Ureteral-iliac artery fistula is a rare and potentially life-threatening complication, typically occurring after radiation therapy in already surgically treated cancer patients. This case report describes the diagnostic challenges and the successful management, with the positioning of an intra-arterial prosthesis, of a fistula between the internal iliac artery and the left ureter presenting as massive hematuria in a young woman with history of total colectomy and pelvic radiotherapy for rectal cancer and subsequent wide ileal resections and bilateral ureteral stent positioning for radiation enteritis. Ureteroiliac artery fistulas require a prompt diagnosis and intervention, to avoid life threatening clinical events. In October 2008, a 29-year-old woman was admitted as emergency to the Department of Urology with massive hematuria and left hip colic pain. In 2004 she underwent a total colectomy followed by adjuvant systemic chemotherapy and radiotherapy for rectal carcinoma arising on colon familial adenomatous poliposis. Between 2005 and 2007 she developed several intestinal occlusions secondary to radiation enteritis requiring four laparotomies followed by resections of aderential bridles and wide ileal segments. Finally a cutaneous ileostomy was confectioned and daily Parenteral Nutrition prescribed. In 2006 intestinal continuity was restored. In February 2008, a Computed Tomography (CT) scan showed a bilateral hydroureteronephrosis due to a nonhomogeneous mass completely filling the pelvic region and bilateral ureteral stents were placed in order to preserve renal function. In April 2008, an exploratory laparotomy was performed which identified an abscessual collection due to the dehiscence of ileoanal anastomosis: the collection was drained and a new cutaneous ileostomy confectioned. In July and in September 2008, the right and left ureteral stents were, respectively, replaced due to infection. On admission, a three-way catheter with a bladder washing was placed. A CT scan with contrast medium (CM-CT) showed bladder tamponade  and blooArterioureteral fistulae occur very rarely, often difficult to indentify, like the one described in this case report, and could be associated with a high mortality rate  mainly dThe treatment of these fistulae has also changed overtime, from open surgery to stent-graft repair, which is less invasive than the open approach –6.


Ovarian fibroma is a rare neoplasm and the one with focal proliferations of sex cord type elements is rarer. Histopathological importance lies in the recognition of this entity due to the diagnostic dilemmas that these tumors can pose. To the best of our knowledge only 9 cases of ovarian fibroma with minor sex cord elements have been documented in world literature till date.We report the case of a 65-year-old Indian female who presented with postmenopausal bleeding and pain abdomen. An ultrasound scan of the abdomen revealed a right ovarian mass. Histologically, the ovarian tumor was a fibroma with minor sex cord elements.Clinical manifestations of a hyperestrogenic state in postmenopausal female should raise suspicion of this entity in the mind of a physician. Also a thorough evaluation of an ovarian fibroma would help detection of minor sex cord elements within the tumor and thus be a stepping stone for better evaluation of the pathogenesis and clinical behaviour of these tumors. A close follow up of the patient should be done as hyperestrogenemia may predispose to endometrial cancer. Ovarian fibroma with minor sex cord elements is a rare entity that was first described by Young and Scully in 1983. It is defined as a predominantly fibromatous or a thecomatous tumor containing scattered minor sex cord elements in less than 10% of the tumor area.We report case of a 65 year old female with complaints of bleeding and pain abdomen for the past 6 months. The uterus was enlarged and abdominal ultrasonography revealed a right ovarian solid mass. Simple endometrial hyperplasia with endometrial polyp was noted and this probably was a result of hyperestrogenic state due to hormone production by the ovarian tumor. This could predispose to endometrial cancers as well. Though these tumors like, fibromas are thought to behave in a benign fashion, concrete evidence in their clinical behaviour is still a challenge that needs further evaluation.The importance of recognition of ovarian fibroma with minor sex cord elements lies in the diagnostic dilemmas that they can pose, as they have on various occasions been mistaken to be Brenner tumors, adenofibromas, or metastatic carcinoids.We herein review the clinicopathological features of this rare entity.A 65 year old Indian female, gravida 7, para 7, non smoker, non alcoholic, housewife weighing 60 kgs, height 5'6" presented to the gynecology outpatient with complaints of bleeding and pain abdomen for the past 6 months. No history of any drug intake or previous medical problems or family history of any disease was present. On vaginal examination uterus was enlarged to 8 weeks in size, retroverted with clear bilateral fornices. Abdominal ultrasonography revealed a right ovarian solid mass. The left ovary was normal. Endometrial curettings revealed simple glandular hyperplasia without cytological atypia. A clinical diagnosis of dysfunctional uterine bleeding was made. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed.Grossly we received a specimen of uterus with cervix along with bilateral adnexa. The right ovary measured 5 × 4 × 2 cm. It was globular, nodular and externally encapsulated with no capsular breech Fig . SectionHistologically, the right ovarian tumor was highly cellular composed of uniform spindle cells arranged in sheets and intersecting fascicles Fig . The celThe spindled out cells stained blue with Masson Trichrome stain. Immunohistochemically, the spindled cells were diffusely positive for smooth muscle actin (SMA) and weakly expressed vimentin and inhibin. These spindled cells were negative for epithelial membrane antigen (EMA) and cytokeratin. The uniform large cells in nests and cords were strongly immunoreactive for inhibin and negative for vimentin, SMA and EMA. Based on these above findings a final diagnosis of fibroma with minor sex cord elements was made.Ovarian stromal tumor with minor sex cord elements is a rare neoplasm, which was first described by Young and Scully as a predominantly fibromatous or a thecomatous tumor containing scattered minor sex cord elements in less than 10% of the tumor area.[To the best of our knowledge only 9 cases of ovarian fibroma with minor sex cord elements have been documented in world literature till date. -7Sex cord-stromal tumors represent a heterogeneous group of lesions, including Leydig cell tumor, Sertoli cell tumor, mixed Sertoli-Leydig cell tumor, granulosa cell tumor, and a poorly defined tumor group referred to as unclassified sex cord-stromal tumors.The stromal component is usually fibromatous or thecomatous. They are firm, solid, grey white to grey yellow in colour. Microscopically they are composed of spindled cells, arranged in intersecting fascicles with variable amount of collagen deposition. The nucleus of the stromal cells is elongated with tapering ends and no prominent nucleoli. The term "minor" component of sex cord elements is defined as sex cord elements occupying no more than 10% of the area of the tumor on any slide.,6Their importance lies in the diagnostic dilemmas that they can pose, as they have on various occasions been mistaken to be Brenner tumors, adenofibromas, or metastatic carcinoids. Sex cord elements can be distinguished by their strong immunoreactivity to inhibin. The epithelial aggregates of Brenner tumor are composed of transitional cells, mucinous cells or both and sometimes have a central lumen containing eosinophilic secretions. The glands of adenofibroma are abundant, larger, and tubular and more variable in size than the uniform tubules of minor sex cord elements.In the study by Young and Scully (1983), These tumors like, fibromas are thought to behave in a benign fashion and have a good prognosis. Our patient in one year post surgery follow up has been asymptomatic and healthy.Fibroma with minor sex cord element is a rare pathological entity among the unclassified sex cord stromal tumors and awareness of its occurrence is important for a practicing pathologist. Detection of these tumors would serve a basis for further research in their pathogenesis and provide a better insight of the clinical behaviour of these rare neoplasms.Clinical manifestations of a hyperestrogenic state in postmenopausal female should raise suspicion of this rare entity in the mind of a physician. Also for a pathologist, a thorough evaluation of an ovarian fibroma would help detection of minor sex cord elements within the tumor and thus be a stepping stone for better evaluation of the pathogenesis and clinical behaviour of these tumors. A close follow up of the patient should be done as hyperestrogenemia may predispose to endometrial cancer.This case has been presented to enlighten the physicians and pathologists of the rare gynecological neoplasms and pave way to further research in this field.The authors declare that they have no competing interests.VK analyzed and interpreted the patient data regarding the disease. VK, PG and NK performed the histological examination of the ovary, and all contributed in writing the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Although rare in children, aggressive fibromatosis or desmoid tumors require wide surgical excision for durable relief. The resultant defect poses many challenges for reconstruction. The authors report reconstruction of such a wound using a pedicled omental split skin graft, which resulted from the excision of a locally recurrent desmoid tumor. Aggressive fibromatosis or desmoid tumor is a rare soft tissue tumor in the pediatric age group. Arising The authors were involved in the management of a large recurrent chest and abdominal wall desmoid, whose surgical extirpation led to the creation of a full thickness abdominal wall defect, which was reconstructed using the pedicled omentoplasty and split skin graft (POSSG) technique.A 12-year-old female presented with a rapidly increasing mass located over the lower left chest wall and the abdomen. The mass had first been noted in the year 2000, and was confined to the chest wall, and local excision had been done in the same year. Histology had revealed aggressive firbomatoisis and the child was on follow up for a year, after which she dropped out.th and 10th ribs. The defect was repaired by inserting a prolene mesh, and the skin was closed primarily.In 6 months, the mass made a reappearance in the scar tissue of the previous surgery. She underwent a second excisional surgery in 2003, when the tumor involved the upper part of both recti and excision was accomplished with excision of the anterior part 9After 6 months, the tumor recurred and the parents started traditional treatment and did not report for follow-up. The mass grew extremely slowly over the next 2 1/2 years, but since then had grown aggressively to reach large dimensions.General physical examination was unremarkable. Local examination revealed a 15 cm × 12 cm exophytic nodular mass arising from the lower left chest wall and the contiguous anterior abdominal wall. The mass was hard in consistency, crossing the midline, with scars of the previous surgery visible over the mass. Investigations revealed a normal hemogram, renal functions and liver function. Chest radiograph was normal and a computed tomogram (CT) scan revealed that the mass was arising from the lower chest wall and abdominal wall, and was free from the underlying viscera, including the liver . With a th and 9th ribs. The mesh placed previously was removed. The diaphragm was sutured to the 7th rib, closing the thoracic cavity. This left a full-thickness defect on the anterior abdominal wall measuring 14 cm × 12 cm. The omentum was detached from the transverse colon and the right gastroepiploic artery was divided. The omentum was then detached from the greater curvature, keeping the epiploic arcade intact. A prolene mesh was then sutured to the muscles in the margin of the wound, leaving a small gap superomedially through which the omentum was brought out and spread over the surface of the mesh. The omentum was loosely tacked to the mesh and skin margins and covered with Vaseline gauze and a dressing was applied.Excision was accomplished with resections of the anterior portions of the 8th postoperative day, she was returned to the operation theater and split skin grafts were taken from the thigh and placed on the granulating surface of the omentum. She recovered without any complications and was discharged after 10 days with a well-taken skin graft covering the mesh. Histology revealed a desmoid tumor with clear surgical margins.On the 7On follow-up, she had a small nonhealing discharging sinus on the superomedial aspect of the wound that responded to local probing and removal of a suture. She has been on follow-up for 3 years without any evidence of local recurrence or ventral hernia and she is pleased with the outcome .Aggressive fibromatosis or desmoid tumors are soft tissue tumors that are rare in the pediatric age group. ConsistiSurgical excision without damage to vital neurovascular structures remains the cornerstone of therapy. PatientsAdequate excision of these tumors proves a challenge for reconstructing the resultant defect, especially in areas such as the chest wall and upper abdomen. The goals of reconstruction are to provide optimum structural support with stable soft tissue and good aesthetic results. Division6The procedure as described above is technically simple and requires no specialized instrumentation or microvascular anastomosis and can thus be used in centers with limited resources.


