Hibernomas are uncommon benign soft tissue tumours mimicking brown fat. They are mostly seen in the fourth and fifth decades of life. Only few cases in the cervical area have been reported. Because of its rarity in pediatrics and diffcult diagnosis, we report a tow year-old patient with a cervical tumor. Ultrasound and computed tomography exams showed an infiltrative, with hypervascular and lipomatous features. After tumor excision, histopathological exam confirmed the diagnosis of hibernoma or brown fat tumor. This presentation describes the characteristics of this type of tumor, rare in children. Hibernomas are uncommon benign soft tissue tumors, developed from fetal brown fat tissue, vestigial remnants of the evolution of the species. We present a case of neck hibernoma in a 2 year old boy patient and discuss the radiographic, pathologic, and clinical features of this tumor.A two year old boy, presented with a six-month history of a left supraclavicular mass, which had increased in size over the previous twomonths prior to presentation. The swelling caused discomfort with movement but there were no neurological deficits, the patient did not have difficulty in swallowing or breathing, his medical history was unremarkable, Clinical examination revealed a mobile, soft mass compatible with a lipoma. This lesion measured approximately 9 cm in its maximum diameter; we found no cervical, supraclavicular or axillary node . LaboratHibernoma is a rare benign soft tissue tumour composed of multiloculated fat cells derived from brown fat. This tumour was first described in 1906 by Merkl. The term hibernoma was proposed in 1914 by Gery because of its morphologic similarity to the cells of the so-called hibernating gland of animals Brown adipose tissue, the function of which is to promote non-shivering thermogenesis. In man, it is found physiologically in newborns in the axillary and the subpleural regions but is said to disappear after 8 weeks of life . In ourkHibernomas are mostly seen in the fourth and fifth decades of life, previously afemale predominancewas reported , 2, 4. CHibernomas are usually depicted as heterogeneous masses with marked contrast enhancement. The CT and MR imaging examinations show a well-demarcated mass with signal intensity intermediate between subcutaneous fat and muscle and that enhances after contrast injection. Although they present as brown fat, the imaging characteristics on T1- and T2-weighted images demonstrate high signal intensity but slightly less than that of the subcutaneous fat. On fat suppression sequences, there may be incomplete fat suppression because of the nature and amount of lipids. On MR imaging, flow voids can be identified, though not in this case. In T1inside the tumour, there were areas of intermediatesignals between that of the muscle and thesubcutaneous fat. Contrast enhancement was significantafter injection of gadolinium, particularlyin low-signal areas. In T2, the mass signal was oftenvery near that of the subcutaneous fat .As needle biopsy carries a risk of haemorrhage and often leads to inconclusive results, definitive pathological diagnosisis based on surgical resection . Upon miCurative treatment of hibernomas is a complete excision, preserving vital structures, no case of recurrence has been reported , 2, 5.Hibernoma is a rare benign tumor, the cervical location is exceptionally, curative treatment is a complete excision, no recurrence has been reported.


Neonatal testicular tumors are rare and should be considered in the differential diagnosis of newborn scrotal masses. Juvenile granulosa cell tumor (JGCT) accounts for about 5% of all prepubertal testis tumors. As a benign neoplasm, radical orchiectomy is sufficient for treatment. We report a case of a newborn with a prenatal diagnosis of scrotal mass. After surgery, the histological diagnosis was juvenile granulosa cell tumor. To date the patient is healthy. Prepubertal testicular tumors are rare and they account for 1% of all pediatric solid tumors. Granulosa cell tumor is a benign neoplasm, and it can be distinguished by adult or juvenile type, with the juvenile type accounting for 1% to 5% of all prepubertal testis tumors. Although rare, it is the most common stromal cord neoplasm of the testis in infancy. Only onth week of gestation showed a multicystic testicular mass on the left side. Postnatal ultrasound revealed increased size of the testicle (1.57 × 1.33 cm) due to a well encapsulated, complex cystic mass and a Doppler scan showed increased blood flow. The controlateral gonad was normal and showed homogeneous echotexture. After the birth, the baby was admitted to our department for the management of a "left scrotal mass". Family history included two cases of Down's syndrome and no other urogenital problems. The baby was in good health and without clinical evidence of dysmorphic features or ambiguous genitalia. The right testicle had descended, hypoplastic and the penis was normal. The left testicle was in situ and painless, with increased size and consistency. Bilateral inguinal hernia and palpable lymphadenopathy were absent. We performed ultrasonography of the abdomen and testis, as well as karyotype, blood chemistry and hormone profile. The abdominal ultrasound, blood chemistry and karyotype were normal. Testicular scans confirmed the presence of a cystic mass in the left gonad  is a distinctive form of gonadal sex cord stromal tumor and accounts for 1-5% of all prepubertal testis tumors. It is a benign neoplasm, hormonally inactive and its prognosis is very good.th week of gestation showed a multicystic alteration of the left testicle. As confirmed by our case, prenatal diagnosis is difficult but possible. Evidence of a general testicular alteration in the unborn baby enabled early diagnosis at birth by clinical examination. Sometimes the tumor presents concomitantly with neonatal torsion[Although usually diagnosed in the first year of life with a typical clinical presentation characterized by a painless testicular mass that may involve an undescended or scrotal testis, some authors reported a prenatal diagnose of testicular mass. Peterson and Skoog reported a case of a cystic structure seen with an ultrasound evaluation at 35 week’s gestation[ torsion,4.Our patient was a neonate and the testis involved was in situ, without torsion. As the tumor may be associated with anomalous karyotype or ambiguous genitalia,6 we perPostnatal management consisted of abdominal and testicular ultrasound, karyotyping, blood chemistry and hormonal evaluation. Abdominal ultrasound was negative, whereas testicular scans showed a left testicle of increased size and echotexture.In our practice we use to determine serum AFP and B-HCG in all infants with a testicular tumors. In our case serum levels of AFP and B-HCG were elevated at preoperative evaluation, according to the reference range for normal AFP established by WU et al., as manyIn our case we decided to perform a total orchiectomy because of the presence of elevated values of serum AFP. We performed a subinguinal approach with the possibility to realize a safe orchiectomy with an high clamping of spermatic vessels. This approach is less invasive as an inguinal approach and it allows to perform a safe orchiectomy. This incision enables a good visualization of the testicle and spermatic cord, allowing complete excision of the intact mass and thorough assessment of the margins for partial resection if possible.Chemotherapy and radiotherapy are not contemplated for this tumor because it is non invasive and metastases have never been described.Follow-up is a controversial topic; some authors suggest that it should be performed for at least 5 years after surgery, as for most other tumors. Others argue that because orchiectomy is the only treatment, no further management is required after surgical removal of the testicle[We agree with other reports that although neonatal testicular tumors are rare, they should be considered in the differential diagnosis of scrotal masses in newborns. Testicular masses should be considered pathological until proven otherwise and a prenatal diagnosis of a scrotal mass is possible. We therefore recommend thorough inspection of the genitalia at birth, followed if necessary by hormonal assessment and testicular ultrasound. In patients affected by a testicular neoplastic disease, we argue that the only possible approach is inguinal. A subinguinal approach enables the testicle and spermatic cord to be exposed, allowing complete excision of the intact mass and thorough assessment of the margins for partial resection if possible. Follow-up of the present case is still too short to exclude recurrence, although no cases of recurrence have been reported in literature. In conclusion, the main aim of our follow-up of this patient will be to avoid damage to the surviving testicle, protect fertility and monitor for eventual recurrence.Written informed consent was obtained from the patients parents for publication of this report and any accompanying images.The authors declare that they have no competing interests.All authors read and approved the final manuscript.


We describe a case of adenomatoid odontogenic tumor (AOT) associated with odontoma occurring in the posterior mandible of a 32-year-old man. Although calcifications are commonly found in the AOT, the presence of rudimentary dental structures is a very rare phenomenon. Cases with similar aspects have been described as ameloblastic dentinoma, ameloblastic odontoma, adenoameloblastic odontoma and AOT associated with odontoma. After a careful analysis of the literature we describe the clinical aspects of this tumor. Further case reports and surveys of odontogenic tumors are necessary to define whether AOT associated with odontoma is a variant of AOT or a distinct clinicopathologic condition. Odontogenic tumors and hamartomas encompass a large variety of rare lesions that originate from odontogenic tissue and present with variable levels of differentiation. Determination of their precise nature  is difficult and sometimes inconclusive. This, in turn, makes it difficult to devise a nomenclature for this group of lesions.In 1998, Allen and co-workers  and was A 32-year-old man presented with an asymptomatic, well-delimitated, 2.6 x 2.1 x 1.3 cm unilocular hypodense tumor in the left posterior mandible  or rosette-like structures and a variable number of duct-like formations lined by cuboidal or columnar cells. Interconnecting strands and ribbons with two or more cells are present throughout the lesion. In our case we did not find duct-like structures typically reported in AOT. However, due to the overall morphologic aspect of the tumor, this diagnosis can be made without the presence of these structures . The preAOT associated with odontoma should not be confused with adenomatoid odontogenic hamartoma (AOH). The AOH is characterized by the deposition of dentin in a ring-like pattern with odontoblasts, dental papilla, lined on the outer surface by enamel, ameloblasts and stellate reticulum-like cells ,11. SmalIn the case we report, we found a cystic cavity lined by stratified squamous, non-keratinized epithelium. The same microscopic appearance was reported by Tajima et al. , indicatAlthough some AOT with odontoma are large lesions ,6, theirIn the present report we review the literature and describe the clinical and histological aspects of AOT associated with odontoma. Although this tumor differs in some aspects to classic AOT, further case reports and surveys of odontogenic tumors are necessary to define whether it is a variant of this odontogenic tumor or a distinct clinicopathological condition.The authors declare that the patient had given consent for the case report to be published.The authors declare that they have no competing interests.WHC performed surgery and drafted the manuscript. AML, RSG and CCG performed histopathological examination, conducted a review and analysis of the literature, and drafted the manuscript. All authors read and approved the final manuscript.


