Osteomas are benign osteogenic neoplasms or hamartomas with a very slow growth rate. Osteoma is the most common mesenchymal neoplasm of the paranasal sinuses. In the jaws, the mandible is more commonly involved than the maxilla. Osteomas may occur at any age, but most frequently are found in individuals older than 40 years. Although most osteomas are small, some may become large enough to cause severe damage, especially those that develop in the frontoethmoid region. Osteomas composed solely of compact bone are uniformly radiopaque and those containing cancellous bone show evidence of internal trabecular structure. To determine and evaluate the exact extension and internal structure of these lesions, computed tomography (CT) is a more useful imaging modality in comparison to conventional radiography. Hereby, we discuss clinical and imaging features of two osteomas (one in the ethmoid sinus and the other in the mandible) along with the main differential diagnoses and pathologic features. Osteoma is a slow growing, benign and rare encapsulated bone neoplasm located in the bone tissue of the skull and the face 2]. It m. It m2].Histologically, osteoma may be of two types:1) Compact or “ivory” and 2) Cancellous, trabecular or spongy 9]. The . The 9].Most osteomas are small; however, in rare cases they may become large enough to cause displacement and damage to adjacent structures. Although osteomas may occur at any age, they are most frequently found in people over 40 years old 10]. The. The10].A 75-year-old man was referred to the department of otolaryngology of Imam Hospital of Jundi Shapur Ahvaz University of Medical Sciences complaining of headache. On clinical examination, the left globe had severe pro-ptosis causing visual loss and lid retraction . This prA 26-year-old woman came to the department of oral and maxillofacial surgery of Imam Khomeini Hospital of Jundi Shapur Ahvaz University of Medical Sciences for evaluation of a one-year-duration swelling in the left mandible which had grown slowly. She complained of dull pain in the left mandible in the last two weeks. A mild facial asymmetry was observed. Clinical examination revealed a painful firm well-circumscribed palpable mass in the buccal and lingual vestibule of the left mandible. The lesion was covered by normal mucosa. The patient had no paresthesia. The patient was in good health with a history of previous first molar extraction a few months ago.On panoramic radiography, a moderately well-defined radiopaque lesion was seen adjacent to the inferior border of the left mandible extending from the first premolar to the third molar, not associated with the teeth and with some degree of extension to the ramus . CT reveMicroscopic examination revealed mature bone with prominent compact components . The hisOsteomas, which are benign, slow-growing and well-defined neoplasms may originate from membranous maxillofacial bones 12]. Ost. Ost12].The tumors are often asymptomatic and are usually detected as an incidental finding on radiographic examinations, “revealed in roughly 1% of routine scans” 14]15][[15][14][[[15][14]In the frontal sinus, an osteoma can cause erosion of the posterior wall, resulting in spontaneous pneumocephalus and cerebrospinal fluid (CSF) rhinorrhea . ObstrucThe mandible is more commonly involved than the maxilla. They usually occur in the posterior region of the mandible on the lingual side of the ramus or on the inferior mandibular border below the molars . Other lCT, particularly three-dimensional CT scans, is so useful in defining the exact extension of the tumor and to determine the position of the lesion in relation with adjacent anatomical structures, when removal of the lesion is considered 16]17][[17][16][[[17][16]The differential diagnosis includes exostoses–bony excrescences considered as hamartomas that stop growing after puberty, but osteomas may continue growth after puberty; peripheral ossifying fibroma–a reactive focal lesion; periosteal osteoblastoma; osteoid osteoma–that occur in young patients and are rare in the maxillofacial regions and parosteal osteosarcoma–that present as painful destructive masses with rapid growth . The appOsteomas involving the condylar head may be difficult to differentiate from osteochondromas, osteophytes or condylar hyperplasia and those involving the coronoid process may be similar to osteochondromas.A person who manifests with multiple intraoral or head and neck osteomas requires further radiographic work up to rule out Gardner’s syndrome. This syndrome, consisting of multiple epidermoid or sebaceous cysts, supernumerary teeth, retinal pigmentation and intestinal polyposis, necessitates a gastrointestinal radiographic evaluation because the polyps involved are premalignant . The treCT scans, particularly CT scan in bone window and magnetic resonance imaging (MRI) give very good diagnostic possibilities, but plain radiography is also sufficient for the purpose of post operative follow-up. “Scan should be performed at least in six-month intervals during the first few years after surgery” . Recurre


There exist only a few reports in the literature on desmoids related to the diaphragm, but only one on a diaphragmatic desmoid that is possibly primary.We report an unusual presentation of a sporadic intra-abdominal desmoid tumour, possibly arising from the diaphragm, masquerading as a hepatic mass in a young female without any history of surgery or trauma. Histopathology ruled out a hepatic origin of the tumour as was inferred from pre- and intraoperative evaluation. Immunohistochemistry showed positivity of lesional fibroblastic cells for  Desmoid tumours are monoclonal, fibroblastic proliferations arising from musculoaponeurotic structures. These lesions infiltrate locally, recur frequently after resection but do not metastasize. Originally described as a tumor of the abdominal wall in women who had recently been pregnant, these rare, slow-growing tumors can arise at any site in the body. They have been classified according to anatomical location as extra-abdominal (60%), abdominal wall 25%), and intra-abdominal 15%) [5% [1]. A5%, and iA 17-year-old unmarried female patient presented with complaints of vague upper abdominal pain for the preceding six months with fullness of upper abdomen for the preceding one month. There was no history of jaundice, altered bowel habits, gastrointestinal bleeding, or abdominal trauma. Past medical or surgical history was unremarkable. There was no history of weight loss, loss of appetite, or oral contraceptive intake. No family history of similar ailment or malignancy was reported.Abdominal examination revealed a firm, nontender, intraperitoneal mass (about 15 cm × 8 cm) with bosselated surface and rounded lower margin, which occupied the epigastrium and left hypochondrium. The lump moved with respiration. There was no organomegaly and no evidence of free fluid within the abdomen. An ultrasonography (USG) of the whole abdomen revealed a 14 cm × 10 cm mass arising from the left half of right lobe of liver with increased echogenicity suggestive of hepatoma. However, serum alpha fetoprotein 2.87 ng/mL) and liver function tests were normal. A contrast enhanced CT (CECT) scan of abdomen revealed a large, lobulated well-encapsulated hypodense, heterogeneously enhancing mass (178 mm × 99 mm × 182 mm) with an exophytic component arising from left lobe of liver, extending upto the gastrosplenic ligament, compressing the stomach and the spleen, and also abutting the anterior abdominal wall . CT-guid.87 ng/mLβ-catenin . The patient is doing well for the last 6 months with no evidence of local recurrence on follow up USG abdomen.Desmoids account for about 0.03% of all neoplasms and <3% of all soft tissue tumors. Individuals in the age group of 15–60 years can be affected; desmoids are rare in the young and in the elderly , more coIntra-abdominal desmoids are often observed in FAP (3.5–32%) and Gardner's syndrome or following abdominal trauma  . The ass Intra-abdominal desmoids have been reported to arise from the retroperitoneum, pancreas, mesentery, and pelvis , 10–14.  There exist only a few reports in the literature on desmoids related to the diaphragm. Desmoid tumour of the posterior mediastinum, which has invaded into the diaphragm, has been reported , 16. In  In the case we report, the tumour was most densely adherent to the under surface of diaphragm. The lesion appeared to arise from the left lobe of the liver on imaging  as well In both FAP and familial non-FAP tumors, mutations of the APC gene on the long arm of chromosome 5 have been incriminated. 85% of patients with desmoids were shown to have mutations in the beta-catenin gene. Somatic APC mutations as well as activating mutations of the beta-catenin gene have been discovered in the majority of sporadic desmoids. The resultant loss of ability to degrade beta-catenin and consequent elevation of beta-catenin levels promote fibroblastic proliferation through a nuclear mechanism . ElucidaSymptoms depend on the site of the tumor. Patients with intra-abdominal desmoid may have asymptomatic masses, symptoms of intestinal, vascular, and urinary obstruction, or neural involvement –5. The dImaging in the form of CECT or Magnetic resonance imaging (MRI) is required to assess the degree of extension of the tumour to adjacent structures . IncisioDesmoids are characterized by variable clinical behaviour. Although most grow progressively larger over time, growth is indolent. A multidisciplinary approach including surgery, chemotherapy, and radiation therapy is required for treatment.Sporadic abdominal desmoids are rare tumours with varied presentations. We describe a desmoid tumour possibly arising from the diaphragm but presenting as a hepatic mass. This very rare case indicates that desmoid tumour should be included in the differential diagnosis of hepatic masses especially ones which are closely related to the diaphragm.


