Bronchial leiomyoma is extremely rare. To date less than 60 cases have been reported in the world literature. The presented case here is a 30 year old woman who had been treated for bronchial asthma for several years. Her chest radiograph showed bulluos emphysematous changes in the right lung and computer tomography scan found the tumor in the right main bronchus near carina. Diagnosis was made by histological and immunohistochemical examination of the specimens obtained during bronchoscopy. The patient was treated by bonchoscopic resection of the 3 centimetre firm tumor and its removal through a tracheostomy incision. Primary pulmonary leiomyomas are extremely uncommon both in adults and children, constituting approximately 2% of benign lung tumors.1134Herein an additional case with endobronchial leiomyoma is reported and a simple surgical method for removing large tracheal and bronchial lesions is explained. The literature is also reviewed.A 30 year old non- smoker woman was admitted to our centre with a 10 year history of asthma like symptoms which did not respond to bronchodilators anymore.Her chest radiograph showed bullous lesions, widespread infiltrates and volume reduction in the right lung. Computed tomography of the thorax demonstrated a mass lesion in the right main bronchus extending to the trachea as well as unilateral bullous emphysema with relatively thick septa, pleural thickness and reduced volume of the right hemi thorax .Fiberoptic bronchoscopy detected a pink large mass completely obstructing the lumen of right main bronchus and extending to a point close to carina . Due to Histopathologic examination revealed that immediately beneath the intact pseudostratified ciliated columnar epithelium with some focal squamous metaplesia, the neoplasm composed of bundles and whorls of spindle shaped cells with monomorphous fusiform nuclei and acidophilic cytoplasms without cytonuclear atypia, mitotic figures or necrosis . Also, sThe patient was treated by endoscopic resection. However, the tumor was firm and large (3 centimeters in diameter) to remove through the rigid broncoscope despite great effort. In order to avoid tracheotomy and resection of a large portion of lung, a small cut was made in the neck area and the trachea was incised horizontally (tracheostomy). With cooperation of the anesthetics the tumor was brought to the incised region and removed by surgical forceps . Then thPrimary leiomyoma is one of the most rarely encountered benign tumors of lung, accounting for less than 2% of all cases.152779Symptoms depend on the location of the tumor, its size and the secondary changes of the lung distal to it. Patients with bronchial leiomyomas can have respiratory symptoms such as coughing, wheezing, dyspnea, chest pain or fever, due to partial or complete obstruction of the affected bronchus and superimposing infection resulting from atelectasis or bronchiectasis distal to obstruction).418The chest radiographic findings of endo- bronchial leiomyomas range from normal in patients with small tumor nodule to a solitary round mass or pneumonic infiltration, mediastinal shift, and collapse of lung to unilateral emphysema or hyperlucency according to obstructive sequel of bronchus due to the tumor.9101414The exact diagnosis of endobronchial leiomyoma can be made by broncoscopy in most cases because it can provide biopsy specimen for histological examination besides visualizing and localizing of the tumor.4Bronchial leiomyomas are thought to derive from smooth muscle layer of bronchi, bronchiols, or blood vessels.Pulmonary nodules with features of small muscle tumors may be in fact metastasis from extra pulmonary leiomyoma/leiomyosarcoma. Uterine is the major primary site in such cases in females and sometimes the diagnosis of secondary pulmonary leiomyomatosis is made several years after hysterectomy.2072021Differential diagnosis includes other spindle cell tumors and tumor lesions such as bronchial carcinoid of the large spindle cell variant, pleural fibrous mesothelioma, metastatic malignant melanoma, metastatic synovial sarcoma and occasionally plasma cell granuloma.8Leiomyomas of the respiratory system are essentially treated with surgical or bronchoscopic resection.153893232428Development of smooth muscle neoplasm have reported in different conditions with immune deficiency, including acquired immunodeficiency syndrome (AIDS), particularly in children,11303533In summary, endobronchial leiomyomas are among the rarest of benign tumors of the respiratory tract. These neoplasms may mimic asthma or other obstructive diseases of the lung and should be kept in mind as a rare cause of asthma like symptoms especially in an adult female who is no longer responsive to bronchodilators. Histological examination and immunohistichemistry provide the exact diagnosis which can always exclude the possibility of a metastatic leiomyoma/leiomyosarcoma. Treatment is as conservative as possible and includes bronchial resection, segmentectomy, lobectomy or pnemonectomy.


Chronic expanding heamatomas may present as masses mimicking chest wall tumors. We report the case of a patient who was presented with a giant posterior extrathoracic chest wall tumor. The mass was proven to be a chronic heamatoma possibly developed after a blunt thoracic injury which took place 2 years before presentation and was growing thereafter. Clinicians should have high suspicion of rare entities which mimic tumors and consider any information reported by the patient's history in their diagnostic process. Uncommon entities are rarely presented as lesions or masses, mimicking thoracic or pleural tumors, leading clinicians to establish wrong diagnosis -3.Hemorrhagic manifestations complicate falls, which occur more frequently in older patients, who receive anticoagulant therapy for different pathologies. The commonest presentation of such hemorrhagic manifestations is cuts and bruising, with more serious complications, such as intracranial heamatomas or bleeding because of fractures being also not uncommon among such patients . ThoraciWe herein report a case of a male patient who was presented with a giant posterior chest wall tumor, which was eventually proven to be a growing chronic heamatoma due to a blunt thoracic injury 2 years before presentation.A 76 year old male was presented to our department with a huge mass 20 × 15 cm) in his left posterior thoracic cage, extending between the medial edge of the scapula to the spine. The patient reported that the mass appeared 2 years ago and that it was slowly growing bigger ever since. From his past medical history, he had a myocardial infarction treated with angioplasty for which he was on a regime of acetyl-salicylic acid, with a dosage of 325 mg once per day. He also reported an ipsilateral chest wall injury after a fall 2 years ago for which he did not seek medical help. On examination the mass's texture was solid and fixed on the chest wall, inflicting pain to the patient who additionally complained of cosmetic discomfort. The patient was subjected to a thoracic computed tomography which revealed a huge extrathoracic tumor extending  from the left side of the spine  to the tip of the scapula and (superiorly) below the scapula to the anterolateral thoracic wall (inferiorly). The mass did not seem to enter the thoracic cage or to invade the ribs and it had a tissue density (Housfield Units 40-50) of fat and muscle (Figure 5 cm in hIntra-operatively, the mass Figure  was dissThe patient's recovery was uneventful. The drain was removed the day after the operation and the patient was discharged two days after the operation.The mass was proven to be a heamatoma, as per the histopathology report with the mass being a calcified fibrous capsule without neoplasia.Different pathologies of the thorax, rarely, may be presented as chest wall tumors. Chest wall heamatomas should be considered in elder patients on anticoagulation therapy sustaining trauma.Heamatomas may rarely be organized to mimic soft tissue tumors -3. This Almost all cases reported in the literature involve heamatomas developing within the pleural cavity ,3. In ouChronic expanding heamatomas usually develop over a clinical background, such as tuberculosis, with patients forming an appearance of a heamatoma, many years after the tuberculus manifestation ,5,6. In Patients receiving anticoagulation treatment are theoretically under an increased danger of bleeding and therefore developing heamatomas . The mosThe type of anticoagulation treatment is reported to be important for the hemorrhagic phenomena, with warfarin being the drug inflicting the most severe hemorrhagic complications ,9. AlthoIn conclusion, heamatomas may mimic masses, a fact that clinicians should keep in mind, and therefore should consider all history and examination data in order to establish a diagnosis before proceeding to surgery.The patient has given written consent for his clinical and imaging details to be published in this Case Report. The signed consent is at the disposal of the Editor for inspection.The authors declare that they have no competing interests.VKK, AGR, KS and IB operated the patient. VKK wrote the case report. IB edited the text. All authors read and approved the revised manuscript.


Mutations of the proto-oncogene BRAF have been described in many cancers. Mutated BRAF causes overactive downstream signaling via MEK and ERK leading to excessive cell proliferation and survival. Their identification is of real interest because specific inhibitors have been developed.We report the case of a patient with an aggressive cystadenocarcinoma of the parotid with synchronous metastases. Cisplatine/5FU chemotherapy associated with palliative radiation therapy was used first without any efficency nor clinical improvement. A molecular analysis revealed a BRAF mutation. A compassionate treatment with a BRAF inhibitor showed very good results from the first month. The patient reported real improvement in clinical condition and pain. From an imaging point of view, computed tomographies reported a complete response on mediastinal lymph nodes and regeneration on bone metastases.This first report suggests BRAF could be a potent oncogenic driver in salivary gland carcinoma. It deserves a multicenter academic prospective trial to provide proof of efficiency with BRAF inhibitors in theses tumors. Malignant tumours of the parotid gland are unusual. They represent fewer than 5% of tumours in the head and neck region Spiro . SalivarMr B. is a 69 year-old man with no significant past medical history. He presented to our Institute with a left pre-tragus mass that appeared a few weeks ago. His general practitioner ordered a Computed Tomography (CT) scan then a Magnetic Resonance Imaging (MRI) that revealed a bifocal parotid mass. The first nodule extended into the superficial lobe of the parotid and the second through the angle of the mandible with a marked osteolysis. A nodule was also seen at the upper front of the maxillary left sinus without continuity with previous one. Clinically no mucosal lesion was identified. The fine needle aspiration biopsy of the parotid lesion exhibited glandular epithelial cells suspicious of malignancy. The biopsy then demonstrated a papillary adenocarcinoma suggesting a cystadenocarcinoma. Immunohistochemical assessment of HER2 showed grade 2+ overexpression but no HER2 gene amplification by FISH (fluorescence in-situ hybridization). Positron Emission Tomography (PET) staging showed distant metastases. Multiple bone hyperfixations were localized in C3 right costal arch, C6 with posterior wall destruction, L4 pedunculate, left femur and pelvis.2 and 5-fluorouracil 1000 mg/m2/d (J1-J4) were delivered with good tolerance. The CT scan evaluation revealed a stabilization of the mass developed at the expense of the superficial lobe of the parotid but a marked progression of bone localizations of the malar mass (33 mm versus 14 mm) and of mandible osteolysis with pathological fracture. Distant bone metastases progressed too on the MRI with an epidural extension of C6 damage and appearance of T8 and L5 lesions.A chemotherapy was initiated on July 2011. Three cycles of cisplatin 100 mg/mIn October 2011, palliative radiation therapy was administered on the primary parotid mass, the adjacent mandible lesion and on symptomatic distant bone localizations (C6 and L4). The dose delivered was 30 Gy in 10 fractions.The April 2012 CT scan evaluation reported a discrete regression of the irradiated parotid mass but a further progression of the malar mass measured at 53 mm. Moreover, enlarged mediastinal lymph nodes appeared in 2R, 4R and 7 as well as multiple osseous sites throughout the pelvis and spine.Given the aggressiveness and resistance of this disease to radio-chemotherapy, an additional molecular analysis was requested to attempt to identify mutations on EGFR, KRAS and BRAF genes. No mutations were found except for BRAF. A polymerase chain reaction followed by an allele specific oligonucleotide revealed a V600E mutation of BRAF.A compassionate treatment with a BRAF inhibitor (Vemurafenib) was started at a dose of 240 mg bid for 2 months after approval of internal ethic committee. The patient reported a great improvement in clinical condition from the first month. His fatigue declined allowing him to enjoy activities such as gardening. His vision improved with ptosis regression. Clinical examination found a clear regression of the malar mass. The CT scan obtained after 2 months of treatment confirmed the good clinical impression. The malar mass regressed by 42% (60 × 47 × 53 mm versus 46 × 42 × 45 mm) Figure A,B. MediThe RAF/MEK/ERK signal transduction cascade is an important mediator of a number of cellular outcomes including growth, proliferation and survival. The BRAF gene is one of the human isoforms of RAF activated by oncogenic RAS and leading to cooperative effects in cells responding to growth factor signals.Mutations of BRAF have been described in about 15% of all human cancers (Davies et al. Specific inhibitors of BRAF have been developped and are now currently used in advanced melanoma with any V600 BRAF mutation. Chapman et al. reported the results of a phase 3 randomized clinical trial comparing vemurafenib with dacarbazine in 675 patients with metastatic melanoma with the BRAF V600E mutation. At 6 months, overall survival was 84% in the vemurafenib group and 64% in the dacarbazine group. Response rates were 48% for vemurafenib and 5% for dacarbazine (Chapman et al. For salivary glands carcinoma, immunohistochemical procedures and molecular biological studies become more and more important to classify this wide variety of tumours. Overexpression of transmembrane receptors of type tyrosine kinase have been reported (HER2/neu (Cornolti et al. Written informed consent was obtained from the patient for the publication of this report and any accompanying images.


