A 32-year-old male patient presented to our clinic with chronic left knee pain that was ongoing for about 1.5 years. The patient visited several times our clinic and the other clinics; conservative treatment  was recommended by various different doctors. The anamnesis, physical examination, and plain radiography were nonspecific. Early MRI findings mislead us to believe it is bone marrow edema. One and half years with noneffective treatment, the knee pain persisted. At the latest visit intra-articular osteoid osteoma was suspected and the knee MRI with CT was employed. Even though the diagnosis of intra-articular osteoid osteoma often presents a challenge for the surgeons, with a present awareness of intra-articular osteoid osteomas which lack the characteristic sclerotic lesions and nidus on plain X-rays and the aid of multislice CT, a correct diagnosis which warrants proper treatment can be achieved. The possibility of osteoid osteomas, especially in young adults with persistent knee pain with unknown reasons that show normal plain radiographs results, must not be overlooked. The treatment method of these lesions should be customized depending on the location of the lesion, experience of the surgeon, and cost of method. Osteoid osteoma, first described by Jaffe in 1935 . AccordiApproximately 13% of osteoid osteomas arise within the joint (intra-articular). Hip joint is the most commonly affected area, followed by the ankle, elbow, wrist, and knee .Intra-articular location of the osteoid osteoma obscures classical symptoms and radiologic appearance, which, thus, can cause misdiagnosis and delayed proper treatment for the condition .In this report, we would like to make a contribution to the literature by sharing our experience on a case with a lesion located on anteromedial tibia plateau (within joint capsule) and a delayed diagnosis by 1.5 years.A 32-year-old male patient presented to our clinic with chronic left knee pain that lasted for about 1.5 years. The patient visited several times our clinic before conservative treatment  was recommended by two different doctors. The pain persisted during resting period and got worse during the night. NSAIDs caused temporary and partial pain relief. No significant medical stories from the patient or his family were seen. Physical examination showed some swelling and tenderness on anteromedial side of the left knee. Meniscal tests were negative, while the left quadriceps muscle showed moderate atrophy with an intact range of motion. Left knee radiographs showed no abnormalities .When patient's MRI results were assessed, initial MRI of the patient, taken 1.5 years ago, at the beginning of the complaints, showed bone marrow edema. Second MRI, which is recent, showed a nidus-like view with bone marrow edema .CT scans showed a small radiolucent zone, surrounded by reactive circumferential sclerosis, which is typical for osteoid osteoma . Based oUnder general anesthesia, pneumatic tourniquet was applied (350 mmHg) and a medial parapatellar incision was made. After opening the joint capsule, the Hoffa were stripped in the direction of lesion , exposing the undersurface of anterior horn of medial meniscus. Intervention area was detected after the discolored and irregular lesion surface was marked . Tumor tHistopathological examination of the surgically removed lesion confirmed the initial diagnosis of osteoid osteoma . The patIn this article, we would like to highlight the difficulties on the diagnosis of the intra-articular osteoid osteoma. This atypical presentation with uncharacteristic radiological findings and the lack of trauma history usually directs the surgeon not to order unnecessary MRI/CT images, which causes delay on correct diagnosis.Szendroi et al.'s  study coAnother study done by Kattapuram et al.  reportedIn addition to other authors, the low capability of producing new thick bone of the intracapsular periosteum was first underlined by Freiberger et al. . Bauer eThese atypical anatomical, pathological, and physiological features of the affected intracapsular bone and adjacent synovium are all contributing factors in diagnosis delay of intra-articular osteoid osteoma. The patient can be subjected to redundant treatments such as unnecessary arthroscopies and/or arthrotomies with a delay in correct diagnosis and proper treatment .As plain radiographs usually show no abnormalities in the joint, they have little value on the diagnosis. However, they are still required for elimination of other possible conditions and should be the first in line for diagnostic investigation in a normal diagnostic algorithm.Another valuable investigation technique for classic extra-articular located osteoid osteomas is scintigraphy which shows the characteristic double density sign . HoweverMRI images can also be misleading for the surgeon, as the detection of synovitis or bone marrow edema during the early stages of the disease might lead the surgeon to misdiagnose the condition as arthritis or stress fracture of the bone. As in our case, nidus appearance usually develops at the late stages of the disease and is not evident on MRI until that time. Krause et al.'s  case repAs opposed to our case, in the cases where the patient had a trauma or bruising history, the surgeons usually tend to suspect other causes such as meniscal tears, chondral lesions, and collateral ligament tears or bone bruising. In those situations, the surgeon is likely to order X-rays and MRI for diagnosis. Bone marrow edema view during early stages of the osteoid osteoma might lead the surgeon to misdiagnose the condition as a bone bruise or a stress fracture, therefore delaying the correct diagnosis, as in our case.CT remains the method of choice for investigating intra-articular osteoid osteomas . As in o99mTc–methylene diphosphonate (MDP) bone scintigraphy (BS) with SPECT/CT for clinically and/or radiologically suspected osteoid osteoma, retrospectively. In this study they compared the sensitivity, specificity, and accuracy of SPECT/CT, CT alone, and bone scintigraphy. They concluded that 99mTc–MDP BS with SPECT/CT shows excellent diagnostic accuracy for osteoid osteoma and can be used as a one-stop imaging modality for the same. They also concluded that 99mTc–MDP BS with SPECT/CT is superior to planar BS and CT alone for the diagnosis of suspected osteoid osteoma [Recently, the new imagining methods such as SPECT/CT have gained popularity. SPECT/CT can be very useful especially in those cases when the osteoid osteoma is intra-articular and the X-ray and MRI are not informative. Sharma et al.  evaluate osteoma .Latter Squier et al.  used 99mFarid et al.  publisheEven though there were several reports on intra-articular osteoid osteomas in the distal femur , patellaDespite the fact that CT-guided thermoablation is getting more and more popular for treating osteoid osteoma, it has several prerequisites such as assistance from a radiologist and the fact that the procedure has to be performed in either a CT room or an operating theatre equipped with a CT scanner. RF ablation might also cause cartilage degeneration when used for resecting subchondral osteoid osteomas , 42. TheIn conclusion, here we presented an osteoid osteoma case that arises within knee joint which was successfully treated by open excision. Even though the diagnosis of intra-articular osteoid osteoma often presents a challenge for the surgeons, with a present awareness of intra-articular osteoid osteomas which lack the characteristic sclerotic lesions and nidus on plain radiography and the aid of multislice CT, a correct diagnosis which warrants proper treatment can be achieved. The possibility of osteoid osteomas, especially in young adults with persistent knee pain with unknown reasons that show normal plain radiograph results, must not be overlooked. The treatment method of these lesions should be customized depending on the location of the lesion, experience of the surgeon, and cost of method.


