Background. Lymphatic malformations or lymphangiomas are rare benign hamartomas that result from maldevelopment of primitive lymphatic sacs. They are most frequently found in the neck and axilla, while intra-abdominal and mediastinal lymphangiomas are uncommon. These are primarily tumours of infancy and childhood and are successfully treated with surgical excision. Summary of Cases. Five cases of lymphangioma comprising three intra-abdominal lymphangiomas and two unilateral axillary lymphangiomas presenting at one institution in Trinidad W.I. between 2005 and 2012 were examined. The presentations, location, workup, treatment, and outcome of these patients were studied. Conclusion. This paper discusses a range of extracervical lymphangioma cases seen at San Fernando General Hospital, Trinidad W.I. We report three intra-abdominal cases and the most common clinical presentations were abdominal pain and distension. Also two axillary cases were reported, which presented as painless axillary masses. The major concerns for excision of axillary lymphangioma by parents and surgeons were cosmesis and feasibility of complete resection without disruption of developing breast tissue and axillary vessels. We believe that ultrasound scan is very good at detection of the lesion, while CT is better at determining tumour content and planning for the operation. It is our opinion that complete surgical excision can be achieved. Lymphangiomas are benign lesions characterized by proliferation of lymphatic vessels. Approximately 50% are present at birth and 90% are diagnosed before the age of 2 . They arThe first patient was a 6-year-old female who at 6 weeks of life had a surgically resected cystic lymphangioma of the sigmoid colon . She was previously well; however, she began experiencing symptoms of intermittent periumbilical abdominal pain, accompanied by vomiting, constipation, and abdominal distension, which necessitated two separate admissions. On the first admission, she was treated for acute intestinal obstruction, which spontaneously resolved after several days at the hospital. Three months later, she presented with periumbilical pain for two days followed by vomiting, abdominal distension, and headaches. On examination, her abdomen was noted to be mildly distended, but no discrete masses were palpated. She had no family history of malignancy or congenital malformations. On this admission, her haemoglobin (Hb) was found to be 5 gm/dL and she required transfusion of 250 mLs of packed red cells. Her posttransfusion Hb increased to 9.5 gm/dL. Abdominal X-ray did not show any bowel dilation or air fluid levels. Given the patient's past surgical history, there was a high index of suspicion for recurrence of the intra-abdominal lymphangioma. Other differentials included intestinal obstruction and mesenteric adenitis. A computed tomography (CT) scan of the abdomen with IV (intravenous) contrast was performed which showed a cystic mass on the colon and she had surgical intervention. Findings of the surgery included a retroperitoneal cystic lymphangioma enclosing a 50 mL organized clot in the left iliac fossa, multiple peritoneal adhesions, mesenteric windows, adhesions enclosing small bowel into artificial sac, and a ventral incisional hernia. Histology confirmed cystic lymphangioma. The patient has been followed up with regular ultrasound scans (USS) for the past 9 years and there has been no evidence of recurrence or intestinal obstruction thus far.A 4-year-old male presented with 2-day history of periumbilical pain and a past history of occasional constipation without any significant past medical history and no family history of malignancy or congenital abnormalities. On examination he was found to have a mildly distended, nontender abdomen with diffuse left flank firmness, but no discrete mass was appreciated. The patient continued to have colicky abdominal pain but no constipation or vomiting. CT scan abdomen with IV contrast was performed which showed a 30 cm by 10 cm left sided isodense retroperitoneal mass attached to the lower pole of left kidney . Based oThe patient was a 4-year-old female who was referred from a rural health center with 2-week history of progressive abdominal distension. She was otherwise asymptomatic with a positive history of passing stool and flatus. There was no significant past medical history or history of prior abdominal surgery or trauma. She had no family history of malignancy or congenital abnormalities. On abdominal examination, a mass arising from the pelvis was palpable. An abdominal USS revealed a 14 cm by 7 cm by 12 cm fluid filled structure in the left half of the abdomen extending into the pelvic cavity . AbdominThe patient was an 8-year-old female who presented with a 4-day history of a swelling to the left side of her chest that was increasing in size and she was otherwise asymptomatic. She had no medical problems and no significant family history. Interestingly, she was known to have a lymph node in the same area 7 years prior and was scheduled for surgical excision, but it resolved and hence no surgery was done at that time. On examination, she was found to have a 3 cm by 3 cm firm, smooth mass in her left axilla with no surrounding lymphadenopathy. USS of the chest showed a heterogeneous solid and cystic mass in the left axilla . The patThis male patient was referred to us at birth with a right chest swelling . USS of Lymphatic malformations or lymphangiomas are congenital anomalies composed of dilated lymphatic channels. They are filled with a proteinaceous fluid and generally do not have connections to the normal lymphatic system . LesionsCavernous lymphangiomas occur in areas of loose connective tissue, areola, and are found primarily during infancy, and most are diagnosed by the age of 2 . They arAbdominal cystic lymphangioma (ACL) may occur anywhere along the course of the gastrointestinal tract and visceral organs. ACL has been found to occur in the small bowel mesentery in 80% of cases, while retroperitoneal location appears to be less common . AbdominAxillary lymphangiomas typically present as painless swellings, which are soft, compressible, nontender, and transilluminant and are without a bruit on physical examination . AxillarAxillary lymphangiomas can be complicated by infection usually secondary to a respiratory tract infection. Infected lesions become red and tender and the patient may become pyretic. In some cases, they may turn into abscesses and require incision and drainage . AnotherRadiological investigations greatly aid in the preoperative diagnosis of lymphangioma with ultrasound scan (USS) being used as the initial mode of investigation, detecting the lesion in 100% of cases in one study . In caseSurgical excision is known to be the gold standard for treatment of all types of lymphangioma and hence was the mode of treatment in all of the above cases. However, incomplete surgical resection is linked with recurrence as seen in case 1. Recurrence rate accounts for 10% of cases due to difficulty in resecting the entire cyst wall and is especially so for retroperitoneal cysts due to close relationship to vital retroperitoneal structures which make resection very hazardous or even impossible . PostopeUse of sclerosing agent such as bleomycin at the time of operations remains controversial but may have some benefit in management of extra-abdominal lymphangioma . Ozeki eLaparoscopic resection of ACL is not well documented in children but Son and Liem strongly advocate that laparoscopic surgery is both safe and feasible in resection of ACL in children. In their study of 47 children with ACL, there were no reports of mortality or intestinal obstruction postoperatively and there was a conversion rate of only 6.8%. They suggest that many cases can in fact be performed by a single port technique .The diagnosis of lymphangioma is confirmed by histology, which shows benign cystic proliferation of lymphatic tissue. However typically they do not communicate with the lymphatic system . Immunoh Intrathoracic cystic hygroma in an infant with respiratory failure, Balkaran et al. (Trinidad) [ Orbital lymphangioma in a child: a diagnostic dilemma, Mowatt and Crossman (Jamaica) [There is very limited regional data regarding lymphangioma. Only two regional publications exist,rinidad) , and OrbJamaica) . No publThis paper discusses a range of extracervical lymphangioma cases seen at San Fernando General Hospital, Trinidad. We report three intra-abdominal cases, and the most common clinical presentations were abdominal pain and distension. Also two axillary cases were reported, which presented as painless axillary masses. The major concerns for excision of axillary lymphangioma by parents and surgeons were cosmesis and feasibility of complete resection without disruption of developing breast tissue and axillary vessels. We believe that ultrasound scan is very good at detection of the lesion, while CT is better at determining tumour content and planning for the operation. It is our opinion that complete surgical excision can be achieved.


