Background: Inverted papilloma (IP) of the nasal cavity is a benign tumor that represents 0.5–4% of all nasal tumors and have been known to rarely undergo malignant transformation to squamous carcinoma and even more rarely adenocarcinoma. Synchronous association with low-grade esthesioneuroblastoma (ENB) has been reported in only one case report where a small-sized lesion was treated with surgery alone. Here we report the first case of invasion of IP by high-grade ENB with nodal metastasis that was treated with combined modality therapy.Case Presentation: A case of a 64-year-old African American gentleman presented to the otolaryngology with a 3-month history of recurrent epistaxis. Imaging revealed a large right nasal cavity mass extending into the right sphenoid sinus but without intracranial extension. Surgical pathology revealed high-grade ENB invading IP. An orbitofrontal craniotomy approach was used to achieve complete resection of the mass but with positive margins. Post-operative positron emission tomography/computed tomography showed nodal metastasis. The patient was then treated with adjuvant chemoradiation and remains without evidence of disease at 42 months post-treatment. We discuss the disease presentation, histopathologic features, and disease management with literature support.Conclusion: In this very rare disease presentation where two extremely rare malignancies collide, we show that aggressive management with trimodality therapy of surgery, adjuvant radiation with stereotactic radiosurgical boost, and adjuvant chemotherapy gives excellent results. Given the natural history of the disease, however, long follow-up is needed to declare complete freedom from the disease. Inverted papilloma (IP) of the nasal cavity is a benign but locally aggressive, benign nasal lesion remarkable for its tendency for local recurrence. These tumors represent 0.5–4% of all nasal tumors and are associated with sinonasal squamous cell carcinoma in approximately 5% of the cases and even more rarely adenocarcinoma . EsthesiA 64-year-old African American gentleman presented to otolaryngology head and neck surgery clinic with a 3-month history of recurrent epistaxis. On physical examination and nasal endoscopy, the patient had a right nasal cavity mass. Computed tomography (CT) revealed a right nasal cavity lesion extending into the ethmoid and sphenoid sinuses. The mass was locally destructive, with bony remodeling surrounding it. It measured 2.9 cm in the transverse dimension by 3.9 cm in the cranial–caudal dimension by 6.6 cm in the anterior–posterior dimension. On MRI, the mass obstructed the right sphenoid sinus with inspissated secretions surrounding the mass Figure . The masSurgical resection was performed via anterior and subfrontal craniotomy. Sphenoid sinus disease was described to attach anteriorly through the sphenoid ostium but without direct evidence of sphenoid mucosal disease. Complete surgical resection was reported. Pathological examination, however, showed positive margins on the superior border of the resection. Given this margin positivity and high-grade pathological features, the decision was made to pursue adjuvant concomitant chemoradiation, which was initiated following his surgical recover at 9 weeks post-operatively. Positron emission tomography (PET)/CT scan conducted for radiation treatment planning revealed increased metabolic uptake in the bilateral levels I and II neck nodes consistent with nodal metastasis. His final stage was T2N1M0.The determination of target volumes was based on pre-operative and post-operative CT scans, 1 mm MRI images with VIBE sequence, and thin sliced PET/CT complemented by clinical and endoscopic information. The target volume included the regions of high-risk and regions of lower-risk for microscopic tumor spread. This consisted of the surgical bed with margins, bilateral comprehensive lymph node volume levels 1–5 including all PET positive disease, and the bilateral retropharyngeal lymph node volumes. Using 6 mV photon energies, the plan was designed with intensity modulated radiation therapy (IMRT) to improve conformality and reduce dosage to critical structures. A prescription was written for 28 fractions in 180 cGy each for a total dose of 5040 cGy. Due to temporary machine malfunction during the treatment, dose adjustment was made for 29, 180 cGy fractions for a total dose of 5220 cGy. This was completed over a period of 6 weeks. Using stereotactic radiosurgery with Cyberknife (Accuray Inc.), a reduced field was designed to the surgical bed and bilateral retropharyngeal lymph node volumes in five fractions of 250 cGy each. The bilateral PET positive levels I and II neck nodes were then boosted with 6 mV photons with IMRT in five fractions of 250 cGy. The total cumulative dose was 6470 cGy. Figure 2) and etoposide (100 mg/m2) for three cycles during weeks 1, 4, and 7 of the radiation treatment. He suffered the expected toxicity from the chemoradiation with intractable nausea, vomiting, grade III mucositis, and dysphagia. He was treated symptomatically but required two hospitalizations for failure to thrive and symptom management. His pain was managed with patient-controlled analgesia pump and for nutritional supplementation, total parenteral nutrition was initiated toward the end of his treatment. On his 3-month visit following the end of his radiation treatment, he had fully recovered from the rigors of the treatment. At his 42 months follow-up visit, his clinical examination and all of his radiographic imaging studies including MRI and PET/CT were without evidence of disease.Concomitant chemotherapy included cisplatin  with 390 patients . AdjuvanChemotherapy has been generally accepted for patients with ENB with high-grade, recurrent, or unresectable disease . The comIn this paper, we reported a very rare and unique pathologic presentation of a collision of IP and ENB. The pathological and immunohistochemical features were diagnostic of high-grade ENB, which drove the clinical management of the disease. The patient received complete surgical resection with adjuvant chemoradiation for positive microscopic margins and high-grade pathological features. Radiation dose escalation to areas of high-risk disease was achieved with a combination of IMRT and SBRT. At 42 months post-treatment, the patient remains without evidence of disease. However, long term follow-up (>10 years) remains the ultimate test in determining the success of this therapy given the extended time to local and regional recurrence of ENB (The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Malignant rhabdoid tumors of the kidney (MRTKs) are extremely rare. Pure MRTKs in adult patients are particularly rare and have not been previously reported in China. Due to the non-specific clinical symptoms, it is difficult but also essential to be able to give a definite diagnosis. The present study reports a case of pure adult malignant rhabdoid tumor in a patient’s left kidney with characteristic clinicopathological features. Considering the fact that the characteristic findings are often not observed in clinical symptom and imaging studies, the histological features, immunohistochemical staining and cytogenetic studies may aid in confirming the diagnosis of pure MRTKs. Although pure adult MRTKs remain extremely uncommon, it is necessary to consider this possibility when such types of renal tumors are encountered. Malignant rhabdoid tumors of the kidney (MRTKs) are uncommon renal tumors which mainly occur in children and are extremely rare in adult patients. The present study describes a malignant rhabdoid tumor identified in a patient’s left kidney and the diagnosis which was made mainly based on characteristic histological findings and immunohistochemical features. To the authors’ knowledge, only five adult cases have been reported in the English-language literature and the present case is the first report of adult MRTK in China –5. We prThe study was approved by the ethics committee of the Second Hospital of Tianjin Medical University, Tianjin Institute of Urology . Informed consent was obtained from the patient prior to the study.A 59-year-old male patient was admitted to the Second Hospital of Tianjin Medical University due to an asymptomatic mass located in the left kidney which was revealed by ultrasonography one week before. The patient had no other symptoms with the exception of a weight loss of 6 kg over the past months. Physical and laboratory examination revealed no abnormalities. Ultrasonography revealed the presence of a mass, measuring 4.9×3.8×5.0 cm in the left kidney, with medium echo, as well as an unclear boundary and internal inhomogeneous echo. A computed tomography scan revealed a mixed density renal mass in the lower pole of the left kidney, measuring 5×4×5 cm. The lesion exhibited clear peripheral enhancement at the cortical phase and a low density at the parenchymal and delayed phase. There was also increased density in the left perirenal fat. In addition, the following were observed: a shadow with liquid density in the left pleural cavity, nodules with ring-enhancement posterior to the left costophrenic angle and lymph node enlargement around the left abdominal aorta . A chestAn initial diagnosis of a space-occupying lesion of the left kidney, retroperitoneal and left costophrenic angle lymph node metastases and a space-occupying lesion of the left lung was proposed  and subsequently, the patient underwent left radical nephrectomy. Surgery revealed one mass in the lower pole of the kidney which extended locally into the capsule. The cut surface of the tumor was white to gray with a fleshy texture and focal areas of necrosis and hemorrhage .Microscopically, the tumor cells were noncohesive, large and round to polygonal, with vesicular nuclei and prominent nucleoli. A number of the neoplastic cells had eccentric nuclei and large round eosinophilic cytoplasmic inclusion-like structures. Certain areas of the tumor exhibited hemorrhage and/or necrosis . ImmunohAccordingly, a pathological diagnosis of pure malignant rhabdoid tumor of the left kidney was established based on the microscopic features and immunohistochemical findings.A 10-month postoperative follow-up revealed no indications of tumor recurrence or metastasis.MRTKs were originally described as a ‘rhabdomyosarcomatoid variant of Wilm’s tumor’ by Beckwith and Palmer in 1978 due to the resemblance of the cells to rhabdomyoblasts . SubsequMRTK may be associated with other malignancies (composite) or constitute the only component (pure). Several carcinomas arising in the kidney have been observed to have rhabdoid features, including renal clear cell, papillary, chromophobe, transitional cell and collecting duct carcinomas –12. HowePatients typically exhibit an abdominal mass but only a minority have hematuria and flank or abdominal pain. In a small subset of patients the tumor is discovered incidentally in radiological examination –5. HowevMacroscopically, MRTK is generally a single, poorly circumscribed mass, located in the middle of the kidney which exhibits infiltrating growth. Sections of MRTKs are white to grayish with fleshy or soft textures. Necrosis and hemorrhage foci may also be observed. The classic histological appearance of MRTK is that of patternless sheets of noncohesive, large, ovoid or round to polygonal cells with vesicular nuclei and prominent nucleoli, with certain neoplastic cells exhibiting eccentric nuclei and large round eosinophilic cytoplasmic inclusion-like structures. These were all consistent with the present case. In addition, certain inflammatory cells, particularly lymphocytes or histiocytes, may accompany the neoplastic cells and the rhabdoid elements are of high nuclear grade. Ultrastructurally, the rhabdoid cells have paranuclear intermediate filament aggregates, which are arranged haphazardly. In addition, paranuclear condensation of organelles associated with peripheral vacuolization also occurs –5,15,16.Immunohistochemically, the tumor cells are frequently stained diffusely positive for vimentin and focally positive for EMA, cytokeratin, NSE and S-100. However, staining for myoglobin, desmin, MSA, SMA, human melanoma, black-45 (HMB-45) and CD99 are often negative ,16, whicMolecular studies have revealed an apparently characteristic presence of mutations in the hSNF5/INI1 gene on chromosome 22, which has become the hallmark of cranial, renal and other rhabdoid tumors, particularly in children. The lack of immunohistochemical staining for the INI1 gene product facilitates the diagnosis of such diseases. In adults, the rhabdoid phenotype is viewed as a non-specific morphological feature due to the ‘dedifferentiation’ common to numerous neoplasms, including various carcinomas, sarcomas and meningiomas. These tumors do not exhibit the deletion of the h5NF5/INI1 gene so the nuclear immunostaining for INI1 is retained. However, it remains possible to identify the inactivation of h5NF5/INI1 in certain adult MRTs when properly tested. Consequently, whether all tumors within one individual exhibit the downregulation of hSNF5/INI1 remains controversial .In the present case, although electron microscopic examination and genetic and/or molecular analysis were not performed due to technical limitations at the time, a pathological diagnosis of pure MRTK was established based on the histological and immunohistochemical analysis, whereas several previous researchers have based the diagnosis of rhabdoid tumors solely on morphological and immunohistochemical findings –3.et al’s study reported a response to sorafenib with overall disease stabilization in a patient with adult rhabdoid RCC, indicating that tyrosine kinase inhibitors may be used for effective therapeutic strategies  but a poorer outcome compared with older children (2–18 years old). The tumor stage significantly affects the outcome but the use of radiotherapy is not associated with the difference in outcome . In the In conclusion, the present study reports one case of pure adult MRTK with characteristic clinicopathological features. Considering the fact that the characteristic findings are often not observed in clinical symptom and imaging studies, the histological features, immunohistochemical staining and cytogenetic studies may aid in confirming the diagnosis of pure MRTK. In addition, further study and a larger case series are required to fully clarify the natural history and identify the ideal postoperative treatment protocol for these aggressive tumors.