Fetus in fetu is a rare congenital anomaly and is defined as a monozygotic twin incorporated into the abdomen of its sibling during development. Fetus in fetu is often overlooked in the differential diagnosis of an abdominal mass. Unlike teratomas, fetus in fetu is a benign disorder.We describe the clinical characteristics of two patients, a thirty-months old boy who was found to have abdominal distension and a neonate who was diagnosed antenatally with abdominal mass. Computed tomography scan revealed the mass in which the contents favor a fetus in fetu rather than a teratoma. Surgical removal revealed that the anencephalic fetus have limb buds situated relative to a palpable vertebral column, supporting the diagnosis of fetus in fetu. In the present report, presentation, diagnosis, pathology, management, and recent literature are also reviewed.Fetus in fetu is a rare entity that typically presents in infancy and early childhood. It should be differentiated from a teratoma because of the teratoma’s malignant potential. Preoperative diagnosis is based on radiologic findings. The treatment of fetus in fetu is operative to relieve obstruction, prevent further compression and possible complications. Complete excision allows confirmation of the diagnosis and lowers the risk of recurrence. Fetus in fetu (FIF) is a rare cause of abdominal mass in children. The pathogenesis of FIF can be explained by the ‘included-twin’ theory in which the FIF is a diamniotic, monochorionic, monozygotic twin that becomes incorporated into the body of the host twin after anastomosis of the vitelline circulation . Althougβ-human chorionic gonadotropin (β-HCG) and serum α-fetoprotein (AFP) levels were normal. Serum carcinoembryonic antigen (CEA) level was 52.86 ng/mL . Computed tomography scan of the abdomen showed a large, complex, retroperitoneal mass with solid, cystic, and calcified elements. The calcifications in the mass had the appearance of vertebral body  , in whicEighty-nine percent of FIF lesions were noted before 18 months of ages . Most FITo qualify as an FIF, one of the following characteristics must be present: a mass enclosed within a distinct sac, partially or completed covered by skin, grossly recognizable anatomic features and attached to the host by a pedicle containing a few relatively large blood vessels . The twoFIF is usually overlooked in the differential diagnosis of a newborn abdominal calcification. In some cases, FIF may be confused with meconium peritonitis, which is commonly associated with calcifications . Other cAs described above, many authors agree that FIF corresponds to a monochorionic, monozygotic twin contained with the host ,19. In tβ-HCG and AFP is often used and is further supported on the basis of malignant recurrence of FIF. The detection of raised CEA levels generally indicates advanced malignant disease. Therefore, the raised CEA level in our first patient is of great concern. Whether this association of abnormal CEA level is a manifestation of the FIF or an incidental finding is unclear based on our case. Further studies are needed to establish the significant of this phenomenon.The recommended treatment for FIF is surgical excision. Because the final diagnosis of FIF is not made until pathological analysis, all parts of the mass should be removed to prevent malignant recurrence. Postoperative follow-up with screening for the tumor markers In conclusions, the cases presented in our report meet all the accepted criteria of an abdominal FIF. The preoperative diagnosis of FIF is based on the observation of vertebral column or limbs in a mass on imaging modalities. The treatment of choice for FIF is complete resection. Future research efforts should be made to establish the true nature of FIF. Further studies to determine the possible association between FIF and highly differentiated teratoma are also warranted.Written informed consent for publication these case reports and accompanying images were obtained from the patients’ parents. Copies of the signed informed consent forms are available for review by the Series Editor of BMC Pediatrics.The case reports were approved by the Ethics Committee of the West China Hospital of Sichuan University. Written informed consent was obtained for use of the images, according to the provisions of the Declaration of Helsinki.β-human chorionic gonadotropin; AFP: α-fetoprotein; CEA: Serum carcinoembryonic antigen.FIF: Fetus in fetu; β-HCG: The authors declare that they have no competing interests, either financial or non-financial, that could be perceived as prejudicing the impartiality of the research reported.YJ, SYC, LZ, XPJ, SGJ, FTK, QW and BX were involved in the clinical management of this patient and collected clinical details and photographs of this case report. QW and CHL collected the figures of microscopically histopathological examination. YJ and SYC reviewed the literature, and drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/14/88/prepub


T-cell lymphomas involve the testis infrequently, which deserve special attention because of the poor prognosis and the need to make an appropriate diagnosis, which could lead to a better therapeutic strategy.A 40-year-old man presented with right testicular swelling for past three months. The swelling was painless, hard and rubbery. Testicular ultrasound showed diffuse increase in size of the testicle, with alteration in its echogenicity. The patient underwent orchidectomy, and based on histopathological and immunohistochemical tests, a peripheral T-cell lymphoma, not otherwise specified was diagnosed.Testicular peripheral T-cell lymphomas are rare and aggressive cancers, with clinical differentials of seminoma and non-neoplastic conditions. Testicular lymphomas comprise 5% of testicular malignancies and these account for about 1% of all lymphomas. Most of these present at the age of over 60 years, with mean age 56 years. The testicular lymphomas are usually disseminated at the time of presentation . The pheThe gross morphology of a lymphoma appears as white-tan-pink coloured, and fleshy, resembling a seminoma, and it often presents with extratesticular involvement ,4. MicroA 40-year old Asian male patient reported to the general surgical outpatient department at Mayo Hospital, Lahore in October 2011 with the history of a rapidly enlarging painless lump in his right scrotum for the past two months. There were no comorbid conditions. He was married with three children; all of them were alive and healthy. His previous medical and surgical history was unremarkable.Mycobacterium tuberculosis was negative. His complete blood counts at the time of presentation were within normal limits. On discussion with the patient, he was informed that benign pathology such as isolated tuberculous orchitis was a possibility and informed consent was taken.On physical examination, a non-tender lump measuring 4.0 × 3.5 cm, firm-to-hard in consistency, was present as a right testicular swelling. It was associated with slight skin puckering. Examination of the other, that is, the left testis was unremarkable. There was no generalized lymphadenopathy on general physical examination. The liver and spleen were of normal size. Sonographic examination of the scrotum revealed a well-defined, hypoechoic space-occupying lesion in the cranial and lateral aspect of the right testis. Findings on sonographic and computerized tomography (CT) examinations of the abdomen were normal. Differential diagnosis for this sonographic appearance was seminoma and orchitis. His erythrocyte sedimentation rate (ESR) was within normal range and the Montoux test for Testicular biopsy was performed under general anesthesia and the specimen was sent in formalin to the Histopathology Laboratory, Aga Khan University Hospital, Karachi. The histopathological examination revealed markedly necrotic tissue with foci of the lesion. Histologic examination of the specimens revealed a diffuse proliferation of malignant round cells within the interstitium of the testicular parenchyma. The cells were present in the form of sheets with scant cytoplasm and slight variation in size and shape of medium-to-large nuclei, which frequently showed irregular foldings and granular chromatin. Mitotic activity was also observed with mitoses seen at a rate of 16/10 high power fields. Intervening scattered vessels were also present. These cells infiltrated around the seminiferous and epididymal tubules and presented in a discohesive pattern  is the most common form of testicular cancer in men over the age of 60, and accounts for 7% of all testicular tumors, it accounts for only 1% of all non-Hodgkin’s Lymphomas and represents up to 38% of bilateral tumors. It is the most common testicular tumor in the patient age range 60 to 80 years and has a mean age on presentation of 64 years, but our patient unusually presented at 40 years of age [In primary T-cell lymphomas, most case reports are of T-cell/Natural Killer (NK) cell lymphoma with very few cases of peripheral T-cell lymphoma (NOS). Our case represents one of those few cases of peripheral T-cell lymphomas previously reported in the literature -6. EBV-aClinical presentation is usually of a painless, unilateral testicular swelling. Symptoms of occasional sharp pain have been documented, with cases of abdominal pain with ascites being reported due to large retroperitoneal lymph nodes. Our patient had also had a painless testicular mass for the past three months. No pain or ascites was reported at the time of presentation ,8. AssocA malignant lymphoma in which the tumor mass is limited to the testis at the time of clinical onset of the disease is rare. Since the first report of non-Hodgkin lymphoma manifesting as a testicular mass, described by Malassez in 1877, primary testicular lymphoma has attracted attention because of its rarity and poor prognosis. Testicular lymphoma is a lethal disease with a median survival of approximately 12 to 24 months [Most of patients with testicular large-cell lymphoma have a poor outcome and the long-term survival curves show no clear evidence of a substantial proportion of cured patients. Even for patients with stage I disease and good-risk International prognostic index (IPI), the outcome seems worse than that reported for diffuse large cell lymphoma (DLCL) at other sites -9. ThereThis report indicates that testicular T-cell lymphoma deserves to be distinguished from the other testicular lymphomas for example, diffuse large B-cell lymphoma and Hodgkin’s lymphoma, because of the different treatment options. In fact, this lymphoma tends to occur at a younger age, to disseminate early, to have an aggressive course, and is strongly associated with EBV ,10. RespTesticular peripheral T-cell lymphomas are rare and highly aggressive cancers, with clinical and histological differentials of seminoma and non-neoplastic conditions. Correct diagnosis with immunohistochemical techniques is mandatory for the proper treatment and further directed management of these tumors.Written informed consent was obtained from the patient for publication of this report and any accompanying images.BACOP: Bleomycin adriamycin cyclophosphamide, vincristine, and prednisone; CNS: Central nervous system; CT: Computerized tomography; CHOP: Cyclophosphamide adriamycin vincristine, and prednisolone; DHAP: Dexamethasone high dose Ara C and cisplatin; DLCL: Diffuse large cell lymphoma; EBV: Epstein-Barr virus; ESHAP: Etoposide methylprednisolone cytarabine, and cisplatin; ESR: Erythrocyte sedimentation rate; ICE: Ifosfamide carboplatin and etoposide; LMP: Latent membrane protein; PTL: Primary testicular lymphoma; NK: Natural killer; IPI: International prognostic indexThe authors declare that they have no competing interests.SH carried out the literature search and contributed in writing the manuscript. AA reviewed the slides and drafted the manuscript. All authors read and approved the final manuscript.


