We describe the case of a 50-year-old woman who was admitted to a pheriferal department for heart failure. The echocardiography revealed a small mass measuring about 1.3 × 1.0 cm adhering to the non-coronary cusp of the aortic valve, mild dilated cardiomiopathy and severe biventricular dysfunction. This mass had erroneously been considered a thrombotic lesion, so the patient was treated with thrombolysis and heparin e.v. Only after a transoesophageal echocardiography a tumour cardiac mass was suspected. The diagnosis of fibroelastoma was confirmed by MRI and then from the anatomic and histoligical definition after surgery. Cardiac papillary fibroelastoma (PFE) is a rare primary cardiac neoplasm of unknown prevalence . Since tWe describe the case of a 50-year-old woman who was admitted to a pheriferal department for heart failure (NHYA class III) in mild idiopathic dilated cardiomyopathy. She had chronic atrial fibrillation and hypertension in anamnesis. On admission to the hospital, the patient's blood pressure and heart rate were normal. Her oral temperature was 36.5°C. Examination of the head and neck revealed no abnormalities; the external jugular vein was distended; no adenopathy was present. Abdominal examination revealed mild hepatomegaly. Cardiac examination revealed a systolic murmur at the fourth intercostal space on the marginal sternal line. The laboratory results were normal; no increase in inflammatory index. Chest radiograph showed an enlarged cardiac silhouette and the ECG showed atrial fibrillation. The patient also underwent echocardiography, which revealed a small mass measuring about 1.3 × 1.0 cm adhering to the non-coronary cusp of the aortic valve, mild dilated cardiomiopathy and severe biventricular dysfunction. In order to the presence of AF, this mass had erroneously been considered a thrombotic lesion, so the patient was treated with thrombolysis and heparin e.v.After fibrinolysis, the dimension of this lesion did not change, so the patient was transferred to our department. Transthoracic and transoesophageal echocardiography was performed to define the mass. It showed a highly mobile, homogeneous echodense mass with a smooth surface from a pedicle to the closing margins of the noncoronary aortic cusp. All three aortic cusps had no signs of thickening and appeared normal as judged by echocardiography. Colour Doppler revealed no valvular incompetence. From echocardiographic findings, a tumour of the aortic valve rather than a thrombus or a vegetation was suspected Figs.  and 2. MTo prevent systemic embolization, the patient underwent excision of the tumor. The echocardiographic and MRI findings were confirmed during surgery. A 1-cm papillary mass was found attached to the noncoronary cusp of the aortic valve and was treated by simple excision of the tumour without aortic valve replacement. Histological examination revealed several fragments covered by flattened cells. The core was composed of dense fibrous tissue with hyalinization, consistent with a papillary fibroelastoma of the endocardium.In the following days, the patient no longer showed signs of dyspnoea. An echocardiogram was performed at discharge without evidence of a mass attached to the noncoronary aortic cusp.Papillary fibroelastoma (PFE) is a benign, rare, gelatinous tumour derived from the endocardium; concerning frequency, it corresponds to the third most common primary intracardiac tumour, preceded by myxomas and lipomas . ApproxiApproximately 44% of PFE are found in aortic valves, followed by the undertaking of mitral valve in 35% of cases, tricuspid valves in 15%, and pulmonary valves in 8% . ReportsThe size of described PFE varies from 0.1 to 4 cm, and most of them are smaller than 1 cm in diameter . The agePFE is an incidental finding in most cases, although among symptomatic patients the clinical presentation is variable and dependent on location, motility and size of tumour -9. As moElectrocardiographic findings are non-specific. Thoracic radiography may demonstrate signs of increase of cardiac chambers, pulmonary hypertension or congestion, especially if the tumour is occluding the mitral valve. Transthoracic, particularly transoesophageal, echocardiograms are the ideal method for tumour diagnosis and characterization, as they usually show the mass with its varied proportions, motile or not, well-delimited, pedunculated or sessile, of round, oval or irregular shape. They are mostly small (99% less than than 2.0 cm). Magnetic resonance imaging reveals the mass in valve leaflet or cardiac chamber, and the presence of enhancement with gadolinium in the tumoral mass increases the suspicion level . CardiacPFE has a characteristic appearance, resembling a sea anemone, with multiple ramifications held by a pedicle to the endocardium. At histological examination, it consists of an endothelium coat, which covers a connective tissue matrix with variable amounts of collagen, smooth muscle cells and elastic fibres .For symptomatic patients, surgical exeresis is the choce of treatment, in an attempt to preserve valve tissue and function . Among aManagement before a left side isolated lesion includes surgical removal, when the mass is big and/or movable or in the precence of patent oval foramen due to the possibility of paradoxical embolism . When thTransoesophageal echocardiography is proving to be superior to transthoracic echocardiography, not only in confirming the precence of a cardiac mass but also in defining its attachment to the underlying tissue, its exact location and its relation with surrounding structures .In our case transthoracic echocardiography wasn't be able to correctly diagnosed fibroelastoma and so it managed to a wrong diagnosis and so to a wrong therapy. So there is the extreme necessity to perform always a transoesophageal echocardiography and particularly when a scarce acoustic window is present at the transthoracic one in order to give the correct diagnosis and the correct theraphy. In our case the probability that the mass could be a thrombus was very low. There are no definitive features on TTE that distinguish papillary fibroelastoma from other intracardiac masses. The sensitivity and specificity of TTE are in the order of 88.9% and 87.8%, respectively, with an overall accuracy of 88.4%, when the tumour is larger than 0.2 cm. When the tumour is less than 0.2 cm, the overall sensitivity of TTE is 61.9%, compared with 76.6% for TEE . Single Echocardiographic diagnosis is not easy, particularly when PFE is small in size, when an associated lesion is masking the tumour, when there is a lack of significant characteristics to differentiate PFE from degenerative valve disease, and when the index of suspicion during the examination is insufficient . DiffereHowever, it is almost impossible to define tissue character using this tecnique alone, as in our case. Magnetic resonance imaging excels at making a differential diagnosis of various soft tissues and organs because of its high resolving power . CardiacWe have presented a case of fibroelastoma that was initially incorrectly diagnosed by transthoracic echocardiography; it was detected and diagnosed by TTE echocardiography and magnetic resonance imaging. In cases of cardiac and valvular tumour, transoesophageal echocardiography and magnetic resonance imaging play important roles in making a diagnosis and selecting the optimal surgical treatment.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.EC and PF performed transthoracic and thransesophageal echocardiography. EV, GZ and EA treated and follow-up the patient during the admission and the stay in the hospital. SN and LDC gave us the supervision.


Mesenteric cysts are rare intra-abdominal lesions with variable clinical symptoms and signs that make pre-operative diagnosis difficult. Optimal treatment is surgical excision of the cyst with laparotomy or laparoscopy. We present a case of mesenteric cyst that was misdiagnosed as para-ovarian cyst and managed laparoscopically by gynaecologists. Mesenteric cysts are rare intra-abdominal tumors with prevalence 1:100.000 in adults and 1:20.000 in children [We present a case of mesenteric cyst that was misdiagnosed as para-ovarian cyst and managed successfully laparoscopically.A 30 years old, G0P0, Caucasian, housewife, refer red to our department for surgical management of a left-sided para-ovarian cyst. Her only complaint was a vague, non-specific lower abdominal pain for the previous 6 months. She had an appendicectomy at the age of 12 but the rest of her medical and family history were unremarkable.Clinical examination was also unremarkable and her blood tests were normal. Bimanual gynaecological examination revealed a palpable, motile tumor in the left adnexae. Trans-vaginal ultrasound revealed a 4.33 × 4.84 × 4.52 cm thin-walled, simple, unilocular cyst, located next to the left ovary Fig. . A para-At laparoscopy a simple cyst was seen lying inferior and lateral to the aortic bifurcation, arising from the mesenterium of the descending colon, in contact with left ovary. During exploration the cyst was found movable, attached only posteriorly to the mesenterium. The cyst was carefully disected with the assistance of ultracision harmonic scalpel  and removed intact. Thorough examination of the integrity of the bowel and the mesenteric vessels was followed. The specimen was placed in an endobag, aspirated and extracted from the peritoneal cavity through the 10 mm suprapubic port. Histopathological examination revealed a simple, benign mesothelial cyst of the mesenterium.The patient's post-operative period was uneventful and she was discharged free of symptoms the following day. One year after the surgery she remains completely asymptomatic.Mesenteric cysts are quite rare intra-abdominal lesions. Italian anatomist Benevenni first described this entity performing an autopsy in an 8 years old boy in 1507 .In most of the cases the cysts are located in the mesenterium of small intestine, but they can also be found in the descending colon and rectum . Their hMesenteric cysts size ranges between a few centimeters and 10 cm . UsuallyCorrect pre-operative diagnosis is quite difficult due to the rarity of the entity and the lack of specific symptoms and signs. It can be achieved when the phycisian is alerted concerning this condition and includes it in the differential diagnosis of intra-peritoneal cysts. Clinical imaging   may aid The treatment of choice is complete surgical excision of the cyst. This can be done either by laparotomy or laparoscopy ,8. The dMesenteric cysts, although quite rare tumors of the mesenterium, must always be considered in differential diagnosis of pelvic cystic lesions. Laparoscopic enucleation of mesenteric cysts is feasible and should be considered as the treatment of choice.Written informed consent was obtained from patient – in her native language – for publication of this case report and accompanying image. Copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.TDT and LZ conceived the study and participated in patient management and surgery, acquisition of data, interpretation of data, and were major contributors in writing the manuscript. DA participated in patient management, acquisition of data, and drafting of the manuscript. FT and DK revised critically the manuscript adding substantial intellectual content. JB coordinated the study and patient management and revised critically the manuscript. All authors have read and approved the final manuscript. The manuscript is not under consideration and has not been published by another journal.


