A polyp is defined as a mass of the mucosal surface that protrudes into the lumen of the gastrointestinal tract. Neoplastic epithelial polyps are classified histologically as either benign adenoma or malignant carcinoma. The colonic polyps that most commonly present in children occur sporadically and individually and are of the juvenile type; they are most frequently associated with painless rectal hemorrhage (which is the most common symptom). Adenomatous polyps are similar to other nontumoral polyps, and it is very rare for children to have symptoms other than rectal bleeding. This report describes two rare cases of polyps in pediatric patients. An 11-year-old girl presented with tubulovillous adenoma and a 13-year-old boy with tubular adenoma; both patients complained of rectal hemorrhage as well as anemia and abdominal pain. Epithelial adenoma is a tumor that is rarely found in adults or children. Colonoscopic perforation and biopsy are mandatory for establishing a definitive diagnosis and avoiding medical mismanagement. Polyp is a tumoral mass that protrudes into the lumen of the digestive tract. Histologically, colorectal polyps may be classified as epithelial or nonepithelial and neoplastic and nonneoplastic type .Most epithelial polyps in children are classified as nonneoplastic, single, and sporadic. Juvenile polyps are the ones more commonly found in children and are reported to account for 84% to 97% of pediatric cases of polyps. They occur most commonly in children 2 to 6 years of age and are slightly more frequent in males than in females –6.Other types of nonneoplastic epithelial tumors include hyperplastic and inflammatory polyps. Some studies report that the combined prevalence in both men and women is 10% , and somThere is little tendency for recurrence in any type of nonneoplastic epithelial tumors, and their progression to malignancy is virtually nonexistent , 9. TheiThe presence of dysplasia in cells of this type of tumor differentiates it from the nonneoplastic types. The dysplastic changes include nuclear hyperchromasia, abundant mitosis, and loss of polarity, and the tumors are categorized from low- to high-grade based on the severity of these changes. If the tubule formation is more than 75%, the tumor is categorized as tubular adenoma, and if the villous component is more than 75%, the tumor is called villous adenoma. If the content of villous and tubule is 50% it is called tubulovillous adenoma .Adenomas are capable of progressing to malignancy, the process of which requires 7 to 10 years on average. Rectal polyps may occur in children who have polyposis syndromes, including the adenomatous or hamartomatosis syndromes [All these familial polyposis syndromes may predispose the patient to malignancy , 8, 9. CPolyps of the colon, whether single or multiple, sporadic or familial, or neoplastic or nonneoplastic, will manifest with abdominal cramping and pain, mucous diarrheal stool, rectal prolapse, and (in long-standing cases) anemia , 4.These symptoms, however, may be found in other disorders such as bacterial or amoebic dysentery, ulcerative colitis, and other inflammatory conditions. Colonoscopy with biopsy will distinguish between these disorders .The first patient was a 13-year-old boy who presented with symptoms of mucous diarrheal stool, cramps, and fresh blood discharge as well as hypochromic microcytic anemia that had started 4 to 5 months earlier .The patient had no history of polyposis syndromes or adenocarcinoma of the digestive tract or of any family history of breast tumor, ovarian tumor, or brain tumor. The colonoscopy revealed a sessile, cauliflower-shape, deformed polypoid mass in the rectum with the appearance of an adenocarcinoma. The patient underwent surgery, and the tumor was removed. The surgery reported a polyp measuring 5 × 4 × 3 cm located at 3 cm along the pectinate line. Specimens were obtained from II, III, and VI o'clock positions. Microscopy showed the hyperplastic structures of the tubular glands standing back-to-back on an inflammatory and vasculated background. The cells contained enlarged, elongated nuclei and lost polarity, with increased chromatic density, prominent nucleoli, and abundant mitosis. Some parts of the polyp were ulcerated. However, there was no sign of invasion to the submucosal tissue, and a diagnosis of tubular adenoma was established Figures  and 2.The second patient was an 11-year-old girl with hematochezia (passage of fresh blood from the rectum) that had begun 6 months earlier. The clinical history included no mention of any polyposis syndrome in the patient's family. αFP), which were normal. Colonoscopy revealed ulcerating and scaring in certain areas of the rectum as well as a sessile , sedimentation, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alpha fetoprotein  cauliflower-shaped masses at 4 cm along the pectinate line, raising the suspicion for adenocarcinoma. Pathologic finding diagnosed tubular and tubulovillous adenoma. The aim of this report was to emphasize the importance of hematochezia in children and the need for colonoscopy. A complete and thorough examination of the patient will help to prevent errors in diagnosis that could lead to catastrophic results for the patient.


Behcet’s disease (BD) is a chronic immune-mediated, inflammatory disorder which may affect a number of different systems . Neurological manifestations are present in 5–10%, and gastrointestinal tract involvement in 10–15% of cases. The simultaneous involvement of two systems, neurological and gastrointestinal tract, is very rare and represents the aim of our case report.We describe a case of a 12-year-old girl with neurological  and gastrointestinal tract  involvement and with a history of recurrent oral aphthosis; therefore, according to both International Criteria for Behcet’s Disease (ICBD) and Paediatric Behcet’s Disease criteria (PEDBD) the diagnosis of BD was confirmed.This case report is one of the few described in literature with simultaneous involvement of the two systems, neurological and gastrointestinal tract, in paediatric BD. The diagnosis is really difficult because there is no specific diagnostic test. We think that our clinical case should help clinicians to suspect a BD with an unusual onset. Behçet disease (BD) was first described by the Turkish dermatologist Hulusi Behçet in 1937 as a syndrome with oral and genital ulcerations and ocular inflammation . It is dA 12-year-old child was admitted to our Unit after 2 weeks of persistent symptoms of headache, nausea and abdominal pain. Physical examination revealed stiff neck, left oculomotor paresis, left facial nerve paresis, left hemiparesis; laboratory tests showed a neutrophilic leukocytosis, thrombocytosis, increased C-reactive protein and a raised erythrocite sedimentation rate. Ophthalmological exam and fundus evaluation showed a bilateral papilledema and retinal vasculitis with loss of visual acuity. Brain computed tomography (CT) scan was performed and was normal. A brain magnetic resonance imaging (MRI) confirmed papilledema and showed a mild inversion of the optic papilla on the optic disk on both sides, with prominent subaracnoid space around the optic nerves, and a partially empty sella turcica. These findings appeared compatible with a condition of Pseudotumor cerebri (PTC) Fig. . HistoloThis clinical case demonstrates that BD is not a rare clinical entity in the paediatric population. Neurological involvement affects 5–10% of patients, is quite common in adults, and rarely occurs in children and adolescents , 12. It Although there is no specific diagnostic test for BD, diagnostic clinical criteria are available. Rheumatologists and gastroenterologists are mainly involved in the diagnosis and management of this disease. We believe that the report of this clinical case can be useful to paediatricians to make an appropriate differential diagnosis between BD and CD.


Melanoma is a tumor that virtually involves any tissue and commonly metastasizesto the heart. It is usually not diagnosed because of the absent/nonspecificcardiac signs and symptoms. Herein, we present a case of a 41-year-old manwithout any cardiovascular risk factor, admitted to the emergency room withchest pain, diagnosed with a myocardial infarction. Due to the presence of amass adjacent to the mitral valve on the cardiac ultrasound examination, causingmitral regurgitation, the patient was referred to surgery. Pathological analysisof the excised specimens diagnosed the melanoma. The chemotherapy was startedand achieved a partial response. Cardiac metastases usually affect themyocardium, leaving the valves unaffected. In this case, the acute coronarysyndrome was the first manifestation of the malignant melanoma. We highlight thehigh level of suspicion needed in these cases. It commonly metastasizes to the heart (40-45% of thecases), but usuallycardiac involvement is only diagnosed post-mortem because of the absent ornonspecific cardiac signs and symptoms. Secondary cardiac lesions are up to 100 times more frequentthan primary tumors. Althoughthey usually tend to remain silent, cardiac melanoma can cause serious mechanical(e.g. limitation of blood flow through the cardiac chambers)and electrical complications  and embolization of the tumor. In this article, we present a case of a patient admitted tothe hospital with chest pain and diagnosis of myocardial infarction, with aventricular mass identified. Histologic analysis after surgical resection revealedan occult metastatic melanoma.Melanoma is a tumor that arises from melanocytes or melanocyte precursors, and mayvirtually involve any tissue in the bodyA 41-year-old man without any cardiovascular risk factor presented to the emergencydepartment with a 2-hour history of atypical chest pain. The patient had no historyof previous episodes, or any other sign or symptom. At the examination, his pulsewas arrhythmic at 125 beats/min. The electrocardiogram showed atrial fibrillationand 5 mm-ST-segment elevation on the inferior derivations. Troponin T was 3628 ng/L.The patient underwent immediate coronariography, and a thrombotic occlusion wasvisualized in the right coronary artery , which wth intercostal space and peripheral cannulationcardiopulmonary bypass was established. On the epicardial adipose tissue darklesions were observed and excised for pathology. After left atriotomy, a large (2 x2 cm), round and solid mass adjacent to the papillary muscle  adjacent to the mitral valve, causing mild to moderate mitralregurgitation . The masy muscle  was causy muscle . AfteraPathological examination revealed that undifferentiated tumor cells infiltrated boththe papillary muscle and epicardial adipose tissue. The tumor cells were positive onthe immunocytochemistry to melan-A, vimentin, MITF and HMB45 , concluding that the tumor was amelanoma . The preThe patient's postoperative course was uneventful. He was discharged on the fourthpostoperative day and referred to the oncology department. The patient underwent athoraco-abdominopelvic computed tomography, which revealed metastatic disease to thelungs, liver, skin and lymph nodes. The patient started chemotherapy withvemurafenib and cobimetinib, to which he remains with partial response.. Mostcases are not diagnosed antemortem due to the silent clinicalcourse.Although cardiac involvement in metastatic melanoma is frequent, symptomaticpresentations are rare. Whensearching for a primary focus of the metastatic melanoma, mucosal  and ophthalmologic examinations are essential and must not bedisregarded.Most metastasis are located in the myocardium and valvular structures are typicallyunaffectedFew articles have been published reporting cardiac metastasis of malignant melanomawith unknown primary origin. In this case, the acute coronary syndrome was its firstmanifestation, since the patient had no history of previous mucosal and/or skinlesions or surgery.We highlight the essential high level of suspicion, since cardiac tumors should raisethe possibility of being a metastatic melanoma.