Glucagonoma and pancreatic serous oligocystic adenoma (SOA) are rare neuroendocrine and exocrine tumors of the pancreas, respectively. The coexistence of glucagonoma syndrome (GS) and SOA is a rare clinical condition and has not yet been reported. Additionally, necrolytic migratory erythema (NME), a hallmark clinical sign of GS, is often misdiagnosed as other skin lesions by clinicians due to their lack of related knowledge, which delays diagnosis of GS and thus exacerbates the prognosis.A 50-year-old male patient was admitted to our department because he presented with diabetes mellitus and a recurrent ulcerated skin rash. Prior to the accurate diagnosis, the skin manifestation was considered to be diabetic dermopathy.The patient's fasting serum glucagon level was up to 871.5 pg/mL. A biopsy of the pancreatic tumor revealed a pancreatic neuroendocrine tumor, and immunoperoxidase staining revealed glucagon-positive cells. In addition, the histological examination of the pancreatic cystic lesions showed typical features of SOA.The patient received a pancreaticoduodenal resection and radiofrequency ablation for the hepatic nodular lesion.One week after surgery, the glucagon concentration decreased to near normal levels. The cutaneous lesions spontaneously resolved within 4 weeks after surgery.Because almost all glucagonomas are malignant or have malignant potential, their early recognition and correct diagnosis are very important for a better prognosis, especially in cases with NME as the only manifestation during the development of glucagonomas. It is therefore imperative that clinicians recognize NME early to make an accurate diagnosis. Glucagonoma is a type of PNET derived from islet alpha cells and has an estimated incidence of approximately 1 in 20 million people per year. SOA, which represents approximately 10% of serous cystic neoplasms, is a relatively rare tumor lesion of the pancreas. Although serous cystadenomas are often reported to coexist with other pancreatic neoplasms, the coexistence of SOA and a rare pancreatic endocrine neoplasm is an uncommon clinical condition and has not yet been reported.Pancreatic serous cystic neoplasm, including serous microcystic adenoma, serous oligocystic adenoma (SOA), and serous cystic carcinoma, account for 1% to 2% of all exocrine pancreatic tumors.We herein present a case of GS combined with SOA arising from the pancreas, which is a rare combination of pancreatic endocrine and exocrine tumors.2Our study was approved by the Institutional Ethic Committee of West China Hospital, Sichuan University. Written informed consent was obtained from the patient before data collection.2) with reddish-crusted lesions mainly in the perioral region and distal extremities.In August 2015, a 50-year-old male patient of Chinese Han nationality was admitted to the hospital's Endocrinology Department because of an ulcerated skin rash that recurred for 11 years and hyperglycemia for 8 years. The patient had diffuse and recurrent erythematous and erosive lesions that were primarily on his extremities, perioral region, gluteal sulcus, and perineum , hypoalbuminemia , and hyperglycemia . The level of glycosylated hemoglobin was elevated to 7.5%. The level of fasting chromogranin A, which is a serum marker for neuroendocrine neoplasia, was elevated . The level of fasting serum glucagon was also elevated  and was accompanied by an elevated glucose level of 8.01 mmol/L.A biopsy of the skin lesion showed acanthosis and diffuse parakeratotic hyperkeratosis in the epidermis. Neutrophil infiltration and focal hemorrhage were present in the cornified layers of the skin, and perivascular lymphocytic infiltration was observed in the upper dermis Fig. A. Based On hospital day 25, the patient was transferred to the Department of Pancreatic Surgery and then underwent a pancreaticoduodenal resection with the da Vinci Surgical System Fig. D and radThe association of a glucagonoma tumor with NME confirmed the diagnosis of GS. One week after the surgery, the patient's cutaneous lesions almost disappeared. Simultaneously, the glucagon concentration decreased to near normal levels (248.8 pg/mL) and was accompanied by a fasting glucose level of 8.73 mmol/L. Moreover, the total daily insulin dose was reduced from 60 units before the operation to 26 units after the glucagonoma was removed. Within 4 weeks after surgery, the skin manifestations spontaneously resolved Fig. E. At 3 m3,6 NME is a hallmark clinical sign of GS and is present in approximately 70% of GS patients. Although the exact pathogenesis remains unclear, the development of NME is considered to be due to the direct action of glucagon in inducing skin necrolysis, hypoaminoacidemia or a deficiency of essential fatty acids or zinc. As NME may be the only manifestation during the development of glucagonomas that is malignant, its early recognition and correct diagnosis is very important for a better prognosis. Unfortunately, clinicians often misdiagnose NME as eczema, psoriasis, or contact dermatitis on account of their lack in related knowledge. In the present case, the patient was thought to have eczema and was treated for eczema for almost 3 years before being diagnosed with diabetes mellitus. Regardless of whether the combination of NME and diabetes developed, community doctors did not recognize the disease, which was misdiagnosed for almost 11 years.Glucagonoma is an extremely rare neuroendocrine tumor, comprising only 2% to 5% of all islet cell tumors. Previous studies reported that the blood glucose level of GS patients was mildly elevated and well controlled with dietary measures. By the time of diagnosis, a Mayo Clinic report suggested that only 38% of GS patients presented with diabetes mellitus, which generally developed before NME in patients with both conditions. However, our patient presented with thirst, polyuria, polydipsia, and rapid weight loss  before diabetes was established. At the onset of the patient's diagnosis of diabetes, he had to use insulin injections to control blood glucose because his fasting capillary blood glucose was up to >26 mmol/L. The development of diabetes in this patient seemed to be rapid. We speculate that the clinical findings may be associated with his pancreatic atrophy, of which the exact cause is still unclear. The other basic clinical features of the disease are weight loss, anemia, diarrhea, thromboembolism, and neuropsychiatric symptoms. Our patient did have obvious weight loss, normocytic anemia, diarrhea, calf muscular venous thrombosis, and agitation.Diabetes mellitus is another common finding. Case studies suggest that 80% to 94% of patients with GS gradually develop diabetes mellitus during the course of the disease. However, the tumor in our patient was located in the head of the pancreas, which is uncommon for this disease. There was a node in the liver that might also be considered liver metastasis.The symptoms and signs constituting GS reveal the presence of a glucagonoma. However, the diagnosis of GS still requires an elevated serum glucagon level  and imaging confirming a pancreatic tumor. Almost 75% of glucagonoma was located in the tail of the pancreas, and most patients already present with metastatic disease, for which the most common site is the liver. To our knowledge, however, this is the first report of GS coexisting with SOA. As glucagonoma may present as part of the multiple endocrine neoplasia (MEN) diseases, we originally suspected the presence of a MEN in the patient; however, except for the 2 rare neoplasms, we did not find clinical or imaging results related to other neoplasms such as pituitary adenoma, thyroid tumor, or adrenal adenoma. Although the coexistence of pancreatic endocrine tumor with serous cystadenoma has also been described in certain cases, the endocrine tumors reported in these studies were accidentally discovered based on postoperative histological pathology rather than clinical signs of hormone hyperproduction. So far, the coexistence of GS with typical clinical manifestations and SOA has not yet been reported.In our case, it was most surprising that GS coexisted with a rare exocrine pancreatic tumor, SOA. Previous studies reported that serous cystadenomas often coexisted with other pancreatic neoplasms. Patients with metastatic disease can still experience a relatively prolonged survival (>20 years) because this tumor type is slow-growing. In addition, treatment by resection of the tumor produces rapid clinical resolution, as noted in our patient. For patients with contraindications to surgery, long-acting somatostatin analogs and systemic chemotherapy, which are considered as palliative treatments, are also alternative treatment strategies and may provide good control of symptoms.–16Presently, surgical therapy is still the most effective treatment and should be considered as an optimal choice for patients with GS, regardless of whether most patients have metastasis at diagnosis.In summary, we presented a very rare case of coexisting GS and SOA. The fact that the patient remained without a correct diagnosis for a long time indicates again that it is very important for clinicians to be familiar with NME to diagnose GS early. Once the combination of NME and diabetes developed, the initial clinical impression of GS should be considered.


Hematometrocolpos is a rare congenital abnormality of the female urogenital system that leads to an imperforate hymen and subsequent retrograde menstruation. We present the case of a 14-year-old female patient who presented to the emergency department with amenorrhea and abdominal pain, and was found to have an imperforate hymen and hematometrocolpos on trans-abdominal point-of-care ultrasound. It is important for emergency physicians to consider this diagnosis in pubescent female patients presenting with abdominal pain, as missed diagnosis can lead to infertility and other complications. Hematometrocolpos is a rare congenital abnormality that is infrequently diagnosed in the emergency department (ED). The hymen, which is part of the urogenital sinus, fails to perforate during genitourinary development in approximately one in 2,000 females.A 14-year-old female patient presented to the ED with intermittent lower abdominal pain for three weeks. Her pain was bilateral and cramping, with episodes of intense worsening that were associated with non-bloody, non-bilious emesis. She reported abdominal distension, constipation, and breast tenderness, and denied urinary changes, vaginal bleeding, or discharge. She had not yet experienced menarche and she denied sexual activity. The patient had seen her pediatrician at symptom onset, and it was documented that the patient had Tanner Stage IV development but no menstruation. No genitourinary exam had been performed. At that visit, the patient was diagnosed with constipation and counseled on diet changes. Two weeks later, the patient returned to her pediatrician for the same symptoms, and an outpatient transabdominal US was ordered to evaluate her pelvic organs. Her pain worsened prior to her scheduled US, so she presented to the ED.The patient was afebrile with a pulse of 105 beats per minute, blood pressure of 125/91 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 100%. She was actively vomiting and reporting abdominal pain. Abdominal examination was notable for mild distension, suprapubic tenderness, and a palpable mass in the lower abdomen and pelvis. Bowel sounds were normal. Pelvic examination was notable for a bulging, tense, blue, imperforate hymen. Transabdominal POCUS showed a distended vaginal canal, markedly enlarged uterus, and moderate hydronephrosis bilaterally . Renal fWhile rare, imperforate hymen and hematometrocolpos are important diagnoses to consider in pubescent females who have not yet menstruated and present with abdominal pain. Patients with this congenital abnormality are typically asymptomatic until menarche. Most patients present symptomatic during menstruation, as the retained blood and endometrial tissue accumulates and distends the vaginal canal (hematocolpos), uterus (hematometra), or both (hematometrocolpos). Patients commonly present with abdominal pain, pelvic pain, and vomiting. Less common symptoms include back pain, constipation, urinary retention, or urinary incontinence.Ultrasonography is the preferred imaging modality to evaluate for hematometrocolpos, given that it is rapidly performed at the bedside and does not expose the patient to radiation. Transabdominal POCUS typically reveals a large, hypoechoic mass with smooth walls just posterior to the bladder. Depending on the extent of dilation of the pelvic organs, the uterus may appear normal or be dilated. The blood and endometrial tissue within the uterus appears hypoechoic.Treatment of imperforate hymen consists of surgical repair, ideally after the tissues have undergone estrogen stimulation. An elliptical incision is made in the membrane adjacent to the hymenal ring, followed by evacuation of the blood and tissue. Redundant hymenal tissue is also removed. If the diagnosis of hematometrocolpos is missed or delayed, patients may develop retrograde menstruation, endometriosis, pelvic adhesions, fallopian tube damage, and infertility.6Hematometrocolpos is a rare congenital abnormality of the female urogenital system that leads to an imperforate hymen and subsequent retrograde menstruation. Complications of hematometrocolpos include abdominal and pelvic pain, hydronephrosis from extrinsic compression of the ureters, and infertility. It is therefore important to consider the diagnosis of hematometrocolpos in young female patients presenting with abdominal pain, which can be confirmed by examination and transabdominal POCUS.CPC-EM CapsuleWhat do we already know about this clinical entity?Hematometrocolpos is caused by an imperforate hymen and subsequent retrograde menstruation. It presents in young women and can have damaging consequences.What makes this presentation of disease reportable?Imperforate hymen is a congenital abnormality that is rarely seen in the emergency department. In this case, the diagnosis was made with thorough physical examination and point-of-care ultrasound (POCUS).What is the major learning point?Consider the diagnosis of hematometrocolpos in pubescent women with abdominal pain who have the appropriate findings on exam and POCUS.How might this improve emergency medicine practice?Early suspicion and confirmation of hematometrocolpos can lead to early treatment, preventing unnecessary pain and complications, including infertility.VideoBedside ultrasound showing a distended uterus measuring 6.0 × 4.4 × 6.8cm and containing hypoechoic blood and endometrial tissue, consistent with hematometrocolpos.