Stroke is an extremely uncommon cause of transient global amnesia (TGA). Unilateral lesions of the fornix rarely cause amnesia and have not previously been reported to be associated with the distinctive amnesic picture of TGA. We describe the case of a 60-year-old woman who presented with acute onset, recent retrograde, and anterograde amnesia characteristic of TGA. Serial magnetic resonance imaging showed a persistent focal infarction of the body and left column of the fornix, without acute lesions in the hippocampus or other structures. Amnesia resolved in 6 h. Infarction of the fornix should thus be included in the differential diagnosis of TGA, as it changes the management of this otherwise self-limited syndrome. Transient global amnesia (TGA) is a clinical syndrome characterized by transient loss of recent retrograde and anterograde memory with preservation of immediate recall, remote memory, visual-spatial function, attention, and language . Most paThe fornix comprises efferent fibers from the hippocampus to the mammillary bodies and anterior thalamic nuclei, connecting structures involved in processing and storing memory. While amnesia may occur following ischemia of the bilateral fornices , isolateA 60-year-old woman presented to the Emergency Department at our institution with sudden onset of retrograde amnesia for events of the previous day along with severe anterograde amnesia. Although she had spent the day doing various chores with her brother, she could not recall any events after eating breakfast. She repeatedly asked her brother the date and what they had done that day, despite just having heard the answer. She was unable to recall other recent events such as a family friend falling ill or political news she had been following. Her symptoms began while running errands, approximately 3–5 h after undergoing an abdominal CT scan. She could not identify any other discrete stressful event preceding symptom onset. She endorsed intermittent headaches for the previous 5 days that lasted about 45 min without features of migraine; some worsening of long-standing mild left-sided residual weakness from prior embolic stroke; and a recent urinary tract infection.Past history was notable for paroxysmal atrial fibrillation complicated by prior embolic stroke and retinal artery occlusion, bicuspid aortic valve status-post prosthetic aortic valve replacement, hypertrophic cardiomyopathy, prior non-ST elevation myocardial infarction (NSTEMI) secondary to demand ischemia, cervical myelopathy, hypothyroidism, hyperlipidemia, and depression. She never used tobacco, alcohol, or illicit drugs. Medications included warfarin, celecoxib, dronedarone, ezetimibe, colesevelam, furosemide, spironolactone, levothyroxine, and zolpidem.Physical examination was notable for mild hypertension (136/99 mm Hg) and a grade III/VI harsh crescendo-decrescendo systolic murmur at the left upper sternal border. She was alert and oriented, without facial droop, dysarthria, aphasia, diplopia, or changes in hearing, taste, or sensation. She had normal cranial nerves, sensory and cerebellar function, narrow-based shuffling gait, brisk and symmetric reflexes, equivocal Babinski’s sign, and left pronator drift. Power was 4/5 in the left upper and lower extremity, as well as the right wrist extensors, finger extensors, and hallucis longus. Laboratory tests were remarkable for mild leukocytosis with neutrophilia, therapeutic INR (2.5), microscopic hematuria, and normal electrolytes and renal and liver function. Troponin was mildly elevated (0.7 ng/mL) and EKG showed no ST elevation. Head CT without IV contrast showed scattered intraparenchymal calcifications consistent with old neurocysticercosis, and no acute abnormalities.Aspirin 81 mg and atorvastatin 80 mg were administered in the Emergency Department based on initial suspicion for nSTEMI or stroke. Amnesic symptoms resolved within 6 h of onset. The mild pronator drift, shuffling gait, and exacerbation of left-sided weakness also resolved. MRI and MRA with Multihance IV contrast on a 1.5 T scanner showed a small focus of restricted diffusion involving the body and left column of the fornix consistent with acute infarction , over the next 2 days of inpatient stay and at 1-month follow-up.Our patient presented with classic symptoms of TGA and had evidence of unilateral infarction of the left fornix on imaging. To our knowledge, there is only one previous report of an isolated unilateral infarction of the fornix . That paPrevious reports have described memory impairment associated with unilateral lesions of the fornix, usually a consequence of accidental trauma or surgical injury rather than infarction Table  5–10). –10. 5–10Similarly, while cases of infarction of the fornix resulting in memory loss have been reported, these patients had bilateral fornix ischemia or simultaneous ischemic damage to additional structures involved in memory, making it difficult to attribute the amnesia to the fornix lesion alone . When thInstead, our patient presented with a classic case of TGA. However, the characteristic pattern of memory loss as well as the etiopathological and anatomical correlates in TGA  are quitOur patient did not participate in any physical activities, or have any of the clinical or psychological events, medical procedures, or medication changes reported to precipitate TGA. She had numerous risk factors for cardioembolic and atherosclerotic small vessel occlusive stroke, as well as for intracranial hemorrhage given concurrent use of both warfarin and celecoxib. This infarction was unlikely due to cardioembolism, despite the history of atrial fibrillation because the vascular supply of the fornix consists of small perforating branches of the anterior communicating or proximal anterior cerebral arteries. Our patient was treated with standard secondary stroke risk factor modification, including continuing her anticoagulation with warfarin, a cholesterol-lowering agent, blood pressure recommendations, and lifestyle coaching.Transient global amnesia can occur in association with small, isolated unilateral lesions of the fornix, extending the locations of lesions that cause this syndrome. Since TGA is rarely associated with irreversible brain lesions, resolves spontaneously, and usually does not recur, standard management is expectant. Timely evaluation by MRI should be strongly considered in cases of TGA in order to exclude the possibility of infarction, particularly in patients with risk factors for stroke. Though a rare cause of TGA, infarction should be included in the differential diagnosis since it will change management and prognosis.Study concept and design: Mihir Gupta, Molly A. Kantor, Christie E. Tung, and Gregory W. Albers. Acquisition, analysis, or interpretation of data: Mihir Gupta, Molly A. Kantor, Christie E. Tung, and Gregory W. Albers. Drafting of the manuscript: Mihir Gupta, Molly A. Kantor, Christie E. Tung, Niushen Zhang, and Gregory W. Albers. Critical revision of the manuscript for important intellectual content: Mihir Gupta, Molly A. Kantor, Christie E. Tung, Niushen Zhang, and Gregory W. Albers. Study supervision: Gregory W. Albers.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Hip arthroplasty represents one of the greatest technological developments of the modernmedicine that is beneficial to a wide range of patients. However, like every surgery, it issubjected to a series of complications, some of them easily and other not so easilyrecognizable, as in the case of inflammatory pseudotumor..Pseudotumors may be found in cases of well-functioning hip prostheses as well as in painfulhips, and for this reason a clinical evaluation associated with a correct diagnosis areessential both for the prognosis and for the definition of the therapeutic approach to thepatients, since the presence of a periprosthetic cystic collection is not necessarilyconnected with a revision of the prosthesis in thepresent issue of Radiologia Brasileira, one can notice that this diagnosispractically represents a challenge to this clinical specialty.In such cases, magnetic resonance imaging (MRI) has shown to be effective and accurateprincipally in the assessment of soft parts. However, after reading the review articlepublished by Vilas Boas et al..Firstly, the presence of magnetic susceptibility artifacts caused by the prosthesesgenerates great image distortion which limits the appropriate visualization and,consequently, makes the diagnosis more difficult. Despite the availability of innumerabletechniques and sequences to reduce such artifacts, varying according the equipment, manytimes they determine loss of images resolution. In the diagnosis of the latter, besides a detailed clinical history,diffusion-weighted MRI shows to be extremely effective, but due to prostheses-relatedtechnical limitations, it cannot be performed.Once the technical issues are overcome, there are still the main differential diagnoses tobe faced, namely, sarcomas  that hardly can be recognized, truly awolf in sheep's clothing, and also abscessesFinally, the lack of personal contact between physicians and patient in addition to anincomplete or inappropriately collected clinical history result in failure to detect such asurgical complication.Thus, radiologists should be quite attentive and recognize that innumerable variablescontribute to failure in the early diagnosis of inflammatory pseudotumors. Medical wisdom,besides clinical attention towards the patient and, obviously, technical skills arefundamental in such cases. Reaching this goal will be possible with a technical teamconstituted of skilled MRI technologists and nursing technicians, besides experiencedradiologists with appropriate knowledge.


Perivascular epithelioid cell tumors are mesenchymal tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells. This type of tumor is rare but bladder localization is even rarer.A case of bone metastatic bladder perivascular epithelioid cell tumor in a 65-year-old Caucasian man treated with surgery and chemotherapy is described and compared with other reports in the literature.The rarity of perivascular epithelioid cell tumors hinders the development of a standard therapeutic approach, and thus requires case report descriptions. There is a need for cooperative studies to enlarge the case series and establish the best treatment strategy for this rare disease. The PECg others .PEComas are rare and only 13 cases of bladder localization have been reported in the literature [2) had a history of ischemic heart disease and lower urinary tract symptoms secondary to benign prostatic hyperplasia, which was under pharmacological treatment with alpha-blockers. He consulted us due to recurrent hematuria and back pain that had been unsuccessfully treated with antibiotics and anti-inflammatory drugs in the previous 2 months. His physical examination was normal. A digital rectal examination revealed a moderate increase in prostatic gland size without any finding suspicious for neoplastic disease.The results of his blood tests were normal and his total prostate-specific antigen value was 2.2ng/mL. An abdominal ultrasound showed normal kidneys and a lesion of his right bladder wall associated with a 2cm calculus. On cystoscopy, his bladder lesion was a solid, sessile, mass of 2.5cm on the right lateral wall, 3cm from his right ureteral orifice; a 2cm bladder stone was confirmed. Abdominopelvic contrast computed tomography (CT) showed mild heterogeneous enhancement of the lesion, which infiltrated his bladder wall. No other lesions or local or systemic adenopathy were observed . The treatment was well tolerated and analgesics were not necessary. Side effects were nausea, asthenia, moderate thrombocytopenia  and neutropenia (4100 white blood cells/mcL).Based on the histopathological examination and negative CT findings with symptoms (persistent back pain), positron emission tomography (PET) was performed, which showed an increased uptake of the radiopharmaceutical drug at specific skeletal segments: somas of L1, L5, and the left iliac wing. After surgery, he had a performance status of 1 and reported a moderate pain in his lumbar region with a visual analog scale  of 5. Chemotherapy was therefore planned. Previous ischemic heart disease and the echocardiographic finding of reduced systolic function with first-degree diastolic dysfunction prevented the use of anthracyclines, which are the standard first-line treatment for soft tissue sarcomas -10. GemcSix months after starting chemotherapy, CT assessment showed a stable disease according to the response evaluation criteria in solid tumors; no bladder recurrence was observed on PET or cystoscopic control; skeletal metastases were reduced and no other secondary lesions were observed. He is presently clinically stable.et al. in 1996 to identify a group of mesenchymal neoplasms originating from perivascular epithelioid cells [The definition of PEComa was suggested by Zamboni id cells . Howeverid cells . We therid cells .Based on this classification, adding medical treatment to surgery in patients with these histopathologic findings is advisable. Unfortunately, the authors who reported their experience of PEComas used different therapies and reported different follow-up procedures, thus preventing comparison of outcomes and assessment of a standard protocol for treatment . Specifiet al. treated a bladder PEComa with primary excision and adjuvant interferon-alpha immunotherapy with evidence of remission until 48 months of follow-up [In the present case, gemcitabine was selected as chemotherapy due to the patient’s cardiovascular disease, which did not allow the use of drugs with cardiotoxic risk. At present, he is clinically stable with no cystoscopic, PET, or CT evidence of disease progression, thus implying good efficacy of our therapeutic approach. Conversely, Parfitt ollow-up . No otheTSC1 (9q34) or TSC2 (16p13.3) genes, which seem to have a role in the regulation of the Rheb/mTOR/p70S6K pathway.In terms of medical treatment, even though not specifically for bladder localization, encouraging outcomes have been reported with administration of mammalian target of rapamycin (mTor) inhibitors. In particular, a case of retroperitoneal PEComa was reported in a man with complete disease regression after treatment with everolimus . PEComaset al., it should be noted that these approaches derive from anecdotal cases as no therapeutic trial has so far been implemented due to the rarity of the disease [However, as reported by Martignoni  disease . An inteThe majority of bladder tumors are of urothelial origin and, generally, small lesions are considered to have limited metastatic risk. However, the case reported here shows that the histopathological characteristics of a bladder tumor may sometimes be different and carry a high metastatic risk.PEComas are very rare, but they may occur in the urinary bladder; the case reported here adds to the small body of literature that demonstrates that they can metastasize in different sites of the human body. Surgical removal remains the most important therapeutic approach while controversy is still ongoing about the best postoperative therapeutic management. Based on the large body of experience present in the literature on the treatment of soft tissue tumors, the use of anthracyclines could also be considered a good therapeutic option for PEComas, but single-agent chemotherapy with gemcitabine should be considered an option in patients selected for comorbidities until standard treatment protocols can be generated from larger comparative trials.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.CT: Computed tomography; PEComas: Perivascular epithelioid cell tumors; PET: Positron emission tomography; TSC: Tuberous sclerosis complex; VAS: Visual analog scale.The authors declare that they have no competing interests.GP and ALP conceived the study and design. GP, ALP, LS, LR, CDC, NP, SE, VP, ST, and AC undertook acquisition of data. GP, ALP, LS and SE analyzed and interpreted the data and drafted the manuscript. SE, LR, and NP performed critical revision of the manuscript. AC, ALP, ST supervised the study. All authors read and approved the final manuscript.