We report a case of an adrenal lymphangioma removed by retroperitoneal laparoscopy. A 45-year-old female was referred to the urological ward for an adrenal mass that was incidentally detected by ultrasound examination one month earlier. An abdominal ultrasonography (US) scan revealed a 3.0 cm anechoic cystic mass, while a computed tomography (CT) scan revealed a 3.0×2.7 cm left adrenal cystic mass, which was suspected to be an adrenal cyst. The patient underwent retroperitoneoscopic removal of the tumor. Pathological evaluation revealed a cystic lymphangioma in the left adrenal gland. Adrenal lymphangiomas are rare and non-functioning benign tumors, which are usually asymptomatic. Laboratory findings are nonspecific. As imaging techniques have improved, Adrenal lymphangiomas usually appear as incidental findings at abdominal ultrasonography and computed tomography scan examinations. The most effective treatment option is surgical removal of the tumor. Herein, we report a case of an adrenal lymphangioma that was removed by retroperitoneal laparoscopy.A 45-year-old female was referred to the urological ward of The First Affiliated Hospital, College of Medicine, Zhejiang University, China, for an adrenal mass that had been detected incidentally by ultrasound examination one month earlier. The physical examination results were normal. A hormonal examination revealed that the function of the left adrenal gland was also normal. An abdominal ultrasonography (US) scan revealed a 3.0-cm anechoic cystic mass of the left adrenal gland. A computed tomography (CT) scan revealed a 3.0×2.7-cm hypodense non-enhancing lesion of the left adrenal gland, which was suspected to be an adrenal cyst .crista iliaca. Two additional supracostal trocars (5 and 10 mm) were subsequently inserted in the anterior and posterior axillary lines, respectively. These two trocars were then guided by the index finger into the first port. Thereafter, a pneumoretroperitoneum was created by maintaining a carbon dioxide pressure of ∼5 mmHg, and retroperitoneoscopy was performed. Following confirmation of the location of the tumor, the tumor was successfully mobilized and removed using an ultrasonically activated scalpel and clip. The tumor was removed through an incision and subsequently placed in a specimen bag. The operating time was 80 min and blood loss was ∼30 ml. A drainage tube was put in place for 2 days. No complications were observed either intra- or postoperatively. No recurrence has been observed in the 6-month follow-up period. Pathological evaluation revealed a cystic lymphangioma in the left adrenal gland (Retroperitoneoscopic removal of the tumor was successfully performed via a posterior approach. For the first trocar insertion, a 2.0-cm transverse incision was made at the midaxillary line, approximately 3 finger-breadths cephalad to the al gland .Lymphangiomas are benign malformations of lymphatic vessels that originate from an abnormal embryologic development of the lymphatic system. There are four histological subtypes of lymphangiomas: cystic, capillary, cavernous and vasculolymphatic malformation . CombinaLymphangiomas of the adrenal gland are rare. They are characterized by multiloculated cystic- and endothelial-lined cavities . The end


Malignant SFT of the kidney is particularly rare. Here, we report a 66-year old woman with a right flank mass that has been proved clinically and radiographically. Grossly, the largest diameter of the mass were measured up to 23 cm, was poorly circumscribed. Approximately 80% of the neoplasm consisted of hyperchromatic and pleomorphic spindled cells surrounding staghornlike blood vessels. Tumor cells frequently had mitoses and necrosis. However, the remainder of the mass was composed of haphazard, storiform or short fascicular arrangements of spindle cells in a loose myxoid to fibrous stroma. Immunohistochemically, we observed diffusely strong CD34 staining and an 85% Ki-67 proliferative index. The tumor partly showed negative CD34 and a 20% proliferative index. To our knowledge, this is the largest malignant renal SFT in the reported literatures and shows an obviously high proliferative index. It rarely occurs in extrapleural sites like upper respiratory tract, lung, nasal cavity, paranasal sinuses, orbits, mediastinum, major salivary glands, breast, meninges, liver and urogenital organs,2. Morphet al.; howeveret al.. We hereA 66-year old woman was admitted to our hospital with two-year history of a right flank mass, without other constitutional symptoms. The patient denied a history of unhealthful environment and asbestos exposure, malnutrition and treatment of additional diseases. Laboratory findings were unremarkable. Physical examination revealed a hard right abdominal mass. A subsequent computed topography (CT) of the abdomen showed a huge lobulated cystic-solid tumor occupying the perirenal space of right kidney without evidence of either local invasion or lymphadenopathy Figure . The patA nephrectomy specimen (26 × 20 × 12 cm) with attached ureter and perirenal fibroadipose tissue was received. The specimen was bisected to reveal a 23 × 18 × 12 cm irregular and unencapsulated tumor occupying the perirenal space of the upper and middle poles of kidney. The tumor was firm and showed a yellowish white to tran-gray, myxoid and lobulated cut surface with prominent hemorrhage and necrosis [et al.[The majority of SFTs are benign; however, a few have revealed histologically malignant features. The criteria for clinical malignancy in intrathoracic SFT, first proposed by England enchyma). The diaenchyma). Maligna[et al. reportedde novo occurrence or (2) dedifferentiation or sarcomatous overgrowth from a pre-existing histologically benign SFT[et al. and Fine et al. have reported two cases of malignant renal SFTs developing via dedifferentiation or sarcomatous overgrowth from a pre-existing benign SFT[et al. showed a case of de novo malignant renal SFT without any areas of dedifferentiation[et al. had infiltrative borders and focal necrosis, and invaded beyond the renal capsule. The tumor described by Margo et al. was a circumscribed mass devoid of either hemorrhage or necrosis with a 3-cm nodular area. In contrast, the tumors of Hsieh et al. and us showed an unencapsulated border with prominent necrosis and hemorrhage. Microscopically, the tumor reported by Fine et al. and Margo et al. showed typical features of benign SFT with 90% and 30% of dedifferentiation or sarcomatous overgrowth, respectively. In contrast, the tumors of Hsieh et al. and us appeared to develop de novo since we did not find any areas of dedifferentiation after extensive tumor sampling.Malignant phenotypes can occur in 10% to 15% of intrathoracic SFTs and up to 10% of extrathoracic SFTs. Malignanign SFT. Margo enign SFT. Hsieh entiation. The tumet al. postulated that the loss of CD34 expression might promote tumor metastasis tot other organs, and could lead to malignant transformation from the benign tumor relevant to fatal outcome. Similarly, our case of SFT showed negative CD34 and a lower proliferative index in part of the lesion. The CD34-negative part of the lesion was morphologically indistinguishable from its CD34-positive region, which may participate in malignant outcome. Further research is needed to clarify these points.SFT shows a wide variety of microscopic growth patterns and should be distinguished from benign and malignant spindle cell tumors. Positive immunoreactivity for CD34 and CD99 is characteristic of SFT, and highly valuable in differentiating from other mesenchymal tumors. However the expression of CD34 and CD99 may be decreased or absent in areas with marked atypia or dedifferentiation,24. in aet al. have attempted to manage with subcutaneous interferon achieving 23 months of progression-free survival[th month of followpu following surgery in our patient.SFTs must be differentiated from the malignant and benign spindle cell tumors of the kidney. Its differentiation from other primary monomorphous benign and malignant spindle cell tumors of the kidney, such as fibroma, benign fibrous histiocytoma, hemangiopericytoma, inflammatory myofibroblastic (pseudo-)tumor, leiomyoma, angiomyolipoma with predominant spindle cell smooth muscle component, benign peripheral nerve sheath tumors, renal mixed epithelial/stromal tumors, adult type mesoblastic nephroma, fibrous type monophasic synovial sarcoma, malignant peripheral nerve sheath tumors, fibrosarcoma, and low-grade fibromyxoid sarcoma. It is psurvival. Given tWritten informed consent was obtained from the patient for the publication of this report and any accompanying images.The authors declare that they have no competing interests.HW, CL carried out the molecular experiments, GW, XL performed image observation, QL analyzed the data, ZGL, LZ participated in histological observation and LZ drafted the manuscript. All authors read and approved the final manuscript.


Rectal lesions without anal sphincter trauma in childbirth are only sporadically described in literature. We describe the case of a 29-year-old primigravida who delivered a child in frank breech presentation. During the second stage of labour a foot presented transanally through a rectal laceration with intact anal sphincters. The laceration was repaired immediately after delivery in theatre. Follow-up visits showed a properly cured laceration and no complaints of incontinence or foul discharge. Obstetric perineal and anal sphincter injuries have been well described. Perineal tears are divided into four grades according to the extent of the lesion . There iA 29-year-old primigravida was admitted to the labour room at 38 5/7 weeks amenorrhea for delivery with frank breech presentation. She was referred to us from primary care by the independent midwife at a gestational age of 35 weeks because of breech presentation. Her medical history was uneventful. External cephalic version was unsuccessful, and after counselling a vaginal delivery was accepted.The first stage of labour progressed normally with support of low-dose oxytocin. Second stage of labour started after full dilatation was reached with the breech at level Hodge 3. A left mediolateral episiotomy was placed when the foetal anus remained visible in the vaginal introitus between contractions. Before the start of the next contraction, the left foot and lower part of the left leg of the baby was born through the rectovaginal septum and the anus. . ImmediaAfter secondary breech extraction using the Løvset and Mauriceau maneuver, a boy of 2860 grams was born with an Apgar score of 6 after 1 minute and 9 after 5 minutes and umbilical artery pH of 7.06 and BE of −11.6. After short resuscitation with three rescue breaths, he recovered spontaneously and developed well during the first months.Rectovaginal examination immediately after delivery showed a “button-hole lesion” of the rectovaginal septum of 2 to 3 centimetres length situated one centimetre cranial of the anal canal and just medial of the vaginal part of the episiotomy. Both the internal and external sphincter appeared to be intact. The laceration was repaired under general anaesthesia in theatre. The rectal mucosa and rectovaginal septum were sutured with interrupted Monocryl 4-0 (poliglecaprone 25) sutures. The vaginal mucosa was sutured with continuous Vicryl 2-0 sutures. The episiotomy was then repaired routinely according to our local protocol. Amoxycilline/Clavulanic acid (Augmentin) was given intravenously as prophylaxis. Postoperatively, oral magnesiumoxide was given as stool softener. Both the rectovaginal tear and the episiotomy healed primarily. At the follow-up visit after 6 weeks, and after three months, our patient had no complaints of incontinence or foul discharge. Rectovaginal examination, including endo-anal ultrasound, showed a properly cured laceration and episiotomy. Both anal sphincters appeared to be intact.A review of the literature revealed very few cases reporting an isolated rectal lesion during parturition –7. This It is important to recognize obstetric anal sphincter and rectal injuries. These lesions can be missed if rectal examination is not carried out as a standard procedure prior to suturing. This can have a devastating effect on the physical and emotional well-being of women. Rosenhein et al.  give a c Several factors may play a role in the aetiology of these lesions, including instrumentation, birth weight of more than 4 kilograms, persistent occipitoposterior presentation, nulliparity, tissue factors, and second stage >1 hour . It is aOur patient and the presented cases in the literature show that uneventful recovery of an isolated rectal lesion is very well possible, without the necessity of a diverting colostomy or incision of the perineum through the anal canal, if recognised and repaired immediately.