Odontomas are considered as benign tumors of odontogenic tissue origin and are more over non-aggressive. They can also be categorized as hamartomas and are a result of developmental malformation of odontogenic tissues. As the name suggests, they are composed of mature tooth substances. They possess limited and slow growth potential and are well differentiated. They can be ectodermal, mesodermal or mixed in origin. Mixed variety may be further divided into compound or complex depending upon their radio-graphical resemblance to the tooth. Compound odontomes are reported to be twice more common than complex odontomes. Among them, complex odontomes are asymptomatic unless they cause bony expansion of the jaws.This paper aims to report and discuss a case of complex odontoma with unusually large size leading to gross facial asymmetry. Further this paper will highlight the important information the general dental practitioner must possess to diagnose such lesions at an early stage.Odontomas are benign odontogenic tumors with unusually large size leading to gross facial asymmetry. The general dental practitioners must possess the knowledge and important information to diagnose such lesions at an early stage. Odontomas are benign in nature and arise from the odontogenic tissues -15. ThesIt was in 1947 when the term Odontoma was coined by Paul Broca , 20, 21.Several authors have classified odontomas into various varieties , 16. WHOErupting odontom is the one in which the hemartomatous mass is visible inside the oral cavity clinically , 13, 19.Although odontomes are a benign entity and can be easily diagnosed, the dental professionals must be well versed with the clinical presentation as well as the radiological presentation of the same. Sometimes, the lesion attains an unusual large size -26. HencA 35 years old male patient visited the department of Oral Surgery of the Consultation Center of Dental Treatment (CCDT) of Rabat with a swelling on the left side of the mandible. The swelling was painless and was present since last 2 weeks. His medical history was not significant. Clinically, the patient presented with asymmetry of the face. There was a diffuse bony hard swelling present on the mandibular angle region of the left side. On the contrary, the overlying skin was normal with no tenderness with normal mouth opening.1). There was evidence of bucco-lingual expansion of the mandible in the same region which was hard and non tender on palpation. Further there was no significant lymphadenopathy. Provisional diagnosis considered was impacted by third molar with suspected dentigerous cyst. An Orthopantomogram was taken .Intraorally, the patient presented with missing left first and third molar along with a breach in the corresponding alveolar mucosa in relation to 38 region . The clinical and radiographic presentation of the lesion led to a diagnosis of complex odontoma. Under loco-regional anesthesia, the surgery was performed, consisting of the excision of the whole impacted teeth and the lesion all around Fig. (4). The excised lesion specimen  was sent to anatomopathological study which concluded a complex odontoma. The histological examination was also done which revealed that the lesion was encapsulated with evidence of cementum and dentine like structures along with pulpal tissue and epithelial remnants. The patient was followed-up over a period of one month .The Orthopantomogram (OPG) revealed a spectacular well-defined radiopacity, of about 6 cm x 6 cm in dimension, surrounded by a radiolucent halo with corticated margin approaching the apical region of 37. Further there was evidence of secondary inferior displacement of inferior alveolar nerve canal around the 37  or pheripheral (extraosseous) -15, 25. et al. were of the view that it is the growth of capsule that contributes to the eruption of odontoma [Certain authors are of the view that since the complex odontome is associated with unerupted tooth, hence it is the eruptive force of the concerned uneruptive tooth that can lead to eruption of the odontoma in the oral cavity -12, 22. odontoma , 23-25. odontoma -18. Thisodontoma , 27. On odontoma -30.Complex odontomas are odontogenic tumors and are asymptomatic in nature. They are usually found during routine dental radiographic examination and are not associated with any other systemic disease. They can even erupt inside the oral cavity and can lead to pain and inflammation. Large lesions can cause expansion of the cortical plates of the jaws leading to facial asymmetry. Henceforth, the dental professionals must be well aware of the clinical as well as the radiological findings of such lesion so as to provide prompt treatment with better prognosis.


Although secondary liver involvement of the lymphoma is common and occurs in 50% of patients with non-Hodgkin’s lymphoma, liver tumor rupture in malignant lymphoma is extremely rare. We report a case of a spontaneously ruptured secondary liver involvement of non-Hodgkin’s lymphoma that was successfully treated with transcatheter arterial embolization (TAE) to obtain hemostasis, and subsequent hepatectomy and systemic chemotherapy. To the best of our knowledge, this is only the second reported case of a ruptured hepatic lymphoma.A 74-year-old man with sudden-onset right shoulder and upper quadrant pain was transferred to our hospital via an ambulance. His vital signs were stable. Contrast-enhanced computed tomography showed a large hypo-enhancing tumor (94 × 81 mm) in the posterior segment of the liver, with intratumoral extravasation and a 12 × 10 mm daughter tumor in segment 5 of the liver. Hemoperitoneum due to rupture of hepatocellular carcinoma with intratumoral hemorrhage was suspected, although the serum alpha-fetoprotein and protein induced by vitamin K absence-II levels were within normal range. TAE was used for hemostasis. Extended posterior segmentectomy including tumor resection in segment 5 was performed on day 23 after embolization. The postoperative course was uneventful. Pathological examination of the resected specimens revealed that the ruptured tumor was diffuse large B-cell lymphoma. Postoperative fluorodeoxyglucose positron emission tomography-computed tomography showed uptake in the left parotid gland, pancreas, and thoracic vertebra. Based on these findings, the final diagnosis was a ruptured secondary hepatic malignant lymphoma. Complete remission was achieved with chemotherapy. He remains alive 30 months after hepatectomy without evidence of relapse.We report the first case describing a hepatic tumor rupture as the first presentation of a primary or secondary hepatic malignant lymphoma. The patient was successfully treated with TAE, hepatectomy, and subsequent systemic chemotherapy for non-Hodgkin’s lymphoma. The liver is an organ that can either be involved in widespread lymphoma or rarely as a primary site of lymphoma. Secondary liver involvement of the lymphoma is common and occurs in 50% of patients with non-Hodgkin’s lymphoma. Moreover, the liver is the third most common abdominal organ with lymphoma involvement, following the spleen and gastrointestinal tract , 2. The To the best of our knowledge, this is only the second reported case of a ruptured hepatic lymphoma. Herein, we describe a patient with a spontaneously ruptured secondary liver involvement of non-Hodgkin’s lymphoma successfully treated via transcatheter arterial embolization (TAE) to obtain hemostasis and via subsequent hepatectomy and systemic chemotherapy.A 74-year-old man with sudden-onset right shoulder and upper quadrant pain came to our hospital via an ambulance. His medical history included chronic obstructive pulmonary disease and appendectomy. He reported no history of trauma or falls. He had not been prescribed anticoagulants or antiplatelet agents. On physical examination, he was conscious and alert, and his blood pressure was 109/65 mmHg; heart rate, 97 beats/min; and respiratory rate, 20 breaths/min. He complained of mild abdominal distension and tenderness on the right upper quadrant area. Laboratory examination showed white blood cells of 15,700/μL; hemoglobin, 11.3 g/dL, platelet count, 236,000 /µL; aspartate aminotransferase (AST), 57 U/L; alanine amino transferase (ALT), 43 U/L; serum level of lactate dehydrogenase, 454 U/L; alkaline phosphatase, 218 IU/L; and total-bilirubin, 0.5 mg/dL. The results of coagulation tests were normal. Serum alpha-fetoprotein and protein induced by vitamin K absence-II levels were within normal range . Hepatitis B virus surface antigen and hepatitis C virus antibody were negative.Contrast-enhanced computed tomography (CT) showed a large hypo-enhancing tumor (94 × 81 mm) in the posterior segment of the liver with intratumoral extravasation and a 12 × 10 mm daughter tumor in segment 5 (S5) of the liver Fig. b. HemopeExtended posterior segmentectomy (resection of S6 + S7) including removal of a tumor in S5 of the liver was performed on the 23rd day after TAE. Substantial clots and old blood were found in the abdominal cavity. A tumor in the posterior segment adhered to the right diaphragm, and a part of the tumor capsule had been ruptured. Intraoperative echogram and palpation revealed an incidental tumor of 1.2 cm in diameter in S3 of the liver. Additional procedure included partial resection of S3 of the liver. The resected specimen revealed that the ruptured tumor in the posterior segment was 97 × 67 mm in size, and the majority of the tumor was necrotized due to TAE  performed 1 month after operation showed an uptake in the left parotid gland, pancreas, remnant liver, and the thoracic vertebrae. For systemic non-Hodgkin’s lymphoma, the patient received eight cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone regimen and achieved complete remission, which has been maintained to date for 30 months.Rupture of a liver tumor occasionally occurs, and the associated intraperitoneal hemorrhage is potentially life-threatening. The most common symptom of ruptured liver tumor is sudden onset of abdominal pain with shock. HCC is the most common cause of a spontaneous hemorrhage with 10% of these cases presenting with abdominal bleeding , 7. HoweTsutani et al. first reported a case of ruptured malignant lymphoma in 1999 . FollowiOur case presented herein is the second report describing hepatic tumor rupture and hemoperitoneum that occurred in malignant lymphoma. The patient has ruptured hepatic tumor treated successfully via TAE followed by hepatectomy. The clinical diagnosis was HCC rupture. Pathological examination of the resected specimens revealed that the ruptured tumor was non-Hodgkin’s lymphoma. Postoperative PET-CT revealed that the patient had systemic disease of non-Hodgkin’s lymphoma. In non-Hodgkin’s lymphoma, liver involvement is observed in as much as 50% of autopsy cases. However, tumor rupture and hemoperitoneum have never been described as a first presentation of primary or secondary hepatic malignant lymphoma , 9. ThisTsutani et al. suggested that one of the reasons for the low incidence of rupture of malignant lymphoma might be its hypo-vascularity . MajoritThe mechanism of spontaneous rupture in HCC has been discussed and might most likely involve various factors. Spontaneous rupture tends to occur in large tumors , but smaIn the present rare case of rupture of secondary hepatic lymphoma, systemic malignant lymphoma was diagnosed as a result of hepatic tumor rupture. The cause of the tumor rupture might include bleeding from arterial channels coursing through the hypo-enhancing tumor, which was demonstrated by the existence of intratumoral extravasation of contrast medium on contrast-enhanced CT. The mechanisms of tumor rupture in the present case of malignant lymphoma might be the same as those of HCC rupture resulting from initial bleeding within the tumor due to impairment of the vascular integrity and the subsequent sudden increase in pressure within the tumor followed by bursting through the tumor capsule. Although clinical diagnosis before treatment was ruptured HCC and the treatment strategy applied was similar for HCC, the addition of chemotherapy for malignant lymphoma after surgery contributed to good patient prognosis.We report the first case of a hepatic tumor rupture as the first presentation of a primary or secondary hepatic malignant lymphoma. The patient was successfully treated via TAE, hepatectomy, and subsequent systemic chemotherapy for non-Hodgkin’s lymphoma.