The endodontic treatment of teeth with dens invaginatus, characterized by an infolding of enamel and dentin, extending deep into the pulp cavity near the root apex, may be complicated and challenging. The complexity of the internal anatomy may create challenges for the complete removal of diseased pulpal tissue and the subsequent sealing of the canal system. Because of the bizarre root canal anatomy and widely open apex, a combination of nonsurgical and surgical endodontic treatment or extraction is the most common choice of therapy. This article describes case reports of nonsurgical endodontic treatment of Type II dens invaginatus associated with periradicular lesion. Dens invaginatus is a developmental malformation of teeth, showing a wide spectrum of anatomical variations. Salter first described anatomical anomaly in 1855 as “a tooth within a tooth.” Ploquet first described it in 1974, which found this malformation in a whale′s tooth. Dens invaginatus is a deep surface invagination of the crown or root that is lined by enamel. Affected teeth show a deep infolding of enamel and dentin starting from the foramen cecum or even the tip of the cusps, which may extend deep into the root. MaxillarOehlers was the first to classify three different types of dens invaginatus according to depth of invagination into the root: Type I: A 23-year-old male patient reported to Department of Conservative dentistry and Endodontics, V.S. Dental College and Hospital, Bangalore with the complaint of pain and swelling of the gums and subsequent pus discharge from that swelling in the upper right front tooth region of the jaw since a month. A history of recurrent development of gumboil in that region, usually associated with dull-ache was presented. Clinical examination revealed a parulis in the attached gingiva of maxillary right lateral incisor . Tooth wA 23-year-old female reported to our hospital for endodontic treatment of the maxillary right lateral incisor. The chief complaint of the patient was discolored tooth in relation to maxillary right lateral incisor with a history of recurrent painful swelling over the palatal area for the past 3 years. Medical history was not contributory. Clinical examination showed that both the hard and soft tissues were within normal limits. Maxillary right lateral incisor revealed a yellowish discoloration, distal tilting of clinical crown and a deep depression on lingual surface near the distal marginal ridge . This toUnder rubber dam isolation, access cavity was prepared. It was found that an invaginated mass of hard tissue almost occupied the whole pulp space. During root canal instrumentation using hand files, a large volume of pale yellow fluid was continuously draining from canal. The canals were irrigated with 5.2% sodium hypochlorite solution along with passive ultrasonic irrigation. Calcium hydroxide (Metapex) was used as an inter-appointment intracanal dressing. The invaginated mass was continuously removed using hand files in combination with copious irrigation. Shaping and cleaning of the canal was completed at the subsequent visit. The tooth was obturated with Gutta percha and root canal sealer using lateral compaction technique. With the evidence of healing, the tooth was restored with post and metal ceramic crown Figure  and d.A 19-year-old girl was referred to our hospital from her village practitioner for the evaluation of a recurrent sinus tract in the lower left lateral incisor region. History revealed recurrent episodes of pain and swelling in that region with subsequent drainage of pus and pain relief since a year. On examination, mandibular left lateral incisor had a comparatively larger crown with an attempted access cavity preparation and an associated draining intraoral sinus. Both teeth were associated with tenderness to percussion and no response to thermal and electrical pulp testing. Periapical radiograph showed a type II dens invagination of lateral incisor and a periapical radiolucency . A cliniThere have been few reports of cases involving endodontic treatment of dens invaginatus. The cases described here demonstrated the anatomical difficulties that can lead to endodontic failure and the development of periapical pathology. Nonsurgical endodontic treatment should be attempted first. Regardless of the size of the periradicular lesion, surgical treatment is the second option only when the nonsurgical endodontic treatment has failed. The successful treatment of this case indicates that the size of the periradicular lesion does not dictate the treatment procedure and influence the treatment outcome of nonsurgical root canal therapy.Many factors might affect the prognosis of nonsurgical endodontic treatment of this case. First, the severely invaginated central mass of hard tissue almost occupying the whole pulpal space rendered debridement of the canal difficult. Second, the continuous drainage of fluid from the canal during treatment prevented dryness of the canals. Third, the widely open apex negated apical seal of the root canal filling.Completely debriding the infected canal is the key to the success of this case. The removal of invaginated mass of hard tissue in the canal is difficult and challenging. In this case, it took three visits to totally remove the deeply invaginated mass using hand files.Calcium hydroxide has been used as interappoinment intracanal medicament. It also The use of MTA as an apical seal for immature root allows the immediate rehabilitation of the crown, thus increasing the resistance to fracture and enhancing the esthetic result.The above case illustrates that even in a tooth with dens invaginatus and an associated large periradicular lesion, nonsurgical endodontic treatment without surgical intervention, can result in satisfactory periradicular healing.The accurate knowledge of variations in the morphology of pulp cavity will greatly assist the dentist in performing successful endodontic therapy. In cases with complex internal morphology access, cavity refinement may be required for stress-free entry to the root canal system.


Giant intradural extramedullary schwannomas of the thoracic spine are not common. Schwannomas, that is, tumors derived from neoplastic Schwann cells, and neurofibromas represent the most common intradural extramedullary spinal lesions. We report the case of a patient with a giant thoracic schwannoma presenting unusually with acute abdominal pain and with delayed neurological impairment.A 26-year-old Hispanic man with no previous medical problems presented with acute periumbilical pain. After extensive work-up including an exploratory laparotomy for appendectomy, magnetic resonance imaging scans of the lumbar and thoracic spine revealed a giant intradural extramedullary thoracic schwannoma within the spinal canal posterior to the T9, T10, and T11 vertebral bodies. Magnetic resonance imaging signal prolongation was noted in the spinal cord both rostral and caudal to the schwannoma. The patient underwent an urgent laminectomy from T8 to L1. After sacrificing the T10 root, the tumor was removed en bloc. Postoperatively, the patient improved significantly gaining antigravity strength in both lower extremities.The T10 dermatome is represented by the umbilical region. This referred pain may represent a mechanism by which a giant thoracic schwannoma may present as acute abdominal pain. Acute, intense abdominal pain with delayed neurologic deficit is a rare presentation of a thoracic schwannoma but should be considered as a possible cause of abdominal pain presenting without clear etiology. Although these lesions may be delayed in their diagnosis, early diagnosis and treatment may lead to an improved clinical outcome. Schwannomas, that is, tumors derived from neoplastic Schwann cells, and neurofibromas represent the most common intradural extramedullary lesions, accounting for approximately 30% of all nerve sheath tumors in adults ,2. TheseSchwannomas commonly appear radiographically as 'dumbbells' that traverse across the dural lining, and comprise about 25% of all spinal tumors -10. ThesA 26-year-old Hispanic man with no previous medical problems, presented with chronic abdominal pain that he had been experiencing for 2 years. Approximately 1 year before presentation at our facility, he underwent a peritoneal biopsy which did not reveal anything abnormal. Over several days, the patient developed acute periumbilical pain and was admitted for work-up of this acute presentation of abdomen pain. The patient had not had this acute periumbilical pain before but had experienced chronic abdominal shooting pain for up to 2 years previously. He reported no cramps, no nausea, no vomiting, and no migration of the pain. The periumbilical pain was a new onset, abrupt continuous sharp feeling of pain that was different from his chronic abdominal discomfort. On physical examination, he was afebrile and had a soft and minimally tender abdomen. Although he had periumbilical pain, it was not exacerbated by palpation, and there was no rebound and no guarding on examination. His bowel sounds were normal. His laboratory tests revealed a normal white cell count, liver function, and chemistry panels.The work-up for this abrupt onset of acute abdominal pain was evaluated by upper gastro-intestinal (GI) endoscopy, radiographic upper GI series, and finally a surgical exploratory laparotomy which revealed no apparent bowel pathology and during which an appendectomy of a grossly normal appearing appendix was performed. All of these procedures revealed normal anatomy of the peritoneum and abdominal organs. During the week of admission for work-up of this abrupt onset of acute abdominal pain, the patient developed sudden, severe lower extremity weakness and an abrupt lower extremity decrease in sensation.Within 48 hours of onset, the patient's physical examination demonstrated a flaccid paraplegia of the lower extremities. There was decreased sensation to light touch and joint position sense below approximately T10. Pinprick and temperature sensation were diminished below the T9 dermatome. The patient did have some minimal distal lower extremity muscle function intact without antigravity. His rectal tone was mildly decreased and his lower extremity reflexes were hyper-reflexive with an up-going Babinski reflex.Emergency magnetic resonance imaging (MRI) scans of the lumbar and thoracic spine revealed an intradural extramedullary mass within the spinal canal posterior to the T9, T10, and T11 vertebral bodies. The mass was multicystic and well circumscribed with contrast enhancement of the periphery Figure . The MRIThe patient underwent an urgent laminectomy from T8 to L1. Intra-operatively, it was noted that the spinal cord was severely compressed most markedly at T10. After sacrificing the T10 root, the tumor was removed en bloc. With the gross appearance of a schwannoma intra-operatively, the histologic tissue analysis confirmed this diagnosis with observation of spindle-shaped Schwann cells and elongated nuclei consistent with a schwannoma tumor. There were no malignant or atypical features on the tissue histologically on pathologic analysis. Postoperatively, after resection of this giant thoracic schwannoma, the patient improved significantly gaining antigravity strength in his lower extremities.Patients with nerve sheath tumors generally follow an indolent clinical course related to slow tumor growth; this gradual displacement of the spinal cord causes symptoms proportionally less severe than expected from the tumor size. Back pain without other neurological signs is the most common complaint from these patients . The delThe presentation of symptoms can be extremely diverse depending on the areas of the spine affected by nerve cord tumors ; tumors In spinal lesions between T8 and T12, the patient is likely to feel pain on the surface of the abdomen or within the abdominal cavity . The corIn a report of two cases of patients with spinal disease, Jooma and Torrens  presenteNeinstein reported a similar case in an 18-year-old man who presented with a 1.5-year history of left lower quadrant abdominal pain, left-sided flank pain and left lumbar back pain radiating to the buttocks. The correct diagnosis of a T11 schwannoma was reached after almost 1 year, upon which he underwent a T10-T11 laminectomy and postoperatively, recovered sufficiently to return to normal activities .Cox and Alter report a challenging diagnosis in a 30-year-old man who presented with unilateral abdominal and back pain. Despite multiple evaluations, the cause of the symptoms was not identified until 11 months after the beginning of the symptoms, when an MRI scan showed an intradural extramedullary schwannoma at the T10 level .This case report presents a giant thoracic schwannoma as a difficult and challenging diagnosis for acute abdominal pain with delayed neurologic findings. Giant thoracic schwannomas rarely present in this manner because most schwannomas become significantly symptomatic once the spinal cord is compromised. This usually occurs before the schwannoma can grow to a giant size. Hence most neoplasms are detected before they grow to such large sizes in the thoracic spinal canal. Furthermore, the evidence for referred pain between the abdominal viscera and the innervations of specific spinal cord levels indicates a possible mechanism by which a slow-growing giant neoplasm could present with the abrupt presentation of an acute abdomen.Patients with low thoracic or high lumbar lesions with unusual presentations and late neurologic symptoms may experience a significant delay in diagnosis and treatment of their tumor. In a retrospective study of 42 patients with spinal schwannomas, Asahara and Kawai  report tReaching the decision to test for schwannomas when faced with unusual symptoms is problematic, but once a peripheral nerve sheath tumor is suspected, the testing is relatively straightforward. The advent of computed tomography (CT) and MRI has decreased mortality and morbidity rates and these technologies are still the main methods for diagnosis and detection of the lesions. MRI is the method of choice over CT since it has been proved to be equal to or better than CT in analyzing this type of tumor ,11,13,14Although MRI has improved the diagnosis of spinal cord tumors, the precise histologic diagnosis cannot be made with radiographic studies alone. Tissue diagnosis is required to establish diagnosis in most spinal cord tumor cases.Finally, because of the propensity for neurofibromatosis type 2 patients to develop schwannomas, genetic testing for the neurofibromatosis mutation as well as merlin, a tumor suppressor gene localized on chromosome 22q12, should be performed in patients diagnosed with spinal cord schwannomas. Malignant lesions are more commonly associated with neurofibromatosis type 1 and should be considered in solitary tumor cases if other cutaneous manifestations are present. Neurofibromatosis type 2 is more commonly associated with multiple benign tumors.Thoracic schwannomas can present with acute onset of abdominal pain without clear etiology and without neurologic deficit. We report an unusual case of a patient with a giant thoracic schwannoma, who presented with abrupt and acute onset of abdominal pain over several days and underwent a completely negative gastrointestinal evaluation with endoscopy, radiographic studies, and finally a surgical abdominal laparotomy. This acute abrupt onset of periumbilical pain with delayed neurological deficit was finally diagnosed as being caused by a T10 schwannoma. Abdominal symptoms can be a manifestation of a spinal lesion because of the referred pain through cross innervations between the abdominal viscera and organs with varying spinal dermatomes. Although thoracic lesions commonly present as back pain, thoracic lesions such as schwannomas must be considered in the differential diagnosis of acute abdomen without clear etiology.GI: gastrointestinal; MRI: magnetic resonance imaging; CT: computed tomography.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.IY analyzed and gathered the data and was a major contributor to the manuscript. EP and NH gathered data, references, analyses and contributed to the manuscript. ATP and CPA were the senior authors and provided input, reflection, and overall guidance of the manuscript. All authors read and approved the final manuscript.


