Internal hernia is a rare cause of intestinal obstruction, and sigmoid mesocolon hernia is an extremely rare form of this condition.Among sigmoid mesocolon hernias, intramesosigmoid hernia is the least frequent subtype.We described a case of intramesosigmoid hernia through the orifice on the right leaf of the mesosigmoid with an incarcerated ileum of 6 cm in length without strangulation. This case was diagnosed by multidetector computed tomography with multiplanar reconstruction images and treated without resection of the small intestine in a 52-year-old man with characteristic diagnostic images.A 52-year-old man suffering periumbilical cramping pain with sudden onset that had persisted for 1 week without recovery was referred to Fukui Katsuyama General Hospital. Multidetector computed tomography revealed small bowel obstruction, and an incarcerated short intestinal loop was revealed by sagittal slices of the multiplanar reconstruction images of the routine study of the left side of the pelvic space. Sagittal multiplanar reconstruction images also showed narrow belt-shaped fluid retention contacting the tip of the incarcerated short loop toward the cranial direction localized in the mesosigmoid. These findings indicated that the fluid and the herniated small bowel were wrapped together in the mesosigmoid, which was characteristic of intramesosigmoid hernia.The patient underwent laparotomy operation 2 days after admission. The ileum, which was approximately 75 cm proximal to the ileocecal junction and herniated into the mesosigmoid through the right leaf, was released without resection. The orifice located in the central part of the right leaf was oval shaped and measured less than 2 cm in diameter. The left leaf of the mesosigmoid was intact. The orifice of the right lobe was closed by suture. The patient showed an uneventful recovery.We report an extremely rare case of incarcerated intramesosigmoid hernia that was diagnosed by multidetector computed tomography with multiplanar reconstruction images. The finding of narrow belt-shaped fluid retention contacting the tip of the incarcerated short intestinal loop is characteristic of intramesosigmoid hernia and will be useful for conclusively differentiating this disease from transmesosigmoid hernia. Although intramesosigmoid hernia is a rare cause of internal hernia, multidetector computed tomography and multiplanar reconstruction images can provide the characteristic findings and proved useful for the precise preoperative diagnosis and treatment of intramesosigmoid hernia. Among the causes of internal abdominal hernia, sigmoid mesocolon hernia (SMH) is a very rare form of this disease and has been infrequently reported –7. AlthoSMH is classified into three types; among them, intramesosigmoid hernia (IMSH) is the rarest type and is characterized by a congenital, oval-shaped defect on only one leaf of the sigmoid mesocolon .We describe a case of IMSH through the orifice on the right leaf of the mesosigmoid that was diagnosed by characteristic multidetector computed tomography (MDCT) and multiplanar reconstruction (MPR) images; this IMSH patient, a 52-year-old man, had an incarcerated ileum of 6 cm in size without strangulation and was treated without resection of the small intestine.A 52-year-old man with a history of appendectomy presented to his family physician suffering periumbilical cramping pain with sudden onset. He received oral medication, but the symptoms persisted.3/μL) without any elevation in the C-reactive protein (CRP) level (0.12 mg/dL).One week later, he was referred to Fukui Katsuyama General Hospital, and his symptoms continued to persist. He received a liquid-only diet over this period without vomiting. On physical examination, he showed a pulse of 108 beats/minute, a blood pressure of 140/80 mmHg, and a body temperature of 37.2 °C. Anemia, jaundice, edema, and malnutrition were not found. Abdominal distention with mild tenderness on palpation was noted. No external hernia was present. Laboratory data showed only a mild elevation of the white blood cell (WBC) count  after surgery. Oblique coronal images revealed the incarcerated intestine and the converging mesenteric vessels to indicate the hernia orifice more clearly, which measured 18 mm in width Fig. .Fig. 3ReInternal hernia represented by paraduodenal hernia, pericecal hernia, and others is a rare cause of intestinal obstruction and is estimated as responsible for only 0.5–0.9% of intestinal obstruction in patients with no history of abdominal surgery . Among iOf the three types of SMH, TMSH showed the highest rate of bowel resection (50%) compared with ISH (18.8%) and IMSH 13.9%) [.9% [3]. Regarding the modality to facilitate a precise diagnosis, MDCT is most useful; ISH cases should be visualized such that the small bowel goes across the ventral part of the sigmoid colon once, and then, the incarcerated small loop is formed from the lower-left abdomen to the cranial side because the hernia orifice of ISH is located at the attachment of the lateral aspect of the sigmoid mesocolon. In cases of TMSH and IMSH, as for the congenital oval-shaped foramen of the sigmoid mesocolon that can occur in both lobe sides, it is necessary to consider that the short bowel could herniate into or through the mesosigmoid from either side. However, it is difficult to preoperatively distinguish between IMSH and TMSH by MDCT.In the presented case, routine sagittal MPR imaging showed narrow belt-shaped fluid retention contacting the tip of the herniated short loop of the intestine. This indicated that the fluid and the herniated small bowel were wrapped together in the mesosigmoid, which precisely indicated IMSH. This finding seems to be characteristic of IMSH and may be useful for conclusively differentiating this disease from TMSH.Our case showed the characteristic findings noted above by routine sagittal MPR images and provided sufficient information on the IMSH before the operation; however, it is difficult to obtain high-quality image views of diagnostic value by routine images alone in many cases. Kumagai  reportedShibuya  reportedThere are two points of reflection on the treatment course of this case. First, despite being able to diagnose IMSH from the images, surgery could not be performed immediately. Due to the rarity of this disease and the inexperience with image findings, we could not share our understanding of the disease condition among surgeons, and therefore, we were not able to comply with the emergency surgery policy. This report was motivated by our reflection and the need to publish on this disease and describe its characteristic imaging findings. A long tube was inserted before the operation using a routine technique at the time of an intestinal obstruction operation at our facility; however, it is thought that this will not be routinely necessary in the future because there are many reports in which a long tube was not used for IMSH operations, and the clinical course thereafter did not show any problems.We reported an extremely rare case of incarcerated IMSH that was diagnosed by MDCT with MPR images. The finding of narrow belt-shaped fluid retention contacting the tip of the incarcerated short intestinal loop is characteristic of IMSH and will be useful for conclusively differentiating this disease from TMSH. Although IMSH is a rare cause of internal hernia, MDCT and MPR images can provide the characteristic findings and are useful to precisely diagnose and treat IMSH.


Dentigerous cysts (DC) are cystic lesions radiographically represented by a well-defined unilocular radiolucent area involving an impacted tooth crown. We present an unusual radiographic feature of dentigerous cyst related to the impacted mandibular right second molar, in a 16-year-old patient, which suggested an ameloblastoma or odontogenic keratocyst (OKC) because of its multilocular appearance seen on the panoramic radiography. A multi-slice computed tomography (MSCT), however, revealed a unilocular lesion without septations, with an attenuation coefficient from 3.9 to 22.9 HU suggesting a cystic lesion. Due to its extension, a marsupialization was performed together with the histopathological analysis of the fragment removed which suggested a dentigerous cyst. Nine months later, the lesion was reduced in size and then totally excised. The impacted mandibular right second molar was also extracted. Histopathological examination confirmed the diagnosis of a dentigerous cyst. One year later, the panoramic radiography showed a complete mandible bone healing. Large dentigerous cysts can sometimes suggest other more aggressive pathologies. Precise diagnosis is important to avoid mistakes since DC, OKC and ameloblastoma require different treatments. Histological examination is, therefore, essential to establish a definitive diagnosis. In our case, MSCT and the tissue attenuation coefficient analysis contributed to guide the diagnosis and management of the dentigerous cyst. A dentigerous cysts (DC) are defined as cystic lesions involving the crown of impacted teeth caused by fluid accumulation between the follicular epithelium and the crown of the tooth. It is considered the most common type of noninflammatory odontogenic cyst, and it occurs mainly in the lower third molar tooth of male patients with peak incidences in adolescents or young adults. Dentigerous cysts present a slow painless swelling and can cause the teeth displacement or teeth and bone resorption. Large cysts, however, may be associated with pain ,2,3,4. HRadiographically, DCs often present a unilocular radiolucent area around the crown of the impacted tooth surrounded by a well-defined sclerotic area ,2,4,5. LComputed tomography (CT), such as Cone Beam CT (CBCT) or multi-slice computed tomography (MSCT), has an important application in the evaluation of head and neck lesions. It is a non-invasive technique that permits the lesion size and margins, the bone destruction and expansion patterns to be precisely analysed ,7. In adThis paper illustrates a case of an unusual dentigerous cyst initially diagnosed as ameloblastoma due to its multiloculated feature observed in panoramic radiography.A 16-year-old male was referred to the Centre for Diagnosis and Treatment of Oral Diseases with a clinical diagnosis of ameloblastoma having hemi-mandibulectomy as the suggested therapy. At admission, no relevant aspects within his medical history were observed. He brought a panoramic radiography  which recandida (Candida sp.) infection of the contents coming from the cavity (not shown) was detected through cytological examination and promptly treated with itraconazole capsules (1× daily for 10 days). After nine months, a considerable decrease of the lesion was observed on panoramic radiography (not shown). Excision of the cystic lesion, as well as extraction of the impacted mandibular right second molar, was then performed. Histopathological examination confirmed the diagnosis of a dentigerous cyst . The cytological smear is used in clinical practice [Through cytological examination, practice  and may After a considerable decrease nine months later, the lesion was excised, and the impacted mandibular right second molar was extracted. According to Anavi et al. , the aveIn case of large or radiographically unusual cystic lesions, it is mandatory to perform a biopsy before planning surgical treatment. Depending on lesion size and diagnosis, an enucleation, marsupialization or decompression could be the forms of treatment chosen. In our case, the initial incisional biopsy made during the marsupialization process provided the diagnosis of a dentigerous cyst allowing a conservative approach. In addition, the tissue attenuation coefficient analysis done by MSCT was also useful in the diagnosis process to eliminate the possibility of other lesions such as a solid ameloblastoma or an odontogenic keratocyst.