Hydatid disease caused by larval stage of Echinococcus has been recognized endemically in many countries. Liver and lungs are the most commonly affected organs. Involvement of the head and neck region is rare and bony erosion due to hydatidosis is even rarer.We report a case of a 17-year-old girl from a poor socio-economic background who presented with a right sided supraclavicular lump, which after surgical excision and histopathological examination was diagnosed as hydatid cyst of neck.Because of its rarity in the neck region, primary diagnosis of hydatid cyst is overlooked and usually not included in the differential diagnosis of cystic neck swellings. A high index of suspicion is necessary to diagnose hydatid disease in an unusual location even in endemic areas. Hydatid disease, also known as hydatidosis and cystic echinococcosis, is a cyclozoonotic infection caused by cestodes of genus echinococcus, usually Echinococcus granulosus . The endFor the completion of its life cycle, Echinococcus requires two distinct mamma- lian hosts. Dogs, wolves, and foxes are the definitive host. Intermediate hosts are herbivores like sheep and cattle . Humans Though hydatidosis can affect almost every part of the body, the liver and lungs are the most commonly affected organs. Multiple organ involvement is common. Primary hydatid disease involving the head and neck region is extremely rare even in geographical areas known to be endemic for echinococcus infestation. Until now, only a few cases of hydatid cyst have been reported in the head and neck, an unusual location ,6. AmongA 17-year-old uneducated girl from poor socio-economic background residing in an overcrowded locality came to our OPD with a complaint of a lump on the right side of the neck in the supraclavicular region. She first noticed the swelling 4 months ago, which gradually increased in size without any pain. The detailed family history revealed that her mother suffered a case of pulmonary tuberculosis and was on anti-tubercular treatment. The patient had only been involved in household work without any engagement with pets. She was on mixed diet with normal appetite without any history of weight loss or fever. Clinical examination of the lump revealed a uniform non-tender, cystic swelling of around 5-6 cm with slight fluctuation as well in the right supraclavicular region . There were no signs of erythema and echymosis. A presumptive diagnosis of tubercular cold abscess was made on the basis of her family history. Complete blood count was normal except for slight eosinophilia. Mantoux test was negative and chest radiograph was absolutely normal. Absolute eosinophil count was raised (850 cells/microlitre). Ultrasonography of the neck showed a thick walled cystic lesion having internal septations and echoes with peripheral vascularity in the subcutaneous plane in the right supraclavicular region. Due to the USG findings, aspiration of the swelling was performed under aseptic conditions using an 18G needle. The aspirate in the syringe was clear watery fluid and was sent for cyto-chemical analysis. The fluid was reported to be acellular with some proteinaceous content. The swelling completely regressed after aspiration. Because of the clear fluid aspirate, the differential diagnosis of hydatid cyst was considered. Ultrasonography of the abdomen revealed no abnormality.th post aspiration day, the patient presented with a tense and tender swelling in the same region. Again aspiration was done and pus came out in the syringe. Despite all our aseptic precautions, the swelling got infected during the first aspiration. Intravenous antibiotics were initiated and contrast enhanced computed tomography (CECT) of the neck and thorax was planned. CECT showed a heterogen- eously enhancing lesion at the level of the thoracic inlet just posterior to the lateral aspect of the right clavicle. Medially the lesion was abutting and causing erosion of the transverse process of T1 vertebra and the first rib , ELISA, and western blot are widely used especially in abdominal disease as they have low diagnostic sensitivity and specificity in extra hepatic hydatidosis . These tWe performed fine needle aspiration as hydatidosis was not considered as the differential diagnosis and, when the aspirate yielded clear fluid, only then did we think of echinococcal infection as one of our probable diagnosis. Luckily there was no anaphylaxis though the mass got infected following aspiration.The most effective treatment for hydatid cyst is surgical removal and utmost care should be taken to prevent rupture of the cyst as spillage of the contents can result in anaphylactic reaction, recurrence, and multiple hydatidosis . If the Even in an endemic area a high degree of suspicion is required for diagnosing hydatid disease in an unusual location like the neck, where they may lead to bony erosion. Thus it should be considered in the differential diagnosis of slow growing cystic swellings of the neck. Radiological imaging facilitates diagnostic and therapeutic procedures in view of complete surgical removal, following which the prognosis is excellent.


Laparoscopic sleeve gastrectomy (LSG) is a frequently used bariatric surgery method. It is possible to incidentally detect gastrointestinal stromal tumors (GISTs) of stomach or other gastric tumors during this procedure. In the literature, there is limited data about cooccurrence of GIST in obesity, and treatment of such cases is still controversial. On the contrary, currently accepted treatment of local and nonmetastatic GIST cases is surgery alone, and of cases with systemic disease is surgery combined with imatinib mesylate therapy. Incidental detection of GIST during bariatric surgery may require a modification in the planned procedure, and an extensive exploration and picking a convenient surgical procedure will become necessary. Here, we present two cases – a gastric GIST and a GIST of small intestine – both of which were incidentally detected during LSG performed for obesity.Atas H, Bulus H, Akkurt G, Yavuz A, Tantoglu U, Alimogullari M, Aydin A. How to approach Incidentally detected Gastrointestinal Stromal Tumor during Laparoscopic Sleeve Gastrectomy: A Report of Two Cases. Euroasian J Hepato-Gastroenterol 2016;6(2):173-175. Complete surgical excision is still the most important treatment component in cases with incidentally detected GIST during obesity surgery. Combination with adjuvant imatinib mesylate  is the currently an accepted treatment modality for high-risk lesions or cases of systemic disease.145 In some cases, the localization, size, and extent of the intraoperatively detected mass may require an alteration in the intended surgical procedure. Focusing on the important aspects of the subject, we aim to present two cases with stomach and small intestine GISTs, both of which were detected incidentally during LSG performed for morbid obesity.Bariatric surgery procedures are increasingly being performed as obesity becomes a global epidemic. Laparoscopic sleeve gastrectomy (LSG) is a frequently used bariatric surgery method. Gastrointestinal stromal tumor (GIST) or other tumors of stomach can incidentally be detected during this procedure. In the literature, GIST incidence is reported to be higher among obese patients who underwent bariatric surgery (0.6–0.8%), than the general population (0.0006–0.0016%).2 was admitted to Kecioren Training and Research Hospital, Ankara, Turkey. She did not have any accompanying disease. Routine laboratory tests, an abdominal ultrasonography (USG), and an upper gastrointestinal endoscopic examination were performed, and all of these investigations were within normal range. An LSG procedure was planned for morbid obesity. During the procedure, following the dissection of gastroepiploic vessels and omentum liberation, a nodular lesion of about 1.5 cm size with a smooth surface and off-white color located on the major curvature at the posterior side of the stomach was detected , than the general population (0.0006–0.0016%).2 A majority of GIST cases are older than 50 years. Males and females are equally affected, with a slight male predominance.78 Our first case was a 52-year-old female, and the second was a 60-year-old male. This suggests that an extensive preoperative abdominal computed tomography (CT) or magnetic resonance imaging (MRI) examination for bariatric surgery candidates older than 50 years old may be useful.Incidence of cancer is increasing with obesity.10 Gastrointestinal stromal tumors with gastric origin are generally localized on fundus or cardia, possibly because of the fact that Cajal’s interstitial cells, the cells of origin of the GISTs, are accumulated in these localizations.12 Malignity risk categories and prognosis criteria in GISTs are summarized in 5Although these tumors may originate from anywhere along the gastrointestinal tract, the most frequently encountered origin is stomach (60%), followed by small intestine (30%), colon (5%), and rectum (5%).In our first case, the GIST originated from gastric fundus, in accordance with the literature. Preoperative endoscopic examination was normal, and the 1.5-cm mass grew exophytically. The initially planned sleeve gastrectomy procedure was performed, as the tumor size was under 2 cm, and the lesion was suitable for being excised within the surgical specimen. Histopathological diagnosis was benign GIST and no further treatment was needed. In our second case, the intraoperatively detected lesion originated from the serosa of small intestine. The mass was larger than 10 cm. The intended bariatric procedure was canceled, since the mass had a high malignancy potential and would possibly require postoperative adjuvant chemotherapy. A complete resection including the tumor was performed. Imatinib chemotherapy was administered postoperatively. Computed tomography controls at 3, 6, and 12 months revealed no signs of metastasis.Bariatric surgeons should be aware of benign, premalignant, and malignant tumors because of the increased malignancy incidence among obese patients. Preoperative routine workup of obese patients does not include abdominal CT or MRI studies. On the contrary, abdominal USG is usually suboptimal because of extensive fatty tissue; thus, even a 12.5-cm mass growing toward the meso of the small intestine may be overlooked. Routine endoscopic examinations can occasionally detect GISTs with submucosal localization; however, masses with exophytic growth into abdominal cavity may be missed. Therefore, an extensive exploration performed at the beginning of the operation may help in detecting possible tumors.


