Angiomyofibroblastoma is a benign soft tissue tumor with tendency to arise in the vulva.We report a 36-year-old Greek Caucasian man presenting with a left inguinal painless mass. This is the second case of angiomyofibroblastoma of the spermatic cord. At operation, a 4.5 cm well-circumscribed solid tumor was found adherent to the spermatic cord. The tumor consisted of spindle-shaped cells proliferating in short fascicles between numerous medium-sized blood vessels with thin and hyalinized walls. Neoplastic cells had eosinophilic cytoplasm with neither mitotic figures nor nuclear atypia. The stroma included abundant mast cells and few mature lypocytes. Immunostaining showed positivity for vimentin, CD34, desmin and smooth muscle actin. Our patient was treated by simple excision and was followed up for five years with clinical examination and ultrasonography, revealing no evidence of local recurrence or metastasis.This unusual neoplasm should be distinguished from aggressive angiomyxoma and other myxoid malignant tumors with widespread metastatic potential. The purA 36-year-old Greek Caucasian man presented with a left inguinal painless mass that had been growing slowly for six months. During operation, a 4.5 cm well-circumscribed solid tumor was found adherent to the spermatic cord. The testis and the epididymis were not involved. The lesion was pale gray with a vague lobular and focally glistening cut surface. On microscopic examination, the tumor was well-demarcated and consisted of spindle-shaped cells proliferating in short fascicles between numerous medium-sized blood vessels with thin and hyalinized walls Figure . FocallyAMF is a recently-described soft tissue tumor characterized by unique morphologic features, a tendency to emanate from the vulva, and a benign biologic behaviour ,2. ThereThe cell of origin of AMF among males has not been identified with certainty. Regarding the female patients, it is believed that the tumor is derived from mesenchymal cells in the subepithelial myxoid stromal zone that extends from the endocervix to the vulva , this hyThe most crucial issue is to determine whether this case should be assigned to AMF or to aggressive angiomyxoma (AAM). The latter is a histologically benign soft tissue tumor, associated with a high risk of local recurrence as well as with local infiltration that often results in entrapment of nerves and mucosal glands, thus making complete excision difficult . It has Nevertheless, although desmin expression was previously thought to be specific of AMF, this protein is no longer considered as a reliable marker for distinguishing the latter from AAM, inasmuch as immunopositivity for desmin and muscle-specific actin has more recently been shown in a substantial proportion of AAM . RegardiThe differential diagnosis of AMF also includes smooth muscle tumors, peripheral nerve sheath tumors, glomus tumor, chondroid syringoma, myxoid malignant fibrous histiocytoma, angiomyolipoma, spindle cell lipoma and myxoid liposarcoma. The distinction between AMF and these tumors has been described in detail elsewhere . As mostAlthough the exact nosologic position of AMF is still surrounded by some controversy and requires further elucidation, we conclude that our case represents the second report of AMF of the spermatic cord, based on its conventional histopathologic and immunophenotypic features. Simple excision appears sufficient for the surgical management of AMF, whereas wide excision after histological examination is needed for the management of the related AAM, which is associated with a high risk of local recurrence and infiltration.Written informed consent was obtained from our 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.NT analyzed and interpreted our patient data, GG, SE and GR contributed equally in designing and writing the paper with NT. Meanwhile, NN was involved in drafting the manuscript and revising it critically. All authors read and approved the final manuscript.


Granular cell tumour, also known as Abrikossoff's tumour, is a rare entity occurring in the skin as well as in internal organs, more common among the third to fifth decade of life. It has often been described as a peripheral neuroectodermal tumour and its clinical behaviour is usually benign although malignant and multifocal forms are also known to occur.We report a case of multiple granular cell tumour in a 17-year-old Caucasian woman who presented with a nodular lesion in the popliteal cave, diagnosed as an Abrikossoff's Tumour, followed 2 years later by another soft tissue mass in the neck.This case is quite rare: only a few cases were presented in literature with an extended period of time before the clinical presentation of subsequent disease. Granular cell tumour (GCT) is an uncommon soft tissue neoplasm, first described by Abrikossoff in 1926 . It can We report a rare case of GCT in a young woman which first presented with a nodular lesion in the left popliteal cave and two years later showed a neck subcutaneous nodule.A 17-year-old Caucasian woman presented to our department with a palpable lesion in the left popliteal cave. Family history and past medical history were not of significant interest. The lesion appeared 9 months as a 0.5 cm mass, and had slowly enlarged, evolving into a 2 × 1 cm mobile subcutaneous nodule, with clinically distinct margins. The tumour was covered by apparently normal skin. At first the lesion was clinically suspected to be a fibrolipoma and so a simple surgical excision was performed. Histological examination revealed that large polyhedral cells arranged in sheets, with eosinophilic granular cytoplasm. Small oval nuclei were eccentrically placed. Mitotic activity was < 2/10 high power field (HPF). Histological features were suggestive of granular cell tumour. Immunohistochemical study of the nodule was positive for S100 protein, CD68 and p53 in less than 30% of cells. Surgical margins were positive for tumour involvement so a second radical excision including the skin and the subcutaneous tissue was performed. Second histopathological examination assured total excision , not significant nuclear to cytoplasmic (N:C) ratio and no pleomorphism detected, we graded both lesions as benign.Sites of metastases are mainly regional lymphatic nodes, brain tissue, skeleton and lungs.Initially Abrikosoff suggested that GCT originate from skeletal muscle cells and so referred to them as myoblastomas; this suggestion probably arose from examination of tumours of the tongue in which infiltration between the striated muscle bundles gave the impression of a muscular origin. Recent studies suggest derivation from Schwann cells of the peripheral nerves, and the presence of S100 protein supports this . The KP-The presentation of the second lesion in our patient makes this case report quite distinctive. Few cases were previously described with a second presentation such temporally far from the primary neoplasm.Even if 10-15% of granular cell tumours present with satellite nodules, in our case clonality was excluded due to the different topographic involvement occurred.Crawford and De Bakey  reportedThe treatment of choice for GCT is wide local excision. In the malignant variety, the treatment should include wide local excision with regional lymph node dissection and radiological evaluation for metastasis. Radiotherapy and chemotherapy are used with variable success, but their effectiveness remains unproven .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.GFM and PP performed the surgical procedures and contributed to the analysis of the clinical data. BB performed the histological examination of the lesion. VT and PG contributed to the interpretation of the data and to the discussion of the manuscript. VT was a major contributor in writing the manuscript together with IP. All authors read and approved the final manuscript.


Today, laparoscopy tends to become a useful alternative to open procedure for the surgical treatment of spleen disorders, offering at the same time a conservative approach for the management of selected spleen lesions such as posttraumatic cysts.This article describes two cases of posttraumatic splenic cysts, one of which was treated with laparoscopic total splenectomy and the second with laparoscopic cystectomy. The procedure was carried out successfully with no complications in both cases, and the patients were discharged a few days after the operation.Laparoscopy with preservation of functional splenic parenchyma, when feasible, should be the procedure of choice in cases of posttraumatic splenic cysts, as it provides safe and definite treatment with all of the other advantages of minimally invasive surgery. The great success and acceptance of laparoscopic cholecystectomy has developed strong trends towards the modification of nearly all intra-abdominal operations to laparoscopically-assisted procedures. Nevertheless, not all of these attempts achieved the same amount of success . RegardiIn the case of splenic cysts, the first trend suggested total splenectomy as the procedure of choice . HoweverA 38-year-old Caucasian woman presented to our clinic with the major complaint of abdominal fullness and left upper quadrant heaviness. The history mentioned a blunt abdominal trauma three years earlier. On physical examination, a large painless tumor was found in the left upper quadrant. The tumor was not mobile with the turning of the patient. Hematology was indiscriminatory, whereas tumor markers and indications for parasites were negative. Ultrasound revealed a large cyst evolving from the spleen and computed tomography (CT) showed a 5 × 4 cm cystic lesion of the spleen. The cyst was resected along with the spleen, using a standard technique laparoscopic splenectomy . Patholo3 of serous-bloody liquid. The cystic wall is fibrotic with epithelial lining, indicating a posttraumatic splenic pseudocyst”. No postoperative complications occurred and the patient was discharged five days after surgery with a negative abdominal ultrasound examination.A 37-year-old Caucasian woman presented to our hospital with acute abdominal pain after trauma in the left lower hemithorax seven hours prior. Computed tomography (CT) revealed a 5 cm cyst with liquid content, occupying the upper pole of the spleen, but no involvement of the liver, kidney and chest . LaparosAfter the overwhelming success of laparoscopic cholecystectomy, laparoscopic techniques have been applied to various surgical conditions of the abdomen, in an attempt to achieve analogous improvements . The splet al reported on two cases of splenic cysts with a history of preceding trauma out of 19 patients [et al found only one out of six such cases [Laparoscopy has also been employed in the management of splenic cysts of all kinds. All types of splenic cysts are rare . In a repatients , and Touch cases . Splenicch cases . True cych cases  and reprch cases .et al reported on two patients with posttraumatic splenic cyst who were treated with laparoscopic total cystectomy and splenorrhaphy, using a specifically developed intra-abdominal ultrasound probe in order to accurately determine the thinnest splenic parenchyma bordering the cyst [Before the 1980s, the treatment of choice for cysts of the spleen was total splenectomy . Neverththe cyst . Percutathe cyst .The clinical manifestation of the splenic cysts varies accordingto their size, location and complications. Most patients present with minor, non-specific symptoms of local compression of adjacent structures, such as local or referred pain and abdominal distension . SplenicLaparoscopy offers satisfactory visualization of the spleen. The avoidance of an upper abdominal incision leads to low postoperative pain and discomfort of the patient as well as to short length of hospital stay. It is a surgical procedure that offers complete treatment, better quality of life and increased self-manageability of the patient during the postoperative period, lower postoperative morbidity and mortality and, of course, better cosmetic results, which is essential to female and especially to younger patients, who are prone to traumatic lesions of the spleen. As a result, we believe that laparoscopy with preservation of functional splenic parenchyma, when feasible, should be the procedure of choice in patients with posttraumatic cysts of the spleen, as it provides safe and definite treatment with all the other advantages of laparoscopic surgery.


