Primary adrenal leiomyosarcoma is a rare form of adrenal mesenchymal tumors. Immunohistochemistry (IHC) together with histology takes a major role in determining the tumor type and predicting their biological behavior and differentiating them from adrenal cortical carcinoma. Appropriate radiological investigation is necessary to rule out metastatic disease from primary tumors elsewhere in the body. In this case, we report a primary leiomyosarcoma of the adrenal gland in a 61-year-old Bahraini male clinically presumed to be a renal neoplasm. Primary adrenal leiomyosarcomas are rare and represent 0.1-0.2% of intra-abdominal soft tissue malignancies in adults. It usually presents itself as a retroperitoneal mass with pain, mass effect, and pressure effect on the surrounding organs. Most of the adrenal mesenchymal tumors belong to benign categories like myelolipomas and haemangiomas . DiagnosAvailable information on the Internet indicates approximately 20 reported cases of leiomyosarcoma around the world so far. The case of adrenal leiomyosarcoma reported in Bahrain was originally thought to be a renal tumor. However further radiological and immunohistological study led us to correct diagnosis.The 61-year-old Bahraini male patient with a known history of diabetes and hypertension presented with left flank pain of few months duration. He had no other significant complaints or relevant past history. He went initially to a tertiary hospital where he was clinically diagnosed to have a renal tumor. The CT abdomen with contrast showed a large mass in the upper pole of the left kidney with heterogeneous enhancement measuring 16 × 10.7 × 11.7 cm displacing the lower pole of the kidney with mild stranding of the perinephric fat giving a radiological diagnosis of renal neoplasm.However, the patient went to another hospital for further investigations and treatment. Multiplanar MRI in that hospital using T1 and T2 weighted TSE SPIR postcontrast sequence showed an 11 × 12 × 13 cm oval mass with heterogeneous enhancement with nonenhancing area due to cystic degeneration in the anteromedial aspect of the left kidney displacing it posteroinferiorly. The tumor was seen abutting the splenic vein and abdominal aorta and stretching the left renal vein and artery leading to the diagnosis of adrenal tumor rather than renal origin  showed RBC 3–5/HPF, WBC 2–4/HPF, and no protein, cast, crystals, or bacteria were found. Other laboratory investigations were within normal limits and no tumor marker estimations were done.The complete blood count showed mild normochromic normocytic anemia with Hb of 10.2 × 10Prior to operation, according to the hospital protocol, the patient received two units of PRBCs, and then he underwent laparotomy with removal of the adrenal tumor. Intraoperatively, the tumor was arising from the left adrenal gland pushing the kidney inferiorly with no fixation to kidney or other adjacent organs. Excision of the tumor with preservation of the left kidney was performed. The patient withstood the operation well and was discharged on 5th postoperative day without any complication. Postoperatively, we lost contact with the patient as he sought further overseas oncology management.Grossly, multiple pieces of greyish white friable tissue with attached small amount of fatty tissue were received in the lab altogether weighing 1040 g and measuring 17 × 13 × 8 cm in maximum dimension. The cut surface was solid and grayish white in color with few mucoidal areas. Tiny hemorrhagic areas were present. No normal or residual adrenal gland was identified. Microscopic examination revealed a high grade spindle cell malignant tumor composed of diffuse proliferation of large pleomorphic spindly cells with eosinophilic cytoplasm and spindly, blunt ended vesicular nuclei . Many laPrimary adrenal mesenchymal tumors are very rare and are mostly composed of benign tumors like myelolipomas and haemangiomas . The mosThe age of patients ranged from 30 to 73 years with male to female ratio of 3 : 1 and median size of the tumor is 11–25 cm , 5. WithThe origin of the tumor cells is widely presumed to arise from the smooth muscle wall of the inferior vena cava, central adrenal vein, and its tributaries , 2, 5–8.Morphological changes and clinical behaviors can be related to chromosomal aberrations , 6. For Although the tumor is unilateral, it affects both the sides equally. The patients usually present with abdominal flank pain, mass or symptoms of adjacent organ involvement like IVC obstruction leading to lower limb swelling, venous gangrene, and pulmonary embolism. They can also present with symptoms of metastasis to liver, lung, and bone leading to shortness of breath, jaundice, bone pain, and paresis –6, 11.As there are no definitive biomarkers, preoperative diagnosis is difficult . AlthougMetastatic tumors, malignant melanoma, GIST, MPNST, sarcomatoid renal cell carcinoma, malignant fibrous histiocytoma, and primary retroperitoneal sarcoma infiltrating the adrenal gland should be considered in the differential diagnosis along with the native adrenal tumors , 5. BeniGrossly, leiomyosarcomas usually attain large size with rubbery consistency and soft if necrotic and usually show areas of hemorrhage and cystic degeneration –5. MicroPrimary adrenal LMS can be categorized as conventional or pleomorphic type. The former being more common shows good positivity for smooth muscle markers 90–95%) while the latter pleomorphic variant shows variable expression (37.5–50%) , 5.% while tThe mainstay of treatment is early diagnosis and the survival depends on tumor size, location, and complete surgical resection with free margins as well as morphologic grading. Chemotherapy and/or radiotherapy show inconsistent results , 4, 6. HIn spite of having slow growth and late metastasis, leiomyosarcomas carry poor prognosis and unpredictable course with high incidence of local recurrence . The mosIn conclusion, this is a rare case of primary adrenal leiomyosarcoma which was originally thought to be a renal tumor. We stress here that when analyzing large adrenal tumor, primary soft tissue sarcomas should be considered in the differential diagnosis along with the other adrenal and metastatic tumors and appropriate immunohistochemistry should be performed to reach a specific diagnosis. Radiological investigations should also be included in the workup to reach an appropriate diagnosis and to assess the prognosis. Even with complete resection, the prognosis is generally poor and appropriate long standing follow-up is required.


Solid pseudopapillary neoplasm is a rare cystic tumor of the exocrine pancreas. Abdominal pain or discomfort is the most common symptom, usually in young females.Herein we report the case of an 8 - year old child presenting with symptoms of gastric outlet obstruction.A solid pseudopapillary neoplasm of the pancreatic caput was diagnosed and surgically removed. Solid pseudopapillary neoplasm (SPN) is a rare cystic tumor of exocrine pancreas with a female predominance. Clinically, it presents as a mass in the pancreas with a wide range of symptoms. Surgical exploration is indicated to release the intra-abdominal extrusion and for histopathology. SPN to the best of our knowledge has so far not been reported in patients below 9 years of age. Besides, gastric outlet obstruction has not been reported as the first sign of SPN.An 8-year old female patient presented in the pediatric unit with abdominal discomfort, nausea and bitter vomitus. Physical examination revealed a mass in the abdomen. Abdominal ultrasound sonography revealed a 3 cm large mass in the head of the pancreas. Endoscopic sonography confirmed a cystic tumor of the pancreatic caput and fine needle biopsies were taken for histopathology, Fig. Magnet resonance imaging (MRI) of the abdomen showed a thick-walled, cystic mass in the head of the pancreas with compression of the duodenum, Fig. A well capsulated mass of the pancreatic head without macroscopic signs of malignancy was found and completely enucleated during laparotomy, Fig. Histopathology confirmed the diagnosis of SPN following positive stains on immunohistochemistry with antitrypsin, vimentin, beta-catenin, CD 56 and CD 10, Fig. SPN of the pancreas was first reported by Lichtenstein in 1934 [The incidence of SPN varies widely amongst reported series. Cubilla and Fitzerald  reportedThe limited amount of publications on SNP is a reflection of the rare nature of this entity. In fact, a vast majority of the medical literature on this entity consists of case reports and small case series. The largest series so far is a review by Papavramidis et al.  includinAlthough SPN can be clinically silent, patients might present with a mass in the upper abdomen with discomfort or pain . PhysicaOn like in other reports, signs of gastric outlet obstruction, i.e. mechanical obstruction of the upper gastro-intestinal tract with recurrent bitter vomitus in this case heralded SPN. Although no enzymatic analysis of the vomitus for bile of gastric enzymes was performed, the bitter nature of the vomitus suggested a proximal gastro-intestinal obstruction. This was confirmed by the identification of a large mass in the pancreatic head with duodenal compression Fig. . A well-There are two distinctive findings in this case: the age at the time of presentation and the initial symptom. This to the best of our knowledge is the first reported case of SPN in a patient below nine years. The child in this case was eight years old at the time of diagnosis and gastric outlet obstruction has not been previously reported as an initial presentation of SPN.Taken together, this is the first reported case of SPN in a child below the age of nine presenting with bitter vomitus as a sign of gastric outlet obstruction. An interdisciplinary board should discuss all such cases. Surgical exploration with the goal of releasing symptoms is the main stay of treatment. Although SPN is mostly benign, there is a minimal risk of malignant transformation. Therefore, histopathology with immunohistochemical staining should be performed to confirm the diagnosis of SPN and role out malignant pancreatic tumors.Written informed consent was obtained from the patient´s legal representatives 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 present study reports a rare case of large capillary hemangioma of the temporal bone with a dural tail sign. A 57-year-old female presented with pulsatile tinnitus and episodic vertigo associated with a ten-year history of an intermittent faint headache. Magnetic resonance imaging revealed a mass in the right petrous bone, which was hypointense on T1-weighted images and heterogeneously hyperintense on T2-weighted images, and showed a dural tail sign following gadolinium administration. Pre-operatively, this tumor was believed to be a meningioma. During surgery, the vascular tumor was removed by a modified pterional approach. A histopathological examination indicated that the tumor was a capillary hemangioma. Although intraosseous capillary hemangiomas are rare, they most frequently affect the temporal bone. Hemangiomas of the temporal bone may mimic other more common basal tumors. The diagnosis is most often made during surgical resection. The dural tail sign is not specific for meningioma, as it also occurs in other intracranial or extracranial tumors. The treatment of intratemporal hemangiomas is complete surgical excision, with radiotherapy used for unresectable lesions. To the best of our knowledge, the present study is the fourth case of intraosseous intracranial capillary hemangioma, but the largest intratemporal hemangioma to be reported in the literature to date. Intracranial capillary hemangiomas (ICHs) are rare benign vascular tumors that may occur at birth or in early infancy ,2. PrimaA 57-year-old female presented with pulsatile tinnitus and episodic vertigo associated with a ten-year history of intermittent faint headaches. There was no history of facial twitching or weakness. There was no evidence of facial nerve dysfunction upon physical examination. Pure tone audiometry revealed a hearing level of 28 dB on average in the right ear and a normal hearing level on the left. There was no history of trauma or neurological disturbances. Gadolinium-enhanced magnetic resonance imaging showed a mass measuring 42×36×35 mm in the right petrous bone, which was hypointense on T1-weighted images and heterogeneously hyperintense on T2-weighted images. Additionally, a dural tail sign was shown following gadopentetate dimeglumine administration .Surgery was performed using a modified pterional approach. Abnormal vascular soft tissue was identified in the skull base, with skull invasion and involvement of the dura. The invaded temporal bone had cavernous blood-filled spaces within the bony trabeculae. The adjacent dura mater was involved with thickening, but remained intact. The tumor did not affect the bony walls of the horizontal semicircular canal and the facial nerve canal. The patient’s post-operative course was uneventful, and the tinnitus and vertigo disappeared completely in the ensuing weeks. The symptoms did not recur, even after one year of follow-up examinations.The histological examination revealed aggregates of primarily capillary-sized microvessels in a vaguely lobular arrangement, with diffusely fibrosed intrabecular spaces containing numerous proliferated, partially small and dilated, thin-walled blood vessels. Factor VIII, vimentin and cluster of differentiation 31 was detected in the blood vessel walls by immunohistochemistry, while epithelial membrane antigen was not . These fet al (Intraosseous hemangioma most commonly affects the vertebral column or skull ,10, but et al  reportedHistopathology classifies intraosseous hemangiomas into the venous, cavernous and capillary types ,15. CapiIntraosseous hemangiomas are benign tumors that are slow growing and mostly asymptomatic . HemangiIn the present study, although the hemangioma intruded into the brain tissue, the adjacent dural mater remained intact, revealing no tumorous invasion of the nerve sheath. This is consistent with other previous studies on hemangioma and indicates a compression neuropathy rather than direct invasion ,18. Moreet al (Hemangiomas of the temporal bone may mimic other more common cranial base tumors, including acoustic tumors, facial neuromas, meningiomas, cholesteatomas, glomus tumors and metastatic tumors ,16,23,24et al , also deThe treatment of ICH remains empirical . The majIn conclusion, the present study reports the fourth case of intraosseous ICH, but the largest intratemporal hemangioma thus far. ICH may be considered as a likely diagnosis when the tumor involves the skull with a dural tail sign.