MIB-1 index was approximately 5% in immature cells observed in granulomatous areas. We thus suspected a coexisting neoplastic component. The residual lesion persisted in a dormant state for 2 years following biopsy. Surgical resection of a lipoma is extremely difficult and potentially dangerous. However, in the present case, the lesion was accompanied by atypical, expanding, and perifocal edema. Surgical treatment was inevitable for the purpose of histological confirmation, considering differential diagnoses such as dermoid, epidermoid, and glioma. In the end, anticonvulsant therapy proved effective for controlling epileptic seizures.This report describes a rare case of a patient with lipoma presenting with epileptic seizures associated with expanding perifocal edema. The patient was a 48-year-old man who presented with loss of consciousness and convulsions. Magnetic resonance imaging (MRI) revealed a calcified mass in the corpus callosum with perifocal edema causing mass effect. An interhemispheric approach was used to biopsy the mass lesion. Histological examination revealed typical adipose cells, along with hamartomatous components. These components contained neurofilament and S-100-positive structures showing marked calcification. Fibrous cells immunoreactive for  Intracranial lipomas are rare, accounting for 0.1–0.5% of all primary brain tumors. Intracranial lipomas are attributed to abnormal differentiation of persistent primitive meninx , followed by transformation into mature adipose cells . LesionsIn general, intracranial lipomas are asymptomatic. Epileptic seizures are a common symptom and are sometimes refractory to anticonvulsant treatment –10.Histological findings of intracranial lipoma have been described in detail in the literature , 12. BudDifferential diagnosis for intracranial lipoma includes radiographically similar lesions such as dermoid, epidermoid, and gliomas, and differentiation from these pathologies is important for appropriate therapeutic planning.Radical surgical resection is usually contraindicated because of the nature of the lesion and may result in high morbidity and mortality rates, given the vascularity and strong adhesion to surrounding tissue , 13. HowA 48-year-old man presented with loss of consciousness on two occasions and paresthesia of the right extremities. A calcified cystic lesion was noted in the corpus callosum on computed tomography (CT) . MagnetiAs the differential diagnoses included oligodendroglioma, metastasis, and teratoma, in addition to lipoma, the patient underwent left frontal craniotomy via an interhemispheric approach. The mass was located extra-axially and was not attached to the falx , consistα-smooth muscle actin (SMA) were seen intersecting fascicles with deposition of collagen fibers .Intracranial lipoma was originally described in 1856 by von Rokitansky and was considered a benign, slow-growing, and congenital hamartomatous condition . These lIn general, lipomas are asymptomatic, and the association between epileptic seizures and intracranial lipoma remains controversial. When symptomatic, lipomas in the sylvian fissure or cortex, or associated with focal cortical dysplasia, usually present with epileptic seizures, presumably due to irritation of the cortex –10. It iSurgery is unnecessary for stable or asymptomatic cases, since the risks for radical resection far outweigh any potential benefits , 13. EveAs described above since the radical resection was seldom attempted, very few reports have described histological findings of the intracranial lipoma , 14, 15,Rubinstein described that the intimate relationship of neuroglial to mesenchymal elements in intracranial lipomatous hamartoma possibly coexisted with muscle fibers, nerve cells, calcifications, and bone formation . Histolo


Solitary fibrous tumor (SFT) is a rare neoplasm occurring in the central nervous system. It rarely occurs in the spine. This paper reports the fifth case of SFT in a 34-year-old female and focusses on differential diagnosis and importance of surgical treatment. Solitary fibrous tumor (SFT) is a rare neoplasm that was initially described in the visceral pleura and subsequently reported in extrapleural sites including the pericardium, peritoneum, mediastinum, lung, upper respiratory tract, thyroid, liver, testicle, nasal cavity, parotid, orbit, and meninges –3. The lA 32-year-old female, with no significant medical history, has had paresthesia of both lower limbs for one year. This paresthesia was associated with nocturnal lumbar pain decreasing with nonsteroidal anti-inflammatory drugs (suggesting osteoid osteoma). Three months ago, she noted an aggravation of her low back pain which became resistant to all types of medication. She also noted a limitation of her walking distance without any motor symptom or neurologic claudication.On physical examination, she presented a normal motor exam of both upper and lower limbs. She only had diminution of proprioception in distal right lower limb (no definite dermatome). She had normal osteotendinous reflexes, normal anal sensation, and bilateral absence of Babinski sign.X-ray did not show any abnormality. An MRI showed a hyperintense lesion of the lumbar spine on T1 weighted images on the posterior aspect of the L3-L4 disc. The lesion is hypointense on T2 weighted images. It showed contrast uptake with gadolinium injection . The difShe was operated on with resection of hard, highly vascular tumor in a piecemeal fashion. The tumor had a dural attachment to the anterior part of the dural sac. Her postoperative period was noticeable for disappearance of her symptoms and total recovery. Her follow-up at 16 months is unremarkable.The literature review yielded only 4 well-documented studies describing mSFT of the lumbar spine. All characteristics as well as our case are described in SFT was first described in the meninges as a lesion distinct from fibrous meningioma in 1996 . Since tLumbar mSFT presents with the signs of local compression of the conus terminalis, cauda equina, or the exiting nerve roots. Lumbar pain is a frequent sign , 6, 9. OThis tumor may mimic other dural-based tumors such as hemangiopericytoma, fibrosarcoma, schwannoma, and neurofibroma, all of which may share pathological similarities with SFT  Table 2Table 2. Histologically, SFT consists of monomorphic spindle cells both organized into straight, curving, or undulating fascicles and arranged in an unstructured fashion. Focally prominent bands of hyalinized collagen are characteristic and spindle cells are typically embedded in a conspicuous fibrous matrix . It is n


