Lung cancer is known to metastasize to the pancreas with several case reports found in the literature, however, most patients are at an advanced stage and receive palliative treatment.We describe the case of a 56 year old male patient who presented with a picture of obstructive jaundice. Investigations revealed an obstructing lesion in the pancreas and a further lesion in the lung with benign appearances. The patient underwent a pancreatectomy and, unexpectedly, the histology of the resected specimen demonstrated metastatic adenocarcinoma of bronchogenic origin. He was referred to a cardiothoracic team who proceeded to resect the patient's thoracic lesion before administration of adjuvant chemotherapy. The patient was reviewed 18 months post operatively and remains symptom free with no clinical or radiological evidence of recurrence. We were unable to identify any previous case reports (of lung adenocarcinoma) with such a presentation which were ultimately treated with resection of both lesions.Similar situations are bound to arise again in the future and we believe that this report could demonstrate that there is a case for aggressive surgical management in a highly selected group of patients: those with NSCLC and a synchronous solitary pancreatic deposit. That a variety of malignant tumours can metastasise to the pancreas is well documented. Several case reports have reported patients with lung cancer whose clinical presentation was that of obstructive jaundice .Most patients presenting in this manner are at an advanced stage with widespread disease, and are usually managed symptomatically. This generally involves palliative chemotherapy and/or radiotherapy coupled with other measures to relieve the biliary obstruction such as biliary stent insertion. In the few cases where operative intervention is considered, it is usually limited to a biliary bypass to relieve the jaundice.We describe an unusual presentation where an adenocarcinoma of the lung with a synchronous solitary metastatic deposit in the pancreas (not visible on CT) was treated with operative resection of both lesions. The uniqueness of this case is enhanced by the fact that both lesions were identified preoperatively although their nature was not.A 56 year old male lawyer presented to his local hospital complaining of a recent change in his urine colour (to bright orange) and general malaise. The patient suffered from moderate bronchiectasis and asthma for which he took inhalers . He was also known to be hypertensive (controlled on diltiazem) and suffered from severe eczema. He had never been a smoker but his daily consumption of alcohol amounted to 1.5 bottles of wine.Initial workup revealed deranged liver function tests and relevant tumour markers were raised . A subsequent abdominal ultrasound showed biliary dilatation to the level of the pancreas. This was confirmed on an MRCP. However CT  and MRI examinations failed to reveal any pancreatic mass . There was no evidence of intra-abdominal spread at laparotomy. The head of the pancreas contained a palpable mass. This was resected in routine fashion. The histology of the resected specimen was a single poorly differentiated adenocarcinoma figure  11 mm i, and negIn view of the reported immunohistochemical profile, coupled with the identification of a lung lesion, the tumour was interpreted as metastatic adenocarcinoma of bronchial origin rather than as a primary pancreatic lesion. As a result the patient was referred to a thoracic surgeon for consideration of removal of the lung lesion. Six weeks later the patient underwent a mini thoracotomy where a 2 × 3 cm lesion was identified in the medial segment of the upper lobe of the right lung. The segment was removed along with hilar and mediastinal lymph nodes for staging. Histology of this specimen reported a lung adenocarcinoma with complete excision and no lymph node involvement.Three weeks after his lung resection the patient was started on adjuvant chemotherapy with gemcitabine and carboplatin. This regime was continued for 6 months. The patient was seen eighteen months from presentation. Clinically he remained symptom free and a follow-up CT of his chest and abdomen revealed no evidence of recurrence.Pancreatic cancer is one of the leading causes of cancer deaths ranking 4th in the US and 6th in Europe . HoweverLung cancer metastasizes to many sites, but most frequently to bone, the liver and the adrenal glands ,10. Appret al, where 333 cases with secondary deposits in the pancreas were reviewed. Of these, 234 had treatment information of which 150 (64.1%) underwent pancreatic resections [et al [Of secondary deposits discovered in the pancreas, lung cancer makes up  a high percentage table  7,17-36-3617-36.s [et al , suggestet al [Stage IV NSCLC has a poor prognosis. Median survival with best supportive care is reported as 3.6 months  whilst platinum based chemotherapy regimes increase this statistic to 6.5 months . This patient is alive and disease free 18 months following presentation. It is accepted practice today to consider selected patients with solitary intracranial deposits for resection -41. Alsoet al , howeverIn the majority of cancers, synchronous presentation generally carries a worse prognosis than a metachronous one. Our case is an example of a synchronous metastatic deposit resected  inadvertently. However, resection of both lesions has led to long-term disease-free survival. Therefore we believe that this report demonstrates that in selected cases consideration should be given not just to palliation but to potentially curative surgery whether it be synchronous or more likely metachronous presentation of metastatic lung cancer to the pancreas. This is very different from what has been described previously where very few operations with curative intent have been carried out, in particular on patients with NSCLC.CT: Computed Tomography; MRCP: Magnetic Resonance Cholangiopancreatography; ERCP: Endoscopic Retrograde Cholangiopancreatography; CBD: Common Bile Duct; FDG-PET: Fluorodeoxyglucose – Positron emission tomography; NSCLC: Non-small cell lung carcinoma; TTF-1: Thyroid Transcription Factor-1; PSA: Prostate Specific Antigen; CK7, CK20: Cytokeratin 7, Cytokeratin 20.Written consent was sought and obtained from the patient prior to publication of this article.The authors declare that they have no competing interests.SP operated on the patient, conducted the collection of the data and the literature and conceived the case report. SM was involved in collection of literature and drafting the article. RRH was the principal investigator, operated on the patient collected data and was involved in the drafting of the article.All the authors have read and approved the final manuscript.


Cystic hygromas, also known as lymphangiomas, are unusual congenital malformations of the lymphatic system. They are normally seen in the head and neck region and very rarely occur in the scrotum. This anomaly manifests as a painless scrotal swelling and is easily misdiagnosed. We report a rare case of a 3-year-old boy who presented with a gradually enlarging, painless scrotal mass which was identified sonographically and histologically as a scrotal lymphangioma and treated by surgical excision. A brief review of the literature is included. Lymphangiomas are benign non-encapsulated lesions composed of sequestered non-communicating lymphoid tissue which is lined by lymphatic endothelium. They are subclassified by increasing vessel size, into (i) capillary, which is rare and located in the subcutaneous tissue, (ii) cavernous (located around the mouth and tongue), and (iii) cystic. Cystic hygromas show a predilection for the neck (75%) and maxilla (20%), with the remaining 5% arising in rare locations such as the mediastinum, retroperitoneum, bone, kidney, colon, liver, spleen and scrotum . ScrotalA 3-year-old Caucasian boy presented with a 4-month history of a gradually enlarging, painless swelling in his left scrotum. Scrotal examination showed retractile testes of normal size. The left side of the scrotum was visibly enlarged with a bluish tinge, and contained a non-tender, soft swelling distinct from the testes. It was possible to palpate above the swelling, which did not transilluminate. In view of the indeterminate nature of the examination an ultrasound of the testes was done and this demonstrated a multilocular cystic structure containing both clear and echogenic fluid in the left scrotum. The testes appeared normal. These findings were consistent with either a cystic hygroma or a complex spermatocoele Fig. .A left inguinal scrotal exploration and excision of cystic swelling was performed. The left testis was 1.7 cm by 1 cm in size. The vas deferens had moderate-sized vessels associated with a large patent processus vaginalis. A multiseptate swelling separate from the left testis but infiltrating the scrotal skin was identified. Further surgical findings included a few separate cysts filled with haematoma. The swelling was dissected and excised from the adnexal tissues and histology revealed dilated lymph channels Fig. .Macroscopy showed dark red tissue measuring 3.7 cm by 2.3 cm by 1.0 cm and on slicing released blood. The cut surface showed a spongy texture but incorporated a central cyst 1 cm in diameter. Microscopy identified fibroadipose tissue surrounding a cavernous angiomatous malformation, consistent with a diagnosis of cystic hygroma. The parents were reassured of the findings. The postoperative recovery was unremarkable with complete resolution of symptoms.Cystic hygromas, more widely known as lymphangiomas, are rare, hamartomatous, congenital malformations of the lymphatic system with no risk of malignant transformation. They mostly occur in childhood and have no sex or race predilection. Commonly found in the head and neck, they theoretically can occur anywhere in the skin or mucous membranes. Very rarely they can be found in the mediastinum, intestines, pancreas, mesentery, groin or bladder . The intIn general, the diagnosis of a lymphangioma is based on the clinical history, physical examination and conventional light microscopy. The diagnosis of a scrotal lymphangioma , is confounded by multiple differential diagnoses including a hernia, hydrocoele, haematocoele, spermatocoele and varicocoele . Rarely,Local recurrence is common and can only be prevented by complete surgical excision. Therefore, when suspected, imaging in the form of ultrasound and/or magnetic resonance imaging (MRI) is of critical importance to accurately define the extent of the lesion preoperatively, so an adequate resection may be performed in the first instance . LymphanWritten informed consent was obtained from the patient for the publication of this case report and the 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.AMG and TAJ made substantial contributions to the analysis of data. AMG wrote the manuscript. TAJ edited the manuscript. AMG performed the literature search. All authors have approved the publication of this case report.