Background. Squamous cell carcinoma of the gallbladder is a rare disease with symptoms developing late in its course, so that it often presents as an aggressive tumor with a poor prognosis. Case report. We describe a 58-year-old male with a 5-week history of hypodynamia. He was found to have squamous cell carcinoma of the gallbladder with liver invasion and lymph node metastases. He underwent treatment with 3-dimensional conformal radiation therapy (CRT). A follow-up computer tomography (CT) scan showed complete tumor remission 2 months after the completion of CRT. The patient survived for 14 months after the end of treatment and died of multiple liver metastases. Conclusion. The efficacy of radiotherapy in this case is encouraging and suggests a potential role for such therapy in similar cases. The benefit in terms of survival warrants further study. Primary carcinoma of the gallbladder is the fifth most common malignancy of the digestive tract . Squamou9/L, hemoglobin 153 g/L, white blood cells 5.2 × 109/L, Neutrophils 58.2%, platelets 211 × 109/L, total bilirubin 10.4 mmol/L, alanine aminotransferase 24 U/L, aspartate aminotransferase 31 U/L, alkaline phosphatase 71 U/L, α-fetoprotein (AFP) 1.8 μg/L, carbohydrate antigen 19.9 (CA19.9) 8.5 U/L, and carcinoembryonic antigen (CEA) 4.56 U/mL. According to the CT, the surgeons figured that the tumor had lymph node metastases, which involved portal vein lymph node, inferior vena caval lymph node, and peripancreatic lymph node. They considered that the tumor was unresectable. The patient was recommended to receive conformal radiotherapy due to consideration of the advanced nature of the disease.A 58-year-old male was admitted to the local hospital with hypodynamia for 5 weeks. Physical examination was unremarkable, but ultrasound examination showed liver and gallbladder space-occupying lesions. Then an abdominal computer tomography (CT) scan was recommended and showed a tumor involving the gallbladder and the surrounding liver tissue, with possible portal lymph node metastases and gallstones . For furThe patient provided written informed consent regarding treatment. No systemic chemotherapy was added during radiotherapy. He underwent three-dimensional (3D) CRT with limited-field external beam radiation using a linear accelerator with 15 megavoltage photons at an outpatient clinic. For radiotherapy planning, the patient underwent a CT scan in the supine position with both arms raised above the head. The CT images were transferred to a 3D CRT planning system (Pinnacle 7.6C). The gross target volume included the gallbladder tumor, involved liver tissue, and abnormally enlarged portal lymph nodes. The clinical target volume included the gross target volume and the peripancreatic and celiac trunk lymph nodes, which were at risk for metastases. The planning treatment volume included the clinical target volume and 0.7 cm margins for geometric uncertainties. The treatment portals encompassed the planning treatment volume plus 0.7 cm in each direction. Dose-volume histograms of the planning treatment volume, kidneys, liver, and spinal cord were necessary to select the optimal dose distribution plan. Coverage of 99.9% of the planning treatment volume by the 95% isodose line was required. The clinical target volume was subject to 40 Gy, with 14 Gy delivered to the gross tumor volume through reduced fields. The dose was in fractions of 2.0 Gy, once daily, five times per week for 5 weeks.During the entire period of radiation therapy, physical examination, routine blood tests, and serum biochemistry tests were performed once a week and remained normal. The patient's hypodynamia was relieved after completion of radiotherapy. The tumor marker levels were similar before and after treatment and considered normal .The patient was advised to return for follow-up 6 weeks after completion of the radiotherapy. Response to radiotherapy was evaluated at that time with an enhanced abdominal CT . CT showGallbladder cancer is the most common malignant originating from biliary tract and represents approximately 8.4% of the estimated cases of hepatobiliary cancers diagnosed in the USA . SquamouThe only potentially curative therapy for gallbladder carcinoma is surgical resection. Unfortunately, most patients with this type of cancer have unresectable disease—only 10%–30% of patients are candidates for surgery at presentation. At present, no therapy is defined for unresectable cancer of the gallbladder, especially for squamous cell carcinoma. Reports on the efficacy of radiotherapy for gallbladder carcinoma are disappointing; most series have a small number of patients and results regarding survival are inconsistent. However, one study indicated that external beam radiotherapy, as an adjuvant to surgical treatment, has some beneficial effect on survival . Radioth


We highlight the orbital manifestations of acute myeloid leukemia and the role of peripheral blood smear in the diagnosis of these cases. A total of 12 patients who presented with proptosis and were subsequently diagnosed to have acute myeloid leukemia based on incision biopsy or peripheral blood smear were included in the study.A retrospective review of all cases of acute myeloid leukemia presenting to the Orbital clinic was performed. The age at presentation, gender, presenting features, duration of symptoms and fundus features were noted. In addition the temporal relationship of the orbital disease to the diagnosis of leukemia, laterality, location of the orbital mass, imaging features and the diagnostic tools used to diagnose leukemia were noted. The median age at presentation was 6 years. The male: female ratio was 0.7:1. None of these patients had been diagnosed earlier as having acute myeloid leukemia. The presenting features included proptosis in all patients, orbital mass in 5 (41.7%), visual symptoms in 2 (16.7%) and subconjunctival hemorrhage in one patient (8.3%). A diagnosis of acute myeloid leukemia was established by incision biopsy in 4 patients, subsequently confirmed by peripheral blood smear testing and bone marrow biopsy in 2 patients which revealed the presence of systemic involvement. Imprint smears of the biopsy identified blasts in 2 of 4 cases. In 8 patients presenting with ocular manifestations, diagnosis was established by peripheral blood smear examination alone which revealed a diagnosis of acute myeloid leukemia.A peripheral blood smear should be performed in all cases of sudden onset proptosis or an orbital mass in children and young adults along with an orbital biopsy. It can always be complemented with a bone marrow biopsy especially in cases of aleukemic leukemia or when the blood smear is inconclusive. Acute myeloid leukemia (AML) accounts for nearly 15% of all leukemias in children . Allen BThe natural history of these tumors can be variable. This tumor can present prior to, concomitantly or even during remission of systemic leukemia ,6. DiagnIn this report we describe 12 cases of acute myeloid leukemia that presented to the ophthalmology clinic with proptosis and a diagnosis of AML was subsequently made by a peripheral blood smear or incision biopsy. This case series emphasizes the importance of these simple yet valuable investigations in making a diagnosis of this grave systemic malignancy.Twelve cases of acute myeloid leukemia had presented with proptosis. None of these patients had been diagnosed earlier as having acute myeloid leukemia. The median age at presentation was 6 years ,  and Stockl et al 8.8 years in their studies ,6. ThougGranulocytic sarcoma is thought to originate in the bone marrow and the cells are believed to spread via the Haversian canals to collect in the subperiosteum and form a soft tissue mass . They moIn our series the most common presenting features were an orbital mass and proptosis. Various other studies have described proptosis as the most common presenting feature -11, Tab. ZimmermThe onset of orbital granulocytic sarcoma in relation to systemic AML can be variable. The orbit can be involved even before the bone marrow and peripheral blood show features of the malignancy. In Zimmerman's series, in 88% of the cases the orbital granulocytic sarcoma developed before the development of systemic leukemia . VariousThe diagnosis of this tumor can be challenging especially when there are no signs of systemic leukemia. In the presence of systemic malignancy, a peripheral blood smear or a bone marrow biopsy may provide useful clues to the diagnosis. Zimmerman et al reported that the most common misdiagnosis was malignant lymphoma. HoweverEvaluation of the peripheral smear is an invaluable tool in the diagnosis if the systemic manifestations are already present as in our series. Previous reports have highlighted the role of this inexpensive investigation in all cases of childhood proptosis,12. The The prognosis for patients with granulocytic sarcoma depends on the course of the underlying systemic malignancy,5. InitiGranulocytic sarcoma is a rare cause of childhood proptosis. A peripheral blood smear should be performed in all cases of sudden onset proptosis or an orbital mass in children and young adults. It should be complemented with a bone marrow biopsy especially in cases of aleukemic leukemia and biopsy of the orbital lesion especially in cases where the blood smear is inconclusive. The use of special stains and immunohistochemical techniques can help further in establishing the diagnosis in orbital GS. Early treatment and diagnosis is the key to prolonging the survival in this aggressive malignancy.A retrospective review of the records of all the patients in the ophthalmic pathology service was performed from January 1998 to September 2008. There were 13 cases of leukemia involving the eye or the orbit  as per the FAB classification. In cases that underwent incisional biopsy, intraoperative diagnosis was attempted by squash and imprint cytology. Myeloperoxidase staining was performed on the smears or biopsy specimens. All the patients were referred to a pediatric oncologist for further management.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-chief of this journal.The authors declare that they have no competing interests.RM conceived the idea, collected data and drafted the manuscript; GKV performed histopathologic studies and contributed to the manuscript writing; SGH participated in the study design and provided critical inputs; MN and VR participated in the study design and provided critical inputs. All authors read and approved the final manuscript.