The current case report describes an adult male with an intracortical lipoma accompanied by cystic changes in the tibial diaphysis. To the best of our knowledge, intracortical lipoma in an adult tibia has not been previously described. An anteroposterior radiograph of the tibia revealed an osteolytic lesion on the diaphysis. Magnetic resonance imaging and computed tomography revealed that the lesion was located in the cortex and consisted of fat and cyst tissue. Surgical excision of the lesion confirmed diagnosis of an intracortical lipoma. Intraosseous lipoma represents a relatively rare lesion composed of mature adipose tissue. The true incidence remains unknown, as the majority of lesions are asymptomatic and do not require medical attention. A number of authors have characterized these lesions as benign tumors of the medullary fat tissue ,2. HowevA 23-year-old male presented to the Department of Orthopedic Surgery  with pain and discomfort on the lateral aspect of the tibia. The patient denied history of trauma and had no past medical history. On physical examination, no visible or palpable mass, erythema, or warmth were noted. However, there was mild local tenderness on the lateral side of the tibia. Radiographs showed a well-defined osteolytic lesion in the tibial diaphysis with bulging on the posterolateral side. Plain radiographs did not show any evidence of periosteal reaction or cortical destruction , howeverExcisional biopsy was performed to clarify the diagnosis. Following an incision on the anterolateral skin, periosteal dissection of the anterior compartment muscles was completed. The lesion was then identified to be bulging laterally and the surrounding cortical bone was removed. Macroscopically, the lesion showed cystic changes and was composed of fat tissue. Curettage was performed and the true cortex was located beneath the lesion . HistopaIntraosseous lipoma is a rare, benign bone tumor that accounts for <0.1% of primary bone tumors . DiffereRadiographic appearance of intraosseus lipomas varies but can include well-defined osteolytic lesions with marginal sclerosis. Radionuclide bone scanning can be positive or negative and, therefore, has limited diagnostic utility . AlthougPreviously, Milgram  subdividThe pathogenesis of intracortical lipomas remains controversial. A number of authors have suggested that lesions represent benign tumors of medullary adipose tissue ,2. OtherThe majority of intraosseous lipomas can be managed conservatively. Surgery is indicated for symptomatic lesions, malignancy, or risk of pathological fracture. Surgical treatment usually consists of curettage and bone grafting . For theIn conclusion, the current report presents a case of an adult male with an intracortical lipoma accompanied by cystic changes in the tibial diaphysis. Intracortical lipoma represents a rare, benign bone tumor typically discovered incidentally. Although biopsy is required to confirm diagnosis, CT and MRI are useful imaging modalities to elucidate lesion characteristics and location. Intracortical lipomas should be included in the differential diagnosis of intracortical, osteolytic lesions of long bones.


We describe the presentation, management, and clinical outcome of a massive acinic cell carcinoma of the parotid gland. The primary tumor and blood underwent exome sequencing which revealed deletions in CDKN2A as well as PPP1R13B, which induces p53. A damaging nonsynonymous mutation was noted in EP300, a histone acetylase which plays a role in cellular proliferation. This study provides the first insights into the genetic underpinnings of this cancer. Future large-scale efforts will be necessary to define the mutational landscape of salivary gland malignancies to identify therapeutic targets and biomarkers of treatment failure. Salivary gland cancers account for 0.3–0.9% of all cancers , 2, and Our patient is a morbidly obese (375 lbs) 58-year-old woman who presented to the head and neck surgery clinic with a right parotid mass and intact facial nerve function. She underwent a fine needle aspiration which was consistent with a Warthin's tumor. CT imaging demonstrated a 5.8 cm right parotid mass. She was scheduled for surgery, but was lost to followup. She presented again to the head and neck surgery clinic one year later with significant interval growth of the mass and a partial right facial paresis Figures . A CT scEthical approval was obtained from the University of Western Ontario Health Sciences Research Ethics and informed consent was obtained from the patient. DNA extraction from blood and tumor samples was carried out as previously described . Exome sP value threshold value of 0.05. A comprehensive listing of the single-nucleotide variants, (SNVs) identified including noncoding regions is provided in the Supplementary Table  S1 available online at http://dx.doi.org/10.1155/2013/270362. The amplifications occurred preferentially in chromosome 2 (P = 2.91 × 10−21) and chromosome 9 (P = 1.59 × 10−18), with single-amplification loci in chromosomes 14 and 22  was identified. This protein functions as a histone acetyltransferase that regulates transcription via chromatin remodeling and is important in cell proliferation and differentiation . EP300 iThere was also a deletion identified in PPP1R13B which encodes the apoptosis stimulating of p53 protein 1 (ASPP1) . Specifiin vitro and in early-stage clinical trials .Click here for additional data file.


Hamartomas are benign malformations composed of tissue elements normally found at that site, but which are growing in a disorganized fashion. Cutaneous hamartomas containing only neural and/or neurovascular elements are very rare, with very few case reports in the literature. Herein we describe a case of congenital neural angiomatous hamartoma of the skin. Cutaneous hamartomas (CH) are benign proliferations of normal skin elements growing in a disorganized fashion. These include a small group of rare neural hamartomas with very few case reports in the literature. CH is usually a congenital lesion, although occasionally it can be acquired. It occurs more often in children and young adults as a solitary, fleshy lesion of the skin. However, CH may appear at any age and in rare circumstances; they may be multiple lesions associated with particular syndromes. Among many examples of CH characterized by a variety of different components, neural and neurovascular hamartomas are very rare. To the authors, knowledge herein is the first case of the acral cutaneous neural angiomatous hamartoma in a child, which reveals an increased number of fine vascular elements intimately admixed with the obvious neural component.A 4-year-old left-handed boy presented to our outpatient clinic with a small, solitary, bluish, and slightly elevated skin lesion on the tip of his left index finger. The lesion was present since birth and did not enlarge with age. His parents had never sought any medical attention for their son's skin lesion. However, recently the boy was complaining of pain while playing and holding things in his left hand. Clinical examination revealed a 0.3 cm, slightly elevated, bluish lesion tender on light pressure. There was no history of significant trauma. No axillary lymphadenopathy was noted. The lesion was shaved off with the clinical differential diagnosis of a blue naevus or a myxoid cyst.Macroscopically, the specimen consisted of a 0.3 cm fragment of skin. Microscopically, the section revealed a small fragment of acral skin. The epidermis was unremarkable. Within the dermal papillae there were regularly distributed Meissner's (tactile) corpuscles. In the papillary/reticular dermis was a poorly defined proliferation of haphazardly arranged, small nerve twigs admixed with somewhat increased number of capillary-like, thin-walled vessels some of which displayed variable size and shape . Some neImmunoperoxidase studies were performed. The nerve twigs were positive for S100 . EpithelCutaneous hamartomas are rare benign lesions. They may be congenital or acquired. Various types of hamartomas have been described depending upon the components of lesion seen on the histopathological examination. Components of hamartomas usually depend on the site at which they occur. Neural and neurovascular hamartomas are very rare. We found very few case reports of cutaneous hamartomas containing only neural and/or neurovascular elements.Al Habeeb et al. have described a case of cutaneous solitary neural hamartoma in a 51-year-old man [A case of congenital neural hamartoma on the leg of a male infanthas been described by Argenyi et al. . This leAnother case of a cutaneous neurovascular hamartoma on the left upper back of a 29-year-old man has been described by Lee et al. . MicroscPalmar cutaneous hamartoma was first described by Damiani and Riccioni in 1998 . This leHa et al. have described two cutaneous hamartomas of the hand . NeurovaOur case of a painful palmar lesion in a child showed complex structures composed of bundles of nerve closely associated with thin-walled blood vessels. Occasional small blood vessels surrounded by bundles of nerve were noted. These complex structures are similar to those previously described as neurovascular bodies. No other adnexal component was present in the lesion. To the best of our knowledge, there is no previous case report of a similar congenital hamartoma with neurovascular bodies. Considering the palmar location, painful nature and presence of neurovascular bodies on microscopic examination in our case, and review of the previously mentioned case reports, this acral neural angiomatous hamartoma may be a variant of palmar cutaneous hamartoma.


Adenocarcinoma and squamous cell carcinoma account for the vast majority of oesophageal malignancies. Other malignancies known to occur in the oesophagus include melanoma, sarcoma, and lymphoma. Among the sarcomas, carcinosarcoma is the commonest with both carcinomatous and sarcomatous elements followed by leiomyosarcoma of mesenchymal origin. Other sarcomas reported in the literature are liposarcoma, synovial sarcoma, myxofibrosarcoma, Ewing's sarcoma, granulocytic sarcoma, histiocytic sarcoma, schwannoma rhabdomyosarcoma, and epithelioid sarcoma. We report a case of malignant spindle cell tumour of oesophagus. Sarcomas of esophagus present as a polypoid exophytic soft tissue mass. Our patient presented with a stricture which is a rare presentation. Locally aggressive treatment with surgery is beneficial, and local palliative treatment including radiotherapy is worthwhile. Ninety-five percent of esophageal malignancies are of epithelial origin: adenocarcinoma and squamous cell carcinoma . SarcomaSixty-three-year-old man who was a dentist by profession from West Bengal presented in March 2005 with complaints of dysphagia to solids for 12 yrs aggravated for 1 month. He had no loss of appetite but had loss of weight. His physical examination was unremarkable. Upper gastroesophagoscopy revealed a smooth, benign appearing stricture at 36 cm beyond which the mucosa was normal. There was a 1.5 cm diameter smooth mucosal bulge noted in the fundus of the stomach just beyond the gastroesophageal (GE) junction. Biopsy form of the bulge was taken and was reported as mild chronic gastritis with Helicobacter pylori infestation. He was treated with proton pump inhibitors for six weeks. The dysphagia worsened within a span of ten months, and repeat endoscopy revealed a stricture at the same place. Biopsy was not suggestive of malignancy. Barium swallow revealed dilated thoracic esophagus with smooth tapered narrowing . CT scan2, Day1) and Ifosfamide  given at 3 weekly intervals. Third cycle was given at a delayed date with reduced dose due to earlier neutropenic sepsis and herpes zoster. After literature search, the decision was made to treat as sarcoma esophagus with palliative intent as no formal protocols were available. He received radiation therapy of 46 Gy in 23 fractions by AP-PA portals using Telecobalt machine. CT scan done 6 weeks after radiotherapy showed stable disease. He received 4 cycles of chemotherapy with Doxorubicin   results in the fusion gene product SYT-SSX . Leiomyosarcoma has elongated cells forming interlaced bundles. Leiomyosarcoma constitutes about 0.5% of the malignant neoplasms of the oesophagus . OesophaLiposarcoma has the lipogenic component containing giant multinucleated lipoblasts with multiple cytoplasmic lipid vacuoles giving grape-like appearance. The nonlipogenic component can resemble pleomorphic and/or myxoid MFH expansion of Malignant Fibrous Histiocytoma, a round cell sarcoma, a spindle liposarcoma, and/or an epithelioid carcinoma . Histiocytic sarcoma has medium-sized tumor cells, indistinguishable from reactive histiocytes with moderate pleomorphism. The tumor in our case was unique in that it did not have carcinomatous component and it was focally positive for Vimentin not making it any of the above-mentioned sarcomas of esophagus.Surgery, wherever possible, remains to be the mainstay of treatment . OesophaFactors affecting survival included completeness of resection, growth pattern, postsurgical stage, tumour grade, and tumour location . A rare Sarcoma is a rare entity among all esophageal malignancies. It presents as an exophytic mass, and in this case, it has presented as a stricture esophagus. Most of these tumors present in locally advanced and disseminated condition, one of the reasons being difficulty and hence delay in diagnosis. Inspite of best efforts, a group among them remains to be histologically uncharacterized. Here, we report a case of malignant spindle cell tumor of esophagus, a cause for a stricture esophagus. A definitive histopathological diagnosis could not be achieved. Regarding treatment, there is a role of palliative resection even in case of inoperable disease. In view of locoregional failure, the role of aggressive local treatment should be emphasized.


