Mesenchymal chondrosarcoma (MCS) is a rare malignant variant of chondrosarcoma with a high tendency of recurrence and metastasis. Intradural extramedullary spinal MCS is exceedingly rare and usually found in pediatric patients. Herein, we present an elderly patient with primary intradural extramedullary spinal MCS. Relevant literatures are reviewed to disclose characteristics of intradural extramedullary spinal MCS.HEY1-NCOA2 fusion transcript, the diagnosis of MCS was confirmed. Neurologic deficit recovered nearly completely after surgery. No evidence of local recurrence or distant metastasis was found 5 years after treatments. Including the current case, a total of 18 cases have been reported in the literature with only one case with local recurrence and one case of mortality. The current case was the eldest patient diagnosed with primary intraspinal MCS in the literature.A 64-year-old female presented with urinary difficulty and tightness of upper back preceding progressive weakness of right lower extremity. Magnetic resonance imaging revealed an intradural extramedullary tumor at the level of 3rd thoracic vertebra. This patient underwent total tumor resection and then received adjuvant radiotherapy. Histopathological examination showed that the tumor composed of spindle and round cells with high nucleocytoplasmic ratio accompanied by scattered eosinophilic chondroid matrix. Along with immunohistochemical findings and the existence of MCS rarely appears in the intradural space of the spine. In contrast to classic MCS, treatment outcome of primary intradural extramedullary spinal MCS is usually excellent as total tumor resection is commonly achievable. Adjuvant radiotherapy may reduce local recurrence and chemotherapy may be associated with fewer recurrences especially for unresectable tumors.The online version of this article (10.1186/s12891-019-2799-2) contains supplementary material, which is available to authorized users. HEY1-NCOA2, has been identified and adopted to confirm the diagnosis of MCS [Mesenchymal chondrosarcoma (MCS) is a rare malignant variant of chondrosarcoma whose incidence accounts for 0.2–0.7% of all malignant bone tumors or 3–10% of chondrosarcoma [s of MCS . MCS is A 64-year-old woman initially experienced urinary difficulty and felt tightness at upper back. Weakness of right lower extremity developed 2 months later and rapidly progressed to inability of ambulation in following 2 weeks. She visited authors’ institute with presentation of monoplegia of right lower extremity and asymmetrically decreased response to light touch and pain below nipples, more prominent on the left side. Hyper-reflexia and positive Babinski sign at bilateral lower extremities were also noted. The results of routine blood tests were unremarkable and the patient had no family history of cancer or genetic disease. As the clinical manifestation was compatible with Brown-Séquard syndrome, a compressive lesion to spinal cord at the thoracic spine was suspected. Magnetic resonance imaging (MRI) revealed an intradural extramedullary mass at the level of 3rd thoracic (T3) vertebra with severe compression to the spinal cord Fig. . The tumen bloc after detached from dura mater. Posterior instrumentation and fusion were performed to prevent post-laminectomy kyphosis.The patient received surgical treatment for removal of the tumor mass on the next day after MRI study. During the surgery, the posterior surface of dural sac was exposed after total laminectomy from T2 to T4 vertebrae and then the intradural space was accessed through longitudinal opening of the dura mater. Grossly, the tumor sized 2 × 1.5 × 1.5 cm and was firm, reddish, lobulated, and hypervascular. The mass was attached to the inner surface of dura mater with no involvement of arachnoid or spinal cord. The tumor was removed HEY1-NCOA2 fusion transcript


A mucocele is the most common minor salivary gland disease and among the most common biopsied oral lesions in pediatric patients. Clinically, a mucocele appears as a round well-circumscribed painless swelling ranging from deep blue to mucosa alike in color. Mucoceles rarely resolve on their own and surgical removal under local anesthesia is required in most cases. Different treatment options are described in the literature, including cryosurgery, intra-lesion injection of corticosteroid, micro-marsupialization and conventional surgical removal using a scalpel, and laser ablation. Therefore, the goal of this paper was to report three cases of mucocele removal in pediatric patients using a diode laser with a one-month follow-up. Mucoceles were removed by a pediatric dentist using a diode laser with a wavelength of 930 nm in continuous mode and a power setting of 1.8 Watts. In all cases, no bleeding occurred during or after the procedure and there was no need for suturing. On clinical examination during the one-month follow-up, in all three cases there was minimal or no scarring, minimal post-operative discomfort or pain, and no recurrence. Diode lasers provide an effective, rapid, simple, bloodless and well accepted procedure for treating mucocele in pediatric patients. Minimal post-operative discomfort and scarring was reported by all the three patients. A mucocele is considered the most common minor salivary gland disease  and amonBased on etiology, mucoceles are classified as retention and extravasation mucoceles ,4,6. ExtMucoceles rarely resolve on their own and surgical removal is required in most cases ,5,9, whiThe conventional surgical removal of mucoceles using a scalpel is considered the most common option and requires complete resection of the mucocele and the neighboring glands before closure to decrease the risk of relapse . Only liCase 1: An eight-year-old, healthy, African-American female patient presented with her mother at the department of Pediatric Dentistry at Tufts University School of Dental Medicine (TUSDM) complaining of asymptomatic swelling in the labial mucosa of her lower lips. No significant medical history or known allergies were reported. Examination revealed a 0.70 cm silver blue, translucent swelling opposite the right mandibular canine. The mother reported that the swelling started four months before and changed episodically in size and color. They denied any previous trauma or habit of lip biting  . First, a topical Benzocaine gel 20% anesthetic gel  was applied for 2 min, followed by infiltration around the periphery of the lesion with Lidocaine 2% with 1:100,000 epinephrine . Following the manufacturer’s instructions, the fiber tip was moved across a piece of articulating paper with the unit set to one W to accomplish the initiation of the fiber to become a useful hot-tip-thermal 600 °C contact device . The patient, operating pediatric dentist, and the assistant all wore safety laser-specific eye wear during the procedure. The staff also wore laser plume safety masks. After the initiation, mucocele excision was performed by separating the lesion and its associated minor salivary gland from the adjacent mucosa A tissue holding forceps was used to retract the mucocele tissue to one side carefully with laser beam parallel to the long axis of the tissue to avoid damaging the adjacent tissues.Intermittently, water cooling with water-moistened gauze was used to control tissue temperature and to remove any tissue debris and char adhering to the hot fiber tip. High speed air suction of the tissue plume and air cooling over the treatment site was also employed. There was no bleeding during or after the procedure in any of the cases and the wounds were left open without suture. No antibiotics or anti-inflammatory analgesics were prescribed. The excised lesions were placed in water for two minutes and then were stored in 10% formalin and sent to the Department of Oral Pathology at TUSDM. The results confirmed the initial diagnosis.All patients were advised not to consume hot, spicy food for a day and to rinse with normal saline mouthwash three times daily for the following five days. The patient with a history of lip biting was advised not to bite his lower lip. Parents were instructed to come for follow-up visits two weeks and one month after the procedure. The parents were contacted by phone the same day and two days after the procedure to evaluate the post-operative discomfort and pain felt by the patient. At the one-month follow-up, examination revealed minimal or no scarring and no recurrence in all cases; all patients reported minimal post-operative discomfort and pain and none of them required post-operative pain medication.Microscopic examination revealed a soft tissue lesion covered by a stratified mucous epithelium. The lamina propria consisted of fibrous connective tissue that was replaced focally by a superficial pool of mucin and surrounded by a granulation tissue wall. Bolus of minor salivary gland with chronic inflammation and dilated duct was also reported in the specimen from the third case. The histologic diagnosis confirmed the initial diagnosis of extravasation mucocele. 2) [This paper reports the removal of three cases of mucoceles in pediatric patients using diode laser with a one-month follow-up Laser ablation ,15,16 is2) ,8,16, er2)  and diod2) ,20,21.The laser diode was first introduced in dentistry in the mid 1990s. It is manufactured from semiconductor crystals with a short-wave length  and works by transmitting photo-thermal energy to cells it contacts that causes an increase in temperature, protein denaturation, vaporization, and carbonization ,22. A di2 laser [Small, inexpensive, portable machines are considered among the advantages of a diode laser by comparison to other lasers . A diode2 laser . Therefo2 laser ,25. Mucocele removal with laser provides rapid, bloodless procedure, with minimal if not bleeding, swelling, scaring and post-operative discomfort ,16,17,18At the one-month follow-up, clinical examination revealed no scar formation and all patients reported minimal post-operative discomfort and pain. These results coincide with the findings in previous case reports ,20. In 2Diode lasers can be used on pediatric patients to remove mucocles. It provides an effective, rapid, simple, bloodless and well-accepted procedure for treating mucocele in pediatric patients. In addition, minimal post-operative discomfort and scarring were reported by all the cases presented.


