Three cases of incidental carcinoid tumors have been identified in the surgical margin of rectal adenocarcinoma resection specimens. In all cases the rectal carcinoids exhibited low-risk features, such as a tumor size <10 mm, no muscularis propria invasion and no lymph node involvement. No further excision was conducted and the three cases were followed up for 38, 26 and 14 months, respectively. No regional or distant rectal carcinoid recurrence was identified. Occasionally this is inevitable in order to achieve a positive resection margin for the microcarcinoid during the surgical treatment of another malignancy. However, such carcinoids are usually low-risk and behave less aggressively than same-site adenocarcinomas. Thus, it appears reasonable to avoid further excision in patients who are undergoing a rectal adenocarcinoma resection that exhibits a positive margin for low-risk carcinoid tumor. The term carcinoid is synonymous with the term well differentiated neuroendocrine tumor. Recently, carcinoids of the colon and the rectum have been grouped together. However, rectal carcinoids tend to behave less aggressively than colon carcinoids. Rectal carcinoids are often only diagnosed incidentally during routine lower endoscopy procedures due to the fact that such tumors are small, submucosal in location and rarely metastatize –3. In adIn total, three pathology reports, which revealed incidental carcinoids in the surgical margin of radical rectectomy specimens were retrieved from the pathology database of The First Affiliated Hospital , from January, 2007 to April, 2013. Clinical details were acquired from medical records retrospectively, such details included patient gender, age, medical history, symptoms at presentation, modality of diagnosis and treatment. The pathological features were identified from the pathology reports and the carcinoid tumor size was reported as the largest diameter that was recorded microscopically. The follow-up was conducted via telephone interview and through examination of laboratory, endoscopy and imaging results that were obtained during clinical visits. The examination results were documented in the laboratory and imaging databases, which were also reviewed. This study was approved by the institutional ethics committee of The First Affiliated Hospital, College of Medicine, Zhejiang University . Informed consent was obtained from the patients families.All three patients were male and were aged 62, 66 and 54 years at presentation. They all experienced hematochezia, leading to endoscopic evaluation and biopsy. This resulted in the identification of adenocarcinoma and subsequently a radical rectectomy (Dixon’s operation) was performed. Features of the primary adenocarcinomas are displayed in The distal margins of the resection specimens were 2–3 cm from the respective adenocarcinoma and were removed during surgical procedures. Sections of each distal margin revealed an unexpected microcarcinoid tumor within it. Their sizes were all <0.5 mm in diameter . All tumors invaded the submucosa only, without lymphovascular invasion, lymph node involvement or distant metastasis. Immunohistochemical staining was performed on all carcinoid tumors. The tumor cells were identified to be positive for synaptophysin, chromogranin A and cluster of differentiation 56, but were negative for Ki-67 .Following diagnosis, patients were treated without further surgical or endoscopic resection. This decision was made by the patient and was based on the consideration that benign-like carcinoids have little effect on patient prognosis compared with adenocarcinoma. None of the patients underwent chemotherapy or radiation following the radical rectectomy. Patients were followed up for 38, 26 and 14 months, respectively. Case three suffered hepatic metastasis of the adenocarcinoma in the 13th month following the rectectomy and underwent partial resection of the liver. However, none of the three patients demonstrated carcinoid recurrence or metastasis.et al  are a common observation in carcinoid tumor patients ,5,14–17.The etiology of this associated high risk of SPM remains unclear. It may be hypothesized that neuroendocrine factors secreted by carcinoids enhance the development or growth of other neoplastic tissue . In suppIt is generally accepted that rectal carcinoids >20 mm in size require radical resection –22 due tThe necessity for achieving a microscopically negative margin has been questioned in the past . CurrentThe identification of an incidental gastrointestinal carcinoid during the operative treatment of another malignancy does not worsen the prognosis of the individual; complete resection is sufficient for therapy . Howeveret al (Examination following resection of small rectal carcinoids is controversial. The latest consensus with regards to treatment guidelines for small rectal carcinoids is that tumors without lymph node involvement require no long-term follow up ,22; howeet al  reportedet al .In conclusion, patients with rectal carcinoids, in particular those that are low-risk, have a favorable five-year survival rate. Such carcinoids behave less aggressively than same-site adenocarcinomas. Furthermore, the identification of an incidental rectal carcinoid during operative treatment of another malignancy is possible. However, it is possible to forgo further excision as incidental carcinoids are usually absent of risk factors and are unlikely to recur prior to another malignancy.


Teratomas are neoplasms that arise from pluripotent cells and can differentiate along one or more embryonic germ lines. Renal teratoma is an exceedingly rare condition. Teratomas commonly arise in the gonads, sacrococcygeal region, pineal gland, and retroperitoneum. They present mainly as an abdominal mass with few other symptoms. Majority of the tumors are benign, situated on the left side and para renal, occasional lesions are bilateral. If diagnosed early, they are amenable to curative excision.Renal teratomas are rare and most have been dismissed as cases of teratoid nephroblastomas or retroperitoneal teratomas secondarily invading the kidney. The differentiation between these two neoplasms in the kidney is often problematic.We present a case of intrarenal immature teratoma in a six-month-old baby girl.http://www.diagnosticpathology.diagnomx.eu/vs/1746249869599954.The virtual slides for this article can be found here:  Teratomas are neoplasms that arise from pluripotent cells and can differentiate along one or more embryonic germ lines . Renal tTo the best of our knowledge, our patient is the second known case with an immature teratoma arising from ectopic kidney the first one was developed in a horseshoe kidney.We present a case of intrarenal immature teratoma in a six-month-old baby girl and discuss the pathology of this rare entity.A six-month-old baby girl was admitted in the department of paediatric surgery of Hassan II university hospital in Morocco, with the complaints of abdominal distension and pain since one month. On examination her weight was 5.5 kgs and her abdomen was hugely distended. On palpation, a firm mass occupying all of the left lumb of the abdomen was palpable, which was tender, moving with respiration and the margins were irregular. Both the renal and liver functions as well as the findings of hematological studies were within the normal limits. A chest x-ray showed no abnormality. Abdominal ultrasonography demonstrated a pelvic left kidney measuring 18 cms in diameter with an important expansion of the excretory cavities and internal cystic and solid changes. Computed tomography showed a mass containing low-density areas of the left kidney. The right kidney was normal. The patient did not found any more tumors in the other organs. Because the most frequent tumor of the kidney occurring in newborns is congenital mesoblastic nephroma and patients with ectopic kidneys have a high risk for Wilms’ tumor, a diagnosis of either mesoblastic nephroma or Wilms’ tumor arising from ectopic kidney was tentatively made, and she was thus considered to be indicated for surgery.Patient was operated upon; laparotomy was done through a median underumblical incision. A large partly cystic and partly solid mass with extensive areas of haemorrhage in the cystic areas was present in the left pelvic region. It was roughly spherical in shape. Postoperative recovery of the patient was uneventful and she was discharged on 10th postoperative day. The specimen was sent for histopathological examination.Grossly a large mass was received measuring 18×12×8 cms in maximum dimensions. It weighed 200 Gms, linked to an ureter of 3×0,2 cms. On sectioning a multilocular circumscribed lesion was identified measuring 2,5 at 10 cms. It was attached to the cystic wall, which focally showed thickened brownish areas in the wall  with tissue derivatives of all three germ layers . TeratomThe clinical symptoms are an abdominal mass, abdominal pain, abdominal discomfort, pyelonephritis, and constipation . OccasioIn mature teratomas skin with dermal appendages, bronchial structures with bronchial glands and cartilage, neuroglial tissue, and teeth are commonly present and regarded as evidence of organogenesis. In the other hand immature teratoma contained neuroepithelial components with an embryonic appearance and ependymal rosette-like .Only six cases of primary carcinoid tumor arising in a mature teratoma of the kidney have been reported in the world medical literature to date . Otani eThe differential diagnosis of intrarenal teratoma include Wilms’ tumor ,23. The The second differential diagnosis is congenital mesoblastic nephroma . SonograOther differential diagnosis is cystic neuroblastomas . This neAn immature teratoma has a strong resemblance to small, blue round cell tumors which commonly include Wilm’s tumor, metanephric adenoma, lymphoma, peripheral neuroectodermal tumor and rhabdomyosarcoma; and rarely metastatic small cell tumors from lung . It may Beckwith suggests that for a tumor to be termed a renal teratoma it should meet two criteria: (a) the primary tumor should be unequivocally of intrarenal origin, the entire lesion should be contained within the renal capsule and there should be no teratomas in remote sites which might have metastasized to the kidney. (b) the tumor should exhibit unequivocal heterotopic organogenesis . Our casAn accurate histologic diagnosis is very important. Complete excision of the tumor mass is recommended and anticancer drug treatment is unnecessary. Patients with pure immature teratomas can be effectively treated with a surgical excision alone because the 3-year event-free survival is more than 85% .Follow-up data after surgical removal for intrarenal teratomas in children are limited. Mature teratomas are usually benign, but they have the potential for malignant transformation. All patients with the diagnosis of benign teratoma should undergo regular long-term follow-up examinations .The purpose of this review was to stress on the fact that though primary renal teratomas are extremely rare, this entity must be taken into consideration in the differential diagnosis of any renal mass in childhood.Written informed consent was obtained from patient’s parents for publication of this case report.CT: Computed tomography.The authors declare that they have no competing interests.All authors read and approved the final manuscript.


