Background. The Essure device is a method of permanent sterilization widely used in the US that has proven to be safe and effective in most cases. However, there have been reports of device migration that have led to failed tubal occlusion as well as several other serious complications resulting from the presence of the device in the abdominal cavity. Case. This paper represents two cases of failed tubal occlusion by an appropriately placed Essure device without signs or symptoms of further complications related to device migration. Conclusion. Although there have only been 13 reported cases of abdominal device migration since November 2014, this case indicates that the actual number may be higher than reported since it is possible for migration to occur without additional complications. In the majority of reported cases of abdominal migration a major complication requiring surgical correction occurred, such as adhesions, small bowel obstruction, bowel perforation, or persistent pelvic pain. To avoid these complications it is recommended that migrating implants be removed; however, this case also represents an example of when a migrating device may remain in situ in an asymptomatic patient. The Essure pbc (Permanent Birth Control System) device is a dynamic expanding microinsert that stimulates benign tissue growth when placed in the proximal section of the fallopian tube, eventually occluding the tube. The device was approved in 2002 as a means of permanent sterilization by the US Food and Drug Administration (FDA), and initial reports showed a high rate of safety and patient acceptability –4.The benefits of the Essure hysteroscopic tubal occlusion/sterilization procedure are unique from other permanent birth control methods because it is hormone-free and does not require a skin incision , 5. EssuUpon placement of Essure, ideally 3 to 8 outer coils of the expanded Essure microinsert should be trailing into the uterus . A folloThe Essure procedure is 99.83 percent effective at preventing pregnancy when used according to the approved instructions for use based on five-year clinical study data , 5. DespThe patient is a 29-year-old Hispanic, para 3003, with no past medical or surgical history, who was satisfied with her parity and electively underwent an uncomplicated hysteroscopic tubal sterilization with Essure device in January 2013.Intraoperatively, eleven coils were seen outside the right ostium and four coils were seen at the left ostium upon Essure placement. Her 6-month follow-up HSG, in May 2013, showed proper Essure placement with bilateral tubal occlusion with no spillage of the contrast materials .However, in January 2014, the patient was evaluated for low abdominal pain. Ultrasound at that time showed an intrauterine pregnancy (IUP) with 2.42 cm Crown Rump Length (CRL), corresponding to 9 weeks and 2 days of gestational age (GA).Patient had an uncomplicated spontaneous vaginal delivery in November 2014 and underwent postpartum bilateral salpingectomy. It was noted intraoperatively that no Essure microinserts were identified in the fallopian tubes. Postpartum X-ray of abdomen and pelvis identified Essure coils in the peritoneal cavity Figures . PatientThe patient is a 35-year-old para 6016, Hispanic female, with history of appropriately placed Essure device in 2011. Intraoperatively, six coils were seen outside the right ostium and one coil was seen at the left ostium upon uncomplicated Essure procedure placement. Patient did not come back for 3-month post-Essure hysterosalpingogram.The patient became pregnant in 2015 while both Essure inserts were still present in both fallopian tubes Figures  and 5 anX-ray of the abdomen and pelvis only showed one Essure insert in the right upper quadrant near the liver, while the other Essure insert was at the level of lumbar vertebra . The patAbdominal displacement of the Essure pbc is a very rare complication. Only 14 cases had been reported out of the 750,000 devices that had been placed to date, according to the US Food and Drug Administration. Case reviews suggest that several factors influence the likelihood of complications, including physician experience in placement and anatomical anomalies in the patient .Device displacement has been reported in three cases complicated by laterally sited ostia, tubal resistance, or endometrial adhesions but displacement was also reported in five women who had uneventful procedures, such as our patient. In the majority of cases of abdominal displacement, the patients were asymptomatic and migration of the device was diagnosed at the 3-month follow-up HSG , 12–14.  in situ after noting that the pelvic organs were healthy and normal. They did not report any later complications for those patients [The first patient in this case, however, declined laparoscopic removal of the Essure device. This was observed to be a safe option by Kerin et al. , 15 who patients , 3.The cause of device migration is not fully understood in all cases. Some cases have been reported where displacement was due to uterine or tubal perforation, but there have also been cases where no signs of perforation were seen, as in the first patient highlighted in our report. It is suspected that migration in those cases occurred through the natural opening in the fallopian tube , 12, 13.In other reported cases it was observed that the left implant is more commonly implicated in migration than the right, suggesting that proper insertion of the device into the left tube by right-handed physicians may be difficult ; howeverAs of November 2014, there were only 14 cases of Essure abdominal migration in the literature . In someIncorrect position of Essure microinserts can be seen postoperatively, when the initial placement procedure was difficult. In these cases, it is recommended to perform a transvaginal ultrasound (TVU) or pelvic X-ray 4 weeks after the procedure or after the first vaginal bleeding. It is also recommended that removal of the migrating device should be performed as soon as possible . Moreove


Dear Sir,Cysticercosis is caused by the larval form of the parasite Taenia solium (T. solium). The central nervous system and orbits are the most frequently involved sites.[1-3] Isolated cysticercosis presenting as a lump in the lower extremity is very unusual in children and may present a diagnostic challenge.A 6-year-old boy presented with a progressive lump along the anterolateral aspect of the left thigh for a month. There was no history of trauma, fever, anorexia, or weight loss. The patient was a non-vegetarian. The family of the patient was neither involved in pig-farming nor were wild boars common in the area of patient’s residence. On examination, the swelling was mildly tender, non-pulsatile, fluctuant, and transilluminant. Ultrasonography (USG) revealed a well-defined cystic lesion with internal echoes located in the superficial fibres of vastus lateralis muscle, measuring 4.0cm x 1.9cm x 1.5cm. The wall-thickness of the cyst measured 4mm and there was a tiny echogenic nodule along the anterior wall on the luminal side. MRI showed intermediate signal on T1W and hyperintense signal on T2W sequence, and also revealed sharp peripheral wall enhancement upon intravenous administration of gadolinium . The tiny nodule along the luminal surface of the anterior wall appeared hypointense on all pulse-sequences and did not reveal enhancement on post-contrast images, suggestive of a scolex . Based on the imaging findings, a diagnosis of isolated giant muscular cysticercosis was suggested. The Enzyme-linked Immunosorbent Assay (ELISA) titre for T. solium was raised (1:500). Haemogram was unremarkable, except for mild increase in differential eosinophil count (8%). ESR was mildly raised (20 mm/hr). Stool examination was normal.In view of the superficial location and relatively large size, surgical excision was advised. Since the parents did not agree for the same, albendazole 15 mg/kg/day in two divided doses was administered orally for 4 weeks and patient was closely monitored. A short, tapering course of prednisolone starting at 2mg/kg/day was also administered. At the end of 4 weeks, the swelling had completely subsided on palpation with no residual symptoms. An USG at this time showed complete regression of the cyst. Follow-up examination 2 months later did not reveal any evidence of recurrence.Most cases of muscular cysticercosis are asymptomatic, but when it manifests clinically, it generally belongs to one of the three types – the myalgic type, the nodular type, or the pseudohypertrophy type.