Despite being among the common primary intracranial tumors, intraosseous craniofacial meningioma is the least common subtype of meningioma accounting for only 1-2% of intracranial meningiomas. Interestingly, it can display clinical and radiologic features that can be confused for fibrous dysplasia. Scan imaging and biopsy are crucial for the diagnosis as well as for further proper treatment. We report a case of unilateral eye proptosis and optic neuropathy which was initially thought for fibrous dysplasia. Later the histopathology revealed meningioma grade 1. As the clinical presentations are almost undifferentiated, diagnosis and further prompt treatment are challenging. Meningioma is a benign, neoplastic lesion which originates from arachnoid cells. It constitutes the most common tumor of the skull, with an incidence of 2.3/100,000 [A 48-year-old lady with underlying controlled hypertension presented to our eye clinic with the complaint of gradual protrusion of the left eye for the eight months which worsened in the past month. It is painless, but she experienced intermittent redness of the eye. Otherwise, there is no history of trauma and no reduced vision. Systemically it was unremarkable.Visual acuity in the right eye was 6/7.5, and the left eye was 6/9. There was a presence of left relative afferent pupillary defect. Mild restriction in all directions of gaze was seen on the left side, as well as a relative proptosis of five millimeters as compared to the right eye Figure .Optic nerve function tests and anterior segments were normal in both eyes. The intraocular pressure was normal. Fundoscopy of the left eye showed swelling of optic disc with tortuous and dilated vessels Figure .There was no peripapillary haemorrhages or choroidal folds. The macula was normal, and the retina was flat. The right eye fundus was normal. Humphrey visual field demonstrated a left eye inferior field defect. Other neurological examinations were normal.CT scan of the brain revealed the presence of an expansile osteoblastic bony lesion involving the left greater wing of sphenoid and left zygomatic arch Figure .The bony lesion showed ground glass appearance with an area of irregular surface. It also associated with enhancing soft tissue mass. The lesion caused mass effect, pushing the orbit and its content anteriorly. At the same time, there was also another well-defined homogenously enhancing lobulated right sellar mass with extension into right parasellar region. On MRI, the lesion followed grey matter intensity on T1 and T2 weighted images and vividly enhanced post-contrast, suggesting meningioma Figure .Later she developed compressive optic neuropathy with worsening of vision, diplopia, and impaired optic nerve function test. She agreed for medical and surgical decompression. Intravenous methylprednisolone was given 1 g per day for three days before proceeding with the endoscopic orbital and optic nerve decompression and incisional biopsy. Another course of methylprednisolone was given 1 g per day for three days post-operatively. Subsequently, her symptoms improved well. HPE revealed benign meningioma with WHO grade 1.Our patient presented with unilateral gradual exophthalmos, swollen optic disc, and later worsened with optic nerve decompression. Initial presentation is compatible with either CFD or meningioma; however, the initial scan is evocative of the CFD.CFD is a benign condition where the fibrous tissue and woven bone replace the normal bone and marrow. The most common locations are the craniofacial bones, rib, and proximal femur, which the craniofacial region, particularly the anterior cranial base, is involved in over 90% of cases . It usuaContrarily, while meningiomas represent almost 15% of all brain tumors .Intraosseous meningioma (IM) may show osteoblastic, osteolytic, or mixed appearance on CT scan. While slightly less commonly encountered, osteolytic IM lesion is usually associated with intraosseous mass and is more likely to be malignant meningioma . CommonlAs the optic foramen is gradually narrowed, compression of the optic nerve is inevitable. Therefore, it is strongly recommended to decompress the optic canal in all involved cases to at least preventing more significant loss of vision . In advaEven with the typical presentation of fibrous dysplasia, a high level of suspicion for intraosseous meningioma is crucial, especially in regards to the sphenoid bone mass. This is to ensure early diagnosis, and further prompt treatment emerges. Biopsy and optic nerve decompression are vital nearly in all cases, and further radical resection is essential to prevent a recurrence.


Primary pancreatic tumours are a rare and unusual entity in children. In this article, we present the case of an 8-month-old girl who presented with obstructive jaundice. The differential diagnosis based on imaging studies was that of a pancreatic vascular neoplasm; however, with the laboratory evidence of Kasabach–Merritt phenomenon (KMP), this prompted the diagnosis of pancreatic kaposiform hemangioendothelioma. A core biopsy of the pancreatic mass was taken at laparotomy and confirmed this diagnosis. The pancreas is an exceedingly rare site of occurrence for this tumour, with only nine cases being published to date. The clinical, biochemical, imaging and pathological findings are discussed to highlight a rare and potentially life-threatening vascular tumour. Serology revealed elevated liver ductal and transaminase enzymes with conjugated hyperbilirubinaemia, normocytic anaemia, thrombocytopenia and coagulation abnormalities. The liver function test results were as follows: total bilirubin 92 µmol/L , conjugated bilirubin 86 µmol/L , gamma-glutamyltransferase (GGT) 967 U/L , alkaline phosphatase (ALP) 1117 U/L , alanine transaminase (ALT) 134 U/L  and aspartate transaminase (AST) 99 U/L . The haemoglobin level was 9.0 g/dL , mean corpuscular volume (MCV) 84.4 fl  and platelets 21 ×10The abdominal ultrasound (US) demonstrated a bulky, homogeneous, soft tissue mass in the head of the pancreas that was isoechoeic to the remainder of the pancreatic gland, with associated findings of dilated intrahepatic bile ducts and ascites. Internal flow was demonstrated within this lesion on colour flow Doppler assessment.This was followed by a computed tomography (CT) scan of the abdomen and pelvis with an intravenous and oral contrast agent. Computed tomography imaging showed an ill-defined, enhancing mass in the head of the pancreas –3, with The parents of the child decided to use a traditional healer, which delayed the magnetic resonance imaging (MRI) of the abdomen by 2 months. The MRI abdomen demonstrated a pancreatic mass of poorly defined margins that had progressively enlarged and extended across tissue planes  and b. TThe differential diagnosis based on the imaging studies was that of a pancreatic vascular neoplasm; however, with the laboratory evidence of Kasabach–Merritt phenomenon (KMP), this prompted the diagnosis of a pancreatic KHE. Given the large size and peripancreatic extension of this lesion, a differential diagnosis of pancreaticoblastoma was considered; however, these lesions are typically heterogeneous in appearance with both cystic and solid components and often have calcifications.After correction of the patient’s thrombocytopenia, an open biopsy of the pancreatic mass was taken at laparotomy. Macroscopy of the specimen demonstrated a dark brown wedge of tissue measuring 10 mm × 5 mm× 6 mm. Microscopy  showed rAlthough the ascites had improved, the jaundice and thrombocytopenia had become progressively worse. The patient was treated with interferon alpha but subsequently demised.1 This is secondary to the activation and aggregation of platelets, which results in thrombocytopenia, consumption of fibrinogen and ongoing fibrinolysis, which ultimately leads to tumour enlargement with intralesional bleeding. Kasabach–Merritt phenomenon is typically associated with larger, more aggressive lesions and there are currently no specific criteria to risk-stratify patients with regard to the occurrence or recurrence of KMP.3 Cutaneous lesions with a maximal diameter greater than 8 cm, or lesions with involvement of the retroperitoneum or visceral organs, have been implicated as risk factors.3 Despite KMP traditionally being described as thrombocytopenia or coagulopathy associated with any vascular anomaly, it is not a complication of infantile or congenital haemangioma and is a common occurrence with KHE.5In approximately 70% of cases, KHE may be complicated by KMP, a life-threatening complication characterised by profound thrombocytopenia and consumptive coagulopathy.6 This together with laboratory evidence of KMP may assist in the differentiation between these two entities.Haemangiomas may appear similar to KHE on imaging, except for the more aggressive and locally invasive nature of this lesion.6 All previously reported cases described a mass in the head of the pancreas, as in this case report.6 Although the possibility of a vascular tumour could be suggested on US, a more specific diagnosis cannot be made because of the limitations in demonstrating the infiltrative portions and exact extent of KHE. Computed tomography and MRI together with magnetic resonance cholangiopancreatography (MRCP) are of added value in localising the mass, assessing the tumour extent and giving information of any associated findings such as dilation of the pancreatic and biliary ducts, duodenal obstruction and ascites. Leung et al. presented a case of a pancreatic KHE presenting with neonatal duodenal obstruction.1On ultrasound, KHE appears as a homogeneous, ill-defined, soft tissue mass, which may be isoechoeic or hyperechoic compared to the pancreas, with associated mild to marked increased vascularity on colour Doppler.2 MRI findings typically show a lobulated, invasive mass with increased signal intensity on T2WI and avid enhancement following intravenous gadolinium.6 Ryu et al. reported 12 cases of pathologically proven KHE across the body, with lesions demonstrating heterogeneous regions of isointensity or mild hyperintensity on T2 weighted imaging (T2WI) and heterogeneous enhancement post-contrast administration.2 Regions of low signal on T2WI are likely secondary to hemosiderin deposition and dense hyaline stromal responses.2 The heterogeneous enhancement was likely associated with the pathological nature of vascular channels and thin-walled lymphatic vessels in KHE.2The infiltrative nature of these lesions has been reported as a unique characteristic of KHE, assisting in differentiating this from other vascular tumours, with the exception of angiosarcomas.6 Medical therapies for KHE and KMP include systemic steroids, vincristine, inteferon-alpha and aspirin.7 In cases with associated biliary obstruction, complete surgical resection with a Whipple operation has been reported and there have also been successful attempts at biliary stenting and external drainage , pending spontaneous tumour regression.6 Historically, angiography and embolisation have been used for the diagnosis and treatment of KHE.8 These procedures are currently primarily used as an adjunct to planned surgical resection to minimise bleeding intra-operatively.8The treatment of pancreatic KHE is variable and depends on associated vascular invasion, extent of the mass and the degree of biliary obstruction.7 Triana et al. described a case of pancreatic KHE not responding to sirolimus and suggested the possibility of a different molecular profile compared to the cutaneous form as a result of the resistance to mTOR inhibitors treatment.7Mammalian target of rapamycin (mTOR) inhibitors such as sirolimus have proven to be effective in the treatment of cutaneous KHE.Pancreatic KHE is an exceedingly rare vascular tumour that mostly occurs during infancy and early childhood. KHE may be misdiagnosed on imaging as a congenital or infantile haemangioma; however, the infiltrative pattern of KHE with its ill-defined margins and extension across tissue planes is a unique feature of KHE and may assist in the differentiation. The presence of KMP is useful in supporting the specific diagnosis. Despite KMP traditionally being described as thrombocytopenia or coagulopathy associated with any vascular anomaly, it is not a complication of infantile or congenital haemangioma. Although imaging modalities such as CT and MRI may assist in delineating this lesion, the formation of a clear pre-operative diagnosis remains difficult and early surgical exploration and rapid frozen biopsy are recommended. Pancreatic vascular malformations are best managed in a multidisciplinary setting with extensive experience in the treatment of vascular anomalies, as the treatment differs based on the size, location, associations and complications.