We present the clinical case of a patient who was admitted with an onset of diabetes mellitus (DM) with associated ketosis and whose clinical, hormonal, and radiological evolution revealed the presence of primary hyperparathyroidism, pancreatic neuroendocrine tumor, and GH-producing pituitary macroadenoma in the context of multiple endocrine neoplasia type 1 (MEN1). DM is relatively common in cases of acromegaly, but it is not generally associated with ketosis. Simultaneously, the patient presented a meningioma, which is associated with pituitary macroadenoma only in extremely rare cases. Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant syndrome characterized by the combined appearance of tumors in the parathyroid glands, pancreas islet cells, and the anterior pituitary. This type of syndromes is known to be associated with the secretion of a wide range of hormones which are often responsible for alterations in the glucose metabolism. However, the presence of diabetic ketosis and/or ketoacidosis is a rare clinical situation, with very few cases reported so far. Also, and in an even less common case, the patient simultaneously presented a GH-producing pituitary macroadenoma and a meningioma, a combination which is extremely rare.We present the clinical case of a 35-year-old woman with a history of Chagas disease who was admitted in the Unit of Endocrinology with hyperglycemia and ketosis in the context of onset of DM with weakness, polydipsia, and polyuria of 4 months of evolution, together with a weight loss of 10 kg over the last 6 months. Also, she presented amenorrhea for 4 months and hyperhidrosis. The examination revealed a slight prognathism, growth of acral parts of the body, and grade 1 goiter with a 2-cm left thyroid nodule.The analysis showed glucose 248 mg/dL, HbA1c 14.6%, calcium 11.3 mg/dL, phosphorus 2.3 mg/dL, and urine calcium 513 mg/24 h. Given the initial findings, the study was expanded to include a hormone profile test , a thyroThe endocrine study confirmed the clinical suspicion of primary hyperparathyroidism and GH hypersecretion. The parathyroid SPECT/CT was compatible with right parathyroid adenoma. A nuclear magnetic resonance (NMR) revealed a pituitary macroadenoma of 20 × 13 × 15 mm which spread to the right cavernous sinus, with displacement of the optic chiasm, and a left superior extra-axial parietal lesion of 20 × 20 × 12 mm which suggested a meningioma .Given these findings and the clinical suspicion of MEN1, the study was completed with a CT scan of the neck, chest, abdomen, and pelvis, which showed a hypervascular heterogeneous mass with lobulated and well-defined edges of 6.8 × 7.7 × 6.4 cm in the tail of pancreas, plus another mass of similar characteristics of 6 × 4.2 cm in the uncinate process and at least three more pancreatic focal lesions of less than 1 cm on the head and neck of pancreas . In the ∗).A somatostatin receptor scintigraphy (OctreoScan) was performed showing a pathological deposit in the tail of pancreas which suggested a tumor with expression of somatostatin receptors and also at the upper left parietal level, which was caused by a meningioma . The endThe patient started treatment with high doses of basal-bolus insulin therapy, somatostatin analogs, and cinacalcet. Afterwards, cabergoline was added due to the persistence of high levels of IGF1. The pituitary macroadenoma was resected through a transnasal transsphenoidal and the IGF1 levels went back to normal, with octreotide treatment. The anatomic pathology revealed a pituitary somatotroph adenoma (densely granulated) and the immunohistochemical study: CAM 5.2 (+++), GH (+++), p53 (−), and MIB-1 <1%. An abdominal NMR was performed to control the evolution of her condition, and it still showed two heterogeneous lesions on the head and tail of pancreas, of 5.5 × 4.5 × 4 cm and 6 × 7.5 × 8 cm, respectively, contrast-enhanced and with well-defined edges. Also, the liver had normal size, morphology, and intensity, and the image did not reveal the lesions described in the CT scan image.After an assessment by an interdisciplinary board, the patient underwent total pancreaticoduodenectomy, cholecystectomy, and splenectomy. The anatomical pathology showed 7 well-differentiated (G1) NETs in the pancreas, 1 well-differentiated NET (G1) in the pylorus of <0.5 cm, 14 lymph nodes in the tail of pancreas with no sign of malignancy, and 2 lymph nodes with NET metastasis out of 12 isolated nodes on the head of pancreas (pT2N1). All the tumors expressed chromogranin A and synaptophysin, with proliferation mediated by Ki67 <1%, except for the node found in the neck of pancreas, in which it reached 2-3%. Also, 2 out of the 7 tumors were intensely positive for glucagon (100%) , and an We present the case of a patient with MEN1 with some peculiar features.1) DM with ketosis as its first manifestation: alterations in the metabolism of glucose are a common characteristic in acromegaly, with a described prevalence of DM ranging from 19 to 56%  DM with . However(2) Another peculiar trait in our case is the concomitant presence of a pituitary tumor and meningioma, because this is a rare clinical situation, with only 33 cases described , 9. Meni


Fluorouracil implants are widely used in peritoneal interstitial chemotherapy. Curative effects have been obtained, but implants have also caused some complications.We performed an analysis of a 66-year-old male patient’s case history, as well as conventional pathological analysis and Raman spectroscopic detection of the diaphragmatic tumor. We also analyzed the underlying causes of this condition to prevent complications and reduce misdiagnoses in future cases. The patient had a history of peritoneal fluorouracil implantation. Pathological analysis of the diaphragmatic mass revealed foreign particles, and Raman detection showed that the mass contained fluorouracil.Fluorouracil implants may persist due to the high concentrations of this drug used in peritoneal chemotherapy. This finding should provide guidance and improve the application of peritoneal implants. In clinical trials, and the diagnosis of liver metastasis should be based on pathological results. Since the 1990s, carmustine implants have been used for glioma, and they were approved by the US Food and Drug Administration (FDA) for marketing in 1996 . CompareA 66-year-old male patient was diagnosed with sigmoid colon cancer by colonoscopy 3 months previously. No neoadjuvant therapy was done before surgery. The surgery consisted of sigmoid colon cancer resection performed at Qilu Hospital of Shandong University. It was an open operation. When exploring the abdomen, liver and peritoneum, no metastatic nodules were found, but a tumor, about 5 × 3 cm in size, was located in the sigmoid colon. The tumor was removed, an anastomosis was done at the rectum end of the sigmoid colon and plasma muscularis sutures embedded the anastomosis. 800 mg Sinofuan was planted in the abdomen for adjuvant chemotherapy, and a drainage tube was installed to protect the anastomosis. The operation went smoothly. Postoperatively, the patient presented abdominal pain, fever, and abdominal fluid. Encapsulated fluid measuring approximately 6.3 cm × 3.4 cm was detected in the right upper abdominal cavity, appearing as an echo-free space on ultrasonic screening. After paracentesis drainage and anti-infection treatment, the patient’s condition improved and he was discharged. One month ago, the patient came to our hospital for further chemotherapy. Physical examination showed no abnormalities. Computed tomography (CT) examination revealed a right liver lobe lesion of lower density on the eighth segment, with a diameter of approximately 2.0 cm. On CT the arterial phase, portal venous phase, and venous phase showed no obvious enhancement. However, the patient had normal levels of alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen 19-9 (CA19-9), gamma-glutamyltransferase (GGT), and lactate dehydrogenase (LDH). Before the colon cancer surgery they were also at normal levels. Combined with the history of colon cancer surgery and the CT manifestations, this case was initially diagnosed as liver metastasis. After three rounds of chemotherapy, CT showed no significant changes compared with the previous examination. The patient was then transferred to the surgical ward for further surgery. During surgery, a 3 cm × 2 cm × 0.7 cm encapsulated white porcelain-like tumor was detected on the diaphragm oppressing the liver, which caused liver capsule depression with local shallow sclerosis , and the fluorouracil injection . WIRE4.0 spectral software (see Fig. −1 of roughly the same height. Thus, it was concluded that both the cylindrical foreign body in the pathological wax blocks and Sinofuan contained fluorouracil.The Invia confocal Raman microscope by Renishaw was used to test the remaining foreign bodies in the diaphragm. A 785-nm wavelength laser was used and focused by an objective lens with 50X magnification. The irradiation power was set to 1 %, and the integration time was 10 s. The collection range of the spectrum was from 500 to 3200 cmLocal recurrence and distant metastasis especially liver and pulmonary are common in colon cancer. In 50 % of colorectal cancer patients an increase of CEA is a signal of recurrence after tumor resection and 15 % of colorectal tumors do not release CEA . In the In this case, the center of the diaphragmatic mass showed some white porcelain-like cylindrical particles see Fig. . The patIn clinical practice, abdominal foreign bodies become fiber-wrapped due to inflammation caused by the formation of lumps, and misdiagnosis is not uncommon . Items sIntraperitoneal chemotherapeutic drugs such as epirubicin, mitomycin, and cisplatin are in the experimental stage, and there have been no reports of complications such as in this case. In this case, the foreign body was aggregated Sinofuan. These implants, which should be biodegradable, gathered in the diaphragm due to their high concentration, causing local tissue necrosis and becoming fiber wrapped to cause liver tumor oppression. This situation was unlike anastomotic bleeding, abdominal aortic hemorrhage , liver gThis report demonstrates a new, rare complication of Sinofuan. Our findings suggest that high-concentration fluorouracil implants can cause local tissue necrosis and fiber-wrapped formations. Therefore, the application of fluorouracil implant surgery must be improved. In particular, Sinofuan should be used during the preoperative period under strictly controlled indications , such as


