Extramedullary plasmacytoma is an uncommon tumor that most often involves the nasopharynx or upper respiratory tract. Extramedullary plasmacytoma is a type of plasma cell neoplasm that can present as a primary tumor or secondary to another plasma cell neoplasm, such as multiple myeloma. Secondary extramedullary plasmacytoma is usually noted in the advanced stages of the disease. Involvement of the gastrointestinal tract occurs in approximately 10% of cases.A 71-year-old Caucasian woman with known diverticular disease of the colon and multiple myeloma diagnosed 3 years previously, with monoclonal bands of immunoglobulin A, lambda light chains, and multiple osteolytic lesions, presented to our hospital with abdominal pain, abdominal discomfort, and pneumoperitoneum. She underwent left colectomy for diverticulitis with perforation, and an extramedullary secondary colonic plasmacytoma was found in histopathological examination of the sigmoid colon.Plasmacytoma is known to occur in extraosseous sites. The stomach and small intestine are the most commonly involved sites in the gastrointestinal tract. Secondary extramedullary plasmacytoma of the colon is rare. Colonic plasmacytoma may have varying clinical presentations, such as inflammatory bowel disease and multiple colonic strictures. Although these cases are rare, treating physicians as well as radiologists, pathologists, and surgeons should be aware of this entity. Plasma cell tumor is an immunoproliferative monoclonal disease of the B-cell line that originates from malignant transformed plasma cells. It is composed almost exclusively of plasma cells that are arranged in clusters or sheets with a scant, delicate, supportive connective tissue stroma. Plasmacytoma and multiple myeloma (MM) are two main groups of plasma cell tumors.Plasmacytoma includes solitary plasmacytoma of bone and solitary extramedullary plasmacytoma (EMP). Secondary EMP has been reported rarely, and its natural history and diagnosis is not well defined. EMP of the colon is rare –3.18F-labeled fluoro-2-deoxyglucose/computed tomography has also been found to be useful in staging and follow-up of EMP [The presentation of gastrointestinal plasmacytoma is different from that occurring at other sites in the body. The most common presenting symptom is abdominal pain. Symptoms can include rectal bleeding, a change in bowel habits, weight loss, nausea, vomiting, large bowel obstruction, and intussusception . They arp of EMP . We repo2-microglobulin level of 4.2 mg/L and serum albumin level of 37 g/L. No study was performed for amyloidosis.A 71-year-old Caucasian woman with known diverticular disease of the colon and MM diagnosed 3 years previously, who was receiving chemotherapy with melphalan, bortezomib (a proteasome inhibitor), and a moderate dose of dexamethasone, presented to the emergency department of our hospital with abdominal pain, abdominal discomfort, and pneumoperitoneum. The clinical examination revealed acute abdomen with free air on an abdominal plain x-ray, and elevated levels of leukocyte cells at 18,000/μl and C-reactive protein at 145 mg/L. The patient had a family history free of cancer, and the last time she underwent colonoscopy was 1 year before admission. She had been diagnosed 3 years previously with stage II MM based on the International Staging System with a βAn abdominal CT scan showed a 5-cm-wide, 12-cm-long sigmoid mass with medial extension into the fatty tissue at the same localization, pneumoperitoneum, diverticula, free abdominal fluid collections, and distended loops of the small and large intestines Figs.  and 4. T−, CD5−, CD79a+, CD138+ (moderate), CD38+ (moderate), CD56+, CD10−, CD30−, CD117+ (a few), keratins AE1/AE3−, and S-100−  is a type of hematological malignancy arising as a result of monoclonal proliferation of plasma cells (lymphoid cell line) and is associated with production of monoclonal proteins. These malignancies include monoclonal gammopathy of undetermined significance, solitary plasmacytoma of the bone, EMP, and MM.EMP is a type of PCN that can present as a primary tumor or secondary to another PCN, such as MM. In the primary subtype, it occurs alone in the absence of another PCN, unlike in the secondary subtype, often with MM. MM is a monoclonal, immunoproliferative plasma cell neoplasm of the B-lymphoid cells. Secondary EMP is usually noted in the advanced stages of the disease. Primary and secondary EMPs mainly affect the upper aerodigestive tract .EMP represents approximately 3% of all PCNs and occurs when malignant plasmablastic clones migrate into soft tissues. Plasmacytomas, first described by Schridde in 1905, are clonal proliferations of plasma cells that are cytologically and immunophenotypically identical to plasma cell myeloma but manifest a localized osseous or extraosseous growth pattern . They arThe pathophysiological mechanism of EMPs is not yet fully determined. One suggestion is that MM cells and the bone marrow microenvironment tightly interact with each other. This is mediated by multiple soluble factors and adhesion molecules. Integrins acting as receptors on stromal cells and the extracellular matrix play an important role in the homing of MM cells in the bone marrow . ChangesThree-fourths of EMP cases are in males. EMP progresses to MM within 10 years in 11–30% of patients. Overall survival in 10 years is 70%. The median age of patients with either solitary bone plasmacytoma or EMP is 55 years. This median age is 10 years younger than that of patients with MM. EMP presents as a mass growing in the aerodigestive tract in 80–90% of patients, often with spread to lymph nodes, although other sites are affected as well.Common complaints include swelling, headache, nasal discharge, epistaxis, nasal obstruction, sore throat, hoarseness, dysphonia, dysphagia, dyspnea, epigastric pain, and hemoptysis –12. SympEMP involving the lung most commonly presents as a pulmonary nodule or hilar mass. Although EMP can occur in any site, 80–90% of tumors develop in the head and neck area, especially in the aerodigestive tract. Approximately 80% of cases involve the paranasal sinuses, pharynx, nasal cavity, or gums and oral mucosa –15. A maIn 30–40% of cases, local lymph nodes are involved at presentation or upon relapse. Because of the presentation of EMP in the mucosa of the aerodigestive tract (> 80%), the etiology may be related to chronic stimulation of inhaled irritants or viral infection. CT scanning, MRI, and complete endoscopic examination of the aerodigestive and gastrointestinal tracts are required to determine the exact extent of the tumor and its potential for resectability . These lEMP biopsy of the soft tissue lesion shows infiltration by monoclonal plasma cells. In EMP, the soft tissue lesion commonly exhibits submucosal growth, requiring deep biopsy, open biopsy, or complete excision, depending on the tumor location .Histologically, EMP may be classified as low, intermediate, or high grade . Bone maet al. reported no recurrent tumor at 17-month follow-up in a case of EMP invading all the layers of the colon with metastases in three lymph nodes after postoperative adjuvant chemotherapy [et al. reported a recurrent case 4 months after operation [Prognosis and long-term follow-up of primary isolated EMP in the colon are not well known. Gupta otherapy . Howeverperation . Chemothet al. reported that median survival of 9.5 years, and 56% of patients were free from systemic disease at 5 years [The prognosis of primary EMP is generally good. Liebross  5 years . One-thiDevelopment of visceral secondary EMP involving the GIT in the course of MM  is extremely rare, estimated to occur in 0.9% of cases . Only 17et al. proposed surgery, radiotherapy (RT), and chemotherapy for gastrointestinal plasmacytomas according to the degree of disease extent [Our patient was receiving chemotherapy for MM. In general, EMPs are considered to be radiosensitive, with a local control rate of 90–100% . Allisone extent .et al. provided evidence that surgery alone gives the best results in cases of solitary plasmacytoma when resectability is good. However, if complete surgical tumor resection is doubtful or impossible and/or if lymph node areas are affected, then combined therapy (surgery and radiation) is recommended [Colonic plasmacytoma occurs only rarely, and a definitive algorithm for treatment has not been determined. Endoscopic treatments such as submucosal resection or polypectomy have proven to be sufficient in selected cases –27. RT iommended . In one ommended .In only one randomized trial of chemotherapy did patients receiving melphalan and prednisone show an improved disease-free survival rate . The usePatients with EMP characteristically present with localized disease, and the incidence of lymph node involvement is 10–20%. The overall 10+-year survival rate is 70% . SurvivaEMPs are rarely seen in the GIT. It is important to consider this possibility during the evaluation of a mass in the GIT because placmacytomas of GIT have different treatment and follow-up modalities than adenocarcinomas and other tumors of the GIT. Surgical treatment is usually sufficient in localized solitary plasmacytoma of the GIT.In cases of secondary EMP, radiotherapy or surgery alone is insufficient, and systemic therapy is required. In younger patients, the use of immunomodulatory drugs with induction agents in combination with autologous hematopoietic stem cell transplant results in higher remission rates and overall survival . The proet al. [et al. had fatal outcomes not long after diagnosis with EMP [The prognosis of intestinal EMP is unclear. In nine selected patients with MM-associated EMPs, Vaiopoulos et al.  reportedwith EMP .Because secondary EMP in the colon is rare, the clinical course, treatment guidelines, and prognosis are not very well defined. To provide adequate treatment, further study of the clinical features of secondary EMP of the colon is necessary.