Giant leiomyosarcoma of scrotum is a rare tumour. A case of scrotum leiomyosarcoma is presented in a 67 year old patient with scrotal filariasis which was managed successfully with total scrotectomy with bilateral orchidectomy, degloved penis reconstructed with rotation advancement supra pubic fasciocutaneous flap. We made a literature search proving the rarity of this lesion type. Only 36 cases have been described and the first case in a filarial scrotum Leiomyosarcoma of the scrotum is a rare tumour. Scrotal leiomyosarcomas (LMS) are slow growing tumours that present as firm rubbery nontender irregular mass . They maA 67 years old patient of high socioeconomic status reported to the outpatient clinic with complain of rapidly ulcerated mass in the scrotum. He had history of filariasis and scrotal swelling of more than 40 years duration. His Eastern Cooperative Oncology Group (ECOG) performance Status was 3, capable of only limited self care, confined to bed or chair more than 50% of waking hours, due to large painful swelling of the scrotum .On local examination, huge filarial scrotum with skin changes and buried penis, 30 × 30 cm ulcerated firm diffuse mass of the scrotal skin encroaching over the root of penile skin figures , 2. The Post operative histopathology revealed 28 × 25 × 15 cm fleshy tumour with an over lying ulcer. Testes were not involved by the tumour. All resected margins were negative. Microscopically a malignant mesenchymal neoplasm was identified with smooth muscle differentiated intermingling bundle of cells with eosinophilic abundant mitotic figure 15 mitosis per 10 high power. Tumour was positive for actin, vimentin and desmin and negative for S 100. Based on histopathology findings and Immunohistochemistry markers diagnosis of scrotal leiomyosarcoma was made.Patient received postoperative external beam radiation 60G/30fractions. He is on regular follow up for past 19 months and is disease free.Soft tissue Sarcomas are 1% of all malignancies. Leiomyosarcomas constitutes 10 to 20% of soft tissue sarcomas. They arise most often from uterus, gastrointestinal tract and retroperitoneal region . Among gScrotal elephantiasis is caused by acquired filarial infestation with Wuchereria bancrofti. Occasionally it has been attributed to radiotherapy, neoplasm and lymphadenectomy. It is emotionally distressing and physically disabling. With problems of hygiene, urinary incontinence, unesthetic appearance, loss of libido and immobility are severely debilitating symptom .Filariasis in advance stages may evolve into scrotal lymphedema and scrotal elephantiasis. In 1948 Stewart and Treves first described the association of chronic lymphedema with lymphangiosarcoma . LymphanThe paucity of literature in this area often makes treatment decisions difficult. Simple excision proved to be inadequate treatment for sarcomas in the paratesticular region. In the Princess Margaret Hospital report, wide excision revealed microscopic residual disease in 27% of completely excised cases . The pri• Scrotal leiomyosarcoma is a rare clinical entity and scrotal leiomyosarcoma in a filarial lymphadenomatous scrotum; this is the first case to be reported.• Aggressive surgical resection including tumour and diseased filarial skin is recommended.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MT, SVSD, NKS, AK and MG prepared the manuscript and reviewd the literature. All authors read and approved the final manuscript.


Metastatic seeding along image-guided brain biopsy tracts is an uncommon phenomenon. We report a case of meningeal glioblastoma (GBM) metastasis at the site of a previous image-guided biopsy site, which developed 14 months after completing concurrent chemo-radiotherapy. This is the first reported case of successful treatment of an intracranial GBM metastasis with resection followed by radiotherapy. Image-guided brain biopsy is now commonly utilised for diagnosis of brain neoplasms. Metastatic seeding along the biopsy tract is a rare but recognised complication in a range of different pathologies and more recently in glioblastoma (GBM). We present the first reported case of successful resection and radiotherapy treatment of a meningeal GBM metastasis.A 52-year-old right-handed gentleman was presented in April 2008 with a mild left hemiparesis and slurred speech. An MRI of the brain showed a 25 × 24 mm mass lesion in the deep right hemisphere area adjacent to the thalamus, which was well defined and of low-signal intensity on T1-weighted images and high-signal intensity on T2 with some low-signal septations within it. There was significant perilesional oedema, and following gadolinium there was ring enhancement and some enhancement within the septations. Appearances were therefore in keeping with a high-grade glioma .2 and escalating to 200 mg/m2 from cycle 2. An interval MRI scan in November 2008 showed slight but definite partial response but significant residual tumour volume, so he continued to a total of six cycles of Temozolamide which completed in February 2009. This was then followed by a period of observation, and a further MRI in May 2009 showed a marked reduction in the size of the tumour, with >50% reduction in tumour volume and only a very mild degree of peripheral enhancement.The patient went on to have a CT-guided biopsy , and the histology confirmed GBM multiforme, WHO grade 4. He therefore went on to be treated with radical radiotherapy to a dose of 60 Gy in 30# over six weeks with concurrent Temozolamide chemotherapy. An MRI scan following this showed stable disease, so he proceeded with adjuvant Temozolamide chemotherapy starting at 150 mg/mThe patient remained well until September 2009, when he was presented with a visual aura, and an urgent MRI scan showed that the primary tumour continued to decrease in size, but that there was an additional 27-mm enhancing extra axial lesion in the right frontal lobe, appearing to arise from the dura just adjacent to the burr hole site from the previous biopsy . This waOn reviewing the patients’ previous radiotherapy plans, it was noted that the new nodule was 7 mm from the previous radiotherapy field, and further treatment with radiotherapy would therefore require a significant overlap in radiotherapy fields, although no critical structures such as the optic chiasm were close to this region of overlap. Following discussion with other centres regionally and nationally, a consensus was reached to retreat with radiotherapy, and the patient was consented for a 10% risk of brain necrosis in the region of overlap. He had further radiotherapy to a dose of 30 Gy in 6# over two weeks (three times a week) in December 2009, and a follow-up MRI scan in May 2010 showed no residual enhancement in the original tumour, and the meningeal deposit was no longer visible.The patient continued to remain well until January 2011, when a routine MRI scan showed tumour recurrence and he commenced palliative chemotherapy with PCV; unfortunately despite an initial good response to PCV he began to deteriorate clinically, and chemotherapy was stopped in July 2011.Metastases of GBM multiforme are uncommon and when they do occur, they are often related to surgical procedures such as brain biopsy and ventriculo-peritoneal shunt insertion. Frameless stereotactic biopsy with image guidance using neuro-navigation systems are now commonly used for biopsy of brain tumours with high-diagnostic yield and low morbidity. Possible complications described include haemorrhage and infection or neurological deficit. Cases have been reported of seeding along biopsy sites in brain neoplasms including: brain metastases, craniopharyngioma, and anaplastic astrocytoma. There are three previously reported cases –3 of intThe first case reported  was of GOur case is the first reported of treatment of an intracranial GBM metastasis with further radiotherapy after resection. Re-treatment of our patient with radiotherapy did involve an area of overlap with the original radiotherapy field but was successfully completed and the patient had 13 months before further disease progression. A review of re-irradiation tolerance of the brain with respect to treatment of gliomas  found thThere have been an increasing number of reports of patients with both intracranial and distant metastases in GBM multiforme in recent years. Although this is still a very uncommon occurrence, it may be that improvements in survival since the Stupp trial  will als