Primary hepatic angiosarcoma (PHA), a rare and aggressive malignancy, has rarely been reported to present with disseminated intravascular coagulation with liver hemorrhage. Incidence is estimated at 0.5–2.5 cases per 10,000,000. To our knowledge, it has not been reported to mimic liver abscess with a septic presentation. Advanced imaging techniques may aid in the diagnosis, though biopsy with microscopy and immunohistochemistry is the mainstay. Prognosis is very poor, with a 5-year survival rate estimated at 6.4%. We present the case of a 70-year-old man who presented with sepsis thought to be due to a multifocal liver abscess, who did not respond to drainage and antibiotics. This atypical course led to further workup which subsequently revealed a diagnosis of PHA. Primary hepatic angiosarcoma (PHA) is a very rare and highly aggressive malignancy, with an estimated incidence of 0.5–2.5 cases per 10,000,000 persons. An extremely vascular malignancy, PHA may rarely cause liver hemorrhage and intravascular coagulation abnormalities. It is known to have a very poor survival rate. To our knowledge, PHA has not been reported to present mimicking a liver abscess with a septic presentation. We present the case of a 70-year old man who presented with sepsis thought to be due to a multi-focal liver abscess diagnosed on computed tomography (CT). He did not respond to antibiotics with percutaneous drainage, and further workup performed resulted in the diagnosis of PHA.3 cells/ml with 89% neutrophils, hemoglobin of 11.8 g/dl, albumin of 2.8 g/dl, and alkaline phosphatase of 157 IU/l. There was no transaminitis, hyperbilirubinemia, coagulopathy, electrolyte disturbance, or acute kidney injury. Contrasted abdominal CT showed two fluid collections in the right lobe of the liver measuring up to 7 cm and 3 cm, with surrounding inflammatory changes (Figure A 70-year-old Caucasian man presented to the emergency department with two days of fevers, chills, and abdominal fullness. His past medical history was significant for hypertension and fully excised rectal carcinoid tumor two years prior with subsequent negative metastatic workup. He had no recent travel history or immunocompromising conditions. He endorsed decreased appetite, fatigue, and minimal weight loss during the preceding two months, but otherwise had previously felt healthy. Physical examination was significant for fever of 39°C, tachycardia, tachypnea, and mild abdominal distention, but was otherwise unremarkable. Initial blood work showed leukocytosis of 19.9 x 10A moderate amount of serosanguineous fluid was returned and sent for analysis which was negative for infection, including gram stain, culture, acid-fast, parasitic, and fungal examinations. Repeat abdominal CT demonstrated significant interval growth in the lesions Figure . MagnetiPathology from the liver biopsy showed marked neutrophilic infiltrate and necrosis with diffuse infiltration of highly atypical and pleomorphic cells within disrupted sinusoids, forming large anastomosing channels suspicious for angiosarcoma Figure . AdditioPHA is a rare and aggressive malignancy, estimated to occur at a rate of 0.5–2.5 cases per 10,000,000 persons, and accounts for 2% of all primary hepatic malignancies [A 2015 review of CT and MR findings of 35 patients with proven angiosarcoma noted multifocal involvement in all cases, as well as rapid interval size progression in 96% of cases . The remThe presentation is highly variable and fulminant hepatic failure, disseminated intravascular coagulation, and fatal hemorrhage have all been reported -6. DiagnIdeally, treatment is complete resection, especially when the disease is limited to one segment, though many patients have multi-lobar involvement, metastases, or life-threatening complications on the presentation that preclude surgery . Liver tSurvival after PHA is very poor, with 5-year survival estimated at 6.4% . To our PHA is a rare and aggressive malignancy that presents a significant diagnostic challenge. The presentation is highly varied, and can include life-threatening manifestations including fatal hemorrhage, acute liver failure, and DIC. Though not typical, CA 19-9 may be significantly elevated. Treatment is surgical resection, especially if the lesion is limited to one lobe. Liver transplant is generally avoided. Prognosis remains very poor with estimated 5-year survival of 6.4%. This case highlights the rarity of the disease, difficulty of diagnosis, and the importance of early recognition when possible.


Clostridium, E. coli, Klebsiella, Streptococci). Predisposing factors include diabetes mellitus, immunosuppression, peripheral vascular disease, abdominal surgery and trauma. Initial assessment with ultrasound may show reverbation artifacts due to the presence of air. CT scans are considered more specific and sensitive, demonstrating a gaseous halo around the gallbladder as well as air within its lumen. Emphysematous cholecystitis is a surgical emergency. Early intervention with surgery or percutaneous cholecystostomy is the mainstay of therapy. Left untreated, it can progress to perforation, pericholecystic abscess or bile peritonitis. Mortality rate for uncomplicated emphysematous cholecystitis is 1.4%, whereas for complicated cases it can reach up to 25%.A 43-year-old, otherwise healthy, male patient presented at the emergency department, with a 3-day history of right upper quadrant abdominal pain and fever of 39°C. Physical examination revealed positive Murphy’s sign and jaundice. Laboratory values revealed leukocytosis , elevated CRP and liver function tests . Ultrasound scanning demonstrated distention of the gallbladder, with wall thickening, pericholecystic fluid and a gallstone impacted in cystic duct. The patient was empirically started on broad-spectrum antibiotics. An abdominal CT scan on the following day revealed gas in the gallbladder wall and lumen . A percutaneous cholecystostomy was placed (C) and his clinical condition improved dramatically over the following hours, with normalisation of inflammatory indices and liver chemistry. He is scheduled to undergo laparoscopic cholecystectomy in 8 weeks. Emphysematous cholecystitis usually begins as a typical case of acute cholecystitis, but ischemia and gangrene soon develop in the gallbladder wall, due to intramural translocation of gas-forming microorganisms (


Encephalomeningoceles are subtypes of neural tube defects (NTD). We present the case of a one-day-old neonate who was found to have a posterior fontanelle encephalomeningocele that was only discovered after birth. The unique presentation of this case and the surgical management is also considered. Neural tube defects (NTD) are developmental abnormalities of the neural tube, the most common type being spina bifida. Since the widespread public health initiative of introducing folic acid supplementation, NTDs have decreased in prevalence . EncephaA newborn male child, less than one day old, was found to be leaking clear fluid from the skull one hour after birth whilst the mother was holding the child. The child was born at forty-one weeks through a normal vaginal delivery with forceps assistance and no immediate complications. Prenatal screening was unremarkable. The mother was from an indigenous background and in good health and there was no family history of any other similar illnesses. She denied smoking and alcohol use during pregnancy. At birth, no issue with the skull was noted. On further inspection of the child, after the mother raised concerns about the clear fluid leaking from the skull, a 1.5 cm circular defect was identified in the area of the posterior fontanelle with macerated skin edges and underlying membranes and evidence of clear fluid flowing from it. The child had normal haemodynamic parameters throughout and was otherwise examined normally. Further testing of the fluid for beta-trace protein was positive for cerebrospinal fluid (CSF). The neurosurgery team at the tertiary referral centre was contacted at this stage for a suspected encephalomeningocele and the child was transferred there for further management. Further examination at this stage showed a child who was otherwise well, feeding normally, and with normal system review.Further imaging with computed tomography (CT) scan of the head, magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA), and magnetic resonance venography (MRV) identified a likely encephalomeningocele Figures -2. The dThe child was booked in for emergent repair of the encephalocele. During the operation, a vertical incision with an elliptical extension around the defect was marked. Careful dissection from superior and inferior aspects of the incision to the pericranium and then working towards the defect identified the defect which appeared to consist of meninges. There were adjacent large venous structures visible beneath the defect and superiorly the superior sagittal sinus was identified in the midline. The defect was dissected from a peripheral direction towards a centre where the herniation appeared to arise from. At this stage, a small pedicle of tissue was holding the structure at the centre. This was tied off with absorbable sutures as there was a high possibility of vascular structures within the pedicle. Bipolar cautery was used to separate the defect. No obvious vessel injury was identified. A pericranial flap was mobilised inferiorly and was reflected around its pedicle from below and over the defect and sutured in place beyond the superior aspect of the defect to pericranium. A piece of synthetic dural graft material was secured over this repair. The wound was closed in two layers with braided absorbable sutures to the galea and then unbraided absorbable sutures to the skin. No further leak was identified at the conclusion of the operation. There was no obvious brain tissue on view during surgery, subsequent pathology also confirmed that no brain tissue was included in the specimen sent. This would support a diagnosis of a meningocele as only meninges were involved rather than an encephalomeningocele. The patient returned to the neonatal intensive care unit postoperatively and was extubated without issue. The child made an excellent recovery and was discharged six days after surgery.In countries that hold accurate records, NTDs have shown decreased prevalence . DefectsMost are managed conservatively and repaired in a delayed manner, within months to a few years later, to minimise surgical morbidity and mortality. CSF leak, in this case, was an indication of early repair due to the risk of meningitis. This case was unusual in that the defect and associated leak was identified an hour after birth. This may have been due to a spontaneous rupture and leaking, or failure of the delivery suite in examining the child thoroughly enough to miss an obvious defect. The child was delivered with forceps assistance; however, there is no clear indication what role this played in this instance. It is possible that instrumentation, in this case, could have caused a puncture of the herniated meninges but there is a lack of evidence to support this. Review of the literature failed to identify any similar cases of a meningocele, in the context of a forceps delivery presenting with a delayed CSF leak. Work up should include careful assessment of the bony structures as well as identification of often-associated vascular anomalies. Persistent fetal veins can be present . In addiOperative management can include many approaches, and careful workup and meticulous technique can decrease the risk of adverse outcome. Due to the great healing potential of the young child and the fusion of the cranial bones as a part of normal development, skull defects often heal very well. The long-term prognosis is usually excellent in cases with small defects and where imaging identifies normal brain development. Larger defects and/or those associated with significant underlying brain development abnormalities often carry worse outcomes .This case highlights a rare type of defect still seen in the developed world. It is evident that careful skull examination of the newborn should be carried out at birth to identify such defects and care should be exercised in using instrument-assisted delivery. The child was investigated with MRI brain, CT head, MRV, MRA and MRI spine. Surgery was planned to avoid potential large vascular structures. An emergent repair was carried out due to the presence of an ongoing CSF leak and the risk of meningitis that this represented. A simple repair technique was presented to manage such a condition and the child made an uneventful recovery and was discharged home to the care of his parents.


