Pediatric head and neck masses are commonly congenital in origin or of infectious etiology. We present a rare case of benign mesenchymoma in close proximity to the submandibular gland in an otherwise asymptomatic child. Computerized tomography (CT) scan of the head and neck area revealed a benign lesion, which was later determined to be a benign mesenchymoma on histopathology. The child did well after surgery without any reported recurrence. We discuss the salient features of a benign mesenchymoma in a child and also discuss relevant imaging and management. Pediatric head and neck masses are often congenital in origin or may be associated with infection. The diagnosis and management of such lesions are usually straightforward. Uncommonly, some patients develop unusual masses that require further workup and require excision biopsy for a definite diagnosis. We present a rare case of a benign, noninfective lesion in close proximity to the submandibular gland in a child. Permission for publication of this case was obtained by the University of Texas Medical Branch Institutional Review Board.A 9-year-old girl presented to the Outpatient Otolaryngology Department with swelling under the right jaw that had slowly increased in size for the past two years. There was no associated fever, pain, voice changes, breathing difficulty, dysphagia, odynophagia, weight loss, and/or history of exposure to tuberculosis. There was a history of exposure to cats. Exposure to cats with the onset of symptoms in the patient led to cat scratch disease and fungal infections being included in the differential diagnosis. These were ruled out with a negative cat scratch titer and negative toxoplasma IgG.Physical exam showed the presence of two distinct swellings in the submental and right submandibular (SM) area. The swelling in the right SM area was about 2 × 2 inches and the submental area swelling measured approximately 1.5 × 1.5 inches. The swellings felt firm and nodular and were not freely mobile. The remaining of the ear, nose, and throat and general physical exam was normal. Laboratory tests were negative.Ultrasound (US) of the neck showed the presence of two calcified masses with heterogeneous echotexture. A computerized tomography (CT) scan of the head and neck area with contrast was obtained. A nonenhancing, multilobulated mass with peripheral rim calcification was noted in the SM region mostly on the right side but crossing the midline. The peripheral rim calcifications could signify precursor to bone development within the mass or local necrosis due to mass effect. It measured 4.88 × 3.55 cm . The rigSurgical excision of the mass was performed through a routine right SM approach. The entire mass was removed along with a surrounding cuff of normal tissue. Since the right submandibular gland was distinct from the swelling and did not seem to be involved at the time of surgery, it was not removed. The mass was a well circumscribed and encapsulated soft tissue lesion with adipose tissue, fibrosis, smooth and skeletal muscle, cartilage, and bone fragments. A thin outer rim was calcified, but the rest of the cut surface was mostly yellowish white with a whorled pattern. The findings were consistent with those of a benign mesenchymoma. The child did well at one- and 6-month follow-up periods without any recurrence of the lesion.Benign mesenchymoma is a rare soft tissue tumor that consists of fibrous tissue and two or more differentiated types of cells with mesenchyme origin that are not found together at the host site . It is sBures and Barnes  reportedBures and Barnes  stated tCT scan is usually required to define the extent of the lesion and determine its relationship to the important structures in the head and neck. Typically, the lesion appears well defined, with predominance of soft tissue, adipose tissue, and bony or hyaline components . AbsenceSurgical excision is usually curative. It is important to excise the lesion completely with a small amount of surrounding normal tissue to prevent recurrence.We report a rare case of benign mesenchymoma in the neck of a child closely related to the SM gland. This case is unique, the occurrence of the tumor in this location has not been reported before, and surgical excision with follow-up proved successful. Further research is required on long-term follow-up to determine the behavior patterns, recurrence, and optimal therapy for this rare lesion. Physical exam and imaging techniques are adjunctive to surgical excision and pathological diagnosis.


Abdominal pregnancy is a rare form of ectopic pregnancy with a high rate of maternal and fetal complications. Most of the reported cases are diagnosed in early trimesters, usually after presenting with complications. Advanced abdominal pregnancy poses a huge diagnostic and management challenge, particularly in low-income countries. A term abdominal pregnancy diagnosed pre-operatively and resulting in a surviving neonate is quite rare.A 35-year-old, para 2, unbooked, Ethiopian Somali woman presented with amenorrhea of 9 months’ duration, abdominal pain, and painful fetal movements of 4 months’ duration. Her physical examination revealed a uterus sized 36 weeks’ gestation with easily palpable fetal parts. Her laboratory test results were unremarkable except for mild anemia. Her ultrasound findings were suggestive of abdominal pregnancy. Laparotomy was done to salvage an alive healthy neonate from the peritoneum with removal of placenta implanted on the right broad ligament. The mother had a smooth post-operative course.An advanced abdominal pregnancy diagnosed pre-operatively with delivery of a surviving neonate is rare. A high index of suspicion and thorough clinical and ultrasound evaluation are crucial to making an early diagnosis. This is particularly important in areas where advanced imaging technologies are not readily available. Timely surgical intervention is imperative to avert maternal and fetal complications.The online version of this article (doi:10.1186/s13256-015-0712-7) contains supplementary material, which is available to authorized users. Advanced abdominal pregnancy (AAP) is defined as a pregnancy of over 20 weeks’ gestation with a fetus living, or showing signs of having once lived and developed, in the mother’s abdominal cavity , 2. AbdoThe clinical presentation is variable, and the optimal approach to the evaluation and management of abdominal pregnancy is not well determined , 3. A hiA 35-year-old, married, para 2 (both stillbirths), Ethiopian Somali woman presented to Karamara Regional Hospital on 16 August 2014 with diffuse abdominal pain and recurrent vaginal spotting of 4 months’ duration associated with nausea, anorexia, and occasional vomiting. She had been amenorrheic for 9 months and had noticed painful fetal movements during the previous 2 months. She had never attended antenatal care. Both her previous deliveries had been spontaneous vaginal deliveries that ended in stillbirths.Her physical examination revealed stable vital signs, mild pallor, distended abdomen with a uterus sized at 36 weeks’ gestation, easily palpable fetal parts, fetus in transverse position, and diffuse abdominal tenderness but no guarding or rigidity. There was no sign of fluid in her peritoneum. The fetal heart beat was positive. The cervix was firm, smooth, and closed.The laboratory findings were all unremarkable, except for mild anemia (hemoglobin of 10g/dl). Ultrasound scanning revealed an enlarged, otherwise empty uterus with a thick endometrial echo and a 37 weeks’ gestation singleton, viable pregnancy in transverse lie with no intervening myometrial tissue (echo) between fetal parts and the abdominal wall (Fig. The woman was counseled on the diagnosis, and informed consent was obtained for surgery. After securing 4 U of whole blood, laparotomy was done through a subumbilical midline incision that revealed the following findings: an alive, meconium-stained male neonate retrieved free from the peritoneum, weighing 2600g, and having Apgar scores of 7 and 9 in the first and fifth minutes, respectively. The baby had no gross congenital anomalies. The movie file in Additional file Ectopic pregnancy is estimated to occur in 1–2% of pregnancies . Over 90The clinical presentation of abdominal pregnancy is variable, based on the location and the gestational age at diagnosis . SimilarA high index of suspicion is vital in making the diagnosis of AAP. The classic ultrasound finding of absence of myometrial tissue between maternal bladder and fetal parts was evident in our patient, along with an empty uterus and other suggestive findings, including poor definition of the placenta, oligohydramnios, and transverse lie , 8. An AIt is widely accepted that the treatment of AAP is immediate surgery once fetal viability is achieved. But the management of the placenta is controversial. In our patient, laparotomy was done immediately upon the diagnosis of AAP, and the fetus was delivered easily. Fortunately, the placenta was also retrieved relatively easily without significant bleeding, as the vessels supplying the placental bed were easily ligated and there were no major adhesions. An alternative management of the placenta suggested by most authors is ligating the umbilical cord and leaving the placenta in situ with or without administration of methotrexate. This is preferred, especially if the placenta is implanted on vital abdominal organs or major vessels , 8, 9. MMaternal and fetal prognoses are generally grave in AAP. Maternal death in these cases is usually the result of uncontrollable hemorrhage and has been reported in as many as 20% of cases . PerinatAn AAP diagnosed pre-operatively and resulting in the delivery of a surviving neonate is rare. A high index of suspicion, a thorough clinical evaluation, and comprehensive ultrasound scanning are crucial to making an early diagnosis, particularly in areas where advanced imaging technologies are not readily available. Timely surgical intervention is imperative to avert maternal and fetal complications.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.