In view of the many white or predominantly white lesions of the oral mucosa it is a challenge for dentists to clinically identify a leukoplakia, being a potentially (pre)malignant lesion.Based on the available literature and experience of the authors the parameters of a clinical diagnosis of oral leukoplakia have been studied.A guide has been presented that should help dentists to establish a clinical diagnosis of leukoplakia as accurate as possible.Probably in most parts of the world dentists will need the help of a specialist for confirmation or exclusion of the clinical diagnosis of oral leukoplakia and for further management of the patient, including patient information. Key words:Oral diseases, oral leukoplakia. Oral leukoplakia, being a predominantly white change of the oral mucosa, is the most common potentially (pre)malignant lesion. It is a relatively rare disease with an estimated prevalence of less than 1%. Men and women are more or less equally affected. Oral leukoplakia rarely occurs in the first two decades of life and is much more common in tobacco users than in non-tobacco users. Leukoplakia may occur everywhere in the oral cavity and is often asymptomatic otherwise. The clinical diagnosis is primarily based on visual inspection and manual palpation. There are no other useful diagnostic aids for the clinical diagnosis.The histopathological findings in leukoplakia range from hyperkeratosis without epithelial dysplasia to various degrees of epithelial dysplasia and even carcinoma in situ, frank squamous cell carcinoma and verrucous carcinoma.The annual risk of malignant transformation of leukoplakia, if not malignant already at the first visit, is approximately 2%-3%. There are many, statistically somewhat useful, predictive factors of malignant transformation, such as the seize of the lesion, the clinical subtype, the oral subsite, and the presence or absence of epithelial dysplasia as assessed by histopathological examination, but these can not reliably be used in the individual patient. This also applies to numerous molecular markers that have been reported as predictive markers of malignant transformation.Spontaneous regression of leukoplakia is exceedingly rare. Surgical and non-surgical treatments have not been shown to be effective in preventing possible future malignant transformation .It is a challenge for the general dentist to be able to timely identify a leukoplakia. The most recent definition, formulated at a World Health Organization supported meeting, reads: “A white plaque of questionable risk having excluded (other) known diseases or disorders that carry no increased risk for cancer” . For useA clinical diagnosis or differential diagnosis of a mucosal lesion is the result of a number of parameters. The importance of each parameter varies according to the type of lesion. The parameters and their relevance with regard to the establishment of a clinical diagnosis of leukoplakia have been listed in Traditionally, leukoplakias are clinically subdivided in a homogeneous and a non-homogeneous variant. In homogeneous leukoplakia the lesion is uniformly white and the surface is flat or slightly wrinkled. In non-homogeneous leukoplakia there is a mixed white-and-red color (“erythroleukoplakia”); the surface may be flat, speckled or nodular. A separate variant of non-homogeneous leukoplakia is the wartlike, verrucous type. In case of a widespread presentation and depending on other criteria such as worsening along time, this type is referred to as proliferative verrucous leukoplakia. Non-homogeneous leukoplakias carry, statistically, a higher risk of malignant transformation.A list of leukoplakialike, well-defined predominantly white lesions and their main diagnostic criteria is depicted in The benign white oral mucosal lesions that may be encountered in genodermatoses should not be difficult to diagnose by the dentist, provided the patients have, indeed, disclosed their medical history. This partly also applies to the diagnosis of hairy leukoplakia although there are cases in which the patient is unaware of the underlying HIV infection or immunosuppressive state for other reasons. Another challenge is the diagnosis of white oral lesions as manifestation of the second stage of syphilis. Here, too, the patient may be unaware of the relevance of lifestyle aspects or may be reluctant to disclose these to the dentist. In such instances, a biopsy or another diagnostic aid, particularly serology, may be required.In some of the listed entities it is questionable whether or not to consider them as a well-defined entity and not as leukoplakia. This particularly applies to “epithelial peeling”  and glasIn case of a possible etiologic factor, such as tobacco use or the presence of an amalgam restoration in close contact with the lesion, the dentist may await the result of the elimination of such factor for no longer than a somewhat arbitrarily chosen period of three months, provided the patient is asymptomatic otherwise. In the presence of symptoms a biopsy should be taken first. In case of a provisional diagnosis of cinnamon-induced lesions or Sanguinaria-associated keratosis it may be difficult to prove the causitive role of such agents.In the absence of possible etiologic factors or lack of response to the elimination of such factors, referral to a specialist is recommended, both for assessment of the final diagnosis, the further managment of the patient and the provision of adequate patient information.Probably the most common diagnostic challenge is the distinction between leukoplakia and non-reticular lichen planus and lichenoid lesions from. An example is shown in figure As a general rule each leukoplakia should be biopsied irrespective of the presence or absence of symptoms, the clinical subtype (homogeneous or non-homogeneous), the seize and the oral subsite. In extensive leukoplakias the taking of multiple biopsies (“mapping”) may be considered. Probably in most parts of the world dentists are not trained to perform incisional or excisional biopsies; therefore, referral to a specialist for such procedure is advised.The treatment policy, particularly in leukoplakias that are otherwise asymptomatic, is an issue of debate in view of the questionable effectiveness of whatever type of surgical or non-surgical treatment .The present definition of leukoplakia has been worded in a negative way by excluding well-defined predominantly white lesions. Therefore, the accuracy of the clinicians’ diagnosis very much depends on their diagnostic capabilities. The use of artificial intelligence may become of great help in the near future to support the dentist in obtaining a correct clinical diagnosis of leukoplakia, similar as has been demonstrated in the clinical diagnosis of melanoma of the skin by the use of dermascopic pictures . IncorpoThe various terminologies that are being used in relation to the many predominantly white lesions of the oral mucosa, as shown in table II, are somewhat confusing, particularly at the level of the dentist-general practitioner. For instance, hairy leukoplakia is clearly a misnomer since 1) it is a well-defined entity, 2) it is not a potential (pre)malignant lesion, and 3) the lesion is not always “hairy” clinically. The category of so-called keratotic lesions is another source of confusion. Some of these lesions, such as reversed smoking keratosis and tobacco pouch keratosis are indisputily potential (pre)malignant and are not always characterized histopathologically by (hyper)keratosis. Admittedly, the risk of malignant transformation in predominantly white lesions of the alveolar ridge  and the buccal gingiva  is lower than for similar lesions located on the borders of the tongue or the floor of the mouth. It seems questionable, however, to remove such lesions from the category of leukoplakia. Of course, it is well recognized that avoidance of the term leukoplakia for lesions which carry a low risk of malignant transformation is an attractive option with regard to patient information.The distinction between leukoplakia and non-reticular lichen planus seems to be the biggest challenge in the clinical diagnostic process. Theoretically, these lesions may occur simultaneously or may perhaps transform in time in one another, e.g. lichen planus transforming into leukoplakia.The recommendation that each leukoplakia should be biopsied may be somewhat questionable at the specialists’ level, but seems a safe advise for dentists.In case of a clinical diagnosis of leukoplakia or where such diagnosis is part of the differential diagnosis the dentist-general practitioner is advised to look for consultation with a specialist both for confirmation or exclusion of the diagnosis and the further management of the patient. Also patient information about leukoplakia can probably better be provided by a specialist than by a general practitioner who is rarely confronted with this lesion.


Beside hepatocellular carcinoma, metastasis, and cholangiocarcinoma, the imaging findings of other relatively uncommon hepatic lesions are less discussed in the literature. Imaging diagnosis of these lesions is a daily challenge. In this article, we review the imaging characteristics of these neoplasms.From January 2003 to December 2014, 4746 patients underwent liver biopsy or hepatic surgical resection in our hospital. We reviewed the pathological database retrospectively. Imaging of these lesions was reviewed.Imaging findings of uncommon hepatic lesions vary. We discuss the typical imaging characteristics with literature review. Clinical and pathological correlations are also described. Primary hepatic lymphoma consists only of 1% of the extranodal non-Hodgkin lymphoma, and is defined as the one involving only the liver and perihepatic lymph nodes within 6 months after diagnosis. Combined hepatocellular and cholangiocarcinoma (cHCC-CC) shares some overlapping imaging characteristics with both HCC and cholangiocarcinoma because of being an admixture of them. Angiosarcoma is the most common hepatic mesenchymal tumor and is hypervascular in nature. Inflammatory pseudotumor is often heterogeneous on ultrasonography and with enhanced septations and rims in the portovenous phase after contrast medium. Angiomyolipoma (AML) typically presents with macroscopic fat components with low signal on fat-saturated magnetic resonance imaging (MRI) and presence of drainage vessels. Intraductal papillary neoplasm of the bile duct (IPNB) is thought of as a counterpart to the pancreatic intraductal papillary mucinous neoplasm. Most of the IPNBs secrete mucin and cause disproportional dilatation of the bile ducts. Mucinous cystic neoplasm (MCN) contains proteinaceous and colloidal components without ductal communication and characterizes with hyperintensity on T1-weighted imaging. Other extremely rare lesions, including epithelioid hemangioendothelioma and inflammatory pseudotumor-like follicular dendritic cell sarcoma, are also discussed. Hepatoblastoma and mesenchymal hamartoma, mostly in children, are also briefly reviewed as well.It is important for radiologists to be familiar with the typical imaging features of the uncommon hepatic neoplasms. If imaging findings are not typical or diagnostic, further biopsy is required. Among them, the most common primary malignant tumors are hepatocellular carcinoma (HCC) and cholangiocarcinoma. Metastasis is another common lesion as well. There are many literatures discussing these common hepatic lesions, and each of them has its own imaging