Pseudomyxoma peritonei is a rare, chronic relapsing disease with a guarded prognosis. Here, we describe such a case of a young patient presenting with primary infertility, who conceived following in-vitro fertilization with donor egg and had a successful pregnancy outcome. Literature regarding fertility and pregnancy outcome in this condition is reviewed. Pseudomyxoma peritonei (PMP) is a rare, chronic and poorly understood disease. It is characterized by mucinous ascites and a protracted clinical course with multiple recurrences despite surgery and/or chemotherapy. There is limited data available addressing the reproductive prognosis in these patients. Also, the course of pregnancy in these patients is largely unknown. Only three pregnancies in patients with PMP have been reported to date.2in-vitro fertilization (IVF), using donor eggs.Here, we present a case of a young girl, with PMP secondary to a mucinous cystadenoma of the ovaries, who presented with primary infertility and had a successful pregnancy outcome, having conceived with A 25-year-old patient, presented to us with primary infertility since four years. She had undergone an appendectomy at the age of 14 years and a laparotomy at the age of 20 years for acute abdomen secondary to intestinal obstruction. There were no records available of the first surgery. The intraoperative findings of the second surgery revealed jelly-like material filling the peritoneal cavity suggestive of pseudomucinous peritonei. Both ovaries were replaced by huge multiloculated cystic masses 10 × 10 cm each, densely adhered to the omentum and the sigmoid colon. There was a constriction band at the ileocaecal junction that was resected and intestinal continuity reestablished. The ovarian masses were suboptimally debulked. Both tubes were reported to be distorted and atrophic. She did not receive intraperitoneal chemotherapy as there were no facilities available. Histology revealed a benign mucinous cystadenoma of both ovaries. After the surgery, she was lost for follow-up.At presentation to us, she had regular menstrual cycles, her FSH and LH levels being 12.1IU/L and 10.8 IU/L respectively. Other than her fertility concerns, she was asymptomatic. Transvaginal scan revealed a bulky uterus with heterogeneous multiloculated cystic masses 10 × 10 cm each, in both adnexae. Normal ovarian tissue could not be demonstrated. CA125 and CEA were normal. The patient was referred to a gynecological oncologist, who advised revision laparotomy in view of probable recurrence of the disease, but she refused. Hysterosalpingogram confirmed the bilateral tubal block. Her husband's semen parameters were normal.Options of controlled ovarian hyperstimulation could not be considered due to the presence of persistent large cysts in both ovaries and the inability to visualize normal ovarian tissue. In such a situation, to fulfill her desire to have a child, we counseled the couple to opt for an IVF with donor oocyte. The endometrial preparation consisted of luteal downregulation with 0.5 ml of leuprolide acetate , followed by sequentially increasing doses of oral estradiol valerate , for a period of twelve days. Injectable progesterone 50 mg  was administered daily from the day of the oocyte pickup. She had two, grade A, 8-cell stage embryos transferred. The dose of progesterone was increased to 100 mg on the day of embryo transfer and continued till 12 weeks of pregnancy. She conceived in the first cycle. The antenatal period was uneventful. The masses were persistent during the pregnancy and did not increase in size. She underwent a caesarean section for failed induction and delivered a healthy baby weighing 3 kg. Peroperatively, there were dense adhesions between the anterior abdominal wall and the uterus. The bladder was pulled up and was densely adherent to the anterior uterine wall.There was an inadvertent injury to the bladder, which was repaired and she had an uneventful recovery. She is now 3-months postnatal. On rescan, the ovarian cysts were persistent. She has been referred to a gynecological oncologist for further management.The term PMP was coined by Werth in 1884 to descrThe treatment of PMP primarily remains aggressive surgical debulking, which may have to be done repeatedly, due to its recurrent nature. Postoperative adjuvant therapy includes the use of intraperitoneal 5-fluorouracil, mitomycin-C and cisplatin.et al.,[et al., reported a case of primary infertility, scheduled for a laparoscopic cornual detachment of the hydrosalpinx prior to IVF. On laparoscopy, besides the hydrosalpinx, a thin layer of mucus was found covering the uterus and the tube, which on biopsy proved to be PMP, the origin of which was later found to be a low-grade mucinous appendiceal neoplasm. They concluded that malignancies, although rare, should always be part of the differential diagnosis of external causes of tubal disease.[et al., reported a case of PMP secondary to ovarian mucinous cystadenocarcinoma, who conceived naturally, twice, after surgical clearance and postoperative adjuvant chemotherapy.[A pubmed search for the terms ‘infertility’ and ‘pregnancy in PMP’, revealed only four case reports,–9 probabet al., reported disease. Niwa et otherapy. A case oIn this case report, we wish to highlight that although patients with PMP have a guarded long-term prognosis, their desire to have a child needs to be addressed. Presence of the pseudomucin in the peritoneum and the distorted tubo-ovarian relation, secondary to the dense adhesions, may impair fertility. Natural conception can occur after surgical clearance and chemotherapy. IVF may be the only option wherein corrective surgery is not possible due to dense adhesions. In our case, the presence of persistent multiloculated cysts in both ovaries and the absence of demonstratable normal ovarian tissue made controlled ovarian hyperstimulation impossible. Hence, we counseled her to opt for donor eggs.During pregnancy, complications related to PMP, like bowel obstruction, fistula formation may occur. Dense adhesions should be anticipated at caesarean section.To the best of our knowledge, this is the first case report of a patient with PMP, who conceived with IVF using donor eggs. The case emphasizes that pregnancies are possible in impossible situations like PMP, through ART.


Liver and lungs are common locations of distant metastases of colorectal cancer. Skin metastases of colorectal cancer are very rare, and facial lesions are extremely uncommon.An anterior resection of the rectum was performed for rectal cancer T3N0M0G3. A small ulcer on the upper lip developed 3.5 years after primary operation. Metastasis of adenocarcinoma was confirmed histologically, and local excision was performed. At the same time, a solitary metastasis in the right lung was diagnosed, and the right lower lobectomy was performed. No other metastasis or local recurrences were observed during the next 7 months.Skin metastases in the face from colorectal cancer are very rare and may indicate tumour relapse several years after primary resection. These patients have a worse prognosis. Liver and lungs are common locations of distant metastases of colorectal cancer. Skin lesions are very rare they occur in 4-6.5% of cases ,2. The mth week after primary operation.A circular tumor of the rectum located at 10 cm from the dentate line was diagnosed 4.5 years ago in a 65 year-old Lithuanian male. Histologically, well-differentiated adenocarcinoma G1 was identified. No distant metastases were found, and endorectal ultrasound revealed uT3N0 stage of the disease. Preoperative radiation was applied with the total dose of 45 Gy. After 6 weeks, low anterior resection with preventive ileostomy was performed. The postoperative period was uneventful. Postoperative histological examination showed infiltrative mucinous adenocarcinoma of the rectum pT3 N0 M0 L0 V0 R0 G3, Astler - Coller B1. Six postoperative courses of 5-fluorouracil were applied. Preventive ileostomy was closed uneventfully on the 7The follow-up included twice-yearly abdominal ultrasound, chest x-ray, colonoscopy, and carcinoembryonic antigen.A small 0.5 cm diameter ulcer on the upper lip developed after 42 months following the removal of the primary tumor, and biopsy confirmed metastasis of the colorectal adenocarcinoma Figure . and 1b.Simultaneously, chest computed tomography scan showed a solitary mass of 3.4 cm in diameter in the lower lobe of the right lung, irregularly accumulating contrast medium. Consequently, lobectomy was performed. Postoperative histological examination showed moderately differentiated metastasis of the colorectal cancer G2. The postoperative period was uneventful. No progress of the disease was observed during the subsequent 7 months.We have found only 15 articles describing metastases of colorectal cancer to the skin of head and neck. Facial localization is especially rare; and it has been mentioned in only in the 4 publications in English -5. One mCancer of the large bowel most frequently metastasizes into the liver and lungs, but a skin lesion is very rare and could be observed in only 4-6.5% of cases . Skin deThe most frequent localization of skin metastases of the colorectal cancer is abdomen, especially in the postoperative scars - up to 0.6% of all patients . AccordiClinically, metastases present as nodules, ulcers, cellulites or fibrous depositions. Histologically, they are classified as adenocarcinoma, squamous carcinoma, non-differentiated carcinoma, or other types. All described facial metastases from colorectal cancer were adenocarcinomas.Colonic mucosa typically expresses cytokeratin (CK) 20 but not CK7. In this case CK20+/CK7-profile has been used to distinguish colonic adenocarcinoma from others arising in the lung, breast, or genitourinary tract, salivary gland. CK7 expression in colorectal adenocarcinoma has been reported to be rare, and when present, a metastatic origin needs to be excluded.Skin metastases are a poor prognostic sign and medium survival after diagnosis ranges between 2 and 4.5 months .Colon carcinoma is believed to metastasize initially through lymphatics and later through the haematogenous route. In this case, it is interesting and not clear, how after 42 months following the radical resection of the primary tumor (pT3 N0 M0 L0 V0 R0) and postoperative courses of the chemotherapy, the tumor metastasized to the facial region and lung.Skin metastases in the face from colorectal cancer are very rare and may indicate tumour relapse several years after primary resection. These patients have a worse prognosis.CK: cytokeratin.Written informed consent was obtained from the patient for the publication of this case report. 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.ZS operated the patient and performed an anterior resection of the rectum, later closed preventive ileostomy, and was a major contributor in writing the manuscript. AT was the doctor of the patient and observed him at ambulance, analyzed and interpreted the patient data regarding the metastatic large bowel cancer and contributed in writing the discussion of the manuscript. SP performed literature search and analysis regarding metastatic rectal cancer and metastatic skin tumors, analyzed and interpreted the patient data. DP performed the histological examination of the resected rectal cancer and excised skin lesion. DPS analyzed and interpreted the patient data and contributed in writing the discussion of the manuscript, critically revised it for important intellectual content. All authors gave final approval of the version to be published.