Extended liver resections are being performed more liberally than ever. The extent of resection of liver metastases, however, is restricted by the volume of the future liver remnant (FLR). An intervention that would both accomplish tumor control and induce compensatory hypertrophy, with good patient tolerability, could improve clinical outcomes.A 53-year-old woman with a history of cervical cancer presented with a large liver mass. Subsequent biopsy indicated poorly differentiated carcinoma with necrosis suggestive of squamous cell origin. A decision was made to proceed with pre-operative chemotherapy and Y-90 microsphere SIRT with the intent to obtain systemic control over the disease, downsize the hepatic lesion, and improve the FLR. A surgical exploration was performed six months after the first SIRT (three months after the second). There was no extrahepatic disease. The tumor was found to be significantly decreased in size with central and peripheral scarring. The left lobe was satisfactorily hypertrophied. A formal right hepatic lobectomy was performed with macroscopic negative margins.Selective internal radiation treatment (SIRT) with yttrium-90 (Y-90) microspheres has emerged as an effective liver-directed therapy with a favorable therapeutic ratio. We present this case report to suggest that the portal vein radiation dose can be substantially increased with the intent of inducing portal/periportal fibrosis. Such a therapeutic manipulation in lobar Y-90 microsphere treatment could accomplish the end points of PVE with avoidance of the concern regarding tumor progression. Extended liver resections, with an operative mortality of less than 5%, are being performed more liberally than ever. This has come about as a result of advances in surgical, anesthetic and perioperative care, along with improvements in medical imaging that have allowed better patient selection and surgical planning. At many centers, more than two-thirds of liver resections now consist of major hepatectomies. Liver resection has also been recognized as the only treatment that offers meaningful improvement in survival in patients with colorectal cancer liver metastases (CRCLMs). Indications for surgical resection continue to expand. An increasing number of patients with hepatocellular carcinoma (HCC), neuro-endocrine tumor metastases, and, more selectively, patients with other metastatic cancers are being considered for surgical treatment .The extent of resection of liver metastases is restricted by the volume of the future liver remnant (FLR). Among different strategies, portal vein embolization (PVE) has gained wider acceptance to achieve the goal of increasing the volume of the FLR . First rSelective internal radiation treatment (SIRT) with yttrium-90 (Y-90) microspheres has emerged as an effective liver-directed therapy with a favorable therapeutic ratio. SIRT, both as a stand-alone therapy and in conjunction with systemic or regional chemotherapy (chemo-SIRT), has been demonstrated to be an effective modality in the management of primary and metastatic liver tumors -16. Y-90We suggest that the portal vein radiation dose can be substantially increased with the intent of inducing portal/periportal fibrosis. Such a therapeutic manipulation in lobar Y-90 microsphere treatment could accomplish the end points of PVE with avoidance of the concern regarding tumor progression.99 mTC) macroaggregated albumin (MAA) liver scan confirmed the absence of extrahepatic GI and pulmonary uptake. Next, medical internal radiation dosimetry (MIRD) was used to determine projected tumor and liver absorbed doses. Y-90 resin microspheres  were administered to the right hepatic lobe 24 hours after initiation of systemic chemotherapy with 5-fluorouracil (5-FU)-leucovorin-oxaliplatin (FOLFOX-6). Microspheres were instilled directly into the right hepatic artery via a 3 french microcatheter. A maximum safe administered dose was given  with estimated tumor and liver absorbed doses of 90 Gy and 30 Gy, respectively. The treatment was well tolerated with no untoward effects. A 4-week post-treatment FDG-PET/CT scan demonstrated a complete metabolic response, and a 25% decrease in anatomic volume  positron emission tomography (PET)/computed tomography (CT) indicated a large necrotic tumor occupying the greater part of the right lobe Figure . This pae Figure , 2. Livee Figure , 2. No ie Figure , 3. LiveA surgical exploration was performed six months after the first SIRT (three months after the second). There was no extrahepatic disease. The tumor was found to be significantly decreased in size with central and peripheral scarring. The left lobe was satisfactorily hypertrophied Figure . No evidSurgical pathology indicated microsphere localization within the tumor producing more than 90% pathologic response. The surrounding liver tissue showed portal triaditis with mononuclear inflammatory cellular response predomination and portal and periportal fibrosis Figure . HepatocTumor progression in nonembolized liver segments during the hypertrophy induction period is more than a theoretical concern. A number of reports have shown that the volume of metastatic liver tumors increased more rapidly compared with the volume of the liver parenchyma after PVE, both in nonembolized and embolized liver segments -21. HemmTrans-arterial Y-90 microspheres are a viable treatment option for unresectable liver tumors. Y-90 microspheres always localize in the portal tracts. The deposition of the majority of the absorbed dose is within a very tight zone immediately surrounding the microspheres. Even though the maximum range of β particles in the liver is slightly greater than 10 mm, more than 90% of the absorbed dose is deposited within the portal tract at a distance within 30 μm from the microspheres [unpublished data]. The clinical translation of this result is that the greatest absorbed dose effect is exerted on the portal triad structures. An interlobular portal vein branch, at a distance of 50 μm from a microsphere (microsphere cluster), could receive twice the average liver dose calculated by standard MIRD technique.Gray et al. have indicated that SIRT could be associated with subclinical portal hypertension . These aObviously, the major advantage of SIRT is the effective control of the tumor in the target liver lobe. The value of initiating chemotherapy concomitantly with Y-90 microsphere administration not only serves the objective of radiosensitization, but also accomplishes the need/benefit of tumor suppression at a systemic level. Fong et al. have recently demonstrated that chemotherapy could minimize/eliminate the risk of tumor growth, which otherwise could be problematic if PVE was performed without a systemic coverage [unpublished data].Y-90 microsphere SIRT/chemo-SIRT effectively controls tumor growth. With appropriate scaling of radiation absorbed dose to the lobar portal microvascular bed, it also could induce contralateral lobe hypertrophy. The simultaneous accomplishment of tumor control and FLR recruitment might offer a better therapeutic profile compared with that of PVE. Clinical indications, patient selection criteria, and dosimetry for this therapeutic manipulation require further investigation.Written informed consent was obtained from the patient for publication of this case report.The authors declare that they have no competing interests.SG is the authorized user for Y-90 microsphere administration and performed the hepatic resection. MH is the interventional radiologist who performed the Y-90 microsphere treatment. KP is the medical oncologist. SG, MH, and YF co-wrote the case report.


Fluoro-Deoxy-Glucose Positron Emission Tomography/Computerized Tomography scan is a very useful method in the diagnosis and follow-up of gastrointestinal malignancies, although it may cause confusion in differential diagnosis.We present a 48-year-old man admitted with a right lower quadrant mass. Upon an unyielding colonoscopy due to inability to pass beyond the hepatic flexure, a Fluoro-Deoxy-Glucose Positron Emission Tomography/Computerized Tomography strongly suggested a right colonic or cecal malignancy. Eventual laparatomy revealed a periappendiceal plastron due to appendicitis that was subsequently proven histological diagnosis.Although Fluoro-Deoxy-Glucose Positron Emission Tomography/Computerized Tomography is a reliable diagnostic tool for colonic malignancies, it can misdiagnose such masses due to inflammatory process around the cecum. Positron emission tomography (PET), using 18F-fluoro-2-deoxy-d-glucose (FDG) as a tracer, is preferentially taken up by most malignant neoplasms with altered glucose metabolism. In recent years, the fusion of images from FDG-PET with those of computed tomography (PET/CT) has aided in the precise localization of increased FDG uptake sites, which may occur not only in malignant tumors but also in areas of inflammation and in areas of physiologic glucose uptake [We aimed to discuss the reliability and applicability of PET/CT scan when diagnosing colonic malignancies in the event of intra-abdominal inflammatory processes such as appendicular plastrons in context with a case.A 48-year-old Caucasian Turkish male was admitted to ER with right lower quadrant pain, and accompanying fever, sweating, constipation and significant weight loss (>10%) during the last two months. Physical examination revealed normal findings apart from painful right lower quadrant palpable mass. Routine biochemical analysis and CBC were unremarkable. CT examination revealed a 3 × 2 × 2 cm size conglomerated solid mass with no contrast localization. The patient improved and passed flatus after five days of supportive therapy with IV fluid replacement and antibiotic therapy and discharged from hospital. It was considered as a plastroned appendicitis  and periodic ultrasonographic examinations (USG) were planned for follow-up. However, the USG two weeks after CT scan, revealed a 5 × 3 cm size irregular contoured, heterogenous caecal mass that was neighboring with the urinary bladder. We also proved the increase in size of the mass by physical examination. This finding has led us to the primary diagnosis of a colonic malignancy.In an attempt to rule out a colonic malignancy, an urgent colonoscopy was performed, which was unyielding due to inability to pass beyond the hepatic flexure. Therefore, we performed an FDG PET/CT study to aid in the differential diagnosis, which showed markedly increased glucose metabolism in two masses localized in the right lower quadrant which were 2 cm in diameter ,2.The high SUV values  suggested that these masses were most likely related with malignant tissue . Later iCombined PET/CT imaging is a non-invasive nuclear medicine procedure that is gaining increasing application in oncology as a standard modality in the diagnosis of occult cancers, restaging and monitoring of therapeutic efficacy. Metabolic abnormalities detected on PET images can be precisely localized anatomically by hardware fusion with the CT images obtained in the same sitting. Tissues with increased glucose metabolism, such as malignant lesions, appear as areas of increased activity on PET scans due to the trapped FDG within the cells. We observed a strong FDG activity in right lower quadrant of the patient on PET/CT scans, which was strongly suggesting malignant tissue, with concomitant clinical signs and symptoms. The diagnostic use of FDG-PET has been established in colon cancer . Tahara Annovazzi et al  evaluateFDG trapped tissues are analyzed semi-quantitatively using the standard uptake value (SUV), which relates the activity concentration in a fixed volume of tissue to the amount of the injected dose and the patient’s body weight. SUV characteristic of a tissue is as important as the uptake of the radiopharmaceutical. Gutman et al  found a False positivity still seems a diagnostic dilemma of FDG-PET/CT. False positives may be reduced with the use of multitracer studies and labelled amino acids instead of the FDG scan . A diffeBecause FDG is a tracer of glucose metabolism, its distribution is not limited to malignant tissue. To avoid misinterpretations, the interpreter must be familiar with the normal pattern and physiologic variations of FDG distribution and with clinical data relevant to the patient. It still seems a diagnostic dilemma to differentiate a peri-appendicular mass due to an appendicitis from a malignant mass by means of PET/CT scan. Our case is a demonstration of a misinterpretation of colonic tumor due to its high metabolic rate. This clinical condition has emerged a need for further study on the diagnostic accuracy of PET/CT scan in the diagnosis of acute appendicitis and/or peri-appendicular mass.