[4] Though histopathological analysis after fine needle aspiration cytology or biopsy provides the most conclusive evidence of muscular cysticercosis, imaging in combination with serology is usually sufficient to make a fairly accurate diagnosis.[5] Presence of a cyst with an eccentrically located scolex is the classical imaging appearance of muscular cysticercosis on USG as well as MRI. Nodular type cysticercosis, which was seen in our patient, is the result of degeneration of the cyst with intermittent leakage of fluid in the surrounding tissue resulting in perilesional inflammatory response. In addition to mild pain, the relatively thick wall around the cyst, presence of internal echoes on USG, and peripheral enhancement on post-contrast MRI were consistent with a degenerating cyst inciting an inflammatory response. USG alone can be suggestive of a diagnosis of muscular cysticercosis. However, in addition to corroborating the USG diagnosis, MRI provides information regarding the exact location, extent and multiplicity of the lesions.[5] In our case, the relatively thick wall of the cyst and presence of internal echoes on ultrasound warranted further characterisation of the lesion with MRI, as cold abscess was another diagnostic consideration.Whenever feasible, surgical excision is advisable for symptomatic isolated muscular cysticercus lesions.[8] Where surgery is not possible, medical therapy with albendazole or praziquantel is recommended. A short course of steroids is also recommended to reduce the inflammatory reaction to antiparasitic treatment.[8]Source of Support: NilConflict of Interest: None declared


Echinococcus granulosus demonstrates an endemic infection in several countries such as Middle Eastern countries. Liver is the most frequently involved organ, followed by the lung. The case we present is solitary primary localization of cyst in abdominal wall which is extremely rare. A 57-year-old woman presented with an abdominal wall lesion in umbilical area that had been evolving for about 2 years with recent complaint of pain and discomfort. We detected a midline abdominal mass 12⁎13 centimeters in diameter which was bulged out in umbilicus. Preoperative clinical diagnosis of incarcerated umbilical hernia was made due to its physical examination while surgical exploration disproved the primary diagnosis and we found cystic mass adherent to superficial fascia without any communication to peritoneal space. The cyst was excised completely without any injury or perforation of containing capsule. The diagnosis of hydatid cyst was confirmed by histopathological examination of specimen. The retrograde evaluation showed no involvement of other organs. The patient was followed for two years and no recurrence of hydatid disease has been observed. Hydatid cyst should be considered as a differential diagnosis of abdominal wall and umbilical lesions especially in endemic regions.Hydatid cyst caused by Echinococcus [ Echinococcus granulosus is widespread through many regions of Asia including Middle Eastern countries. Cystic hydatid disease is endemic in most parts of Iran and is hyperendemic in some areas [Hydatid disease is a zoonotic parasitic cystic disease caused by the larval stages belonging to the genusnococcus . Echinocme areas . Hydatidme areas . Liver ime areas , 3. The me areas . In our ∗13 centimeters in diameter which was bulged out in umbilicus. The mass which was a painful swelling seemed to be cystic lesion with palpable solid components. Overlaying skin was intact with evidence of mild chronic irritation. Preoperative clinical diagnosis of incarcerated umbilical hernia was made due to its physical examination and recent symptoms such as pain. Therefore, she was scheduled for operative intervention. The preoperative examinations such as chest radiograph, complete blood count, blood biochemistry, and blood coagulation tests revealed no abnormalities. Complete blood count demonstrated white blood cell count of 9610 with 78 percent of neutrophils and no eosinophils. Surgical exploration disproved the primary diagnosis of umbilical hernia. The cystic mass was found to be adherent to superficial fascia without any communication to peritoneal space. It was not involved in peritoneum or abdominal organs. The cyst was excised completely and dissection was done without any injury or perforation of containing capsule and wound closure was done by primary repair. The macroscopic appearance of mass suggested a hydatid cyst and diagnosis was confirmed by histopathological examination of specimen (A 57-year-old woman presented to surgical clinic in Tehran, Iran, with an abdominal wall lesion in umbilical area which had been evolving for about 2 years . Her comspecimen . Postope Echinococcus granulosus and has a global distribution. Hydatid disease is known as an endemic parasitic disease in Iran and it is responsible for approximately 1% of admission to surgical wards [Human hydatid disease is caused byal wards . Althougal wards . E. granulosus accounts for 1%–4% of reported hydatid cases [It had been reported that primary muscle infection withid cases . Low preid cases . Howeverid cases , thoraciid cases , 10, sarid cases , 12, supid cases , gluteusid cases , and solid cases .Solitary abdominal wall hydatid cyst is a rare finding. We mentioned only a few cases reported to have primary abdominal wall lesions and most of them presented with right iliac or paraumbilical region –22. AbhiIn our case, presented region and acute symptoms brought to mind that misdiagnosis of umbilical hernia may be more probable. Due to the importance of intact resection in hydatid mass, any suspicious lesion during operation should be resected en bloc and prevented from rupture.The patient surgery was based on our most possible diagnosis which was umbilical hernia, but in the operation room and under the surgery we found that the thing in that umbilical bulging is most likely a hydatid cyst. As a result of the pathology, our diagnosis was approved and the hydatid cyst was confirmed.Surgery with total resection, if applicable, is the treatment of choice for primary hydatid cysts.During resection, the wall should be kept intact and the resection should be done very carefully without causing any rupture. If not, dissemination of the disease and anaphylaxis may occur. Srivastava, though, suggests that hydatid cyst should be considered as a possible diagnosis of abdominal wall cystic lesions and open biopsy should be avoided. If resection of cyst in an intact form is not possible, removal of the content of the cyst should be considered. Endocystectomy, pericystectomy, marsupialization, capitonnage, simple drainage of the cyst, and resection of the infected organ are surgical methods used in practice. Then, the cavity of cyst should be irrigated with scolicidal agents , 23–25. In endemic areas such as Iran, hydatid cyst should be considered as one of differential diagnosis in approaching the cystic lesions in any organ of the body even in abdominal wall or umbilicus. We suggested that, in the cases of primary hydatid disease in abdominal wall, complete resection is the treatment of choice.