characteristics. Beside the above tumors, other relatively less encountered lesions are often difficult to be diagnosed solely by imaging and are also less discussed. We review these uncommon hepatic lesions and describe the typical imaging findings with pathological correlation. Physicians should be familiar with these lesions to make a correct diagnosis.From January 2003 to December 2014, 4746 patients underwent liver biopsy or hepatic surgical resection in our hospital. The most common hepatic neoplasms in our hospital were hepatocellular carcinomas , metastatic tumors , and cholangiocarcinomas . The uncommon hepatic neoplasms include lymphomas, combined hepatocellular and cholangiocarcinomas, angiosarcomas, inflammatory pseudotumors, hepatoblastomas, angiomyolipomas, intraductal papillary neoplasms, mucinous cystic neoplasms, epithelioid hemangioendotheliomas, mesenchymal hamartomas, inflammatory pseudotumor-like follicular dendritic cell sarcoma, and hydatid cyst. We retrospectively reviewed the available images, including ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and angiography images. After extensively reviewing the literature in English, the typical imaging findings, clues to differential diagnosis, clinical manifestations, and final pathologic correlation are discussed.2Ethical approval was waived for our study because the results for publication only involved deidentified imaging.2.1We used the pathological database in our hospital. Retrospectively, the pathological diagnosis of the liver lesions from January 2003 to December 2014 was collected and reviewed. A total of 4746 patients underwent liver biopsy or surgical resection were included.2.2The most common pathologically diagnosed hepatic lesions in our hospital were hepatocellular carcinoma (2176 cases), metastatic tumors (1490 cases), and cholangiocarcinomas (457 cases). After exclusion of these common lesions, the relatively uncommon lesions were lymphomas (33 cases), combined hepatocellular and cholangiocarcinomas (26 cases), angiosarcomas (22 cases), inflammatory pseudotumors (22 cases), hepatoblastomas (13 cases), angiomyolipomas (13 cases), intraductal papillary neoplasms of the bile duct (11 cases), mucinous cystic neoplasms (8 cases), epithelioid hemangioendotheliomas (5 cases), mesenchymal hamartomas (2 cases), inflammatory pseudotumor-like follicular dendritic cell sarcoma (1 case), and hydatid cyst (1 case).2.3Two board-qualified experienced gastrointestinal radiologists reviewed the provided images through our picture archiving and communication system (PACS). Ultrasonography, angiography, contrast-enhanced studies, including CT and MRI, were reviewed. Typical or specific images of each lesion were selected.2.4The pathological panels of the above selected cases were reviewed and confirmed by 1 pathologist after radiologic review.33.1After careful selection of the characteristic images and an extensive literature review, a total of 4746 cases were included. Those without definite pathological diagnosis and with more than 1 pathological diagnosis in the same lesion are excluded. The number of these cases is 466. Different gender compositions of the enrolled uncommon hepatic lesions in our collected cases are listed in Table 3.2The typical imaging findings and brief clinical manifestations are listed in Tables 44.1Hepatic lymphoma can be either primary or secondary. Overall, hepatic lymphoma contributes about 8% to the focal hepatic lesions. The lymphoma nodules often tend to be multifocal and with prominent lymphadenopathy not confined to perihepatic nodes. The most secondary hepatic lymphoma is non-Hodgkin lymphoma.Secondary liver involvement of the lymphoma is common. The liver is the third-most common abdominal organ with lymphoma involvement, following the spleen and gastrointestinal tract. PHL is defined as lymphoma involving only the liver and perihepatic lymph nodes without distant metastasis. A 6-month observation is often used in clinical settings for the distant metastasis after hepatic symptoms occur. Lei proposed that the clinical criteria of PHL exclude palpable lymph nodes, splenic, or bone marrow involvement. Many etiologic factors were described, yet the definite cause of the PHL remains uncertain. Hepatitis B virus (HBV), hepatitis C virus (HCV), the Epstein–Barr virus (EBV) in the posttransplant patients, and the human immunodeficiency virus (HIV) are statistically associated with the PHL. Gisbert et al reported that the prevalence of HCV infection in patients with B cell lymphoma (15%) is higher than in the general population (1.5%), suggesting a close association between HCV and B cell lymphoma. The symptoms of PHL are not specific, including typical systemic B symptoms or abdominal fullness.Primary hepatic lymphoma (PHL), in contrast, constitutes only less than 1% of the extranodal non-Hodgkin lymphoma. The hepatic lesions may be either multiple hypoechoic lesions or a solitary confluent hypoechoic mass  typically enhances arterially and tends to wash out in the portovenous phases. Capsular retraction and enhancement may also be present in typical HCC; these imaging characteristics are not seen in lymphoma. Hypovascular metastasis, most commonly originating from the colon or lung, often manifests as multiple hypovascular nodules with rim enhancement, similar to lymphoma. Generally, metastasis is less likely in a cirrhotic liver. Clinical history may aid in the differential diagnosis and sometimes biopsy is needed. Both pyogenic abscesses and fungal microabscesses can appear similar to lymphoma, and may need further clinical clues for differential diagnosis.PHL is treated with chemotherapy. Surgical resection is only preserved for selected patients with small and focal lesions. Since the most common entity of the PHL is diffuse large B-cell lymphoma, CHOP -based chemotherapy is most commonly used and with relatively low risk of disease recurrence.4.2 Allen and Lisa classified cHCC-CC into 3 categories. The first type is the separate type, also termed double cancer or collision tumor. The tumor consists of varying degrees of a combination of HCC and cholangiocarcinoma. Both the hepatocyte-derived and cholangiocyte-derived parts are separated. The second type is the combined type, or transition type, in which both HCC and cholangiocarcinoma grow contiguously yet independently. The third type is when both elements are almost indistinguishable from each other, termed mixed or intermediate type. Risk factors include cirrhosis, hepatitis B, hepatitis C, older age, and male gender.Combined hepatocellular and cholangiocarcinoma (cHCC-CC) is a rare entity. The incidence of this primary liver malignancy is about 0.4% to 14.2%.  than in cholangiocarcinoma, have been described.The major differential diagnosis of the cHCC-CC is the mass-forming cholangiocarcinoma. Both mass-forming cholangiocarcinoma and cHCC-CC have capsular retraction, bile duct dilatation, and peripheral rim enhancement. The shape of the former is more commonly lobulated due to the tendency to form satellite lesions when invading bile duct branches. reported that radical hepatic resection provides a better outcome for cHCC-CC. Reported prognosis varied. Most English literatures indicated poorer outcome of cHCC-CC, and some reported it as an intermediate prognosis between HCC and CC. Recurrent tumors of cHCC-CC are often hypovascular. Transarterial embolization is of limited role in the recurrent tumors, and radiofrequency ablation may be used. The use of chemotherapy remains controversial. Transplant is performed in selected patients, and the 5-year recurrence rate is 78%.,16Surgical resection is the treatment of choice when feasible. Yin et al4.3 The most common primary locations of angiosarcoma are the skin and breast. The exact etiology of the tumor is uncertain, although several environmental exposures, including thorium dioxide (Thorotrast), arsenic, vinyl chloride, and radiation, have been reported as risk factors.,21 The prognosis of angiosarcoma is poor, with the reported median survival of around 3.4 years. The clinical symptoms of angiosarcoma are nonspecific, such as abdominal pain, fatigue, or weakness. AFP is not elevated within most of the reported angiosarcomas. Surgical resection is usually performed only when the tumor is resectible. Adjuvant chemotherapy or radiation therapy is often applied, yet without significant survival benefits. Most angiosarcoma is not indicated for operation upon diagnosis, and palliative chemotherapy is then used. Transcatheter arterial chemoembolization (TACE) was been reported as one of the treatment options, regardless of intrahepatic metastasis.The primary angiosarcoma is the most common mesenchymal tumor in the liver, and makes up around 2% of the primary hepatic tumors.The solid mass of angiosarcoma is composed of spindle cell-formed disorganized vessels, creating a sinusoidal or cavernous space. Therefore, this hypervascular tumor typically demonstrates irregular vascularity on enhanced images Fig. . Spontan Recent reports indicate that centripetal enhancement is actually rarely seen in angiosarcoma, which aids in the differential diagnosis of angiosarcoma from hemangioma. In fact, the focal arterial enhancing areas, with less enhancement than the aorta, bizarrely shaped peripheral enhancement, and the tendency to be multifocal lesions of the angiosarcoma, decrease the possibility of the hemangioma. Hypointense internal septations may be observed on T2-weighted images. Slight elevations of the ADC level were reported.Dynamic images depict the arterial enhancement of the angiosarcoma well on both CT and MRI. A hypodense mass with some internal necrotic areas is observed on the precontrast CT scan. Peripheral enhancement without significant washout in the portovenous phases is the typical imaging feature.4.4 IPTs usually present with dominant spindle cell infiltrates and pathological IPTs usually present with various degrees of inflammatory cells. Tang et al reported that the IPTs are more common in young male adults, and often present with abdominal pain or fever; some cases are asymptomatic. The exact etiologies of the IPTs are uncertain. Risk factors, such as previous bile tract obstruction, infection, previous appendicitis, or underlying autoimmune disorders, have been described. Decreased tumor mass size, either spontaneously or after treatment with anti-inflammatory agents, was reported.,32 The regression of the tumor mass after treatment with anti-inflammatory agents may increase the likelihood of IPTs. Generally, the prognosis of IPT is favorable, and there were rare recurrences after surgical resection.The inflammatory pseudotumor (IPT) is synonymous with the inflammatory myofibroblastic tumor and was first described by Pack and Baker. Internal septations and calcification may be present. Ding et al described that IPTs had no enhancement in all phases after contrast injection in contrast-enhanced ultrasonography. The IPT masses typically show rim-like portovenous enhancement in CT imaging. An enhancement of the septations may also be observed. The various areas of delayed enhancement depend partially on the areas of fibrosis  with a low b value to differentiate IPT from cholangiocarcinoma because IPT demonstrates higher signal than cholangiocarcinoma. Some atypical IPTs may present with arterial enhancement, and are difficult to differentiate from hepatocellular carcinomas (HCCs). Since the imaging features of the IPTs share some overlapping