Background. Genital leiomyomas fall under the broader category of cutaneous leiomyomas, which are rare smooth muscle neoplasms accounting for 5% of all leiomyomas. Genital leiomyomas arising from the dartos muscle are exceedingly rare with fewer than 30 cases reported in the literature. They are typically benign and adequately treated with simple surgical excision; however, previously reported cases of malignant transformation and a possible link to the hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome warrant closer follow-up. Case Presentation. We report a case of a 47-year-old male refugee from Rwanda found to have a mobile, pea-sized, mildly painful scrotal lesion near the left penoscrotal junction and 1.5 cm indeterminate vascular mass in the right kidney. Surgical excision of the scrotal nodule was performed and the diagnosis of a dartoic leiomyoma was rendered. The presence of moderate nuclear atypia, rare mitotic activity, and close surgical margins prompted a wide reexcision. We report the surgical approach, pathologic findings, and clinical follow-up related to this scrotal lesion. Conclusion. Scrotal leiomyomas demonstrate a high rate of recurrence and pose a risk for malignant transformation. They may also indicate an underlying autosomal dominant syndrome associated with increased risk for development of an aggressive form of renal cell carcinoma. When discovered, management should include surgical excision, screening for syndromic features, and routine follow-up. Leiomyomas are benign smooth muscle neoplasms commonly found in the uterus and gastrointestinal tract. Cutaneous leiomyomas are a subcategory of leiomyomas comprising less than 5% of the total number of these tumors. Within this category are genital leiomyomas, which can arise from the smooth muscle of the tunica dartos, areola, or vulva. Although leiomyomas can originate anywhere along the male genitourinary system, scrotal leiomyomas arising from the tunica dartos are exceptionally rare with fewer than thirty cases having been reported in the literature –3. Here The patient is a 47-year-old male refugee from Rwanda who was referred for urologic evaluation by his primary care physician for a mildly painful, slowly enlarging nodule on his left hemiscrotum. The lesion had been present for two years, having become painful over the past 6 months. The patient reported no associated discharge or changes in color or texture. He denied any personal or family history of genitourinary malignancies or dermatologic issues.A genitourinary examination demonstrated a mobile, pea-sized, scrotal lesion near the left penoscrotal junction. No other masses, lesions, or inguinal adenopathy were noted. At the time, the lesion appeared to be most consistent with a sebaceous cyst. A complete dermatologic examination was also performed which did not demonstrate any other lesions.Given the unknown etiology of this scrotal lesion, a scrotal ultrasound was performed to evaluate any deeper involvement. This demonstrated a 7 mm superficial, hypoechoic soft-tissue nodule . An inciDue to the uncertain nature of the scrotal nodule and the patient's report of bothersome pain, the patient was offered continued observation or surgical excision and elected for the latter. After infiltration of the area with 1% lidocaine, an elliptical skin excision was made encompassing the lesion measuring approximately 1.0 cm × 2.0 cm. This was then dissected free from the subcutaneous tissue, showing no obvious extension of the nodule into deeper tissue. The patient tolerated the procedure well and was able to return home in stable condition.Gross evaluation of the specimen revealed a well-circumscribed, subcutaneous nodule measuring 0.8 cm. The nodule revealed homogenous, tan, whorled cut surfaces. Histologic evaluation revealed a well-circumscribed, nodular lesion arising from the tunica dartos, comprised of interlacing fascicles of bland, spindled cells with eosinophilic cytoplasm and blunt-ended, elongated, cigar-shaped nuclei with perinuclear halos and mild to moderate cytologic atypia Figures . Rare miAfter discussion of the pathology results with the patient including the close margin status of the original excision (less than 1 mm margin), the patient was offered observation or wide reexcision to prevent tumor recurrence. The patient wished to proceed with reexcision, which was performed without complication. Pathologic examination of the reexcision demonstrated chronic inflammation and fibrous tissue, consistent with a previous surgical site, but no residual leiomyoma. His follow-up two-week later examination demonstrated an appropriately healing surgical site.The presence of a dartoic leiomyoma in this patient with a renal mass of undetermined etiology raised the possibility of hereditary leiomyomatosis and renal cell carcinoma syndrome (HLRCC). The underlying defect of this disorder is an inactivating germline mutation in fumarate hydratase (FH). Although not employed currently as a routine clinical screening method for HLRCC, we acquired an antibody directed against FH  and performed staining on the lesion using two benign uterine leiomyomas as positive controls. By this method, we found intact FH expression in the patient's lesion  suggestiCutaneous leiomyomas are rare tumors of smooth muscle origin that may arise in sporadic fashion or in the setting of HLRCC, a heritable tumor predisposition syndrome. Three subtypes of cutaneous leiomyoma are currently recognized, including piloleiomyomas (arising from pilar erector muscle), angioleiomyomas (arising from vascular smooth muscle), and genital leiomyomas , 2. GeniLeiomyomas of the tunica dartos are typically well-circumscribed, unencapsulated nodules located in the subcutaneous tissue with a minimal to moderate amount of atypia , 3. GeniFeatures suggestive of malignant transformation in these tumors include hemorrhage as well as diffuse cytologic/nuclear atypia, two or more mitotic figures per 10 high-power fields, and/or necrosis. As with all smooth muscle neoplasms of somatic soft tissues, distinction between cytologic atypia of malignancy and degenerative atypia can be problematic in clinical practice, although the suspicion for malignancy is increased when multiple ominous features are observed, particularly if necrosis is also present . Cases oIn an effort to describe the salient features and further define the diagnostic criteria of scrotal smooth muscle neoplasms, a recent comparative study by Matoso et al. reviewed 24 smooth muscle tumors of the scrotum. The case series included usual leiomyomas, symplastic leiomyomas, and leiomyosarcomas. In this study, the benign entities of usual and symplastic leiomyomas were small in size (less than 1.5 cm in diameter) and well-circumscribed, often contained lymphoid aggregates, and showed low proliferation indices (<5%) as demonstrated with Ki-67 staining with lack of significant mitotic activity. The level of atypia and increased cellularity were the main distinguishing features when making a distinction between usual and symplastic leiomyomas. The leiomyosarcomas, on the other hand, averaged 2.0 cm in diameter, were well-circumscribed with less ill-defined borders, did not contain lymphoid aggregates, and showed increased proliferative indices and mitoses . While tMost cutaneous leiomyomas have unknown and sporadic pathogenesis. However, some occur in the setting of an underlying hereditary autosomal dominant tumor predisposition syndrome that is associated with increased risk for development of an aggressive form of renal cell carcinoma , 8. PatiIn patients with HLRCC syndrome, Malik et al. recommend annual full-body skin exams and biyearly radiological investigation in addition to surgical excision for evaluation and treatment of cutaneous leiomyomas . Due to Genital leiomyomas of the scrotum are rare neoplasms. When this diagnosis is rendered, it is important to recognize that these neoplasms usually behave in a benign fashion but demonstrate a high rate of recurrence, can undergo malignant transformation in some cases, and may be the first clue suggesting a diagnosis of HLRCC. As such, it is important not only to ensure that the surgical margins are clear on initial excision but also to closely monitor the patient over time for the development of new or recurrent leiomyomas and/or renal tumors and to consider ancillary tests for HLRCC, such as FH immunohistochemistry and germline molecular testing.


Pulmonary epithelioid hemangioendothelioma (PEH) is a rare vascular tumor of borderline malignancy that originates from endothelial cells. Chest computed tomography (CT) performed during a routine cancer screening revealed multiple small pulmonary nodules in a 50-year-old man who had previously undergone endoscopic submucosal dissection of early gastric cancer. To rule out metastatic nodules, a wedge resection of the left upper lobe was performed and the frozen biopsy reported a benign fibrotic nodule. Using immunohistochemistry, the final pathology was indicated to be PEH, and consecutive surgery for the right-side nodules was planned and performed. Epithelioid hemangioendothelioma is a rare vascular tumor, originating from endothelial cells, which is histologically characterized by an epithelioid appearance . The terWe describe a case of PEH misdiagnosed as a benign fibrotic nodule from frozen biopsy analysis following video-assisted thoracoscopic surgery (VATS). We performed a consecutive operation for the other nodules after confirming PEH based on the permanent biopsy report.A 50-year-old man who visited the hospital every year after endoscopic submucosal dissection of early gastric cancer underwent a chest computed tomography (CT) for cancer screening. The patient was a 50-pack-year current smoker, but he did not have any respiratory or systemic symptoms. The chest CT scan showed small nodules on both sides of the lungs. There was a peripherally located small nodule with lobulation in the apicoposterior segment of the left upper lobe (LUL) and two tiny nodules in the posterobasal segment of the right lower lobe (RLL) Figure . Levels Under general anesthesia, the surgeons performed a wedge resection by VATS. The LUL nodule was palpable to the finger and was 1 cm in size, hard, and capsulated in nature. There was no adhesion with the lung parenchyma or pleura. The frozen biopsy showed a hypocellular nodule in a fibrotic stroma. It was reported as a fibrotic nodule. The RLL nodules were also considered as benign because of similar features. A CT follow-up of these nodules was planned rather than surgical resection. Postoperatively, the patient did not show any surgical complications.The pathological findings of the resected LUL nodule indicated a well-demarcated hypocellular hyalinized nodule. Generally, the neoplastic cells were loosely embedded in hyalinized fibrous stroma individually, although it was more dense cellularly at the periphery of the nodule. The neoplastic cells showed no nuclear atypia and contained variably prominent eosinophilic cytoplasm with or without cytoplasmic vacuoles which was reminiscent of endothelial differentiation. The tumor cells also showed immunoreactivity for CD31 Figure . These fEpithelioid hemangioendothelioma is a rare tumor, which mainly affects the liver and, more rarely, the lung. The other organs affected tend to be superficial or deep soft tissues of the extremities. The estimated prevalence of epithelioid hemangioendothelioma is less than 1 in 1 million . InitialOur patient’s age was 50 years, which is somewhat older than the age at which patients typically present with PEH. He had bilateral pulmonary nodules and showed lobulated lesions without pleural thickening. Given the multiple small round pulmonary nodules, we considered metastatic nodules to be a possibility. From the results of the frozen biopsy analysis, we did not deem it necessary to resect all of the nodules; however, the final pathologic finding was indicated to be a PEH, consecutive surgery was performed.In conclusion, this case of PEH indicates the difficulty in diagnosing this rare tumor. Clinicians should be aware of the possibility of a low-grade malignancy, even if surgical frozen biopsy analysis indicates benign features.The study was performed in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. The study was approved by the Institutional Review Board of Chonnam National University Hwasun Hospital. Written informed consent was obtained from the patient for publication of this case and for the accompanying images.