Carcinosarcoma of the uterus is a rare tumor representing 2-4% of uterine malignancies. Its prognosis is poor with a 5 years survival rate of 10-30%. We report a first documented case of carcinosarcoma occurring in a 62 years old woman who presented with postmenopausal vaginal bleeding for one year. The preoperative biopsy of endometrium revealed a leiomyosarcoma. Total body Computerized Tomography (CT) Scan revealed a mass limited to the uterus without other abnormalities. We carried out a total abdominal hysterectomy with bilateral salpingo-oophorectomy. Post operative histology of the specimen found a carcinosarcoma. The patient underwent a course of radiotherapy and a total body CT Scan done eight months later revealed no signs of recurrence or metastasis. Clinicopathological aspects, treatment options and prognosis of this aggressive neoplasm are reviewed. We recommend practitioners to be aware of this lesion for an early diagnosis and appropriate treatment. Carcinosarcomas (CS) also called Malignant Mixed Müllerian Tumors (MMMTs) are very rare and extremely aggressive tumors of the uterine corpus containing both malignant epithelial and malignant mesodermal elements originating from the same precursor cell . They acMrs MNO 61 years old, G10P9018 is a retired teacher, menopaused since 9 years. She was referred to out unit for better management of a leiomyosarcoma diagnosed in a secondary hospital one month earlier on a specimen of endometrial biopsy (curettage) indicated for painless mild per vaginal bleeding evolving for one year. She had her first menses at 14 years old; she is menopaused since 9 years and she has had no sex for the past 15 years; there is no notion of sexually transmitted infection she has never done a pap smear cervical cytology; there is no personal history of gynecological malignancy. There is no contact cervical bleeding.She is G10P9018 with 9 normal deliveries and one first trimester spontaneous abortion. The last child is 24 years old. She used to breastfeed for 18 months. Our patient has essential high blood pressure diagnosed nine years ago and treated with indapamide without visceral complications. She underwent two eye surgeries for cataract. Her blood group is A rhesus positive, she has never received blood products. She has no known allergy and consumes neither alcohol nor tobacco. She has three siblings who are apparently well as their mother. Her father died after a road traffic accident. She has no family history of cancer.On systemic enquiry we found a foul smelling vaginal discharge, no pelvic pain, no cough, no chest pain, no weight loss, no anorexia and no vomiting. Her general condition was good and the blood Pressure was 140/88 millimeters of mercury. The weight was 116 kilogrammes and the height 1.64 meter (body mass index of 43.13 kilogrammes / meter square). The respiratory rate was 18 cycles per minute, the temperature 37.3° Celsius. Cardiac, pulmonary and breast examination were normal. Abdomen circumference was 125 centimeters. Inspection under vaginal speculum revealed a necrotic and hemorrhagic mass of seven centimeters of diameter protruding from the cervix. Digital vaginal examination was not done to avoid contact bleeding. Digital exploration of the rectum revealed no abnormalities. Varicosities were found on both legs.The following work up was done: chest radiography revealed a heart of increased size but no pulmonary abnormality; Electrocardiogram revealed ventricular extra-systoles; ultrasonography and CT Scan of the abdomen and pelvic revealed a mass limited to the uterine cervix without others abnormalities. The full blood count, liver and function tests and hemostasis work up were normal. Hepatitis B and Human Immunodeficiency Viruses test were negative. Fasting blood sugar level was normal. The working diagnosis was a uterine leiomyosarcoma at stage II of the FIGO  staging system. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was carried out under general anesthesia. The findings were: normal size uterus containing a seven centimeters mass prolapsed through the cervix; uterine serosa invaded by the tumor; macroscopically normal adnexae. The pelvis was free of adhesions. The post operative course was complicated by infection of the abdominal wall. The abscess was drained and secondary closure of the wound was done 22 days after surgery and the patient sent for adjuvant radiotherapy. The Macroscopy showed bulky and necrotic poorly circumcised mass of the corpus uterus . The HisSince carcinosarcomas are very rare their risk factors have not been widely studied. Nevertheless the following factors are known to increase the risk of having a carcinosarcoma: prior pelvic irradiation, chronic estrogen exposure, tamoxifen use and African-American race . Our patThis CS has been managed according to international standards in our resource-poor setting with success. We recommend to practitioners and researchers to report other cases to increase awareness on mixed malignant mesodermal tumor.


Here we present a case in which acute hemoperitoneum was observed after administration of prostaglandin E2 in a pregnant woman. The patient had a history of endometriosis, and a severe pelvic adhesion (ASRM stage IV) was found during her last laparoscopic surgery 3 years previously. In cases with endometriosis, use of prostaglandin E2 for induction of labour in pregnant women must be done cautiously.Prostaglandin E The case of acute hemoperitoneum after intravaginal administration of PGE2 for cervical ripening has been rarely reported. Here we can learn that induction of labour with PGE2 in women with endometriosis may be associated with acute hemoperitoneum.Endometriosis is usually a common gynaecologic condition. It is associated with chronic inflammation, which causes tissue injury, painful symptoms, and infertility . In receA 25-year-old woman (G1P0) was admitted to the hospital at 41 weeks of gestation with a 5-year history of endometriosis. Laparoscopic excision of endometriotic lesions had been performed in this hospital 3 years previously. Ultrasound demonstrated that there was an ovarian endometrioma with a diameter of 3.8 cm on her right ovary . The end2 preparations were inserted into the posterior fornix at 9:20 a.m. The patient had symptoms of regular abdominal pain from 11:30 a.m. And then, the cardiotocography recorded six contractions lasting 40 to 50 seconds per time within 10 minutes around 12 p.m. Her blood pressure was 95/58 mmHg and her pulse rate was 100 beats per min. However, it was not helpful to reverse the effects of hyperstimulation and tachysystole in the hour following removal of the PGE2 vaginal insert. Vaginal examinations subsequently identified that the cervix was still closed. Meanwhile, she complained of persistent inferior abdominal pain with symptoms including nausea and vomiting. Her blood pressure rose to 120/65 mmHg, and her pulse rate increased to 110 beats per min.She felt no contractions and denied having vaginal bleeding. Clinical pelvimetry and foetal size and presentation were examined before initiating attempts to induce labour. Her Bishop score was 4, so PGEAn emergency caesarean delivery was scheduled at 3 p.m. When the peritoneal cavity was entered, a hemoperitoneum was clearly seen, which consisted of fresh liquid and clotted blood scattered into the intestinal walls and mesentery. About 1000 mL of blood and 1500 g of clotted blood were evacuated. The uterine wall was then transversely incised, the foetus was extracted, and the placenta was routinely separated from the uterus. The placenta appeared normal and complete. We excluded the possibility of placental abruption after further examination. The new born baby survived, with an Apgar score of  7 and 10 at the first and fifth min. Then adhesions were extensively detected between the bilateral adnexa, omentum majus, and uterus. Part of the ruptured cyst and the right ovary were tightly adhered to the posterior uterine wall. The region of the adhesion on the surface of the uterus appeared as an inflammatory exudation with small bleeding vessels. Active bleeding from the ovarian cyst wall and posterior uterine wall vessels was observed. The maternal haemoglobin levels dropped significantly to 6.3 g/dL from the initial 9.2 g/dL.After adhesiolysis and ovarian cystectomy, the original region that was bleeding was sutured, and then haemostasis was achieved. Haemorrhage from the left ovary and the upper abdomen was excluded through a more comprehensive pelvic and abdominal exploration. The patient received a blood transfusion consisting of six units of packed red blood cells and 800 mL fresh frozen plasma, which temporarily corrected her anaemic condition. The postoperative histological examination from the ovarian cyst proved to be similar to the endometrium with signs of decidualization . She wasOur findings support those of the previous reports that endometriosis might be related to acute spontaneous hemoperitoneum. Janicki et al. reported a case of hemoperitoneum secondary to the rupture of an ovarian endometrioma in a nonpregnant woman with severe endometriosis . In contAziz et al. tried to explain the aetiology of acute hemoperitoneum . One posThe size of the ovarian endometrioma is another question of concern. The potential for vessels to rupture becomes more serious as the cyst grows larger. To the best of our knowledge, the 3.8 cm ovarian cyst in our case is the smallest reported to have ruptured in a pregnant woman. We conclude that the severity of the pelvic adhesion and the intensity of uterine contractions are more important than the size of the ovarian cyst.2 was uterine tachysystole [2 is not contraindicated in patients with ovarian endometrioma. During general labour without PGE2, uterine contractions also tend to pull the uterus away from the ovaries and increase the blood pressure in the utero-ovarian circulation. In our case, more than 5 contractions triggered by PGE2 over a 10-minute period obviously increased the risk of vessel rupture.Evidence showed that one of the most common adverse effects of PGEysystole . Cases oysystole , but theysystole  or the Uysystole , PGE2 is2 may be associated with acute hemoperitoneum. Therefore, we should be very cautious when PGE2 is used to induce labour in women with endometriosis, particularly when the patient has a history of severe pelvic adhesions.This case illustrates several points that may prove useful to clinicians when dealing with these conditions. Induction of labour with PGE