Intussusception in pediatrics is widely documented and well described. On the basis of the literature, however, adult intussusception is a rare entity with a prevalence of from 1% to 5%. The majority of adult patients with intussusception have an underlying pathology that needs to be identified by performing a proper physical examination and a wide array of investigations.We present a case of a 66-year-old African man who presented to our emergency department with a mass protruding per anus with obstipation. During laparotomy, we found that the sigmoid colon had intussuscepted into the rectum and out from the anus. Other abdominal viscera were normal and without any obvious mesenteric lymphadenopathy. Sigmoid colectomy and spectacle colostomy were performed. Grossly, the excised bowel looked normal, but the histologic results showed features of necrosis and chronic inflammation.While 70% to 90% of cases of adult intussusception have an identifiable cause or lesion, most pediatric intussusceptions are idiopathic. The presentation in an adult described herein was of an uncommon idiopathic type with no identifiable cause found on the basis of the history, physical examination, or histological findings. The telescoped part is referred to as the "intussusceptum," and the receiving part is called the "intussuscipiens." This condition is commonly described in infants and rarely in adults. Adult intussusception represents 5% of all cases of intussusception and accounts for only 1% to 5% of intestinal obstructions in adults ["Intussusception" refers to the telescoping of the proximal bowel into the distal bowel or n adults . Almost n adults . In thisA 66-year-old African man from a rural area presented to our emergency department complaining of persistent, dull lower-back pain of three months' duration and a mass protruding per anus for the previous four days. His lower-back pain was radiating to both thighs and was aggravated by farming activities. His pain was relieved by resting, and the pain was not accompanied by numbness of the limbs. He had no history of difficulty in micturition. The mass protruded per anus spontaneously while he defecated and was associated with severe pain followed by obstipation. There was no obvious bleeding per rectum upon his presentation to our emergency department. He had no history of constipation prior to the protrusion of the mass. He had no history of on-and-off mass protrusion per anus even when lifting loads. In addition, he had no history of changes in bowel habits or blood-stained stools, no history of tenesmus, and no history of incomplete bowel emptying post-defecation. He had no history of feeling any abdominal swelling and no history of significant weight loss. An attempt to reduce the mass was made at the district hospital, but the procedure failed; hence the patient was referred to Bugando Medical Centre. His medical history was uneventful.His physical examination revealed that he was in pain, alert, afebrile (body temperature 37°C), and dehydrated, but he was not pale. His blood pressure was stable at 100/70 mmHg, and his radial pulse was 90 beats/minute, weak, regular, and synchronous with other pulses. He had no cervical lymphadenopathy, and no Virchow's node was palpable. He had a scaphoid abdomen that moved with respiration, but no visible peristalsis was observed, his abdomen was not tender, and no obvious mass was palpable. His liver, spleen, and kidneys were not palpable, and a tympanic percussion note was heard throughout the abdomen. His bowel sounds were increased on auscultation. The digital rectal examination revealed a large, foul-smelling, gangrenous sigmoid-shaped mass protruding per anus Figures . The resA provisional diagnosis of sigmoid intussusception with a differential diagnosis of rectal prolapse was made. Blood samples were taken to measure his hemoglobin level and blood grouping. His hemoglobin level was 10 g/dL. Pre-operatively the patient received 3 L of Ringer's lactate solution over the course of one hour, intravenous ceftriaxone 1 g, and metronidazole 500 mg, and he was prepared for emergency exploratory laparotomy. The abdomen was approached through an extended mid-line incision. The intra-operative findings were that the sigmoid colon had telescoped into the rectum and out per anus Figure , and theIntussusception in adults is an uncommon condition, representing 1% of cases of adult bowel obstruction and less than 1% of hospital admissions . It is aWhile 70% to 90% of adult intussusceptions have an identifiable cause or lesion, most pediatric intussusceptions are idiopathic ,2. The cIntussusception is a well-described condition that has been documented mostly in pediatric patients. Adult intussusception is a rare entity. Prolapsed intussusception per anus has rectal prolapse as its most likely differential diagnosis; hence sigmoid prolapse has to be kept in mind, since adult intussusception usually has an underlying cause. All stigmata for the cause should be ruled out on the basis of the patient's history and physical examination as well as during laparotomy.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.CA, PS, and VK operated on the patient. VK, PS, and CA wrote the manuscript. All authors read and approved the final manuscript.


Synovial sarcomas of the pericardium are extremely rare and associated with poor survival rate. The current case report describes a 45-year-old female who presented with dyspnea upon exertion, a paroxysmal cough, night sweats and recurrent pericardial effusion. The patient was diagnosed with tuberculous pericarditis and received antituberculous drug therapy. Echocardiography and magnetic resonance imaging (MRI) revealed a pericardial mass lying predominantly over the right atrium. The patient was treated by surgical excision and a subsequent histological analysis confirmed the diagnosis of a pericardial synovial sarcoma. Under high power examination, a characteristic biphasic appearance consisting of hypercellular spindled cell sheets was observed. Immunohistochemistry demonstrated positive staining for epithelial membrane antigen (EMA), vimentin and Bcl 2. The patient was then referred for adjuvant chemotherapy with a combination of adriamycin and ifosfamide. The patient has since remained clinically free of disease for 32 months. Primary cardiac sarcomas are extremely rare, with angiosarcoma, fibrosarcoma, rhabdomyosarcoma and malignant fibrous histiocytoma occurring in order of decreasing frequency . SynoviaA 45-year-old female presented in January 2010 with progressive dyspnea upon exertion, a paroxysmal cough and night sweats. The patient was diagnosed with tuberculous pericarditis and received antituberculous drug therapy. A physical examination revealed quiet heart sounds. Echocardiography  revealed a mass measuring 3.8×5.2 cm within the pericardial space and predominantly over the right atrium, as well as a pericardial effusion. Contrast-enhanced computed tomography  demonstrated a low-attenuation lesion in the pericardium, with inhomogeneous peripheral enhancement. Magnetic resonance imaging  revealed a 3.4×5.2-cm, high-signal, heterogeneous, multilocular mass on 2D fast imaging employing steady-state acquisition (FIESTA) sequence images. The lesion was present in the pericardium adjacent to the right atrium, which was significantly extruded. T1-weighted post-gadolinium imaging identified mild heterogeneous enhancement . No posiA thoracotomy was performed and revealed marked soft pericardial adhesions. The tumor was located between the pericardial serous layer and the right atrium, arising from the junction of the inferior vena cava and the pericardium. The tumor was excised and a partial pericardiectomy was performed with negative microscopic margins. The pericardial effusion cytology was negative for malignant cells.2, 3 times every 3 weeks) and ifosfamide .The excised mass measured ∼5×6 cm and had a friable texture consisting of blood clots and necrotic tissue. Microscopically, the tumor exhibited a characteristic biphasic appearance consisting of hypercellular spindled-cell sheets. Hemorrhaging, necrosis, heteromorphism and Allotypic nuclear division were also noted . ImmunohPrimary sarcomas of the heart are rare  and inclet al(et al Hemorrhaging was noted in >40% of the lesions, which demonstrated high-intensity signals on T1- and T2-weighted images. No difference was noted between MRI characteristics for the monophasic and biphasic pathological subtypes.In the early stages of pericardial synovial sarcoma, symptoms are usually nonspecific or slight chest tightness is noted . With thet al, MRI wasDue to the rarity of primary pericardial synovial sarcoma, there are no standard treatment guidelines currently available ,5. HowevImmunohistochemical markers, including vimentin, EMA and cytokeratin, are used to aid the pathological diagnosis of synovial sarcoma . HoweverAlthough primary cardiac synovial sarcoma is associated with an extremely poor survival rate, for tumors of pericardial origin, the overall survival remains unknown. In the present case, following surgical excision and post-operative adjuvant chemotherapy, the patient has remained clinically free of disease for 32 months.


Angiomyolipoma of the liver (AML) is an infrequent neoplasm composed of three tissues . In spite of advances in radiology, preoperative correct diagnosis is difficult. Clasically, a conservative management strategy was adopted in patients with asymptomatic tumors less than 5 cm with undoubtful diagnosis. But after publishing some few cases of malignant angiomyolipoma a more radical has been advocated. Laparoscopic resection of liver tumors is becoming a excellent approach for operating on benign liver tumors. Usually is performed using five trocars but in some cases a less invasive technique with three trocars could be used. We present a laparoscopic resection of liver angiomyolipoma in a 65 year-old male using only three trocars and also discuss the optimal management of AML and technical tips of three-trocar technique. The angiomyolipoma of the liver (AML) is a very infrequent benign tumor characterized by three components: adipose, vascular, and muscular –7. ProgrA 65-year-old male patient presented with epigastric pain, with no medical records of interest, and was not affected by tuberous sclerosis. Ultrasonography and abdominal CT  revealedRegularly, the hepatic angiomyolipoma (AML) is a solitary mesenchymal tumor, not encapsulated and of a variable size 1 to 36 cm)  to 36 cm, 6 that There are 3 types of AML, histologically speaking, depending on the amount of fat they contain, which are called lipomatous tumors (>70% of fat), myomatous <10%), and angiomatous and mixed variants 0%, and a, 5. The The combined use of abdominal ultrasonography, CT, and MRI has increased preoperative diagnostic certainty of AML, especially in those cases when a fat component and some central and prominent abnormal vessels can clearly be detected; however the correct preoperative diagnosis does not exceed 50% –5. The uAML is generally asymptomatic, but big-sized tumors may produce compressive symptoms, such as abdominal pain in superior hemiabdomen, plenitude sensation after intake of food, palpable mass, and other symptoms that include weight loss or fever –4, 6. ThGeneral indications for the resection of benign liver tumor (BLT) include diagnostic doubt, occurrence of symptoms, or onset of complications , 10. BLTAccepted indications for resection of AML include symptomatic patients, those cases where malignancy cannot be excluded, rapid growth tumors, and lesions with an exophytic component, as this last increases the risk of rupture . Some auThe first laparoscopic resection of the liver (LRL) was performed in 1992, but it had no exponential growth until the last five years when it coincided with a better technology that did not exist previously , 12. Then  =  1253) of LRL procedures dealt with BLT cases [RLR on BLT is an excellent indication since it rules out the risk of tumor dissemination, presents the benefits of the laparoscopic surgery for usually young patients, and reduces the mean in-hospital stay and recovery time , 9, 12. LT cases , 9; the LT cases , 9. The LT cases , 9.The classical LRL technique employs 5 trocars  and systematic portal clamping , 9. HoweThe SILS technique is another option for these minor resections. The main problems for liver SILS surgery are new learning curve, loss of instrumental triangulation, vision problems because camera and instruments are parallel, expensive costs and incisional hernias –19. AfteSo, three-port laparoscopic resection is safe and feasible in some liver lesions. Pringle's maneuver should be prepared but frequently is not necessary to use. AML is a rare neoplasm of the liver with not well-defined malignant potential so surgical resection in suitable patients is indicated.


