The aim of this study was to report surgical strategies and clinical outcomes for thoraco-lumbar intradural lipomas. Intraspinal lipomas are rare congenital histologically benign neoplasms, which account for less than 1% of all spinal cord tumors. These tumors are most frequently found in the lumbosacral area as components of a dysraphic state, however, intramedullary lipomas are not associated with spina bifida or cutaneous malformations and have only been described as isolated cases among spinal lipomas, where the thoracolumbar region is rarely affected.Three patients with thoracolumbar intradural lipomas were admitted to our clinic at different points of time. Partial resections and debulking of the tumors were achieved with the guidance of an operating microscope. We performed laminectomies or laminoplasties, for tumor resections.Postoperatively, the patients demonstrated significant clinical improvements. In this manuscript we presented our surgical experiences for intraspinal lipomas. Intramedullary lipomas, not associated with spina bifida or cutaneous malformations, have only been described as isolated cases -4. The eA 43-year-old female was admitted in January 2006, with a history of 10 months of lumbago. She had experienced six months of pain and numbness and two months of motor weakness in the left leg. The symptoms had progressed rapidly in the last two months. The neurological examinations showed motor weakness in her lower extremities, predominantly on the left side on tibialis anterior and also crural weakness. She had sensory impairment below the L1 dermatome of the left leg and hypoactive deep tendon reflexes in the lower extremities. She had no urinary incontinence. Rectal tone and sensation were both normal. Routine laboratory studies yielded normal values. Plain radiographs showed no evidence of bone destruction. Magnetic resonance imaging (MRI) revealed a 10 × 14 × 20 mm intradural mass lesion, between Th12 and L1. The lesion was hyperintense on T1-weighted (W) images and less intense on T2-weighted images, indicating the presence of fat tissue , 1B. TheDue to the progressive neurological symptoms, surgery was recommended. The patient underwent a Th12 to L1 laminectomy. Almost no epidural fat was detected at these levels. The dura matter was tight and appeared to be under significant pressure. Following the opening of the dura matter, a typical extramedullary lipoma was apparent. Normal spinal cord was identified above and below the subpial yellow fatty tumor, displacing the spinal cord anteriorly and to the right. The nerve roots were involved bilaterally. The mass was at the extramedullary location but the lack of a cleavage plane was the main difficulty in performing the resection. As a result, extensive debulking of the tumor was achieved with the guidance of an operating microscope and the whole procedure was done using microsurgical instruments only.Histological examination confirmed the tumor was a lipoma. The postoperative course was uneventful and the patient was discharged on day 10 post-surgery, with improved walking ability. After a 6 year follow-up course, the patient’s walking ability had improved significantly.A 20-year-old female was admitted to our department in September 2005, with a 6-month history of back pain. She had become aware of difficulty in walking and numbness of her legs for four months and the symptoms had progressed rapidly during the last five months. Neurological examination showed dominantly left-sided sensory loss and motor weakness below L1. Sensation to light touch was diminished below L1 and the deep reflexes in the lower extremities were hypoactive. Sagittal MRI showed a tumor mass from the Th10 to the L1 level , 2B. TheAn 18-year pregnant woman, was admitted to the hospital in 1997 with progressive weakness in her legs and bladder dysfunction for the previous 2 months. Sensation to light touch loss and severe weakness below Th11 was detected, with hypoactive deep reflexes. MRI showed an intradural tumor mass, displacing the cord anteriorly from the Th4 to the Th10 level. The provisional diagnosis was an intradural lipoma. The patient underwent a Th4 to Th10 laminectomy, during which about 40% of the tumor, which was firmly adherent to spinal cord, was resected. During the operation an ultrasonic aspirator and operating microscope were used for debulking intramedullary lipoma. Although the patient was young, we chose laminectomy, since the thoracic localized masses (Th4-Th10), rarely develop post-laminectomy spinal instability and affect the patient’s active life. Spinal canal diameter was extended sufficiently.Motor function improved slightly after the operation. Histopathological diagnosis was lipoma. During the postoperative period, the patient’s condition improved rapidly and she was able to walk better on the fourth postoperative day. After a 15 year follow-up, improved walking ability was observed.Gowers was the first to describe an intraspinal lipoma in 1876 . The morThese lesions are likely to develop at the cervicothoracic, thoracic or cauda equina regions, but may also involve the entire length of the cord  and exte(a) metaplasia of the adipose tissue in the pia-arachnoid membrane,(b) a developmental error, in which lipoma can arise from inclusions of embryonic rests, within the meninges during the formation of the neural tube and(c) proliferation of fat cells, which are occasionally found in the pia matter.Experiences with imaging of the isolated lipomas are very limited, due to the scarcity of these tumors. The low density of the fat tissue produces the pathognomic appearance of lipoma on computed tomography. The characteristic MRI findings of lipomatous tissue are relatively high signals on T1W images and relatively low signals on T2W images. Although lipomas may tend to adhere to the surface of the cord, a chemical shift artifact may erroneously suggest the presence of a thick fibrous tissue plane between the cord and the mass .Although it is benign, surgical removal of an intradural spinal lipoma is virtually impossible due to the extensive adhesions to surrounding neural tissues . Trying Many authors claim that the extent of tumor removal in these cases does not influence long-term results and that total excision of the lipomatous lesion is difficult and may not be necessary to reduce symptoms -9. The mDebulking of intraspinal lipomas should be performed if it is possible for surgeon to easily dissect it from surrounding neural tissues. If extensive adhesions to neural tissues were observed on surgery, partial resection of intraspinal lipoma should be performed.In most cases additional decompression of neural structures by laminectomy or laminoplasty is also necessary to relieve the neurological symptoms. Laminectomies should be preferred after partial resection of the lipomas located at the thoracic levels, which are the more stable segments of the vertebral colon and if the patient is not young. If additional need for spinal instrumentation occurs after performing laminectomies in young-aged patients, laminoplasties should be chosen.In our cases, the tumors were intradural and firmly blended with the cord, with the spinal roots embedded in the adipose tissue. During the surgery, we encountered difficulties posed by the absence of a cleavage plane and adhesion of tumor tissue to neural structures. We decided to extensively debulk the patient’s lipoma, using an operating microscope and were able to avoid damage to adjacent neural tissue. Adding decompression to partial tumor resection in case 2 and case 3, significant improvements were observed in postoperative neurological status. In case 1, an intramural extramedullary lipoma was localized on the conus medullaris. Although the lipoma was extramedullary, some parts of the mass adhered to the spinal cord. For this reason, the only option left was extensive debulking. Th12-L1 laminectomies were performed for spinal cord decompression in this case. We preferred laminectomies because the patient was middle-aged (43). Preserving the facet joints, when doing laminectomies, there was no need for spinal instrumentation. In case 2, intramedullary lipoma located at Th10-L1 levels was adherent to the spinal cord and spinal roots were embedded in the lesion. We performed partial tumor resection (20 % of the mass) and Th10-L1 laminoplasties. By doing laminoplasties, we achieved spinal canal diameter expansion. We chose to perform laminoplasty to ensure a longer active life expectation, due to the patient’s very young age (20) and the probability of developing spinal instability in the future due to the dynamic structure of the thoracolumbar region. In case 3, lipoma was an intramedullary lesion, located at Th4-Th10 levels. The tumor did not allow more extensive resection. Partial tumor resection and decompression was performed by doing thoracic laminectomies. We did not prefer to choose laminoplasty, although the patient was very young (18) or did not perform spinal stabilization after laminectomies for the preservation of facet joints, due to the stable structure of the thoracal segment of the spine. We summarized the cases and performed surgical intervention at Indications for surgery and the surgical strategies for treatment of spinal intradural lipomas are still discussed controversially.