Here, we report the complete resolution of a calcifying cystic odontogenic tumor (CCOT) in the right mandible after marsupialization in an 8-year-old girl with a mixed dentition. Clinical, radiographic, and histopathological findings showed a simple cystic variant of CCOT in the region of the deciduous second molar, with dislocation of the permanent second premolar tooth germ. Initial treatment involved marsupialization, including extraction of the involved deciduous tooth, incision of pathological tissue, and creation of a window in the extraction socket. The crown of the dislocated second premolar was exposed at the base of the cystic cavity after marsupialization. One year and nine months later, complete bone healing and spontaneous eruption of the second premolar were observed, providing evidence of the bone regeneration capacity and tooth germ eruption potential in children. No recurrence was observed after 7 years. The findings from this case suggest that marsupialization can be successfully applied for the treatment of CCOT in children with a mixed dentition. The 2005 World Health Organization (WHO) Classification of Odontogenic Tumors renamed calcifying odontogenic cysts (COCs) as calcifying cystic odontogenic tumors (CCOTs) –3. The cCCOTs are generally benign, and the recommended treatment involves simple enucleation and curettage, regardless of the variant , 3. HoweHere we present the second case, to the best of our knowledge, of CCOT in an 8-year-old girl with a mixed dentition that was successfully treated by marsupialization only, which resulted in excellent bone healing and facilitated physiological eruption of a dislocated permanent tooth.An 8-year-old healthy girl was referred to our hospital by her general dentist who suspected the presence of an odontogenic cystic lesion in the region of the deciduous mandibular right second molar. Intraoral examination during her first visit revealed buccal bone expansion in the mandibular right molar region. Panoramic and periapical radiographs revealed a unilocular cystic radiolucency around the roots of the deciduous second molar Fig. . In addiFor further confirmation of the diagnosis, incisional biopsy was performed as follows. First, needle aspiration was performed, but only a small amount of mucoid liquid was obtained, which was not adequate for cytological or microbiological examination. Then, the deciduous second molar was extracted, followed by tissue incision through the extracted socket. The crown of the developing second premolar was exposed at the base of the cystic lesion, suggesting the presence of a unicystic lesion. Finally, we created a window in the extracted socket for marsupialization to decrease the lesion size.A biopsy specimen showed inflamed granulation tissue intermingled with ameloblastoma-like epithelium Fig. , which cOn postoperative day 10, the packing gauze was removed and an acrylic obturator positioned to keep the cavity open. The patient and her parents were instructed to irrigate or rinse the cavity with saline solution twice a day. After 4 months of follow-up, the size of the lesion had significantly decreased, with spontaneous eruption of the permanent second premolar. The obturator was then replaced by a lingual arch as a space maintainer, which guided the premolar into its correct position. One year and nine months later, progressive bone healing and normal eruption of the second premolar were observed on panoramic and periapical radiographs Fig. ; this prWe reported a case involving an 8-year-old girl with the simple variant of CCOT that was successfully managed using marsupialization alone. The noninvasive features of these lesions warrant enucleation and curettage rather than extensive surgical treatment, which is often required for more aggressive neoplastic lesions such as DGCTs and GCOCs –3. HowevMarsupialization or decompression has been applied in only four pediatric cases of CCOTs thus far , 5. All The surgical procedure of marsupialization in our patient involved extraction of the involved deciduous tooth, incision of pathological tissue for microscopic examination, and creation of a window in the extracted socket. The same technique is widely used for inflammatory dentigerous cysts associated with an infected deciduous tooth and an impacted permanent successor in children with a primary or mixed dentition , and it Similar to the results for dentigerous cysts, complete bone healing and normal eruption of the dislocated permanent tooth were observed after marsupialization in our patient. Thus, in addition to an excellent capacity for bone regeneration, the involved permanent tooth germ exhibited an excellent eruptive potential because of its immature roots. Moreover, there were no odontoma-like structures or large calcified masses that could have prevented shrinkage of the lesion. Collectively, these factors predicted successful healing after the single surgical procedure of marsupialization. Although the residual mucosa was not subjected to histopathological examination, our clinical and radiographic findings suggested that the pathological cells of CCOTs disappear by undergoing metaplasic transformation to normal mucosal cells; this has also been confirmed after marsupialization or decompression of KCOTs , 10.No signs of recurrence were observed during 7 years of follow-up in our patient. However, further follow-up is necessary because CCOT recurrence has been reported to occur after 1–8 years .In conclusion, we reported a pediatric case of CCOT that completely resolved with subsequent physiological eruption of the involved permanent tooth by marsupialization only, illustrating the excellent potential of bone regeneration in children. Marsupialization should be considered the first choice of treatment for pediatric CCOTs in order to minimize the damage to adjacent anatomical structures caused by enucleation and curettage.Written informed consent was obtained from the parents of the patient for publication of this Case Report and any accompanying images. A copy of the written consent form is available for review by the Editor-in-Chief of this journal.


Although malakoplakia has been reported to occur at various body sites, pancreatic malakoplakia with simultaneous colonic involvement is very rare. Lesions of malakoplakia can masquerade as tumor masses leading to unwanted resections. Nevertheless, malakoplakia can occur in association with frank carcinomas, especially in the colon. By reporting a case of pancreatic malakoplakia diagnosed by fine needle aspiration cytology, this paper aims to describe cytologic features of malakoplakia and to further review findings from previous reported cases of pancreatic malakoplakia in the literature. With advances in minimally invasive, image-guided aspiration technologies, cytomorphological analyses can diagnose lesions of malakoplakia. This may help avoid surgeries that would have otherwise been carried out due to a misleading impression of tumor. However challenges remain as to the further management of patients diagnosed with this condition. More studies are necessary to determine the probability of malignancies arising in association with malakoplakia, in order to devise appropriate treatment protocols. A seemingly indolent disorder of immune function, malakoplakia, has been known to occur in various body sites, most commonly involving the urinary tract (in at least 70% of cases), with isolated reports of involvement of the colon, stomach, liver, pancreas, skin, and brain. On several occasions, malakoplakia presents as a “mass lesion” misleading clinicians toward a suspicion of a tumor. Conversely, malakoplakia has been shown to occur in organs otherwise harboring a malignancy . In these instances, the malakoplakia occurs either as a response to the tumor or as an inciting agent. Other notable associations of malakoplakia include immune deficiency disorders, autoimmune conditions, organ transplantation (as a consequence of immunosuppression), and metabolic syndromes. Malakoplakias involving the pancreas are rare and may be diagnosed incidentally during elective cholecystectomy procedures . MalakopA 59-year-old gentleman presented to our institution with anemia (hemoglobin: 9.4 g/dL) noted during preoperative evaluation for a cataract surgery. He was asymptomatic and had no history of immunodeficiency. His only previous history was a cholecystectomy performed 11 years prior to his current admission. He was noted to have a positive fecal occult blood test prompting colonoscopic evaluation revealing an 8 mm sessile polyp in the sigmoid colon which was resected. A second polyp, 3 mm in size, was identified within the ascending colon. No other large masses or mucosal ulcerations were identified. A few weeks later, the patient presented with abdominal pain and nausea, and a Computed Tomography (CT) scan of the abdomen was performed which revealed a vague mass like area within the pancreas. This was followed up with an endoscopic ultrasound which revealed a 33 × 32 mm mass with well-defined borders involving the pancreatic head. No cystic areas were present within the mass. No other abnormalities were detected in the remainder of the pancreas, bile duct, or liver. A fine needle aspiration of the pancreatic mass was performed. Escherichia coli and hence antibiotic therapy was initiated. Impaired glucose tolerance was detected in the ensuing hospital stay. His general condition remained unimproved and he continued to experience reduction in weight and loss of appetite. Having counseled the patient on the possibility of a malignancy occurring in association with malakoplakias and in the absence of any other cause for his cachectic symptoms, the patient elected to undergo a pancreaticoduodenal resection (Whipple procedure). The patient reported improvement in his symptoms following surgery. Three months after surgery, he developed recurrent ascites with no additional imaging abnormalities detected.During the next 3-4 weeks, the patient developed gradually worsening abdominal pain, fatigue, and weight loss. A repeat abdominopelvic imaging study revealed ascites and the pancreatic mass which had slightly enlarged. Cultures of the ascitic fluid grewThe fine needle aspirate obtained from the pancreatic head revealed abundant histiocytes and few admixed lymphocytes. Majority of the histiocytes were present in large sheets. On the Diff-Quik stained smears, the histiocytes were found to contain refractile bodies . OccasioThe sigmoid colon polyp showed lymphohistiocytic infiltration of the lamina propria and submucosa . Few scaOn gross examination of the Whipple specimen, the pancreatic parenchyma was indurated and mildly congested. No discrete mass was present. No mucosal abnormalities were visible within the distal stomach, duodenum, or the common bile duct. On light microscopy, sections from the pancreatic head revealed established chronic pancreatitis with many areas of lymphocytic inflammation, acinar and ductal atrophy, and fibrosis. Few scattered plasma cells were present. Additional areas of malakoplakia adjacent to atrophied pancreatic acini were identified . Interes Escherichia coli infection has been identified in many cases of malakoplakia involving the urinary tract, although other bacteria, viruses, and even protozoa have been implicated [In recognition of the original discoverers of this condition, malakoplakia is ubiquitously characterized by the presence of targetoid mineralized bodies known as Michaelis-Gutmann bodies. In fact a diagnosis of malakoplakia may be missed in the setting of a paucity of these characteristic bodies . These rplicated . Malakopplicated , a 6-weeplicated , and a 7 Corynebacterium equi and Klebsiella) which presented as a retroperitoneal mass with additional involvement of the pancreatic tail and mesenteric root of the transverse colon. A year after antibiotic therapy he developed recurrent malakoplakia involving the right femur which also grew Corynebacterium, raising the possibility of immunodeficiency in the patient. Zuk et al. [The most common site of involvement of malakoplakia is the urinary tract. Malakoplakias involving the urinary bladder often present as white plaques noted on cystoscopic examination. The second most frequently involved site is the gastrointestinal tract, particularly the colon. Involvement of various other sites continues to be reported in the literature. As mentioned earlier, cases of malakoplakia involving the pancreas are relatively rare. A PubMed search revealed three publications reporting malakoplakia involving the pancreas. Zuk et al.  describek et al.  describek et al. , 8 and ik et al.  the patiMalakoplakia is notorious for mimicking a malignant neoplastic process. In fact, in a great majority of cases, the diagnosis first comes to light when a resection has been undertaken for the “malignant neoplasm.” Conversely malakoplakias have been reported to occur in association with adenocarcinomas including those of the colon and prostate –12. MalaNo specific treatment protocols have been established in the management of malakoplakia. Although primarily considered a disorder of immune function, malakoplakia by itself is not particularly debilitating and patients diagnosed with lesions of malakoplakia generally do well. Fluoroquinolones, among other classes of antibiotics, have been utilized in the management of malakoplakia, especially in immunocompromised patients or those with systemic involvement, due to their ability to achieve therapeutic concentrations within histiocytes , 15. MalMalakoplakias continue to be reported to occur at unusual sites, such as the spleen, nasal cavity, and oropharynx –18. The