Polypoid adenomyoma is a rare uterine endometrial polypoid tumor of mixed epithelial and mesenchymal origin. Although the clinical and pathologic features of polypoid adenomyomas have been described extensively, imaging findings for these tumors have not been frequently reported in the literature. On imaging, their features may be confused with prolapsed leiomyomas or malignancy. Hemorrhagic cystic spaces in a prolapsed uterine tumor within the vagina should raise consideration of a diagnosis of polypoid adenomyoma. Such blood-containing cystic spaces would be unusual findings in leiomyomas and malignancy. Diagnosing polypoid adenomyoma is vital because it can potentially be managed by hysteroscopic resection, unlike an ordinary form of adenomyosis. Polypoid adenomyoma of the uterus is an endometrial polyp in which the stromal component is made up of smooth muscle . These aWe report a case of a 44-year-old woman with urinary retention who had a prolapsed polypoidal uterine lesion on imaging which was confirmed to be polypoid adenomyoma on histopathology. We aim to review the imaging findings and the relevant literature on this rare entity.A 44-year-old previously healthy woman presented to the emergency department complaining of urinary retention. Transabdominal Figure  and tranMagnetic resonance imaging (MRI) of the pelvis with contrast was then done which demonstrated a large, well-defined abnormal signal intensity polypoidal mass distending the endocervical canal and extending through the external os  into the upper one-third of the vagina. It was measuring 46 x 46 x 58 mm in maximum dimensions. It appeared to be connected to the uterine endometrium by a T2-hypointense stalk seen within the endometrial cavity. No evidence of invasion into adjacent structures was seen. The uterine junctional zone was also thickened and ill-defined, which was suggestive of adenomyosis. The lesion contained rounded T1-hyperintense cystic spaces with fluid-fluid level within it, suggestive of hemorrhages. The lesion did not show significant diffusion restriction, and enhanced heterogeneously in the post-contrast study. Post-contrast enhancement was relatively less than that of myometrium Figures -5.The initial differential diagnoses included endometrial polyp or submucosal leiomyoma with cystic degeneration. Prolapsed malignancy was a less likely differential because there was no diffusion restriction. The patient proceeded to have a hysteroscopy, endometrial biopsy and vaginal myomectomy. Histopathology of the specimen revealed polypoid adenomyoma, with no evidence of malignancy.An adenomyoma, which protrudes into the endometrial cavity, is referred to as a polypoid adenomyoma . These tOn ultrasound, polypoid adenomyomas can appear as solid, well-circumscribed endometrial masses with cystic areas . On MRI,Therefore, hemorrhagic cystic spaces in a prolapsed uterine tumor are suggestive of a diagnosis of typical polypoid adenomyoma, especially in a premenopausal female with additional findings suggestive of adenomyosis as seen in our case. Blood-containing cystic spaces would be infrequently seen in leiomyomas and malignancy, although potentially can be seen in the setting of leiomyomas with red degeneration and in uterine sarcomas . The enhAlthough the clinical and pathological features of polypoid adenomyomas have been described extensively, imaging findings for these tumors have been infrequently reported in the literature. Hemorrhagic cystic spaces in a prolapsed uterine tumor within the vagina should raise consideration of a diagnosis of polypoid adenomyoma. Such blood-containing cystic spaces would be unusual findings in leiomyomas and malignancy.


Background: Abnormalities of mesonephric ducts are rare congenital conditions, which can present with vague symptoms in otherwise healthy men. Zinner's syndrome is the association of an enlarged seminal vesicle cyst with ipsilateral renal agenesis, which can be symptomatic and require operative interventions.Case: We present the case of an otherwise healthy 24-year-old man who presented with a symptomatic 15 cm seminal vesicle cyst, which was completely excised using a robot-assisted approach.Conclusion: Use of robotic surgery for excision of large seminal vesicle cysts is a safe and effective operative procedure. Wolffian) duct gives rise to multiple genitourinary organs, including the seminal vesicles, ejaculatory ducts, epididymis, and the vas deferens, along with the trigone of the bladder. Abnormalities from the 4th to 13th week of gestation in the mesonephric duct can lead to ipsilateral failure of ureteral bud proximal growth and association with the metanephric blastema and, in theory, renal agenesis or dysgenesis. Furthermore, ipsilateral abnormalities in the differentiation of the mesonephric duct can also lead to atresia of the ejaculatory ducts, resulting in chronic obstruction of the seminal vesicle and corresponding cystic dilation. The eponym Zinner's syndrome1 refers to the triad of renal agenesis, ejaculatory duct obstruction, and seminal vesicle cyst, a rare condition that has an estimated incidence of 0.00035%.1The mesonephric (1 Larger or symptomatic cysts have been managed with transurethral unroofing, open, laparoscopy, and robot-assisted laparoscopic methods. We report the use of the daVinci robotic platform to facilitate minimally invasive complete en bloc removal of a massively dilated seminal vesicle in a symptomatic patient with ipsilateral renal agenesis.Although these cysts represent benign entities, their management is dictated by the presence of symptoms, including dysuria, frequency, urgency, as well as abdominal, perineal, or scrotal pain. In addition, some patients report pain with ejaculation, recurrent epididymitis, or infertility. Small asymptomatic cysts can be safely monitored for growth.A 24-year-old male student presented to a community hospital emergency department in September 2016 for a 2-day history of lower abdominal pain, suprapubic pressure, radiating pain to right testicle, subjective fevers, and frequency of urination. He was afebrile, with stable vital signs, and his laboratory work was only notable for a mild leukocytosis to 12,200/μL and a urinalysis with four RBC per high power field. His past medical history was notable for an appendectomy 15 years prior, before start of puberty. He had no notable family history and no children. He underwent a scrotal ultrasonography and a contrast-enhanced CT abdomen and pelvis, which interestingly showed a hypertrophied solitary left kidney and a large cystic mass in the pelvis of unclear etiology. The mass was 11 cm in maximum dimension. He was then transferred to a tertiary care hospital for further evaluation by urology and radiology.His physical examination was notable for absence of his right vas deferens and for mild suprapubic tenderness to palpation without rebound or guarding. A digital rectal examination was performed, which revealed no abnormalities. He subsequently underwent an MRI with and without IV contrast, to further delineate the anatomy  and 2. TAfter extensive discussion of the risks, benefits, and alternatives the patient was subsequently taken for a robot-assisted laparoscopic removal of the right seminal vesicle cyst. Preceding surgical incision, a cystourethroscopy was performed, which showed a normal anterior and posterior urethra, normal verumontanum, no prostatic utricle, and systematic evaluation of the bladder was notable for absence of the right ureteral orifice, although the trigone itself did not otherwise look atypical.Abdominal access was performed just superior to the umbilicus with a Veress needle to obtain pneumoperitoneum. Surveillance of the abdomen confirmed the large cystic mass and some minor adhesions in the right lower quadrant from his previous appendectomy. A right vas deferens could not be identified, but the left vas deferens was confirmed to be in orthotopic position. Both deep inguinal rings were closed. Two ports were placed in the patient's left side to assist with taking down of the adhesions, which was performed without issue. Three more ports were placed on the patients' right side: one additional robotic port and two assistant ports. The patient was secured in steep Trendelenburg position and the robot was docked.The peritoneum was incised to access the seminal vesicle cyst, which was easily identified . CarefulThe patient had an uneventful postoperative course and was discharged postoperative day 1 after having his JP drain and foley catheter removed. On follow-up, he has had significant improvement in his voiding and abdominal pain symptoms. His erections and ejaculatory status was unchanged postoperatively.2 Zinner's syndrome is a rare condition with fewer than 300 cases reported in the literature. The equivalent syndrome in women has not officially been described, but the obstructed hemivagina and ipsilateral renal abnormality have been implicated in the literature, although this is debatable as it would imply that the embryological origin of the upper vagina would have a Wolffian origin rather than the more traditionally accepted Mullerian origin.3Originally described in 1914,1 Their analysis showed that patients can have multiple symptoms, which could come to the attention of a urologist, from lower urinary tract symptoms of obstruction or irritation to nondescript perineal or scrotal pain. A postpubertal male without an ejaculatory duct to drain the seminal vesicle can lead to dilation and swelling of the vesicle until it becomes a cyst large enough to cause these local symptoms. Ouden's review showed that 100% of patients managed with surgical removal of the cyst have improvement in their symptoms, whereas 75% and 30% improve with transurethral unroofing and aspiration, respectively.1The largest pooled analysis of 52 patients with Zinner's was performed by van den Ouden et al. in 1998.4 The cyst was ∼11 cm in diameter and is the largest reported to our knowledge (The use of the daVinci robotic surgical device for benign and malignant cases has increased, and previous case reports of robotic excision of these cysts have shown that it can be a safe modality.nowledge . Our pat1 Symptoms develop in the second through fourth decade of life as the cyst grows in size and causes local mass effects. Management depends on size, location, symptoms, and comfort of the surgeon. We described the case of a megaseminal vesicle cyst in a patient with Zinner's syndrome removed safely through robot-assisted laparoscopic surgery, the largest cyst reported to have been removed this way.Zinner's syndrome is the rare triad of seminal vesicle cyst, ipsilateral renal agenesis, and ejaculatory duct obstruction, caused by a congenital abnormality of mesonephric development.