Patients with a primary pure seminoma in the testis who have elevated serum alpha-fetoprotein are rare and should be treated as patients with nonseminomatous germ cell tumors. However, nonpalpable testicular tumors in this condition have never been reported. We describe a case of nonpalpable pure testicular seminoma with elevated serum alpha-fetoprotein presenting retroperitoneal metastasis.A 29-year-old Asian man was referred to our hospital with right flank pain. Computed tomography showed a mass located between his aorta and inferior vena cava, but a testicular tumor was not detected. His serum levels of lactate dehydrogenase, alpha-fetoprotein, and DUPAN-2 were high. Although no tumor or nodule was palpable in his testis, ultrasonography revealed multiple low echoic lesions in his right testicular parenchyma. He was diagnosed with right testicular cancer with retroperitoneal lymph node metastasis and underwent right high orchiectomy. A pathological examination revealed pure seminoma and no nonseminomatous components were found in the specimen. Three courses of induction systemic chemotherapy  normalized his serum alpha-fetoprotein and DUPAN-2 levels. Three additional courses of chemotherapy (etoposide and bleomycin) were performed, and treatment was completed with laparoscopic retroperitoneal lymph node dissection. Pathology of the dissected specimen showed fibrous and necrotic tissue with no viable cells. He is alive without recurrence 54 months after orchiectomy.We report a case of pure testicular seminoma with elevated serum alpha-fetoprotein and DUPAN-2 presenting retroperitoneal metastasis. We recommend an ultrasound examination of bilateral testes when large retroperitoneal tumors are detected in young men, even if a mass is not palpable in the scrotum. Testicular cancers are categorized into seminomatous and non-seminomatous germ cell tumors (NSGCTs), each with a 50 % incidence. Distinguishing NSGCTs from seminomas is important because the therapeutic strategy is different. Many patients with NSGCT have elevated serum tumor markers, such as lactate dehydrogenase (LDH), alpha-fetoprotein (AFP), and human chorionic gonadotropin (hCG). Since seminoma does not induce AFP production, the guidelines recommend that cases with increased AFP levels be treated as cases of NSGCT , 2. BecaWe report a case of a 29-year-old Asian man with nonpalpable testicular cancer presenting retroperitoneal lymph node metastasis. Although his testicular histology showed pure seminoma at orchiectomy, preoperative serum AFP levels were elevated.A 29-year-old Asian man with no remarkable past history was referred to our hospital presenting with right flank pain. He had an episode of right flank pain 2 weeks before the first visit. Computed tomography (CT) revealed a retroperitoneal mass (52×36×31 mm) located between his aorta and inferior vena cava Fig. , but a tet al. [Patients with elevated serum AFP levels and a primary pure seminoma are treated as patients with NSGCTs, because some nonseminomatous components are presumed to be present either in the testis or at a metastatic site. Therefore, we treated the current case as NSGCTs, and induction chemotherapy followed by RPLND was performed after orchiectomy as in stage IIB NSGCTs. Peterson et al.  reportedet al. ; of the et al. . Therefoet al. reported immunohistochemical analyses of DUPAN-2 expression using paraffin-embedded specimens of 30 testicular germ cell tumors, and DUPAN-2 was expressed in all of the specimens from nine patients with embryonal carcinoma [DUPAN-2 is a well-known tumor marker for pancreatic, bile duct, and colorectal cancers ; in our arcinoma . In our et al. reviewed 3854 testicular ultrasound examinations; they hypothesized that intratesticular microcalcifications outside the margin of the tumor might represent a phenomenon of burned-out tumor [Seminomas typically appear as solid, round, homogeneous, low reflective masses contained within testes, without calcification inside the tumors. On the other hand, embryonal carcinomas and teratomas appear as inhomogeneous masses with calcification inside the tumor mass and, generally, a normal gonadal stroma does not contain calcifications. Miller ut tumor . In our In conclusion, here we report a case of pure testicular seminoma with elevated serum AFP and DUPAN-2 presenting retroperitoneal metastasis. We recommend an ultrasound examination of bilateral testes when large retroperitoneal tumors are detected in young men, even if a mass is not palpable in the scrotum.We report a case of pure testicular seminoma at orchiectomy with elevated serum AFP and DUPAN-2 presenting retroperitoneal metastasis. When a retroperitoneal mass is detected and a testicular tumor is not palpable, we recommend consideration of the possibility of a testicular tiny tumor or of a burned-out phenomenon.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.


This case study reports the successful treatment of an immature upper premolar with periapical pathosis and sinus tract using revascularization technique. Clinical and radiographic examination demonstrated the recovery of vitality, continued root development, and periapical healing at the 7-month follow-up. In addition, severe calcification of the canal was noted at the 36-month follow-up. At the 66-month follow-up, cone-beam computed tomography (CBCT) revealed complete periapical healing, apical closure, increase in root length and thickness of dentin, and severe calcification of the root canal. Even though the nature of tissue within the root canal is unknown, revascularization appears to give good clinical and radiographic success. This case report highlights that severe calcification of the canal is one of the long-term outcomes of revascularized root canals. It is often challenging to treat cases of pulpal necrosis involving immature teeth with open apices, as the root canal walls are often thin and prone to fracture. This makes it difficult for root canal instrumentation and obturation . HistoriTo overcome the shortcomings of apexification, mineral trioxide aggregate (MTA) has been advocated as the apical root filling to create a barrier . The advMore recently, revascularization/regenerative procedures have been favored as they allow for the continued growth of immature root. The concept of revascularization is such that it focuses on gaining of blood supply into the disinfected root canal space, triggering a process similar to wound healing in surgical procedures . The priA 12-year-old male patient with noncontributory medical history was referred to Prince Phillip Dental Hospital, a dental teaching hospital in Hong Kong, for root canal treatment of tooth 15. The patient complained of swelling on the upper right region for the past 3 months. Clinical examination revealed a fractured tubercle (dens evaginatus) of tooth 15. A draining sinus tract was observed on the buccal attached gingiva between tooth 14 and tooth 15. Tooth 15 was tender to percussion and palpation and had negative responses to cold and electric pulp testing. Radiographic examination revealed immature root formation of tooth 15, with a periapical radiolucency measuring approximately 5 mm in diameter. A diagnosis of an open apex with necrotic pulp and chronic apical abscess was made based on the clinical and radiographic findings.After informed consent was taken, local anesthesia was given using 2% Xylestesin with 1 : 80 000 epinephrine , and tooth 15 was isolated with a rubber dam. An access cavity was prepared using a high-speed handpiece with copious water spray. The necrotic pulpal remnants were removed under copious irrigation with 3% sodium hypochlorite (15 mL) and sterile saline, along with gentle debridement of the canal walls. Working length was determined by estimating the radiographic working length. The canal was dressed with calcium hydroxide medicament  by injecting it directly into the canal and a temporary filling consisting of Cavit  and Intermediate Restorative Material (IRM)  was placed.At the second visit 3 weeks later, the buccal sinus tract was noted to have healed and the tooth was asymptomatic. The tooth was reopened to replace the calcium hydroxide dressing. At the third visit another 2 weeks later, local anesthesia was given using 3% Mepivastesin . The root canal was irrigated copiously with sterile saline and dried with sterile paper points . Bleeding was induced by overinstrumentation of the canal length with a size #40 K-file, and a blood clot was formed at the middle third of the root. Grey MTA  was placed over the blood clot, followed by a moist cotton pellet above. The access cavity was then restored with IRM . The patient was seen 1 week later and the temporary restoration was removed under rubber dam isolation. After confirming that the MTA has set, the tooth was restored with glass-ionomer cement  and universal composite resin .In follow-up visits , no clinical signs or symptoms were detected. Healing of the periapical lesion was observed at the 4-month follow-up. After 7 months, continued root growth was noted, and the tooth gave positive responses to both cold and electric pulp tests . Apical Regenerative endodontics has been described as procedures to replace the original structure and histology of damaged or lost dentin, root structures, and cells of the pulp-dentin complex . HoweverPublished case reports have shown that successful treatment outcome can be obtained when there is (i) eradication of bacteria from the root canal system, (ii) construction of a scaffold for the ingrowth of new tissue, and (iii) prevention of reinfection by creating a bacteria-tight seal . The choA limited field-of-view CBCT was used to assess the treatment outcome of this tooth 15 at the 66-month follow-up. It is effective in assessing radiographic changes that may occur in the medullary bone, with the advantage of viewing at various  directions . The advIn this case report, severe calcification of canal space was noted, similar to findings reported by other authors . It is oIn conclusion, this case report showed good clinical and radiographic outcomes for a revascularization procedure involving an immature tooth with pulpal necrosis and chronic apical abscess. However, clinical success may not equate to histological success. Long-term root canal calcification may be one of the treatment outcomes of revascularized teeth.


A 16-year-old adolescent boy presented to our clinic with an extensive hyperpigmented lesion on the left side of the scalp, neck, and face involving the entire left ear. The lesion was present at birth, increasing proportionally in size and developing nodules and coarse hair follicles as the patient advanced in age. Excision of part of the lesion on the neck in a peripheral hospital 4 years earlier resulted in a hard, nodular, and itchy lesion that has continued to increase in size beyond the original surgical scar.Discuss the diagnosis of the primary lesion.Discuss the diagnosis of the secondary lesion.What are the differential diagnoses of the primary lesion?What are the goals of treatment of the primary lesion?,3,4This rare and disfiguring skin lesion is a giant congenital melanocytic nevus (GCMN). It is characterized by variability in size and shape, dark pigmentation, and verrucous hair-bearing surfaces.1The secondary lesion on the neck resulting from surgical excision is a keloid, resulting from a fibroproliferative disorder of wound healing with unsavory reputation for recurrence. Occurring in genetically predisposed individuals, the etiopathogenesis of keloids is as uncertain as is its protean manifestations. Keloid formation has remained the bane of plastic surgical practice in sub-Saharan Africa. The bedrock of management has included intramarginal excision, intralesional injection of steroids, and radiotherapy, either individually or in any combination, yet control rather than cure remains the measure of success.The differential diagnosis of GCMN in the early stages includes other epidermal pigmented skin lesions such as hemangiomas, nevus psoriasis, verruca vulgaris, inflammatory linear verrucous epidermal nevus, and hamartomas. In its advanced stages, lesions such as cylindroma presenting as the turban tumor, malignant melanoma, pigmented basal cell carcinoma, dermatofibroma, and dermatofibrosarcoma deserve due consideration.,6The goals of treatment of GCMN are 2-fold: reducing nevocytic density albeit risk of malignancy and providing cosmetic relief for the disfigurement. Full-thickness surgical excision with reconstruction of the resultant defect is therefore the mainstay of treatment. Lesions in the head and neck region often constitute significant reconstructive challenges requiring the deployment of the full armamentarium in the plastic surgeon's arsenal—from skin grafts through tissue expansion to microvascular free flap reconstruction.5,Experience with hypertrophic scarring and keloid formation continues to play a major role in the choice of reconstructive techniques in our patient population.7