Skene's glands, also known as paraurethral glands, are homologues of the male prostate, in which painless cystic masses and inflammation due to obstruction have been rarely found and reported. In addition, there have been rare reported cases of adenocarcinoma of Skene's glands. Recently, the authors experienced the first case of adenofibroma arising in Skene's glands of a 62-year-old woman with coital pain. Hereby, we present the case with pathologic and immunohistochemical findings and a short review of literature. Skene's glands and ducts are one of thirty normal duct structures in the female genital tract which were first introduced and described by Alexander Johnston Chalmers Skene in 1880. These have been thought to be homologues of the male prostate. A pair of glands is located posterolaterally to the urethra and opens its opening at the end of the urethra. Histologically, it is composed of glandular structures which are lined by pseudostratified columnar epithelium and ductal structures which are lined by either stratified squamous or transitional epithelium. Skene's glands secrete a small amount of mucoid material for sexual stimulation. A few kinds of diseases such as painless cystic mass and inflammation due to ductal obstruction were rarely documented . In addi Adenofibroma is a mixed biphasic tumor with glandular and fibrous proliferation. Most adenofibromas have been reported from ovary, breast, and uterine cervix. Rare cases of testicular and endometrial adenofibromas have been reported, but to the best of our knowledge, no cases have been reported from Skene's glands. Recently, we experienced a case of adenofibroma arising in Skene's glands of a 62-year-old woman with coital pain. Hereby, we present the first such case of adenofibroma of Skene's glands with pathologic and immunohistochemical findings and a short review of literature.A 62-year-old woman presented to our hospital with a red erythematous tumor in the external genitalia and coital pain. She had no specific past or family history and did not show any other abnormality except the tumor on physical examination. An excision on that lesion was performed with the clinical impression of urethral caruncle. Serum prostatic specific antigen (PSA) was not measured preoperatively.Grossly, the tumor was of a reddish tan ovoid mass, measuring 1.2 × 1 × 1 cm, covered by pale tan mucosa with focal increased vascularity and showing gray white homogenous fibrotic cut surface. Microscopically, the external surface was covered by stratified squamous epithelium and the inner part of the tumor revealed a moderate proliferation of two kinds of atypical glandular structures, relatively large glands containing mucoid material and tiny glands dispersing irregularly  and On follow-up physical examination after the surgery, the patient did not complaint about coital pain anymore.Adenofibroma is a term which designates a benign biphasic tumor composed of atypical proliferation of glandular epithelium and surrounding fibrous stromal cells. Most of adenofibroma have been reported from the ovary and breast. A few cases in the uterine endometrium , cervix Microscopically, the lesion described herein could be best classified as an example of adenofibroma with glandular and fibrous stromal proliferation. Because the glandular structures were lined by transitional type cells, urethral caruncle was the main differential diagnosis. However, because of lack of vascular dilatation and inflammatory background, urethral caruncle was easily excluded. Since the lesion was located at the paraurethral area, the possibility of Skene's gland origin lesion was raised. This case was unique for it has been confirmed with the immunohistochemical stain for PSA. When patients present with paraurethral mass, the main clinical differential diagnoses include urethral caruncle, cyst, inflammatory abscess, and a possibility of malignant tumor. In our case, the main pathologic differential diagnoses included adenofibroma, urethral caruncle, and less likely an adenocarcinoma with stromal reaction. Based on the lack of inflammatory and vascular changes as well as obvious malignant cytohistomorphologic changes, the possibility of caruncle and carcinoma was excluded. The reason why there have been no reported cases of adenofibroma in this location is a possibility that adenofibromas of Skene's glands could be misdiagnosed as urethral caruncle, clinically and pathologically. To find out the etiology or pathogenesis of this disease, however, further studies on this disease might be needed. When we face lesions from the paraurethral locations, besides of common cystic lesions or abscesses, the possibility of adenofibroma should be considered with doing PSA immunostaining.


We report the case of ovarian carcinoma with skin and umbilical metastasis in a 30-year-old female. The computed tomography (CT) scan of the abdomen showed a right ovarian mass with anterior abdominal wall metastasis. The CT-guided fine needle aspiration cytology (FNAC) from the ovarian mass showed adenocarcinoma. FNAC from the umbilical and skin metastasis also showed adenocarcinoma. Because of the unresectability of the mass, the patient was put on taxol-based chemotherapy, which she took for two cycles, and then died of progressive disease after three months. Ovarian cancer, a disease of ‘older women’ occurs primarily in postmenopausal women, with a peak incidence from 50 through 70 years of age. The disease is relatively uncommon before 40 years of age. Metastasis occurs primarily through the lymphatic and hematogenous pathways. A metastatic malignancy of the umbilicus commonly termed ‘Sister Mary Joseph nodule’ (SMJN) is a rare occurrence. Metastasis to the skin is still rarer, the reported incidence being 3%. We reporA 30-year-old female presented to our Outpatient Department (OPD) in October 2007, with a history of vague gastrointestinal complaints of dyspepsia, nausea, and constipation for the past three months, and a progressively increasing abdominal swelling for the past one month. She had developed a nodule in the epigastric area ten days back and another nodule in the periumbilical area a week back.On examination, the abdomen was distended and tense. Fluid thrill could be elicited. Bilateral inguinal lymphadenopathy was present. There was presence of umbilical hernia along with a nodule present over it discharging a serosanguinous fluid. An ulcerated nodule discharging a serosanguinous fluid was present in the epigastric area also .The CT scan of the abdomen  showed vMultiple small-to-medium sized hypodense heterogeneously enhancing lesions were seen in both lobes of the liver. Anterior abdominal wall deposits were present. There was a presence of retroperitoneal, diaphragmatic, and bilateral inguinal lymphadenopathy along with the ascites.CT-guided FNAC from the right ovarian solid cystic mass showed loosely cohesive ball-like clusters, acini and singly dispersed atypical cells on a proteinaceous background. Some of the clusters showed papillary disposition. The tumor cells displayed marked pleomorphism, high nucleocytoplasmic ratio, scant-to-moderate amount of pale cytoplasm, ill-defined cell borders, round-to-irregular nuclei, open chromatin, and prominent nucleoli. Mucin was present extracellularly as well as intracellularly. Binucleated and bizarre tumor cells were also present. The above-mentioned features were indicative of an adenocarcinoma of the ovary .FNAC from the skin and umbilical nodule showed atypical cells disposed in discohesive sheets and clusters, having a morphology similar to the primary ovarian adenocarcinoma . Her CA-Surgical resection was not possible due to the extensive local spread. In view of the fact that the primary tumor was not resectable and skin metastases were present, the patient was put on chemotherapy. She was planned for Taxol-based chemotherapy, which she took for two cycles and then died of progressive disease after three months.We report this case as a rarity of occurrence of adenocarcinoma ovary in a young female and also for the presence of skin and umbilical metastases.et al. had reported three cases of SMJN, with the primary tumors being, adenocarcinona of the sigmoid colon, carcinoma of the bladder, and adenocarcinoma of the gallbladder, respectively.[A periumblical nodule (Sister Mary Joseph nodule) is mostly suggestive of an abdominal malignancy. In about 75% of the cases, the histological type is adenocarcinoma, and is very rarely epidermoid, undifferentiated or carcinoid. In over 55% of the cases, the origin is from the digestive tract. A case report describing SMJN with a gastric primary has been recently published. Andreas ectively. A gynecoectively.5 This isectively. The inte