In muscular skeletal oncology aiming to achieve wide surgical margin is one of the main factors influencing patient prognosis. In cases where lesions are either meta or epiphyseal, surgery most often compromises joint integrity and stability because muscles, tendons and ligaments are involved in wide resection. When lesions are well circumscribed they can be completely resected by performing multi-planar osteotomies guided by computer-assisted navigation. We describe a case of low-grade chondrosarcoma of the distal femur where a simple but effective technique was useful to perform complex multiplanar osteotomies. No similar techniques are reported in the literature.A 57 year-old Caucasian female was referred to our department for the presence of a distal femur chondrosarcoma. A resection with the presenting technique was scheduled. The first step consists of inserting several K-wires under CT-scan control to delimitate the tumor; the second step consists of tumor removal: in operative theatre, following surgical access, k-wires are used as guide positioning; scalpels are externally placed to k-wires to perform a safe osteotomy.Computed assisted resections can be considered the most advantageous method to reach the best surgical outcome; unfortunately navigation systems are only available in specialized centres. The present technique allows for a multiplanar complex resection when navigation systems are not available. This technique can be applied in low-grade tumours where a minimal wide margin can be considered sufficient. In muscular skeletal oncology aiming to achieve wide surgical margin is one of the main factors influencing patient prognosis . In caseWhen lesions are well circumscribed they can be completely and safely resected by performing multi-planar osteotomies guided by computer-assisted navigation. This technique was recently applied in select patients with sarcomas; however, the costs limit the procedure to being carried out in highly specialized centres where computer assisted navigation systems are available .We report a case of low-grade chondrosarcoma of the distal femur where a new, safe, surgical technique permitted a minimally extended wide resection.This technique could also be performed in a non-specialized centre where computer assisted navigation is not available, sometimes allowing to spare joint integrity and to reduce the need of prosthesis reconstruction, assuring improved functional outcome.A 57 year-old Caucasian female was referred to our department complaining of a pain in her right knee for the last six months. Imaging showed a non-homogeneous sclerotic lesion located in the medial aspect of the distal femur without cortical erosion resembling a benign chondroma Figure . Due to The main objective in oncological surgical orthopaedics is to achieve a wide surgical margin; it is one of the most important prognostic factors . Wide suIn low grade tumours obtaining minimal wide resection can allow the patient to maintain a satisfying quality of life. Computed assisted resections can be considered the most advantageous technique to reach the best surgical outcome; unfortunately, navigation systems are only available in specialized centres.The reported case shows how it is possible to perform a multiplanar complex resection also when navigation systems are not available. This technique allowed resection of the mass, sparing the joint and collateral ligaments, sacrificing just medial patellar retinaculum and can be applied in low-grade tumours where a minimal wide margin can be considered sufficient.The surgical treatment of low-grade chondrosarcoma of the appendicular skeleton remains controversial. Some authors prefer wide resection margins, while others consider intralesional curettage sufficient for adequate local control ,6. This Our group sustains the use of wide resection for low-grade chondrosarcoma to minimize risk of local recurrence. We also maintain that to reduce the risk of undertreating a lesion that could be more aggressive than expected at definitive histology.The present technique allows for a safe multiplanar complex resection when navigation systems are not available. It can be applied in low-grade tumours where a minimal wide margin can be considered sufficient. More studies are advocated to verify its reliability.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 of this journal.The authors declare that they have no competing interests.ZC devised the technique, performed the surgery and has given final approval of the version to be published; RB participated to surgery and cared the patient follow-up; FV supervised the draft and cared the patient follow-up; AV performed the CT-guided K-wires insertion; RA wrote the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/14/52/prepub


Endometriosis is presence of functional endometrium outside of uterine cavum. As a pluripotent tissue, endometrium has the possibility of implanting itself almost everywhere; even implantation in abdominal wall was described, but it is not common site. This case report presents implantation of functional endometrium in abdominal wall, inside scar tissue, and after insertion of a laparoscopic trocar port. Final diagnosis was confirmed by pathohistological examination. Endometriosis is defined as a presence of functional endometrium outside of uterine cavum and is usually localized in the pelvic cavity. Cause of this disorder is still insufficiently known, and the most popular theory is reflux of endometrium and its implantation, mostly on the organs and peritoneum of the pelvic cavity. Reflux theory cannot explain presence of endometriosis inside of parenchymatous organs as the lungs, brain, or gastrointestinal wall. Other popular theories are immunologic alteration, pluripotent celom epithelium alteration, and the differentiation of progenitor stem cell . PresencForty-three-year-old patient is admitted to the surgical clinic because of a tumor localized on inferior left side of abdominal wall. Two years before patient underwent laparoscopic surgery for uterine endometriosis. After several months, patient noticed the tumor in scar area of trocar port, which had been growing during this time. Tumor did not cause any discomfort, it was painless on palpation, and it did not change during the menstrual cycles. After surgical examination, the possibility of endometrial implantation is considered, and radical excision of tumor is indicated. Irregularly shaped tumor about 4 cm in diameter, which had infiltrated the complete thickness of the abdominal wall including muscles and fascia, had been found. The complete tumor had been removed and sent to pathohistological examination. Postoperative recovery went without complications, with the wound healing by primary intention.Material is a slice of tissue measuring 3.5 cm on the longer axis, haemorrhagic on section. Upon pathohistologic examination fat and connective tissue was seen as well as parts of muscle tissue with endometrial glands surrounded with endometrial stroma and filled with blood. Histological finding primarily fits the diagnosis of endometriosis .First case report about endometriosis inside of a scar after laparoscopic procedure was reported by the American author Healy in 1995. He had logically predicted that similar cases would appear with increasing use of laparoscopy in diagnostic and operative procedures. He had also stressed the importance of general surgeons in treatment of such findings . PatientRecidive of endometriosis in scar after recent operation, especially laparoscopic one, is not a common finding and because of that it is often overlooked. In patients with palpable tumor on site of the surgical scar, which does not have to be changed with menstrual cycles, and with recent surgically treated endometriosis, possibility of recidive of endometriosis in form of endometrioma has to be considered. Listed data and clinical findings are sufficient for proper diagnosis. Preoperative conformation can be obtained by fine needle aspiration biopsy of tumor.


Introduction. Aggressive angiomyxoma is a rare, slowly growing, and benign tumour of mesenchymal origin, which affects women of reproductive age and is associated with a high risk of local recurrence. Case Presentation. A case of a 47-year-old white female is presented herein, with a large polypoid, gelatinous mass on the right labia majora, measuring 26 × 21 × 6 cm. Histopathologically, the lesion was composed of spindle and stellate-shaped cells embedded in a myxoid matrix. Another specific feature was the presence of variable-sized thin-walled capillaries and thick-walled vascular channels. The patient underwent wide local excision of the tumour with clear margins and developed local recurrence 18 months later. Discussion. Aggressive angiomyxoma of the vulva needs to be distinguished from benign myxoid tumors with a low risk of local recurrence as well as from malignant myxoid neoplasms. Usually wide local excision with tumour-free margins and occasionally hormonal manipulation is the treatment of choice. Aggressive angiomyxoma (AA) is a rare, slowly growing, and benign tumour of mesenchymal origin. AA was described by Steeper and Rosai in 1983 as a tumour with a predilection for the perineum of reproductive-age women . There iA 47-year-old female was admitted to our hospital with an enormous polypoid mass on her right labia majora initially noticed three years ago. The mass has gradually increased in size. On clinical examination a well-circumscribed polypoidal mass measuring approximately 25 × 20 × 6 cm was revealed. The lesion was soft and gelatinous in consistency, covered by normal appearing skin. The tumour was painless with no associated lymphadenopathy. On gynaecological examination the cervix and vagina were unremarkable. Her laboratory investigations were within normal limits and ultrasonography of the abdomen had nothing to add. Moreover, ultrasonography of the perineum showed a large mass with peripheral vascularity, heterogenous hyperechoic areas, measuring approximately 26 × 21 × 6 cm, and magnetic resonance (MRI) of the pelvis confirmed these features Figures . The iniHistopathological examination revealed an encapsulated neoplasm composed of stellate and spindled cells, embedded in a loose matrix with wavy collagen. The lesion contained thin-walled capillaries and thick-walled vascular channels. Neoplastic cells had relatively scant eosinophilic cytoplasm and their nuclei were ovoid, containing finely dispersed chromatin with one or two small eosinophilic nucleoli . There wThe patient developed local recurrent disease 18 months later, which was revealed on her follow-up visits.In general, angiomyxomas are classified either as superficial  or AA. Superficial angiomyxoma may occur in the setting of Carney complex . This leAAs affect almost exclusively the genital, perineal, and pelvic regions of reproductive-age females and especially the vulva. Rarely AAs are reported in men, and when they do the scrotum is usually involved. Although growing slowly, these lesions behave “aggressively” by infiltrating the perivaginal and perirectal tissues and are characterized by very high rates of local recurrence .The imaging characteristics of this tumour are interesting. On computed tomography (CT) scan, a circumscribed mass with attenuation less than or equal to that of adjacent skeletal muscle is the norm, with swirled enhancing tissue internally . On MRI The main theory for AA pathogenesis is that a primitive multipotent mesenchymal cell of the lower female genital tract that has the capability of differentiating by various ways gives rise to the lesion. The latter is mainly supported by immunohistochemical expression of desmin and, in some cases, a smooth muscle actin along with desmin by tumour cells .Interesting molecular studies have linked a consistent clonal aberration of the chromosome 12, in the region 12q13–15, associated with rearrangement of the HMGIC gene (high-mobility group protein isoform I-C) with AA. The study claims that AA is molecularly part of the benign group of mesenchymal tumours showing multiple aberration region involvement , 10. HMGMacroscopically, AA is a soft, well-defined, sometimes polypoid mass, ranging in size from a few centimetres to 20 cm or even more, as in our case. The main feature is a shiny, homogenous, gelatinous appearance on gross sections . MicroscThe greatest clinical problem of AA is its high propensity for local recurrence. That is why differential diagnosis includes other benign myxoid neoplasms, such as angiomyofibroblastoma, intramuscular and juxta-articular myxoma, cutaneous myxoma , myxoid neurofibroma, cellular angiofibroma, myxoid leiomyoma, and fibroepithelial stromal polyps . On the Therapeutic strategy relies on surgical approach with wide local excision with clear margins. The operative decision for adjacent organs, such as the rectum and bladder to which the tumour may be attached, is to spare them, as the morbidity of extensive surgery may not be justified. Local recurrences are treated with reoperation when possible and cannot be predicted neither from size nor from tumour cellularity. Recurrences are reported from months to several years after excision . In our Radiation therapy and chemotherapy have no practical implications due to low mitotic activity. Hormonal manipulation with tamoxifen, raloxifene, and gonadotropin-releasing hormone analogues has been tried and results in downsizing of the tumour in the neoadjuvant setting . Long-te