Talon cusp (TC) and dens invaginatus (DI) are relatively rare developmental anomalies which affect the shape of teeth. TC is an additional cusp that projects predominately from the lingual surface of anterior teeth. DI is a deep surface invagination of the crown or root which is commonly detected on routine radiographic examination. Both of these anomalies are observed more frequently in permanent maxillary lateral incisor. Isolated cases of single TC and DI are extensively reported in dental literature. Occasionally two talon cusps (TCs) in the same tooth as well as double and triple invaginations in one tooth are reported separately. Coexistence of these two anomalies in a single tooth is considered extremely rare, but still there are few reported cases. However, coexistence of two TCs and double DI in a single tooth is not reported till date. We hereby report the first case of coexistence of two TCs and double DI in a single tooth of a 23 year old female and use of platelet-rich fibrin (PRF) in the management of associated radicular cyst. Also, literature on coexistence of these two anomalies in a single tooth is reviewed. Key words:Coexistence, dens invaginatus, radicular cyst, talon cusp. TC is a rare developmental anomaly of teeth which was first recognized in 1892 by Mitchell . It is mDI is another rare developmental anomaly of teeth which was first described by a dentist named ‘Socrates’ in 1856 . The repIsolated cases of single TC and DI have been reported extensively in the dental literature. Rarely, two or more TCs occur in a single tooth. Sarraf-Shirazi  reportedA 23 year old female reported with the complaint of recurrent swelling in the upper left anterior region of jaw since last 4-5 months. Her medical and family history was noncontributory and general physical examination revealed no other abnormalities. On intraoral examination a diffuse, firm and tender swelling was seen in the labial vestibule in relation to maxillary left lateral incisor. Loss of labial vestibular depth was noted. The overlying mucosa was pink in colour and had smooth surface Fig. . InvolveIntraoral periapical radiograph [IOPA] of the lateral incisor was taken Fig.  which reAfter performing root canal treatment on the lateral incisor Fig. , enucleaThe exact etiology of TC and DI is still not well understood. Simultaneous occurrence of these two anomalies in a single tooth suggests common etiological factor. TC originates during the morpho-differentiation stage of tooth development and may occur as a result of abnormal proliferation of inner enamel epithelial cells and transient focal hyperplasia of the peripheral cells of mesenchymal dental papilla -4,6-8. BA total 12 teeth having a combination of TC and DI in 8 patients are reviewed.  In the set al. (All the teeth in the reviewed cases showed type 1 TC 12/12] ,6-10 and/12 ,6-10et al.  classifiThe most commonly used classification of DI was proposed by Oehlers  in 1957.Both TC and DI can cause a variety of clinical problems. Presence of TC may result in occlusal interference, accidental cusp fracture, compromised esthetics, irritation to the tongue during speech and mastication. Also, developmental grooves on the TC trap plaque and increase susceptibility to caries and pulpal involvement ,3,9. DI Clinical management of TC and DI varies from case to case depending on the symptoms and associated clinical problems . Periodiet al. (In the present case, as there was periapical infection, after completing root canal treatment of lateral incisor, enucleation of cystic lesion was done followed by placement of PRF in the surgical defect. PRF was prepared as described by Harish et al. . Use of A rare case of coexistence of two TC and two DI in maxillary left lateral incisor of a 23 year old female is reported. Such a combination increases the risk of periapical infection in associated tooth. Hence, regular follow up of these cases is important and in cases of associated radicular cysts PRF may be used to speed up the healing of surgical defect.


Anastomotic site adenocarcinoma of the present case is potentially of urothelial origin because of unusual clinical manifestation and immunohistochemistry as a colon cancer.Ureterosigmoidostomy is associated with the risk of several late complications including cancer development at anastomotic sites. We present an unusual case with adenocarcinoma of the anastomotic site associated with multiple adenocarcinoma lesions in the upper urinary tract. A 69-year-old man complained of persistent melena and hematuria. He had undergone radical cystectomy for high-grade bladder cancer and ureterosigmoidostomy 30 years before. Colonoscopy showed a tumor at the right ureterocolonic anastomosis, which was endoscopically resected and histologically diagnosed as adenocarcinoma. Seven years later, a tumor of the left ureterocolonic anastomosis associated with hydronephrosis was found. He underwent temporal percutaneous nephrostomy followed by sigmoidectomy and left ureterocutaneostomy. Eighteen months after the operation, computed tomography (CT) detected left renal pelvic tumor with a mass along the former nephrostomy tract. Left nephroureterectomy and resection of the nephrostomy tract tumor revealed adenocarcinoma with multiple lesions of adenocarcinoma in the ureter. These tumors showed atypical immunohistochemistry as a colonic adenocarcinoma: positive for cytokeratin 7, negative for cytokeratin 20, and negative for  Ureterosigmoidostomy is associated with an increased risk of several late complications. Of particular, the incidence of colon adenocarcinoma is 100- to 550-fold higher compared to that of the general population [A 69-year-old man visited our hospital because of persistent melena and hematuria. Thirty years before, he had undergone radical cystectomy with bilateral ureterosigmoidostomy for high-grade urothelial carcinoma of the urinary bladder. Colonoscopy showed a tumor at the site of the right ureter-colon anastomosis, which was managed by endoscopic mucosal resection and histologically confirmed as adenocarcinoma. He had no known genetic predisposition for colorectal and urothelial carcinoma.Seven years later, follow-up colonoscopy detected a tumor of the left ureterocolonic anastomosis. Computed tomography (CT) demonstrated invasive colonic cancer and left hydronephrosis. He underwent temporal left percutaneous nephrostomy followed by sigmoidectomy and left ureterocutaneostomy. The tumor was located around the anastomotic site, and it was undetermined whether the tumor had originated from either the colon or the ureter .β-catenin nuclear accumulation (Eighteen months after the operation, the patient complained of pain and induration in his left back. CT showed a 2 cm mass in the left renal pelvis and a soft tissue mass posterior to the kidney along the former nephrostomy tract without distant metastasis . We perfmulation . Three mβ-catenin nuclear accumulation, which is uncommon for colon cancers. These findings suggest that anastomotic site tumors of our case might have originated from urothelium at the anastomotic site rather than colonic mucosa.The pathogenesis of adenocarcinoma at the ureterosigmoid anastomotic site is not well understood. A possible mechanism is that the bacterial flora in the colon actively reduced urinary nitrate to nitrite, resulting in formation of carcinogenic N-nitrosocompounds –4. OtherMultiplicity of tumors in the upper urinary tract may be explained by primary multicentric development of urothelial adenocarcinoma or tumor implantation of the anastomotic adenocarcinoma. Tumor implantation may be more likely in this case, since multiple cancerous lesions were found in the ureter, renal pelvis, and nephrostomy tract, with all the lesions showing indistinguishable histological appearance and identical immunohistochemistry, although primary multicentric adenocarcinoma of urothelium origin has been reported. .Anastomotic site adenocarcinoma of the present case is potentially of urothelial origin because of unusual clinical manifestation and immunohistochemistry as a colon cancer.


Disseminated Peritoneal Adenomucinosis (DPAM) is an infrequent presentation of appendiceal cancer. Infrequently, umbilical or inguinal hernias could be the first clinical manifestation of this condition; DPAM extension to the scrotum may be anatomically viable. Treatment with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard of treatment for DPAM. We hypothesize that these same treatment principles, consisting of CRS with hyperthermic chemoperfusion of the scrotum (HCS), could be applied to the scrotal dissemination of DPAM. We reviewed our Institution's prospective cancer database and identified two cases of DPAM with extension to the scrotum. Their medical records were examined, and close follow-up was performed. Tumor histopathology and cytoreduction scores were evaluated. Tumor progression was monitored on follow-up by physical examination, tumor markers  and abdomino-pelvic CT scan. Two patients who previously had CRS/ HIPEC for DPAM were successfully treated with HSC. Both patients are alive and free of disease at 88 and 57 months following initial CRS/HIPEC, and 50 and 32 months following CRS/HCS, respectively. Increased awareness by surgeons to the coexistence of inguinal hernia with peritoneal neoplasm and the need for a surgical repair is raised. CRS/HCS may be employed to treat patients with DPAM extension to the scrotum. Successful outcome is dependent on complete cytoreduction of metastatic tumor.  These catheters were secured temporarily with sutures . While tA 65-year-old male presented with an inguinal and incarcerated umbilical hernia. At the time of surgery, he had mucinous collection in the umbilical hernia sac. The procedure was converted to a laparotomy with an appendectomy and peritoneal biopsy. He required umbilical and inguinal herniorrhaphy, requiring mesh for the latter after excision of the hernia sac. Pathology revealed that the tissue specimen was consistent with mucinous cystadenoma of the appendix with pseudomyxoma peritonei - DPAM. A CT scan revealed multiple areas of mucinous collection around the liver and omental involvement of the tumor A.Two months later, the patient was referred to our center specializing on peritoneal surface malignancy. Following a detailed history, the groin was carefully examined and hernia recurrence was ruled out. The CT scan showed diffuse peritoneal implants. No tumor was seen in the groin B. The paA 63-year-old male presented with right lower abdominal pain. Appendicitis was suspected and his appendectomy was converted to an exploratory laparotomy due to incidental findings of ruptured tumor of the appendix and DPAM. The patient required a right hemicolectomy at that time. Pathology showed ruptured mucinous cystadenoma of the appendix with pseudomyxoma peritonei - DPAM. Eleven months later, a left inguinal hernia was diagnosed, and during the mesh herniorrhaphy peritoneal and hernial sac mucinous deposits were identified. in-situ Prolene® mesh, HCS  in the scrotum should be an indication for complete removal of all tumor and hyperthermic chemoperfusion. Herein, the same principles that are applied for intra-abdominal recurrence, like hernias, are a direct extension of the peritoneum.In conclusion, increased awareness by surgeons of the coexistence of inguinal hernia with peritoneal neoplasm and the need for a surgical repair is raised. CRS and HCS may be employed in treating patients with DPAM extension to the scrotum. Successful outcome is dependent on complete cytoreduction of metastatic tumor.


We present a surgical case of a rare primary tracheal tumor. In a 44-year-old asymptomatic man, computed tomography (CT), performed as part of health check-up, revealed a tumor measuring 1.5 cm in diameter in the mediastinal trachea. Biopsy failed to yield a definitive diagnosis, but the tumor tended to grow rapidly; therefore, surgery was performed. Five tracheal rings were resected through median sternotomy, followed by interrupted suture with 3–0 absorbable thread. The postoperative course has been favorable with no evidence of recurrence. The pathological diagnosis was leiomyoma. We report this case with literature review. Primary tracheal tumor is a relatively rare condition. More than 90 % of all cases of primary tracheal tumor are malignant, and benign leiomyomas account for approximately 1 % of such tumors . When a The patient was a 44-year-old man with a timorous lesion in the trachea detected on computed tomography (CT) screening for lung cancer. He was referred to our hospital for further examination and treatment. No particular subjective symptoms were observed. The patient was 171 cm tall, weighed 73 kg, and had clear respiratory sounds. There was no palpable enlargement of surface lymph nodes. There were no abnormalities in his blood biochemistry findings, and tumor markers were all within the normal ranges. Spirometry results were normal . On CT and magnetic resonance imaging (MRI), a smooth, well-circumscribed nodular shadow measuring 1.3 × 1.5 cm was revealed in the posterior wall of the thoracic trachea 5 cm below the glottis Fig. . Both brPrimary tracheal tumor is a relatively rare disease. Of all cases of primary tracheal tumor, more than 90 % are malignant tumors, such as adenoid cystic carcinoma and squamous cell carcinoma, and tracheal leiomyomas are said to account for approximately 1 % of such lesions . AdditioRemoval of the tumor is the basic treatment, but the question is whether to take a surgical or endoscopic approach. In recent years, some reports have been published on resected cases of relatively small, pedunculated tumors in which a high frequency snare , 6 or YtWe reported a case of primary tracheal leiomyoma, a rare disease, in which we performed tracheal segmental resection and anastomosis.Written informed consent was obtained from the patients 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.