Inflammatory fibroid polyps are rare, localized, non-neoplastic lesions originating in the submucosa of the gastrointestinal tract. Intussusception due to inflammatory fibroid polyps is uncommon; moreover, ileo-ileal intussusception has only rarely been reported. Here, we report an 11 × 7 cm giant inflammatory fibroid polyp of the small bowel that presented as intussusception in a 73-year-old woman. Ultrasonography demonstrated a solid, homogeneous, echogenic mass surrounded by the typical mural layers of an invaginated ileum. The immunohistopathological diagnosis after segmental ileal resection was an ileal inflammatory fibroid polyp. Although encountered rarely in adults, physicians should be aware of invagination and consider it in each case of acute abdomen because of the wide spectrum of clinical settings. Intussusception occurs when a more proximal portion of bowel invaginates into more distal bowel . Adult iA 73-year-old Turkish woman was admitted to our emergency unit suffering from abdominal pain, nausea and vomiting, constipation, no passage of gas or feces, and abdominal distension for 5 days. Laboratory investigations showed the following: blood urea nitrogen, 27 mg/dl; creatinine, 0.9 mg/dl; and C-reactive protein, 72 mg/L. The blood cell count revealed leukocytosis at 18,000/μl, hemoglobin of 13.7 g/dl, and a platelet count of 524,000/μl. Other serum parameters were within normal limits. The physical examination revealed muscular guarding and rebound tenderness in the periumbilical region. An upright plain abdominal film revealed small bowel obstruction with marked small bowel air-fluid levels. Abdominal ultrasound revealed a target lesion in a small bowel segment, indicating intussusception . The patIntussusception develops due to a difference in motility between two intestinal parts. One segment (the intussusceptum) enters a neighboring one (the intussusceptiens) . BarbettInflammatory fibroid polyps are rare, benign, tumor-like lesions of the gastrointestinal tract. The lesion was first described by Vanek in 1949. Most frequently, they are localized in the gastric antrum, but can develop anywhere in the gastrointestinal tract. In the small intestine, the ileum is the most common site where these polyps cause intussusception. An IFP is a benign reactive lesion that occurs predominantly in adults. Most IFPs are polypoid masses smaller than 5 cm, although sizes up to 20 cm have been reported -12. In tA preoperative diagnosis of intussusception is rare, but can be made on finding a palpable mass in the abdomen or with the use of imaging techniques . The priMorphologically, IFPs can mimic several other tumor and non-tumor processes of the gastrointestinal tract, including inflammatory myofibroblastic tumors, eosinophilic gastroenteritis, gastrointestinal stromal tumors (GISTs), and other mesenchymal lesions. Sometimes differentiation is difficult, especially differentiation between inflammatory fibroid polyps and GIST . In our In conclusion, the recommended treatment of adult intestinal invagination is surgical resection of the intestinal segments involved. This case report demonstrates that intussusception, although rare in adults, should be considered in the differential diagnosis of abdominal pain.


We report a case of a 44-year old female who presented to her physician complaining of mild dyspnea. A follow-up chest X-ray and chest computed tomography scan revealed a giant bilateral intrathoracic mass, filling the right thoracic cavity and extending across the anterior mediastinum into the left chest cavity. This large mass caused a marked shift in the midline structures, displacing the heart to the left hemi-thorax. The patient underwent surgical removal of the thoracic and breast mass, with histologic examination confirming the diagnosis of a giant intrathoracic lipoma, weighing 4,320 grams and measured 34 × 28 × 11 cm. It is the largest intrathoracic lipoma documented in the modern literature. A 44-year old African American female who worked as a phlebotomist presented to her primary care physician complaining of mild shortness of breath and a 4-pillow orthopnea for many years (>10 years). She was a non-smoker, and maintained a healthy weight of 142 pounds for her 68" height. Her past medical history was significant only for uterine fibroids, for which she had undergone a myomectomy. She had conceived six healthy children, and the remainder of her family had no health problems. A subsequent chest x-ray and CT scan revealed a large mediastinal mass which occupied the majority of the right thoracic cavity and further extended across the anterior mediastinum into the left thoracic cavity figure . The posIn order to remove this large intrathoracic mass, the patient was explored through a transverse sternothoracotomy (clam-shell incision) to allow complete access to both pleural spaces and the mediastinum. Upon exposure of the anterior mediastinum, a large mass was visualized crossing this area and extending into both thoracic cavities figure . The masThe patient's postoperative course was complicated by the development of several partially gangrenous and necrotic toes bilaterally, with the right toes affected greater than the left toes. A full hypercoagulation work-up was negative, and no evidence of arterial or venous thrombosis was ever identified. It is strongly suspected that this occurred as the result of a fatty embolic event related to the removal of the large tumor mass. This, in turn, required a partial amputation of the distal portion of 5 toes on the right and 2 toes on the left. Approximately 3 months after her initial hospitalization and surgery, the patient had complete resolution of her shortness of breath and was ambulatory.Final histologic analysis of the tumor revealed an encapsulated tumor with abundant mature adipose tissue, a few scattered strands of fibroconnective tissue, multiple foci of calcification and fat necrosis. The bland histological features were consistent with the diagnosis of a lipoma figure . LiposarClinically, the finding of a lipoma is very common, mostly found within the subcutaneous areas of the body. These are almost always benign in nature with only rare malignant degeneration reported anecdotally. Such benign findings within the thoracic cavity are extremely uncommon, with only rare reported cases of giant intrathoracic masses reported. These well-circumscribed mesenchymal tumors originate from adipose tissue, are fully encapsulated in most cases, and are typically very slow growing, often over many years . They arCurrent recommendations include complete en-bloc removal of such tumors whenever possible, as this is the only definitive treatment option. Once resected, local recurrence of intrathoracic or mediastinal lipomas is uncommon. Mediastinal lipomas typically arise within the anterior mediastinum and represent only 1.6–2.3% of all primary mediastinal tumors . ThymoliWritten 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.RH assisted with the surgery, wrote the case report, performed the literature review and obtained informed consent, AR and LD carried out the patient diagnosis, performed the surgery, removed the mass, and were major contributors in drafting the manuscript, AR and RH were involved in the patient's post operative management, GN conducted the histopathology and provided the photographs. All of the authors were involved in the patient's care and all authors read and have been involved in approving the final manuscript.


A retained surgical sponge in the abdomen is uncommon although it is likely that this finding is underreported in the medical literature. The intravisceral migration of retained surgical gauze is even rarer, as demonstrated by the very few cases reported.Three years after undergoing anterior resection of the rectum, a 75-year-old man presented with symptoms of small bowel obstruction. Plain abdominal radiography and CT showed a radio-opaque marker; a foreign body was suspected, probably a piece of retained surgical gauze. An ileotomy of about 5 cm. was performed to confirm this diagnosis and remove the gauze.Although rare, retained gauze in the abdomen is a complication of surgery. The authors consider that this event may be more frequent than it appears from reports in the literature, probably because of its medico-legal implications. If all such cases were reported, it would be possible to estimate their exact number, classify the occurrence as a possible surgical complication and thus modify its medico-forensic consequences. Retained surgical gauze in the abdominal cavity is an infrequent event but it may cause symptoms, both in the early postoperative period as well as months or years after the original operation. Non-specific clinical symptoms and inconclusive imaging findings may preclude an accurate diagnosis . It can,A 75-year-old man, who had undergone anterior resection of the rectum in our department three years previously for rectal carcinoma, was readmitted into our surgical unit because of a series of symptoms including abdominal colic, pain in the epigastrium, nausea, alvus closed to faeces but not to gas and fever (38.5°C). Clinical examination revealed abdominal tension, with intense pain on palpation in the epigastric region and in the right iliac fossa. Whole blood analysis showed a marked leukocytosis (white blood cells: 23.200/mm3) while the other biochemical parameters were within normal limits. Plain abdominal radiography figure  and succWe performed a xifo-pubic laparotomy and, after detaching several dense adhesions, observed that the final ileal ansa was deformed by the presence in its lumen of a pulpy, ovaliform structure, 10 cm in width. No signs of previous fistulas or abscesses of the intestinal wall were detected. An ileotomy of about 5 cm made it possible to remove the foreign body, which proved to be a piece of laparotomic gauze of 40 × 40 centimeters figure . The ileA gauze swab left in the abdomen represents an extremely serious iatrogenic complication in major abdominal laparotomic surgery. The most frequent 69%) type of foreign body left inside the abdomen during surgery is, in fact, laparotomic gauze. Several factors which may make it necessary to cut down on operating time may lead to a consequent increase in the risk ratio of such an occurrence by from 1,1 to 8,8; these include not only emergency surgery, but also a high body mass index of the patient and intraoperative complications, such as hemorrhage [9% type oSeveral measures might help to avoid the problem of leaving foreign bodies inside the abdomen, especially in the case of high-risk patients, for example, an accurate swab count prior to surgery, during the operation and finally after the incision has been closed. Further measures include the use of radio-opaque sponges only and a careful control of the inside of the abdomen by the surgeon before closure. Moreover, if there is any doubt about the accuracy of the final swab count, intraoperative radiologic screening may detect any retained surgical material impregnated with a radio-opaque marker.It is not easy to say whether cases of gauze left in the abdomen are always due to a real lack of quality on the part of the surgeon or of the theater nurse. Most retained sponges, in fact, occur after "normal" swab counts, perhaps falling outside the human safeguards designed to prevent these types of errors .Clinical symptoms may be various and closely connected to the subsequent destination of the textile aid. Abscess formation with peritonitis or systemic septic symptoms has been reported to occur in 16.7% of the cases, hemoperitoneum secondary to a vessel lesion or an abdominal mass with no apparent symptoms in 8.3% and intestinal obstruction in 58.3% of the cases. Moreover it has been reported that the interval between the probable causative operation and the diagnosis of retained gauze may range from 11 days to 28 years [It is extremely difficult to reach a correct diagnosis of retained surgical gauze and in particular of any transvisceral migration by means of clinical examination only. Instrumental examinations, such as plain abdominal radiography, which will show a radio-opaque marker, and abdominal USG and contrast-enhanced abdominal CT in order to show up the mass image, are generally essential , even thAlthough a surgical sponge may migrate completely into the ileum without any apparent opening in the intestinal wall , variousEven though prevention is the best treatment as in many other medical problems, the only considered therapy for a retained surgical swab in the abdomen remains surgical removal, which may lead to a 10% mortality rate if there is delay after diagnosis . In factThe incidence of the phenomenon "retained textile aid" during surgical procedure, reported in several case reports, is of about 1/1000–1500 procedures on average [Nevertheless, in spite of continual improvement in surgical procedures and the technical evolution aimed at protecting patients in the operating theatre, published data report that the problem of residual foreign bodies after surgery is still unresolved and, furthermore, the scarcity of reports regarding this event, probably due to the inevitable medico-forensic implications, means that its incidence is still underestimated.It is therefore to be hoped that cases of retained surgical gauze in the abdomen will be constantly reported in the medical literature in future, in order to make a real estimate of the incidence of this event, to standardize recommended procedures for avoiding it, but above all, in order to modify the medico-forensic implications of the phenomenon.The author(s) declare that they have no competing interests.Grassi N., Torcivia A. and Bottino A. performed the operation, assessed the didactic importance of the clinical case and acquired the data; Cipolla C. Pantuso G. and Torcivia A. were responsible for drafting the manuscript and its revision; Fiorentino E. and Ficano L gave their final approval of the version to be published. All Authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this Journal.