Maxillary osteomyelitis is a rare condition defined as inflammation of the bone primarily caused by odontogenic bacteria, with trauma being the second leading cause. The present report documents a rare case of maxillary osteomyelitis in a 38-year-old female who was the victim of domestic violence approximately a year prior to presentation. Intraoral examination revealed a lesion appearing as exposed bony sequestrum, with significant destruction of gingiva and alveolar mucosa in the maxillary right quadrant, accompanied by significant pain, local edema, and continued purulence. Teeth numbers 11, 12, 13, 14, and 15 were mobile, not responsive to percussion, and nonvital. Treatment included antibiotic therapy for seven days followed by total enucleation of the necrotic bone tissue and extraction of the involved teeth. Microscopic findings confirmed the clinical diagnosis of chronic suppurative osteomyelitis. Six months postoperatively, the treated area presented complete healing and there was no sign of recurrence of the lesion. Maxillofacial trauma is a form of injury that can affect males and females of all ages and can result in facial bone fractures, dentoalveolar trauma, and soft tissue lesions, occurring in isolation or in association with other lesions in the body . The maiAccording to Gassner et al. , males aMaxillofacial injuries are commonly seen in victims of domestic violence , 8. A woA possible complication of maxillofacial trauma may be chronic osteomyelitis, defined as inflammation of the bone primarily caused by odontogenic bacteria; trauma is the second leading cause of chronic osteomyelitis . ChronicThe aim of this report is to present a case of chronic suppurative osteomyelitis occurring in the maxilla of a female patient as a result of maxillofacial trauma caused by domestic violence, to emphasize the lesion characteristics , the treatment rendered, and the impact on the patient's quality of life.A 38-year-old female was referred (May 2011) to the stomatology clinic with a lesion on the anterior right maxilla. Her medical history was unremarkable, she denied taking any medications, and she reported being a cigarette smoker (20-pack-year exposure). Approximately a year prior to presentation, she was victim of domestic violence. Her husband had punched her in the face. The patient did not report complaints to the police and did not seek medical attention after the incident. After a few months, she noticed the appearance of purulent exudate from the attached gingiva in the area between teeth 11 and 12. Since the original appearance of the fistula, the lesion increased in size and was accompanied by significant pain, local edema, and continued purulence.Extraoral examination revealed slight facial asymmetry, caused by elevation of the right wing of the nose and edema in the midface. The overlying skin color was normal. Head and neck lymph nodes were normal to palpation. Intraoral examination revealed a lesion appearing as exposed bony sequestrum, with significant destruction of gingiva and alveolar mucosa in the maxillary right quadrant . Edema . Based oIn addition to the lesion in the anterior maxilla, clinical and radiographic examination revealed poor dental health, with periodontal, endodontic, and restorative treatment needs.Initial treatment consisted of oral antibiotic prescription (amoxicillin 500 mg tid and metronidazole 400 mg tid) and antimicrobial mouthwash (chlorhexidine digluconate 0.12% bid) for seven days. Following this regimen, the patient reported improvement of symptoms; however, the clinical appearance of the lesion remained unchanged. Surgical enucleation of the lesion was treatment planned and requested preoperative hematological exams were all within normal ranges.The surgical intervention, performed under local anesthesia, consisted of total enucleation of the necrotic bone tissue and extraction of teeth 11, 12, 13, 14, and 15 . The palThe surgical specimen, including the extracted teeth, was submitted for routine histopathology (hematoxylin and eosin stain). Histopathologic analysis identified the presence of acellular, avascular bone tissue, with reversal lines, irregular surface, extensive marrow spaces, and Haversian canals. An amorphous material, acellular and slightly basophilic, suggesting microbial colonies, was also observed . The micAt the first postoperative visit (7 days) the surgical site exhibited partial healing and sutures were removed. The patient was subsequently referred to the integrated clinic for follow-up and for continuation of required additional dental treatment (including restorative work). At the 6-month postoperative visit the surgical site had completely healed and there was no sign of recurrence .This report presented a case of chronic suppurative osteomyelitis in the anterior maxilla associated with maxillofacial trauma resulting from domestic violence. To the best of our knowledge, this is the first reported case of maxillary osteomyelitis in a context of domestic violence.The majority of osteomyelitis cases of the jaws involve the mandible while maxillary cases are much less common, due to differences in vascularization . The posRegarding management of the reported maxillary osteomyelitis case, therapy was initiated with oral antibiotics (amoxicillin and metronidazole combination) and followed by surgical removal of the necrotic bone tissue and extraction of associated teeth; this approach achieved good results with no signs of recurrence at the 6-month follow-up. Combination of antibiotic therapy and surgical debridement is effective for the treatment of chronic suppurative osteomyelitis of the jaws , 11. AltLocal and systemic host factors are important in the pathogenesis of osteomyelitis . OsteomyA partially healed fracture and osteomyelitis of the radius in a victim of child abuse have been previously reported ; the ostInterpersonal physical violence (IPV), which encompasses domestic violence, is a major cause of craniomaxillofacial injury occurring in females aged 15–50 years, with most injuries located in the middle third of the face . Soft tiMost maxillofacial IPV injuries are caused by punching, followed by kicking and slapping . Female Maxillofacial trauma caused by domestic violence can lead to chronic osteomyelitis of the maxilla. The recognition of the injury pattern caused by interpersonal physical violence is important for the diagnosis and management of such cases.


Non malignant invasive tumors of the colon and rectum are very rare. Gastrointestinal Basidiobolomycosis can present as a mass lesion mimicking colorectal cancer.A 56 year old Caucasian male was evaluated for abdominal and pelvic pain for 4 weeks complicated by acute urinary retention. Radiological evaluation showed him to have recto-sigmoid and cecal mass. Endoscopic examination and biopsies did not reveal a definite diagnosis. Computerized tomography guided biopsy of the mass showed fungal elements consistent with gastrointestinal basidiobolomycosis. He was treated with Itraconazole for 12 months with very good clinical and radiological response.Basidiobolomycosis of the gastrointestinal tract should be considered during evaluation of colorectal masses with atypical presentation. It is a rare entity seen more in endemic regions of the world for basidiobolomycosis including southwestern United States. Basidiobolus ranarum, a saprophytic fungus found in the environment worldwide. Review of literature over the last two decades shows increasing reports on gastrointestinal basidiobolomycosis in immunocompetent individuals in arid regions of the world, particularly in the southwestern United States and the Middle East. We report a patient with obstructing rectal and cecal mass from invasive basidiobolomycosis which was treated without surgery. This case report and literature review would increase the awareness of GIB which is a serious but completely curable condition.Rapidly progressing infiltrative lesions of colon and rectum are malignant unless proved otherwise. Benign invasive tumors of the colon and rectum are very uncommon. Gastrointestinal Basidiobolomycosis (GIB) should be considered when clinical suspicion for non malignant causes for colorectal tumors are being sought. Basidiobolomycosis is a rare but emerging cause of abdominal pain, rectal pain, and abdominal mass that is being increasingly recognized in the literature as a potential mimicker of gastrointestinal malignancy. It is caused by A 56 year old Caucasian male with history of non insulin dependent diabetes presented with lower abdominal pain with increasing frequency of bowel movements for 3 months, rectal pain for a month and acute onset urinary retention. He also reported sporadic night sweats and subjective fever for 5 months. Earlier work up by his primary physician failed to elucidate a cause for his symptoms. On presentation, he was afebrile and remained hemodynamically stable. His physical examination showed right lower quadrant tenderness with no signs of peritonitis. Digital rectal examination showed tender, firm nodular mass along the anterior wall of rectum. Laboratory results revealed leukocytosis with neutrophilia and eosinophilia. Radiological examination included Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) scan of abdomen and pelvis. They demonstrated circumferential thickening of recto sigmoid region measuring 16 cm in length with significant luminal narrowing  with significant improvement in pain, frequency of stools and urinary retention within 4 days. His anti fungal treatment was continued over the next 12 months with periodic clinical and radiological examinations. Although no specific guidelines are available on the duration of the treatment and surveillance for treatment response, we chose to evaluate him with MRI scans at 3 month intervals to evaluate the response to antifungal treatment. He continue to improve symptomatically with near resolution of the lesion on the MRI scan of pelvis after 12 months of treatment , but it would depend on the clinical presentation and the response of the lesion to antifungal treatment. If surgery is required, conservative resection to reduce the bulk of the lesion and to maintain GI and biliary continuity would be sufficient. This has been reported to improve response to medical management. Close follow up is recommended in the postoperative period to ensure eradication of the disease. Investigations during the follow up period would depend on the mode of presentation and the site of the lesion. Response to medical treatment of lesions involving the cecum, ascending colon and recto-sigmoid region can be evaluated with MRI of abdomen and pelvis.Management of GIB depends on the clinical presentations. Patients who present with complete bowel obstruction would need emergent surgery to relieve the obstruction. Failure to identify and appropriately treat this rare diagnosis has been complicated by acute colonic obstruction necessitating emergency colostomy  and mortet al. reported relapse with discontinuation of treatment after 3 months based on symptomatic improvement.Duration of treatment has not been standardized. Most of the patients have been treated with antifungal treatment ranging from 6 months to 1 year. Vikram et al. reported a mortality with GIB from septic shock and pulmonary insufficiency despite successful diagnosis and treatment with Itraconazole and amphotericin B. Surveillance of treatment response could be performed with MRI or CT scans. There are no consensus opinion on the imaging modality and duration of surveillance in the literature. We propose the surveillance imaging could be performed with CT scan or MRI scans depending on the local availability and expertise.Diagnosis of basidiobolomycosis require culture of B ranarum from the tissue specimen. But, presumptive diagnosis could be made from the histopathological appearance. Microscopic appearance of B ranarum include scarce, broad and thin walled pleomorphic hyphae surrounded by collar of eosinophilic material known as Splendorehoeppli phenomenon . SusceptIn summary, GIB is a rare invasive fungal infection involving the gastrointestinal tract and liver. If identified early and treated appropriately, it is curable and surgery can be avoided. Surgery is unavoidable if GIB is complicated by bowel obstruction. Awareness and knowledge is important for early diagnosis and treatment of GIB and prevent morbidity and mortality from delay in diagnosis.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 large airways can be affected by a wide spectrum of acquired benign and malignant diseases. These lesions may present as focal or diffuse processes and with narrowing or widening of the airway. Some of these may be asymptomatic for quite some time and may be incidentally detected on imaging, while others may be symptomatic, causing airway compromise. There may be a characteristic radiograph and computed tomography (CT) appearance, suggesting a narrow differential. When the imaging findings are not definitive, tissue may be obtained for pathological analysis. It behooves the radiologist to be familiar with the pathologic findings that correlate with the radiographic or CT appearance of the most frequently seen large airway lesions. In this way, we may improve our diagnostic accuracy. This paper will present the imaging findings of the most prevalent tracheobronchial lesions along with any associated pathology.Teaching PointsThe large airways can be affected by many acquired benign and malignant diseases.• Large airway lesions may present as focal or diffuse processes, with narrowing or widening.• There may or may not be characteristic imaging appearance of large airway disease.• If imaging findings are not definitive, tissue may be obtained for pathological analysis.•  There is a wide range of lesions found on imaging of the large airways. These lesions can fall into a number of categories, namely benign or malignant, focal or diffuse, and narrowing or widening of the airway. Observation of the morphology of the lesion on radiographs and computed tomography (CT) can often narrow the differential substantially; therefore, knowledge of the radiographic presentation of various large airway masses can be instrumental in determining the next step in management.The imaging characteristics of various tracheobronchial masses are often nearly definitive in determining the diagnosis; however, if not, then tissue may be obtained for pathological analysis. It behooves the radiologist to be familiar with the pathologic findings that correlate with the radiographic or CT appearance of the most frequently seen large airway lesions. In this way, we may improve our diagnostic accuracy. This paper will present the imaging findings of the most prevalent tracheobronchial lesions along with the associated pathology. We have chosen to organize these lesions first as benign versus malignant, then by radiological morphology such as focal/diffuse and narrowing/widening of the airway Fig. .Fig. 1BeThe trachea conveys air from the larynx to the bronchi. In addition, it assists with humidification and warming of the inspired air and with mucocilliary clearance . It exteThe tracheal wall constitutes of the inner mucosa, sub-mucosa, cartilage, longitudinal and transverse muscle fibres, and an outer adventitial layer. The endoluminal diameter in the coronal plane ranges from 13 to 25 mm in men and 10 to 21 mm in women. The sagittal diameter ranges from 13 to 27 mm in men and 10 to 23 mm in women [At the tracheal bifurcation, the right mainstem bronchus emerges as a shorter, more vertically oriented structure with a larger diameter than the left mainstem bronchus. The right and left mainstem bronchi form 20–30° and 45° angles with the trachea, and are approximately 2.5 and 5 cm long, respectively [Benign tumours of the trachea are exceedingly rare. One of the most common of these rare tumours is squamous cell papilloma. On CT, there may be multiple protrusions into the airway or nodular thickening of the airway leading to intrinsic narrowing Fig. . TracheoEctopic thyroid tissue is usually found along the course of the thyroglossal duct , and mayEpidermolysis bullosa is an inherited connective tissue disease that manifests as blistering of the skin and/or the mucosa following minor trauma. It most commonly affects the oesophageal mucosa, but can also be found in the trachea, presenting as diffuse circumferential thickening with narrowing of the trachea Fig. .Fig. 4TwPost intubation stenosis is an example of focal tracheal narrowing. A similar injury can occur with the placement of a tracheostomy tube. The high pressure of the endotracheal tube balloon can lead to mucosal necrosis resulting in scarring and stenosis . The advSubsternal goiter is a one of the most common causes of external compression of the trachea . ClinicaAllergic bronchopulmonary aspergillosis usually presents in patients with a pre-existing pulmonary disease such as asthma . It is aSaber sheath trachea is seen within the intrathoracic trachea, demonstrating a reduction in the coronal diameter and thickening of the trachea relative to the sagittal diameter  Fig. 8)8). It isTracheobronchomalacia is defined as collapse (greater than 50–70 %) of the tracheobronchial wall with expiration  Fig. 9)9). This Tracheal diverticula can be congenital or acquired. The congenital tracheal diverticulum is typically smaller and possesses all layers of tracheal soft tissue, whereas the acquired type is larger, wider, and has a wall consisting solely of respiratory epithelium. An acquired tracheal diverticulum can be an associated finding in patients with chronic cough, such as occurs with chronic obstructive pulmonary disease. This entity typically occurs at a weak point in the tracheal wall, most often along the posterolateral trachea at the junction of the cartilage and membranous portions . It is tThere are several infections that involve the tracheobronchial tree. Endobronchial tuberculosis is found in 10–40 % of patients with active infection. Approximately 90 % of patients with endobronchial tuberculosis have a degree of bronchial stenosis . AnotherBronchitis (inflammation of the large airways) and bronchiolitis  may be inflammatory or fibrotic Fig. . The infGranulomatosis with polyangiitis is a systemic necrotizing granulomatous vasculitis commonly affecting the upper and lower respiratory tracts as well as the kidneys , 15, 20.Amyloid is an insoluble fibrillary protein which may form extracellular deposits in multiple locations . PulmonaSarcoidosis is a systemic disease that usually manifests as multiple non-caseating granulomas of the mediastinal and hilar lymph nodes and lungs , and rarTracheobronchopathia osteochondroplastica is characterized by submucosal osseous and cartilagenous deposits arising from tracheobronichial enchondromas anterolaterally, sparing the posterior membrane , 11–13, Tracheobronchomegaly (including Mounier-Kuhn syndrome) consists of dilation of the trachea greater than 3 cm and the mainstem bronchi greater than 2.4 cm , and canBronchiectasis represents a dilation of the bronchi usually secondary to infection, obstruction, or traction. It is often associated with allergic bronchopulmonary aspergillosis, in which case it will frequently be located in the proximal upper lobes. However, the lower zones are the most common location for bronchiectasis. Imaging demonstrates the classic “signet ring” appearance of bronchi larger than adjacent vessels  Fig. 1818. TypesThe symptoms of a tracheal neoplasm are nonspecific and include cough, wheeze, hemoptysis, and stridor. Dysphagia and recurrent laryngeal nerve paralysis can indicate involvement of adjacent structures. Primary malignancies of the trachea are rare and account for only 0.1 to 0.4 % of all malignancies in adults. However, 80–90 % of tracheal tumours are malignant . PrimarySquamous cell carcinoma has a strong association with smoking and occurs more commonly in men in their sixth to seventh decades . While iAdenoid cystic carcinoma affects men and women equally, occurs most often in the fifth decade, and is not associated with cigarette smoking . It arisCarcinoid tumors originate from neuroendocrine (Kulchitsky) cells and represent less than 2 % of all tracheobronchial primary malignant neoplasms . PatientAtypical spindle cell carcinoma is a rare pulmonary neoplasm sometimes referred to as sarcomatoid carcinoma or pleomorphic carcinoma. It is most often seen in middle aged men with a history of smoking and may present on imaging with a polypoid soft tissue mass  Fig. 2222. This Metastatic lesions to the trachea can occur from either direct or hematogeneous spread, with direct invasion being more common . The CT Oesophageal carcinoma can lead to the formation of a tracheoesophageal (TE) fistula in 5–10 % of patients Fig. , particuDirect invasion of the trachea by lung carcinoma by definition places the patient in the T4 category of the TNM/American Joint Committee on Cancer (7th edition) lung cancer staging system. Involvement of lymph nodes then determines the staging of T4 lesions as stage IIIA or IIIB. Stage IIIA cancers are a heterogeneous category and some may be resectable, whereas stage IIIB cancers are largely unresectable . CT imagEndobronchial metastases of non-Hodgkin lymphoma (NHL) are very rare. Type 1 endobronchial NHL is described as arising from hematogenous or lymphatic routes. Type 2 arises via direct invasion or primarily from bronchus associated lymphoid tissue and is the less common of the two types  Fig. 2525.Fig. 2Renal carcinoma metastasis to the large airways most often manifests with symptoms similar to a primary endobronichial tumour such as hemoptysis . These lAlthough the lung is a common site of metastatic melanoma, the bronchi are not. It is a less common source of non-pulmonary endobronchial metastases than breast, colorectal, and renal carcinomas . CT imagKaposi sarcoma is a multisystemic disorder involving the skin, gastrointestinal tract, lymphatic system, lungs, and tracheobronchial mucous membranes . This caWe have reviewed a wide range of lesions found on imaging of the large airways, lesions that fall into a number of categories, specifically benign versus malignant, focal versus diffuse, and narrowing versus widening of the airway. In addition to this algorithm, evaluation of the circumferential or membranous location of the lesion may also be used to aid in diagnosis, and where appropriate this has been described in the text. Knowledge of the radiologic appearance of these lesions is crucial in developing a differential diagnosis and determining the next step in management. When a pathological specimen is obtained, critical radiologic-pathologic connections can be determined, and diagnostic accuracy may be improved.