High-grade endometrial stromal sarcoma (HG-ESS) is a rare clinical entity, particularly among young women, and only few cases have been reported in the literature. Herein, we describe the case of a 21-year-old woman who presented with a four-month history of excessive bleeding per vagina. Endometrial curettage and cervical biopsy revealed a malignant round cell tumor suggestive of metastatic sarcoma of uterine origin. Computed tomography of the abdominopelvic region showed an enlarged uterus with diffused thickening throughout the entire endometrial cavity. Intraabdominal lymphadenopathy and ascites in the pelvic cavity were noted. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, resections of the enlarged pelvic nodes, omentectomy, and biopsy of the peritoneal nodules in the cul-de-sac. Histological examination revealed a tumor with a permeative growth pattern composed of uniformly high-grade round cells with brisk mitotic activity and extensive lymphovascular space invasion. Sections of the pelvic lymph nodes on both sides and the peritoneal nodule revealed multiple metastatic foci. Immunohistochemical studies showed positive diffuse staining for vimentin, CD 10, and cyclin D1. The pathological diagnosis was HG-ESS stage IIIC. The patient experienced rapid progression of the disease while receiving adjuvant treatment and succumbed eight months after the operation. HG-ESS is a rare cause of AUB in adolescents and young women but should be considered in the differential diagnosis. Abnormal uterine bleeding (AUB) is characterized as excessively heavy, prolonged, and/or frequent bleeding of uterine origin . ApproxiEndometrial stromal tumors (EST) are rare tumors of endometrial stromal origin and account for less than 2% of all uterine tumors , 4. AccoHG-ESS is rare, particularly among young women . An accuA 21-year-old, G0P0 woman presented with a four-month history of excessive and prolonged bleeding per vagina, as well as a palpated mass at the lower abdomen that was rapidly increasing in size. Her past history was unremarkable. Two months before this visit, she had presented at the provincial hospital with severe anemic symptoms. She was found to have severe anemia and received a blood component transfusion. The excessive vaginal bleeding had persisted until one month prior to her presentation at our hospital. She had undergone endometrial curettage at the provincial hospital, and the pathological report indicted an atypical round cell tumor.-eosin stained (H&E) slides of the endometrial specimen were reviewed. The sections showed a malignant round cell tumor with scattering foci and vascular architecture mixed with benign-looking endometrial glands. Computed tomography (CT) of the abdominopelvic region showed an enlarged, well-defined uterine border with diffused enhancing thickening in the endometrial cavity involving entire uterine body and cervix  markers. The pathological examination showed a malignant small round cell tumor suggestive of metastatic sarcoma of uterine origin. Immunohistochemical studies showed negative staining for multi-cytokeratin (AE1/AE3), S-100 protein, CD 10, cyclin D1, caldesmon, myogenin, and desmin. The patient's tumor exhibited focal positive staining for smooth muscle actin. The preoperative differential diagnoses were HG-ESS and UUS.At laparotomy, the uterus and obturator lymph nodes on both sides were enlarged. There were multiple nodules in the cul-de-sac. Neither the adnexae nor the omentum appeared remarkable. The surgical procedures included total abdominal hysterectomy, bilateral salpingo-oophorectomy, resections of enlarged pelvic nodes, omentectomy, and biopsy of peritoneal nodules in the cul-de-sac.Macroscopically, the uterus weighed 714.67 grams and measured 13x13x7 cm with an intracavitary polypoid mass that occupied the entire endometrial cavity . The tum2) and Ifosfamide (5 g/m2) given every three weeks. After receiving four courses of this chemotherapy regimen, the patient refused further adjuvant chemotherapy due to her inability to tolerate the side-effects. Pelvic radiation was then administered thereafter. Despite undergoing radiation treatment, the patient experienced rapid disease progression and succumbed eight months after operation.The postoperative clinical course was uneventful. The patient was started on adjuvant chemotherapy consisting of Adriamycin (50 mg/mAbnormal uterine bleeding is a common reason for adolescents and young women to present at healthcare facilities . There aHigh-grade endometrial stromal sarcoma is rare, constituting of less than 1% of uterine malignancies and less than 10% of uterine sarcomas , 4. The Endometrial stromal sarcoma is a genetically heterogenous group of uterine sarcomas –11. HighHigh-grade endometrial stromal sarcoma is also a group of tumors with heterogenous morphologic features . ScialliAccording to the National Cancer Database, which is a nationwide, facility-based, comprehensive database established by the American Cancer Society and Commission on Cancer of the American College of Surgeons, survival in patients with HG-ESS remains poor . The medIt is extremely rare for HG-ESS to be diagnosed in adolescents and young women, and only a few cases have been reported in the literature –16. The We describe a case of HG-ESS stage IIIC diagnosed in a 21-year-old woman who presented with abnormal vaginal bleeding and a pelvic mass. Our report confirms the relatively poor prognosis of this subtype of ESS. Our patient experienced rapid disease progression during adjuvant treatment and passed away at eight months after surgery. This report highlights that HG-ESS is a rare cause of AUB in adolescents and young women but should be considered in the differential diagnosis.


A huge spherical intracranial mass can sometimes be misdiagnosed, due to the lack of typical radiographic features. Thrombosed giant intracranial aneurysms (GIAs) are an uncommon but still a possible differential diagnosis that must be kept in mind to guarantee the best surgical approach and resection of the lesion. We describe an extremely rare case of a huge bifrontal mass mimicking a cystic echinococcosis, in which the surgery unveiled a completely thrombosed GIA of the left anterior cerebral artery (ACA).A 61-year-old patient complained about intermittent weakness of the right leg, mild holocephalic headache, beginning cognitive deficits and lethargy. Magnetic resonance imaging (MRI) showed a huge partially calcified and bilobed frontal mass with peripheral edema. Based on a time-resolved angiography with interleaved Stochastic trajectories MRI (TWIST-MRI), a vascular origin of the lesion was considered unlikely. Therefore, the surgery was performed under the suspicion of a cystic echinococcosis but revealed a bilobed GIA of the left ACA with a parent vessel thrombosis. Although only a limited left frontal craniotomy was performed, a proximal control of the parent vessel could be ensured, and the aneurysm was successfully clipped. The patient showed postoperatively no new neurological deficits.Completely thrombosed GIAs with parent vessel thrombosis are rare lesions that might be misdiagnosed if typical radiographic features are missing. Thus, in case of an intracranial spherical mass with signs of intralesional hemorrhage and mural calcifications, presence of a completely thrombosed GIA should be considered as a possible differential diagnosis. Giant intracranial aneurysms (GIAs) are rare and heterogeneous lesions with complex vascular anatomy  and reprIn this report, we present an unusual case of a completely thrombosed GIA of the left ACA, that was preoperatively misdiagnosed because of the lack of typical radiographic features.A 61-year-old male patient was referred to our neurosurgical department with a 10-day history of an intermittent weakness of the right leg, mild holocephalic headache, beginning cognitive deficits and lethargy. A recent stay in America, China and East Africa was reported. There was no fever and no weight loss. Physical examination showed an ataxic gait. During the hospital stay, the patient developed a focal seizure of the right leg, which was treated with levetiracetam.Magnetic resonance imaging (MRI) obtained from the referring hospital reported two well-defined frontal bihemispheric masses, 54 and 40 mm in diameter, with a slight perifocal edema. The patient was admitted to the intermediate care unit and a computed tomography angiography was performed. The latter showed two large lesions in both frontal regions, partly inhomogeneous, with central hyperdense parts and with partial mural calcifications. A thorax and abdomen CT showed no tumor manifestation. A time-of-flight MRI (TOF-MRI) demonstrated the right ACA shifted to the lateral wall of the lesion, whereas only the proximal left ACA (A1-segment) was displayed. Time-resolved angiography with interleaved stochastic trajectories MRI (TWIST-MRI) was also performed and showed neither contrast enhancement nor intraluminal filling of both masses.Blood and cerebrospinal fluid (CSF) screening presented no signs of infection. There were no tumor cells in the CSF. Parasitological examination of blood and CSF was performed. A low antibody concentration against Echinococcus multilocularis was detected in the patient’s CSF (1:20).Because of the recent foreign stay in East Africa and the above-mentioned CSF results, the diagnosis of a cerebral cystic echinococcosis was suspected. Consequently, no digital subtraction angiography (DSA) was performed, as a GIA in this case was besides radiologically considered extremely unlikely, and a microsurgical resection of the lesion was indicated. Thus, a left frontal craniotomy was performed. The preparation showed a very hard cystic lesion with vasa vasorum at the lesion wall evoking the differential diagnosis of a thrombosed aneurysm. The preparation of the GIA was most difficult due to the absence of a proximal control through the performed frontal craniotomy. After a careful and meticulous dissection, the lesion could be finally prepared in all directions. Furthermore, the aneurysmal parent vessel was found. The intraoperative Indocyanine green angiography demonstrated a very low blood flow in this thrombosed vessel. After clipping of the parent vessel, the two aneurysmal sacs were opened, and the thrombi and calcifications were resected.Histopathological examination revealed wall fragments of an artery of large caliber adjacent to thrombotic material. The vessel wall was irregularly thickened with eccentric fibrosis or abnormal wall thinning; an internal elastic lamina was seen only focally. Hemosiderin deposits, calcifications and inflammatory infiltrates were detectable within the remnants of the vessel wall.Postoperatively, the patient did well and had no neurological deficits. A DSA showed no aneurysmal remnant after clipping. A collateral circulation coming from both MCAs and the posterior circulation was detected. At the 6-month follow-up, the patient recovered from the operation and could walk without assistance.The natural history of GIAs is featured with three pathological events: spontaneous thrombosis, growth leading to a mass effect and rupture causing a subarachnoid hemorrhage . These aComplete intraluminal thrombosis is uncommon and occurs especially in large and giant cerebral aneurysms in 13–20% of cases . This phMoreover, the left A2-segment was not detected on the TOF-MRI. Based on this MRI feature and on the intraoperative fact that the parent vessel was probably coming from the left ACA, spontaneous occlusion of the parent artery (left A2-segment) harboring the GIA was suspected. Indeed, although this scenario is extremely rare,  it wouldIn this way, because of the limits of imaging, in front of a huge intracranial mass presenting with mural calcification and signs of hemorrhage, a completely thrombosed GIA must be considered as a differential diagnosis and must not be ruled out until the operation is performed. Preoperatively, a DSA is always helpful and must be included in the preoperative workup to visualize the parent vessel of the IA and plan the operation. Even though, in the case of a completely thrombosed aneurysm, DSA could be negative . FurtherCompletely thrombosed GIAs with parent vessel thrombosis are rare lesions that might be misdiagnosed if typical radiographic features are missing. Thus, in case of an intracranial spherical mass with signs of intralesional hemorrhage and mural calcifications, presence of a completely thrombosed GIA should be considered as a possible differential diagnosis.