Acute adrenal hemorrhage is an uncommon entity. Although trauma is the most common cause of adrenal hemorrhage, non-traumatic etiologies have also been reported. We report an unusual case of a spontaneously ruptured adrenocortical carcinoma that initially presented as a critical massive retroperitoneal hemorrhage. The case was treated successfully using a combination of emergency interventional radiology and elective surgery.A 47-year-old woman was transported to our hospital because of the sudden onset of severe pain in her left lower back. The shadow of a tumor-like soft mass accompanied by bleeding was observed in the upper pole of the left kidney, together with vascular leakage from the middle suprarenal artery on computed tomography. Transcatheter embolization of the left middle adrenal artery was administered based on a diagnosis of acute adrenal hemorrhage. Further observation indicated that the bleeding was caused by rupture of an adrenocortical carcinoma. Left adrenalectomy was subsequently carried out via laparotomy.We experienced an unusual case of acute massive adrenal hemorrhage caused by the rupture of a non-functional adrenocortical carcinoma, which was treated successfully by ambulatory transcatheter embolization therapy and elective surgery. Adrenocortical carcinoma is an uncommon disease, accounting for approximately 0.02% of all malignant tumors -3. This We report an unusual case of a spontaneously ruptured, non-functional adrenocortical carcinoma that initially presented as a critical massive retroperitoneal hemorrhage, and which was successfully treated by a combination of emergency interventional radiology and elective surgery.en bloc by partially excising Gerota’s fascia, without leaving any remnants. No invasion into the surrounding organs, lymph node metastasis, or liver metastasis was observed. The operative time was 229 min, and the surgical blood loss was approximately 500 mL. The patient recovered uneventfully. The tumor measured 13.5 × 8.6 × 4.2 cm and weighed 380 g. The cut surface indicated a yellowish solid tumor, with areas of bleeding accompanied by necrosis in a branched pattern (Figure A 47-year-old woman was transported to our hospital because of the sudden onset of severe pain in her left lower back. She was alert and conscious, with a blood pressure of 165/95 mmHg, pulse of 77 beats/minute, and oxygen saturation of 95%. She appeared to be in distress and complained of sharp spontaneous pain in her left lower back. She was 162.0 cm tall and weighed 84.5 kg. There were no physical features suggestive of Cushing’s syndrome. The patient had been healthy with no particular past medical history or familial disease. Her white blood cell count was 11,800/μL and her hemoglobin level was 8.8 g/dL. Other than these findings, biochemical tests and urinalysis on admission demonstrated no particular abnormalities Table a, b. No Adrenocortical carcinoma is an uncommon disease found in 0.5–2 per million people, accounting for only 0.02% of all malignant tumors -3. ApproCT and MRI are useful modalities for diagnosing adrenocortical carcinoma -12. TumoSurgical resection is the treatment of choice in patients with adrenocortical carcinoma, and survival can be prolonged significantly among patients able to undergo radical excision ,14. The Adrenal hemorrhage is an uncommon entity. Although trauma is the most common cause, non-traumatic etiologies have also been reported. Large and progressively growing tumorous lesions, such as adrenocortical carcinomas, pheochromocytomas, metastatic tumors, and myelolipomas, may carry a risk of tearing or rupture, either alone or in combination with hemorrhagic diathesis, stress, or other idiopathic causes ,16,17. MWe experienced an unusual case of acute massive adrenal hemorrhage caused by the rupture of a non-functional adrenocortical carcinoma, which was treated successfully with ambulatory transcatheter embolization therapy and elective surgery.We experienced an unusual case of acute massive adrenal hemorrhage caused by the rupture of a non-functional adrenocortical carcinoma, which was treated successfully by ambulatory transcatheter embolization therapy and elective surgery.Written informed consent was obtained from the patient for publication of this case report, including the associated images.


A neovesicocutaneous fistula is a rare complication after orthotopic bladder reconstruction, particularly in the late postoperative period. We report the case of a 59-year-old man who had undergone ileal neobladder construction 17 months previously. He presented with urinary retention concomitant with urinary tract infection due to a neovesicourethral anastomotic stricture. After a combination of transurethral catheter drainage and broad-spectrum antibiotic therapy for 3 weeks, the fistulous tract completely closed. Therefore, conservative treatment may be regarded as a valid option for a delayed neovesicocutaneous fistula. Although the use of detubularized ileum for total bladder reconstruction has gained wide acceptance, this easy-to-use substitute is associated with certain specific complications. A neovesicocutaneous fistula is a rare complication following an ileal neobladder construction. In most cases, it develops during the early postoperative period because of suture failure; in some cases, it may occur because of local tumor recurrence in the late postoperative period. In this report, we present a case of a delayed neovesicocutaneous fistula that was caused by overdistention and bacterial urinary tract infection, which was successfully managed with conservative treatment.A 59-year-old man presented with a 1-week history of abdominal distention, decreased urine output, and the body temperature of 39°C. He had undergone retroperitoneoscopic nephroureterectomy with open excision of the bladder cuff 22 months earlier for urothelial carcinoma (UC) of the right ureter. His kidney along with the ureter was removed using a median incision in the lower abdomen. Five months after his nephroureterectomy, radical cystoprostatectomy and orthotopic ileal neobladder construction were performed for UC of the bladder in 2011. According to the classification of TNM, his clinical stage was T2aN0M0. A reservoir was created with a detubularized ileal U-shaped neobladder using 45 cm of the terminal ileum as described by Koie et al. [3; platelets, 200,000/mm3; serum creatinine, 2.15 mg/dL; and C-reactive protein, 30.74 mg/dL. Unenhanced computed tomography (CT) revealed a distended neobladder with left-sided hydroureteronephrosis and subcutaneous fluid accumulation in the lower abdomen  with orthotopic neobladders had at least one transient episode of urinary retention . UrinaryMultiple adhesions can occur during neobladder healing in the decompressed state during the first 3 weeks after operation. These adhesions may create wall tension areas during filling, which eventually results in wall thinning and reduced elasticity. These can lead to a seromuscular tear of the bladder wall during overfilling. An orthotopic neobladder can open up to nearly all the surrounding pelvic structures, including the small bowel, colon, rectum, vagina, and iliac vessels. Therefore, the formation of fistulas in these structures has been reported, usually during the immediate postoperative period due to suture failure –6. In coDamage to an orthotopic ileal neobladder plays an essential role in the formation of a delayed neovesicocutaneous fistula that is not caused by tumor recurrence. Mechanical damage may result from the rupture and perforation of an orthotopic ileal neobladder , 8. OverThe treatment algorithm for urinary fistulas of a neobladder initially involves adequate, uninterrupted urinary drainage and broad-spectrum antibiotics. Recently, cyanoacrylate glues were used to manage urinary fistulas, including neovesicocutaneous fistulas, with high success rates . When thA neovesicocutaneous fistula is a rare complication that occurs after orthotopic bladder reconstruction, particularly during the late postoperative period. Adequate, uninterrupted urinary drainage and broad-spectrum antibiotic therapy may be a treatment option for this condition.


