 months after the diagnosis .A case of an 83 year-old men with locally advanced adenocarcinoma of the rectum underwent perianal resection following neoadjuvant chemoradiation. Because of symptomatic cholelithiasis, he had a concomitant LC. Pathological examination of the gallbladder demonstrated metastatic rectal adenocarcinoma, which in 2008 was the first described such case and no other such cases were found in our review .A 45-year old man developed symptomatic cholecystitis form a metastatic lesion with histological origin of non-small lung cancer . In a seMetastatic melanoma is the most commonly found deposit in the gallbladder. Clear indications for surgical intervention are disease limited to the gallbladder and symptomatic disease for palliation. Laparoscopic cholecystectomy without a lymphadenectomy appears to be the most consensus agreement in the literature. Other cases for metastatic melanoma to the gallbladder must be addressed in a case-to-case basis. RCC metastatic to the gallbladder appears to have a good prognosis for cure and most of these cases necessitate a cholecystectomy, which might be approached laparoscopically. Patients with metastatic breast cancer to the gallbladder are women who typically present with symptoms and a history of lobular breast cancer. Because of symptomatic disease, a cholecystectomy is invariably the rule and this can be approached laparoscopically. Metastatic disease from other malignancies should be addressed in a case-to-case basis.The authors declare that they have no competing interests.ZK conceived the study, performed chart review, literature search and drafted the manuscript. JH helped with chart review and revision of the manuscript. PK provided pathology images. SH made revisions to manuscript and participated in study design and coordination. All authors read and approved the final manuscript.Consent for patient in the case report was obtained from the family of the deceased.


Neurogenic tumors of the larynx are extremely rare. The goal of this report is to advert to this rare disease, to review and discuss diagnostics, differential diagnoses and treatment options. Study Design: Retrospective case report and review of the literature. Methods: Case report of a schwannoma of the supraglottic larynx and review of the English- and German-language literature regarding neurogenic tumors of the larynx. Results: Neurogenic laryngeal tumors typically involve the supraglottic larynx, rarely the glottis. They can course globus sensation, dysphagia, dysphonia and upper airway obstruction. Imaging does not yield a definite diagnosis. The only curative treatment option is complete surgical resection. Conclusions: A definite diagnosis can only be made histologically. Endoscopic (laser-) resection for smaller lesions and external approaches for larger lesions are recommended treatment options. About 45% of all neurogenic tumors occur in the head and neck region and are mostly located in the parapharyngeal space ,2. Two tThe location of Schwannoma or neurofibroma within the larynx is very uncommon. They represent 0.1% to 1.5% of all benign laryngeal tumors, schwannoma being slightly more frequent than neurofibroma . 80% areA 44-year-old woman was referred by her ENT physician for clinical diagnosis and treatment of a mass discernable endoscopically under the intact mucosa of her left false vocal cord. She had a 2- to 3-year history of hoarseness and dyspnoea on exertion with no complaint of dysphagia. She had a 15 pack-year smoking history. Further medical history was unremarkable, physical examination was normal.Fiberoptic laryngoscopy revealed a large submucosal mass within the left false vocal cord obstructing the view of the hypo-mobile true vocal cord Fig. . The mobComputed tomography (CT) demonstrated a 22 × 23 × 28 mm well defined, round to oval, mass in the left supraglottic larynx growing under intact mucosa. Compared to muscle it was hypodense, slightly inhomogeneous with a clear capsule and no sign of infiltrative growth or cartilaginous destruction  of the lesion revealed it to be isodense compared to muscle in T1-weighted images with strong, inhomogeneous enhancement of Gadolinium. In T2, the lesion was hyperintense and also inhomogeneous. The lesion was well defined with no sign of infiltrative growth Fig. .Suspension microlaryngoscopy was performed under general anaesthesia, with trans-oral laser assisted incision biopsy. The supraglottic findings were consistent with the fiberoptic examination. The glottis and subglottis were normal. In frozen sections, the diagnosis was: benign mesenchymal tumor, probably schwannoma. To obtain a definite diagnosis, the tumor was resected as far as possible through the incision in the false vocal cord and sent for histopathological evaluation. The patient was extubated primarily and recovered well.Meanwhile, MRI scanning of the neurocranium, cerebellopontine angle and spine yielded normal findings without signs of further nerve sheath tumors or Neurofibromas.Definite histopathological evaluation confirmed the diagnosis of laryngeal schwannoma with low proliferative activity Fig. .2 