Genital rhabdomyoma is very rare tumor that usually occurs in the vulvar of young women. Epididymis rhabdomyoma in a young man is extremely uncommon and has rarely been reported. Here, we report a case of epididymis rhabdomyoma of a 17-year-old man and review the literatures.The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1177628224692794 Rhabdomyoma is an exceedingly rare benign tumor of striated muscle. It can be divided into the following categories: cardiac rhabdomyomas and extracardiac rhabdomyomas, which are relatively rare . GenitalA 17-year-old Chinese man presented with a painless, indurated, right testicular mass and no other associated symptoms. The patient felt the mass increased slowly during the past 2years. He denied any history of trauma to testes, systemic TB (tuberculosis), genital infections, or STD . The patient denied his family history ever had male genital tumor, such as von Hippel-Lindau disease  or other genitourinary diseases . During A firm mass with tan white fibrous capsule measured 1.5cm1.0cm1.0cm in the head of epidymis  and immunohistochemical (IHC) stains were performed. IHC staining was performed using the streptavidin-peroxidase system  according to the manufacturer's instruction. Commercially available prediluted monoclonal antibodies against the following antigens were employed: Actin  , Merck), CK , Merck), S-100 , Merck), CD34 , Merck), Vimentin , Merck), Desmin , Merck) and Ki-67 . The immune reactions were visualized with the use of DAB as the chromogen . All internal and external controls worked appropriately.D-G). Immunohistochemical stains showed these lesional cells to be negative for CK, CD34, S-100, Actin (sm), and positive for Vimentin and Desmin. Ki-67, a proliferation marker, was positive in less than 1% of lesional cells , which are rare  . Based oThe differential diagnosis of an epididymal tumor includes TB, spermatic granuloma, adenomatoid tumor (a common tumor in this location), mesothelioma, papillary cystadenoma , and embryonal rhabdomyosarcoma. The right epididymal tumor removed from the young patient showed clinicopathologic features typical of the genital variant of extracardiac rhabdomyoma. Additional histologic considerations consist of other benign processes, such as leiomyoma and fibromatosis; the presence of cross-striations and IHC steins rule out leiomyoma or fibromatosis. Histologically, the fetal variant of rhabdomyoma shares many features of the genital variant, and usually has a more myxoid and less collagenous stroma with proliferation of immature mesenchymal cells and is more cellular. Embryonal rhabdomyosarcoma should be considered in the differential diagnosis, in which one would expect to find necrosis, increased mitotic activity, abnormal mitoses, nuclear atypia, pleomorphism, anaplasia and a high proliferation index, e.g. Ki67>5% .Here, we report this quite rare tumor and provide comprehensive figures, including gross appearance, HE and IHC staining. This is the third epididymal rhabdomyoma described in the English literature ,5. The fThe authors declare that they have no competing interests.YH analyzed the data, diagnosed and wrote the manuscript as a major contributor. XQ, QL, YH, XL, QZ, JW contributed to diagnose and management of the patient. EW carried out the histopathological evaluation and helped to write manuscript. ZL performed the operation. All authors have read and approved the final manuscript.


Computertomographic and magnetic resonance imaging revealed the envelopment of the left 7th and 8th spinal nerve along with the anterior displacement of the left vertebral artery. The interdisciplinary surgical strategy consisted of a partially incomplete cyst resection, subtotal spondylectomy with posterior screw-and-rod fixation from C6-Th1, iliac crest bone grafting and anterior plating from C6-Th1. With regard to the high rate of recurrence after incomplete resection published in the recent literature, the patient was postoperatively treated by megavoltage radiotherapy with a total dose of 30Gy (daily dose of 1.8 Gy for 3 weeks). The clinical and radiographic follow-up showed complete recovery of all neurologic impairments and no signs of tumour recurrence at 3, 6 and 12 months after surgery. This case highlights diverse treatment regimens and shall outline the challenge and the problems of the interdisciplinary decision-making in adolescents presenting with ABC in high-demanding anatomical regions.The aneurysmatic bone cyst (ABC) is a benign primary bone tumour. If located in the cervical spine, its expansive growth and destructive behaviour may lead to instability and serious neurological impairment. We report a case of a 16-year-old boy with an aggressive ABC in the 7 Aneurysmatic bone cysts (ABC) are described to be benign, but locally destructive bony lesions. Representing approximately 1% of all primary bone tumours, 10-30% of ABC cases involve the spine, with approximately 22% of these located in the cervical spine region [To date, the etiology of ABCs remains uncertain. Possible explanations include a posttraumatic intralesional hematoma, whereupon ABCs may be classified into primary (idiopathic) and secondary ABC, either evolving from a bleeding into a preexisting traumatic, infectious or malignant lesion . RespectAccording to Enneking's classification, ABC may be subdivided into three developmental stages:1. State of latency without progressive growth and the tendency to spontaneous remission.2. Active state with progressive growth, but without extravagating anatomic borders.3. Aggressive state with expansive and osteolytic growth, thereby extravagating diverse tissue layers.Radical surgical debridement and complete excision of the cystic wall should be the primary therapeutic option. When complete excision of the cystic wall is achieved, the overall prognosis is good and tumour recurrence is highly unlikely. The risk of local recurrence, however, correlates well both with the preoperative state and the radicalness of resection . Therefoth cervical vertebra (stage 3 according to Enneking).In the following, we report our therapeutic regimen and surgical strategy in the case of a 16 year old boy who presented with an expansive growing bone cyst of the 7A 16 year old patient presented with a 4-month history of cervical pain, which was accompanied by a progressive radicular pain of his left arm. Within this time period he remarked a slight swelling of soft tissue in the neck and a weakness of his left arm when performing weight training.His previous medical history was without comorbidities or surgical interventions. His family history was clear of malignancies.On clinical examination there was a soft tissue swelling of the left anterior and lateral region of the neck and atrophy of the left biceps muscle. Neurologic examination revealed a slight weakness (4 out of 5 according to the Janda classification) and numbness of the left forearm and hand.th cervical vertebra in both lateral and ap views  demonstrate an expansive growth and destructive behaviour with a high rate of recurrence. Neurologic impairment and pain may be a clinical prodrome for the manifestation within the spinal column. In conventional radiographs ABC appear as expansive osteolytic bone lesions with a round-oval and polycystic structure, delineated from the surrounding tissue by a thin radiopaque layer. The three-dimensional expansion of the cyst is best evaluated by CT scan. The typical CT images outline a fluid-filled cavern, often confirmed and more precisely detected on MRI, hence with improved sensitivity for the diverse fluid layering .The differential diagnosis of the ABC includes the giant cell tumour, hemangioma, fibrotic dysplasia, the osteosarcoma and spinal metastasis of any other distant tumour.The primary goal in the therapeutic regimen of spinal ABC is to completely resect, decompress neurologic and vascular structures and to re-establish and secure biomechanical stability. However, these goals may provoke ambivalent thinking when the sufficient degree of surgery for an otherwise benign tumour and the protection of sensitive neurologic structures and their anatomical surrounding are considered.Cervical spine ABC's often involve the posterior column, which then require posterior decompression and/or resection in terms of a laminectomy, respectively. In order to prevent postlaminectomy kyphosis, additive fusion is highly recommended .The low incidence of cervical spine ABC, the small and inhomogeneous number of reports and the absence of applying any form of classification make a comparison among different surgical techniques and treatment concepts difficult. Moreover, most studies involve long follow-up periods and therefore bear the risk of changing therapeutic modalities within the study itself.Therefore, with regard to the case reported here, we aim to discuss the different modalities prophylaxis of tumour recurrence, even in cases where a complete resection is not feasible due to the expansion of the bone lesion.Recent studies have reported a high incidence of tumour recurrence in cases of incomplete primary resection, most of which appeared within the initial 6 to 12 months after surgery ,8,9. PerABC at the spine requires an angiography in the diagnostic set-up to analyse the vascularity and to support the decision making process regarding the proper therapeutic approach. As mentioned above, embolization as alternative treatment option has to be taken into account. This procedure has shown to be successful in case of ABC located at the extremities. There are cases described in the literature, where embolization alone was able to heal SAE localized at the spine without further complications . If ABC Other reports have suggested postoperative radiotherapy with a high-energy low-dose application in cases with incomplete resection -12. To dPast studies have demonstrated the effective use of megavoltage radiotherapy in both a monotherapeutic or combined surgical and radiotherapeutic approach. Yavuz and colleagues  demonstrth and 8th spinal nerve, as well as a long section of the vertebral artery was necessary allowing only for intralesional/incomplete resection.Thus, we believe that megavoltage radiotherapy for the prophylaxis of tumour recurrence in ABC is justified in cases, where the anatomical region is highly demanding, especially in case of possible ABC recurrence. As presented in our case, careful preparation of both the 7The decision should then be based on an interdisciplinary approach amongst others evaluating body height of both parents and the skeletal maturation of the patient to estimate possible growth disturbances. In our case, this evaluation revealed a state assuming skeletal growth completion and the postoperative megavoltage radiotherapy discussed and agreed upon as a decision by consensus of the interdisciplinary tumour conference.Postoperative megavoltage radiotherapy applied within the range of today's standardized protocols can be an effective adjuvant in the treatment of ABC of the cervical spine. Exact preoperative staging and multiple biopsies to confirm the diagnosis, along with the careful evaluation of all risk factors, should be mandatory. This also implies the need for a comprehensive and continuous follow-up of patients receiving such complex treatments. More particular, this case demonstrates the challenges of the decision-making process in the treatment strategy of stage 3 ABC to be a rather complex and interdisciplinary issue as the case arises. Therefore, each case is to be evaluated individually.The authors declare that they have no competing interests.JR and SKT wrote the manuscript. JG and MW collected the data pre- and postoperatively. UE and CEH operated the patient and revised the manuscript critically. CEH and GVS-S gave input regarding the design and gave the final approve of the version to be published. All authors read and approved the manuscript.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.