We report a case of intra-abdominal testicular tumor in a 36-year-old married lady presenting with chief complaints of primary amenorrhea. The patient was later diagnosed with testicular feminization syndrome, a form of male pseudohermaphroditism. This testicular tumor was histologically proven as seminoma. Due to rarity, imaging findings in patients with testicular feminization syndrome and intraabdominal testicular tumor have been poorly documented. So far, only one case report had described the combined role of CT and MR imaging in intraabdominal testicular sex-cord stromal tumor. To our knowledge, this case is first to document USG and MR imaging in addition to MR spectroscopy features in intraabdominal testicular seminoma. As many as 1 in 3000 babies are born intersexed . Thus, tA thirty-nine-year old married lady presented with chief complaints of primary amenorrhea. She also had abdominal distension and palpable swelling over the abdominopelvic regions since last two years. There were no constitutional symptoms or weight loss. There was no history of prior biochemical or radiological investigations during her teens. The physical examination revealed normally developed breasts but sparse pubic and axillary hair. On local examination, there was a large firm nontender mass extending over the abdominopelvic regions. Gynecological examinations revealed normal labia; however, vagina was blind (5 cm) with absent cervix. A solid mass was felt at anterior aspect of pelvis. Her hormonal assay revealed raised testosterone levels up to 3.94 . Tumor markers showed raised beta-HCG levels up to 159 IU/L . Carcinoembryonic antigen (CEA) and alpha-fetoprotein (AFP) levels were within normal limits. Blood karyotyping was performed which surprisingly revealed a chromosomal abnormality with 46, XY. Further assessment of mass by an ultrasound showed a large predominantly hypoechoic solid mass measuring 22 cm × 17 cm × 10.56 cm with minimal echogenic internal septations and central necrosis . Few vasIntersex disorders result from a genetic defect in chromosomal presentation. They often present with ambiguous external genitalia and on the basis of their gonadal presentation, are categorized into true hermaphrodites and mixed gonadal dysgenesis (pseudohermaphrodites) . Remarka“Feminizing” testis (testicular feminization syndrome), is an inherited sex-linked recessive disorder, a rare form of a male pseudohermaphroditism, characterized by androgen insensitivity resulting from an absence or abnormal cytosol receptor for androgens . Thus, dThe estimated risk of malignancy in testicular feminization is 5% . In compGonadoblastoma is the most commonly seen tumor in dysgenetic gonad . The semIn conclusion, though definitive diagnosis of testicular feminization syndrome relies on biochemical tests, imaging findings are useful in documenting the absence of mullerian duct derivatives, identifying the location of the undescended testes, and evaluating the accompanying intraabdominal masses. Imaging may also be helpful in providing tissue characteristics of a potential neoplasm arising from the gonads, their accurate extent and staging which are essential for further management.


Mediastinal teratomas are usually asymptomatic tumors, located most commonly in the anterior mediastinum. Very rarely, such tumors may rupture into the tracheobronchial tree, lung, pleura or pericardium. Computed Tomography (CT) is helpful in the diagnosis and differentiation of ruptured and unruptured tumors.We report a case of ruptured anterior mediastinal teratoma in a 20-year-old female presenting with recurrent hemoptysis and cough; thus, mimicking a lung malignancy or tuberculosis. CT demonstrated a heterogeneous fat containing lesion in the anterior mediastinum with extension into the lingular lobe. Subsequent fine needle aspiration cytology (FNAC) yielded plenty of anucleate squames and debris, and a clear cut diagnosis could not be made. Total excision of the tumor was performed and histopathology of the surgically excised mass confirmed the CT diagnosis. Teratomas are the most common germ cell tumors of the mediastinum . Mostly,A 20-year-old female presented with complaints of frank hemoptysis for five days. In addition, for the past three years she had recurrent episodes of hemoptysis and cough, for which she was given repeated courses of antibiotics. Recently she completed the full course of antitubercular treatment from a primary healthcare physician. Previous chest radiographs were reviewed that showed persistent opacity in the left paracardiac region .The patient was admitted and a thorough diagnostic workup was done. Routine hematological investigations were unremarkable and the sputum test was negative for acid fast bacilli (AFB). Chest CT revealed a heterogeneous mass with an irregular margin, 3.7 × 4.8 cm in size, involving the lingular lobe and the left mediastinum . The masPresence of air within the tumor with narrowing of the lingular lobe bronchus suggested the possibility of communication with the bronchus. CT guided FNAC of the tumor was performed and the cytological findings were inconclusive and there was suspicion of squamous cell carcinoma. Lobectomy of the left lingular lobe with total excision of the tumor was performed. At surgery, a brown tumor was seen in the mediastinum extending to involve the adjacent lingular lobe of lung, with adhesion to the thymus and pericardium. Tumor extension into the bronchial tree was also found. Macroscopy revealed a ruptured cystic structure (4 × 3.5 cm) with a bunch of hairs . MicroscMediastinum is the most common extragonadal primary site of germ cell tumors, teratoma being the commonest of all mediastinal germ cell tumors. In the mediastinum, teratomas are most frequently located in the anterior compartment . They ar


The cystic lymphangiomas (LC) are polymorphous tumors of undecided origin, , observeFE, a man of 71 years, comes to our attention in July 2009 complaining about one month from the onset of dyspeptic disorders and a sense of weight reported in epigastrium. In his history, in addition to this, the patient reported the removal of a cystic lymphangioma in the left cheek a few years before. On physical examination, in the right hypochondriac region, there is the presence of swelling of tense-elastic consistency, mobile on superficial and deep plans and painless, about 10 cm in maximum diameter. Ultrasound, CT and MRI documented the presence of an oval formation, with cystic charateristics 144x68 mm in diameter that extends caudally to about 10 mm in the context of the peritoneum in close proximity with the front lower edge of the small wing of the liver and the gastric body. The patient underwent exploratory laparotomy, where we found a massive lesion, well encapsulated, of elastic consistency, brown stalk, originating from the hepato-gastric ligament and we proceed with the removal of the mass “en bloc” after ligation of the vascular pedicle. No additional excision was necessary. The histological examination demonstrated a cystic lymphangioma. The post-operative course was regular, the patient was discharged on the third day. After six months of follow up the patient is disease free.The cystic lymphangioma is a rare, hamartomatous tumor whose etiopathogenesis seems secondary to a congenital malformation of the lymphatic system ,4. The iThe LC is a rare disease in adults; the authors describe the case of a person 71 years of age with a cystic lymphangioma of the peritoneum of the lesser omentum. Ultrasound, CT and magnetic resonance imaging for evaluating the characteristics and location of the tumor. The surgical excision is the treatment of choice, allowing a histological diagnosis.


Ependymomas are glial tumors derived from ependymal cells lining the ventricles and the central canal of the spinal cord. It may occur outside the ventricular structures, representing the extraventicular form, or without any relationship of ventricular system, called ectopic ependymona. Less than fifteen cases of ectopic ependymomas were reported and less than five were anaplastic. We report a rare case of pure cortical ectopic anaplastic ependymoma. Ependymomas are tumors derived from ependymal cells lining the ventricles or from the central canal of the spinal cord , 2. It rAlthough it is a lesion arising from the ventricular system, sometimes it has extension outside the ventricles, through the cerebral tissue, representing the extraventricular form. Also, they may occur outside the ventricular structures, without any relationship of ventricular system, representing the rare group of ectopic ependymona. Less than thirty cases of ectopic ependymomas were reported, and almost fifteen were purely cortical, and only five cases were anaplastic lesions . We report a rare case of pure cortical ectopic anaplastic ependymoma. A 23-year-old male presented with seizures and progressive headache. Neurological examination showed right hemiparesis and motor aphasia. MRI  demonstrA left frontal craniotomy was performed allowing a microsurgical left frontal approach to the tumor. Total macroscopic removing was made and histological and imunohistoquimical examination confirmed typical findings of anaplastic ependymoma . After tAlthough approximately half of the supratentorial ependymomas arise from the wall of third or lateral ventricles and are purely intraventricular, the remaining has extension through adjacent cerebral tissue, representing extraventricular forms of ependymoma. Only few cases occur in distant places of the ventricular system, representing rare cases of ectopic lesions . It is sBesides supratentorial ependymoma grow up of third or lateral ventricle, it is predominant involving the brain parenchyma at the diagnosis , 10. HamThe principal differential diagnosis of extraventricular supratentorial ependymoma should include astrocytoma (both low grade and glioblastoma multiforme), supratentorial primitive neuroectodermal tumor (PNET), ganglioglioma, gangliocytoma, and oligodendroglioma , 7, 10. Histologically, the tumor cells are characteristically organized in perivascular pseudorosettes and, less commonly, ependymal rosettes , 4. AlthPrognostic factors of ependymomas that positively contribute to progression-free survival and longer survival are still elusive, even histologic characteristics , 10, 12.Age at presentation is also a significant prognostic factor , 9, 17. The best treatment is radical resection, because it appears that tumor resectibility is the most important factor associated with recurrence , 3, 17. Our patient was treated with radical surgery and postoperative radiation therapy, because their anaplastic grade tumor. There was no evidence of residual tumor at postoperative imaging. The patient had a good recovery of neurological symptoms, and after 5 years, he was tumor free at clinical and radiologic examination.