Squamous cell carcinoma is the major pathology type of esophageal cancer in China, where adenocarcinoma is rare and adenoid cystic carcinoma (ACC) is more rare comparing to the western countries. We report the surgical and pathologic findings of two cases of primary ACC of the esophagus, and review of the Chinese literature of this tumor.The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1507582238843246 Adenoid cystic carcinoma (ACC) is not uncommon in the salivary glands and respiratory tract; however, it occurs extremely rarely in the esophagus, where its behavior is biologically aggressive . It consA 70-year-old man was hospitalized with a 3-month history of progressive dysphagia. This patient’s occupation as a cook, he likes to eat hot, spicy foods, and no previous history of viral infection, there is no contact with any external toxic substances. However, this patient usually have reflux esophagitis. Barium esophagram revealed a protruding lesion of 5cm in length in the middle third of the esophagus Figure . ComputeA 65-year-old man who is a miner, no bad eating habits, but the long-term smoking, was admitted to our hospital with a 2-month history of dysphagia. Results of the examination of his chest and abdomen were unremarkable. Blood values were all normal on admission. The barium esophagogram showed a large protrusive smooth tumor, which was 5 cm in size in the mid-thoracic esophagus Figure . ComputeThe resected tumor was a cauliflower-like mass, measuring 5.5 × 4.2 × 3 cm in size, and pathologically invaded adventitia with no metastases to lymph nodes Figure . The tumThe patient was diagnosed with anastomotic leak on post-operative day 10, then we gave him jejunal feeding tube guided by esophagoscopy. Barium esophagogram indicated the anastomotic leak was cured one month later. Nine months postoperatively, the computed tomography of the abdomen demonstrated liver metastasis.ACC of the esophagus was rare, since Gregg  first reThe clinical data of the total 15 cases are summarized in Table Biopsy of the tumor by preoperative endoscopy gave poor diagnostic results. In fact, only 1 of 14 such reported biopsies suggested ACC at that time. 10 biopsy specimens were misinterpreted as squamous cell carcinoma being the most frequent misdiagnosis, 2 cases were misdiagnosed as leiomyomata because of the normal esophageal mucosa overlying the tumor and 1 case was misdiagnosed as upper esophageal sphincter achalasia. Sweeney and Cooney reported  that oneBecause of the rarity of ACC of the esophagus and paucity of data in the literature, few treatment guidelines are available for esophageal ACC. The first choice for treatment of ACC of the esophagus is radical excision. Chemotherapy is not usually chosen due to a poor response rate -10. PostIn a word, ACC of the esophagus is extremely rare. Its diagnosis must be based upon histopathological characteristics. Surgery is the first choice for resectable lesions.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.X-FG analyzed the data and wrote the manuscript as a major contributor. TM, Z-TG, W-TF and W-HC helped to revise the discussion section of this manuscript. J-CS conducted the pathological examination. All authors have read and approved the final manuscript.


Lipoblastomas are benign tumors of the embryonic lipoid cells mainly occurring in infancy and early childhood. They are clinicopathologically distinguished in two forms: the well-circumscribed and localized type and the diffuse, irregularly confined type with infiltrative growth pattern, also called lipoblastomatosis. We report two pediatric cases of a mesentery localized and cervical diffuse lipoblastomas investigated both with ultrasound and computed tomography examinations. Lipoblastoma (LB) is a rare tumor of soft tissues which mainly occurs in infancy and early childhood –4. It isA 3-year-old male was brought to our institution suffering from abdominal pain and vomiting. An intra-abdominal painless palpable mass was appreciable and blood tests were normal.Abdomen ultrasonography (US) showed a huge coarse mass of mixed echogenicity in paravertebral region dislocating pancreas and intestinal loops . US coloA 3-year-old girl underwent neck US at our institution because of a right cervical swelling departing from homolateral supraclavicular fossa. When the child was 6 months old, she was surgically treated for a cervical lipoblastomatosis which was not excised as a whole because of its expansion in depth. Thus she continued to complain from severe dyspnea.US examination revealed a slightly hyperechoic mass longitudinally extending with close adherence to the right wall of the trachea. The mass pushed forward the right lobe of thyroid gland and diverted laterally the great vessels of the neck. No vascularity of the mass was shown on color-Doppler evaluation .To better determine the extension of the mass, CT examination was further performed.On CT scan the cervical mass appeared dishomogeneously hypodense with thin internal septations, extending from supraclavicular right fossa up to the retropharyngeal space, lining the trachea and reaching the great vessels of the upper left side of the neck. The mass exercised a compressive effect on adjacent structures, displacing the right cervical vasculonervous bundle, the trachea, and thyroid gland. Contrast enhancement was poor and limited to a solid nodule infiltrating the right side of trachea Figures .LB is a rare, benign tumor of the embryonic lipoid cells presenting mostly in children and infants below 3 years of age, with no clear sex predominance –5. It reLess than 200 cases of LBs  at various locations have been reported in literature: LB is mainly located in the soft tissues of the trunk and extremities, while it is rarely reported in the face, neck, buttock, perirectal area, and abdomen , 6.Among rare localizations, occurrence at the mesentery is described in less than 20 cases until today showing a male predilection , 4. The Although most LBs are asymptomatic at presentation, they can manifest, as in our cases, with a painless palpable mass and progressive symptoms of various organ compression according to the site of origin , 7. As iFor both our patients, CT densitometry and morphologic features suggested diagnosis. Indeed, the consistent radiologic feature of LB is the presence of fat within the lesion. It has been reported that in an infant or child, the most likely diagnosis for a well-circumscribed soft-tissue lesion that mainly contains fat is a LB .The fatty nature of the two tumors was suspected at US exams because both masses showed features in agreement with LB typical US appearance: a homogeneously to finely textured, echogenic mass .US elastography also confirmed the nonsolid nature of the mesenteric mass because the tumor appeared almost entirely green (soft) on hardness colorimetric scale. However US does not allow the total mass volume assessment often leading to underestimation of tumor size as clearly demonstrated by Case 2 .Then, CT or magnetic resonance (MR) imaging is typically required to accurately demonstrate the complete extent of disease and for characterization also thanks to both CT and MR imaging ability to confirm the presence of fat within the lesion. LB usually appears as an encapsulated mass with fatty content and internal septa, showing absent to mild enhancement when it is mostly fat and marked and heterogeneous enhancement when fat component is limited .Furthermore, MR imaging allows the evaluation of fat cells maturity through T1-weighted sequences because lipocytes have comparatively high signal intensity, whereas lipoblasts, typical for LB, have lower signal intensity . Thus, LIn pediatric patients, the differential diagnosis for a fat-containing mass includes LB (circumscribed or infiltrative), teratoma, fatty overgrowth related to vascular malformations, lipoma, and liposarcoma. Lipoblastomatosis may show signs of muscular infiltration. Both lipomas and liposarcomas are very rare in young patients. Teratomas tend to contain calcification, which is not a feature of lipoblastoma . HoweverSome reports support that LBs undergo cellular maturation and may evolve into mature lipomas or spontaneously regress . When LBAlthough complete surgical excision is recommended to minimize local recurrence rates it has not been performed at the expense of disfiguring or debilitating surgery , 8. If tPostoperative surveillance is important to detect relapses but there is no agreement on the appropriate length of followup for LB . Accordi