Tuberculosis is endemic in many counteries like India. It can infect any site in the central nervous system. However, islolated involvement of the sellar and suprasellar region is rare. Sellar tuberculoma with hemorrhage is even more rare. We present magnetic resonance (MR) findings in case of sellar and suprasellar tuberculoma with hemorrhage.A 40-year-old female patient presented with a 1-month history of persistent headache and blurred vision on the left side. A contrast-enhanced MR study revealed peripherally enhancing sellar and suprasellar mass with hemorrhage with compression of the left half of the optic chiasma. There was also evidence of infundibular thickening and enhancement of the adjacent dura. The mass was approached through a transphenoidal approach and was partially resected. Subsequent histopathology was suggestive of tuberculosis. The patient was put on anti-tubercular therapy. Patient reported significant improvement in symptoms. Follow-up MR done 8 months later confirmed complete regression of the mass.Because of its rarity, sellar tuberculoma is seldom considered in the differential diagnosis and is often mistaken for pituitary macroadenoma, which is the most common tumor in this region. Although rare, presence of infundibular thickening and enhancement of the adjacent dura should suggest the presence of a granulomatous lesion like tuberculoma. Intracranial tuberculosis is a common infection is India. However, involvement of the pituitary gland is very unusual. There are only isolated reports. To our knowledge, there are about 51 case reports of sellar tuberculosis.16101113–1510112A 40-year-old female patient presented with persistent headache and blurring vision on the left side for 1 month. She had no history of trauma or menstrual complaints. She was on hormonal replacement therapy for thyroid hormone deficiency for 2 months. She had no history or evidence of tuberculosis elsewhere in the body. A contrast-enhanced magnetic resonance (MR) study was performed. A sellar mass with suprasellar extension was seen. It appeared isointense, with multiple hyperintense areas on T1W images. Suprasellar extension of the mass was bulging to the left of the midline and was causing compression of the left side of the optic chiasma . The maset al.[et al.[Sellar tuberculosis is a very rare infection. It was first described long back in 1940 by Coleman l.[et al. There isl.[et al. The mostl.[et al.Pituitary apoplexy is a condition characterized by acute neurological symptoms due to hemorrhage in the pituitary. Pituitary adenoma is the predominant cause in a large proportion of the cases, and most of these are non-functioning macroadenomas. Other reOn MR imaging, tuberculomas closely mimic pituitary adenoma. They present as a largely isointense mass on T1 and T2W images with heterogeneous areas. Uniform, heterogeneous as well as peripheral rim-like enhancement is described, the non-enhancing areas being attributed to caseation necrosis. Other findings that have been considered useful include thickening of the pituitary stalk and enhancement of the adjacent dura.14Our index case showed a heterogeneous mass on T1W images with multiple hyperintense areas which bloomed on the GRE images, indicating hemorrhage. It was heterogeneous, predominantly hypointense on T2W images. On post-contrast images, it showed ring-like enhancement. The pituitary stalk was mildly thickened. The adjoining dura also showed enhancement. Although findings indicate the possibility of some granulomatous lesion, diagnosis of tuberculosis was not considered because of its rarity and due to the presence of the associated hemorrhage. A follow-up scan after surgery and antitubercular therapy showed that the mass had largely regressed. However, thickening of the pituitary stalk was still persistent, which has also been reported previously.[It has been suggested that in any sellar mass with thickening and enhancement of the pituitary stalk, diagnosis of tuberculosis should be considered especially in places where tuberculosis is endemic. Thickening of the pituitary stalk can also be seen in other conditions like sarcoidosis, lymphocytic hypophysitis, lymphoma and eosinophilic granuloma.14Hemorrhage in a sellar tuberculoma is extremely rare, with only two case reports in the literature.5 The firIn conclusion, sellar tuberculoma is a rare condition and is difficult to diagnose on imaging. The presence of hemorrhage is even more atypical. Findings that can be useful in diagnosis include ring enhancement, thickening of the pituitary stalk and enhancement of the adjacent dura. These features can help one to consider the possibility of some granulomatous condition and guide further investigations to reach the correct diagnosis.


Benign myoepithelioma is extremely rare in the lung, to the best of our knowledge; only five cases have been reported in the literature.An 18-years woman complained from tiredness and fever during four months. Laboratory findings and fibroscopies were normal. CT of the thorax demonstrated a nodule in the left segment of the Fowler. Left inferior lobectomy was performed comporting a firm nodule of 25 mm, lifting the bronchial mucous membrane. Histologically, there was a proliferation of small cells of a plasmocytoid-type, with a predominantly whorled pattern. No mitotic activity or necrosis was seen in the tumor. Immuhistochemically, the tumor cells positive for smooth muscle actin, vimentine, and S100 protein. They were negatives for cytokeratine, chromogranine and HMB45. The diagnosis of benign myoepithelioma of the lung is so confirmed. The patient recovered well at 6 months follow-up.Benign myoepithelioma is a rare pulmonary neoplasm distinct from pleomorphic adenoma, which should be considered in the differential diagnosis of lung nodules. The histological types of primitive "salivary gland-type" tumors arising in the lung are very infrequent. They are essentially represented by the mucoepidermoid carcinoma, the adenoid cystic carcinoma and the pleomorphic adenoma .Benign myoepithelioma is extremely rare in the lung, to the best of our knowledge; only five cases have been reported in the literature -5.An 18-years non-smoker woman complained from tiredness, fever and sweating essentially by night, and during four months. Physical examination was normal except a fever at 39°c. Laboratory findings particularly, complete blood count (CBC) revealed anemia of inflammation; immune-serology was negative for CMV, EBV, toxoplasmosis, HIV, B and C Hepatitis. Biochemical tests were within normal ranges. There was only a major inflammatory disorder especially erythrocyte sedimentation rate (ESR) was elevated > 100 mm/hour, CRP was high in level about 62 U/ml. BK search and IDR reaction were negatives. Digestive and colonic fibroscopy were normal. The initial chest radiograph revealed inter-bronchial centimetric lymph nodes of the left-basal pyramid, without parenchymal lesions. Fiberoptic bronchoscopy was initially normal, with negative core biopsy, aspiration sample and cytology. At an early age, night sweats, the inflammation without obvious port of entry and the fact that Tunisia is an endemic country, the patient was treated as tuberculosis during 2 months. Unfortunately, there was no improvement with persistence of fever and recent weight loss. A new check-up was initiated to absolutely exclude neoplasia. Computed tomography of the thorax finally demonstrated a 25 mm nodule in the left segment of the Fowler, with no extension of the pleural surface. No calcification was seen in the lesion. Fiberoptic bronchoscopy revealed a reddish, hyper-vascularised, gleaming tumor of the Nelson. A carcinoid tumor was suspected. The patient underwent video-assisted thoracoscopic surgery, and a left inferior lobectomy was performed. Gross pathologic findings consisted on a lobectomy measuring 9 × 5 × 4 cm and comporting at 5 mm of bronchial section a firm round nodule. It measured 25 × 20 × 20 mm with well-demarcated margin and lifted the bronchial mucous membrane.Histological findings revealed an endobronchial and submucosal tumor composed of a proliferation of small cells, with a predominantly whorled pattern Fig , 2. TherMyoepithelial cells are usually seen between epithelial cells and basal cells in intercalated ducts and acini of exocrine glands. Myoepithelioma have been described most commonly in salivary gland and accounts for 1% of all tumors developing in the salivary gland. Other sites include soft tissue; breast and skin are well-described entities . In 1987Myoepithelioma is classified by morphologic appearance into four architectural subtypes; solid, myxoid, reticular and mixed, and into five cellular subtypes; spindle, plasmocytoid, epithelial, clear and mixed ,12. LackNuclear expression on P63 was recently described on salivary gland Myoepithelioma .Like any small pulmonary nodule, the myoepitheliomea should be considered as differential diagnosis. Management decisions should not be based on nodule size alone, but patient's age, clinical datas. In fact, previous CT scans, chest radiographs, and other pertinent imaging studies should be obtained for comparison whenever possible, as they may serve to demonstrate either stability or interval growth of the nodule in question. As seen in our case, noncalcified nodules larger than 8 mm diameter can bear a substantial risk of malignancy and should be managed accordingly ,15. DepePositron emission tomographic scanning has revolutionized evaluation and staging of benign and malignant pulmonary tumors. Because of the recent advent of this imaging method and because of the rarity of some types of pulmonary nodules, the fluorodeoxyglucose uptake of many such tumors is unknown. In only one patient a positron emission tomographic scan on a benign pulmonary Myoepithelioma was performed for the first time . No fluoOur case is typically a benign-myoepithelial lesion as the tumour lifted the bronchial mucosa up with no evidence of invasion into it and surrounding lung tissue. No nuclear pleomorphism, hyperchromatism or atypical mitosis was seen. On immunostaining, tumour cells showed positivity for S-100 protein, vimentin and smooth muscle actin.In salivary gland counterpart, and according to well-documented series, myoepitheliomas are less prone to recur than pleomorphic adenomas. However, others have reported higher recurrence rates. Recurrence is correlated with positive margins at the first excision.The recommended treatment is complete surgical excision. Benign Myoepithelioma can undergo malignant transformation, especially in long standing tumors with multiple recurrences . This faIn summury, benign Myoepithelioma is a rare pulmonary neoplasm distinct from pleomorphic adenoma, which should be considered in the differential diagnosis of lung nodules, especially when using fine-needle aspiration biopsies. Immunohistochemical stains and electron microscopy, when possible, can accurate diagnosis.Written informed consent could not be obtained because the patient was lost to follow-up. Despite repeated attempts we were unable to trace the patient or her family. We believe this case report holds a worthwhile clinical lesson, which could not be communicated effectively in any other way. Every effort has been made to keep the patient's identity anonymous. We would not expect the patient or her family to object to publication.The authors declare that they have no competing interests.BHS and TK analyzed and interpreted the patient data regarding the pumlmonary disease. They also performed the surgey. JK, OI and AA performed histological examination of the lobectomy. JK and OI collected clinical data's and were the major contributors in writing the manuscript. FEM confirm hisyological diagnosis. All authors read and approved the final manuscript.