Introduction. Many different etiological factors are involved in the development of hepatocellular carcinoma (HCC). We report the case of HCC in a 37-year-old male professional bodybuilder with extensive anabolic androgenic (AAS) steroid abuse. Case Presentation. Because of increasing epigastric and abdominal pain, abdominal ultrasound was performed in a 37-year-old male professional bodybuilder. A hyperechoic lesion in the liver was detected in segment VI. The magnetic resonance imaging showed hepatomegaly and confirmed the lesion, which showed features of a hepatocellular adenoma (HCA). Laboratory values were inconspicuous. After laparoscopic segmentectomy the histological examination revealed HCC. Conclusion. While the development of HCA in the liver by chronic intake of AAS is well known, little is known about the association with HCC. The presented case may indicate aetiological association of chronic intake of AAS and the development of HCC. Oxymetholone or methandienone was discontinued three weeks before competition. In addition, he took spironolactone 100 mg, mesterolone 25 mg, fluoxymesterone 10 mg four weeks, and torasemide eighteen hours before competition. Furthermore, a daily intake of amino acid, vitamins, and mineral tablets, T4 (200 μg), and growth hormones (8 I.E.) was reported. The nutritional protocol consisted of six small, protein-rich meals , a high caloric and high protein-containing diet to build up muscle mass. Eight weeks before competition, the meals and consequently the caloric intake were reduced by 50% to reduce subcutaneous fat. Torasemide, a diuretic, was taken to achieve a more muscular bodily contour by reducing extracellular and subcutaneous tissue volume.The patient reported AAS use with different kinds of anabolic substances and a stringent diet for increasing muscle mass. For a period of at least five years he has been consuming the following AASs in a daily medication schedule: Testosterone propionate, testosterone phenylpropionate, testosterone isocaproate, testosterone decanoate 250 mg, trenbolone acetate 75 mg, 5alpha-androstanediol 100 mg, boldenone and methandriol dipropionate 240 mg, 17A laparoscopic segmentectomy of the liver was performed, and a 6 × 6 × 5 cm tumor was resected from the right hepatic lobe.A partial hepatectomy specimen of 256 g, measuring 12.1 × 8.2 × 5.8 cm, was examined in the department of pathology. The surface was partly shiny, partly covered with white fibrous membranes with few adhesions. Slicing the specimen revealed a 6 × 6 × 5 cm tumor with central necrosis.A histological examination was performed on formalin-fixed and paraffin-embedded sections: noncirrhotic liver parenchyma was infiltrated by an extensive necrotic carcinoma. The tumor consisted of trabeculae of medium-sized polygonal cells resembling hepatocytes separated by sinusoidal spaces and containing cytoplasmic bile inclusions. In places, pseudoglandular tumor cell formations were seen . The traβ-catenin, progesteron, and oestrogen receptors showed a weak nuclear staining. The mitotic index analysed by Ki-67 was low with 5-6% of positively stained cells.Immunohistochemically, there was a diffuse and strongly positive cytoplasmic, granular staining in all tumor cells for CK 8 as well as for Hep-Par 1. CD 10 and CEA showed an intense canalicular staining pattern in the tumor cells. The endothelium, which surrounded the trabeculae, showed a clearly positive immunohistochemical staining for CD 34 . A weakeA moderately differentiated HCC was diagnosed .α-fetoprotein every three months (highest level 3 μg/L) and magnetic resonance imaging every six months. He is doing fine after a follow-up period of 27 months without a sign of recurrence.The clinical course was uneventful, and the patient was discharged on day 7. He has been followed up regularly by ultrasound and We report the remarkable case of a young professional bodybuilder who has been consuming high doses of AAS over a long period of time and who developed hepatocellular carcinoma in the liver without AFP elevation.Histopathological findings revealed unequivocal evidence of HCC with characteristic features like cytological atypia and a neoplastic trabecular pattern. As we have not been able to find HCA-like areas in the tumor, the mechanisms of carcinoma development remain elusive and have to be discussed.It is well known that the liver is a hormone-sensitive organ expressing oestrogen and androgen receptors , 6. HCAsβ-catenin mutation [β-catenin mutation reveals nuclear atypia and overexpresses β-catenin. In our case immunohistochemistry revealed β-catenin overexpression suggestive for carcinoma development from a preexisting HCA. However, β-catenin overexpression can be found also in “de novo HCC.” The patient has been AFP negative, which might be an argument for the adenoma-carcinoma sequence; however, there are AFP-negative de novo HCCs as well. Thus, the possibility of malignant transformation of an HCA cannot be proven in the case presented and we discuss that in our patient de novo carcinoma development is most probable.The adenoma-carcinoma sequence has recently been described for a subgroup of adenomas with mutation . HCA witA growing number of reports about abuse of anabolic androgen steroids in Western Europe and the USA by competitive and noncompetitive bodybuilders is reported in the literature especially since the 1990s . A correIn the literature the correlation between anabolic misuse by bodybuilders and the development of HCC is reported only in seven cases retrospectively. In contrast, numerous cases about the development of HCC in patients taking anabolic steroids because of other underlying diseases have been referred , 9.Bodybuilders, who abuse anabolic androgen steroids over a long period of time have a great risk of developing an HCA or HCC and should therefore be well monitored. Periodic hepatic ultrasound seems to be an adequate screening procedure to detect the development of hepatic lesions . AlthougIn conclusion, this case demonstrates the development of HCC in a noncirrhotic liver probably based on the chronic intake of AAS. The mechanisms of carcinoma development in this case remain elusive. Bodybuilders should be aware of the risk of carcinoma development when abusing AAS.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Purpose. To prospectively evaluate regional referrals into a soft tissue sarcoma service from outside the tertiary centre with local hospital imaging. Materials and Methods. Consecutive referrals were prospectively assessed for: patient demographics, source, referral date, date received by Multidisciplinary Team (MDT), lesion size, local radiology, MDT radiology and final diagnoses. Radiology diagnosis was categorised benign, indeterminate or malignant by consensus. Delays were defined as >10 days. Results. 112 patients were included with high correlation between local and MDT radiology categrorisation and histology . There was only a trend for MDT radiology diagnosis to downgrade local imaging diagnosis . 48 cases (43%) had ultrasound and MRI at referral and 20 (18%) ultrasound only. 85% of cases were benign (lipoma most common), 15% malignant (sarcoma most common). Delay occurred in 34% of cases. Discussion. In comparison to previous series these results show a reduction in benign lesions, increased biopsy and malignancy rate for lesions referred to a tertiary centre when imaging is performed and reviewed by local radiologists. Advances in Knowledge. Imaging triage of soft tissue masses can decrease benign referral rates and increase the proportion of indeterminate and malignant lesions referred to specialist centres. Soft tissue sarcomas account for approximately 1% of all adult primary tumours, which equates to approximately 2000 cases per year in the UK  and prevManagement of soft tissue sarcomas is focussed in tertiary centres, where at least 100 new sarcomas are treated per year. A far greater number of patients than this present to primary and secondary care with clinically suspicious soft tissue masses, which are ultimately not sarcomas, but require further clinical and radiological investigation.Previous studies have suggested unacceptable delays in presentation and clinical guidelines have been published stating which soft tissue mass characteristics are concerning  and promIn our region, a soft tissue sarcoma pathway was established in 2010 for both GP's and secondary care clinicians and states all relevant imaging investigations should be performed locally prior to tertiary referral.The aim of this study was to prospectively evaluate all regional referrals from outside the tertiary centre hospital with local hospital imaging looking particularly at the source of referral, referral timings, the number of biopsies performed, the rate of benign versus malignant cases, and the level of agreement between the provisional imaging diagnosis (referrer and Multidisciplinary Team (MDT)) and the final diagnosis.Consecutive referrals, over a six-month period, into a regional soft tissue sarcoma service from outside the tertiary hospital were evaluated. Institutional ethics committee approval stated that individual patient consent was not necessary.The following data was collected for each case: patient demographics, source and date of referral, date of referral receipt by MDT staff, details of imaging performed prior to referral, provisional radiology diagnosis, MDT date, radiology MDT, and final diagnoses.The timing between last local imaging performed and the referral being made were calculated as well as the time between source referral date and date received by MDT staff. Delays at either of these stages were categorised into <10 days (no delay) or >10 days (delay).The initial local radiology reports were assessed for provisional radiological diagnosis and categorised as benign, indeterminate, or malignant.Imaging studies were also evaluated by 2 MSK radiologists (12 and 3 years of experience), blinded to the provisional diagnosis and categorised as benign, indeterminate, or malignant by consensus using established criteria  5, 6]. , 6. 5, 6Core biopsy, open biopsy, and/or resection histology reports were documented following the procedure. Correlation between the local radiology diagnosis, MDT radiology diagnosis, and final diagnoses was analysed using the Chi-square test. This was performed using the pathology results as the expected finding and comparing both the provisional and MDT diagnoses with this, respectively (95% confidence limits). The patients were categorised according to final diagnosis to see if the provisional diagnosis had an influence on the urgency/speed of referral.112  patients were referred from outside the main tertiary centre in the 6-month study period. 40/112 (36%) of cases were referred from primary care and 72/112 (64%) were referred by a hospital clinician.The length of time between imaging and the subsequent referral to the MDT ranged from 1 to 180 days with a mean of 11.7 days and a mode of 1 day. A small number of cases were delayed for >100 days hence the significant difference seen between the mean and the mode. No delay was seen in 67% of the referred patients. There was no established pattern in terms of which patients experienced a delay in the referral pathway.All cases had either ultrasound or MRI performed prior to referral. 48 cases (43%) had both ultrasound and MRI performed prior to referral whilst 20 (18%) had only ultrasound; of these cases it was felt ultrasound was sufficient in 16 cases however in the remaining 4 cases MRI was performed following initial MDT discussion of the case. In each of these cases MRI was required to more accurately assess the depth of the lesion or its anatomical relations to other structures but did not alter the MDT radiology diagnosis as determined on ultrasound imaging. 44 (39%) had only MRI performed and none of these patients were referred for additional ultrasound imaging following MDT discussion.n = 13) (n = 4)  with lipoma being the most common diagnosis in this group . 49/112 n = 13) , soft tircinoma,  and coloHistology was available for 92 of the 112 patients in the study. In 20 patients no pathology was available; in these cases the patient was either referred back to the base hospital for conservative management or removal of a benign lesion or a decision was made to perform serial imaging followup as opposed to biopsy or excision. On clinical and radiological followup after 12 months none of these masses had changed significantly and no sarcomas were excised elsewhere in the region in this patient group.P = 0.54 and P = 0.49, resp.). These calculations are based on the assumption that pathology for the 20 cases which were not excised would follow the same distribution as the cases for which histology was available. Although there was no statistical difference in referrer and MDT imaging diagnoses and final pathology there was a trend for the MDT imaging diagnosis to downgrade the referrer imaging diagnosis to benign. 11 of these cases were downgraded to benign lipoma (see below); further 4 cases were downgraded to benign at MDT and included 2 inflammatory masses, nodular fasciitis, and myositis ossificans.Comparing the local referrer provisional categorisation diagnosis with histopathology and MDT imaging diagnosis with histopathology showed no significant difference between diagnosis by either the referrer or the MDT radiologists compared with final histology  , 8. CorrLipomas are primarily referred into specialist MDT as a result of NICE guidance . AlthougIt is recognised that a delay in presentation or referral and subsequent diagnosis is a significant cause of morbidity for sarcomas . HoweverLimitations of this study include lack of detail on patient delay in presenting to primary care and patients with local normal or nontumour imaging findings that were never referred onwards. However there has been only one other sarcoma pathology recorded in the region, outside the tertiary hospital pathway, and that patient had no preoperative imaging. Pathology was not available in all cases but this reflects the prospective nature of this study and the offer to local radiologists to have a low threshold for referring indeterminate lesions. However, this is a potential bias in previous studies which retrospectively evaluate imaging of lesions via pathology databases.Although possible algorithms have been suggested for the investigation of soft tissue masses , definin