The transformation of a benign hemangioma into a malignant angiosarcoma has been rarely reported, with only 11 cases reported in the literature. There have been no reports of malignant transformation of hemangioma into angiosarcoma in association with epithelioid hemangioendothelioma, to our knowledge. The existence of precursor malignancies in the tumorigenesis of sarcomas is still not clearly defined. We describe the case of a 40-year-old woman with a preceding history of a suspected hemangioma for ten years, who upon resection was found on histology to have evidence of a hemangioma with an associated area of epithelioid hemangioendothelioma as well as areas of overt high grade epithelioid angiosarcoma. These findings raise the possibility of the evolution of hemangioma to epithelioid hemangioendothelioma, and the latter to overt angiosarcoma. The patient was managed as having a high grade sarcoma with wide resection and radiation. She declined systemic adjuvant chemotherapy after a thorough discussion about the risks and benefits of chemotherapy, and she currently remains disease free one year after the surgery. Soft tissue sarcomas are rare malignant neoplasms comprising <1% of all adult malignancies [In the case of malignant vascular tumors such as angiosarcoma, there have been several case reports of angiosarcomas arising at the site of irradiated hemangiomas , 3. TherA 40-year-old woman was referred to The Orthopaedic Oncology Center with a chief complaint of “pain in my left calf for the past ten years.” She reported that her symptoms of pain in her calf began approximately 10 years ago. She described the pain initially as throbbing in nature that was exacerbated with activity and with ankle dorsiflexion and was relieved with rest and warm compresses. At that time, she noted a mass in her left calf that was about 2 inches in size, which did not fluctuate in size and was nontender. She continued to have mild to moderate pain on a regular basis but did not seek medical attention. Instead, she avoided prolonged walking. Approximately three years ago, the pain became more constant and severe. She began walking with a limp due to the inability to dorsiflex her foot to neutral position and she walked on the tip toes of her left foot. For the past 3 years, she has only been able to walk on her tip toes due to an equinus contracture. Three months prior to presentation, in our office, the patient experienced an acute exacerbation of pain in her left calf and sought medical attention from her primary physician. She was prescribed narcotic analgesia without significant relief of her symptoms. The patient was subsequently referred for an MRI. As initial work-up for this lesion, she had an MRI of the left lower extremity.This showed an ovoid mass centered in the soleus muscle measuring 6.8 cm in the craniocaudal dimension, 5.2 cm in the transverse oblique dimension, and 4.6 cm in the oblique dimension. Edema in the soleus muscle and surrounding musculature were noted .Following the MRI, she was referred to the orthopaedic oncology service. She believed that the mass had increased slightly from the time she first noticed it 10 years earlier. She had no other associated symptoms. Her past medical history included only a previous hysterectomy with tubal ligation and unilateral oophorectomy and gastroesophageal reflux. She had no history of prior radiation therapy. The only medication she was taking was low dose narcotics for her pain. Her only allergy was a rash to nitrofurantoin. She was married and denied any alcohol, tobacco, or illegal drug use. She had no family history of sarcomas, only a grandmother with non-small cell lung cancer and a paternal aunt and uncle with adenocarcinoma of the colon and an aunt with uterine cancer. Her physical exam revealed an equinus contracture of 20 degrees with plantar flexion from 20–30 degrees of the left ankle. There was a well-defined, firm, and tender deep-seated 5 × 5 cm soft tissue mass in the midcalf. There were no cutaneous changes or skin discoloration or lymphadenopathy. The mass did not change in size when the extremity was elevated or placed in a dependent position. Though this lesion was suspected to be a benign cavernous hemangioma, due to the patient's significant symptoms, she elected for the resection of her left lower extremity soft tissue tumor.At the time of surgery, a longitudinal incision along the posteromedial aspect of the left leg was made. The plane between the gastrocnemius and soleus was developed and the mass was easily identified. Grossly, there was an irregular red-brown to tan-appearing friable mass intertwined with skeletal muscle with associated large vascular channels consistent with a cavernous hemangioma. Manipulation of the ankle under anesthesia was performed bringing the ankle to 10 degrees of dorsiflexion in order to correct the equinus contracture. She was placed in an ankle dorsiflexion splint postoperatively.The pathology specimen consisted of multiple irregular fragments of soft tissue including skeletal muscle. Sectioning revealed a poorly defined, hemorrhagic, and red-brown lesion measuring at least 5 cm in the greatest dimension. Multiple cystic spaces with blood clot suggestive of blood vessels were noted.On sectioning, the majority of the lesion was indistinguishable from a cavernous hemangioma with large blood-filled spaces lined by flattened bland endothelium . There wEpithelioid angiosarcoma, apparently arising in a 10-year-old hemangioma. Some areas are indistinguishable from epithelioid hemangioendothelioma, but other foci show high grade epithelioid angiosarcoma.Immunohistochemical stains show that the lesion expresses CD31, consistent with a vascular neoplasm. Pankeratin, S100, desmin, and HMB45 are negative. There was virtually no Ki67 staining of the hemangioma-like areas ; howeverOnce the patient was diagnosed with angiosarcoma, she underwent a noncontrast CT of the chest that did not show any evidence of pulmonary nodules. She then proceeded to a wide local reexcision which did not show any residual tumor. She received adjuvant radiation therapy, but she elected to decline adjuvant chemotherapy after discussion of the risks and benefits. She is currently alive and free of disease recurrence, one year after the surgery.The tumorigenesis in sarcomas is still debated, compared to tumorigenesis in carcinomas where precursor malignancies are well understood. Most angiosarcomas arise de novo. Since the 1970s, there have been only four case reports and two case series, comprising 11 cases, describing angiosarcomas (AS) arising from benign hemangiomas in the absence of irradiation, suggesting that, for this subtype of soft tissue sarcoma, the pathogenesis may follow the malignant transformation of a benign lesion in some cases –11. HoweWe describe a case of a patient with a presumed hemangioma for ten years preceding her diagnosis of angiosarcoma. Her pathology shows areas of benign hemangioma and epithelioid hemangioendothelioma and a focus of high grade epithelioid angiosarcoma. There are two possible explanations for this pathologic result. The first possibility is the malignant transformation of a hemangioma to angiosarcoma, with an intermediate step of low-grade malignancy. The second possibility is a composite hemangioendothelioma. This rare entity was first described by in 2000 by Nayler et al. . So far,Therefore, our case likely represents the transformation of a benign hemangioma or low-grade hemangioendothelioma which had been present for 10 years into a high grade angiosarcoma. This supports the hypothesis that benign vascular tumors can undergo malignant transformation and argues for increased surveillance in those patients with a previous diagnosis of a benign hemangioma that have changing symptoms or size of their lesion.In summary, we describe a case of a 40-year-old woman with a ten-year history of a hemangioma that upon resection showed an area of transformation into high grade angiosarcoma, supporting the hypothesis that benign hemangioma can transform into more malignant tumors.