Lesions were examined not only by magnetic resonance imaging (MRI) but also by positron emission tomography-computed tomography (PET-CT) and proton magnetic resonance spectroscopy (11C-methionine-PET (MET-PET) showed an obvious increase in methionine uptake in the lesion corresponding to enhanced areas with gadolinium-enhanced MRI. MRS showed a decrease in the N-acetylaspartate/creatine (NAA/cr) ratio and a slight elevation of the choline/creatine (cho/cr) ratio and a lactate peak in the lesion. A follow-up MRI at 6 and 12 months showed a gradual decrease in the initial hyperintense lesions in FLAIR without any treatment.A 33-year-old woman presented an incidental 3.7 × 3.3-mm unruptured cerebral aneurysm (CAn) in her basilar artery, which was successfully coiled with balloon assistance. A follow-up brain MRI at 1 and 2 months showed a gradual increase in several white matter hyperintense lesions in the left cerebellar, bilateral occipitotemporal and left parietoccipital lobe during fluid-attenuated inversion recovery (FLAIR). These were the only lesions associated with perfused CAn. However, the patient did not show any additional symptoms such as visual disturbance throughout the entire course. We present a case of an unusual complication after a coiling procedure. Although it is difficult to identify this etiology without a pathological examination, it is importance to increase awareness of such a potential complication arising from coiling procedures, because interventional procedures have become the first choice of treatment for cerebrovascular diseases in many countries. AlthougA 33-year-old Japanese woman first visited Okayama University Hospital in February, 2011 to evaluate numbness in her bilateral lower limbs, a condition that had developed since the age of 29, when she had a cervical spinal cord injury due to a car accident. The patient had no other previous medical history.General medical and neurological examinations showed no other particular findings except for decreased vibration sensation and increased tendon reflexes in her bilateral lower limbs, which were present 4 years after the car accident.Biochemical blood tests showed no abnormal findings. A brain MRI revealed no lesion in fluid-attenuated inversion recovery  PET studies showed that glucose uptake in the lesion with areas enhanced by gadolinium-enhanced MRI  peak with a mean cho/creatine (cr) ratio of 1.10 versus 0.89 in the control. The mean N-acetylaspartate (NAA) peak was reduced with a mean NAA/cr ratio of 1.29 versus 2.34 in the control. An elevated lactate peak was also noted  and A follow-up MRI at 6 and 12 months showed a gradual decrease in the initial hyperintense lesions in the left cerebellar, bilateral occipitotemporal and left parietoccipital lobe (Figure We report on a patient who presented several asymptomatic cerebellar and cerebral white matter lesions after coiling of the CAn. These lesions recovered completely without any treatments. The occurrence of brain lesions has been described after coiling procedures -6. HydroAlthough there was no diagnostic finding in FDG-PET in this case, MET-PET showed an obvious increase in methionine uptake in the lesion corresponding to the enhanced areas with gadolinium-enhanced MRI (Figure In this case, MRS showed a decrease in the NAA/cr ratio and a slight elevation of cho/cr and lactate peaks in the lesion Figure , suggest1H-MRS findings in this case may explain how the etiology of white matter lesions is suspected of contributing to some kind of inflammation associated with the remote complication of the coiling procedure.Uchiyama et al. , Deus-SiMiddleton et al. demonstrated that the degradation time of PGA to complete resorption into a living body is a period of 6 to 12 months . In our In conclusion, we present a case of an unusual complication after a coiling procedure. Although it is difficult to identify this etiology without a pathological examination, it is importance to increase awareness of such a potential complication arising from coiling procedures because interventional procedures have become the first choice of treatment for cerebrovascular diseases in many countries.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Clear cell adenocarcinoma of the cervix is a rare tumor of the lower genital tract. It has been described in young women with a history of intra uterine exposure to diethylstilbestrol. This tumor is characterized by a greater tendency for late recurrences. In this article, we report the case of one exposed-patient who developed recurrence as liver metastases, 24 years after the initial treatment. This case demonstrates the need and the importance for continued follow-up in individuals prenatally exposed to diethylstilbestrol. It has t et al.  and its t et al. –8. We rein utero DES exposure. Physical examination revealed a budding tumor involving the anterior lip of the uterine cervix. The pelvic Computed Tomography (CT) scan showed an enlargement of the cervix which was deviated to the right. The mass came in contact with the rectal wall but did not invade the bladder or the parameters. Biopsy confirmed the diagnosis of clear cell adenocarcinoma of the cervix. Disease extention evaluation including chest and abdominal scan was normal. A laparotomy with bilateral ovarian transposition and iliac lymphadenectomy was performed. The pathological examination of resected lymph nodes was negative. After the initial surgery, the patient was treated with brachytherapy (65 Grays). Because of an insufficient tumor response to the brachytherapy, the patient underwent two cervical conizations. After the second conization, surgical margins were negative for malignancy. The patient was then followed up regularly with colposcopic evaluation and annual Pap smear.In July 1990, a 20-year-old woman presented with abnormal vaginal bleeding. Her past medical history was only significant for 2), carboplatin (AUC = 5) and bevacizumab (7.5 mg/kg) both administered every three weeks. To date, she has received 7 cycles of this combination with excellent tolerance and the follow up CT scans have showed a partial response with reduction of tumor size after 3 and 6 cycles  is an oral synthetic nonsteroidal estrogen that was used to prevent miscarriage, premature birth and other pregnancy complications between 1938 and 1971 in the United States . Exposureoplasia .DES related clear cell adenocarcinoma usually occurs between the age of 15 and 27 with a median of 19 years  and haveMost recurrences of clear cell adenocarcinoma of the vagina and cervix are diagnosed within the 3 years after primary tumor treatment  but lateIn the cases reported by Herbst et al. , recurreLocal recurrences of clear cell adenocarcinoma of the cervix can be effectively treated with surgery, radiotherapy or combined modality . SurgeryTo summarize, this case represents the longest reported disease-free interval till recurrence and the first description of metastatic liver disease of DES related clear cell adenocarcinoma of the cervix. It reemphasizes the necessity of long term surveillance of DES exposed women and confirms previous reports recommending the importance of frequent follow-up examination not only of the pelvis but also of all distant potential sites of metastasis. It also shows that treatment with paclitaxel, carboplatin and bevacizumab can be an effective and safe therapeutic option for treating recurrence of this rare tumor.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.


Yolk sac tumor (YST), also known as an endodermal sinus tumor, is a rare malignant germ cell tumor. Primary retroperitoneal YST (PRYST) is extremely rare and, to the best of our knowledge, has only been described in case reports. The histogenesis of PRYST and the appropriate treatment strategy remain unclear due to the rarity of this type of tumor. The present study reports a case of YST in the retroperitoneum. A 19-year-old female presented with abdominal distension and edema of the lower limbs. A computed tomography scan revealed a large, solid mass located in the retroperitoneum. The tumor size was 20×25×30 cm and widespread metastasis was identified during the exploratory laparotomy. The postoperative histopathology report showed a malignant retroperitoneal tumor . The patient underwent three surgical procedures and 17 cycles of five different chemotherapy regimens. The patient succumbed to cachexia, which was due to tumor recurrence, and liver and spleen metastases 21 months after diagnosis. PRYST may relapse following surgical treatment; however, surgical resection is currently the optimal treatment method. In this case, bleomycin, etoposide and cisplatin; bleomycin, vincristine and cisplatin; and vincristine and cisplatin chemotherapy regimens were effective for the patient with PRYST, although the tumor was not completely resected. α-fetoprotein (AFP) is an important tumor marker for monitoring PRYST recurrence and observation of elevated serum AFP levels during chemotherapy indicates a poor prognosis. A yolk sac tumor (YST) is a malignant germ cell tumor (MGCT), which typically occurs in the gonads. Extragonadal YST is rare, particularly in the retroperitoneum . Due to The YST represents a highly malignant germ cell neoplasm in adult cases and is generally characterized by a high serum α-fetoprotein (AFP) level. Serum AFP is one of the hallmarks of YST and facilitates its diagnosis. The serial measurement serum AFP is useful for monitoring its clinical course and response to treatment .Extragonadal germ cell tumors are considered to be a consequence of the mismigration of germ cells along the urogenital ridge during embryogenesis and are estimated to represent ~2–5% of all adult germ-cell malignancies . ExtragoA 19-year-old female presented with abdominal distension and edema in the lower limbs for six months. The patient was admitted to Chunan Chinese Traditional Medical Hospital  and an abdominal computed tomography (CT) scan revealed a solid mass located in the retroperitoneum . A palliative tumor resection was performed during the first exploratory laparotomy on October 28, 2009; the large pelvic mass was not completely removed and widespread metastasis was found. The histopathology report revealed a malignant retroperitoneal tumor  and two cycles of single-agent mitomycin (10 mg) chemotherapy were performed by intraoperative intraperitoneal and intravenous administration.The patient was transferred to the Zheijiang Cancer Hospital  on November 17, 2009. The α-fetoprotein (AFP) serum levels were elevated to 9,859.76 ng/ml ; cancer antigen 125 (CA-125) levels were elevated to 51.90 U/ml ; the serum β-human chorionic gonadotropin , carcinoembryonic antigen , carbohydrate antigen 19-9  and squamous cell carcinoma (SCC) antigen  were within the normal ranges. A pelvic CT scan revealed a pelvic mass , etoposide (150 mg for four consecutive days) and cisplatin , the serum AFP levels decreased to 1,251.27 ng/ml on January 7, 2010 and the CT scan revealed that the tumor size had significantly reduced . The intHowever, tumor recurrence occurred three months after the final BEP regimen. The serum AFP levels elevated to 193.99 ng/ml on June 4, 2010 and magnetic resonance imaging (MRI) revealed a cystic and solid mass in the right parametrium . A salpiHowever, tumor recurrence occurred just three months following the final BVP regimen. The serum AFP level elevated to 72.80 ng/ml on January 10, 2011 and the CT scan revealed that the cystic and solid mass in the right parametrium had markedly increased (compared with the prior MRI) . Radical® (210 mg on day one), ifosfamide (2 g on day one and 1 g on days two and three) and cisplatin , while the serum AFP level continuously increased to 3,500.01 ng/ml following the final TIP regimen on May 23, 2011. The patient presented with liver and spleen metastases and succumbed to cachexia 21 months after diagnosis.Following surgery, the patient received two cycles of chemotherapy consisting of vincristine (1 mg on day one), actinomycin D (400 μg for five consecutive days) and cyclophosphamide . However, the serum AFP level increased to 465.27 ng/ml following the final VAC regimen on March 14, 2011 and the positron emission tomography/CT revealed tumor metastases to the liver and the spleen. Therefore, the patient was administered three cycles of chemotherapy consisting of taxolet al  have been widely used and have markedly improved the prognosis of patients with MGCTs. The administration of cisplatin-based combination chemotherapy regimens has improved the curative effect on MGCT patients. Cicin et al  reportedet al . The BEPet al . In the et al (et al (The VAC and TIP regimens are classic chemotherapy regimens for germ cell tumors. Lertkhachonsuk et al  reportedl (et al  demonstret al (et al (et al (Approximately 10–20% of patients experience a YST relapse following the first treatment ,18 and tet al  reportedl (et al  reportedl (et al ,19; howel (et al ,4,8–22. In conclusion, the current study presented a rare case of YST originating in the retroperitoneum. PRYST is an extremely rare malignant tumor with a poor prognosis. Although PRYST may relapse promptly after surgical treatment, surgical resection is considered to be the optimal treatment, particularly when performed prior to PRYST recurrence, as it markedly decreases the AFP level. In addition, it was observed that the BEP, BVP and VP chemotherapy regimens are effective for patients with PRYST even when the tumor is not completely resected. Thus, AFP is an important tumor marker for monitoring PRYST recurrence and the observation of elevated serum AFP levels during chemotherapy indicate a poor prognosis.