Primary gallbladder neuroendocrine tumors are extremely rare, representing 0.2% of all neuroendocrine tumors. The diagnosis is incidental in most cases.111In-pentetreotide scintigraphy, and hormone-specific marker results were negative. He is disease-free 45 months after surgical treatment.We describe the case of a 57-year-old Caucasian man who underwent laparoscopic cholecystectomy for the evaluation of a gallbladder polyp that had been incidentally detected by ultasonography. Histologically, his lesion was composed of monomorphic cells that contained small round nuclei and that were organized in small nodular, trabecular, and acinar structures. His cells were positive for chromogranin A and synaptophysin, and a diagnosis of "typical" carcinoid of the gallbladder was made. His post-operative computerized axial tomography, Characteristic pathological findings of the gallbladder neuroendocrine tumors predict the prognosis. Whereas classical carcinoids of the gallbladder only rarely have a metastatic or invasive phenotype, the "atypical" variants are more aggressive and are associated with a poorer prognosis. Given the difficulty in distinguishing between benign and malignant lesions in the pre-surgical setting, we tend to consider each polypoid-like lesion of the gallbladder to be a high-risk lesion if it is larger than 1 cm and, as a result, to emphasize the need for cholecystectomy in all cases, relying on the pathological and immunohistochemistry analyses for the final diagnosis. Carcinoids are rare neuroendocrine tumors (NETs) derived from enterochromaffin or Kulchitsky cells, which are widely distributed in the body ,2. ConseAccording to American epidemiological data, gallbladder (GB) NETs are rare, representing only 0.2% of all NETs . ApproxiA 57-year-old Caucasian man with a seven-year history of hepatitis B virus infection was admitted to our hospital for the treatment of a GB polyp. The abdominal ultrasonography (US) revealed the presence of a well-defined polypoid mass of approximately 12 × 8 mm in his GB fossa  on admission were normal. On the basis of these data, a pre-operative diagnosis of a single polypoid lesion of the GB (PLG) of larger than 1 cm was made and a laparoscopic cholecystectomy was performed.On gross inspection, the GB measured 6 cm and no evidence of stones in our patient's lumen was found. However, a polypoid, yellowish lesion, measuring 11 × 8 mm, was found between the body and the neck of his GB. Histologically, his tumor was composed of monomorphic cells containing small, round nuclei and eosinophilic cytoplasm. His cells were organized in small nodular, trabecular, or acinar structures surrounded by a richly vascularized stroma but showed no mitotic structures Figure . Immunoh111In-pentetreotide scintigraphy, which is used to detect cells with somatostatin receptors, were also normal. His blood levels of glucagon, serotonin, vasoactive intestinal peptide, somatostatin, and gastrin were normal, as were his 24-hour urinary levels of 5-hydroxyindoleacetic acid (5-HIAA) and CgA. After an uneventful recovery, our patient was discharged in good condition, and he is disease-free 45 months after surgical treatment.Post-operatively, our patient underwent a total body computed tomography (CT) scan and bone scintigraphy and the results were normal. The results of his Primary GB carcinoids are extremely rare. The first case of a carcinoid tumor of the GB was reported in 1929, and 43 cases of carcinoid tumors have been reported to date. Approximately half of the reported cases of GB carcinoid tumors appear to be endocrine cell carcinomas . At presThe case reported here was initially diagnosed as a polyp after an ultrasound examination. PLGs are readily detected by US  with higThe majority of GB polyps are non-neoplastic and most commonly include cholesterol polyps (60%) or inflammatory ones (10%). Adenomyomas represent the second most common type of GB polyps (25%). This type of lesion is associated with an increased incidence of GB cancer, and the GB should be removed surgically. Adenonomatous polyps represent a minority. They can progress to cancer, and this risk is related to their size: polyps larger than 1 cm are considered high-risk lesions. The fifth class of GB polyps consists of rare lesions that include heterotopic gastric glands, neurofibromas, carcinoid tumors, leiomyomas, and fibromas.The specificity of abdominal US in PLG detection is high , but theOperative indications for PLGs included a maximal diameter of 1 cm, a wide-base lesion, lesions tending to become enlarged in a short period, patient age of more than 50 years, a single polypoid lesion, coexisting GB stones, and a PLG associated with irregular thickening of the local GB wall.Our patient's histological results after cholecystectomy were suggestive of an NET tumor. The determination of the histological type of the tumor and differential diagnosis from GB adenocarcinoma are often difficult. The identification of neuroendocrine cells and the immunohistochemical expression of marker proteins as well as other cell type-specific amines and peptides are necessary to define a GB NET. Our patient's immunohistochemistry test results were negative for cytokeratin, vimentin, and CD-31 and CD-34, allowing us to exclude a likely diagnosis of adenocarcinoma, sarcoma, or vascular tumor, respectively. The combination of the high histological differentiation, the tumor size, the absence of angioinvasion and infiltrative growth, and the immunohistochemical staining supported the final diagnosis of a "typical" rather than of an "atypical" NET tumor.When feasible, surgical treatment, with the goal of complete resection, is the gold standard for typical carcinoids of the GB. For pre-invasive and early-detected cancer T1s and T1), simple cholecystectomy is probably an adequate therapy. For advanced lesions, a more aggressive radical surgery, including radical cholecystectomy and regional lymphadenectomy combined with a hepatic resection in order to obtain adequate free margins, is needed [s and T1,111In-pentetreotide has a high affinity for somatostatin subtype 2 and 5 receptors, which are present on the cell membranes of carcinoid tumor cells, making 111In-pentetreotide scintigraphy a good technique for imaging carcinoid tumors [111In-pentetreotide scintigraphy, and bone scintigraphy tests in our patient were all normal, indicating the lack of metastases and the successful surgical treatment of a "typical" carcinoid of the GB. Indeed, in one study, 82.4% of GB carcinoids remained localized and only 11.8% of patients demonstrated distant metastases [For many years, sieric CgA and urinary 5-HIAA, each of which has a specificity of nearly 100% but a low sensitivity, have been the gold standard for detecting carcinoids and conducting follow-up . 111In-pd tumors . Standard tumors . Post-optastases . The samConsidering the difficulties in making a pre-operative differential diagnosis between a benign "typical" carcinoid and the more aggressive "atypical" variants or between NET, adenocarcinoma, and benign lesions of the GB, we emphasize the need for surgical management for any suspected polypoid lesion, relying on the pathologist and immunohistochemistry analyses for the final diagnosis. We underline the need to distinguish between different forms of NETs of the GB with different metastatic potential, prognosis, and clinical course.5-HIAA: 5-hydroxyindoleacetic acid; CgA: chromogranin A; CT: computed tomography; EUS: endoscopic ultrasonography; GB: gallbladder; HRUS: high-resolution ultrasonography; NET: neuroendocrine tumor; PLG: polypoid lesion of the gallbladder; SEER: Surveillance, Epidemiology, and End Results; US: ultrasonography.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SM drafted and wrote the manuscript and was involved in data interpretation. EO was involved in the conception and design of the study. FLT and VLT were involved in the care of our patient. VP was involved in histological diagnosis, pathological findings, immunohistochemical studies, and figures and contributed to writing the manuscript according to his specialty. ML was involved in immunohistochemical studies and figures. OS provided scintigraphic images and was responsible for critical revision of CT images. BC was involved in administrative support. All authors read and approved the final manuscript.