Kaposi's sarcomas have been associated with different conditions of immunosuppression and are also known to be a typical complication of solid organ transplantations.We report the case of a 65-year-old Turkish man with a history of heart transplantation 10 months ago who presented for clarification of his dyspnea. The patient had a known history of chronic obstructive pulmonary disease and a smoking history of 40 pack years. Radiologically, three progressively growing intra-pulmonary nodules were detected. The histology was diagnostic for a Kaposi's sarcoma. Visceral and especially primary intra-pulmonary Kaposi's sarcomas are very rare and have been described to have a rather unfavorable prognosis.Even with a history suggestive for conventional lung cancer, Kaposi's sarcomas should be considered in patients after transplantation of solid organs. It should be noted that in a minority of cases this tumor exists in the absence of the typical cutaneous lesions. Kaposi's sarcomas are infrequent malignant tumors in the USA derived from vasoformative mesenchyme with a higher regional prevalence (endemic form) in the Mediterranean basin, the Middle East and Eastern Europe and in immunocompromised patients . The latIn the 1990 s the connection between the human herpes virus 8 (HHV8) and Kaposi's sarcomas was established. Virtually all Kaposi's sarcomas are thought to harbor this virus which can be detected by immunohistochemical and molecular-pathological techniques [In this case report we describe the rare case of a primary intra-pulmonary Kaposi's sarcoma in a human immunodeficiency virus (HIV)-negative 65-year-old man with a history of heart transplantation 10 months previously.A 65-year-old Turkish man presented to the hospital for clarification of dyspnea. Computed tomography (CT) showed a small tumor in the lower lobe of the left lung. Subsequent bronchial lavage was non-contributive concerning possible viral, bacterial (including mycobacteria) and fungal causes or malignancy. It was decided to perform a follow-up CT in three months.Our patient had a medical history of heart transplantation 10 months previously due to biventricular heart insufficiency, chronic atrial fibrillation and multi-vessel coronary heart disease. Additionally, he had known chronic obstructive pulmonary disease , hyper-cholesterinemia, substituted hypothyroidism, articular gout, normocytic normochromic anemia, steroid induced myopathia and obesity, hypertrichosis (following therapy with cyclosporine) and a recently polymerase chain reaction (PCR)-confirmed cytomegaly virus infection. Follow-up CT after three and four months displayed three progressively growing tumors in the upper and lower lobe of the left lung (up to 1.6 cm) and in the lower right lobe Figure . PhysicaSince the above described lesions were not thoracoscopically detectable, an open thoracotomy was performed. The tumors in the left upper and lower lobe were surgically removed by wedge resection. One of the tumors was sent for intra-operative frozen section. Macroscopically, the tumor was red-brown and well demarcated from the surrounding parenchyma. Histologically, the frozen section revealed an intra-pulmonary spindle-cell tumor. Intra-operatively the dignity of the tumor could not be definitely determined. On paraffin sections, the hematoxylin and eosin staining in all obtained specimens displayed rather monomorphic spindle-cell tumors Figure  with sliIn the post-operative course our patient was transferred to the intensive care unit for two days for short-term intubation owing to pulmonary edema and reduced diuresis. He recovered well and was transferred back to the normal ward. Heart and lung function were normal. Our patient was able to leave hospital on the tenth post-operative day. Immunosuppressive therapy was changed from cyclosporine to everolimus and a follow-up CT in three months was arranged. In the meantime the immunosuppressive therapy might be further adapted to a possible chemotherapy.Iatrogenic (post-transplantation) Kaposi's sarcomas are most often detected in patients with a previous history of kidney transplantation, which reflects the higher frequency of these transplantations. The rate of post-transplantation Kaposi's sarcoma was estimated at about 0.5% (range 0.06% to 4.1%). The majority of cases, including the one described, have been of patients originating from the Mediterranean, the Middle East area or African regions, known for the endemic form of this tumor entity. For some of the patients with iatrogenic Kaposi's sarcoma the hypothesis is that the tumor cells originated from infected progenitor cells received from the donated organ.et al. reported a case of cutaneous and diffuse pulmonary involvement six months after heart transplantation [Larger studies have already described Kaposi's sarcomas following heart transplantation ,3. In moantation . Indeed antation . The oveantation . Howeverantation . Table 1et al. reported the case of a 42-year-old man who had developed multiple intra-pulmonary Kaposi's sarcomas 28 days after heart transplantation [Wasywich antation . As in oantation .Cases of primary pulmonary Kaposi's sarcoma were mostly associated with AIDS, but have also been described as rare complications of other solid organ transplantations . Like inTypical but unspecific radiological features of Kaposi's sarcoma in such patients were nodular or reticular opacities, pleural effusions and hilar/mediastinal lymphadenopathy.Interestingly, in contrast to our case, most reports in the literature describe primary and secondary pulmonary Kaposi's sarcoma with multiple nodular manifestations. Although this case underlines that, even in the absence of skin manifestations, one should consider Kaposi's sarcoma as a possible cause of an intra-pulmonary tumor, common lung cancers  are also important and frequent differential diagnoses in heart transplant patients.et al. therefore recommended a more aggressive combination therapy in such cases [For post-transplantation patients with Kaposi's sarcoma the five-year survival rate was observed at about 68% and these patients had a rather high rate of visceral involvement (47%) . CompletIn conclusion we report a rare case of Kaposi's sarcoma following heart transplantation with primary intra-pulmonary manifestation without skin lesions. Even with a history suggestive for lung cancer, Kaposi's sarcoma should be considered as a differential diagnosis in patients after transplantation of solid organs. The prognosis of patients with visceral Kaposi's sarcoma seems to be rather serious and requires intensive follow-up and consideration of different therapeutic measurements.The authors declare that they have no competing interests.FRF, GK and MM interpreted and diagnosed the histological results, conceived the report and provided histological images. MT and IO provided clinical data and contact with patient. RH provided radiological images. All authors contributed to, read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Persistent retroversion of a gravid uterus (incarceration) in the third trimester is an extremely rare diagnosis and is only scarcely been described. Its prevalence may lead to increased foetal mortality and maternal morbidity.We present a case where a 35-year-old patient had undiagnosed (recurrent) uterine incarceration at term. Operative delivery proved difficult due to distorted anatomy. Therefore, in our case delivery of the fetus through transvaginal caesarean section was required.This case report discusses the diagnosis and management of (recurrent) incarceration of the retroverted uterus at term resulting in two successful transvaginal caesarean sections. In presenting this case, we aim at improving awareness, diagnosis and treatment of the retroverted incarcerated gravid uterus. Incarceration of a retroverted gravid uterus has only scarcely been described. The condition is rare and its prevalence may lead to increased fetal mortality and maternal morbidity. Patients with an incarcerated retroverted uterus may present symptoms of urinary retention, lower abdominal pain, constipation or rectal pressure. Diagnosis is difficult due to variable clinical manifestations and operative management is technically complicated because of distorted anatomy.Here we present a case of (undiagnosed) incarceration occurring in two succeeding pregnancies. In both cases, incarceration resulted in transvaginal caesarean section. In presenting this case, we aim to improve awareness, diagnosis and treatment of the retroverted incarcerated gravid uterus.A 35-year-old primigravida, with no significant medical history, presented at 33 weeks gestation because of uncertain presentation of the foetus. Her pregnancy had been asymptomatic. An initial ultrasound reported to show a single foetus in breech position and a complete placenta previa. There were no other signs that made us suspect distorted anatomy. Ultrasound measurements further showed intra-uterine growth restriction (5th percentile) with a normal amniotic fluid index. Doppler examination of the umbilical artery revealed a PI from 1.028 which is within normal range. A primary caesarean section was planned at 38 weeks of gestation.At 37+6 weeks of gestation, the patient was admitted to the hospital with spontaneous rupture of membranes and loss of amniotic fluid. A caesarean section was performed. During the caesarean section a Pfannenstiel incision was made and the bladder and uterovesical peritoneum were deflected inferiorly. What appeared to be the lower segment was then incised but instead of entering the uterine cavity a second apparent uterine surface was encountered. Although the foetal breech could be felt within the underlying uterine surface, the anatomy was unclear. Therefore, a second transverse incision was made revealing a third uterine surface. After a third transverse incision was made, the uterine cavity was entered, presenting the breech. A live male infant, birth weight 2570 grams (5-10 percentile), was born. Apgar scores were 9 and 10 at 1 and 5 min post partum respectively. Arterial pH was 7.36. After closure of the uterine incision we carefully examined the abdominal organs. The incision appeared to be corporal and on the posterior side of the uterus Fig. , indicatThe placenta previa was misdiagnosed due to distorted anatomy and was really situated in the fundus. No cause for the retroversion was detected. The initial incisions had been made through the anterior and posterior walls of the vault of the vagina, which was stretched by the growing incarcerated uterus. At that point the uterus was almost completely detached Fig. . The babOne year later, during her second pregnancy, ultrasound examination again revealed a uterus in retroversion at 18 weeks of gestation. We considered the possibility of turning the uterus to an upward position . FurtherThe pregnancy progressed asymptomatic and at 37+5 weeks of gestation a repeat transvaginal caesarean section was preformed in the same manner as described above. A girl weighing 2810 grams (10-25 percentile) was born with apgar scores 9 and 9 at 1 and 5 min post partum respectively. The postoperative course was uncomplicated and mother and child left the hospital seven days postoperative. Six weeks after delivery, ultrasound examination showed the uterus in anteverted flexion.Retroversion of the uterus is found in approximately 11 to 19% of women at the time of conception . UsuallyThe obstetrician should always consider the possibility of turning the uterus to an upward position . In the Some authors suggest that patients carry more risk of recurrence of retroversion of the uterus . Our casRetroversion of the gravid uterus presenting as late as in the third trimester been scarcely reported. According to Singh and