This is an unusual case of a 26-year-old P2L2 lady who presented with chief complaints of pain abdomen and irregular bleeding p/v with history of post-coital bleeding.On per speculum examination, cervix was replaced by an irregular friable growth, which was bleeding on touch. A clinical diagnosis of carcinoma cervix was made but the cervical biopsy revealed granulomatous inflammation with presence of acid-fast bacilli on cervical smear consistent with tuberculosis. The patient responded to six months of anti-tubercular therapy.To conclude, cervical tuberculosis should be considered in the differential diagnosis of carcinoma cervix in young women with suspicious cervix. A case of tuberculosis of the cervix presenting as cervical carcinoma is being reported for its rarity.2L2 Indian lady, housewife by occupation, presented with chief complaints of pain abdomen, irregular bleeding and discharge per vaginum for three years. She had history of post-coital bleeding and inter-menstrual bleeding; and significant weight loss over the last two years. There was no history of genitourinary malignancy or tuberculosis in the past or in the family. The patient was a non-smoker, non-alcoholic and did not have any other significant medical or surgical illness in the past.A 26-year-old PGeneral physical examination was essentially normal with no palpable lymph nodes. Systemic examination did not reveal any abnormality. On per speculum examination, cervix was replaced by an irregular friable growth, which was bleeding on touch Figure . On bimaGenital tuberculosis is common in 20-40 years of age group in developing countries. Genital organs most frequently affected include fallopian tubes 95-100%), endometrium (50-60%), and ovaries 20-30%) [00%, endo0% [00%, Pelvic organs are infected from a primary focus, usually the chest, by hematogenous spread. The cervix is infected, as a part of this process, by lymphatic spread or by direct extension. In rare cases, cervical TB may be a primary infection, introduced by a partner with tuberculous epididymitis or other genitourinary disease. It has been suggested that sputum, used as a sexual lubricant, may also be a route of transmission .Cervical tuberculosis may present as papillary or vegetative growths on cervix, a military appearance, and/or ulceration simulating invasive cervical cancer . The diaThis case emphasizes that though uncommon, tuberculosis is an important alternative in the differential diagnosis of a malignant appearing lesion of the cervix. With resurgence of tuberculosis worldwide, there should be a high index of suspicion of tuberculosis in women with an abnormal cervical appearance.P2L2: Para 2 with 2 living issues; PAP smear: Papanicolaou smear; AFB: Acid-fast bacilliWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SA examined the patient, made a clinical diagnosis and conducted the cervical biopsy while CR analyzed and interpreted the data. MM performed the colposcopic examination of the cervix, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.


We present a case of a migrated biliary stent that resulted in a distal small bowel perforation, abscess formation and high grade partial small bowel obstruction in a medically stable patient without signs of sepsis or diffuse peritonitis. We performed a percutaneous drainage of the abscess followed by percutaneous retrieval of the stent. The entero-peritoneal fistula closed spontaneously with a drain in place. We conclude, migrated biliary stents associated with perforation distal to the Ligament of Trietz (LOT), may be treated by percutaneous drainage of the abscess and retrieval of the stent from the peritoneal cavity, even when associated with a large intra-abdominal abscess. Endoscopic biliary stent placement is a well established, safe and minimally invasive modality for the treatment of biliary diseases such as choledocholithiasis.,2 Over tA 76-year-old woman was admitted with cholecystitis and choledocholithiasis diagnosed via computed tomographic (CT) scan. Her past medical and surgical history was significant for paroxysmal atrial fibrillation, a right hemicolectomy and right oophorectomy for colon cancer, pulmonary embolism requiring inferior vena cava filter placement, endovascular abdominal aortic aneurysm repair, and a stroke resulting in vascular dementia. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy was performed with removal of an impacted common bile duct stone and placement of an uncoated 10F plastic endostent, though the duct was radiographically clear. Four days later, after her liver function test normalized, she underwent a laparoscopic cholecystectomy during which an intra-peritoneal abscess was found surrounding a markedly inflamed and necrotic appearing gallbladder. The cholecystectomy was performed without complication and the abscess was drained adequately. The remainder of her post-operative course was unremarkable and she was discharged home on post-operative day five.per os, as well as obstipation for 24 hours. She denied any fevers or chills. An abdominal x-ray performed was consistent with a partial small bowel obstruction and a demonstrated a radiodense object consistent with a common bile duct stent overlying the lower pelvis. A CT scan was then performed which demonstrated a 5.8 × 6.2 cm abscess within the right lower quadrant with an extraluminal, radiodense biliary stent within the abscess cavity  is preferable in cases involving choledocholithiasis. A straight stent may migrate since there is nothing to hold it in place, even though there are side flaps. An exception might be an impacted stone that is tight on the stent and prevents migration. Dislodged straight stents are more likely to perforate bowel whereas perforation with a pigtail is much more rare. Furthermore, straight 10 F plastic stents should generally be used for conditions such as strictures and tumours. The rationale for a double pigtail stent (7F) in this case is not known to the authors.Migrated stents causing complications have either been retrieved endoscopically or via laparotomy.,7,14 TheThe existing literature on this subject would advocate prompt and aggressive surgical intervention because of gross contamination, intraperitoneal abscess, and bowel perforation.,5 PromptGiven the patient's past medical history, including advanced age, prior abdominal surgery, and cardiac status, we surmised that percutaneous drainage of the abscess posed a lower risk than a laparotomy. We concluded that drainage of the abscess would alleviate her small bowel obstruction, allow her inflammatory changes to resolve, and provide the time necessary for her to become nutritionally replete. In essence, we chose to treat this patient in a fashion similar to a complicated diverticular abscess or a perforated appendicitis with abscess formation. Prior reports involving biliary stent migration have advocated aggressive surgical intervention for patients with large infected intra-abdominal collections, delayed or critically ill clinical presentations, or a low physiologic reserve.,5 We hadAs percutaneous interventional techniques improve, cases that now require emergent surgical intervention may soon be better served by these less invasive techniques. In this circumstance, fluoroscopically guided percutaneous removal of a migrated biliary stent distal to the LOT, coupled with traditional conservative management principles in the treatment of enterocutaneous fistulas obviated the need for aggressive surgical intervention. This approach has not been previously documented. We conclude that fluoroscopic retrieval of migrated biliary stents associated with perforation distal to the LOT, along with percutaneous abscess drainage, may be a safe and effective treatment alternative to laparotomy for stable patients, even when associated with a large intra-abdominal abscess.The following abbreviations were used in this manuscript: LOT: Ligament of Trietz; CT: Computed tomographic; ERCP: Endoscopic retrograde cholangiopancreatography.The authors declare that they have no competing interests.DMC drafted the manuscript. BJC, HS and RAC co-authored the writing of the manuscript. All authors participated in this case study. All authors read and approved the final manuscript.This activity was screened by our Institutional Review Board for exempt status according to the policies of this institution and the provisions of applicable regulations and was found not to require formal IRB review because it did not meet the regulatory definition of research.