A mesenteric cyst is a rare cause for abdominal pain. This umbrella term includes cystic entities which reside in the mesentery. We present a case of an infected false mesenteric cyst in a 24-year-old female patient without prior surgery or known trauma. Mainstay of treatment involves surgical resection, although less invasive treatments have been described. Prognosis depends on the origin of the cyst. The mesenteric cyst is a rare entity. It has been reported as an umbrella term that comprises any cystic mass which manifests within the mesentery, including lymphangioma, benign and malignant cystic lymphangioma, enteric duplication cyst, dermoid cyst, and pseudocyst . Mesente9/L. Urinalysis was normal. As a result acute appendicitis was suspected and imaging evaluation was performed.A 24-year-old female without previous abdominal surgery or relevant medical history presented at her general practitioner because of severe abdominal pain, principally in the right lower quadrant, gradually increasing over the last 4 days. In addition she complained about lower back pain and feeling feverish. Consequently, she was admitted to the emergency department for advanced assessment. On physical examination at the time of admission, the patient experienced severe pain if palpitated in the right lower abdomen. Her vital signs were stable and cardiac and pulmonary examination were normal. She was afebrile; however, this could also be attributed to the use of anti-inflammatory drugs (NSAIDs). Laboratory results confirmed inflammation with an elevated C-reactive Protein (CRP) of 162 mg/L and a normal leucocytes amount of 9.8 × 10Ultrasound revealed a large, moderately anechoic, multilocular mass in the right hemiabdomen with echogenic components extending from the caudal border of the liver into the right lower quadrant . Due to The patient retained severe, unceasing abdominal pain; consequently laparotomy was proposed. At surgery, enucleation of the cystic mass from the mesentery was attempted; however, due to the intraoperative findings of enlarged lymph nodes and the diffuse mesenteric infiltration in close relationship with adjacent ascending colon, an ileocecal resection was performed. Intraoperatively the cyst was partially opened and did not contain pus but rather greasy, brown, hemorrhagic-like material . MacroscMicroscopic examination of the specimen showed lining of the cystic wall with a flatted cell layer. Additional staining with mesothelial markers and endothelial markers was negative . The perMesenteric cysts are one of the rarest abdominal tumors with less than thousand cases reported in literature, with a reported incidence rate of approximately 1/100.000 admissions in adults , 4. TheySymptoms are variable and rather nonspecific in case of a complicated cyst. Complications include infection, rupture, hemorrhage, and torsion. If large, the cyst can cause intestinal obstruction or bowel ischaemia on account of bowel compression or arterial compression, respectively , 7. AlthUltrasound and contrast-enhanced abdominal CT are crucial in the diagnostic workup. The US appearance is reported to be diverse but should be considered if an avascular oval mesenteric mass is visualized . CT is hMesenteric cysts can occur anywhere in the mesentery along the gastrointestinal tract but most frequently appear in the small bowel mesentery, particularly the ileum . NonetheNumerous classifications have been reported to categorize mesenteric cysts based on pathology and etiologic origin , 13. In Although the exact etiology is uncertain, an accepted theory for cysts of lymphatic origin entails a congenital benign proliferation of ectopic lymphatic tissue in the mesentery, which does not communicate accurately with the residual lymphatic system. By contrast, mesothelial cysts are believed to be a result of congenital failure of the mesenteric leaves to fuse . False cTreatment of choice for complicated mesenteric cysts is surgery with complete resection of the cystic mass. This can be accomplished by either laparotomy or laparoscopy. An advantage of laparoscopy includes the shorter hospital stay but comes with longer procedure time and technical difficulty when the cyst is large or if infected . In suchPrognosis depends largely on the nature of the mesenteric cyst. Most are benign and therefore have a general good prognosis. Even so, mesotheliomas and lymphangiomas especially have a tendency to recur if resected incompletely .Mesenteric cysts are rare abdominal tumors and encompass cysts from different origins with different etiologies. Consequently they can occur at diverse sites in the abdominal cavity. Symptomatic mesenteric cysts are preferably treated by surgical resection, through either laparotomy or laparoscopy. Also sclerosis of the cyst might be a feasible alternative, though with limitations. Diagnosis might be challenging and is mainly obtained with CT and US; therefore, radiologists should be aware of the existence of the (complicated) mesenteric cyst.


Tumors of the jugular foramen remain challenging lesions despite advances in surgical technique and medical technology. Tumors with extensive extra- and intracranial components necessitate both radical neck dissection maneuvers combined with skull base approaches. We present a single surgeon’s perspective in managing these difficult tumors. Due to its deep location in the skull base with its associated intricate interweaving of neural and vascular structures, the jugular foramen remains very difficult and hazardous to access in modern neurosurgery. The removal of a large tumor of the jugular foramen with significant extracranial component requires a combination of skull base approaches. Most of these techniques involve the mobilization of cranial nerves and ligation of the jugular vein and sigmoid sinus . The risThese surgically complex and highly invasive approaches may therefore be over-aggressive for a Kaye type A jugular foramen tumor, located primarily within the intracranial compartment ,6. On thThis study involves three patients with intracranial jugular foramen tumors, which illustrates the evolution of a single surgeon’s thought process in approaching these rare tumors. Case PresentationInformed consent was obtained in all patients prior to surgical evaluation and treatment.Case 1A 42-year-old male presented with debilitating headaches. A radiographic evaluation revealed an intracranial tumor in the region of the jugular foramen, with extension into the foramen itself Figure .A far-lateral, retrolabyrinthine, transmastoid, transcondylar approach was performed to access the tumor Figure .Postoperatively, the patient was neurologically intact, with no sign of dysphonia or dysphagia. No tumor residual was seen on the magnetic resonance imaging (MRI) scan Figure .However, three years later, an intraforaminal regrowth was noted, and the patient was treated with stereotactic radiosurgery to 21 gray (Gy) in three sessions. The patient has been progression free since that time.Case 2A 55-year-old female presented with sensorineural hearing loss and tinnitus on the left. An MRI performed showed an enhancing, dural-based tumor centered on the left jugular foramen, impinging on the brainstem  for feeding. Over a prolonged follow-up, the patient’s swallowing function improved and she remains asymptomatic without need of her PEG tube, eating normally. She is being followed with a stable residual tumor on serial imaging Figure .Case 3A 39-year-old male presented with severe headaches and pulsatile tinnitus on the right. The MRI showed an egg-shaped tumor, with the narrow portion buried in the right jugular foramen and the broad portion jutting into the cerebellopontine angle. A retrosigmoid approach was performed to resect the tumor. After the cerebellopontine angle component of the tumor was removed, the endoscope was used to visualize the remnant inside the jugular foramen. Under visualization with a combination of the endoscope and microscope, the intraforaminal component was removed completely Video .The patient experienced dysphagia and dysphonia after surgery. The latter resolved after 10 days, but the swallowing problem remains at the time of writing. The patient continues to use a gastrostomy for feeding at most recent follow-up.A wide variety of approaches to the jugular foramen have been described and these can be distilled into three groups: the lateral, anterior, and posterior approaches -8. The aWhether starting anterior or posterior to the auricle, the lateral approaches all proceed transtemporal or subtemporal to gain access to the anterolateral aspect of the jugular foramen. All of the approaches in this group require gaining control of the carotid artery and ligating the jugular vein. Some of these approaches, such as Fisch type A, involve the transposition of the facial nerve, thus risking facial paresis . The juxThe posterior group is used for tumors located mainly in the cerebellopontine angle with limited extension into the jugular foramen. Although some approaches involve the presigmoid corridor, most use the corridor posterior to the sigmoid sinus . The claRecently, Katsushima et al. described a suprajugular extension of the retrosigmoid approach to gain access to the intraforaminal tumor . The bonSamii et al. applied the endoscope in their vast experience with jugular foramen access. Through a retrosigmoid infralabyrinthine approach, they found that five out of seven patients benefited from endoscopic assistance in aiding tumor resection within the foramen . Our experience with these rare and challenging tumors has mirrored the descriptions in the literature, and the evolution of our thought process and surgical technique has progressed with our clinical experience. This is illustrated best by the three cases that are described in this study. Early in our experience, the prevailing idea was that more bone removal translates to better visualization and access of the foramen. We thought this led to better results. However, in case 1, the additional mastoid and petrous bone removal in fact did not significantly enhance the access to the foramen. Furthermore, despite the large amount of bone removed combined with microscopic total resection at the time of surgery, the tumor recurred inside the foramen within three years.Case 2 illustrated the second “milestone” in our thought evolution. Similar to Sedney et al.’s experience, we began to think that additional bone removal was perhaps unnecessary and, in fact, may be over-aggressive . Thus, wWe applied the retrosigmoid approach as a stand-alone in our next “milestone,” illustrated in case 3. After the main portion of the tumor was removed from the cerebellopontine angle, the endoscope was used to visualize and remove the foraminal portion. We found that the endoscope fit through the surgical corridor safely, and provided panoramic visualization of the tumor inside the jugular foramen. Furthermore, while the surgeon held in the endoscope in the non-dominant hand, the dominant hand was able to switch between instruments without difficulty. Although we still used the microscope at the end of the procedure, the endoscope was a critical adjunct. It was able to provide the additional visualization of the jugular foramen, that mastoid and petrous bone removal did not in Case 1. This highlights the marriage of open microsurgical skull base techniques with recent endoscopic advances, as also experienced by other institutions .Exactly how much bone one needs to eliminate to access a jugular foramen tumor clearly depends on the individual characteristic of each tumor. Early in our careers, the dogmatic belief was that drilling more bone means better results. This has gradually been replaced by a less-invasive stance. This study once again illustrates that endoscopic and microscopic techniques must not be thought of as separate disciplines in skull base surgery, but a continuum of tools, seamlessly interchangeable, equally facile, to be utilized in these challenging procedures.