De Garengeot's hernia is a rare clinical entity. Appropriate and acute diagnosis in emergency basis is challenging , and the surgical management varies from case to case. This report emphasizes the importance of including De Garengeot's hernia in the differential diagnosis of incarcerated groin hernias and the need to establish a well‐defined strategy regarding surgical management options. Prompt diagnosis on emergent basis is challenging , and the surgical management varies from case to case.We present the case of a 77‐year‐old woman who presented in the emergency department complaining of enlarging tender mass in the right groin. A CT of the abdomen‐pelvis showed the top of the appendix in the femoral sac with signs of inflammation. The patient underwent appendectomy and hernioplasty through the femoral sac without any complications. This report emphasizes the importance of including De Garengeot's hernia in the differential diagnosis of incarcerated groin hernias and the need to establish a well‐defined strategy regarding surgical management options.The femoral canal is anatomically located in the groin, medially to the vascular compartment containing the femoral artery and vein. It is a funnel‐shaped canal, approximately 1‐2 cm in length and 10‐20 mm in diameter, defined laterally by the sheath of the femoral vein, medially the aponeurosis of the transversus abdominis, anteriorly the inguinal ligament and posteriorly the pectineal ligament of Cooper.2A 77‐year‐old woman presented in the emergency department complaining of enlarging painful mass in the right groin for the past 2 days. She denied any nausea, emesis, diarrhea, or constipation. The patient was afebrile upon presentation, and the rest of her vital signs were normal. Physical examination revealed a bulging tender mass in the right groin consistent with femoral hernia, which was non‐reducible. Laboratories were remarkable for elevated WBC count 13 500/μL) and CRP (34 mg/L). A CT of the abdomen‐pelvis showed the top of the inflamed appendix within the femoral sac and a small fluid collection in the femoral canal area (Figure 3 500/μL 3De Garengeot's hernia is a rare clinical entity that should be suspected especially in elderly patients with clinical signs of nonreducible, tender femoral hernia. The differential diagnosis from incarcerated femoral hernia is difficult, can be facilitated by imaging and is sometimes achieved intraoperatively. Imaging findings on abdominal CT include the presence of the appendix within the femoral sac and signs of inflammation in the femoral canal. Complications of untreated De Garengeot's hernia include necrosis of the hernia contents with perforation and sepsis or abscess formation,4De Garengeot's hernia is a rare type of femoral hernia that contains the appendix and can be complicated by appendicitis. High clinical suspicion is required for early diagnosis and prompt surgical management in order to avoid further complications. The surgeon should feel free to choose the surgical approach appropriate for each case, depending on the preoperative and intraoperative findings.An informed consent form from the patient in order to present the case for scientific purposes has been obtained.None declared.NF: is the corresponding author; a member of the surgical team; involved in the study, design, and analysis of data; drafted and critically revised the manuscript. DF: is a member of the surgical team: involved in the study, design, and analysis of data; drafted and critically revised the manuscript. GA: is a member of the surgical team; involved in critical revision of the manuscript. GOP: involved in the study, design, analysis and interpretation of data; drafted the manuscript. DF: involved in the design and analysis of data; drafted and critically revised manuscript. PS: supervised the drafting and critical revision of the manuscript.


Primary angiosarcomas of the kidney are very rare, but highly aggressive tumors showing poor prognosis. Patients frequently complain of flank pain, hematuria, or a palpable mass. We present a case of primary renal angiosarcoma occurring in a 61-year-old man. CT images depicted a huge exophytic mass (16 cm in diameter) in the right kidney, exhibiting extensive hemorrhage. The mass showed centripetal peripheral nodular enhancement on dynamic contrast-enhanced images. Furthermore, MR imaging revealed a tangled mesh of tumor vessels in the periphery of the mass. We suggest its inclusion in the differential diagnosis of cases of hemorrhagic renal tumors with prominent vasculature. Primary renal angiosarcomas are exceedingly rare, but highly aggressive tumors showing poor prognosis . The eti3 . The serum levels of blood urea nitrogen and creatinine, and urinalysis were within normal limits.A 61-year-old man was admitted to our hospital with a hematoma in the right kidney. This diagnosis had been made 20 days prior to his admission. His clinical symptoms included pallor and anemia, but physical examination revealed no rigidity or distension of the abdomen; however, he complained of discomfort on palpation in the right flank area. The initial routine laboratory tests showed the hemoglobin level 10 g / dL  and platelet count was 85 x 103 / mmCT images  depictedUsing a transperitoneal approach, the patient underwent a radical right nephrectomy. The macroscopic appearance showed a huge mass in the right kidney that extended up to the perirenal space. The mass showed extensive hemorrhage and proliferation of the tumor vessels. The microscopic features revealed complex anastomosing channels with obvious vasoformation and endothelial papillae . ImmunohAngiosarcoma is an aggressive malignant neoplasm originating from endothelial cells of the blood and lymphatic vessels , 6. AmonPatients frequently present with flank pain and a palpable mass –4. As thWith respect to imaging findings, the tumors have been described as a hypodense mass, with variable peripheral enhancement, or a large necrotic mass –5. HowevDue to the rarity of this tumor, there are no standard treatment guidelines for primary renal angiosarcomas –3, 5. HoTo summarize, we present a case of primary renal angiosarcoma with extensive hemorrhage and suggest its inclusion in the differential diagnosis of cases of hemorrhagic renal tumors with prominent vasculature.


Recurrent testicular torsion after previous orchiopexy is rare and needs high index of suspension to avoid misdiagnosis and delayed management. This case showed that this diagnosis can occur even when the testis is still fixed to the scrotal wall. A 31-year-old male who had previous testicular fixation for testicular torsion with a single stitch to the lower pole before 6 years presented with recurrent testicular torsion and missed diagnosis. This case confirm that recurrent testicular torsion after previous fixation should be included in the differential diagnosis of acute scrotum and emphasis on the testicular fixation with nonabsorbable suture in at least two points to prevent recurrent torsion. Testicular torsion is considered one of the important causes of acute scrotum condition. It is most common just after birth and during puberty. It occurs in about 1 in 4,000 to 1 per 25,000 males per year before 18 years of age [Testicular torsion is mainly diagnosed by history and physical examination then immediate surgical exploration is indicated but scrotal ultrasonography can be useful diagnostic tool if it is available and there is doubt in diagnosis . Late prA 31-year-old male patient presented to the emergency complaining of left testicular pain for 5-day duration since the onset of pain, continuous pain associated with swelling, gradually increased. He had previously undergone bilateral orchidopexy before 6 years for left testicular torsion. Patient visited general practitioner on the same day of onset of pain and was diagnosed as epididymitis and given antibiotics with analgesics and discharged. On examination the entire left hemiscrotum was swollen and tender and appeared as a confluent mass without identifiable landmarks. Scrotal ultrasonography showed hypoechoic left testis without intrinsic vascularity  and modeUrgent surgical exploration of left side revealed intact tunica vaginalis with moderate hydrocele, left testis delivered which was black, torsed, and attached with old stitch from lower pole to the side wall of scrotum . Old stiThe right testis was explored and it was attached with single stitch to the lower pole; old stitch was removed and fixation with three stitches 3/0 vicryl to the scrotal wall was done . PatientEarly diagnosis and management of testicular torsion is important to save the testis. Correction within 4-6 hours gives good testicular preservation but if it is done after 12 hours there is high risk of testicular atrophy [The diagnosis of testicular torsion after previously fixed testicles is rare but it should be included in the differential diagnosis of acute scrotum.There have been reported cases of recurrent testicular torsion after the previous –14. SomeAs in our case, only two reported cases with torsion occurred while the testis is attached to the scrotum through the stitch in the lower pole , 14. SinFixation of the detorsed testis and the contralateral testis using nonabsorbable suture is recommended to prevent metachronous or recurrent torsion . FixatioTesticular torsion leading to orchidectomy is a major catastrophe for the patient and previous history of orchiopexy does not exclude the diagnosis.Recurrent testicular torsion after previous orchiopexy is rare but should be included in the differential diagnosis of acute scrotum. Testicular fixation with nonabsorbable suture and in at least two points can help to prevent recurrent torsion.


All efforts should be aimed to safe permanent tooth for adolescents. Presented rare case confirms a possibility to save a tooth with Oehlers Type 3 anomaly with peri‐invaginated periodontitis and to preserve vitality of the tooth pulp, even when surgical cyst removal is performed. It manifests as deepening or invagination of the enamel organ into the dental papilla prior to calcification of the dental tissues.Several explanations of this phenomenon have been published; however, the etiology of dens invaginatus remains unclear. DI might be caused by a focal failure of growth of the internal enamel epithelium leading to proliferation of the surrounding normal epithelium with eventual engulfment of the static area. According to Oehler,The prevalence of DI is reported being between 0.3% and 10%.OehlersThe morphology of the crown and the root canal is often complicated. 2D radiographs may not produce sufficient diagnostic information about complexity of the dens invaginatus anatomy. Cone‐beam computed tomographic (CBCT) imaging allows visualization of the third dimension and eliminates superimpositions.Any communication between the oral cavity and the invaginatus foramen can lead to an inflammatory response within the periodontal tissues. The disease is called “peri‐invagination periodontitis” (PIP). Where PIP exists along with the healthy pulp, all efforts should aim to preserve the vitality of the pulp. The objective should therefore be to treat the invagination in isolation of the root canal where possible.The purpose of this article was to describe the successful case of endodontic and surgical treatment of a maxillary right incisor diagnosed with infected invagination (Oehlers' type 3) associated with apical cyst‐like bone destruction while maintaining vitality of the surrounding pulp.2A 14‐year‐old male patient was referred to the Clinic of Dental and Oral Pathology at Lithuanian University of Health Science, Kaunas, Lithuania, by his general dentist for evaluation and treatment of the maxillary lateral right incisor (tooth #12). The patient complained about constant mild pain, tenderness to bitting and touching mucosa near the tooth #12. He reported swelling history in the infraorbital region about a month ago.On the appointment day, the extra‐oral examination revealed no abnormalities. The intraoral examination showed infra‐occlusion of tooth #12. Sinus tract was observed in the alveolar mucosa, proximally to the apical area of tooth #12. The tooth reacted normally to percussion, however, was somewhat sensitive to palpation. Response to cold test was positive, indicating the unaffected vitality of the pulp. There was no evidence of caries in the hard tissues as well as no increased tooth mobility and probing depths  scan  with exposure parameters of 80 kVp, 5 mA, and 12‐24 seconds was taken of the area of interest. The CBCT scan revealed the presence of a large periapical radiolucency related to the tooth #12. Radiolucency had a quite well‐circumscribed sclerotic border and no connection with maxillary sinus or the nasal cavity. Coronal and axial CBCT images showed that the invagination was separated from a circular vital root canal and had a different portal of exit Figure .The final diagnosis was defined as chronical apical periodontitis with a cyst‐like lesion of tooth #12 with an infected Oehlers' type 3 invagination and the surrounding vital pulp. The treatment plan was to perform endodontic treatment of the invagination and then to enucleate the cystic lesion surgically, while maintaining the pulp vitality.On the first visit, the endodontic cavity of tooth #12 was carefully reshaped without penetrating the pulp using local anesthesia  and rubber dam isolation. Under the dental operating microscope , a wide infected invagination in the middle of the cavity was observed. It was not possible to visualize the end of invagination because of the curvature. The pulp horns were hidden behind a thin layer of dentin and located in the mesial and distal corners of the cavity.The space of invagination was instrumented with K‐files  and generously irrigated with 2.5% NaOCl and 17% EDTA, using an ultrasound activation. Calcium hydroxide paste was inserted for 2 weeks, and the cavity was sealed with temporary material .On the second appointment, the patient had no complaints, and the sinus tract was closed. The tooth was anesthetized as previously described and isolated with a rubber dam. Then, the apical entrance of the invagination was sealed with mineral trioxide aggregate  and condensed with hand pluggers and paper points.After allowing 20 min for setting of MTA, the remaining space of invagination was filled with thermoplastic gutta‐percha  and AHplus sealer . Furthermore, the dentin walls near the vital pulp were covered with “Biodentine” , and the final composite restoration was placed .In 3 months, the surgical enucleation of the cyst was performed. Under the dental operating microscope, using intrasulcular incision and vertical release, a full‐thickness flap was reflected and thin cortical bone was removed to create the bony window. The cystic lining/granulation tissue was carefully enucleated, without damaging the periapical region of teeth #11, #12, #13. The integrity of maxillary sinus and nasal cavity was not damaged. The histological evaluation of the biopsy confirmed the diagnosis of a radicular cyst.The follow‐up visits of the patient were made after 1, 2, 3, 6, 12, and 24 months. Tooth #12 maintained a normal response to cold test for the entire period. The clinical examination revealed normal function of tooth #12 Figure , 6, 7.3Clinical management of teeth with infected type 3 invagination and PIP is a real challenge for clinicians. Based on the complex dental anatomy, different treatment models may be suggested, including nonsurgical endodontic treatment of the infected invagination,A 3‐dimensional picture of the invaginated tooth can be very helpful in the process of treatment planning.The positive response of tooth #12 to cold test as well as the signs of blood supply in the pulp horns  led us predict that the pulp in the main root canal was still viable. Due to the complex anatomy, it was considered to avoid, as much as possible, perforation of the main root canal or devitalization of the pulp while treating the invagination or damaging it retrogradically on surgical phase.Disinfection of the DI was achieved by irrigation with copious amount of 2.5% NaOCl and the final rinse with 17% EDTA, owing to their antibacterial activity and reduction in the endodontic biofilms. Minimal hand instrumentation was made in the DI space. Rotary instrumentation within the invagination is not recommended because the surface may be covered by enamel and has an unpredictable shape with the possibility of the instrument fracture. K‐files have been routinely recommended for instrumentation of such cases.For the apical barrier formation, MTA Angelus was used, due to its biocompactability, sealing abilities for open apices cases and relatively short setting time.3, there was 80% probability of a cyst. In our case, the volume of the lesion also was more than 247 mm3. These findings fulfill the diagnosis of radicular cyst, which was confirmed by histological evaluation. Reported case confirms the advantages of CBCT use for periapical pathology differentiation.Guo et alEnucleation of the cystic lesion under the dental microscope resulted in high precision of the procedure, and prevented perforation of the sinus or, the nasal cavities, as well as unnecessary damage of the apical region of tooth #12. In the invagination space, root dentin was covered with impermeable enamel layer, so there were no lateral canals, apical seal was made with MTA, and the real canal space of the tooth was not infected. The possibility of reinfection into periapical area from the tooth was considered as very low, and no root resection or retrograde filling was indicated.Preservation of the pulp vitality allowed us to save as much as possible of the root dentin and consequently increased our expectations for the long‐term treatment success. The extended follow‐up period of 24 months proved the successful outcome of the selected treatment procedures.Thus, the presented case confirms a possibility to save a tooth with Oehlers Type 3 anomaly, with the preserved vital pulp, even when surgical cyst removal is performed. To our knowledge, no such cases have been described in the literature before.4In the presented case, endodontic treatment success was based on careful diagnostics and on adequate treatment planning. All efforts should aim to treat peri‐invaginated periodontitis and to preserve pulp vitality in Oehlers Type 3 anomalies.5All efforts should be aimed to safe permanent tooth for adolescents.Endodontic treatment success was based on careful diagnostics and on adequate treatment planning.Presented case confirms a possibility to save a tooth with Oehlers Type 3 anomaly and to preserve vitality of the tooth pulp, even when surgical cyst removal is performed.None declared.AD and RV: performed the treatment; AD: performed the follow‐up; and VM and RV: led the writing.