Esophageal melanocytosis is a rare and benign condition, characterized by melanocytic proliferation of the esophageal squamous epithelium with heavy melanin deposition. The etiology and pathogenesis has not been exactly known but it seems to be a chronic stimulus such as gastroesophageal reflux. This condition is very rare and about 35 cases have been reported so far, most of which have been from India and Japan. Herein, we present a case of esophageal melanocytosis in a patient with long history of oral opium consumption. To the best of our knowledge, such a history has not been reported. Esophageal Melanosis or melanocytosis is a rare and benign condition, which is first described by De La Pava in 1963 . No defiA 75 year-old man was referred to gastroenterology clinic with the chief complaint of epigastric pain and dysphagia. His past medical history was unremarkable. No positive family history was identified. He has been a heavy smoker since 40 years ago. He has also been an opium addict since 30 years ago. He used to consume opium poppy until 10 years ago, but since then he has been using opium orally. The entire basic laboratory tests results including white blood cell count, hemoglobin, and renal and liver function tests were within normal limit.Results of physical examination of the heart, lungs, abdomen and anogenital region were completely normal. Findings of computed tomography (CT) scan of chest and abdomen were normal. Conventional upper endoscopy showed black discoloration in the middle part of the esophagus . StomachEsophageal melanocytosis is a rare and benign disease defined as melanocytic proliferation in the basal epithelium of esophagus with increased quantity of the melanin in the mucosa . It is rThe etiology and pathogenesis remain uncertain; however it may be the result of gastroesophageal reflux and other continued and chronic stimuli . It has The presenting symptoms in the majority of the previous cases have been dysphagia and abdominal discomfort . Upper eOther differential diagnoses in the histology and endoscopy are blue nevus and malignant melanoma . There i


Inflammatory myofibroblastic tumor has been defined as a histologically distinctive lesion with uncertain behaviour. The term inflammatory myofibroblastic tumor more commonly referred to as “pseudostumor ”, denotes a pseudosarcomatous inflammatory lesion that contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes. It exhibits a variable biological behavior that ranges from frequently benign lesions to more aggressive variants. Inflammatory myofibroblastic tumor mostly occurs in the soft tissue of children and young adults, and the lungs are the most commonly affected site, but it has been recognized that any anatomic localization can be involved. Inflammatory myofibroblastic tumors in adults are very rare, especially in the stomach. We present a case of a 43-year old woman with primary inflammatory myofibiroblastic tumor in the stomach and a review of the literature. Inflammatory myofibroblastic tumor (IMT) has been defined as a histologically distinctive lesion of uncertain behavior. It has also been previously known as inflammatory pseudotumor, plasma cell granuloma, inflammatory myofibroblastoma, and inflammatory myofibrohistiocytic proliferation. IMT frequently recurs and rarely metastasizes .It seems that a large proportion of these lesions are true mesenchymal neoplasms and the term IMT more commonly referred to as “pseudotumor”, refers to a pseudosarcomatous inflammatory lesion that mostly occurs in the soft tissue of children and young adults, and contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes ,3. The p2, and she had Karnofsky score of 100%. Physical examination showed mild abdominal tenderness in the epigastric region, but no palpable abdominal mass. Her laboratory analyses were unremarkable. The chest X-ray film was normal. Round, sharply contoured filling defect, situated on the lesser curvature of the stomach, near the angular incisure, approximately 2.5 cm in diameter, was demonstrated by a double-contrast barium meal  was 37,2 kg/mDue to gastric tumor with unclear tumor histology, surgical excision was suggested. The patient underwent an exploratory laparotomy. During surgery tumor formation was found in the distal part of the stomach closer to small curvature. The tumor mass involved the entire thickness of the gastric wall. There were no signs of adjacent organs infiltration or metastatic disease. Subtotal gastrectomy with D2 lymph node dissection and Roux-en-Y reconstruction was performed. Early postoperative course was uneventful and patient was discharged from the hospital 8 days following the surgery. Macroscopic examination of the resected portion of the stomach revealed a well demarcated tumor mass in the distal part of the stomach, 60 × 40 mm in diameter, with superficial polypoid protrusion, which on cut surface resembled an ill defined whitish nodular fraction measuring 25 × 17 × 17 mm. Histologically, there was an ill-defined proliferation composed mostly of spindle-shaped mesenchymal cells admixed with diffusely scattered inflammatory cells. The mitotic count was 1/10 high power fields (HPF), and Ki-67 labeling index was estimated at 8%. Cellular atypia was focal and seemed reactive, as mostly observed in the vicinity of ulcerative superficial portions. There was no tumor necrosis. Lymph nodes found in the perigastric region and celiac trunk all tested negative for tumor. Contrary to the inflammatory fibroid polyp, the lesion had less eosinophils and fibroses but more lymphoid cell infiltrates. Moreover, a regular vascular pattern or “perivascular cuffing” was not observed, which is regarded as a feature of inflammatory fibroid polyps, rather than inflammatory myofibroblastic tumors. On immunohistochemistry, tumor cells showed positive immunoreactivity for vimentin, although only focal smooth muscle actin (SMA) and sparse desmin immunoexpression, while remainnig negative for pan-cytoceratin, c-kit, CD 34 and S-100. These findings and evident immunoexpression of anaplastic lymphoma kinase (ALK) protein were consistent with an IMT originating from the gastric wall. Having in mind the positive immunoreactivity for ALK and on consulting referent data it was concluded that the particular IMT might have recurrent potential and possible aggressive prognosis, thus representing uncertain metastatic biological behavior (Figure The patient was without symptoms over 24 months of follow-up. During this period the US, CT and upper flexible endoscopy showed no signs of tumor recurrence or metastatic disease.IMT is a rare lesion, considered to be morphologic expression of reactive, reparative, infective and neoplastic processes . There hWe presented the case of a 43-year old caucasian woman with prior medical history of a c-section a year, as well as a laparoscopic cholecystectomy two years prior to this medical consultation. It has been suggested that IMT is a reactive, reparative lesion which occurs after trauma or surgery Table , 6,11].,11.6,11]In this case, due to relatively small tumor, patient had dyspeptic symptoms for two years. However, IMT clinical presentation varies depending on its anatomical localization in the stomach and size Table .Even with a thorough diagnostic workup, which included CT, US, EUS, laboratory analyses, upper flexible endoscopy with biopsy in this case, it was difficult to make an accurate preoperative tumor diagnosis. In most cases IMT features mimic malignancy on upper flexible endoscopy and radiological imaging. For that reason, most IMT cases require surgical exploration and complete resection to obtain an accurate microscopic diagnosis, .Due to a good general condition and no signs of metastatic disease, a radical surgical procedure was performed including a subtotal gastrectomy with D2 lymph node dissection and Roux-en-Y reconstruction. A complete surgical resection remains the only proven mode of cure, and is proposed as the first line of treatment in all IMT cases . Types oIn the given case, pathology revealed a clearly demarcated tumor mass located in the distal part of the stomach which involved full thickness of the gastric wall, without any signs of adjacent organs infiltration. The lymph nodes were all negative for tumor. The histological features of the tumor included myofibroblastic proliferation and a varying degree of inflammatory cells mainly consisting of lymphocytes, histiocytes and plasma cells. Similar histological patterns were described in other cases of primary gastric IMTs, Table .In this case the tumor cells showed a positive immunnoreactivity with ALK protein. The presence of ALK protein expression essentially serves as a surrogate marker for the translocation involving the ALK locus at chromosome 2p23, hence excluding a reactive myofibroblastic proliferation. These results were suggestive of IMT with possible aggressive prognosis and metastatic potential. However, recently published data suggest that ALK protein expression and epitheliod or round cell morphology rather than other pathologic features correlate well with the behavior. For those cases, the term epithelioid inflammatory myofibroblastic sarcoma has been proposed .Within a year of a surgery, 15% to 37% cases of primary gastric IMT ended with tumor recurrence . In everWritten 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.ALK: Anaplastic lymphoma kinase; BMI: Body mass index; CT: Computed tomography; EUS: Endoscopic ultrasound; HPF: High power field; IMT: Inflammatory myofibroblastic tumor; SMA: Smooth muscle actin; US: Ultrasound.The authors declare that they have no financial and non-financial competing interests.Milos M. Bjelovic MD, Ph.D.Name and Surname: rd, 1963; Belgrade, SerbiaDate and Place of Birth December 23Academic Degrees University of Belgrade, Ph.D. 2003.Research: “Role of the splenectomy and dissection of lymph nodes along the upper border of the pancreas in the radial surgical treatment of gastric cancer”Faculty Appointments University of Belgrade, School of Medicine Professor of Surgery 2012.Hospital Appointments The First University Surgical Hospital, BelgradeHead of the Department for Minimally Invasive Upper Digestive Surgery and Assistant Director of the Hospital 2010.Education abroad Digestive and Oncologic Surgery, National Cancer Center Hospital, Tokyo and Tokushukai Medical Group, Japan 2002.Bariatric Surgery, Dr Miler, Salzburg, Austria 2004.and 2010.Training course in advanced laparoscopic procedures, Center for the Experimental and Microsurgery, University “Victor Babas” Temisuara, Romania 2004.Minimal Invasive Surgery of the Esophagus, Prof. James Luketich, Department of Cardiothoracic Surgery, UPMC, Pittsburgh, PA, USA 2007. and 2009.Minimal Invasive Surgery of the Incisional and Umbilical Hernias, Dr Tim Tollens, Mehelen, Denmark 2009.LEES Training Course, Olympus Training Center Hamburg, Germany 2010.Master Course TME, Covidien Training Center Erlancourt, France 2011.Single Incision and Reduced Port Surgery Training Course, Vienna, Austria 2011.MB, TB contributed equally to this work. MB, BS and TB designed reasearch. MB, BS, TB, DG, performed reasearch. AD analyzed radiografic images. MM performed pathohistological and immunohistochemistry evaluation. BT wrote the paper. MB, MM, PP revised article for important intelectual content. MB, MM, PP gave final approval for version to be published. All authors read and approved the final manuscript.