Mr. B. is a 39-year-old male with no significant medical history who began experiencing progressive abdominal girth and bloating.Ultrasound and CT of the abdomen and pelvis revealed moderate to large abdominal ascites. Ultrasound-guided paracentesis yielded7 L of serous fluid, with cytology showing atypical mesothelial cells. Upper endoscopy and chest CT were unremarkable. Exploratorylaparoscopy demonstrated a large amount of abdominal ascites and carcinomatosis involving the peritoneal surfaces, omentum, andsurfaces of the left and right lobes of the liver. Biopsies of peritoneal surfaces and liver implants confirmed a diagnosis ofmesothelioma, and Mr. B. was referred to surgical oncology.Mr. B. presents to the surgical oncology clinic with right upper quadrant pain extending to the right flank, 7/10 on the pain scale,exacerbated by lying on his right side. He has not been taking any pain medication. He reports abdominal bloating, progressiveabdominal girth since paracentesis, early satiety, excessive gas with large meals, subjective weight gain, and dyspnea on exertionafter climbing one flight of stairs. He denies nausea, emesis, melena, hematochezia, diarrhea, constipation, fevers, night sweats, andchills.Mr. B. has never had a colonoscopy. He is a lifelong nonsmoker and denies any alcohol or drug use or any prior asbestos exposureto his knowledge. He works as a customer service representative at a department store and specifically denies any knowledge ofoccupational or recreational chemical exposure.Upon physical exam, Mr. B. is a healthy-appearing male of stated age, in no apparent distress. His vital signs are normal.Abdominal exam reveals a dome-shaped abdomen with gross ascites. Normoactive bowel sounds are present with nohepatosplenomegaly. Shifting dullness and fluid wave are noted. There is mild tenderness to deep palpation of the right mid-abdomen. No stigmata of cirrhosis, jaundice, scleral icterus, or lower extremity edema are noted. Cardiac exam is unremarkable.Laboratory analysis reveals Mr. B.’s CA-125 level to be 263.3 U/mL . His CEA and CA 19-9 levels arenormal, as are his complete blood count, liver function tests, and kidney function.Cross-sectional imaging of the abdomen and pelvis  show a large amount of ascitic fluid extending into the pelvis,with the omentum displaced and compressed by fluid as well as omental caking. No dominant mass is identified, and intra-abdominal and pelvic organs are unremarkable except for a hepatic cyst. Repeat ultrasound-guided paracentesis is performed forsymptomatic relief, yielding 5 L of green fluid, with cytology again revealing atypical mesothelial cells. Mr. B. subsequently undergoesan exploratory laparoscopy revealing a large amount of abdominal ascites and carcinomatosis involving the peritoneal surfaces,surfaces of the left and right lobes of the liver, and the omentum. Representative biopsies of peritoneal and liver implants areconsistent with mesothelioma.Malignant peritoneal mesothelioma is a rare and fatal malignancy originating from the mesothelial cells that line theperitoneum. Mr. B.’s symptomatology is characteristic of this disease, as patients typically present with a combination of ascites,abdominal pain, swelling, and early satiety . There are approximately 400 new cases diagnosed annually in the UnitedStates, with an equal incidence in both males and females . Although there has been an association ofasbestos exposure with this malignancy, the cause ultimately remains unknown . On gross examination, there aremany tumor nodules of varying size diffusely seen throughout the peritoneal cavity, often leading to massive malignant ascites. Theomentum is typically infiltrated by disease; thus, radiographic evidence of omental nodularity and caking is not uncommon.Malignant peritoneal mesothelioma should be suspected in any individual with a diffuse malignant process in the abdomen. Aswas the case for Mr. B., it is not uncommon for the cytology on the ascitic fluid to be negative. A definitive diagnosis can beestablished only through tissue biopsy with appropriate immunohistochemical staining. The major histologic variants for malignantmesothelioma are epithelioid and sarcomatoid. The epithelioid subtype accounts for approximately 75% of patients and is typicallyassociated with better response to therapy and subsequently a better prognosis than the sarcomatoid subtype.The role of CA-125 as a tumor marker in this malignancy is not well understood. A study assessing 46 patients undergoingcytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for malignant peritoneal mesotheliomareported a preoperative diagnostic sensitivity of 53.4% for CA-125 . In a follow-up report, the authors describedan 82% 5-year overall survival for patients with baseline CA-125 35 U/mL and a 42% 5-year overall survival for patients with CA-125> 35 U/mL. Thus it is possible that CA-125 may parallel with disease progression and regression after CRS/HIPEC, implying that themonitoring of serial measurements in follow-up patients may be helpful.Benign multicystic peritoneal mesothelioma typically occurs in women of reproductive age (83%), is usually clinically benign, and is often discovered incidentally when a patient is having surgery for another reason . The most common presenting symptoms are chronic or intermittent abdominal or pelvic pain. Given Mr. B.’s gender and symptomatology, this is an unlikely diagnosis.Well-differentiated papillary mesothelioma is a subtype of epithelioid mesothelioma that is less aggressive, slower growing, and typically does not metastasize to other parts of the body. Similar to benign multicystic peritoneal mesothelioma, this disease also affects women of reproductive age and is often discovered incidentally when a patient is having unrelated pelvic or abdominal surgery . Patients with this condition are often asymptomatic, although chronic abdominal or pelvic pain can be present. Ascites is not typically seen with this condition. Thus, like benign multicystic peritoneal mesothelioma, papillary mesothelioma is an unlikely diagnosis for Mr. B. given his symptomatic state, especially in the presence of massive ascites.Without treatment, the median overall survival for patients with malignant peritoneal mesothelioma is about 6 months . Systemic chemotherapy using pemetrexed and cisplatin has been associated with an overall response rate of about 25% and a median overall survival of approximately 1 year. Currently, CRS with HIPEC is the treatment of choice. The goal of this type of surgery is to remove all gross disease; chemotherapy is administered intraoperatively following optimal debulking. A multi-institutional registry combining retrospective data on 405 patients with malignant peritoneal mesothelioma treated with CRS and HIPEC at 29 centers worldwide reported a median actuarial overall survival of 53 months.Mr. B. underwent CRS and HIPEC with cisplatin. His tumor was reduced to a CCR = 1 (completeness of cytoreduction), meaning that there was remaining disease that was 2.5 mm in thickness, with the bulk of the disease remaining along the interface of the mesentery to the small bowel. He was discharged from the hospital on postoperative day 8 with no postoperative complications but does suffer from minimal high-frequency hearing loss as a result of the cisplatin. Mr. B. received adjuvant carboplatin and pemetrexed for 4 cycles and is currently on maintenance pemetrexed with radiographically stable peritoneal implants.


Congenital fourth branchial arch anomalies are uncommon entities. Most of these anomalies are diagnosed in childhood. The majority of cases occur on the left side. The clinical presentation of these anomalies varies with age. A respiratory distress is the usual clinical presentation in neonates, cervical cutaneous fistulas in late childhood or acute suppurative thyroiditis. Multiples diagnostic options have been described with different modalities of treatment. The majority of cases of fourth branchial arch anomalies are described only in case reports. We report a clinical case of recurrent cervical abscess in a young woman due to a residual fistula of fourth branchial arch. The branchial arches give rise to specific derivatives, which for the fourth arch include the laryngeal cartilages, the laryngeal and pharyngeal muscles, the superior laryngeal nerve, the left thoracic aorta, the right proximal subclavian artery, the interfollicular cells of the thyroid, and the superior parathyroid glands .Congenital fourth branchial arch anomalies are uncommon entities. They typically present as a cervical inflammatory process primarily affecting children. Acute suppurative thyroiditis is a common presentation for this pathology (45%). Almost all cases of these anomalies are described only in case reports (526 cases were found in the literature) [Multiple diagnostic and treatment options have been described with a large variety in outcomes.The first published description of a branchial cleft lesion was in 1832 by Ascherson .We report a clinical case of a recurrent left-side cervical abscess in a young woman due to a residual fistula between the pyriform sinus and the thyroid lobule on the left side. She had been operated for an excision of a cervical cyst in the left side 6 years before with an initial diagnosis of a fourth branchial anomaly.A 20-year-old woman presented in January 2013 with an inflammatory left-side cervical swelling. She had been in a good general condition and only experienced an excision of a left-side cervical cyst 6 years before with an initial diagnosis of a fourth branchial arch anomaly. The follow-up did not show any recurrence or inflammatory process during the last 6 years. The clinical examination showed a left-side inflammatory and painful cervical swelling without evidence of external skin fistula or spontaneous discharge of pus. She had no dyspnea or dysphagia. The ENT examination did not show any pathological signs in the oropharynx, hypopharynx, or larynx. The biological findings showed an acute inflammatory syndrome with leukocytosis and elevated CRP. A cervical CT-scan showed a multilobulated liquid formation in the left lateral cervical region, measuring 29 × 15 × 55 mm, in contact with the left thyroid lobule, as well as the presence of a fistula tract between the thyroid lobule and the pyriform sinus on the left side  of these presented with respiratory distress [Fourth branchial arch anomalies represent vestiges of a sinus tract, originating from the apex of the pyriform sinus . Some auThe clinical presentation of fourth branchial arch anomalies varies with age. A respiratory distress is the usual clinical presentation in neonates. Cervical cutaneous fistulas develop only in late childhood. Acute suppurative thyroiditis is a late clinical presentation. Cases of mediastinal abscess of fourth branchial arch origin have been reported , 9.The left side predominance of the disease might be because of the more complex and extended pathway of the fourth branchial tract on the left side .In a meta-analysis of 526 cases published in a literature, the fourth branchial arch anomalies were almost always located on the left side (94%) and generally presented as acute suppurative thyroiditis (45%) or recurrent neck abscess (42%) [A large variety of diagnostic procedures have been described. The barium esophagogram may fail to demonstrate a sinus tract during acute inflammation . In contThe treatment options are multiple. Incision and drainage is frequently performed but carries a high recurrence rate. By contrast, open neck surgery, especially when combined with partial thyroidectomy, has the lowest recurrence rate but yields a higher rate of complications in infants and small children , with moIn our case, the 2 episodes of acute inflammation presented as left sided neck abscess without signs of thyroiditis and were treated by incision-drainage followed by antibiotic therapy. After the acute phase, open neck surgery with complete excision of the fistula's tract combined with left side partial thyroidectomy and cauterization of the internal opening of the left pyriform sinus tract by endoscopic approach were performed. No complications or recurrence of inflammation was noted in the postoperative follow-up. The patient had no difficulties with swallowing. A postoperative indirect laryngoscopy showed normal vocal cord mobility and absence of edema in the pyriform sinus. We noted good healing of the cervical wound.Fourth branchial arch anomalies are more common than previously suspected. The usual clinical presentations of these anomalies are recurrent neck abscess, acute suppurative thyroiditis, and respiratory distress in neonatal period. Complete excision of the fistula tract during a quiescent period combined with partial thyroidectomy appears to be the treatment of choice with a lower recurrence rate. This surgery is recommended for patients older than age 8 to minimize complications. Before the age of 8, a medical treatment is recommended. Endoscopic cauterization can be an effective alternative strategy with an outcome similar to open surgery.