Chronic constipation can lead to fecal impaction. It can also rarely lead to catastrophic complications like perforation, colonic obstruction, and fecal peritonitis. We report a rare case of stercoral sigmoid colonic perforation with fecal peritonitis and pneumoperitoneum, which was diagnosed on preoperative CT scan. Stercoral peritonitis is fecal contamination of the peritoneal cavity due to various causes, most commonly diverticular disease and colorectal tumor. Stercoral peritonitis is associated with a high morbidity and mortality rate; therefore an early diagnosis is important. StercoraA 67-year-old female was admitted in the emergency department with a history of constipation for 5 days, abdominal pain, and increasing abdominal distension. Her WBC count was within normal limits (WBC count may not be elevated in elderly patients presenting with an acute abdomen). On physical examination, the patient had a distended abdomen and signs of peritonitis. CT scan of abdomen and pelvis was performed with oral and intravenous contrast. Scout antero-posterior (AP) and lateral images demonstrated free air and abundant fecal material in the pelvis Figures , B. ContStercoral perforation is a rare surgical condition, with fewer than 90 cases reported in the literature upto 2002.4 This coThe pathogenesis is related to poor hydration of the feces, resulting in hard and impacted feces, also called fecaloma. This increases intraluminal pressure and causes ischemic necrosis of the colonic wall, stercoral ulcer formation and, subsequently, colonic perforation. The most24et al.[2The mean age of presentation in such cases is 59 years and the age range is 22–85 years. In 60% o37We conclude that in patients with a history of severe or chronic constipation presenting with acute symptoms, the possibility of stercoral perforation should be considered.


Glial tumours associated with subarachnoid haemorrhage are very rare. A 64-year-old woman admitted with a history of 3 weeks seizures and a left sided hemiparesis and dysphasia. The magnetic resonance disclosed heterogeneously enhancing a right temporal mass. During surgery, suddenly an abrupt and extensive swelling had occurred both in tumour and the brain tissue. The surgery was completed with a gross total tumour resection together with a partial temporal lobectomy. Postoperative computerized tomography demonstrated a massive subarachnoid hemorrhage (SAH). A cerebral Magnetic Resonance (MR) angiography showed neither an aneurysm nor arteriovenous malformation. Coincidence of an intracerebral tumour and subarachnoid haemorrhage would be devastating. Glial tumours associated with intracranial haemorrhage are seldom but well known pathologies. As regarding the coexistences of glial tumours and haemorrhages, all the reported cases are interested in either preoperative or postoperative conditions ,2. To thA 64-year-old woman admitted with a history of 3 weeks seizures. Neurologic examination revealed a left sided hemiparesis and dysphasia. The magnetic resonance (MR) images disclosed a right temporal mass with a surrounding oedema. The lesion was heterogeneously enhancing on post contrast images Figure . The tumThe most common tumours associated with SAH are pituitary tumours and meningiomas ,4. The cThe previously described SAH and tumour associations are all in preoperative or postoperative period, however the presented case is unique in respect to intraoperative SAH. The intracranial haemorrhages following supratentorial craniotomy is reported remote from surgical site either in supratentorial or infratentorial area ,12. HoweIn the presented case, the amount of blood and distribution pattern was far beyond to be explained with localized tears in bridging veins or changes in the dynamics of the intracranial compartment. In our case, coincidental vascular pathologies were suspected because intracranial tumours are rarely associated with intracranial aneurysms. Despite a cerebral MR angiography revealed no vascular pathology neither intracranial aneurysm nor arteriovenous malformation, we believe DSA would be very valuable if it could be performed. Another limitation of our paper is not being able to make an autopsy because of the rejection of the patient's family.Unrecognized incidental aneurysms may increase the risk of bleeding after surgery for the tumours. In the literature, glial tumours are reported to present with subarachnoid haemorrhage , furtherTheoretical bases for the association of tumour and aneurysms are variable; changes in the hemodynamic factors with increased vascular supply of the tumour , hormonaIt is not hard to acknowledge that coincidence of the tumour resection and subarachnoid haemorrhage would be devastating, as it did in our case. The following case presents a simultaneous subarachnoid bleeding during the initial part of a GBM resection. There was neither venous compromise nor arterial destruction or rapid and extended decompression had provided yet. It can be speculated that the tumour tissue would be compressing an unrecognized coincidental aneurysm. The aneurysm would have been ruptured when the dura opened and the tumour partially resected that provided minimal changes in dynamics of the intracranial compartment. Indeed, invasion of vascular structures by tumour was not concordant with the surgical findings. Whatever reason of the incidence is, what makes this case unique is real time observation of one of the disastrous combination in neurosurgical practice. The presented case, as far as we know, is the first report of simultaneous SAH during GBM excision.In conclusion, we present the first case of a real time spontaneous SAH arising during intracerebral glioma resection. After excision of the tumour and stabilization of the patient, it should be managed as if it is a primary SAH. In selected cases, performing cerebral DSA in evaluation of the intracerebral malignant tumours locating in the insular region or around sylvian fissure may be warranted to exclude incidental cerebral aneurysm or to verify tumoural implications on the vasculature.Written informed consent was obtained from the patient for publication of this case report and accompanying images.The authors declare that they have no competing interests.TH, HÇ were involved in the patient care, acquisition of data, analysis and interpretation of data, review of literature, drafting and revising the manuscript. CÇT was involved in review of literature, revised the manuscript for important intellectual content. All authors read and approved the final manuscript.