Cardiac paragangliomas are among the rarest primary cardiac tumors. We present a case of left atrial paraganglioma in a patient who presented with symptoms and signs of catecholamine excess in which cardiovascular magnetic resonance in multiple orientations and PET-CT played an important role in the diagnosis and tissue characterization. Pheochromocytomas or functioning paragangliomas are catecholamine-producing tumors arising from secretory chromograffin cells of neuroectodermal origin. These lesions commonly originate from the adrenal medulla. Approximately 18% of pheochromocytomas are extra-adrenal . Recent A 25-year-old female in her third trimester of pregnancy, presented with paroxysmal headache, palpitations, sweating, and hypertension of up to 230/130 for three weeks. Her medical history was negative for previous hypertension, and physical examination was unremarkable. Initial work-up for hypertension excluded pre-eclampsia. Further biochemistry evaluation revealed markedly elevated urine catecholamines;18 Levo-DOPA positron emission tomography-computed tomography or PET-CT scan of the whole body was performed to localize the lesion . The intravenous F18 Levo-DOPA dose was 6.9 mCi, and the patient was pre-medicated with 200 mg of carbidopa 45 minutes before the scan to enhance the uptake of F18 Levo-DOPA. On PET-CT, a large hyper-metabolic soft tissue mass measuring 4.5 × 2.7 × 3.9 cm in the region of posterior mediastinum near the left atrium was noted , Norepinephrine 978 μg/24 hours range 15 - 80), Metanephrine 108 μg/24 hours (range 24 - 96), Normetanephrine 4067 μg/24 hours (range 75 - 375), and Vanillyl mandelic acid 13.6 mg/24 hours (range 2 - 7). Epinephrine level was 0.8 μg/24 hours (range 0.0-20.0). A diagnosis of pheochromocytoma was considered and the patient underwent abdominal magnetic resonance imaging (MRI) which demonstrated a 28 × 19 mm left juxta-adrenal mass. Treatment with phenoxybenzamine  was initiated. Six weeks following uneventful delivery by Cesarean Section, the patient underwent left laparoscopic adrenalectomy for suspected pheochromocytoma. Histopathology showed normal adrenal gland and brown fat in the juxta-adrenal mass. The patient's symptoms continued, and with the suspicion of extra-adrenal pheochromocytoma, F5 - 80, MFour days following the PET-CT examination, cardiovascular MR (CMR) was performed on a 1.5 Tesla MR scanner  to further characterize the lesion and its anatomical relation to the atria and surrounding structures. On Steady State Free Precession (SSFP) breath-hold cine MRI , the epicenter of the hypo-intense soft tissue mass was noted to be in the posterior mediastinum with no apparent fat plane between the lesion and the posterior wall of the left atrium Figure , arrow. During administration of 5 mL of gadopentetate dimeglumine , T1-weighted inversion recovery gradient-echo myocardial perfusion imaging was performed which demonstrated heterogeneous dynamic contrast filling of the mass Figure . In addiThe patient remained asymptomatic during the 4-month follow-up period without local recurrence on echocardiography.Primary cardiac tumors are rare with a reported prevalence of 0.001% to 0.03% on autopsy series . Of thesClinical presentations of cardiac paraganglioma range from an incidental finding  to constThe incidence of malignancy is reported to be approximately 10% . HoweverCardiac paragangliomas are echogenic masses on echocardiography and are reported as circumscribed, heterogeneous masses with low attenuation on un-enhanced CT  with mar131I or 123I metaiodobenzylguanidine or 18F-DOPA, which are actively transported into neurosecretory granules of catecholamine-producing cells [18F-DOPA PET studies have yielded promising results in the imaging of pheochromocytoma [18F-DOPA by the paraganglional cells of the lesions, as showed in our case.These lesions can be localized using very specific radiotracers such as Due to its higher spatial resolution and multiplanar image acquisition, CMR is considered an important technique in diagnosis and characterization of cardiac tumors. Cine SSFP and pre-contrast T1- and T2-weighted imaging are useful for evaluation of anatomic features, whereas first pass dynamic perfusion and late gadolinium enhancement sequences are important in assessment of vascularity.As seen in our patient, cardiac paragangliomas are typically iso- or hypo-intense relative to myocardium on T1-weighted, and markedly hyper-intense on T2-weighted images . They arSurgical resection of cardiac paraganglioma results in complete cure and relief of symptoms ,12. SurgThe combination of CMR with various image acquisition sequences in multiple orientations and PET-CT studies, provides a powerful tool for non-invasive morphological assessment and tissue characterization of cardiac paraganglioma, especially when correlated with clinical history and appropriate biochemistry evaluations.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors were involved in the conception and design of the manuscript, acquisition of data, drafting the manuscript, critical revision of the manuscript for intellectual content, and final approval.


Undifferentiated endometrial sarcomas (UESs) of the ovary are very rare tumors. This paper presents a case of a 56-year-old patient with a history of hysterectomy and bilateral salpingectomy seven years ago for uterine leiomyomata. Intraoperatively, a tumor originating from the left ovary, adherent to the sigmoid colon, with infiltration of the small intestine and the vaginal apex was found. Histologically, the tumor was composed of pleomorphic round and oval to spindled cells with polymorphous vesicular nuclei with coarse chromatin and large nucleoli. Mitotic activity was brisk. There were large necrotic areas. Adjacent to the tumor tissue endometrium-like glands surrounded by fibrous stroma with macrophages corresponding to ovarian endometriosis were noted. Tumor cells showed diffuse strong immunoreactivity for vimentin and patchy strong staining for CD10; no reactivities were found for AE1/AE3, desmin, S-100, LCA, CD20, c-kit, and CD31. The patient died of her neoplastic disease four months postoperatively. CD10 is frequently expressed in different gynecopathological as well as other lesions, and, thus, nonspecific without relevance to the classification of this case. Morphological features, extensive sampling, and appropriate immunohistochemistry including markers for cytokeratins and myogenic differentiation are mandatory to arrive at the correct diagnosis. Ovarian endometrioid stromal sarcomas (ESSs) are rare tumors with about 50 cases reported in the literature. They are composed of cells resembling the stromal cells of normal proliferative endometrium. These tumors are reported at any age, but most of them occur in the fifth and sixth decades. At presentation, the symptoms are nonspecific and attributable to the presence of a pelvic mass. At the time of operation, most of ovarian ESS are high stage –6.Previously, ESSs in general and in the ovary were categorized in low and high grade tumors based on mitotic counts. High grade ESS of the ovary accounted for 17% of cases only in one study , 5. HoweA 56-year-old patient presented with a tumor of the left ovary, which was found during abdominal sonography. She noted an increase of her abdomen associated with a feeling of swelling. Her history was remarkable for hysterectomy and bilateral salpingectomy seven years ago for uterine leiomyomata. Gynecological examination showed a tumor filling the pelvis minor. Computed tomography revealed a 12 × 9 cm partially solid, partially cystic lesion of adnexal origin; no enlarged lymph nodes were identified.Intraoperatively, a tumor originating from the left ovary and adherent to the sigmoid colon, the small intestine, and the vaginal apex was found in the pelvis minor. The right ovary was unremarkable. Tumor, vaginal apex, omentum majus, a segment of the small intestine as well as right ovary were removed; there were no ascites and no clinical impression of residual tumor.μm. Besides hematoxylin and eosin staining (H&E), a standard immunohistochemical testing was conducted using a BenchMark series automated slide stainer  with commercially available antibodies form DAKO  to the cytokeratin marker AE1/AE3 (1 : 50), desmin (1 : 50), vimentin , MIB-1 (1 : 100), LCA (prediluted), S-100 (1 : 200), CD20 (1 : 4) as well as prediluted ready-to-use antibodies from Ventana to c-kit, synaptophysin, estrogen- and progesterone receptor, CD31 and CD10. Additionally, a reticulin-staining after Gömöri was performed.The tumor was submitted for frozen section examination, and a diagnosis of an undifferentiated ovarian neoplasia was given. The resected specimens were fixed in 10% neutral buffered formaldehyde solution. The tumor was surrounded by a smooth capsule, which showed broad defects. The cut surface consisted of gray-yellowish friable and partially necrobiotic tissues. Stainings were carried out on sections of the paraffin-embedded tissue blocks cut at 3 Histologically, the tumor was composed of pleomorphic round and oval to spindled cells. Their nuclei were polymorphous vesicular with coarse chromatin and large nucleoli . The cytImmunohistochemically, tumor cells showed diffuse strong reactivity for vimentin and patchy strong staining for CD10 in about 50% of cells ; there wThere was histological evidence of tumor infiltration in the resected specimens of the vaginal apex and the segment of the small intestine with microscopically positive margins at the latter. The right ovary as well as the omentum majus was free of tumor. The sections of the previous hysterectomy specimen were reviewed; they showed benign leiomyomata and discrete foci of adenomyosis without architectural or cytological atypia, and there was no evidence for sarcomatous changes.Based on these findings the tumor was interpreted as high-grade ESS or UES, respectively, of the ovary with infiltration of the vaginal apex and the small intestine.There was no postoperative adjuvant therapy. A second-look laparotomy two months later was done due to a CT scan showing an intestinal mass and revealed a conglomerate tumor of 10 × 10 cm, involving small and large intestine. This tumor was biopsied only and was histologically identical to the previously diagnosed UES. The patient was referred to an oncological center for radiation therapy and died four months postoperatively of her neoplastic disease.The common acute lymphoblastic leukemia antigen (CALLA or CD10), a 90 to 110-kDa membrane-bound endopeptidase, is expressed on the cell surface of most cases of acute lymphoblastic leukemia, other types of leukemia, as well as lymphomas and nonhematopoietic neoplasms . This ceAlthough CD10 has been considered a marker for ESS , some stCD10 expression of UES of the ovary is not well characterized. The previously published data are mainly available on uterine high-grade ESS. In such tumors, McCluggage and Sumathi  observedThere are several aspects that need to be considered in the differential diagnosis of the presented case. UES of the ovary should be diagnosed only after excluding an undifferentiated carcinoma, malignant mixed Müllerian tumor or carcinosarcoma, respectively, and high-grade myogenic sarcoma. Therefore, extensive sampling to exclude skeletal or smooth muscle differentiation or even small foci of carcinoma is mandatory . RecentlKurihara and Oda recommended a new terminology and classification of non-low-grade endometrial sarcomas . They diSince this case of ovarian UES infiltrated the intestines, the possibility of a gastrointestinal stromaltumor (GIST) must be considered. Indeed, a recent study by Irving and Lerwill reported on gastrointestinal stromal tumors metastatic to the ovary . These aESS metastatic from the uterus must be excluded before giving a diagnosis of primary ovarian ESS or UES, respectively . The patIn conclusion, CD10 immunoreactivity must be interpreted with caution since CD10 is frequently expressed in different gynecopathological as well as other lesions and, thus, nonspecific. Sarcomatous overgrowth of Müllerian adenosarcoma and high-grade leiomyosarcoma is important entities entering the differential diagnosis. Morphological features like association with ovarian endometriosis in this case, extensive sampling and appropriate immunohistochemistry including markers for cytokeratins and myogenic differentiation are mandatory to arrive at the correct diagnosis. Based on the recent literature and the findings in this case, CD10 immunoexpression is of no diagnostic value and not indicative as evidence for endometrioid stromal differentiation. UES should be considered as a high-grade sarcoma with no specific differentiation .