Objectives. Organized hematoma (OH) is a rare, nonneoplastic, hemorrhagic lesion causing mucosal swelling and bone thinning, mainly in the maxillary sinus. We aimed to clarify the clinical presentation and treatment of OH. Methods. Three cases of maxillary sinus OH and a literature review are presented. Results. Three men aged 16–40 years complained of nasal obstruction, frequent epistaxis, and/or headache. Clinical and radiological examinations revealed a maxillary sinus OH. They were cured in a piecemeal fashion via endoscopic middle meatal antrostomy. Furthermore, vascular endothelial growth factor and its receptor were expressed in the lesion. Conclusions. The pathogenesis of OH is unclear and it presents various histological and imaging findings; however, it is not difficult to rule out malignant tumors. Minimally invasive surgery such as endoscopic sinus surgery can cure it completely. Thus, it is important to determine the diagnosis using CT and MRI and to quickly provide surgical treatment. An organized hematoma (OH) is rare, mainly arises from the maxillary sinus, and is a nonneoplastic, hemorrhagic lesion causing mucosal swelling and bone thinning . The firThree patients with OH of the maxillary sinus who were treated in our department from 2010 to 2011 were retrospectively analyzed on the basis of their medical records. The patients' clinical features are summarized in 1-weighted imaging (2-weighted imaging (1-weighted imaging and demonstrated high intensity on T2-weighted imaging. Pathologic evaluations were performed, but there was no evidence of malignancy. The lesions were curetted by a piecemeal approach via an endoscopic middle and inferior meatal antrostomy with the assistance of a microdebrider. The masses were brittle and hemorrhagic, but it was easy to exfoliate the capsule from the maxillary mucosa. Complete removal of the tumor was accomplished, and the remainder of the maxillary sinus mucosa was slightly edematous and was kept intact. The total blood loss during surgery was 700 mL, and no blood transfusion was needed. Operation time was 127 min. The maxillary sinuses were well-opened and no evidence of recurrence was observed (A 35-year-old man had frequent epistaxis and nasal obstruction. None had a past history of paranasal sinus surgery or trauma or was receiving anticoagulant drugs for the treatment of an underlying disease. On paranasal endoscopy, an extension of the medial wall of the right maxillary sinus to the nasal side with a polyp and  a blood  imaging  and iso- imaging . The cen imaging . The surobserved . There w1-weighted imaging and iso intensity was observed on T2-weighted imaging. The central region showed low intensity and was strongly enhanced by gadolinium on T1-weighted imaging and demonstrated high intensity on T2-weighted imaging. Pathologic evaluations indicated no evidence of malignancy. The lesions were curetted by a piecemeal approach via an endoscopic middle meatal antrostomy with the assistance of a microdebrider. Complete removal of the tumor was accomplished. The total blood loss was 300 mL, and no blood transfusion was needed. Operation time was durations 95 min. The maxillary sinuses were well-opened and no evidence of recurrence was observed.A 16-year-old man had nasal obstruction and headache without significant past history and anticoagulant drug use. Paranasal endoscopic examination revealed an extension of the medial wall of the right maxillary sinus to the nasal side with a polyp. CT showed an expansile, homologous, enhancing mass with bone destruction of the maxillary sinus. The size of the mass was 5 × 5 cm. MRI images were similar to Case 1. Briefly, low intensity was observed in the periphery on TA 40-year-old man had frequent epistaxis, and none had a significant past history or was receiving anticoagulant drugs. Paranasal endoscopic examination revealed an extension of the medial wall of the right maxillary sinus to the nasal side with a polyp. CT and MRI images supported the specific features of OH, the same as in Cases 1 and 2. The size of mass was 6 × 4 cm. Pathologic evaluation indicated no evidence of malignancy. Complete removal of the tumor was accomplished by an endoscopic middle meatal antrostomy. The total blood loss during surgery was 450 mL, and no blood transfusion was needed. Operation time was from 155 min. There were no postoperative complications, and the postoperative courses of the patients were uneventful.Histologically, the specimens of all cases consisted of dilated vessels, hemorrhage, fibrin, exudation, fibrosis, hyalinization, and neovascularization without atypical cells Figures . FurtherThe term “organized hematoma” is not unified in the English literature and many terms, such as blood boil, hematoma-like mass, hematocele, blutbeule, and organizing hematoma, are used . Song et1-weighted imaging with contrast, and high intensities are observed on T2-weighted imaging. It is suggested that inflammatory changes result from obstruction by the lesion. These points differ from a malignant tumor that causes invasive bone destruction and from mucosal invasion. The existence of blood with low flow was thus considered in the central region, which matched the presence of a hematoma in the pathological findings. However, the peripheral regions were less enhanced and matched the zone of fibrosis. Therefore, a biphasic appearance is an important imaging characteristic of this lesion and it is important to cite in the differential diagnosis before determining a treatment strategy [A correct preoperative diagnosis is important for determining a therapeutic plan, and CT and MRI are strongly recommended , 3, 6–8.strategy .The pathogenesis of maxillary OH is not fully understood. A possible mechanism for the formation of OH has been suggested . AccordiWe are the first to demonstrate that VEGF is expressed in nearby inflammatory cells and VEGFR is expressed in parts of the hemangioma. Although statistical analysis could not be performed because of being short of cases, these data provide some evidence that VEGF and VEGFR2 expression are related to the cause of OH.Surgery is mandatory to remove the OH as first-line treatment strategy. Preoperative embolization can decrease the intraoperative bleeding volume but is unnecessary in all cases , 2. PrevAs a matter of course, the important things are to verify the surgical method to other approaches when ESS is not easy for OH removal during the surgery and to discuss with patients the possibility of modification of surgical approach during the surgery preoperatively.The pathogenesis of OH is unclear, and OH presents various findings in histological and imaging diagnoses, but it is not difficult to rule out malignant tumors. Furthermore, minimally invasive surgeries such as endoscopic sinus surgery can cure it completely. Thus, it is important to determine the diagnosis using CT and MRI and to treat the lesion quickly with a surgical operation.