Liver metastases are rare in salivary gland tumors and have been reported only once to be the first manifestation of the disease. They are usually treated with surgical resection of the primary tumor and systemic chemotherapy. Drug-eluting bead chemoembolization has an evolving role in the treatment of hepatocellular carcinoma, as well as in the treatment of metastatic disease of the liver. Nevertheless, it has never been used in a patient with salivary gland liver metastases.We report a case of a 51-year-old Caucasian Greek woman who presented to our hospital with liver metastases as the first manifestation of an adenoid cystic carcinoma of the left submandibular gland. The liver lesions were deemed inoperable because of their size and multi-focality and proved resistant to systemic chemotherapy. She was curatively treated with a combination of doxorubicin eluting bead (DC Beads) chemoembolization, intra-operative and percutaneous radiofrequency ablation, and radiofrequency-assisted surgical resection. The patient remained disease-free one year after the surgical resection.In conclusion, this complex case is an example of inoperable liver metastatic disease from the salivary glands that was refractory to systemic chemotherapy but was curatively treated with a combination of locoregional therapies and surgery. A multi-disciplinary approach and the adoption of modern radiological techniques produced good results after conventional therapies failed and there were no other available treatment modalities. Salivary gland tumors are rare, histologically diverse, and exhibit a variety of biological behaviors. They account for 11% of all oropharyngeal neoplasms, with an incidence of 11.95/1,000,000/year in the United States ,3. LiverTreatment of primary and secondary liver tumors has changed during the past few years. New techniques, both invasive and minimally invasive surgery, have emerged and offer potential cure to patients who in the past would have been considered candidates only for palliative treatment. These treatments include drug-eluting bead (DEB) chemoembolization, percutaneous and intra-operative ablation, and atypical surgical resection techniques. There is no report in the literature on the use of DEB chemoembolization for this type of metastatic tumor.We report a rare case of a patient with salivary gland cancer who presented to our hospital with initially inoperable advanced metastatic liver disease as the first manifestation of the disease. The patient was first treated successfully with a combination of locoregional treatments and then underwent curative surgical resection.A 51-year-old Caucasian Greek woman had a routine liver ultrasound examination following a history of large-bowel polypectomies. Multiple hypoechoic liver lesions were found, the largest of which, on segment VI, measured 2.2 cm. The patient was asymptomatic, and her physical examination was unremarkable. Routine laboratory examinations showed no abnormal findings. Apart from her history of large-bowel polypectomies, she only had a history of appendectomy 35 years ago and bilateral saphenectomy 23 years ago. To avoid exposing the patient to ionizing radiation, the referring physician decided to further evaluate the lesions with MRI of the abdomen, which demonstrated a total of eight liver lesions in both lobes. The lesions had reduced signaling on T1-weighted sequences and increased signaling on T2-weighted sequences. They did not show enhancement in the arterial phase and had reduced enhancement compared to the normal liver parenchyma in the portal venous phase. On the basis of these features, metastatic liver disease was considered as the first-line diagnosis. MRI did not show any other abnormal findings.To reveal the primary lesion, the patient was further investigated with gastroscopy, colonoscopy, and computed tomography (CT) of the head, lung, and abdomen, all of which were unremarkable. Fine-needle aspiration under CT guidance was performed on the lesion in segment VI. The cytology was positive for malignancy, the type of which, though, could not be defined. Diagnostic laparoscopy was then performed, and the anterior superficial lesion in segment II was resected. The biopsy specimen submitted for pathological examination showed metastatic cancer with features of primary disease from a cystic adenoid carcinoma of the salivary gland. Neck CT was performed, which revealed a 1.5 cm hypodense area on the left submandibular gland , cisplatin, and cyclophosphamide. After 3 more months, MRI demonstrated further enlargement of the liver lesions, with the diameter of the biggest of them measuring 10 cm . The patient was discharged 15 days after surgery in good general condition.Follow-up CT three months after surgery showed a new lesion measuring less than 1 cm on segment III. This was treated with a single session of percutaneous RF ablation. Eight months after surgery CT of the neck, chest, abdomen, and pelvis showed that the patient was free of disease. At the one-year post-operative follow-up examination, a positron emission tomography (PET) scan Figure  and MRI Liver metastasis from salivary gland cancer is an uncommon manifestation of the disease, so evidence is scarce concerning the appropriate treatment. Adenoid cystic carcinoma, contrary to most other salivary gland tumors, is an aggressive tumor with a relatively high ratio of distant metastases. Patients with distant metastases have been shown to have a three-year survival rate of 41% to 46% . SurgicaChemoembolization has been widely used for liver metastatic disease, mainly for colorectal and neuroendocrine tumor metastases . Drug-elBearing in mind the chemotherapeutic agents to which the patient showed no response when treated systemically, as well as the regimens proposed in the literature for metastatic salivary gland tumors, we decided that doxorubicin was the best choice. The ability to load it into DC Beads was another advantage that could not be overlooked. Because of the size of the lesion, the chemoembolization could not be selective. Given also the fact that the liver of the patient was not cirrhotic, both lobes were treated each time.The good response of the patient to the first two chemoembolizations posed a therapeutic dilemma about the next step. Our goal was to offer surgery to the patient as a potentially curative treatment. The minor down-sizing of the lesions, along with the left lobe hypertrophy, allowed us to proceed with surgery. Resection of the tumor with a remaining functional liver volume greater than 20% is considered to be safe for a non-cirrhotic liver. In our patient, the estimated relative liver remnant was calculated to be 41.8%. This would also allow the safe intra-operative ablation of any remaining foci in the left lobe. Portal vein embolization was also considered before starting the chemoembolization as an alternative treatment that could produce left lobe hypertrophy and potentially offer the opportunity to perform surgery. However, this option was rejected because of the rapid progression of the lesions.During surgery, intra-operative ultrasound revealed one more lesion that was not visible on CT scans. It has been shown that intra-operative ultrasound is a very sensitive modality for the detection of small metastases in the liver  and is cSurgery is definitely not the treatment of choice for patients with metastatic liver disease from an adenoid cystic carcinoma, since even without treatment survival can be prolonged and there is no solid evidence that resection of the metastases prolongs survival. However, the biologic behavior of the tumor of this particular patient, bearing in mind the rapid increase in the size of the lesions, was quite aggressive. Furthermore, the age of the patient rendered her a good candidate for surgery, and she urged us to offer a more aggressive therapeutic approach to offer her a chance of living disease-free and possibly prolonging her survival. Nevertheless, further follow-up is needed, since late recurrence occurs quite often in patients with adenoid cystic carcinoma, but since the tumor burden in our patient was reduced, any recurrence would be more easily treatable with RF ablation.It is important to highlight the synergistic role of modern diagnostic and interventional techniques to the outcome of this case. Chemoembolization with DC Beads hindered the progression of the disease and achieved a partial response. Thin-section CT volumetry contributed to the decision to perform surgery by accurately calculating the functional liver remnant. Intra-operative ultrasound revealed a lesion that had not been pinpointed by conventional imaging techniques and also provided real-time guidance for the intra-operative ablation. Finally, percutaneous RF ablation permitted treatment of the disease recurrence with minimal invasion.In conclusion, this case is a rare manifestation of adenoid cystic carcinoma of the salivary glands. Additionally, it is an example of inoperable liver metastatic disease refractory to systemic chemotherapy which was curatively treated with a combination of locoregional therapies and surgery. A multi-disciplinary approach and the adoption of modern radiological techniques produced good results after conventional therapies had failed and there were no other available therapeutic modalities.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.AK participated in the interventional radiology procedures and the review of the imaging examinations and was a major contributor in the writing of the manuscript. KK participated in the interventional radiology procedures, performed the intra-operative ultrasound, and was a major contributor in the revision of the manuscript. IM performed the surgery and contributed to the surgical aspects of the manuscript. CK reviewed the imaging examinations and revised the manuscript. ET performed the surgery and revised the manuscript. DK participated in the interventional radiology procedures and made the final changes to the manuscript. All authors participated in the decision making of this case. All authors read and approved the final manuscript.


Symptomatic mitral stenosis caused by a left atrial mass as the first sign of metastasis of a malignant tumor is extremely rare and frequently associated with poor prognosis. We report a case of a 59-year-old man with a history of grade 3 malignant fibrous histiocytoma on his left tigh treated by limb-sparing surgery 17 months earlier, who was admitted with 10-days of worsening dyspnea. Imaging revealed a left atrial mass protruding through the mitral valve that resulted in severe mitral stenosis. Biopsy confirmed metastasis of malignant fibrous histiocytoma. Symptomatic mitral stenosis caused by a left atrial mass as the first sign of metastasis of a malignant tumor is extremely rare and frequently associated with poor prognosis. Atrial tumours presenting as mitral stenosis are most commonly myxomata, occasionally pedunculated sarcoma, and very rarely metastases.2  treated by limb-sparing surgery 17 months earlier, was admitted with 10-days of worsening dyspnea. The patient underwent postoperative chemotherapy after surgery and had follow up visits every six months. Blood pressure and heart rate were 150/85 mmHg and 136 beats/minute, respectively. Cardiac auscultation revealed a diastolic murmur. End-inspiratory crackles suggested pulmonary edema. Echocardiography revealed a left atrial mass protruding through the mitral valve (Figures bN0M0 tre Figures . AdditioAtrial tumours presenting as mitral stenosis are most commonly myxomata, occasionally pedunculated sarcoma, and very rarely metastases ,2.Symptomatic mitral stenosis caused by a left atrial mass as the first sign of metastasis of a malignant tumor is extremely rare and frequently associated with poor prognosis -3. HowevWritten informed consent was obtained from the patient for publication of this report and any accompanying images.The authors declare that they have no competing interests.JA wrote the manuscript and formatted the images. FG provided cardiovascular images and reports. RB supervised and revised the draft manuscript. All authors read and approved the final manuscript.


A 28-year-old female with history of chest wall extraskeletal myxoid chondrosarcoma (EMC) presented to the emergency department complaining of two weeks of lightheadedness and fatigue. Laboratories showed hemoglobin of 7.6 g/dL and a positive hemoccult test. Upper and lower endoscopies were unremarkable, and the patient was discharged after blood transfusion. The next day she returned to the ED with left-sided weakness and perioral numbness. Brain CT scan revealed a 6 cm right frontal mass with midline shift and edema that required urgent craniotomy with resection of a hemorrhagic tumor. The patient continued dropping her hemoglobin, and CT scans showed a rounded 3 cm small bowel mass in the mid ileum. Repeat upper endoscopy revealed a 2 × 2 cm ulcerated mass in the fourth portion of the duodenum. The patient was taken to the operating room and was found to have two lesions; one in the distal duodenum and a second one in the mid ileum causing small bowel intussusception. Pathology was consistent with metastatic EMC grade 2/3, involving the bowel and mesenteric fat. Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft-tissue sarcoma with unique features that distinguishes, it from other sarcomas. It has been often described as a low-grade sarcoma although there are certain characteristics like high mitotic activity and the presence of focal regions of Ki67 staining above 25% that correlate with aggressive behavior of the tumor. This is the first case of EMC metastatic to the small bowel to be reported to the medical community. A 28-year-old female with history of chest wall extraskeletal myxoid chondrosarcoma (EMC) presented to an outside hospital with two weeks of lightheadedness, and fatigue. Initial laboratories showed hemoglobin of 7.6 g/dL and a positive guaiac test. The patient underwent upper and lower endoscopies that were found to be unremarkable. Patient was discharged home after blood transfusion and scheduled for outpatient follow-up visit. The next day the patient returned to the emergency room with sudden left facial droop, left upper extremity weakness and perioral numbness. Emergent brain CT scan revealed a 6 cm right frontal mass with midline shift and edema. The patient was stabilized and transferred to our institution. She was taken to the operating room for an urgent right frontotemporoparietal craniotomy with resection of hemorrhagic tumor. During her postoperative period the patient continuously dropped her hemoglobin and a fecal occult blood test persisted being positive. For that reason, CT scans revealed a rounded 3 cm small bowel lesion in the mid ileum . RepeateP < 0.0001). The overall survival was 12.5 months with Pazopanib versus 10.7 months with placebo but it was not statistically significant (p < 0.25) [Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft-tissue sarcoma with unique clinicopathological, immunohistochemical, and genetic features that distinguishes it from other sarcomas –3. EMC h < 0.25) .To the best of our knowledge, this is the first report of EMC metastatic to the small bowel. Our case has several peculiar characteristics including the lack t mutation, the very high mitotic rate, and the significant percentage of viable tumor at the time of resection which translated into a particularly aggressive behavior of the disease. EMC is a rare sarcoma that should be evaluated by a multidisciplinary team including an experienced pathologist as soon as possible to avoid delays in the surgical removal of the tumor which at this point is the only effective therapeutic option available. Patients with metastatic disease should be evaluated for participation in clinical trials.