A 4-year-old male child presented to our outpatient department with large swelling in the parotid region. Routine investigations were all within normal limits, and evaluation of complete blood count was normal except for anaemia. Excisional biopsy as a therapeutic diagnosis was done. Microscopic examination showed monomorphic population of discohesive, hyperchromatic small round cells having high N : C ratio, coarse chromatin, conspicuous nucleoli, and sometimes angulated nuclei lying in sheets. Immunohistochemistry was done to rule out possible differential diagnosis. Fine needle aspiration from the swelling showed predominant population of blast cells. Myeloperoxidase and PBO were strongly positive, and diagnosis of granulocytic sarcoma was confirmed. Granulocytic sarcoma (GS) also earlier referred to as chloroma or myeloblastoma is an extra medullary tumour composed of granulocytic precursor cells. The term granulocytic sarcoma was coined by Rappaport in 1966 [in association with acute myeloid leukaemia,in nonleukemic patients with normal peripheral blood and bone marrow findings, but who in due course of time develop acute myeloid leukaemia,in myelodysplastic syndrome (MDS) with leukemic transformation,in association with myeloproliferative disorders, where it heralds the onset of blastic transformation.Granulocytic sarcoma occurs in various settings  as folloA four-year-old febrile healthy male child presented with a lump in the right parotid region. On examination, the swelling was about 6 × 5 cm in size, nontender, irregular, and firm to hard in consistency with obvious proptosis. Swelling extended superiorly up to zygomatic region, inferiorly up to mandible, anteriorly up to maxillary region, and posteriorly up to retromandibular space. Radiological examination showed a large solid ill-defined lesion along the ramus of the mandible extending into masseteric space and until skull base of the right side. Involvement of nasopharynx, posterior ethmoid, and sphenoid sinus with sinus wall remodelling was suggestive of neoplastic mass . ClinicaGranulocytic sarcoma (GS) is characterized by localized infiltration of immature granulocytes in an extramedullary site or soft tissue, and it was first described in the early 1800s as a tumour on the retroorbital site with a green-colour appearance, which caused proptosis . The mos The GS is a rare neoplasm in this early age group especially in the head and neck region, and it is frequently confused with other tumours. The diagnosis of the GS is always challenging for both the physician and the pathologist, mainly when it is not associated with the myeloid leukaemia, when it is necessary to differentiate it from other malignant tumours, such as the lymphomas. The careful morphological analysis and the staining by immunohistochemistry are vital for establishing the diagnosis. Even though this lesion is rarely found in the oral cavity, its occurrence may never be ignored.


Streptococcus constellatus. Patient had an uneventful recovery. Moreover, a brief literature review on pyometra is presented.Spontaneous perforation of pyometra resulting in generalized diffuse peritonitis is extremely uncommon. Herein, we report the case of a 63-year-old woman who presented to emergency department with a 2-day history of severe diffuse abdominal pain, high-grade fever, nausea, and vomiting. Acute abdomen series was done, and upright plain chest radiograph showed free air under diaphragm. A noncontrast-enhanced computed tomography scan showed a significantly distended fluid-filled uterus measuring 10 × 7.8 × 10 cm, in addition to a single focus of perforation involving the uterine fundus and associated with presence of free air within the nondependant area. No evidence of ascites or pelvi-abdominal lymphadenopathy was identified. A preoperative diagnosis of generalized peritonitis secondary to spontaneous perforation of uterus was established. Subsequently, patient underwent urgent exploratory laparotomy which revealed pus-filled uterus with perforated fundus. Diagnosis of generalized peritonitis secondary to spontaneous perforation of pyometra was established. Consequently, patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, as well as thorough drainage and irrigation of pelvi-abdominal cavity. Postoperatively, patient was admitted to intensive care unit. Histopathological examination of uterus was negative for malignancy, and surgical culture grew  Pyometra is defined as buildup of pus  in the uterine cavity . Its repA 63-year-old woman presented to emergency department with a 2-day history of severe diffuse abdominal pain, high-grade fever, nausea, and vomiting. Patient was sexually active and denied any recent history of abnormal bleeding, spotting episodes, or vaginal discharges. Past medical history and surgical history were unremarkable. Systemic review was remarkable for decreased appetite and fatigue.9/L (high neutrophilia), lactic acid of 2.1 mmol/L, and normal hepatic, coagulation, bone, renal, and electrolyte profiles. On physical examination, she looked ill and in pain. Her vitals were as follows: temperature of 38.7°C, blood pressure of 104/71 mmHg, heart rate (pulse) of 116 beats/minute, respiratory rate of 23 breaths/minute, and oxygen saturation of 97% in room air. Abdomen was slightly distended with positive guarding and positive rebound tenderness. Per vaginal examination showed no cervical/vaginal anomalies, vaginal discharge, or detectable pelvic mass. Initial laboratory results showed a white blood count (WBC) of 27 × 10Streptococcus constellatus organism which was sensitive to penicillin and ampicillin. Acute abdomen series was done, and upright plain chest radiograph (X-ray) showed free air (gas) under diaphragm . A noncoPatient had an uneventful recovery afterwards and was discharged on the 15th postoperative day without complications.Pyometra is defined as buildup of pus  in the uterine cavity . It is aPyometra primarily results from obstruction of cervical canal which in turn interferes with its natural drainage and increases susceptibility to infections leading to accumulation of pus and bloody material . PossiblPotential predisposing risk factors for pyometra are numerous and include coexistence of comorbid chronic illnesses , restricted mobility, bowel incontinence, malnutrition, poor hygiene, compromised immunity, excessive sexual activity, age-related genital tract atrophy, and uterine circulatory insufficiency—all of which lead to increased vulnerability to uterine infections and subsequent pus formation , 4. LongDetermining the definitive diagnosis of pyometra preoperatively is largely difficult . This isSpontaneous perforation of pyometra is exceedingly rare . Using PDefinitive preoperative diagnosis of spontaneous perforation of pyometra is very infrequent  and requManagement of pyometra depends on the clinical setting (emergency or nonemergency) and status of pyometra (ruptured or nonruptured). Urgent and ruptured pyometra cases should be managed by total abdominal hysterectomy with bilateral salpingo-oophorectomy, thorough drainage and irrigation of pelvi-abdominal cavity, postoperative intensive care support, and administration of broad-spectrum antibiotics , 14, 15.Pyometra, an extremely rare gynecologic condition, is defined as build up of pus  in uterine cavity. Although exceedingly uncommon, spontaneous perforation of pyometra should be considered in the differential diagnosis of any elderly postmenopausal woman presenting with acute abdomen and signs of generalized peritonitis. Only around 50 case reports of spontaneous perforation of pyometra have been documented in the English literature so far. Urgent exploratory laparotomy is fundamental in confirming diagnosis and successfully managing patient. Abdominal hysterectomy with bilateral salpingo-oophorectomy, thorough drainage and irrigation of pelvi-abdominal cavity, postoperative intensive care support, and administration of broad-spectrum antibiotics is the mainstay of management in emergency settings. An underlying gynecologic malignancy is considerably high in pyometra and must be ruled out.


Actinomyces that mimics other intra-abdominal pathologies especially neoplasms. Correct diagnosis can be rarely established before radical surgery. On the other hand Entamoeba infection affects a considerable number of people worldwide. To our knowledge only one case has been reported to be affected by both organisms. We report a man who has been operated for a mass in the cecum mimicking a perforated colon cancer. Abdominal CT revealed a mass with features of an invading neoplasm. After radical surgery, definitive pathology revealed that the mass was due to actinomycosis associated with Entamoeba infection. The postoperative period was uneventful and the patient was on long-course antibiotherapy. It is important to consider actinomycosis especially in patients with intra-abdominal masses with unusual aggressiveness to prevent unnecessary surgery. However, surgery can be unavoidable especially in the presence of complicated disease or high index of suspicion for malignancy.Actinomycosis is a granulomatous disease caused by  Actinomyces is an anaerobic, gram-positive saprophytic organism normally present in the gastrointestinal tract, female genital tract, and bronchus [bronchus . It is nbronchus –3. The ibronchus . Bowel obronchus . Entamoeba infections are prevalent worldwide and the clinical course may vary from asymptomatic states to “amebomas” which are exophytic, cicatricial, and inflammatory masses due to longstanding and partially treated infections. These are seen in only 1.5% of patients with amebiasis [On the other hand, mebiasis . Entamoeba in a mass formed by Actinomyces infection has not been reported in the literature and the only report regarding the association of these two microorganisms is by Arroyo who wrote about an intrauterine contraceptive device user colonized by Actinomyces and Entamoeba [To our knowledge the presence of ntamoeba .  Entamoeba leading to a mass mistaken for perforated colonic carcinoma in a 52-year-old man.The present paper discusses a case of actinomycosis associated with3; haemoglobin level was 11 gr/dL with normal platelet count. Liver and kidney function tests were in normal limits except an increased blood glucose level (146 gr/dL) but the patient denied a history of diabetes. Computerized tomography (CT) scans of the abdomen demonstrated a 90 × 83 × 95 mm mass with gas containing abscess involving cecum and distal ileum with luminal narrowing and marked inflammatory changes in the contiguous tissues. Multiple lymph nodes measuring up to 19 × 11 mm were seen in the pericecal region (A 52-year-old man applied to the outpatient clinics with the complaints of abdominal pain and weight loss for two months. Abdominal pain had worsened for the last two days. He also complained of diarrhea for the last week. His past history revealed restless leg syndrome. He had undergone an operation for sinusitis four months before the admittance day. Physical examination revealed a mass and tenderness in the right lower quadrant with local signs of peritonitis. White blood cell count was 11,330/mml region . On the Actinomyces with periodic acid-Schiff and Grocott's dye (Entamoeba trophozoites on the surface of the necrotic tissue (The mass was 11 × 8 × 3 cm in macroscopic evaluation. Pathology revealed pseudotumor formation with necrosis of cecum and ileocecal valve  involvintt's dye . There wc tissue . TransmuActinomycosis is a chronic suppurative disease characterized by the formation of multiple abscesses, draining sinuses, abundant granulation, and dense fibrous tissue . ActinomThe diagnosis of abdominal actinomycosis is challenging before surgical intervention. The clinical appearance is not specific and the most common symptom is abdominal pain although it may depend on the involved organ , 13. TheEntamoeba infection. The harvested lymph nodes were reported to be reactive in the final pathological examination. The order of infective process in the present case is contentious. Asymptomatic Entamoeba infection might have led to actinomycosis with destruction of the mucosal barrier although there has been no evidence supported by the literature. The second scenario is that the patient has been infected by Entamoeba after actinomycosis developed. Whatever is true, the patient has ended up by surgery which is not the primary treatment for both infections. Computerized tomography is an important imaging modality for diagnosis, degree of involvement, and monitoring the effectiveness of the treatment , 16. DirActinomyces [Actinomyces cultures can yield a false negative result in up to 76% of abdominal actinomycosis [Actinomyces granules regularly show a positive reaction with periodic acid-Schiff and Grocott's dye which differentiates them from Nocardia and Streptomyces species [The major flaw in preoperative diagnosis is that the findings in the imaging modalities cannot discriminate between actinomycosis and malignant process, Crohn's disease, appendicitis, diverticulitis, or tuberculosis , 20. Fininomyces . In the inomyces  whereas inomyces . Howeveromycosis . In the  species .Reports increasingly support that medical therapy alone, without surgical exploration, is usually sufficient for cure, irrespective of extensive actinomycosis , 22. TreOur patient received ceftriaxone and metronidazole until the definitive pathology. Afterwards he received amoxicillin plus clavulanic acid and metronidazole . After oEntamoeba infection. Whatever the presentation is, main challenge in abdominal actinomycosis is preoperative diagnosis. Imaging modalities and tissue samples may not be conclusive and surgery may be necessary to exclude other intra-abdominal pathologies especially malignant processes. The clinician should be aware of potential pitfalls in diagnosis and treatment whereas maintaining suspicion for actinomycosis may prevent unnecessary radical surgery for presumed pelvic malignancies. Abdominal actinomycosis can be associated with