Vasitis or inflammation of the vas deferens is a rare condition, and few case reports with computed tomography images have been published since 1980.A 50-year-old man presented with severe right inguinal and lower abdominal pain. Initial diagnosis at the emergency department was incarcerated or strangulated inguinal hernia. The computed tomography scan revealed diffuse edematous changes of right spermatic cord and vas deferens with peripheral fat stranding. Correlating with his clinical symptoms, signs, and imaging findings, the diagnosis of vasitis was made. We report a case of acute vasitis about the cause, symptom, pathogen, differential diagnoses, image findings, and treatment.Although very rare, vasitis should be listed as one of the differential diagnosis for inguinal mass lesions. Cross-sectional imaging may be necessary to confirm the diagnosis and exclude differentials such as an inguinal hernia. Recognition of the characteristic image findings can help to make the correct diagnosis and avoid unnecessary surgery. Acute vasitis or inflammation of the vas deferens is an extremely rare disease, with only about twenty adult case reports published since 1980. Few of these contain computed tomography (CT) images . ClinicaA middle-aged male presented to our emergency department with severe right inguinal and lower abdominal pain, exaggerated by walking and Valsalva’s maneuver. He did not have a fever or chillness. The patient has no other prior medical history, no trauma history, no recent travel history, and no habitual alcohol and cigarette consumption. The patient is of Han Chinese origin and is currently working as an office clerk. He denied any family history of similar symptoms, no recent heavy lifting activities, and no high-risk sexual behaviors. The physical examination revealed tenderness and swelling in the right inguinal area. The laboratory tests revealed leukocytosis (11.39 × 103 /uL), elevated C reactive protein (35.4 mg/L) and leukocyturia, but a negative result of the urine culture. Due to the progression of localized right inguinal pain, the emergency doctor arranged computed tomography scan to rule out incarcerated inguinal hernia. The scan revealed diffuse edematous changes of right spermatic cord and vas deferens with peripheral fat stranding and no herniated bowel loop Figs. . CorrelaInflammation of the vas deferens or vasitis is a rare condition categorized by Chan and Schlegel as acutely painful infective vasitis or asymptomatic vasitis nodosa . VasitisHaemophilus influenza and Escherichia coli. However, urinary culture is usually negative. Other rare pathogens reported include Chlamydia trachomatis and Mycobacterium tuberculosis [Acute infective vasitis is thought to be due to the retrograded spread of common urinary pathogens including rculosis , 6.Most cases of the previously reported vasitis patients have histories of surgeries in close proximity to the affected vas deferens. Due to the low prevalence nature of acute vasitis, other risk factors have not been credited to this condition. A retrospective review was conducted by Clavijo et al. in 2010 where the clinical characteristics of eleven patients were thoroughly evaluated [Clinical symptoms include localized pain or palpable mass in the scrotal or inguinal region, some of them with leukocytosis or fever. Acute vasitis could be classification as three groups depending on involved site: scrotal, suprascrotal, and prepubic. It can be easily confused when there is isolated site involvement . The comThe diagnosis of vasitis could be a challenge by its rarity and unclear image findings. We review past reports that suggest appropriate tools include ultrasound, computed tomography and magnetic resonance imaging (MRI). Ultrasound can be used to exclude orchitis, epididymitis, and testicular torsion by color Doppler. Acute vasitis often reveals heterogeneous, hypoechoic spermatic cord and echogenic fat surrounding the lesions. However, ultrasound is relatively challenging to differentiate from incarcerated inguinal hernia to vasitis . CT and Based on the available literature, the majority of the reported vasitis can be resolved with the use of anti-inflammatories and antibiotics alone , 8. SomeIn summary, we present a rare case mimicking incarcerated inguinal hernia, and although vasitis is very rare, physicians should keep in mind that patients might present with similar symptoms, especially when the patient has risk factors such as previous vasectomy and concurrent leukocyturia. CT or MRI scan can play an important role to prevent unnecessary surgery.


Diagnosis of Fitz‐Hugh–Curtis is challenging due to its rarity and its similar presentation to common intra‐abdominal conditions, such as cholecystitis or appendicitis. In our case, the adherent cecal and omental mass felt on examination were thought to be an appendiceal mass secondary to perforation, hence the patient underwent a diagnostic laparoscopy. A 17‐year‐old woman presented with right‐sided upper and lower abdomen pain of several days duration, with no associated history of vaginal discharge or urinary symptoms. Examination findings revealed pyrexia and guarding in the right abdomen. Deep palpation revealed a mass in the right iliac region, thought to be an appendiceal mass.Blood workup revealed raised inflammatory markers. Urine dipstick and pregnancy testing were negative.The patient underwent a diagnostic laparoscopy. Operative findings revealed an adherent mass of cecum and omentum to the anterior abdominal wall Fig. A, with aWJ: was involved in obtaining consent and drafting of the manuscript. FF: was involved in writing of the manuscript. Both were involved in her clinical case.None declared.


Teratoma can be defined as a true neoplasm that contains tissues that either are foreign to the primary site of origin or are histologically diverse and represent more than one of the embryonic germ layers. A 20-year-old female patient presented with chief complaints of swelling in the right upper abdomen since childhood and back pain for the past 4 years. Per abdomen, examination revealed a lump of around 15 cm in size in the right hypochondrial region extending to the epigastric region. Contrast-enhanced computed tomography abdomen revealed a 14.3 × 14.1 × 17.4 cm well-defined heterogeneously hypoattenuating nonenhancing complex cystic mass with focal areas of calcifications and fat attenuation in retroperitoneum. The patient was taken up for exploratory laparotomy and a tumor was found in the retroperitoneum, retrocavally and was excised with due care. Histopathological examination features were suggestive of mature cystic teratoma. The postoperative stay was uneventful. Teratoma can be defined as a true neoplasm that contains tissues that either are foreign to the primary site of origin or are histologically diverse and represent more than one of the embryonic germ layers.A 20-year-old female patient presented with chief complaints of swelling in the right upper abdomen since childhood and back pain for the past 4 years. The swelling progressed in size with time and for the past 2 months, she noticed a rapid increase in size. The swelling was associated with dull aching back pain, more pronounced in the past 4 years. There was no associated history of any gastrointestinal symptoms. Per abdomen, examination revealed a nonmobile lump of around 15 cm in size in the right hypochondrial region extending to the epigastric region. All routine laboratory investigations were unremarkable. Ultrasonography showed a large heterogeneous mass with multiple internal septations and areas of fat within it in the right hypochondrium and the mass was displacing the inferior vena cava anteriorly. The features were suggestive of retroperitoneal dermoid. Upper gastrointestinal endoscopy was unremarkable. Contrast-enhanced computed tomography (CECT) abdomen revealed a 14.3 × 14.1 × 17.4 cm well-defined, heterogeneously hypoattenuating, nonenhancing complex cystic mass with focal areas of calcifications and fat attenuation in retroperitoneum . The lePrimary retroperitoneal masses can be classified as benign or malignant or as solid and cystic. Benign tumors account for around 20% of retroperitoneal tumors and include lipoma, neurofibroma, neurilemmoma, leiomyoma, extra-adrenal chromaffinomas, paraganglioma, mucinous cystadenoma, and hamangiopericytoma. Malignant tumors account for around 80% of retroperitoneal tumors and include liposarcoma, leiomyosarcoma (50%), lymphoma (commonly non-Hodgkin lymphoma), malignant tumors from specific organs, germ cell tumors, chordomas, and Retroperitoneal Lymph Node (RPLN) secondaries with hard nodules.Teratomas belong to a variety of nonseminomatous germ cell tumors and are therefore usually found within the testis or ovary.Mature cystic teratomas are known as dermoid cysts and are composed of tissues from at least two of the three germ layers. They commonly present as back pain  or nausea, vomiting, constipation/obstipation, colicky pain, urinary retention, hypertension, mesenteric ischemia, intermittent claudication, renal insufficiency, pedal edema, tingling, numbness, and weakness of lower limbs.Retroperitoneal dermoid is a rare presentation and is usually not detected due to its small size and asymptomatic nature. When large, it presents as a nonmobile mass, associated with back pain and other symptoms due to compression of adjacent organs. CECT is a very useful modality in diagnosing the retroperitoneal dermoids as well as in planning surgery. Complete enucleation is the surgical goal except malignancy where it may be difficult due to metastasis. Follow-up is warranted when malignancy is confirmed with regular CT scans and tumor marker levels.