Primary tuberculous pyomyositis is a rare manifestation of musculoskeletal tuberculosis especially in immunocompetent individuals without a focus of tuberculosis in the body and the underlying bone disease. It can cause a diagnostic dilemma for a physician and surgeon because of its similar presentation to soft tissue sarcomas, hematomas, and myopathies. We present a case of a 45-year-old immunocompetant gentleman with a thigh swelling with sepsis due to pyomyositis of the quadriceps requiring a multimodal management of drainage of abscess, debridement of devitalized muscle, antitubercular drugs, and physiotherapy. In a tubercular endemic country, a high index of suspicion is required to diagnose this disease which can be cured completely. Musculoskeletal tuberculosis occurs in only 3% of patients with tuberculosis, mostly presenting with spondylitis, osteomyelitis, or arthritis . PrimaryA 45-year-old male patient presented with an 8-day history of painful, progressively increasing swelling of the right thigh. There was no history of fever, weight loss, and anorexia. There was no preceding history of any trauma, diabetes, immunosuppression, corticosteroid usage, or renal failure and no past history of tuberculosis or contact. On examination, patient had tachycardia. The right thigh was diffusely swollen, tender, firm, and warm without any scars or sinuses. Distal neurovascular status was normal. There was no lymphadenopathy, spinal tenderness, or paraspinal swelling. The movements of the hip and knee joint were normal . RadiogrExtra pulmonary infection accounts for 40% of all tuberculosis cases . Common The few case reports in the literature about tubercular pyomyositis are in immunodeficient, HIV infected, and renal failure patients or in patients on corticosteroids, immunosuppressive drugs, or chemotherapy –10. It aCommonest route of involvement is by contagious spread 63% cases). Haematogenous spread accounts for 29% of cases. In 8% of the cases cause is direct inoculation. The most common sites of involvement are paraspinal and chest wall muscles by contagious spread 3% cases..Tubercular pyomyositis in the absence of direct spread from underlying bony lesion or haematogenous spread could occur in an immunocompromised patient , by direSkeletal muscles are considered to be “forbidden tissue” for growth and multiplication of tubercle bacilli  because Clinical manifestations are usually nonspecific. This might lead to diagnostic dilemma. Tubercular pyomyositis is commonly misdiagnosed as a soft tissue sarcoma, parasitic infection like cysticercosis or hydatid cyst, and inflammatory myositis or hematoma with secondary infection because of its close resemblance clinically . There iBlood investigations usually are normal except a raised ESR which is a consistent finding .DNA-PCR is a highly sensitive investigation especially to differentiate tubercular from nontuberculous mycobacteria which cause soft tissue infection. With its multiplanar capability and contrast for soft tissue, MRI is the investigation of choice. Most cases of M. tuberculosis myositis are initially diagnosed as bacterial pyomyositis. Although it is difficult to differentiate between M. tuberculosis and Staphylococcal pyomyositis in the early stage of disease, MRI findings can help to distinguish between them. On MRI exam, M. tuberculosis myositis is characterized by low signal intensity on T1WI and high signal intensity on T2WI in a single muscle, with peripheral rims showing subtle hyperintensity on T1WI and hypointensity on T2WI. After gadolinium infusion, peripheral rim enhancement is observed in all cases . Unlike This report is unique because primary tubercular pyomyositis of the quadriceps has been reported only on three occasions—Abdelwahab et al. , Simon e


MYC and one of the Ig gene heavy or light chain loci. Supportive treatment was administered until early delivery, after which the patient was treated according to protocol LMB96. Pregnancy and tumorogenesis share some important events such as immunologic tolerance, angiogenesis, and editing the host immune response. Little is known about the relationship between these events in pregnancy and in tumorogenesis.Burkitt's lymphoma (BL) is an aggressive B-cell malignancy with very high proliferation rate, more common in males than females. Here, we describe a case of Burkitt's lymphoma in a 24-week pregnant woman with cervical and abdominal involvement. The common genetic event of virtually all BL is a reciprocal chromosomal translocation involving the proto-oncogene  Burkitt's lymphoma was first described in 1957 by the Irish surgeon Dennis Parsons Burkitt, after observation of a so-called “sarcoma of the jaws” in children in Uganda, Africa. Burkitt's lymphoma (BL) is a highly aggressive non-Hodgkin lymphoma (NHL), with a very fast growth rate, often affecting extranodal sites or with leukemic presentation . Based oThe sporadic form (5–15% associated with EBV) affects mainly abdominal viscera, terminal ileum, caecum, mesentery, and Waldeyer ring; the third variant is usually associated with HIV infection, and 45% of patients are coinfected with EBV. Burkitt's lymphoma is more common in males than females [MYC (on chromosome 8) and one of the Ig gene heavy or light chain loci  [c-myc is overexpressed under the influence of Ig enhancers regulatory regions. Constitutive expression of c-myc oncogene promotes an increased B-cell proliferation, as well as a reduced capacity for induction of apoptosis [The common genetic event of virtually all BL is a reciprocal chromosomal translocation involving the proto-oncogene poptosis .Burkitt's lymphoma/leukemia was one of the first malignancies shown to be curable with intensive chemotherapy, and the majority of children and young adult patients are curable today with aggressive combination chemotherapy regimens . A twenty-five years old woman, in the 24th week of gestation, presented with a voluminous cervical mass located on the left front neck. She had first noticed an enlargement of her neck 3 months earlier, and, apart from tiredness, she was completely asymptomatic. On observation, she had an isolated cervical mass of about 5 × 10 cm long, hard on palpation, not mobile.Fine needle aspiration showed a high grade B-cell lymphoma, CD10+ (flow cytometry), and the biopsy to the cervical lesion confirmed the diagnosis of Burkitt's lymphoma with gene break point on MYC (8q24) determined by FISH (fluorescent in situ hybridization). The tumour was CD20 (+), CD10 (+), Ki67 (+) (>90% of cells) , CD3 (−)μL/L). According to the Murphy/St. Jude staging classification for Burkitt's lymphoma, the patient was in stage III. In an intention to safely carry on the pregnancy until week 28 of gestation, under monitoring by an obstetrician, chemotherapy with agents potentially less harmful for the baby was proposed. Cyclophosphamide, doxorubicin, vincristine, prednisone, plus rituximab (R-CHOP) was performed with reduction of the cervical mass; however, in two weeks' time, the mass started growing again and LDH increased. Delivery was performed at 28th week of gestation +5, and a healthy baby was born by caesarean section. After delivery, the patient proceeded with conventional treatment for BL according to LMB-96 protocol, group B [As she was pregnant at the time of diagnosis, a total body MRI (magnetic resonance imaging) was used for staging instead of conventional CT scan. MRI revealed a cervical mass of 104 × 63 × 75 mm deviating the trachea and oesophagus leftwards and in the infra diaphragmatic compartment, a mass measuring 135 × 116 × 94 mm in the right flank and a fetus of approximately 25 weeks . There wAssessment of treatment response after R-CYM  by CT and PET scan showed complete remission, and the patient completed chemotherapy according to LMB96 group B protocol in August 2012, with persisting complete remission. MYC translocation is found in almost all BL, it may be seen as well in some cases of diffuse large B-cell lymphoma (DLBCL) which is much more common, and may have a different treatment approach [Whereas approach . Burkitt's lymphoma's brief and intense treatment regimens have led to high cure rates even in adults, especially when immunotherapeutic approach is used . RituximThis is an interesting case not only because it was not possible to determine if it is purely extranodal BL (most common), but also because the patient was pregnant.A diagnosis of Burkitt's lymphoma during pregnancy implies difficulties both in staging procedures and in treatment decision. Conventional staging methods as CT and PET scan should not be performed, and BL treatment protocol such as LMB-96 includes high-dose methotrexate and cytarabine which are contraindicated during pregnancy. Using alternative diagnostic means, chemotherapy regimens with drugs potentially less harmful for the baby and a close followup together with obstetric consult are crucial. Immunologic tolerance, establishment of a nutrient supply system (angiogenesis), and evasion or editing the host immune response are essential steps for a normal pregnancy and also for tumorogenesis. Epithelial-mesenchymal transition, loss of integrin, and E-cadherin expression are essential for the invasion processes in pregnancy and tumor growth. Vasculogenic mimicry  is a process observed in extra villous trophoblast (EVT) cells  and in some aggressive melanoma cells, sharing the same event—expression of galectin 3 . Immunol