Pseudomyxoma peritonei (PMP) is a rare clinical condition, where copious mucinous ascites accumulate in the peritoneal cavity due to dissemination of mucin-producing tumor. Because of this disseminating, yet nonmetastasizing, behavior, PMP attracts much interest from surgical oncologists in that aggressive locoregional therapy can give the opportunity of long survival and even cure. Although extra-abdominal metastasis is exceptionally rare, the lung is the most likely site in such a case. In this paper, the clinical findings and treatment of eleven cases with pulmonary metastasis from PMP were reviewed, including ten cases in the literature and one case which we experienced. The clinical features of PMP cases with pulmonary metastasis were similar to cases without pulmonary metastasis. The histological type was low-grade mucinous neoplasm in most cases. Pulmonary lesions were resected in seven cases in which abdominal lesions were controlled by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy or another therapeutic modality. Disease-free state was maintained in five cases at the end of the follow-up period. However, it should be noted that rapid progression after resection was seen in two cases, suggesting that biological features may have changed by surgical intervention. Pseudomyxoma peritonei (PMP) is a rare clinical condition, where copious mucinous ascites accumulate in the peritoneal cavity due to dissemination of mucin-producing tumor . It is iAlthough extra-abdominal metastasis is very rare, the lung is one of the most probable sites in such a case. Once pulmonary metastasis occurs, it is important to consider that the biological features of PMP with metastasis may be different from those without metastasis. It is not clear whether surgical resection of metastatic lesions improves prognosis. In addition, if the biological features of PMP cases with pulmonary metastasis are more aggressive than those without pulmonary metastasis, CRS and HIPEC may not be indicated for these cases. In this paper, the clinical findings and treatment of eleven cases with pulmonary metastasis from PMP were reviewed, including ten cases reported in the previous literature and one case which we experienced.A 60-year-old female was referred to us for the treatment of PMP. She had undergone palliative resection and HIPEC for PMP one year before. Histological diagnosis was low-grade appendiceal mucinous neoplasm with peritoneal dissemination, classified as disseminated adenomucinosis (DPAM) according to the criteria by Ronnett. At the time of referral, tumor was diffusely spread in the peritoneal cavity and single nodule was observed in the right lower lung . CRS andEleven cases of pulmonary metastasis from PMP have been reported including the present case –10 Tabl. PatientIn the three cases which were reported earlier by Berge, Chevillotte et al., and Kreissig et al. –6, patieExtra-abdominal metastasis of PMP is exceptionally rare, but the lung and pleura are the most likely sites in such a case . The majResection of metastatic lesions was indicated, when abdominal lesions were controlled by CRS and HIPEC. Wedge resection would be enough except such occasions where the possibility of primary lung cancer cannot be excluded. Prognosis was fairly good, although the follow-up period was rather short. It is noteworthy that long survival was achieved in one case in which multistep pulmonary resection was performed for multiple and bilateral lung metastases. However, it should be cautiously noted that rapid progression after pulmonary resection was seen in two cases. It was suspected that inflammatory reaction caused by CRS and abdominal infection may have changed biological features towards rapid deterioration , 19.A more recent retrospective study showed that 42 cases of intrathoracic metastases were found out of 626 cases of appendiceal adenocarcinoma , which iPulmonary resection for pulmonary metastasis of colon cancer is recommended by NCCN guidelines , but fewExtra-abdominal metastasis from PMP was exceptionally rare, but the lung was the most likely site in such a case. Clinical findings of PMP cases with pulmonary metastasis were similar to those without pulmonary metastasis. Resection of pulmonary lesions was indicated, and long survival may be expected when abdominal lesions were controlled by CRS and HIPEC. However, it should be cautiously noted that rapid progression after resection was seen in some cases, where biological features may be changed.


The current paper describes a case of prostatic adenocarcinoma metastatic to the skin presenting as an extrammamary Paget's disease, a very rare and poorly characterised morphological entity. We report a case of prostatic carcinoma metastatic to skin showing a pattern of extramammary Paget's disease which has not been clearly illustrated in the literature Case presentation: A 63 year-old man with prostatic adenocarcinoma developed cutaneous metastases after 16 years. The inguinal metastases were sessile and 'keratotic.' The tumour displayed solid, glandular areas as well as a polypoid region suggestive of extramammary Paget's disease were identified.We review the diagnostic criteria that have led to the correct histopathological diagnosis in this case. A differential diagnosis of the pagetoid spread in the skin and various forms of cutaneous metastases determined by a prostatic adenocarcinoma as well as the role of immunohistochemistry in establishing the prostatic origin are presented in the context of this case. Although, morphologically the cells presented in the skin deposits were not characteristic for adenocarcinoma of prostate, immunohistochemistry for PSA and PSAP suggested a prostatic origin.http://www.diagnosticpathology.diagnomx.eu/vs/1395450057455276The virtual slide(s) for this article can be found here:  Prostate adenocarcinoma is one of the most common cancers in Australia. The Melbourne Collaborative Cohort Study revealed that 8.4% of the subjects enrolled in the study developed over 15 years prostatic adenocarcinoma and more than 10% of these patients died . EvaluatInitially, a 63 year-old male was diagnosed with locally metastatic prostatic adenocarcinoma, moderately differentiated, Gleason score 3 + 3 = 6 (T3NxM0). However, no prostatectomy was performed after the initial clinical diagnosis. Subsequently, the patient elected to receive radiation therapy and long-term flutamide. A bone scan performed after eight years revealed no proliferative lesions. However, at 16 years after the initial diagnosis he was admitted to dermatology clinic with an eruption of multiple tan keratotic polypoidal lesions located on his scalp, abdomen and bilateral groin areas. Bilateral inguinal lymphadenopathy was also noted. Clinical and radiological evaluation revealed an irregularly enlarged prostate. The MRI showed abdominal lympadenopathy. Several atypical areas were detected in bone pelvis but a clear diagnosis of bone metastasis was not possible. However, no other masses were detected elsewhere. Immediately prior to his anatomo-pathological evaluation, the patient developed macroscopic haematuria, overflow urinary incontinence and renal failure with increased creatinine. The general status of the patient did not allow a prostatic biopsy and the patient was transferred for palliative care and expired after three weeks. However, during his hospital stay the PSA level increased from 24.3 ng/ml to 46.3 ng/ml. A skin biopsy of a fibroepithelial-like lesion located in the right lower abdominal quadrant  was performed a diagnosis of skin metastasis was made. Histopathological evaluation of this lesion revealed several patterns of metastatic prostatic adenocarcinoma. The dominant feature was represented by solid and glandular areas. In addition, large areas of hyperplastic epidermis revealed clear tumour cells suggestive of extramammary Paget’s disease (EMPD) (Figure The skin and subcutis represent the site for a large variety of epithelial stromal and lymphovascular tumours but also metastatic deposits are identified at this site. Thus metastases from most internal organs and breast have been described in the skin. The real incidence of skin metastasis determined by internal organs is difficult to be ascertained with precision but it seems to be between 2.8 and 5% ,5. In thIn our reported case, the background where the prostatic cells have lodged was represented by papulo-nodular skin with preservation of the adnexae Figure . This obVery importantly, this pattern of prostatic metastasis needs to be recognised since many other cancers present similarly and the differential diagnosis could be rather vast Table .The currently reported EMPD pattern in a site not prone to the development of a “primary” extrammamary Paget’s makes this lesion exceptional. However, the currently described lesion represents the dissemination from the initial prostatic adenocarcinoma rather than a “primary” EMPD. The first argument, upholding this would be the clinical history. It is likely that dormant neoplastic foci of prostatic adenocarcinoma have been reactivated. Subsequently, the patient has developed skin metastases. Reedy et al.  highlighWe present a rare pattern of prostatic adenocarcinoma metastatic to the skin. Immunohistochemistry for PSA and PSAP along with clinical and radiological examination and personal history were corroborated for the final diagnosis. For the histo/dermatopathologist it is important to recognize the plethora of various patterns displayed by cutaneous metastases of a prostatic adenocarcinoma. Last but not least, we should be aware that the PSA/PSAP might not be helpful in confirming the diagnosis if the skin lesion represents the extension of a poorly differentiated prostatic adenocarcinoma and other markers and/or methods need to be employed.The authors declare that they have no competing interests.EBP: drafted the manuscript, provided histopathological material, took digital pictures, AGS: helped drafting the manuscript, provided clinical background and interpretation, RGW: provided advice on interpretation and took digital pictures, MS: provided histopathological research information, helped drafting the manuscript, KB: helped drafting the manuscript, provided basic research information and histopathological evaluation. All authors read and approved the final manuscript.