Spontaneous perforation is a very rare complication of pyometra. The clinical findings of perforated pyometra are similar to perforation of the gastrointestinal tract and other causes of acute abdomen. In most cases, a correct and definite diagnosis can be made only by laparotomy. We report two cases of diffuse peritonitis caused by spontaneous perforated pyometra. The first case is a 78-year-old woman with abdominal pain for which laparotomy was performed because of suspected incarcerated hernia. The second case is a 61-year-old woman with abdominal pain for which laparotomy was performed because of symptoms of peritonitis. At laparotomy of both cases, 1 liter of pus with the source of uterine was found in the abdominal cavity. The ruptured uterine is also detected. More investigations revealed no malignancy as the reason of the pyometra. Pyometra is the collection of pus in the uterine cavity, and it is known as a rare condition . The maiThe first case is a 78-year-old multiparous woman who had Le Fort surgery five weeks ago because of procidentia and medical problems. She was admitted because of fever, vomiting, and diffused abdominal pain during the last 24 hours. She had epigastric hernia in her past medical history. The vital signs were stable. She had tender abdomen and normal pelvic examination. The laboratory tests included hemoglobin = 8.7 g/dL, BUN = 64 mg/dL, and creatinine = 1.1 mg/dL. Other tests were in normal ranges.She was diagnosed with incarcerated hernia and then laparotomy was performed. At the laparotomy, 1 liter of pus arising from a perforated uterus was found in the abdominal cavity. The fundus of the uterus was found to have a perforation about 2 cm in diameter with purulent discharge. Abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Histopathological findings revealed severe inflammation and necrosis involving endometrium, myometrium, upper part of cervix, and right fallopian tube. She was discharged with good condition on the 20th postoperative day.The second case is a 61-year-old multiparous menopaused woman who had history of treatment of pyelonephritis one week ago. The surgery which was performed was total abdominal hysterectomy and bilateral salpingo-oophorectomy. She was admitted because of fever, nausea, and diffused abdominal pain during the past 48 hours. Her gynecologic history was unremarkable. She had history of low abdominal pain for many days. She looked very ill with unstable vital signs  and also having no urine output. Her abdomen was distended with generalized tenderness and rebound tenderness. The laboratory tests were as follows: white blood cell count 21000 with 90% neutrophils, hemoglobin 10.2 g/dl, prothrombin time = 18 seconds, partial thromboplastin time = 40 seconds, INR = 2.1, C reactive protein = 102 mg/dL, BUN = 35 mg/dL, creatinine = 1.8 mg/dL, and platelet count = 137000.She was diagnosed as having diffuse peritonitis due to rupture of ovarian abscess, and laparotomy was performed. At the laparotomy, 1 liter of pus arising from a perforated uterus was found in the abdominal cavity. The posterior wall of the uterus was found to have a perforation about 2 cm in the diameter with purulent discharge. Pathological investigation of the surgical specimen revealed endometritis and myometritis of the uterus and bacterial aggregation and fat necrosis, but there was no evidence of malignancy. She was discharged on the 30th postoperative day after treatments.Accumulation of purulent material in the uterine is termed as pyometra. It is an uncommon condition occurring mainly in elderly postmenopausal females and due to impaired drainage of uterine cavity. Impaired drainage conditions include cervical canal stenosis, benign or malignant cervical lesions, and surgical complications . AlthougSpontaneous rupture of pyometra is extremely rare and the incidence is 0.01–0.05% with only 28 cases reported and indexed in the English literature , 8–10. AFrom a report of Saha et al., 73% of the nonmalignancy cases had favorable prognoses for survival, whereas only 33% of malignancy cases did so . ConsideAlthough spontaneous rupture of pyometra is rare, it should be kept in mind as a differential diagnosis in postmenopausal women presenting with acute abdomen, because correct diagnosis, early intervention, intensive pre- and postoperative care, and proper treatment can reduce morbidity and mortality.


Malignant transformation of a mature cystic teratoma (MCT) is an infrequent, often asymptomatic event. We report the first example of a struma ovarii with a focus of follicular variant of papillary thyroid carcinoma (a), mucinous adenocarcinoma (b), and strumal carcinoid tumor (c)—all three arising in one mature cystic teratoma of the ovary. From our reviews, we found limited data to guide management when these malignant foci occur within an MCT. Consideration should be given to thyroidectomy followed by total-body scanning and serum studies for foci of thyroid carcinoma and adjuvant therapy with thyroidectomy and radioablation if residual disease is identified (a). Additionally, extrapolating from data for mucinous adenocarcinomas, consideration could be given to adjuvant chemotherapy after appropriate staging (b). Strumal carcinoid tumors should be treated as tumors of low malignant potential. Observation is appropriate if after complete staging, no invasive implants are noted (c). Mature cystic teratoma (MCT) is not a rare occurrence, accounting for about 20% of ovarian tumors, but malignant transformation of MCT is infrequent . ReportsStruma ovarii is a rare monodermal ovarian teratoma, diagnosed when a teratoma specimen contains at least 50% thyroid tissue. These represent about 2% of MCT and most commonly occur in the fifth or sixth decades of life. Malignancy within struma ovarii occurs in roughly 5%, or roughly 0.1% of MCT. Typically these malignancies are found postoperatively. These carcinomas can be classified into three types: papillary, follicular variant of papillary, and follicular . Mucinous tumors are classified as a surface epithelial tumor. However, 3–5% of such tumors develop in association with MCT. Historically, mucinous tumors have been difficult to interpret and are classified as either benign, borderline, or carcinoma. Borderline tumors can be of two types, endocervical or intestinal. Sometimes, mucinous tumors are actually metastatic to the ovary from another intra-abdominal organ. Typically, metastatic disease to the ovary is indicated bilaterally, by smaller dimension (<10 cm), and advanced stage .Primary ovarian carcinoid tumors are also very rare and account for fewer than 0.1% of all ovarian carcinomas. They can be subdivided into four types: insular, strumal, trabecular, and mucinous. They may occur with or without an associated MCT, and although most commonly as a singular subtype, mixed primary ovarian carcinoids have been reported . PresentForthcoming is a case report of a postmenopausal patient with a cystic and solid right ovarian mass. The mass was found to be a mature cystic teratoma containing three separate and different malignant foci.A 74-year-old, gravida1 para1 Caucasian female presented following an incidental finding of a pelvic mass noted on CT scan completed for the evaluation of postoperative edema. The patient recently underwent open heart surgery with two valve replacements approximately two months prior to presentation at our center. Postoperatively she experienced generalized edema and a workup to elucidate the underlying cause was significant for a CT scan demonstrating a 13 × 9 cm right adnexal mass with fat, soft tissue, and bony elements, consistent with a teratoma. Notably, the CT was negative for adenopathy or omental caking. Subsequent ultrasounds corroborated these findings and additionally noted an endometrial lining of 7 mm. Except for the above mentioned edema, her review of systems was entirely negative. Her medical history is significant for coronary artery disease, atrial fibrillation, congestive heart failure, hypertension, and type 2 diabetes mellitus. The patient underwent a robotic assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (BSO), bilateral pelvic and para-aortic lymph node dissection, infracolic omentectomy, and staging biopsies. Intraoperative pathology suggested a portion of the right ovary contained malignant cells, suggestive of thyroid carcinoma. There was no gross evidence of metastatic disease. Pathologic gross examination revealed a previously ruptured, right ovarian mass weighing 143 grams that measured 8.5 × 7.3 × 5.5 cm. The outer surface was pink-white, hyperemic and smoothly bosselated. On opening, the mass was cystic, filled with grumous tan-brown material and had a raised, 2.5 × 2.0 × 1.5 cm protrusion and multiple solid tan-yellow to tan-white tissue with minimal hemorrhage. A minimal amount of hair was also identified. No normal appearing ovarian parenchyma was seen grossly. Two representative portions are submitted for frozen section evaluation. Additionally, eight more sections submitted for permanent diagnosis. Intraoperative consultation revealed cells with high nuclear cytoplasmic ratio, chromatin clearing, pseudoinclusions suggestive of malignant tumor arising in teratoma possibly thyroid carcinoma. Microscopic evaluation of permanent sections demonstrated a mature cystic teratoma with struma ovarii component arising from the right ovary with multiple malignant foci. The mature cystic teratoma components consist of skin, cartilage, benign colonic, and thyroid tissues . The mal131I. One of the 24 patients experienced persistent disease postoperatively, but 8 of 23 recurred after complete response to initial surgery. All eight recurrences were noted in patients who did not receive adjuvant therapy. No recurrences were noted in the group of seven patients receiving adjuvant therapy after complete response to initial surgery [A Medline search using keywords malignant struma ovarii and teratoma revealed numerous case reports as well as two recent reviews , 4. The n = 5) were classified as mucinous carcinoma and 40% were classified as mucinous cystadenoma. Three of five carcinomas had peritoneal carcinomatosis and classical pseudomyxoma peritonei noted during initial surgery. Treatment was not discussed, and follow up was only available for the aforementioned three. One died of disease at 6 months, and two were alive with disease, one immediately after surgery and the second at 29 months [A Medline search using combinations of keywords mature teratoma and intestinal type and mucinous and glandular epithelial neoplasms returned little data applicable to our patient. In one case series of 42 patients with mucinous epithelial tumors arising in association with mature ovarian teratomas, 12%  was given, but the patient died of her disease one year after diagnosis of recurrence. Interestingly, although this patient was diagnosed with a strumal carcinoid, only the carcinoid element metastasized. In this same case series, five patients were deceased from other causes, but 90% of patients were alive and well . These aA second review of 150 patients with primary ovarian carcinoids published in 1984 also concluded that these metastasize only occasionally and should be treated as ovarian tumors of low malignant potential [131I resulted in regression of metastatic disease [Subsequent to these reviews, Armes reported on a 24-year-old pregnant female presenting with torsion who was found to have widespread metastases of a strumal carcinoid. This patient's pathology, interestingly, was reported as more reminiscent of a malignant struma ovarii, as only the thyroid follicular carcinoma component was noted to be metastatic. The pregnancy was terminated, and she was initially treated with 3 cycles of bleomycin, etoposide (VP-16), and cisplatin. This was unsuccessful, but further treatment with thyroidectomy and A third review of 17 primary ovarian carcinoid tumors published in 1996 included four not previously reported primary ovarian carcinoids with strumal histology treated with cystectomy (one) or hysterectomy and BSO (three). All were stage I at presentation and none had evidence of disease at 2 or more years from diagnosis. In addition to the new patients, a literature review was also included which was notable for 32 patients with strumal carcinoid with MCT. All were stage I at presentation with only one patient (or 3%) died of her disease. For the 17 new patients, five-year survival was excellent (100%) when disease was confined to one ovary (11 of 17). One patient recurred at 13 years and died of disease at 14 years. The 6 patients with stage III or IV disease all had insular histology, and their five-year survival was reported as 33%. The authors concluded that primary ovarian carcinoid tumors treated with surgery alone and found to be confined to the ovary are expected to have an excellent outcome [131I ablation, and thyroxine suppression therapy [131I scintiscan to assess for residual malignant disease and trending serum thyroglobulin levels to monitor for recurrence and adjuvant therapy only if these were positive, and this should be used with caution if not in the setting of thyroidectomy as most malignant struma ovarii have poor iodine uptake and thyroid hormone synthesis [Likely due to the rarity and resulting inability to design management trials, there is no consensus on the treatment of malignant struma ovarii. Various case studies recommend different treatment options. Surgical treatment ranges from unilateral oophorectomy to complete staging. Adjuvant treatment possibilities include radiation, traditional chemotherapy, thyroidectomy and  therapy , 14. Somynthesis . The ratynthesis . PatientAs expected, treatment is even more complex when future fertility is desired. Although not applicable to our patient, if fertility is desired consideration could be given to retaining the uterus and contralateral ovary when there is no evidence of extra-ovarian spread during staging surgery. Post-operative management could include suppressive treatment with thyroxine.There is little information on treatment outcomes with mucinous adenocarcinoma within MCT without evidence of metastatic spread. One proposed approach is to treat this disease as one would treat primary ovarian mucinous type epithelial carcinomas. A second approach is expectant management without further surgical staging . A post-131I ablation, similar to the treatment of metastatic struma ovarii [All of the reviewed literature suggests that stage I strumal carcinoid tumors can be treated with surgical excision. Most commonly this is done by salpingo-oophorectomy , but there are reports of 5 year disease free survival with cystectomy alone , 10. Met131I total-body scintiscan was done, recognizing the limitations of this study, and did not show any extrathyroidal functioning tissue. For her mucinous adenocarcinoma and stromal carcinoid elements, it was decided that surgical resection was sufficient treatment. We will continue to follow her every three months for clinical evidence of disease.In summary, this is a very unique patient with multiple malignant transformations within one MCT. Six months postoperatively, she is doing well and has no evidence of disease. After a multidisciplinary meeting and then discussions with the patient and her family, keeping in mind her medical comorbidities, surgical findings, pathology, and wishes, no further surgery or chemotherapy is planned. For the component of malignant struma ovarii, a