Central odontogenic fibroma is a very rare benign odontogenic tumour characterized by a fibrous mature stroma with variable strands or islands of inactive-looking odontogenic epithelium. Our aim is to report a case of a central odontogenic fibroma and describe the clinical usefulness of Er:YAG laser for the surgical treatment of this tumour. A 74-year-old woman presented with an expansive lesion located in a mandible with multilocular and mixed radiographic appearance. A conservative excision using Er:YAG laser was performed. Complete removal was obtained. There were no postoperative complications. The histopatologic features were consistent with the diagnosis of central odontogenic fibroma of rich-epithelium type. No recurrence was observed during follow-up. Central odontogenic fibroma (COF) is a very rare benign neoplasm characterized by a fibrous mature stroma with variable strands or islands of inactive-looking odontogenic epithelium . COF accClinically, COF may appear as an asymptomatic slow growing lesion associated with cortical expansion. Radiographically COF presents as a unilocular or multilocular radiolucent area or sometimes with a mixed radiolucent/radiopaque appearance . BilaterHere we report a case of a central odontogenic fibroma of the mandible with partially ill-defined margin treated with conservative excision using Er:YAG laser. The clinical, imaging, surgical, and pathological findings are discussed altogether with a brief review of the literature.A 74-year-old Caucasian Portuguese woman was referred to our Oral Medicine and Surgery Department by her general practitioner because of a painless swelling of the mandible. The patient reported that the nodular lesion was present for 8 years without pain and notable changes in size. Anamnesis disclosed presence of osteoporosis, hypercholesterolemia, arterial hypertension, and peripheral venous insufficiency.At oral examination an enlargement of the mandible in buccal left premolar region extending from the canine to the first molar  was evidPanoramic radiography showed a radiolucent lesion with a multilocular appearance between the mandibular left canine and second premolar . The uppDifferential diagnosis included odontogenic myxoma, central giant cell granuloma, osseous dysplasia, desmoplastic fibroma, calcifying epithelial odontogenic tumour, keratocystic odontogenic tumour, ameloblastic fibroma, and ameloblastoma.2, and fluence of 38.22 J/cm2. During the excision, we observed that the lesion was almost encapsulated except at its inferior margin with a more ill-defined border. Because of this, additionally to the enucleation and curettage of the lesion, a peripheral osteotomy was performed until clear bone tissue was obtained to ensure complete elimination of the tumour. There were no postoperative complications such as pain, paresthesia, and swelling one week after surgery. Histopathologic examination of the whole specimen confirmed the diagnosis of central odontogenic fibroma, epithelium-rich type (complex or WHO type). No recurrence was seen at the follow-up visits . Histopathological evaluation showed a lesion composed of a fibroblastic/collagenous tissue with many strands or nests of odontogenic epithelial cells without cytological atypia. Focally prominent hyaline calcified foci, resembling osteoid and dentinoid material, were also present . Such fep visits  during aCentral odontogenic fibroma is a very rare benign odontogenic tumour, described in less than a hundred cases in indexed literature , 14–17. The clinical characteristics of COFs observed in our case are within the reported in the literature , 9. The Conservative excision through enucleation and curettage of the lesion is the treatment of choice for COF , 9, 17. Recurrence is uncommon , 26, 34.In conclusion, the radiological and histological features of the case reported here were consistent with the diagnosis of central odontogenic fibroma of rich-epithelium. The conservative excision using Er:YAG laser appears to be an effective procedure for the treatment of this very rare odontogenic tumour.


Metastatic pancreatic adenocarcinoma involving the testis is a rare condition with a poor prognosis. The current study describes the case of a 69-year-old male who presented with a painful swelling of the left scrotum. Scrotal ultrasonography revealed hydroceles in the scrotal sacs, with the left one being larger in size. The patient underwent left hydrocelectomy and was eventually diagnosed with metastatic adenocarcinoma. Abdominal computed tomography, which was performed to detect the primary cancer, showed a pancreatic tail carcinoma with liver and multiple lymph node metastases, and peritoneal carcinomatosis. The patient received gemcitabine-based chemotherapy but resulted in progressive disease. This case shows that in a patient in whom a primary testicular tumor is unusual due to their age, a testicular mass or hydrocele should be a suspect for possible metastatic disease. Metastatic testicular tumors that are formed from another solid tumor origin are relatively uncommon. Malignant tumors are known to account for 32.9% of testicular tumors, and metastatic tumors are reported to account for only 6–8% of the malignant tumors –2. The mThe present study reports a case of metastatic adenocarcinoma spreading from the pancreas to the testes, which initially presented as a painful scrotal swelling. Written informed consent was obtained from the patient.A 69-year-old male admitted to Seoul National University Bundang Hospital  presented with a painful swelling in the left scrotum, which was gradually increasing in size. The patient had no history of trauma, no medical history of genitourinary tract anomalies or complaints and did not exhibit any other subjective symptoms.A physical examination using transillumination revealed a soft, tender mass in the left scrotum and edematous swelling of the surrounding tissue. There were no abnormal findings in the abdomen, chest or extremities. The complete blood cell count, liver function test and serum electrolyte and serum creatinine levels were all within the normal range.Scrotal ultrasonography showed a large amount of fluid collection in the left scrotal sac, a small amount of fluid with internal echogenic material in the right scrotal sac and diffuse swelling of the scrotal epithelia. The sonographic findings were consistent with a hydrocele of the left testis, a smaller hydrocele of the right testis and associated inflammatory changes in the surrounding soft tissue .A left hydrocelectomy was performed with the presumptive diagnosis of a benign hydrocele. The pathological diagnosis was consistent with metastatic adenocarcinoma .Immunohistochemical staining showed that the tumor cells were positive for cytokeratin 7 and were negative for cytokeratin 20, thyroid transcription factor-1, prostate-specific antigen, estrogen receptor and calretinin.Following the diagnosis of metastatic cancer, several examinations were performed to detect the primary cancer. Abdominal-pelvic computerized tomography demonstrated a low-attenuating mass (4.0×2.2 cm) in the pancreatic tail encasing the common hepatic artery. Multiple scattered lesions in the liver, nodular infiltrates in the omentum and peritoneal thickening in the pelvic region were also found, indicating pancreatic tail cancer with liver and multiple lymph node metastasis and peritoneal carcinomatosis . Whole-bOn the basis of these findings, the patient was diagnosed as having pancreatic cancer with metastasis to the liver, peritoneum, lymph nodes and testes. The patient received 3 cycles of gemcitabine-based chemotherapy but resulted in progressive disease. No further chemotherapy was available due to general deconditioning and palliative care was provided.Metastatic testicular tumors originating from pancreatic cancer are rare. In total, <20 cases have been reported, and it is known that the right testis is more commonly involved –6.Although the current patient first presented with left scrotal swelling without any other symptoms, imaging studies showed hydroceles of the testes, with the hydrocele of the left testis being larger in size. A left hydrocelectomy was performed, as the patient had symptoms only in the left side. However, considering the final diagnosis of metastatic pancreatic cancer and the large extent of the disease, tumor formation in the right testis was suspected also. The treatment plan for the right testis was systemic chemotherapy considering the origin of the metastatic tumor. To the best of our knowledge, this is the first case of metastatic pancreatic adenocarcinoma involving the left and right testes.Invasion of the testes and paratesticular organs by a metastatic epithelial malignant tumor is rarely the initial clinical manifestation of a primary tumor and may occur as a part of a widely disseminated disease, indicating a poor prognosis with a survival of only 9.1 months from the time of diagnosis . The mosSeveral routes of metastasis to the testicular tissues have been proposed. These pathways include direct invasion from the contiguous lesion, retrograde venous or arterial embolism, retrograde lymphatic extension from the paraaortic lymph nodes, transperitoneal seeding through a congenital hydrocele and retrograde extension from the vas deferens ,3,7. NumAs observed in the current case, metastatic adenocarcinomas of the pancreas, particularly carcinomas of the pancreatic tail, reveal late or no definite clinical symptoms associated with the original tumor. The prognosis of this type of cancer is unfavorable in the majority of cases. In total, <1% of the patients with metastatic pancreatic cancer will survive 5 years following diagnosis ,9.The current case indicates that possible metastatic disease should be suspected in patients presenting with a testicular mass or swelling at an age in which a primary testis tumor is unlikely. Such patients should undergo an extensive metastatic evaluation as well as a standard evaluation for a primary testis tumor, particularly if the clinical findings indicate the involvement of other organs ,10.


Congenital adrenal hyperplasia (CAH) and vanishing testes are uncommon diseases that can result from hormonal and mechanical factors. Classic CAH is determined by ambiguous genitalia and increase in amount of 17-Hydroxyprogesterone. Simultaneous occurrence of CAH and vanishing testes is a rare condition.A 22-year-old boy, known case of CAH who was diagnosed as female pseudohermaphroditism due to ambiguous genitalia, was referred to Shahid Sadoughi Hospital, Yazd, Iran with colicky abdominal pain and hematuria. Ultrasonography has been performed and prostate tissue was reported. Karyotyping was done because of uncertainty in primary diagnosis, which revealed 46XY. For finding location of testes, ultrasonography and MRI were done and nothing was found in abdomen, inguinal canal or scrotum. Inhibin B serum level was measured to find out whether testis tissue was present in the body, which was <1 pg/ml and vanishing testis was confirmed.Early diagnosis and treatment are essential to prevent further sequels and karyotyping for all patients with CAH is recommended. Lifelong treatment with synthetic glucocorticoid replacement is necessary. Congenital adrenal hyperplasia (CAH) refers to any of several autosomal recessive diseases resulting from deficiency of one of five enzymes required for synthesis of cortisol in adrenal cortex. Most frequent is 21-hydroxylase deficiency and about 1 in 16,000 children are born with classic 21-hydroxylase deficiency  is a rare syndrome in which testes are absent in male person and is seen in˂5% of cryptorchidism cases. The specific factor has not yet been known. This disease can be unilateral or bilateral and commonly external genitalia are normal.Diagnosis of vanishing testis syndrome is based on clinical presentation. Micropenis due to prenatal disorders is an important symptom in infants with bilateral anorchia. Also delayed puberty  is a common complaint in males with congenital anorchia. On examination, physician cannot palpate testes and blind-ending spermatic cords are a common finding that shows the presence of the testis in early fetal life. Testosterone and gonadotropin concentrations are commonly low in this syndrome .The aim of present report was to analyze the clinical and hormonal findings in a patient affected with congenital bilateral anorchia and CAH and also to determine any possible relationship with congenital adrenal hyperplasia.A 22-year-old boy, known case of CAH who was diagnosed as female pseudohermaphroditism due to ambiguous genitalia, was referred to Shahid Sadoughi Hospital, Yazd, Iran with colicky abdominal pain and hematuria. His first presentations were ambiguous genitalia, nausea and vomiting. He was under irregular treatment with prednisolone and fludrocortisone since diagnosis. Parents were relatives. No CAH or other endocrine abnormalities had been diagnosed in his family members.2), blood pressure was 125/80 mmHg, with no orthostatic change. Thyroid and abdomen examination were normal. In breast examination, there was no gynecomastia. Skin examination revealed marked genitalial, areola and gingival hyperpigmentation. Phallus length was 6 cm. testes were not palpable in scrotum. He had axillary and pubic terminal hair (his pubarche was Tanner V). His bone age was 18. Other systemic examinations were normal.He was referred because of colicky abdominal pain and hematuria without nausea or vomiting. He weighed 60 kg . More than 95% of cases are caused by 21-hydroxylase deficiency  is a rare birth defect. It may be seen in less than 5% of cryptorchidism cases in which a baby boy is born without testes but the penis and scrotum will form with good development , 16. HorThe diagnosis of congenital vanishing testes should be suspected in a patient with 46XY karyotype, no detectable testes and lack of secondary sex characteristics. The boy presented in this report, had all these characteristics of the disease . UltrasoIn conclusion, because of simultaneous occurrence of CAH and vanishing testes, which is a rare condition, we recommend that karyotyping be done for all patients with CAH.There is no conflict of interests of each author.