A 5-year-old healthy boy presented with cervical tumors, present since birth, causing only cosmetic complaints. Physical examination showed bilateral tumors, free from underlying structures, and no other deformities. Abdominal and cardiac ultrasound studies showed no anomalies. A brother presented with a similar, unilateral tumor. Histology after excision showed hyaline cartilage.Which diagnosis should be suspected when looking at the pictures and what are the objective and histological findings?What is the embryological development connected to this condition?Are further investigations indicated?Which treatment should be offered?Cervical chondrocutaneous branchial remnants (CCBRs) are rare, benign neck tumors, first reported in 1858.5In the fourth week of embryogenesis, the neural crest cells migrate into the future head and neck forming 6 branchial arches. In the fifth week, the auricle develops around the first and second arch and 6 auricular hillocks appear in the sixth week. During the seventh week, the auricular hillocks start to enlarge and differentiate. The auricle starts to translocate from its initial ventral position on the lower side of the lateral neck to its ultimate lateral cranial destination. During this migration, it follows the anterior border of the sternocleidomastoid muscle.6,4,CCBRs have proven to be visible markers for more serious anomalies. Approximately one-third of patients with CCBRs have associated anomalies,1Treatment is simple surgical excision. It is not recommended to shave the lesion but to remove it completely. Treatment is recommended before school age for social reasons and for histopathological verificationCCBRs are rare, benign malformations usually found in the lower neck, consisting of normal skin with a cartilage core. Since CCBRs can be seen in some rare syndromes and associated anomalies have been reported in up to 76%, a thorough physical examination and ultrasound study of the abdomen and heart are recommended. Treatment is simple surgical excision.


Desmoplastic fibroblastoma is benign soft tissue tumor, with fibroblastic or myofibroblastic origin, that rarely occurs in oral cavity. We reported the case of a 56-year-old man who presented a tumor in the left mandibular alveolar ridge, with slow and asymptomatic growth, with no osseous involvement. The tumor was sessile with lobulated surface, covered by healthy mucosa with erythematous areas. The lesion was excised and specimens sent to histopathology and immunohistochemistry. Histopathological exam showed a non-encapsulated fibroblastic proliferation, characterized by myofibroblasts, spindle and stellate fibroblasts with large or oval nuclei and bi or tri nucleation, immersed in an abundant hypocellular dense collagen stroma. Tumor cells were positive for vimentin, HHF35, α-smooth muscle actin and factor XIIIa. The diagnosis of desmoplastic fibroblastoma was based in the clinical history of absence of trauma related to the growth in the alveolar ridge, associated with macroscopic, microscopic and immunohistochemical features. The patient is free-diseases by eight months. Key words:Collagenous fibroma, desmoplastic fibroblastoma, neoplasm of connective and soft tissue. Desmoplastic fibroblastoma (DF) is a rare benign neoplasm originated from fibroblastic and myofibroblastic cells described by Evans in 1995 , depictsA 56-year-old man was referred to the Oral Medicine Clinic of Odilon Behrens Hospital to evaluate a mass in the left mandibular alveolar ridge, with slow and asymptomatic growth. The intraoral inspection revealed a sessile well-defined tumor with lobulated surface, covered by healthy mucosa with erythematous areas, extending from the retromolar region to the 33 tooth Fig. . His medThe specimen was fixed in 10% neutral formalin buffer and embedded in paraffin. Macroscopic examination revealed a tumor mass with gelatinous aspect in some areas after cross section of the surgical specimen. The microscopic exam showed a non-encapsulated fibroblastic proliferation, characterized by spindle or stellate fibroblasts within a highly collagenous matrix. Some fibroblasts presented bi or tri nucleation Fig. . ImmunohThe patient is on following and disease-free for eight months.The case described in this report met the clinic-pathologic-immunohistochemistry features of DF and reveals a different intra oral site and clinical presentation from previously reported cases. A painless mass, with slow growth, covered by normal mucosa is the usual DF clinical aspect. In our case we observed a lobulated mass localized on alveolar ridge. DF arises despite no traumatic injury and no inciting event may be identified ,8,10. ThThe DF´s histological differential diagnosis should be made with inflammatory fibrous hyperplasia (IFH), giant cell fibroma (GCF), traumatic fibroma (TF), benign mesenchymal neoplasms as myofibroma, neurofibroma and solitary fibrous tumor, also with less frequent soft tissue lesions as nodular fasciitis and fibromatosis ,7. The pImmunohistochemical panels provide evidence for differentiation of these lesions and are important to exclude lesions of others origin. However, it is not mandatory to DF diagnosis. GCF is negative for α-smooth muscle actin and rarely positive for factor XIIIa , in contCytogenetic analyses suggest that rearrangement of chromosome band 11q12 is recurrent and associated with DF, however no target gene has been described as diagnostic tool. Most recent evidence indicates that the FOSL1 gene is overexpressed in DF due to this chromosomal rearrangement . AlthougThe current case study demonstrated a clinic-pathologic-immunohistochemistry of DF localized oral cavity, a rare fact. It is important to discuss features new of oral DF providing more know about this disease.


Surgical site infections are potential complications following open myomectomy. These infections usually develop immediately after the surgery, and are most often located in the myometrium. Pyogenic cervical cysts are rare and have not been previously reported to occur at the site of myomectomy.Escherichia coli, old blood, and evidence of endometriosis. A pathological review did not show malignant cells within the cyst. The pyogenic cyst originated from the upper anterior cervix, which was one of the sites involved in the previous myomectomy.A 41-year-old nulligravida Japanese woman was referred to our hospital with a large cervical cyst (>15 cm in diameter). She had undergone a myomectomy 13 years previously, and the surgical site had extended to the endocervical gland. Standard blood tests did not show any evidence of inflammation. The patient underwent a total abdominal hysterectomy, which revealed that the cyst contained multiple components, including We reported a huge pyogenic cervical cyst exhibiting signs of endometriosis, in the vicinity of the uterine scar from the open myomectomy. The previous surgery and endometriosis might have contributed to the formation of this rare pyogenic cyst. Uterine fibroids are commonly observed, affecting >30% of women of reproductive age . FertiliA 41-year-old nulligravida Japanese woman was referred to our hospital  due to the presence of a large cervical mass. Thirteen years previously, she had undergone myomectomy for the treatment of multiple uterine fibroids in the lower uterine segment, including one weighing 1.4 kg. Penetration beyond the endocervical gland had occurred during resection, and the anterior endocervical canal had been opened during the surgery. Her original follow-ups were approximately once a year at another hospital, where cancer screening was performed using transvaginal ultrasonography and cytology of the cervix and endometrium. Eight years after the original surgery, she had undergone pelvic magnetic resonance imaging (MRI), which did not detect any abnormal masses in the uterine body or cervix. Twelve years after the original surgery, she underwent transvaginal ultrasonography, and no abnormal masses were detected.However, a pelvic examination, performed 13 years after her myomectomy, indicated marked enlargement of the cervix, which was suspected to be a cervical malignancy. The patient had experienced no symptoms prior to the examination, and given the lack of observed progression, we were unable to estimate the period over which the mass developed. Transvaginal ultrasonography indicated that the mass contained multilocular, hypoechoic lesions, with heterogeneous internal echogenicity. Furthermore, MRI confirmed the presence of a multilocular, irregularly shaped cystic mass  in the upper anterior cervix Figure .Escherichia coli was identified as the causative bacteria. Microscopic examination revealed the coexistence of endometriosis, and an abscess was confirmed within the cyst, although malignant cells were not identified. An additional pathological review was performed at the University of Tokyo, which confirmed the absence of atypical or malignant cells. Thus, we diagnosed the mass as a pyogenic cyst, with endometriosis, which most likely occurred at the site of the uterine scar.Following culture of the abscess tissue, Surgical site infections are common complications of myomectomy, and the development of infection should be carefully examined, particularly in patients where the scar extends to the uterine cavity -8. Howevde novo within the endometriosis. Patients should be carefully monitored for development of pyogenic cervical cysts; this case may indicate the currently unknown etiology of these cysts.One previous study has described how the vagina can act as a bacterial reservoir during the fecal-vaginal course of transmission in extraintestinal infections , which cE. coli infection, in the vicinity of the uterine scar from previous open myomectomy. The previous surgery might be associated with the endometriosis at the site of infection, and endometriosis and/or infection might have contributed to the formation of the cyst.We have reported the rare case of a pyogenic cervical cyst, containing signs of endometriosis and The patient gave written consent for the case report to be published.CT: Computed tomography; MRI: Magnetic resonance imaging; SCC: Squamous cell carcinoma antigenThe authors declare that they have no competing interests.KO and YI treated the case and wrote the manuscript. DM and MF diagnosed the case pathologically. TA, KK, YO, and TF contributed to the diagnosis, obtained informed consent, and determined the management of the case. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/14/104/prepub