co-workers, only 28 cases were reported in the English literature between 1967 and 2006 . Incarcee.g. bleeding, miscarriages due to compromised uterine circulation; [e.g. lower abdominal pain; [e.g. urinary frequency, dysuria, incontinence; and [e.g. rectal pressure, tenesmus, constipation [Clinical manifestations occur after the first trimester and can be divided into four categories;  Obstetriulation;  Pressureal pain;  Urinary nce; and  Gastrointipation ,3,10. Ontipation ,7,11, astipation ,5,13. ThIndicators for an incarcerated uterus at physical examination include low fundal height, a filled cul-de-sac and an unreachable cervix 2. The cervix wasn't palpable, but was visible with transvaginal ultrasound, during her first pregnancy the possibility of an incarcerated uterus was not considered. It was unknown whether the patient had a retroverted uterus prior to pregnancy. When uterus incarceration occurs, the cervix becomes displaced upward above the symphysis, making vaginal delivery impracticable. Two previous cases of vaginal deliveries resulted in foetal death ,15. TherTo our knowledge our case is the first case which describes two successful transvaginal caesarean sections. Still, in hindsight we wouldn't recommend a transvaginal caesarean section. Preoperative recognition of retroversion is essential and can prevent intraoperative complications.Due to the incarceration of the uterus the cervix, vagina and bladder might become elongated. Localization of the elongated vagina, cervix, as well as the urethra and bladder are essential for surgery. Proceeding to caesarean section without correct diagnosis will cause difficulties identifying these structures and in opening the lower uterine segment. This may lead to bladder injuries, vaginal transsection and trans- or supracervical hysterectomy. Magnetic resonance imaging offers a non/invasive method to confirm the diagnosis and to reconstruct the exact anatomy . In thise.g. previa, breech) are not specific. Late (very late) identification of the incarceration, lack of symptoms, absence of anatomic abnormalities contributing to the incarceration, recurrence of incarceration in the same patient and surgical approach to the caesarean section can be challenging. Because of the increased risk for recurrence in subsequent pregnancies, we stress the importance of pelvic examination before the 15th week of pregnancy. By then, correction of the normal anatomy may still be possible, reducing the risk of foetal and maternal morbidity. When retroversion is suspected, MRI can be used to confirm the diagnosis and to reconstruct the exact anatomy. We don't recommend a transvaginal caesarean section but advise a midline laparotomy.In conclusion, the diagnosis of uterus incarceration is rare, rendering case reports the source of most information and improve awareness of this complication. Here, several aspects underscore the need to maintain an index of suspicion for incarceration as findings on ultrasound (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.KT made substantial contributions to conception and design, analysis and interpretation of data, and was the major contributor in writing the manuscript. RAK made substantial contributions to conception and design, analysis and interpretation of data. GK made substantial contributions to conception, design and revising the article critically for important intellectual content. WMM made substantial contributions to conception, design and revising the article for important intellectual content. The manuscript has been read and approved by all named authors or their next of kin.


We report an unusual presentation of a small hepatic cyst causing cholangitis.A 70-year-old Asian man was hospitalized for aggravated chronic pain in the right upper portion of his abdomen. Fever developed after admission. Laboratory tests revealed elevated hepatobiliary enzymes, inflammatory markers and carbohydrate antigen 19-9 without hyperbilirubinemia. Ultrasound and computed tomography demonstrated dilatation of the left intra-hepatic bile ducts. Endoscopic retrograde cholangiopancreatography showed that the right intra-hepatic bile ducts were normally filled with contrast medium, but the left intra-hepatic bile ducts were not seen in the confluence. A left hepatectomy was performed because a hidden malignancy could not be excluded. The surgical findings showed no tumor around the bile duct but rather a 2 cm cyst in segment four of Couinaud's category of the liver around the hilum. The pathology report was a solitary non-parasitic hepatic cyst compressing the bile duct.A very small solitary hepatic cyst might cause hepatic duct stricture if it is located near the hepatic hilum, and should be considered in the differential diagnosis of a hepatic duct stricture. Solitary non-parasitic hepatic cysts (SNHC) are usually asymptomatic. Only a small fraction of them are associated with symptoms such as abdominal pain, an abdominal mass, early satiety, nausea, and vomiting. These symptomatic SNHCs are usually larger than 10 cm and can cause obstructive jaundice and cholangitis because of their mass effect on the bile ducts. In this case, we present a 70-year-old man with a very small (2 cm) cyst in the hepatic hilum compressing the left hepatic duct.A 70-year-old Asian man presented to the out-patient department complaining of pain in the upper portion of his abdomen. The pain, which started seven months previously, had worsened, and our patient complained of fever and chills with the pain. However, he was never hospitalized and did not recall any prior medical evaluation for this problem. The patient denied any other systemic symptoms such as nausea, vomiting, jaundice, and weight loss. He had no significant medical history and was not taking any medication.On physical examination, our patient's temperature was 38.3°C with a blood pressure of 129/67 mmHg, a heart rate of 89 beats per minute and a respiratory rate of 18 breaths per minute. The abdominal examination revealed localized tenderness to palpation in the right upper quadrant but no guarding, rebound, or percussion tenderness. The rest of the physical findings were unremarkable.9/L with a predominance of neutrophils, aspartate aminotransferase 72 IU/L, alanine aminotransferase 137 IU/L, total bilirubin 0.7 mg/dL, direct bilirubin 0.5 mg/dL, alkaline phosphatase 405 IU/L, and gamma glutamyl transpeptidase 155 IU/L. The carbohydrate antigen 19-9 level was slightly elevated (49.1 U/mL) and the carcinoembryonic antigen level was within the normal range.Laboratory investigation showed the following results: white blood cell count 16.4 × 10Ultrasound (US) was performed first. This showed a distended gallbladder with sludge in it and dilated intra-hepatic bile ducts (IHBD). Endoscopic retrograde cholangiopancreatography (ERCP) showed that the right IHBD normally filled with the contrast medium, but the left IHBD could not be differentiated from the confluence. We assumed that the left hepatic duct was compressed by something or that there was a stricture at this site; perhaps caused by a tumor near the hepatic hilum. An abdominal contrast-enhanced computed tomography (CT) was performed to confirm the findings. However, no abnormality was detected except for the dilated left hepatic bile ducts on the CT scans Figure . An intrWe performed a left hepatectomy on July 11, 2007 because we could not exclude a malignancy of the left hepatic duct. There were mild adhesive changes around the liver that might have been caused by cholangitis. No tumor lesions were found around the bile duct. Only a small hepatic cyst (1.5 × 2.0 cm size) was present, in segment four according to Couinaud's classification at the level of the transverse fissure, compressing the left hepatic duct Figure . Our patet al. in 1950 [SNHCs are usually asymptomatic but may occasionally present with abdominal pain, an abdominal mass, early satiety, nausea, and vomiting. However, even with symptomatic hepatic cysts, obstructive jaundice or cholangitis is rarely seen. Several reports on SNHC causing obstructive jaundice are presented in the medical literature since first described by Caravati et al. and Matthieu et al. each reported very exceptional cases of 3 cm and 4 cm sized SNHCs causing dilatation of the IHBD [Most prior cases were over 10 cm and the symptoms usually resulted from a mass effect of the enlarging cyst on the neighboring bile ducts ,3. Howevthe IHBD . Both ofIHBD strictures can be malignant or benign. Malignant causes are mostly cholangiocarcinoma, hepatocellular cancer and metastatic cancers to the liver. While benign causes are numerous and include recurrent pyogenic cholangitis related to hepatolithiasis , primary sclerosing cholangitis, radiation, blunt abdominal trauma, polyarteritis nodosa and systemic lupus erythematosus, tuberculosis and histoplasmosis, chemotherapeutic drugs infused into the hepatic artery, a choledochal cyst, cystic fibrosis with liver involvement, space occupying lesions in the liver such as SNHC, focal nodular hyperplasia and hemangioma, eosinophilic cholangitis, idiopathic and others .The standard treatment is surgical resection for malignant biliary stricture. However, balloon dilation or stent insertion has been attempted for benign strictures without the requirement for extensive surgical resection. In addition, deroofing of the cyst, partial hepatectomy including the cyst, percutaneous drainage of the cyst, and the administration of a sclerosing agent can be used as less invasive methods for the treatment of a symptomatic hepatic cyst. However, the differentiation of benign and malignant bile duct strictures is not easy pre-operatively; in cases with a bile duct stricture without a demonstrable mass on CT or US, the distinction cannot be made.This case represents the smallest SNHC reported to date with symptoms. We could not identify the cyst prior to surgery and had no information on the cause of the left hepatic duct stricture from the imaging studies used in the evaluation, US, ERCP and CT. We performed a left hepatectomy because we could not exclude a malignancy. Because a 2 cm cyst could theoretically be seen on an US or CT, we reviewed the imaging studies retrospectively and found that there was a lesion that could be regarded as cyst on the CT Figure . HoweverIf the differential diagnostic markers such as tumor markers, radiological evaluations, cytology by endoscopic approaches, and tissue diagnosis were reliable for the differentiation of benign from malignant bile duct strictures, a less invasive treatment modality might have been appropriate. There have been several reports on the accuracy of the diagnostic markers for the differentiation of benign from malignant bile duct strictures. However, none of these markers are universally accepted for a definitive diagnosis to date ,8. This A very small solitary hepatic cyst might cause hepatic duct stricture if it is located near the hepatic hilum, and should be considered in the differential diagnosis of a hepatic duct stricture.CT: computed tomography; ERCP: endoscopic retrograde cholangiopancreatography; IHBD: intra-hepatic bile ducts; SNHC: solitary non-parasitic hepatic cysts; US: ultrasound.The authors declare that they have no competing interests.TH collected the information and carried out the research. He was the main writer of the manuscript. KL advised, read and approved the final version.