Objective: The aim of this study was to demonstrate the clinical feasibility of intraoperative photodiagnosis (PD) of malignant brain tumor using talaporfin sodium (TPS), which is an agent used in photodynamic therapy (PDT) for cancers.Methods: Forty-seven patients diagnosed with malignant gliomas by preoperative imaging (42 patients with gliomas and 5 patients with other brain tumors) received an intravenous injection of TPS at 40 mg/m2 24 h before resection. During surgery, these patients were irradiated with diode laser light at 664 nm, and tumor fluorescence was observed. The fluorescence intensity was visually rated on a 3-point rating scale . TPS concentrations in 124 samples from 47 cases were measured by HPLC (High performance liquid chromatography).Results: The fluorescence intensity was confirmed to be weak in all patients with Grade II gliomas and strong in almost all patients with Grade III or IV gliomas, reflecting the histological grade of malignancy. In patients with non-glioma brain tumors except for 1 patient with a metastatic brain tumor, the fluorescence intensity was strong. The mean TPS concentration in tissues was 1.62 μg/g for strong fluorescence areas, 0.67 μg/g for weak fluorescence areas and 0.19 μg/g for no fluorescence areas.Conclusions: Establishment of an appropriate fluorescence observation system enabled fluorescence-guided resection of malignant brain tumors using TPS, and the fluorescence intensity of tumors correlated with the TPS concentrations in tissues. These results suggest that TPS is a useful photosensitizer for both intraoperative fluorescence diagnosis and photodynamic therapy. The use of photosensitizers (PSs) for malignant gliomas has been aimed mainly at tumor control by photodynamic therapy (PDT). In 1980, a clinical report related to PDT, in which patients with gliomas underwent helium-neon laser irradiation after the administration of Photofrin II, was submitted by Perria et al. –5. The mAfter administered to a patient, PS is transformed from the ground state to the excited state by laser irradiation, and immediately returns to the ground state with emitting fluorescence. In 2000, Stummer et al. established a methodology called fluorescence-guided resection (FGR) where tumors are resected using an intraoperative photodiagnosis (PD) of malignant gliomas with the fluorescence as a guide , 9. The in vitro study in human glioma cells , which is a second-generation photosensitizer, by conducting an ma cells , an in v in rats , 17, and in rats , 19. Par in rats , TPS andIn our previous clinical research on PDT, all patients preoperatively predicted to have malignant gliomas received TPS and underwent FGR . Then, PTalaporfin sodium  is a photosensitizer, a hydrophilic compound manufactured by coupling aspartic acid and chlorine, utilized in PDT, which was approved for use in Japan in 2003 as treatment for early-stage lung cancer, in combination with a diode laser  at a wavelength of 664 nm . TPS is The PD Laser®, installed in the MM30 microscope , is combined into a system that provides laser irradiation (664 nm) from the operating microscope from a plane nearly coaxial to the surgical view. The laser light is introduced into the microscope by a quartz fiber, and provides a laser transmission path close to an observation light path using a conventional halogen light. This allows surgeons to accurately identify an irradiation target area during surgery. The wavelength of fluorescence from tumor tissues is 672 nm. To detect this fluorescence, a system was established using a very narrow notch filter  that can capture an 8-nm difference. The system gathers emitted fluorescence through a cooled charge-coupled device (CCD) and visualizes images on the monitor. The system is designed for enhancing the contrast between the brain surface and the tumor, by mounting 6 white light-emitting diodes (LEDs) as light sources  around the objective lens to achieve a clear fluorescence observation by brain surface illumination with LEDs allowing 6-level light intensity control .We conducted an experiment to examine whether this microscopic system allows appropriate intraoperative fluorescence observation during brain tumor surgery. TPS at 3 concentrations of 1, 10, and 100 μg/mL each was mixed with 10% bovine serum albumin . Then, a cotton ball was moistened with each mixture. These cotton balls were irradiated with a diode laser at 664 nm under the irradiation conditions described later, and then observed the emitted fluorescence at 672 nm using the microscopic system to determine whether the dose-dependent fluorescence intensity is grossly detectable.The study subjects were 47 consecutive patients who received the protocol-specified surgery after being diagnosed with glioma by preoperative diagnostic imaging by a single surgeon (JA) from April 2005 to December 2008 at the Department of Neurosurgery, Tokyo Medical University. The final pathological diagnosis was glioma in 42 patients, newly diagnosed tumor in 24 patients, and recurrent tumor in 18 patients. The histological malignancy grade was Grade I in 1 patient, Grade II in 5 patients, Grade III in 8 patients and Grade IV in 28 patients. There were 5 patients whose final pathological diagnosis was not glioma after undergoing the protocol-specified surgery based on the diagnosis of glioma made by preoperative diagnostic imaging. The final pathological diagnosis in these patients was metastatic brain tumor in 2 patients (from lung cancer and mammary gland cancer), primary central nervous system lymphoma in 1 patient and meningioma in 2 patients. The institutional review board approved the participation of humans in research at Tokyo Medical University approved our fluorescence-guided intracranial tumor resection protocol, and all patients gave their informed consent before participating.2 in light-shielded conditions 24 h prior to surgery. Craniotomy was performed under illumination at ≤500 lux. First, the brain surface was observed under halogen light illumination. Then, the halogen light was turned off, and the brain surface was irradiated with a diode laser at 664 nm at a power density of 10 mW/cm2, with a beam diameter of 40 mm and an irradiation area of 12.6 cm2, to observe the presence or absence of tumor fluorescence. The illuminance of the white LEDs was adjusted as appropriate to check the difference in color tone from the brain surface. Every time tumor tissue was resected, the resected tissue was irradiated with a laser in order to check the intensity of the tumor fluorescence. The fluorescence intensity displayed on the monitor was grossly assessed in three grades: strong fluorescence (S), weak fluorescence (W), and no fluorescence (N). The tumor resection was performed using an optical navigation system , as awake craniotomy and fluorescence-guided resection, under physiological monitoring. When reaching the limit for resection, the resection cavity was irradiated with a diode laser. When weak or strong fluorescence was grossly detected in the cavity, PDT was performed as reported previously , and the operation was ended. After the operation, the patient was managed in a shielded condition under illumination at ≤500 lux, until the result of the skin photosensitivity test turned to negative.TPS was administered as a bolus intravenously at a dose of 40 mg/m3OH (1:9) was added, then the tissue was homogenized while cooling in ice for 1 min, and the supernatant was used as a measurement sample. The TPS and the internal standard, fluoranthene , in each measurement sample were separated based on the principle of reverse phase liquid chromatography , and detected by a fluorescence detector. Based on each peak area obtained, the peak area ratio relative to fluoranthene was calculated and used the values as TPS concentrations. For patients in whom the concentration was measured at multiple sites in each area assessed as strong, weak or no fluorescence, the mean concentration was used for the evaluation.TPS concentrations were measured according to the method reported by Yoshida et al. , using 5Based on MRI images obtained before surgical resection and within 3 days of the resection, the extent of resection was determined. For gadolinium-enhanced tumors, gadolinium-enhanced T1-weighted axial imaging was used. The sum of the products of perpendicular diameters (SPD) of the contrast-enhanced lesions was calculated. Then, the SPD of residual lesions on immediate postoperative imaging was determined, and the extent of resection was calculated. For non-gadolinium-enhanced tumors, the SPD of the areas of prolonged T2 on T2-weighted imaging was assessed to calculate the extent of resection.t-test, using SPSS analysis software .A significance test for TPS concentrations in each tissue was performed by Student's From the cotton balls impregnated with mixtures of the TPS solutions at 3 concentrations and 10% BSA, red fluorescence with intensities dependent on the concentration of TPS was observed by laser irradiation. A clear fluorescence was observed in light shielded conditions. However, in the case of laser irradiation under halogen light illumination, red fluorescence was visible only from the tissue containing TPS at the concentration of 100 μg/mL, but fluorescence was hardly perceived at other concentrations. In the case of laser irradiation under white LED illumination, both the dose-dependent red fluorescence at all concentrations of TPS and the background are considered observable .Case 10: A 56-year-old man had glioblastoma in the right parietal lobe, manifested by involuntary twitching at the left corner of the mouth. The tumor was resected en bloc using an optical navigation system under continuous somatosensory evoked potential monitoring. Being irradiated with a laser, resected tissues emitted strong red fluorescence, with weak red fluorescence in the surrounding area. The TPS concentration in tissue was 2.9538 μg/g in the area of strong fluorescence and 1.5765 μg/g in the area of weak fluorescence. The area of strong fluorescence was within the tumor bulk, and the area of weak fluorescence was within the surrounding brain tissues infiltrated with tumor cells. When the resection cavity was observed under laser irradiation, an area of weak fluorescence was detected and therefore was additionally resected. Pathologically, this area was assessed as a tumor infiltration area containing MIB-1 positive cells. A postoperative contrast-enhanced MRI revealed that the tumor was totally resected, and the additionally resected area was clearly identifiable .Case 18: A 41-year-old woman had glioblastoma in the left frontal lobe, manifested by mild motor aphasia and right hemiplegia. She underwent awake surgery, and laser irradiation was performed on the brain surface during the operation. By the laser irradiation, strong red fluorescence suggestive of a localized tumor was observed on the brain surface along with fluorescence from the blood vessels on the brain surface. When a laser was irradiated under white LEDs, a clear contrast was observed between the fluorescence and the surrounding brain surface. The tumor was resected en bloc and examined on the longitudinal cross-section. Strong ring-like red fluorescence was observed, which was similar to the ring-like enhancement surrounding the central necrosis on MRI images. Observation under LED illumination revealed a more detailed relationship with the surrounding brain tissue. The TPS concentration in tissue was 2.1861 μg/g in the strong fluorescence area, 0.9349 μg/g in the weak fluorescence area, and 0.4044 μg/g in the no fluorescence area in the periphery. A postoperative MRI confirmed that the contrast-enhanced lesion was totally resected .Case 2: A 30-year-old man had oligoastrocytoma in the left frontal lobe, manifested by a first episode of generalized tonic-clonic seizures. No obvious contrast enhancement was observed on the preoperative contrast-enhanced MRI. When the resected tumor tissue was irradiated with a laser, weak red fluorescence was observed at the site where the tumor had been located. The TPS concentration in tissue in this area was 0.6914 μg/g. A postoperative MRI confirmed that the lesion of prolonged T2 was totally resected .Case 1: An 18-year-old man had pilocytic astrocytoma in the vermis cerebelli, manifested by sudden headache and nausea. A preoperative contrast-enhanced MRI showed an enhanced mural nodule. During the surgery, the cyst was opened and irradiated with a laser. As a result, nodular fluorescence, tending to be strong, appeared with weak fluorescence from the surrounding cystic wall. The TPS concentration in tissue was high, being 3.163 μg/g in the strong fluorescence area and 1.614 μg/g in the weak fluorescence area. A postoperative MRI confirmed that the lesion including the cystic wall was totally resected .In glioma cases, 1 case of Grade I pilocytic astrocytoma showed strong fluorescence. In five Grade II cases, none showed strong fluorescence, but all showed weak fluorescence. In eight Grade III cases, all showed at least weak fluorescence, including 5 cases (62.5%) showing strong fluorescence. In 28 Grade IV cases, 22 cases (78.6%) showed strong fluorescence and 26 cases (92.9%) showed weak fluorescence; thus all showed fluorescence, as seen in Grade III cases. In the Grade IV cases, strong fluorescence was shown in 14 (93.3%) of 15 newly diagnosed cases and 8 (61.5%) of 13 recurrent cases. In the recurrent cases, some showed