characteristics with other primary hepatic malignancies, imaging diagnosis should only be made after the exclusion of these malignancies.As for the differential diagnosis, the major considerations are pyogenic abscess, metastasis, and peripheral cholangiocarcinoma. Patients with typical pyogenic abscesses might have infectious symptoms, such as leukocytosis or fever. Liquefied abscesses have typical central fluid-containing areas, which are different from the solid nature of IPTs. Peripheral cholangiocarcinoma might have the imaging features of a heterogeneous mass with delayed enhancement, and cannot be completely excluded solely by imaging. Kitajima et al4.5 Adult hepatoblastoma has been reported but is extremely rare.,40 Over half of the cases (68%) are diagnosed under the age of 2 and 90% of the cases are under 5 years of age. Male predominance has been reported. The clinical symptoms are usually abdominal fullness or jaundice. Elevated serum levels of AFP are seen in most cases. Ishak and Glunz classified the hepatoblastoma into epithelial, mixed epithelial, and mesenchymal types. By their names, the epithelial type is composed of fetal and embryonic cells and the mixed type is composed of mesenchymal and epithelial components as well.Heptoblastoma is the most common primary hepatic malignancy before 2 years of age. The peak incidence of the hepatoblastoma is around 6 months to 3 years.The imaging features of the tumor depend on the various degrees of the epithelial or mesenchymal components. Epithelial-type hepatoblastoma is typically homogeneous, and the mixed type has a heterogeneous appearance due to the presence of osteoid, cartilaginous, or fibrous contents. Amorphous calcification may be observed in mixed-type hepatoblastoma Fig. A and B. The major differential diagnosis of the hepatoblastoma is HCC. Both tumors cause AFP elevations and can have arterial enhancement. HCC is more commonly seen in a diseased liver after 5 years of age, whereas hepatoblastoma generally manifests in a cirrhotic liver before 5 years of age.Surgical resection is the treatment of choice. Yet, most of the hepatoblastomas are unresectible upon diagnosis. Neoadjuvant chemotherapy is applied to reduce the tumor size and most of them can then be treated with surgical resection. Systemic chemotherapy is used for those with disseminated presentation.4.6 Furthermore, the presence of hepatic AML is related to the presence of renal AML, and is more common in patients with germline mutations in TSC2 (9q34) than in TSC1 (16p13). AML is a benign entity, and rare malignant transformation has been reported. Although invasive growth of the tumor can occur, this pathological finding is not diagnostic of malignancy. Most patients with hepatic AMLs present with no specific symptoms. There are no reliable serologic markers to date.Hepatic angiomyolipoma (AML) is composed of 3 major components: thick-walled vessels (angio-), smooth muscle cells (myo-), and adipose cells (lipoma); the percentages of each component vary. Patients with tuberous sclerosis (TS) commonly develop renal AMLs, which have a tendency to hemorrhage. Hepatic AMLs, although uncommon, are also associated with TS complex. The angiomyomatous components of AMLs demonstrate arterial enhancement and the lipomatous components have with hypodense lipid attenuation without significant enhancement on CT. Overall, a heterogeneous enhanced mass is often observed. The degrees of fat components vary from 10% to 90%, and a cutoff value of minus 20 Hounsfield units (HU) by CT was used to determine the definite presence of adipose tissues.The typical hyperechoic lipomatous components may not be observed on ultrasonography. Therefore, hepatic AMLs are sometimes indistinguishable from common hemangiomas. Hepatic AMLs present with an inhomogeneous and hyperenhancing pattern in the arterial phase and prolonged enhancement in the later phases. Identification of the tumoral efferent veins toward the hepatic vein makes the impression more likely to be an AML.The macroscopic fat components present with low signal in fat-suppression images on MRI Fig. . Althoug4.7 The previously termed cystadenomas/cystadenocarcinomas with bile duct communication are now classified as IPNBs. Tumors with intraductal growth of the papillary fronds and fine vascular cores, such as some intraductal cholangiocarcinomas and papillary carcinomas, are also currently considered IPNBs. An IPNB is defined as a premalignant lesion and is subgrouped into intraductal papillary neoplasms (IPNs) with low-, intermediate-, or high-grade intraepithelial neoplasia and IPNs with invasive carcinoma. An oncogenic pathway of adenoma-carcinoma with KRAS activation and a loss of function of the tumor-suppressor genes TP53 and p16 has been postulated. Long-term survival may be achieved after complete resection. The IPNB is thought of as a counterpart to the pancreatic intraductal papillary mucinous neoplasm.Intraductal papillary neoplasm of the bile duct (IPNB) has been a distinctive part of biliary lesions in the WHO classification since 2010. reported different types of IPNB-related bile duct dilatation, including generalized, segmental and aneurysmal appearances. The disproportional bile duct dilatation of the aneurysmal or cyst-like IPNB refers to insufficient downstream biliary outflow due to the viscous nature of the mucinous secretion.IPNB occurs as either intrahepatic or extrahepatic neoplasms. The papillary or villous growth of the tumors in the bile ducts vary in degrees. Most of them secrete viscous mucin, causing bile duct dilatation. Lim et al Both CT and MRI have high sensitivities in the detection of the intraductal masses, and the use of MR cholangiography (MRCP) further depicts the dilatation of the bile ducts and the extent of ductal infiltration well. DWI may be beneficial in tumor detection and to determine its invasiveness.The imaging characteristics of IPNBs are soft tissue-attenuated tumor masses and variously degreed dilatations of the bile ducts Fig. . UltrasoAlthough IPNB is a disease spectrum ranging from benign lesion to malignancy, management based on this histological spectrum is not yet determined. Overall, a long-term survival may be achieved with complete resection.4.8 Cystadenoma and its malignant counterpart, cystadenocarcinoma, should be better termed “MCN with low-, intermediate-, or high-grade dysplasia” and “MCN with an associated invasive carcinoma,” as suggested by the latest edition of the WHO classification.Mucinous cystic neoplasm (MCN) of the liver, or previously known as cystadenoma, is one of the biliary benign entities. According to the WHO classification in 2010, mucinous cystic neoplasm is defined as a cystic lesion with epithelial origin in association with ovarian-type subepithelial stroma.The MCN is predominantly in females. The tumor contains variable degrees of proteinaceous and colloidal contents. Septations and compartments are typically present. Although malignant transformation exists, the presence of soft tissue attenuation does not always indicate malignancy. Its malignant counterpart, previously termed cystadenocarcinoma, may not be fully excluded solely by imaging.The imaging characteristics of the MCN include a well-defined margin with septations, hypodense fluid-containing components, and rare enhancement except for the mural nodules. Hemorrhage or calcification may be present. On MRI, T1 hyperintensity is observed due to its proteinaceous and colloidal contents Fig. . The purely homogeneous appearance of the simple cyst and hamartoma can lead to the correct diagnosis. Zen et al reported that the differential diagnosis between IPNB and MCN is important due to their different natures; IPNB tends to grow in connection with the bile duct, whereas MCN does not. MRCP depicts the relationship of the lesion to the bile ducts well and therefore aids in diagnosis.The differential diagnosis of the MCN with other benign cystic lesions is important. Other benign cystic lesions, such as simple cyst or biliary hamartoma, are sometimes treated by drainage to relieve the mass effect, whereas MCN needs resection to prevent recurrences.4.9 The peak incidence is at ages between 30 and 50 years old, and the disease more commonly affects females. It has been proposed that taking oral contraceptives or having contact history with vinyl chloride may increase the risk of HEHE. The most common clinical presentation of HEHE is abdominal pain, especially the right upper quadrant of the abdomen. About one-fourth of patients were asymptomatic initially. Hepatomegaly and weight loss are also common initial presentations. Lab data are not helpful in diagnosing HEHE. Alkaline phosphatase (Alk-P) may be elevated in some patients with HEHE, though it is a nonspecific marker.Hepatic epitheloid hemangioendothelioma (HEHE) is a rare entity of vascular origin, with an incidence less than 0.1 per 100,000 people per year. It is a low-grade malignant tumor that has an intermediate clinical outcome between benign hepatic cavernous hemangioma and malignant angiosarcoma.HEHE is diagnosed by pathologic examination. The histopathologic features of HEHE include mixed epithelioid and dendritic cells in a proliferative fibrous stromal background. Endothelial cells are stained positively by immunostaining markers, including antibodies for factor VIII-related antigen, CD31, or CD34 Fig. . The epi In the literature, multifocal involvement  (85%) is more common than unifocal involvement  and IPT-like FDC sarcoma was reported. Surgical resection of the tumor is the standard treatment; the use of adjuvant chemotherapy remains controversial.The inflammatory pseudotumor-like follicular dendritic cell (IPT-like FDC) sarcoma is an uncommon malignancy; the rare entity was first described by Selves et alA definite diagnosis of IPT-like FDC sarcoma is challenging, due to lack of reliable serologic markers, nonspecific symptoms, and nonspecific imaging features. The tumor appears as a well-defined, heterogeneous arterial enhanced mass without significant portovenous washout. Central necrosis or hemorrhage may be present Fig. A–D. Thes  should be fulfilled. All tumor cells show strong nuclear in situ labeling for EBV-encoded small RNAs (EBER), indicating a strong relation to EBV Fig. E–H.4.12Echinococcus tape worms. Human beings usually become infected by eating the eggs from contaminated food. The embryos then invade the bowel mucosa, and enter the liver parenchyma through portovenous flow.The presence of a hydatid cyst is due to the infection of  Intrabiliary rupture of the hydatid cyst can occur, and MRCP may help detect the connection of the lesion to the bile duct.The imaging appearances of the hydatid cyst range from unilocular-cystic to multilocular-cystic and partially calcified to completely calcified Fig. , dependi Collapsed parasite membranes may also be noted as linear structures within the lesion. The hydatid matrix is typically a hypointensity in T1-weighted images and a hyperintensity in T2-weighted images (Fig. A hypointense rim on both T1- and T2-weighted images may be observed on MRI, which indicates the collagen produced by the host on the periphery of the pericyst. This thin hypointense rim is recognized as the “frontline” between the host and the parasite antigen.ges Fig. C and D.5It is important for radiologists to be familiar with the typical imaging features of the uncommon hepatic neoplasms. If imaging findings are not typical or diagnostic, further biopsy is required.