Primary hepatic leiomyoma (PHL) is a rare manifestation of tumors in the liver; it is mainly characterized by its origin in the mesenchymal tissue. To date, the mechanisms underlying the pathogenesis of this disease remain unclear, however most reported PHL patients suffer from acquired immunity deficiency syndrome (AIDS) or take immunosuppressive medications after organ transplantation.In this case report we describe a rare case of PHL in a middle-aged Chinese woman who was asymptomatic with no history of hepatitis or other liver disease. She had no history of immune suppression medication therapy. In view of the benign features of the hepatic lesion, along with our implementation of the respecting the patience choices, a laparoscopic partial hepatectomy of the right lower liver was performed, which appeared to be highly effective and give a good prognosis.Clinical characteristics of the patient should be compared to previously reported aspects of this disease to reach a clear diagnosis. Moreover, although PHL is extremely rare, it should still be considered a possibility. Surgical intervention is effective in treating this disease.The online version of this article (10.1186/s12893-019-0598-1) contains supplementary material, which is available to authorized users. Primary hepatic leiomyoma (PHL), a rare manifestation of tumors in the liver , 2; is mTo date, the pathogenic mechanisms underlying this disease remain unclear. While it has been postulated that the neoplasia may arise from atypical growth of hepatic vessels and abnormal proliferation of bile ducts , 4, 5 thSince 1926, when the first case of PHL was described, most PHL cases have been reported among patients suffering from acquired immunity deficiency syndrome (AIDS) or AIDS in combination with Epstein-Barr virus (EBV) infection, or taking immunosuppressive medications after organ transplantation [In this case report, we describe an unusual case of PHL in a middle-aged Chinese woman who was asymptomatic with no immunosuppressive disorders, no history of hepatitis or other liver disease, and no history of immunosuppressive medication use. After a successful laparoscopic partial hepatectomy, the patient has an excellent prognosis.A 46-year-old Chinese woman consulted a physician in our department for an intrahepatic mass incidentally detected by an abdominal ultrasound (US) during her annual physical examination. After a 7-cm hypoechoic mass in the right lobe of the liver was identified and confirmed, the patient was admitted to our hospital for further investigation and treatment of the hepatic lesion. She reported no immunosuppressive medication use and no history of liver disease or surgery.No mass and discomfort and no signs of other clinical symptoms were detected during the abdominal examination. Hematological and serum biochemical profiles were within normal ranges. Tumor markers including alpha-fetoprotein (AFP), carcinoembryonic (CEA), carbohydrate antigens 199 (CA199), and carbohydrate antigens 125 (CA125) were also normal.Further investigation of the hepatic lesion with computed tomography (CT) revealed a slightly hypodense 6.5 × 7.2 cm mass in the right lobe of the liver with heterogenous enhancement of arterial phase, and prolonged enhancement through portal venous phase and the lesion Fig. a, b, c. As the CT imaging was inconclusive, further evaluation with magnetic resonance imaging (MRI) as well as US-guided fine needle aspiration (FNA) biopsy of the tumor for pathological examination was recommended. However, the patient preferred an operation without additional preoperative assessment of the lesion.In view of the benign features of the hepatic lesion and in accordance with our patient’s choice of treatment, we carried out laparoscopy . A 12-mm optical trocar at the umbilicus as well as three other trocars was used. Two 12-mm trocars were used through the epigastrium and right upper abdomen. A 5-mm trocar was used through the right abdomen near the anterior axillary line. After a laparoscopic exploration and US, a solid 6.5 cm × 7.0 cm × 7.5 cm mass was clearly located in the segment 6 of the liver and outwardly protruding from the liver surface  the tumor originates from the hepatic mesenchymal tissue; and (2) there are no primary tumors elsewhere in the body. However, despite this clear criteria for identifying this rare type of intrahepatic tumor, a successful preoperative diagnosis of PHL is challenging, mainly due to imaging features being similar with other benign hepatic tumors as well as a lack of specific characteristics to guide physical and laboratory examinations , 8, 23.Several common imaging patterns have been identified in PHL patients. On US scans, PHL appears as heterogenous hypoechoic nodules , 18, 20;Of the reported PHL cases in the literature, Sousa and colleagues achieved an accurate diagnosis of PHL in a healthy middle-aged woman by undertaking an imaging-guided fine needle aspiration (FNA) and a 18G tru-cut liver biopsy of the tumor tissue . Sadler After a postoperative pathological examination was carried out on the biopsy specimen, the pathological features were noteworthy. A benign smooth muscle tumor containing the mesenchymal tissue with clear margins was visualized. Positive staining for SMA, which is observed in most reported PHL cases and is a hallmark of PHL, was confirmed in this case. Moreover, positive staining for desmin and H-caldesmon, as observed in some reported PHL cases , was alsIn this case, given the benign features of the hepatic lesion, which usually signifies treatment with surgery  as well In conclusion, the imaging and pathological features of the patient should be added to previously reported aspects of this disease. Moreover, although PHL is extremely rare, it should still be considered a possibility. Surgical intervention is effective in treating PHL.Additional file 1:Data of Patients. (XLSX 10 kb)


Pheochromocytoma is a rare benign tumor of the adrenal gland. A select few cases may be malignant, and metastatic cases are exceedingly rare. It often presents with symptoms of catecholamine excess, such as sweating, palpitations, headaches, and characteristic paroxysmal hypertension. Due to its diffuse symptoms, it is difficult to diagnose and is often diagnosed late. We describe the unique case of a 44-year-old female patient who presented with uncontrolled hypertension and vomiting, accompanied by lower back pain. She was diagnosed with malignant pheochromocytoma with multiple metastases to the lungs, vertebrae, scapulae, and skull. Because of the advanced state of her disease, the patient was started on treatment with the chemotherapeutic combination of cyclophosphamide, vincristine, and dacarbazine. However, she had a complicated hospital course and died because of aspiration pneumonia and sepsis. Pheochromocytomas are tumors of chromaffin cells present in adrenal glands. In 1905, Poll described the tumor as a dusky (pheo) colored (chromo) tumor (cytoma), and hence brought about its name ‘pheochromocytoma’ . Owing tA 44-year-old lady presented to the emergency department with vomiting for four days and uncontrolled hypertension. Blood pressure was poorly controlled (230/130 mmHg) due to the erratic use of antihypertensives over the past 25 years. She also had lower back pain, managed by non-steroidal anti-inflammatory drugs (NSAIDs). Her review of systems was only significant for chronic renal insufficiency and a past history of liver abscess.On examination, she was afebrile but hypertensive, with a blood pressure of 180/100 mmHg and a pulse of 160/min. She was alert and oriented to time, place, and person. The respiratory and cardiovascular examination yielded no findings; however, on abdominal examination, there was right upper quadrant tenderness on palpation. Her liver and spleen were not palpable.Lab investigations of the patient were as shown in Table The abdominal ultrasound revealed a 10.3 x 9.6 x 6.7 cm heterogeneous cystic lesion in the right lobe of the liver. A computed tomography (CT) scan of the chest and abdomen showed that the suspected liver mass was actually an 11.3 x 8.0 cm heterogeneous mass in the right adrenal gland with a normal liver and spleen Figure -3. The cOvarian and gastrointestinal pathologies were ruled out; however, lactate dehydrogenase (LDH) was elevated (1080 IU/L). The patient was tested for 24-hour urine vanillylmandelic acid (VMA), which was significantly high at 175 mg . She was investigated for the possibility of endocrine syndromes, such as multiple endocrine neoplasias (MEN) I or II; however, her parathyroid hormone levels were within normal limits at 37.30 pg/mL and an ultrasound of her thyroid gland showed no focal lesions. Thyroid stimulating hormone (TSH) and calcitonin were within normal limits.Her blood pressure was controlled using α- and β-blockers. A biopsy of the left acetabular lesion was positive for cytokeratin AE1/AE3, chromogranin A, and neuron-specific enolase (NSE) antibodies, consistent with the diagnosis of metastatic pheochromocytoma. Due to the extent of her disease, excision of her primary lesion was not done, and she was started on chemotherapy with cyclophosphamide, vincristine, and dacarbazine. Her clinical course was complicated with febrile neutropenic episodes, and she died three months later, secondary to aspiration pneumonia and sepsis.Pheochromocytomas are tumors of chromaffin cells, originating embryonically from neuroendocrine cells. Chromaffin cells are found concentrated in the adrenal gland, which explains why pheochromocytomas occur there most frequently . About 9Pheochromocytomas are also associated with other endocrine tumors, as seen in syndromes such as MEN I, MEN II, von Hippel Lindau disease, and neurofibromatosis type 1. They can present with pancreatic tumors, parathyroid hyperplasia, and/or thyroid cancer. It has also been linked to mutations in the gene for succinate dehydrogenase (SDHD) subunits, rearranged during transfection (RET), and many other genes, which are autosomal dominant in nature .The incidence of pheochromocytomas is 2-8 per million people. Of these cases, about 10%-15% turn out to be malignant and only a further 10% metastasize -4. ObserDue to the rarity of this tumor, there is limited data available regarding the presentation and management of malignant pheochromocytomas. While some centers practice surgical interventions, such as open laparotomy and regional lymphadenopathy for local disease, studies are now looking into chemotherapy and radiotherapy as alternatives . AccordiSutinib, a tyrosine kinase inhibitor, was approved in 2006 to treat renal cell carcinoma and neuroendocrine tumors. It works by reducing hypoxia-induced factor (HIF) transcription factors, which have been associated with increased cell growth and angiogenesis. They are present in high concentrations in cells with germline mutations, such as VHL and SDHD; mutations that are heavily associated with pheochromocytomas .Regardless of advances being made in forming innovative and effective treatments for pheochromocytoma, the prognosis remains poor, as most cases are identified after metastasis has occurred and the disease has advanced significantly. Malignant pheochromocytoma remains a rare tumor that has a complicated and difficult road to recovery. We recommend the publication of more data in the form of case reports and case series along with the treatments employed at centers worldwide so that a standardized evidence-based protocol can be devised for the management of patients with this condition and the prevention of complications.