Infantile myofibromatosis is a rare mesenchymal disorder of infancy that can extensively involve the viscera including the gastrointestinal tract.In this report, an exceptional case of infantile myofibromatosis is described in which rectal prolapse and sigmoid colo-colonic intussusception were the initial presentations of colorectal involvement in a 2-month-old premature female infant.To the best of our knowledge, this is the first case reporting rectal prolapse and the second case documenting intussusception secondary to gastrointestinal involvement by infantile myofibromatosis. Infantile myofibromatosis (IM) is a rare mesenchymal disorder that can be solitary, multicentric or generalized . VisceraIn this report, we describe an exceptional case of IM that occurred in a premature infant with multiple skin and soft tissue nodular lesions. Her colorectal involvement was discovered due to the occurrence of rectal prolapse and sigmoid colo-colonic intussusception.in vitro fertilization pregnancy for a bicornuate uterus. While in the neonatal intensive care unit (NICU), the baby was found to have multiple nodules on her abdomen, chest and extremities, the largest measuring 1.8 cm on greatest dimension. Head, thoracic, abdominal and pelvic magnetic resonance imaging revealed the nodules to be primarily in the skeletal muscle and subcutaneous tissue. In addition, a 5 mm metaphyseal enhancing lesion was noted in the right proximal femur. Incisional biopsy was performed on the large nodule shown in Figure The patient was a 2-month-old premature infant who was twin A of a set from fraternal twin girls, and was born at 32 weeks of gestation age via Cesarean section to a 33-year-old gravida 2, para 0 woman who underwent an During her NICU course, she also had frequent heme-positive stools but no feeding intolerance or clinical signs of bowel obstruction. She presented with rectal mucosal prolapse. A 5 mm polypoid lesion was noted in the rectum while the prolapse was treated by submucosal injection of 50% dextrose solution as a sclerosing agent. The patient presented one day later with what appeared to be recurrent rectal prolapse that was manually reduced. To further evaluate her gastrointestinal tract, a barium enema was performed, which revealed a colo-colonic intussusception localized to the sigmoid colon that was not reducible by hydrostatic technique, laparoscopic maneuver, or manual reduction. The patient underwent a sigmoid colectomy with primary anastomosis. A barium enema of the entire colon 3 months after resection did not identify any additional lesions. Her postoperative course was uneventful and she has been doing well for the past 6 months after the surgery.The sigmoid resection specimen consisted of a 6 cm segment of large intestine with a 2 cm intussusception Figure . SuperfiThe biopsy of the subcutaneous nodule consisted of a 1.0 × 0.8 × 0.7 cm and a 1.4 × 0.6 × 0.2 cm white-tan soft tissue fragments that also showed myofibroblastic proliferation histologically. The myofibroblasts were plump with modest eosinophilic cytoplasm and arranged in irregular fascicles, reminiscent of nodular fascitis. There was no significant nuclear atypia or mitotic activity. Occasional inflammatory cells and multinucleated giant cells were present.Given the clinical findings of multiple nodules throughout the body, a diagnosis of IM with colorectal involvement was rendered. Cytogenetic studies performed on the subcutaneous nodule biopsy revealed a normal karyotype.Up to 40% of the patients with IM have visceral lesions that are invariably present at birth . The mosThere has been only one IM case that presented with intussusception reported in the literature . The patOur case is unique in that colorectal IM caused rectal prolapse, which has not been documented in previously reported cases. Colo-colonic intussusception observed in our case is also a unique finding because the sigmoid colon is an unusual location for intussusception to occur and IM nodules apparently served as the lead. Another interesting observation in our case is that visceral IM was only detected in the colorectum but spared the small intestine and the most frequently involved visceral site, the lungs, at least by imaging studies. The etiology for this unusual IM case remains unclear but it is interesting to note that the other twin was completely devoid of any myofibroblastic lesions.Because of its rarity, the histologic features of intestinal IM are poorly defined. An earlier case report of gastrointestinal multicentric IM described the histologic features as diffuse and nodular mucosal and submucosal fibrosis, small fascicles of plump fibroblast-like cells, decreased mucosal glands, and sparing of the muscularis mucosae . The hisIt has been shown that solitary and multicentric IM in the absence of visceral involvement bears an excellent prognosis. The lesions may either undergo spontaneous regression or be cured by simple local excision. The prognosis is poor in infants with visceral lesions . This isWritten informed consent was obtained from the patient' parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DD performed the histologic examination of the surgical specimens, did literature search and wrote the manuscript. PKF collected clinical data and critically read the manuscript. HLW performed the histologic examination of the surgical specimens, did literature search, and edited the manuscript. All authors have read and approved the final manuscript.


Bronchogenic cyst is a rare clinical entity that occurs due to abnormal development of the foregut; the majority of bronchogenic cysts have been described in the mediastinum and they are rarely found in an extrathoracic location.We describe the case of an intra-abdominal bronchogenic cyst of the mesentery, incidentally discovered during an emergency laparotomy for a perforated gastric ulcer in a 33-year-old Caucasian man.Bronchogenic cyst should be considered in the differential diagnosis of subdiaphragmatic masses, even in an intraperitoneal location. The laryngotracheal groove appears at the end of the third week of gestation in the embryonic foregut ; the dorBronchogenic cysts form from accessory ventral buds arising from the foregut distal to the future lung at about the fifth week of intra-uterine life; the majority of bronchogenic cysts have been described in the mediastinum  and tWe report a bronchogenic cyst incidentally discovered as a small intra-peritoneal mass in our patient, who was admitted to our surgical unit for acute abdominal pain due to gastric ulcer perforation.3 (polymorphonuclear leukocytes 84.6%) and sluggish peristalsis. He had a history of misuse of a non-steroidal anti-inflammatory drug (NSAID) used to manage his back pain without any medical prescription.Our patient, a 33-year-old Caucasian man, was referred to our institution for acute abdominal pain; the symptoms had begun two days earlier as a mild epigastric pain that localized the following day in the right iliac fossa. He had no instances of nausea or vomiting at admission, a body temperature of 37.2°C, a white blood cell count of 20.30 cells/mmPlain X-rays of his abdomen did not show pneumoperitoneum or fluid levels; plain X-rays of his chest were also normal. An abdominal ultrasound scan showed a 3.2 cm pre-aortic mass and some fluid in the Douglas pouch Figure .Our patient underwent a laparotomy, which revealed some purulent fluid with mild inflammation of the appendix; the jejunum and ileus were normal. An exploration of the supramesocolic space revealed a gastric perforation of the anterior wall just before the duodenum Figures  and 3.An appendectomy and suture ligation of the gastric ulcer was performed. Arising from the ileal mesentery was a 5 cm spherical brown mass that on histological examination was revealed to be a bronchogenic cyst  Figures  and 5.Our patient was discharged on the twelfth post-operative day.Bronchogenic cysts originate from an accessory lung bud of the primitive foregut after the third week of embryonic life. Most commonly they migrate caudally with the esophagus and are eventually found in the posterior mediastinum near the carina, attached to the tracheobronchial tree or to the esophagus. Rarely the cyst may separate completely from its origin and may be found in unusual sites, such as pericardium, skin ,14 or inA subdiaphragmatic location is extremely rare, with only about 20 cases reported in the literature -19. ThisBronchogenic cyst should be considered in the differential diagnosis of subdiaphragmatic masses, even in intra-peritoneal location.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.AP analyzed and interpreted the data from our patient; CB and EE were major contributors to the writing of the manuscript. All authors read and approved the final manuscript