Pediatric soft tissue sarcomas account for approximately 10% of all pediatric malignancies. Malignant ectomesenchymoma is rare biphasic sarcomas consisting of both mesenchymal and neuroectodermal elements. Approximately 64 cases have been reported in the literature and are believed to arise from pluripotent embryologic migratory neural crest cells. We report a 4-year-old boy who initially presented with a pelvic mass and inguinal lymphadenopathy at 6 months of age. Inguinal lymph node biopsy revealed a distinct biphasic tumor with microscopic and immunophenotypic characteristics diagnostic for both alveolar rhabdomyosarcoma and poorly differentiated neuroblastoma. The patient received national protocol chemotherapy against rhabdomyosarcoma with good response and presented with a cerebellar mass 21 months later. The metastatic tumor revealed sheets of primitive tumor cells and diagnostic areas of rhabdomyosarcoma and neuroblastoma were identified only by immunohistochemistry. Cytogenetic analysis of metastatic tumor demonstrated complex karyotype with multiple chromosomal deletions and duplications. The patient received national protocol chemotherapy against neuroblastoma and adjuvant radiotherapy after surgical resection of the cerebellar tumor with good response. He is currently off from any treatment for 18 months with no evidence of tumor recurrence or metastasis. Pediatric soft tissue sarcomas account for approximately 10% of all pediatric malignancies and are considered the fifth most common pediatric soft tissue neoplasm following leukemia/lymphoma, central nervous system tumor, neuroblastoma, and Wilms' tumor . BecauseOur patient is a 4-year-old Hispanic boy. He first presented at 6 months old to the Emergency Room with a chief complaint of left leg swelling and pain for a month. Further work-up including pelvic and thigh magnetic resonance imaging (MRI) revealed a heterogeneous partially cystic enhancing bilobed mass at the left side of the pelvis, measuring 5.7 × 4.3 × 4.0 cm . The lefAcross all ages with MEM, the mesenchymal component is generally RMS with predominantly embryonal subtype , 24–27 bCase  1. A 5-month-old girl with pelvic mass . ial mass : 84–87, Case  5. A 6-month-old girl with protruding vaginal mass /46,XX [3].nal mass : 46,XX,dCase  6. A 6-month-old boy with pelvic mass (our case):  71, XYY, add(1)(p13), −3, −4, +5, +7, +19, +22.Four of these cases had complex karyotypes. Trisomies 2, 8, and 11 were the most commonly reported genetic abnormalities , 25, 30.


Retroperitoneal haemorrhage  refers to an accumulation of blood found in the retroperitoneal space. It is a rare clinical entity with variable aetiology including anticoagulation, ruptured aortic aneurysm, acute pancreatitis, malignancy, and bleeding from renal aneurysm. Diagnosis of retroperitoneal bleed is sometimes missed or delayed as presentation is often nonspecific. Multislice CT and arteriography are important for diagnosis. There is no consensus about the best management plan for patients with retroperitoneal haematoma. Stable patients can be managed with fluid resuscitation, correction of coagulopathy if any, and blood transfusion. Endovascular options involving selective intra-arterial embolisation or stent-grafts are clearly getting more and more popularity. Open repair is usually reserved for cases when there is failure of conservative or endovascular measures to control the bleeding or expertise is unavailable and in cases where the patient is unstable. Mortality of patients with retroperitoneal haematoma remains high if appropriate and timely measures are not taken. Haemorrhage from a benign renal tumour is a rarer entity which is described in this case report which emphasizes that physicians should have a wide index of suspicion when dealing with patients presenting with significant groin, flank, abdominal, or back pain, or haemodynamic instability of unclear cause. Our patient presented with features of acute abdomen and, being pregnant, was thought of having a ruptured ectopic pregnancy. A 24-year-old primigravida with 6-week pregnancy was brought into emergency department with severe abdominal pain which started two days earlier and had worsened suddenly in the morning she was admitted. She was referred with a suspected diagnosis of ruptured ectopic pregnancy. Initial examination showed tachycardia of 124 beats per minute, marked pallor, and generalised tenderness in abdomen. The rest of her physical examination was normal. There was no history of vaginal bleeding. Her initial blood counts showed haemoglobin of 4.5 g/L. A FAST (Focused Assessment with Sonography in Trauma) scan appeared to suggest intraperitoneal bleed. Abdominal pain with pallor, low haemoglobin, and positive FAST scan was very suggestive of ectopic pregnancy. Therefore, a CT scan of abdomen was arranged. The scan showed large left retroperitoneal hypodense mass with hyperdense strikes. There was evidence of compression on the left kidney, pancreas, and bowel loops with associated moderate amount of ascites. Findings were consistent with massive retroperitoneal haematoma extending from diaphragm Figures  displaciThe haematoma was causing marked displacement of the left kidney and was showing varying shades of hyper- and hypodensities. Varying shades of hyper- and hypodensities were suggestive of haemorrhages of different ages which were periodic and of slow episodes Figures . The maiPatient was kept in intensive care unit under observation and blood was transfused to her to support haemodynamics and achieve a target of Hb% of 10 G/L. Unfortunately, the lesion could not be evaluated with MRI due to technical problem with the MRI scanner.Initial attempt of embolisation of the lesion failed and next day the haemoglobin level started dropping and therefore a decision was made to intervene. She was taken to operation theatre and partial nephrectomy with evacuation of haematoma was carried out through retroperitoneal approach. Preoperative findings showed a small cystic lesion on upper pole of left kidney which was later confirmed to be renal angiomyolipoma on histopathology. Postoperative period was uneventful and she was discharged back to the care of obstetrician. An uneventful delivery via elective caesarean section was later reported.This case highlights the silent behaviour of renal angiomyolipomas with slow episodic haemorrhage which can cause damage and displacement of adjacent structures and can actually prove lethal. This patient could have died secondary to haemorrhagic shock. In particular the retroperitoneal haemorrhage could have been easily missed and recurrent haemorrhage on top low haemoglobin could have proven fatal.Angiomyolipomas of kidneys are the most common benign renal tumours. Majority of them are sporadic (80%) and are typically identified in adults (mean age of presentation: 43 years), with a strong female predilection (F : M ratio of 4 : 1) . In thesRenal angiomyolipomas are often found incidentally when kidneys are scanned for some other reasons but may be present with symptoms like spontaneous retroperitoneal haematoma (like what happened in our case) or other symptoms and signs, for example, palpable abdominal mass, flank pain, recurrent urinary tract infections, haematuria, renal failure, or hypertension due to haemorrhage. The clinical state of shock due to severe haemorrhage from rupture of tumour mass is known as Wunderlich syndrome , 3.Angiomyolipomas are members of the perivascular epithelioid cells tumour group called PEComas and are composed of variable amounts of three components and hence they are named blood vessels (angio), plump spindle cells (myo), and adipose tissue (lipo). Angiomyolipomas are usually benign but they do have the risk of rupture with bleeding. They can also cause secondary damage or destruction of surrounding structures as they grow and pressurise adjacent tissues , 4. A vaThe cornerstone of diagnosis on all modalities is the demonstration of macroscopic fat, however, in the setting of haemorrhage, or when lesions happen to contain little fat, it may be difficult to diagnose with certainty .In ultrasound, these tumours tend to appear as hyperechoic lesions, located in the cortex and with posterior acoustic shadowing . In contIn CT scan, lesions can be seen involving the cortex and can demonstrate macroscopic fat clearly but if lesions are small, differentiation from a small cyst becomes difficult which was the case in our patient . You rarMRI is an excellent modality to evaluate fat containing lesions and two methods have been described. First is fat saturated technique which demonstrates loss of signals in fat containing areas of lesion and high signal intensities in nonfat containing portions making the differentiation quite easy. Second method employed is in and out of phase imaging which enhances the interface between fat and nonfat components by generating an India ink like artifact .Since angiomyolipomas are hypervascular lesions, DSA  perhaps can best describe the detailed features like micro- or macroaneurysms, dense arterial network, sharp margins, and absence of arterial-venous shunting of blood.It is essential to remember that rarely renal cell carcinomas (RCC) have macroscopic fat components and as such the presence of fat is strongly indicative of an angiomyolipoma, but not pathognomonic. Since macroscopic fat in RCC almost always occurs in the presence of ossification/calcification, the absence of ossification/calcification on imaging is in favour of angiomyolipoma.Angiomyolipomas if small usually require no therapy although follow-up is recommended to assess their growth.Larger angiomyolipomas or those that have been symptomatic can be electively embolised and/or resected with a partial nephrectomy. Lesions with retroperitoneal haemorrhage often require emergency embolisation as a life saving measure . In our