laser excision of the tumor. After surgery, the patient was extubated primarily and recovered well. She was discharged on postoperative day three. Histopathological evaluation confirmed the diagnosis of a relapse of the schwannoma that was resected three months earlier. The proliferative activity was still low with no sign of malignancy.Three months after initial surgery, the patient was re-admitted for persisting hoarseness, dyspnoea and sore throat. She still had no complaint of dysphagia. Fiberoptic laryngoscopy again showed fullness of the left false vocal cord with partial obstruction of the supraglottic airway. The left true vocal cord was immobile. CT scan demonstrated a 20 × 20 × 25 mm relapse of the well-defined, slightly inhomogeneous tumor in the left supraglottic larynx extending to the infraglottic space. The patient was taken back to the operative theatre for COThe final examination three months after the second surgery revealed no sign of recurrence of the tumor Fig. , the patTwo different types of neurogenic tumors of the larynx have been described: Schwannomas and neurofibromas. Both entities are rare and comprise only about 0.1% to 1.5% of all benign laryngeal tumors . NeurofiThe clinical symptoms of the disease are those usually associated with a slow growing lesion of the larynx: Over a period of years the patient gradually develops hoarseness, globus sensation, dysphagia, dyspnoea on exertion with inspiratory, sometimes biphasic stridor ,6. Some The true vocal cord on the affected side is usually immobile or hypomobile ,11,12, aThe diagnostic workup should include indirect and fiberoptic laryngoscopy which usually reveals a submucosal mass in the described location. Such a lesion coupled with impaired vocal cord mobility should draw attention towards a neurogenic tumor.In CT scans of the disease, most authors describe a well defined, hypodense submucosal mass without signs of infiltrative or destructive growth ,16-19. MOn MRI scanning, the lesion is expected isointense to slightly hyperintense in T1-weighted images with strong, inhomogeneous enhancement of Gadolinium, in T2 the lesion is hyperintense ,17,18,21The differential diagnoses of neurogenic tumors of the larynx include chondroma and adenoma . Also laA definite diagnosis can only be made histologically. Schwannomas almost exclusively are comprised of spindle cells with long, oval nuclei and indistinct cell membranes. These Schwann cells either form cellular regions with compact cell bundles with nuclei lining up in palisades (Antoni A regions) or edematous regions with loosely arranged cells in a myxoid matrix prone to degeneration (Antoni B regions) ,6. Two cNeurofibromas like Schwannomas exhibit an abnormal proliferation of Schwann cells. However, while Schwannomas emanate from Schwann cells, neurofibromas emanate from perineural fibrocytes. They are not encapsulated and comprise a variety of cell types: elongated spindled Schwann cells interwoven with axons and collagen fibers ,6,22. ThThe surgical separation of the tumor from the nerve is theoretically possible in Schwannoma, whilst in neurofibroma it is impossible .The only effective therapeutic option in benign neurogenic laryngeal tumors is complete resection. Since the diagnosis can only be made histologically, direct laryngoscopy with biopsy of the lesion will usually be the first step in treatment ,13,18,23In some cases including ours, rapid regrowth after incomplete resection of laryngeal schwannomas has been described .At least one case has been reported where histologically verified laryngeal schwannoma revealed an unknown Neurofibromatosis type II . Thus, iAn association of benign solitary schwannomas with malignant tumors  has been reported . Dermato• Laryngeal schwannoma is a rare, slow growing, benign neurogenic tumor usually located in the supraglottic larynx, rarely in the glottis.• It grows submucosal and is well encapsulated.• It can cause globus sensation, dysphagia, dysphonia and upper airway obstruction.• A definite diagnosis can only be made histologically.• The only curative treatment option is complete surgical excision.• Incomplete excision can result in rapid regrowth with life threatening complications.• In cases of solitary schwannomas, Neurofibromatosis as well as malignant tumors especially of the skin and breast should be ruled out.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.JE performed the literature research, composed the manuscript and performed the surgeries. UR critically revised the manuscript. HBG performed the radiological studies, critically revised the manuscript with special regard to radiologic findings. UH performed and evaluated the histology, critically revised the manuscript with special regard to histologic findings. RM critically revised the manuscript. ME performed pre- and postoperative examinations of the patient, provided photographs, drafted a first version of the manuscript. TU critically revised the manuscript with special regard to language. HS supervised the work, performed the surgeries and critically revised the manuscript. All authors approved the final manuscript.