only weak fluorescence. In the other 5 cases, except for 1 case of metastatic brain tumor, 4 cases showed strong fluorescence.P < 0.001). In the glioma cases, 1 Grade I case showed strong fluorescence with a tissue concentration of 3.1628 μg/g, but all Grade II cases showed weak fluorescence. The tissue concentrations in strong fluorescence areas in Grade III and IV cases were 1.3751 ± 0.7480 and 1.4948 ± 0.7783 μg/g, respectively, showing no significant difference between the Grade III and IV cases (P = 0.718). In Grade IV cases, the mean tissue concentrations in strong, weak and no fluorescence areas were 1.4948, 0.6752, and 0.1655 μg/g, respectively, showing significant differences (P < 0.001) among the tissue concentrations in these areas. The tissue concentration in the strong fluorescence area in Grade IV cases was 1.5797 ± 0.9082 μg/g in newly diagnosed cases and 1.3589 ± 0.5239 μg/g in recurrent cases, showing no significant difference between the newly diagnosed and recurrent cases (P = 0.493). Also in the weak and no fluorescence areas, no significant differences were observed between the newly diagnosed and recurrent cases (P = 0.821 for weak fluorescence area and P = 0.853 for no fluorescence area). In non-glioma cases, the tissue concentration in the strong fluorescence area was 2.100 ± 1.528 μg/g, showing no significant difference from the result obtained for the strong fluorescence area in Grade IV cases (P = 0.153).The TPS concentrations in tissue in the strong, weak and no fluorescence areas that were assessed grossly were 1.6184 ± 0.9661, 0.6708 ± 0.3765 and 0.1885 ± 0.1253 μg/g, respectively. There were significant differences in concentration between the strong and weak fluorescence areas and between the weak and no fluorescence areas  of 42 patients with gliomas. In most of the 24 newly diagnosed cases, a clear difference in fluorescence intensity was obtained, allowing the resection of not only strong fluorescence areas but also weak to no fluorescence areas. As a result, total resection was achieved in 16 cases (66.7%). Even in cases with residual lesions, the resection of 94 ± 4.3% (89–99%) of the tumor was achieved, according to an SPD analysis. On the other hand, in 18 recurrent cases, it was difficult to obtain a clear difference in fluorescence intensity. In the majority of these cases, weak fluorescence was blurrily spread, making it difficult to grossly determine the disappearance of the fluorescence. Consequently, total resection was achieved only in 6 cases (33.3%), which is an extremely low extent of resection. In cases showing residual lesions, the extent of resection was limited to 81.4 ± 8.9% (63−95%). Of course, when a tumor clearly infiltrates in the functional regions of the brain, it is difficult to resect the tumor even though fluorescence is detected, and PDT should be performed additionally. PDT was performed in 5 newly diagnosed cases and 11 recurrent cases. In most of these recurrent cases, PDT was added due to concern that there may be residual tumors because it was difficult to confirm the disappearance of fluorescence. In non-glioma cases, 1 case with atypical meningioma with repeated recurrences underwent PDT for the residual tumor because total resection had to be abandoned due to intracerebral infiltration of the tumor in the motor cortex, although fluorescence was identified. In this case, however, total resection of other tumor lesions was achieved.In the surgery of glioma, which is characterized by invasive growth, the concept of “maximal safe resection” is important. Evidence for the fact that enhancement of the extent of surgical resection leads to improved prognosis of malignant gliomas has been accumulating, and there have been a series of discussions regarding how to achieve total resection of gadolinium-enhanced lesions on MRI images and, at the same time, how to protect neurological functions –24. FGR A scheme proposed by Wilson for the extent of tumor cell infiltration shows that curative resection cannot be achieved by glioma surgery, as well as that resection of not only contrast-enhanced lesions on imaging but also the surrounding tissue infiltrated by tumor cells can contribute to reducing the residual tumor cells . In receIn this article, we report that intraoperative PD using TPS and an excitation diode laser can identify gadolinium-enhanced lesions and non-gadolinium-enhanced lesions infiltrated by tumor cells, based on differences in fluorescence intensity, in glioma cases. In particular, a positive correlation was observed between the histological malignancy grade and the fluorescence positive rate or the fluorescence intensity. In particular, in Grade IV cases, strong fluorescence was observed in 93.3% of newly diagnosed cases and 61.5% of recurrent cases, and there were no cases without fluorescence. In recurrent cases, the fluorescence intensity tended to be weaker than that observed in newly diagnosed cases. The reason for this might be associated with the use of radiotherapy in these cases. Even in cases of lower grade gliomas, in which the detection of fluorescence with the use of 5-ALA is difficult, weak fluorescence was observed, although the number of cases was limited. These results suggest the usefulness of FGR using TPS in all glioma surgeries. Very strong fluorescence was observed in 1 case of pilocytic astrocytoma. In addition, strong fluorescence was observed also in cases of malignant lymphoma, metastases and malignant meningioma. These results suggest that FGR using TPS can be performed for tumors enhanced by gadolinium on MRI, regardless of histological type.Tsurubuchi et al.  examinedThe finding that the fluorescence intensity was dependent on the histological malignancy grade of glioma cells suggests that the fluorescence intensity of TPS reflects the tumor cell density, proliferative capacity or vascular bed volume, as seen in the studies of 5-ALA . Therefo1/2α and t1/2β of TPS are 14.6 ± 2.96 and 138 ± 21.4 h, respectively . In humans receiving an intravenous injection of TPS at 40 mg/m2, the plasma TPS concentration 24 h after administration was 11 μg/g. The TPS concentration in normal cerebral tissue 24 h after administration of TPS at 40 mg/m2 is calculated to be 0.24 μg/g. On the other hand, the mean TPS concentration in no fluorescence areas measured by the methodology presented in this article was 0.21 μg/g. Since this measured value is very close to the calculated value, this method for measuring TPS concentrations is judged as appropriate.According to the drug information of TPS, the tectively . ExperimBy the FGR using TPS, total resection on imaging was achieved in 52.3% of glioma cases. Particularly in newly diagnosed cases, a clear difference in fluorescence among tumor areas was easily identified also under a microscope. As a result, total resection was achieved in 66.7% of the cases, and PDT was properly performed for tumors infiltrating in the functional regions in the brain. On the other hand, in the majority of recurrent cases, weak fluorescence appeared blurrily, and even though the resection was continued, the fluorescence persisted. The resection was extended to the boundary of the functional regions in the brain and then PDT was implemented in many cases. The reasons for this may include tumor vascular changes due to radiotherapy and decreased proliferative capacity of recurrent tumors. In fact, TPS concentrations in tumors tended to be lower in recurrent cases than in newly diagnosed cases, although there was no significant difference. This issue also needs to be studied in future.2 in 16 patients with early head and neck cancer (Yoshida et al. reported 0.36- to 5.69-fold higher TPS concentrations in cancer tissue than in normal tissue, measured 4 h after the administration of TPS at 40 mg/mk cancer . In addik cancer . In the There are several limitations to acknowledge in this study. First, since this case group was enrolled only for a certain period of time, it can not deny that there was a limit in the number of cases. In particular, as TPS is a photosensitizer that is used for PDT, which is generally only performed on patients who are suspected of having a malignant brain tumor on preoperative neuroimaging, there is little data on the use of TPS in brain tumors except glioma. Second, there was lack of investigation of relationship between histopathological findings and fluorescence intensity or TPS concentration. Such analysis is the focus of our ongoing study.We examined the fluorescence emission from malignant brain tumors, using TPS, a second-generation photosensitizer, and an excitation laser specific to it, and demonstrated that TPS is applicable to FGR. In glioma cases, the fluorescence intensity and the TPS concentration in tumor tissue have been found to be correlated with the histological malignancy grade, and, particularly in newly diagnosed patients, have been suggested to contribute to improving the extent of resection. We will further investigate the relationship between histopathological images of brain tumors and the fluorescence intensity or tissue TPS concentration, in order to verify the usefulness of FGR using TPS in malignant brain tumor surgery.MK and AM supervised the project. JA, SF, and MI developed the concept and the design of the study. JA and SF designed and made the experimental set up for data acquisition. JA, SF, and MI carried out patient care, surgery, and sample acquisition. JA performed data collection. JA, SF, MI, AM, and MK analyzed and interpreted the data. JA drafted the manuscript. SF and MK critically revised the manuscript. AM was contributed to the review of the manuscript and answer to the reviewer's comment. All authors have approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Lipomas are the most common benign neoplasms, occurring in any part of the body where fat is present. Their occurrence in the head and neck is not common. Here, we report a large laryngeal lipoma with extra laryngeal component, mimicking mixed form of laryngocele.A 47-year-old man presented with a 3-year history of hoarseness, intermittent dyspnea and mass sensation in the neck. The patient was submitted to indirect laryngoscopy; a large submucosal mass obliterating the left side of the supraglottic larynx and partially obstructing the airway was found. Enhanced computed tomography (CT) scan demonstrated non-enhancing homogeneous hypodense fat density mass lesion measured 55*45*32 mm, extending through the thyroid membrane to parapharyngeal space and showing extra laryngeal component with an intact laryngeal mucosa lesion. Open surgery of the submucosal mass was performed. Pathology examination confirmed the diagnosis of lipoma.Neck lipomas are also typically asymptomatic, but can compress nearby structures, causing symptoms such as hoarseness, dyspnea and dysphagia. When symptomatic, they should be removed via surgery. Lipomas are slow growing, well circumscribed and benign tumors, which is one of the most common benign neoplasms, appearing in any part of the body, where fat is present. Lipomas are more commonly found in males and their peak incidence is in the fourth and fifth decade of life . They ocA 47-year-old man presented with a 3-year history of hoarseness, intermittent dyspnea and mass sensation in the neck. He had no special past medical history, smoking or alcohol abuse. In physical examination, a soft mass in the left cervical region near trachea was palpable. The patient was submitted to indirect laryngoscopy, and a large submucosal mass obliterating the left side of the supraglottic larynx and partially obstructing the airway was found. At the next step, endoscopy showed a large mass arising from the left supraglottic and glottic region. Contrast enhanced computed tomography (CT) scan images demonstrated non-enhancing homogeneous hypodense fat density mass lesion (average density was −86 HU) measured 55*45*32 mm, extending through the thyroid membrane to parapharyngeal space, and showing an extra laryngeal component with an intact laryngeal mucosa lesion, appearing as hypodense as air and mimicking a large laryngocele in paranchymal window . In the The patient was discharged the day after excision of the lipoma. He was symptom-free upon discharge. He was followed up in the clinic after two months and again at six months, and reported complete resolution of his symptoms.Lipomas could be categorized into extrinsic and intrinsic types. Extrinsic lipomas, arising from the posterior surface of arytenoid, lingual surface of the epiglottis and pharyngeal wall, were more common than true intrinsic laryngeal lipomas (77% versus 23%). This is due to the presence of small amounts of adipose tissue in the larynx, found at the aryepiglottic fold, false cords and epiglottis. Lipoma occurs much less frequently in true vocal cords, which has a scant amount of fat tissue , 6. In oCT scan has a role in terms of evaluating the size and extent of the tumor. Laryngeal lipomas appear frequently as a single hypodense non- enhancing mass, with density ranging from −60 to −120 Hounsfield Unit (HU). Magnetic resonance imaging (MRI), if performed, would help for exact demarcation. It shows a high intensity lesion on T1 weighted images and T2 weighted fast spin echo sequences .Neck lipomas are also typically asymptomatic, but can compress nearby structures, causing symptoms such as hoarseness, dyspnea and dysphagia. When symptomatic, they should be removed via surgery.