Gallbladder perforation is a rare but life threatening event. We describe a case of gallbladder perforation encountered at initial presentation.rd post-operative day. He returned to the clinic after one week whereby his drain was removed and his wound closed.A 51 years old male, without any known medical co-morbidity, presented with a 1-day history of sudden-onset abdominal pain and abdominal distension. On examination, his abdomen was distended with generalized tenderness on palpation. Abdominal x-ray showed no signs of intestinal obstruction or pneumoperitoneum. Computed tomography scan of the abdomen showed appearance suggestive of gallbladder perforation. The patient was taken to the operating room and a diagnostic laparoscopy was performed revealing yellowish green fluid in the peritoneum. Difficulty in visualization of the anatomy led to conversion of the procedure to an open laparotomy. Intra-operative findings included a perforation near the neck of the gall bladder in association with a 2 × 1 cm gall stone. Near-total cholecystectomy was performed and a single large gall stone was retrieved. The peritoneal cavity was washed with normal saline and a drain was placed. The rectus sheath was closed but the wound was kept open for healing by delayed primary closure. The patient's hospital course was uneventful and he was discharged from the hospital on the 3Gallbladder perforation is an unusual initial presentation of gallbladder disease. Early diagnosis of gallbladder perforation and immediate surgical intervention are of prime importance in decreasing morbidity and mortality associated with this condition. Empyema, gallstone ileus, cholecystoenteric fistula, emphysematous cholecystitis, gallbladder perforation and biliary peritonitis are among the severe complications of acute calculous cholecystitis. These complications are associated with increased morbidity and mortality , and canAccording to one study, 12 3.3%) cases of acute cholecystitis were complicated by gall bladder perforation out of a total of 386 patients [.3% casesWe report here the case of a 51 years old gentleman who presented with acute free perforation of the gall bladder and associated biliary peritonitis in the absence of any previous clinical episodes of acute cholecystitis.A 51-years-old Pakistani male, without any known medical co-morbidity, presented to the emergency department at our institution with a 1 day history of sudden-onset and severe abdominal pain along with abdominal distension. The pain had started after a long drive of 12 - 14 hours. It was initially localized to the right upper quadrant and right lumbar region but had evolved to a more generalized distribution over time. The pain was aggravated on movement and relieved by rest. There were no other associated symptoms. His past surgical history was significant for a repaired left sided inguinal hernia 10 years back.The patient was in obvious anxiety and distress when first encountered in the emergency room. His vital signs were stable except for an increased pulse of 105 beats per minute. Examination of his respiratory system revealed vesicular breathing with decreased intensity of breath sounds in the right lung base as well as dullness on percussion on the right side of the chest. His abdomen was distended with generalized tenderness on palpation and minimal movement with respiration. No organomegaly was appreciated on the physical examination. His bowel sounds were sluggish.The laboratory tests done at the time of admission are shown in table The patient's emergent management included nothing per oral status, regular vitals and input/output charting, insertion of nasogastric tube, administration of intravenous fluids, narcotic analgesics, proton pump inhibitors, metochlopramide, ceftriaxone, metronidazole, and ampicillin.The patient was then taken to the operating room and a diagnostic laparoscopy was performed. It revealed free yellowish green fluid, most likely bilious, in the peritoneum. As the triangle of Calot could not be identified on laparoscopy, the procedure was converted to an open laparotomy. Intra-operative findings included presence of frank bile in the abdomen and a thick walled gall bladder. Dense adhesions of the gall bladder with surrounding structures were observed. A small perforation was visible near the neck of gall bladder in association with a large gall stone. The anatomy of the Calot's triangle was still obscure. A near-total or partial cholecystectomy including the perforated area was performed and a single large gall stone measuring around 2 × 1 cm was retrieved. The peritoneal cavity was washed with copious amounts of normal saline and a drain was placed. The rectus sheath was closed with loop polydioxanon (PDS) but the wound was kept open for healing by delayed primary closure.Histopathology of the specimen showed full thickness gallbladder wall lined by mucosa with focal ulceration. Rokitansky aschoff sinuses were also seen. A pathological diagnosis of acute on chronic cholecystitis was made.The patient's hospital course was uneventful. His symptoms significantly improved and he was discharged from the hospital on the third post-operative day. He returned to the clinic after one week when his drain was removed and his wound closed.Gallbladder perforation is a rare but life threatening event . BroadlyNiemeier in 1934 classified free gallbladder perforation into 3 types. Type 1 (acute) is associated with generalized biliary peritonitis, type 2 (subacute) consists of localization of fluid at the site of perforation, pericholecystic abscess and localized peritonitis while type 3 (chronic) comprises formation of internal or external fistulae . Recent In a study reporting the features of gall bladder perforation in 19 patients with acute cholecystitis, the mean age of the patients was 69 years with a female: male ratio of 3:2. It was also seen in this study that most of the patients had a history suggestive of gallbladder disease and had medical co-morbidities such as cardiac, pulmonary, renal, nutritional or metabolic diseases. The perforation occurred in most of these patients within 72 hours ,10.Our case is unusual because our patient was younger in comparison, had no prior history suggestive of gallbladder disease and had no known medical co-morbidity. Histopathological examination of the specimen showed features of acute-on-chronic cholecystitis leading to the derivation that the prior episodes of cholecystitis in this patient were clinically silent. Per-operatively our patient's gallbladder showed dense adhesions with the surrounding structures and no signs of gangrene of the rest of the gallbladder. This further strengthens the possibility of clinically covert episodes of acute cholecystitis in the past due to the adhesions noted; however the patient denied any past history of abdominal pain. The gallbladder perforation in our case presumably occurred within the first 12-18 hours of the onset of symptoms. In addition, the perforation occurred at the neck of the gallbladder which is an uncommonly reported site for such an event. The most common sites for the perforation of the gallbladder are the fundus and the body of the gallbladder due to poorer vascular supply of these areas as compared to the neck of the gallbladder .We initially performed an x-ray of the abdomen in this patient. When no signs of pneumoperitoneum or intestinal obstruction were demonstrated, a CT scan of the abdomen was performed. In a series of 17 patients with gallbladder perforation who presented with an acute abdomen, CT scan was the preliminary radiological investigation [Early surgical intervention is an important step in the management of gallbladder perforation. It is important to be mindful that increased morbidity and mortality is associated with this condition because of delay in diagnosis and initiation of treatment.Early diagnosis of gallbladder perforation and immediate surgical intervention are of prime importance in decreasing morbidity and mortality associated with this condition. The presence of risk factors certainly warrants an aggressively oriented investigation stratagem to rule out this serious complication. However, it is also important to consider this condition as an important differential in patients without any prior features or history of gallstone disease but whose acute presentation may be indicative of biliary pathology as was the case in this patient.CT: computed tomography; PDS: polydioxanon.The authors declare that they have no competing interests.SA and TS were involved in data collection, interpretation and writing the manuscript. ARA was involved in study conception and design, drafting the manuscript and providing overall supervision in the project. All authors read and approved the final manuscript.Written, informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the consent form is available for review by the Editor-in-Chief of this journal.


Saf-T-Coil” IUCD into the abdominal cavity, where it became embedded in the omentum and ultimately, 31 years after deployment, coiled both arms around a loop of ileum. This late complication underlines the dangers of intra-abdominal foreign bodies, even when chemically and biologically inert.The incidence of transuterine perforation and migration of intrauterine contraceptive devices (IUCDs) into the abdominal cavity has been estimated at less than 0.1%. It has been suggested that intraperitoneal IUCD have low morbidity and may be left in situ. We report the first case of closed loop small bowel obstruction due to migration of a “ A 64-year-old post-menopausal lady presented with a one day history of vomiting and severe right iliac fossa pain. This had been preceded by 2 months history colicky lower abdominal pain for which she had not sought medical advice. She continued to vomit in the ED and on admission .Her past surgical history consisted of open appendicectomy at 21 years of age, termination of pregnancy at 31 years, and a laparoscopic tubal ligation at the age of 38. (She underwent menopause at the age of 54.)Saf-T-Coil”  IUCD was placed when she was 30 years old [A “9/L, and CRP was 4. Liver function tests, urea, and electrolytes were within normal limits.On Examination, she was apyrexial and haemodynamically stable with a pulse of 78/min and a BP of 110/74 mmHg. Other than a respiratory rate of 24, her cardiorespiratory examination was unremarkable. Her abdomen was obviously distended, and while it was soft, there was marked right iliac fossa tenderness. WBC was 16.6 × 10Her abdominal radiograph (AXR) taken on presentation is shown in Saf-T-Coil” IUCD, fitted some 31 years earlier, had become embedded in the omentum, and each of the two “arms” of the coil had encircled the lumen of a segment of mid ileum, giving rise to a closed loop obstruction. A segmental resection was performed with stapled side-to-side  anastamosis. The uterus was small and retroverted, without obvious scarring. Postoperative recovery was unremarkable and pathology revealed a 14 cm segment of infarcted bowel.The migratory “Intrauterine contraceptive devices (IUCDs) are the worlds most widely used method of reversible birth control. Their modern use dates from 1909, but a high rate of intrauterine infection led to their withdrawal until redesigned from inert materials and reintroduced in the late 1950s . ComplicIncidence of uterine perforation is estimated to be less than 0.1%, and is a consequence of uterine injury at the time of insertion in most cases , 7. EarlThe fate of IUCD once they have entered the abdominal cavity varies. The majority perforate the uterus completely and most remain in the pelvic cavity; a significant minority become embedded in the omentum . Early cWhile 85% of reported cases of uterine perforation have not caused major complications at the time of diagnosis, 15% have presented with serious complications of visceral perforation, with IUCD eroding partially or completely into the bladder, small bowel, appendix, colon, or rectum. Recto-uterine fistula and rectal stricture have also been reported , 9. EctoSaf-T-Coil IUCD, due to direct strangulation of the bowel by the device.Visceral complications have been reported at a median time interval of 17 months (varying from four weeks to 13 years) . This caIn the case of partial uterine perforation or other visceral involvement, careful pre-operative CT imaging and planning is of great value. When IUCD ectopy is diagnosed in an as yet asymptomatic patient, one should be aware that late complications can occur in rare cases, and consider elective removal.