A 69-year-old woman was diagnosed with alveolar rhabdomyosarcoma (ARMS) of the nasopharynx. She has a history of catastrophic thromboembolic event in the abdomen that caused short-gut syndrome and dependence on total parenteral nutrition (TPN) twelve hours per day. She was treated for short-gut syndrome with teduglutide, a glucagon-like peptide-2 (GLP-2) analog, which led to reduction of TPN requirements. However, a few months later, she developed metastatic alveolar rhabdomyosarcoma. Though a causative relationship is unlikely between the peptide and ARMS due to the brief time course between teduglutide therapy and sarcoma diagnosis, neoplastic growth may have been accelerated by the GLP-2 analog, causing release of IGF-1. The transmembrane receptor for IGF-1 is frequently overexpressed in ARMS and is implicated in cell proliferation and metastatic behavior. This case describes a rare incidence of metastatic alveolar rhabdomyosarcoma in a sexagenarian and possibly the first case reported associated with the use of teduglutide. Teduglutide was discontinued due to a potential theoretical risk of acceleration of sarcoma growth, and the patient's rhabdomyosarcoma is in remission following sarcoma chemotherapy. Soft tissue sarcomas are a heterogeneous group of mesenchymal neoplasms that affect patients of all ages. The incidence of soft tissue sarcoma is about 30 per million persons per year; in the United States about 12,000 people are diagnosed with soft tissue sarcoma each year . The twoTreatment of rhabdomyosarcoma is based on risk stratification at the time of diagnosis, which is based on several criteria developed by the Soft Tissue Sarcoma Committee (previously the Intergroup Rhabdomyosarcoma Study Group (IRSG)) of the Children's Oncology Group (COG). Treatment is multidisciplinary in nature, including surgery, radiation therapy, and chemotherapy. Favorable prognostic indicators include gross complete surgical removal of the tumor at the time of diagnosis, tumor size <5 cm, and age older than 1 but less than 10 years at diagnosis. Regional lymph node involvement in patients with alveolar rhabdomyosarcoma and distant metastasis is associated with a less favorable prognosis compared with those patients with localized disease .In adults, soft tissue sarcomas comprise about 1% of solid tumor malignancies, and RMS makes up about only 3% of adult soft tissue sarcomas. If a patient over the age of 18 years is diagnosed with rhabdomyosarcoma, it is much more likely to be pleomorphic (adult-type) RMS than one of the pediatric iterations of the disease. There are case reports in the medical literature about adults with ARMS, but cases are exceedingly rare. Adults with ARMS have a very high risk of developing metastases and usually die from the disease . This reThe patient is a 69-year-old woman who presented with a chief complaint of unilateral clear rhinorrhea for two weeks. She was treated with steroid nasal spray without benefit. Due to persistent symptoms, she was treated with antibiotics for acute sinusitis, again without improvement. A few weeks later, she noted left-sided nasal occlusion with difficulty breathing through her nose and an enlarging left neck mass. She underwent computed tomography scanning of the neck that showed a left nasopharyngeal mass measuring 3 × 2.4 × 2.6 cm, extending from the skull base along the anterior inferior aspect of the left clivus inferiorly through the level of C1-C2. The mass encased the left upper internal carotid artery. A second mass was in the midline on the posterior choana abutting the nasal septum, measuring 2.2 × 2.2 × 1.8 cm, and a mass-like area between the nasal septum and the left middle turbinate was present, measuring 1.7 × 1.6 × 0.5 cm. Left submandibular and upper deep cervical chain adenopathy and a soft tissue mass in the flank detected on fluorodeoxyglucose-positron-emission tomography (FDG-PET) suggested metastatic cancer.An excisional biopsy of the nasopharyngeal mass was performed. Pathology was consistent with ARMS. Immunohistochemical staining was notable for diffuse and strong positivity for CD56, vimentin, desmin, and myogenin see . There wR), which is indicated for the treatment of adult patients with SBS who are dependent on parenteral support [The patient has a past medical history of a catastrophic thromboembolic event in the abdomen that resulted in necrotic bowel. She had a partial small bowel resection and subtotal colectomy with placement of ileostomy about 15 months prior to presentation to our medical center. This resulted in short bowel syndrome (SBS) and dependence on total parenteral nutrition (TPN) 12 hours per day. About three months prior to diagnosis of RMS, the patient was started on the recently approved medication, teduglutide (rDNA origin)  in contrast to a wide range of cancers examined . The bio


Fibrovascular polyps occur most commonly in the cervical esophagus and are extremely rare in the hypopharynx. In this paper, we report a case of fibrovascular polyp of a 52-year-old female, who presented with progressive dysphagia and weight loss and regurgitating a mass from her mouth. By the endoscopic examination, a polyp covered by normal mucosa with a wide stalk was detected at the hypopharynx. The pedicle of the mass was identified under general anesthesia and the 13 × 3 × 2 cm mass was completely resected perorally. Histopathological examination of the tumor showed oedematous subepithelial fibrous stroma, surrounded by squamous epithelium and containing many congested vascular structures. No recurrence was detected over one year of follow-up. This case highlights the need for clinicians to be aware of this rare entity and to develop the best approach to patient management. Fibrovascular polyp of the hypopharynx and esophagus, a rare, benign, intraluminal, submucosal tumor, is most commonly originated from proximal esophagus , 2. ThisThe most common complaints include dysphagia and a sensation of a mass. Other complaints are retrosternal or epigastric discomfort, odynophagia, vomiting, weight loss, and respiratory symptoms such as persisting cough and shortness of breath. The most distinctive feature of a fibrovascular polyp is regurgitation into the mouth . The aspA 52-year-old woman presented to the gastroenterology department with complaints of progressive dysphagia, and regurgitating a mass from her mouth. The patient suffered from this complaint for 1 year. She also suffered from losing weight. Her past medical history was not significant except for diabetes mellitus of 2 years. The patient underwent endoscopy in the gastroenterology department. The esophagogastroscopy demonstrated a 50 mm sized polyp with stalk at the hypopharynx. The patient was referred to the Otolaryngology Department of Adana Numune Training and Research Hospital with the impression of polyp of the hypopharynx. The endoscopic examination showed a mass with wide pedicle covered with smooth mucosa at the hypopharynx. An operation was planned. The laryngoscopic and esophagoscopic evaluation of the hypopharynx under general anesthesia revealed that the stalk was attached to the posterior wall of the hypopharynx . The pedThe patient has been informed and the approval form has been signed by the patient to publish her medical data for scientific publications and presentations.Benign hypopharyngeal tumors are uncommon and their exact incidence is unknown . FibrovaIt is reported that sarcomas can develop from the lipomatous component of the esophageal polyp; otherwise, the squamous carcinomas can develop from the mucosa of the polyp separately .Fibrovascular polyps usually originate as small mucosal tumors; then, they grow up by the pressure changes with the constant downward urge of both food and peristalsis . FibrovaFibrovascular polyp may remain asymptomatic for long years because of its slow-growing nature. In the literature, dysphagia is the most common complaint. Other complaints are sensation of a mass, retrosternal discomfort, epigastric pain, regurgitating the polyp into the mouth, loss of weight, and persistent cough , 12. In Because of its progressive nature and the risk of sudden death by asphyxia, surgical removal of the polyp is recommended and local excision of the polyp is curative; the recurrence is rare .The surgical technique is chosen after assessing the origin, size, and vascularity of the pedicle . Small pIf the stalk of the polyp can be visualized completely, peroral excision with the assistance of electrocautery is also an option. For larger polyps, Owens et al. reported two patients operated on by lateral pharyngotomy .Hoseok et al. reported performing a biapproach surgical treatment  for excision of a giant fibrovascular polyp of the upper digestive tract .In our case, we performed a peroral excision with the assistance of electrocautery. The bipolar cautery was used for controlling hemorrhage. We had no complication and bleeding problem during the operation. The patient has been followed up without any recurrence for 1 year postoperatively.If the patient presents with slow growing, progressive dysphagia, endoscopic evaluation is needed. Although the hypopharyngeal and esophageal tumors are mostly malign, the specialist must bear in mind that the tumor could be benign. Fibrovascular polyps should be considered in the differential diagnosis of the tumors in this area. Excision the fibrovascular polyp is curative and the recurrence risk is rare. If the stalk of the fibrovascular polyp is completely in view, there is no need to perform an open surgery because of the increased morbidity.