Intimal (spindle cell) sarcomas of the left atrium are extremely rare primary cardiac tumours with three cases reported , Cho et al. (2006), and Modi et al. (2009)). We present a 69-year-old man who first came to medical attention after experiencing abdominal discomfort. He had a 30 lb weight loss apparently due to dieting. He denied any other constitutional symptoms. His symptoms persisted despite a course of antibiotics for presumed diverticulitis. Laboratory values were within normal limits, though the haemoglobin was 131 g/L . Subsequent abdominal computed tomography (CT) scan revealed an abdominal wall mass and intracardiac lesion; the cardiac mass was further characterized by transesophageal echo (TEE), magnetic resonance imaging (MRI), and dedicated cardiac CT. TEE revealed a mass attached to the posterolateral wall of the left atrium above the mitral annulus, and the cardiac CT and MRI confirmed the TEE findings. The patient underwent extensive surgical resection and repair of the left side of the heart. Postoperatively, he developed acute renal failure requiring dialysis and reintubation for volume overload. He became acutely hypotensive, developed multiorgan failure, and succumbed to his illness. Histopathologic examination of the left atrial mass showed an intimal sarcoma. Cardiac tumours may be primary or secondary, with secondary tumours being far more common (100 to 1000 times) . PrimaryA 69-year-old man was referred for surgical assessment after the findings of an abdominal wall and left atrial (LA) mass. He had mild obstructive lung disease and a 30-pack-year smoking history. He sought medical attention after experiencing abdominal discomfort and had noted a 30 lb weight loss over the last few months, apparently related to dieting. There were no other constitutional symptoms. His symptoms persisted despite a course of antibiotics, for presumed diverticulitis. Physical examination was unremarkable. Laboratory investigations revealed a hemoglobin of 131 g/L , with all other values within normal limits. Emergency computed tomographic (CT) scan revealed a 5 × 4 cm heterogenous mass in the left anterior abdominal wall and an intracardiac mass. CT head, chest, and abdomen did not show any other masses.Two biopsies of the abdominal wall mass were examined, and most of the tissue was necrotic. The conclusion was that a definitive diagnosis was not possible (in spite of the immunohistochemistry) and that the definitive diagnosis was best accomplished following cardiac and abdominal mass resection.Transesophageal echocardiogram (TEE) revealed a 4.4 × 3.5 cm mass attached to the posterolateral wall of the left atrium, above the mitral annulus. Mean and peak gradients across the mitral inflow were 4 and 12 mmHg, respectively . CardiacCoronary angiography showed a 90% right coronary artery (RCA) lesion. The patient underwent extensive resection of the LA mass and repair of the left atrium, left ventricle, left ventricular outflow tract, as well as mitral valve replacement and saphenous vein graft to RCA. The postoperative course was complicated by acute renal failure requiring dialysis and reintubation for volume overload. Ten days postoperatively, he became acutely hypotensive, developed multiorgan failure, and succumbed to his illness.Macroscopic examination of the cardiac specimen revealed an atrial mass weighing 30.4 grams with a side to side dimension of 4.3 cm, length of up to 4.5 cm, and a thickness of up to 2.9 cm from the atrial endocardium. The mass involved the atrial wall posteriorly and the entire posterior mitral leaflet, except for its free margin . The mosColumbus, in 1562, first described a tumour mass in the heart . In 1835Intimal (spindle cell) sarcomas are mesenchymal tumours, more commonly encountered in large arterial blood vessels and extremely rare in the heart, with only 3 cases reported –6. IntimHistologically, intimal sarcomas are usually poorly differentiated mesenchymal malignant tumours of fibroblastic or myofibroblastic differentiation, consisting of atypical spindle cells with variable degrees of atypia, mitotic activity, necrosis, and nuclear polymorphism. The tumour may exhibit large myxoid areas and or epithelioid appearance of tumour cells , 17. TumThe prognosis of cardiac primary intimal (spindle cell) sarcomas is generally poor. These tumours are highly aggressive with the mean survival being 3 months to 1 year, although survival of up to 11 years has been reported . Due to In a recent study using comparative genomic hybridization (CGH), amplifications of the 12q13-14 region were identified in 6/8 tumours. Other, less consistent alterations were losses on 3p, 3q, 4q, 9p, 11q, 13q, Xp, and Xq, gains on 7p, 17p, and 17q as well as amplifications on 4q, 5p, 6p, and 11q . SynoviaAlthough aggressive surgery can offer dramatic palliation of symptoms caused by valvular and/or vascular obstruction, local recurrence and metastasis occur frequently and early, usually within 1 year . Chemoth