Retroperitoneal leiomyomata are rare. They are either mistaken preoperatively for malignant retroperitoneal tumors or dealt with as cases of subserous leiomyomata that turn out intraoperatively to be huge retroperitoneal masses of unknown nature.We report the case of a 46-year-old nulligravid female patient of Middle Eastern ethnicity who presented to our university hospital with lower abdominal as well as pelvic pain along with a bloated sensation. She also reported noticing an unusual increase in her abdominal girth. These symptoms developed over the previous two months. Preoperative investigation by means of an ultrasound suggested a degenerated subserous huge uterine leiomyoma. An abdominal hysterectomy was planned. Intraoperatively, a normal sized uterus was found, the surface of which was studded with multiple variable sized pedunculated subserous leiomyomata. Another huge retroperitoneal soft to firm mass was found extending from her left pelvic wall to the level of her spleen, with no connections to her uterus. The mass was excised and a histopathological examination revealed a degenerated leiomyoma.Some unusually located extra-uterine leiomyomata have been reported; retroperitoneal leiomyoma being among them. The origin of such tumors is still obscure; a parasitic origin as well as Müllerian cell rests or smooth muscle cells in the retroperitoneal vessels wall have been suggested. An 'iatrogenic' origin for such growths is also a possible theory. The origin of uncommonly located leiomyomata is an unexplored issue that merits more investigation. Kang ber 2008 . We updaber 2008 . This raThe currently reported case is of a 46-year-old nulligravid female patient, of Middle Eastern ethnicity, who presented to the outpatient Gynaecology Clinic of our hospital one year ago. Her complaints included mild pelvic pain requiring the intake of non-steroidal anti-inflammatory drugs once a day two days a week at most. She also complained of pelvic heaviness combined with a gastrointestinal bloating sensation that required the daily intake of antiflatulent medication, which was not helpful in soothing the complaint. She had a past medical history of primary infertility for 20 years. She also had an abdominal myomectomy through a low-transverse abdominal incision 17 years earlier. A clinical examination revealed a huge pelvi-abdominal mass extending up to the level of her xiphisternum. A combined abdominal and vaginal ultrasound (US) revealed the presence of multiple leiomyomata with a huge subserous leiomyoma showing evidence of degeneration and extending to the level of the left lobe of her liver  with no atypia, thus confirming the benign leiomyomatous nature of this huge retroperitoneal growth, with evidence of hyaline degeneration Figure et al. claimed that Müllerian cell rests or smooth muscle cells in the retroperitoneal vessels wall are the putative origin [et al. is the more accepted explanation for such a location for the growth of a leiomyoma [Uterine leiomyoma is the most common benign gynecological tumor affecting as many as 25% of women in the reproductive age group , and is e origin . Kho ande origin . In our eiomyoma .Thorough radiographic imaging of sonographically diagnosed leiomyomata is important, especially for those which are large in size or present in an uncommon location. Several theories have been postulated regarding the origin of retroperitoneal leiomyomata; however, the exact etiology is still an unexplored issue that merits more investigation.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor in-Chief of this journal.The authors declare that they have no competing interests.AS wrote the manuscript and was directly involved in the patient care. BE performed the histological examination, diagnosis and the photo acquisition. NH was directly involved in the patient care and contributed to the review of the literature. HS was involved in the manuscript idea and drafting. TE provided general surgical input and critical reading of the manuscript. All authors read and approved the final manuscript.


Introduction. Although pyogenic granulomas (PG) are common and benign vascular proliferations of the skin and mucous membranes, they are relatively rare on the vulva. Case Presentation. A 57-year-old G7P7 postmenopausal woman presented with a 3-year history of a foul smell and bleeding lesions in the genital region. A gynecologic examination revealed multiple large papillomatous, pedunculated, and lobulated lesions that were cherry-red and infective in appearance. There was a 2-cm lesion at the upper intersection of the labia majora, a 2-cm lesion on the right labium majus, and a 4-cm lesion on the clitoris. The patient complained of itching, and the lesions were asymptomatic, except for occasional bleeding. All lesions were excised and sent for histopathological examination, which revealed an ulcerated polypoidal structure with extensive proliferation of vascular channels lined by a single layer of endothelium. The histopathological features were consistent with PG. Conclusion. The present case is the first case of multiple pyogenic granulomas on the vulva in a postmenopausal woman. Pyogenic granulomas (PGs) (lobular capillary hemangioma) are common and benign vascular proliferations of the skin and mucous membranes . ClinicaPyogenic granulomas of the vulva are a relatively rare finding, and a limited number of cases—to our knowledge, there are two reported cases—have been reported in the literature , 5. In tA 57-year-old G7P7 postmenopausal woman presented with a 3-year history of a foul smell and bleeding lesions in the genital region. A gynecologic examination revealed multiple large papillomatous, pedunculated, and lobulated lesions that were cherry-red and infective in appearance. There was a 2-cm lesion at the upper intersection of the labia majora, a 2-cm lesion on the right labium majus, and a 4-cm lesion on the clitoris . There wAll lesions were excised and sent for histopathological examination , which rAlthough it is believed that PG is a reactional benign lesion formed due to minor trauma and/or chronic low-grade local irritation –8, its eAlthough PGs are seen in every age group, a higher frequency of PG is observed in the second decade of life , with a Although PG usually occurs as a single lesion , there w