Diagnosis is not usually achieved clinically or by laboratory data, but CT imaging is helpful for diagnosis.2 Our patient is a 45-year-old woman presented with intermittent abdominal pain. Physical examination was unremarkable and abdominopelvic sonography and upper GI endoscopy were normal. Abdominopelvic CT-Scan performed during an episode of pain showed thickening and invagination of a bowel segment (Intussusception is an invagination of a portion of bowel into distal segment. While common in children, it is a rare cause of bowel obstruction in adults and usually is caused by a lead point. Most causes of adult small bowel intussusceptions are benign intestinal lesions like lipoma, leiomyoma, neurofibroma, inflammatory polyps, and meckel diverticulum. segment . The pat


Acute torsion of a subserosal myoma is a rare surgical emergency that is infrequently diagnosed preoperatively. Furthermore, laparoendoscopic single-site (LESS) myomectomy with in-bag tissue extraction for the management of this disorder has not yet been described. A 43-year-old, gravida 1, para 1 woman was referred to our department due to a solid pelvic mass associated with persistent abdominal pain. A pedunculated subserosal myoma with torsion was strongly suspected based on ultrasonography and magnetic resonance imaging. Emergency LESS surgery showed that the subserosal myoma arising from the posterior uterine wall torted at its pedicle in the cul-de-sac. The twisted myoma node was excised by coagulation and cut using a LigaSure Atlas, followed by in-bag manual morcellation and extraction through an umbilical wound. The present case report emphasizes that LESS myomectomy with in-bag tissue extraction is a feasible minimally invasive surgical option for the management of subserosal myoma with torsion after a precise imaging-based diagnostic evaluation. Uterine myoma is the most common benign neoplasm in women of reproductive age . The symWhile surgical exploration of the twisted myoma usually resolves the problem, the challenge is in making the appropriate diagnosis, which is difficult because of the limited known imaging-based diagnostic characteristics , 5, 8. AFor the management of acute torsion of myoma, laparoscopic myomectomy has recently evolved as a feasible minimally invasive surgical option , 6, 8–10We herein report a rare case of torsion of a subserosal myoma that was successfully managed by emergency LESS myomectomy with transumbilical in-bag manual morcellation and extraction, after a diagnosis was made based on ultrasonography and magnetic resonance imaging (MRI). Institutional review board approval from Gifu Prefectural Tajimi Hospital was obtained to report this case.µL  and 4.9 mg/dL , respectively. Since the Chlamydia trachomatis antibody testing was positive, minocycline was administered intravenously under a diagnosis of pelvic inflammatory disease.A 43-year-old, gravida 1, para 1 woman without any previous disease history presented to her gynecologist with complaints of lower abdominal pain and was managed conservatively as a pelvic infection without diagnosis of subserosal myoma. Six months later, she was transferred to an emergency department of a hospital due to recurrent severe lower abdominal pain. The white blood cell count and C-reactive protein value at admission were elevated to 9,900/Five days later, she was referred to our department because of persistent abdominal pain. By a vaginal examination, a tender solid mass was palpated in the cul-de-sac. On transvaginal ultrasonography, a solid pedunculated mass measuring 55 × 41 mm was identified . Since tUnder a diagnosis of a pedunculated subserosal myoma with torsion, gasless LESS surgery was performed through an Alexis wound retractor  attached via a 2.5 cm midline umbilical skin incision with the surgical view secured by abdominal-wall lifting with an intra-abdominal fan retractor system   13]..13].Under laparoscopic vision using a rigid 5 mm, 30-degree EndoEYE laparoscope , a necrotized subserosal myoma with torsion at its pedicle was identified in the pouch of Douglas , arrow. After the excised myoma was put into an Endocatch II retriever bag (Covidien Japan), the thread of the retriever bag was pulled outside of the abdomen via the umbilical minilaparotomic incision and the edges of the pouch were exteriorized. For efficient retrieval, another smaller Alexis wound retractor  was placed inside the retriever bag to maximize the size of the opening as well as fixing unevenness in the circumference  14]. Th. Th14]. Among uterine myomas, which are by far the most common gynecological tumors, subserosal myomas located beneath the uterine serosa are the second most common, after the intramural type . AlthougThe severity of symptoms varies, depending on the degree of the rotation and the speed at which the torsion develops. If the torsion is partial and intermittent with spontaneous untwisting, the symptoms may subside, become constant, or spontaneously resolve, as might have occurred after the first event in the present case . In contIf torsion of the myoma would be left untreated, hemorrhagic infarction can cause severe necrosis of the involved myoma, followed by infection, and then peritonitis. This is the most severe and ominous form of leiomyoma degeneration . TherefoThe diagnosis of an acute torsion of subserosal myoma could be made based on the clinical manifestations and diagnostic imaging examinations . The diaIn this clinical context with respect to a pelvic mass, adnexal torsion should be considered first. However, demonstration of normal bilateral adnexa by ultrasonography can easily exclude the presence of adnexal torsion  as in thOnce the diagnostic imaging evaluation indicates the presence of torsion of a subserosal myoma, emergency surgical exploration should be considered to avoid the significant morbidity caused by progression of tissue necrosis. Although laparoscopic myomectomy , 6, 8–10As a potentially less traumatic surgical method with cosmetic advantages, transumbilical LESS surgery was recently introduced for various types of gynecological surgery, including myomectomy , 12. AltPrevious report indicated that gasless single-port laparoscopy with a wound retractor has potential benefits over pneumoperitoneum laparoscopy ; since gFor the retrieval of an excised myoma during laparoscopic myomectomy, fragmentation of the myoma tissue is required to remove it out of the body through the minimal incision . To achiTo avoid this potentially health-threatening issue, a number of procedures that can be used to morcellate the myoma tissues under closed conditions have recently been advocated , 17. In The present case report emphasizes that LESS myomectomy with in-bag tissue extraction is a feasible minimally invasive surgical option for the management of a pedunculated subserosal myoma with torsion after a precise diagnostic evaluation imaging is performed.


Intestinal obstruction is a frequently encountered entity in surgical practice. The signs & symptoms, many a times, are suggestive of the level of obstruction, making the diagnosis of obstruction evident. There are various causes of intestinal obstruction which diversify to an enormous extent, stamping on the famous paradigm for the mysterious nature of the abdomen being referred to as the Pandora's Box. In accordance with the above saying, we report a rare case of a desmoid tumour, presenting as intestinal obstruction, which entices us to strongly believe the same. The abdomen is well known as a “Pandora's Box” and “Intestinal Obstruction” form a major bulk of the disease burden in this “Box”. In accordance with the above saying, we report a rare case of a desmoid tumour, presenting as intestinal obstruction, which entices us to strongly believe the same.A 28 year old female presented to the emergency department of our hospital, with complaints of early satiety, intermittent episodes of bilious vomiting, a slow growing, painless abdominal mass and an inability to pass motion and flatus since 2 weeks. On examination, a lobulated firm mass extending from the epigastrium to the pubic bones and bilateral lumbar region was found, becoming prominent on straight leg raising test. She also reported a history of appendicectomy and two pregnancies with spontaneous deliveries in 1994 and 1999. Analysed blood parameters were within normal limits. A standing abdominal film showed a soft tissue mass over the whole abdomen. A preoperative CT scan revealed a left lower abdominal wall tumor of unknown dignity .The patient was taken up for an emergency laparotomy and intraoperatively, resection of the tumor with excision of the internal oblique abdominal muscle followed, and the defect was subsequently covered with a mesh and strengthened with omentum. Intraoperatively, the anterior rectus sheath was found tightly adherent to the mass. The tumor was also adherent to the parietal peritoneum and bladder on its posterior surface with strong adhesions to the pubic bones inferiorly as well as to the external iliac vein on the right side, which necessitated a vascular repair with prolene 6-0, round bodied, continuous sutures, after excision of the tumor. The tumor was found to cause compression of the intestines & the stomach leading to vomiting & early satiety. The excised tumor weighed 4.6 kg . SubsequDesmoid tumors are histologically benign fibrous neoplasms originating from the musculoaponeurotic structures throughout the body. The term desmoid, coined by Muller in 1838, is derived from the Greek word desmos, which means “tendon-like”. Although desmoid tumors most commonly arise from the rectus abdominis muscle in postpartum women and in scars due to abdominal surgeries, they may also arise in any skeletal muscle. The tumors tend to infiltrate adjacent muscle bundles, frequently entrapping them and causing their degeneration. Although fixation to musculoaponeurotic structures is apparent, the overlying skin is normal. The myofibroblast is the cell considered to be responsible for the development of desmoid tumors.Desmoid tumors occur at a rate of 10-15% in patients with Familial Adenomatous Polyposis (FAP), an autosomally inherited disease caused by germline mutations in the APC gene. Sporadic forms have no hereditary background . The relCT and MRI are the investigative modalities used to diagnose and for the follow up of desmoid tumors. They can help determine the extent of the tumor and its relationship to nearby structures, especially prior to surgical removal. MRI is superior to CT scan in defining the pattern and the extent of involvement as well as in determining if recurrence has occurred after surgery. The diagnostic test is a biopsy of the tumor. Electron CT scan and MRI are used for the diagnosis and follow-up of desmoid tumors. Microscopy may also be performed. On electron microscopic examination, the spindle cells of desmoid tumors appear to be myofibroblasts. This finding is thought to represent an abnormal proliferation of myofibroblasts, which normally disappear gradually during the later stages of wound healing. Colonoscopy and fundal examination are indicated to investigate for the presence of Gardner's syndromePrimary surgery with negative surgical margins is the most successful primary treatment modality. Positive margins after surgery reflect a high risk for recurrence . In thos“what the mind knows is what the eyes see”.A high index of suspicion is needed for prompt diagnosis and subsequent timely intervention in cases presenting with intestinal obstruction. Conditions like the one enumerated and discussed above must be borne in mind whilst dealing with unexplained or unremitting abdominal distention, pain or a difficulty in passage of motion-flatus. Thus a high index of suspicion is must for an accurate and timely management even in the rarest of presentation. As the saying goes-