Introduction: Gallbladder volvulus (GV) is a rare disease with less than 400 cases reported in the English literature. The pre-operative diagnosis of GV is difficult as none of the imaging modalities are accurate. Once diagnosed, the mainstay of treatment is emergency surgical derotation and cholecystectomy.Presentation of case: A 83-old lady presented with right upper quadrant pain and fever for 3 days. Abdominal imaging revealed the presence of a distended, floating gallbladder located outside its normal fossa with thickened non-enhancing wall and a twisted pedicle suggestive GV. The patient underwent emergency laparotomy because the laparoscopic approach was refused by the anesthetist due to the history of pulmonary emphysema. Intraoperatively, the gallbladder was found be gangrenous and rotated in anti-clockwise direction around the cystic pedicle. The gallbladder was de-rotated followed by cholecystectomy.Discussion: GV is an uncommon cause for abdominal pain and occurs due to rotation of gall bladder on its mesentery along the axis of the cystic duct and the cystic artery. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging. This case is one of the rare cases diagnosed with pre-operative imaging. It is often misdiagnosed as acute cholecystitis before surgery. However, critical constellation of presenting signs and symptoms along with radiological findings may guide the surgeon to accurate and timely diagnosis of GV before surgical intervention.Conclusion: Although rare, it is important to consider GV as a differential diagnosis in an elderly patient with acute cholecystitis. It main2A 83-old lady, a known case of pulmonary emphysema, presented to our hospital with right upper quadrant pain evolving since 3 days. On clinical examination, the patient was febrile, hemodynamically stable, with tenderness in the right upper quadrant and a palpable tender gallbladder. Laboratory tests showed leukocytosis (WBC-16000 cell/ mm3) and liver function tests were normal.The abdominal ultrasonography revealed a distended gallbladder with thickened edematous wall and surrounding loculated ascites. No gallstones were seen and the intrahepatic and extrahepatic bile duct were not dilated. Abdominal computed tomography (CT) revealed the presence of a distended, floating gallbladder measuring 12.2 × 8.2 × 7.6 cm located outside its normal fossa with thickened non-enhancing wall and a twisted pedicle .Fig. 1AbThe diagnosis of acute cholecystitis complicating gallbladder volvulus was made. Intravenousfluid, broad spectrum antibiotics and analgesics were administrated followed by emergency laparotomy via right subcostal incision, the laparoscopic approach was refused by the anesthetist due to the history of pulmonary emphysema. At surgery, a distended gangrenous gallbladder was found. The gallbladder was completely rotated anticlockwise (360°) around the cystic artery and the cystic duct . After u3The volvulus of gallbladder was first described by Wendel in 1898 as a floating gallbladder . The cliGV is characterized by mechanical clockwise or counter clockwise organo-axial torsion along the longitudinal axis of the gallbladder involving cystic artery and cystic duct.There are 5 recognized position of the gallbladder in relation to the liver: 1) intrahepatic; 2) closely attached to the liver surface by the peritoneum; 3) a complete mesentery but held closely to the liver; 4) a complete long mesentery that allows gallbladder to hang freely; 5) an incomplete mesentery which is attached along the cystic duct that allows gallbladder to hang freely in the peritoneum cavity. Only situation 4 and 5 can predispose to torsion .Though the variation in peritoneal attachment of the gallbladder is congenital, the predisposing factor that are more commonly acquired include age > 70 years, female sex, weight loss, liver atrophy, kyphoscoliosis, and loss of visceral fat which results in the elongated gallbladder mesentery necessary for torsion to occur ,6.The importance of gallstones is unknown as approximately 70–80% of patients with gallbladder torsion had no gallstones. One study of 245 patients found stones in only 24.4% patients .The inciting events of torsion may be either mechanical or hormonal changes that affect the gallbladder. The mechanical events may be sudden shifts in body position, intense peristalsis of adjacent viscera, and blunt trauma. Increased cholecystokinin production leading to gallbladder peristalsis after a fatty meal may facilitate gallbladder torsion .The clinical features of gallbladder torsion are similar to those of acute cholecystitis. A low frequency of fever and jaundice, poor response to antibiotic therapy, and acute onset of abdominal pain may be helpful in the differentiating GV from acute cholecystitis and cholangitis ,8.•Patient’s characteristics: thin, old patients with chronic lung disease or a spinal deformity.•Symptoms: abdominal pain, short duration, early onset of vomiting.•Signs: abdominal mass, lack of toxemia or jaundice, discrepancy in the pulse and the temperature.Lau et al. has described a triad that is suggestive of GV :•PatientDespite the technological advances in various imaging modalities, the pre-operative diagnosis of GV is very challenging with only 4 cases reported in the literature diagnosed with pre-operative imaging, the remaining cases were found intra-operatively ,7. This Once diagnosed, the appropriate treatment is emergency derotation and cholecystectomy. This can be performed by laparoscopy, which was first performed by Schroder and Cusumano in 1994, or by open technique . With exPrognosis is excellent if diagnosed and treated early. However, a delay in diagnosis and management may lead to sequelae associated with gallbladder rupture and biliary peritonitis increasing the mortality rate to up to 5% .4Although rare, it is important to consider GV as a differential diagnosis with acute cholecystitis in an elderly patient. The pre-operative diagnosis of GV is difficult and none of the imaging modalities have proven to be very sensitive. Early intervention can result in rapid resolution thus preventing the potential complication of perforation of the gallbladder into the peritoneal cavity.The authors declare that they have no conflict of interest.This study has not received any funding.The study was approved by Ethics Committee of Hospital Sahloul Sousse.Written informed consent was obtained from the patient.Study concept or design – MBM, HA.Data collection – HA, WF, RG.Data interpretation – MBM, WF, RG.Literature review – WF, ABA, MM.Drafting of the paper – HA, YB, SL.Editing of the paper – MBM, AS, AM.As this was a case report and not a clinical trial, this study does not require registration.Mohamed ben Mabrouk.Houssem Ammar.Not commissioned, externally peer-reviewed


In addition, a secondary focus of increased 18F-FDG uptake was detected on the left liver lobe, segment 2, approximately 1,5 cm in diameter. Histopathological examination revealed HCC in the larger mass lesion with a lower 18F-FDG uptake, and cholangiocellular carcinoma in the smaller mass lesion with a higher 18F-FDG uptake. To our knowledge, this is the first case report of two histopathologically different primary malignant liver tumors in two distinct segments of the liver detected by PET/CT.A 43-year-old male patient presented with a mass lesion on the right liver lobe, segment 5, in radiological imaging and elevated alpha-fetoprotein levels (323 ng/mL) compatible with hepatocellular carcinoma (HCC). Positron emission tomography/computed tomography (PET/CT) images showed background level


Root resorption is a pathological condition that may be an endodontic challenge if not diagnosed and treated correctly. The recent advances in the imaging technologies and material science have enabled the clinician to visualize the structural changes accurately and repair them with materials providing favourable seal ability.In this article, we report three cases of root resorption with different presentations which were diagnosed with the help of cone beam computed tomography (CBCT) and successfully managed. The series highlights the importance of diagnosis in unusual clinical situations and recommends early commencement of optimal management for longevity of tooth for health and function. Root resorption, a physiologic process in deciduous teeth, is a pathological condition if encountered in permanent teeth. This may result in loss of tooth, if not diagnosed and treated correctly .The process of tooth resorption is a highly structured interaction amongst inflammatory cells, resorbing cells  and hard tissues, initiated by injury to the non-mineralized tissues covering the external surface of root (precementum) or the internal surface of the root canal (predentin) ,3. The tResorption can broadly be classified as External resorption, Internal resorption or both depending upon the location of the process.Internal root resorption (IRR), commonly referred to as intracanal resorption, is a rare occurrence resulting in dystrophy of the pulp that leads to destruction of the hard tissues, leading to morphological changes. Its prevalence ranges between 0.1 and 1.6% [External root resorption could be surface, inflammatory, replacement, and cervical resorption. External root resorption is more common than internal resorption and is frequently confused radiographically as internal resorption.Invasive cervical resorption (ICR) is a clinical condition which exhibits a relatively uncommon and often aggressive form of external tooth resorption. Its cervical location and invasive nature, lead to progressive and extensive loss of tooth structure . The diaThis paper insights a varied series of management and follow-up of three cases of resorption with satisfactory healing.Case 1: Inflammatory non-perforating internal root resorptionA 35-year-old healthy female patient presented to the Department of Conservative Dentistry and Endodontics, Army College of Dental Sciences, Secunderabad, India, with dull pain in right upper front tooth region for one week. The patient gave a history of trauma 10 years ago, and previous dental treatment with respect to the same tooth.Clinical examination revealed previously initiated endodontic therapy in tooth 11 and 21 Figure . Tooth 2Cone beam computed tomography (CBCT)  was done using field of view 5 × 5 and axial, sagittal, and horizontal sections were obtained that aided in the diagnosis of inflammatory non-perforating internal resorption with symptomatic apical periodontitis for tooth 21 Figure  and chroFirst AppointmentInformed consent was obtained from the patient and treatment initiated by administering an infiltration of 2% Lignocaine with 1:80,000 adrenaline . The tooth was isolated using rubber dam  and coronal access was prepared using an Endo‑Access bur . The working length was determined using apex locator  Figure  which waCleaning and shaping was performed by crown-down technique using Protaper Universal  up to finishing file number 3 (F3), under copious irrigation using 2.5% sodium hypochlorite  and normal saline. Ultrasonic irrigation using Irrisafe ultrasonic tips  Figure  was perfSecond AppointmentOn two-week recall visit, the intracanal medicament was removed using 10% citric acid  using ultrasonic irrigation. The tooth was asymptomatic, and prepared for obturation.Since the resorptive defect involved the middle and apical region of tooth 21, the entire canal was obturated with thermoplasticized gutta-percha, using Obtura II  while tooth 11 was with lateral compaction