Enterobius vermicularis is an intestinal nematode of humans. Adults usually have low worm burdens and are asymptomatic. Ectopic infections in the pelvic area or urinary tract rarely occur in women. We report a case of the patient with mild voiding difficulties such as urgency, frequency, nocturia, dysuria, mild low back pain or perineal discomfort. The patient's prostatic secretions showed a large number of inflammatory cells and several eggs. The size and the shape of the eggs identified them as a group of E. vermicularis. On examination we found a soft palpable material which was 5 mm diameter in size and spherical shape. Palpation gave the impression of a tissue than a stone. An incision was performed and a 4 mm long living worm was found. The microscopic examination identified the worm as E- vermicularis. It is an extremely rare manifestation of enterobius vermicularis infection since an intestinal-breeding worm is rarely found in the male genital tract. Enterobius vermicularis is an intestinal nematode of humans and its principal mode of transmission is direct contact between infected and uninfected persons. Human infections occur when the eggs in the infective stage are accidentally ingested in a contaminated environment. Although the majority of infections are asymptomatic, it induces bothersome symptoms in some cases. This condition is referred to as "enterobiasis" and it includes perianal itching and dermatitis .Adults usually have low worm burdens and are asymptomatic. However, in children, particularly when there are heavy worm burdens, neurological symptoms such as nervousness, restlessness, irritability and distraction may occur, and these may influence on child growth . Rarely We report a case of the male adult patient with a prostatitis and a chronic pelvic pain syndrome due to Enterobius vermicularis which was successfully treated with antihelmintic regimens.A 65-year-old man presented to the Outpatient Department of Elpis Hospital, for evaluation of a chronic bacterial prostatitis. He reported mild irritative voiding difficulties such as urgency, frequency, nocturia, dysuria, a mild low back pain and perineal discomfort. Although there was no urethral discharge, the patient complained of local burning sensation on urination and an itching sensation in the urethra. The symptoms lasted for fifteen days.A complete review of systems was unremarkable as well as his medical and family history. The patient's hemogram was normal without leucocytosis. The midstream urine showed microscopic hematuria, pyuria but no bacteriuria indentifying the organism infecting the urinary tract was present. The PSA values were elevated 7,6 ng/ml with a free PSA/total PSA ratio 39%. The transrectal ultrasonography revealed a cystic mass in the transitional zone of the prostate with a solid and a nodular inner portion.On rectal examination, the prostate was normal in size and consistency. The prostatic secretions obtained by prostatic massage showed a number of inflammatory cells (more than 30 white cells per high-power field) but no causative infectious agent was found by culture or other means. Several eggs were observed amongst the inflammatory cells measured 51–59×26–29 μm with one convex side , for the presence of Enterobius vermicularis eggs. All three samples were positive for parasite eggs and the children were treated with the same antihelmintic regimen.Enterobius vermicularis is one of the most frequently encountered and ubiquitous nematodes. It is highly contagious and parasitizing the human intestinal tract. The majority of human infections have been shown to occur in preschool children and grade school children, particularly those who engage in group activity.It is known that the transmission of enteroparasites depends on the presence of infected individuals, sanitation deficiencies and, principally, the socioeconomic and cultural conditions of the population. Among adults, Enterobius vermicularis infection is similar in both sexes, but it was commonly observed that many adults seemed not to get infected even when subjected to contaminated environments due to personal hygiene .According to our case, the urethra seemed the only route that the threadworm could have reached