Lymphatic malformations are benign anomalies derived from the abnormal development of lymphatic channels. Usually asymptomatic, they can cause compression on adjacent structures or present acute complications (bleeding or infection). Small asymptomatic lesions can be conservatively managed since the possibility of spontaneous regressions is described, while symptomatic lesions require active management. Less invasive therapeutic options are now preferred instead of surgery . However, there are not uniform therapeutic protocols.We present the case of a term newborn with an abdominal cystic lymphangioma extending from the umbilical to the right inguinal area, reaching the medial surface of the right tight. Despite its large dimensions, which classically request surgical management, the patient was by chance asymptomatic, and the mass did not determine compression on the surrounding organs. Therefore, conservative management was tried, and a close clinical and radiological follow-up was started. This approach permitted a spontaneous regression of the mass and to avoid major surgical intervention.Our purpose is to underline the possibility of conservative management of the major multicystic masses and to focus on less invasive therapeutic options, like sclerotherapy, oral therapy, and laser therapy. They consist of dilated lymphatic channels forming multiple cysts. LMs can be classified into macrocystic, microcystic, or mixed cystic lesions. The overlying skin is normal, but it can also have a bluish hue or contain pink vesicles, that can appear similar to capillary malformations, angiokeratomas, or angiomas. Cutaneous manifestations are often the main clue that reveals the presence of further complex underlying condition, with deeper lesions involving different tissue planes.Macroscopically, they can give rise to the formation of masses of different sizes that depending on their location can be variably appreciated through deep palpation as soft, non-pulsatile, and painless masses.The cervicofacial region is most affected (48%). LMs can also be found in the trunk, axilla, and extremities (42%). The mediastinal and abdominal locations are rare (10%). Half of these lesions are typically present at birth and are often diagnosed prenatally. Nevertheless, 90% are diagnosed at 2 years old. Only a minority of cases cannot be detected due to their deep localization or absence of symptoms.Here, we discuss the case of a term newborn with an abdominal cystic lymphangioma, diagnosed through prenatal ultrasound screening, and its management.22.1A female caucasian baby was born by cesarean section at 39 weeks of gestation to a 37-year-old mother. Family medical history was unremarkable. The pregnancy had a normal course until 32 weeks of gestation when an obstetric ultrasound (US) showed the presence of a cystic abdominal mass of about 3 cm in diameter, localized between the bladder and the umbilicus, which was suggestive of an urachal cyst without other structural alterations of the urinary apparatus. At birth, APGAR score was 9/10 and birth weight 3200 g.2.2At physical examination, a vascular lesion (4 cm × 4 cm) was detected in the right lower abdominal quadrant. The presence of a soft suprapubic mass was also appreciated, without alterations of the overlying skin. The patient was otherwise asymptomatic.The dermatologist confirmed the diagnosis of complex vascular malformation: it consisted in a venocapillary superficial lesion associated with multicystic lymphangiomatous lesions in the subcutaneous tissues, involving the right lower abdomen and the homolateral inguinal area and tight. Also, a small angiomatous lesion of the right first toe with no dysmetria of the affected limb was detected at physical examination.2.3Table 2.4On the second day of life the abdominal US was performed, and no congenital urachus abnormalities were detected, but rather some hypo-anechoic cysts of about 3.1 × 0.5 cm that extended from the umbilical to the right inguinal area, reaching the medial surface of the thigh, with a little extremity just above the homolateral knee Fig. .2.5As surrounding abdominal organs were not involved and compressive complications on adjacent organs were not present, given the possibility of spontaneous regression of the lesion, a “wait and see” strategy was adopted, and the patient was closely monitored through a multidisciplinary follow-up program.2.6A size reduction and progressive discoloration were macroscopically appreciated, and progressive regression was confirmed through serial US evaluations.Sixteen months later, the presence of a new cystic formation (3.6 cm × 2.1 cm × 1.9 cm) with irregular morphology and corpuscular content was detected at the US scan, referable to an intracystic bleeding. Since the patient was asymptomatic and no other complications were detected, the conservative approach was carried on.During the following months, some millimetric angiokeratomas developed.Almost 3 years later, the cystic lymphangioma appears significantly reduced in extension, and the cysts now have a maximum diameter of 0.8 to 1 cm. No alterations or compressions of adjacent organs were present. The patient is 3 years old, has normal neurodevelopment and does not have any abdominal disturbances. No compression on adjacent organs nor dysmetria at the inferior limbs is present.,5However, given the risk of bleeding or ulceration of the superficial angiokeratomas, pulsed dye laser seems now the best treatment choice.3Intra-abdominal cystic lymphangiomas are a rare type of lymphangioma. Their clinical manifestations are highly polymorphic. A large tumor volume usually appears as a palpable mass which can cause abdominal pain (in older patients), an increase in waist circumference and, in severe cases, acute abdominal emergencies like intestinal obstruction or volvulus. The two most common acute complications are bleeding and infection. Bleeding is typically intra-cystic with a consequent bluish discoloration of the LM, swelling, and pain. Infection can progress rapidly to sepsis and hospitalization is often necessary to provide an adequate intravenous antimicrobial therapy.As associated manifestation, superficial angiokeratomas can develop which can easily bleed or ulcerate under mechanical stimuli.Ultrasound examination is an excellent modality to detect these lesions, and it is the gold standard to monitor their clinical evolution. The computed tomography (CT) and MRI scanner are a valuable initial diagnostic tool. However, MRI is the most informative exam. Histologic confirmation of LMs is rarely necessary.The goal of LM management and treatment is to maintain the functionality, to preserve the aesthetic integrity, and to control associated symptoms. Given the large heterogeneity of LM, therapy should always be individualized. It consists in the complete resection of the lesion but presents a high complication rate  without guaranteed success. In multicystic/combined LMs, resection is usually incomplete since lesions involve several tissue planes, with a recurrence rate of 35% to 64%, which decreases to 17% to 22% in case of total excision. For these reasons, surgical excision is reserved for selected cases such as well-localized and unicameral LMs for which it may result to be curative, obstructing masses, which compromise vital functions, complicated or symptomatic macrocystic/combined LMs unsuitable for sclerotherapy.Surgical excision has been historically considered the treatment of choice for macrocystic/unicameral LMs.,9–11Today, less invasive therapeutic options are preferred Table . Small aSclerotherapy has become the main therapeutic choice. It consists of US-guided percutaneous cysts aspiration and subsequent injection of a proinflammatory substance , which cause scarring of the cyst walls  production. It has been successfully used to treat vascular anomalies in children and newborn. Described side effects are mucositis, hypercholesterolemia, headache, elevation of transaminases, neutropenia.Case reports show that sildenafil can decrease LM size and alleviate associated symptoms.New surgical techniques have also been utilized in the treatment of LMs. Ultrasound-guided liposuction was shown to be efficient and has been used in conjunction with sclerotherapy to treat multicystic LMs better.,8In this clinical case, the patient had a voluminous multicystic malformation involving the abdominal subcutaneous tissues from the mesogastric region to the right inguinal area, reaching the medial surface of the homolateral thigh. In such extended and multicystic lesions, surgical excision is frequently incomplete, and this implicates high risk of failure and high recurrence rate. Moreover, special considerations have to be taken into account for the neonatal patient, for example, the risks related to total anesthesia and the need for mechanical ventilation, the risk of major blood loss, infections, and iatrogenic injury. Pain control is also challenging. The postoperative scar and deformity after removal of the LM should be weighted. For all these reasons, we would have considered surgery only in case of compressive, symptomatic or complicated masses, trying to postpone the intervention as much as possible.,20In our patient, the lesions did not involve primary structures and did not cause compressive complications on adjacent organs. This favorable situation permitted us to choose a conservative management (“watchful waiting”), hoping in the spontaneous regression of the cysts, as suggested by the recent literature.2 laser can achieve successful results, it has some disadvantages, such as the requirement of anesthesia and the risk of scarring. As reported in previous cases, pulsed dye laser is used to treat vascular lesions and lymphangioma circumscriptum with a lower risk of complication such as pigmentation or scarring.,5,22 For these reasons, we opted for pulsed dye laser to treat the cutaneous manifestations and prevent local complications.Since it was a complex malformation, a close clinical and radiological follow-up was needed. As we expected, serial ultrasounds showed a progressive reduction of the cysts. Bleeding occurred just once, with no other complications associated. The patient remained asymptomatic for almost 2 years, and then some millimetric angiokeratomas developed. Angiokeratomas are superficial vascular anomalies with a tendency to bleeding and ulceration as a consequence of mechanical or traumatic stimuli. At 3 years of age, the patients started to attend the nursery school, and some minimal bleeding occurred. To avoid major complications, we decided to consider a non-invasive treatment. Although COThis clinical case demonstrates that, if the mass does not compromise vital function or undergoes acute complications, a conservative approach is a reasonable choice in the management of large and complex LMs. This approach permits to take advantage of spontaneous regression in most cases and to consider less invasive therapeutic options later.


Hyaline ring granuloma (HRG) is an uncommon histopathologic finding of unsolved etiopathogenesis. According to the exogenous theory, HRG develops due to implantation of foreign material, most probably indigestible plant fragments. HRG is a comparatively rare condition in humans, mostly involving the oral cavity with very rare extraoral locations.An 1-year-old mixed-breed dog in good condition was presented for routine ovariohysterectomy. Disseminated HGR were accidentally found in the omental adipose tissue during surgery. Histopathology revealed the presence of ring-like hyaline structures surrounded by granulomatous inflammation including foreign body-type multinucleated giant cells. The histochemical examinations indicated the exogenous plant origin of the foreign material.The lesions were similar to the findings in humans with HRG. The definitive diagnosis remains largely based on histopathological examination supported by special histochemical stains. To the best of our knowledge, this is the first case of hyaline ring granuloma reported in a non-human species. Moreover, the omentum is an uncommon location for this condition. Candida glabrata (formerly Torulopsis glabrata). As the origin of these structures is still unsolved and it is important to use a uniform nomenclature to avoid controversies in diagnostics, the descriptive term ‘hyaline ring granuloma’ seems most adequate [Hyaline ring granuloma (HRG) is a rare inflammatory lesion with unresolved etiopathogenesis and being characterized histologically by the presence of hyaline rings and foreign-body giant cells –3. The fadequate . Non-expAn approximately 1-year-old mixed-breed female dog was presented at the Small Animal Clinic, Warsaw University of Life Sciences, Poland, for routine ovariohysterectomy. The dog had been adopted and dewormed, and had received its first vaccinations a few months before. On physical examination, the dog was in good condition with a body score of 4  and withHistochemical stains and polarized light microscopy demonstrated features characteristic of HRG similar to those reported previously , 16, 17.Omental HRG has only been reported in a woman, where a gastric ulcer with small perforations and passage for food particles into the omental space was suggested as the port of entrance . In the HRG should be considered in the differential diagnosis of omental thickening to avoid misdiagnosis and treatment , 23. In


We report a 58-year-old woman with a solitary type of nevus lipomatosus superficialis on the left proximal arm. To our knowledge, the occurrence of a solitary type of nevus lipomatosus superficialis on the arm has very rarely been reported. A perusal of the literature revealed but one case, to which we are going to add another one. Recognition of this clinical manifestation is important so that a proper diagnosis can be made. Nevus lipomatosus superficialis is a hamartoma characterized by ectopic mature adipose tissue in the papillary dermis. The condition was first described by Hoffman and Zurhelle in 1921 . We descA 58-year-old woman presented with a slow-growing multilobulated plaque on the left proximal arm of approximately 2 years' duration. The lesion was asymptomatic with no history of ulceration or discharge. There was no history of preceding trauma. The patient was otherwise in good health. Family history was noncontributory.Physical examination revealed a soft, skin-colored, multilobulated, nontender, well-defined, discrete, dome-shaped plaque on the left lateral proximal arm adjacent to the axilla . There wExcisional biopsy of the lesion showed islands of mature adipocytes in the papillary dermis, confirming the clinical diagnosis of nevus lipomatosus superficialis .Nevus lipomatosus superficialis is an uncommon condition. In a retrospective study, 8 cases were seen in an 11-year-period from 2001 to 2011 at the Department of Dermatology, Venerology and Leprology, Postgraduate Institute of Medical Education and Research in Chandigarh, India . In anotThe condition is usually idiopathic and the exact pathogenesis is not known . TheorieThe classical type is usually present at birth or appears within the first two decades of life . TypicalThe solitary type, on the other hand, often appears between the third and sixth decade of life and typically presents as an asymptomatic, solitary, yellowish to skin-colored, dome-shaped or sessile papule or nodule, as is illustrated in the present case . The lesAlthough the solitary type of nevus can develop anywhere on the body, the occurrence on the arm has rarely been reported; a perusal of the literature revealed only one case. The occurrence of the lesion on the arm may be more common than is presently appreciated. Recognition of this clinical manifestation is important so that a proper diagnosis can be made.