Middle ear glandular neoplasms are infrequent causes of a middle ear mass. They can have exocrine and/or neuroendocrine differentiation. It is currently thought that these tumors are indistinguishable each from another. Herein, we present a new case of a middle ear glandular neoplasm. Our objective is to review all cases described in the literature in order to identify the clinical features, the gross pathology, the histopathology, the immunohistochemistry, to discuss the differential diagnosis, the treatment, the rate of recurrence, the follow-up, the incidence of metastasis, the prognosis and to present a new classification of middle ear glandular neoplasm.We performed a MEDLINE database search for MEA-related articles published between 1950 and March 2008. The information from the reports was analyzed.Ninety-four patients with a middle ear adenoma are included in this report. We uncovered 75 patients with a carcinoid tumor and 19 patients with a middle ear adenoma diagnosis; the most common presenting symptom was a conductive hearing loss. Middle ear adenomas are lesions that are typically white, gray or reddish brown. They are grossly vascular and well circumscribed, but not encapsulated, and can entrap and destroy the ossicles. Histologically, the cuboidal to low columnar cells are arranged in a solid, trabecular or glandular architecture. The tumor's cells are immunohistochemically positive for a variety of keratin antibodies and most of them are also positive for neuroendocrine markers. Surgical excision is the treatment of choice. Local recurrence following complete excision is quite uncommon and metastases are rare.Our study and the review of the literature showed adenomas and carcinoid tumors of the middle ear to be essentially indistinguishable benign tumors with metastatic potential. Based on the presence or absence of immunohistochemical markers and metastasis, we have classified these lesions into three types. Complete surgical treatment is recommended with an indefinite follow-up for possible recurrence. Middle ear glandular neoplasms are seldomly the source of a middle ear mass. Hyams  was the Middle ear glandular neoplasms can present both a neuroendocrine and an epithelial differentiation. This has led some early authors to maintain that neuroendocrine (carcinoid) tumors and middle ear adenomas were different tumors . HoweverIn this paper, we present a new case of a middle ear adenoma / carcinoid tumor. Our objective is to review all cases described in the literature in order to identify the clinical features, the gross pathology, the histopathology, the immunohistochemistry, to discuss the differential diagnosis, the treatment, the rate of recurrence, the follow-up, the incidence of metastasis, the prognosis and to present a new classification of middle ear glandular neoplasm.We performed a MEDLINE database search for MEA-related articles published between 1950 and March 2008. The electronic search was conducted with the keywords "carcinoid", "middle ear adenoma", "middle ear mass", "middle ear tumor", "ear adenoma", "tympanic mass", "temporal bone tumor", "neuroendocrine", and "neuroendocrine immunohistochemistry". The results yielded 74 relevant studies, in which 93 patient records were transcribed. In addition, we adjoin our case to this series. The information from the reports was analyzed to characterize the clinical aspects, the radiologic findings, the histopathology and immunohistochemistry, the treatment, the rate of recurrence, the follow-up, and the incidence of metastasis related this disease.In January of 2006, a 32-year old man presented at our otolaryngology department for a second opinion regarding a seven-year history of right aural fullness and mild hearing loss. Five years prior to this consult, he had been examined by an otorhinolaryngologist for a right-sided otalgia associated with a right facial paralysis. He had been given oral amoxicillin and steroids for a probable middle ear otitis complicated with a facial paralysis. A few months after this episode, an antero-inferior myringotomy was performed for a presumed middle ear effusion and revealed neither liquid, nor mass. He had never noticed any discharge, vertigo, tinnitus, visual symptoms or headaches, as well as any other significant past or present disease.The otoscopy showed the presence of a posterosuperior retrotympanic mass with normal tympanic membrane. The hearing test revealed a right mixed hearing loss. A computed tomography (CT) scan of the temporal bone revealed opacity in the superior part of the middle ear extending into the mastoid cavity Figure . There wIn March 2006, he underwent a right postauricular canal wall-up mastoidectomy and an extended facial recess approach procedure. A multilobulated, polypoid, fibrotic, grey tumor was observed filling the middle ear cavity. The mass was located in the mesotympanum, epitympanum and hypotympanum components. There was a prolongation into the antrum, the mastoid, and the Eustachian tube without any involvement of the facial nerve or evidence of bone erosion. Even if the ossicles were embedded in the tumor, there was no ossicular chain erosion, but the malleus was fractured, the incus and the stapes were dislocated. The malleus and incus were removed and a piece of fascia was placed on the oval window to avoid a perilymphatic fistula. The intraoperative frozen study was not conclusive. A total macroscopic excision of the lesion was performed; a second look procedure for ossicular chain reconstruction was to be performed five months later. There were no major postoperative complications. The hearing test showed a right severe sensorineural hearing loss, which was improved by a hearing aid.Histologic examination of the excised tumor showed an epithelial neoplasm with a predominantly glandular architecture embedded in fibrous tissue. The tumor was composed of cuboidal cells with uniform nuclei and no identifiable mitotic activity or necrosis Figure . FocallyWe uncovered 74 relevant studies. Ninety-four cases of middle ear adenoma/carcinoid tumor of the middle ear have been published; including our own afore-described case. We identified 75 patients with a diagnosis of middle ear carcinoid tumor and 19 patients with a diagnosis of middle ear adenoma. The patient's age in this series ranged from 16 to 77 years with a mean age of 44.6 years. The incidence of right versus left involvement was equal. There were 41 women and 53 men yielding a female to male ratio of 1:1.3.Hearing loss (HL) was the most common presenting symptom (86.3%). The majority had conductive HL Table ; four paA CT scan of the temporal bones was performed in 68% of patients and demonstrated a soft tissue mass in the middle ear. The ossicles were embedded by the tumor without bone or ossicular erosion in all the cases except for one patient Table . An evalGrossly, the tumors present different appearances. The aspect was clearly described in 48 patients Table . It was In this series, 75 cases were diagnosed as carcinoid tumor because of their positivity to neuroendocrine markers on immunohistochemistry Table . The 19 All patients were primarily treated with surgery. Transcanal tympanotomy (TM) or tympano-mastoidectomy approaches were used. Seventeen patients underwent an initial biopsy followed by a more definitive procedure such as canal wall up (CWU) mastoidectomy, canal wall down (CWD) mastoidectomy, or radical mastoidectomy (RM). A secondary ossicular reconstructive procedure was only documented in our reported case. The definitive surgical treatment was through a transcanal TM in 46% of patients, CWU mastoidectomy in 21% of patients, CWD mastoidectomy in 16%, and RM in 22% of patients. Four patients underwent a subtotal petrosectomy, three patients simply underwent a biopsy, one was treated by the excision of the EAC mass, and eight had unspecified surgery combined with postoperative radiation therapy; a dose ranging from 45 to 60 Gray. Chemotherapy was not prescribed in any other cases.Sixty-one patients were disease free at their last follow-up, 21 patients had an unspecified follow-up while twelve (12.7%) patients developed a localized recurrence of the disease Table . Only onThe disease-free interval after definitive surgery was available for 73 of the patients. This interval ranged from two months to 33 years with an average of 53 months. The follow-up for the patients treated with radiotherapy was not indicated. The interval between initial surgery and first recurrence was available for eleven patients and ranged from 16 to 396 months with an average of 52 months. The duration of the follow-up after treatment for a recurrent or a metastatic disease was available for nine of the patients, ranging from five months to five years with an average of 26 months.Middle ear adenomas are unusual neoplasms with epithelial and neuroendocrine differentiations. They are composed of two types of cells; exocrine and neuroendocrine in which neuroendocrine granules and sometimes neuropeptides  are detected ,5.Carcinoid tumors of the lung are thought to originate from enterochromaffin cells (Kulchitsky cells), which are neuroendocrine normal cells present in the lung. However, epithelial cells with neuroendocrine characteristics are not noted in the middle ear cavity. An undifferentiated pluripotential endodermal stem cell may still be present within the surface mucosa, giving rise to carcinoid neoplasms similar to the Kulchitsky cell . Hyams aThe mean age being the forties and there was no gender difference. Patients typically present with conductive hearing loss, aural fullness, and tinnitus. An examination usually reveals a gray-white or fibrotic mass behind an intact tympanic membrane. Facial palsies associated with middle ear carcinoid have been reported in the literature. Krouse et al. presented one patient with transient paresis  and simiSince the clinical features and otological findings are not characteristic, one must rely on radiological findings. The imaging characteristics of adenomatous middle ear tumors have not been clearly defined because of their rarity. However, the CT of the temporal bone is the key procedure. It highlights a nonspecific opacity, well limited, being able to extend to the whole of the tympanic cavity and the mastoid and posing mainly the differential diagnosis from a glomic tumor. The ossicles are generally embedded in the mass without ossicular or bony erosion. No characteristic differences between the benign and malignant tumors are detectable on a CT . On an MAll patients presented with a unilateral disease. Most of the lesions were excised in a piecemeal fashion and they peel off the bony walls of the middle ear, but may entrap and destroy the ossicles. The biological nature of the tumors could not even be assessed intraoperatively. Facial paralysis, bone lyses, or chronic otorrhea can exist in the case of a malignant lesion. None of these symptoms is specific. The surgeon should keep in mind the possibility of a middle ear adenoma especially in the presence of a fibrotic mass behind an intact tympanic membrane.Microscopically, all tumors were unencapsulated and of moderate cellularity. They were predominantly composed of cuboidal-to-columnar cells with indistinct cytoplasmic borders. The cytoplasm was eosinophilic and homogenous to finely granular. The nuclei tended to be round to oval with minimal pleiomorphism . The chrImmunohistochemistry reveals that the tumor is typically keratin-, vimentin-, pancreatic polypeptide-, and chromogranin-positive, with a lesser number of tumors proving to be neuron-specific-enolase (NSE), synaptophysin-, serotonin- and S-100 protein-positive . ImmunohAn analogy between MEA and carcinoid has been proposed. Torske and Thompson have suggested that both are the same tumor . On the Complete surgical removal of the neoplasm including the encased ossicles should be the preferred treatment. When the ossicular chain is involved, but not removed, the recurrence of the lesion is more likely to occur. The surgery should be determined on the basis of the clinical and radiological findings. The incidence of recurrence is higher with transcanal tympanotomy (14%) than with a radical mastoidectomy (9%). This is insufficient evidence to suggest superiority of one procedure over another. CWU mastoidectomy with an extended facial recess approach could be an option. In some cases, patients were treated with repeated debulking-excision procedures to preserve the ossicular chain and thus, retain their hearing. Discouraged by surgeons, this technique would require a continued long term clinical follow-up and patient compliance. In order to prevent recurrence, the treatment of choice is total exploration and surgical excision with removal of the ossicular chain .Radiation, chemotherapy and somatostatin analogues have been used in the treatment of gastrointestinal and pulmonary carcinoid tumors, but no data exists for the treatment of middle ear carcinoid. Radiation therapy is not required for these tumors . In factIn all recurrences, the initial excision was conservative, leaving the ossicular chain intact and the immunohistochemistry, when done, was positive. We noted that all the patients who underwent biopsy followed by definitive surgery had no recurrent disease. Regional metastasis occurred in four patients. They should be managed surgically with a parotidectomy or a neck dissection. Nikanne et al used octreotide scanning in one case in the management of a carcinoid tumor . In anotThe disease-free interval after definitive surgery averaged 53 months. All of the authors recommend a long-term clinical follow-up, but most of them do not specifically recommend a radiological control. When an ossicular chain reconstruction is performed and the usage of cartilage for tympanoplasty middle ear examination becomes impossible, we recommend that either a CT scan or an enhanced MRI be completed.Middle ear glandular neoplasms are uncommon well-documented neoplasms of the middle ear. We suggest a prognostic helpful classification based on the presence or absence of markers and metastasis; type I (NEAME), type II (MEA), and type III (CTME). Despite considerable debate over the similarities and differences between these tumors, we believe they are clinically identical, but immunohistochemical results make the difference. This review demonstrates a 12.7% recurrence rate after excision. Surgical management with ossicular chain removal is the recommended treatment to ensure a complete excision. Long-term follow-up is important because of the late recurrences and metastases."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 patient prefers to remain anonymous.The authors declare that they have no competing interests.IS involved in drafting the manuscript, revising it critically for important intellectual content, analysis and interpretation of data and have given final approval of the version to be published. AS have made substantial contributions to conception and design, acquisition of data and have been involved in drafting the manuscript.