Ovarian steroid cell tumors (SCTs), not otherwise specified (NOS) are particularly rare ovarian tumors, which are composed of steroid-hormone secreting cells. The majority of patients with this tumor produce excessive quantities of testosterone and virilization is common. The current report presents a rare case of SCT in a 59-year-old female who presented with postmenopausal vaginal bleeding. The patient had experienced irregular vaginal bleeding for two months, 12 years after menopause. Transvaginal ultrasound and magnetic resonance imaging identified a solid adnexal mass and the pathological result of diagnostic curettage showed a proliferative endometrium. The patient’s serum estrogen and testosterone levels were elevated . The patient underwent an exploratory laparotomy, hysterectomy and bisalpingectomy. The neoplasm was well-circumscribed, solid, homogeneous and yellow in color. Microscopically, the tumor was predominantly composed of granular eosinophilic or vacuolated cytoplasm. Reinke’s crystals, prominent nucleoli and Call-Exner bodies were not observed, and there was no mitotic figure. Immunohistochemistry demonstrated that the tumor cells were strongly positive for inhibin. The present rare case aims to expand the current knowledge of this type of ovarian tumor. Steroid cell tumors (SCTs) of the ovary account for <0.1% of all ovarian tumors and these tumors may present at any age along with notable presentations as a result of the hormonal activity and virilizing properties of the tumor –11. In tIn August 2012, a 59-year-old female  presented to the Department of Gynecology at The Third Affiliated Hospital of Sun Yat-sen University following two months of irregular vaginal bleeding, 12 years after menopause. A transvaginal ultrasound scan identified an enlarged uterus with a 5-mm endometrium, a 22 × 19 mm left ovarian adnexal solid mass and a small quantity of free fluid in the pelvis. The patient had undergone diagnostic curettage at the Zhaoqing First People’s Hospital  two weeks prior to attending The Third Affiliated Hospital of Sun Yat-sen University and the pathological result had shown a proliferative endometrium. The patient had a history of hepatitis B and diabetes mellitus, however, the systemic examination was unremarkable. A vaginal examination revealed a small amount of blood in the vagina and a small uterus, while the assessment of the adnexa of uterus was limited due to atrophy of the ovaries following menopause. A transvaginal Doppler ultrasound scan showed that the uterus was normal and the endometrium was 2-mm thick. In addition, a 30×17-mm left ovarian adnexal solid mass was observed as well as 20 mm free fluid in the pelvis. A pelvic magnetic resonance imaging (MRI) scan showed a 20×15-mm left adnexal cystic-solid mass. The patient’s liver enzyme levels were marginally elevated, with alanine aminotransferase levels of 50 U/l and a fasted blood glucose level of 7.27 mol/l. The level of cancer antigen (CA)-125 was 95.6 U/l  and other tumor markers, including CA19-9, CA15-3, carcinoembryonic antigen and α-fetoprotein (AFP) were within the normal limits. The patient’s total serum testosterone level and estradiol (E2) level were 22.28 nmol/l  and 393.71 nmol/l , respectively. Normal levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH) and dehydroepiandrosterone (DHEA) were observed.A laparotomy was undertaken and 100 ml fluid was observed in the peritoneal cavity, in addition, a solid mass measuring 3×2 cm was identified in the left ovary. The uterus, the right ovary and the fallopian tubes appeared normal. A hysterectomy and bilateral salpingo-oophorectomy were performed. The final pathology result showed a well-circumscribed tumoral mass, size 3×3 cm. The cut surface of the solid neoplasm was homogeneous and yellow. Microscopically, the tumor was predominantly composed of granular eosinophilic or vacuolated cytoplasm. Reinke’s crystals, prominent nucleoli and Call-Exner bodies were not observed, and no mitotic figure was present. Immunohistochemistry of the neoplastic cells exhibited positive staining for inhibin, however, was negative for cytokeratin CK; . There wSCTs of the ovary are particularly rare and account for <0.1% of all ovarian tumors .Ovarian SCTs, NOS, may occur at any age, however, generally occur at younger ages compared with other SCTs and occasionally prior to puberty . The typElevation of testosterone levels to >200 ng/dl is the significant diagnostic threshold level for the discrimination of androgen-secreting tumors and non-neoplastic lesions. Elevated testosterone levels may result in adrenal, ovarian and iatrogenic causes and therefore, must be determined in order to diagnose or rule out disease/tumor. Elevated testosterone levels that present with normal DHEA, LH, FSH and 17-hydroxyprogesterone levels warrant the diagnosis of a virilizing ovarian tumor. MRI, endovaginal ultrasound and color flow Doppler imaging also contribute to differential diagnosis. Various other serum tumor markers (including AFP and CA-125) facilitate the differential diagnosis of ovarian adenocarcinoma , 94% of the tumors were found to be unilateral  and complete surgical staging are recommended. However, subsequent monitoring of hormone levels is required as part of the patient’s postoperative follow-up. To the best of our knowledge, there are no reports concerning the efficacy of radiation or chemotherapy. In recent years attempts have been made to describe the use of gonadotropin-releasing hormone analogues to induce the suppression of secretions and apoptosis, which may lead to a non-surgical cure, however, these approaches have primarily been attempted with inoperable cases or patients with recurrent disease.In conclusion, ovarian SCTs, NOS  are a particularly rare type of ovarian tumor. They are usually benign, unilateral and are characterized by hyperandrogenism and virilization. However, in a rare case, such as the present patient, hyperandrogenism and hyperestrogenism were present and the clinical manifestation was not considered to be typical. The primary treatment method was surgical extirpation of the primary lesion. We recommend that any patient who presents with high testosterone levels should be investigated systematically in order to determine whether the origin is adrenal or ovarian. An awareness of this entity will extend the appreciation of NOS ovarian steroid cell tumors.


Although cavernous hemangiomas (CHs) can be found anywhere in the central nervous system, CHs of the third ventricle have been reported in only 29 patients (including our case). In the current case report, we discuss the clinical characteristics and surgical outcome of CHs of the third ventricle.A 64-year-old female was admitted to our emergency room with a sudden decreased level of consciousness. Brain imaging studies demonstrated a multi-lobulated hemorrhagic mass in the third ventricle. The lesion was removed via the transcallosal-interforniceal approach and pathologically diagnosed as CH. Postoperatively, the patient had a transient neurological deficit due to hypothalamic injury and recovered to the normal status at 2 months after the operation. In the review of 29 cases, the mean age of the patients was 40 years with a slight female preponderance . The majority of the patients complained of a mass effect with signs of increased intracranial pressure; only one case was asymptomatic. Gross total resection was achieved in 81% of the cases. Around 80% of the patients were asymptomatic or improved from the initial symptoms. Mortality rate was 6.9% and the most common complication was hydrocephalus.As demonstrated in the review of the previous reports, the outcome is favorable after surgical excision for CH of the third ventricle. Hence, surgical excision appears to be the treatment of choice for CH located in the third ventricle, which tends to grow rapidly resulting in a mass effect. Due to the increased use of computerized tomography (CT) scan and magnetic resonance imaging (MRI), more CHs have been diagnosed in recent years. However, intraventricular location of CHs is uncommon, and the incidence of intraventricular CHs has been reported to be only about 2.5 to 10.8% of all intracranial CHs[reported-20.We present the case of a patient who had a CH in the third ventricle that was resected through the transcallosal interforniceal approach. In addition, we also review the previously reported cases and discuss their clinical characteristics and surgical outcomes.A 64-year-old female was admitted to our emergency room with a sudden decreased level of consciousness. Except for an intermittent and mild degree headache, there was no specific history of head trauma and medical illness. On neurological examination, she showed a drowsy mentality with Glasgow Coma Scale score of 14/15 and the right homonymous hemianopsia. She did not have motor/sensory and cranial nerve deficits, and cerebellar signs. There were no abnormal laboratory findings. Non-contrasted CT scan showed a heterogeneously hyperattenuated hemorrhagic mass within the third ventricle compressing the hypothalamus, without definitive hydrocephalus Figure .Right-siCHs are vascular hamartomas which are reported to be found anywhere in the CNS. However, intraventricular CHs are rare and their incidence was reported to be only about 2.5 to 10.8% of all cerebral cavernous malformations reportedOverall, 29 patients with a well-described CH in the third ventricle have been reported in the literature, including our case-20 Tabl, with a The radiological findings of the intraventricular CHs do not differ from those of the intraparenchymal type. GeneralA conservative treatment is appropriate for an asymptomatic CH located in the supratentorial parenchyma. However, CHs located in the third ventricle, surrounded by vital structures, are especially dangerous. It has also been documented that these lesions show a rapid growth, resultiSurgical excision appears to be the treatment of choice for CHs located in the third ventricle, which tend to grow rapidly and cause a mass effect. Using the short corridor to the third ventricle, obtaining wide exposure of the lesion, and minimizing resection of the surrounding hemosiderin-stained tissue can lead to a favorable surgical outcome, as demonstrated in the previous reports, including this report.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.CH: Cavernous hemangioma; CNS: Central nervous system; CT: Computed tomography; MRI: Magnetic resonance imaging.The authors declare that they have no competing interests.MSH and KSM drafted manuscript. KHL and SKL revised manuscript critically for important intellectually content. KHL and KSM helped acquisition and interpretation of data. KHL and SKL participated in reviewing literature and helped in conception and design of the study. KSM and SJ conceived the study and participated in its design and coordination. All authors read and approved the final manuscript.