Surgical removal of a giant mediastinal lipoma or liposarcoma involving both chest cavities is always challenging.We present 2 cases of giant mediastinal tumor, one of which was a 22-year-old female who was admitted to our hospital due to a mild dyspnea after running. Computed tomography (CT) scan revealed a large mass with low density occupying the entire right hemithorax and extending anteriorly into the left. The other patient was a 43-year-old male, who was presented to the hospital with complaints of gradually progressive dyspnea. CT scan revealed a mass comprised of fat density with areas of soft-tissue density in-between, involving in both chest cavities, draping around the heart and great vessels.Both of the patients receive complete resection through a standard median sternotomy.Histologic examination revealed lipoma for the first patient, and well differentiated liposarcoma for the second.Both of their symptoms were improved after surgery and the postoperative courses were good.Our experience indicated that complete surgical removal through a standard median sternotomy is a safe and efficient approach for the treatment of giant mediastinal lipoma and liposarcoma. Nevertheless, the management of a very huge mediastinal tumor involving both chest cavities is always challenging.–6 Herein, we present our experiences on the surgical management of 2 cases of giant mediastinal tumors, one of which was lipoma and the other one was liposarcoma.Lipomas are very common benign neoplastic mesenchymal tumors arising from adipose tissue, while liposarcomas are the most common soft-tissue sarcomas in adult.2The 1st patient was a 22-year-old female, who was admitted to our hospital with complaint of a mild dyspnea after running. The patient had no history of cough, loss of weight, hemoptysis, or other constitutional symptoms. Physical examination showed the right lung field was dull to percussion with decreased breath sounds on auscultation. Chest computed tomographic (CT) scan revealed a large mass with low density occupying the entire right hemithorax and extending anteriorly into the left hemithorax, causing mediastinal shift and lung collapse , indicating that VATS surgery may not be a good approach for the removal of malignant tumors of the mediastinum. Huang and Jiang reported complete removal of a giant mediastinal liposarcoma using a “ shape” incision, indicting this kind of incision is a good backup for the extension of standard median sternotomy and provides a better exposure for both mediastinum and hemithorax.Berry et al and Klimstra et al reported that the average size of liposarcoma was 15.7 cm, ranging from 6 to 40 cm, and the average weight was 1.5 kg. Such giant mass usually compress the intrathoracic organs, such as the heart, pericardium, great vessels, the lung, esophagus, and superior vena cava, causing life-threaten conditions.For our 2 patients, extended surgical removals were performed through a sternotomy to allow complete access to both chest cavities and the mediastinum. With sufficient exposure, both of the giant mediastinal tumors could be easily and completely removed. The postoperative courses were good. Our experiences on these 2 cases suggest that complete surgical resection through a standard median sternotomy is a safe and efficient approach for the treatment of giant mediastinal lipoma and liposarcoma.Conceptualization: Chen Chen, Yunchang Yuan.Data curation: Wenliang Liu.Formal analysis: Wenliang Liu.Investigation: Chen Chen, Mingjiu Chen.Methodology: Yunchang Yuan.Resources: Yunchang Yuan.Writing – original draft: Chen Chen.Writing – review & editing: Fenglei Yu.


Gossypiboma is an iatrogenic granuloma caused by retained surgical gauze. A 48-year-old woman with a history of cesarean section was incidentally found to have a pelvic mass on preoperative computed tomography examination for pectus excavatum. Abdominal enhanced computed tomography showed a 40-mm mass containing air in the pelvis. The mass was suspected to be continuous with the ileum. Transanal double-balloon enteroscopy showed a small fistula that was likely caused by penetration of the ileum dozens of centimeters from the ileocecal valve. A yellow–brown, movable, and fibrous body was found in the fistula. A part of the fibrous body was extracted with forceps. Pathological examination revealed that it was gauze. This is the first reported case of an asymptomatic gossypiboma penetrating the ileum that was diagnosed with double-balloon enteroscopy. Our results suggest that double-balloon enteroscopy is useful for early diagnosis of pelvic mass penetrating intestine, including gossypiboma. Gossypiboma is an iatrogenic granuloma caused by retained surgical gauze. The term gossypiboma originates from the Latin word “gossypium”, which means “cotton”, and the Swahiri word “boma”, which means “place of concealment ”. The te2. The white blood cell count was 3600/μL; hemoglobin level, 13.5 g/dL; and CRP level, 0.02 mg/dL. A blood test for tumor markers including carcinoembryonic antigen, CA19-9, and CA125 showed negative results. Abdominal plain radiography showed no remarkable findings. Abdominal enhanced CT  as a screening before surgery for pectus excavatum, and was incidentally found to have a pelvic mass. She was examined by a local gynecologist but showed no remarkable findings and was then referred to our hospital for further investigation of the pelvic tumor. Her height was 169.0 cm; body weight, 52.7 kg; and BMI, 18.5 kg/mRetained surgical gauze induces two types of responses in the body: exudative and aseptic fibrinous responses. Exudative response is characterized by fever and pain in the early postoperative period and progression to a serious condition with formation of abscess and fistula. Aseptic fibrinous response is characterized by adhesion to the surrounding tissue (without causing inflammation), encapsulation, organization, and subsequent formation of a granuloma . An asepShe was then referred to the university hospital, which belonged to the same group of hospitals as the one in which she had undergone a caesarean section. She underwent surgery at the university hospital to remove the retained gauze. We tried to obtain the surgical records and pathology reports to gain information about the nature of the lesion. However, these data were not made available due to medical concerns. Gawenda et al. found that the frequency of leaving instruments and foreign bodies in the abdomen ranged from 1 in 8801 operations to 1 in 18,760 operations . In our In the present case, we were able to diagnose the pelvic mass as a gossypiboma penetrating the ileum, using double-balloon enteroscopy, when it was still asymptomatic. Our results suggest that double-balloon enteroscopy is useful for early diagnosis of pelvic foreign-body granuloma penetrating intestine, including gossypiboma in patients with a history of abdominal surgery and presenting with a pelvic mass whose imaging diagnosis was difficult.


Ossifying fibroma is a rare benign bone neoplasm common in middle age, with definite female predominance. Here, we describe a case of an ossifying fibroma in a 36-year-old female, with a right facial deformity. The lesion had been present for almost 10 years. The panoramic image showed a multilocular appearance with scattered radiopacities. Advanced imaging revealed an expansile multilocular lesion with multiple small radiopaque foci and a few dense radiopaque masses. A histopathological examination confirmed the diagnosis. The case represents a non-aggressive form of an immature ossifying fibroma. Cemento-ossifying fibroma (COF) is classified as, and behaves like, a benign bone neoplasm. It is often considered a type of fibro-osseous lesion (FOL) . These FFibro-osseous lesions are benign lesions of a heterogeneous group with an unknown etiology, affecting the maxilla, mandible, and other craniofacial bones . LesionsThe COF presents radiographically as a well-defined, either unilocular or multilocular lesion with smooth contours . The degIn the past, COF lesions were classified as two separate entities, depending on the type of internal content. When the predominant calcified material was bone, the term ossifying fibroma was used. With predominantly cementum-like material, the term cementifying fibroma was used -7. They A 36-year-old female presented to the oral diagnosis clinic at Ain Shams University's dental school for the evaluation of a swelling in the lower right quadrant. The patient reported the swelling to be of 10 years' duration with a progressive course during the last year. The patient reported some pain and difficulty during mastication. There was a history of surgical biopsy several years ago, but a biopsy report was not available.An extraoral examination revealed right facial asymmetry with normal overlying skin Figure . SubmandA massive buccolingual expansion of the lesion was noted, possibly crossing the midline. The lesion was tender. There was no associated tooth mobility. However, drifting and displacement were noticed Figure . The relThe panoramic radiograph  showed an expansile multilocular radiolucent lesion involving the mandible. The lesion extended from the lower-right second molar to the contralateral second premolar crossing the midline. The borders were well demarcated and sclerotic. Superiorly, the lesion extended to the alveolar crest, causing expansion. Inferiorly, it spread to the inferior border, causing displacement. Extreme thinning and bowing of the inferior cortex of the mandible was evident but contained an intact cortex. The inferior alveolar canal on the right side appeared to be displaced inferiorly. The divergence of the roots of the related teeth showed a loss of the lamina dura, as well as evidence of slight root resorption in the lower right canine. Multiple radiopaque masses with density compared to that of bone were seen within the lesion , using Scanora 3D  with 3.5 mm slice thickness, revealed a lesion measuring 45.9 mm x71 mm. The CBCT images showed massive buccolingual expansion with extreme thinning of the cortical plates. The internal structure showed a multilocular appearance with fine septa. Some slices showed fine granular radiopaque foci, while others showed dense radiopaque masses. Although evidence of expansion was noted all over the lesion, the cortical plates appeared to be intact with no perforation , calcifying epithelial odontogenic tumor, central giant cell granuloma, and adenomatoid odontogenic tumor. The well-defined border of the central cemento-ossifying fibroma helps to differentiate it from the aggressive mixed lesions as chondrosarcoma, osteosarcoma and metastatic malignant lesions ,8.Aspiration biopsy was negative. An open bone biopsy was performed via the intraoral approach, and multiple soft tissue and bone fragments were removed and submitted in 10% formalin for histological evaluation.The microscopic