Osteochondroma and synovial chondromatosis are frequently reported benign bony and cartilaginous lesions. Osteochondroma is distinguished by a cartilage-capped bony exostosis on the exterior surface of the bone, whereas synovial chondromatosis is secondary to metaplasia and is characterized by multiple cartilaginous loose bodies within the synovium. We present an atypical case of synovial chondromatosis developing in a bursa secondary to an underlying osteochondroma of the proximal medial tibia in a child. It is extremely rare to see both these conditions occurring in one location simultaneously. Moreover, this association is an unusual occurrence in the pediatric age group. The patient underwent surgical excision of the lesions and the final diagnosis was confirmed on histology. Simulation to malignant degeneration is often observed and vigilant assessment of both lesions is essential to exclude the possibility of sarcomatous transformation in those who present with these conditions since clinical, radiological, and histopathological features may overlap. However, a proper preoperative distinction may prevent an unnecessary aggressive therapeutic approach, which stood true for our case. Synovial chondromatosis in a bursa may develop as a result of chronic friction from an underlying osteochondroma. It is suggested that the osteochondroma causes an inflammatory reaction within the adjacent tenosynovium, which, over the passage of time, leads to chondromatous metaplastic transformation and formation of secondary synovial chondromatosis -3.We present such a rare, histologically proven case of osteochondroma with secondary synovial chondromatosis simultaneously occurring in one location. This dual pathology is an unusual occurrence in the pediatric age group. Only a handful of case reports have documented this entity in adults, and, in most cases, the conditions were mimicking neoplastic degeneration of osteochondroma on imaging . In instA 15-year-old boy presented to our hospital with a bump over the medial aspect of the right leg for one year. The mass was painless at first, however, it started to increase in size, producing symptoms of discomfort for the last four months. His physical and systemic examination was otherwise unremarkable. Magnetic resonance imaging (MRI) was performed on clinical suspicion of a neoplastic mass. The scan revealed a pedunculated bony protuberance originating from the medial aspect of the proximal right tibia, measuring approximately 46 x 22 mm. It was demonstrating corticomedullary continuity with the underlying bone. The imaging features were consistent with an osteochondroma. A distinct cartilaginous cap was identified, which measured 2.5 mm in thickness . Multiple cartilaginous loose bodies were found within the cystic sac Figure .Two separate surgical specimens were sent for histopathological analysis. Sections examined from the bony lesion revealed normal bone with an outer layer that was the fibrous perichondrium and was continuous with the periosteum of the underlying bone. Within the cartilage cap, the chondrocytes were clustered. No evidence of a spindle cell component or atypia, necrosis, or mitosis was seen. Sections examined from cystic tissue revealed a cystic cavity lined with flattened cells with mild, nonspecific inflammation. It contained nodules of mature cartilage with a cut surface that was tan-white myxoid in appearance. The largest nodule measured 5 x 3 cm . Osteochondromas are often asymptomatic but can present with a painless swelling, protrusion, or bulge on the affected extremity. Two distinct clinical forms have been described, solitary or multiple osteochondromas [th to 5th decade of life) with a male preponderance. Synovial chondromatosis has been reported to occur in all synovial joints, including the temporomandibular joint. However, the knee joint is the most commonly affected [Synovial chondromatosis is a condition in which there is a formation of osteochondral bodies in the synovial cavity due to metaplasia of the synovium. This condition mostly occurs in adults  and MRI are vital to establish a diagnosis. On CT and MRI, osteochondroma characteristically shows continuity with the medullary cavity of the bone. On MRI, the cartilaginous cap shows an intermediate intensity on T1-weighted images and high signal intensity on T2-weighted images. Generally, it is thought that if the cartilaginous cap thickness is more than 2 cm on T2-weighted images, it is suspicious for malignant degeneration to peripheral chondrosarcoma .Classical imaging features of synovial chondromatosis include multiple intra-articular cartilaginous nodules/loose bodies with specific “ring-and-arc” chondroid mineralization and extrinsic erosion of bone on both sides of the joint . The MRIDespite the above-mentioned features, a diagnosis based on clinical and radiographic findings may sometimes be challenging because synovial chondromatosis adjacent to osteochondroma can often simulate a peripheral chondrosarcoma. Between 1% and 5% of solitary osteochondromas have been reported to undergo a malignant transformation to the peripheral chondrosarcoma. Additionally, there have been special cases described in the previous literature in which transformation from synovial chondromatosis to chondrosarcoma has also occurred. The prevalence has been reported to be up to 5%. -8. OsteoThe imaging features were quite distinctive in our case, thus sparing the patient from a more aggressive therapeutic approach, leading to a shorter postoperative recovery time and faster regaining of the full range of motion. However, overlapping imaging features include an extension into the nearby soft tissues, especially into the bursa, and extrinsic erosion of bone. These may be seen in both synovial chondromatosis and chondrosarcoma, which is why it is sometimes difficult to distinguish between the two . An MRI The true diagnosis is almost certainly based on the histology of the specimens. However, a pathological analysis of secondary synovial chondromatosis can sometimes lead to overdiagnosis of chondrosarcoma because there is a marginal difference between such benign cartilaginous lesions and low-grade chondrosarcoma . TreatmeOsteochondromas and synovial chondromatosis are common, benign bony and cartilaginous lesions; however, it is unusual to see both conditions in the same anatomic location simultaneously. This association is especially unusual in the pediatric age group, where synovial chondromatosis itself is rarely encountered. In instances where there is an abnormal calcified mass overlying an osteochondroma, the diagnosis is most often peripheral chondrosarcoma, but the possibility of benign synovial chondromatosis in an overlying bursa should always be considered in the differential diagnosis. Imaging modalities, such as CT and MRI, may help to establish the diagnosis; however, the final verdict is based on histopathology of the resected specimens.


A bezoar is a collection of indigestible material found in the alimentary canal, which can cause mechanical obstruction of the gastrointestinal tract. Phytobezoar is a variant composed of mostly plant material and indigestible fiber. Phytobezoar is a rare cause of small bowel obstruction (SBO) and happens more commonly in patients with risk factors predisposing to impaired gastrointestinal motility. We present a rare case of SBO secondary to phytobezoar in a 60-year-old female patient with type 2 diabetes. There was no prior history of any abdominal surgery. The abdominal computed tomography (CT) scan was inconclusive. Laparoscopy was found to be an effective diagnostic and therapeutic procedure in this patient. Small bowel obstruction (SBO) is routinely seen in surgical clinics and emergency departments. SBO is a common disease and has a few common etiologies such as adhesions (73.8%) and hernia 18.5%) [8.5% [1].Bezoars are classified according to the composition. The four types of bezoars are phytobezoar, composed of vegetable fibers and undigested fruit fibers; trichobezoar, composed of hairs; lactobezoar, made up of milk curd; and pharmacobezoar, composed of different kind of drugs . PhytobeDiagnostic laparoscopy has revolutionized the modern surgical practices and has a valid role in diagnosing the pathology in obstructed bowel without increasing morbidity, and it can be used not only as a diagnostic tool but can be used therapeutically as well. In this study, we present a case of SBO, which was diagnosed and managed through laparoscopy successfully when a computed tomography (CT) scan was unable to reach a diagnosis. In doing this, laparotomy was avoided.A 60-year-old type 2 diabetic female presented to the emergency department with a four-day history of generalized abdominal pain and absolute constipation. The pain was continuous and aching in nature and was relieved by taking prokinetics. She had a past history of on-and-off constipation, which resolved with laxatives. There was no history of vomiting, fever, preceding diarrhea, weight loss or dyspepsia. There was no significant past surgical history.An examination revealed a pulse of 94/min and BP 120/75 mm Hg. The abdomen was distended with sluggish bowel sounds. On deep palpation, there was mild generalized tenderness, but no sign of peritoneal or gall bladder inflammation was seen. A rectal examination revealed an empty rectum. She was managed in the emergency room on suspicion of acute abdomen. A nasogastric (NG) tube was passed and she was kept nil per os (NPO/nothing by mouth) and given intravenous (IV) fluids. The working diagnosis was sub-acute intestinal obstruction, which might have been due to colon cancer, pancreatitis, tuberculosis, or adhesions.She was further investigated and the laboratory workup showed hemoglobin (Hb): 12.0 g/dl, total leukocyte count (TLC): 6800, amylase: 34 U/L, lipase: 19 U/L, and normal electrolytes. Her HbA1c was found to be 13.5%. Abdominal X-rays showed distended small bowel loops with no air fluid levels. She was admitted for conservative treatment but her distension increased the next day. CT of the abdomen and pelvis with oral and IV contrast revealed transition level at mid-ileum or distal jejunum with dilated proximal bowel. There was no obvious mass or lymph node enlargement. There was mild mesenteric congestion and minimal ascites. The CT scan gave no clue towards the cause of intestinal obstruction.Given her history, physical exam, and laboratory investigations, a minimally invasive diagnostic laparoscopy were planned. The patient was taken to the operation theater. Through the infra-umbilical incision, a Veress needle was inserted and pneumoperitoneum was created with great caution. Laparoscopy confirmed the CT scan findings. There were dilated small bowel loops up to the mid-ileum level and a stricture causing partial obstruction with no obvious mass and collapsed distal bowel. This is shown in Figure A pathological bowel segment was brought outside through a small incision in the right iliac fossa. The stricture was causing partial obstruction. The bowel was opened for stricturoplasty and it revealed undigested phytobezoars causing obstruction. This is shown in Figure All undigested food particles were removed and extracorporeal stricturoplasty was done. This is shown in Figure The postoperation recovery was uneventful, and on close questioning, the patient gave a history of intake of “spinach“ before this episode. She was discharged home on the third postoperative day in stable condition and was advised to increase water intake, modify diet  and chew food properly.This case report signifies the role of laparoscopy in SBO due to phytobezoars, which gives an actual diagnosis with less morbidity as compared to laparotomy. A bezoar is a rare cause of SBO and can be difficult to diagnose and manage . There iTraditionally CT scans have been used to diagnose gastrointestinal bezoars. CT scans may demonstrate the bezoar as an intraluminal mass in the obstructed segment of the bowel. The mass may also appear mottled due to the presence of trapped air inside it . As seenIn recent times, laparoscopy has been used vastly in the diagnosis and management of small bowel obstruction due to experienced operators and increased availability. It can reveal the etiology of SBO well before the development of any serious complications, which in turn confers a favorable prognosis to the patient. As in our case, the patient underwent endoscopy immediately after the decompression of the gut and improved hydration status. The patient had an uneventful postoperative period with effective treatment of the SBO. Laparoscopy is a very safe and effective procedure with a strikingly lower rate of complications as compared to conventional laparotomy. Pathologies treated with laparoscopy instead of classic laparotomy incisions have shown to have a better postoperation outcome . The comPhytobezoars should be considered in the differential diagnosis of SBO, especially in patients who have significant risk factors for the development of phytobezoars. Laparoscopy is a safe and effective diagnostic and therapeutic procedure in patients presenting with SBO secondary to phytobezoar. There is a need to formulate proper guidelines regarding the diagnosis and management of SBO due to phytobezoars.