the urinary tract. Ordinarily, after a nocturnal egg laying excursion, the gravid female worms either die or return through the anus to their proper intestinal habitat. Occasionally, they lose their way and enter the vagina. They may then ascend to the genital tract, and even reach the peritoneal cavity along the lumen of the uterine tubes. Ovarian enterobiasis is rare but several cases have been recorded . The uteOther orifices, whether it is natural or as result of a disease, may also mislead them. Surprisingly, there seems to be no indisputable record of threadworms entering the urethra, in spite of its accessibility. There are, however, a few published observations supporting the possibility that sometimes they may take this path, and these have been cited elsewhere ,8. MainlEffective antihelmintic regimens have been developed and used for decades. However, the control of enterobiasis is difficult due to frequent recurrences and a short life cycle. Therefore, continuous health education concerning improvement of personal hygiene and regular inspections are required to control enterobiasis.Repeated health education concerning improvement personal hygiene and regular inspections are required to control enterobiasis. Worm infection should be rarely suspected in patients with genitourinary symptoms or pelvic pain, in which a complete laboratory evaluation fails to establish the diagnosis.The author(s) declare that they have no competing interests.AZ was involved in the case directly and drafted part of the manuscript.MK was involved in the literature review and helped draft part of the manuscript.PP was involved in the case directly and performed the literature search and drafted part of the manuscript.


Metastatic tumour involvement of the anal canal is rare. Routine pathological evaluation of haemorrhoidectomy specimens has been suggested to be unhelpful and expensive. Selective rather than routine pathological evaluation of haemorrhoidectomy specimens has been recommended.We report the case of a 69-year-old woman with metastatic colorectal carcinoma who presented with metastatic carcinoma within thrombosed haemorrhoids.We suggest that in patients with colorectal cancer, careful examination of haemorrhoids on colonoscopy as well as histological examination of suspected haemorrhoidal tissue after surgical resection be performed to evaluate for metastasis. Metastatic tumour involvement of the anal canal is rare. There have been around 200 cases of metastatic anorectal melanoma, with the first case described in 1857 by Moore . MetastaLemarchand et al.  performeA study by Cataldo et al.  looked aA 69-year-old woman presented in February 2003 with a 6-week history of progressive change in bowel habit. She had noticed fresh blood mixed with her stools, a 1-stone weight loss, and pelvic pain.Blood tests showed an elevated carcino-embryonic antigen (CEA) of 560 ng/ml and colonoscopy revealed a fixed, circumferential rectal carcinoma at 6 cm. No other synchronous tumours were noted to the level of the caecum. Computed tomography scan showed bilateral pulmonary metastases, multiple liver metastases, and a large mass in the recto-sigmoid region consistent with known carcinoma. Magnetic resonance imaging of the pelvis confirmed a large infiltrative tumour seen in the upper rectum with ill-defined margins. Rectal biopsy confirmed a moderate to poorly differentiated adenocarcinoma of large bowel type.The patient was commenced on palliative chemotherapy with irinotecan and infusional 5-FU. After 14 cycles, the patient unfortunately developed progressive disease with new pulmonary metastases and an increase in the size of her liver metastases as well as an increase in her CEA from 113 ng/ml to 710 ng/ml. Consequently, in January 2004, treatment was changed to oxaliplatin and infusional 5-FU chemotherapy.After three cycles, the patient presented complaining of prolapsed 'piles' and on examination was found to have pedunculated, hard and ulcerating haemorrhoids. Tumour deposits were noted at the 6 and 12 o'clock positions Figure .This case is, to the best of our knowledge, the first case that demonstrates bowel adenocarcinoma deposits within haemorrhoids. We suggest that in patients with a history of colorectal cancer, careful examination of haemorrhoids during colonoscopy, as well as histological examination of suspected haemorrhoidal tissue after surgical resection, be performed to evaluate for the possible presence of metastasis.The authors declare that they have no competing interests.DMG, PH and GWM were all involved in the clinical care of the patient. DMG, SB and PH conceived, researched, wrote the paper and revised the final manuscript. All authors read and approved the final manuscript.Written consent was obtained from the patient's next-of-kin for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