technique using gutta-percha  and AH Plus  Figure . The tooCase 2: Inflammatory perforating internal root resorptionA 20-year-old male patient presented with pain for one week and gave a history of trauma seven years back leading to fracture of tooth 21. Clinically, the tooth 21 showed grossly destructed crown, a 6 mm deep periodontal pocket distally and grade one mobility. Intra oral periapical radiograph revealed a well-defined radiolucency in the coronal third of the radicular surface Figure . Images First AppointmentAn informed consent was obtained and root canal was accessed after administration of 2% local anaesthesia with 1:80,000 adrenaline under rubber dam isolation, using an Endo‑Access bur. The intracanal bleeding was controlled by gently irrigating with 2.5% sodium hypochlorite. Working length of 23 mm was established Figure  and cleaSecond AppointmentCalcium hydroxide dressing was removed with 10% citric acid, using ultrasonic irrigation and internal walls of the canal were repaired with mineral trioxide aggregate (MTA) , sealed with a wet cotton pellet and temporized with Cavit, and allowed to set for 24 hours Figure . SectionA full thickness mucoperiosteal flap was reflected Figure  and the Figure Case 3: Invasive cervical external root resorptionA 43-year-old male patient presented with pain in left upper quadrant from the past one month. The patient gave a history of trauma 12 years back for which surgery was performed on the left upper lateral incisor 10 years ago. Clinically, tooth 22 was asymptomatic; however, the tooth 23 presented with an intraoral sinus and showed moderate sensitivity to percussion. Cold test and electric pulp test revealed a delayed response for tooth 23. An 8 mm deep periodontal pocket was present on the palatal surface of tooth 23 Figure . RadiogrTo obtain specific knowledge about the three-dimensional (3D) anatomy, the patient was referred for a CBCT analysis. CBCT revealed a class 3 cervical root resorption on buccal and palatal aspects, which perforated and involved the main canal Figure , 9C, 9D.First AppointmentAfter obtaining an informed consent the tooth was isolated using rubber dam, access cavity was prepared in tooth 23 using an Endo‑Access bur. Working length of 25 mm was established using apex locator. Cleaning and shaping of canals was performed followed by placement of calcium hydroxide for a period of four weeks, and temporized with Cavit.Second AppointmentAt the recall visit, medicament was removed using 10% citric acid. A surgical intervention was planned to make the cervical defect accessible. A triangular full thickness flap was reflected buccally and palatally to expose the large defect Figure . The necSectional obturation was done followed by backfill using thermoplasticized gutta-percha and MTA Fillapex . The flap was repositioned and sutured. The patient was instructed to report after a week for suture removal. A four-year follow-up radiograph shows satisfactory periradicular healing with bone formation Figure , 11B.In endodontic practice, root resorption is one of the commonly encountered challenges. Early detection and accurate differential diagnosis are important factors that determine the successful clinical outcome of cases with resorption.It is important for the diagnostician to differentiate internal resorption from external tooth resorption. Radiographs and knowledge of internal root anatomy help a lot in these matters. With the development of technology and CBCT as diagnostic aids the accurate diagnosis and predictable treatment and prognosis.If the tooth is restorable and has a reasonable prognosis, root canal is the treatment of choice. The aim of root canal treatment is to remove all vital and necrotic tissue, to ensure that the resorbing cells are lysed and to disinfect and obturate the root canal system .The complexities of the root canal system and inaccessibility of the defect offer technical difficulties for thorough disinfection of the root canal, thus a chemo-mechanical approach along with an intracanal antibacterial medicament is advocated in such cases to render the canal bacteria free .In cases with perforating defects, the resorptive cavity is sealed with calcium silicate-based materials that form a hard tissue barrier against which the obturating material is condensed . In someCase report 1 presents a non-surgical approach for an inflammatory non-perforating internal root resorption obturated using thermoplasticized gutta-percha after thorough debridement and disinfection of root canal.Cases 2 and 3 that presented with extensive resorptions were treated by a hybrid technique, where after chemomechanical debridement, the defects were sealed surgically with MTA and Biodentine, respectively. These materials are biocompatible , have goStudies have reported that traditional radiography does not always reliably reveal the presence of a lesion and does not show the real size, extent of the lesion and its spatial relationship with anatomic structures. On the contrary, 3D imaging allows us to visualize the third dimension while eliminating superimpositions of surrounding anatomic structures and provides geometrical accuracy of linear measurements .In the present case series, 3D imaging by CBCT has helped in assessment of the resorptive defects by predicting the treatment complexity and expected outcome based on the location and extension of the defect.Timely diagnosis, removal of the cause and proper treatment are obligatory for successful treatment outcome. With the advent of superior diagnostic technologies like, CBCT, a more conservative management can be expected. Modern endodontic techniques including optical aids, ultrasonics, and thermoplastic filling techniques and use of materials such as MTA and Biodentine offer opportunities for rehabilitation of the resorbed teeth.


The aim of this study was to report two rare cases of ectopic tooth into the nasal cavity. The first case reports a 32-year-old female patient with the main complaint of having a tooth inside her nose. According to her, this condition causes pain and sporadic nosebleed. The patient had a facial trauma when she was 6 years old. The second case refers to an 8-year-old girl with left incomplete unilateral cleft lip and palate. The main complaint was left-sided nasal obstruction by a white hard mass. The treatment for both cases was surgical removal of the ectopic erupted tooth under general anesthesia. In conclusion, we can state that the surgical removal of intranasal tooth is a safe procedure and improves patient's quality of life. An aberrant tooth can be found in sites outside of the oral cavity and can be a supernumerary, deciduous, or permanent tooth . The maxThe exact etiology of eruption of a tooth into the nasal cavity remains obscure. A few theories have been proposed to explain it, including the theory of developmental origin, which states that ectopic eruption may occur either due to reversion to the dentition of extinct primates having three pairs of incisor teeth, defect in migration of neural crest derivatives destined to reach the jaw bones, or due to a flaw in the multistep epithelial-mesenchymal interaction . Other cThe purpose of this paper is to report two rare cases of ectopic tooth into the nasal cavity, with different etiologies, one caused by childhood trauma, while the other is associated with cleft lip and palate.A 32-year-old female patient, presenting normal facial growth, was referred to the Oral and Maxillofacial Surgery Service at Federal University of Paraná, Curitiba/PR, with the main complaint of having a tooth inside her nose. She reported this condition causes pain and sporadic nosebleed, especially on cold days. Patient's clinical history revealed that she had a facial trauma when she was six years old, affecting her superior anterior teeth, which was the etiological factor of the ectopic position of the tooth.She had no history of systemic diseases or previous surgical procedures, although she was allergic to cephalexin. On clinical examination, raising the nasal tip, it was possible to observe the crown of the maxillary central incisor inside the right nostril.The patient was submitted to a panoramic radiography, which showed the presence of a radiopaque mass similar to an incisor tooth on the right nasal cavity. For detailed radiographic examination, a computed tomography (CT) was requested and a high-density area was found located in a nasal nostril, horizontally arranged, incomplete rhizogenesis, with the crown facing to the exit of the nasal cavity .The surgical removal of the ectopic tooth was performed under general anesthesia, mainly because of the potential transoperative bleeding. After infiltration of local anesthesia with a vasoconstrictor, the tooth was removed using an intranasal approach with the aid of nasal speculum. Succeeding the extraction, nasal packing was placed to prevent postoperative epistaxis, which was removed 12 hours later, with no complications .One-year follow-up shows resolution of the patient's main complaint, who reports a better breathing, no more nosebleed, or bad smells.An 8-year-old girl with left incomplete unilateral cleft lip and palate was referred to the Cleft Lip and Palate Integral Care Center (CAIF) with left-sided nasal obstruction due to an intranasal hard white mass surrounded by granulation tissue. The patient had no pain or any other complaints regarding the white mass, but because it was hypothesized to be an ectopic eruption of a dysmorphic lateral incisor with no possibility of orthodontic traction, the patient was advised to surgically remove the dysmorphic tooth. Intraoral examination and CT scan assured the hypothesis of ectopic eruption since the left lateral incisor was missing and the radiopacity of the mass matched the radiopacity of other teeth. The patient's surgical history was cheiloplasty at 4 months old, palatoplasty at 1 year old, microotological surgery and tonsillectomy at 5 years old, septoplasty at 6 years old, adenoidectomy at 7 years old, and alveoloplasty and autogenous iliac crest bone craft for oronasal fistula repair at 8 years old. No comorbidities were elicited.CT scan revealed a radiopaque mass situated in the middle of the palatal cleft towards the left nasal cavity. Despite the superior portion, the dysmorphic lateral incisor was inserted in soft tissue . The tooBecause the dysmorphic tooth had no bone insertion and could be accessed using a nasal speculum, Kelly hemostatic forceps were chosen to remove the tooth . HemostaIntranasal tooth represents a small portion of all reported cases of ectopic eruption in the literature. Although the occurrence of supernumerary teeth is rare, up to 1% , it overBoth cases agree with previous reports regarding no predisposition for left or right nostril , no occuThe 32-year-old woman reported a traumatic injury involving her teeth when she was 6 years old, age when the front incisor are in eruption route . On the To accomplish a precise diagnosis in both cases, CT scans were requested for both patients in order to make a differential diagnosis between tooth in the nasal cavity, benign tumors, rhinolith , 9, 14, To solve symptoms and prevent further complications, surgically removing the tooth has been proposed as treatment , 9, 14. Finally, intranasal ectopic tooth is somehow rare but is potentially harmful when left untreated; thus, surgically removing the intranasal ectopic tooth is important to improve patient's quality of life. Furthermore, the diagnosis is simple, fast, and cheap.