Left atrial intramural hematoma is a seldom cause of left atrial mass. It has been described to occur spontaneously, after interventional procedures, after blunt chest trauma, or after aortocoronary bypass surgery. We present a case of mitral valve replacement together with the removal of a large intraatrial space-occupying lesion. Intraoperative transesophageal echocardiography confirmed a successful resection of this mass. Surprisingly, upon admission to ICU, transesophageal and transthoracic echocardiography revealed a recurrence of an intramural lesion, closest matching a hematoma, which was confirmed by contrast-enhanced computed tomography. Surgical intervention was thoroughly discussed but a conservative management was favoured. 3 months after surgery, a reassessed transthoracic echocardiography and computed tomography demonstrated an almost complete resolution of the pre-existing hematoma. Atrial intramural hematomas are severe but rare complications of cardiac surgery and only few cases are described in literature. We present a case of an unexpected intramural left atrial hematoma following mitral valve replacement and concomitant left atrial thrombus resection and the beneficial role of perioperative echocardiography in detecting and monitoring this event.2, transmitral pressure gradient 9 mmHg), and the presence of a large intracavitary, space-occupying lesion attached to the left atrial roof , mitral valve stenosis , extirpation of the intracavitary mass and ligation of the left atrial appendage. Intraoperative transesophageal echocardiography revealed satisfactory valve function and confirmed the successful removal of the intracavitary lesion. Histopathological examination revealed a spherical mass which was subsequently confirmed to be a partially calcified and connective tissue-organized thrombus.Surprisingly, upon admission to ICU echocardiography revealed a reappearance of a new homogenous mass arising from the left atrial wall Figure . NeitherIn-house follow up serial echocardiography demonstrated a stable-to-improving left atrial hematoma. A transthoracic echocardiography and contrast-enhanced computed tomography 3 months after surgery revealed an almost complete resolution of the pre-existing hematoma Figures  and 5.Intramural left atrial hematomas are a very uncommon entity, but have been described to occur spontaneously -4, afterIn our case, routine postoperative transesophageal echocardiography revealed an acute 5 cm diameter intramural hematoma in the left atrium, which could have remained undetected as our patient was asymptomatic. Pre-  and intrJudging by the spontaneous regression, a conservative approach seemed justified, despite anticoagulation.A conservative approach with close-meshed serial echocardiographic examinations in a hemodynamically stable and asymptomatic patient with a left atrial intramural hematoma seems to be an appropriate strategy. This case demonstrates the usefulness and necessity of perioperative echocardiographic imaging in the detection and monitoring of this unexpected event.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DB reviewed the case, conducted a review of the literature and drafted the manuscript. SS and MP performed the echocardiographic studies and participated in the design of the case report. RS and CS performed the operation described. BR and DC confirmed the patient's diagnosis and revised the manuscript, contributing important intellectual content. All authors read and approved the final manuscript.Preoperative transesophageal echocardiogram demonstrating a voluminous intracavitary mass attached to the left atrial roof.Click here for filePostoperative transthoracic echocardiogram showing development of an echogenic mass arising from the left atrial wall.Click here for filePostoperative axial CT images.Click here for fileTransthoracic echocardiogram three months following surgery revealing an almost complete resolution of the pre-existing hematoma.Click here for fileAxial CT images three months following surgery.Click here for file


In the assessment of polytrauma patient, an accurate diagnostic study protocol with high sensitivity and specificity is necessary. Computed Tomography (CT) is the standard reference in the emergency for evaluating the patients with abdominal trauma. Ultrasonography (US) has a high sensitivity in detecting free fluid in the peritoneum, but it does not show as much sensitivity for traumatic parenchymal lesions. The use of Contrast-Enhanced Ultrasound (CEUS) improves the accuracy of the method in the diagnosis and assessment of the extent of parenchymal lesions. Although the CEUS is not feasible as a method of first level in the diagnosis and management of the polytrauma patient, it can be used in the follow-up of traumatic injuries of abdominal parenchymal organs , especially in young people or children. Ultrasonography (US) is highly sensitive in the assessment of the abdominal trauma, particularly in the detection of intra-abdominal fluid with a percentage varying from 63% to 99% 1.2]; the sensitivity of US is significantly reduced in the diagnosis of traumatic parenchymal lesions [; the senCurrently, in the evaluation of patients with abdominal trauma, Computed Tomography (CT) is the reference standard . The intThe first results in the literature indicates the use of CEUS in patients with blunt abdominal trauma after the FAST (Focused Assessment with Sonography in Trauma) or the US, in hemodynamically stable patients with a history of low-energy trauma ,4,6. CT In the management of the polytraumic patient it is necessary to plan an effective, efficient and rapid diagnostic and therapeutic procedure, in order to reduce the morbidity and mortality of said patient.The Authors assess the current role of CEUS in diagnosis of blunt abdominal trauma, analyzing limitations and advantages.The contrast agents eco-amplifiers are able to modify the acoustic impedance of tissues, interacting with ultrasound beams and increasing the echogenicity of the blood. The contrast media (CM) ultrasound  consist of microbubbles containing inert gases and surrounded by membrane stabilizers.The power of echogenic microbubbles and acoustic impedance depends on the size of the microbubbles. The microbubbles, unlike the tissues and the free gas, are not simply passive reflectors, but expand and compress in response to the stages of compression and rarefaction of the acoustic wave, with increasingly large hikes in diameter. The non-linear oscillation of microbubbles determines the emission of frequencies of said second harmonic with a frequency which is twice the insonation. Through the use of specific software, low acoustic pressures and an algorithm of specific processing, it is possible to selectively display the signals from the CM, separating the signal of the microbubbles from the one regarding the tissue. This particular signal is identified in real time by means of two main algorithms: Pulse Inversion (PI) and Contrast Pulse Sequence (CPS) ,8.The first generation contrast agents, consisted of air-filled microbubbles: they were particularly fragile and their quick and easy break involved a large inter-and intra-individual variation of the signal amplification with short duration of contrast effect.The second-generation contrast agent (SonoVue - Bracco), used in our experience, is represented by inert gas-filled microbubbles and denser than air (sulfur hexafluoride) and delimited by membranes made of phospholipids stabilized, giving high strength and flexibility. Sulphur hexafluoride is eliminated via the respiratory system while the membrane phospholipids are metabolized in the liver. This CM is well tolerated (side effects-based incidence of anaphylactoid reactions have 0.001%), non-nephrotoxic  and withThe CEUS technique involves the continuous insonation of the region of interest after the injection of CM with real-time and continuous evaluation of all the contrastrographic phases . The CEUS enhancement patterns in each phase are similar to that of CT or MRI; however, due to the different pharmacokinetics of the CM, the late phase of CEUS does not correspond to equilibrium phase as described for the extracellular CM used in CT . The CEUThe appearance of a normal abdominal parenchymal organ is homogeneous and hyperechoic in the absence of distortions of the echogenicity and vascular structures clearly distinguishable. Traumas can cause various parenchymal changes: bruises, lacerations, bruising, bleeding, heart attack or arteriovenous fistulas . AccordiThe first diagnostic step in cases of abdominal trauma is the relief of payment intraperitoneal, indirect sign of parenchymal injury ,5. The hThe spleen is the organ most frequently affected intra-abdominal trauma . His expThe splenic arterial phase of enhancement (early start at 12-18 seconds) has a relatively long duration with an aspect of organ uneven and called "zebra" (due to the movement of two circuits with red pulp and white pulp), which makes it difficult if not impossible the identification of tissue damage. Venous phase  is accurate in the detection of traumatic lesions of the spleen  and does not correspond to the equilibrium phase described for the extracellular contrast media used in CT or MR [Dose: for adults using a range between 1.2 and 2.4 ml. For children, the dose in ml is calculated using the following formula: age in years/10. [CEUS in the healthy liver parenchyma shows diffuse and homogeneous hyperechoic in the absence of echotexture distortions. Traumatic injuries parenchymal are hardly appreciable examination U.S.  and occuThe full exploration of the liver can be affected from the large surface of the liver to explore and limited to the study of areas not easily accessible , particularly in uncooperative patients (inability to vary the respiratory phases or decubitus) by interposition of coasts and bloating stomach and intestines. In addition, the hematoma or laceration severe hepatic entity are not easily found in the acute phase as yet isoechoic compared with adjacent healthy parenchyma. For these reasons, the CT examination remains the imaging modality of reference, in particular in high-energy trauma.US is limited in the evaluation of retroperitoneal structures due to their depth and the interposition of the bowel .Contrast-enhanced CT is the imaging modality of choice in diagnosis of retroperitoneal emergencies, providing important informations in the detection and the stage of parenchymal lesions and in definition the type, site and extent of abdominal fluid collections for a proper management ,18.Pancreatic traumatic lesions are less frequent than spleen or liver ones, occurring in less than 2% of the cases. Since the high mortality and morbidity rates associated to these lesions, it is essential to come promptly and effectively to the diagnosis. Usually the pancreas is difficult to explore due to the interposed intestinal bloating. In literature very few studies reported low sensitivity and specificity of the US in cases of post-traumatic pancreatic damage , assertiRenal trauma is relatively frequent and represents about 5% of the abdominal trauma .The kidnTraumatic lesions of the adrenal glands are extremely rare and often express a high-energy trauma therefore with high mortality or morbidity. US is particularly useful in emergency in children: an adrenal traumatic lesion can be realized in a heterogeneous nodular appearance with increased echogenicity compared with hepatic or renal parenchyma or as heterogeneous structural alteration of the adrenal region. However, the sensitivity of ultrasound is significantly lower compared to CT, currently considered to be gold standard for diagnosis of adrenal traumatic lesions . CEUS caTraumatic injury of the abdominal aorta and retoperitoneal great vessels are infrequent but lethal due to the peritoneal or retroperitoneal rapid hemorrhage. The chances of survival increase with early intervention, so it is essential to get to diagnosis immediately. The retroperitoneum remains unknown to the FAST examination and poorly evaluated by US that underestimate free fluid -24. ThusTraumatic pulmonary hernia is a complication that may rarely be associated with blunt abdominal trauma. US can detect the interruption of the echogenic diaphragmatic band or of gaseous artifacts indicating digestive hernia and also it can identify the presence of hepatic or splenic parenchyma ectopic. US has a high number of false negative and is limited in estimating the extent of the lesions. At CEUS, as at B-mode US examination, the lesions of the diaphragm remain difficult to assess. In the emergency, CT is the gold standard for suspected diaphragmatic injuries due to the high spatial resolution and the ability to perform multiplanar reconstructions, which are essential for the diagnosis ,28.Ultrasonography (US) is a useful imaging modality in the detection of traumas, due to its high sensitivity for free intraperitoneal fluid. The execution is rapid even at the bedside. However, US does not show as much sensitivity for the detection of solid abdominal organs traumatic injury; furthermore, the absence of hemoperitoneum does not allow the exclusion of the presence of post-traumatic parenchymal injuries .The introduction in clinical practice of contras-enhanced US (CEUS), increases the sensitivity and accuracy of the US; hovewer, the CEUS has some limitation in the evaluation the parenchymal injuries and retroperitoneum.With respect to parenchymal injuries by CEUS, similarly to US, some locations (e.g. hepatic dome and the upper pole of the spleen) are poorly inaccessible. CEUS is enable to evaluate simultaneously abdominal parenchyma. In order to overcome this limitation, some authors propose to split contrast material in two or more boluses to study one or at most two ipsilateral parenchyma. According to this diagnostic strategy, the kidney must be the first organ to be studied because of the early and short enhancement peak (first two minutes), the same bolus (volume of about 2.4 ml) can be used for the study of the liver or the spleen in relation to the late reaching of a homogeneous enhancement  respectively for the abdominal quadrants of the right or left . The stuWith respect to retroperitoneal injuries similarly to US, the CEUS is limited by the interposition of the gastric and intestinal bloating, the constitutional habitus of the patient and in particular, the exploration of the retroperitoneum, which is sometimes impossible.CEUS should be performed by operators at a high level competence. In fact administration of an excessive dose of contrast agent due to poor experience of the operator can affect the diagnosis: the dose depends on the target organ but also on the characteristics of the equipment used, the use of high doses of contrast agent results in excessive hyperechogenicity of the parenchyma which disturbs the identification of small traumatic injuries .Additional limitations of the CEUS are the absence of three-dimensional scanning, the lack of whole-body exploration, extreme difficulty in detecting traumatic bowel and mesenteric lesions and the operator dependence that makes the technique "subjective". CT remains the imaging of the choice in trauma due to its high sensitivity and specificity ,30,31 anIn the low-energy trauma and in hemodynamically stable patients, the US can be used as a first-level examination; when US detect intra-abdominal fluid CT examination is need. In the high-energy trauma the use of US as first line diagnostic is superfluous and damaging and the use of CT without and with i.v.c onstrast material is imperative. In order to reduce the radiation dose, particularly in young people or children, CEUS has an important role in the follow-up of conservatively treated traumatic injuries of the abdominal parenchymatous organs  diagnosed by CT ,40.The authors declare that they have no competing interests.