Spontaneous rupture of the right gastroepiploic artery is an extremely rare case which can be a cause of abdominal apoplexy.We present a case of a 64-year old woman with a Spontaneous rupture of the right gastroepiploic artery with hemorrhagic shock that was successfully treated by emergency surgery.Simultaneous restoration of circulating volume and rapid diagnosis are keys in determining the patient outcome in this situation. Though the mortality is high if untreated, the operation is relatively simple and carries a low risk. Spontaneous rupture of the right gastroepiploic artery is an extremely rare case which can be a cause of abdominal apoplexy, and which should be considered in the differential diagnosis of unexplained hemorrhagic shock and if hemoperitoneum is encountered while performing a laparotomy. Simultaneous restoration of circulating volume and rapid diagnosis are keys in determining the patient outcome. Though the mortality is high if untreated, the operation is relatively simple and carries a low risk.A 64-year old woman was presented to the emergency department with acute abdominal pain and breathlessness of which she was suffering few hours before her presentation to the emergency room. Her medical history revealed recurrent upper abdominal discomfort over the last 4 months, and did not suggest any major disease except hypertension, that she has been treating since seven years. Besides, she had no prior history of abdominal surgery or trauma.The physical examination revealed a conscious woman with discolored conjunctives and severe cutaneous paleness, shortness of breath, tachycardia with a weak and rapid pulse rate of 126 beat per minute, and hypotension with a systolic blood pressure of 80 mmHg. At the abdominal examination, there was a general abdominal tenderness.Laboratory data showed a white blood cell count of 7 900/mm3, a hematocrit of 18%, and serum hemoglobin concentration of 6,1 g/dl, with a normal blood platelet level (390 000/mm3), a blood urea of 0,25 g/L, and a creatinine level of 10 mg/L. Hemostasis laboratory data, chemistry and Serum lipase were within normal limits.The patient was shift to the intensive care unit (ICU) with a swift assessment of her airway, breathing and circulation. The initial resuscitation was begun by physiological serum and conventional crystalloid solutions; then she was transfused by 8 units of red blood cells. After hemodynamic stability, an abdominal computerized tomography (CT) was performed and revealed the presence of an important hemoperituneum with two fluid densities around the spleen and the liver Figure , it alsoIt was impossible to obtain the opinion of either a vascular surgeon or an interventional radiologist for this acute intraabdominal hemorrhage, and it was indispensible to shift the patient to the operating room for an emergency surgery to control the source of bleeding. An emergency exploratory laparotomy was performed under general anesthesia. This Surgical exploration showed an important hemoperituneum and a large periduodenal hematoma which was extending into the retroperitoneal space. Two liters of blood were evacuated from the free peritoneal cavity. Besides, we noted a significant bleeding from the right gastroepiploic artery, with no obvious aneurysm, that was successfully ligated. Further exploration identified no additional bleeding, and the retroperitoneal hematoma was respected. The patient recovered well without postoperative complications and she was discharged 5 days after the surgery.Idiopathic spontaneous intraperioneal hemorrhage (ISIH) was first reported by Barber in 1909 and was later termed "abdominal apoplexy" by Green and Powers in 1931. Its true incidence is unknown . BleedinSpontaneous nonaneurysmal right gastroepiploic artery rupture (RGEA) is among the rarest . None ofThe presentation and clinical progression of abdominal apoplexy frequently follows a rather predictable course. Before rupture, there may be a history of vague abdominal pain which is the case of our patient. The symptoms are usually non specific. Physical examination before or soon after rupture is likely to be relatively normal although no one finding is pathognomonic. Hypotension may be present depending on whether the hemorrhage is contained or free intra-abdominal rupture exists. The presentation of acute hemoperitoneum is divided into three main phases: an early phase of mild-to-severe abdominal pain, a latent phase lacking any symptomatology, lasting from hours to days and a final phase of acute hemoperitoneum in which the patient experiences a rapid increase in the severity of the symptoms, especially the abdominal pain . The diaWritten informed consent was obtained 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.KI is a surgeon who was drafting the manuscript and revising it critically for content and was involved in literature research. AB and JMG were surgeons treating of the patient and were involved in revising the draft critically for content. All authors read and approved the final manuscript


Human tails and pseudotails are rare sacrococcygeal lesions that are associated with a wide variety of anomalies and syndromes. Anorectal malformations are also relatively uncommon congenital defects that often occur in conjunction with syndromes or other congenital abnormalities. The anomalies associated with both disorders determine the timing and approach to surgical correction. We present an unusual case of a patient with both imperforate anus and a pseudotail in the absence of a syndrome or other associated anomalies and we emphasize the necessity of a thorough preoperative evaluation.A Caucasian girl was born at term after an uncomplicated pregnancy and was noted at birth to have a skin-covered posterior midline mass and imperforate anus with a fistula to the vaginal vestibule. Ultrasound and magnetic resonance imaging revealed a predominately fatty lesion without presacral extension and ruled out associated spinal and cord abnormalities. The patient underwent diversion with colostomy and a mucous fistula in the newborn period as a fistulogram demonstrated a long fistulous tract to normal rectum and it was anticipated that anoplasty and resection of the mass would require extensive posterior dissection. The sacrococcygeal mass was removed during posterior sagittal anorectoplasty at the age of six weeks which was determined to be a pseudotail because of the composition of brown fat and cartilage. The patient is now 14 months old with normal bowel function after a colostomy takedown.A comprehensive preoperative assessment and thoughtful operative plan were necessary in this unusual case because of the extensive differential diagnosis for sacrococcygeal masses in the newborn and the frequency of anomalies and syndromes associated with tail variants and imperforate anus. The pediatricians and neonatologists who initially evaluate such patients and the surgeons who correct these disorders must be aware of the potential pitfalls in their management. Human tails and pseudotails are rare congenital lesions that have been reported since the late 19th century. These entities typically present as skin-covered lumbosacral masses seen in the newborn period. The possible diagnoses for this presentation are broad, ranging from benign hamartomas to aggressive malignancies and meningoceles. As one series illustrates, the management can be complicated not only by the spectrum of disorders and associations but also by parental resistance to crucial preoperative imaging [Human tails may occur alone or associated with other anomalies. The most common abnormality associated with a tail is spinal dysraphism, which occurs in 49% of cases and can be diagnosed as meningocele, myelomeningocele or spina bifida. Other associated anomalies include: lipoma 27%); tethered spinal cord (20%); coccygeal vertebrae (12%); syndactyly, hemangioma; cleft palate; Crouzon syndrome; clubfoot; omphalocele; congenital tracheal stenosis; Von Recklinghausen disease; digit hypoplasia; and tetralogy of Fallot [7%; tetheet al. reported a vestigial tail in an infant with most of the major and minor defects of the VATER syndrome (see Abbreviations) including imperforate anus [et al. reported a case of pygomelus (a pseudotail variant) in association with lipomyelomeningocele and an incomplete expression of Currarino's triad including anal atresia with recto-vaginal fistula [Tails and imperforate anus are both congenital anomalies that are commonly associated with syndromes. Dusmet ate anus . A true ate anus ,5. Kahle fistula .We are not aware of any cases of tails or pseudotails associated with an anorectal malformation in the absence of a syndrome. We describe a newborn girl with a pseudotail and isolated imperforate anus and discuss the diagnostic evaluation necessary for operative planning.A Caucasian girl, born at 3580 g at 39 weeks and one day gestational age, was transferred to our hospital on her first day of life for evaluation and management of imperforate anus and a perineal mass. The 20-year-old mother had standard prenatal care and an uncomplicated pregnancy. She underwent ultrasonography at 21 weeks gestation and there was no evidence of congenital anomalies. The child was born by spontaneous vaginal delivery and had Apgar scores of 9 and 9 at one minute and five minutes, respectively.On physical examination, she was noted to have a soft, skin-covered, midline mass, measuring 3 cm × 1 cm and emanating from the perineum posterior to the vagina  anomalies known to be associated with imperforate anus. These studies were negative for cardiac, vertebral and renal anomalies. The spinal cord terminated normally at L2 and there was normal motion of cauda equina nerve roots. There was no tethered cord.Ultrasound was done in order to further characterize the perineal mass and it revealed a 2.5 cm × 3.6 cm × 1.3 cm lesion with internal vascular flow and a possible extension into the presacral space. These findings were suggestive of a presacral teratoma, which warranted more urgent resection. The serum alpha-fetoprotein levels were not inappropriately elevated for a newborn. Magnetic resonance imaging (MRI) revealed a pedunculated mass with predominantly fat intensity and a single central vessel (Figures Air and contrast enemas were performed through the vestibular fistula in order to evaluate the distance between the distal rectal pouch and the skin. The long, narrow, fistulous tract connected to the distended colorectal pouch, which was approximately 3 to 3.5 cm from the skin Figure . The patPrior to her definitive surgical repair, a contrast enema of the distal colon through the mucous fistula was done in order to define the level of her rectum. Colostogram revealed that the distance from the rectal pouch to the perineal surface ranged from two to three vertebral body heights. There were no strictures of the colon. At six weeks of age, she underwent posterior sagittal anorectoplasty and excision of the perineal mass. A midline incision was made anterior and posterior to the perineal mass, and the skin of the mass was surrounded circumferentially. Upon palpation, the mass seemed to have a central bony structure. The subcutaneous tissues surrounding this structure were divided and the bony structure was found to extend toward the sacrum, but terminated prior to reaching it. Pathologic analysis revealed a mass composed of benign skin including normal adnexal structures with underlying brown fat and a central mature cartilage core, and it was designated a pseudotail due to its cartilage component Figure . The patDao and Netsky proposed the distinction between tails and pseudotails in 1984 . A true This traditional classification has been recently challenged by some authors ,10. The Both human tails and imperforate anus are congenital anomalies that may occur alone or be associated with a wide range of abnormalities and syndromes. The differential diagnosis for a sacrococcygeal mass in a newborn is extensive and includes teratoma, extra-spinal ependymoma, extremely rare malignancies such as chordoma, benign entities such as lipoma and hemangioma, rectal duplication and meningocele.Optimal operative intervention for a patient with imperforate anus and a sacrococcygeal mass requires a thorough diagnostic evaluation to define the anatomic relationships and to identify associated anomalies, such as cardiac defects, which might limit the extent of intervention that can be undertaken in the newborn period. Suspected locally aggressive tumors, such as chordomas or lesions with an age-dependent likelihood of malignancy, such as teratomas, mandate an urgent operative intervention. The correction of associated anomalies, such as spina bifida or cord tethering, can require neurosurgical expertise.This patient had an unusual combination of disorders but she did not have significant comorbid anomalies. Diversion with subsequent anoplasty was undertaken because of the long fistulous tract which is needed to mobilize the rectum and the additional perineal dissection required to resect the likely benign tail variant.Anorectal malformations and skin-covered midline masses represent challenging diagnostic and therapeutic entities because of the extensive differential diagnoses and the array of associated anomalies. This case presents the unusual combination of imperforate anus with a rectovestibular fistula and a human pseudotail in the absence of associated anomalies or syndromes. It also illustrates the necessity for a thorough preoperative evaluation and careful therapeutic decision making.vertebral anomalies, anal atresia, cardiovascular anomalies, tracheoesophageal fistula, esophageal atresia, renal or radial anomalies, and limb defects; VATER: an acronym representing an association of birth defects including vertebral anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal or radial anomalies.VACTERL: an acronym representing an association of birth defects including Written informed consent was obtained from the parent of the described minor 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.MDR reviewed the literature and was primarily responsible for writing the manuscript. MLW analysed the surgical specimen, reviewed the manuscript and provided images of the specimen. GPJ oversaw the clinical care of this patient, performed the operations and made revisions to the manuscript. All authors have read and approved the final manuscript.