Excessive ethanol consumption is a leading preventable cause of death in the United States. Much of the harm from ethanol comes from those who engage in excessive or hazardous drinking. Rectal absorption of ethanol bypasses the first pass metabolic effect, allowing for a higher concentration of blood ethanol to occur for a given volume of solution and, consequently, greater potential for central nervous system depression. However, accidental death is extremely rare with rectal administration. This case report describes an individual with klismaphilia whose death resulted from acute ethanol intoxication by rectal absorption of a wine enema. Nearly one-third of US adults consume enough alcoholic beverages to cause or place them at risk of adverse consequences. According to the Centers for Disease Control and Prevention, nearly 5% of the US population drinks heavily, and 15% engages in risky, binge drinking patterns that could lead to ethanol problems . A tube Another group using ethanol enemas practice klismaphilia, receiving sexual arousal from introducing liquids into the rectum and colon via the anus. It is a paraphilia that often involves the use of enemas . The terA 52-year-old male was found unresponsive in his home by a coworker performing a welfare check due to unexplained work absence. He was last seen alive 66 hours prior to discovery. His medical history consisted only of hypertension, treated with metoprolol and valsartan. Emergency medical services were summoned, and on arrival the presence of a middle aged white male, lying on his left side in bed, was noted. The patient was in fixed rigor and livor mortis, was asystolic, and was pronounced dead. An enema bag was hanging from a coat rack next to the bed and contained a yellow colored fluid. A tube was connected to the enema bag and the other end inserted into the patient's rectum. Several empty boxes of white wine were also discovered during the scene investigation. The patient was wearing a condom and women's underwear, and numerous pornographic materials were found throughout the room. The patient was transported to a nearby hospital and an autopsy was performed that day.Pertinent autopsy findings included no external injury or indicia of IV drug abuse. Internal examination revealed pulmonary congestion and edema, fatty change of the liver, and 500 mL of yellow fluid in the colon, of the same color and consistency as that in the enema bag. The toxicology screen revealed a blood ethanol concentration of 350 mg/dL and a vitreous ethanol concentration of 410 mg/dL. Analysis of the liquid in the enema bag revealed the presence of alcohol and the liquid was concluded to be white wine. The cause of death was acute ethanol intoxication by ethanol enema.Rectal administration of ethanol has been described in eight previous case reports –13. In tOf the intentional cases, two were discovered to be in association with sexual fetishes , 11, theThe importance of this case also lies in reminding the clinician of the significant consequences inherent to ethanol intoxication and how the route of ethanol absorption plays a role in its clinical effects. Metabolism of ethanol begins as soon as it reaches the gastric mucosa. Rectal absorption of ethanol bypasses the first pass metabolic effect, allowing for a higher systemic concentration of blood ethanol to occur for a given volume of solution prior to hepatic degradation and, consequently, greater potential for central nervous system depression , 5. In fA significant proportion of ethanol related morbidity is associated with excessive episodic or “binge” drinking, especially in intolerant users. Ninety percent of ethanol consumed by underage drinkers is consumed while binge drinking, according to the Centers for Disease Control . EquallyDespite the plethora of alcoholic beverages available to the public, one common factor is the fact that they are all manufactured for oral consumption. Practitioners should be mindful that ethanol intoxication may occur through additional routes and that the degree of intoxication may be less predictable. We report what we believe to be the second case of lethal ethanol intoxication resulting from the rectal administration of a wine enema. Fluids with lower ethanol content may be less likely to induce colonic inflammation; however, rapid absorption of ethanol through the colonic mucosa can lead to significant CNS depression and possibly death.


A 61-year-old man presented to the Emergency Department with vomiting and progressively worsening abdominal pain. A computed tomography (CT) was performed. The diagnosis of patient was acute cholecystitis and the patient was referred to general surgery clinic. In addition CT scan showed bilateral ectopic kidneys with urinary bladder herniation  and 2. BPancake kidney is very rare type of congenital fusion anomaly of the kidney. It is described as a renal mass located in the pelvis which is formed by complete medial fusion of renal parenchyma without intervening septum . Each ki


We describe a case of renal carcinoid tumor with liver metastasis followed up postoperatively for 9 years.A 33-year-old man presented with left flank dull ache. On the abdominal computed tomography, a solid renal mass in the upper portion of the left kidney was detected. The patient had no other abnormal findings, such as suspected distant metastasis or lymph node metastasis. Radical nephrectomy was performed on 14/9/2005. Histological examination and immunohistochemical staining confirm primary renal carcinoid tumor. 9 years after radical nephrectomy, computed tomography of the abdomen demonstrated a 2 cm × 1.8 cm cyst mass in the right liver. Similar pathologic characteristics were found between the renal carcinoid tumor and liver tumor.We present a primary renal carcinoid tumor with liver metastasis 9 years after radical nephrectomy. With literature review, renal carcinoid tumors exhibit heterogenous behavior. Carcinoid tumors of the kidney are extremely uncommon. Primary carcinoid tumors of the kidney are low-grade, malignant tumors that arise from neuroendocrine cells. Since then, no more than 100 cases have been reported in the literature, and approximately 20 cases developed liver metastases at the time of initial diagnosis . Only twA 33-year-old man presented with left flank dull ache. On the abdominal computed tomography, a solid renal mass in the upper portion of the left kidney was identified.The mass was measured 2.8 cm × 2.8 cm × 2.5 cm in size, was well-defined. The patient had no other abnormal findings, such as suspected distant metastasis or lymph node metastasis. Radical nephrectomy was performed on 14/9/2005. On gross examination, the nephrectomy specimen measured 11.5 cm × 6.5 cm × 4.5 cm and the tumor was a solid, grayish-brown mass measured 3.5 cm × 2.5 cm × 2.2 cm in size. Histologic examination demonstrated trabecular and ribbonlike patterns with minimal fibrotic stroma. The cytoplasm was granular and eosinophilic with uniform round to oval nuclei with finely stippled chromatin and inconspicuous nucleoli. Mitoses were not found (0 per 10 high-power fields) on H&E stain. The final pathologic examination revealed a well-differentiated neuroendocrine (carcinoid) tumor confined to the kidney , neuroblastoma, paraganglioma, metanephric adenomas. In contrast to small cell carcinoma, renal carcinoid tumors lack a brisk mitotic rate, apoptotic activity, nuclear molding, necrosis and high proliferation indices. Furthermore, most small cell carcinomas lack the typical organized architecture that is distinctive for the carcinoid tumor . Both PNRadical nephrectomy is the gold standard treatment for renal carcinoid, partial nephrectomy is a good alternative regarding the location and diameter of the tumor. Other neo/adjuvant treatment, such as chemotherapy, sandostatin, targeted therapy, radiotherapy or local lymph node dissection, but no trial has shown its direct impact on survival.Neuroendocrine tumors (NET) commonly express serum somatostatin receptors as determined using somatostatin receptor scintigraphy with radiolabeled form of somatostatin analog octreotide. Octreotide not only plays an important role in decreasing the symptoms of hormonal excess but is considered a first-line antineoplastic systemic therapy for patients with a positive octreoscan . OctreotThe prognosis of renal carcinoid tumors is not predictable because of their rarity. The majority of cases did not present evidence of disease after treatment. According to 2010 WHO classification and grading system, 6 previously reported cases of renal carcinoid tumor should be classified as renal neuroendocrine tumor grade 2 (mitotic activity 2–20/10 high-power fields and/or 3–20 % Ki-67 index level) , 16. TheRenal carcinoid tumors exhibit heterogenous behavior. Although it seems that no good prognostic factors to predict the outcome of patients, Ki-67 index level and mitotic rate might be useful to aid pathologists and clinicians in trying to predict the outcome of a similar case.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.


Congenital hairy polyps are exceedingly rare congenital anomalies. We report a case of congenital hairy polyp arising from posterior tonsillar pillar which was excised with bipolar cautry. Brown Kelly reported first case of congenital hairy polyp, a rare developmental anomaly with less than 150 cases reported so far. It has a predilection for female gender with an incidence of 1 in 40000 live births. It was previously mislabeled as teratoma, hamartomas, and dermoid. Majority of the cases present soon after birth with a pedunculated polypoid mass often extruded from mouth. Few cases in adults have also been reported. It has been associated with cleft palate, agenesis of the uvula, external auricle, facial hemihypertrophy, and left carotid artery atresia. The lesion often located in nasopharynx; other sites are palate, tongue, tonsils, ear, esophagus, and trachea [1-7]. We herein report a case of congenital hairy polyp arising from posterior tonsillar pillar.A 1-day-old female neonate, born at term to a primigravida, presented with a pedunculated skin covered finger like lesion extruding from within oral cavity. The lesion was associated with feeding difficulty however there was no respiratory distress present. General physical examination was unremarkable. Oral examination divulged a finger like projection appearing from posterior pharynx . There was no cleft palate or other anomalies present. The patient was anesthetized by nasotracheal intubation as existence of intra-oral lesion constrained oral intubation. After employing mouth gag, the lesion was noted emerging from posterior tonsillar pillar. The lesion was excised with bipolar cautry. Bleeding was arrested with two stitches of absorbable suture. Patient had uneventful recovery and discharged on the next morning with full oral feeding established. Histopathology detected keratinizing stratified squamous epithelium lining the lesion with fibrous connective tissue, fatty tissue, and skeletal muscle fibers in deeper layers. Many sebaceous glands and hair follicles were embedded in the tissue.The presentation of congenital hairy polyp is variable and characterized by respiratory difficulties owing to blockage of trachea by pedunculated mass which occasionally causes a ball valve like effect leading to cyanosis and acute airway emergency; feeding problems often occurs in case when it impinges the esophagus leading to drooling of saliva, vomiting, and inability to feed; nasal blockade; and a visible mass intra-oral or extruded from mouth. Few reports describe polyhydramnios; postnatal complications are failure to thrive, acute airway blockade, autoamputation of the hairy polyp, and hemorrhage . MRI and CT scan are good diagnostic tools however final diagnosis is made on documentation of derivatives of ectoderm and mesoderm on histopathology . Differential diagnoses are teratoma, dermoid, and epignathus. In our case, the child born without polyhydramnios and respiratory difficulties; however, there was difficulty with feeding the baby. At presentation, our preoperative diagnosis was oral teratoma; histology and literature search acquainted us of this entity.Histopathologically, they are composed of skin with appendages  along with fibro-fatty tissue and skeletal muscles in deeper layers. No case of malignant transformation is reported to date. Treatment is surgical excision with cautry or suture ligation. Nasotracheal intubation should be preferred in case of intraoral lesion causing difficult oral intubation as we did in our case. Immediate postoperative concern is postoperative bleeding or airway problems [1-5]. A case of recurrent hairy polyp due to incomplete excision has been reported over a period of 6 years depicting a slow growing nature of this entity [7]. Source of Support: NilConflict of Interest: None