The appearance of a primary germinoma in the central nervous system but not on or near the midline or within the brain is exceptional. It may occur at any age; however, it is rare in patients over 50 years old. Only a handful of cases of germinomas located in the cerebellopontine angle were presented, but to our knowledge, there has been no description of an isolated germinoma in the internal auditory canal. We report a case of germinoma in the internal auditory canal in a 51-year-old man simulating the clinical and radiological characteristics of a vestibular schwannoma. Extragonadal germ cell tumors located in the brain are rare and are most commonly found in the pineal and suprasellar region. Germinoma is the most frequent intracranial one. It has a good prognosis and response to treatment and a high incidence among the Chinese and Japanese population . The comWe describe a case of a germinoma in a male without any risk factor, located in a place where it has never been previously reported: the internal auditory canal (IAC). The patient had an unusual age for the appearance of a primary germinoma (51 years old). We observed a tumor that both clinically and radiologically mimicked a vestibular schwannoma.The patient is a 51-year-old man with right facial weakness of three weeks of evolution, including the inability to close the right eye , bad response to oral corticoids, and deviation of the mouth on the same side. The patient did not present hearing loss, tinnitus, or ear fullness.The pure tone audiometry demonstrated a mild bilateral sensorineural hearing loss, predominantly in high frequency tones. The tympanogram showed type A curves without ipsi- and contralateral blink reflex in the right ear. Otoacoustic emissions were absent in both ears. Brainstem auditory-evoked potential showed morphologically normal curves in both ears. The videonystagmography (VNG) did not detect spontaneous nystagmus and caloric tests were normal.The nuclear magnetic resonance (NMR) demonstrated a mass of 0.8 × 0.4 mm into the right IAC .The patient underwent a total resection with a right retrosigmoidal approach to the cerebellopontine angle (CPA). Intraoperatively, we found that the tumor involved cranial nerves VII and VIII.Microscopic examination revealed histopathologic findings of germinoma .It shows an irregular structure comprising cords of epithelial-like cells with a large nucleus. Nucleoli are evident and there are a clumped chromatin with occasional mitotic figures, between which there is a scarce vascular connective stroma and leukocyte infiltrates of variable density.In the immunohistochemical study, the cellularity was positive for cytokeratins of low, medium, and high molecular weight and for cytokeratins AE1, AE3, and EMA. Vimentin was also positive. The PLAP provides small foci discontinuous positivity and lymphocytic cellularity was predominantly positive for CD43 and to a lesser extent for CD20. B-HCG was negative. Ki67 was positive in 15–20% of the cells. GFAP, neurofilament, and ENE were negative.The described data, both morphologically and immunohistochemically, are compatible with germinoma.Concerning audiovestibular symptoms, our patient showed dizziness for three months after surgery because the auditory nerve was not preserved.Further research for the primary tumor site (including positron emission tomography) was negative in all cases.0–14 years: 34% of cases,15–29 years: 57% of cases,30–44 years: 9% of cases.Medical Subject Headings (MeSH) has defined germinoma as “a malignant neoplasm of the germinal tissue of the gonads, mediastinum or pineal region” , 5. GermOtherwise, vestibular schwannomas and meningiomas represent more than 95% of the CPA neoplasms , 7. TherAnyway, germinomas in people over 50 years old are rare, germinomas affecting the CPA are extremely rare, but and germinomas in the IAC have never been reported.Metastases and extra-axial primary malignancies are often initially misdiagnosed as benign disease  due to tAdhesion of the tumor to cranial nerves and surrounding tissues at surgery suggests uncommon tumor entities .Clinical and radiological signs for CPA and IAC lesions are nonspecific. A final diagnosis can only be established based on histopathological analysis .Although malignant tumors rarely appear in the CPA and IAC, they need to be included in the differential diagnosis. In patients without known malignancies, short duration of symptoms and rapid progression suggest malignant tumor entities . In our


Meningiomas are common neoplasms arising from the central nervous system meninges. On the other hand, primary ectopic meningiomas are extremely rare and usually limited to the head and neck region or to the paravertebral soft tissues. Their occurrence in the mediastinum is even rarer. Until now, only 4 cases of primary mediastinal meningioma have been reported in the literature searched on Medline. Because of its rarity and intriguing pathogenesis, we report here a case of primary mediastinal meningioma that was treated by surgical resection. The clinical features, treatment, pathological findings, and prognosis are analyzed, and the literature on ectopic meningioma is reviewed. Meningiomas are one of the most common neoplasms of the central nervous system, and the cell of origin for the meningioma is called the arachnoid cap cell, found on the surface coverings of the brain in the pacchionian granulations. Meningiomas are usually benign and slow-proliferating and account for about 15-20% of all intracranial tumors. On the other hand, primary ectopic meningiomas are exceedingly rare, and they are usually found in the head, neck, or paraspinal soft tissues . A MedliHere, we report an ectopic atypical meningioma arising from the anterior mediastinum because of its extreme rarity.A 64-year-old male was referred to the Gunma University Hospital with complaints of a progressive oppressive feeling in the left thoracic region. His past medical history was unremarkable. At admission, general conditions were satisfactory, and a physical examination of the thorax was normal. Routine laboratory tests were within normal values, but a chest roentgenogram revealed an oval-shaped anterior mediastinal mass in the left hemithorax. An enhanced computed tomography (CT) scan of the chest revealed the presence of an ovoid mass about 9-cm at its greatest dimension in the left anterior mediastinal region. Its border, adjacent to the left lung parenchyma, was poorly demarcated. The mass showed a heterogeneous densitometric characteristic accompanied with areas of necrosis after contrast enhancement Figure . From thWritten informed consent concerning the operation was obtained from the patient before surgery, and the patient was admitted to the Gunma University Hospital for surgical resection of the tumor. The patient underwent tumor excision and thymectomy through sternotomy with continuous anterior thoracotomy of the third intercostal space. During the operation, the tumor, as seen on the CT scan, was 9-cm wide, elastic, and off-white in color. It was found to have infiltrated the upper lobe of the left lung. Based on this surgical finding, partial resection of the lung together with the tumor was performed with a sufficient surgical margin. On the basis of its morphologic and immunohistochemical features, the tumor was diagnosed as a mediastinal atypical meningioma. The patient had an uneventful recovery and was discharged on postoperative day 6. An ectopic pulmonary site of origin, such as the mediastinum in this case, should be accepted only after the possibility of spread or metastasis from primary intracranial or intraspinal origin has been excluded. One month after operation, the patient had an enhanced magnetic resonance imaging (MRI) of the head and spine, and no abnormal findings were observed, which eliminated the possibility of an intracranial or intraspinal origin. He has been monitored for 12 months as an outpatient without any symptoms of recurrence or metastasis.The surgical specimens were routinely fixed with 10% formaldehyde and embedded in paraffin. Tissue sections (6-μm thick) were stained with hematoxylin and eosin (H-E), and periodic acid-Schiff (PAS) with and without diastase digestion. For immunohistochemical studies, tissue sections were incubated using the standard avidin-biotin peroxidase complex (ABC) method with the following antibodies: epithelial membrane antigen (EMA), vimentin, S-100, MIB-1, CD34, D2-40, αSMA, desmin, synaptophysin, and neurofilament. Macroscopically, the resected tumor measured 9-cm in its greatest dimension and adhered to a parenchyma of the left lung. The oval-shaped tumor had a smooth surface, and its cut surface was homogenously solid and yellow-white in color (Figure Microscopically, the tumor was partially encapsulated and composed of bundles of spindle-shaped cells with elongated nuclei and syncytial nets of tumor cells with oval nuclei. A few tumor cells had an intracellular cytoplasmic inclusion. In some areas, many typical whorl formations for fibrous meningioma were observed Figure . There wMeningiomas usually arise in the cranial cavity or spinal canal. On the other hand, because meningiomas arise from arachnoid cells present in the meninges, they can occur in any location where meninges or ectopic meninges exist. Primary ectopic meningiomas are extremely rare pathological entities and have been reported sporadically. They usually occur in cephalic and paravertebral soft tissues and skin and, more rarely, in the ear , temporaTo make a definite diagnosis of an ectopic meningioma is difficult, and such a diagnosis can only be made on the basis of microscopic morphological and immunohistochemical findings. In this case, and despite the unusual location of the tumor, the morphological and immunohistochemical findings closely resembled a meningioma in the central nervous system. Furthermore, as there was no clinical or radiological evidence of any intracranial or intraspinal lesion, we concluded that the meningioma in this case was of complete mediastinal origin.In view of the rarity of extracranial meningiomas, caution must be used in ruling out possibilities in the differential diagnosis. Regarding the histological differential diagnosis of epithelial thymomas, they are composed of cells with large numbers of desmosomes often containing numerous cytoplasmic cytokeratin filaments in the desmosomes per se and lying free in the cytoplasm . CytokerHistological grading of meningiomas is based on the 2007 WHO classification . AtypicaAs for the clinical course, the surgical excision was as curative as a complete resection with a sufficient surgical margin. Although this was an atypical meningioma with invasion into lung tissue, no adjuvant therapies, such as radiotherapy, were performed. This decision was based on the fact that Mair et al. retrospectively reviewed the records of 114 consecutive patients with diagnosed WHO grade II meningiomas and reported that radiotherapy for WHO grade II atypical meningiomas was not appropriate after a first-time resection of those lesions in which a gross-total resection has been achieved . In addiAccording to our review of the literature, this is the first reported case of primary mediastinal atypical meningioma Table . Of all Here, we report an ectopic atypical meningioma arising from the anterior mediastinum because of its extreme rarity. Surgery is a feasible and effective treatment strategy for ectopic meningioma of the mediastinum.Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in -Chief of this medical journal.CT: computed tomography; MRI: magnetic resonance imaging; H-E: hematoxylin and eosin; PAS: periodic acid-Schiff; ABC: avidin-biotin peroxidase complex; EMA: epithelial membrane antigen; αSMA: α smooth-muscle actin; hpf: high-power fields.The authors declare that they have no competing interests.AM drafted and co-wrote the manuscript with JH and HK. AM, TK, and EY were involved in the clinical care of the patient. JH reported pathological findings and prepared slides for manuscript inclusion. All authors have read and approved the final version of the manuscript.