The purpose of this review is to illustrate the imaging findings of childhood osteomyelitis. The diagnosis of childhood osteomyelitis can be challenging. Clinical presentation and laboratory results can differ and are relatively unreliable. To date, its role in the assessment of treatment efficacy is not yet clear.This review article provides an overview of the different imaging modalities and imaging characteristics of childhood osteomyelitis. Levels of evidence for different modalities are presented.Paediatric radiology plays a pivotal role in the diagnosis of childhood osteomyelitis and can also be used to guide therapy and intervention.Although imaging is essential in the diagnostic process, cooperation between the physician and radiologist remains the cornerstone in accurately diagnosing childhood osteomyelitis.Imaging plays a pivotal role in the diagnosis of childhood osteomyelitis.• Cooperation between the clinician and radiologist is a very important aspect of making the diagnosis.• The initial imaging modality in childhood osteomyelitis is conventional imaging.• Normal conventional imaging does not exclude osteomyelitis.•  Childhood osteomyelitis can be a challenging problem to both the clinician and the radiologist as the clinical presentation can be variable in severity, and laboratory results are relatively unsupportive in the diagnostic workup. Radiology plays a pivotal role in its diagnosis and can also be used to guide therapy and intervention. This review discusses the pathophysiology of childhood osteomyelitis and the clinical presentation. With respect to radiological imaging, it will focus on the application of radiological techniques in the diagnosis of childhood osteomyelitis and the reported levels of evidence for the use of these techniques Table .Table 1COsteomyelitis is defined as an infection of the bone, bone marrow and surrounding soft tissue. In childhood the most common route of infection is haematogenous spread of a microorganism. Secondary spread by contiguity and direct spread of infection, for example due to direct penetration e.g. in cases of comminuted fractures, are seen less often , 3. OsteIn order to understand the clinical and radiological findings in childhood osteomyelitis, it is important to recall the anatomy of the paediatric skeleton. In growing bone the diaphysis and metaphysis share the same nutrient arteries and veins. These arteries and veins form a fine network of arterioles and venules in the metaphysis, which leads to the formation of so-called sinusoidal lakes. These sinusoidal lakes can act as pools where microorganisms can accumulate, thus leading to a focus of osteomyelitis. In contrast to the adult situation, in young children the epiphysis has its own nutrient vessels. After 12 to 18 months of age, these transphysial vessels disappear. As a result the physis acts as a natural border and prevents the spread of osteomyelitis from the metaphysis to the epiphysis. Spread to the epiphysis and joints is less common.Neonates are more prone to osteomyelitis. Because of a less developed immune system, osteomyelitis can be caused by less virulent agents and tends to present fewer clinical signs. The combination of unclear symptoms in neonates and the presence of transphysial vessels can lead to indolent infections that are often discovered at a late stage , 4.The reported annual incidence of childhood osteomyelitis is 3 to 20 per 100,000. For acute osteomyelitis the incidence is 8 per 100,000 and for sub-acute osteomyelitis 5 per 100,000 . The incThe most common site of infection is the long bones, especially the femur and tibia. Most infections are mono-ostotic, but polyostotic involvement of up to 6.8 % is reported in infants, and even 22 % in neonates . AThe most common organism causing acute haematogenic osteomyelitis is Staphylococcus aureus up to 95 %), followed by β-haemolytic Streptococcus, Streptococcus pneumoniae, Escheria coli and Pseudomonas aeruginosa. Besides these microorganisms, fungi, viruses and parasites have been reported to cause childhood osteomyelitis Table  3, 9].T, 9.T3, 95 %, follIn recent years the prevalence of methycillin-resistant Staphylococcus areus (MRSA) osteomyelitis has increased. MRSA leads to more aggressive cases of osteomyelitis, also with a higher prevalence of abscess formation and other complications such as myositis and pyomyositis .Specific pathogens strongly depend on age, the immune status of the patient and the geographic location for endemic diseases, such as tuberculosis .Since the introduction of the Haemophilus influenza type b vaccination in the national vaccination programs, the incidence of septic osteomyelitis and arthritis due to this organism has been significantly reduced. Nevertheless, this organism should be kept in mind as a causative agent in areas without a vaccination programme and also in possible cases of failure of the vaccine , 13.In sickle cell disease the diagnosis of osteomyelitis can be more challenging, and in these patients clinical signs and laboratory testing can be misleading. Pain in joints and bones can be a sign of a sickle cell crisis/osteonecrosis but also of osteomyelitis. Interpretation of imaging, especially MR, as discussed below, can be challenging when differentiating between osteomyelitis and sickle cell crisis/osteonecrosis .A complication of osteomyelitis can be the development of an abscess, typically known as Brodie’s abscess. Also the development of sequesters, fistulas and sinus tract lesions can be seen. Although CT and MR imaging is useful in delineating the extension of abnormalities, it is difficult to differentiate between an active or an inactive focus of osteomyelitis. In these cases, PET-CT, which has a high sensitivity for disease activity, might play a role . Other rIdeally treatment is based on the isolation of the pathogen from the focus of infection or blood. If this is not possible, empirical treatment, consisting of intravenous antibiotics in haematogenous osteomyelitis, should be started. Once the pathogen is known, treatment should be changed if needed. This approach has been shown to be effective, resulting in a cure rate of over 95 % . In a sySurgical intervention is used as an adjunct to antibacterial treatment. The aim of surgery should be to drain intra-osseous abscesses, removal of sequestra and debridement of adjoining infectious foci. Interventional radiology plays a role in percutaneous drainage of soft-tissue abscesses. Duration of therapy depends on the effect of therapy and surgical intervention . For thePoly-microbacterial infections give rise to more complications. Response to treatment is often monitored by ESR and CRP. Follow-up imaging may be used to evaluate complications .Conventional radiography is the initial modality of choice to evaluate osseous changes. In the majority of cases it will be the only imaging technique used in the diagnosis and treatment of childhood osteomyelitis.The ease of access and the relatively low radiation dose make it an ideal imaging tool for skeletal pathologies. Also it is possible to exclude other pathologies such as malignancies and fractures. However, conventional imaging should not be used to exclude osteomyelitis in the first 10 days of symptoms , 20.Karmazyn et al. advise performing at least two orthogonal views of the body part of interest . CompariConventional imaging has a reported sensitivity of 20–75 % and a specificity of 75–83 %, but evidence is limited (level of evidence II–III) , 9.Ultrasonography, especially in children, is a very useful and versatile modality. It allows correlating the physical exam with US findings and comparing the affected side with the opposite side , 21, 22.US has a high reported sensitivity for detection of sub-periostal abscesses and fluid collections , 22, alsIn the acute workup of osteomyelitis, computed imaging plays no role.In chronic osteomyelitis, it is more useful and superior to MR in detecting cortical destruction, air and sequesters , 24–26. A major disadvantage of CT is the relatively high amount of radiation; therefore, CT should be used according to the ALARA principle (As Low As Reasonably Achievable) .No specific literature was found on the sensitivity and specificity of CT in detecting acute osteomyelitis and its complications. Based on a systematic review, the sensitivity and specificity of CT in chronic osteomyelitis were found to be respectively 67 % and 50 % (level of evidence: III) .After conventional imaging MRI is the most important imaging modality for the evaluation of osteomyelitis. MRI not only allows excellent delineation of the osseous component but also soft tissue extension, joint effusion and complications of osteomyelitis such as abscess formation, especially in case of failure to respond to therapy .In young children the main disadvantage of the use of MRI is the long scan time during which the patient has to remain immobile. This leads to the need for general anaesthesia (intubation) or sedation in young children. Other approaches, such as immobilisation with for example a vacuum mattress or a feed and swaddle protocol, have been advocated, thus obviating the need for general sedation . For oldFirst of all, it’s important to choose the appropriate coil for the maximum zone of interest and adequate details. There always needs to be a balance between the signal-to-noise ratio and image resolution. In children, it is wise to start with the most important sequences, in case the examination