examination showed a highly cellular fibrovascular lesion with spindle fibroblasts forming a whorled pattern. Irregular bone trabeculae with osteoblastic rimming, dystrophic calcifications, and areas of cementum-like tissue were also noted Figure . No signHere, we report a case of COF with a long-standing history of 10 years. Fibro-osseous lesions are a heterogeneous group of benign lesions of unknown etiology affecting the jaws and other cranial bones. Lesions in this category include fibrous dysplasia (FD), cemento-osseous dysplasia (COD), and cemento-ossifying fibroma (COF) .In 1992, WHO classified COF as a true bone neoplasm, and the term cemento-ossifying fibroma was replaced by ossifying fibroma in the WHO classification of 2005 .It’s been previously suggested that the origin of this tumor is either odontogenic or from the periodontal ligament. However, identical neoplasms with the cementum-like material have been identified in the orbital, frontal, ethmoid, and sphenoid bones. This negates the previous theories .Ossifying fibromas (OF) are more frequent in females than in males, with a female-to-male ratio as high as 5:1 . AlthougThe above features were very consistent with our case. The patient suffered from facial deformity and gave a history of a slowly growing mass over a period of 10 years. The patient also reported some pain during mastication. The lesion caused tooth displacement without affecting their vitality, and the overlying mucosa remained intact.The radiological features are variable depending on the stage of development. According to Eversole, two basic patterns of ossifying fibroma may be encountered: (1) The more prevalent unilocular radiolucency with or without radiopaque foci and (2) the multilocular radiolucent configuration . In the The presented case showed a multilocular appearance with an internal structure varying from small radiopaque foci that were seen in the cross-sectional images. CBCT images revealed large dense radiopaque masses, which were evident in both a panoramic radiograph and CBCT. The multilocular configuration wasn’t widespread for ossifying fibroma. Although the lesion has been present for almost 10 years, it doesn’t appear in the mature form, i.e., a completely radiopaque mass surrounded with a radiolucent periphery. Thus, this case could be considered an immature form of an ossifying fibroma.Regardless of the stage of development, the lesion is always well-circumscribed and well-demarcated. In this case, the radiographic borders of the tumor appeared to be relatively smooth, well-defined, and mostly corticated. Some areas of the lesion showed bone sclerosis. A marked expansion, displacement of the inferior alveolar canal downwards, and the bowing of the inferior cortex of the mandible were seen in the panoramic radiograph. These features characterize ossifying fibroma ,8. In thThe radiologic differentiation of a central ossifying fibroma is challenging; however, it was included here in the differential diagnosis because of the characteristic centrifugal growth pattern. The final diagnosis was confirmed by the histologic appearance. In fibrous dysplasia, an intimate continuity is found between the lesion and the adjacent normal bone. The tumor expands throughout its length, and the margins are diffuse and radiographically poorly defined. Its radiological structure is more homogenous than that of ossifying fibroma, both of which appear with internal radiopacities. Ossifying fibroma is a well-circumscribed tumor that grows expansively, its boundaries are better defined, and these lesions occasionally have a soft tissue capsule and cortex -4. The dHistopathologically, ossifying fibroma consists of fibrous tissue that exhibits varying degrees of cellularity and contains mineralized material. The hard tissue portion may be in the form of trabeculae of osteoid and bone or basophilic poorly cellular spherules that resemble cementum . Here, tIt is generally claimed that ossifying fibromas are lesions that are well-separated from the adjacent cancellous bone. They are encapsulated lesions that help to separate them from the surrounding bony bed and tend to be removed with ease during surgical treatment ,14.These lesions are treated by radical resection or conservatively by local excision with curettage. Most lesions are treated by enucleation, and recurrence is low. Slootweg and Müller suggested that there were no differences between the cases that have limited surgical treatment and those with significant surgery with respect to results, and they recommended conservative surgery. Sweet et al., however, did report a recurrence rate of almost 25% for maxillary lesions, but some of these may have been examples of juvenile active ossifying fibromas, which are more aggressive than ossifying fibroma -16. TherFibro-osseous lesions are benign lesions of a heterogeneous group with a broad spectrum of clinical, radiographic features. COF lesions can be very slow growing. Symptoms are often gradual and long-standing in some cases. Follow-up is required for these cases.


We present a rare case of follow-up by neuroimaging in a 57-year-old man with a previous pneumoencephalography to evaluate ventricular tuberculosis (TB). Magnetic resonance imaging (MRI) of the whole head was performed at 3T using T1‐weighted magnetization‐prepared rapid gradient echo (T1‐MPRAGE). A full quantitative sensory testing battery on the forearm was also performed, alongside a brief clinical examination. All test results were normal with the exception of the T1-MPRAGE which showed enlarged ventricles and a cyst-like focal changes, mistaken for a sign of old ischaemic infarct. The change, however, is consistent with the insertion of a cannula for the pneumoencephalogram. This is the first follow-up report with neuroimaging presented nearly 40 years after the diagnosis of ventricular TB. Tuberculosis (TB) is an infectious disease usually caused by Mycobacterium tuberculosis. In rare cases, TB may migrate into the central nervous system, which presents the most severe form of TB. One complication of TB in the central nervous system is tubercular ventriculitis, which remains an under-recognised complication . Thus, tThe diagnosis of tubercular ventriculitis is typically done through magnetic resonance imaging (MRI) , with thTypically, tubercular ventriculitis is treated by anti-TB treatments, cerebrospinal fluid (CSF) diversion, for example, ventriculoperitoneal shunt, and occasionally with the addition of other surgical interventions such as temporal cranioectomy or temporal lobectomy, although operative interventions as such are often restricted to cases also presenting with seizures -3. PatieWe report the first follow-up of a 57-year-old man who suffered tubercular ventriculitis aged 16.A 57-year-old man took part in a research trial at the Clinical Research and Imaging Centre, Bristol, United Kingdom. The man was screened for pre-existing conditions including musculoskeletal pain, cardiovascular, respiratory, psychiatric, immunological, oncological, urogenital, gastrointestinal, endocrine, neurological, rheumatologic and ophthalmic disorders. Importantly, the medical history was only taken with respect to on-going diagnoses with the exception of oncological disorders. In addition, a 12-lead electrocardiogram (ECG), clinic and ambulatory blood pressure and full-screen sensory testing on the forearm was performed for research purposes, which were all confirmed to be within the normal range.During the research MRI scan, a T1‐weighted magnetization‐prepared rapid gradient echo (T1‐MPRAGE) of the whole head was obtained (Figure A less prominent hypointensity was observed in the left hemisphere Figure .In addition to the main focal lesion in the parietal white matter, at least three smaller focal lesions were seen in the frontal lobe white matter, two in the right hemisphere and one at a similar lateral and frontal position in the left hemisphere Figure .Based on a preliminary report of the T1-MPRAGE, it was recommended that the patient be followed up in the Stroke Clinic as the suspected lesion was thought to represent small vessel ischaemia possibly with lacunar infarct.The patient was invited for a clinical MR scan through a stroke clinic in the South of England. This scan showed bilateral susceptibility artefact lateral to the third ventricle, bilateral signal change adjacent the posterior horn of the lateral ventricles, prominent lateral ventricles, and linear signal voids extending to the cortical surface, with overlying cortical defects. The clinician noted that this was likely the site of previous craniotomy or intervention.The patient was followed up by consultation, which revealed that he had suffered tubercular ventriculitis at age 16 and had been admitted to the Midland Centre for Neurosurgery and Neurology. At the time, pneumoencephalography was performed to assess the patient, which resulted in a coma lasting approximately one week, after which the patient recovered with anti-TB treatment.No previous reports have shown follow-up MR of patients with tubercular ventriculitis; nor have we found reports of cases followed up 40 years after pneumoencephalography, a procedure known to carry a high risk of organic cause sequalae [One report on the use of pneumoencephalography in children with tuberculous meningitis showed that of 26 children with abnormal anatomy only eight were alive at the 11-month follow up, and of these, all patients showed neurological or mental residual sequelae . UnfortuIn the present case report, the patient showed several large lesions in the parietal cortex, as well as some lesions in the frontal lobe and enlarged ventricles. Interestingly, there were no detectable sequelae; the patient presented with no signs or symptoms suggestive of the presence of such anatomical lesions. Whilst the parietal lesions are consistent with the placement of a shunt for the pneumoencephalography, it is interesting that several smaller lesions are present which could indicate organic injury as a consequence of central nervous system TB. However, as a differential diagnosis, it cannot be ruled out that the smaller lesions (as seen in Figure The present incident also demonstrates the case for comprehensive history taking in otherwise healthy patients prior to imaging for research purposes. This is emphasised by the initial report mistakenly suggestive of old ischaemic infarct, which could have been ruled out had the history of the pneumoencephalographic procedure been known.The present case is a unique incidental follow-up of ventricular TB in a patient who previously had invasive pneumoencephalography at the age of 16. We present a curious case of a relatively large lesion to the parietal cortex with no documented functional impairment. The patient in question has achieved high academic honours, and present with no discernible neurological deficits.