Solitary fibrous tumor (SFT) is an uncommon neoplasm that usually arises from the pleura. To our knowledge, only 30 cases of SFTs in the nasal cavity and paranasal sinuses have been reported in the literature. We describe an SFT that arose from the right sphenoid sinus and extended to the nasal cavity and epipharynx. The tumor was completely removed by endoscopic sinus surgery without complication. The patient is taking an uneventful course without any evidence of recurrence of the disease 8 months after surgery now. Solitary fibrous tumor (SFT), also known as benign fibrous mesothelioma or submesothelial fibroma, is an uncommon neoplasm first described as a primary spindle cell tumor of the pleura in 1931 . RecentlThe patient was a 74-year-old woman with a right nasal tumor that had caused progressive right nasal obstruction over two years. Nasal endoscopy revealed a pinkish tumor arising from the ostium of the right sphenoid sinus and extending to the right nasal cavity and epipharynx Figures . Plane-computed tomography (CT) showed a soft tissue density in the nasal cavity, sphenoid sinus, and nasopharynx without bone destruction on the right side. Magnetic resonance imaging (MRI) showed a mass with a hypointense signal on T1-weighted images  and heteThe ESS was performed under general anesthesia. During the sphenoethomoidectomy, the root of the tumor was clearly identified on the lateral edge of the ostium of the right sphenoid sinus. The tumor was successfully resected “en bloc” and was removed through the oral cavity . The posHistopathological examination of the tumor revealed the spindle cells showing a patternless arrangement within the collagenous matrix and numerous thick-walled vessels with dilated vascular spaces . ImmunohThe first identification of SFT as a distinct entity is generally credited to Klemperer and Rabin . PlueralAn SFT typically presents as a slow-growing, painless mass. To date, 30 cases of SFTs in the nasal cavity and paranasal sinuses have been reported in the English literature , 13–19. SFTs have, however, been reported to be malignant in 13%–23% of cases. Factors associated with malignancy include high cellularity, more than 4 mitoses per 10 high-power fields, pleomorphism, hemorrhage, and necrosis . The diagnosis of malignancy is based on both clinical features and these histologic findings , 15. ProSince ESS for SFT was first described in 2003  in the cESS is considered the first-line approach for achieving the complete removal of benign tumors such as an SFT, as long as it is delineated within the level of the nasal cavity and paranasal sinuses except the frontal sinus. However, the STFs extended to the skull base; these tumors should be removed through a transcranial approach or an open transfacial approach –19.


Five patients with papillary adenocarcinoma of the common bile duct (CBD) are described.These are rare tumors and make up 5% of all malignant tumors of the biliary tract. Thesymptoms and signs at the time of initial diagnosis resemble benign obstructive lesions of the bileducts. The tumor is soft, less invasive to adjacent tissues and tends to grow into the lumen. Theearly onset of the symptoms results in early intervention, with a better prognosis. Two of ourpatients are doing well after two and four years, where as three others were readmitted withrecurrent disease.


Meckel's diverticulum represents a true diverticulum of the ileum containing all three layers of the bowel wall and is found on the wall of the distal ileum, usually about 2 feet from the ileocaecal valve. Although Meckel's diverticulum is a common congenital abnormality of the gastrointestinal tract, it is often difficult to diagnose. Patients with perforation of Meckel's diverticulum may present with right iliac fossa pain, which mimics acute appendicitis.A 17-year-old man presented with a 3-day history of lower abdominal pain. On examination, the patient had tenderness in his right iliac fossa. A provisional diagnosis of acute appendicitis was made. The patient was taken to theatre for laparoscopy with the option of appendicectomy. The appendix was found to be normal. An inflamed and perforated Meckel's diverticulum was found to be the cause of the abdominal pain. Meckel's diverticulectomy was performed. The patient made an uneventful recovery and was discharged with further follow-up in the outpatient clinic.Complications of Meckel's diverticulum can be fatal and early recognition leads to appropriate management. This case report highlights the importance of considering Meckel's diverticulum as a differential diagnosis of acute abdomen in a young patient. Meckel's diverticulum represents a true diverticulum of the ileum containing all three layers of the bowel wall and is found on the wall of the distal ileum, usually about 2 feet from the ileocaecal valve. It is the vestigial remnant of the omphalomesenteric duct and occurs in approximately 2% of the population, found twice as frequently in men as in women. Only 2% of those individuals who have Meckel's diverticulum are symptomatic and they tend to be typically below the age of two, thereby accounting for why this congenital gastrointestinal anomaly is comparatively better studied in adolescents than in adults.The complications caused by Meckel's diverticulum include intussusception and volvulus in adolescents and acute bleeding in adults . This isA 17-year-old man presented with a 3-day history of lower abdominal pain. He denied any other symptoms apart from weight loss of 6 kg over the past 2 months. On examination, the patient had tenderness in the right iliac fossa. He had been admitted 2 weeks earlier with rectal bleeding, and was transfused 4 units of red blood cells as his haemoglobin level had dropped to 6.0 g/dL. Gastroscopy and colonoscopy were performed and no abnormalities were found. He was then discharged home with further follow-up in the outpatient clinic.On this admission, vital signs were within the normal range. Routine blood tests, erect chest and abdominal X-rays were unremarkable. A provisional diagnosis of acute appendicitis was made and initial management included intravenous fluid resuscitation. The presence of peritonism in acute abdomen demands urgent surgical intervention. The patient was consented and taken to theatre for diagnostic laparoscopy with the option of appendicectomy under general anaesthesia.A normal appendix was identified during laparoscopic examination of the abdomen. An inflammatory mass was seen with turbid fluid collection in the pelvic area on laparoscopy. The inflammatory mass turned out to be a perforated Meckel's diverticulum. The adjacent loop of small bowel was grossly inflamed and dilated. Wedge resection of the perforated Meckel's diverticulum was performed with primary anastomosis of the adjacent small bowel. A small piece of chicken bone was found within the Meckel's diverticulum. The patient made an uneventful recovery postoperatively and was discharged on day 5 with further follow-up in the surgical outpatient clinic.Meckel's diverticulum was originally described by Fabricius Hildanus in 1598. However, it is named after Johann Friedrich Meckel, who established its embryonic origin in 1809. Although Meckel's diverticulum is a common congenital anomaly of the gastrointestinal tract, it is often difficult to diagnose.A very small percentage of ingested foreign bodies can cause perforation of the bowel, leading to acute abdomen requiring surgical intervention. Foreign bodies such as dentures, fish bones, chicken bones, toothpicks and cocktail sticks have been known to cause bowel perforation. There are more than 300 cases in the literature of bowel perforation caused by foreign bodies . The majThe most common site of perforation is the terminal ileum and colon, although an increased incidence of perforation has been reported in association with Meckel's diverticulum, the appendix and diverticular disease. Perforation of Meckel's diverticulum is usually caused by foreign bodies, a very rare complication as most foreign bodies pass through the gastrointestinal tract without any consequences. Perforation of Meckel's diverticulum caused by a chicken bone has rarely been reported in the literature -5.Perforation of Meckel's diverticulum remains a differential diagnosis of right iliac fossa pain. Meckel's diverticulum is notoriously difficult to diagnose both clinically and radiologically as the symptoms and imaging features are non-specific. The utility of Tc99m-pertechnetate scintigraphy in the diagnosis of ectopic gastric mucosa is well established, particularly in the case of Meckel's diverticulum, despite substantial variation in the reported sensitivity. Radiological as well as clinical findings aid clinicians in diagnosing this congenital anomaly. Perforation of Meckel's diverticulum caused by a chicken bone is a very rare complication and may lead to a fatal outcome if not recognised early.Complications of Meckel's diverticulum could be fatal. Early recognition leads to appropriate treatment. This case therefore highlights the importance of considering Meckel's diverticulum as a cause of acute abdomen.The author declares that they have no competing interests.CKW was involved in the conception of the report, literature review, manuscript preparation, editing and submission.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Fecaloma is a mass of feces accumulated that is much harder in consistency than a fecal impactation. The aim of this report is to give a brief review of this entity and discuss the treatment options for these cases.We present the case of a 12-year-old boy who developed a fecaloma associated with chronic constipation. This is a rare case on a child which was treated by a sigmoid colectomy after failure of conservative measures of evacuation.Fecaloma should be considered in the differential diagnosis of patients with history of chronic constipation and abdominal mass. Fecaloma is a mass of feces most frequently noted in the rectum and sigmoid, that is much harder than a fecal impactation due to coprostasis. Usually, the fecal matter accumulates in the intestine, then stagnates and increases in volume until the intestine becomes deformed and acquires characteristics similar to those of a tumor . There aWe report a case of 12 years old boy, black, student who was admitted to our department for a 1 year progressive slowly growing of not painful abdominal mass occupying the right flank and right-lower quadrant. The patient had history of chronic constipation of 2 years referring 1 bowel movements every third-fourth day with hard stools. He denies symptoms of vomiting, nausea, diarrhea, fever, hematocquezia, hematuria, anorexia, lost weight. Not learning or mental disabilities were reported from his parents.The patient was hospitalized previously four times during his life by history of constipation treated with laxatives and enemas and discharged with food recommendations. Only family history of diabetes in his grandmother.On initial evaluation, the patient had a temperature of 37°C, blood pressure of 100/70 mm Hg, a heart rate of 85 beats per minute, a respiratory rate of 18 breaths per minute, with weight 30 kg and height 133 cms .Physical examination revealed a good general condition, cardiac and lungs examination were unremarkable. Abdomen without scars, soft, not distended, tympanic in 4 quadrants, normoactive bowel sound, palpation revealing an abdominal mass smooth, mobile, nontender in the lower right flank and quadrant of ± 13 cm of diameter. Rectal examination revealed no palpable stool in the rectal vault and was hemoccult negative. No malformations were finding during the examination.The laboratory test parameter during admission were: hemoglobin 13.2 g/dl, hematocrit of 39.5%, WBC 5.500, platelets 374.000 mm3; creatinine 0.8/BUN 70, Na:142, K:4.3, urinalysis and liver function tests were normal. Stool samples for parasites were negative.Intravenous pyelogram revealed a large rounded mass of approximately 12 cm. in diameter at the colon which seemed to have an irregular mottled texture. The right ureter seemed to be somewhat displaced by the mass that produce a slightly enlargement of the renal pelvis Fig. . RoentgeUltrasound of the abdomen showed a mass arising probably from the intestine with no evidence of hydronephrosis.The flexible rectosigmoidoscopy was done and only passed through 25 cm of rectum which presented a normal rectum with a roomy sigmoid colon and a large, firm fecal ball. Sigmoidoscopic rectal biopsies were not performed and fragmentation was attempted but abandoned because of pain during the procedure. Repeated enemas and laxatives were unsuccessful in evacuating the fecal mass.The patient underwent elective laparotomy. Preoperative bowel cleaning was performed with phosphosoda solution and lavage with warm saline until evacuations were liquid without fecal residue. A 20-cm midline incision  was made. During the procedure we founded an enlarged sigmoid colon lateralized to the right showing a large, rock-hard mass, smooth and ovoid in shape, measuring about 14 cm, which appeared to be a hardened mass of feces. The rest of the colon appeared normal and empty.The sigmoid colon with the mass was resected Fig.  and an eExamination of the gross specimen after incision of the intestinal wall showed a firm fecal mass covered with a white material (barium) which filled the lumen but was unattached to the wall of the colon Fig. . No lesiFecal impactation is a common condition and fecaloma is an extreme variety of impactation that refers to an accumulation of fecal material which forms a mass separable from the rest of the bowel contents. This condition is uncommon and the majority of reported cases have been in adults. Symptoms of fecaloma are usually nonspecific with "overflow "type of diarrhea, constipation, weight loss and vague abdominal discomfort after meals. Constipation was the main symptom referred by our patient. In fact, constipation is one of the most frequently experienced gastrointestinal complaints and one of the most frequent indications for medical consultation .The composition of the mass is quite inconstant, but usually consists of fecal matter and intestinal debris . Often iIn our case, ganglion cells were not found in the myenteric plexus in the affected part of the colon histopathologically, and nerve trunks in this part were both hyperthrophied and increased in number. However, these primary abnormalities were probably due to a lack of migration of the neuroblast into the alimentary tract during the embryologic development. This alteration can be attributed as the main factor to develop a fecaloma in our patient.Fecaloma should be considered in the differential diagnosis of any patient with history of chronic constipation and abdominal mass. Often the diagnosis can be made form the clinical and radiologic features. In the beginning, therapy should be conservative. Rarely laparotomy is required to remove the mass.The authors declare that they have no competing interests.JGR was a major contributor in writing the manuscript. EE and LC were the surgeons that perform the laparotomy with JGR. TH with LC were the attendings for the department of pediatrics and surgery that follows the patient after discharge. RE performed the histological examination of the sigmoid colon. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's mother for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