Megacystis Microcolon Intestinal Hypoperistalsis Syndrom (MMIHS) is a quite rare congenital and fatal disease which was firstly defined by Berdon and his colleagues. Itappears through a widely enlarged bladder and microcolon and its cause is unknown . The disease is found in females three or four times more than in males . Most of thecases die within the early months of their lives . We present the case of a femalenewborn with antenatal ultrasound revealing intestinal mass and bilateralhydroureteronephrosis. The case was admitted for intestinal obstruction after birth. A female infant with an antenatal diagnosis of intra-abdominal mass and bilateral hydronephrosis was born at a gestational age of 37 weeks through caesarean section to a grand multipar mother. After 24 hours delay of urination and meconium, she was referred to our department. Physical examination showed a distended abdomen and bladder and enlarged kidneys were palpated bilaterally. A 5 Fr urethral catheter was inserted and urine was drained. Negligible amount of meconium was seen by rectal tube insertion. Abdominal X-Ray showed a dilated stomach and minimal gas in the distal bowel segments. Abdominal ultrasound imaging revealed an enlarged urinary bladder and bilateral hydronephrosis with urethral dilatation.The case was operated for intestinal obstruction 72 hours after birth. The findings included an unused microcolon with a plug from the ileocecal valve . IleotomThe kidneys on both sides were hydronephrotic by palpation nearly twice of the normal size, and the bladder was observed to be gigantic with megasystic property Figures  and 3. TGastrointestinal dysmotility can appear as different phenotypes of an enteric neuromuscular disease globally considered as chronic intestinal pseudo-obstruction, a disorder characterized by persistent failure of the intestine to propel its contents through an unobstructed lumen. Chronic intestinal pseudoobstruction may be primary, as in most pediatric cases, or secondary to various disorders  that usually occur in adults. The congenital conditions are associated with extraintestinal symptoms. Eighty-five percent of patients with myopathy and 10% with neuropathy have megacystis  [MMIHS, which is a rare reason of the neonatal intestinal obstruction, is a congenital disease with high mortality rates , 2. It iMMIHS is part of the spectrum of intestinal motility defects . AutosomOur case was a female infant who was the 8th life birth of a 37-year-old mother. The parents were first degree relatives.A consensus on the theory of the pathogenesis of the disease does not exist yet. Some of the theories are the lack of nicotinic acid receptor subunits, a defect in fiber synthesis, an inflammatory process of the gastrointestinal and urinary tract, generalized axonal dystrophy in central, and peripheral and autonomic nervous system , 11–15.Normal or excessive amounts of ganglion cells have been reported. Also, a case without ganglion cells has been reported, too , 16, 17.The ganglion cells obtained from the narrow distal ileal segment were mostly immature but positive and in normal number according to pathological examination result. The immaturity in our case is supporting the theory about cell defect.Although there has been publications about maternal drug usage for defining the etiology, there is an emphasize on the necessity of advanced experimental studies , 8. We lThe antenatal diagnosis of the MMIHS is very difficult. However, publications about antenatal symptoms and additional urinary system anomalies were reported –7, 13. AOur case was admitted to our clinic because of mass in the abdomen due to globe vesicale and bilateral Grade III-IV hydronephrosis in antenatal and postnatal USG and was hospitalized. Surgical treatment choices are limited, and an effective surgical method has not been defined yet. Several intestinal diversions have failed to be successful , 10, 16.These cases mostly die from malnutrition, sepsis, kidney failure, and liver failure depending on TPN and the complications of TPN. , 17, 20 Prenatal diagnosis of MMIHS is possible by antenatal ultrasound. Studies of the contribution of MRI in the prenatal evaluation of digestive tract anomalies are still rare. MRI also appears useful for diagnosing microcolon associated with an enlarged bladder, suggesting MMIHS .In our case, antenatal USG revealed intraabdominal mass and bilateral hydronephrosis at 32 weeks and resulted with a live birth at 34 weeks.We suggest that an antenatal USG finding of an enlarged urinary bladder and intraabdominal mass in female fetus should alert the physicians for MMIHS. Clinical genetic counseling is indicated for further pregnancies.


Primary carcinoid tumors of the liver are uncommon and rarely symptomatic. The diagnosis of primary hepatic etiology requires rigorous workup and continued surveillance to exclude a missed primary.We present a case of a 62-year-old female with a primary hepatic carcinoid tumor successfully resected, now with three years of disease-free follow-up. We present a review of the current literature regarding the diagnosis, pathology, management, and natural history of this disease entity.Primary carcinoid tumors of the liver are rare, therefore classifying their nature as primary hepatic in nature requires extensive workup and prolonged follow-up. All neuroendocrine tumors have an inherent malignant potential that must be recognized. Management remains surgical resection, with several alternative options available for non-resectable tumors and severe symptoms. The risk of recurrence of primary hepatic carcinoid tumors after resection remains unknown. Although carcinoid tumors can be found throughout the body, 90% occur within the gastrointestinal tract . They prEG is a 62-year-old female who presented with right upper quadrant abdominal pain, intermittent in timing and dull in nature, not related to oral intake and not associated with nausea or vomiting. Her past medical history included hypertension, irritable bowel syndrome, osteoarthritis, and a history of recurrent bilateral lower extremity deep venous thrombosis on Warfarin. On physical exam there were no abdominal scars, normal bowel sounds on auscultation, minimal right upper quadrant tenderness to palpation, no rebound tenderness or guarding, no hepatomegaly and a negative Murphy's sign. Her laboratory studies were significant for a GGT of 162 U/L , with otherwise normal liver function tests. Tumor markers were negative, with an AFP of 3.1 ng/ml.Diagnostic imaging included an abdominal ultrasound Figure  which reA CT-guided biopsy was performed which yielded scant tissue with poorly cohesive cells arranged in papillae. PAS-D stain showed focal, small mucin droplets in some cells. Immunohistochemistry was positive for CEA and CK-7 and negative for calretinin, CDX-2, CK-20, Muc-2 and Muc-6. The limited sample was diagnosed as papillary adenocarcinoma, favoring metastasis, on the basis of morphology, special stain results and immunoprofile. However, a second panel of immunohistochemical stains for synaptophysin, CD56 and chromogranin were performed on the biopsy specimen. The tumor cells were negative for chromogranin but expressed synaptophysin and CD56, consistent with the immunoprofile of a neuroendocrine tumor (NET).Further workup for a primary tumor or other metastatic sites included a negative CT scan of the chest, upper and lower gastrointestinal endoscopy, and a Technetium-99m bone scan. The decision was made to resect the hepatic tumor.An uncomplicated left lateral segmentectomy (II & III) and cholecystectomy were performed. No peritoneal carcinomatosis was noted upon exploration. The postoperative course was uneventful and she was discharged home on the fourth postoperative day.Grossly, the tumor measured 5.2 × 5.0 × 5.0 cm and had a tan gray, soft, fish-fleshy cut surface Figure . AlthougMicroscopically, the tumor consisted predominantly of solid sheets and organoid nests of uniform, intermediate-sized, polyhedral cells Figure  in a vasImmunohistochemistry was consistent with the immunoprofile of the biopsy specimen, i.e. positive staining for synaptophysin Figure  and CD56Follow-up over the subsequent three years included CT scans of the abdomen at six month intervals. To date, no recurrent or metastatic disease has been identified. She remains symptom free and in good health.A total of sixty cases of primary hepatic carcinoid have been reported, with the largest series being eight patients , with loPrimary hepatic carcinoid tumors may be an incidental finding or can present with severe symptoms including abdominal pain, jaundice, palpable right upper quadrant mass, carcinoid syndrome , carcinoImaging studies of any hepatic mass should begin with ultrasound and a triple-phase CT scan. One report supports the use of contrast-enhanced ultrasound, although there is limited experience with that modality . MRI is A monoclonal antibody to stain for NETs, therefore NETs expressing chromogranin B may be non-reactive with this antibody, as was the case with our specimen.The differentiation between primary and secondary NETs of the liver is not possible by histology alone, although a centrally located solitary tumor may suggest a primary . AdditioAll neuroendocrine tumors have malignant potential. As such, some authors recommend using the terms "low-grade neuroendocrine tumor," "well-differentiated neuroendocrine tumor," "well-differentiated endocrine tumor" or "grade I neuroendocrine carcinoma" instead of "carcinoid tumor" to emphasize their biologic behavior. The value of the term "neuroendocrine tumor" reflects a particular phenotype that may respond to specific targeted therapies .Despite the classic low-grade cytoarchitectural morphology present in this patient's tumor, its large size (5.2 cm in greatest dimension) and focally infiltrative border are worrisome. As a general principle, NETs smaller than 1.0 cm, in any anatomic location, usually behave in an indolent fashion with only rare recurrences or distant spread while those larger than 2.0 cm are usually more aggressive . HoweverAfter the appropriate workup of a hepatic mass, initial management is surgical resection when possible. Extent of resection is determined by location and size of the tumor(s), with multicentric bilobar disease often precluding resection. When this is the case, alternative therapies include radiofrequency ablation , hepatecThe rigorous follow-up and frequent monitoring of patients with hepatic carcinoid also serves as screening for recurrent disease. Recurrences have been reported as early as one year postoperatively and as late as thirteen years, and can occur in the liver or in regional lymph nodes -16. DistCarcinoid tumors involving the liver are common, but primary hepatic carcinoid tumors are rare. Classification as a primary hepatic tumor requires extensive workup and prolonged follow-up. Regardless of their size, location, and degree of differentiation, NETs have an inherent malignant potential that must be recognized. Management remains surgical resection, with several alternative options available for non-resectable tumors and severe symptoms. The risk of recurrence of primary hepatic carcinoid tumors after resection remains unknown.The authors declare that they have no competing interests.GS drafted the case presentation and literature review sections of this manuscript. AC and HG reviewed the specimens and drafted the review of the pathological findings associated with this disease entity. FA and JO were the primary physicians diagnosing, treating, and currently following the referenced patient.