To describe a novel endoscopic approach to the posterior third ventricle through a cavum septum pellucidum.Retrospective case review of a 7-year old boy with a tectal plate mass.The clinical and operative notes, operative videos, and imaging were reviewed. A literature search was also performed.The patient was referred for neurosurgical opinion due to a 2-week history of gait instability on a background of progressive ataxia and urinary incontinence. MRI showed triventricular hydrocephalus due to a tectal plate mass with thalamic extension.On examination, his GCS was 15/15 and he demonstrated truncal ataxia, gait instability, and upper limb dysmetria. He was admitted for an endoscopic third ventriculostomy with biopsy.Operative approach: The patient was anaesthetised and placed supine. Incision and burr hole were over the left coronal suture. A third ventriculostomy was performed for hydrocephalus.The tumour was then approached through the cavum septum pellucidum. Septal fenestrations allowed easy access to the cavum. Internal cerebral veins were identified and the velum interpositum opened with sharp scissors. The opening was dilated and an endoscope advanced into the posterior third ventricle. The tumour was identified and biopsies obtained.He had a satisfactory recovery and was discharged 6 days later. Histology showed a low-grade glioma, which remained stable on follow-up MRI.When present, the cavum septum pellucidum provides a viable alternative route to the posterior third ventricle.


Odontogenic myxomas (OMs) are benign mesenchymal locally aggressive neoplasms of the jaw bone. Although OMs predominantly involve the mandible, maxillary tumors are usually more aggressive than mandibular tumors. The present study describes the case of a 37-year-old male with a large odontogenic myxoma of the bilateral maxillae, which caused a defect in the right skull base bone. The tumor was successfully removed through radical resection of the hard tissue and local resection around the envelope of the soft tissue. The tumor exhibited no recurrence. However, the current methods for bilateral maxillary reconstruction to restore the maxillary buttress and achieve an optimal aesthetic appearance are complicated due to the lack of suitable conditions for oral rehabilitation with good dentition. Odontogenic myxomas (OMs) are benign, slow-growing, locally aggressive and non-metastasizing neoplasms of the jaw bone. OM is derived from embryonic mesenchymal elements of the dental anlage –3. AccorOM of the maxilla was first reported by Thoma and Goldman in 1947 . While OThe present study reports the case of a male patient with a large maxillary OM. Although the mass was removed successfully, repairing the defect in the maxilla was a complex process. Patient provided written informed consent.A 37-year-old male presented with a mass on the right side of the face, which had persisted for five years, with accelerated growth for one year, causing serious facial deformity and difficulty in eating. The painless mass was ~16×16 cm and occupied the right maxilla and the nose, extending superoinferiorly from the right orbit and infraorbital rim to the bilateral alveolar bone and hard palate. Part of the mass displaced the teeth and protruded outward from the mouth, with a rough surface that released a purulent discharge upon palpation. No superficial ulceration, sinuses or fistulas were observed on the overlying skin, which did not adhere to the mass. The patient had bilateral nasal obstruction with effluvial secretion and normal vision, even though the infraorbital rim disappeared, as the mass displaced the optic nerve .Enhanced computed tomography revealed that an irregular and low-density shadow without obvious enhancement was displaced in the maxillae, and that a high-density shadow was interspersed in it. Magnetic resonance imaging identified that the well-circumscribed tumor had already obliterated the maxillae, the maxillary process of the right zygomatic bone, part of the left maxilla, the ethmoidal sinuses, the sphenoid sinus and the nasal cavity. The nasopharyngeal cavity and the left maxillary sinus were observed to be narrow, and the turbinate bones and the nasal septum had been resorbed due to the tumor pressure. Although the large mass grew into the intracranial cavity through a bone defect in the sphenoid wing caused by tumor pressure-induced resorption, the tumor was present with well-defined borders under the dura mater . Accordi®  and the defect cavity was filled with large numbers of staple slivers with iodoform. No intracranial infection or cerebrospinal leakage were observed. No clinical or radiographical signs of recurrence were observed, and the soft- and hard-tissue defects were covered with compact mucosa after one year of post-operative control. The right side of the patient’s face and nasal bridge collapsed and the right eyeball moved down, as the defects were not repaired using soft flaps.Following a tracheostomy, the patient underwent right radical maxillectomy and left partial maxillectomy, which included the partial right zygomatic bone and zygomatic alveolar ridge of the left maxilla, with a 1-cm healthy margin. Moreover, the mass was enucleated from the soft tissues around its capsule. A small quantity of bone surrounding the bone defect in the skull base, as well as the turbinate mucosa and the thin skin covering the mass were also resected. The medial rectus in the right eye, the septum mucosa, the left nasal mucosa, the thin bone of the left infraorbital rim and the residual posterior wall of the maxillary sinus were retained. Subsequent to tumor removal, the cavernous, ethmoid and left maxillary sinuses were exposed . The patMacroscopically, the surgically resected mass measured ~15×16×16 cm and appeared as a completely encapsulated whitish-grey, lobulated, smooth and hard mass. Microscopically, the tumor was composed of a faintly basophilic myxomatous ground substance and a mount of spindle- and stellate-shaped cells. Variable quantities of fibrous tissues were found throughout the mucoid-rich matrix. Furthermore, minimal and inconspicuous thin-walled vessels and residual bone fragments were interspersed within the tumor. Islands of odontogenic epithelium, hyalinization and calcification were not found. The mass was diagnosed as an OM.An OM is a mesenchymal benign tumor with the potential for extensive bone destruction, cortical expansion and a relatively high recurrence rate ,12. It het al (While surgical intervention is recommended, no consensus has been reached with regard to the surgical method for the treatment of OM due to its aggressive nature and high rate of recurrence, which is between 10 and 43%, particularly in patients who are treated with curettage or local surgical excision . Boffanoet al  reportedet al ,16,17. Let al ,18. In tet al (The development of microsurgery and reconstructive surgery techniques have enabled the basic functional and aesthetic aims of maxillary reconstruction to be achieved. Various methods have been used to reconstruct maxillary defects, including vascularized soft- or hard-tissue grafts from the radial forearm, rectus abdominis, anterolater thigh, scapular and fibular, iliac crest flaps, vascularized free fibular flaps and cranial bone flaps, as well as material implants using, for example, titanium mesh –23. Accoet al  reportedet al  used a lTo the best of our knowledge, the present study is the first report of such a large maxillary OM. In the present study, without surgical intervention, the patient had a high risk of succumbing due to increasing intracranial pressure. The mass was removed successfully without any complications and did not recur within one year despite the unsatisfactory results with regard to the external facial features and their function. Due to the structure of the maxillae and the local infiltration of OM, radical resection may the best treatment choice for maxillary OM in hard tissue and local resection may be best around the envelope in soft tissue. It is difficult to restore the maxillary buttress and achieve an optimal aesthetic appearance using current methods for reconstructing midfacial defects due to the lack of suitable conditions for oral rehabilitation with good dentition. Further investigations are required to develop appropriate, satisfactory reconstruction methods for midfacial defects.