The oral cavity is very unusual site of metastases even though wide spread metastatic disease may be present. The most common primary sites that metastasize to the oral cavity are lung, kidney, breast, and hepatocellular carcinoma. We present a rare case of a 77-year-old Caucasian female with metastasis from a cholangiocarcinoma to the oral floor contiguous with lingual gingival mucosa. The patient presented with left sided rib pain. A CT scan of the chest, abdomen, and pelvis showed multiple pulmonary nodules and a single dominant mass in the right lobe of the liver. This tumor was 6.5 cm with multiple satellite lesions surrounding it. The liver biopsy was diagnostic of a moderately to poorly differentiated adenocarcinoma, consistent with a primary cholangiocarcinoma. After undergoing one cycle of gemcitabine chemotherapy, the patient noticed an extremely rapidly growing mass involving her right lower gingiva and the entire right floor of her mouth. The biopsy of that mass also showed a moderately to poorly differentiated adenocarcinoma. The gingival tumor had a similar cytomorphology and immunophenotype as her cholangiocarcinoma. Therefore, an unusual site for metastatic cholangiocarcinoma was confirmed. The oral cavity is very unusual site of metastasis accounting for only 1-2% of oral malignancy . The mosThe patient was a 77-year-old Caucasian female with a surgical history of tonsillectomy with adenectomy, appendectomy, partial gastrectomy for bleeding secondary to peptic ulcer disease, ovarian cyst, partial knee replacement, and cataract removal. The patient presented complaining of left sided rib pain that started in November, 2012. This was sudden in onset and was worse with coughing and movement. A chest X-ray showed some vague nodular densities in both lung fields. A CT scan of the chest, abdomen, and pelvis in mid-January, 2013, showed multiple pulmonary nodules and a single dominant mass in the right lobe of the liver, which was 6.5 cm with multiple satellite lesions. Bulky retroperitoneum and upper abdominal lymphadenopathy were present. Laboratory data showed increased serum levels of the tumor marker, CA19-9 at 560.1 (0.0–35.0 U/mL). Upper and lower gastrointestinal endoscopy did not show any malignancies. A liver biopsy was performed and reviewed at Roswell Park Cancer Institute. The diagnosis was a moderately to poorly differentiated adenocarcinoma. The tumor cells are positive for cytokeratin 7, cytokeratin 20, and CA19-9, and they are negative for TTF-1, CA125, thrombomodulin, and mammaglobin. The patient was diagnosed with a primary cholangiocarcinoma based on laboratory data and radiologic and pathologic findings. After undergoing one cycle of gemcitabine chemotherapy, the patient noticed an extremely rapidly growing mass involving her right lower gingiva and the entire right floor of mouth. This mass grew as a discrete pedunculated lesion between the teeth and within the lingual gingiva, causing significant trismus. Histologic examination showed a moderately to poorly differentiated adenocarcinoma, consistent with metastatic cholangiocarcinoma (Figures The oral cavity is very unusual site of metastasis. Metastatic disease accounts for about 1-2% of oral malignancy , 4. ThesOral metastases are usually evidence of a widespread disease, as occurred in this case, and indicate a grave prognosis . HoweverOral metastasis may be present in the soft tissues or in the jawbones . There a


Chordomas are primary low grade malignant tumors of bone that usually arise within both ends of axial skeleton. The Notochord is a midline, ectoderm-derived structure that defines the phylum of chordates. Chordomas may pose difficult diagnostic challenges when encountered in secondary locations, such as lungs or other parenchymatous organs. We report the cytologic findings of a metastatic chordoma sampled through CT-scan guided fine needle aspiration (FNA) of lower lobe lung nodule in a 54-year-old man diagnosed with recurrent chordoma involving the lumber spine and paraspinal region. Chordomas are primary low grade malignant tumors of bone that usually arise within both ends of axial skeleton. Chordoma has a phenotype that recapitulates notochord. The notochord is a midline, ectoderm-derived structure that defines the phylum of chordates . In humaThe patient is a 54-year-old male with a history of lumbar and paraspinal chordoma. He presented initially with left gluteal, left thigh, and left groin pain that led to an MRI of the lumber spine that showed a lesion at L2 expanding to L4 with paraspinal involvement Figures . A CT-guThe initial abdominal MRI showed a lobulated and expansile multiseptated mass with markedly intense T2 signal. The mass is located anterior and lateral to the L3, L4, and L5 vertebral bodies, which is consistent with tumor or neoplastic lymphadenopathy. This mass lesion measured approximately 4.3 cm × 4.0 cm × 4.5 cm and abuts the lower abdominal aorta and the proximal left common iliac artery, without evidence for encasement. The tumor was surgically excised.Few months following the surgical excision, abdominal MRI was performed and showed that residual/recurrent chordoma involving right posterior L2 elements with large right anterolateral epidural tumor extensions at L2 and L3 level has further progressed, now causing severe compromise of the thecal sac at L2-3 level. There was also interval increase in the size of the left retroperitoneal lymphadenopathy and the large left flank soft tissue metastasis. Tumor extension was also noted within the L2-L3 and L3-L4 neural foramina and right psoas muscle. There was no evidence of obvious intrathecal extension Figures .Shortly after the MRI, patient had a full body PET scan which showed large low density hypermetabolic mass, SUV max 2.8, in the left flank involving the musculature of the left posterior abdominal wall and extending through the rib cage Figures .Chest CT-scan showed borderline enlarged right hilar lymph node. There was no left hilar adenopathy with normal sized mediastinal and axillary lymph nodes. There was a soft tissue confluence in the left lower lobe measuring approximately 1.8 cm .Diff-Quik smears from the CT-guided FNA of the lung nodule were moderately cellular and showed multiple fragments of fibrillary matrix material intimately admixed with epithelioid cells in a background of red blood cells. The epithelioid cells were present in large branching three-dimensional groups associated with fibrillary matrix or as single cells and small loosely cohesive clusters. The fibrillary matrix appeared intensely magenta to purple in Diff-Quik-stained smears Figures . A cell Chordomas were first described by Lushka et al. in 1856 , 8. ChorThe differential diagnosis of metastatic chordoma includes benign pulmonary hamartoma  which isThe other differential diagnosis is myxoid/round cell liposarcoma which is a spindle cell neoplasm, deeply located with plexiform vascular growth. However, it rarely occurs in the lung and in this case there were no lipoblasts or pleomorphic round cell component .The other differential diagnosis is extraskeletal myxoid chondrosarcoma, which consists of multilobulated malignant cartilaginous growth. However, there were no anastomosing cellular cords or cartilaginous cells .Brachyury is a transcription factor that is required for posterior mesoderm formation and differentiation as well as for the notochord development during embryogenesis. It is expressed in the neoplastic cells of chordoma, a malignant tumour deriving from notochordal remnants . BrachyuAdjuvant therapy is controversial but known to contribute to long-term disease control and survival. Postoperative patient followup should continue long-term CT-scan surveillance; and any signs or symptoms consistent with possible local recurrence or metastasis should prompt a thorough workup. In the absence of symptoms, surveillance CT-scans can detect potential treatable recurrence. Recurrent disease can be treated aggressively with curative intent including surgery and adjuvant radiation therapy . S. cerevisiae yeast that expresses human brachyury protein. This vaccine is the fifth of a novel class of yeast-based immunotherapeutics designed to stimulate immune responses to eliminate diseased cells. Patients who were vaccinated have shown a good tolerability profile in clinical programs to date. Expected adverse events from these products are limited to redness, swelling, and tenderness at the injection site, and mild, brief flu-like symptoms [Brachyury vaccine has been designed to stimulate the human immune system to target chordoma. The vaccine is composed of heat-inactivatedsymptoms .


Metastasis from various neoplasms to the spleen is very rare and most of the cases are found at autopsy. We report a patient presenting with uterine cervical cancer with splenic metastases. A 49-year-old woman presenting with genital bleeding was referred to our hospital and diagnosed with stage IIB cervical cancer. She underwent concomitant chemoradiotherapy (CCRT) consisting of 50 Gy whole pelvis irradiation, high-dose-rate intracavitary brachytherapy 24 Gy/4 fractions and six weeks of paclitaxel and carboplatin administration. Ten months after the initial therapy, CT revealed recurrence at spleen. Although she received 5 courses of nedaplatin, enlargement of the tumor was noticed. She underwent a splenectomy and the result of histology was compatible with metastasis of cervical cancer. Improvement of chemotherapy, irradiation, and surgical treatment has resulted in better control of disease and longer survival of cancer patients and also has led to high incidences of distant metastases. However, metastasis from cervical cancer to the spleen is very rare and most of the cases are found at autopsy. Here we report a case of cervical cancer metastasizing to the spleen.A 49-year-old woman presented to our department with massive genital bleeding. Vaginal examination revealed a protruding mass in the cervical os. A cervical biopsy was performed and the pathological examination of the biopsy showed undifferentiated carcinoma .She was diagnosed with stage IIB cervical cancer by rectal examination and was admitted to our hospital. The levels of squamous cell carcinoma antigen (SCC) and carcinoembryonic antigen (CEA) were elevated to 7.2 ng/mL and 7.18 ng/mL, respectively. Magnetic resonance imaging (MRI) of the pelvis revealed a large mass infiltrating to the uterine corpus and vagina .2/week) and carboplatin (AUC = 2/week) administration. When the therapy was completed, MRI revealed almost complete remission. The levels of SCC and CEA decreased to normal ranges. Cytological test of the cervix was negative. The patient remained free of disease for 10 months. Then a routine follow-up CT suspected spleen metastasis. Although five courses of nedaplatin (70 mg/m2/4 weeks) were administered, the level of SCC was elevated to 19.45 ng/dL and the mass in the spleen enlarged  consisting of 50 Gray whole pelvis irradiation in 25 fractions at 2 Gray per fraction, high-dose-rate intracavitary brachytherapy 24 Gray/4 fractions, and six weeks of paclitaxel (60 mg/menlarged .An exploratory laparotomy was performed and the spleen was removed . The res2/3 weeks) were administered. Then CT revealed stable disease. She underwent 7 courses of systemic chemotherapy consisting of irinotecan (60 mg/m2/3 weeks) and nedaplatin (70 mg/m2/3 weeks). CT revealed stable disease again. Five courses of paclitaxel and carboplatin were administered. She is alive with the disease 20 months after splenectomy.Four months after the surgery, CT revealed clavicular, axillary, mediastinal, and para-aortic lymph nodes metastases. Three courses of irinotecan (60 mg/mCarlson et al. reported in their review that overall incidence of distant metastasis of 2200 cases of squamous cell carcinoma of the cervix cancer was 15.3% [Metastasis from cervical cancer to the spleen is very rare and most of the cases are found at autopsy. Spleen metastasis at autopsy is reported to be 1.6% to 30% . The firGoktolga et al. reported that the interval between initial treatment and spleen metastasis was 20–42 months . Klein eThe present case was followed up with vaginal examination, cytological test, and serum tumor markers every time and CT. The serum levels of SCC and CEA were elevated. SCC is a glycoprotein with a molecular weight of approximately 45 kDa which was first reported by Kato and Torigoe . Pang reSplenic metastasis of uterine cervical cancer is rare but has poor prognosis. Surgical treatment is indicated in case the patient has symptoms. Many patients have no symptoms but some patients have spleen rupture. All abdominal organs, not only in the pelvic space, must be evaluated for metastasis.