A 66 year old man initially presented with haemoptysis and subsequently required a pneumonectomy for a lung mass, following this he had a finger swelling which was found to be a rare leiomyosarcoma and this was a metastatic deposit. This pattern of metastasis for this type of tumour has not been described before. A 66-year-old man, with a previous left ring finger ganglion, presented with haemoptysis. Radiographic investigations revealed a left lung mass; he underwent a left pneumonectomy for this. The lesion was found to be a rare pulmonary leiomyosarcoma. No further treatment was required, until he was referred to Orthopaedic Surgery, with a possible recurrent left ring finger ganglion (see Figure Written informed consent could not be obtained because the patient was deceased. We believe this case report holds a worthwhile clinical lesson which could not be communicated effectively in any other way. Every effort has been made to keep the patient's identity anonymous. We would not expect the patient or their family to object to publication.The authors declare that they have no competing interests.RMG and MCS analysed and interpreted the patient data from the case notes. GPA provided the clinical image and was a major contributor in both suggesting the report and reviewing the manuscript. All authors read and approved the final manuscript.


While retroperitoneal abscess is a known complication, hepatic portal venous gas and rectal perforation have not been reported as a concomitant sequelae of acute appendicitis. Here we report a case of a patient with a perforated appendicitis that was associated with these triad of complications.In addition to report our case, we carefully reviewed the literature in order to detect similar cases and the causes of such rare conditions.Only 26 cases (including our patient) of acute appendicitis complicated by retroperitoneal abscesses have been published in the English literature between 1955 and 2008. There was one case having hepatic portal venous gas, and one further case with a rectal perforation associated with acute appendicitis. All patients with retroperitoneal abscess presented with non specific clinic symptoms that not revealed any suspicion for such a complicated disease. Hence, delayed diagnosis and treatment are not uncommon.So far, no patient has been described with such a triad of rare complications related to acute appendicitis. We want to emphasize the insidious onset of retroperitoneal abscess formation, and the need of prompt recognition and adequate treatment to avoid deleterious outcome. Acute appendicitis is a very common disease with low morbidity and mortality rates in most countries. While uncomplicated appendicitis can easily be treated, complicated appendicitis with perforation and abscess formation remains a challenging treatment. In particular, large abscess and advanced peritonitis often require repeated surgical interventions combined with percutaneous drainage performed by interventional radiology, as well as intensive care and antibiotic treatment. Such treatment is associated with markedly increased complications, e.g. sepsis, prolonged ileus, and adhesion formation . The devA 43-year old man was admitted to the Emergency Department with progressive abdominal pain, nausea, reduction in defecatory frequency and change in stool appearance as hard separate lumps that started almost three weeks before, and in addition, new onset of anal bleeding. There were no preexisting co-morbidities. The patient had tachycardia (up to 140 bpm), arterial hypertension (170/70 mmHg) and fever (38°C). Clinical examination revealed an abdominal distension with a palpable mass in the lower abdomen, as well as signs of peritoneal irritation. The rectal examination was very painful, and an ulcerative lesion was perceived on the anterior rectal wall. Anal bleeding could be confirmed.The laboratory findings revealed increased C-reactive protein (CRP) levels up to 100 mg/l, leucocytes 8.8 G/l, and serum lactate levels of 4.5 mmol/l.The abdominal CT scan with only IV contrast showed a perforation of the anterior rectal wall, 10 cm proximally from the anorectal border with multiple, partially confluent large abscesses located extra- and retroperitoneally Figure . FinallyThe patient underwent emergency laparotomy. Intraoperatively, a necrotizing appendicitis was found with multiple abscess formation in the retroperitoneal space. The abscess extended from the perirectal area in the pelvis up to the left kidney. The sigmoid colon, the upper and mid rectum were surrounded by the abscess. Perforation of the anterior rectal could be confirmed. Sigmoid and the upper two third of the rectum were resected, and a Hartmann's situation created. The appendix was excised and all abscess were drained by widely opening the retroperitoneal space.Due to the severe sepsis, the patient stayed for three days in the ICU, and another 18 days on the normal ward. Initial blood cultures were positive to Bacterioides fragilis and turned sterile after a week. Cultures of the abscesses were positive to Bacterioides fragilis, Escherichia coli and Streptococcus anginosus. IV antibiotic treatment (Piperacillin-Tazobactam 4.5 g three times per day) was performed for 15 days and a further per os antibiotic treatment (Levofloxacin 500 mg twice per day) was introduced for 7 days. The patient fully recovered, and was finally discharged after 21 days. Restoration of the bowel continuity was performed after 3 months. During follow-up of one year, the long-term course was uneventful.Histopathology showed a perforated appendicitis with severe peritonitis, as well as large necrosis formation of sigmoid mesenteric adipose tissue and a necrotic ulcer measuring 1 cm square on the anterior wall of the rectum. Since no diverticular disease could be detected, it was strongly assumed that necrotizing appendicitis being the trigger of this massive inflammatory process that also facilitated rectal wall necrosis and stercoral perforation, respectively.Large retroperitoneal abscess represents a potentially life-threatening complication of hollow viscus organ perforation, e.g. appendicitis ,5, diverHsieh et al. recently reported two cases and summarized the literature, whereby they found only additional 22 cases . The maiThe presence of air bubbles in the extrahepatic and/or intrahepatic portal venous system is primarily a radiological finding that is detected by performing an abdominal CT scan for various reasons. Despite portal venous gas is generally a late feature of advanced intestinal necrosis with an increased mortality, there are various other clinical conditions that may also cause portal venous gas formation, i.e. inflammatory bowel disease, biliary tract infections, cardiac and liver transplantation, acute pancreatitis, and blunt abdominal trauma . It is aPortal venous gas formation due to perforated appendicitis has been previously reported in two cases ,12. In oRectal perforation and necrosis represents an extremely rare event after retroperitoneal abscess formation. So far, only one case of rectal necrosis and simultaneous pelvic abscess as a consequence of perforated appendicitis was published in 1968 by Gostev . In our In conclusion, this patient presented with three very rare complications of acute appendicitis that all occurred at the same time. Despite the delayed diagnosis, the final outcome was good due to the rapid surgical intervention that aimed to control all infectious areas in order to assure patient's survival.The authors declare that they have no competing interests.MD and AP drafted the manuscript, ND et MS critically revised the manuscript. All authors read and approved the final manuscript.