To the Editor: Mycobacterium tuberculosis can affect any part of the gastrointestinal tract from the mouth to the anal canal along with the other organs of the peritoneal cavity, but the gall bladder is unlikely to be primarily involved. The incidence of localization of the tubercular bacilli in the gall bladder is uncommon as the intact gall bladder mucosa is resistant to the bacterium because of the concentrated bile acids present in the organ. The spread of infection to the gall bladder could be hematogenous, from an adjacent caseating lymph node or from the peritoneum.12A 26-year-old female presented to the surgical outpatient department with right upper on-and-off abdominal and epigastric pain with dyspepsia for 8 months. After taking a detailed clinical history, ultrasonography of the abdomen revealed a thickened gall bladder wall with multiple gall stones, leading to a diagnosis of chronic cholecystitis with cholelithiasis. Gastroduodenoscopy of the patient was normal. X-ray of the chest and all other hematological parameters were also normal. The patient underwent a routine laparoscopic cholecytectomy, which was uneventful. After the extraction of the gall bladder, the specimen was opened to reveal a palpable nodular induration in the wall at the fundus of the organ. As facilities for frozen section biopsy were unavailable, and the possibility of malignancy was present, an imprint cytology was sent, which demonstrated abundant epithelioid-like cells with some necrosis. No malignant cells were seen. The surgery was terminated and the histopathology closely followed. Tuberculosis of the gall bladder showing caseous necrosis with Langhans' giant cells with epithioloid cells and lymphocytes  was diag7The first case of tuberculosis of the gall bladder was described in 1870 by Gaucher.1There are no pathognomic features for the preoperative diagnosis of gall bladder tuberculosis


Background. Epstein-Barr virus (EBV)-related smooth muscle neoplasms (SMNs) have been associated with immune dysregulation, most notably in patients who have undergone solid organ transplantation or in patients with HIV/AIDS. Objective. to report our experience with EBV-related neoplasms as well as describing the first EBV-related SMN in the setting of administration of glucocorticoids and the tumor necrosis factor inhibitor etanercept. Design. We have case reports, of minimum 3-year follow-up, 2002–2005. Setting. It was held in an academic and tertiary referral cancer center. Patients. Patients are with dysregulated immunity after solid organ transplantation, HIV/AIDS, or with psoriasis after treatment with etanercept. Interventions. There were discontinuation of etanercept, right hepatic trisegmentectomy, and chemotherapy. Measurements. We use survival as a measurement here. Results. Patients who were able to withstand reduction in immunosuppression survived. Surgical resection or chemotherapy was successful in delaying progression of disease. Limitations. There was a relatively short follow-up for these slow-growing neoplasms. Conclusion. EBV-related SMNs have variable aggressiveness. While chemotherapy may slow disease progression, resection and improving the host immune status provide the best opportunity for primary tumor control. Immunocompromised patients have anincreased incidence of immunosuppression-associated malignancies. Whileunusual, smooth muscle neoplasms (SMNs), such as leiomyomas andleiomyosarcomas, occur at a greater frequency in immune-dysregulated patientscompared to the general population , 2. SMNWe report three cases of EBV-associatedSMN, one in a patient with psoriasis who had received the tumor necrosis factor(TNF) antagonist etanercept, and describe our institution’s recent experiencewith this entity.Patient 1. A 55-year-old Asian man presented in 2002 with hepatitis B, hypertension, penilecarcinoma status postresection and lymphadenectomy in 1988, and chronic renalinsufficiency. He had undergone cadaveric renal transplant in 1994 and remainedrejection free on cyclosporine, azathioprine, mycophenolate mofetil, andprednisone.In March 2002, hedeveloped abdominal pain and a 15-pound weight loss. Computed tomography (CT) scans (7/02)revealed an unresectable 14 cm caudate-based mass; multiple pulmonary noduleswere visualized. Alpha-fetoprotein level was normal. Core needle biopsydemonstrated a well-differentiated SMN. His immunosuppressive therapy was notreduced because of the likelihood of transplant rejection. The patient refusedsystemic chemotherapy. By November 2002,he developed jaundice and increasing debilitation. CT scan revealed rapiddisease progression with pulmonary metastases and ascites. He died later thatmonth.Patient 2. An 18-year-old woman diagnosed with congenitalAIDS began to experience abdominal pain at age 11, in 1995. Colonoscopy was initiallynegative, but laparoscopy in 1997 revealed a well-differentiated SMN arisingfrom the rectosigmoid, unchanged in 1998 and 1999 on subsequent colonoscopies. InOctober 2002, during an evaluation for persistent abdominal pain and areflexiain the left ankle and knee, magnetic resonance imaging (MRI) revealed multipleabdominal and paraspinal masses. She underwent resection of the lumbarparaspinal tumor and rod placement. Pathology demonstrated an EBV-related SMN.By 2003, CD4count was 8, and viral load was 15 000. Medications included stavudine andlamivudine. She then presented, wheel-chair bound, with fatigue and refractoryabdominal pain, weighing 19 kg. Eastern Cooperative Oncology Group (ECOG)performance status was 4. CT scans (3/03) demonstrated low-attenuation lesionsin the liver and a 9 cm mass arising between the stomach and the liver. She demonstratedmarked clinical improvement after starting doxorubicin in October 2003, and 5–10% decrease inmasses on reimaging. She interruptedtherapy in mid 2004, starting dacarbazine in November 2004 for persistent diseaseaffecting the chest, abdomen, and paraspinal areas. Despite her noncomplianceand neutropenia, the tumors decreased in size further, her weight doubled, shebegan to walk, and has an ECOG performance status of 1 as of January 2006. Sheis still alive with disease (AWD) but without progression as of last follow-up inOctober 2008.Patient 3. The patient is a 25-year-old woman with left kidney agenesis, history ofpsoriasis since childhood, and seven episodes of shingles. In August 2004, shebegan intravenous etanercept. One month later, she developed left cervicallymphadenopathy and right lower extremity numbness and tingling. A positivemonospot test led to a diagnosis of mononucleosis. Etanercept was discontinued;her symptoms resolved. In October, she began prednisone (40 mg daily) treatmentfor increasing dyspnea attributed to asthma; this was tapered off in January2005 when she saw her primary care provider and chest radiograph revealedbilateral infiltrates. Chest CTdemonstrated infiltrates andthree liver lesions. Lung biopsy revealed Pneumocystiscarinii pneumonia. CT scan (1/05) confirmed three liver lesions, thelargest measuring 7 cm with central necrosis. Fine needle aspiration of a liver mass revealed a well-differentiated SMN.CT scan (4/05) noted that the largest liver lesion was 7.5 cm in size. Subsequent CTscan (8/05)revealed no change. Positron emission tomography (PET) scan (9/05) showedtracer uptake in the liver lesions ( lesions . In Octo lesions . She remμm) and stained withhematoxylin and eosin for conventional histology. IHC analysis was performedusing standard techniques with the following antibodies : HHF-35, smooth muscle actin (SMA),desmin , CD117 , S100 protein , and HMB-45.Formalin-fixed,paraffin-embedded tissue blocks were sectioned (4 Detection of EBV-encodedearly RNA transcripts (EBER 1 and 2) was performed using biotin-conjugatedoligonucleotides , using standard protocols according to the manufacturer’sinstructions. The positive control used was a posttransplant EBV-associateddiffuse large cell lymphoma. All steps were performed under RNAse-freeconditions.Tissue for EM was available in Case 3.Representative fresh tumor was fixed in 3% formaldehyde—3% glutaraldehyde, postfixed in 1% osmiumtetroxide, embedded in epoxy resin, and stained with uranyl acetate-leadcitrate using standard procedures. The thin sections were examined using aPhilips-410 electron microscope.All patientsamples were positive for EBV-EBER by ISH , and theThe liverspecimen from Patient 3 revealed multicentric EBV-associated SMNs consisting offour nodules ranging in size from 0.4 cm to 6.7 cm . ModeratMultiple lines of evidence implicate EBVin the formation of SMNs , 8. EBVHistologically, EBV-associated SMNs havea mild to moderate increase in cellularity, low mitotic count (<1/10 HPF),and little to no areas of necrosis. Others have reported foci of primitive-roundedcells and intratumoral T lymphocytes , 15, butIn a literature review of 19 reports ofEBV-associated SMNs following organ transplantation , SMNs ocImmunosuppression predisposes patients tothe development of SMNs, first described 40 years ago . InitialIn our caseseries, the three patients with SMNs were immunodeficient for different reasons. WedescIn summary, these cases highlight thevariable aggressiveness and clinical outcomes of SMNs in patients withimmunosuppression on the basis of autoimmunity, iatrogenic immunosuppression,and that caused by HIV. Chemotherapy and surgery both play a role in patientswith these usually indolent diseases. It remains to be seen whether effects onEBV itself with antiviral agents or with EBV-specific T cell therapy  mightha