A baby boy who had a left facial mass detected on antenatal ultrasound was delivered by Caesarian section after foetal distress was detected. Imaging investigations by plain radiographs and MRI showed a large mass with calcifications, soft tissue, fat and fluid components. A total surgical excision was perfomed and histology examination showed teratoma with no malignant features. Two weeks postoperatively, there was rapid recurrence of the tumour with intracranial involvement and obstructive hydrocephalus shown on MRI. The tumour was inoperable at surgery and the baby subsequently died at 5 weeks of life. This case describes the clinical course and imaging features of a neonatal epignathus teratoma with malignant and aggressive features. Head and neck teratomas are rare congenital tumours, usually benign in nature. They are usually of enormous size and commonly cause respiratory compromise to the upper airway. The term ‘epignathus tumour’ refers to teratomas of the oropharyngeal cavity in neonates without specifying the site of origin . EpignatA baby boy was born to a 32-year-old primigravida at 34 weeks gestation. Antenatal ultrasound done at 28 weeks detected polyhydramnios and foetal anomaly, where a huge mass of mixed cystic and solid echogenicity was detected arising from the left side of his face, measuring more than 10 cm in its maximum dimension. The baby was born by Caesarian section after foetal distress was detected. He developed respiratory distress at birth which required intubation and assisted ventilation.Physical examination revealed a large spherical mass at the left cheek measuring approximately 8 cm x 10 cm in size. There was significant displacement of his mouth to the right, his nose superiorly and his left eye superolaterally, due to the sheer size of the mass . The oveHaemoglobin, white blood cell count and platelets were normal. Serum α-fetoprotein (AFP) measured 56852 IU  and β-human chorionic gonadotropin (β hCG) 14 IU . The high levels were in keeping with a teratoma. A plain radiograph of the face and skull showed a wide opened oral cavity, poorly developed left temporomandibular joint and calcifications within the large soft tissue density mass . On MRI,Surgery on day 7 of life revealed findings which largely corresponded to findings on MRI. The tumour extended from the left temporomandibular joint to the nasal septum. It occupied the oropharynx and nasopharynx, caused elevation of the buccal mucosa and upper airway obstruction. There was extension superiorly into the base of the skull and inferiorly into the oral cavity, displacing the left mandible, as well as posteriorly to the lesser wing of the sphenoid where there was a defect covered by a thin membrane. The condyle and coronoid process of the left mandible were not well developed and no articulation existed between the left mandibular condyle and the temporal bone. The tumour was removed en-bloc with minimal difficulty and the cavity packed with surgicel and gelfoam. A skin flap was raised via circumferential dissection to cover the incision site over the left side of the face.Cut section of the tumour showed multi-loculated cysts containing serous fluid and solid areas. Histopathology revealed tumour tissue consisting of a haphazard mixture of organoid mature tissue composed of skin adnexal tissue and microtubular structures. Calcifications and cysts lined by stratified squamous epithelium with rosettes were identified in one area of the section. These features were in keeping with a teratoma with immature neural elements. No mitotic or undifferentiated elements were seen .Post-operatively, there was a significant decrease in serum α-fetoprotein to 4408 IU/ml. However, the left side of the face became increasingly swollen and there was difficulty extubating the baby despite clearance of tumour from the airway at surgery. A repeat MRI and CT scan done 2 weeks after surgery showed a mass of solid and cystic nature occupying the oral cavity with extension into the left temporal fossa. It showed avid enhancement with contrast and it extended posteriorly compressing the brain stem and causing obstructive hydrocephalus . The endIn Greek, teratoma means “monsterous tumour”. It is a tumour composed of multiple tissues foreign to the normal organ in which it arises. These tissues contain all three primordial germ cell layers  1, 2, 3, 4] and histologically they may be mature, immature or malignant. Teratomas occur with an incidence of 1:4000 live births , 3, 4 an. Other sTeratomas can be detected early with antenatal ultrasound. MRI has the advantage of not utilising ionising radiation and antenatal MRI diagnosis of teratoma in the foetus has been described , 6. UltrEpignathi involving and destroying brain tissue has been described and is associated with poor prognosis . ExclusiMortality rate associated with large teratomas in the head and neck are generally high in the absence of a well-prepared resuscitation team or meticulous delivery planning to secure the airway, as the majority of these teratomas are associated with obstruction of airway and difficulty in intubation. In the patient described here, marked distortion of facial anatomy with involvement of the nasopharynx and oropharynx as well as extension into the posterior pharynx led to initial respiratory distress. Subsequently, brain stem compression by recurrent tumour accounted for respiratory difficulties.Ninety percent of neonatal teratomas are benign and treatment is primarily by surgical removal . In the In conclusion, we describe a rare case of epignathus teratoma showing malignant features clinically and on imaging. The case proved to be a great challenge for all disciplines involved in management of the baby.


Primary abdominal extraskeletal osteosarcoma (EOS) is a rare carcinoma. The present study reports a case of a primary abdominal EOS involving the greater omentum and also presents a review of the literature on the etiology, diagnosis, differential diagnosis, pathological features, treatment and prognosis of the disease. The patient in the present study underwent laparoscopic surgery. A pathological examination revealed that the tumor tissues contained malignant and primitive spindle cells with varying amounts of neoplastic osteoid and osseous or cartilaginous tissue. The post-operative follow-up appointments were scheduled at three-month intervals for two years. The tumor recurred three months after the surgery. Primary abdominal extraskeletal osteosarcoma (EOS) is rare. EOS is a malignant mesenchymal tumor, which is formed of neoplastic cells that produce bone osteoid. Since it was first described by Wilson  in 1941,2 i.v. on day 1), cyclophosphamide (750 mg/m2 i.v. on day 1) and doxorubicin (50 mg/m2 i.v on day 1) for 6 cycles; however, the patient demonstrated a poor response. The patient succumbed to systemic failure with lung metastases on June 30, 2009.A 39-year-old female was admitted to Shaoxin Hospital on December 1, 2008 due to lower abdominal pain and discomfort for a duration of four days. Prior to admittance, the patient experienced lower abdominal pain with no obvious incentive, continuing perineum radiation pain with nausea, but without vomiting, and syncope once for ~30 sec. No chills, fever or other particular discomfort were noted and the patient had no history of surgery, trauma or radiotherapy. A physical examination revealed pain, a flat abdominal area and mild lower abdominal tenderness, but no rebound tenderness. A 6×5-cm tender mass was palpated in the left ovarian area. An ultrasound examination revealed a 6.9×4.6-cm mixed echo mass in the left side of the pelvic cavity; irregular dark areas and free dark areas were observed in the surrounding area of the mass and in the Pouch of Douglas, with cloudy areas of light . The labEOS is a rare osteosarcoma that occurs outside the bone tissue, accounting for only 1% of all soft tissue sarcomas and 4% of all osteosarcomas. EOS is a result of metaplasia of the mesenchymal tissue. The most frequent sites that are involved are the limbs, particularly the thighs and buttocks, followed by the upper extremities, retroperitoneum, gallbladder and bladder . EOS wasEOS has been reported to be associated with trauma, local radiotherapy, malignant fibrous tissue disease or myositis ossificans. There are two theories reported with regard to the mechanism behind EOS. The tissue residue theory suggests that the mesoblastic component forms during embryonic development and then the formation of bone and osteosarcoma occurs. The metaplasia theory suggests that muscle interstitial fibroblasts are subject to external or internal stimulation, including trauma and inflammation and metaplasia of the osteoblasts or chondrocytes, which evolves into osteosarcoma .et al and metastasis (65%) rates. Recurrences and/or metastasis usually occur within three years following the initial diagnosis. The most common site of metastasis is the lung >80%), followed by the regional lymph nodes, liver and heart ,8. The m0%, folloet al reportedet al. EOS rec


Histopathologically, the tumor comprised mainly of hyaline cartilage containing chondrocytes with chondrocytic lacunae and was diagnosed as a chondroma. The postoperative period was uneventful, and there was no evidence of recurrence at the 2-year followup. We describe the clinical characteristics of our case and review the literature, emphasizing the differential diagnosis.An extraskeletal chondroma is a rare benign cartilaginous tumor that develops in soft tissue. Histologically, it is a lobulated nodule surrounded by a fibrous capsule; the inside consists of mature hyaline cartilage containing a few normal chondrocytes. We present a rare case of extraskeletal chondroma in the preauricular region. A 43-year-old man presented with a 2-cm-diameter right preauricular tumor that had been developing for 1 year. Magnetic resonance imaging showed a solid lobulated tumor in the right preauricular region, which was proximate to the capsule of the right temporomandibular joint (TMJ). This was subsequently resected under general anesthesia. The tumor was not in contact with the TMJ capsule and had not invaded the surrounding tissue, facilitating  Extraskeletal or soft-tissue chondromas are rare benign cartilaginous tumors that develop in soft tissues without bone or joint involvement, occurring predominantly in the hands and feet of adults in their third and fourth decades of life , 2. In tA 43-year-old man was referred to our department complaining of a mass in the right preauricular region, which had been developing painlessly over 1 year. The physical examination revealed a hard mass approximately 2 cm diameter in the right preauricular region. Otoscopy showed swelling of the anterior wall in the right external acoustic meatus, covered by normal skin. There was no temporomandibular joint (TMJ) pain, trismus, or hearing loss, and there was no history of facial trauma. The general physical examination did not disclose any abnormalities.Magnetic resonance imaging (MRI) revealed a solid lobulated lesion in the right preauricular region, which was proximate to the capsule of the right TMJ . The lesen bloc excision.A benign tumor in the right TMJ was suspected clinically. The lesion was removed surgically via a preauricular incision under general anesthesia to determine the histopathological diagnosis. The lesion was independent of the parotid gland and was not in contact with either the TMJ or the cartilage of the acoustic meatus . AlthougThe specimen was a 2.5 × 2 × 1.5 cm, well-circumscribed, nodular, white-grey, hard, elastic mass. Histopathologically, the tumor was well circumscribed and encapsulated by thin fibrous connective tissue. The tumor comprised mainly of hyaline cartilage, which contained chondrocyte with chondrocytic lacunae, with collagenous fibrous tissue in the center of lesion . The tumThe postoperative period was uneventful, and there was no evidence of recurrence at the 2-year followup.Extraskeletal or soft-tissue chondromas are rare benign cartilaginous tumors that occur in tissue unrelated to bone and are usually found in close proximity to tendons or joint capsules , 2. ThesThe literature review of extraskeletal chondromas of the parotid region is summarized in The etiology of extraskeletal chondroma is uncertain. In the literature on tongue chondromas, it is felt that either these lesions develop from residual embryonal tissue in an area of preexisting fetal cartilage or pluripotent mesenchymal cells undergo metaplasia, differentiating into cartilage as a result of some irritating stimulus . HoweverHistologically, the lesion is a lobulated nodule surrounded by a fibrous capsule filled with mature hyalinized cartilage tissue, with no association with underlying bone. Locally, it may be associated with secondary degeneration within the matrix, such as cystic change, ossification, calcification, fibrosis, and mucinous change , 2.Radiologically, extraskeletal chondromas are well-demarcated extraskeletal masses with a periarticular location. Computed tomography (CT) shows an iso- or hyperdense soft-tissue mass without underlying bone involvement; calcifications are seen in 33–70% of cases . MRI shoFor lesions in the preauricular region, the differential diagnosis includes parotid gland and TMJ tumors, such as osteochondromas and synovial chondromatosis. The chondromatosis change of a pleomorphic adenoma or mixed parotid tumor can be similar to that of a chondroid tumor . An osteIt is also important to distinguish chondromas from malignant cartilaginous neoplasms; however, it may be difficult to distinguish between a chondroma and low-grade chondrosarcoma histologically. Some clinical features should raise a suspicion of malignancy, including older age at presentation, rapid growth, and the invasion of surrounding structures . RecurreWide local excision is recommended for treatment owing to the 10–15% recurrence rate . In our In conclusion, we present a very rare extraskeletal chondroma of the preauricular region and review the literature on extraskeletal chondromas of the parotid region.