Melanotic schwannoma (MS) is a rare nerve sheath tumor with fewer than 200 cases reported. MS has uncertain malignant potential and comprises 1% of all nerve sheath tumors with a predilection for the spinal nerve roots. An even rarer location for this tumor is the vagina. Up to 55% of MSs that contain psammoma bodies are associated with the Carney complex, an autosomal dominant syndrome. Criteria for malignancy in MS are still not well established and long term follow-up of patients is recommended. A 26-year-old woman presented with a bleeding vaginal tumor which was diagnosed as MS following excision. The clinical, histopathological, and immunohistochemical features of this tumor are discussed. Melanotic schwannoma (MS) is a rare nerve sheath tumor composed of Schwann cells, some of which are pigmented , 2. MS iA 26-year-old Para 0+0 woman presented to our facility in December 2008, complaining of prolonged, heavy bleeding of two weeks' duration during her last menstrual period. This was the first such episode. In addition, she also had episodes of postcoital bleeding. She had not missed her menses and a pregnancy test was negative. General examination was clinically normal with no significant findings. A speculum examination revealed a polypoid lesion in the upper vagina measuring 4cm across. The cervix was not distinctly seen . The inith 2009 suggested a blue nevus with a differential of schwannoma. The patient was subsequently counselled for an examination under anaesthesia and excision of the tumor. The initial excision was incomplete with subsequent colposcopic examination showing a residual 2.5cm tumor in the posterior vaginal wall. The adjacent cervix was now visible and was normal , an autosomal dominant syndrome that is characterized by, among other things, spotty pigmentation of the skin, cardiac, mammary, and uterine myxomas, primary pigmented nodular adrenocortical disease with Cushing's syndrome, growth hormone producing pituitary adenoma, Sertoli cell tumors of the testis/ovaries, thyroid adenomas, and breast adenomas –3. Anoth et al. who found that only 53% of the 77 patients they reviewed were disease-free after a follow-up period of more than five years [Histopathologically, this tumor's features were identical to those described in the literature . Histopave years . Ten (10ve years –12.To our knowledge, this is the first case of MS of the vagina that has been reported. In line with the clinicopathological features of MSs at other reported sites, they are of uncertain malignant potential and may be associated with CC and neurofibromatosis. Their correct diagnosis ensures appropriate management with adequate excision and long term follow-up.


Cerebral amyloidomas are rare cerebral mass lesions often associated with significant morbidity. Cerebral amyloid accumulation can be the result of a number of disease states and it is crucial for proper patient care to identify the pathogenic process leading to amyloidoma formation. Low grade clonal B-cell processes are one cause of cerebral amyloidomas. We report a case of an 87-year-old woman who presented with a lymphoplasmacytic lymphoma associated cerebral amyloidoma complicated by cerebral hemorrhage, discuss the proper workup of this disease entity, and present a review of the literature on this topic. Cerebral amyloidomas are uncommon cerebral mass lesions that prior to biopsy are often thought to be glial neoplasms, high grade lymphomas, or immune mediated processes. Following identification of a brain mass as amyloidoma, the etiology of the massive central nervous system (CNS) amyloid deposition must still be determined. Causes of CNS amyloidomas include clonal CNS B-cells, cerebral amyloid angiopathy (CAA), and inherited amyloidopathies. We report a case of an 87-year-old with a biopsy diagnosed cerebral amyloidoma, discuss the appropriate workup to identify the underlying disease cause and present a literature review of cases of B-cell associated CNS amyloidomas, and raise the possibility that patients with cerebral amyloidomas may be at risk for cerebral hemorrhages.A previously well 87-year-old Caucasian woman living in a senior assisted care center presented to the neurology clinic with complaints of six months of slowly progressing left sided weakness. Initial difficulty in ambulating and using the stairs progressed to being wheelchair bound. Neurologic exam revealed diffuse 3/5 left sided weakness, left leg drift, and left facial droop. Brain magnetic resonance imaging (MRI) revealed a large confluent white matter T2-hyperintensity in the right frontal lobe with multifocal nodular enhancement of the left cerebral hemisphere . Foci ofAll sample analysis described below were performed on material obtained by brain biopsy as part of clinical care. All samples were obtained with appropriate consent.A biopsy of the mass was performed and revealed extensive parenchymal lakes and vascular and perivascular deposition of amorphous, amyloid like material . Congo-rλ-type and not β amyloid or an amyloid associated with a hereditary amyloidosis. Further analysis of the perivascular lymphoid populations was undertaken. Histologically, the monotonous populations of perivascular lymphoid cells demonstrated a lymphoplasmacytic appearance  resulting from a primary CNS lymphoplasmacytic lymphoma. Lymphomas confined to the brain, primary central nervous system lymphomas (PCNSL), are rare and account for only 2-3% of all brain tumors and <1% of all non-Hodgkin's lymphoma (NHL). A recent epidemiological review of the data from 10 Surveillance, Epidemiology, and End Results (SEER) cancer registries in the United States between 1992 and 2011 estimated that 90% of PCNLs are B-cell lymphomas, of which the vast majority (75%) are aggressive diffuse large B-cell lymphomas. Primary brain involvement by less aggressive small mature B-cell lymphomas is even more rare. Close to 40% of PCNSL are associated with immunosuppression, in the form of either human immunodeficiency virus (HIV) infection or drug induced immunosuppression. No immunodeficiency was identified in the patient in this case. Over the last few decades the incidence of primary central nervous system (CNS) lymphomas has however shown a significant increase in immunocompetent patients [The amyloidoma in this case was caused by a CNS low grade lymphoplasmacytic lymphoma. Low grade small B-cell lymphomas can have overlapping morphological and immunophenotypic features and varying degrees of plasmacytic differentiation that make their diagnosis challenging. Typically, LPL involves the bone marrow but may also involve other sites such as spleen and lymph nodes. The majority of LPL produce IgM monoclonal paraprotein, which is also known as Waldenström macroglobulinemia and may cause systemic hyperviscosity related symptoms. Rarely, systemic LPL may involve the central nervous system, a condition known as Bing Neel syndrome. In our case, no systemic LPL was identified. Recently, Xu et al. reported the presence of MYD88 L265P) mutations in approximately 90% IgM paraprotein producing LPLs [P mutatioβ-amyloid accumulation in Alzheimer's disease and cerebral amyloid angiopathy. However, primary CNS involvement by AL subtype are less common. It is important to note that CNS involvement by systemic amyloidosis seldom occurs due to the extremely ineffective passage of systemic amyloid across the blood brain barrier [Monoclonal immunoglobulin deposition in the brain, like elsewhere in the body, can either be in the form of light chain deposition disease (LCDD) or amyloidosis. In LCDD, the light chain deposits are characterized by less structural organization and do not stain positive on Congo-red stain. In amyloidosis on the other hand, the light chains form compact beta pleated sheet predominant structures that stain positive for Congo-red and show a characteristic apple-green birefringence on polarization . Amyloid barrier .β et al. demonstrated clonality in cases of CNS AL amyloidomas with background nonspecific inflammatory infiltrates by chromogenic in situ hybridization (CISH) for kappa and lambda light chains and IgH rearrangement studies [To gain further insight into the occurrence of low grade B-cell lymphomas and their association with the formation of CNS amyloidomas, we performed a literature search of the PubMed database for primary CNS small low grade B-cell lymphoma. Our search identified 12 cases of primary CNS lymphoplasmacytic lymphoma –10, one  studies . AL amyl studies .There is no clear treatment modality of choice for AL amyloidomas with low grade lymphomas of the CNS, and the cases reported have been treated with surgery, radiation, and chemotherapy either in isolation or in combination. Irrespective of treatment method, these low grade lymphomas tend to behave in an indolent manner. One patient  relapsedIn conclusion, workup of a cerebral amyloidoma should include studies to characterize the nature of the amyloid and if indicated to identify a clonal/neoplastic B-cell population. If a B-cell neoplasm is identified, treatment of the underlying B-cell tumor is indicated. Increased surveillance for hemorrhagic vascular infarcts is warranted given the association of vascular amyloid deposition and a risk of cerebral hemorrhage.