This is the first reported case of perforation and haemorrhage of a Meckel's diverticulum leading to the incidental finding of a gastrointestinal stromal tumour within the diverticulum. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, however, when symptomatic, it is often misdiagnosed at presentation. Common complications presenting in adults include bleeding, obstruction, diverticulitis and perforation. Tumours within a Meckel's diverticulum are a rare but recognised complication. We discuss the management of a gastrointestinal tumour within the diverticulum.A 59-year-old Caucasian man presented with acute right iliac fossa pain with localized peritonism. At surgery, he was found to have a perforated and haemorrhagic Meckel's diverticulum, associated with a gastrointestinal stromal tumour within the apex of the diverticulum. The absence of necrosis and a low mitotic rate indicated primary resection with subsequent computed tomography surveillance to be the most appropriate management strategy.We report a unique triad of complications associated with the presentation of a Meckel's diverticulum. This article reviews this common congenital abnormality and discusses the management of a gastrointestinal tumour. Meckel's diverticulum will mimic other intra-abdominal pathologies in presentation and should therefore often be considered as a differential diagnosis. This is the first reported case of perforation and haemorrhage of a Meckel's diverticulum leading to the incidental finding of a gastrointestinal stromal tumour within the diverticulum. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, however, when symptomatic, it is often misdiagnosed at presentation. Common complications presenting in adults include bleeding, obstruction, diverticulitis and perforation. Tumours within a Meckel's diverticulum are a rare but recognised complication.9 (neutrophils 8.1 × 109) and with C-reactive protein (CRP) <5. Acute appendicitis was diagnosed clinically and a diagnostic laparoscopy performed.A 59-year-old Caucasian man presented with peri-umbilical pain that had localized to the right iliac fossa. On examination, he was tender in the right iliac fossa, with localized peritonism. His white cell count was 10.2 × 10A perforated Meckel's diverticulum was found, associated with free intra-abdominal fluid and haemorrhage. At subsequent laparotomy, 75 mm of small bowel was resected and primary anastamosis was performed. Histology confirmed a Meckel's diverticulum and with a 25 mm area of perforation Figures -3. An in1.Â Full thickness tumour of the bowel wall, extending to serosal surfaces Figure .2.Â No areas of tumour necrosis.3.Â Less than one mitotic figure in 10 × 40 high powered fields.4.Â Interlacing bundles of spindle cells with elongated blunt ended nuclei.5.Â Some nuclear variability and tumour giant cells present.6.Â Positive for CD117 and smooth muscle actin Figures  and 6, nThis was, therefore, confirmed to be a GIST. Resection margins were found to be complete. The patient received 72 hours of intravenous antibiotics and made a good recovery. Surveillance abdominal computed tomography (CT) scan at one year was unremarkable.Meckel's diverticulum is a congenital abnormality that arises at the site of the vitelline duct, which in the embryo connects the primitive gut to the yolk sac. If this fails to obliterate by the seventh week of gestation, congenital defects can persist that include umbilical sinus, omphalomesenteric fistula, enterocyst, fibrous band and most commonly Meckel's diverticulum. The diverticulum is a true diverticulum containing all layers of the intestinal wall and most commonly arises from the antimesenteric aspect of the ileum, proximal to the ileocaecal valve. It has an independent blood supply from a remnant of the vitelline artery, a branch of the superior mesenteric artery.The diverticulum is commonly described by the rule of '2s': occurring in 2% of the population, approximately 2 inches long, arising within 2 feet of the ileocaecal valve, commonly affecting children less than 2 years of age and occurring twice as often in men . Althouget al. report the most common presentations of symptomatic Meckel's diverticula in adults to be bleeding (38%), obstruction (34%), diverticulitis (28%) and perforation (10%) [Meckel's diverticulum can either be an incidental finding or present symptomatically. It is thought that between 4.2% and 6.4% become symptomatic, with the incidence falling with increasing age [on (10%) . Due to leeding 3%, obstruet al. state the prevalences of tumours of Meckel's diverticula to be: carcinoid tumour (31.5%), leiomyosarcoma (25.5%), adenocarcinoma (11.4%) and leiomyoma (9.4%) with overall malignancy in 77% of cases [KIT or PDGFRA) [Tumours are reported to occur in 0.5% and 3.2% of symptomatic Meckel's diverticula . In a reeiomyoma .4% with  PDGFRA) .GIST accounts for 0.1% and 3% of all gastrointestinal neoplasms, most commonly occurring in the stomach or small bowel, and is now the most common sarcoma of the small intestine . Small bThere are little prognostic data regarding GISTs and current prognostic indicators are based on consensus guidelines. The most important adverse factors are thought to be a tumour diameter of greater than 5 cm and a high mitotic count exceeding five mitotic figures per 50 high powered fields on light microscopy ,11. OtheSince 1978, there have been approximately 10 reported cases of tumour-associated perforation of a Meckel's diverticulum, however, only two of these were histologically classified as GISTs . Our casCRP: C-reactive protein; CT: computed tomography; GIST: gastrointestinal stromal tumour.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.RW conceived the original article design, drafted the original manuscript reviewing current literature and corresponded with the editorial team. NB summarized the case and helped substantially with the drafting and critiquing of the original manuscript. KB and GP were the surgeons who operated on the patient, and helped substantially with critiquing of the original manuscript. DP examined the histological specimens and provided the histological diagnosis. All authors read and approved the final manuscript.


Patients with Neurofibromatosis type 1 (NF1) have an increased risk of developing neoplasms. The most common brain tumors, found in 15%–20% of NF1 patients, are hypothalamic-optic gliomas, followed by brainstem and cerebellar pilocytic astrocytomas. These tumors generally have a benign nature. NF1 patients are predisposed to a 5-fold increased incidence of high-grade astrocytomas, which are usually located in supratentorial regions of the brain. We present an NF1 patient who developed a high-grade astrocytoma in the posterior fossa and discuss possible pathophysiological mechanisms. Neurofibromatosis type 1 is the most common neurocutaneous disease with a prevalence of approximately 1 in 2600 to 1 in 3000 individuals . In addiThe astrocytomas observed in 15%–20% of these patients generally have a benign nature . NF1 patThese tumors are usually located in supratentorial regions of the brain. We present a 28-year-old female NF1 patient who developed a GBM in the posterior cranial fossa and discuss the possible pathophysiological mechanisms. The patient, a 28-year-old woman with NF1 was regularly seen for follow-up of a cerebellar lesion, suspected to be a hamartoma. This lesion was accidentally discovered during a radiological exam performed for a facial neurofibroma, when she was 21 years old. Successive MRI-scans of the brain were performed. At the age of 28, she was referred to our hospital because of complaints of progressive balance disturbance, ataxia of the right arm and leg, diplopia, and a sense of pulsation at the back of her head. She mentioned that a “bump” at the back of her head had increased in size over the preceding months.Neurological examination revealed nystagmus of her right eye, diplopia, loss of sensibility of the face, and ataxia of the right arm and leg. Romberg's test was positive.An occipital/cerebellar solid mass of 4 by 5 cm was palpable. An MRI-scan of the brain Figures  showed aNeurosurgical resection of the lesion was subsequently performed. Histological analysis revealed two distinct lesions: a mitotically active pleomorphic astrocytoma with pathologic vascular proliferation that was classified as glioblastoma multiforme  Figures  and a diOn immunohistochemistry, the first lesion was positive for GFAP , the secApproximately 30% of the cells in the first lesion showed immunopositivity for p53 .Upon recovery from surgery, the patient underwent both radiotherapy and chemotherapy. Six months later, MR-imaging showed progression of the tumor. After another six months metastases were present in the right frontal lobe and spine. The patient died shortly thereafter.NF1 patients have an increased risk of developing central nervous system malignancies . BesidesThis risk is accompanied by a 5-fold increased incidence of high-grade astrocytoma . SeveralMutations at the NF1 gene, which is a tumor suppressor gene located on chromosome 17q11.2, can partly explain the clinical susceptibility for malignancies. The NF1 gene product neurofibromin functions in part as a negative regulator of the p21 Ras proto-oncogene by accelerating the conversion of active guanosine triphosphate- (GTP-)bound Ras to its inactive guanosine diphosphate- (GDP-)bound form. Active Ras, as a result of reduced or absent neurofibromin expression, leads to increased cell growth and facilitates tumor formation . This grSeveral groups have confirmed the cooperation of mutations in NF1 and p53 in the development of astrocytomas in transgenic mice , 16. ZhuAs in the NF1/p53 transgenic mouse model, the GBM tumor in this NF1 patient also showed loss of p53. The cerebellar location of this tumor seems to be associated with a pre-existing lesion, which may have created an environment conducive to mutagenesis and/or supportive for tumor initiating cells. The characteristics of this single case suggest that brain-lesions in NF1-patients should be closely monitored for potential development of high-grade astrocytomas. A similar suggestion was made earlier by Carella et al. . However


Proliferating trichilemmal tumour defined with more than one terms by many author, after well documentated series reported as "proliferating epidermoid cysts" by Wilson-Jones, firstly in 1966. They are rare, slowly growing, lobular masses inherited autosomal dominantly and localized on scalps of older women and believed to arising as a complication of a trauma and inflammation and effect 5-10% of people.We intented to present the case of a 62 years old Turkish woman with a history of slowly growing scalp mass after the trauma, especially during last 15 years. After surgical evaluation, histopathological slides exhibited the characteristic structures of proliferating trichilemmal tumour. The patient was lost to follow-up and no recurrens or distance metastasis detected during 40 months follow-up.In our opinion, widely surgical excision with long-term surveillance is the best choice for both diagnosis and treatment still today. Besides terms of proliferating trichilemmal cyst (PTC) and proliferating trichilemmal tumour (PTT), it is called as the terms like invasive pilomatrixoma, trichochlamydocarcinoma, giant hair matrix tumour, scalp pilar tumour, trichilemmal pilar tumour, proliferating follicular cystic neoplasm  by many 62 years old Turkish woman having the history of trauma to her 0.5 × 0.5 cm mass on her frontal region of scalp 46 years ago, applied to our clinic. There was a history of growing slowly and complaint of itch on the described mass after the trauma especially during last 15 years.On physical examination, there was a mass lined with hair on the frontal region, 4 cm superior to starting point of hair of forehead and partially ulcerated, fluctuated, size of which is approximately 2.5 × 2 cm. There was no fixation to underlying area of bone and no lymph nodes were palpabl in the neck. The clinical diagnosis was made as sebaceous cyst and the lesion was totally excised.The resected tissue was set in 10% formalin for histopathological examination. Macroscopically, the tissue was rubbery firm in consistency, filled with tan brown necrotic material covered with hairy skin and contain ulcerated skin material on it which constitude nearly 2/3 of surface of the whole mass. Microscopically, histopathological slides revealed the characteristic structures of PTT. Trichilemmal type keratinization and focal epidermal keratinization, bands of squamous epithelium and within the bands basaloid cells at periphery, hemorrhagic areas within the cystic cavity, mitosis, moderate mononuclear inflammatory infiltrate areas, eosinophilic center surrounded with stratified squamous epithelium and lobulated cyst wall filled with squamous epithelium were observed (Figure PTTs are the masses localized in dermis or subcutaneous tissue, may become exophytic, sometimes exhibits ulceration, and are solid or partially cystic. The size of which ranges from 2 to 15 cm ; but alsHistologically, PTT exhibit tichilemmal keratinization areas. However, some cases may include the areas of focal epidermal keratinization. They comprise eosinophilic center is surrounded with stratified squamous epithelium and lobulated cyst wall is filled with squamous epithelium Figure .As the oncological transformation of trichilemmal tumour, Saida et al.  defined 2 laser, cryotherapy, radiotherapy or topical applications of aspirin derivatives are reported treatment modalities of cylindromas [Contrary to simple trichilemmal cysts, widely local excision, additional reconstruction if necessary and long term follow-up is required in these tumours to prevent recurrence . It is aindromas . For theindromas .Squamous cell carcinoma is the second leading cause of skin cancer in whites and accounts for 20% of cutaneous malignancies  having tDermoid cysts are rare subcutaneous cysts of ectodermal origin occur mostly on the face, forehead, neck, or scalp . Clear-cIn conclusion, our case of a 62 years old woman, having the history of trauma to her mass is mentioned about was macroscopically and microscopically benign. So, we have prefered follow-up and have not detect any recurrence during that period. We hope evaluation of well documented comprehensive series will let the improvement of more sophisticated prognostic schema for PTT s and it may asist in the solution of dilemma about malignant transformations of PTT and for the solution of differential diagnosis, also. It must been vigilant for the differential diagnosis and the rare malignant variant of this tumor even the metastasis from that malignant pilar tumor is extremely rare . If thesPTC: proliferating trichilemmal cyst; PTT: Proliferating trichilemmal tumour.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DS provided the photos of the histopathological sections of the proliferating trichilemmal tumour and was the contributor in writing the manuscript, especially for the parts are related to histopathological assesments of the proliferating trichilemmal tumour and in the linguistic revision of the whole manuscript. IS performed the the preoperative, perioperative and the postoperative evaluation and the management of the patient, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.