Midgut malrotation is a congenital anomaly of intestinal rotation and fixation that is generally seen in neonatal population. Adult cases are rarely reported. Early diagnosis is crucial to avoid life threatening complications. Here, we present an adulthood case of midgut volvulus as a rare cause of acute abdomen. Midgut malrotation (MM) as a congenital anomaly of intestinal rotation and fixation is generally seen in the neonatal population . It usuaμL  and C-reactive protein value was 0.3 mg/L . Computed tomography (CT) showed whirl-like appearance of the superior mesenteric vein and the bowel around the superior mesenteric artery axis (An 18-year-old female admitted to our emergency clinic with complaints of abdominal pain and vomiting for the last three days. Her past medical history revealed chronic abdominal pain and occasional vomiting since her childhood but she did not go under further investigation. Vital signs were within the normal range. Physical examination revealed only nonspecific abdominal tenderness without abdominal guarding, rebound tenderness, and abdominal distention. White blood cell count was 6500/ery axis . It was The patient was taken to the operating theatre with the diagnosis of MM. At the exploration, rotation of minimally dilated small intestines  with no Intestinal rotation and fixation begin at the 6th gestational week with a total of 270 degree anticlockwise rotation. At the 12th week, the intestinal segments were fixed as the ascending and descending colon on the right and left quadrants, respectively [Due to presence of the atypical symptoms, the diagnosis of MM is mostly made either incidentally during surgery or in autopsies . There wIn case of MM, the most commonly encountered presentation is the inability of cecum positioned to the right-lower quadrant and the pressure on the duodenum due to peritoneal Ladd's bands that fix the ectopically established cecum to the posterior wall . FollowiAs a conclusion, in case of intermittent intestinal obstruction in young adults, the physicians should keep in mind that early and accurate diagnosis of MM with an appropriate surgical treatment may save patients from unexpected complications. In acute presentations, CT should be chosen as the primary imaging modality.


In order to improve the diagnosis and therapy of undifferentiated embryonal liver sarcoma (UELS), the present study presents the case of a 9-year-old female with UELS and discusses UELS in childhood. The patient presented with abdominal pain and fever. The laboratory tests, radiographic examination and pathological features presented by the female were similar to those of typical cases of UELS reported in childhood. The patient initially received surgical treatment and the immunohistochemical findings suggested that the patient had UELS. The patient’s parents refused adjuvant chemotherapy and demonstrated a right prerenal mass 6 months post-surgery. Microscopic examination revealed that the tumor was evidence of undifferentiated embryonal sarcoma recurrence. However, the patient was comfortable and physical examination revealed no abnormal conditions. In addition, the laboratory results were normal. Abdominal computed tomography scan and ultrasound were performed every 3 months to monitor the tumor recurrence. At the time of writing, it has been 6 months after the second surgical procedure and there has been no appearence of abnormalities. Previous studies have shown that patients who receive combined therapy with complete tumor resection and adjuvant chemotherapy have a longer survival time than those who undergo surgical therapy alone. Complete tumor resection combined with adjuvant chemotherapy may reduce the risk of recurrence and enhance the survival time in patients with UELS. Undifferentiated embryonal liver sarcoma (UELS) is a rare and highly malignant hepatic tumor of mesenchymal origin, which often occurs in individuals between 5 and 10 years old, as well as in young adults . Patient3 and a well-defined border, which involved the right lobe of the liver and had a non-homogeneous density , and presented with abdominal pain and fever. Upon examination, the patient’s temperature was 38°C, the pulse was 86 beats per minute, the blood pressure was 103/53 mmHg and the respiratory rate was 20 breaths per minute. Abdominal tenderness was identified in the right upper quadrant without rebound tenderness. The remainder of the examination was normal and the results are shown in  density . The den density . The cliSurgery was performed to resect the tumor. A right subcostal incision was made and, following entry into the abdomen, the ligamentum teres hepatis and falciform were incised. Examination of the future liver remnant and abdominal cavity revealed no evidence of tumor metastasis. The tumor had ruptured at the diaphragmatic surface and had adhered to the diaphragm. The surgical margin distance from the tumor was at ≥1 cm. The tumor was resected following the margins, until it was completely removed. A drainage tube was inserted under the right diaphragm and exited the body through the right abdominal wall. The abdominal wall was closed using standard procedures. During surgery, the patient had 300 ml bleeding and was transfused with 1.5 units of red blood cells.Histological examination revealed pleomorphically shaped tumor cells with marked nuclei and clear to the eosinophilic cytoplasm . All the2 and a well-defined border , cystic, solitary and well-circumscribed masses with variable areas of necrosis and hemorrhage ,16. On eMicroscopically, UELS is characterized by cellular proliferation of oval, spindle or stellate pleomorphic cells with poorly defined cell borders ,3. Immunet al (et al (The prognosis of UELS is poor even if the tumor is completely resected. Previous reports have demonstrated that treatment with surgery and adjuvant chemotherapy is curative for UELS in certain cases ,9,29. Maet al  reportedet al . Kim et l (et al ,30,31. Ol (et al . HoweverIn conclusion, complete tumor resection combined with adjuvant chemotherapy may reduce the risk of recurrence and improve the survival time in patients with UELS. Further investigations are required to identify more effective strategies for treating pediatric patients with UELS.


We herein report a case of a bronchogenic cyst arising from the esophagogastric junction treated by laparoscopic full-thickness extirpation. The full-thickness defect was closed by hand sewing a T-shaped line over the gastroendoscope as a bougie to prevent postoperative deformity or stenosis. Partial fundoplication (Toupet fundoplication) was added to prevent reflux.2 was admitted for treatment of a cyst-forming submucosal tumor (60 mm in diameter) on the anterior wall of the esophagogastric junction, which was detected during screening endoscopy before bariatric surgery. The tumor was an extraluminal growing type but exhibited severe erosion at the mucosal site. A cystic tumor such as a duplication cyst, bronchogenic cyst, or cyst-forming gastrointestinal stromal tumor was suspected, and the abovementioned surgery was carried out. The postoperative course was uneventful. The pathological findings revealed the tumor to be a benign bronchogenic cyst. Endoscopic examination 3 months postoperatively showed no deformity or stenosis, and the patient complained of no reflux symptoms.A 32-year-old woman with a body mass index of 43 kg/mThis procedure may be an efficient option for treatment of submucosal tumors on the esophagogastric junction to maintain function or avoid excessive surgery. Bronchogenic cysts are one of several bronchopulmonary foregut malformations. The most common location is in the mediastinum. Bronchogenic cysts in the abdominal cavity are rare, but the esophagogastric junction (EGJ) is reportedly a relatively common site . Surgica2 presented to the bariatric surgery center at another hospital. Sleeve gastrectomy was scheduled, but gastroendoscopy screening revealed a submucosal tumor (SMT) on the EGJ. She was referred to us for further evaluation. Endoscopy findings showed an SMT on the anterior wall of the EGJ with severe erosion on its mucosal surface. The epicenter was estimated to be 10 mm distal to the EGJ  and snake retractor to ensure adequate visibility around the EGJ. The lesser omentum was dissected to expose the abdominal esophagus. A smooth extraluminal tumor originating from the right side of the EGJ was seen. The base of the tumor was carefully exposed and excised circumferentially to its full thickness using the ultrasonically activated device Fig. . The defThe postoperative course was uneventful. Esophagography performed 3 days after the surgery using Gastrografin showed no leakage or stenosis; also, reflux to the esophagus was not observed, even in head-down-tilted position Fig. . She wasBronchogenic cysts arise due to a lack of continuity between the tracheobronchial tract and the lung buds after abnormal germination and segregation. Until week 7 of gestation, when the pleural and peritoneal cavities are separated by the formation of the diaphragm, these cavities are formed intra-abdominally . Most brSurgical excision of SMTs on the EGJ remains challenging because of the anatomical complexity and delicate function. Clinical decision-making may need to be employed with consideration of the individual patient. Wedge resection involving the EGJ using a stapler seems unsuitable because of postoperative deformation and stenosis. Proximal gastrectomy with lower esophageal resection will lead to remarkable decline in the patient’s quality of life. As alternatives, several novel techniques with which to minimize the extent of resection of the normal gastrointestinal tract wall were recently published, such as laparoscopic and endoscopic cooperative surgery or percutaneous endoscopic intragastric surgery –9.To the best of our knowledge, five English language publications have reported laparoscopically treated bronchogenic cyst located close to the EGJ Table  2, 10–1–110–13. We considered the patient’s obesity in our treatment strategy. Had the tumor been definitely diagnosed as benign and located at the greater curvature site, we could have performed a sleeve gastrectomy. Currently, the patient’s weight is controlled only by diet, but if its control becomes poor, surgical treatment may be required. If her esophageal reflux is still a problem at that time, Roux-en-Y gastric bypass may be a first choice rather than sleeve gastrectomy.We have reported a case of a bronchogenic cyst arising from the EGJ treated with laparoscopic full-thickness resection with a unique suturing technique to prevent postoperative deformity and stenosis. When treating an SMT on the EGJ, the optimal surgical method should be chosen on an individual patient basis. This procedure may be an efficient option for such a tumor to maintain function or avoid excessive surgery.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.