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Upper urinary tract transitional cell carcinoma (TCC) accounts for up to 10% of cases of neoplasm of the upper urinary tract. The “gold standard” management of upper tract TCC is nephroureterectomy. Technological innovations, miniaturisations and increased availability of energy sources such as Holmium laser fibers have improved the armamentarium of endoscopic management of upper tract TCC. Endoscopic management of upper tract TCC includes the percutaneous (antegrade) and retrograde approaches. Modern flexible ureterorenoscopy allows retrograde approach to small (<1.5cm), low grade and noninvasive tumors, which is inaccessible to standard rigid ureteroscopes without breaching the urothelial barrier. In patients with large tumors or in whom retrograde access is difficult, the percutaneous approach to the renal pelvis, although more invasive, provides an alternative access and control. Both retrograde and percutaneous approaches allow instillation of various chemotherapeutic agents. Careful selection of patients is the key point in the successful endoscopic management of upper tract TCC. Patient selection is based on tumor size, grade and multifocality and other patient factors such as comorbidities, single kidney, post kidney transplant and patient choice. Both motivation and compliance of patients are needed for long-term successes. However, until large randomized trials with long term follow-up are available, endoscopic management of upper tract TCC should be reserved for only selected group of patients. This review summarizes the current techniques, indications, contraindications and outcomes of endoscopic management of UTTCC and the key published data. Upper urinary tract transitional cell carcinomas (TCC) are defined as tumors located anywhere on the urothelial lining between the renal calyces and vesicoureteric junction (VUJ) of the distal ureter. They are less common than TCCs that originate in the bladder, though the true incidence is difficult to identify due to epidemiological data often merging tumors of the renal pelvis with renal cell carcinoma statistics. Also, there is considerable geographic variability, with the highest reported incidence occurring in Balkan countries, associated with a degenerative interstitial nephropathy. Other riUpper tract TCC most commonly presents either with macroscopic or microscopic haematuria, or is discovered during follow-up imaging of patients with bladder TCC. Upper tract TCCs typically appear as a filling defect (that may cause obstruction) on intravenous pyelography, delayed phase CT urogram or retrograde urography. The bladder and contralateral tract must be carefully examined due to the significant incidence of multiple lesions. The role of pre-treatment histological diagnosis with cytology or ureteroscopy and biopsy is controversial due to reported poor sensitivity for low grade tumors in the former, and a small size of tissue obtained in the latter modality. It is thought that ureteroscopy with brush or forceps biopsy is not mandatory, but should be used in cases where the diagnosis is in doubt, or the management would be significantly altered by ureteroscopic findings.Although the purpose of this review is to describe the current practice of endoscopic treatment of upper tract TCC, for completeness, the indications of non-endoscopic surgical treatment will be summarized. Historically, the “gold standard” treatment for upper tract TCC in suitable patients is nephro-ureterectomy, with resection of a cuff of bladder around the VUJ. Particular indications include muscle invasive or high grade TCC. The surgWe are in the modern era of the ageing patient; in the UK, the number of people aged over 65 exceeds 10 million, and worldwide, by 2025, the number of people worldwide aged over 60 will exceed one billion.9 This trThe feasibility of using an endoscopic approach to upper tract TCC is dependent on the location of the tumor(s), available expertise (e.g. expertise to create percutaneous access) and the availability of often expensive technical equipment (such as flexible ureterorenoscopes and laser generators). A retrograde ureteroscopic approach has the advantage of maintaining a closed system - i.e. the urothelial barrier is not breached, hence reducing the risk of tumor seeding. Also, this approach does not require the expertise of percutaneous access and formation of a tract, which have the associated risk of bleeding , infection and damage to adjacent viscera including pneumothorax and bowel injury.A retrograde approach with a semi-rigid ureteroscope is usually the most appropriate endoscopic modality to access ureteric tumors. If accessibility to the upper ureter is difficult or the tumor is located in the renal pelvis, flexible ureterorenoscopy is deployed. Modern flexible ureterorenoscopes allow deflection angle of up to 270°. However, passing a laser fibre leads to loss of deflection of between 4 and 10%, and causes a reduction in the irrigation volume of 54%.et al, with a subsequent larger series reported by Smith et al.[An antegrade approach via percutaneous access to the collecting system was first described by Tomera th et al.13 Percutth et al. A furtheth et al.15 A combth et al.et al.[A retrograde approach using a semi-rigid ureteroscope to treat localized low-grade upper tract tumors was first described by Huffman et al. Informedet al. There haet al.19 SampleThe two commonly described laser sources are holmium:yttrium-aluminium-garnet (Ho:YAG) or neodymium:yttrium-aluminium-garnet (Nd-YAG). Characteristics of the energy sources are depicted in . A uretein situ, beyond the PUJ. Smith and co-workers advocate performing a nephrostogram within 24 hours to exclude extravasation.[Prior to the procedure, informed consent for the procedure is obtained, with an explanation of the risks of hemorrhage (transfusion rate of up to 37%), damage to the kidney or adjacent viscera, pneumothorax, infection, residual tumor, pelvic-ureteric junction (PUJ) obstruction/stricture and (rarely) tumor seeding.2425 Urin24vasation. Althoughvasation.23 A ‘secThe aim of instilling chemo- or immunotherapeutic agents post resection is to reduce tumor recurrence. Agents can be administered via a percutaneous nephrostomy after percutaneous management, or via an ureteric catheter following ureteroscopic treatment. Essentially, the same agents have been used to treat the upper tract as have been used in the bladder, namely mitomycin C, thiotepa and Bacillus Calmette-Guérin (BCG). The fact that many different agents and different timing protocols have been reported demonstrates that there is no standardized regime established from prospective randomized trials. SuggesteAlthough there have been no published prospective, randomized trials regarding the endoscopic management of upper tract transitional cell carcinoma, there is a wealth of retrospective experience published as case series and review articles.33 ComparTechnological advances have led to an increase in endoscopic management of upper tract TCC. However, all published data are small, retrospective with a short follow-up and high recurrence rate. Careful selection of patients is the key message. Endoscopic management of upper tract TCC is particularly suited to small (<1.5cm), low grade and noninvasive tumors, in comorbid patients who are at high risk for major radical surgery or who have compromised renal function (including a single functioning kidney), and patients who refuse radical surgery. For high grade tumors, endoscopic management is essentially palliative. Patients should also be highly motivated and compliant as lifelong surveillance is necessary. Until large randomized trials with long follow-up are available, endoscopic management of upper tract TCC cannot be recommended as an alternative to nephroureterectomy.


We report a case of primary mucinous cystadenocarcinoma of renal pelvis which radiologically resembled large multicystic mass in 45 years old man.The patient referred to our center with loin pain and progressive abdominal distention from 4 years ago. In the previous published literature, four cases of mucinous cystadenocarcinoma of renal origin have been published. Abdominal CT showed complete replacement of left kidney by a large multiloculated cystic mass accompanied with multiple large nephrolithiasis. Nephrectomy was performed and histopathology revealed covering of epithelium of renal pelvis by columnar epithelium and scattered goblet cells and mucous gland.Mucinous cystic neoplasms of kidney are rare entity and our case and few similar reported cases showed that this tumor is an unique clinicopathologic renal mass that may be classified by World Health Organization classification in the future The most common neoplasms in the renal pelvis are urothelial in origin, although infrequently, squamous and glandular neoplasm may arise within the renal pelvicalyceal system through metaplastic transformation of the urothelium due to long-standing obstruction and infection and chronic irritation by urolithiasis . In prevBecause knowledge about renal mucinous cystic neoplasms is extremely limited and they have not been recognized in the World Health Organization classification of pelvicalyceal system malignancy. We describe the clinical, radiological and pathological findings of a 45 years old man with mucinous cystadenocarcinoma arising in a background of extensive mucinous metaplasia of pelvicalyceal urothelium secondary to probably chronic nephrolithiasis and hydronephrosis.A 45-year-old man presented with a history of a dull aching pain in the left flank and progressive abdominal distention since 4 years ago. Recently the patients complain from aggravation of abdominal pain and new onset constipation. He had no history of passing stones. He had not history of haematuria, dysuria, frequency or fever during 4 years ago.General physical examination revealed nothing positive. Abdominal examination revealed asymmetrical buldging of abdomen on inspection and a firm fixed mass in the left hypochondrium that extended to the epigastrium and hypochonderium on palpation. Figure Laboratory investigations showed haematuria, mucosuria and 10-12 pus cells/high power filed in urine examination. Urine culture was negative.Routine hematological investigations were within normal limit.Intravenous pyelography revealed the non-functioning left kidney with multiple large opaque stones. In transabdominal sonography a huge cystic mass with internal echo debris and multiple stones without remarkable renal parenchyma was observed that mimicked sever long-standing hydronephrosis accompanied with pyonephrosis.Abdominal CT scan  with IV and Oral contrast revealed a huge lobulated multicystic thin wall mass measuring 25*20*30 cms with thick septation accompanied with solid component without marked enhancement and some large nodular calcified density (stone) that completely replaced left kidney. .Tumors of the renal pelvis are uncommon, with relative frequency of transitional cell carcinoma (90%), squamous cell carcinoma 10%) and adenocarcinoma (1%) 0% and ad and 4 maThese tumors occur as a result of metaplasia of the transitional epithelium of the calyces and pelvis into glandular epithelium, which then undergoes a malignant transformation . PresencPatients are often asymptomatic. Hematuria is the most common presenting sign and loin pain and palpable abdominal mass are the late presentation of this tumor. Our patRadiological studies may not be able to identify malignant tumor . In our Mucinous cystic neoplasms of kidney are rare entity and our case and few similar reported cases shwe that this tumor is an unique clinicipathologic renal mass that may be classified by World Health Organization classification in the future.Written informed consent was obtained from the parents of 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.MF and KM were the attending doctor, carried out the surgical procedure and literature review. AM was the attending doctor and collected the data and literature review, and wrote the manuscript. All authors read and approved the final manuscript.