Colorectal cancer (CRC) is one of the most common cancers and the second highest cause of cancer-related deaths . Common presentations of CRC include alterations in bowel habit, weight loss, and lower gastrointestinal bleeding. We report a case of a 74-year-old male who presented with fever and right upper quadrant pain, with positive Murphy's sign on examination. The case was initially managed with a routine cholecystectomy. Histological examination revealed a moderately differentiated adenocarcinoma with a superimposed histologically proven acute acalculous cholecystitis. CT scan done postsurgery showed a cecal mass with retroperitoneal lymphadenopathy. Biopsy result of cecal mass was remarkable for colon adenocarcinoma. We are not aware of any similar prior cases reported in English literature. CRC is the third most common cancer in men and the second in women worldwide . Around The intestinal tract venous drainage is through the portal circulation. Therefore, the first site of hematogenous spread of CRC is usually the liver, followed by the lungs, bone, and multiple other sites. However, distal rectal cancers may metastasize initially to the lungs through the inferior rectal vein, which drains into the inferior vena cava rather than into the portal venous system .Throughout the literature search, we came across 2 cases of transverse colon cancers with metastasis to gallbladder masquerading as cholecystitis , 5.μl with 80% neutrophils, and other tests were within normal range .A 74-year-old male with history of stage III sigmoid adenocarcinoma 15 years ago treated with sigmoid colectomy followed by adjuvant 5-fluorouracil (5-FU) chemotherapy presented to his local hospital with acute worsening of epigastric pain associated with nausea and vomiting. On physical examination, the patient was febrile at 38.5°C, tachycardic, and normotensive. Abdominal examination revealed tenderness in the right upper abdomen and rigidity of the abdominal wall with positive Murphy's sign. Laboratory testing revealed a hemoglobin level of 11.5 g/dl and a white cell count of 16/μg/l.CA19-9 was elevated at 4945 IU/ml, and the CEA level was measured at 24.11 Abdominal ultrasound revealed a sludge and irregular thickness of the gallbladder.The patient was started on intravenous broad-spectrum antibiotics immediately. Laporascopic cholecystectomy was performed the day after admission. Unfortunately, the postoperative course was complicated by a septic shock and required ICU admission for few days . The iniThe patient was referred to our hospital where he had a biopsy of the latter mass, and the histopathology result was consistent with a moderately differentiated adenocarcinoma of colonic origin. A comprehensive pathological review of the gallbladder specimen was performed, and reexamination and further immunohistochemical analysis including epithelial cytokeratins 7 and 20 (CK7 and CK20) and homeobox protein-2 (CDX-2) were done. Tumor cells isolated from the specimen were positive for CK20 and CDX-2 and negative for CK7.Our patient was confirmed to have metastatic disease from colon primary; therefore, he was started on palliative capecitabine with significant symptomatic improvement reported after two cycles. He continues to tolerate chemotherapy.CRC is one of the most common cancers worldwide. Patients with right-side colon adenocarcinoma usually present with cachexia, weight loss, anemia, and positive fecal occult blood unlike those with left-sided colon cancers, which usually manifest with changes in bowel habit, hematochezia, and symptoms of obstruction.The gallbladder is an extremely rare site of CRC metastasis, with very few cases reported. However, tumors like melanoma may metastasize to the gallbladder . Other lChen et al. reported a case of transverse colon cancer presenting with manifestations of cholecystitis. They suggested that invasion of the gallbladder caused an inflammatory adhesion which resulted in an acute acalculous cholecystitis .Munghate et al. also described a case of transverse colon presenting with cholecystitis .Adenocarcinomas are epithelial cancers arising in glandular tissues. They constitute the largest group of epithelial cancers .CK are keratin proteins found in the cytoskeleton of the epithelium . CK7 andThe homeobox protein-2 (CDX-2) test result was also helpful in our case to further distinguish colon adenocarcinoma from other gastrointestinal and hepatobiliary tumors.CDX-2 is normally expressed within the nuclei of the intestinal epithelium, from the duodenum to the rectum, and it is a sensitive and specific marker of adenocarcinomas of intestinal origin , 14.The CK7-negative/CK20-positive expression pattern with CDX2 positivity is consistent with colorectal primary, while gallbladder cancers tend to be both positive for CK7 and CK20 –14.Our case had two distinguishing features; the first one was the primary site being the cecum. The second interesting finding was features of concomitant acute acalculous cholecystitis and metastatic adenocarcinoma. We hypothesize that the local spread resulted in metastasis and subsequently acute cholecystitis mimicking primary gallbladder adenocarcinoma and causing diagnostic confusion.Colon adenocarcinoma metastasizing to the gallbladder is extremely rare. To our knowledge, this is the first case of primary cecal adenocarcinoma with metastasis to the gallbladder presenting with acute acalculous cholecystitis.


Nodular fasciitis is a benign, self-limited myofibroblastic proliferative lesion of unclear aetiology. It is often misdiagnosed as a malignant tumour due to its rapid growth, high cellularity, and increased mitotic activity.We present a case of nodular fasciitis occurring in the medial canthus of a 64-year-old, otherwise healthy, woman. The patient complained of rapidly enlarging asymptomatic subcutaneous nodule over a period of 6 months. The tumour was firm, smooth, and indolent with limited mobility. Fine-needle aspiration was inconclusive, and the CT scan showed a well-defined nodular lesion in the soft tissue without bone destruction. A local excision was performed, and the histopathological findings were consistent with nodular fasciitis.Although rare, nodular fasciitis is the most common pseudosarcoma of soft tissues. Local excision is recommended; however, the tumour often regresses spontaneously, and recurrence is exceedingly rare.Awareness of nodular fasciitis and its benign nature is essential to avoid misdiagnosis and subsequent inappropriate aggressive treatment of the patient. The process was first described in 1955 by Konwaler et al and was initially named subcutaneous pseudosarcomatous fibromatosis . HoweverWe present a case of nodular fasciitis occurring in the face to raise awareness of nodular fasciitis as a differential diagnosis in rapidly growing solitary tumours.2A 64-year-old, otherwise healthy, female presented with a 6-month history of a rapidly enlarging asymptomatic tumour in the left medial canthus. There was no history of trauma. A fine-needle aspiration performed by an otolaryngologist was inconclusive. A contrast-enhanced CT scan showed a well-defined nodular lesion in the soft tissue measuring 16 × 12 mm without bone destruction or remodeling. Physical examination in our outpatient department revealed a firm, smooth, indolent process of 20 × 15 mm with limited mobility and no evidence of skin involvement. An excisional biopsy was performed, and macroscopically the lesion was round, greyish-white, unencapsulated and well-circumscribed. Histopathologic examination showed a subcutaneous tumour profoundly in close relation with sparse skeletal muscle. It consisted of a cellular proliferation of myofibroblastic spindle cells with a tissue-culture like growth pattern. The background was myxoid with extravasated red blood cells and few lymphocytes. The cells had small distinct nucleoli without significant atypia. Scattered mitoses were observed, but there were no atypical forms. Immunohistochemical staining was positive for smooth muscle actin while negative for S-100, CD 34, desmin, epithelial membrane antigen, and cytokeratin AE1/AE3 staining. The histopathological findings were found to be consistent with nodular fasciitis , Fig. 5.3Nodular fasciitis is a benign and self-limiting pseudosarcomatous tumour composed of a vascular and fibroblastic proliferation. It has traditionally been considered as a reactive lesion rather than a true neoplasm. The pathogenesis of nodular fasciitis is not entirely known. Trauma has been implicated as a triggering factor . HoweverClinically, Nodular fasciitis usually presents as a solitary rapidly growing tender subcutaneous nodule of a few weeks duration and rarely exceeding 2–3 cm in diameter. It occurs mainly during the third to sixth decade of life with men and women equally affected . The mosHistologically, nodular fasciitis is characterized by a proliferation of spindle cells arranged haphazardly in a myxoid stroma accompanied by a network of capillaries and extravasated erythrocytes. The cells may display an abundance of mitotic figures, however atypia is not observed ,18. NoduImmunohistochemistry is useful to obtain an accurate diagnosis. The characteristic profile is positivity for smooth muscle actin, vimentin, and occasionally focally for desmin, whereas S-100, cytokeratin, and CD34 are not expressed ,18,19.Consideration of clinical differential diagnosis includes lipoma, fibromatosis, dermatofibroma, neuroma, neurofibroma, myxoma, benign cyst, benign and malignant fibrous histiocytoma, dermatofibrosarcoma protuberans, fibrosarcoma, leiomyosarcoma, spindle cell carcinoma and melanoma ,10,17,18Local excision of the lesion is the preferred method of treatment, although partial excision may be sufficient as residual nodular fasciitis may subsequently regress by scarring. Even conservative treatment and clinical follow-up may be a good option as many tumours regress spontaneously. Recurrence of nodular fasciitis has been documented, however, it is so rare that recurrence of a lesion classified as nodular fasciitis should lead to a critically review of the original diagnosis as reappraisal often reveals a malignant disease ,5,10,19.4Diagnostic issues with nodular fasciitis are common. The lesion may easily be mistaken for a malignant tumour due to its rapid growth and histopathologic similarities. Awareness of nodular fasciitis and its benign nature among clinicians is essential to avoid misdiagnosis and subsequent inappropriate aggressive treatment of the patient.This work has been reported in line with the SCARE criteria .The authors have nothing to declare.The case report is exempt from ethical approval in our institution.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 on request.Shems Al-Hayder: study concept and design, data collection, data interpretation, writing the paper.Mads Warnecke: Study concept, data collection, data interpretation, writing the paper.Jørgen Hesselfeldt-Nielsen: data interpretation and writing the paper.N/A.Shems Al-Hayder.Not commissioned, internally peer-reviewed.The authors have nothing to declare.