The patient, at one year of follow-up is asymptomatic with normal liver function tests.A 34-year-old female presented with right hypochondrial pain of 6 months following an uneventful open cholecystectomy about 5 years ago. A firm intra abdominal lump was felt in the right hypochondrium. Ultrasonography and computed tomography of the abdomen showed a large cystic lesion in relation to the porta hepatis. On exploration, a large cystic mass was found in relation to the undersurface of liver, adherent to the colon and duodenum. The cyst was excised leaving a cuff of cyst wall, densely adherent to the duodenum. A small opening with bile trickling through it was noted in the region of the confluence of hepatic ducts. Choledochotomy was done and T-tube placed. The bilious output from the sub-hepatic drain gradually decreased and the repeat T-tube cholangiogram on 14 A 34-year-old female of Asian origin presented with dull aching pain over the right hypochondrium, radiating to the back for 6 months with no history of fever, jaundice, hematemesis or malena. She had undergone an open cholecystectomy about 5 years back with an uneventful post operative period and was discharged on the tenth day following surgery. Rest of the history was unremarkable. On examination, a tender, firm intra abdominal lump of size 7 × 5 cm was felt in the right hypochondrium. The lump was extending to the lumbar region and was moving well with respiration. It was dull on percussion and continuous with liver dullness. Laboratory parameters were within normal limits except for an elevated serum alkaline phosphatase of 420 U/L . Ultrasonography (US) of the abdomen showed a cystic lesion involving the segment V of the liver with a huge extra hepatic component along with small septations and internal debris. Contrast enhanced computed tomography (CECT) of the abdomen Figure  showed aDuring the period of investigation, pain and the lump increased in size. The patient was explored through a right subcostal incision under general anesthesia. A large cystic mass of size 10 cm × 10 cm was found in relation to the undersurface of liver. The mass was adherent to the colon and duodenum and was overlying the region of porta hepatis. Aspiration of the cyst revealed bilious fluid. The cyst was excised leaving a cuff of cyst wall, which was densely adherent to the duodenum. Frozen section of the cyst wall showed only fibrocollagenous tissue. After excision of the cyst porta hepatis as exposed and an induration was noted in the region of the confluence of hepatic ducts with a small opening through which bile was trickling. The opening was cannulated and the cholangiogram was done to delineate the anatomy. Since biliary anatomy was not clear on intra operative cholangiography, opening was closed Choledochotomy done and a T tube placed in the bile duct. Abdomen was closed after placing a sub hepatic drain. In the post operative period, the drain output was bilious in nature. The drain output gradually decreased and finally stopped. A T-tube cholangiogram done on day 14 after surgery showed a normal bilio-enteric pathway with no leakage Figure . The draA biloma is a well-demarcated, encapsulated or not, bile collection outside the biliary tree secondary to iatrogenic, traumatic or spontaneous injury of the biliary tree. Gould and Patel used the term biloma for the first time in 1979 to describe a loculated collection outside the biliary tree but were then extended to include both intra and extra hepatic collections of bile. [Before the era of laparoscopy the rate of major bile duct injury for open