Fibrolipomas are a rare subtype of lipomas and very rare in the oral and maxillofacial region. Lipomas affecting the central nervous system are even more infrequent occurring with a frequency of 0.1%.Case report.This report includes a patient who had a nasal septal fibrolipoma and an accompanying corpus callosum lipoma.To our knowledge, this is the first reported nasal septal fibrolipoma case in the literature. The diagnostic and surgical features of this case and the unity of septal fibrolipoma and intracranial lipomas are discussed. Lipomas are benign, slowly growing neoplasms composed of mature fat cells grouped in lobules by connective tissue septa. These tumors are very rare in the sinonasal tract . FibroliAn 18-year-old male patient presented with a two year history of nasal obstruction to the otorhinolaryngology department with no additional complaints. His medical family history had revealed nothing abnormal. An endoscopic examination revealed a soft, painless, well circumscribed 2.5x1.5 cm sized mass coated with normal mucosa in the left nasal cavity, localized from the anterior portion of the nasal septum to the posterior Figure A. A 2.5xLipomas are well circumscribed, slow growing, benign tumors composed of mature fat cells, of which 13% arise in the head and neck region . LipomasFibrolipomas are classified as a variant of lipomas by the World Health Organization (WHO) and they are very rare in the oral and maxillofacial regions. Both lipomas and fibrolipomas are well circumscribed and have a thin capsule. Fibrolipoma differs from the classic variants because the mature adipose tissue is interspersed by bands of connective tissue . AdditioFibrolipomas occur in the subcutaneous tissue, oral cavity, esophagus, pharynx, colon, trachea, larynx, parotid gland, and the spermatic cord as a slow growing mass ,3. HowevMRI is very useful for the diagnosis of all kind lipomas. Tumors have high signal intensity on T1-weighted images, with relative decreasing signal on T2-weighted images . A fat-sOn the other hand, lipomas affecting the central nervous system are even more infrequent occurring with a frequency of 0.1%, with most localized in the corpus callosum. Although most are asymptomatic, some present with seizure, dementia, raised intracranial pressure, and hemiparesis. Surgical resection of a callosal lipoma is technically difficult because of the close association with anterior cerebral arteries and the adherence of the capsule to the adjacent brain. If seizures occur because of the callosal lipomas, anti-convulsants can be prescribed . The curIt is very rare to observeboth nasal lipoma and intracranial lipoma in the same patient. In the literature, there are a few cases presented as a rare entity called Pai syndrome, consisting of a midline cleft of the upper lip, facial skin polyps and central nervous system lipomas . Hollis The classic treatment for lipomas is surgical excision with capsular dissection. Upon learning of the diagnosis of lipoma, it was believed that excision would be simple, due to its well circumscribed capsule. Yet during the operation, this was not the case, because, the lateral border of the mass was adhered to the submucosal tissues of the nasal septum, thus a mucosal part of nasal septum was excised, due to its lateral location in relation to the mass which was unexpected. This may be the future of nasal submucosal fibrolipoma, but it is quite assertive to say so. This point should be highlighted for surgeons who will encounter such septal fibrolipomas.As an uncommon variant of a common neoplasm, fibrolipoma can develop in the nasal septum. This case report is the first presentation of a fibrolipoma in the nasal septum, and discusses the difficulties encountered in surgery. It should be kept in mind that an accompanying intracranial lipoma can also exist, if the patient has symptoms such as seizure, dementia, hemiparesis, or raised intracranial pressure findings.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images.The authors declare that they have no competing interests.The author MO has made the study design and concept, drafted the manuscript, and made critical review. KI and AK have obtained the data and figures, and drafted the manuscript and references. MI has made a critical review for the manuscript and added comments to discussion. All authors read and approved the final manuscript.


Enterobius vermicularis is responsible for a variety of diseases but rarely affects the liver. Accurate characterisation of suspected liver metastases is essential to avoid unnecessary surgery. In the presented case, following a diagnosis of rectal cancer, a solitary liver nodule was diagnosed as a liver metastasis due to typical radiological features and subsequently resected. At pathological assessment, however, a necrotic nodule containing E vermicularis was identified. Solitary necrotic nodules of the liver are usually benign but misdiagnosed frequently as malignant due to radiological features. It is standard practice to diagnose colorectal liver metastases solely on radiological evidence. Without obtaining tissue prior to liver resection, misdiagnosis of solitary necrotic nodules of the liver will continue to occur. Enterobius vermicularis, is considered the most common and least pathogenic of human helminthic infections.E vermicularis infections in the liver are extremely rare.E vermicularis infection.Pinworm, A 44-year-old male with a 2-month history of rectal bleeding presented to his local hospital with abdominal pain and distension. He was a smoker, consumed moderate amounts of alcohol with a history of type 2 diabetes, hypertension and hypercholesterolaemia. Left-sided colonic obstruction was identified and at laparotomy a defunctioning colostomy was created proximal to a locally advanced rectal tumour (TNM stage T4NxMx). His staging computed tomography (CT) and magnetic resonance imaging (MRI) were reviewed at a dedicated hepatobiliary multidisciplinary meeting. A liver lesion consistent with a 2cm subcapsular CRLM was identified in segment 7  with no Following completion of neoadjuvant chemoradiotherapy to downstage the pelvic disease, the patient underwent an uncomplicated non-anatomical liver resection. At this operation the liver was found to be macroscopically normal with the exception of the presumed CRLM. Intra-operative ultrasonography confirmed the presence of a hypoechoic lesion in keeping with appearances of a CRLM.E vermicularis, having both concave and convex surfaces. The specimen was excised completely with margins of normal liver. Prior to liver resection, the patient’s white cell and eosinophil count were normal . There was no personal or family history of appendicectomy or perineal discomfort.At pathological assessment, necrotic material was found in a fibrous capsule . The capLiver resection for CRLM is the standard of care when possible.E vermicularis infection can result in a variety of diseases that typically affect the gastrointestinal tract and perineum. In female patients this can be manifested as lower urinary tract symptoms and in children/adolescents as perineal discomfort.E vermicularis is an accepted cause of appendiceal pain where infection can obstruct the lumen of the appendix, creating appendiceal colic.E vermicularis is found outside of the gastrointestinal tract in the peritoneum, fallopian tubes and liver.E vermicularis liver infection are very limited but tend to be misdiagnosed as hepatic metastases in patients with established malignancy.The patient in the presented case had no history of an appendicectomy or perineal discomfort. The rectal tumour was locally advanced (T4) and presumably provided a route of access out of the patient’s intestine, possibly spreading to the liver via the peritoneal cavity. The subcapsular location of the nodule supports this hypothesis. Previously published cases of The lesion described in this report demonstrates features consistent with the solitary necrotic nodule of the liver (SNNL). SNNL typically consist of central necrosis surrounded by fibrosis. These are uncommon lesions that are usually benign and often misdiagnosed as metastases.E vermicularis infection of the liver is exceptionally uncommon but has been reported previously following a history of colorectal carcinoma. It is unclear whether these asymptomatic liver lesions are being detected by coincidental cross-sectional imaging or whether there is a causal mechanism whereby the parasite may migrate from the intestine at the site of the tumour. The radiological features of E vermicularis infection in the liver mimic those of CRLM and of SNNL. For this reason, unless the fidelity or techniques of routine cross-sectional imaging change, benign liver lesions will continue to masquerade as metastases resulting in inappropriate intervention.


Colonic lipomas are rare benign tumors infrequently met in clinical practice. Most of them are asymptomatic making frequent their fortuitous discovery. The therapeutic approach to the fortuitous discovery of a lipoma is even less clear. The treatment depends essentially on the clinical picture, on the size of the lipoma and on its location. We report the case of a 31-year old woman, which sub-occlusive accidents events revealed a lipoma of the descending colon. The diagnosis was suspected on colonoscopy and segmental colectomy was performed. The diagnosis was confirmed by histological examination. We review the literature and discuss the clinical features, diagnosis and treatment of this uncommon disease. Colonic lipoma is a rare benign tumor. Colic lipoma was described for the first time by Bauer in 1757. The incidence of this lesion is estimated between 0.2 and 4.4% . ApproxiMrs. X is 31 years old, without surgical history. The patient had presented within the past six months with violent episodes of spasmodic abdominal pain, aggravated by the recent installation of sub-occlusive episodes witch resolved spontaneously.Clinical examination, including digital rectal examination at the time of the crisis revealed a diffuse distention with thickening at the left flank. Radiography of the abdomen without preparation and abdominal echography have not been of great contribution to orient to the diagnostic. Colonoscopy revealed a lesion in the left colon, six inches in diameter, obstructing the colonic lumen and covered by a whitish coating. This lesion was still passable and the colon upstream was free of any lesion.Biopsies performed showed only a-cellular material largely necrotic. Abdomino-pelvic scan confirmed the existence of an intra-colonic mass of 55 mm in diameter, consisting mostly of fat tissue. No other abnormality was visualized on CT scan. There was no biological inflammatory syndrome, or anemia and tumor markers CEA and CA19-9 were normal. The diagnosis of colonic lipoma was suspected. With the persistence of sub-occlusive symptoms, we decided to operate.The patient was operated by median laparotomy. Exploration discovered just below the splenic flexure a large mass, supple and mobile. Besides, there was no adenopathy or peritoneal nodules of carcinosis. A segmental colectomy was realized and allowed identification of the lesion which was fatty, submucosal and pedunculated . PatholoColonic lipoma is the second most common benign tumor of the colon after adenomas. There is a feminine predominance, and the age of discovery is generally between 50 and 65 years ,4. The pThe symptomatology is not specific. Only 6% of lipomas are symptomatic –7. Most One of the remaining challenges in the management of colonic lipoma is to establish the diagnosis preoperatively. Three diagnostic tools can bring arguments in favor of the diagnosis: colonoscopy allows mostly visualizing the lipomatous lesion characterized by a rise of the mucous membrane, softness of the mass under the biopsy forceps and finally the visualization of yellow fat on biopsy . Barium In front of a symptomatic lipoma, the treatment is the rule. Two options are possible: endoscopic excision or surgical excision. Certain authors suggest that the size of the lipoma is the limiting factor for endoscopic excision; the maximum size limit for endoscopic excision is fixed at most to 2.5 cm ,10; beyoThe lipoma of the colon is a benign and rare tumor. Most lipomas are asymptomatic, thus their frequent fortuitous discovery. The diagnosis is easy by colonoscopy coupled with biopsies. The treatment depends essentially on the clinical picture, on the size and location of the lipoma and involved endoscopic or surgical excision.