A hepatic angiomyolipoma is a rare benign tumor of the liver composed of a mixture of smooth muscle cells, blood vessels and a variable amount of adipose tissue. Differentiating them from malignant liver tumors can often be very difficult.We report the case of a 43-year-old Caucasian man presenting with a large liver mass in the right lobe. The results of magnetic resonance imaging and contrast-enhanced ultrasonography were consistent with a well-demarcated adipose tissue- containing tumor, showing prolonged hyperperfusion in comparison with the surrounding liver tissue. Surgery was performed and the diagnosis of hepatic angiomyolipoma was made with histopathology.Preoperative radiological characterization using magnetic resonance imaging and contrast-enhanced ultrasonography may improve diagnostic accuracy of hepatic angiomyolipoma. Identification of smooth muscle cells, blood vessels and adipose tissue with a positive immunohistochemical reaction for HMB-45 is the final evidence for an angiomyolipoma. An angiomyolipoma is a rare benign mesenchymal tumor composed of a mixture of smooth muscle cells, blood vessels and a variable amount of fat. The appearance of an angiomyolipoma has often been reported in the kidney but rarely in the liver. The first hepatic angiomyolipoma was described by Ishak in 1976 . There iA 43-year-old Caucasian man was found to have a large echogenic mass in his right liver lobe by abdominal ultrasonography. The hepatic lesion measured about 5 × 9 cm with a well-demarcated border Figure . Color DAfter presenting all imaging results in an interdisciplinary liver conference, an atypical resection of the right lobe of his liver was recommended. Our patient underwent surgery without any problems. After nine days, he left the hospital in good clinical condition. The macroscopic examination revealed a solitary tumor with a mottled yellow color and a soft consistency in the right lobe of his liver Figure . The micHepatic angiomyolipoma has been considered as a benign disease in the past. However, spontaneous tumor rupture, malignant transformation and recurrence after primary resection, as well as concurrent hepatic angiomyolipoma and hepatocellular carcinoma, have been reported ,4. SurgiBecause of the variable amount of adipose tissue in hepatic angiomyolipoma, it is sometimes difficult to distinguish between benign and malignant tumors. It is possible to misdiagnose hepatic angiomyolipoma as lipoma, hepatocellular adenoma or carcinoma, sarcoma or metastasis before surgery. Contrast-enhanced spiral computed tomography shows a marked enhancement in the arterial and the portal venous phase of the soft tissue components . RecentlAlthough the combination of various imaging modalities increases preoperative diagnostic accuracy it is reported to be less than 25% . A definWritten 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.SK and OE wrote the manuscript. CL was the physician who performed CEUS. JG was the radiologist in charge of the MRI. RMS gave final approval. All authors read and approved the final manuscript.


It is uncommon that fertility is preserved in young nulliparous females with low-grade endometrial stromal sarcoma (ESS). Therefore, successful pregnancy following such conservative management has been rarely reported in previous literature. A 25-year-old female  underwent hysteroscopic surgery and was pathologically diagnosed with an endometrial stromal nodule. The patient underwent fertility-preserving local resection and uterine reconstruction, with a final pathological diagnosis of low-grade ESS. Endocrine therapy was then administered. Conservative management resulted in the complete remission of low-grade ESS. The patient naturally conceived and successfully delivered a healthy baby at 42 weeks’ gestation by cesarean section, ~30 months following diagnosis with low-grade ESS. In conclusion, conservative management, including fertility-preserving local mass resection and endocrine therapy, can be effective for low-grade ESS and may yield a favorable outcome for young nulliparous females desiring fertility preservation. Endometrial stromal sarcoma (ESS) is a rare malignancy and accounts for <1% of all uterine malignancies and ~15% of all uterine sarcomas ,3, and <The current report presents a case of low-grade ESS which was initially misdiagnosed as submucous myoma according to the ultrasonic examination. The patient was diagnosed with an endometrial stromal nodule following primary hysteroscopic surgery and was eventually diagnosed with low-grade ESS at the subsequent laparotomy. A desired outcome was achieved; the patient successfully conceived and delivered a healthy baby following the second local excision and endocrine therapy.A 25-year-old female was admitted to the Qilu Hospital of Shandong University  complaining of menorrhagia and shortened menstrual cycles of three months and acute lower abdominal pain lasting for 10 h. The patient had a surgical history of right breast fibroadenoma removal at 23 years of age. The patient’s medical history was unremarkable. A previous B ultrasound examination demonstrated a hypoechoic lesion (6.1×5.2×5.9 cm) with a clear borderline on the left posterior wall of the uterus. Physical examination of the external genitalia, vagina and cervix showed no abnormalities. Pelvic examination revealed a regularly enlarged uterus, the size of 70 days pregnancy. No adnexal masses were palpated. Primary diagnosis was determined as submucous myoma and a myomectomy was performed by hysteroscopy. During surgery, a submucous mass that resembled type II myoma was found in the left posterior wall of the patient’s uterus, with a hemorrhagic and necrotic surface. Due to the incomplete resection, as a section of the mass was in the wall, subsequent surgery was suggested. One week later, histological results of the formalin-fixed resected mass confirmed a submucous endometrial stromal nodule, immunohistochemically positive for CD10. The patient recovered satisfactorily and was discharged from hospital six days later.Three months later, the patient returned to the hospital for a laparotomy in order to resect the residual lesions. The surgery was performed on May 31, 2010. During surgical exploration, a convex mass with a diameter of 5 cm was detected on the posterior wall of the enlarged uterus and the decision was made to perform resection. The mass, which was detected to be trans-endometrial and well-circumscribed from the surrounding myometrium, was completely resected. Histological examination of frozen sections of the resected mass during the surgery suggested low-grade ESS. Thus, radical hysterectomy was proposed to the patient’s family, but the family rejected and expressed a desire for fertility preservation since the patient was nulliparous. As there were no signs of tumor infiltration and metastasis, the surgical procedure was changed to preserve and reconstruct the uterus, which was successfully accomplished. Final pathological examination of the formalin-fixed resected tissue (4.5×3.3 cm) confirmed the diagnosis of low-grade ESS. Various levels of staining intensity are indicated by −, +, ++ and +++; negative, weak, moderate and strong, respectively Immunohistochemistry showed CD10(+), desmin(+), smooth muscle actin (SMA)(−) and 30% Ki67(+). Further detection of estrogen receptor (ER), progesterone receptor (PR) and p53 by immunohistochemistry showed ER(+++), PR(+++) and p53(−) .Chemotherapy and endocrine therapy were suggested as adjuvant treatments, but the patient declined chemotherapy considering its side effects and the patient’s desire for fertility. Medroxyprogesterone (250 mg) was administered daily for one year to inhibit tumor recurrence. No abnormal abdominal or pelvic observations were identified.Following six months of medroxyprogesterone withdrawal, the patient conceived naturally. Pregnancy was uncomplicated and the patient delivered a healthy baby of 3,300 g at 42 weeks’ gestation by cesarean section on November 22, 2012. On January 9, 2013, the patient returned to the gynecological clinic of the hospital for a general check-up and no signs of tumor recurrence were identified. Written informed consent was obtained.ESS is a rare malignant disease with an overall five-year survival rate of ~30% . ESS accThe mainstay treatment for ESS is total abdominal hysterectomy and bilateral salpingo-oophorectomy. Due to the rarity of ESS in young nulliparous females, the occasional cases of ESS in young patients are usually identified in histological examinations of resected presumed leiomyomas of the uterus ,9. The cet al previously reported a case of a 34-year-old female with a diagnosis of low-grade ESS who underwent a severe peritoneal recurrence following the successful delivery of a healthy baby (et al also identified that surgery sparing ovarian function increased the risk of recurrence of ESS compared with those without the preservation of ovarian function (et al (et al (Previous relevant literature concerning ESS were extensively reviewed. Indeed, fertility-preserving surgery in young nulliparous females had been proposed in several cases –5 and suthy baby . Li et afunction . In addin (et al  and Pickl (et al  each repl (et al . TherefoAlthough ESS is a rare uterine malignancy with poor prognosis, in selected cases with a local uterus mass and no signs of metastasis and infiltration, conservative management, including local surgical resection and adjuvant treatment, may be performed to preserve fertility. The present case report suggests that fertility preservation by local resection and uterine reconstruction may be a viable option for young females with low-grade ESS.