cholecystectomy was about 0.1% and the total biliary injury rate was 0.1%. With laparoscopic technique the rates for major bile duct injury and the total biliary injury rate range from 0.3%-0.6% and 0.6%-1.5% respectively . BilomasBilomas usually present with abdominal pain, nausea, anorexia, jaundice, fever and abdominal tenderness. The median time of diagnosis is usually 1-2 weeks . The symThe clinical history with the US, CT findings often establishes the diagnosis. Magnetic resonance cholangiopancreatography (MRCP) helps to find the site of leakage but useful only in the presence of an active leak. Percutaneous aspiration under US or CT guidance with biochemical test for Bilirubin confirms the diagnosis .The appropriate treatment for biloma is drainage as everyone with undrained bile is at risk. Spontaneous reabsorption of bile collections larger than 4 cm is found to be rare and unpredictable . EndoscoBilomas must be considered in the differential diagnoses of abdominal cystic lesions even many years following surgery on the gallbladder and hepatobiliary system.CECT: contrast enhanced computed tomography; ES: endoscopic sphincterotomy; MRCP: magnetic resonance cholangiopancreatography; UGIE: upper gastrointestinal endoscopy; US: ultrasonography.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.UK was a major contributor in writing the manuscript, RP made substantial contribution in conception, design and analysis of patient data. SKR contributed in conception and analysis of data.


Adenosquamous carcinoma of the pancreas is a rare variant of exocrine pancreatic tumor. This type of tumor is extremely rare as only few similar cases have been described in the literature.We present a case of a 72 years old male patient who was admitted to the hospital complaining of epigastric pain and jaundice. Pancreatic carcinoma of the head was diagnosed and a pylorus preserving pancreaticoduodenectomy was performed.This type of cancer is a very aggressive tumor followed by a dismisal prognosis. Multimodality therapy seems to be a reasonable approach but more studies are needed, to propose the most effective treatment. Pancreatic cancer is the 6th leading cause of death in Europe, while the incidence rate approaches the mortality rate . Adenosqnd and 3rd portion of the duodenum  and consumed alcohol (wine) occasionally, in small quantities. Physical examination revealed a distressed male patient with a body temperature of 37°C, blood pressure of 130/85 mmHg and pulse rate about 85/min. Painless jaundice was the presenting symptom and Courvoisier sign was present. The patient had no sings of ascites, or gastrointestinal obstruction. Hematocrit was 31%, white blood cells 10630/μL with neutrophil prevalence 77% and platelets 341.000/μL. Biochemical profile showed Tbil: 7.50 mg/dl, Dbil: 5.50 mg/dl, SGOT: 109 U/L, SGPT: 145 U/L, γGT: 517 U/L, ALP: 467 U/L, LDH: 503 U/L, CA125: 244, 50 U/L, CA19.9: 51.30 U/L. The patient was receiving digoxin and warfarin for chronic atrial fibrillation. Thin section computer tomography showed dilatation of the gallbladder and intra/extrahepatic biliary tree, while a 5 cm mass of the uncinate process of the pancreas was identified to invade the intrapancreatic portion of the bile duct, as well as the 2Histological evaluation of the pancreatic tumor showed an adenosquamous carcinoma which was extensively infiltrative with perineural invasion, involvement of peripancreatic lymph nodes and all the thickness of the duodenum wall. The tumor elicited an intense desmoplastic stromal reaction and areas of necrosis Figure . Focal aThe immunohistochemical study showed that the tumor cells were positive for cytokeratin AE1 and AE2. Cam 5.2 and Ker 7 were reactive predominantly in the adenocarcinoma component and in few squamous cells Figure . A few n2 5-FU by intravenous bolus delivered daily for the initial 3 days of each radiation course and then weekly. The patient 24 months postoperatively, remains disease free.The patient received adjuvant therapy (5-FU in combination with radiation). He received 40 Gy in two 20 - Gy courses and 500 mg per mThe incidence of adenosquamous carcinoma of the pancreas ranges among studies from 3%  to 11.1%Preoperative diagnosis is often