Abdominal trauma is a source of significant mortality and morbidity. Bowel injury as a result of blunt abdominal trauma is usually evident within hours or days of the accident.A 38-year-old Caucasian Greek man presented with a subtle and delayed small bowel obstruction caused by a post-traumatic ileosigmoid fistula and ileal stricture four months after a road traffic accident.Delayed occurrence of post-traumatic small bowel stricture and ileosigmoid fistula is an uncommon surgical emergency. General surgeons as well as emergency physicians should bear this manifestation in mind should a patient return to the hospital several weeks or even years after blunt abdominal trauma with symptoms or signs of bowel obstruction. The abdomen is the third most commonly injured body part following trauma . In 85% A 38-year-old Caucasian Greek man presented to our emergency department complaining of a three-month history of intermittent abdominal pain and frequent episodes of diarrhea. He had a history of a previous admission in another surgical department four months earlier for BAT after a road traffic accident. At that time he underwent an abdominal ultrasound, which showed no intraperitoneal fluid or solid organ injury, and he was admitted for observation. We also recovered from his discharge note that, during the first 48 hours of his hospitalization, a progressive decrease in the hematocrit value from 41% to 28% was noted. An abdominal CT scan at that time showed a small amount of fluid in the rectovesical pouch with no solid organ abnormalities and a large hematoma in the subcutaneous fat tissue on both lumbar areas. He was hemodynamically stable and he had a transfusion with one unit of packed red blood cells and three units of fresh frozen plasma. He improved rapidly with conservative treatment and was discharged on the fifth day, asymptomatic. One month later he started to have episodes of vague abdominal pains and frequent episodes of diarrhea after meals. Our patient also mentioned that during that four-month period he had lost 10 kg in weight. Due to his fear of the resulting diarrhea, he had cut down on eating.On our patient's current admission he complained of a colicky pain at the periumbilical region for the last 24 hours and two episodes of vomiting. On physical examination his abdomen was mildly distended with a diffuse tenderness on the hypogastrium. There was no rebound or guarding and palpation did not reveal any abdominal masses. His bowel sounds were increased. His blood tests were unremarkable. Plain abdominal X-rays revealed a dilated small bowel loop consistent with intestinal obstruction. He was initially treated with intravenous fluid replacement and nasogastric tube but his symptoms did not resolved. An enhanced-abdominal CT scan showed a small bowel loop with a thickened wall and narrow lumen with proximal bowel dilation. There was also increased density of the adjacent mesenteric fat Figure . BearingTraumatic small bowel stricture and delayed small bowel obstruction secondary to BAT is a rare clinical entity. It is the result of local ischemia of the bowel wall and its subsequent healing with fibrosis and stricture, which causes the delayed onset of symptoms . This loPatients suffering from post-traumatic small bowel obstruction usually present with intermittent abdominal pain and vomiting . The intThe presence of free intraperitoneal fluid in the abdomen without any evidence of solid organ injury is indeed an intriguing diagnostic challenge. Concerning the role of CT, it is unclear if it can provide a solid and conclusive answer as to whether surgery or close observation is best. Although CT exhibits very high sensitivity and specificity in detecting most solid organ injuries, it can still miss up to 15% of small bowel and mesenteric injuries . We beliPatients with BAT who have small amounts of intraperitoneal fluid as the only finding on CT and are hemodynamically stable can be safely managed without surgical intervention. Delayed occurrence of post-traumatic small bowel stricture and ileosigmoid fistula is indeed a rare entity. Diagnosis of post-traumatic small bowel stricture could be difficult but general surgeons and emergency physicians should bear in mind this clinical manifestation and remain vigilant, especially when a patient presents with free intraperitoneal fluid after BAT on imaging, even if there are no signs of solid organ injury.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.BK performed the literature search and was the chief author in writing the manuscript. DK performed the literature research and co-authored the paper. KS was the attending surgeon of the case and checked the paper. SG assisted with the linguistics and performed the literature research. EA helped with illustrations and submitted the radiological images. GA was the chief surgeon and performed the final check of the paper. All authors read and approved the final manuscript.


Objective. Aim of our study is to present a case of a twin pregnancy following invitro fertilization cycle complicated with hemoperitoneum at third trimester. Case. A 26-year-old nulliparous pregnant woman at 32 weeks of gestation with twin pregnancy following invitro fertilization cycle complained of abdominal pain. After 48 hours of admission, laparotomy was performed with indications of aggravated abdominal pain and decreased hemoglobin levels. Utero-ovarian vein branch rupture was detected on the right posterior side of uterus and bleeding was stopped by suturing the vein. Etiopathogenesis of the present case still remains unclear. Conclusion. Spontaneous rupture of the uterine vessels during pregnancy is a rare complication and may lead to maternal and fetal morbidity and mortality. Diagnosis and treatment are based on the clinical symptoms of acute abdominal pain and laboratory tests of hypovolemic shock signs. Hemoperitoneum in pregnancy is a rare but a dramaticlife threatening complication that results from ruptured uterine vessels . Even thA 26-year-old nulliparous woman with a dichorionic-diamniotic twin pregnancy achieved by assisted reproductive techniques was admitted at 32 weeks of gestation. At admission, her complaints were epigastric pain and flank pain. Until that time, the patient had an uneventful pregnancy without history of vaginal bleeding, abdominal trauma, uterine contraction, or recent sexual intercourse. Her past medical history included neither abdominal surgery nor myoma uteri. On physical examination, the temperature was 36°C, the blood pressure was 110/70 mm Hg, the pulse was 92 beats per minute, and respiratory rate was 24 beats per minute and vital parameters were normal. At initial abdominal examination, she had no rebound tenderness. Pelvic examination was one cm dilated with a soft cervix. Cardiotocography showed irregular contractions with reactive fetal heart rate tracing. Hemoglobin (Hb) was 10.3 g/dL, hemotocrit level (Hct) was 31.4%, white blood cell count (WBC), C-reactive protein (CRP) level and other laboratory results were normal. Urinalysis revealed 100 mg/mL protein and leucocyte (++). Obstetrical ultrasonography examination revealed two otherwise healthy fetuses with apppropriate biometrical calculations and with normal amniotic fluid, Doppler flow velocimetry indices. Maternal abdominal ultrasound examination revealed minimal anechoic free fluid in the right lower quadrant but appendix was not observed. Transvaginal ultrasound examination revealed a 26 mm cervical length.3/UL. Since leucocyte counts increased gradually and symptoms became more obscure, surgery had been decided with the diagnosis of acute abdomen. Under spinal anesthesia, laparotomy was extended through pfannenstiel incision and 300–400 mL hemoperitoneum was observed in the peritoneal cavity. Pelvic exploration revealed blurish color on the posterior right side of the uterus, active bleeding from right uterine vessel, and a torn uterine serosa  was performed for lung maturation. Nifedipine 10 mg 6 times a day  and then beta-agonists was administered for 24 hours for accelerated uterine contractions. Within 24 hours of admission the patient gradually complained of progressive nausea and vomiting. The patient was consulted to general surgery department, and oral intake was stopped, a nasogastric catheter was placed, a proton pump inhibitor was started intravenously, and an antibiotic regimen was administered ) and metronidazole 1 gr/day  for suspicion of appendicitis. Whole abdominal and pelvic magnetic resonance (MR) imagings were performed and revealed a minimal intra-abdominal free fluid without any pathological signs. On the second day, abdominal pain with nausea and vomiting gradually increased but no rebound tenderness was experienced. Hg level decreased to 9.53 g/dL, htc level decreased to 29.4%, and WBC increased in value of 19.4 × 10e serosa . A 8-9 ae serosa . PostopeIn 1950, the largest published series, a review of 75 cases due to utero-ovarian vessel rupture, reported a 49% of maternal mortality; however mortality rate declined to 3.6% by subsequent developments in medicine [Sudden onset of abdominal pain, hypovolemic shock signs, and decreased hemoglobin levels indicate utero-ovarian vessels rupture such as other intra-abdominal bleeding causes. Amount, rapidity of blood loss and location of bleeding changes symptoms of hemoperitoneum . TherefoIn the English literature, until now there has been six reported twin cases of hemoperitoneum with stage IV endometriosis and one case with stage I endometriosis –13. ChroWe present the fifth twin pregnancy following IVF treatment. Twin pregnancy incidence is increasing which may be due to frequent use of assisted reproductive technologies and has higher rates of obstetrical complications compared with single pregnancies. Therefore similar complications may increase. For the present case, the mechanism of rupture was indefinable, because of lack of endometriosis, adhesions, prior surgery, and myoma uteri. We do not know whether or not during ovum pickup procedure, damaged vessel wall or uterus was prone to rupture as a consequence of hemodynamic alterations of pregnancy such as increased cardiac output. However 3rd trimester ruptured vessel due to ovum pickup as a long term complication was not reported in the literature.The preoperative diagnosis was so difficult because the patient had normal hemodynamic parameters and had a variety of clinical symptoms. Hemoglobin levels did not decrease rapidly which may be due to uterine pressure on the uterine vessel. When acute abdomen is diagnosed, hemoperitoneum should be considered in the differential diagnosis during gestation . NonspecIn conclusion, spontaneous uterine vessel rupture is a rare dramatic event in pregnancy. In a case presenting with severe abdominal pain with either fetal distress or maternal hemodynamic instability, spontaneous uterine venous rupture should be considered. Close observation and early intervention were essential for maternal and fetal survival.


A 54-year-old female presented with a large pancreatic tumor of the tail during a regular physical examination. The patient underwent surgical intervention and the surgeon identified that the tumor originated from the retroperitoneal region. Markedly severe hemodynamic fluctuations occurred during the manipulation of the tumor and continued to occur subsequent to the tumor being removed. The vital signs were adequately managed and the surgery was successful without complications. The patient was discharged without any sequelae days later. The pathology report indicated a diagnosis of pheochromocytoma. Unexpected pheochromocytoma may lead to a fatal hypertensive crisis with catastrophic sequelae during surgery. The peri-operative management of pheochromocytoma remains a complicated challenge that requires intensive pre-operative preparation and vigilant peri-operative care. For surgeons and anesthesiologists who may encounter an unexpected hypertensive crisis during abdominal tumor surgery, undiagnosed pheochromocytoma should always be considered. Pheochromocytomas occur most frequently in individuals aged 40–50 years, with a slight predilection in females . The tumA 54-year-old female , was transferred to Tri-Service General Hospital on account of an unexpected large pancreatic tumor. The clinical history of the patient included paroxysmal headaches, mildly elevated blood pressure (BP), diaphoresis and occasional palpitations. The patient was previously diagnosed with ventricular arrhythmia by cardiovascular departments in numerous hospitals, without any other significant findings. The patient was not administered regular treatment for the headaches or hypertension as the symptoms were considered insignificant. One month prior to surgery, the patient underwent a detailed health checkup and an abdominal mass was identified using abdominal sonography. A large, well-encapsulated pancreatic tail tumor, measuring 9 cm in length, was observed on abdominal computed tomography . The patOn admission, mildly elevated BP (138–160/80–90 mmHg) with a heart rate (HR) of 70–90 beats per minute (bpm) was noted. The ECG revealed a normal sinus rhythm with two ventricular premature contractions (VPCs). Other laboratory tests showed no significant abnormalities. An exploratory laparotomy with a resection of the tumor was scheduled. Thoracic epidural anesthesia was initially performed without adverse events, followed by general anesthesia. When the pancreas was approached, no any abnormal lesions were identified, with the exception of a bulging mass from the retroperitoneal region. The mass originated from the adrenal gland and presented as a capsulated, vessel-rich tumor. The systolic BP surged to 260 mmHg abruptly with fluctuations and the HR increased to 150 bpm during the manipulation of the tumor. The concentration of the anesthesia was increased along with an additional administration of 100 μg intravenous (i.v.) fentanyl. The fentanyl was ineffective and 5 mg i.v. labetalol was administered twice. However, the hypertensive crisis remained. The surgeon made a temporary stay of surgery until the vital signs were under control and then the tumor was removed.The BP dropped (75/50 mmHg) once the tumor was removed. Aggressive fluid replacement and vasopressors were administered until the patient was hemodynamically stable. The endotracheal tube was then removed. At one day post-surgery, the patient was completely asymptomatic and no sequelae were identified. The pathological report confirmed a diagnosis of pheochromocytoma  and the Although the majority of pancreatic tumors are malignant, others, including insulinomas, gastrinomas and vasoactive intestinal peptide-producing tumors (VIPoma), are benign endocrine tumors . The mosPheochromocytoma is one of these adrenal tumors and may lead to life-threatening events if precautions are not taken, particularly during surgery. The symptoms and signs that may be solicited are paroxysmal attacks of sweating, headaches, hypertension, glucose intolerance and arrhythmia, which may occur in certain cases ,7,8. The