Dear Sir,Bezoar is the foreign body material in the digestive tract. Primary colonic lithobezoar is rarely reported in childhood and is usually associated with the history of iron deficiency anemia, pica or psycho-social disorders. [1] These cases may present with chronic constipation, recurrent abdominal pain, and painful defecation. Evacuation under anesthesia is the usual treatment, but surgery can be considered if this procedure fails or colonic injury occurs.[2-4]A 4-year old boy presented with acute constipation for three days. He had a history of recurrent abdominal pain and painful defecation for the last few months. There was the history of pica (crushed pieces of bricks) for one year. He belonged to a poor socio-economic class and was the 3rd among the 4 siblings of the family. On general physical examination, he was mildly pale. On abdominal palpation, there was mild tenderness. A mass was palpable at the hypogastric area. On digital rectal examination, the anal canal was found full of pieces of red brick. Finger couldn’t be negotiated around the mass. X-ray abdomen showed calcified areas diffusely scattered in the abdomen .Under general anesthesia lots of small pieces of red brick mixed with feces were manually removed . Colon was washed with saline. Oral laxative was started in postoperative period. He passed few brick pieces for a couple of days. Post-evacuation X-ray, done on 4th postoperative day, showed no opaque areas in the abdomen. Psychiatric consultation showed no gross abnormality. On 5th post evacuation day, the child was discharged on oral iron supplements and with parental counseling as well.Colonic crunch sign is the typical feature of colonic lithobezoar. Colonic crush sign is defined as palpation of spiky mass on digital rectal examination.[5] In our case, abdomen was not distended and lithobezoar had blocked the recto-sigmoid colon. A plain X-ray abdomen in these cases shows scattered radio-opaque shadows throughout the colon which is peculiar of colonic lithobezoar, this peculiar appearance is called corn on cub.Source of Support: NilConflict of Interest: None declared


Although lipomas are encapsulated benign tumors, systemic lipomatosis defines infiltrative nonencapsulated tumors resembling normal adipose tissue. Abdominal lipomatosis and intestinal lipomatosis are different clinicopathological entities with similar clinical symptoms. We describe here a case presenting with upper gastrointestinal bleeding from eroded submucosal lipoma at duodenum secondary to intestinal lipomatosis and abdominal lipomatosis. Multiple systemic lipomatosis (MSL) is a rare disorder with unknown etiology, characterized by the accumulation of nonencapsulated adipose tissue at face, head, neck, upper and lower extremities, trunk, abdominal cavity, and pelvis . Involve2). On physical examination, blood pressure was 120/70 mmHg and pulse rate 86/min. There was a 2 cm mobile painless submucosal nodular lesion on the left neck. His abdomen was soft with no tenderness, rebound, mass lesion, or ascites. The patient was promptly given intravenous crystalloid and colloid fluid replacement; parenteral proton-pump inhibitor was administered. Initial laboratory values were as follows: leukocyte: 5800/mm3, hemoglobin: 14.8 g/dL, platelet: 347.000/mm3, prothrombin time: 12 sec, and INR: 1.05. Biochemical parameters were normal.A 35-year-old man was admitted to emergency department with one-day history of hematemesis and melena after taking nonsteroidal anti-inflammatory drug. He had no medical illness. He denied smoking, alcohol consumption. The height and weight of patient were 178 cm and 68 kg, respectively  and then decreasing prevalence in the small bowel, stomach, and esophagus . We founIntestinal lipomatosis related GI bleeding revealed coexistence of these two very rare diseases. In patients presenting with obstructive symptoms, paroxysmal abdominal pain, or GI hemorrhage, endoscopic treatment including endoscopic submucosal dissection, endoscopic snare resection, or surgical intervention might be definitive treatment , 9. With


An 80-year-old woman with a history of congestive heart failure, atrial fibrillation, and hypertension was transferred to our institution with hematemesis. Her drug regimen included 2 mg warfarin potassium/day to prevent thromboembolic events. Transthoracic echocardiography (TTE) performed at 78 years of age revealed a mass attached to the noncoronary cusp and a cardiac tumor was suspected. The patient declined surgery and was meticulously followed up with periodic TTE. Upper gastroendoscopy revealed a gastric ulcer with an exposed blood vessel; anticoagulant therapy was ceased. On day 15 of admission, acute cerebral infarction occurred. Heparin sodium and warfarin potassium were administered rapidly, and her symptoms improved. TTE revealed no alteration of the mobile, string-like mass attached to the noncoronary cusp. Cardiac tumor was considered the cause of cerebral infarction, and the patient consented to surgical therapy. Pathological examination of the resected tumor suggested papillary fibroelastoma (PFE). Although no guidelines exist for PFE management, a mobile, cardiac tumor necessitates surgical resection to prevent thromboembolic events, even when small in size. Primary cardiac tumors are rare, accounting for 0.002%–0.3% of all cardiac tumors ; moreoveAn 80-year-old woman was transferred to our institution with hematemesis. She had a history of congestive heart failure, atrial fibrillation, and hypertension; moreover, she had a history of hepatocellular carcinoma at the segment S5 caused by chronic hepatitis C, which was treated by transcatheter embolism. She underwent treatment for congestive heart failure and was prescribed warfarin potassium at a dose of 2 mg/day to prevent thromboembolic events. Transthoracic echocardiography (TTE) performed at 78 years of age revealed a 7 mm small, mobile, string-like mass attached to the noncoronary cusp . Infecti4/μL; hemoglobin levels: 8.2 g/dL), slightly low platelet count (12.5 × 104/μL), slightly elevated serum urea nitrogen levels (29.6 mg/dL), mild hypoproteinemia (6.1 g/dL), mild hypoalbuminemia (2.3 g/dL), slightly elevated C-reactive protein levels (1.3 mg/dL), and coagulation dysfunction . Upper gastroendoscopy revealed a gastric ulcer with an exposed blood vessel situated posteriorly in the body of the stomach. Anticoagulant therapy was ceased, and a proton pump inhibitor was administered.Thereafter, the patient was transferred to our institution with complaints of upper abdominal pain and hematemesis. Her blood pressure was 130/90 mmHg, and heart rate was 130 beats/min. Physical examination revealed mild anemia, a soft, flat abdomen with no palpable masses, and normal bowel sounds. On auscultation, her chest was clear and no abnormal murmurs could be heard. Chest radiography did not present any signs of cardiomegaly or pulmonary congestion. Electrocardiography revealed atrial fibrillation. Blood chemical analyses revealed mild anemia  endothelial cells.When presentations suggestive of PFE are revealed by echocardiography, heparin sodium administration should be initiated, and tumor resection should be considered as soon as possible . BecausePFE is considered a hamartoma or organized thrombus. Therefore, complete resection of the lesion and papillary proliferations is considered sufficient to prevent tumor recurrence. In many cases , tumor rEndocarditis should be ruled out whenever we encounter a mass in a cardiac valve. Usually, when fever is absent and blood chemistry analyses reveal no elevation of inflammatory markers, endocarditis is unlikely. When inflammation with fever is evident, the diagnosis is more complicated. In our case, the patient exhibited no fever during the followup of cardiac mass, and thus endocarditis was considered unlikely.Upon the discovery of a cardiac tumor, it is important to rule out endocarditis. Especially when the tumor is mobile, even when small in size, operative resection should be considered as soon as possible to prevent devastating thromboembolic events.