Osteoid osteoma (OO) is a benign osteogenic lesion that is extremely rare in jaws. It is characterized by proliferation of either cancellous or compact bone and can be central, peripheral or extraskeletal. Pain is a distinctive feature of this lesion accompanied by vasomotor disturbances, which occur long before radiographic and histopathology findings manifest. Here, we present a rare case report of OO of maxilla in a 40-yr-old male patient with noteworthy clinical, radiological and histological presentation. The diagnosis of OO is usually obtained by radiographs confirmed by histopathological analysis. Thus, the oral physician should have keen observation and appropriate knowledge concerning the same to avoid confusion with similar bony lesions. Osteoid osteoma (OO) is a benign tumor of bone accounting for less than 1% in jaws. It was first described as a distinctive clinical entity , 3.This entity accounts for 3% of all primary bone tumors and 10% of benign bone tumors. PubMed Central literature review revealed only seven cases involving the jaws for the last 15 yrs , had set certain criteria for OO: a) benign neoplasm; b) formed large amounts of osteoid which became calcified; c) an inflammatory process; d) characteristic radiographic changes, such as focal rarefaction and reactive bone formation; e) occurred most frequently in young adults; f) an outstanding feature of pain; and g) complete removal as the treatment of choice .Various theories have been put forward regarding the nature and genesis of OO. Jaffe 1935) considered it as a variant of osteoblastoma . In the  considerOO generally involves the tibia, femur, fibula, humerus and vertebral arch. Jaw involvement is rare, lingual surface and lower border of the body of mandible being the most common sites. It is seen more commonly in males compared to females with a ratio of 2:1, affecting in the second and third decades of life . This fiOO is clinically characterized by dull, throbbing, intermittent, local and nocturnal pain relieved with aspirin and associated with slight local swelling. Various theories were brought forward to elucidate the reason for pain. Arteriolar blood supply was observed to the lesion whereas others reported pressure exertion upon the surrounding bone, suggesting that the pain was produced by the vascular tumor lying within the confines of the sclerosed bone trabeculae .The classical radiological appearance of OO is a small, radiolucent intracortical nidus, <1 cm in diameter, surrounded by a large, dense sclerotic zone of cortical thickening. Jaffe emphasized these features to be the definitive diagnosis of this lesion. The radiodensity of the nidus was considered to be less and surrounded by a reactive radiopacity at a variable distance from the same. Radiopaque nidus suggested a less mature lesion whereas radiolucent nidus was indicative of a fully mature OO. Advanced imaging modalities like computed tomography and scintigraphy are considered as a useful adjunctive test .The histological appearance of OO varies with the age of the lesion and its site. Huvos distinguished three distinct evolutionary stages of modification of OO. Initially, dense osteoblasts are seen proliferating actively in a highly vascularized stroma followed by deposition of osteoid matrix between the osteoblasts in the intermediate phase. In the mature stage, the osteoid is transformed into well-calcified, compact trabeculae of atypical bone, which are neither typically woven nor lamellar .Ossifying fibroma, peripheral osteoma, and osteoblastoma were considered as differential diagnosis for the aforementioned case. Ossifying fibroma and peripheral osteoma are usually asymptomatic, increases in size, lack nidus and cause resorption and displacement of teeth. Osteoblastoma and OO are clinical, radiographically and histologically very similar lesions. Although pain is a common presenting feature, pain associated with OO response to aspirin and other nonsteroidal anti-inflammatory drugs, whereas an osteoblastoma does not .Complete excision is considered as the treatment of choice. The nidus should be removed intact. If the entire lesion is not removed or destroyed, the clinical complaints will remain and recur at a later stage. Malignant transformation of OO has not been reported in the literature until date , 6.The diagnosis of OO is usually obtained by radiographs and is confirmed by histopathological analysis. The oral physician should have keen observation and apt knowledge concerning the same to avoid confusion with similar bony lesions.The authors declare that there is no Conflict of Interests.


Nasal arterio-venous malformations (AVM) are uncommon lesions. We present a rare case of huge, long standing AVM in the nasal area which was treated by angioembolization, followed by surgical excision and forehead flap reconstruction. They typically present during infancy and are more prevalent in females.2 Hemangiomas are the most common tumors of the head and neck in infancy and childhood which are in differential diagnosis with vascular malformation. Their clinical presentation is a vascular lesionin nose, ears or eyelids.3,4Vascular lesions of the head and neck can cause cosmetic issues for the patient and some of them may lead to serious, life-threatening bleeding. Vascular lesions are divided into “vascular tumors”  and “vascular malformations” .5 Vascular malformations are sub-classified into capillary, venous, arterial and lymphatic, based on the tissue type. They are also divided into two categories: low-flow and high-flow lesions. Capillary, venous and lymphatic malformations are “low-flow” lesions while arterial and arterio-venous malformations (AVM) are “high-flow” and are capable of severe hemorrhage with significant morbidity.5These lesions usually resolve over time. Concomitant hemangiomas can be seen in other organs, most commonly in liver, especially in case of multiple cutaneous hemangiomas.The patient was a 28-year-old man with a huge, necrotic, erythematous inflamed lesion on the glabella, nasal dorsum and paranasal area. On physical exam, the lesion was not tender or warm, did not have pulsation and the margins were vague. The patient first noticed the lesion when he was 9 years old. At the beginning, it had been an erythematous lesion in the nasal area which enlarged over time and used to bleed with patient’s manipulation . No concAt age 28, he was visited in our center . MRI andStage 2: Embolization was done to reduce the size of the lesion and the risk of bleeding. However, no obvious change in the size, color or consistency of the lesion was noticed. Stage 3: After 48 hours the lesion was excised. Before excision, two rows of deep sutures were applied around the lesion to reduce the risk of bleeding. The feeding vessels of AVM were ligated and the lesion was completely excised off the bone and cartilage and the wound was left open  and 4.Stage 4: After another 48 hours the patient was taken to the operating room again. The wound was irrigated. An extended forehead flap on the base of supratrochlear artery was designed and rotated to cover the defect site. The donor site was closed primarily  and 6. T6AVMs are diagnosed by history and physical examination. They usually present as a pink-red cutaneous stain without a palpable trill or bruit. These patients are at risk of pain, ulceration or bleeding. They may also cause disfigurement and vital structure obstruction. Moreover, AVMs may eventually lead to high-output cardiac failure. Magnetic resonance imaging (MRI), CT-scan and Doppler are all used for vascular malformation evaluation, to document the lesion’s extension to the surrounding structures and to differentiate low-flow from high-flow lesions.7 As we noticed in this patient, sclerotherapy alone was not effective. Selective embolization is usually used pre-operatively as an adjuvant therapy, to reduce bleeding and shrink the lesion, followed by surgical debulking.8 These lesions are usually excised macroscopically. Surgery is necessary to correct facial deformities.9-12There are different therapeutic methods for AVMs, including sclerotherapy, embolization, stereotactic radiation and surgery, which are used in combination.To conclude, a multi-disciplinary approach, including selective embolization followed by surgical excision and appropriate reconstruction is the best treatment for head and neck AVMs. In some cases (as in the present case) embolization cannot effectively reduce the size of lesion and surgery is the only effective treatment.The authors declare no conflict of interest.