Acute pericarditis is common but illusive, often mimicking acute coronary syndrome in its clinical and electrocardiographic presentation. Regional pericarditis, though rare, presents further challenge with a paucity of published diagnostic criteria. We present a case of postoperative regional pericarditis and discuss helpful electrocardiographic findings. A 66-year-old male with history of open drainage of a liver abscess presented with abdominal pain and tenderness. CT of the abdomen was concerning for pneumatosis intestinalis of the distal descending colon. He underwent lysis of liver adhesions; exploration revealed only severe colonic impaction, for which he had manual disimpaction and peritoneal irrigation. Postoperatively, he developed sharp chest pain. Electrocardiogram revealed inferior ST elevation. Echocardiogram revealed normal left and right ventricular dimensions and systolic function without wall motion abnormalities. Emergent coronary angiography did not identify a culprit lesion, and left ventriculogram showed normal systolic function without wall motion abnormalities. He received no intervention, and the diagnosis of regional pericarditis was entertained. His cardiac troponin was 0.04 ng/dL and remained unchanged, with resolution of the ECG abnormalities in the following morning. Review of his preangiography ECG revealed PR depression, downsloping baseline between QRS complexes, and reciprocal changes in the anterior leads, suggestive of regional pericarditis. Prompt evaluation of an electrocardiogram (ECG) remains the basis for the initial workup and early implementation of life-saving therapy in patients presenting with chest pain suggestive of acute coronary syndrome (ACS). Vigilance, however, is recommended in the interpretation of the ECG, paying attention to atypical clinical or electrocardiographic features which may point at an alternative diagnosis, mandating further diagnostic studies and different management. We present a case of regional pericarditis with electrocardiographic features mimicking an inferior myocardial infarction, prompting early cardiac catheterization. Subtle ECG findings, however, can serve as clues to the presence of pericarditis rather than myocardial ischemia. Review of pertinent literature is provided.A 66-year-old white male with known hypertension and diabetes mellitus and prior open drainage of a liver abscess presented to our emergency department with abdominal pain and tenderness. The patient underwent computed tomography (CT) scan of the abdomen which revealed findings consistent with fecal impaction and pneumatosis intestinalis of the distal descending colon. He was taken to the operating room where he underwent extensive lysis of liver adhesions thought to have been caused by his prior liver surgery, and exploration revealed only severe colonic impaction. He underwent manual disimpaction of fecal material and gas, peritoneal irrigation, and closure. His initial postoperative course was uneventful, and he was quickly weaned off the ventilator. However, later in the evening he developed chest pain, described as retrosternal sharp to tight feeling, without radiation. Deep inspiration caused worsening of his abdominal pain at the incision site but did not alter his chest pain severity. The patient's blood pressure and heart rate remained stable. ECG revealed inferior ST elevations with reciprocal ST depressions in the anterior leads suspicious of myocardial injury ; therefoBarnes and Burchell  reportedCharacteristic ST and T-wave abnormalities and evolution patterns have long been observed in patients with postinfarction regional pericarditis . LocalizRegional pericarditis has also been observed in the absence of infarction. Youssef et al.  reportedThe American Heart Association, American College of Cardiology Foundation, and Heart Rhythm Society (AHA/ACCF/HRS) guidelines  recommenAlthough the absence of elevated cTnI may help differentiate pericarditis from myocardial infarction, cTnI elevation is often observed in viral or idiopathic acute pericarditis . EchocarOur patient developed early postoperative inferior ST elevations, together with reciprocal anterior ST depressions, suggestive of an acute inferior ST-elevation myocardial infarction , which pPericarditis is a common condition with clinical and electrocardiographic features which can mimic ACS. The subtle differences between the two conditions are often overlooked due to the fear of missing the more serious diagnosis of ACS and the window for timely reperfusion. Even though ancillary tests, such as echocardiography and cardiac biomarkers, can aid in diagnosing pericarditis or excluding ACS, careful attention to specific characteristic findings on the ECG remains the mainstay of initial and timely recognition and triage of patients to avoid the potentially harmful consequences of inappropriate therapy. Helpful electrocardiographic features in differentiating acute pericarditis from ACS include PR-segment depression, a downsloping ECG baseline from one QRS complex to the following PR-segment (Spodick's sign), and, in regional pericarditis, reciprocal ST changes (“reverse” Spodick's sign).


Giant cystic meconium peritonitis is relatively rare. Patients often present with nonspecific physical findings such as distension and emesis. Plain abdominal films remain invaluable for identifying the characteristic calcifications seen with a meconium pseudocyst, and large eggshell calcifications are pathognomonic for the giant cystic subtype.We present classic plain X-ray findings and an intraoperative image of a premature low birth weight two-day-old Hispanic male baby treated for giant cystic meconium peritonitis with a staged procedure involving peritoneal drainage, ostomy creation and closure.Pediatric surgeons have a range of potential therapeutic approaches for giant cystic meconium peritonitis. A delay of definitive surgical management in the setting of massive abdominal soiling is a safe and acceptable strategy if adequate temporizing drainage is performed in the early perinatal period. This perforation is often secondary to ischemia or obstruction and although meconium is sterile, chemical irritation of the peritoneum can ensue [Reports of meconium peritonitis appear in the English-language literature beginning in the early 20th century ,2. Infanan ensue . As the an ensue .2 50 torr, and partial pressure of O2 20. His abdomen was markedly distended, exhibited progressive erythema, and radiographs showed dilated bowel loops and significant, well-demarcated bilateral calcifications (Figure A 2.2 kg Hispanic boy was born vaginally to a 21 year-old primigravida woman at 31 weeks and one day of gestation after prolonged rupture of membranes. He had a prenatal history of dilated bowel loops and hydrops on ultrasonography, as well as fetal anemia requiring an intrauterine blood transfusion 18 days prior to delivery. Our patient was intubated at 11 minutes of life for poor respiratory effort. Analysis of his cord arterial blood gas on transfer to the neonatal intensive care unit revealed a pH of 7.32, partial pressure of COOur patient was diagnosed with a giant meconium pseudocyst, a walled-off collection of meconium that can cause neonatal peritonitis, which is distinguished from other forms of meconium peritonitis by the persistence of a communication between the digestive lumen and the peritoneal cavity leading to the entire abdomen becoming filled with meconium . On the Although our patient’s sepsis improved with source control, he remained obstructed with a high nasogastric output. He also had persistent impairment of his pulmonary function from the obstruction and abdominal distension. Therefore, he was taken for a second operation one month later. In this procedure, an extensive lysis of adhesions was performed, revealing a meconium cyst remnant Figure B. His diN-acetylcysteine enema administration, but requires surgical intervention if such measures fail [Broadly, the meconium syndromes constitute a spectrum of diseases, all of which can present with neonatal bowel obstruction . These mres fail . In factres fail . Meconiures fail . In turnres fail .et al. [et al. [The defining characteristic of meconium pseudocyst and meconium peritonitis, which distinguishes these conditions from meconium ileus or meconium plug syndrome, is intrauterine perforation with extralumenal leakage of enteric material into the peritoneal cavity . Outcomeet al.  given th [et al. .A classic appearance of large calcifications on plain abdominal films in the setting of a distended and distressed neonate should place giant cystic meconium peritonitis high upon the differential diagnosis. Initial peritoneal drainage with a delay in definitive surgical management is a reasonable approach in the setting of massive meconium soiling of the abdominal cavity that prohibits the safe identification of bowel loops for stoma creation. At reoperation, bringing out a stoma is a safe option, especially for low birth weight infants.Written informed consent was obtained from the patient’s next-of-kin 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.ERB, ALS and DEL performed the literature search and wrote the manuscript. BJN-M and TG performed the surgeries, provided intraoperative images and critically reviewed the manuscript prior to submission. All authors have read and approved the final manuscript.


We report a case of primary clear cell sarcoma occurring in the humerus. A 20 year old girl was referred to our hospital two years ago with painless swelling of the soft tissue surrounding the proximal right humerus. The conventional radiographic image showed an ill-defined, aggressive, osteolytic lesion associated with a partial cortical defect of the proximal right humerus. Magnetic resonance imaging found an irregularly shaped extraosseous mass extending from the proximal shaft of the right humerus, penetrating through the destroyed bone and invading the biceps brachii. After preoperative chemotherapy, a total tumor resection, internal fixation and bone cement implantation were performed. Histological studies of the resected tumor found that fibrous septa divided into well-defined nests and polygonal and fusiform cells with clear cytoplasm. Immunohistochemical studies demonstrated strong positive cytoplasmic staining with S-100 and scattered positivity with HMB-45. These findings led to a final, definitive diagnosis of clear cell sarcoma of the humerus. After routine postoperative chemotherapy, a 2-year follow-up showed no metastasis. Our findings in this report point out that primary clear cell sarcoma can originate from within the humerus and that limb salvage surgery can obtain a good result. Clear cell sarcoma is a malignant soft tissue neoplasm first described by Enzingerin 1965 -4, but nA 20-year-old girl was admitted to our hospital with painless swelling in the proximal right humerus of 6 weeks' duration.Physical examination revealed a healthy well-developed girl with a tender, palpable, firm mass arising from the proximal shaft of the right humerus. A conventional radiographic image showed an ill-defined, aggressive, osteolytic lesion associated with a partial cortical defect in the proximal shaft of right humerus Figure . There wMagnetic resonance imaging (MRI) showed an irregularly shaped extraosseous mass extending around the right humerus through the destroyed bone and invading the biceps brachii Figure . The lesOne week after preoperative chemotherapy, which included cisplatin and adriamycin, a total tumor excision-alcoholization-replantation (EAR), internal fixation and bone cement implantation were performed. With the patient under general anesthesia; the anteriomedial approach to the humerus which included the pathway of CT-guided biopsy was used. After detachment of the biceps and triceps brachii, the tumor was found to involve the anteriomedial portion of the proximal humerus and part of the biceps brachii. The site of cortical destruction was not related to the attachment of any tendon or ligament. The whole tumor was detached from the bone and resected. Figure  The humeRoutine histopathological studies with hematoxylin-eosin (HE), and immunohistochemical investigations with S-100 and HMB-45 were performed. Histological studies with HE showed fibrous septa divided into well-defined nests and polygonal and fusiform cells with clear cytoplasm   translocation, a feature not encountered in malignant melanoma ,9. This The survival rates and metastatic incidence of primary clear cell sarcoma of the bone are unknown because of the limited number of cases reported. The longest survival time of 65 months was reported by Yokoyama et al . Since, At the outset, we suggested to the patient, considering that this is a very malignant tumor, that she should have an amputation at the shoulder. However, the patient and her family wanted her to keep the limb. Therefore, we decided to do a limb salvage operation. We didn't use tumour prosthesis or osteoarticular allograft because the patient wanted to keep the function of her shoulder joint and we found the joint to be normal. As we have used EAR to treat osteosarcoma for many years, and the results were satisfactory, we perfThe effects of the operation and chemotherapy seem to have been effective, so far, in eradicating the clear cell sarcoma. The patient now feels no discomfort in her right humerus and has no sign of metastasis. We ordered the patient to come in for follow-up every month. Our hope is that this case can be an example of a good outcome of treatment for primary clear cell sarcoma of the bone. We will continue follow up indefinitely.We report the first case of primary clear cell sarcoma of humerus. Our findings in this report point out that primary clear cell sarcoma can originate from within the humerus and that limb salvage surgery can achieve good results.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.XL and YD carried out the operation. XL wrote the article. HZ did the pathological study of the case. All authors read and approved the final manuscript.