Introduction. Splenic tumor is usually found as an incidental finding on CT of abdomen. Traditionally, ultrasound (US) or computed tomography (CT) guided biopsies were employed for the purpose of sampling; however they have been reported to have a complication rate of 5.3%. Endoscopic ultrasound-fine needle aspiration (EUS-FNA) has been recently utilized for the purpose of sampling splenic tumors. In literature there are 7 reported instances where splenic lymphoma was diagnosed using EUS-FNA. We present a case of follicular B cell lymphoma of the spleen diagnosed using EUS-FNA. Case Report. 58-year-old female presented to her primary care physician for left upper quadrant abdominal pain for one week. Physical exam was significant for left upper quadrant tenderness. Her laboratory tests were within normal limits. She underwent CT scan of abdomen which revealed approximately 5 cm × 5 cm mass in spleen. EUS-FNA of the spleen revealed a large hypoechoic, heterogeneous, well-demarcated mass measuring 54.7 mm × 43.0 mm. Fine needle aspiration was performed, and the sample was submitted for cytology and flow cytometry. Flow cytometry revealed a lambda monotypic population of B cells displaying dim CD19 and CD10. Diagnosis of B cell non-Hodgkin low grade follicular lymphoma was made. Conclusion. Endoscopic ultrasound with fine needle aspiration is a very rare but safe, reliable method of diagnosis of splenic lymphomas. Splenic tumor is seldom encountered in clinical practice and usually it is found as an incidental finding on CT scan of abdomen. Lymphoma has been reported as the most common tumor involving the spleen . TraditiA 58-year-old female presented to her primary care physician for left upper quadrant abdominal pain of one week's duration. Pain was not associated with nausea, vomiting, hematemesis, hematochezia, or any changes in bowel movements. She had a past surgical history of cholecystectomy and hysterectomy. Physical exam was only significant for mild left upper quadrant tenderness. Her liver function tests, amylase, and lipase were all within normal limits. She underwent CT scan of abdomen, which revealed approximately 50 mm × 50 mm mass in spleen. She underwent EUS-FNA at our facility to sample the splenic mass.The endosonographic examination of abdominal aorta, celiac axis, and pancreas  was unremarkable. The examination of the spleen revealed a large hypoechoic, heterogeneous, well-demarcated mass measuring 54.7 mm × 43.0 mm . The masCytology revealed a monomorphic population of lymphoid cells of small size, admixed with a minor proportion of medium sized lymphocytes. Flow cytometry revealed a lambda monotypic population of B cells displaying dim CD19 and CD10. The neoplastic lymphoid cells were negative for CD5, CD11c, and CD103. Hence the diagnosis of B cell non-Hodgkin lymphoma (low grade follicular lymphoma) was made. The patient was subsequently referred to Oncology for management of disease.Primary splenic lymphoma is considered an exceptionally rare cause of splenomegaly and its reported incidence is less than 1% . DespiteOn the contrary, spleen can be visualized in great detail through the gastric wall using EUS. Fritscher-Ravens et al.  first reAnother study combined EUS-FNA with flow cytometry to diagnose splenic lesions and correctly identified two patients with splenic lymphomas. However, in this study there was one false negative result, which was later on confirmed to be non-Hodgkin lymphoma after surgery . IwashitAlthough there are cases that support splenic EUS guided biopsy as a safe modality, other studies have supported alternative means. In one multicenter study of image guided biopsy the complication rate was 5.2%, but the rate of major adverse events was still only 0.75% . A meta-In this review we have compiled all the reported cases of primary splenic lymphomas diagnosed using EUS-FNA . Gender EUS is a safe and effective modality for diagnosing primary splenic lymphomas.


Esophageal schwannomas are extremely rare, with few cases reported in the literature. Traditionally, resection of esophageal schwannoma is typically performed using thoracotomy or video-assisted thoracic surgery. However, large, irregular tumors may increase the surgical difficulties of complete enucleation and lead to potential mucosal damage. Moreover, a subtotal esophagectomy cannot be avoided in some conditions. Here, we report the first case of robot-assisted enucleation of a large dumbbell-shaped esophageal schwannoma.A 48-year-old woman presenting with a 1-year history of dysphagia was noted to have a homogeneous irregular mass measuring 70 mm in diameter and arising from the submucosal layer of the distal esophagus. A diagnosis of an esophageal submucosal tumor (SMT) was made, most likely leiomyoma. Robot-assisted thoracoscopic excision of the tumor was performed. The da Vinci Surgical System provided delicate dissection in the confined posterior mediastinal space, and the large dumbbell-shaped tumor was completely removed without damage to the mucosal integrity. The operative time was 108 min, and the blood loss was less than 20 ml. The pathology of the tumor was esophageal schwannoma. The patient experienced an unremarkable recovery and was discharged on the fifth day after operation. No symptoms or recurrence were present at the 50-month follow-up postoperatively.We present a rare case of large irregular esophageal schwannoma that was excised by robot-assisted surgery. A clear operative field and delicate dissections are critical points for the complete removal of this large esophageal SMT. We demonstrate that robotic treatment of large esophageal schwannoma is minimally invasive and can be successfully applied in such cases. Esophageal schwannomas are extremely rare and are the least common esophageal submucosal tumors (SMTs), with less than 30 reported cases in the literature . PreoperA 48-year-old woman presented to the gastroenterologist at a local hospital with a 1-year history of dysphagia, which had been progressively worsening over the preceding two months. During endoscopy, a bulging tumor 70 mm in length with an intact overlying mucosa was observed in the esophagus 30 cm away from the incisor Fig. . Endosco2 insufflation with 8–10 mmHg pressure. After all the trocars were positioned, the robot was brought in from the head of the patient with the assistant surgeon on the patient’s left side. The hook or Maryland was manipulated by the first arm of the robot. The Cadiere forceps was manipulated by the second arm. The right lung was retracted laterally, exposing the esophagus. By incising the mediastinal pleura, a large bulge was clearly visualized in the distal esophagus in the confined posterior mediastinal space . After induction of general anesthesia and placement of a double-lumen endotracheal tube, the patient was placed in the left lateral decubitus position. A 12-mm camera port was inserted at the 10th intercostal space (ICS) at the midaxillary line. Under direct vision, three additional trocars were inserted under thoracoscopic guidance as follows: an 8-mm port in the 7th ICS at the anterior axillary line for the first robotic arm, an 8-mm port in the 10th ICS at the posterior axillary line for the second robotic arm, and finally, a 12-mm auxiliary port in the 9th intercostal space immediately between the camera port and the first robotic port (Fig. ace Fig. . A longiace Fig. . The splace Fig. . The intace Fig. . The lesace Fig. . A 32-FrThe patient was well postoperatively. On the third day, a postoperative gastrograffin swallow demonstrated no leaks or stricture. At this time, the patient started a liquid diet with good tolerance. She was discharged on the fifth day after operation. Histopathological examination revealed compact bundles of spindle cells Fig. . ImmunohEsophageal SMTs represent less than 1% of all esophageal neoplasms . Of thesThe main treatment for esophageal schwannomas is surgical resection . SurgicaRecently, RATS using the da Vinci Surgical System has provided improved visualization and dexterity in esophageal procedures. In our department, we began to perform robot-assisted esophageal procedures on both malignant and benign tumors in May 2015. In the present case, the tumor was located within the esophageal wall in the confined posterior mediastinum and was 70 mm in diameter. Furthermore, this submucosal mass was irregular with a dumbbell-like shape, which increased the difficulty of obtaining complete enucleation. A decision of transthoracic tumor enucleation using the da Vinci Surgical System was made. The robotic approach offers advantages compared with conventional thoracoscopic systems, including wrist-like movement of the instruments, three-dimensional vision and ergonomic comfort for the surgeon. These features facilitated the combination of sharp and blunt dissection in the confined space and subsequently offered the possibility of complete removal of the tumor without interruption of the capsule and the surrounding esophageal mucosa. The integrity of the mucosa was ensured by the precise dissection with robotic surgery and simultaneous intraoperative upper endoscopy. Moreover, the suture and knot for the repair of the myotomy could be easily performed by the wristed robotic instruments, which prevented mucosal bulging and possible formation of a diverticulum after the enucleation of the large esophageal SMT.To the best of our knowledge, this is the first report of robot-assisted enucleation of a large esophageal schwannoma. A clear operative field and delicate dissections are key points. This illustrative case demonstrates the utility of robotic surgery in the removal of a large irregular esophageal SMT with respect to its safety and minimal invasiveness.