The objectives of this paper are to discuss a rare cause of laryngeal multiple myeloma, to review unique pathologic findings associated with plasma cell neoplasms, to discuss epidemiology, differential diagnosis, and treatment options for plasma cell neoplasms of the larynx. Laryngeal multiple myeloma, also noted in the literature as “metastatic” multiple myeloma, presenting as a de novo laryngeal mass is extremely rare with few reported cases. Laryngeal involvement of extramedullary tumors is reported to be between 6% and 18% with the epiglottis, glottis, false vocal folds, aryepiglottic folds, and subglottis involved in decreasing the order of frequency. We present the case of a 58-year-old male with a history of IgA smoldering myeloma who presented to a tertiary care laryngological practice with a two-month history of dysphonia, which was found to be laryngeal involvement of multiple myeloma. We review the classification of and differentiation between different plasma cell neoplasms, disease workups, pathologic findings, and treatment options. The physical exam demonstrated an asymmetric thyroid cartilage with a left-sided 2.5 cm firm, mobile, and nontender mass. Ten years prior, he was treated with radiotherapy for IgA myeloma involving the right acromion and lower extremity with complete resolution. Laboratory results were remarkable for serum IgA of 474 mg/dL, free kappa light chains of 7.92 mg/L, free lambda light chains of 1.96 mg/dL, a free kappa/lambda ratio of 4.04, and Videostroboscopy revealed a large submucosal mass effacing the left ventricle . The vocA fine needle aspiration of the mass  showed aPlasma cell neoplasms are clonal proliferations of immunoglobulin-producing plasma cells. Other monoclonal plasma cell neoplasms include extramedullary plasmacytoma (EMP), solitary plasmacytoma (SP), Waldenstrom's macroglobulinemia, primary amyloidosis, and osteosclerotic myeloma (POEMS syndrome). Multiple myeloma is the most frequent plasma cell dyscrasia and has variable prognosis. MM has an incidence of four cases per 100,000 and accounts for 1% of all malignancies . EMP andMultiple myeloma, also noted in the literature as “metastatic” MM, presenting as a de novo laryngeal mass is extremely rare with few reported cases , 4. It iThe management of plasma cell neoplasms can be performed with radiotherapy, chemotherapy, or surgery. The preferred treatment modality for SP and EMP is radiotherapy, as plasma cell neoplasms are highly radiosensitive . In cont


Ewing's sarcoma (ES) primarily affects bones and commonly presents in adolescents and young adults. This paper reports a rare case of extra osseous ES of the scapular region in a 9 years old girl. She was treated by a multidisciplinary approach including surgery, chemotherapy and radiotherapy. She was followed up for two years and remained well.  ES is a rare and highly malignant small round cell tumor that primarily affects the skeletal system. In primary extra osseous ESs of soft tissue underlying bone involvement is not found. James Ewing described it in 1921 as a tumor arising from undifferentiated osseous mesenchymal cells; however, recent studies suggest that Ewing’s tumor may be of neuroectodermal origin being derived from the primitive neural tissue. It accounts for 4 to10% of all types of bone cancers, with long bones and pelvis being the most common sites. It is the second most common bone tumour of childhood and adolescence, with male preponderance of 1.6:1. It is rarely seen before the age of 5 years and after the age of 30 years [The ES usually arises in the metaphysis or diaphysis of long bones of extremities. The lungs, bones and bone marrow are the most common sites of metastasis. An extensive review of the literature showed only few reported cases of the extra-osseous ES in patients under the age of 10 years. This report describes a case of extra osseous ES of the scapular region in a 9 years old girl. This case elucidates the importance of professional knowledge of the relevant aspects of ES.A 9 year old girl presented in the surgical outpatient department with history of a progressive swelling over right scapular region for the last three years. Swelling started as a small lump that increased in size during last six months. Swelling was not associated with fever, malaise and fatigue. There was no history of exposure to any carcinogenic agent or radiation. Past history was not significant. It was her school teacher who asked her parents to seek medical advise for the swelling, as she was facing difficulty in writing.The general examination of the child was normal. Local examination revealed a globular non tender swelling over the right scapular region, measuring 40x36x38 cm, having firm to hard consistency. It was mobile with well defined margins and not attached to deeper structures. Overlying skin was mobile, shiny with multiple visible vessels and a small ulcer noted in the center of the swelling Fig. . There wBlood complete picture revealed mild anemia. Other blood tests including renal function test, liver function test, and serum calcium and serum alkaline phosphatase were within normal limits. X-ray and CT scan of the scapular region showed soft tissue swelling without any bony involvement Fig. , 3. FineSoft tissue ES is a rapidly growing, round-cell, malignant tumour which can reach 10 cm size by the time diagnosis is made. Commonly affected extra-osseous sites are the paravertebral spaces, lower extremities, head and neck, and pelvis. One paper reported an ES involving the scapular region on literature serach. The most frequent presenting symptom is a rapidly growing mass with local pain. ES may also present with systemic signs and symptoms such as weight loss and fever , 6, 7. TExtraskeletal ES is confirmed by characteristic features on histological analysis, histochemistry, immunohistochemistry and electron microscopy. Differential diagnoses include other small, blue round cell tumours (SBRCTs) and other members of the Ewing family of tumours such as the primitive neuroectodermal tumour (PNET). Findings of X-ray and CT scan of our case showed the tumour as soft tissue swelling over scapular region. Molecular and cytogenetic analysis should be considered as the standard practice in the diagnostic evaluation of ES , 8.The mainstay treatment should include multi-agent chemotherapy and aggressive surgical treatment. Tumours that are not appropriate for surgical resection or have positive margins are treated with radiation. The results of surgery alone for extra-osseous ES are poor in most of the cases, while patients receiving multimodal chemotherapy and radiotherapy have a much better prognosis. With the combination of local surgical treatment and systemic chemotherapy, long-term survival has improved from 10% to 50%-60% or greater. The prognosis for extra-osseous ES appears more favourable than that of ES in bone. More recently, Ifosfamide has emerged as a an effective chemotherapeutic agent, specially in patients resistant to other drugs. Better long term survival can be achieved in patients presenting with non metastatic disease , 9, 10. In summary, surgical resection, multi agent chemotherapy, and radio-therapy are the mainstay of treatment of ES. The treatment plan should be individualized for each patient, which should be based on age, location, stage, size of the tumor and response to therapy.Source of Support: NilConflict of Interest: None declared


Aggressive angiomyxoma is a rare myxoid mesenchymal tumor of the pelvis and perineum, which occurs almost exclusively in adult women. The tumor is especially rare in men.We report the case of a 68-year-old Japanese man with a slowly growing inguinal swelling. At surgery, a huge mass in the soft tissue of the inguinal region was found, not involving the adjacent organs. The morphologic picture was compatible with aggressive angiomyxoma of the inguinal region.Aggressive angiomyxoma is a very rare, locally infiltrative neoplasm. Thus, after surgery, close follow-up is needed because of a high risk of local recurrence. Aggressive angiomyxoma is a rare mesenchymal tumor of the pelvis and perineum that occurs almost exclusively in adult women . It prefA 68-year-old healthy Japanese man presented with a slowly growing swelling of the soft tissue in the inguinal region Figure . The duret al., about 100 cases in both sexes (including 24 men) were reported worldwide [Since 1983, when aggressive angiomyxoma was first described by Steeper Macroscopically, its typical cut-surface appearance is a large, grossly gelatinous, and locally infiltrative tumor. Microscopically, the stroma is rich in collagen fibers with a prominent vascular component, including many thick-walled vessels. The differential diagnosis includes angiomyoblastoma, myxoid neurofibroma, myxoma, spindle cell lipoma, and myxoid liposarcoma ,2. ImmunImmunohistochemical studies have revealed that tumor cells are immunoreactive for no specific marker. Male angiomyxoma may be positive for estrogen and progesterone receptor . The tumHMGIC gene [Cytogenic analysis reveals chromosomal translocation involving chromosomes 8 and 12, associated with rearrangement of the Surgery is the principal first-line treatment to date and, because of the high risk of local recurrence, a long-term postoperative follow-up with either ultrasound (US) or computed tomography (CT) is recommended . The recIn conclusion, aggressive angiomyxoma is a very rare neoplasm that is more predominant in women. After surgery, close follow-up is needed because of the high risk of local recurrence.The authors declare that they have no competing interests.TK performed histologic examination, analyzed the case, and wrote the manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Objective: Sacrectomy creates a large, complex tissue defect that presents a reconstructive challenge for plastic surgeons. Several myocutaneous flaps have been described for reconstruction following sacral tumor extirpation; however, current publications focus on the reconstructive options applicable to adults. We present a method of reconstruction following sacral tumor extirpation in a pediatric patient. Methods: The patient was 22 months old and in need of complex closure following low sacral amputation (S3-S4 osteotomy) and en bloc resection of a yolk sac tumor. Following tumor extirpation, the patient was left with a complex defect including extensive dead space, multiple exposed nerve roots, projection of the rectum into the wound, and inadequate soft tissue for primary closure. Results: Reconstruction with human acellular dermal matrix to address the risk of posterior rectal herniation and bilateral gluteal V to Y advancement flaps for obliteration of the dead space allowed for durable closure of the surgical defect. Conclusions: This represents the first case report documenting sacral resection and reconstruction with bilateral V to Y gluteal advancement flaps in a pediatric patient. Reconstruction of the soft-tissue defects resultant from total or partial sacrectomy is described in the adult population; however, discussion of the reconstructive options available to the pediatric population does not exist. Only 1 pediatric case of reconstruction with a myocutaneous flap closure has been reported through 2013.An Asian female, age 17 months, was diagnosed with a yolk sac tumor after biopsy of a mass emanating from the sacrum and extending into the buttocks. The patient had a normal birth history, with appropriate achievement of developmental milestones including walking without assistance. She did not appear to have pain related to the mass. Determination of bowel or bladder effects was complicated by her age. She underwent bleomycin chemotherapy and had a good response with a reduction in the size of the tumor. It was felt that she could benefit from surgical resection. Magnetic resonance imaging and computed tomographic scans demonstrated that the tumor was located in the presacral region extending up to the S3 nerve roots and involving the distal sacrum and coccyx.At 22 months of age, the Neurosurgery and Orthopedic Surgery Oncology teams performed low sacral amputation and en bloc resection of the tumor through a posterior approach . The resThe posterior rectal herniation was addressed by suturing a 4 cm by 3 cm piece of HADM circumferentially to the deep fascia and muscle edges surrounding the rectum. Bilateral gluteal V to Y advancement flaps were then designed on each buttock. The flap on the right buttock was partially deepithelialized on the medial aspect, dissected near the gluteal perforators, advanced, and inset deep into the wound to obliterate the dead space. The left buttock flap was then advanced to meet the right flap in a pants-over-vest fashion. The V advancements flaps were closed in a Y fashion . The cum2 to 245.7 cm2; our patient had a reconstructed surface area of 152 cm2.2,4,1-4,6,7Resection of sacral tumors by a posterior approach results in large defects that are difficult to reconstruct and present several potential complications including wound dehiscence, impaired motor function, and parasacral herniation. In the adult population, the documented surface area of reconstruction has ranged from 189.8 cm,7,8Because our patient required a low sacral amputation, the entire resection was performed by a posterior approach. Therefore, the option of mobilizing a VRAM flap was not considered advantageous because it would result in donor site morbidity in an otherwise nonoperated field. Furthermore, Garvey et al1,12,1With respect to the unique complications of reconstruction following partial sacrectomy, there is no statistically significant relationship between flap choice and postoperative complications.7Surgical management of complex sacral wounds in the pediatric patient population following tumor extirpation lacks documented literature. The 22-month-old female underwent resection and partial sacrectomy resulting in a significant defect requiring posterior rectal hernia repair with AlloDerm and complex wound closure with bilateral gluteal V to Y tissue rearrangement. Therefore, this represents the first case report documenting this method of complex sacral reconstruction, with HADM and bilateral V to Y advancement flaps, performed in a pediatric patient.