Extra-adrenal paraganglioma of the retroperitoneum with metastasis to the vertebra is very rare. To our knowledge this is the first report of this kind of disease in the literature.Here, we present an oroginal case of paraganglioma of the retroperitoneum with metastasis to the abdominal vertebra in a 42-year-old female patient who was successfully treated by complete removal of the tumor and its metastasis. The patient was followed up for four years and remained disease-free.Our case demonstrated the need to consider paraganglioma of the retroperitoneum in the differential diagnosis of retroperitoneal mass, metastatic tumors to the vertebra, and the importance of radical surgery for a successful management of the disease.http://www.diagnosticpathology.diagnomx.eu/vs/1956611954880197The virtual slide(s) for this article can be found here:  Paragangliomas, also known as extra-adrenal pheochromocytomas, are rare neuroendocrine neoplasms that are derived from the paraganglia, a diffuse neuroendocrine system dispersed from the skull base to the pelvic floor. They are found in many tissues such as the adrenal medulla, the carotid bodies, the organs of Zuckerkandl, and the paraganglia of the sympathetic and parasympathetic neurons ,2. Parag2) in the left adrenal region with cystic changes. The scattered spots indicated the calcification foci. No lymph node swelling and distant metastasis were detected except for the lesion in the first lumble vertebra. Osteolytic bone destruction and punctiform dead bone was detected in the first lumbar vertebra, which affect the posterior margin of the vertebra, bilateral arch and plate, superior and inferior articular processus, processus spinosus and left processus transverses  scan of the mass showed an inhomogeneous density (10.5×6.7 cm3 with integrated surface and full of vascular network. The left kidney and the tumor were resected and the weight of the tumor is 670 grams. Intraoperative blood loss is 300 ml. The intersection of the tumor is red-brown, full of blood vessels, fibrous septa and bone-like substance with some schistic hemorrhage and necrosis in the middle. Macroscopically, no invasion of the tumor into the kidney can be observed. Histologically, the tumor was alveolar-like with many well-vascularized septa (Figure The primary lesion was resected through a thoracoabdominal incision in December 2006. Intraoperative examination showed that the stomach, transverse colon, pancreas and spleen were displaced by the mass, but without significant adhesion to the ventral surface of the tumor. The left kidney tightly adhered to the tumor and was difficult to separate from it. The volume of the solid tumor is about 10×9×7 cma Figure A1, 4A2, After two weeks, the patient was transferred to the Department of Spine Surgery for resection of the lumbar tumor and treated by posterior fixation with Moss Miami system Figure D, 2E, 2FThe clinical, pathologic and radiological features of retroperitoneal paragangliomas have been previously described ,5. ParagCT, MRI or ultrasonographic studies are sensitive in detecting a retroperitoneal mass and could delineate its location, outline, internal structure as well as its relationship with the surrounding organs. However, specific diagnosis for the retroperitoneal mass still relies on postoperative histopathological diagnosis. In addition, histopathological diagnosis is required to define the paraganglioma as benign or malignant tumours exhibit similar clinical diagnosis and imaging findings . ChromogMost paragangliomas are benign in nature and the malignancy rate is about 10%to 15% . The preManagement paragangliomas of the retroperitoneum with metastases remains a very challenging task as complete surgical removal of the tumor as well as the metastasis offer the only chance for cure and no other therapeutic methods have been shown to provide long-term survival. Meticulous and complete surgical removal of the original tumor and its metastasis has been reported to associate with long-term survival . Most paWritten 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.JH and X-JW carried out pathological examination and wrote the manuscript as major contributors. WZ participated in pathological investigations. Y-WZ carried out the immunohistochemical staining and collected the patient’s clinical information. JH gave final approval to the manuscript as a corresponding author. All authors have read and approved the final manuscript.


Lipoma of the adrenal gland is rare with a reported incidence of between 2% to 4%. Improved imaging techniques have helped in the diagnosis of these lesions.We report an incidentally detected giant adrenal lipoma in a 43-year-old Asian man with a six year history of hypertension. He had a myocardial infarction one year earlier, for which he was taking an antiplatelet agent in addition to antihypertensive medication.The tumor was detected by computed tomography and magnetic resonance imaging, and was a large, well-defined, altered signal intensity lesion 12 cm in size in the right suprarenal region. The tumor was resected laparoscopically and sent for histopathologic evaluation. It measured 15 cm × 11.5 cm × 6.5 cm on gross examination, weighed 810 g and had a homogenous yellow cut surface. The postoperative course was smooth. Microscopy revealed mature adipose tissue with myxoid degeneration. Over the course of a four month follow-up the patient recovered.Giant lipoma of the adrenal gland, a benign tumor, is rare compared with myelolipoma. Improved radiologic modalities have led to increased reporting of these benign tumors. Laparoscopic removal of the tumor has helped in early recovery and in reinstating patients to normal lives. Lipomatous tumors of the adrenal gland are rare. Improved diagnostic modalities, including high-resolution ultrasonography, computed tomography (CT) and magnetic resonance imaging (MRI), have led to increased reporting and management of such tumors. We report one such case of an incidentally detected adrenal lipoma.A 43-year-old Asian man was incidentally detected to have a loose, well-defined, homogenously enhancing soft tissue density lesion in the right adrenal gland. This lesion was found while the patient was undergoing investigations for hypertension of six years' duration being controlled with α- and β-blockers and a diuretic. The patient had a history of myocardial infarction nine earlier for which he underwent coronary angioplasty and he was taking an antiplatelet agent.During this admission, he had undergone ultrasonography of the abdomen, which revealed an adrenal mass. No other significant history or findings were noted.On examination, the patient's blood pressure was 150/90 mm Hg. A chest radiograph revealed prominent vascular markings in bilateral lung fields with cardiomegaly. MRI suggested adrenal myolipoma with a large, well-defined, altered signal intensity lesion in the right suprarenal region measuring 119 × 105 mm in size. Other organs were unremarkable. No lymph node enlargement was noted. CT scan revealed a large, well-defined, soft tissue density lesion with intrinsic fat density areas in the right adrenal region measuring 116 × 100 mm in size Figure . The extThe patient had an uneventful postoperative course and is stable with the same medications continued for one month. The patient is now taking a beta-blocker and antiplatelet agents, and he has stopped taking the alpha-blocker and diuretic that he needed previously for blood pressure control.giant lipoma is preferred when the size exceeds 8 cm. Our patient had a tumor of more than 11 cm in diameter, thus falling in the category of "giant adrenal lipoma." No calcification was noted despite the lipoma's large size.Adrenal lipomas are benign tumors with a reported incidence of 2% to 4% of all adrenal tumors -4. The dGiant adrenal lipomas are rare but are being reported more frequently because of improved modern imaging technologies. This tumor was removed with the rarely reported technique of transperitoneal laparoscopic adrenalectomy and was confirmed histologically.The authors declare that they have no competing interests.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.RDP was the major contributor in writing the manuscript and analysis and interpretation of patient data regarding the histopathologic disease. AVV performed the histologic examination and helped in preparation of the final manuscript. PRM did the transperitoneal laparoscopic adrenalectomy and postoperative follow-up of the patient. All authors read and approved the final manuscript.


Ectopic thymoma rarely presents as an intrathoracic tumor. We report a case of ectopic thymoma presenting as a giant right intrathoracic tumor that was treated with resection. The patient was a 50-year-old Japanese woman who presented with the chief complaint of chest pain. Detailed examination revealed a solid tumor measuring 15 × 10 × 8 cm in diameter, with a clear border. The Imaging findings suggested a solitary fibrous tumor, and surgery was performed. At surgery, the tumor was found to beadherent to the diaphragm, mediastinal pleura, and lower lobe of the lung, although it could be dissected with relative ease and was removed. Pathological diagnosis indicated a type B1 tumor with no capsular invasion according to the World Health Organization classification, and a diagnosis of Masaoka stage I thymoma was made. No continuity with the normal thymus tissue was seen, and the thymoma was considered to be derived from ectopic thymic tissue in the pleura. Thymomas usually manifest in the anterior-superior mediastinum, and ectopic thymomas account for only 4% of all thymomas. Among ectopic thymoma, intrathoracic tumors of pleural origin are rather rare. We report, herein, a patient with a giant intrathoracic tumor that was discovered during a clinical workup to determine the cause of chest pain in the patient. The tumor was diagnosed as a thymoma that was difficult to differentiate from solitary fibrous tumor (SFT) by diagnostic imaging.A 50-year-old Japanese woman with the chief complaint of chest pain was examined at a local hospital. A chest radiograph revealed a giant tumor in the right lower lung field, and the patient was referred to our department. The patient had no pertinent personal or family history, and had never smoked. Respiratory sounds in the right lower lung field were diminished, but no other abnormalities were detected on physical examination. Respiratory function tests revealed a vital capacity (VC) of 1,470 mL and a percent predicted VC of 46.7%, indicative of restrictive pulmonary disease. No abnormalities were identified on blood biochemistry. A plaine chest x-ray Figure  showed aThymomas are tumors developing mainly in the thymus, are located in the anterior mediastinum, with 96% of the tumors occurring in the anterior or anterosuperior mediastinum, and only 4% being ectopic tumors ,2. EctopDefinitive diagnosis is needed before surgical removal of a thymoma is planned. The differential diagnosed for giant intrathoracic tumors include SFTs, tumors of pleural origin, such as malignant pleural mesothelioma or sarcoma, chest wall tumors, and metastatic tumors. In our patient, SFT was initially suspected on the basis of the MRI findings, including the shape, signal status under various weightings, and the presence of numerous linear non-signals that were considered to indicate flow voids within the lesion. It was considered that percutaneous needle biopsy would yield a definitive diagnosis, but this procedure was not performed considering the risk of tumor cell dissemination and bleeding from the tumor. Hemorrhagic shock induced by spontaneous rupture of a giant thymoma has been reported , and cauInformed consent was obtained from the patient for publication of this case report and of the 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.MK operated on this case and analyzed all the data. KO, KS, YM, and SH assisted in the operation. YT and NM diagnosed the pathology of this case. TS did a professor of the Department of Surgery and had the guide of this paper. All authors read and approved the final manuscript.