The aim of this report was to characterize osteonecrosis of the jaws (ONJ) in previously irradiated fields in dogs that underwent radiotherapy (RT) for oral tumors. Osteoradionecrosis of the jaw (ORNJ) was further defined as osteonecrosis in a previously irradiated field in the absence of a tumor. Thirteen dogs clinically diagnosed with 15 ONJ lesions were included in this retrospective case series. Medical records were reviewed for: breed, sex, weight, and age of the patient, tumor type, location in the oral cavity and size, location of the ONJ, time from RT to ONJ onset, known duration of the ONJ, and tumor presence. Where available, histological assessment of tissues obtained from the primary tumor, and tissues obtained from the ONJ lesion, was performed, and computed tomographic (CT) images and dental radiographs were reviewed. RT and other treatment details were also reviewed. Twelve dogs developed ONJ in the area of the previously irradiated tumor or the jaw closest to the irradiated mucosal tumor. Recurrence of neoplasia was evident at the time of ONJ diagnosis in five dogs. Time from RT start to ONJ onset varied from 2 to 44 months. In three cases, ORNJ developed after dental extractions in the irradiated field. Dental radiographs mostly revealed a moth-eaten pattern of bone loss, CT mostly revealed osteolysis, and histopathology was consistent with osteonecrosis. To conclude, development of ONJ/ORNJ following RT is a rare, but potentially fatal complication. Patients undergoing RT may benefit from a comprehensive oral and dental examination and treatment prior to RT. Radiotherapy (RT) is an important treatment modality for oral tumors in humans  and dogsThe diagnosis of ORNJ in humans is based primarily on clinical signs; usually ulceration of the mucosa with exposure of necrotic bone is noted. However, additional definitions and classifications have been employed, mainly depending on the persistence or recurrence of a primary tumor, radiologic signs, duration of bone exposure, and extent of the disease , 11–13. The aim of this retrospective study was to characterize osteonecrosis of the jaws (ONJ) in previously irradiated fields in a series of dogs that underwent RT for oral tumors as this entity is poorly defined in the veterinary literature. ORN of the jaw (ORNJ) was specifically defined for the purpose of this study as osteonecrosis in a previously irradiated field in the absence of persistent or recurrent tumor.Medical records from the small animal clinic of the William R. Pritchard Veterinary Medical Teaching Hospital of the University of California Davis, were searched for dogs that had diagnostic and/or treatment procedures for clinically diagnosed ONJ based upon clinical signs of ulceration of the mucous membrane with exposure of necrotic bone, regardless of tumor presence or recurrence. Ten cases met the inclusion criteria and were included in this study. Two additional cases were evaluated at Aggie Animal Dental Center, Mill Valley, CA, USA, and one additional case at the Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, resulting in a total of 13 cases included in this study.This investigation did not seek to identify the incidence of ONJ/ORNJ lesions in previously irradiated fields. The cases series reported here represent patients with ONJ/ORNJ who were seen at three different veterinary dentistry and oral surgery referral hospitals, regardless of where in the USA the cases were treated with RT.T)  , locatioT) . Known dOver a 25-year period 1989–2014), 13 dogs were clinically diagnosed with 15 ONJ lesions in previously irradiated fields , squamous cell carcinoma , and melanoma , and for an undifferentiated sarcoma (N = 1). Slides of the primary neoplastic lesions were available for review in only three cases, with all other tumors diagnosed by outside commercial laboratories. In the three cases with slides available, the neoplasia diagnosis was confirmed histologically by a board-certified pathologist (BGM). Location and size of the oral tumors are presented in Table The dogs were treated for each of CAA  were available for six of the dogs  and revealed bony invasion in three of the T3 cases. Data on the size of the tumors were not available for two dogs.For radiation treatments, patients were treated using a Cobalt-60 (Co-60 unit) , 4 MV linear accelerator , or Clinac 2100 . The source used for treatment of the Case 9 is unknown. Patients were treated with 32–54 Gy in 3–8 Gy fractions depending on the clinical radiation plan. The total number of fractions delivered ranged from 3 to 17 fractions. A total of four patients were treated with a palliative plan (4 × 8 Gy on a once- or twice-weekly basis) for gross CAA, MM, and SCC. A total of six patients were treated with a more coarsely fractionated definitive protocol (7 × 6 Gy once weekly or 12 × 4 Gy Monday–Wednesday–Friday) for CAA and MM. Three cases were treated with more typical fractionated definitive protocols (16 × 3 Gy or 18 × 3 Gy) for SCC and undifferentiated sarcoma. One patient received both a coarsely fractionated definitive protocol (12 × 4 Gy), followed by a palliative protocol 7 months later  prior to RT. The stage of periodontal disease was not established in the majority of cases before RT, but five dogs received full periodontal treatment up to 3 months prior to initiation of RT.Eleven dogs were treated with an antibiotic during or immediately after RT, but the timing and antibiotic selected varied. Only one dog received regular chlorhexidine gluconate oral rinses, starting in the middle of the RT when mucositis developed. In two dogs, a tea rinse was started at the time of mucositis development.Three dogs received intratumoral chemotherapy (substance unknown), and five additional dogs received systemic chemotherapy, or a small molecule inhibitor , or melanoma vaccine  during RT or shortly after the RT was completed.Seven dogs were treated with prednisone, with the treatment initiated during RT in six dogs and at the beginning of RT in one dog. The use of analgesics varied, but typically included an opioid and a non-steroidal anti-inflammatory drug in cases that were not treated with a steroid.Clinically, ONJ lesions were characterized as bone and soft tissue necrosis of variable extent  Figure , regardlAs presented in Table Time from RT to ONJ onset varied from 2 to 44 months , and for ORNJ specifically 3 to 44 months  , and for ORNJ specifically from less than 1 to 16 months  . With the exception of one dog with bony changes in the area of the clinical lesion limited to horizontal bone loss associated with periodontitis, dental radiographs consistently revealed a moth-eaten pattern of bone loss . In six de novo tumor development.Histopathology was performed in eight dogs with clinically diagnosed ONJ/ORNJ lesions, but specimens were only available for review in six dogs, including a dog where two biopsies of a progressive ONJ lesion were obtained 2 months apart. Bone and soft tissues were available for evaluation in three dogs, and only soft tissue was available for the other lesions. Soft tissue changes in all but one dog included pleocellular inflammation with mucosal hyperplasia and/or dysplasia and diffuse subepithelial fibrosis with multifocal vasculopathy and thrombosis. In one dog, the changes were most consistent with suppurative inflammation associated with an extensive area of necrotic tissue, and likely vascular thrombosis. Changes in the bone were described as locally extensive osteonecrosis with bone resorption and osteoporosis Figure . Two of In three dogs (including one dog with two ORNJ sites), the lesions healed after surgical intervention . Two additional dogs received several débridement procedures to remove all grossly non-vital tissue to achieve stable or slowly progressive disease, or débridement was combined with hyperthermia. One patient was managed medically for 6 months prior to euthanasia. In one dog, progressive disease required another débridement procedure, but the dog was euthanized due to perioperative complications, and in another two dogs euthanasia was suggested due to the extent of the disease and poor quality of life. Four dogs were lost to follow-up.The present study describes RT and associated treatments employed in a series of 13 dogs treated for odontogenic or non-odontogenic oral tumors. It further focuses on the characteristics of the ONJ/ORNJ lesions that later developed, especially the site of ONJ/ORNJ in relation to the primary tumor, time to onset, and duration of the necrotic lesion, imaging, and histopathology findings.Radiotherapy alone can provide good tumor control in dogs depending on tumor size and type –4, and lUpon presentation, the dogs in the present study had lesions in the oral cavity that were clinically described as soft tissue necrosis of variable extent with underlying exposed necrotic bone, warranting a clinical diagnosis of ONJ or, specifically, ORNJ if no tumor was noted . AlthougAll but one of the ONJ/ORNJ lesions were found on the site of tumor irradiation or in the jaw closest to the irradiated tumor. Most human patients also develop ORNJ ipsilateral to the tumor inside the radiation field. However, bilateral involvement or involvement of the contralateral jaw may occur , 22, as The time to ORNJ onset varied greatly among dogs (3–44 months after start of RT), which is similar 1–69 months) to observations for mandibular ORN in humans (9 months None of the dogs in this study had undergone major surgery before RT. Importantly, surgery performed immediately before RT may increase the risk of ORN development in humans . In at lPeriodontal disease is a very common dental disease in middle-aged to older dogs ; howeverThe duration of bone exposure  may be vImaging, including dental radiography and CT, can be very useful to further investigate ORNJ lesions . Dental Due to the retrospective nature of the study, certain limitations exist. First, histopathological confirmation of osteonecrosis was not available for all dogs. However, of the seven dogs lacking histopathology review of the clinically diagnosed ONJ lesion, and with an additional three dogs lacking bone in the samples, imaging was available for six. In these cases, the imaging confirmed bony involvement in five cases, supporting the clinical diagnosis of osteonecrosis . In one The clinical consequences of ORNJ are significant, and treatment may not always be possible due to the extent and severity of the lesion. Although ORNJ appears to be a rare complication, clients should be advised of possible development of ORNJ following RT. In cases that are surgically amenable, especially smaller tumors, surgery should be considered a first line treatment, as complete removal of oral tumors can result in cure  with minAll authors substantially contributed to the conception of the work, acquisition, analysis, and interpretation of the data. Agreement was reached by all authors for all aspects of the work in ensuring that questions related to the accuracy and integrity of all parts of the work are appropriately investigated and resolved. Ana Nemec drafted the manuscript, which was critically revised for important intellectual content and the final version approved to be published by all authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.