Most patients referred for lung biopsy have a focal lesion that is likely to be a carcinoma and fine needle aspiration (FNA) is usually sufficient to confirm diagnosis. Percutaneous cutting needle biopsy (CNB) is an important and potential diagnostic technique when non carcinomatous disease is suspected or when the pulmonary disease is unclear, so tissue architecture is very important.We present a case of a 24 year old male arrived at our hospital with dyspnea and unusual computed tomography (CT) findings of sarcoidosis. Chest X-ray and CT scan revealed multiple masses in both lungs suggesting lung metastasis. Bronchoscopy and bronchoalveolar lavage did not reveal any malignant cells. None of the laboratory examinations revealed any primary extrapulmonary tumor. The patient underwent CT-guided core needle biopsy. Histopathological examination confirmed the diagnosis of sarcoidosis.CT-guided core needle biopsy is a very helpful diagnostic tool in order to determine the benign or malignant nature of a thoracic lesion. FNA of focal pulmonary opacities is an accepted technique for the diagnosis of carcinoma, with a reported sensitivity greater than 90% -2.In non-carcinomatous masses, its sensitivity is 22-48% -4.Complication rates are of 29-45% .However it is much less successful in the diagnosis of benign focal lesions, diffuse lung disease (DLD), or when the pulmonary disease is unclear, in which case tissue architecture is important -5.CNB on the other side, provides cores of tissue for histological evaluation, although the American Thoracic Society Guidelines have stated that CNB should not be used in the diagnosis of DLD .However it is an increasing safe procedure in the determination of malignant and non-malignant lesions.The alternatives to percutaneous biopsy include open biopsy, video-assisted thoracoscopic biopsy and transbronchial biopsy. All of these however require general anesthesia.A 24-year old male  presented to our hospital complaining dyspnea.He underwent a chest X-ray that revealed multiple bilateral pulmonary masses.The patient underwent a chest CT scan , that revealed well circumscribed multiple round masses, involving both lungs, suggesting lung metastasis and enlarged mediastinal lymph nodes ,2.Further imaging exams were performed , which excluded any primary extrapulmonary tumor. The patient underwent other laboratory exams (blood tests) which had negative results.The patient therefore underwent a CT-guided core biopsy using a 18 gauge (G) cutting needle .The method was performed under local anesthesia.The patient was placed in the appropriate position considering the location of the lesion.Using a spiral CT, 5 mm slices were taken in order to specify the exact skin entry point, for the needle insertion.The puncture point was prepared in a sterile fashion and then a 20 G needle was inserted.A few CT images were taken to ensure that the chosen point of entry was the appropriate. Then, local anesthetic (20 cc) 2% lydocaine (xylocaine) was instilled. After that, a 18 G and 10 mm long cutting needle was inserted .The distance between the skin and the edge of the lesion was calculated from a relevant CT image. 1-3 specimens were prelevated from the lesion, which were then put in formalin for histological examination.The procedure was successful.No complications occurred.Histopathological examination confirmed the diagnosis of stage II sarcoidosis. It revealed multiple epitelioid cell granulomas with giant cells, in the absence of microbiological or virological abnormalities.The first lung core-needle biopsies were reported by Dutra and Geraci in 1954  after SiThe procedure enjoyed an early period of success in the diagnosis of focal malignant -8, focalHowever, series of reported fatalities during the 70's mainly due to hemorrhage and pneumothorax rates, compared to FNA, cast it into disfavor -11.In 1989 the American Thoracic Society Guidelines stated that CNB remained much less sensitive than open biopsy in the diagnosis of DLD with a sensitivity of 53-94%.The automatic cutting needle biopsy devices introduced over the last few decades, appear to be safer than the older needles.Complication rates in recent series are 15-33%.Mortality rates are 0% ,3,12,13.Specificity of the CNB is 100%.Sarcoidosis is a disease of unknown etiology characterized by non-necrotizing granulomatous inflammation involving one or more organs.Estimates vary, but between 20 to 40% of patients present asymptomatic bilateral hilar lymphadenopathy . In the Tests formerly believed to be diagnostic of sarcoidosis, have proven to be non-specific.These include serum ACE, which can be elevated in a variety of granulomatous diseases and BAL fluid analysis .The Kwiem-Stilzbach skin test, although highly specific, is not standardized and is not widely available.In patients who present findings uncharacteristic of sarcoidosis, such as isolated superficial and/or deep parenchymal nodules or masses and no previous clinical history that suggest the diagnosis, tissue diagnosis is necessary.Core needle biopsy under CT guidance, is a very helpful, minimally invasive technique in the determination of malignant and non malignant lesions, with a few associated complications.We showed successfully the usefulness of the method in the diagnosis of sarcoidosis with unusual CT scan findings.


The location of gastrointestinal stromal tumors (GIST) outside of the gastrointestinal system is a rare event.A 56-year old woman presented with a GIST of the pelvis was misdiagnosed and treated as a uterine leiomyosarcoma. The diagnosis was made after the CD117 (KIT) positivity in the biopsy of the excised bowel mass four years from the first presentation. During this period she presented a bilateral muscle and subcutaneous metastasis in the gluteal area.The correct diagnosis of the extra-gastrointestinal stromal tumor is a challenge even for experienced pathologists. CD117 (KIT) positivity is the most important immunohistochemical feature in the histological diagnosis. To our knowledge a metastatic EGIST  to the skeletal muscle bilaterally has not been described previously in the English medical literature. Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal neoplasms that may occur in any segment of the gastrointenstinal tract. In the earlier medical literature GISTs were diagnosed as smooth muscle tumors  or tumors of the peripheral nerves (neurofibroma and schwannoma). Nevertheless, the application of immunochemistry has reclassified them. GISTs are mostly found in the stomach (60–70%) and in the small intestine 20–30%). The location in the esophagus and in the colon is about 5% ,2. Extra0–30%. ThThe GISTs are usually positive for CD117 (KIT), which is the specific defining immunohistochemical feature for this group of tumors. The accurate surgical resection and the postoperative therapy with the single-agent KIT inhibitor imatinib mesilate  is the gold standard treatment for GISTs. Post-operative recurrence is observed in 40–90% of the cases treated with surgery alone .The differential diagnosis between GISTs and other similar tumors is a challenge. GISTs usually metastasize to the liver and lung, but in recent medical literature an intracranial metastasis from a perisacral GIST has been reported . To the A 56-year old woman was presented to the orthopaedic department with a 3-month history of a painless mass in the upper external area of the left gluteus.Two years, previously she underwent an abdominal hysterectomy because of an enlarging mass found in the pelvis, located between the uterus and the recto-sigmoid area. CA 125 was moderately elevated at 61.9 U/ml. The resected mass was bilobular  with hard and partially soft elements. Multiple intramural uterine leiomyomas were also identified. The tumor was diagnosed as "a leiomyosarcoma" composed of cellular bundles of spindle cells with medium grade atypia and presence of giant cells. The range of mitosis was very high, up to 50/10 H.P.F (high power field). Immunohistochemical analysis with avidin-biotin-peroxidase complex showed positive reaction for vimentin, smooth muscle actin and desmin . This time, a CD117(c-KIT) immunohistochemical stain was performed and the neoplastic cells showed extensive positivity. A diagnosis of a mesenchymal stromal tumor was established Fig . A retroBased on these features, the primary pelvic tumor was most probably an EGIST originally misdiagnosed as leiomyosarcoma. Post-operatively the patient underwent therapy with Imatinib Mesylate  and one year after surgery is now free of symptoms.GISTs are mesenchymal tumors of the gastrointestinal tract, believed to originate from interstitial cells of Cajal or related stem cells. Cajal cells are intermediates between the gastrointestinal (GI) autonomic nervous system and the smooth muscle cells regulating GI motility and autonomic nerve function ,8. GastrThe incidence of GISTs is estimated to be 20/1.000.000 persons per year. The median age of the manifestation ranges between 55 and 65 years of age. These tumors are very rare in individuals before the age of 40 and some studies show a small male predominance [In general the GISTs have a wide clinical manifestation that depends upon the location and the size of the tumor. In colorectal area the tumor may be manifested with lower GI bleeding, perforation, obstruction and pain. The stomach is the most common site of GIST benign tumors, whereas most esophageal and colonic GISTs are malignant . ApproxiIn the case presented herein, the tumor was misdiagnosed and remained untreated for about 4 years. Our hypothesis is that the tumor could have had escaped complete resection from gynecologists either due to small adhesions within the recto-sigmoid area or due to minimal involvement of the gut wall. Histologically a GIST tumor is very similar to leiomyosarcoma (LMS) but in our case non c-KIT positivity was not checked and the tumor was originally diagnosed as uterine leiomyosarcoma. The patient was treated with chemotherapy and radiotherapy but the GISTs are refractory to both . TherefoThe differential diagnosis between leiomysarcoma and GIST remains a challenge. Of a total of 133 rectal and anal GISTs identified in the Armed Forces Institute of Pathology at Washington and in the Haartman Institute of the university of Helsinki, 80 tumors (60%) had been originally diagnosed from other centers as leiomyosarcoma (LMSs), 29 tumors (21.8%) as smooth muscle tumors of uncertain malignant potential, 21 tumors (15.8%) as leiomyoma (LMs) and only 3 tumors (2.25%) as GISTs [Immunohistochemically, the majority of GI mesechymal tumors are GISTs and are strongly c-KIT positive 96–100%) and in particular, esophageal and rectal ones are nearly consistently CD34-positive (95–100%) [00% and iOur case may be considered as EGIST. Traditionally the EGIST are mesenchymal tumors with similar clinicopathologic and genetic profile localized in the omentum, mesentery and retroperitoneum comprising less than 5% of GISTs ,2. In thTo the best of our knowledge, this is the first case of EGISTs to metastasize bilaterally in the gluteal region. In a retrospective study of 118 metastasis to soft tissues over a period of 30 year, regardless of the primary, 5 cases were located in the gluteal region, all from carcinomas and melanoma. In only one case located to the abdominal wall, the primary tumor was GIST of the small bowel .Skeletal muscle is resistant to both primary and metastatic cancer. Previous reports have cited various mechanisms as reasons for muscle resistance to malignancy -16. WeisIn conclusion, EGISTs are rare tumours of abdominal cavity with potentially high malignancy and metastatic capacity, exhibiting clinical and histological difficulty for a correct diagnosis. Metastatic disease may occur in the soft tissues. Early recognition and prompt diagnosis, will allow the proper treatment to be initiated.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DP, EV and PV initiated and co-wrote the paper and performed the surgical excision of the gluteal metastases. AK analysed the MR images, prepared the illustrations and legend, and performed the proof editing. EG and MT examined the specimen and prepared the histological illustrations.