has to be stopped before the end of the planned scan. Long sequences should be avoided, but if really needed, they can be separated in contiguous series. The most important sequences for the diagnosis and follow-up of osteomyelitis are summarised in Table MRI has a high sensitivity for detection of osteomyelitis of 82–100 % and high specificity of 75–99 % (level of evidence: III) , 19, 24.Bone scintigraphy can play a role when localisation of osteomyelitis, based on clinical information or other radiological methods, is not possible . HoweverThe use of FDG-PET CT in the diagnosis of osteomyelitis has mainly been reported in adults . For paeAlthough limited evidence is available on paediatric osteomyelitis, PET CT can effectively differentiate between an active and inactive focus of chronic osteomyelitis . LiteratThe different modalities and their advantages and disadvantages are discussed above. The imaging strategies for these modalities in the setting of acute and chronic osteomyelitis are summarised in a flowchart Fig. .Acute haematogenous osteomyelitis is typically seen in young children and is clinically characterised by a rapid onset of complaints after contact with a pyogenic blood-borne organism. Its typical localisation is the metaphysis of the tibia and femur. Through the transphyseal nutrient vessels, spreading to the physis, epiphysis and joints is possible.In children, compared to adults, the periostium is loosely attached to the bone, and in case of infection it can easily be lifted, thereby creating a space for pus collection.Multiple foci of osteomyelitis can be seen in children with sickle cell disease, diabetes mellitus and chronic granulomatous disease .An osteomyelitis with symptoms longer than 2 weeks is defined as subacute osteomyelitis and shows more classical signs on conventional imaging, including single or laminated periostal reactions, and well-circumscribed metaphysical lucency in the long bones, also known as Brodie’s abscess Fig.  20]..20].In the first 48 h, deep soft tissue swelling in the metaphyseal region and loss of fat planes can be visible on conventional imaging Fig. .Several days after the onset of symptoms, periostal reactions can be seen Figs.  and 5, aUS allows evaluation of soft tissue swelling due to oedema or fluid collection, and hyperaemia can be detected using Doppler techniques. Also periosteal thickening and sub-periostal collections are seen. These findings can precede abnormalities on conventional imaging in the first week Figs.  and 7.US has high sensitivity for detection of intra-articular fluid , 25, 30 In more extensive cases, cortical defects can also be detected Fig. . It can CT is useful in the evaluation of bony destruction Fig.  and in cAfter 3–5 days of onset of infection, MRI can detect osteomyelitis . MRI is MRI criteria for diagnosis are low signal intensity on T1, high signal intensity on T2/STIR, and enhancement of  bone and/or soft tissues and abscess/collections after contrast administration .MRI is also useful for evaluation of complications such as  abscesses, joint effusions and soft-tissue extension that would require surgical treatment Figs.  and 11 .Fig. 10aAcute osteomyelitis on a three-phase bone scintigraphy can show increased blood flow and blood pool activity, and positive uptake on 3 h images in areas of osteomyelitis. However, at this time blood pool flow and pool activity can be normal or photon deficient because of devascularisation of the periostium due to rapid raising of the periostium , 37.PET-CT will show high uptake in areas of osteomyelitis, in bone marrow and in soft tissue.Since defining a differential diagnosis solely based on imaging characteristics can be very difficult, clinical and laboratory parameters and communication with clinicians remain very important in the diagnosis of osteomyelitis. In cases of doubt, fine-needle aspiration or an image-guided biopsy will eventually be necessary to determine the definitive diagnosis.In patients without any infectious parameters, the differential diagnosis is mainly based on disease of vascular origin, neoplasm or trauma. This group without infectious parameters can be the most challenging for the differential diagnosis.Patients with a history of use of medications such as corticosteriods or for example patients with sickle cell disease must raise the suspicion of vaso-occlusive disease. Imaging will show typical serpentinous sclerotic lesions on conventional imaging, whereas MR imaging will show linear hypointense T1- and T2-weighted changes in the meta- and epiphysis .Ewing’s sarcoma produces a large soft tissue mass without calcifications or bone matrix in the tissue. Onion-skin periostitis on conventional imaging is typical.Osteosarcoma shows a lesion usually in the diaphysis with signs of aggressive  bone destruction and periostic reactions such as Codman’s triangle and sunburst spiculated periostitis.In a patient with a history of trauma, stress fractures will show linear, hypointense changes on T1-weighted imaging, without enhancement. Bone marrow oedema can be visible on STIR imaging.When imaging shows an osteolytic lesion with a central nidus surrounded by a sclerotic margin in a patient with a typical history of night pain relieved by use of NSAIDs, one should consider the diagnosis of osteoid osteoma.In patients with suspicion of haematologic malignancy such as ALL, diffuse infiltration of the bone marrow can be seen. Imaging will show diminished signal intensities on T1 imaging; T2 will show heterogenic signals. Metastastic neuroblastoma can show multiple lesions usually characterised only by high signal intensity on STIR imaging.In young children with a red painful or asymptomatic lesion on the sternum with or without infectious parameters, one should consider a self-limiting sternal tumour of childhood (SELSTOC) . UltrasoIn patients with infectious parameters in combination with backache, one must consider a spondylodiscitis. Imaging shows low signal of the disc with surrounding fluid/abscess with destruction of the vertebrae and rim enhancement after gadolinium administration Fig. ; Pott’s After a period of septicaemia, such as a fulminant meningococcemia, septic emboli can occur. This can lead to partial premature closure of the physis leading to joint deformities Fig. .Chronic osteomyelitis is defined as a persistent or recurrent low-grade bone infection. Usually this occurs in older patients after trauma or surgery.Conventional imaging will show the same features as in acute osteomyelitis, although more extensively Fig. . ComplicCT plays an important role in the diagnosis and analysis of chronic osteomyelitis. Imaging of complications of osteomyelitis such intraosseous abscesses, sequesters, and fistulas or cloaca formation is important Figs.  and 9.Soft tissue extension can be evaluated, but to a lesser extent compared to MR. Imaging characteristics are comparable to those for acute osteomyelitis.MR can show soft tissue extension and abscess. Also intraosseous abscesses and fistulas can be seen. Imaging characteristics are comparable to those of acute osteomyelitis. Use of total body STIR can exclude multifocal disease.PET scans will show uptake in the area of osteomyelitis. It can exclude multifocality.The main differential diagnosis of chronic osteomyelitis consists of neoplasms.In Ewing’s sarcoma a large soft tissue mass without calcifications or bone matrix in the tissue can be seen. Onion-skin periostitis is typical.LCH can be difficult to differentiate from multifocal osteomyelitis. LCH typically produces punched-out lesions on conventional imaging. Therefore, conventional imaging can provide a valuable clue.Bone metastases are usually multifocal. In this diagnosis also the clinical parameters are important signs; in most cases, there are no signs of inflammation.Chronic recurrent multifocal osteomyelitis (CRMO) can be part of SAPHO syndrome . It is a very uncommon condition, of unknown aetiology, with a peak incidence between the ages of 4–14 years. Characteristically, there are multiple locations, but only one is symptomatic . The imaTo date no data have been published on the use of follow-up imaging in childhood osteomyelitis. In a retrospective study by Kowalski et al. on the use of follow-up MRI for the prognosis of spinal osteomyelitis, they found that the most valid parameter on follow-up MRI was a change in soft tissue involvement. The authors concluded that only in selected cases were MR findings of additional value .Only data of small-group studies on follow-up of osteomyelitis with bone scintigraphy and FDG-PET are available. These studies suggest that in the follow-up of osteomyelitis, FDG-PET and bone scintigraphy can be useful to analyse the activity of osteomyelitis and that FDG-PET is superior to MRI. Activity can be a parameter to determine the time for termination of therapy , 41.Unique to childhood are the late complications of osteomyelitis due to the growth and developmental disturbances of the affected bone. These developmental changes can involve malformations of the joints Figs.  and 14, Osteomyelitis in childhood can be a challenging diagnosis. Imaging plays a vital role in the diagnosis of childhood osteomyelitis, and the imaging findings are pivotal in the treatment decision. As in all clinical cases the most important aspect of the diagnosis of childhood osteomyelitis lies in good cooperation among the paediatrician, paediatric orthopaedic surgeon and paediatric radiologist.