Cystic lymphangioma of the parotid gland is an uncommon congenital lymphatic malformation. Its occurrence in patients of advanced age is infrequent. Patients usually present with painless soft swelling, often having experienced a long duration of symptoms. Lymphangioma among the salivary glands frequently involves the parotid gland. When evaluating cystic lesions of the parotid gland, cystic lymphangioma should be included in the differential diagnosis in addition to Warthin’s tumor, branchial cyst, cystic pleomorphic adenoma, and cystic mucoepidermoid tumor. Ultrasonography (USG) and magnetic resonance imaging (MRI) are useful in diagnosing cystic lymphangioma and help to identify the lesion. Fine needle aspiration cytology (FNAC) may show lymphocytes, salivary epithelial cells, and rarely, endothelial cells. FNAC is often inconclusive; this was the case in our investigation of the cystic lesion presented here of a 50-year-old woman who presented with a slowly growing swelling and a dull aching pain over the right parotid region for the past two years. On examination, there was a non-tender, cystic swelling of 5×5 cm in the right parotid region causing lifting the earlobe. There was no cervical lymphadenopathy or any facial nerve palsy associated with the swelling. USG of the parotid gland revealed a cystic lesion in the superficial lobe of the parotid. Results of FNAC performed on the lesion were inconclusive. The patient was posted for surgery and the cyst was excised. Final histopathology of the lesion gave the diagnosis of cystic lymphangioma of the parotid gland. The patient was kept under follow up for six months to watch for any local recurrence, but none occurred. Cystic lymphangioma is a benign lesion consisting of multiple lymphatic spaces. Lymphangiomas are benign lymphatic malformations most frequently observed in the pediatric age group and, uncommonly, in the elderly population . The heaA 50-year-old post-menopausal female presented to the outpatient surgical department with complaints of a slowly growing swelling and a dull aching pain over the right parotid region for the past two years. She had no past history of trauma, surgery or infection of the right parotid. On examination, there was a non-tender, cystic swelling of 5×5 cm in the right parotid region causing lifting of the earlobe. The swelling became more prominent on clinching the teeth. The swelling was not fixed to the skin or any underlying structures. Examination of the oropharyngeal and facial nerves showed no abnormalities. There was no cervical lymphadenopathy.Routine blood tests were within normal limits. Ultrasonography (USG) of the parotid gland revealed a cystic lesion measuring 5×6 cm involving the superficial lobe of the right parotid gland. Fine needle aspiration cytology (FNAC) performed on the lesion was inconclusive.The patient was posted for surgery. Intra-operatively, it was discovered that she had a multiloculated cyst arising from the superficial lobe of the right parotid Figure .The cyst was excised in toto. The patient recovered well post-operatively. The histopathological examination found the cyst wall had a flattened outlining. The cyst wall had fibrocollagenous and proteinaceous material along with scattered lymphocytes and macrophages Figures -3.There was serous salivary gland tissue along with some adjacent cyst wall suggestive of lymphangioma of the parotid gland Figure .The patient was kept under medical surveillance for six months to watch for any local recurrence, but none occurred.Lymphangiomas are benign developmental abnormalities of the lymphatic system . During Lymphangioma occurs in the head and neck region most commonly, accounting for about 90% of cases. Among those found in the head and neck region, the posterior triangle of the neck is frequently involved. Other less commonly reported sites include axilla, shoulder, chest wall, mediastinum, abdominal wall, and thigh. Men and women are equally likely to be affected. Most cases are congenital and 90% present within the first two years of age . It is rUSG of a lymphangioma will typically show a multicystic, hypoechoic lesion with thin walls . ComputeThe cyst may present for a long duration without any symptoms. Complications of the cyst include the risk of infection or hemorrhage leading to the effects of compression on the facial nerve and/or cyst rupture. There are no reported cases of malignancy associated with cystic lymphangioma .Conservative treatment can be safely offered to elderly patients exhibiting no symptoms. Though spontaneous regression of the lymphangioma is a rare phenomenon that has been reported in the literature, typically treatment is necessary for adult patients . AspiratSurgical options to consider are enucleation and superficial or total parotidectomy. Surgically, the cyst should be approached with a preauricular incision. Meticulous dissection is needed for complete excision of the cyst. If there is inadequate tumor excision, the rate of recurrence may be high, ranging from 10% to 38% [Lymphangioma is an uncommon congenital lymphatic lesion that uncommonly presents in adults. Most patients are asymptomatic. When symptoms do occur, the lymphangioma requires intervention. USG is recommended for initial non-invasive imaging that leads to a diagnosis. To evaluate the extent of the lesion, MRI is the method of choice. The use of FNAC is often inconclusive, as was seen in our case. Surgical excision of the lesion is often required in the elderly. A definitive diagnosis can be obtained from a final histopathology.


Although extremely rare, sarcomas including malignant peripheral nerve sheath tumors should be considered in the differential diagnosis of sino‐nasal tract lesions. Long‐term cure is possible through definitive operative management followed by adjuvant therapy. Although extremely rare, sarcomas including malignant peripheral nerve sheath tumors should be considered in the differential diagnosis of sino‐nasal tract lesions. Long‐term cure is possible through definitive operative management followed by adjuvant therapy. We present a case report of a malignant peripheral nerve sheath tumor of the nasal cavity and paranasal sinus in an African American female with 13 years of follow‐up. The patient underwent resection of the tumor with operative pathology revealing an intermediate grade malignant peripheral nerve sheath tumor with close margins. She subsequently received adjuvant radiation to a total dose of 50.4 Gy using intensity modulation radiation therapy (IMRT). Although extremely rare, sarcomas including MPNSTs should be considered in the differential diagnosis of sino‐nasal tract lesions. Long‐term cure is possible through definitive operative management followed by adjuvant therapy.Sarcomas of the head and neck region are relatively rare entities, accounting for only 1% of all malignancies in that region.22.1A 47‐year‐old African American woman presented to the clinic on July 2006 with a 1‐year history of left nasal obstruction and intermittent epistaxis. Her past medical history was significant for hypertension, hyperlipidemia, and coronary artery disease all of which were appropriately managed. She had no history of prior malignancy or immunosuppression or neurofibromatosis.2.2She underwent computed tomography (CT) scan of the sinuses which revealed a left nasal mass measuring 3.4 × 3.1 × 2.4 cm with associated thinning of the medial orbital wall, nasal septum, and medial wall of the maxillary sinus. A biopsy of the mass was obtained and reported as a MPNST, intermediate grade. Tissue staining was positive for S100 but negative for EMA, AE1/AE3, and Desmin .After review at multidisciplinary head and neck tumor board, she underwent adjuvant radiation therapy to the postoperative bed to a total dose of 5040 cGy in 28 fractions. A 7‐field IMRT treatment plan with daily image guidance was utilized in her treatment.Six months following the radiation therapy, she underwent lysis of synechiae that was causing obstruction of the left nasal cavity as well as submucosal resection of the bilateral inferior turbinate—pathology was benign. She also underwent debridement of her craniofacial plate and drainage of an epidural abscess a few months later—again, the pathology from this procedure did not show any evidence of disease persistence or recurrence. She has since done well and continues on yearly surveillance with flexible nasopharyngolaryngoscopy and cross‐sectional imaging using MRI scan. Thirteen years after completion of her treatment, she demonstrates no clinical evidence of disease.3We conducted a literature review using the following key words: nasal sarcoma, sarcoma of the nasal cavity and paranasal sinus, head and neck sarcoma, malignant peripheral nerve sheath tumor, and MPNST of nasal cavity. MPNST was previously known as neurofibrosarcoma, neurosarcoma, or malignant schwannoma; so, we added these terms to the literature search, even though these terms are considered obsolete.The majority of the MPNSTs of the nasal cavity and paranasal sinuses reported thus far in the literature were not associated with neurofibromatosis. Most of the patients were managed with definitive surgery using a lateral rhinotomy or endoscopic approach depending upon the extent of their disease. Many of the patients received adjuvant radiation treatment but none received neoadjuvant radiation therapy. Adjuvant chemotherapy use was reported in two patients.44.1Head and neck cancer is common and is the sixth most common cancer globally. Among the different histologies of head and neck cancers, sarcomas are extremely rare, accounting for only ~1% of all the malignancies in the regionSarcomas are cancers arising from cells of mesenchymal origin. Sarcomas account for ~1% of adult malignancies with almost 13 000 new cases expected and 5000 deaths anticipated in 2019.4.2Malignant peripheral nerve sheath tumors are usually large lesions that may sometimes cause a fusiform expansion of the nerve from which they arise.Loss of H3K27me3 staining is observed in 50% of MPNSTs overall, including 30% of the low‐grade tumors and up to 90% of the high‐grade MPNSTs. About half of the tumors express S‐100 protein, typically in only a focal or patchy distribution, although the low‐grade MPNSTs arising in a neurofibroma may show more consistent staining. GFAP and SOX10 are positive in 30%‐40% of cases. CD34 is often positive, sometimes extensively. EMA may show focal staining, and focal desmin expression is not uncommon.4.3Early diagnosis is the key to successful treatment, leading to longer survival. There are no screening guidelines available for nasal cavity mass lesions. A clinical diagnosis of mass lesion in nasal cavity should be confirmed by biopsy. MRI with and without contrast of the head and neck is recommended as it more accurately determines the relationship of the tumor with the surrounding neurovascular bundles and muscles, and thus will assist in surgical and radiation treatment planning.4.4The differential diagnosis for nasal cavity masses includes nasal polyps, mucoceles, Schneiderian papillomas, and malignancies.4.5In the new American Joint Committee on Cancer (AJCC), eighth edition, the staging for head and neck sarcomas has been changed.4.64.6.1The definitive management of sarcomas of the head and neck is surgical resection with appropriate margins.4.6.2Radiation treatment can be considered pre‐ or postoperatively for sarcoma treatment—each approach with its own pros and cons. The potential benefits of pre‐operative radiation include lower radiation dose, shorter treatment course, smaller treatment fields, and potential downstaging of the tumor.The role of pre‐operative radiation treatment in head and neck sarcoma is not well studied. In a report from Princess Margaret Hospital, O’ Sullivan et al reported that pre‐operative radiation treatment to 50 Gy was well tolerated and provided a high rate of local control. They also reported lower rates of major wound complications as compared with extremity sarcomas (20% vs 35%). There are few case reports on pre‐operative radiation for HN sarcomasExternal beam radiation treatment (EBRT) is most commonly used in the treatment of sarcoma. The accepted pre‐operative dose is 50 Gy, and a postoperative boost may be considered if the margins are positive. The boost treatment can be delivered using EBRT, brachytherapy, or intra operative radiation therapy (IORT).4.6.3The role of concurrent chemotherapy with pre‐operative or postoperative radiation treatment is not well established in patients with head and neck sarcomas. Pre‐operative chemoradiation has been used for high‐grade, high‐risk extremity sarcomas and appears to improve local control and overall survival, but has significant treatment‐related toxicity as well.4.7Patients with neurofibromatosis 1 (NF1) are at higher risk of developing MPNSTs in other areas as well as gastrointestinal stromal tumors (GIST). Hence, they need closer monitoring so that any malignancy can be identified early; whole‐body MRI scans can be considered.5Malignant peripheral nerve sheath tumors (MPNSTs) of the nasal cavity and paranasal sinuses are extremely rare entities due to a combination of rarity of the type of the cancer and its rarity at the location cited. Even though the incidence is extremely rare, sarcomas should be considered in the differential diagnosis for sino‐nasal tract lesions. Long‐term cures are possible through definitive operative management followed by adjuvant treatment(s) depending on tumor grade and margin status.None declared.All authors contributed to implementation, monitoring, and research on described methodology.Institutional review board, University of Mississippi Medical Center.Not applicable.