A 62-year-old Turkish female was admitted to our hospital with acute, progressive melena. Gastroscopy and colonoscopy could not reveal the cause of the melena. Subsequent CT angiography demonstrated a large, exophytic mass in the ileocecal junction as a source of the haemorrhage, leading to urgent laparotomy and resection. Histopathology revealed a low grade leiomyosarcoma (LMS) and confirmatory immunological staining. Primary LMS of the small bowel is an extremely rare gastrointestinal (GI) malignancy. Presentation with acute GI bleeding is even more exceptional, since LMS is a mainly intramural, exophytic tumour of the bowel wall. Immunohistochemistry plays a crucial role in differentiating LMS from GI stromal tumour. The work up of occult small bowel neoplasms currently consists of MRI enterography or enteroclysis and wireless capsule endoscopy. Treatment is surgical resection. This case highlights the non-specific imaging features of ileal LMS and highlights the management of acute GI bleed. A 62-year-old Turkish female with a medical history of caesarean section, second degree atrioventricular block treated with a pacemaker and chronic paroxysmal atrium fibrillation treated with fenprocoumon (anticoagulant), presented in the Emergency Room with one day of rectal blood loss. No history of previous gastrointestinal complaints. On clinical examination, patient had a non-tender abdomen. Rectal examination showed dried blood around the anus, no palpable mass and no melena. Patient had a tight tension of 100/60 mmHg, which was 115/70 mmHg after 1 l filling with sodium chloride infusion. Laboratory results showed an International Normalized Ratio (INR) of 2.0 and haemoglobin of 4.9.Patient underwent immediate esophagogastroscopy, which showed no focus of bleeding from stomach into descending part of duodenum. Push gastroenteroscopy  ileum) showed much blood in colon and terminal ileum , suggestA three-phase CTA of the abdomen  was performed. Non-enhanced CT revealed an enlarged cecum and terminal ileum, with an exophytic, isodense mass with some calcifications mainly located in the wall of the terminal ileum . ContrasThe main radiological differential diagnosis at the time an arteriovenous malformation, or a small bowel malignancy, either gastrointestinal stromal tumour or leiomyoma. No angiography with embolisation was performed since no arterial feeding vessel could be identified on CTA. The patient underwent surgery in acute setting since blood loss could not be controlled. During surgery an exophytic, hard palpable tumour was found in the wall of the terminal ileum. Ileocecal resection was performed with a side-to-side primary anastomosis with staplers. Also, the aberrant vein was identified and resected . There wOn histopathology, a greyish-white to blue grey tumour mass of approximately 9  cm was seen, encapsulated by serosa with a solid nodular, fibrous aspect that was hard on palpation . The tumMicroscopically, a cell rich lesion was seen, composed of spindle-shaped cells that were arranged in a palisaded, or fascicular growth pattern with “cigar-shaped” nuclei, embedded in eosinophilic cytoplasm  and 10. 1 Given the large size of this tumour (9  cm), the slight cytonuclear atypia and some mitotic figures that are found, there was a preference to classify the tumour as low-grade LMS of the gastrointestinal (GI) tract over an intramural LM. A GI stromal tumour (GIST) was excluded immunohistochemically. High grade LMS would be characterized by areas of necrosis and haemorrhage, large bizarre nuclei and a large proliferation rate or multiple abnormal mitoses.1In summary, it concerned a mesenchymal spindle-shaped lesion with myogenic differentiation and a slight degree of cytonuclear atypia with some mitotic figures. The pathological differential diagnosis was an intramural leiomyoma (LM) or a low-grade leiomyosarcoma (LMS). Intramural leiomyomas (LMs) of the digestive tract occur; however, they show no cytonuclear atypia and they are rarely larger than 2 cm in diameter, as described in the World Health Origanisation classification of intestinal tumours.2 although GIST has a larger propensity for intraluminal growth than LMS. On CT, both LMS and GIST are large, lobulated, exophytic masses with heterogeneous enhancement and sometimes dystrophic tumoural calcifications.3 LMS tends to be somewhat more homogeneous and hypodense on non-enhanced CT scan. Both LMS and GIST can have cystic or necrotic components, depending on the malignancy grade and size.4 Both tumours can potentially to ulcerate and cause GI bleeding when ulceration reaches the mucosal surface. On MRI scan, LMS is hypointense on T1 weighted images, intermediate of signal intensity on T2 weighted images and shows heterogenous contrast-enhancement with central necrotic areas.5 Both GIST and LMS may metastasize to liver and peritoneum by direct invasion, peritoneal or haematological spread.4 Of all GIST, 50% present with liver or peritoneal metastases.4 Typically, GIST does not display lymphatic spread, but LMS does.6The main radiological differential diagnosis of LMS is GIST, which morphologically resembles LMS. Both LMS and GIST can either grow exophytic (50%) or intraluminal,PDGFRA) gene. Moreover, approximately 95% of GISTs are positive for CD117 by immunohistochemistry.2 LMSs are differentiated from GISTs by the lack of CD117 (c-KIT), DOG1 and CD34 as well as presence of smooth muscle actin (SMA) and desmin.2On both macroscopy and microscopy LMS and GIST share the same features: both are mesenchymal tumours embedded in the muscle layers (muscularis propria) that consist of spindle cells, with a myogenic differentiation, arranged in a palisaded or storiform pattern with pale eosinophilic indistinct cytoplasm. Therefore, immunohistochemistry plays an important role to differentiate LMS from GIST, since these two tumours resemble each other on gross macroscopy. Approximately 85% of GISTs harbour activating mutations in the KIT or platelet derived growth factor receptor alpha , but both LM and LMS can have necrosis and calcifications.5 Their imaging findings are comparable and there are no definite features to preoperatively distinguish low grade LMS from LMs on imaging.The second differential diagnosis are LMs, common benign neoplasms of the small bowel. While LMSs are mostly located in the jejunum, LMs can occur anywhere in the small bowel, but mainly in the ileum and jejunum.8 LMS represents 2–3% of small bowel tumours.8 The incidence is estimated 22.7 cases per million and less than 30 case reports worldwide have been found in literature.8Most tumours of the small bowel are metastases. Primary small bowel tumours are rare, and account for less than 5% of all GI malignancies. Of these, the majority are adenocarcinomas (40%) and carcinoids (31%), followed by lymphomas (20%) and mesenchymal tumours (9%), among which GIST and sarcomas, showing an increasing incidence over the years, partly caused by various associated genetic disorders.6 The most frequent origin is the jejunum, followed by ileum and duodenum, respectively. Most small bowel LMS grow towards the subserosal side of the bowel (66%), without an intraluminal component.1 Therefore, patients remain asymptomatic in the early stages of disease. Later, they can present with ferriprive anaemia or chronic intermittent melena, abdominal pain, a palpable mass or intussusception .9 Because of its aspecific or asymptomatic clinical presentation and the difficulty to visualize the small bowel by upper and lower endoscopy, LMS is discovered at advanced stage.9 Moreover, since LMS grows mainly subserosal, it can easily be missed since endoscopy only covers intraluminal inspection.Patients present between age 50 and 70 with a small male preponderance.6 CT scan has the advantages of low cost and fast imaging. In acute setting, CTA has a high sensitivity between 86% and 95% for detecting the source of GI bleeding.10 In contrary, endoscopy in acute setting suffers from disadvantages as inadequate bowel preparation, low sensitivity of 20–40% 10 and risks of sedation, perforation and bleeding.10 MRI scan offers best soft tissue contrast and may be more sensitive to detect small mucosal lesions, plus it can differentiate tumours based on their signal characteristics without the need for ionisation.6Preoperative diagnosis of small intestine tumours remains difficult, especially distinguishing benign and malignant tumours.9 However, their use may be limited in the setting of acute GI blood loss or obstruction and their sensitivity is low in evaluation of mural and extramural neoplasms.5 Another important limitation of wireless CE is capsule retention in approximately 10–25% of cases, leading to the urge of acute surgery because of acute bowel obstruction and sometimes perforation.5 In patients with suspected small bowel tumours, MRI enteroclysis might be used as the first modality of choice, followed by double-balloon endoscopy for histological determination.5 Finally, positron emission tomography can contribute in evaluating metastases, but imaging results depend on histological grade of the tumour and its metabolism.11 Therefore low grade LMS might not show uptake of radioactive labelled glucose.11Currently, additional techniques such as MRI enterography, MRI enteroclysis and wireless capsule endoscopy (WCE) have shown to detect mucosal abnormalities and thus to diagnose small bowel tumours.9 Preoperative embolisation plays no significant role. Radical resection can be curative, unless there are already peritoneal or liver metastases. While adjuvant chemotherapy is used for GIST and uterine LMS, little efficacy has been reported for small bowel LMS, neither for radiation therapy.12Treatment is primarily surgical resection.2 Second, histological predictors are tumour size, mucosal invasion and cellular atypia.2 Finally, the presence of liver and peritoneal metastases (estimated 24–50%) predicts the 5-year disease free survival, which between 28% and 48%.12 The overall prognosis of small bowel LMSs is better than adenocarcinomas, but it remains poor.The most important prognostic factor is malignancy grade (FNCLCC or Trojani), determined by differentiation grade (I–III), the number of mitoses per 10 high power field  and necrosis LMS is a rare small bowel malignancy that infrequently can present with acute GI bleeding. In emergency setting, CTA has a high sensitivity to detect this large, mainly exophytic mass of the small intestine. Accurate management relies on a surgical approach. Given the relatively inaccessible location of the small intestine to both upper and lower GI endoscopy, this case highlights the importance of imaging and the role for the radiologist when faced with a differential diagnosis of small bowel malignancy. The pathologist makes the final call in differentiating LMS from the much more common GIST.Primary LMS of the small bowel is a rare GI malignancy and can present with acute GI bleeding.Immunohistochemistry plays a key role in differentiating LMSs from GIST, since they are hardly indistinguishable on imaging.When small bowel malignancy is suspected in a patient and upper and lower endoscopies are normal, CTA is the imaging of choice which also has a high sensitivity. In outpatients, diagnostic work-up should include MRI enteroclysis, MRI enterography or wireless capsule endoscopy.Informed consent to publish (including images and data) was obtained and is held on record.