To the Editor: In addition, PET can give false-positive results in cases of inflammatorydisease or concomitant tumors. Imaging studies play an important role in the tumor-node-metastasis staging of lung cancer,particularly in the evaluation of tumor size/extent and regional lymph node involvement.There is a learning curve for interpreting positron emission tomography (PET) findings; PETallows the estimation of the metabolic activity of a lesion, therefore facilitating thedifferential diagnosis between benign and malignant disease, as well as the determinationof the extent of malignancy. When used in the study of lung cancer, PET can givefalse-negative results in cases of decompensated hyperglycemia, small lesions, or lesionswith low metabolic activity, among others.We report the case of a 61-year-old male patient who, in October of 2011, presented to ouremergency room with airway infection. A chest X-ray revealed right upper lobe atelectasis,which was confirmed by chest CT A.Fiberoptic bronchoscopy showed an exophytic lesion in the right upper lobe orifice. Thelesion caused total bronchial lumen occlusion and affected the secondary carina, withouttracheal involvement. The histopathological findings were consistent with moderatelydifferentiated squamous cell carcinoma. Blood and kidney function test results were normal,the exception being serum glucose levels, which were elevated. A PET scan showed a solid, lobulated paramediastinal lesion in the right upper lobe. Thelesion measured 3.0 cm × 2.4 cm, and the standardized uptake value (SUV) was 12.2. Thelesion occluded the right upper lobe bronchus and therefore caused the atelectasis. Inaddition, the PET scan showed a right-sided image that was suggestive of lymph nodeenlargement in the superior mediastinum and measured approximately 2.0 cm, the SUV being3.8 B. The patient underwent right upper sleeve lobectomy and radical lymphadenectomy, theaffected lymph node being resected A.Histop Given that schwannomas show variable 18F-fluorodeoxyglucose (FDG) uptake, withthe SUV ranging from 1.9 to 12.0, PET has limited utility in distinguishing betweenschwannomas and malignant peripheral nerve sheath tumors. In many cases, it is impossible to distinguish between a schwannoma and amalignant tumor before biopsy or surgery precisely because schwannomas can show high FDGuptake. Schwannomas  and neurofibromas account for 95% of all benignneurogenic mediastinal tumors. A schwannoma is a mesenchymal neoplasm originating fromSchwann cells of the nerve sheath. Although schwannomas commonly affect the mediastinum,they can be found in the abdomen, in the pelvis, and, much more rarely, in the chest wall.Schwannomas affect males and females alike, being benign in up to 90% of cases. In general,schwannomas are well defined and asymptomatic, being diagnosed incidentally, usually afterthe age of 30 years. Although the degree of regional lymph node involvement in our patient wasclassified as N2, surgery was recommended because only one lymph node wasaffected, and it was resectable. Accurate staging is required for proper treatment of patients with lung cancer, stagingbeing based on tumor size, regional lymph node involvement, and the presence of metastases.Although chest CT is considered the modality of choice for the diagnosis of intrathoracicmetastases, there is no consensus regarding the study of metastases. PET-CT was introducedand developed as an integrated modality for accurate nodal staging and for detection ofmetastatic lesions in the entire body. Commonly, PET-CT is more effective than chest CT forlung cancer staging, assisting in detecting distant metastases that are not detected bytraditional methods in 5-20% of patients; in addition, PET-CT can influence the treatmentstrategies and assist in predicting survival.Given that schwannomas show highly variable FDG uptake-which is why it is difficult todifferentiate between schwannomas and other tumors by means of images alone-PET findings inpatients with lung masses should be interpreted carefully, as should lymph nodes with highSUV, which should be biopsied, in order to avoid an incorrect diagnosis or incorrectstaging and the hazardous consequences of false-positive results. Ao Editor:positron emission tomography  passa por uma curva de aprendizado na avaliação dosachados; essa técnica permite estimar a atividade metabólica da lesão, facilitando assimo diagnóstico diferencial entre doenças malignas e benignas, bem como a extensão de umadoença maligna. A utilização da PET no estudo da neoplasia pulmonar pode induzir aresultados falso-negativos, tais como na presença de hiperglicemia descompensada, lesõespequenas ou lesões de baixa atividade metabólica. Ademais, podem ocorrer resultados falso-positivos, como nos casos dedoenças inflamatórias ou na ocorrência de tumores concomitantes.Os exames de imagem costumam ter um papel importante no estadiamento pelo sistematumor-nódulo-metástase das neoplasias pulmonares na avaliação dos fatores tumor enódulo. A interpretação da Relatamos o caso de um paciente do sexo masculino (61 anos) com infecção das vias aéreasque procurou atendimento em nossa unidade de urgência em outubro de 2011. A radiografiade tórax revelou atelectasia do lobo superior direito, confirmada pela TC de tórax.À fibrobroncoscopia, foi evidenciada lesão vegetante em óstio do lobo superior direito,causando oclusão total da luz brônquica e envolvimento da carina secundária, semacometimento de traqueia. O estudo histopatológico da lesão foi compatível com carcinomade células escamosas moderadamente diferenciado. Com exceção da glicose séricaaumentada, os demais exames de função sanguínea e renal foram inalterados. standardized uptake value  de 12,2. A lesão determinava oclusão do brônquio para o lobosuperior direito, sendo assim responsável pela atelectasia. Ademais, o exame indicava apresença de uma imagem sugestiva de linfonodomegalia no mediastino superior, à direita,com cerca de 2,0 cm e SUV de 3,8  Como a absorção de 18F-fluordesoxiglicose (FDG) pelos schwannomas évariável, com SUV variando de 1,9 a 12,0, a PET possui uma limitação importante nadistinção entre o schwannoma e as neoplasias malignas da bainha de nervosperiféricos. É justamente devido a essa possibilidade de captação de altos valores deFDG que, muitas vezes, o schwannoma não pode ser distinguido de um tumor maligno antesda biópsia ou cirurgia. Dentre os tumores neurogênicos benignos que acometem o mediastino, os schwannomas  dividem com os neurofibromas a incidência de 95%dos casos. O schwannoma é uma neoplasia mesenquimal originada das células de Schwann dabainha dos nervos e comumente afeta o mediastino, podendo também ser encontrado emabdome, pelve e, com acentuada raridade, na parede torácica. Essas neoplasias costumamatingir igualmente homens e mulheres e são benignas em até 90% dos casos. Apresentam-se,em geral, bem delimitados e assintomáticos, sendo diagnosticados incidentalmente,geralmente após os 30 anos de idade. Apesar de a doença neoplásica ser considerada neoplasia no estádioN2, a cirurgia foi indicada por tratar-se de um só gânglio comprometido,potencialmente ressecável.O tratamento adequado do câncer pulmonar necessita de estadiamento acurado, que ébaseado no tamanho do tumor, no envolvimento linfonodal regional e na presença demetástases. Embora a TC de tórax seja considerada como a modalidade de escolha para odiagnóstico de metástases intratorácicas, não há consenso em relação ao estudo dasmetástases. A PET-TC foi introduzida e desenvolvida como uma modalidade integrada para oestadiamento nodal acurado e a detecção de lesões metastáticas de corpo inteiro.Comumente, a PET-TC tem uma eficácia maior que a TC de tórax para o estadiamento docâncer pulmonar, ajudando a identificar metástases à distância que não são encontradaspor métodos tradicionais em 5-20% dos pacientes, e pode influenciar nas estratégias detratamento e ajudar a predizer a sobrevida.Uma vez que a absorção de FDG pelos schwannomas é amplamente variável, dificultando suadiferenciação apenas por meio de imagens, os achados da PET no estudo de massaspulmonares devem ser analisados com cuidado, assim como os linfonodos com SUV alto quedevem ser biopsiados, a fim de evitar um diagnóstico ou estadiamento errôneo e osefeitos deletérios de resultados falso-positivos.


Introduction. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a common procedure in obesity surgery. The aim of an antecolic approach is to reduce the rate of internal herniation. Our aim is to make bariatric surgeons aware of another possible complication of antecolic LRYGBP. Methods and Results. We present a case report of omental torsion 24 months after antecolic LRYGBP presenting as an acute abdomen, suggesting appendicitis. During diagnostic laparoscopy, omental infarction due to torsion was observed. Resection of the avital omentum was performed. Discussion. Omental torsion after antecolic LRYGBP is a rare complication. When appearing in the early postoperative phase, it may mimic an anastomotic leakage. It may also occur as late complication, presenting with acute abdomen as an appendicitis. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a common procedure in obesity surgery. One aim of an antecolic approach is to reduce the rate of internal herniation . This ca2. During surgery, the great omentum was divided in its length to reduce tension on the gastrojejunal anastomosis.We performed an antecolic LRYGBP on a 31-year-old female patient with a body mass index of 50.3 kg/m2. The palpation at the McBurney's point was painful with rebound tenderness. White blood cell count was not elevated, and C-reactive protein (CRP) was moderately high (42 mg/L). Other routine abdominal laboratory findings were unremarkable. Sonography showed nothing in particular. The patient was discharged on patient's demand and came back the following morning for clinical reevaluation. She presented with progressive pain and an elevation of the CRP (91 mg/L). A computer tomography was performed. The appendix vermicularis showed a diameter of 10 millimeters (24 months later, the patient presented to our emergency room with lower quadrant abdominal pain. Fever was not observed. Her body mass index was 37.7 kg/mlimeters . The patDuring laparoscopy, omental infarction due to a torsion of the right half of the divided great omentum was observed . ResectiThe first case of omental torsion after antecolic gastric bypass was observed by Dallal and Bailey 2006 .Omental torsion after antecolic LRYGBP is a rare complication. When appearing in the early postoperative phase, it may mimic an anastomotic leakage. Its happening as late complication may illustrate an acute abdomen like an appendicitis. Conservative management after accurate diagnosis is also an option .Reviewing the current literature, we believe to report only the sixth case of omental torsion following gastric bypass procedure.