Entamoeba histolytica is a well-known cause of infectious colitis, it has a worldwide distribution. Presentation ranges from mild diarrhea to occasionally frank dysentery and may spread to involve extra intestinal sites such as the liver, lung, and other organs, in the form of amebic abscesses.Herein, we report a case of amebic pseudotumor wherein the diagnosis was revealed after 2 months of diarrhea.Colonic amebiasis, may rarely form a segmental mass called amebic pseudotumor in patient untreated or inadequately treated during the course of proven amebic colitis.Due to the rarity of colonic amoebic pseudo tumor it is usually discovered incidentally during surgical interventions.However if discovered earlier it responds well to medical treatment and usually resolves within few weeks.So surgical intervention is reserved for complications of this entity manifested by fulminant colitis or colonic perforation. Despite its global distribution, it is more common in developing countries with populations at risk in widespread regions, particularly in the tropics and subtropics. Its presentation ranges from mild diarrhea to occasionally frank dysentery and may spread to involve extra intestinal sites such as the liver, lung, and other organs, usually in the form of amebic abscesses, particularly liver abscesses. Years after the last episode of dysentery, localized infection of the colon may, rarely, form a segmental mass, called an “ameboma,” in patients untreated or inadequately treated during the course of proven amebic colitis. The diagnosis of amebomas is difficult if the clinical picture of amebic colitis is unclear. We present a rare case of amebic pseudotumor wherein the diagnosis was revealed after 2 months of diarrhea.The work in this case has been reported in line with the SCARE criteria .2A 51-year-old male patient presented with acute abdominal discomfort with postprandial abdominal distention, associated with diarrhea of 2 months duration. He had no weight loss, melena, loss of appetite, and no other gastrointestinal symptoms. His family history was unremarkable. Physical examination revealed slight tenderness in the right iliac fossa, where a large mass was palpable. The result of the blood tests including complete blood count, electrolytes, BUN, creatinine, liver function tests, amylase and lipase were unremarkable; biochemical parameters including tumor markers (Ca19.9: 20 U/ml (nl <37 U/ml) and ACE: 1 ng/ml (<5 ng/ml)) were within the normal limits. Parasitology and bacteriology stool examinations showed normal findings.A computed tomography scan of the abdomen showed marked concentric wall thickening of the terminal ileum and cecum, and an ascending colon tumor measuring 8 × 8 cm, with lumenal narrowing at the level of the hepatic flexure . The tumWhile awaiting results and with a high index of suspicion of an amebic pseudotumor, treatment was initiated with metronidazole (1500 mg/day). Three days after initiation of treatment, the symptoms disappeared; repeated colonoscopy following the improvement of symptoms showed normal large bowel up to 12 cm in the ileum. The treatment was continued for 2 weeks and a repeated abdominal scan showed total disappearance of the tumor.3Entamoeba histolytica. It was first seen in 1878 but first described in 1903. E. histolytica is a unicellular protozoan organism, which is characterized by motility via pseudopod extension. Seven protozoan species in the genus Entamoeba infect humans, but not all of them are pathogenic. E. histolytica is the primary pathogen; non-pathogenic species  are impE. histolytica. Transmission of E. histolytica is by the fecal-oral route. Infection starts with ingestion of the cyst of E. histolytica from fecally contaminated food or water. The cysts are susceptible to heat (temperature >40 °C), freezing (temperature <−5 °C), and drying and remain viable in a moist environment for 1 month [While endemic in large regions of the tropics, amebiasis also occurs sporadically in the temperate climates of developed countries, most commonly in immigrants, travelers, refugees, aboriginals, residents of penal and mental institutions, and in male homosexuals. Humans are the only known host of the parasite  1 month . The cys 1 month .E. histolytica infection develop tumorous, exophytic, cicatricial, and inflammatory masses known as “amebomas’’ as an uncommon complication of invasive amebiasis. Amebomas result from the formation of annular colonic granulation tissue at single or multiple sites, usually within the cecum or ascending colon [Rarely, patients with long-standing ng colon . The tisng colon . Other sAmebomas may cause obstructive symptoms. Alternating diarrhea and constipation, weight loss, and low-grade fever may be seen. In endemic areas, cramping lower abdominal pain and a palpable mass suggest the diagnosis. The differential diagnoses include Crohn’s disease and appendiceal abscesses in younger individuals, and colon cancer and diverticulitis in the elderly.Rarely, colonic ameboma may be accompanied by amebic liver abscesses and may be misdiagnosed as metastatic carcinoma of the colon. Endoscopic evaluation yields a definitive diagnosis in about 66% of cases; biopsy specimens may be required to distinguish the lesion from carcinoma or a large adenoma ,6.Because cecal ameboma is a rare condition, it is often discovered only at laparotomy. It responds well to pharmacologic therapy and usually disappears within a few weeks after treatment. Surgical intervention may be required if complications such as fulminant amebic colitis and colonic perforation occur.In the absence of the clinical picture of amebic colitis, as in the present case, diagnosis may be difficult. Only a few cases of ameboma have been reported to date. In all reported cases, cecal ameboma was diagnosed when surgery was performed for a preliminary diagnosis of acute appendicitis, carcinoma, or lymphoma, or after histopathologic evaluation of a colonic mass discovered unexpectedly during surgery ,8.4In summary, colonic amoeboma is a rare complication of invasive amoebiasis and the management of this amebic pseudotumor is a rather surgical or intravenous antiparasitic agents. The equivocal clinical symptoms that differentiate invasive amebiasis from Crohn disease and even colon cancer may be controversial.Discerning amebic pseudotumor from other pathology by endoscopy with biopsy and serology bring crucial information. Since most surgeons are probably to confront few case, recognition of this pathology is a must.No potential conflict of interest relevant to this article was reported.There are no sources of funding for this research.Not applicable. The study is exempt from ethical approval in our institution.Consent has been obtained from the patient. No identifying details have been used in the article.E CHOUILLARD: study concept, and final approval. G Doghman and E Chahine treated the patient. E Chahine and R Baghdady wrote the first draft of the manuscript. L El khoury, N El kary, and C Chahine wrote the final draft of the manuscript, MA Chouillard photo editing, K SAFA in editing manuscript. All authors read and approved the final manuscript.Not available.CHAHINE E.Not commissioned, externally peer-reviewed.