Klippel–Feil syndrome is characterized by a congenital fusion of cervical vertebrae. Intracranial teratomas are nongerminomatous germ cell tumors and they account for 0.3 to 0.9% of all intracranial tumors. Teratomas with malignant transformation refer to lesions which give rise to malignant cancer of somatic type. The association between tumors of dermoid origin and Klippel–Feil malformation is extremely rare. Only 23 other cases have so far been reported, and only one case of dermoid tumor with areas of dedifferentiation on squamous cell carcinoma has been described.We report the case of a 72-year-old white man with a 2-year history of gait and balance disturbances. A brain magnetic resonance imaging revealed a fourth ventricle neoplastic process with infiltrative features. He was operated through a suboccipital craniectomy with a C1 laminotomy and bilateral vertebral artery transposition. At 6-months follow-up, magnetic resonance imaging showed an early regrowth of the fourth ventricle tumor, with the same radiological features.Patients with Klippel–Feil malformation could develop posterior fossa dermoid tumors. The malignant potential of such tumors must be considered and surgery is recommended. Particular attention must be focused on the histopathological analysis in order to identify possible foci of malignant transformation. Klippel–Feil syndrome is characterized by a congenital fusion of cervical vertebrae; it was described from autopsy findings in 1912. It is clinically characterized by the classic triad of brevicollis, low posterior hairline and severe restriction of neck motion in combination with two or more non-segmented cervical vertebrae [Intracranial teratomas account for 0.3 to 0.9% of all intracranial tumors . They arThe first association between posterior fossa dermoid tumors and cervical fusion anomaly was described by Love and Kernohan . This asA 72-year-old white man presented with a 2-year history of gait and balance disturbance, associated with paresthesia to his upper and lower limbs and frequent episodes of falling to the ground. He recently referred episodes of morning vomiting. At a physical examination he presented with a short neck and a low hairline at the back of his head. A neurological examination revealed ataxic gait with retropulsion at the Romberg test, slight weakness in his right limbs, tetra hyperreflexia with bilateral Hoffmann and Babinski signs, and dysmetria in the finger-to-nose test. A magnetic resonance imaging (MRI) study revealed a fourth ventricle neoplastic lesion, with infiltrative features and non homogeneous signal. The lesion presented a uniform contrast enhancement in its posterior part while a peripheral enhancement was observed in its anterior portion.A craniocervical computed tomography (CT) scanning revealed a scoliotic deformation of the vertebral column with C3 to C4 synostosis. These features allowed a diagnosis of Klippel–Feil syndrome Fig. .Fig. 1SaThe patient was operated through a suboccipital craniectomy with a C1 laminotomy and bilateral vertebral artery transposition. We performed a subtotal tumor resection using a telovelar subtonsillar route, because of tight neoplastic adhesions to the cranial portion of the floor of the fourth ventricle.A histopathological examination revealed a periodic acid–Schiff (PAS)-positive dysmorphic material with pluristratified epithelial islands. A teratoma, partly cystic, with pseudo-cartilage areas and hair and tooth-like formations was identified. There were also features of a squamous cell carcinoma with atypical polymorphic epithelial cells, necrosis and focal cornification. The lesion was related to a teratoma with malignant transformation Fig. .Fig. 2ImThe postoperative course was uneventful with neurological improvement. The patient was able to walk without ataxic feature and the Romberg test was improved. A postsurgical CT scan demonstrated a partial removal Fig. .Fig. 3PoAt 6-months follow-up, a MRI showed an early regrowth of the fourth ventricle tumor, with the same radiological features Fig. . AccordiThe association between posterior fossa dermoid tumor and Klippel–Feil syndrome is well known. However, the association of cervical fusion anomalies with malignant teratomatous lesions has rarely been reported.Hox and Pax genes, the DNA sequences that control the development of intervertebral disk may be reduced producing the vertebral segmentation. It has also been speculated that this occurrence, during the 28th to 35th days of life, may cause an altered tissue tension at the cervicomedullary junction resulting in the entrapment of dermal elements. This process may be responsible for the formation of posterior fossa dermoid tumors [Many hypotheses have been proposed to explain the embryological association of the two pathological conditions. One theory suggests that failure of the segmentation of the cervical sclerotomes could lead to the Klippel–Feil anomaly. In accordance with this, the absence of the cleavage of the ectoderm from the neuroectoderm would result in entrapment of the dermal elements within the closing neurotube . Anotherd tumors , 16.There are different mechanisms underlying the migration of germ cells including pseudopodial structures, chemotactic factors, basement membrane or extracellular molecules .in vivo and in vitro [Another important structure involved in posterior fossa embryological development is the isthmus; the isthmus develops at the junction of the mesencephalon and metencephalon, thus serving as an organizing center for both midbrain and hindbrain differentiation. The homeobox genes play a crucial role in segmentation and subsequent patterning. Among them, the Sonic hedgehog regulates the midbrain–hindbrain morphogenesis through positive regulation of the Gli activators (GLI1) and inhibition of the Gli repressors (GLI3) and controls the overall growth of this region. Sonic hedgehog also restricts FGF8 expression to the isthmus, which is essential for the differentiation of the tecto-isthmo-cerebellar region . The encin vitro . Sonic hin vitro .In our case we report an early tumor regrowth, after a subtotal removal, due to tight adherences of the tumor to the floor of the fourth ventricle. The extremely aggressive features of this kind of lesion have to be related to the nature of teratomatous tumors. The so-called “growing teratoma syndrome” is a rare complication which follows the resection of a recurrent intracranial nongerminomatous germ cell tumor in adults . It is oThe early regrowth of the tumor from a small postsurgical remnant demonstrates that inside a posterior fossa teratoid lesion, there are some more aggressive areas with malignant transformation. Complete removal of these islands adherent to the floor of the fourth ventricle is extremely dangerous and a total removal is very difficult. The association of posterior fossa teratoid lesion with Klippel–Feil disease is very rare and represents a surgical challenge.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.