Tuberculosis affecting the anorectum is an uncommon extra-pulmonary form of the disease, and its association with malignancy is highly unusual.A 35 year lady presented with lower gastrointestinal bleed, altered bowel habit and significant weight loss. On examination, she had nodular stricture in the lower rectum, with friable mucosa, bleeding easily on touch. With the diagnosis of carcinoma lower rectum, she underwent abdomino-perineal resection of the growth. The histopathological examination revealed carcinoma rectum with coexisting tuberculosis.The aetiological association between the tuberculosis and anorectal cancer is a matter of debate. However, the treating surgeon should be aware of this association, to avoid confusion and delay in the management. Intestinal tuberculosis is primarily located in the ileoceacal region, with anorectal tuberculosis being an uncommon site even in the endemic region . The occA 35 year Mongolian lady presented with history of abdominal pain, bleeding per rectum, gradually worsening constipation along with weight loss of 7 kg over a period of 9 months. There was no history of pulmonary symptoms such as cough, haemoptysis or shortness of breath. Past history of tuberculosis or contacts with diagnosed case of tuberculosis was absent. On examination multiple faeculoma were palpable in the abdomen, rectal examination showed tight, nodular stricture in the lower rectum. The sigmidoscope could not be passed beyond the stricture, and the mucosa was friable and bleeding easily on touch. Rectal biopsy revealed dysplastic cells with features of non specific chronic inflammation on 2 occasions. No abnormality was detected in chest X-ray. Contrast enhanced CT scan of the abdomen and pelvis showed thickened rectal wall alongwith stricture at the lower rectum. Laparotomy revealed dilated and edematous upper rectum and sigmoid colon with multiple nodules on the surface, with presence of hard stricture in the lower rectum. Patient underwent abdomino-perineal resection, resected specimen showing hypertrophic ulcerated stricture involving the lower rectum and upper anal region with enlarged multiple perirectal lymph nodes. Fig.  HistopatColonic tuberculosis is a rare extrapulmonary form of the disease, comprising only 3-4% of intestinal tuberculosis . On the CT: Computed TomographyInformed written consent for the publication of the article and accompanying images was obtained from the patient. One copy of the consent form is available for review by the Editor.The authors declare that they have no competing interests.SK and RK made substantial contributions to concept and design of the article. VCS, RR and SRP were involved in the acquisition of materials. CSA and SA contributed significantly in the critical revision and drafting of the manuscript. All authors read and approved the final version of the manuscript.


Carcinoid tumors are low-grade malignant tumors that arise from neuroendocrine cells. Primary renal carcinoid is extremely rare. We present a case of 57-year-old male with primary renal carcinoid tumor. Presently, the patient is on regular follow up and is doing well. Carcinoid tumors most commonly arise in lung and gastrointestinal tract, but less frequently in kidneys, breast, ovaries, testis, prostate, and other locations. The pathogenesis is uncertain because neuroendocrine cells are not found in renal parenchyma, pelvis, and ureter. Only 43 cases of primary renal carcinoid tumor (RCT) have been reported so far, of these only six had characteristic carcinoid syndrome. We hereby report a case of RCT and provide a review of the literature.A 57-year-old male with painless hematuria and normal physical examination was found to be having left renal mass on ultrasound. He had no symptoms suggestive of carcinoid syndrome like headache, flushing, palpitations, or diarrhea. X-ray of the kidney and urinary bladder revealed calcification in left renal area. CECT  revealedet al. have proposed that surgical resection is indicated if the primary lesion is resectable or has been resected, which makes 90% of liver metastasis either resectable or ablatable. An impressive four-year survival rate of 75% has been achieved with this approach. Cytotoxic chemotherapy has only limited success in treatment of metastatic carcinoid tumors. Long-term follow up is recommended as metastasis can occur years after resection. Resection, ablation, or both in combination can be used to treat tumor recurrences. Somatostatin analogs, like octreotide and more recently lanreotide, which can be given monthly, have been utilized to treat patients with advanced disease[The pathogenesis of RCT is controversial. Primary RCTs are probably derived from interspersed neuroendocrine cells associated with acquired and congenital abnormalities such as metaplasia of pelvicalyceal urothelium induced by chronic inflammation, misplaced or entrapped neural crests or pancreatic tissue in kidney during embryogenesis, activation of gene sequences common to neuroendocrine programed cells in multipotent stem cells, or concurrent congenital abnormalities. The meanEarly surgical intervention together with careful surveillance and follow up can achieve successful long-term outcomes in patients with this rare malignancy.


After osteosarcoma, chondrosarcoma is the second most common primary bone tumor accounting for 26% of all malignancies. In the laryngeal region however, chondrosarcomas are rather rare. Only 300 cases are reported in literature. Considering laryngeal chondrosarcoma, about 75% occur in the cricoid cartilage, whereas 20% occur in the thyroid cartilage. In this paper we report a case of thyroidal chondrosarcoma, and based on a thorough literature search we suggest some practical guidelines concerning diagnosis and therapy. After osteosarcoma, chondrosarcoma is the second most common primary bone tumor accounting for 26% of all malignancies . In the The exact cause of chondrosarcoma still remains unclear. The most common hypothesis is a primary disordered ossification of the cartilages . Other tIn this paper, a case of chondrosarcoma located in the thyroid cartilage in a 61-year-old man is reported. Practical guidelines for diagnosis and therapy are suggested. A 61-year-old man presented to the outdoor department with a painless and rounded swelling at the thyroid level. The swelling had developed over years. He had no complaints, such as swallowing disorders or pain. Routine clinical examination revealed a tender, noninflammatory lesion at the thyroid cartilage. Endoscopy, completed with videostroboscopy and functional evaluation of swallowing (FEES), demonstrated a normal endolaryngeal and pharyngeal anatomy and physiology. Ultrasound was not conclusive but Computed Tomography (CT) provided detailed findings: a structure of 27 × 20 mm arose from the outer cortex of the thyroid cartilage anteriorly, with presentation of calcifications and ossifications . PatholoDefinite histology showed a superficially located cartilaginous tumor, largely benign in its appearance. Minimal nuclear atypia could be observed, however together with myxoid changes of the interstitium and focal invasion of the preexisting cartilage. Histological and clinical findings match the diagnosis of low-grade chondrosarcoma. Head and neck chondrosarcomas account for 10% of all chondrosarcomas in the whole body . PrimaryThere is a male predominance, estimated between 1.29 : 1 and 4 : 1, and it occurs mostly around the sixth decade 59– 64 years) [4 years , 9. Our The signs and symptoms most usually observed in laryngeal chondrosarcoma are specifically: hoarseness, dysphagia, dyspnoea, and stridor. This is a consequence of impaired vocal fold mobility and/or recurrent nerve compression, eventually combined with a “mass-effect” due to endolaryngeal or exolaryngeal tumor growth. Our patient presented with a slowly growing painless swelling on the midline which did not interfere with voicing or deglutition. This suggested the origin from the outer cortex of the thyroid, confirmed by CT. In literature a delay between the onset of the tumor and the presentation of clinical findings  is described . Also thPlain radiology is less conclusive as it only demonstrates a variable overall density . CT, howLichtenstein and Jaffe well established histopathological diagnostic criteria  and a clThe distinction between  chondroma and chondrosarcoma remains difficult as most chondrosarcomas are low-grade , 5, 9. TLocal recurrences are quite frequent , 6, 8, 9The final outcome of laryngeal low-grade chondrosarcomas is excellent. Although one study reported a decrease in overall survival in patients over 60 years old , the oveThe role of radiotherapy still is a matter of debate. Most authors suggest that in low-grade laryngeal chondrosarcoma radiotherapy only provides an alternative treatment method when surgery is not possible , 6, 7, 9Low-grade laryngeal chondrosarcoma is a rather uncommon tumor with an indolent course. The clinical examination should comprise exolaryngeal examination  and endolaryngeal examination. Laryngeal functionality (voicing and deglutition) should be investigated with naso-faryngo-laryngoscopy and/or videostroboscopy. Eventually, in case of swallowing complaints an additional functional evaluation of swallowing could be interesting. We would advise CT or MRI as a diagnostic tool, next to the clinical examination. It is preferential to perform a complete resection for a reliable histopathological diagnosis. As a treatment strategy, complete resection is preferable but conservative surgery is sufficient as mortality is very low. Furthermore, it limits morbidity. Follow up for years is recommended to guarantee an early detection of eventual recurrence providing even then a conservative treatment.