Ceruminous adenomas are benign tumors that are rare in humans and present with a nonspecific symptomatology. The treatment of choice is surgical excision. We present an 87-year-old woman who presented with a reddish, tender, round, soft mass of the outer third of the inferior wall of the left external auditory canal, discharging a yellowish fluid upon pressure. Coincidentally, due to her poor general condition, this patient also showed symptoms consistent with chronic otitis media, parotitis, and cervical lymphadenopathy, such as otorrhea, through a ruptured tympanic membrane and swelling of the parotid gland and cervical lymph nodes. The external auditory canal lesion was surgically excised under general anesthesia, utilizing a transmeatal approach. The pathological diagnosis was ceruminous gland adenoma. The tumor was made of tubular and cystic structures and embedded in a fibrous, focally hyalinized stroma. Immunohistochemistry confirmed the presence of two distinct cell populations. The luminal cells expressed keratin 7, while peripheral  cells expressed keratins 5/6, S100 protein, and p63. The apocrine gland-related antigen GCDFP-15 was focally expressed by tumor cells. The postoperative course was uneventful and at the 2-year follow-up no recurrence of the ceruminous adenoma was noted. Ceruminous adenoma (CA) is a benign neoplasm of ceruminous glands, developing exclusively in the external auditory canal (EAC) . ContrarAn 87-year-old woman was referred to our department for otalgia, yellowish discharge, itching, and hearing loss of the left ear recurring over the last three months. She reported intermittent fever, but neither tinnitus nor vertigo. She denied previous trauma or surgery in this region and was not using a hearing aid. Her past history included atrial fibrillation, diabetes mellitus, arterial hypertension, and glaucoma. Oral antibiotics and anti-inflammatory medications, prescribed elsewhere, were not effective.Physical examination revealed a reddish, round, tender soft mass of the outer third of the inferior wall of the left EAC, discharging a yellowish fluid upon pressure; however, a concomitant ruptured tympanic membrane and otorrhea through this perforation were also found. No cranial nerve palsy was detected. Swelling of the left parotid region and bilateral cervical lymphadenopathy were also present. CT scan of the temporal bone showed a cystic lesion on the inferior cartilaginous part of the EAC but no temporal bone lysis; the middle ear appeared to contain fluid and swelling of the parotid gland and cervical lymph nodes bilaterally were also seen . The audThe patient underwent excision of one cervical lymph node and fine needle aspiration (FNA) of the left parotid. Histopathological examination of the lymph node ruled out malignancy, being consistent with a granulomatous process; however blood tests and thorough immunological and rheumatological examination failed to confirm this hypothesis. The FNA examination was nondiagnostic as it showed normal salivary glands.The EAC lesion was surgically excised under general anesthesia, utilizing a transmeatal approach. Macroscopically the resection specimen was a fusiform skin sample measuring 1.9 × 1.5 × 1 cm. Upon sectioning a 1.4 cm cystic lesion was found in the subcutaneous tissue. Microscopic examination showed an epithelial cystic lesion whose wall contained two cell populations. The inner ones consisted of middle-sized cylindrical or cuboidal cells with an eosinophilic cytoplasm and round nuclei, arranged in tubules . The cylThe postoperative course was uneventful and the excision site was well healed. Moreover, the symptoms of otitis media and cervical lymphadenopathy improved considerably. A week later, the ear was free of secretions and the otalgia disappeared. After 15 days, the rupture of the tympanic membrane had healed and hearing returned to its previous condition. It is possible that, due to her age and poor general condition, this patient presented with multifocal infections, such as chronic otitis media, parotitis, and cervical lymphadenopathy, which were rather coincidental to the presence of CA.No recurrence of the CA has been noted after a 2-year follow-up.According to Mills et al. , CA are Ceruminous adenomas appear as reddish polypoid masses with either a smooth or ulcerated surface, which can mimic a boil , 5, 12. Ceruminous adenoma shows immunohistochemical features similar to those of normal cerumen glands, supporting their origin from these glands , 2. The


Anastomosing hemangioma, a benign vascular neoplasm histologically simulating angiosarcoma, is newly recognized and has been described primarily in the genitourinary tract. Here, we present a case of renal anastomosing hemangioma originating in the left kidney of a 32-year-old Chinese man with detailed computerized tomography (CT) and enhanced CT image information. The patient had no obvious signs and symptoms. The tumor was incidentally found by color Doppler imaging during a routine heath check-up. Subsequently, a detailed CT and an enhanced CT scan were performed. The tumor was well demarcated, and mahogany brown lesions, which measured 2.6 cm in maximum diameter, were observed. Microscopically, the tumor shows a lobular architecture with alternating cellular areas composed of anastomosing sinusoidal capillary-sized vessels lined by hobnail endothelial cells and edematous, hyaline paucicellular areas. Cytologically, the tumor cells were generally bland and exhibited positivity for CD31 and CD34 immunohistochemically. The patient had good status without evidence of tumor recurrence 21 months after the surgery. We suggest that more attention should be focused on this rare renal hemangioma variant and that it should not be over-diagnosed as a malignance, particularly an angiosarcoma.http://www.diagnosticpathology.diagnomx.eu/vs/13000_2014_159The virtual slide(s) for this article can be found here:  Primary benign vascular lesions of the kidney are uncommonly encountered in routine surgical pathology practice. A concern is that these lesions can mimic malignancy. Anastomosing hemangioma is a newly recognized variant of capillary hemangioma. Montgomery and Epstein recently described 6 cases of new variants of benign vascular tumors involving the kidneys, perinephric adipose tissue, and testes, which the authors designated as anastomosing hemangiomas . SubsequA 32-year-old Chinese male patient with no obviously abnormal medical history was incidentally shown to have a left kidney lesion by color Doppler imaging during a routine heath check-up. The lesion was further detected with an abdominal CT scan. An unenhanced axial CT scan showed a left renal sinus mass with a round, well-circumscribed figure that was approximately 3.4 × 2.7 cm in size Figure A. It appHematoxylin-eosin (HE) and immunohistochemical staining were performed on formalin-fixed, paraffin-embedded tissues. For immunohistochemical examination, sections were pretreated in a microwave oven and incubated with primary antibodies against CD31 , CD34 , Ki-67 , and SMA. Immunohistochemistry was performed with an immunohistochemistry autostainer , with diaminobenzidine as the chromogen and Mayer’s hematoxylin as the counterstain.Macroscopic examination demonstrated a round, well-circumscribed mass composed of firm, fleshy, mahogany brown tissue that measured 2.6 cm in maximum diameter, which abutted but did not invade the surrounding renal tissue.Microscopically, the tumor was well demarcated but had no capsula. It demonstrated a loosely lobular architecture and showed no evidence of vascular invasion, necrosis or invasion into the perirenal fat or renal tissue. It showed alternating cellular and paucicellular areas at low power. At higher magnification, the tumor was composed of anastomosing sinusoidal capillary-sized vessels. The vessels were lined by hobnail endothelial cells and a flat endothelium focally. Zones of sclerosis and deposition of collagen between the sinusoidal vessels were observed. Cytologically, the tumor cells lacked cellular atypia, multilayering of endothelial cells and apoptotic figures or mitotic activity, although a slight degree of nuclear enlargement was observed. Scant lymphocytes were found, but no plasma cells or acute inflammatory cells were observed Figure A-D. ImmuThe histopathologic appearance and immunophenotypic feature of the tumor were indicative of a vascular tumor; however, as we lacked experience with tumor diagnosis, we could not exclude a high-differentiated angiosarcoma. After consultation with Dr. Joan Chen at the Elizabeth Hospital , the lesion was diagnosed as an anatomosing hemangioma.Whereas most renal malignancies in adults are epithelial in origin, a small number are mesenchymal. Of these, vascular tumors and tumor-like lesions account for a very small subset . They inIn 2009, Montgomery and Epstein described 6 cases of new variants of benign vascular tumors involving the kidneys, perinephric adipose tissue, and testes, which were designated as anastomosing hemangiomas . SubsequRadiologically, because of their general small size and nonspecific imaging findings, renal hemangiomas were rarely diagnosed preoperatively . ImagingMacroscopically, anastomosing hemangiomas were 0.1–6 cm in diameter and were well demarcated but always with no capsula. They were accompanied by a mahogany brown spongy appearance, and there was no grossly evident necrosis or vascular invasion ,13.Microscopically, most lesions were well marginated, but some showed a focally infiltrative pattern and even areas of intravascular extension ,2,6. At A differential diagnosis occurs both with benign and malignant vascular tumors, benign lesions such as intravascular papillary endothelial hyperplasia , atypicaAll of the reported cases were treated with surgery. Of the 31 cases, follow-up information was available for 26 patients ,13. ExceIn conclusion, we presented a case of anastomosing hemangioma, a recently described variant of a capillary hemangioma in the kidney, with detailed CT and enhanced CT scan image information. In addition, we summarized the clinicopathologic features of all 32 such lesions published in the literature. These lesions are characterized by anastomosing vessel proliferation, which could lead to a false diagnosis of angiosarcoma. As pathologists, we need to be aware of this subset of hemangiomas and should not interpret these lesions as malignant.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.


Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a well-known occurrence; however, the consequences of spillage of gallstones in the peritoneum and particularly intrathoracic complications are less defined. We describe the delayed development of a perihepatic abscess and empyema in a patient five years following laparoscopic cholecystectomy secondary to dropped gallstones. A 53-year-old man with medical history significant for a laparoscopic cholecystectomy five years prior to acute cholecystitis presented with purulent cough, hemoptysis, night sweats, and right-upper quadrant (RUQ) pain. Computed tomography (CT) scan revealed 5.4 cm right-sided subpulmonic and 5.9 cm perihepatic fluid collections with an 8 mm focal radiopaque density within the perihepatic fluid collection. Open intra-abdominal exploration resulted in retrieval of a 1 cm intraperitoneal gallstone. Laparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, causing both intra-abdominal and intrathoracic complications, presenting even years after surgery. This necessitates an attempt to retrieve all free intra-abdominal gallstones during the initial operation. Laparoscopic cholecystectomy is a commonly performed and well-established minimally invasive operation; however, there remain known adverse events and potential complications. Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a recognized occurrence with many case reports of complications secondary to dropped stones. This is in contrast to the reported incidence of dropped gallstones after open cholecystectomy, which is extremely rare . LaparosReported complications after gallbladder perforation and gallstone spillage are low; however, the likelihood of a complication increases when gallstones are not retrieved . AlthougIn this paper we describe a case report of delayed development of a perihepatic abscess and empyema five years following laparoscopic cholecystectomy as a result of dropped gallstones and provide a review of the literature on dropped gallstones during cholecystectomy.A 53-year-old male presented with approximately 2 months of purulent cough, hemoptysis, night sweats, and RUQ pain. Past medical history consisted of diabetes mellitus, hypertension, and laparoscopic cholecystectomy for acute cholecystitis five years earlier. Per operative report, the laparoscopic cholecystectomy was uncomplicated without mention of gallbladder perforation or gallstone spillage. On physical examination the patient had normal vital signs. He reported pain to palpation in the right-upper quadrant of the abdomen. All laboratory values were within normal limits. A CT scan of the chest, abdomen, and pelvis with intravenous contrast revealed a 5.9 cm perihepatic fluid collection  and 5.4  Klebsiella. The patient was placed on a short course of antibiotics and the drain was removed on postoperative day 1.The diagnosis of intra-abdominal abscess and associated empyema was suspected; therefore, the patient underwent a diagnostic laparoscopy for confirmation. Upon laparoscopy, dense perihepatic adhesions were discovered and conversion to an open intra-abdominal exploration via a subcostal incision was performed. A fistulous tract through the diaphragm was palpated. All adhesions were lysed and the subphrenic abscess cavity was opened and drained. A 1 cm gallstone was retrieved. A drain was left in place. Intraoperative cultures grew pansensitive Klebsiella and E. coli discovered in drain cultures. There were no further complications and the patient's symptoms are improved.The patient's symptoms greatly improved during the initial postoperative period and both the perihepatic and subpulmonic fluid collections decreased in size on a follow-up CT scan. Two months following the operation, the patient presented again with hemoptysis. CT-guided drain placement was performed in a residual perihepatic fluid collection. Four weeks of oral antibiotics was prescribed forLaparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, with an incidence exceeding that of the open surgical method. The incidence of gallbladder perforation ranges in the literature with a reported rate of 10% to 40% and retained stones in 1%–13% of laparoscopic cholecystectomies. There are three maneuvers during laparoscopic cholecystectomy reported as being associated with gallbladder perforation. First, the gallbladder is retracted to assist in obtaining the critical view in the dissection of the cystic duct and cystic artery. Secondly, the gallbladder may be perforated during separation of the gallbladder from the liver bed. Lastly, the gallbladder is generally extracted from the abdomen via a small incision and high pressure can result in gallbladder perforation .Despite a high rate of gallbladder perforation and gallstone spillage, the full implication of retained gallstones is unclear. Unretrieved gallstones within the peritoneal cavity may act as a nidus for future infectious complications, such as in this case of intra-abdominal abscess leading to a diaphragmatic fistulous tract and empyema. This tract is thought to have allowed for transdiaphragmatic migration of fluid and bacteria into his thoracic cavity, leading to late empyema formation. There is minimal literature on thoracic complications secondary to retained gallstones following laparoscopic cholecystectomy , 9. AlthIn contrast to laparoscopic cholecystectomy during which gallstone spillage is an acknowledged potential event, few reports of dropped gallstone complications have been reported after open cholecystectomy . TherefoPotential intra-abdominal and intrathoracic significant complications of dropped gallstones can occur. This necessitates precautions against gallbladder rupture and stone spillage. Although not an indication for conversion to an open procedure, if gallstone spillage occurs, a reasonable effort should be made in attempt to retrieve all free intra-abdominal gallstones during the initial operation.