Cemento-osseous dysplasia is a benign fibro-osseous lesion of the tooth-bearing region of the jaws with a periodontal ligament origin. It appears predominantly in Black and Asian middle-aged females. Its importance is that it could mimic a periapical lesion in the early, translucent stage.In this report a rare case of familial cemento-osseous dysplasia is presented: a 50-years old Caucasian woman with labial paraesthesia and radiological translucency around the roots of the mandibular incisors and the first molar teeth. The lesion around the first molar was diagnosed as periapical granuloma and a root canal treatment was carried out. The diagnosis of florid cemento-osseous dysplasia and the treatment plan based on two- and three-dimensional radiographic examinations were certified histologically after surgical removal of the lesion. We screened the family members - including the patient’s mother, daughter and son - and identified a periapical version of cemento-osseous dysplasia in the daughter. Our case highlights the difficulties of differential diagnosis of cemento-osseous dysplasia and other periapical pathologies. The inconsistencies in the present classification of cemento-osseous dysplasia are also discussed with a proposal for a different classification based on new aspects that would be very helpful in setting up a correct treatment plan.Differentiation of endodontic and non-endodontic origin of radiolucency and distinguishing it from anatomical landmarks by appropriate clinical evaluation and using vitality testing can give an opportunity to prevent unnecessary endodontic treatment.The current categories of cemento-osseous dysplasia classification do not cover the early stage of a hereditary florid form of cemento-osseous dysplasia.Instead of anatomical location of the lesion, clinical and genetic features may be recommended as parameters of cemento-osseous dysplasia classification. Cemento-osseous dysplasia (COD) is an uncommon fibro-osseous lesion of the jaws with a periodontal ligament origin –3, whichA 50-year-old Caucasian female visited the regional dental office due to uncertain pain in the right mandibular region. No significant diseases were mentioned in the anamnesis. The patient was diagnosed with gingivitis, and treated with a non-steroid anti-inflammatory drug and oral rinsing with chlorhexidine. The condition of the patient did not improve significantly. When she returned a week later, she had no alleviation, but labial paresthesia on the right side of her lip. As the cause of the new symptom remained unidentified, she was referred to the oral surgery group. Initially, the paraesthesia affected only the right side of the lower lip, but by this time it had spread to the skin of the right side of her chin. The oral surgeons decided to extract the lower right wisdom tooth, but the labial paraesthesia still persisted. Since there was an extended composite restoration in the lower right first molar, and translucency around its apical region was visible, the lesion was diagnosed as periapical granuloma. The lesion on tooth 46 was not close to the mandibular canal; this can be seen on Fig. The root canal treatment was carried out on the lower right canine in a single-visit treatment using local anaesthaesia. We explored the entire root canal length using a size #15 hand instrument. The working length was determined using an apex locator, , then the length was also confirmed with radiographic imaging. Following the length determination, the root canal was shaped using Wave One  rotary instrument. The root canal was obturated using guttapercha and AH Plus sealer  with lateral condensation technique. Glass ionomer cement  was then applied to seal off the access cavity, while the permanent restoration was done.We prepared an intraoral mucoperiostal flap using an L-shaped incision and the surgery was carried out by using a surgical microscope .We opened up the buccal cortical bone using a surgical bur, thereafter we removed the lesion surrounding the apex of the root. The root apex was resected and a retrograde root canal filling was placed using mineral trioxid aggregate .The area of the lesion was augmented using gentamicin impregnated BoneAlbumin . We seeked to lower the chance of osteomyelitis occuring with the use of gentamicin. Sutures were then carefully placed to achieve tensionfree closure of the flap for optimal healing.The 19-year-old Caucasian woman is the daughter of the first patient. CBCT showed a radiolucent lesion around the root of the lower right incisor Fig. . She is Pulp tests and periapical pathology diagnoses were made by authors on teeth 33,32,41,43 with the use of percussion, palpation and sensibility test.Panoramic radiograph and CBCT scans of the first patient showed radiolucent lesions located in the periapical bone, specifically on lower incisors and canines – in the premandibular, and in the right molar region of the mandible with radiopaque parts showing the lesions inside Figs.  and 2. TFigure The removed tissue pieces contained both connective tissue and calcified areas. In the calcified area, beside the irregular trabecular – lamellar bony formations, oval and globular cementum-like structures were present. In the non-calcified area connective tissue was found and connective tissue filled out the centre of another bony sample as well. No elements or remnants of a capsule were visible. The histological diagnosis was cemento-osseous dysplasia Fig. .Fig. 7HiCOD is a sporadically occurring benign lesion in the tooth-bearing areas characterized by fibrosus dysplasia  .FamiliaThe condition is usually asymptomatic, discovered in routine panoramic radiographs, and, in most cases, no treatment is necessary. Apart from certain cases of the florid form, lesions have limited growth potential. The progress of the disease can be divided into three stages: osteolytic, mixed and matured osteogenic .In radiologic imaging COD can easily be confused with inflammatory periapical processes. The typical appearance is a mineralized area visible within the radiolucent lesion. The lesion usually goes through a maturation process, which results in an increasing number of radiopaque areas, until finally a no longer growing radiopaque area with a lobular, ginger root-like appearance remains. In the mixed and densest stage, a radiolucent border separates it from the surrounding healthy bone , 18.Histologically, all forms of COD have similar appearance; the lesion is not surrounded by a capsule, and, in the early, osteolytic stage it consists of fibrotic tissue rich in cells and vessels, from which cement-like deposits are absent. As the maturation progresses over time, cement-like formations and irregular trabeculae appear. In the final osteosclerotic stage, these structures connect to each other, and few cellular elements are visible , 19.Differential diagnosis should be made between COD and the different forms of periodontitis in order to avoid unnecessary endodontic interventions , 20. In fibrosus dysplasia – the distinction may be based on the differences of the mineralized matrix, the significant face asymmetry and the developing malocclusion. COD has recently been differentiated from cemento-ossifying fibroma, where the histological image is similar, but the lesion is encapsulated and clearly separated from the surrounding healthy bone tissue. The option of cementoblastoma also occurs – it always connects to the root apex and is also a tumour [chronic sclerosing osteomyelitis, differentiation may be made based on the lack of inflammatory signs [Distinguishing from Paget’s disease may also cause problems in the early stage. The microscopic image of Paget’s shows the characteristics of fibro-osseous dysplasia . COD maya tumour . In the ry signs , 25, 26.Surgical treatment is limited for patients with severe clinical symptoms including pain and paraesthesia, those with expansive growth of the lesion, and candidates for dental implantation at the affected area , 19.Terminology of COD has varied over the years. These changes depend on whether the focus is on the origin or the clinical presentation. In the latest WHO classification  three clIt connects to the root apex region of the premandibular teeth, affects one or more teeth and is usually asymptomatic. It often leads to a false diagnosis, which may cause unnecessary intervention , 27.It is linked to one tooth, appears in the molar region in the tooth-bearing or edentulous area .The term was introduced by Melrose  who descfamilial gigantiform cementoma is mentioned as the other expansive form of osseous dysplasia, which also shows autosomal dominant inheritance [In the previous publication of the WHO  familialeritance . This tyeritance . In the eritance .expansive and non-expansive, and within the non-expansive group a distinction between florid, focal and anterior mandibular form should be made. Finally, the expansive osseous dysplasia should be divided into familial and non-familial groups [Just like some authors, such as Noffke places emphasis on the fact that the nomenclature should reflect the real nature of the lesion and recommends a different classification that takes both the clinical and biological characteristics into account. According to Noffke’s experience, the epicentre of all lesions was in the periapical region, but none of them was related to the surface of the tooth root: therefore, she suggests that the word “cementum” should be omitted. In her opinion, the term “periapical cemento-osseous dysplasia” is also unnecessary, as the other subgroups also originate from the periapical region. Based on the growth potential she has proposed the following classification: l groups , 33.Raubenheimer, Noffke: “Dividing the OD’s in non-expansive-  and expansive subtypes. This division provides clear guidelines on management, as the approach to the treatment of the expansive group is surgery and the non-expansive types require no treatment unless infected” [The importance of our case is that it is a rare hereditary form of COD. Two regions were affected in the mother, the anterior and the right posterior regions. The diagnosis of COD was confirmed by histology. Based on the clinical characteristics, the case was classified as florid COD. However, if we examine only the daughter, then the diagnosis would be periapical COD, because the pathology developed in the anterior region only. As familial inheritance was described associated only with the florid form, we must classify the second patient as belonging to the florid group according to the present classification. This inconsistency raised the possibility that the periapical and focal form could in fact be the initial or unifocal manifestation of the florid COD , 34, 35.nfected” . It is bnfected” –3, so weCemento-osseous dysplasia is a rare benign fibro-osseous disease of the jaws associated with vital teeth and generally no need for intervention, but follow-up is recommended. The differential diagnosis between the early stage of this fibro-osseous lesion and periapical inflammations and cysts is difficult to make but it is very important in order to avoid unnecessary endodontic treatments. On the other hand, we are faced with the problem that the current categories do not cover the early stage of a hereditary, possible florid form of cemento-osseous dysplasia. Familial occurrence of COD is very rare, and the previous reports found exclusively the florid subtype in all family members. In contrast, in the present report cemento-osseous dysplasia diagnosed in the mother and her daughter were of different subtypes. Our cases attract attention to the fact that the age range given in the literature is a mean calculated based on the time of recognition of the disease, and thus does not always follow the dinamics of the pathogenesis. Due to the fact that in the preliminary stages COD resembles periapical inflammation, therefore very few people diagnose it as COD. It is pertinent to control family members as well, and if a lesion is present make them aware of the implications.


Small bowel evisceration through the vagina is a rare surgical emergency that requires urgent surgical intervention because of the risk of developing acute small bowel ischemia. We present a case of a 91 year old female presenting with acute small bowel evisceration with majority of her small bowel visible outside the vagina. The bowel wall was edematous requiring emergent laparotomy and reduction of bowel with repair of the vaginal vault. The patient did not require bowel resection. Transvaginal small bowel evisceration is uncommonly described in the literature. Rare cases are reported in elderly, post-menopausal women who have undergone hysterectomy. Multiple approaches to surgical management including laparoscopic, open abdominal, transvaginal as well as combined approaches have been described. Perineal herniation must be kept in the differential in elderly post-hysterectomy patients with sudden onset of abdominal pain with urgent surgical intervention advised. Transvaginal small bowel evisceration is a rare but potentially life-threatening emergency requiring urgent surgical intervention to prevent its morbidity and mortality. The risk factors for this presentation include advanced age, enterocele, and previous transvaginal surgery. It usually presents with small bowel obstruction on imaging or diagnostic laparotomy showing a small bowel loop herniating through the vagina . Rarely,We present a case of a 91 year old female with a history of hypertension living independently who presented with sudden onset of severe abdominal pain described as sharp and at an intensity that she had never experienced before. She also reported that she felt she ‘had opened her bowel as the trousers felt heavy’. She had associated light-headedness. The patient’s detailed history showed that she did not have constipation or a coughing episode that would increase the intra-abdominal pressure. She had undergone a laparoscopic hysterectomy and oophorectomy for ovarian cancer a year ago and was on hormonal treatment with the last Computed Tomography (CT) scan showing no evidence of disease.In the emergency room, the patient's blood pressure was 185/75 mmHg, heart rate was 95 per minute sinus rhythm and temperature of 37.8 celsius. She required intravenous analgesia and fluid resuscitation. On examination, her abdomen was distended and tender in the supra-pubic area. Perineal exam showed large prolapse of small bowel with at least 200 cm of bowel visible outside the vagina, the loops appearing edematous and the mesentery dusky and ecchymotic with signs of impaired venous return  because of bowel necrosis which can eventually lead to death.