We present a case of giant cavernous hemangioma ofthe liver with disseminated intravascular coagulopathy(Kasabach–Merritt syndrome) which wascured by enucleation. The 51 year old womanpresented with increased abdominal girth and easybruisability. Workup elsewhere revealed a massivehepatic hemangioma and she was started on radiationtherapy to the lesion and offered an orthotopicliver transplant. After careful preoperative preparation,we felt that resection was possible and sheunderwent a successful enucleation. The operationand postoperative course were complicated bybleeding but she recovered and remains well infollowup after 6 months. All coagulation parametershave returned to normal. Enucleation shouldbe considered the treatment of choice for hepatichemangiomas, including those presenting withKasabach–Merritt syndrome. The benefits of enucleationas compared to liver transplantation forthese lesions are discussed.


Sebaceous gland carcinoma, commonly arises in the periocular area, is an uncommon condition. It represents 1–5.5% of eyelid malignancies and is considered to be the third most common eyelid malignancy after basal cell and squamous cell carcinomas, although few reports placed this tumor as second most common after basal cell carcinoma. It usually affects elderly women and characterized by high rate of local recurrence, regional, and distant metastases. A delay in diagnosis, which can be attributed primarily to ability of this tumor to masquerade as more benign conditions, often leads to inappropriate management with increased morbidity and mortality rates. In this study, the authors discuss key elements of the primary disease and therapeutic options available to treat such devastating problem. Sebaceous gland tumor of the eyelids may arise from the meibomian glands, glands of Zeis or glands associated with the caruncle. They areSebaceous glands are located in the periocular skin, caruncle, and eyebrow skin follicles. The tumor is a very rare, slow growing, and commonly found in elderly population with female predisposition. Mean age at diagnosis is mid-sixties; however, the tumor has been reported in children as young as 3.5 years old. It is ra33On one hand it can mimic as benign lesion as blepharoconjunctivitis, whereas on the other extreme it can have widespread local and fatal distant metastases. Immunohistochemistry, molecular biology, and electron microscopy have greatly improved the diagnosis, management, and prognosis of SGCs overall. Surgery, chemotherapy, and radiotherapy all contribute to the treatment of SGC.The literature was reviewed using online searches of PubMed (1985–2010), OVID, and Google Scholar. The search strategy included MeSH and natural language terms using the keywords mentioned. Reference lists in retrieved articles, and textbooks, were also searched for relevant references.With its two parts; the epithelial or epidermis and the cutaneous or dermis, the skin of the eyelid is the thinnest in the body. Anatomically, the eyelid can be divided into two lamellae. The anterior lamella contains skin, orbicularis muscle, eyelashes, and their follicles whereas the posterior lamella has mucocutaneous junction, meibomian gland orifices, and tarsal plate.The dermis contains sebaceous glands which are found in the tarsal plate, caruncle, and eye brow. There are approximately 25 such oil producing sebaceous glands in the upper tarsal plate and 20 in the lower. Glands of Zeis are small, modified, sebaceous secreting glands that open into the hair follicles at the base of the eyelashes.in situ.Two important features differentiate sebaceous carcinoma from other periocular malignancies. First, unlike single origin of other tumors, sebaceous carcinoma appears to arise from multifocal origins. Second, unlike radial spread of basal cell and SCCs, SGC tends to spread superficially in a pattern known as pagetoid spread.8 This spImmunohistopathology shows that the cells occur in irregular lobular masses with distinctive invasiveness. The cytoplasm is pale, foamy, and vacuolated . This feSGC has a tendency to invade the periocular region. Upper eyelid is most commonly involved followed by the lower eyelid and the caruncle.It bears no characteristic clinical appearance, but pagetoid infiltration of conjunctival epithelium or skin epidermis is a hallmark of this tumor. It is one of the most dangerous eyelid tumors due to; a) the tumor masquerading as inflammatory conditions such as blepharo-conjunctivitis, chalazion or superior limbic keratoconjunctivitis,–12 or as35568In general, there are two main pathological presentations of the SGC - nodular and spreading.In over 50% cases, SGC may present as a pseudochalazion or a chronic blepharoconjunctivitis.–121617 T1216The spreading variety of SGC occurs in pagetoid form with diffuse intraepithelial infiltration of the lid skin.1113 This11An unusual variant of SGC may present as Muir–Torre syndrome which is characterized by squamous differentiation of the tumor, multiple sebaceous adenomas or carcinomas in the skin, and visceral malignancies.SGC is important to know because it is a notorious diagnostic pitfall for the clinician as well as the pathologist. It is the pagetoid spread or the dermal infiltration of the tumor that may confuse both the clinician and the pathologist. The clinician may misdiagnose SGC as blepharoconjunctivitis, and the pathologist as dysplasia. Accurate diagnosis and treatment of SGC are important because this tumor is the most aggressive of the epithelial tumors of the eyelid. Any unilateral blepharoconjunctivitis with loss of eyelashes, thickening of the lid margin and that fails to respond to the treatment should be biopsied, so should be any suspicious area of conjunctiva or the limbus.Sebaceous gland hyperplasia constitutes 8% of caruncular growths. SGC of caruncle may involve mucous membrane graft of the defect after excision of the tumor.The systemic extension of the tumor can occur by continuous growth, lymphatic spread, or hematogenous spread. The most common sites of spread are orbit, preauricular and/or submandibulr nodes, and parotid gland. The less common sites of extension include cervical nodes, lung, pleura, liver, brain, pericardium, lips, ethmoid sinus, or skull.5618195618Diagnosis is frequently difficult due to two main reasons; (1) in early stages the external signs are quite subtle, resembling a benign lesion such as a chalazion or chronic blepharoconjunctivitis and (2) the presence of yellowish material within the tumor gives it resemblance to SCC.Thus, due to high index of suspicion, it becomes mandatory to include SGC in the differential diagnosis of most eyelid masses and recurrent, nonresponding eyelid inflammatory conditions.A delay in clinical diagnosis of SGC can be attributed primarily to its ability to masquerade as more common benign eyelid conditions. This often leads to delayed management with increased morbidity and mortality rates. The actuThe list for SGC includes; congenital sebaceous gland hyperplasia which is common on face or scalp or acquired sebaceous gland hyperplasia which is common on face or forehead. Adenoma sebaceum of Pringle is another diagnosis to consider. It is found in tuberous sclerosis and commonly located in the nasolabial fold and cheek areas. Sebaceous adenoma is common on the eyebrows and eyelids.SGC is included in the group of simulating lid lesions .Occasionally, SGC may diffusely infiltrate conjunctival epithelium. This may resemble lesions such as chronic blepharoconjunctivitis, superior limbal keratoconjunctivitis or cicatricial pemphigoid, and BCC. The tumor may mimick chronic inflammation and even grow bacteria on repeated cultures but does not improve with antibiotics. Conjunctival scrapping may reveal the underlying SGC pathology. Due to such mimicking, SGC is one of the forms of masquerade syndromes. Diffuse intraepithelial sebaceous carcinoma closely resembles SGC in its rarity and indolent course; however, the former is not an obvious primary tumor of the eyelid and may not require exenteration. Papilloma simulates SGC and sometimes may be differentiated only by histology.SGCs are often inadequately treated at first intervention. Different treatment modalities include local excision, orbital exenteration, radical neck dissection, radiation, or chemotherapy depending on the stage of the tumor at the time of presentation. Wide excision at an early stage is important. Prior to surgical excision, it is important to examine the patient carefully for evidence of pagetoid spread or multicentric origin by double eversion of the eyelids, and any conjunctival alteration such as telangiectasia, papillary change, or a mass. In such an instance, conjunctival punch biopsies should be taken in addition to surgical resection of the lid lesion.Surgical treatment may range from a local excision to orbital exenteration . Radical18The advantages of Moh’s micrographic surgery, in comparison to a conventional excision of nonmelanotic skin cancer are; (1) definitive margin excision and (2) minimal loss of surrounding normal tissue.Few patients with regional nodal metastasis remain alive for long time, and radical neck dissection for isolated cervical node disease is often indicated. Local no718Topical mitomycin C has been tried for pagetoid invasion of the conjunctiva by eyelid SGC. CryotherRadiotherapy is usually avoided or may even be contraindicated because of its adverse side effects such as subsequent conjunctival keratinization leading to dry eye, lid atrophy, skin necrosis, lash loss, lid telangiectasia, ectropion, epiphora, keratopathy, cataract, higher rThe reported results of proton electron irradiation in SGC are not excellent.26 Radiot726The overall mortality rate is 5–10% because of frequent difficulties, mistakes in diagnosis, and delay in the treatment. The mortality from metastasis may go up to 25%. The adverse prognostic features include involvement of upper or both eyelid and tumor size of 10 mm or more. Others include duration of symptoms more than 6 months , poorly differentiated tumors, infiltration into blood vessels and/or lymphatics, orbital extension, multicentric origin, and finally pagetoid spread. Tumors less than 6 mm have excellent prognosis. Prognosis of SGC arising from glands of Zeis is more favorable.It goes beyond doubt that SGC is a great mimicker. On one hand, it mimics as simple a clinical condition as blepharitis, on the other hand it may turn out to be a fatal metastatic tumor.