A 39-year-old woman received an intrauterine device (IUD) placement 6 years ago, and lower abdominal pain occurred intermittently 1 year after the placement. Every attack lasted for a few days and was relieved spontaneously. Pain occurred again 2 days before admission, with nausea, vomiting, and constipation. Physical examination revealed a mass in the left lower abdomen with localized tenderness. Abdominal computed tomography showed that a mass, 5.9 × 4.0 cm in size, was adjacent to the aorta abdominalis and below the umbilicus. A 2-cm circinate foreign body was observed close to the mass . ExploraIUDs become embedded in the uterine wall or even perforated into the peritoneal cavity only in very rare cases. It has been reported that perforation of the uterus occurs in 0.87 of 1000 insertions [It is usually considered that IUDs are unrelated to malignancy, and might even act as a protective cofactor in cervical carcinogenesis , but theThe authors declare that they have no conflicts of interest that could be perceived as having influenced the impartiality of the materials presented. FundingThe present study received no grant from a funding agency in the public, commercial, or for-profit sectors.


SummaryCastleman disease is an uncommon disorder affecting the lymphatic system and is characterised by atypical lymphocyte proliferation. The usual clinical presentation is of a solitary mass lesion, frequently within the thorax. A number of different imaging findings have been reported on CT and MRI. We present a case of paracardiac Castleman disease where the diagnosis was suggested by dramatic enhancement of the tumour mass during a dynamic MR perfusion sequence. To our knowledge this is the first report of the use of a first pass bolus tracking technique in the diagnosis of Castleman disease. The patient was a 35 year old woman with an extensive past medical history including pemphigus vulgaris. She had a previous diagnosis of Castleman disease confirmed by pathology following excision approximately 10 years earlier. She subsequently developed bronchiolitis obliterans and underwent bilateral lung transplantation. Subsequent CT follow up demonstrated a soft tissue mass in the mediastinum that remained stable for a number of years. Unfortunately in the decade after her lung transplant she again developed a clinical picture of bronchiolitis obliterans, this time attributed to chronic allograft rejection. Repeat double lung transplant was contemplated and she underwent coronary angiography as part of the pre-surgical work up. At catheterization a vascular mediastinal mass was discovered and MRI examination of the thorax was requested.Pre-contrast imaging demonstrated a 5 × 3.8 × 5.2 cm solid mass in the middle mediastinum. This appeared homogenous and of slightly higher signal than skeletal muscle on T1 weighted images, with moderate signal intensity on fat-suppressed T2 weighted images . Subtle A dynamic multi-slice first pass perfusion sequence was performed in the coronal plane  in subsequent years .We suggest that if Castleman disease is being entertained as a clinical diagnosis, a dynamic sequence may reveal the inherent vascularity of the lesion to a far greater extent than regular post-contrast spin echo imaging. To our knowledge, this is the first time that a gated sequence designed for myocardial perfusion has been used in this way.


The Echinococcus granulosus tapeworm causes hepatic echinococcosis. It is endemic in the Mediterranean region, Middle East, and South America. Human infection is secondary to accidental consumption of ova in feces. Absorption through the bowel wall and entrance into the portal circulation leads to liver infection. This case involves a 34 y/o Moroccan male with an echinococcal liver cyst. His chief complaint was RUQ pain. The patient was treated with albendazole and praziquantel. His PMH and PSH was noncontributory. Patient was not on any other medications. ROS was otherwise unremarkable. The patient was AF VSS. He was tender to palpation in RUQ. Liver function tests were normal. Echinococcal titers were positive. CT demonstrated a large cystic lesion in the right lobe of the liver measuring 13.5 cm in diameter. The patient underwent successful laparoscopic drainage and excision of echinococcal cyst. Final pathology demonstrated degenerating parasites (E. granulosus) of echinococcal cyst. Hepatic echinococcus is acquired by humans secondary to accidental consumption of ova in dog feces . It resuA 34-year-old Moroccan male presented with a several month history of moderately severe, constant, and progressively worsening, dull aching right upper quadrant pain (RUQ). There were no alleviating and precipitating factors. A computed tomography (CT) scan revealed a 13.5 cm cystic lesion in the right lobe of the liver (Gharbi Type I) and densely calcified masses in the right and left sides of the liver (Gharbi Type V). An ELISA test for echinococcal infection was positive. The patient was treated with albendazole and praziquantel for 3 months with no clinical or radiographic improvement . LaparosThe procedure was done using four 12 mm ports as shown in The patient was discharged on postoperative day three with the drain, which had collected a small amount of bilious fluid. The drain was removed after seven days. Pathology showed degenerating stage cysts without any living forms of E. granulosus. The infectious disease service recommended 28 more days of albendazole. At six-month followup, the patient remained asymptomatic and disease-free.Surgery is the primary treatment for echinococcal disease. However, controversy still surrounds the preoperative medical treatment and type of operative procedure. The role of preoperative endoscopic retrograde cholangiopancreatography (ERCP) continues to be debated, with proposed benefits including preoperative definition of cystobiliary relationships, treatment of cholangitis and biliary obstruction, and possible definitive treatment in cases of intrabiliary rupture. In one study, ERCP was reported to be safe method to treat biliary complications of hepatic hydatidosis before and after surgical management . ERCP, hBiliary obstruction only occurs in 5%–10% of patients due to biliary communications that are at least 5 mm in diameter. Communications of this size or larger are more significant due to their ability to carry hydatid debris and daughter cysts into the common bile duct causing biliary obstruction in over 66.6% of cases. In patients without jaundice or cholangitis, ERCP findings are normal in 50% and demonstrate cystobiliary rupture, biloma, or bile duct compression in the other 50% , 9. ÖzasUse of an intraoperative cholangiogram is also controversial. Ramachandran and Arora suggest that an intraoperative cholangiogram is unnecessary and increases morbidity . They stAll surgical treatments require complete cyst exposure, cyst decompression evacuation and sterilization, ligation of bile duct communications, and cavity management . Open prThe chosen operative procedure depends on the location, size, type of cyst, and the surgeon's skills . Total p Laparoscopic treatments that have been described include cystotomy, partial pericystectomy, and total pericystectomy , 13. LapGood laparoscopic candidates include those with superficial and fluid filled cysts, while deep cysts should be approached in an open manner due to the risk of hemorrhage . AdditioLastly, percutaneous methods are becoming increasingly popular. The procedure, initially developed by Ben Amor et al. is called PAIR: puncture-aspiration-injection-re-aspiration . The patPercutaneous drainage of hydatid cysts involves aspiration of the cyst fluid and injection of contrast to ensure no large biliary tract communication. The cyst is then infused with an antiscolecoidal agent and drained with a catheter , 23. OnlOptimal treatment algorithms for hepatic echinococcal cystic disease are not fully defined. Controversies revolve around the use of ERCP and open surgical, laparoscopic, or percutaneous procedures. Although the efficacy of specific laparoscopic techniques remains a debated topic, it has been demonstrated at multiple centers around the world that the principles of open surgical treatment of hepatic echinococcus can be adhered to by laparoscopic intervention.


Bochdalek hernia is the most common type of congenital diaphragmatic hernia. It appears frequently in infants but rarely in adults. We present the case of a 50-year-old female han patient with tremendous left-sided congenital posterolateral diaphragmatic hernia  who also has a pair of supernumerary breasts and pulmonary hypoplasia of the lower-left lobe. The patient had an experience of misdiagnosis and she was treated for bronchitis for one year until being admitted to our hospital. This case study emphasizes the rare presentation of Bochdalek hernia in adults and the necessity of high clinical attention to similar cases. The estimated rate of occurrence of congenital diaphragmatic hernia varies from 1:2000 to 1:4000 live births. Though thousands of such cases are reported during infancy, few reports describe adult patients diagnosed with Bochdalek hernia. Usually, these hernias become evident during the neonatal period, through symptoms and signs of respiratory distress. However the most frequent symptoms found in adult patients are slight respiratory and digestive symptoms. It is also possible for these hernias to be asymptomatic. Here we report a case of mild dyspnea within a congenital posterolateral diaphragmatic hernia.A 50-year-old female patient of Han nationality was admitted to our department with a one year history of slight dyspnea. The discomfort was greatly obvious after heavy physical work, but could be alleviated by taking a rest. She denied having other symptoms such as chest pain, abdominal pain, dysphagia, vomiting, and dyspepsia. There was no history of trauma or surgery. Upon physical examination we inspected nothing characteristic except the remarkable decrease of breathing sounds and increased bowel sounds in the left hemithorax. Contrast-enhanced chest computed tomography(CT) and multiplanar reconstructions(MPRs) showed a notable displacement of the abdominal viscera into the left thoracic cavity and the interrupted hemidiaphragm Figure . The ateBochdalek hernias, first described by Bochdalek in 1848, are characterized by a congenital defect on the posterolateral region of the diaphragm without hernia sac. They are generally discovered in neonates, but is rarely reported in adults. The aetiology factor of Bochdalek hernias is unknown, but we know that the occurrence of this disease is due to the failure of closure of the pleuroperitoneal canal during the ninth to tenth week of gestation . Those wFor Bochdalek hernias, correct diagnosis and early treatment is significant to avoid the occurrence of serious complications. To improve the quality of medical treatment for Bochdalek hernias in adults, more cases will need to be reported and long-term follow up should proceed.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.All the authors declare that they have no competing interests.In the following we specify the individual contributions of authors to the manuscript. All surgical procedures were performed by GWC, YBZ and HD. YBZ and HD managed the perioperative period of the patient. YBZ prepared the manuscript and GWC made final approval. All authors read and approved the final manuscript.