Volvulus in puerperium is a rare event. We present a case of cecal volvulus following normal vaginal delivery that ended with cecal gangrene and hemicolectomy. Intestinal obstruction is a very rare event during pregnancy with reported incidence varying widely between 1 in 1500 to 1 in 66431 . Due to A 26-year-old para two was referred to our hospital on third postpartum day with history of sudden onset lower abdominal cramping pain, abdominal distension, vomiting, and obstipation for two days. The patient had a spontaneous term uncomplicated vaginal delivery at home. The patient was earlier managed at a peripheral health institute conservatively and was referred to our hospital when her condition deteriorated. Her previous delivery was home conducted as well. There was no history of abdominal surgery in the past. Examination revealed moderate pallor and tachycardia. Abdomen was grossly distended and tender. Bowel sounds were absent. Routine investigations revealed hemoglobin of 6.4 gm% and an elevated leucocytic count of 16,000 per cubic mm. Simple abdominal radiograph revealed a hugely distended large bowel segment in the upper quadrant as shown in Volvulus of the cecum is an axial twisting or folding of cecum on its mesentery that results in bowel obstruction . The incThough a rare event, the incidence of intestinal obstruction during pregnancy and puerperium is on the rise due to increasing rate of cesarean deliveries. Hence, an obstetrician is likely to come across a case of bowel obstruction with pregnancy or puerperium in his or her lifetime. Because of peculiar changes of pregnancy and puerperium the diagnosis is often delayed leading to life-threatening complications. We must ask ourselves: is the delay in diagnosis really inevitable? Cecal gangrene ensues in an average duration of 48–72 hours. A high index of suspicion, urgent X-ray in a patient of acute abdomen, followed by computerized tomography if required and laparotomy within golden time that is, 24 hours of onset may prevent gangrene and resultant perforation of the intestine. We believe that a heightened awareness amongst obstetricians regarding the possibility and knowledge of diagnostic tools and their immediate and liberal use, in particular radiograph, can and should prevent the delay in diagnosis.


Gastrointestinal tract perforations can occur for various causes such as peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, foreign body or a neoplasm that require an early recognition and, often, a surgical treatment.Ultrasonography could be useful as an initial diagnostic test to determine, in various cases the presence and, sometimes, the cause of the pneumoperitoneum.The main sonographic sign of perforation is free intraperitoneal air, resulting in an increased echogenicity of a peritoneal stripe associated with multiple reflection artifacts and characteristic comet-tail appearance.It is best detected using linear probes in the right upper quadrant between the anterior abdominal wall, in the prehepatic space.Direct sign of perforation may be detectable, particularly if they are associated with other sonographic abnormalities, called indirect signs, like thickened bowel loop and air bubbles in ascitic fluid or in a localized fluid collection, bowel or gallbladder thickened wall associated with decreased bowel motility or ileus.Neverthless, this exam has its own pitfalls. It is strongly operator-dependant; some machines have low-quality images that may not able to detect intraperitoneal free air; furthermore, some patients may be less cooperative to allow for scanning of different regions; sonography is also difficult in obese patients and with those having subcutaneous emphysema. Although CT has more accuracy in the detection of the site of perforation, ultrasound may be particularly useful also in patient groups where radiation burden should be limited notably children and pregnant women. Gastrointestinal perforation is one of the most common cause of intraperitoneal free air; its detection is important for diagnosis of life-threatening conditions in patients with acute abdomen.Gastrointestinal tract perforations can occur for various causes ; most of these perforations are emergency conditions requiring an early recognition and a timely surgical treatment.The mainstay of treatment for bowel perforation is surgery.Endoscopic, laparoscopic and laparoscopic- assisted procedures are now being increasingly performed instead of conventional laparotomy.Moreover, if any signs and symptoms of generalized peritonitis are absent and the perforation site has sealed spontaneously, then a perforated duodenal ulcer can be treated with non-surgical procedures.It is important to identify location and cause of the perforation correctly for appropriate management and surgical planning.The clinical diagnosis of the site of gastrointestinal tract perforation is difficult as the symptoms may be non-specific.A MEDLINE and PubMed search was performed for journals before March 2013 with MeSH major terms ‘ultrasonography and ‘perforation’. Non-English speaking literature was excluded.Upper and lower gastrointestinal perforation can be differentiate by transverse mesocolon such as the peritoneal cavity, usually divided into supra- and inframesocolic compartments.Subsequently, stomach or duodenal perforation would result in supramesocolic compartment gas and distal small and large bowel perforation in inframesocolic compartment gas.Sections of the GI tract, such as stomach, first part of duodenum (5 cm), jejunum, ileum, caecum, appendix, transverse colon, sigmoid colon and upper third rectum are found within the peritoneal cavity, and are usually mobile,2. The sThe presence of free intraperitoneal gas on a routine radiograph usually indicates bowel perforation. Experimental studies have shown that as little as 1 ml of gas can be detected below the right hemidiaphragm on properly exposed erect chest radiographs.Various radiological descriptions are used for specific distribution of free intraperitoneal gas, such as the Rigler sign (gas outlining both sides of the bowel), football sign , increased lucency in the right upper quadrant (gas accumulating anterior to the liver) and triangle sign (triangular gas pocket between three loops of bowel).Otherwise, the most relevant signs on CT are the “ligamentum teres sign” , the “periportal free gas sign” (strongly suggests upper GI tract perforation) and the “falciform ligament sign”  and bowel ischemia.Perforation of a peptic ulcer is now less frequent because of the availability of adequate medical therapy for peptic ulcer disease. Only 1-2% of patients have free perforation due to acute diverticulitis, also because most perforated diverticula are contained perforations.In the emergency department, an accurate diagnosis can be made exclusively on the basis of medical history, physical examination and laboratory test findings in only a small proportion of patients.The clinical manifestations of the various causes of acute abdominal pain usually are not straightforward; besides the variable symptoms of the underlying mechanism, a rigid abdomen usually is present ,10.For proper treatment, a diagnostic work-up that enables the clinician to differentiate between the various causes of acute abdominal pain is important, and ultrasonography plays an important role in this process. It is widely available and is easily accessible in the emergency department, is a real-time dynamic examination that can reveal the presence or absence of peristalsis and depict blood flow. Otherwise, the major advantage of CT, as compared with radiography and US, is that it can correctly depict the actual site of perforation in 86% of cases. Despite of the difficulty in the detection of perforation at ultrasonography,it could be diagnosed in supine patients, adiacent to the abdominal wall, the radiologist identifies echogenic lines or spots with comet-tail reverberation artifacts ,12.Some authors demonstrated that US has lower sensitivity than radiography   and shouHowever, in literature some authors demonstrated that ultrasonography has greater accuracy (90% vs. 77%) if compared with x-ray (sensitivity 93%vs. 79%) and that ultrasonography is a useful diagnostic modality when x-rays does not reveal pneumoperitoneum in patients with suspected perforation ,15..Moreover, some authors demonstrate that sonography may be useful to determine not only the presence, but the cause of the pneumoperitoneum too .Neverthless, its detection is difficult even for an experienced sonographer  especialThe sonographic appearance of free intraperitoneal air results form scattering of the ultrasound waves at the interface of soft tissue and air which is accompanied by reverberation of the waves between the transducer and the air Figure .This results in an increased echogenicity of a peritoneal stripe associated with multiple reflection artifacts and characteristic comet-tail appearance that can be changed by changing the patient’s position.Conversely, intraluminal bowel gas is always associated with a more superficial, normal thin peritoneal strip.In small air collections reverberation artifacts may not be seen, whereas in extensive pneumoperitoneum found pronounced pre-hepatic echoes with sound shadow phenomenon may obscure the underlying abdominal organs .Direct sign, such localized gas collections related to bowel perforations, may be detectable, particularly if they are associated with other sonographic abnormalities, called indirect signs  Figure  18]..18].The linear array transducers 10-12MHz) are more sensitive than standard curvilinear abdominal transducers (2-5MHz) for detecting intraperitoneal free air because of the broader near-filed size and because of superior resolution in the near filed where the air usually accumulates. Table 0-12MHz a.Patient should be first scanned in the supine position concentrating on the midline and right upper quadrant, then in the left lateral decubitus and prone position ,12, althSome authors affirm that the best position for ultrasound examination of the abdomen is supine with the thorax slightly elevated (10-20 degrees) and that the optimal prone position is in the right paramedian epigastric area in the longitudinal direction .Intraperitoneal free air is best detected in the right upper quadrant between the anterior abdominal wall, in the prehepatic space; the presence of air causing an enhancement of the peritoneal stripe and moving when the patient position changes, especially in abnormal sites such as along with the fissure of ligamentum teres, should raise the suspicion of intraperitoneal free air, meanwhile intraluminal gas can be seen inside a bowel loop having a visible peristalsis and a normal wall thickness .The possibility to observe motion in realtime sonography repeatedly proved to be decisive for the certain diagnosis of free air (the shifting air under patient movement and the immobility of the gas reflex under respiration).An observed step between the air in the costophrenic sinus and the abdominal gas reflex is considered to be an additional sonographic sign .In the right upper quadrant sonograms made during inspiration and expiration help to differentiate pneumoperitoneum from the adjacent lung because pneumoperitoneum overlaps the lung during inspiration, but the lung and pneumoperitoneum are separate during expiration.In case of pneumoretroperitoneum caused by a retroperitoneal perforation it is possible to detect also air around the duodenum and the head of the pancreas and especially ventral to the great abdominal vessel which can lead to the picture of “vanishing” vessels ,21.Karahan introduced a new method for the detection of intraperitoneal free air, the SCISSOR MANEUVER. It consists in applying and then releasing slight pressure onto the abdominal wall with the caudal part of a parasagittally oriented linear-array probe; this maneuver could be a useful adjunct for improving the diagnostic yield of sonography ,23.Meticulous examination focused on the patient problem may yield a causative diagnosis of peritonitis due to perforated gastric or duodenal ulcer, perforated appendicitis o diverticulitis, suggested on the basis of wall thickening, fluid accumulation, inflammatory mass ,thickening of the gallbladder , hyperecGastroduodenal perforations may be suspected in patients with history of ulceration, who present with acute pain and abdominal wall rigidity, but radiological findings in these cases may be unable to confirm a clinical diagnosis.Intraperitoneal free fluid and/or reduced intestinal peristalsis at sonographic examination are considered indirect signs of gastroduodenal perforation Figure . UltrasoUltrasound can also detect a hypoechoic irregular lesion continuous with the jejunum suggestive of the presence of diverticula; the presence of peridiverticular hyperechoic fat, associated with US signs of extraluminal air evoked the diagnosis of a proximal jejunal diverticulitis ; lymph nSonography is able also to detect primary ascaridial perforation as two pairs of parallel lines, representing the worm outer margis, flanking a central sonolucent line, representing its digestive tract. It could be found also in the peritoneal cavity and in some loops of the small bowel ..The exam could be useful also in neonates because the sonographic findings of ascites and intraperitoneal fluid-debris levels in patients with suspected necrotizing colitis are suggestive of perforation .Neverthless, this exam has its own pitfalls. It is strongly operator-dependant ; some ultrasound machines have low-quality images that may not able to detect intraperitoneal free air.; furthermore, some patients may be less cooperative to allow for scanning of different regions; sonography is also difficult in obese patients and with those having subcutaneous emphysema ,31.Ultrasound could be useful as an initial diagnostic test and CT may be reserved for patients with nondiagnostic ultrasonography results.In conclusion, in the absence of direct or indirect findings of pneumoperitoneum, US examination is not so useful for detecting free gas, but could help to confirm intestinal paresis and intraperitoneal free fluid ..If perforation is suspected, patients are usually subjected to abdominal MSCT, especially because ultrasonography is operator-dependent, some patients are less cooperative, the exam is diffucult in obese patients and in those with subcutaneous emphysema; otherwise MSCT, expecially after six hours after symptoms begin, is useful to assess gastrointestinal perforation as it allows detection of even small amounts of free air in the abdomen .The authors declare that they have no competing interests.