Majority of patients with solitary fibrous tumours of the pleura (SFTP) are asymptomatic. Acute presentation with symptoms resulting from mass effect due to rapid expansion of tumour size has not been reported before.This report chronicles the case of a giant SFTP in a 76-year-old lady who presented with acute onset of haemoptysis, left-sided pleuritic chest pain and hoarseness of voice. Her chest radiograph showed a large left upper hemithorax mass with an ipsilateral effusion. Computed tomography (CT) scan of the thorax confirmed the presence of a pleural-based mass lesion in the left apex measuring 9.7 cm with close apposition to the aortic arch. The mass demonstrated neovascularization and there was also presence of a moderate-sized heterogeneous-appearing left pleural effusion. Thoracocentesis yielded deeply haemoserous pleural fluid with a pleural aspirate hematocrit closely approaching that of peripheral blood hematocrit and alongside a 2 unit decrease in haemoglobin, was indicative of a haemothorax. Repeat CT 10 days from initial presentation showed reduction in size of the left apical mass as well as resolution of the left effusion. This was consistent with the occurrence of an intra-tumoural bleed resulting in rapid increase in the size of the SFTP, causing rupture of superficial blood vessels on the tumour surface (haemothorax) and consequential compression of the lung parenchyma (haemoptysis) and left recurrent laryngeal nerve (hoarseness of voice). The patient eventually underwent an uneventful surgical resection.A benign SFTP can present acutely with compressive symptoms as a result of spontaneous intra-tumoural bleed causing sudden increase in its size. It is important to allow temporal regression of these acute changes before deciding on surgical resectability. Solitary fibrous tumours of the pleura (SFTP) are uncommon tumours of mesenchymal origin. Majority of patients with SFTP are asymptomatic. Haemoptysis and spontaneous haemothorax as initial manifestations are uncommon. A definitive diagnosis requires histopathological/immunohistochemical examination of tumour specimens , with th2) who was afebrile with normal blood pressure and pulse rate. Her oxyhaemoglobin saturation on pulse oximetry was normal at 95 % on room air. She had no clubbing or cervical lymphadenopathy. Examination of the lungs revealed stony dullness to percussion in the left lung base with decreased breath sounds throughout the left chest. A radiograph  with a moderately reduced diffusion capacity for carbon monoxide (DLCO) corrected for haemoglobin . Her transfer coefficient of the lung  was normal, at 80 % predicted.The patient’s pre-operative pulmonary function test was normal  in an otherwise well lady, the primary care physicians (the authors of this manuscript) decided to repeat a CT scan about 2 weeks later to reassess the extent of the tumor with regards to surgical resectability. An interval CT scan  –12. At bThe mainstay of treatment for SFTP is a complete en bloc resection of the mass , 10, 12.1 and DLCO would have been 53 and 26 % predicted. The latter value would have rendered her an unacceptable surgical risk [1 or DLCO < 60 % predicted have to undergo further physiological assessment with a cardiopulmonary exercise test (CPET) before determining surgical fitness. However, it was noted that her transfer coefficient of the lung  was normal at 80 % predicted. Her large SFTP had resulted in extrapulmonary reduction in lung inflation, causing a reduced VA. This was largely responsible for the reduction in DLCO [2 max were not required. The patient subsequently underwent excision of the pleural tumour with minimal lung resection, and had an uneventful post-operative recovery. The risk of recurrence after complete surgical resection can range from <2 % in benign SFTP to 63 % in malignant forms [There is a paucity of literature on the pre-operative pulmonary assessment of patients requiring surgery for SFTP and large pleural tumours, as existing guidelines  only descal risk , 15. Acccal risk , patient in DLCO . Hence, This case illustrates that KCO can potentially be useful in pre-operative assessment of patients with giant SFTP that results in reduced DLCO, although evidence from larger scale studies would be required to support this hypothesis. It would be very unfortunate had the patient been denied surgery, had she been deemed a high-risk candidate based on her decreased DLCO alone.This report showcases a rare manifestation of a benign SFTP with an acute increase in size due to spontaneous intra-tumoural bleeding, which in turn led to haemothorax and compressive symptoms. The simultaneous occurrence of these factors resulted in the earlier presentation of an otherwise slow-growing tumour. It is important to allow temporal regression of these acute changes before deciding on surgical resectability. This case also highlights the potential usefulness of KCO in determining a patient’s pre-operative risk for large pleural tumours that may require lung resection. If pre-operative risk was determined by reduced DLCO alone, patients who need surgery would be denied it.1, forced expiratory volume in 1 s; FVC, forced vital capacity; KCO, transfer coefficient of the lung; SFTP, solitary fibrous tumour of the pleura; VA, alveolar volumeDLCO, diffusion capacity for carbon monoxide; FEV


Epidermoid cysts are benign slow growing extra-axial tumours that insinuate between brain structures, while their occurrences in intra-axial or intradiploic locations are exceptionally rare. We present the clinical, imaging, and pathological findings in two patients with atypical epidermoid cysts. CT and MRI findings for the first case revealed an intraparenchymal epidermoid cyst that demonstrated no restricted diffusion. The second case demonstrated an aggressive epidermoid cyst that invaded into the intradiploic spaces, transverse sinus, and the calvarium. The timing of ectodermal tissue sequestration during fetal development may account for the occurrence of atypical epidermoid cysts. Epidermoid cysts are benign, slow growing extra-axial tumours that account for ~1% of all intracranial tumours . They frA 47-year-old male with good past health was admitted for a one-month history of ataxia and headache. Plain CT brain  showed aA 37-year-old male with good past health was admitted for progressive unsteady gait for six months. CT brain  showed aEpidermoid cysts can occur throughout the neuroaxis, most commonly in the cerebellopontine angles 40–50%) and the parasellar region . Convers0–50% andComputed tomographic features for the typical epidermoid cysts include a hyperdense lobulated mass without contrast enhancement , 10, a fThe radiological differential diagnoses of an epidermoid cyst include an arachnoid cyst, dermoid cyst, abscesses, metastasis, or slow growing brain tumours. FLAIR and DWI sequences  have beeCurrent debate is ongoing regarding the optimal treatment for an epidermoid cyst. On the one hand, gross total resection of epidermoid cysts offers a definite treatment with prevention of its occurrence or aseptic meningitis . ConversEpidermoids outside the typical location are exceedingly rare lesions with atypical imaging features, including reversal of the typical T1 and T2 signal, as well as a lack of restricted diffusion. In spite of their slow growth, they also can present with adjacent structure invasion that requires meticulous neurosurgical intervention.


Schwannomas are benign, well-differentiated tumors that originate from Schwann cells. Involvement of the cervical sympathetic nerve is relatively rare. Computed tomography is indispensable for the diagnosis. The treatment is surgical. Histological examination confirms the diagnosis. Horner’s syndrome postoperatively is supportive of the diagnosis. The rarity of giant cervical sympathetic chain schwannoma made the case of our patient interesting to report. Furthermore, our patient’s immense tumor size is very rare, and we could not find any similar report in the literature. Cervical sympathetic chain schwannoma is frequently confused with schwannoma of the vagus nerve on clinical and radiological examination, and its diagnosis can therefore be challenging for clinicians, radiologists, and pathologists.We report a rare case of cervical schwannoma in a 40-year-old Moroccan woman who presented with a large parapharyngeal mass. Computed tomography revealed a giant, heterogeneous, well-defined mass measuring 110 × 100 × 147 mm, occupying the right carotid triangle, and descending to the superior mediastinum. Surgical excision with a transcervical approach was done. Histological examination confirmed the diagnosis. The patient’s postoperative course was marked by Horner’s syndrome.Cervical sympathetic chain schwannoma is a rare, benign tumor. It should be considered in the differential diagnosis in patients presenting with a lateral neck mass. Surgical exploration must be discussed for a tumor with a large volume. Schwannoma is a benign mesenchymal tumor exclusively developed from Schwann cells surrounding the peripheral nerve sheath. Schwannomas are found in 25–45 % of cases in the cervical area, mostly the vagus nerve. Schwannomas arising from the cervical sympathetic chain are very rare . The treWe report a case of a 40-year-old Moroccan woman who consulted our hospital for immense swelling in the right neck area of 2 years’ duration and slowly increasing in size. She had no personal or family history of malignancy. She had slight dysphagia and dyspnea. She had no dysphonia, fever, syncopal attacks, compression complaints, or nasopharyngeal discomfort.The patient’s physical examination revealed unusual swelling measuring approximately 10 × 10 cm in the right carotid triangle . Surgical excision was done using a transcervical approach with the patient under general anesthesia. A large tumor was found deep to the sternocleidomastoid muscle. It was separated from the surrounding structures by blunt dissection using a finger. The carotid artery and the internal jugular vein were displaced anteriorly but were not compressed. The mass appeared to have developed from the cervical sympathetic chain and not the vagus nerve. The mass was removed completely with difficulty after sacrificing some nerve fiber Fig. .Fig. 4ThAfter the operation, the patient was transferred to the intensive care unit. During the first day, a partial, well-tolerated Horner’s syndrome was observed, and the patient was treated with corticosteroids. No significant bleeding was seen. On the third day after surgery, the patient was found to have a rhythm disorder (arrhythmia). Her histopathological report showed a benign Antoni type A schwannoma originating from the cervical sympathetic chain Fig. .Fig. 5HiIn 1899, Ritter reported the first observation of cervical schwannoma . This paCervical schwannomas usually occur between 20 and 70 years of age in both sexes . The cliRadiological investigation is required for better management. Computed tomography allows determination of tumor size and extent to the parapharyngeal area, the degree of tumor vascularity, and the relationship of the tumor with the jugular vein and the carotid artery . When thThe differential diagnosis includes lymph nodes, congenital cysts, paragangliomas of the vagus nerve, and carotid body tumors . Fine-neSurgery is the treatment of choice for schwannomas. During surgery, we found that our patient’s lesion was positioned eccentrically to the nerve. Complete surgical removal of the mass, without sacrificing nerve fiber, is better and is possible only when the capsule is easily separable from the underlying fibers , 8. In oHistological examination revealed that our patient’s tumor was encapsulated. Two microscopic patterns of schwannoma exist: Antoni A and Antoni B. Antoni type A is characterized by broad, interlacing ribbons of extended spindle cells with elongated nuclei arranged in waves, drifts, and whorls. Antoni type B is characterized by hypocellularity with a large quantity of myxoid tissue. In immunohistochemical analysis, S100 protein is positive in all schwannomas and neurofibromas . In our Our patient’s case illustrates that, although cervical sympathetic chain schwannoma is relatively rare, it should be considered in the differential diagnosis of benign and malignant lesions. In all cases, the patient should be advised of the occurrence of postoperative Horner’s syndrome, for which there is no effective treatment. The rarity of giant schwannoma makes our case interesting to report.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.


A 21-year-old carpenter received a blow to the left side of the head during a rugby match but sustained no wound or loss of consciousness. Three months later, he developed a mass on the left temple that expanded in size particularly after exercise and in warm environments .Enter questions here; press return to add another question. Each Interesting case must have 4 questions.Describe the anatomical course of the superficial temporal artery (STA)?What features in the history and examination would guide your diagnosis of aneurysm?Describe the pathophysiology of a post traumatic aneurysm of the STA?What is the management of an STA aneurysm?The STA has a fairly long and arduous anatomical course after its origin from the external carotid artery at the inferior pole of the parotid gland.A review of the literature identifies that diagnosis is largely based in most of the cases on effective patient history that reveals a recent episode of blunt, or possibly penetrating, trauma to the head. Furthermore, possibly more probing, questioning usually allows the patient to reveal or recall the incident between 2 to 6 weeks previously. Although the lesion itself is painless on examination, patients may incidentally report an associated headache since injury. This is followed by clinical examination, in uncomplicated cases, with particular attention to examine the mass in detail, noting size, consistency, adherence to underlying structures as traditionally taught. Experience and correlation with previous literature reports find that the common presentation is of a nonfluctuant, painless, solitary, expansile mass in the temporal and pterional region of the skull.Typically the hematoma formed after injury to the vessel hardens and undergoes fibrosis forming a hard fibrotic capsule. This can often completely occlude the vessel lumen. Resultant luminal thrombosis and lysis allow recanalization.,3,Although much aneurysmal disease often requires fast and immediate treatment, patients suffering from an STA aneurysm can often be brought back for elective surgery and treatment. The risk of local tissue necrosis, damage to local organs (the vestibular center), and possible nerve injury mean that intervention is preferred to prevent serious long-term complications.1Superficial temporal artery aneurysm is a classic example where thorough history and careful examination can provide an accurate diagnosis without expensive or invasive imaging and investigation. It is a condition plastic surgeons should be aware of and capable of managing when similar cases present.