Cholesterol granuloma (CG) is the outcome of the foreign body type of response to the accumulation of cholesterol crystals and is frequently present in conjunction with chronic middle ear diseases. Recently, cases of CG in jaws have been reported, but still, very few cases have been found of CG in dental literature. This article presents three rare cases of CG in the wall of odontogenic cysts emphasizing on its possible role in expansion of the associated lesion and bone erosion. It also lays stress on the fact that more cases of CG should be reported so that its nature and pathogenesis in the oral cavity become more perceivable. Cholesterol granuloma (CG) is a histopathological entity that is characterized by collection of numerous cholesterol clefts, which are associated with foreign body giant cells, foam cells, and hemosiderin filled macrophages . Most co calcifying odontogenic cyst with cholesterol granuloma was made  for the same in private dental clinic but after extraction the swelling persisted. On palpation, swelling was soft and fluctuant in nature extending from the buccal vestibule till midline of the hard palate. FNAC was attempted but the mass bled profusely. CT scan revealed a huge expansile, well demarcated, and osteolytic mass extending from maxilla into the maxillary sinus. A provisional diagnosis of keratocystic odontogenic tumor (KCOT) was made. Surgical enucleation of the cyst was performed and the tissue was sent for histopathological examination. The sections revealed proliferation of cystic odontogenic epithelial lining with palisaded hyperchromatic columnar nuclei, stellate reticulum like areas, and sheets of abundant ghost cells. Surrounding connective tissue stroma showed mature collagen bundles. Abundant hemorrhagic areas and fibrin deposits were evident both in fibrous wall and in cystic lumen. Also visible both in the connective tissue and in cystic lumen were abundant cholesterol clefts and hemorrhagic areas. Focal areas of ghost cell formation were also visible in the stroma surrounded by foreign body giant cells and hemosiderin pigmentation. Thus, based on this a final diagnosis ofwas made . dentigerous cyst with cholesterol granuloma was made  was made. The cyst was surgically enucleated and the histopathology revealed nonkeratinized stratified squamous cystic epithelial lining, 2-3-cell layer thick, which showed proliferation in few areas associated with underlying inflammation. In the connective tissue cystic capsule, mixed inflammatory cell infiltrates with areas of hemorrhage were evident. A part of the tissue revealed abundant cholesterol clefts in the cystic capsule in association with multinucleated giant cells. Based on this a diagnosis ofwas made .A 47-year-old male reported with complaint of pain in lower left posterior mandible for past two days. He gave history of swelling on this side since two months. Mild swelling was present on left side of mandible, which was hard on palpation and nontender. Intraorally the swelling was soft in consistency and painful with a slight opening present on crest region through which yellowish green color discharge was noticed. Computed tomography revealed a well-defined radiolucency (30 × 14 mm in size) present on left angle of mandible region with 38 displaced near the inferior border of the mandible. Incisional biopsy was sent for histopathological evaluation which revealed cystic lining of varying thickness, nonkeratinized stratified squamous in nature with few areas of mucus metaplasia. Connective tissue capsule was fibrocellular with vascular channels and mild inflammatory cell infiltrate and a diagnosis of dentigerous cyst was made. After this the excised tissue was sent which after repeated regrossing and tissue sectioning did not show any cystic lining. The connective tissue stroma was ectomesenchymal and fibrocellular with abundant cholesterol clefts and chronic inflammatory cell infiltrate .CG histopathologically depicts a large collection of longitudinal cholesterol clefts that are formed at the site of cholesterol crystals because of dissolution of crystals at the time of tissue processing and is embedded in fibrous granulation tissue with surrounding foreign body type of multinucleated giant cells and macrophages filled with hemosiderin . After aAn ambiguity has always persisted regarding the terminology of CG in the oral cavity, as Bhaskar, Wood, and Goaz described a lesion in the jaw with similar histopathological features but termed it cholesteatoma . StatingCG should be considered in clinical-radiographic differential diagnoses of odontogenic cysts or tumors. Netto et al. reported a case of mandibular CG mimicking a dentigerous cyst .The cholesterol crystals are reported to occur more commonly in inflammatory cysts, especially in radicular cysts. Lowest incidence was reported in noninflammatory cysts such as odontogenic keratocyst . In all The pathogenesis of CG is controversial as many possible mechanisms have been proposed to explain it but no clear consensus has been made. CG is formed due to irritant effect of accumulated cholesterol crystals as a result of the breakdown of blood, inflammatory tissue, or exudate. They attract foreign body giant cells and thus cause fibrosis . Our casThe buildup of cholesterol crystals in the cyst wall and cystic fluid could result from the disintegrating red blood cells of stagnant blood vessels within the lesion, circulating plasma lipids, or fatty degeneration of connective tissue in a cavity blocked by inflammation . Our casCG could lead to expansion of the lesion with which it is associated. Almada et al.  reportedCG is considered as a nonspecific histopathological reaction to cholesterol crystals rather than a clinical or pathological entity. As its clinical and radiographic characteristics are nonspecific, it should be considered in differential diagnosis of odontogenic cyst and tumors and histopathological analysis is essential for a correct final diagnosis of CG. Due to paucity of the intraoral reported CG cases the true nature and pathogenesis are still ambiguous. There also persists confusion on the terminologies and distinctiveness of CG reported in the oral cavity and ear. More CG cases of the oral cavity should be brought to light so that their unique identity could be revealed and elaborated upon.


Intradural extramedullary cavernous angiomas of the central nervous system are a rare type of cavernous angioma, but they can cause fatal subarachnoid hemorrhage. The efficacy of resection for this type of cavernous malformations remains uncertain. This is the first report to recommend surgical resection of these types of lesions regardless of the fatal condition.Our patient was a 70-year-old Japanese man who experienced a sudden onset of an occipital headache, followed by bilateral abducens nerve palsy. Magnetic resonance imaging revealed a small amount of hemorrhage in both of the lateral ventricles and an intradural extramedullary mass lesion in the left side of his foramen magnum. Two weeks after the appearance of initial symptoms, he became comatose. A computed tomography scan showed an increase in the subarachnoid intraventricular hemorrhaging and of the acute hydrocephalus. Following ventricular drainage, total tumor resection was performed using the lateral suboccipital transcondylar approach in conjunction with a first cervical hemilaminectomy. We observed a grape-like vascular-rich tumor with calcification that was adhering tightly to the wall of his left vertebral artery. A histopathological examination of the surgery specimen identified it as a cavernous angioma. After placement of a ventriculoperitoneal shunt and 2 months of rehabilitation, he recovered completely.An intradural extramedullary foramen magnum cavernous malformation is quite rare. The fragile surface of our patient’s lesion was causing repeated subarachnoid hemorrhage and consequently progressive fatal neurological deterioration. Surgical resection of the lesion to prevent repeated hemorrhage was performed and he recovered fully. Therefore, we recommend surgical resection of the lesion regardless of the potentially fatal condition.  Cavernous angiomas are benign vascular lesions and can occur anywhere in the central nervous system (CNS). The majority manifest as intra-axial lesions , 2. The A 70-year-old Japanese man experienced a sudden onset of an occipital headache. Two days later, he exhibited bilateral abducens nerve palsy. A neurological examination performed on admission revealed bilateral abducens nerve palsy and mild right-sided paresis. A computed tomography (CT) scan showed there were intradural extramedullary calcified mass lesions on his foramen magnum Fig. . MagnetiAfter ventricular drainage and respiratory management, we performed a total cervical tumor resection via a lateral suboccipital transcondylar approach in conjunction with a first cervical hemilaminectomy. During surgery, bloody cerebrospinal fluid spilled out of the opening of the arachnoid membrane. Moreover, we observed a grape-like, dark red colored lesion that was highly vascular Fig. . A slighHis postoperative course was uneventful. He underwent placement of a ventriculoperitoneal shunt for hydrocephalus. Moreover, he showed gradual improvement in his state of consciousness as well as in his bilateral abducens nerve palsy and tetraparesis. After 2 months of rehabilitation, he had fully recovered.Cavernous angiomas occur in 0.39 to 0.9 % of the general population . The natPrevious reports have not described a cavernous malformation originating from the foramen magnum. According to a literature review on spinal cavernous malformations , extrameThe annual hemorrhage risk rate was determined to range from 0.25 to 3.1 % per patient , 6. The Although an intradural extramedullary foramen magnum cavernous malformation is very rare, the fragile surface of this lesion was causing repeated SAH. In spite of the potentially fatal condition, our patient recovered fully because recurrence of SAH was prevented; therefore, surgical resection is strongly recommended for intradural extramedullary cavernous malformations. Intradural extramedullary foramen magnum cavernous malformation causes repeated SAH and progressive fatal neurological deterioration. We recommend surgical resection of the lesion to prevent repeated hemorrhage regardless of the potentially fatal condition.


An 11-year-old boy was assessed for complaints of visual disturbance and left temporal facial paralysis. His medical history and family history were unremarkable. Otological and neurological examinations indicated normal findings. Fundoscopic examination revealed papilledema. Noncontrast-computed tomography detected a voluminous, unilocular, thin-walled lesion without internal solid components in the right temporal lobe. This large cystic lesion had a density similar to that of cerebrospinal fluid (CSF) and showed no enhancement on contrast-enhanced computed tomography Figure . The cysIn both T1WI and T2WI sequences Figure , the cysHydatid disease, also known as cystic echinococcosis, is a worldwide zoonosis caused by infection with the larval stage of the echinococcosis tapeworm. This parasite is incidentally ingested through contaminated food or beverages, and it first reaches the hepatic capillaries via the mesenteric and portal venous system, which explains why the liver is the primary site of echinococcal cysts. This disease is endemic to many places worldwide, particularly the Middle East, Australia, New Zealand, South America, and central and southern Europe. The liver and lungs are the most commonly involved organs.Intracranial hydatid disease (IHD) is relatively rare and accounts for 1–2 percent of cases. IHD can occasionally be very difficult to diagnose on the basis of clinical and laboratory findings. Cerebral cystic echinococcosis lesions are usually singular, and multiple cerebral cysts are extremely rare. These cysts usually occur in the supratentorial area and involve the middle cerebral artery territory. IHD is a slow-growing benign lesion. Small cysts can be asymptomatic, but when enlarged, they can induce symptoms such as headache and vomiting; depending on the location of involvement; occasionally, ataxia, diplopia, hemiparesis, abducens nerve palsy, seizures, and coma can also occur.Both CT and magnetic resonance imaging (MRI) are used to diagnose intracranial cysts . On CT aTotal surgical excision of the lesion is the treatment of choice in symptomatic patients. However, intraoperative rupture of the cyst is commonly encountered. Therefore, anthelminthic agents are usually administered for 2–4 weeks before surgery as an adjuvant treatment to prevent relapse.