difficult, as there are no specific characteristics that can identify the squamous component in the lesion. However, Ga-67 citrate scintigraphy may be useful in detecting adenosquamous carcinoma of the pancreas . Nabae eOnce the diagnosis is established either preoperative or postoperative, the question that rises refers to the best treatment modality for this aggressive tumor of the pancreas. From the literature reviewed, there is no study with significant statistical power to address that question. Smoot et al. demonstrated a longer survival for patients that can undergo an R0 resection. For R0 resection median survival was 14.4 months compared to 8 months for R1 and 4.8 months for patients undergoing palliative therapies . Hsu JT It has become clear that this type of cancer has a dismissal prognosis. Even with aggressive therapies median survival is poor. More studies are needed to address the role of surgery and the use of adjuvant therapy, however this is quite difficult as this tumor entity is extremely rare. Since squamous cell carcinomas seem to respond satisfactory to chemoradiotherapy regimens based on 5-FU, this combination could be potentially used as adjuvant therapy in patients with resectable squamous cell pancreatic cancer, or as palliative therapy for unresectable tumors. R0 resection remains the gold standard for those individuals who are fit enough to undergo such a major operation.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.PL participated in the patient's treatment, made the literature search, contributed in the writing and the revision of the draft. GF contributed in the literature search, co wrote the draft and made the revision. ES carried out the pathological examination and contributed in the writing of the draft. TV participated in the diagnosis of the case and in the presentation of its pathology, contributed in the pathological examination and in the revision of the draft. NP participated in the patient's treatment, had the concept and the coordination of the case report and contributed in the revision. SR contributed in the revision and had the final approval of the draft. All authors read and approved the final manuscript.


Acute promyelocytic leukemia (APL) accounts for less than 10% of pediatric AML. Cases of APL in Down syndrome (DS) have been described in the literature rarely and it is rarer still to find the microgranular variant (M3v) of APL in trisomy 21 patients.We present a case of a five-year-old female with Down syndrome diagnosed with acute promyelocytic leukemia (APL). She came to our hospital with bleeding manifestations. Blood and bone marrow examination revealed promyelocytes showing a few fine granules and occasional Auer rods. Based on this morphology and cytochemistry, a diagnosis of APL microgranular variant (M3v) was made.This case report emphasizes the importance of a high index of suspicion in the diagnosis of acute promyelocytic leukemia microgranular variant in Down syndrome. Acute myeloid leukemia (AML) comprises approximately one-fifth of pediatric leukemias ; and acu3/l; and platelets 12 × 109/l. The peripheral smear demonstrated an increased number of WBCs, neoplastic promyelocytes and occasional blasts (90%) with high nuclear-cytoplasmic ratio and conspicuous nucleoli. These promyelocytes had markedly lobulated and invaginated nuclei. The cytoplasm of the cells contained no clearly recognizable granules but showed occasional Auer rods ; and tests for fibrin degradation products and D-dimer were also negative. Hemogram findings were as follows: Hb 5 g/dl; WBC 80 × 10rods Fig . The redrods Fig . The pro.0 g/l; aAPL is a subtype of AML in which abnormal promyelocytes predominate. APL accounts for approximately 5–8% of AML . AlthougThis case report emphasizes the importance of a high index of suspicion in the diagnosis of acute promyelocytic leukemia microgranular variant in Down syndromeThe author(s) declare that they have no competing interests.DJ wrote the case outline and performed the literature review. TS assisted in reviewing the slides. PA provided images. All authors read and approved the final manuscript.Written consent was obtained from the patient's relative for publication of this case study.