Metastasis to the stomach from nongastric tumors is a rare event. We present a case of ovarian cancer metastasis to the gastric wall that presented as multiple subepithelial gastric lesions. A 55-year-old female with known stage III b serous ovarian cancer was admitted to the hospital with melena and anemia. A 1.5 to 2 cm subepithelial mass with superficial overlying erosion in the antrum was seen in Esophagogastroduodenoscopy (EGD). Initial endoscopic mucosal biopsies were normal. An Endoscopic Ultrasound (EUS) was performed, which revealed two subepithelial lesions with the typical appearance of a gastrointestinal stromal tumor. Fine needle aspiration (FNA) of both masses revealed papillary adenocarcinoma from an ovarian papillary serous adenocarcinoma. This is the first reported case of multiple gastric metastatic lesions from ovarian cancer diagnosed by EUS FNA. Metastasis to the stomach is uncommon. Ovarian tumors comprise 0.013% to 1.6% of all gastric metastatic tumors . GastroiThe patient is a 55-year-old female with known stage III b serous ovarian cancer. She had undergone an abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy, followed by 6 cycles of carbo/taxol chemotherapy with complete clinical response. She was free of disease for 2 years until her disease recurred and was treated with Carboplatin and Taxol. The carboplatin was eventually switched to Doxil. However, the repeat positron emission tomography (PET) scan at that time showed progression of her disease. Thus she underwent exploratory laparotomy with removal of a splenic mass. She was noted to have peritoneal carcinomatosis at that time and was then treated with Gemzar. The patient had stable disease after this treatment. Five years after the initial diagnosis, the patient was admitted to the hospital with anemia, hemoglobin of 7.0 gm/dl, fatigue, and melena. Computerized Tomography (CT) of the abdomen without IV contrast was obtained on admission, which revealed calcified, heterogeneous, mixed intermediate and high-density deposits worrisome for peritoneal carcinomatosis , arrows.The tumors most commonly reported to metastasize to the stomach include melanoma, breast, lung, and esophageal carcinoma , 2, 4, 5Ovarian tumor metastasis to the stomach is uncommon , 2. OvarSimilar to our case, there have been other reported cases of metastatic ovarian cancer presenting as single subepithelial gastric lesions. The diagnoses in these cases were made by surgical exploration and endoscopic submucosal dissection , 13. TheMetastatic disease should be in the differential diagnosis of the patient presenting with subepithelial gastric lesions. Endoscopic ultrasound with fine needle aspiration is invaluable for making the correct diagnosis of gastric subepithelial lesions and should be considered in all cases if available.


Situs inversus is an uncommon anomaly with rare incidence. Some cases of situs inversus totalis have been described with different types of associations. Here we report a case of situs inversus with carcinoma of the gastric cardia. Situs inversus is an uncommon anomaly with an incidence varying from 1 in 4,000 to 1 in 20,000 live births . Some caA 52-year-old male patient, who complained of a stomachache lasting over the last 5 months, along with the symptoms of fatigue and weight loss, was referred to our clinic. An abnormal shadow in the cardia was recognized during routine X-ray examination and an upper gastrointestinal endoscopic examination. Upon admission, a physical examination revealed a pulse rate of 100 beats per minute and blood pressure of 115/68 mmHg, while the liver, spleen, and tumor were not palpable in the physical examination. Results of chest X-ray imaging taken in an erect position showed dextrocardia, a fundic gas shadow on the right dome of the diaphragm, and a liver shadow at the left side. Nothing abnormal was found in the respiratory system.3. Dextrocardia was seen on the chest X-ray  is the preferred operation for carcinoma of gastric cardia. Chemotherapy is essential for patients with lymph node metastasis.Written informed consent was obtained from our patient for publication of this case report and all accompanying images.The authors declare that they have no competing interests.PK, ZD, MX, LG, JQ and LY designed the study, performed the data analysis and wrote the paper together; all authors read and approved the final manuscript.


A rare case of a large fibroepithelial polyp (FEP) of the vulva is described. The polypoidal growth was 10 cm in its largest diameter, having a long pedicle with features of inflammation secondary to infection, and was found arising from the left labia majora. The patient did not manifest any signs of recurrence following excision. A large and infected FEP of the vulva is a rare occurrence and hence reported. The fibroepithelial polyps (FEPs), which are also referred to as acrochordons or skin tags, are common lesions that typically occur in adults, especially obese women. They show a predilection for the neck, axillae, and groin. FEPs of the lower genital tract often develop in young to middle-aged women and present more commonly in the vagina.They are less common in the vulva and are rarely present in the cervix . The polA 27-year-old woman, para 4 living 4, presented with a swelling in the left labia, which was noticed 6 months back. There was a history of pain over the swelling and fever for 3 days. Her menstrual history was normal. She had previous vaginal deliveries and the last childbirth was one and half years back. Her build was average. The general physical examination and systemic examination were normal. Local examination revealed a large polypoidal growth covered by skin measuring 10 × 6 × 4.5 cm. arising from the left labia majora . The skiFEPs of the vulval region are uncommon tumors. They usually arise in hair-bearing skin but may be found on the labia minora . The oriIn conclusion, large FEP of the vulval region is a rare benign tumor that can be misinterpreted as malignant owing to its wide range of morphological appearances. Expert pathological interpretation may be necessary to exclude atypical tumors and malignant neoplasms or to indicate proper treatment.Consent to publish the images in this paper has been obtained from the patient.


Enteral stents are increasingly utilized to palliate malignant gastrointestinal obstruction; however, they can be associated with significant complications. We describe an unusual case of a 67-year-old male with gastric adenocarcinoma who underwent placement of a WallFlex metallic enteral stent to relieve a malignant gastric outlet obstruction. Four months later, while actively undergoing chemotherapy, he developed acute abdominal pain and was found to have delayed stent migration and jejunal perforation. He required emergent surgical resection of the perforated segment of jejunum. Delayed migration of the WallFlex enteral stent with subsequent visceral perforation has yet to be reported in the literature. Chemotherapy after stent placement has been associated with an increase in maintenance of stent patency; however, shrinkage of the local tumor by chemoradiation may increase the risk of stent migration. Care should be taken in placing enteral stents in patients undergoing continued treatment of their malignancy, as delayed migration of even uncovered stents may occur. Endoscopic enteral stent placement is commonly performed for palliative treatment of malignant gastric outlet obstruction . This miA 67-year-old male with stage IIIB gastric adenocarcinoma treated with Billroth-II gastrojejunostomy, adjuvant chemotherapy with oxaliplatin and 5-fluorouracil, and external beam radiation therapy presented one year following completion of adjuvant therapy with abdominal pain and inability to tolerate oral intake. Imaging studies including computed tomography (CT) of the abdomen and pelvis revealed a malignant gastric outlet obstruction at the gastrojejunal anastomosis . FollowiμL (reference: 3.28–9.29 × 103/μL) with 93.0% neutrophils. CT imaging (Four months later, after four cycles of docetaxel, he presented with severe acute abdominal pain with peritoneal signs. Laboratories revealed white blood cell count of 17,720/ imaging  showed m imaging  with priGastric outlet obstruction is a feared late complication of unresectable periampullary, distal gastric, pancreatic, and duodenal malignancy. Symptoms of gastric outlet obstruction include intractable nausea and vomiting, cachexia, and a progressive decline in clinical status and in quality of life . EndoscoDespite widespread use, severe complications of perforation and bleeding have only been reported in 0.7% and 0.5% of patients, respectively . NonseveProspective studies involving the WallFlex stent have only reported rare incidences of stent migration or perforation within the first month following placement , 16. DelAs this case illustrates, care should be taken in placing enteral stents in patients undergoing continued treatment of their malignancy, as delayed migration of even uncovered stents may occur. When evaluating a patient with a history of an enteral stent presenting with acute abdominal pain, it is important to maintain a high degree of suspicion for stent migration resulting in either visceral perforation and/or intestinal obstruction. Immediate imaging should be undertaken to rule out stent-related complications, even if several months have elapsed since stent placement.