Gallstone ileus is an uncommon cause of small bowel obstruction. We present a case of small intestinal obstruction owing to a large gallstone in lower ileum in a 65 years old man. The diagnosis was made by computed tomography. Gallstone ileus is an uncommon condition that may result when a gallbladder stone enters into the intestinal tract, usually as a result of an internal fistula between the gallbladder and the duodenum. It's accounting for only 1-4% of all intestinal obstruction . The morA 65-year old previously healthy man, presented to the Emergency Department, with complaints of abdominal pain, vomiting and absolute constipation of 2 days duration. The patient was not using any specific medication and his medical history did not suggest a major disease. He had no prior history of abdominal surgery or trauma. The patient didn't smoke or drink alcohol.Physical examination revealed conscious dehydrated patient; vital signs were within normal limits. The temperature was of 37°C, a pulse rate 100 beat per minute (bpm), a blood pressure 12/07 mm Hg. Abdominal examination reveals distend abdomen without tender. There were no palpable masses or liver enlargement. The hernial sites were free. On rectal examination there is no stool. Laboratory examination showed hemoglobin of 14 g/dl, leucocytes of 12000 cells per cubic millimeter, blood urea 0.8 g/dl, and a normal liver function profile. An abdominal X-ray showed small bowel air-fluid levels (fig Gallstone ileus is an uncommon cause of small bowel obstruction -6. It ocAlthough it's a rare cause of bowel obstruction, gallstone ileus should be capped in mind when dealing with a case of small bowel obstruction, especially in elderly patient in whom the diagnosis is easily ignored. Early surgical intervention is the mainstay of treatment.Written 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.FZ is a surgeon who was drafting the manuscript and revising it critically for content. EB is a surgeon who was involved in literature research. KM, KA were surgeons treating of the patient and were involved in revising the draft critically for content. AO is a surgeon was getting photographs and was involved in drafting manuscript. All authors have given final approval of the revision to be published.


Lateral meningocele is a very rare disorder. It has been reported in patients with neurofibromatosis or Marfan's syndrome. Previous reports have described lateral meningoceles in the thoracic or cervical region. Lateral meningocele in the sacral area was reported in the literature only once.We describe a 3.5-year-old Iranian girl who presented with a lateral gluteal mass. Neuroimaging and intra-operative evaluation showed that the mass was a lateral sacral meningocele with spinal communication through the iliac bone. We also present a review of the literature about this entity.Although lateral meningoceles especially in the sacral region are rare disorders, their possibility should always be considered in young patients presenting with a paravertebral or gluteal mass. A meningocele is an outpouching of leptomeninges through a developmental defect in the dura. The arches of the vertebrae at one or more levels are involved with protruded meningeal sac covered with only a layer of skin.Lateral meningoceles are extensions of the dura and arachnoid through an enlarged neural foramen. These often occur in the setting of Marfan syndrome or neurofibromatosis type 1 but may also be seen as isolated anomalies. Although they occur in the thoracic or sometimes in the cervical region, localization at the sacral spine is very infrequent .We present the case of a 3.5-year-old Iranian girl who was referred to us from pediatric surgery clinic because of a gluteal mass. Her parents informed us that the swelling of the right buttock of their daughter had been present since her birth. The size of the mass had been increasing gradually. They did not mention any bowel or bladder dysfunctions. A local physician had aspirated the cyst twice, 8 and 4 months prior to this presentation. Clear fluid had been aspirated each time, bur the mass would always reappear after several weeks. Unfortunately the results of the chemical analysis of the fluid were not available.A physical examination of our patient showed a soft, 3 × 4-cm fluctuant and non-pulsatile mass over her gluteal region. It was completely covered with normal skin without any vascular or hairy stigmata. The size of this mass did not increase with crying or coughing. Her transillumination test results were positive. Her midline was normal, with no sinus tract or swelling Figure .Results of her sensory, rectal tone and lower limbs motor exams were within normal limits. No abnormal skin lesions or skeletal deformities were found. The curvature of her spinal column appeared normal.Results of her routine laboratory investigations were also normal. An anteroposterior X-ray examination of her lumbosacral region showed spina bifida of the L5 and S1 vertebrae Figure .An ultrasound scan showed a very well-defined purely cystic, oblong lesion measuring 3.7 × 4.5 × 2.2 cm in size in our patient's right upper gluteal region under the gluteal muscles. There was no evidence of internal echoes or solid component or septae within the sac. We planned to perform myelography but unfortunately found it impossible because of our patient's allergic sensitivity to the contrast agent (omnipaque). A lumosacral magnetic resonance imaging (MRI) showed a well-defined cystic mass measuring 36 × 21 × 45 mm in her right buttock. The cystic mass appeared as a low signal intensity area on T1-weighted images and a high signal intensity area on T2-weighted images, which was similar to her cerebrospinal fluid (CSF) signal (Figure A voiding cystourethrography showed a normal voiding pattern of our patient's bladder and urethra. There was no evidence of vesicoureteral reflux.We then decided to perform resective surgery. After performing a transverse incision at the equator of our patient's lesion, we found a cystic, relatively thin-walled mass with a smooth pink exterior layer and a shiny creamy interior surface lying under the right gluteal muscles. We aspirated the cyst and clear fluid came out of it Figure . OpeningOn histopathology, we found that the wall of the sac was composed of fibrous tissue that had a lining of flattened to cuboidal epithelium. Polymorphonuclear leukocytes, histiocytes, and giant cells were also noted Figure . The finOur patient was found asymptomatic when she was presented for follow-up examination after 18 months.Lateral meningoceles are considered as rare presentations of craniospinal dysraphisms ,2. TheseThe existence of an affected mother and daughter supports the hypothesis that LMS is a dominant disorder affecting primarily the connective tissue . Lateralet al. in India [The incidence of lateral meningoceles was reported to be 0.3% . Lateralin India .Our patient did not show any evidence of abnormal pigmentation or skeletal deformities. The prominent feature of our patient is the isolated occurrence of the meningocele without any associated anomalies. The sac communicated with the lateral spinal canal only through a tract in her iliac bone.Lateral meningoceles are usually associated with vertebral defects such as hemivertebrae, scoliosis, absence of neural arches on the affected side, and widening of the spinal canal and intervertebral foramina. Scalloping of the pedicles, laminae and vertebral bodies that are adjacent to the meningocele result in an enlarged spinal canal. Butterfly vertebra and segmental anomalies of the vertebral bodies may be found in as many as 43% of affected patients. Sacral anomalies, such as confluent sacral foramina and partial sacral agenesis, occur in up to 50% of reported cases ,10.In this case, the lumbosacral vertebrae showed normal appearance except for L5 and S1 spina bifida. Both our patient and the patient described by Navneet Kaur had spina bifida, which supports the presentation of sacral dysgenesis problems .Lateral meningocele should be differentiated from other cystic sacral masses. It may be mistaken for a lipoma in a patient with lipomeningocele or for other cystic lesions such as cystic hygroma, synovial cysts, and large ovarian cysts . PerineuIn large ovarian cysts the determination of the origin of the mass can be difficult. These lesions can be demonstrated on computerized tomography scanning. They usually have a thin walls and attenuation values within the range of water. On MRI they exhibit low signal intensity on the T1- weighted sequences, high signal intensity on T2-weighted sequences, and are well-circumscribed with a thin wall that may enhance after contrast administration on T1-weighted images .Although lateral meningocele especially in the sacral region is rare, its possibility should always be considered in patients presenting with a paravertebral or gluteal mass. The occurrence of a neurological deficit or the presence of a spinal defect should make one suspicious of the presence of an unusually located meningocele. Drainage through needle aspiration or by incision may transform it into a cerebrospinal fluid fistula. Performing adequate imaging studies such as CT myelography and MRI, therefore, are very helpful to avoid mistakes and ensure correct diagnosis.MRI: magnetic resonance imaging; CT: computerized tomography; RBC: red blood cell; WBC: white blood cell; PMN: polymorphonuclear; LMS: Lateral Meningocele Syndrome.Written informed consent was obtained from the patient's next-of-kin 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.AS analyzed and interpreted the patient data regarding the lateral sacral meningocele and performed the surgery. ASS aided in the surgery, performed the review of literature, and was a major contributor in writing the manuscript. Both authors read and approved the final manuscript.