To compare ultrasonographic features of uterine lesions with the findings at macroscopy and microscopy.Case series of ten consecutive women undergoing a hysterectomy for uterine pathology. A preoperative transvaginal ultrasound examination was performed. After hysterectomy, the uterus was re-evaluated by 3D in vitro ultrasonography and in vitro gel instillation sonography (iGIS). The lesion of interest was pinpointed by inserting an intramuscular injection needle using a free-hand 2D-ultrasound guided technique to focus the macroscopic and the microscopic examination by the pathologist.Adenomyosis, benign fibroids and infiltrating endometrial cancer were diagnosed in six, five and one patient, respectively. We found that iGIS improved image quality of in vitro ultrasound. There was a good correlation between the reported ultrasound features and the final histological diagnosis. Some lesions had been misinterpreted during preoperative ultrasonography or at macroscopical examination: e.g. dense myometrial vessels reported as small myometrial cysts at grey scale ultrasound examination; absence of macroscopical lesions in a case of diffuse adenomyosis.In vitro 3D ultrasonography and iGIS allow for accurate mapping of uterine lesions so that ultrasound features can be matched with final histology. Our series demonstrates some pitfalls in the interpretation of sonographic and macroscopic features of uterine lesions. Stereotaxis of focal uterine lesions could focus histological assessment and reduces examination time for the pathologist. Myometrial lesions include adenomyosis, fibroids and sarcomas. Adenomyosis is a common gynaecological disorder characterized by the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia. The exact incidence of adenomyosis is unknown. Based on hysterectomy pathology reports the prevalence ranges from 5 to 70%. The discrepancy in prevalence can be attributed to the various diagnostic classifications, different tissue sample sizes and possible pathologist bias . The preDiagnostic criteria for adenomyosis include a globular uterus, myometrial asymmetry, myometrial cysts, echogenic lines and buds, hyperechogenic islands, fan-shaped shadowing and an irregular or interrupted endometrial-myometrial junction . UterineThe precise correlation between three-dimensional (3D) ultrasound findings of myometrial lesions and histopathological findings has been sparsely described. Two-dimensional (2D) ultrasound guided stereotaxis has been used in comparing ultrasonography and histology of the junctional zone . HistoloThe combined use of vaginal ultrasonography and histology has been shown to optimize diagnostic accuracy for intracavitary lesions . LikewisIn this article, we describe a new method to optimize the histological diagnosis of adenomyosis and fibroids using 3D in vitro sonography and in vitro gel instillation sonography (iGIS) stereotaxis.In this case series, we included ten consecutive women with US diagnosis of uterine pathology, already scheduled for hysterectomy for gynaecological pathology by one of the gynaecologists at the Department of Obstetrics and Gynaecology of the Regional Hospital RZ Tienen in Belgium from November 2014 to April 2015. Approval of the local Committee of Medical Ethics was obtained before study initiation. Patient informed consent was not required.The preoperative transvaginal ultrasound examination was performed using a Voluson S8 with a 4-9 MHz transvaginal probe. A 3D volume was acquired and the image in the coronal plane was reconstructed with volume contrast imaging (VCI) set at 2 mm and tomographic ultrasound imaging (TUI) . For imaImmediately after hysterectomy, the uterus was fixed to a cardboard reniform container and immersed in a 3-liter container filled with water .The uterus was re-evaluated by the same gynaecologist by in vitro sonography and in vitro gel instillation sonography (iGIS) using a Voluson S8 with a transabdominal 4MHz probe covered with an examination glove. For iGIS a 2.0 mm neonatal suction catheter was inserted through the cervix, after which 3-5 cc Instillagel  was instilled under ultrasound guidance. To improve orientation and comparison with the histological examination, the lesion of interest was pinpointed by inserting an intramuscular injection needle using a free-hand 2D-ultrasound guided technique . Due to We compared the ultrasound findings before and after the hysterectomy to show the ability to visualize the same myometrial lesions in vivo and in vitro. We also compared the transversal macroscopic sections with the corresponding ultrasound sections and the ultrasound findings with the microscopic results.A total of ten patients  were enrolled in this study.Indications for surgery included menorrhagia or abnormal pre- or postmenopausal bleeding in eight patients, dysmenorrhea/dyspareunia in three patients, and uterine prolapse in one patient. All uteri were re-evaluated by in vitro sonography, five of them also with iGIS. Adenomyosis, benign fibroids and endometrial cancer were diagnosed in six, five patients and one patient, respectively. An overview of the symptoms, ultrasound findings, macroscopic and microscopic examination is presented in To illustrate the different methods and pathologies, three cases are discussed in more detail:The first case (case #1) is a 49-year old, postmenopausal woman with a cystocoele and a uterine prolapse. On the pre-operative scan the presence of a myometrial cyst suggested adenomyosis. At macroscopic examination, a cyst in the anterior myometrial wall was confirmed. This was verified at microscopy, though the adenomyosis was more extensive than expected based on ultrasonography or macroscopy. The ultrasound findings and the corresponding macroscopic and microscopic findings are presented in The second case (case #7) is a 63-year old patient presenting with postmenopausal bleeding. Ultrasonography showed a globulous uterus myomatosus with a prominent FIGO type 2 fibroid of 41x40x42 mm in the anterior wall and a thickened endometrium. Histological examination of the endometrial sample showed complex endometrial hyperplasia with atypia. The patient underwent an abdominal hysterectomy. At macroscopy, a large submucosal fibroid in the anterior wall was seen with impression on the uterine cavity/endometrium. The latter was confirmed at microscopy showing pressure atrophy of the endometrium . From thThe last case (case #10) is a 56-year old postmenopausal woman on cyclic hormonal therapy with persistent vaginal bleeding and dysmenorrhea. On pre-operative scan the diagnosis of adenomyosis was made based on the presence of myometrial cysts with hyperechogenic rim, hypoechogenic microcysts, linear striations and echogenic buds.On macroscopic examination, we noticed multiple cysts and microcysts, suggestive for adenomyosis. This was confirmed on microscopy . From thIn this study, we illustrated that in vitro ultrasonography with or without iGIS allows for accurate mapping of uterine lesions. We also demonstrated the feasibility of in vitro underwater 3D-ultrasound examination and stereotaxis on a hysterectomy specimen using a free-hand 2D-ultrasound guided technique .This new approach allows to indicate the precise location of the suspected lesions to the pathologist and hence to compare the ultrasound features with macroscopic and microscopic examination.In this study, in vitro gel instillation sonography was used to optimize image quality and to provide additional information about the lesion and the uterine cavity. To our knowledge this is the first report on iGIS.For myometrial lesions and especially in adenomyosis ultrasound findings and pathology results are often not concordant. Because only a limited number of slices of the uterus are examined by the pathologist a lesion may be missed at pathology. By using in vitro underwater ultrasound examination of the uterus after hysterectomy and stereotactic needle localization under ultrasound guidance, it is possible to indicate to the pathologist where to expect the (e.g. adenomyosis) lesions.The best correlation between ultrasound findings and histology was found for fibroids and myometrial cysts. However some (adenomyosis) lesions have been missed on ultrasound. Our series demonstrates possible pitfalls in the interpretation of sonographic and macroscopic features of the uterine lesions. For example, dense myometrial vessels were reported as small myometrial cysts at grey scale ultrasound examination, highlighting the importance of the integration of colour/power Doppler imaging. Furthermore some lesions were also missed at macroscopy in a case of diffuse adenomyosis.We reported one case of an infiltrating endometrial carcinoma, not diagnosed on the pre-operative scan and with negative sampling. The presence of the myometrial invasion largely corresponded to the expansion of the endometrial tumour process in adenomyosis. Adenocarcinoma arising from adenomyosis is a rare entity and the diagnosis is often difficult. In the literature only a few cases have been described .Our study has some limitations. The number of cases is relatively small and the image quality of in vitro ultrasonography could have been improved using a high frequency probe and a high-end ultrasound system. Because the aim of in vitro underwater ultrasound examination and iGIS was to indicate the exact location of the lesion and hence optimize histological assessment, the pathologist was not blinded for the ultrasound findings. To prove the added value of this technique, there is need for prospective randomized trials.Underwater stereotactic needle insertion under ultrasound guidance is technically simple and can be completed within 10 minutes. The proposed methodology can be used in future studies correlating ultrasound features and histology. Stereotaxis using iGIS may also prove to be useful in guiding the histological assessment of uterine lesions e.g. in oncology. The question whether in vitro underwater stereotaxis may improve diagnostic accuracy or could reduce examination time for the pathologist should be addressed in a larger and prospective study.


Although lung cancer has a high propensity for distant metastatic disease, penile metastases from primary lung neoplasms are considered particularly rare. A 71-year-old male presented to our hospital with a rapidly enlarging hard palpable penile mass. MR imaging demonstrated two penile masses centered in the left and right corpus cavernosa. Subsequent CT imaging revealed a spiculated pulmonary mass in the right upper lobe with PET/CT, MRI, and surgical exploration, demonstrating evidence of metastases to the left adrenal gland, right subscapularis muscle, brain, and small bowel. Tissue sampling of lesions in the small bowel, right subscapularis muscle, and penis demonstrated histopathology consistent with an adenosquamous carcinoma which in combination with the appearance of the right upper lobe mass on PET/CT imaging suggested the patient's lung cancer as the primary lesion. Prior to our case, pulmonary adenosquamous carcinoma metastasizing to the penis has only been reported once in the literature. Herein, we report a rare case of penile metastases as the presenting sign of metastatic pulmonary adenosquamous carcinoma characterized with PET/CT and MR imaging.  Lung cancer is currently the leading cause of cancer mortality in the United States, contributing to approximately 25% of all cancer-related deaths . Early dA 71-year-old male with a history of hypertension and hyperlipidemia and a 70 pack-year smoking history presented to our hospital with a two-month history of an enlarging penile mass at the base of the shaft as well as a 10-pound weight loss. Physical examination demonstrated a hard, smooth, approximately 2 cm mass surrounding the base of the penile shaft. In addition, both testes were distended. No palpable pelvic lymphadenopathy was found and vital signs and laboratory data were within normal limits.Penile magnetic resonance (MR) imaging demonstrated a 6 × 2.5 × 6 cm (AP × TV × CC) irregularly shaped mass centered in the left corpus cavernosum involving the proximal and mid aspects of the penile shaft extending across the intercorporal septum . This lemax) of 19.9  was identified in the right upper lobe abutting the mediastinum with areas of central cavitation. The overall imaging features of this lung lesion were suggestive of a primary lung squamous cell carcinoma. Additional mass lesions with similar hypermetabolic activity were identified in the right subscapularis muscle (SUVmax = 15) and left adrenal gland (SUVmax = 15.3). No hypermetabolic lymphadenopathy was identified. Subsequent contrast-enhanced MR imaging of the brain demonstrated multiple supratentorial and infratentorial ring enhancing lesions in keeping with metastases (Subsequent whole-body positron emission tomography/computed tomography (PET/CT) imaging demonstrated hypermetabolism of both penile lesions with a maximum standard uptake value  followed by adenocarcinoma origin (7 of 40 cases) , 14. PenMR imaging is a particularly advantageous imaging modality in evaluating secondary penile metastases due to the superior soft tissue resolution, multiplanar functionality, and ability to accurately characterize disease extension . In the max as a measure of distinguishing a primary penile malignancy versus metastases from a synchronous neoplasm; however, a meta-analysis may be difficult given the rarity of cases. In the posttreatment setting, PET/CT is particularly advantageous for disease restaging when assessing for treatment modification [PET/CT has been described as a valuable imaging tool in the setting of secondary penile metastases for detection of the primary malignancy, identification of additional sites of metastases, and the facilitation of staging, which may all be provided in a single examination , 16, 17.Choice of treatment in the setting of metastatic penile cancer is multifactorial and is based on the type of cancer, size and number of metastatic lesions, age, and patient constitution , 6. WithIn conclusion, this is a case of secondary penile metastases as the initial presentation of metastatic pulmonary ASC and is, to the best of our knowledge, only the second described case of this entity. Penile metastases are rarely identified prior to the diagnosis of the primary neoplasm. Given the rarity of secondary penile metastases from primary lung cancer and the poor prognosis following identification, knowledge of this atypical heralding lesion to prompt further assessment for end-stage extrapelvic metastatic malignancy is crucial when evaluating these patients.