Schwannoma is a rare, benign tumor that arises from the nerve sheath. This tumor usually involves the extremities, but can also be found in the head and neck, trunk, pelvis, retroperitoneum, mediastinum and gastrointestinal tract. In numerous cases, the tumors are asymptomatic and are identified incidentally on physical examination or imaging. Occasionally, schwannoma is symptomatic due to compression of surrounding large nerves. In the present study, a 57-year-old female presented to the surgical outpatient’s department due to a well-localized parietal pain in the left lower quadrant. The onset of the pain occurred three years prior to presentation, without apparent cause and in the absence of other symptoms. Ultrasound and a computed tomography scan revealed a small solid tumor in the anterior abdominal wall, which was dimensionally stable over time, but was not noted in a preliminary analysis by a radiologist. The lesion was surgically removed using an anterior surgical approach. Histopathology revealed the tumor to be benign schwannoma. The painful symptoms completely disappeared. To the best of our knowledge, this is the third case of an abdominal wall benign schwannoma in the medical literature, and the first symptomatic case. Schwannoma (neurinoma or neurilemmoma) is a rare, benign tumor, composed exclusively of Schwann cells, that arises from the nerve sheath, as opposed to neurofibrome consisting of different cell types that constitute the nerve. Schwannoma is the most common tumor of the nerves and the incidence in adults is ~5% . It is cTo the best of our knowledge, the present study is the third reported case of a schwannoma located in the abdominal wall, and the first symptomatic case ,5. WrittA 57-year-old woman presented to the surgical outpatient department due to well-localized parietal pain in the left lower quadrant. The onset of pain occurred three years prior to presentation, without apparent cause and in the absence of other symptoms. The pain was extremely localized, 6–7 cm inferiorly and laterally to the umbilicus, and was not associated with movement, position or particular events such as oral feeding and stress. Overall, the symptomatology increased over time, in terms of frequency and intensity of the abdominal pain. On physical examination, the abdomen was not painful and no mass was identified or suspected. All routine laboratory tests were normal. During the first year of symptoms, a gastroenterological outpatient consultation was performed and a colonoscopy procedure did not reveal any lesions or abnormalities. During the same consultation, an ultrasound examination was performed, notably revealing a well-defined cystic lesion, 1.6 cm in diameter, located in the muscular layer of the left-lower quadrant of the parietal wall. The nodule was not painful upon the administration of pressure. Due to the persistence of the symptoms, one year later an abdominal computed tomography (CT) scan was performed. In a preliminary analysis, no lesions were identified in the peritoneal cavity or abdominal wall, and no parietal defects were found. Three years subsequent to the onset of the symptoms, a novel analysis and review of the radiological images revealed the presence of a small parietal nodule. In order to confirm and verify the possible alteration in the tumor, a novel CT scan was performed.The CT scans were performed on a 16-channel multislice unit  and on a 256-channel multislice unit  prior to and following the administration of intravenous (IV) contrast media with a two-year interval between the two examinations. A 17×11 mm mass was identified in the abdominal wall, on the left edge of the left rectus anterior muscle . The masThe suspected diagnosis was of a benign schwannoma of the anterior abdominal wall. The most notable indication of the cause-effect association between the lesion and the parietal abdominal pain was the considerable topographic coincidence. Presented with this clear association, an indication for surgical removal was discussed with the patient and decided by mutual agreement.A pre-operative ultrasound examination  confirmed the size and shape of the mass, which was hypoechoic with certain internal linear hyperechoic structures .The patient underwent surgery under general anesthesia, which was performed using a direct anterior approach. By making an incision into the anterior fascia of the left rectus abdominis muscle, the lesion was immediately identified at the lateral edge of the muscle . NotablyMacroscopically, the nodule was 2 cm in diameter, rounded and of tense-elastic consistency, exhibiting a white color in the center of the lesion and possessing a peripheral region of myxoid appearance .Microscopically, the lesion demonstrated an alternation of hypercellular and hypocellular areas, each comprising spindle cells without significant atypia. In the hypocellular area, foci of myxoid differentiation were also present. The tumor cells were revealed to strongly and diffusely express the S-100 protein by immunohistochemistry , confirmSchwannomas are benign tumors of the Schwann cells in the neural sheath of cranial and peripheral nerves. The lesions usually involve the extremities, but can also be found in the head and neck, trunk, pelvis, retroperitoneum, mediastinum and gastrointestinal tract. However, the tumors are extremely uncommon in parenchymatous organs, such as the liver and pancreas . There iIn numerous cases the schwannoma is asymptomatic and is identified incidentally upon physical examination or imaging. Occasionally, the tumors are symptomatic due to the compression of surrounding large nerves .To the best of our knowledge, only two cases of benign schwannoma located in the abdominal wall have been reported in the medical literature at present. In the first case , a healtAncient schwannoma is a sub-type of schwannoma characterized by degenerative changes that are observed under microscopy . These cAs in the present patient, the identification of a nerve entering and exiting a mass is pathognomonic for a peripheral nerve sheath tumor and the eccentric association with the nerve is considered to be pathognomonic for a schwannoma rather then a neurofibroma ,13.To conclude, the definitive treatment for benign schwannoma is surgical removal. The prognosis of these lesions is good , recurre


BackgroundSolid pseudo-papillary tumor of the pancreas (SPTP) is a rare disease with a low malignant potential. Though it shows low malignant potential 10% to 15% of the cases show aggressive behavior with metastatic involvement of the liver. The symptoms include abdominal discomfort and abdominal pain. It is very rare in early years of age. This is the case of a 10 year old girl with abdominal pain and her evaluation revealed solid pseudo papillary tumor of pancreas. In family history, her grandmother died because of pancreas cancer. The mass was excised and in her 6-month follow up she didn’t have any problems. This case is presented to point out physicians that more attention to pseudo- papillary tumor can bring us significant improvement in the diagnosis of this pathology, though pseudo- papillary tumor is a rare pathologic condition in children. Solid pseudo-papillary tumor of the pancreas (SPTP) represents less than 10% of cystic neoplasm of the pancreas. SPTP is a rare neoplasm that affects mainly young females. Though it shows low malignant potential, 10% to 15% of the cases show aggressive behavior with metastatic involvement of the liver. The overall five year survival is 97% even in the presence of disseminated disease [The sign and symptom of SPTP is related to mass effect and consists of abdominal pain and abdominal discomfort. Physical examination shows a palpable and significant mass when the symptoms present. These tumors usually have large size with average diameter of 8-10 cm. serologic tumor marker and laboratory tests are in normal ranges. CT scan is an imaging technique of choice for diagnosis and shows a well-defined large solid-cystic mass. Prognosis is excellent and surgical resection can result in complete cure.A 10 years old girl was admitted to the hospital complaining of peri umblical pain. She had suffered from diarrhea and vomiting from one month ago that disappeared after few days and followed by these symptoms: squeezing and abdominal pain. There were no systemic symptoms such as weight loss or etc before admission. Her grandmother died from pancreatic cancer but there wasn't any information about type of her tumor.Sonography and CT scan showed a retroperitoneal mass with measuring 60*58 mm in size compressed liver and right kidney vessels .Tumor markers like CEA and CA19-9 were normal, however CA125 had increased. Other lab tests such as CBC and electrolytes were also normal. The Lowercase underwent surgical laparatomy and after mass excision, the pathologist reported a pseudo-papillary tumor with infiltration to ampulla of vater .Patient was discharged with good condition 4 days after surgery. In her follow-up, after 6 months, her condition was good and level of CA125 had returned to normal range.Solidpseudo-papillary tumor (SPT) is a rare pancreatic neoplasm and it has low potential for malignancy. It is also a rare condition in males and children and occurs mostly in young women. The most common presentations of SPT in children are abdominal mass and abdominal pain.SPT usualPancreatic tumors are classified in 3 following categories: consist of exocrine, endocrine, and mesangial tumors. Papillary tumors account for 1% to 2% of exocrine tumors of pancreas. According to WHO classification, SPT with clear criteria of malignancy  are designated as solid pseudo papillary carcinomas. It usually affects young women between second and third decades of their life. Mostly, SPTs manifested as benign tumors may exhibit malignant behavior with metastatic involvement of adjacent structures. Patient with SPT of pancreas may suffer from uncharacteristic abdominal pain, enlarged abdominal mass which compressed adjacent viscera. It may be asymptomatic that is diagnosed incidentally on ultrasonography or CT scan .The etiology of these tumors is unknown. Size of tumors can reach up to 18cm but rarely have metastatic presentation. CT scan iAbdominal pain and abdominal mass are common presentations of SPTs. These tumors occur mostly in young females and they have low potential for malignancy. They are respectable in most cases and associated with well prognosis.SPTs are not only inactive and slow in comparison to other pancreatic malignancies, though they can also be presented with invasive metastatic tumors.Metastasis has been seen in only 10%–15% of patients who have advanced stages of disease at the time of diagnosis.