T2 weighted MRI in a patient presenting with associated intrauterine leiomyoma and/or a history of previous laparoscopic myomectomy suggests the possibility of DPL. Imaging studies help in diagnosing and delineating the location and extent of the lesion and also follow-up the masses to look for sarcomatous transformation. Here we report the case of a 43-year-old female who presented initially with right lower quadrant pain. Her CT scan and MRI demonstrated a fundal fibroid with multiple intraperitoneal soft tissue masses of similar appearance and contrast enhancement in the sigmoid mesocolon, the left paracolic gutter and adjacent to the ascending colon. The suspected diagnosis of DPL was confirmed during abdominal hysterectomy, bilateral salphingo-oophorectomy and excision of peritoneal masses.Disseminated peritoneal leiomyomatosis (DPL) is an unusual extrauterine form of leiomyoma that has been found to coexist with its intrauterine counterpart in individuals who have previously undergone laparoscopic myomectomy. The presence of extrauterine masses with the density of smooth muscle on CT imaging and/or with a low signal intensity similar to that of smooth muscle on  A 43-year-old female with a history of ulcerative colitis presented with lower abdominal pain of 3-day duration. The pain was continuous, dull aching in nature and associated with low grade fever. The patient also complained of vaginal discharge but with no history of loose stools or dysuria. She gave a history of undergoing laparoscopic myomectomy twice in the past.All laboratory investigations were within normal limits. Clinical examination revealed a firm mass of 16-week size in the hypogastrium extending into the left iliac fossa with restricted mobility. Per vaginal examination showed the uterus to be of 16-week size with restricted mobility. A firm mass, separate from the uterus was felt through bilateral fornices and the posterior fornix.Abdominal CT scan showed a fundal fibroid involving the anterior wall with a large multilobulated soft tissue density mass posterior to the uterus . SimilarT1 and T2 weighted hypointensities (T2 respiratory triggering (RTr) images are available as Supplementary videos A and B.MRI showed multiple intramural fibroids exhibiting ensities . Similarensities . A rightensities  and 2b. The imaging findings were suggestive of uterine leiomyoma with coexisting disseminated peritoneal leiomyomatosis. The patient underwent total abdominal hysterectomy, bilateral salphingo-oophorectomy and removal of peritoneal leiomyomata . HistoloT2 hypointensity of the extrauterine masses similar to that of smooth muscle, with associated intrauterine leiomyoma or previous laparoscopic myomectomy, is suggestive of disseminated peritoneal leiomyomatosis.The presence of characteristic There has been no recurrence of intra- or retroperitoneal masses post surgery.2 Uncommon growth patterns of leiomyoma include disseminated peritoneal leiomyomatosis (DPL), benign metastasizing leiomyoma, intravenous leiomyoma, retroperitoneal leiomyoma and parasitic leiomyoma.Leiomyomas are benign smooth muscle tumours that arise from the overgrowth of smooth muscle and connective tissue, usually from the uterus, small bowel and the oesophagus. Uterine leiomyomas are the most common gynaecological tumours noted to occur in 20% to 30% of women beyond the age of 35 years.3 in 1952; however, the entity was clearly described and named by Taubert et al4 in 1965. About 140 cases of DPL had been reported by 2010 in the literature.5DPL  is an extremely rare benign entity characterized by the presence of multiple leiomyomas throughout the peritoneal cavity. The first case was reported by Willson and Peale6 The basic pathogenesis of DPL is thought to be a multicentric metaplastic change involving the connective tissue of the peritoneum in the abdominal cavity owing to an abnormal response to hormonal stimulation.7 This hypothesis can account for the association of DPL with endometriosis, as the subcoelomic mesenchyme is capable of differentiating into various tissues, including endometrial glandular epithelium. Laparoscopic removal of uterine leiomyomas has also been implicated in the development of DPL owing to spread of tumour cells along the surgical tract.8Although the aetiopathogenesis is controversial, strong hormonal association is attributed owing to coexisting factors such as pregnancy, long-term use of oral contraceptives and oestrogen-producing tumours.Most of the patients with DPL are asymptomatic, with lesions detected incidentally during surgery . Others usually present with non-specific symptoms such as abnormal, heavy uterine bleeding and lower abdominal pain or discomfort. Less common presentations include increased frequency of micturition, mass per abdomen and symptoms of obstructive uropathy.Imaging studies delineate the presence of intrauterine leiomyoma as well as the extent and location of peritoneal deposits. Multiple small subcentimetre peritoneal nodules are below the resolution of imaging techniques and incidental detection is not rare. Ultrasonography and CT scan in patients with DPL show multiple, solid and complex soft tissue masses that are usually large and similar in morphology to uterine leiomyoma. These lesions show heterogeneous attenuation with variable enhancement as that of uterine leiomyoma on post-contrast studies.T1 and T2 weighted images, which show variable post-contrast enhancement. Follow-up imaging and surveillance is mandatory as sarcomatous transformation has been reported in a few cases.9 Positron emission tomography shows absence of fludeoxyglucose (FDG) uptake in nodules of DPL. Positron emission tomography is therefore a problem-solving tool in differentiating DPL from malignant peritoneal disease, which classically shows avid FDG uptake.10MRI features include multiple masses with hypointense signal similar to that of skeletal and smooth muscles on 6 The conservative approach is considered for its benign clinical course when aggressive surgery is not feasible, as in younger age or for want of children. In view of the reported cases of recurrence and sarcomatous transformation, close surveillance of these patients is mandatory.The mainstay of treatment involves curbing the hormonal influence on DPL, which includes a conservative approach and gonadotropin-releasing hormone agonist or surgical castration with or without removal of leiomyomatous masses.11 Pathological hypothesis includes haematogenous dissemination of uterine leiomyoma, with an alternate theory proposing multifocal synchronous metaplasia.12 Imaging features include pulmonary nodules that can be solitary to multiple lung masses that mimic metastasis from a malignant tumour. Intralesional cavitation and calcification are rare, with occasional presentation as pneumothorax. Presence of uterine leiomyoma or history of hysterectomy with previous diagnosis of leiomyoma supports the diagnosis. However, definite evidence is based on image-guided core biopsy.Benign metastasizing leiomyoma presents as multiple well-differentiated lesions at sites farther than the uterus. Lesions most commonly affect the lungs. Other rare sites include heart, brain, lymph nodes and skin.13 The lesion appears as a filling defect i.e. thrombus in the great veins, inferior vena cava and sometimes extending into the right atrium, which is demonstrated by echocardiography. It shows hypointense signal on T1 and T2 weighted MRI, with enhancement on post-contrast images. Differential diagnoses include bland thrombus, tumoral thrombus with visualized primary malignancy and leiomyosarcoma.14Intravenous leiomyomatosis is rare, benign smooth muscle proliferation within the uterine or systemic veins beyond the confines of leiomyoma. Tumoral growth is usually into the uterine and parametrial veins, with rare extension into systemic veins and cardia.15 Ultrasound helps demonstrate concurrent uterine lesions and non-ovarian origin of extrauterine leiomyomas and aids guided biopsy for histological confirmation before surgery.Multiple pelvic retroperitoneal lesions with concurrent uterine leiomyoma are suggestive of retroperitoneal leiomyomatosis. Rarely, leiomyomas adhere to adjacent structures (broad ligament or omentum) to derive vascular supply, hence loosing attachment to the uterus, and are termed parasitic leiomyomas.DPL is a rare benign entity characterized by multiple leiomyomas in the peritoneal cavity seen usually in the presence of uterine leiomyoma or history of hysterectomy due to previous leiomyoma.T1 and T2 hypointense signals similar to smooth muscle in uterine leiomyoma with variable post-contrast enhancement is the diagnostic finding that helps rule out differential possibilities of infectious and malignant aetiologies.Characteristic Positron emission tomography is a key modality to differentiate DPL from malignant peritoneal disease, which demonstrates the absence of uptake in nodules in DPL and avid FDG uptake in malignancy.Close surveillance of patients is mandatory in view of the reported cases of recurrence and sarcomatous transformation.Informed consent has been obtained from the patient after explaining about the publication and usage of images.


An inflammatory pseudotumor of the liver is a rare tumor-like lesion consisting of an inflammatory infiltrate that often can mimic a malignant liver neoplasm. The cause of an inflammatory pseudotumor of the liver is unknown, but it has been reported to be associated with different comorbid conditions most likely inflammatory or infectious in origin. We present an 83-year-old female who presented with a symptomatic gallstones disease and an incidental finding of inflammatory pseudotumor mimicking intrahepatic cholangiocarcinoma in preoperative liver imaging. Differentiating a pseudotumor from hepatic space-occupying neoplasms is crucial since it is one of the most important tumor-mimicking lesions. The imaging findings of this rare tumor can pose diagnostic difficulties because of the amount of fibrosis and cellular infiltration. If malignancy has been excluded, patients can be treated conservatively with steroids and non-steroidal anti-inflammatory drugs. However, complete surgical resection has been the modality of treatment for most of the cases with an indeterminate diagnosis. An inflammatory pseudotumor (IPT) is a benign and rare process composed of polymorphous inflammatory cell infiltrates and variable amounts of fibrosis. IPT most commonly occurs in the lung, but it can be found in other locations, including the central nervous system, major salivary glands, kidneys, liver, omentum, ovaries, larynx, urinary bladder, breasts, pancreas, spleen, lymph nodes, skin, soft tissues, and orbit of the eye -2.An IPT of the liver is a very rare entity consisting of radiologic features, which are variable and nonspecific. While it may rarely lead to biliary obstruction, portal hypertension, and even cirrhosis, the clinical importance is primarily related to the difficult differential diagnosis from malignant tumors . An IPT IPT of the liver is a challenging diagnosis even with histological criteria since needle biopsy alone may be insufficient. Consequently, some authors suggest surgery as the treatment of choice for patients with severe symptoms or an indeterminate diagnosis . InsteadAn 82-year-old female patient with a symptomatic gallstones disease and a recent weight loss was admitted to our hospital. The patient’s past medical history was free of other diseases and on physical examination, a Murphy sign was present. The abdominal ultrasound mentioned a large gallstone in the gallbladder and a hypoechoic liver mass. Liver blood tests, including tumor markers CEA and CA 19-9 were normal. Magnetic resonance imaging-magnetic resonance cholangiopancreatography (MRI-MRCP) revealed a liver tumor mass (4.5x3.5 cm) located mainly in segments IVa and VIII of the liver with an extent to segment I  without any signs of vessel invasion. There were no signs of liver cirrhosis and no dilated bile ducts or capsular retraction were noted. There was no associated lymphadenopathy. At this point, imaging characteristics were controversial regarding diagnosis. The differential diagnosis tilted in favor of ICC, mainly due to the enhancement characteristics and the absence of liver cirrhosis, as seen in Figure The patient was scheduled for exploratory laparotomy with a provisional diagnosis of an ICC. Intraoperatively, a cholecystectomy and lymph node sampling from the hepatoduodenal ligament were performed and both specimens were negative for malignancy on frozen section. Next, the liver was mobilized and the tumor was carefully dissected free of the hepatic veins, the IVC, and the rest of the liver parenchyma. The gross morphology of the liver specimen revealed a solid, grey-yellow liver lesion with a soft consistency. In the center, a light yellow region was noted, as can be seen in Figure The frozen section was negative for malignancy. Histologically, the tumor was characterized by a heavy inflammatory infiltrate in myxoid collagen stroma, consisting primarily of plasma cells, lymphocytes, and eosinophils. Fibroblast cells without significant fibrosis composed the stroma. There was no evidence of malignancy in the tissue examined. The final pathology report revealed an IPT of the liver.The term “inflammatory pseudotumor” describes a heterogeneous group of mass-forming lesions that can involve many organs. The lesions are characterized by a prominent inflammatory infiltrate, namely, plasma cells, lymphocytes, and eosinophils as the predominant cellular component . IPT wasThe etiology and pathogenesis of inflammatory pseudotumors remain unclear for a variety of the rest tumor-like inflammatory lesions that lack the features of the entities listed above ,4,13. MyLiver involvement is rare and is often mistaken as a malignant process particularly metastatic disease or ICC. IPT of the liver has been estimated with an incidence of about 0.7% and accounts for 8% of extrapulmonary IPTs . In the Patients with IPT of the liver present with non-specific clinical symptoms, such as abdominal pain, fever, and weight loss. The lesion may be as large as 25 cm and the radiologic features of IPT of the liver are nonspecific, possibly because of the amount of fibrosis and cellular infiltration -19. DespTreatment is controversial with some authors suggesting surgery as the definitive treatment for patients with severe symptoms or an indeterminate diagnosis. Other multicenter studies, however, have reported good outcomes after conservative management with antibiotics and/or corticosteroids, but some of these lesions recurred ,18-19. HThe absence of the typical features of malignancy on imaging in a liver mass should prompt the consideration of an alternative diagnosis of rare liver lesions, such as an inflammatory pseudotumor of the liver. Differentiating this pseudotumor from hepatic space-occupying lesions is crucial since an inflammatory pseudotumor of the liver may regress spontaneously with conservative management. However, the treatment of choice is still surgical resection for patients with severe symptoms or an indeterminate diagnosis.