Both intraparenchymal papillary meningioma and papillary meningioma with cyst formation of brainstem have never been reported. The authors present an extremely rare case of patient with intraparenchymal papillary meningioma of brainstem. A 23-year-old Chinese male presented with a 4-month history of progressive left upper limb and facial nerve palsy. Magnetic resonance imaging revealed a cystic-solid, heterogeneously enhancing mass in pons and right cerebral peduncle with no dural attachment. The tumor was totally removed via subtemporal approach. During surgery, the lesion was found to be completely intraparenchymal. Histological and immunohistochemical examinations were compatible with the diagnosis of papillary meningioma. The lesion recurred nine months after primary surgery, a second surgery followed by radiotherapy was performed. Till to now (nearly 2 years after the treatment), the patient is tumor free survival. Intraparenchymal meningioma of brainstem with cystic formation is very rare, however, it should be considered as a differential diagnosis of a brainstem neoplasm. The present case strongly recommended that postoperative radiotherapy was essential for the patients with papillary meningiomas. Meningiomas account for nearly 35% of all primary intracranial neoplasms, deriving from the arachnoid cap or meningothelial cells . TherefoCyst formation is uncommon in the meningioma, which most commonly develops in fibroblastic and meningothelial meningiomas. Papillary meningiomas demonstrating cystic changes were reported only in five cases in previous literatures . Here, wA 23-year-old Chinese male presented with a 4-month history of progressive left upper limb and facial nerve palsy. In the month prior to admission, he was suffering from impairment of the left upper limb movement, as well as mild dysphasia. Magnetic resonance imaging (MRI) revealed a cystic-solid mass, sized 35*25*20 mm, located in the brainstem. The solid part of the tumor mainly located in the pons, while the cystic part extended to the right cerebral peduncle. The solid part manifested iso-intense on both T1- and T2- weighted imaging with homogeneous enhancement on T1-weighted gadolinium enhancement, but no dural tail sign was noted. The cystic part was shown of hypo-intense on T1-weighted imaging and hyper-intense on T2-weighted imaging  and vimentin, but negativity for glial fibrillary acidic protein (GFAP), cytokeratin (CK), and S-100 protein Figure . These fNine months later, he was re-admitted with facial palsy and left upper limb weakness again, and brain MRI showed local tumor recurrence Figure . He was Infratentorial meningiomas without dura attachment are uncommon. Reviewing the literatures -12, onlyClinical characteristics of eight infratentorial meningiomas without dural attachment were summarized in table Infratentorial meningiomas without dural attachment represent surgical challenge, requiring special considerations, because of the vicinity of the brainstem, cranial nerves, and veterbrobasilar arteries. Despite recent improvements in surgical techniques, surgical treatment of meningiomas in this area still carries a high risk of morbidity and mortality. In some cases, the lesion might be strongly adherent to these structures, leading to a partial or subtotal resection. Nevertheless, in more than half of the reports (5/8), a total resection was reached with mild complications. This might be largely ascribed to the distinct relationship between lesion and surrounding tissues.Papillary meningioma is an aggressive variant of meningioma, which accounts for 1-2.5% of all meningiomas . In compDue to the rarity of papillary meningiomas, no clear consensus has achieved regarding the proper management of papillary meningiomas. However, aggressive surgical resection plus postoperative radiotherapy has come to represent the standard care . In currThe authors described an extremely unusual case with intraparenchymal papillary meningioma of brainstem with cyst formation. Although this is very infrequent, meningiomas should be included in the differential diagnosis of an intraparenchymal brainstem tumor. Papillary meningioma is a distinct variant of meningioma with highly aggressive behavior. The experience of the present case strongly indicates that postoperative radiotherapy is essential for the patients with papillary meningiomas.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.XJ and CK participated in the study design. All authors participated in the treatment applied and data collection. XJ and ZC participated in literature reviewing and manuscript writing. XJ, ZC and CK participated in editing and proof reading. All authors read and approved the final manuscript.


Multifocal carcinoid is a known phenomenon. We present a rare combination of an ovarian carcinoid synchronous with gallbladder carcinoid. This rare combination has not been reported so far. An asymptomatic 45-years-old perimenopausal lady was diagnosed to have a metastatic ovarian cancer, but on laparotomy she was found to have a primary synchronous metastatic gall bladder as well. On histopathological evaluation she was found to have two separate primary carcinoids. Subsequently the patient received chemotherapy and is completely asymptomatic on follow up. Further research needs to be undertaken and guidelines need to be formulated for management of these cases. Carcinoid tumors are neuroendocrine tumors derived predominantly from the enterochromaffin or Kulchitsky cells . CarcinoMultifocal primary disease is rarely known to occur with carcinoids, although very few cases have been reported till date. Synchronous primary carcinoid tumors have been reported in about 0% to 3% of small bowel carcinoid, and it has been observed that a second primary malignancy occurs in 7% to 32% of cases . We pres45-year-old para 4, living 4 presented to the outpatient department with chief complaints of a progressive abdominal distension over the last 5 months and amenorrhea since the 5 past 3 months. Apart from these the patient was completely asymptomatic.On examination the general condition of the patient was stable and abdominal examination revealed a soft cystic, nontender abdominopelvic lump, corresponding to 22-week uterine size. The gall bladder was also palpably enlarged in the right hypochondrium. On Speculum examination the cervix and vagina were healthy, and vaginal examination revealed bilateral nontender cystic masses with restricted mobility.Ultrasound showed a left ovarian cystic mass in the iliac region with the gall bladder showing a localized heterogeneous echogenic mass. There was minimal dilatation of the common bile duct. This was followed by a contrast enhanced computed tomography scan of the patient that showed a multiseptated mass with solid and cystic components in the adnexal region till the level of L3. The gall bladder fossa showed a heterogeneously enhancing lesion but no lymphadenopathy.Chest X-ray, upper gastrointestinal endoscopy along with colonoscopy were within normal limits. The CA-125 and CEA levels were 102.7 units/mL and 8.23 ng/mL, respectively. Fine needle aspiration cytology of the mass suggested the features of epithelial neoplasia. During preoperative evaluation the malignancy appeared advanced, and hence it was planned for a staging and debulking surgery as a stage IV malignancy. She underwent an exploratory laparotomy with total abdominal hysterectomy, bilateral salpingo o-ophorectomy, infracolic omentectomy, hepatic resection and, cholecystectomy. The segment IV B/5 along with the gallbladder was removed.Intraoperatively there was 200 mL of nonhemorrhagic straw colored ascitic fluid. A right-sided ovarian mass of 20 × 15 cms with solid and cystic areas was noted along with a left ovarian mass of 15 × 15 cms. The uterus and bilateral tubes were looking normal. A liver nodule of 5 × 5 cms in segment 5 on cut section of the gall bladder mucosa was intact on naked eye examination, which later on turned out to be infiltrated by histopathological examination.The peritoneal or the ascitic fluid was free of malignant cells. The right-sided ovarian tumor showed polygonal pleomorphic cells with high mitosis and capsular involvement . ImmunohThe gall bladder also showed similar features of neuroendocrine tumor which was positive for EMA, chromogranin A, and neuron specific enolase. The tumor was infiltrating the liver, but the margins of the liver nodules were free of the tumor. Interestingly enough the omentum and lymph nodes, as well as the ascitic fluid, were free of any malignant cells.Patient had an uneventful postoperative period. Two weeks after surgery patient was started on chemotherapy, which was continued for 5 cycles. She received cisplatin (20 mgs), ifosofamide (2 gms) with mesna (400 mgs) and adriamycin (30 mgs). The patient has been asymptomatic during her followup for ongoing chemotherapy.The incidence of carcinoids is approximately 0.1% of the ovarian neoplasms, whereas amongst the carcinoid clan they are found in 1% of the cases .Carcinoid tumors have a higher incidence in the 5th and the 6th decades of life. The tumor has a predilection for the female gender and is more common in the African American population . Our patCarcinoid tumors of the ovary have been classified under the category of malignant ovarian germ cell tumors. Amongst the malignant germ cell tumors, carcinoids of the ovary are categorized under the monodermal malignant teratomas. Primary ovarian carcinoids are most commonly known to occur unilaterally, in stage I that is not associated with any metastatic disease . PrimaryCarcinoids are asymptomatic in about 40% to 60% of cases. The typical symptoms of carcinoid syndrome are due to the production and release of serotonin in the systemic circulation. Carcinoid syndrome characterized by facial flushing, diarrhea, bronchospasm, and edema has been observed to occur in about one third of patients with ovarian carcinoid tumors . As withCarcinoid tumors are identified on the basis of the granule-associated proteins chromogranin, synaptophysin, and neuron specific enolase by; mmunohistochemistry , 12. ChrThe strategies of management would depend not only on the site, size, and histopathological characteristics of the tumor but also the symptomatology and presence of carcinoid syndrome.The management of an ovarian carcinoid tumor would range from unilateral salpino-oophorectomy to a total abdominal hysterectomy. Robby et al. in his study on 10 cases had shown complete remission following unilateral oophorectomy –16, wherAt present there is no consensus on the role of chemotherapy in cases of ovarian carcinoid. Some authors believe that there is no role of chemotherapy with early stage carcinoid tumors.There have been a few case reports of patients with gynecological literature regarding successful treatment of advanced ovarian carcinoid following chemotherapy and radiotherapy. In patients with metastatic disease, chemotherapy with 5-fluorouracil (5-FU) and leucovorin is offered .The prognosis in our patients is uncertain as this combination has not so far been studied and the patient had synchronous primary tumors of localized spread to the liver. So far the patient has been asymptomatic after the six months of followup.A very rare case of a synchronous combination of ovarian with gall bladder carcinoid has been successfully managed with a multidisciplinary approach; however, long term followup still needs to be done. We need to study these cases more extensively to formulate guidelines for patient management.