Soft tissue sarcomas are rare tumours that are infrequently seen in most surgical practices. They can occur in any anatomic region of the body. The size of a soft tissue sarcoma is an important prognostic variable and so affects the quality of tumour resection.A 25-year-old Nigerian African presented with recurrent huge fibrosarcoma measuring about 55 × 40 × 10 cm at his posterior trunk. The patient's clinical condition was poor; the tumour seemed unresectable and the patient looked inoperable. He had an extensive excision of the tumour but could not afford adjuvant therapies. He was discharged home against medical advice but may succumb to metastases.Sarcomas in black people can present as extremely large masses; the dilemma in management is not only limited to the delay in presentation but also the poor socio-economic status of the patients and the frequent non-availability of supporting services. Treatment grants or subsidies from government may go a long way to ensuring that patients receive appropriate care. Soft tissue sarcomas (STS) are rare tumours that are infrequently seen in most surgical practices. They arise from mesodermally derived extra-skeletal tissues which constitute more than 50% of the body weight. The tumour accounts for about 0.7% of all adult malignancies but up to 15% of childhood malignancies [The patient was a 25-year-old farmer who presented to our unit with a painless mass on his back of 13 years duration. The mass had been increasing in size. There was associated weight loss, cough and features suggestive of chronic anaemia. He had had three previous excisions of the mass at a peripheral hospital and on each occasion, the excised specimen had been discarded.Examination revealed a young man, pale and with a pulse rate of 100 bpm. He had a fungating mass on his posterior trunk extending from inferior angles of the scapula to about 10 cm above the iliac crest, the mass measuring about 24 × 16 × 5 cm. His chest was clinically clear and with no palpable organomegaly. An assessment of soft tissue sarcoma was made. The patient was resuscitated and transfused with 2 pints of blood. A wide excision of the mass was performed. Postoperative radiotherapy was planned before wound cover with split thickness skin graft (STSG). However, the patient discharged himself against medical advice. Histology of the excised specimen confirmed fibrosarcoma.He represented about 7 months later with a similar mass on his back. The mass covered almost the entire posterior trunk, bled with the slightest contact, and restricted his mobility. He had features suggestive of anaemic heart failure; he was pale, had a pulse rate of 130 bpm, bounding and had an audible third heart sound. He was also wasted and in respiratory distress.A huge fungating mass was present measuring 55 × 40 × 10 cm in size as shown in Figure Soft tissue sarcoma has no identifiable aetiology in most cases; while most of the tumours arise de novo, a variety of predisposing or associated factors have been identified. There are approximately 70 different histologic types of STS. Most sarcomas are classified according to the normal cell type they mimic, based on the system proposed by Enzinger and Weiss .Malignant fibrous histiocytoma (MFH) 18%), liposarcoma (20%) and leiomyosarcoma (19%) constitute the majority of adult STS in western countries . This is%, liposaAt the end of the deliberation, it was agreed that the surgical excision should be undertaken. Post surgical excision, the recovery was uneventful; he was transfused with 4 pints of blood intra-operatively. In STS, patients considered to have a high risk of recurrence and death include those presenting with metastatic disease, localized sarcomas at sites other than the extremities, and sarcomas >5 cm of intermediate or high histologic grade . All of In a developing country like ours where the poverty level is very high, there is no special provision available for patients with malignant lesions to access free treatment or to have their treatment highly subsidized by the government. If such provisions were available, many patients of low social class could have their clinical conditions well managed, thereby improving their overall survival rate.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.JOB summarized the patient data and carried out an initial literature search on fibrosarcoma. IAA prepared the initial draft of the manuscript while KOO prepared the final draft. All authors participated in the patient's management, including the surgery. All authors read and approved the final manuscript.


True ossification of the auricle with cartilage replacement by bone, is a very rare clinical entity and can result in an entirely rigid auricle.We present a rare case of bilateral ossification of the auricles in a 75-years old man with profound progressive rigidity of both auricles. His main complaint was a mild discomfort during resting making sleeping unpleasant without any other serious symptoms. His medical history was significant for predisposing factors for this condition such as, Addison's disease and diabetes mellitus. Excisional biopsy was performed confirming the ossified nature of the auricles. Further treatment deemed unnecessary in our case due to his mild clinical picture.True auricular ossification is a quite rare clinical entity with unclear pathogenesis and one should have in mind that there is always the possibility of a serious co-existed disease like endocrinopathy. True ossification or petrification of the auricle with cartilage replacement by bone, resulting in a stiff auricle, is a very rare clinical entity.The commonest cause of "stiff auricle" condition, is ectopic calcification, rather than ossification . BochdalLocal trauma ,17, frosth pathologically documented case of bilateral auricular ossification and review the relevant literature.We present the 18A 75-year-old man presented in our clinic with a history of a progressive stiffness of both auricles over the last 15 years. He was referred to us from the Department of Internal Medicine of our Hospital for further evaluation and due to his complaints for a mild discomfort when resting in each side thus making sleeping unpleasant. He also observed a gradual hearing loss on both ears along with tinnitus and intermittent blockage, especially on the left ear.Routine ENT examination demonstrated a profound bilateral rigidity of both auricles, which were completely inflexible in their entirety except of the lobules, moving as a single unit with manipulation. Lesions resembling chondrodermatitis nodularis chronicus helicis was coexistent in both auricles with typical raised and firm nodules but without tenderness. The rest of the auricles configuration and skin appearance were normal without noticeable cutaneous abnormalities. Some thickening and hardening was noticed on palpation Figure. . There w8  and a severe mixed type hearing loss in the left ear (80 db at 1 kHz), Tympanometry was normal in both ears.Consequently, the patient underwent an excisional biopsy from the left ear for histological evaluation Figure . BecauseHistological sections of the biopsy specimen revealed spicules of lamellar bone with cement lines and Haversian canals, osteocytes, stromal component of adipose tissue, and fragments of elastic cartilage. Osteoblastic activity was not prominent Figure .The auricle is consisted mainly of auricular cartilage, a type of elastic cartilage containing numerous elastic fibers. Except of the auricle, elastic cartilage can be found in the head and neck region as a basic component of the external ear canal, nose and epiglottis and usually does not subjected to calcification or ossification changes. Nevertheless, such changes rarely can occur in the auricular cartilage and have been described by various terms like dystrophic or metastatic calcification and heterotopic or ectopic ossification .Calcification consisted of calcium deposition in a damaged tissue while calcium and phosphate levels are within normal limits in serum. Dystrophic calcification can resulted from mechanical trauma and frostbite, while metastatic calcification occurs in hypercalcemia, milk-alkali syndrome, vitamin D intoxication, hyperparathyroidism and sarcoidosis ,20.Ossification involves new bone development histologically resembling trabecular bone. Ectopic ossification of the auricle (auricular occificans) involves bone formation by the deposition of calcium and phosphorus in a proteinaceous matrix as hydroxyapatite crystals in a tissue that normally does not ossify . X-ray uIn general, ectopic ossification is considered as primary when it occurs de novo and secondary if it develops in a pre-existing lesion. Congenital plaquelike osteomatosis, Albright hereditary osteodystrophy, fibrodysplasia ossificans progressiva and osseous heteroplasia can cause primary ectopic ossification in the human body . VariousClinical manifestations of these conditions are various. The majority of the patients are asymptomatic and the auricle does not change its configuration, thus the physician is rarely consulted. Lister  in his rThe rigidity is progressive over time, as depicted in our case, and usually bilateral involvement is more frequent than the unilateral one. The findings of the physical examination are typical of a partially or complete stiffness of the external ear sparing the earlobe, usually without visible cutaneous irregularity. The diagnosis can easily be made by palpation and patient's clinical history.CT scan can easily depict the hyperdense areas along the auricles, as it is a very sensitive method for the detection of calcifications/ossifications. Furthermore, the detailed scanning with reconstruction and coronal, sagittal and 3D reformatted images can easily demonstrate the size of the abnormal areas. On top of that, the presence of radiolucent areas within the dense opacities is a very strong indicative factor for ossification and true bone formation along the auricles, and can differentiate calcification from ossification  Figures, thus ofLaboratory evaluation is also helpful for detecting any possible metabolic or endocrine underlying cause of this condition. Ossification and calcification of the auricle is clinically identical, thus differentiation between them and confirmation of the diagnosis should be done by histology, although as we mentioned computed tomography studies can also be indicative of ossification demonstrating a trabecular pattern of the ossified auricle .Both conditions may remain localized or diffusely involved the auricle, sometimes with extension to the external ear canal cartilage. Local ossification or calcification often results from local injury, like that due to frostbite or mechanical trauma and clinically presented as a circumscribed, unilateral lesion usually in the upper, outer rim of the auricular helix. On the contrary metabolic and endocrine diseases usually result in bilateral, symmetrical and more diffuse patterns of ossification or calcification.Considering the incidence of ossification or calcification of the external ear in the general population, Scherrer in his large series examined 800 patients, aged 15 to 75 years, but he did not found anyone with auricular rigidity . Gordon Many conditions have been reported over time as causative factors in the development of ossified or calcified auricles. Severe hypothermia has been considered as the most common cause of auricular ossificans . Rapid cIn our patient, Addison's disease and diabetes mellitus could be considered among the possible causative factors for his bilateral auricular ossification. Table There is not a specific treatment for this unusual, irreversible condition. The fact that is a rare condition and usually asymptomatic limits the information about its treatment. When the patient complaints for serious discomfort with pain, making sleeping very difficult, one should consider surgical intervention for symptoms relief. Lister reported a case in which performed wedge biopsy of a calcified auricle curing that way patient's insomnia . Lari etConclusively, true auricular ossification although is a very rare condition, requires thorough evaluation from the physician, as there is a possibility of a co-existed serious diseases like endocrinopathy. The contribution of computed tomography, could be of great importance, as not only can easily depict the abnormality but can also be strongly indicative of true ossification.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.NSM conceived and wrote the study, PZ and CK did the radiological evaluation, VS was the internist referred the patient to us and contribute the literature review, EG did the histological evaluation and TS and PDG along with NSM, jointly prepared the final manuscript