Henoch-Schönlein purpura is a common immunoglobulin A-mediated vasculitic syndrome in children, characterized by purpuric rash, arthritis and abdominal pain. Renal involvement, manifested by the presence of hematuria and/or proteinuria, is also frequently seen. In most cases, patients with this disease achieve complete recovery, but some progress to renal impairment. Gastro-intestinal manifestations are present in two-thirds of affected patients and range from vomiting, diarrhea, and peri-umbilical pain to serious complications such as intussusception and gastrointestinal hemorrhage.We report the case of a 7-year-old Caucasian girl who presented with abdominal pain, labial swelling, and a large abdominal ecchymosis two weeks after having been diagnosed with Henoch-Schönlein purpura. A computed tomography scan revealed abdominal wall edema extending to the groin, without any intra-abdominal pathology. She was successfully treated with intravenous steroids.Circumferential anterior abdominal wall edema and labial edema have never been reported previously, to the best of our knowledge, as a complication of Henoch-Schönlein purpura. These findings further contribute to the wide spectrum of manifestations of this disorder in the literature, aiding in its recognition and management. Henoch-Schönlein purpura (HSP) is an IgA-mediated vasculitis that presents with the common tetrad of abdominal pain, arthritis, purpuric rash and renal involvement. It is usually a benign disease of childhood, typically affecting children between the ages of four and seven years, who achieve complete recovery in most cases. HSP is often preceded by an upper respiratory tract infection, with Group A beta-hemolytic streptococcus responsible for up to 50% of the occurrences .The diagnostic criteria of the American College of Rheumatology for HSP are the following: palpable purpura; patient is aged 20 years or above; acute abdominal pain; and biopsy showed granulocytes in the walls of small arterioles or venules [The presence of two or more of these criteria has a sensitivity and specificity of 87.1% and 87.7%, respectively, for the diagnosis of HSP. A subsequent review of the classification of childhood vasculitides was carried out in 2005 and the diagnostic criteria modified  . These nPalpable purpura (mandatory criterion) in the presence of at least one of the following four features: Diffuse abdominal pain; any biopsy showing predominant IgA deposition; arthritis  or arthralgia; renal involvement (any hematuria and/or proteinuria).Gastrointestinal manifestations seen with HSP have been well described, and vary in their severity. In a study of 100 patients with HSP, Saulsbury reported that 63% of patients complained of abdominal pain . IntussuUltrasound is typically the modality of choice for investigation of abdominal pain associated with HSP, and can detect mural thickness and hematoma, ileus, peritoneal fluid and intussusception .et al. in 2007 [The treatment of HSP remains mainly supportive, as the acute symptoms resolve spontaneously in the majority of patients. For more severe cases with serious complications of the disease, treatment commonly includes corticosteroids, immunosuppressive drugs, and plasmapheresis . The use in 2007 .A previously healthy 7-year-old Caucasian girl was admitted to our hospital with a history of abdominal pain, labial swelling and a large ecchymosis extending from the left subcostal area to the left lower quadrant. Two weeks before being admitted to the hospital, she experienced symptoms of an upper respiratory infection followed by joint discomfort, peripheral edema and a palpable, purpuric rash. She presented to a smaller community hospital, where the additional findings of hypertension and a Group A beta-hemolytic streptococcus-positive throat swab were discovered by a consulting pediatrician. She was diagnosed with Henoch-Schönlein purpura (HSP) and treated with two weeks of Penicillin V for her tonsillitis. Her symptoms improved, but over the course of the next six days, she developed increasing abdominal pain and "distention". She also experienced significant pain in her genital area with associated labial swelling. She was transferred to our institution, a tertiary care Pediatric Center, for further evaluation. There was no history of abdominal trauma.On admission, she was found to be hypertensive, with a blood pressure just above the 90th percentile for age and height. She had an exudative plaque on the left tonsil, but a throat swab was negative. Her abdomen revealed a large ecchymosis, 10 cm in diameter over the left quadrant, with significant edema/swelling extending from the left flank to the labia majora Figure , 3. No iThe reported case describes circumferential anterior abdominal wall edema and labial edema as a complication of HSP. Gastrointestinal manifestations of HSP are common. However, they usually result from edema and ulceration of the bowel wall, leading to pain and hemorrhage. Although only a minority of patients with HSP are investigated with a CT scan, findings usually include multifocal bowel wall thickening with skip areas, mesenteric edema, vascular engorgement and non-specific lymphadenopathy . Our patGenital involvement in HSP has been previously documented in males, and consisted of orchitis and scrotal swelling found in nine percent of boys in Saulsbury's study . There wSimilar to the responses described in several other reports, our patient had significant improvement within hours of initiation of steroid treatment and achieved almost complete resolution of symptoms within three days.This case presents an occurrence of abdominal wall and labial edema as a complication associated with HSP that has not been previously reported. The symptoms resolved promptly upon treatment with steroids. These new findings are of interest, as they further contribute to the wide spectrum of manifestations of HSP already described in the literature, aiding in the recognition and management of this disorder.CT: Computed tomography; HSP: Henoch-Schönlein purpura; kg: Kilograms; mg: Milligrams.Written informed consent was obtained from the parent of our 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.RH and RGS conceived of the project and participated in its design. MR and RH helped draft the manuscript. DS assisted with the interpretation of radiological data. All authors read and approved the final manuscript.


Metastases to the stomach from an extra-gastric neoplasm are an unusual event, identified in less than 2% of cancer patients at autopsy. The stomach may be involved by hematogenous spread from a distant primary , or by contiguous spread from an adjacent malignancy, such as the pancreas, esophagus and gallbladder. These latter sites may also involve the stomach via lymphatic or haematogenous spread. We present three cases of secondary gastric malignancy.The first is a 19-year-old male who received a diagnosis of testicular choriocarcinoma in September 2004. Metastatic malignancy was demonstrated in the stomach after partial gastrectomy was performed to control gastric hemorrhage.The second is a 75-year-old male, generally well, who was diagnosed with adenocarcinoma of the lung in September 2005. Poorly differentiated adenocarcinoma of the lung was demonstrated in a subsequent biopsy of "gastric polyps".The third is an 85-year-old man with no known history of malignancy who presented for evaluation of iron deficiency anemia by endoscopy in February 2006. Biopsies of the colonic and gastric mucosa demonstrated moderately differentiated invasive colonic adenocarcinoma with metastatic deposits in the stomach.While the accurate recognition of these lesions at endoscopy is fraught with difficulty, pathological awareness of such uncommon metastases in the gastric mucosa is essential for accurate diagnosis and optimal patient management. Primary gastric cancer is the second highest cause of global cancer mortality accounting for over 700,000 deaths annually . GastricSecondary gastric cancer however is a rare event and remains a challenging clinical problem ,7. The mThe clinical presentation of upper gastrointestinal bleeding as a manifestation of gastric metastases is unusual. Further, gastrointestinal bleeding due to secondary gastric choriocarcinoma is uncommon . MetastaA 19 year old male presented in September 2004 with a two month history of a left testicular mass. This individual was in good health, a non-smoker, and had no significant medical history. Left inguinal orchidectomy yielded a diagnosis of predominantly choriocarcinoma with a small focus of embryonal carcinoma. The lesion appeared confined to the testis with no apparent vascular or lymphatic invasion. A few weeks later the patient complained of blurry vision, fatigue and headache. Multiple brain metastases were identified by CT scans. Detailed imaging confirmed the presence of bilateral metastases to the lungs. He was aggressively treated with chemotherapy. One month later, the patient presented with melena and falling haemoglobin levels. Gastroscopy revealed mild pangastritis and evidence of prior gastric bleeding, with no obvious ulceration or masses. Shortly thereafter uncontrolled gastric hemorrhage necessitated a partial gastrectomy. Metastatic testicular choriocarcinoma was confirmed on histopathological examination of the resected stomach.Figure Figure Figure An 85-year-old male presented in February 2006 with a diagnosis of iron deficiency anemia. This individual had a history of hypertension, and had recently suffered a small lacunar infarct, but there was no known history of malignancy. On pan-endoscopic examination, a lesion was noted in the right colon at the junction of the cecum and ileocecal valve and on the lesser curvature of the stomach. Biopsy confirmed these lesions to represent moderately differentiated colonic adenocarcinoma, and colonic adenocarcinoma metastatic to the stomach, respectively.Figure Figure A 75 year-old male presented in September 2005 with a two-month history of weight loss. He had also noticed increasing breathlessness and cough over the past month and a half. He was generally well, took no routine prescription medication, and was a non-smoker. There was no known history of malignancy. On plain X-ray, a right sided lung lesion was noted, which proved to have an appearance suspicious for bronchogenic carcinoma on subsequent CT. Adenocarcinoma was confirmed by fine needle aspirate of the lesion and a pleural biopsy. As the patient also complained of significant epigastric and right upper quadrant pain, gastroscopy and biopsy of "gastric polyps" was undertaken. Dysplastic cells most in keeping with poorly differentiated metastatic adenocarcinoma of the lung were identified within the gastric lymphatics.A right-sided pleural biopsy as seen in figure Pathological examination of the endoscopic biopsy of the gastric polyp figure  shows thThe involvement of the stomach by metastases is rare with the most common reported primaries include melanoma, and carcinomas of the breast and lung ,16. The Choriocarcinomas of the testis account for only 0.3% of testicular tumours , and gasAdenocarcinoma of the lung is now the most frequent form of lung carcinoma in the United States , most frColonic adenocarcinoma is the second most common cause of cancer mortality in North America . LymphatThe appearance of metastases to the stomach at endoscopy is variable. The appearance on imaging or gross inspection is generally not suggestive of the primary. Gastric involvement may be characterized by a single lesion in the gastric body or by multiple lesions ,10. OfteGastric metastases may be recognizable as abnormalities on gastroscopy; however as the morphology is variable there are no characteristic appearances that define metastatic disease . LikewisIn conclusion as pitfalls abound in the clinical presentation, diagnostic imaging and histopathology, it is essential to be acutely aware of both common and uncommon metastases to the stomach and to appropriately include these in the differential diagnosis of all gastric lesions for accurate diagnosis and optimal patient management.Written consent for research and publication was obtained from the patient or their relative.The consent forms are mailed to the editorial staff.The authors declare that they have no competing interests.RK is the corresponding, and first author of this manuscript. KS and JLS are undergraduate students who have contributed to the acquisition of data, analysis, and interpretation of data. JF is the postgraduate student who presented these three cases in part as a poster presentation at the Canadian Association of Pathologists' Annual Meeting in July 2006. RC and SCK have made substantial contributions to the conception and design of this manuscript. All authors read and approved the final manuscript.