Paratesticular liposarcoma is a rare neoplasm, described in single case studies or components of larger studies, as histologically well-differentiated liposarcoma (WDL) and dedifferentiated liposarcoma (DL). However, leiomyosarcomatous differentiation is an extremely rare occurrence in WDL and DL. We report a case of leiomyosarcomatous differentiation in a 77-year-old man. The patient presented with a painless right scrotal mass. Magnetic resonance imaging showed a large mass along the right spermatic cord. The resected mass, measuring 17.5 × 12 × 5 cm, was composed of a high-grade pleomorphic undifferentiated sarcomatous component with necrosis. Atypical smooth muscle differentiation was also detected. Additional tumor sampling revealed the presence of a WDL component. Immunohistochemical analysis of the pleomorphic sarcomatous component showed positive staining for MDM2 and CDK4, and negative staining for alpha smooth muscle actin (αSMA) and desmin. The smooth muscle component was positive for αSMA and desmin, and negative for MDM2 and CDK4. Extension from primary retroperitoneal sarcoma was not proved. We diagnosed of DL with leiomyosarcomatous differentiation.http://www.diagnosticpathology.diagnomx.eu/vs/1484291498104021.The virtual slide(s) for this article can be found here:  Liposarcoma is the most common type of soft-tissue sarcoma, accounting for about 20% of all mesenchymal malignant tumors. It usually arises from the thigh and retroperitoneum. However, pleomorphic liposarcomas arising in the foot and ankle have been reported . The occParatesticular liposarcoma with leiomyosarcomatous differentiation is extremely rare; to our knowledge, only single case studies or components of larger studies have been reported in the English literature -9. Here,A 77-year-old man with diabetes mellitus presented with a growing mass in the right testis of 3 months duration. A computed tomographic scan revealed a soft tissue mass, measuring 12 cm in diameter, in the right scrotal sac. The mass showed low signal intensities on T2-weighted magnetic resonance imaging. Radical inguinal orchiectomy was performed because of suspected malignancy.The resected specimens were fixed with 10% neutral-buffered formalin and embedded in paraffin blocks. Four micrometer-thick paraffin sections were cut and mounted on glass slides, deparaffinized in xylene, rehydrated with ethanol, and immunostained with the following antibodies: MDM2 , CDK4 , S-100 protein , alpha smooth muscle actin (αSMA) , desmin , and MyoD1 . Sections were stained using Dako Envision kit .On macroscopic examination, a nodular mass measured 17.5 × 12 × 5 cm, and showed a white-yellow to red-brown cut surface with marked necrosis (Figure On immunohistochemical staining, the high-grade sarcomatous component was positive for MDM2 Figure A and CDKDL with leiomyosarcomatous differentiation was diagnosed. The leiomyosarcomatous component occupied approximately 10% of the tumor. The patient was disease free after at the 2-year follow-up.Paratesticular liposarcoma is rare and has been reported in single case reports or as components of larger series. These tumors are thought to arise de novo from the adipose tissue around the spermatic cord or by malignant transformation of pre-existing lipomas . In 2003To the best of our knowledge, only 3 well-documented cases of paratesticular liposarcoma with leiomyosarcomatous differentiation have been reported in the English literature -8. The cMDM2 and often CDK4 genes [It is important to recognize the coexistence of the ALT/WDL components in order to obtain a definitive diagnosis of DL. However, if these components are not recognized, the differential diagnosis includes a variety of lesions, benign or low-grade mesenchymal tumors for low-grade differentiation, and pleomorphic sarcomas for high-grade differentiation. The general differential diagnosis of adult spindle cell tumors in this site includes primarily fibrous mesothelioma, leiomyosarcoma, malignant fibrous histiocytoma, various benign fibrous tumors, pseudotumors, and fibromatosis . In addiK4 genes . The utiK4 genes . HoweverK4 genes . TherefoClinically, the risk of local recurrence is not affected by myosarcomatous differentiation in DL, although the metastatic rate is relatively low compared to that of leiomyosarcoma. The prognosis of patients with DL with myosarcomatous differentiation is better than that of patients with leiomyosarcoma . TherefoIn summary, we report a rare case of paratesticular DL with with leiomyosarcomatous differentiation in a 77-year-old man. This case highlights the importance of additional sampling for obtaining a definitive diagnosis of DL, especially if the existence of an ALT/WDL component is not noted.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.All authors declare that they have no competing interests.KH and AT participated in conception of the idea and writing of the manuscript. TY and TT performed the histopathological interpretation of the tumor tissue. All authors read and approved the final manuscript.


A previously healthy 34-year-old female presented with a 5-month history of progressive backache and weakness in the left fingers. Magnetic resonance imaging (MRI) showed soft tissue masses in the spinal canal distributed along the nerve course. The patient’s baseline laboratory data were normal. Surgical intervention was performed and histological examination identified isolated spinal granulocytic sarcoma (GS). A bone marrow biopsy also presented normal findings. However, the patient developed numbness and pain in the right lower limb two months later. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) showed FDG uptake in the left trapezius muscle, cervix uteri, iliac bone, lymphadenectasis of the pelvic wall and left axillary fossa. Cerebrospinal fluid (CSF) examination allowed a diagnosis of central nervous system leukemia (CNSL). The patient underwent chemotherapy and intrathecal injection, resulting in the elimination of the residual lesion. Correct diagnosis and adequate treatment are essential to achieve optimal results in patients with isolated spinal GS. Granulocytic sarcoma (GS), also referred to as myeloid sarcoma or chloroma, is a rare malignant tumor caused by the extramedullary proliferation of myeloblasts or immature myeloid cells –3. GS usThe present study describes a case of isolated spinal subdural GS and a further diagnosis of CNS leukemia (CNSL) which was successfully treated with surgery, intensive chemotherapy and intrathecal injection.9/l, hemoglobin count of 119 g/l and platelet count of 200×109/l. The patient immediately underwent surgical intervention with the resolution of the neurological symptoms. The pathological evaluation of the vertebral canal mass showed homogenous malignant infiltration containing round nuclei, dispersed chromatin and ill-defined eosinophilic cytoplasm . Biochemical analysis of the cerebrospinal fluid (CSF) showed that the CSF WBC was 220×106/l and protein was 1.19 g/l. Cytological examination of the CSF revealed a predominance of myeloid cells, including myeloblasts. The final histological diagnosis was CNSL.A previously healthy 34-year-old female exhibited a 5-month history of progressive anesthesia and weakness in the left hand fingers. In March 2012, magnetic resonance imaging (MRI) showed that the neck and thoracic portions of the spine were involved. Soft tissue masses were observed in the spinal canal distributed along the course of the nerve root, at the C6-T1 level . Blood tytoplasm . Immunohytoplasm , partly ytoplasm , positivytoplasm  and negaytoplasm . LaboratSystemic induction chemotherapy was started following diagnosis and consisted of daunorubicin  and cytarabine (200 mg/day continuous i.v. on days 1–7) for 1 course, followed by pirarubicin  and Ara-C (200 mg/day continuous i.v. on days 1–7). During the chemotherapy, the patient also received 6 intrathecal injections containing 15 mg MTX, 50 mg Ara-C and 10 mg DXM each time. At follow-up 2 months later, the CSF WBC had disappeared and protein was 0.24 g/l. Cytological examination of the CSF did not reveal any clear myeloid tumor cells.A visual representation of the disease site and metabolic remission was achieved by FDG-PET. The maximal SUV of the FDG uptake in the left trapezius muscle was 1.2, much lower than pre-treatment value. The maximal SUV decreased from 4.2 to 2.1 in the cervix uteri, while FDG uptake disappeared in the iliac bone, lymphadenectasis of the left axillary fossa and pelvic wall . Bone maGS is a localized tumor formed by primitive myeloid cells at an extramedullary site. GS was first described by Burns in 1811 and named chloroma in 1853 due to the infrequent greenish appearance observed as a result of myeloperoxydase granules in the malignant myeloid cells . GS may Pathologically, the variable morphology may be misleading in GS. The correct diagnosis is sometimes challenging and is obtained in only ∼50% of non-leukemic patients due to the histological and radiological similarities to malignant lymphoma . The defAn early and precise diagnosis of spinal GS with MRI evaluation facilitates appropriate treatment with further therapy . HoweverThe prognosis of patients with GS depends on the initial context in which it occurs. Out of all isolated GS patients, 66–88% develop AML within 9–11 months of diagnosis ,14. In tIn accordance with the previously mentioned studies, the present patient was successfully treated using surgery and intensive anti-leukemic chemotherapy accompanied by intrathecal injections. The present case highlighted the importance of a correct diagnosis. Pre-therapeutic examinations should be the basis for the diagnosis of a mass with an atypical clinical presentation. Notably, treating GS in the same manner as AML may benefit patients with isolated spinal GS.