Primary central nervous lymphoma (PCNSL) is a rare variant of extranodal non-Hodgkin's lymphoma with a especially poor prognosis. The diagnosis is usually encountered in immunodeficient patients but is also encountered, albeit uncommonly, in the immunocompetent. We present a 50-year-old male who developed signs and symptoms of increased intracranial pressure. Imaging revealed the presence of a fourth ventricle mass with obstructive hydrocephalus. First, the patient underwent emergency endoscopic third ventriculostomy followed, few days later, by complete tumor resection via a posterior fossa craniotomy. Postoperative histopathology revealed the lesion to be a PCNSL. He received adjuvant chemotherapy and radiation and remained with no recurrence on regular imaging studies for 18-month followup. We report herein the fourth case of isolated PCNSL lesion to the fourth ventricle in the literature and provide the rationale for our belief that craniotomy and tumor resection, if feasible, should be the initial line of management in similar cases to relieve hydrocephalus and achieve the diagnosis. Primary central nervous system lymphoma (PCNSL) is a rare variant of extranodal non-Hodgkin's lymphoma (NHL) with an uncertain origin and pathogenesis , 2. It aA 50-year-old male physician, with no medical comorbidities, presented to the emergency room with history of forceful unrelenting vomiting associated with moderate nausea that had progressed over the past 2 weeks. Initially attributed to gastritis, his symptoms did not improve with proton pump inhibitor and antiemetic medications. His level of consciousness had started to drop over the preceding 24 hours with significant increase in the severity of his headache. Physical exam showed a depressed Glasgow coma score (GCS) of 12 equally reactive pupils with no focal neurological deficit.An urgent brain computed tomography (CT) scan revealed obstructive hydrocephalus with an infratentorial somewhat hyperdense lesion in the fourth ventricular that enhanced homogeneously .The patient was admitted and urgent endoscopic third ventriculostomy was performed, with rapid recovery of his level of consciousness postoperatively. Cerebrospinal fluid (CSF) analysis and cytology results were within normal and negative for malignant cells.Further brain and spine imaging with magnetic resonance (MR) scan demonstrated a 20 × 25 × 30 mm strongly enhancing mass occupying the inferior half of the fourth ventricle  as well as for CD79a, CD20 (B-cell antigens), and HLA-DR and focally positive for CD10 and vimentin. The morphology and immunohistochemical profile was consistent with a high-grade B-cell lymphoma  lymphomas are considered by neurosurgeons as nonsurgical tumors due to their diffuse infiltration and exquisite sensitivity to chemoradiation . In factThe literature mentions a constellation of radiologic signs that should alert the treating surgeon preoperatively to suspect CNS lymphoma . These sOur case is unusual in that the lesion is isolated to the fourth ventricle, an extremely rare location that has only been documented in three other cases in literature –5 with aSurvival outcomes mentioned for PCNSL have been uniformly disappointing despite recent advances and the often initial dramatic response to therapy , 11. CurThe previously reported similar 3 cases are summarized in We emphasize that PCNSL should be included in the differential diagnosis of intraventricular tumors, considering its implications on management planning. We also believe that resection is worthwhile, not contraindicated, in the context of a fourth ventricle lesion causing hydrocephalus. This will serve to spare the patient the morbidity of shunt dependency.


We describe an epidermoid cyst arising from an accessory spleen of the pancreas. A 56-year-old female with iron deficiency anemia presented with dizziness. During the clinical workup, a 2×4 cm-sized mass was incidentally detected in the tail of the pancreas in a computed tomography (CT) scan. Under a clinical diagnosis of pancreatic cystic malignant tumor, a distal pancreatectomy was carried out. Grossly, the lesion was composed of a solid and cystic portion. Microscopic analysis revealed that the solid portion was an intrapancreatic accessory spleen and the cystic portion was an epidermoid cyst. An epidermoid cyst in an intrapancreatic accessory spleen is extremely rare and hence difficult to diagnose pre-operatively. Taking into account the possibility of such a cyst in the differential diagnosis of intrapancreatic cystic lesion is recommended. The committee approved the waiver of patient consent for these cases.A 54-year-old female with iron deficiency anemia was admitted to hospital complaining of dizziness and abdominal discomfort. During the clinical workup, a 2.3 cm-radiological-sized cystic mass was detected in the tail of the pancreas by abdominal computed tomography CT; . Distal et al are similar to those of other cystic pancreatic neoplasms. As a result, the possibilty of such a cystic lesion should be considered in the differential diagnosis of a pancreatic cystic lesion.


Transection of gut due to adhesive band is an unusual complication of adhesive bowel disease. A 2-year old female presented with signs and symptoms of intestinal obstruction. Eight months earlier she underwent laparotomy for excision of duplication cyst of ileum. Exploratory laparotomy performed during current admission showed complete transection of gut. Intestinal obstruction secondary to adhesions after surgical procedure is not an uncommon entity and is routinely encountered. Due to adhesive bands, complete transection of gut loop is an entity that has not yet been reported in literature. A case of complete transection of gut loop secondary to adhesive bowel disease is being reported.A 2-year old female presented with recurrent pain abdomen and non-bilious vomitting. At the age of 18 months she was operated for duplication cyst of ileum which was located 6 cm proximal to ileocecal junction. During the last eight months she had multiple episodes of adhesive intestinal obstruction responding well to conservative treatment. During last episode she responded initially but symptoms recurred. Her barium follow through study performed showed grossly distended small intestine with a cutoff point beyond which no contrast passed. On exploration, two blind ending loops, lying close to each other , 15cm distal to DJ junction found. Proximal loop was grossly dilated while distal loop was collapsed. Both loops showed signs of scarring. End to end anastomosis was done. Postoperative recovery was uneventful. She is doing fine at eight months follow up.Adhesive bowel disease is an important cause of intestinal obstruction and comprises of 65-75% of all small bowel obstructions [1]. Usually these adhesions respond to conservative management but intervention is required in 15-18% of cases [2]. Any source of peritoneal irritation can result in local fibrin production which may lead to adhesion formation. Most common sites of adhesion are that of anastomosis and raw areas left after attempts at reperitonealization of serosal tear. In addition, presence of trauma, talc, gauze and silk suture predispose to adhesion formation [1]. The adhesions may form a tight band that may ultimately lead to complete transection leading to the formation of two blind loops as happened in our case.Source of Support: NilConflict of Interest: None declared