Adhesive bowel disease is a sequel of abdominal surgeries and has come forth as the leading cause of small bowel obstruction (SBO). It may also lead to chronic abdomino-pelvic pain and infertility in women. Adhesions form as a result of peritoneal irritation, giving rise to an inflammatory process. The treatment of choice for adhesive small bowel obstruction remains controversial, and relies on the surgeon’s judgment.Being described is an unusual case of a young girl who developed complete ileal transection secondary to postoperative adhesive band formation.Adhesive small bowel disease (ASBD) and small bowel obstruction are a major cause of patient distress and financial and clinical practice burden. It is usually a diagnosis of exclusion and leads to delayed treatment and morbidity. Many preventive techniques and materials are being tested to prevent adhesion formation. A lot more needs to be done to prevent, in the first place, the formation of adhesions or treat this condition to reduce such morbid outcomes as strangulation or transection of gut. As muchASBO is a leading cause of surgical admissions 16%) 5 and due to tendency to recur, it markedly increases morbidity and health care costs [6% 5 and Bands formed as a result can be so tight as to case ischemia and necrosis of the affected small bowel segment leading to complete transaction as with our patient . Such a 2The following case is being reported in line with the SCARE criteria . An 18-yShe gave a history of an abdominal surgery at the age of 2 years, of whose nature the parents and the patient were unaware and no documentation was available. Patient was not on any medication and family history was unremarkable. Moreover, patient has had multiple recurrent admissions to the hospital for intestinal obstruction in the past 6 months, which all resolved with conservative management. Patient was of the view that her symptoms are the result of the surgery she had during her childhood.As before, she was put on conservative management with nasogastric decompression and intravenous fluid therapy. Her condition failed to resolve as a radiograph two days later appeared to have even worse dilatation of bowel loops .Fig. 2AbBarium meal follow through revealed thickened folds and dilatation of small bowel , Fig. 4.Surgery was performed by assistant professor of surgery at the hospital. Per-operatively, a band was identified at 2 feet distal to duodeno-jejunal junction. Upon further exploration, two blind ending loops of ileum were found buried in the band , Fig. 6.Histopathology was consistent with an ileal band and the patient is symptom free at 4 months post-operatively.3Small bowel obstruction is a condition where there is interruption of forward flow of intestinal contents. It was first described by Hippocrates and first treatment was performed by Praxagoras in 350 BC . Bowel oLeading cause of small bowel obstruction is adhesions (60%), followed by hernia 25%) and neoplasm (5–10%) 5% and ne. First aAdhesions are pathological bonds between omentum, bowel loops and abdominal wall . These mAdhesions form in 93–100% of cases after upper abdominal surgeries and 67–93% of lower abdominal surgeries . AdhesioFortunately, only 15–18% of these patients require second surgery [Adhesions may even form a tight constricting band around the bowel, leading in time to complete transection and formation of two blind loops , as was Mortality rates for ASBO range from 3% for simple obstruction to a massive 30% with bowel necrosis or perforation .2 pneumoperitoneum and insufflation pressures have been linked to increased adhesion formation [Risk factors for ASBO including type of initial surgery, site of adhesion, timing and recurrence rate of adhesive obstruction haven’t been fully understood . Factorsormation .Adhesion prevention involves general principles and surgical techniques, mechanical barriers and chemical agents .Adhesions can be prevented by following basic Halstedian principles, which should be applied to all surgical procedures . CarefulAddition of 2–4% oxygen during laparoscopic procedure reduces adhesion formation, indicating peritoneal hypoxia as underlying cause [Several liquid and solid barriers have been tested with varying results. Liquid barriers include crystalloids, dextran, hyaluronic acid, cross-linked hyaluronic acid and icodextran. Solid barriers such as oxidized regenerated cellulose, expanded polytetrafluoroethylene, hyaluronic acid-carboxymethylcellulose and polyethyleneglycol have been shown to be of benefit.Chemical agents prevent fibrin organization. Commonly NSAIDs, corticosteroids, calcium channel blockers, histamine antagonists, antibiotics, fibrinolytic agents, anticoagulants, antioxidants, hormones, vitamins, colchicines and selective immune-suppressors have been used and found effective. Local anesthetic agents, owing to their anti-inflammatory properties have also been shown to inhibit adhesion formation .A detailed history, including history of prior surgeries and thorough physical examination are paramount to the diagnosis of bowel obstruction. ASBO is commonly a diagnosis of exclusion . Among mGastrograffin is used to categorize patients for non-surgical management of bowel obstruction. It successfully identified 91% of patients for conservative management in a study .Treatment of ASBO is either conservative or surgical. Studies have reported that 60–80% of the patients are treated conservatively while 20–40% undergo surgery but the choice and timing of management option is still debatable. Bologna guidelines prefer a non-operative approach in absence of strangulation, since re-intervention promotes further adhesion formation. Observation period varies in different studies from 72 h to as long as 10 days .Moreover, persistent abdominal pain, fever, tachycardia, abdominal tenderness, rebound tenderness and muscular resistance indicate strangulation, in which situation surgical intervention should be undertaken .Formation of post-operative adhesions is a common complication. It is the leading cause of small bowel obstruction and can lead to such dreadful conditions as complete bowel transaction. The physician and patient should be aware of possibility of adhesions and it should clearly be mentioned in the informed consent. Etiology, pathophysiology, diagnostic modality and choice of treatment option are not fully understood. Prevention is better than cure holds true in the setting of adhesions.None.None.Yes approval form has been attached.Informed written consent was taken and identity not disclosed.Data collection, literature search and manuscript writing was done by Dr. Qurrat Al Ain Atif, who also assisted the surgery.N/A.Dr. QUrrat Al Ain Atif is the guarantor of submission.Not commissioned, externally peer reviewed.


Distant metastatic disease from gliomas is extremely rare. We report the case of a 17-year-old female with an H3F3A G34R mutated infiltrative glioma who developed painful osseous metastases to her pelvis and spine within 3 months of clinical presentation. The presence of an H3F3A mutation in these patients may indicate further work-up to include intensive staging examination. Pediatric diffuse gliomas are a spectrum of primary central nervous system (CNS) tumors distinguished from their adult counterparts by morphologic and phenotypic characteristics as well as prognostic, genotypic markers . Within Some biological subgroups of pediatric HGGs, characterized by somatic histone mutations , underlie distinct profiles of gliomagenesis . In a reWe describe a case of pediatric HGG with an H3F3A G34R mutation and extraneural metastases. HGGs with G34 mutations are typically diagnosed in adolescence or young adulthood (age range: 10–25 years). They commonly arise in hemispheric or cortical structures and present along with a gradient of GBM, GBM-like, PNET-like, and PNET morphology. Median survival is estimated to be 22 months, possibly as a consequence of the high frequency of MGMT promoter methylation in these tumors and subsequent favorable response to chemotherapy protocols .Patient consent for publication was obtained. A 17-year old female presented to an outside hospital (OSH) after she fell down the stairs in her home. She attributed the fall to a 1-month history of numbness, tingling, and weakness in her bilateral lower extremities (BLE), back pain, as well as the sudden onset of blurry vision. On physical exam, she was found to be areflexic in both legs. An initial non-contrast MRI of the brain shortly after admission  revealedA biopsy of a 0.5 cm right iliac lesion was attempted and demonstrated non-specific atypical cells that stained CD56+ on immunohistochemistry (IHC). The patient then underwent three lumbar punctures (LPs) with high opening pressures and elevated glucose but with negative cytology. Due to her high intracranial pressure, a brain biopsy was deferred at this time.Two months later, the patient again presented to an emergency department following a generalized tonic-clonic seizure. A repeat LP revealed an increased opening pressure of 60 mm Hg and an MRI of the brain demonstrated the continued progression of her existing lesions in the parasagittal right frontal and parietal lobes with associated increasing infiltrative T2 signal. An MRI of the spine see  showed tStereotactic biopsy of the right frontal lobe lesion was performed revealing an infiltrative, diffuse high-grade glioma with diffuse strong expression of p53. An H3F3A G34R mutation of specimen tissue was identified by pyrosequencing analysis. A bone marrow (BM) biopsy from the left anterior iliac crest was performed ~2 weeks following the brain biopsy. Evaluation of the bone marrow specimen revealed diffusely metastatic tumor with metastatic cells representing 30% of marrow cellularity within the sample. The immunohistochemical evaluation of the malignant cells revealed a diffuse strong expression for p53, ATRX expression, and focal weak expression for CD56. The profile of the malignant cells in the bone marrow were thought to be consistent with the recently diagnosed infiltrative brain glioma when compared together.During this admission the patient also underwent a lumbar puncture. Cerebrospinal fluid analysis revealed rare atypical cells thought to be compatible with the glioma. A CT of the chest with contrast performed also at this admission revealed the interval development of a large soft tissue mass in the right lower lateral chest wall centered around a rib . This waThe patient's metastatic disease continued to progress over the next 2 months with an CT of the abdomen and pelvis with contrast ~2 months after the last admission revealing diffuse osseous metastases throughout the bony pelvis and bilateral proximal femora . ExtensiExtraneural HGG metastasis is extremely rare, and the scarcity of this finding may lead to a delay in diagnosis and unnecessary diagnostic considerations. Here we describe the rapid development of widespread osseous metastatic disease from an infiltrative high-grade glioma with an H3F3A G34R mutation which is the first reported case from this genetic variant.The extraneural spread of HGG most commonly occurs secondary to iatrogenic procedures. Examples include tumor implantation along biopsy tracts or seeding of the peritoneum through ventriculoperitoneal shunts, with at least 28 cases reported of pediatric primary brain tumors seeding to the peritoneum . In addiObstacles to extraneural HGG metastasis include shortened patient lifespans, the presence of a thick dura around intracranial veins, and the inability of organ stroma to support and nurture the development of glial cells . Here, wThe presence of an H3F3A mutation was detected in two other documented pediatric HGG patients with bony metastases; however, our patient demonstrated a G34R mutation instead of K27M . Within de novo malignant GCTBs; (2) secondary transformation of malignant GCTBs; and (3) Denosumab-treatment effects leading GCTBs to mimic osteosarcomas  and, to a much lesser extent, osteosarcomas –10. Diresarcomas .Extraneural HGG metastasis likely has a complicated, multifactorial etiology that has yet to be delineated entirely. The identification of risk factors associated with this rare finding may result in earlier detection and treatment, potentially optimizing outcomes, since the presence of an H3F3A mutation in HGG is an important prognostic indicator. The mechanism of spread remains elusive and additional investigation is necessary to tease out its underlying pathogenesis.This study was carried out in accordance with the recommendations of The University of Texas MD Anderson Cancer Center. Case reports do not meet the institutional definition of research and are thus exempt from informed consent. No patient identifying information is included in this report.AJ, MG-M, MC, and JJ contributed to the conception and design of the study. AJ wrote the first draft of the manuscript. MG-M, MC, and JJ wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.