Spigelian hernia (SH) is rare and constitutes less than 2% of all hernias. It is reported that more than 90% of SHs lie in the “Spigelian belt”, but SH in the upper abdominal wall is extremely uncommon. Here, we report a case of SH in the right upper quadrant of abdomen.A 38-year-old female was admitted to hospital with complaints of abdominal pain and right upper quadrant mass for 10 days. Contrast-enhanced computed tomography (CECT) of abdomen revealed the dilated small intestine between the swelling ventral muscles in the right upper abdominal wall which suggested a ventral hernia. The surgeons considered it was a spontaneous hernia because there was no history of surgery or trauma in the upper abdomen. About two hours later, the patient underwent emergency surgery. According to laparotomy, a diagnosis of SH with ileum herniation in the right upper abdominal wall was confirmed. The necrotic ileum segment was resected. Meanwhile the abdominal wall defect was repaired by suturing the internal oblique and transverse muscles to the rectus sheath. The patient had a favorable outcome for 1 year without recurrence.A mass and pain in the upper abdominal wall may suggest an atypical SH. SH occurring in the upper abdominal wall is a rare condition with possibility of dire outcome if not managed early.The online version of this article (10.1186/s12893-018-0449-5) contains supplementary material, which is available to authorized users. Spigelian hernia (SH) is named after Adriaan van Spieghel, who depicted the semilunar line in 1645 . SpigeliA 38-year-old female patient presented with abdominal pain and right upper quadrant mass for 10 days. She had a history of pregnancy and caesarean section in the lower abdominal region 10 years before, but there was no history of trauma and upper abdominal surgery. Clinical examination showed a huge mass about 15 × 10 cm over right upper abdomen. There was moderate tenderness in the area of the mass, and the abdominal skin was intact and smooth except the lower abdominal surgical scar. Abdominal wall ultrasonography showed mixed echo-mass under the muscle layer of right upper abdominal wall. Contrast-enhanced computed tomography (CECT) of abdomen was performed. The images revealed the dilated small intestine between the swelling ventral muscles in the right upper abdominal wall which suggested a ventral hernia in the right upper abdominal wall Fig. . There wSpigelian hernia (SH), also known as spontaneous lateral ventral hernia, usually occurs when abdominal pressure increases. SHs in most cases have explicit predisposed causes, such as chronic coughing, obesity, peritoneal dialysis –12. The Ultrasound is recommended as first line imaging investigation, and CT scanning should be added in challenging cases –15. OtheSH is dangerous and the risk of incarceration is higher than other hernias because the defect can be small. It is reported that the risk of incarceration is up to 21%, and thus patients should be offered prompt surgical repair . SurgicaIn conclusion, a mass and pain in the upper abdominal wall may suggest an atypical SH. In addition, the risk of strangulation of SH is higher than other hernias. SH occurring in the upper abdominal wall is a rare condition with possibility of dire outcome if not managed early.Additional file 1:CT 1. CECT investigation revealed the ventral hernia (transverse section 1). (TIF 73 kb)Additional file 2:CT 2. CECT investigation revealed the ventral hernia (transverse section 2). (TIF 73 kb)


The condition predominantly affects the right hemicolon and imaging plays a crucial role in its diagnosis. Here we report the only second documented case of phlebosclerotic colitis in North America in a 60-year-old Canadian resident of Vietnamese descent with a history of consuming herbal medication ( PC is almost exclusively seen in the Asian population  or those with Asian ancestry. Unlike other forms of ischemic colitis which are primarily caused by arterial obstruction due to arteriosclerosis, thrombosis, or embolism, PC is a rare potentially life-threatening ischemic colitis that develops as a result of mesenteric venous calcification and calcification of the affected colonic submucosa. As biopsy results can be insufficient and even non-diagnostic, knowledge of its characteristic imaging pattern and characteristic endoscopic appearance can help make a diagnosis. We present the second documented case of PC in North America, the first being a Canadian resident of Taiwanese descent, reported in 2004.Phlebosclerotic colitis (PC) also known as idiopathic mesenteric phlebosclerosis is a rare form of ischemic colitis. The first case was brought to the attention of the medical community at a Japanese meeting in 1989 by Iwashita sanshishi) in soup for the past 20–30 years. She is a non-smoker and teetotaler. Her family history was unremarkable, and she had never been on or consumed prescription medications. She had no known allergies, and on physical examination, her abdomen was soft, non-tender with no hepatosplenomegaly.A 60-year-old woman, a resident of Canada and Vietnamese descent, presented for colonoscopy following a fecal immunochemical test (FIT) positive result for cancer screening. She gave a history of recent onset (3–4 months) of intermittent abdominal pain with loose stools up to 3–4 times per day with no nocturnal symptoms and no bright blood per rectum. She gave a history of consuming herbal medication  of the abdomen  was perfThree months later, the patient presented with abdominal pain, for which an abdominal radiography was done. Careful examination of the abdominal radiograph  revealedOn repeat colonoscopy, a demarcation of the normal colon and the area of dark discolouration was identified at 30 cm from the anal verge, and this was marked with a tattoo. The patient was discussed at multidisciplinary meeting for consideration of anticoagulation versus future surgery.,6 The pathogenesis of PC is not clearly understood. However, in majority of the documented cases of PC, it is believed that ingested biochemicals and toxins, especially herbal medicines, invigorant water of unknown contents, and alcohol have been associated with the disease.,6,7 The use of herbal medicine containing sanshishi as an ingredient has been proven to be strongly associated with PC.Patients with PC presented with non-specific symptoms such as diarrhea, nausea, vomiting, abdominal pain, and tarry stool. Some patients in the early stage of the disease can even be asymptomatic, while those with advanced disease can present with intestinal obstruction and even perforation.,9 Few cases have been documented where the pathology extends to involve the transverse colon or even the entire colon. One proven case involved only the left colon, leaving the right colon unaffected.PC primarily affects the right hemicolon, and a proposed hypothesis for this is that the ingested toxins and biochemicals are mostly absorbed from the ascending colon, and chronic stasis within the lumen leads to cephalad migration and along with increased intraluminal pressure causes long-term reduced venous return and ultimately impaired venous drainage and hemorrhagic infarction of the affected colonic wall.,10 However, some patients can have a negative colonoscopy. The most striking and characteristic finding on abdominal radiography and CT are tortuous threadlike or serpentine mesenteric venous calcifications involving the marginal veins, vena recti, and intramural tributaries that are perpendicularly oriented to the long axis of the affected colonic wall. In the initial stage of the disease, calcifications first involve the peripheral mesenteric veins, followed by the intramural tributaries of mostly the right hemicolon along with sclerosis of the colonic muscular wall. Calcifications of the proximal SMV and inferior mesenteric vein generally have been described in the advanced stage of the disease affecting the entire colon.,7,10 In addition to the calcifications, other CT findings include colonic wall thickening and adjacent mesenteric fat stranding. Although CT is the imaging modality of choice for diagnosing PC and for its follow-up, modalities such as barium enema and CTA can also be used for its evaluation. Typical findings on barium enema include luminal narrowing, colonic wall thickening, effacement of the haustral folds, and a “thumbprinting” appearance.,11 On venography, dilatation of the veins may be seen along the vasa recta with a decreased venous perfusion leading to under perfusion of the affected bowel.,9,11PC has a characteristic endoscopic and radiological appearance that can help diagnose the condition when biopsy is inconclusive. On colonoscopy, the affected colonic mucosa has a characteristic dark purple discoloration. Other colonoscopic findings include erythema, mucosal edema, erosion, ulceration, narrowing of the colonic lumen, loss of haustrations, rigidity of the colonic wall, and focal nodular surface.,12 Differential diagnosis for PC includes conditions that cause colonic wall thickening with calcifications such as mucinous adenocarcinoma and leiomyosarcoma. Other causes of chronic mesenteric ischemia such as Churg-Strauss syndrome, Behcet’s disease, lymphocytic phlebitis, Degos disease, Wegener’s granulomatosis, and polyarteritis nodosa do not cause fibrosis or calcifications in the veins.,12Management of PC is mostly conservative with close follow-up. Surgery  is reserved for those patients with severe complications  and for those with persistent symptoms following conservative management.PC is a rare bowel pathology of unclear pathogenesis mostly observed in Asians and those with Asian ancestry. Imaging findings of threadlike or serpentine calcifications along the colon and mesenteric veins on CT and a dark purple-colored colonic mucosa on colonoscopy can help to make the diagnosis. Treatment depends on the severity of the disease, ranging from conservative management to prompt surgical intervention.