Desmoid tumors (DTs) are non-metastatic, locally aggressive neoplasms with high postoperative recurrence rates. The pancreas is an extremely rare location for DTs. The local control of DTs is challenging. Surgery and radiotherapy are currently the principal treatment modalities for DTs; however, some resections might not be radical, and radiotherapy has several drawbacks. Therefore, many studies have been focusing on the molecular pathways involved in DTs in order to develop molecular-targeted therapies or chemotherapy. Cyclooxygenase-2 (COX-2) has been demonstrated to play a role in the growth of DTs, and the pharmacologic blockade of COX resulted in decreased cell proliferation in desmoid cell cultures in vitro.Herein, we report a 57-year-old woman who presented with recurrent epigastric pain and weight loss. An abdominal computed tomography scan showed an approximately 10-cm mass over the pancreatic head region and dilatation of the pancreatic duct. Tumor biopsy and bypass surgery were performed. A DT was confirmed on pathologic analysis. After resection, we prescribed treatment with the COX-2 inhibitor celecoxib. The patient showed complete remission and there was no local recurrence or distant metastasis within the 24-month follow-up period.The outcome of this case study is encouraging, and long-term follow-up studies are required to establish the effect of treatment with celecoxib on the prognosis of DTs. A desmoid tumor (DT), also known as aggressive fibromatosis, is a rare soft tissue neoplasm. Patients with a history of familial adenomatous polyposis, surgery, or pregnancy show higher incidence rates of DT. Although this type of tumor has a benign histology, it is locally invasive. Intra-abdominal DT has a low incidence rate, and DTs of pancreatic origin are rare. The treatment of these rare tumors is challenging because of their potential for recurrence.Resection with negative surgical margins is the most successful treatment modality for DTs . For patHerein, we report a 57-year-old woman who developed DT at a rare location. A cystic and solid mixed lesion was noted at the pancreatic head, and the final pathologic analysis indicated DT. The patient received only medical therapy after the operation and achieved complete remission.A 57-year-old woman had underlying systemic iron deficiency anemia. She presented to our outpatient clinic with abdominal pain in March 2013. Panendoscopy and colonoscopy were performed and no organic lesions were detected in the upper and lower GI tract, and only gastritis was noted. However, the abdominal discomfort could not be eliminated and it worsened. Because of progressive abdominal pain, the patient was transferred to the emergence department after 1 week. Abdominal computed tomography (CT)  celecoxib for half a year. We obtained a follow-up abdominal CT scan in October 2013 after 6 months of celecoxib treatment. The CT images showed a marked regression of the existing pancreatic head mass and complete disappearance of the cystic lesion. Therefore, the dose was modified from one tablet daily to one tablet every other day with the same dose of celecoxib starting from the date of the 6-month follow-up until now. The abdominal CT scan obtained at the 18-month follow-up in September 2014 showed no local recurrence , desmoid tumor(s); NSAID, non-steroidal anti-inflammatory drug


Visceral solitary myofibromas are uncommon in childhood. We report a case of a solitary asymptomatic visceral myofibroma of the bladder trigone occurring in a 3-month-old boy. Once malignancies were ruled out by cystoscopy, radical excision was performed in order to avoid any potential impairment of bladder dynamic. Postoperative course was uneventful and patient was discharged on day 3 after surgery. After 36 months of follow-up, the patient is toilet-trained and remains well; bladder function is normal. Visceral myofibromas are uncommon in childhood. They are often detected in case of infantile myofibromatosis. Solitary visceral myofibromas are exceedingly rare in children; they are congenital and usually detected within 2 years of life.We report a case of a solitary asymptomatic visceral myofibroma of the bladder trigone occurring in a 3-month-old boy. Patient came at our institution because microhematuria was detected. During an ultrasound investigation of abdomen, a mass in the bladder trigone was detected; multiple biopsies of the mass were obtained during cystoscopic procedure and radical excision of the mass was performed 6 weeks later. Patient had a regular postoperative course and remains well after 36 months of follow-up.To our knowledge, this is the first reported case of myofibroma occurring in this anatomic site. Despite solitary visceral myofibromas being of benign features, the anatomic site pushed us to perform a surgical excision in order to avoid any impairment of bladder function.A 3-month-old male patient came at our institution with a recent history of microhematuria detected by urine analysis performed for other reasons. The patient appeared in good general condition. No other clinical signs or symptoms were present, and neither was urinary tract infection. An ultrasound (US) investigation of abdomen was performed and a bladder solitary mass was detected . The masWe decided to perform operative cystoscopy in order to obtain multiple biopsies, allowing us to rule out malignancies. Bladder wall was normal on cystoscopic exploration, and biopsies of the mass were easily obtained. Biopsies showed a low mitotic index and uniform cells, with an eosinophil cytoplasm; no evidence of malignancy was present.Thus, surgery excision of the mass was performed 6 weeks later via a mini-Pfannenstiel. The mass was completely excised . PostopeHe remains well after 36 months of follow-up; actually, the patient showed normal urinalysis: no microhematuria, pH 5.5, specific gravity 1010, and no crystals or casts; UTI were excluded because no nitrites and leukocyte esterase were found, and less than 15 WBCs/hpf were observed.Pathology. The nodular well-circumcised mass measured 2 cm in diameter and was covered by normal urothelial tissue (l tissue . Cross sImmunohistochemical stains were performed, revealing positivity for CD34. Neurofibroma and perineurioma were excluded because of negativity for S100. Histopathological findings, therefore, were oriented to “benign infantile myofibroma.”Solitary myofibromas are rare in children. infantile myofibromatosis. Most often skin and subcutaneous tissue of head and neck are involved.These lesions occur as a solitary mass in 75% of cases; if multiple lesions are detected, the feature is identified asVisceral lesions are exceedingly rare, while only few cases described occur in the urogenital system –4. To ouSolitary infantile myofibromas are congenital, and 90% of cases are detected within 2 years of life, although adult occurrence has been reported . VisceraDespite the good behavior of the feature, complete excision of visceral myofibromas should be performed in children, in order to detect malignancies and to avoid any mass-related signs or symptoms.The differential diagnosis should include sarcomas, neuroblastomas, primary or metastatic, neurofibromas, and inflammatory myofibroblastic tumor. The last is an uncommon entity with variable clinical behavior, rarely showing malignant transformation, as recently reported by Wang et al. .Thus, histopathological investigation is mandatory.In our case, the mass was easily approachable cystoscopically, and biopsies were promptly performed, allowing us to exclude malignancies.Nevertheless, surgical excision was performed in our patient not only to exclude for certain any malignancies but also to avoid any distortion of the normal bladder trigone. The exophytic mass, in fact, protruded into the visceral lumen from the bladder trigone, overhanging the bladder neck Figures  and 2, aThe radical excision was easily obtained, and a Foley catheter was left in situ for subsequent 24 h, and the patient was discharged on postoperative day 3.US investigation was performed once per month in the first year and then every 6 months. Neither urinary tract infection nor hematuria was detected during follow-up.Our patient is toilet-trained now, and a normal bladder function is present after 36 months of follow-up.In conclusion, even if uncommon, myofibroma should be considered in differential diagnosis of pediatric bladder masses. Once malignancies are excluded, surgical excision should be performed in case of any potential mass-related impairment of bladder dynamic.


An 86-year-old female was brought in by ambulance for severe abdominal and back pain. She was hypotensive en route and appeared to be in distress upon arrival to the emergency department. Her abdomen was tense and distended with diffuse tenderness to palpation present. A bedside abdominal ultrasound (US) was done immediately, which raised concern for free air. A portable upright chest x-ray was obtained, which confirmed the diagnosis of pneumoperitoneum .Pneumoperitoneum due to perforated viscus is an emergent diagnosis that requires immediate surgical consultation and intervention. US is a useful tool that can be done at the bedside to rapidly make the diagnosis. Both low- and high-frequency transducers may be used to detect intraperitoneal free air. With the patient in a supine position, the perihepatic space should be evaluated. The patient may also be turned to the left lateral decubitus position to facilitate the rise of free air to the RUQ.4US has been shown to have a sensitivity of 85% and a specificity of 100% for pneumoperitoneum. It has been shown by some to have a higher sensitivity for this diagnosis as compared to plain radiography.