Ameloblastic fibrosarcoma (AFS) is a rare malignant odontogenic neoplasm of the jaw. AFS is characteristically composed of a benign odontogenic epithelium and a malignant mesenchymal component. The posterior region of the mandible is the predominantly occupied site. In the present report, a new case of AFS in a 22-year-old male that originated from ameloblastic fibroma was described. Histologically, the tumor showed biphasic components: Benign epithelium and a malignant mesenchymal component. Immunochemical findings revealed that the tumor cells were positive for cluster of differentiation (CD) 34, vimentin, Ki-67 and p53, but negative for smooth muscle actin, S-100, CD68 and desmin. The clinical presentation, radiographic appearances and treatment measures were additionally described and reviewed. The disde novo . In thisA 22-year-old Chinese male was referred to a local hospital in March 2005 with a two-month history of a painful swelling in his left mandible. Radiographic examination disclosed a unilocular radiolucent lesion located in the left mandible . An inciIn September 2006, the patient came to our oral and maxillofacial center at the Department of Stomatology, Taihe Hospital  and complained of the recurrence of the mass and acute pain within the last five months. Extraoral examination revealed a large, firm swelling extending from the premolar to the temporomandibular joint of the left mandible, as well as apparent asymmetry of the face. Intraoral examination showed a firm swelling located in the retromolar area of the left mandible, with ulceration of the mucosal membranes. The panoramic radiograph showed an extensive, ill-defined multilocular radiolucent area from the first premolar to the ramus of the left mandible . The comThe patient underwent a wide left mandibulectomy including the surrounding soft tissue and destructive bone lesion. The final histopathological diagnosis was identical to that of the incisional biopsy. Postoperative radiotherapy with 50 Gy was implemented after the surgery for five weeks. The patient was under regular follow-up until 2011 (six years) after the surgery and showed no signs of recurrence.AFS is a rare malignant neoplasm, consisting of two components: i) A reductive benign odontogenic epithelium arranged in an island and net pattern, dispersing in the mesenchymal tissue; and ii) malignant hypercellular mesenchymal tissue comprised of spindle and stellate cells, exhibiting nuclear pleomorphism and hyperchromatism ,5. In thRadiographic examination is important to ascertain the correct diagnosis. Panoramic radiography can manifest a macroscopical, effective and low-cost image for the lesions involving the destructed bones. Furthermore, CT scans can provide more detailed information about the lesion and the association with the adjacent organs.In this case, AFS was believed to show recurrence potential following conservative treatment. Compared with the initial lesions, recurrent lesions exhibit decreased epithelial components and increased pleomorphic and mitotic mesenchymal components ,5,6. AFSPreviously, curettage, nucleation and local excision have typically been utilized in the surgical procedure . Since tIn conclusion, AFS is a rare malignant odontogenic tumor. It is difficult to discriminate AFS from AF when relying only on the histopathological results and clinical features. Resection with a wide margin is the optimal treatment strategy, and adjuvant chemotherapy and radiotherapy may additionally be used to reduce the recurrence rate and enhance the quality of life.


Tumor lysis syndrome (TLS) is a potentially life-threating complication of tumors or chemotherapy treatment. TLS commonly occurs in hematological malignancies, but it is very rare in patients with a solid tumor. In cases of solid tumors, TLS usually occurs spontaneously and after the initiation of anticancer therapy, and it has a high mortality rate. We present the novel case of a 62-year-old woman with an ovarian tumor who spontaneously developed TLS. Surgical reduction of the tumor mass vastly improved her condition. She showed no sign of tumor recurrence 8 months after treatment. As TLS is life-threatening, successful treatments must be seriously considered. Tumor lysis syndrome (TLS) is characterized by the massive lysis of malignant cells and the rapid release of intracellular components into the systemic circulatory system. It requires immediate intervention and is sometimes lethal . It is tThe patient was a 62-year-old nonparous woman with no history of a gynecological disease. She had an enlarged abdomen during the 2 months preceding her visit to our hospital, and she had lower abdominal pain 2 days before her visit. She was transported to our hospital by ambulance and complained of disabling back pain. An abdominal examination revealed a palpable mass in the right lateral region of her abdomen. Transabdominal echography and computed tomography revealed a multilocular-solid tumor (>20 cm in diameter) in her pelvis, and massive ascites extended into the liver and spleen . Blood aFollowing admission, the patient had anuria that responded poorly to aggressive fluid administration. We thought that her presentation could not be explained only by fluid shifts. Two days after admission, laboratory data indicated that her condition had worsened. Her respiratory status declined, and she was placed on a respirator. She also received a vasopressor to maintain her blood pressure. We decided to surgically reduce the amount of the tumor mass and to drain her abdomen in order to improve her condition. Abdominal bilateral salpingo-oophorectomy, hysterectomy, and abdominal drainage were performed .We made a midline skin excision extending from the symphysis pubis to the right side of the umbilicus. The abdominal cavity was adequately exteriorized, and 3,300 mL of bloody, viscous fluid was suctioned. The large mass in the right ovary was extracted with the uterus and left ovary, which were macroscopically normal. The abdominal cavity was washed with saline to remove tumor tissue that adhered to the thickened, hyperemic peritonea. A drainage tube was placed in the upper abdomen, and the abdomen was closed. The patient received intensive care postoperatively, and her condition improved. The expression levels of biochemical markers returned to normal.Pathologic examination of the neoplasm from the right ovary showed a well-differentiated (grade 1) endometrioid adenocarcinoma with extensive necrosis and capsular rupture . CytologPostoperatively, the patient received six cycles of combination chemotherapy, which consisted of docetaxel and carboplatin. No signs of recurrence were observed at the 8-month follow-up.TLS is a potentially life-threatening complication of malignancies. It results from massive cytolysis of malignant tumor cells, either spontaneous or chemotherapy-induced, and the release of intracellular components into the circulatory system. TLS is characterized by hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia, increased plasma creatinine levels, and other abnormalities that can lead to acute renal dysfunction, fatal cardiac arrhythmia, central nervous system toxicity, and death . The mosPotential risk factors of TLS in cases with solid tumors include liver metastasis, high lactate dehydrogenase and uric acid levels, renal insufficiency, prior treatment with nephrotoxic drugs, infection, and dehydration . Solid tTreatment of TLS consists of aggressive hydration, the correction of electrolyte disturbances, and uric acid-lowering therapy . The morTLS is a relatively rare event in patients with solid cancers. Nevertheless, clinicians should remember that such patients may develop this lethal complication in response to chemotherapy or even spontaneously.


We report a case of prenatally diagnosed Fetus-in-fetu (FIF) residing in the left retro-peritoneum in a 2-week-old neonate which was also associated with ipsilateral testicular atrophy. A comparison of features differentiating FIF from a retroperitoneal teratoma, and various theories of origin of FIF are described. The causal relationship of ipsilateral atrophic testis with FIF in this case is also discussed. Fetus-in-fetu (FIF) is a parasitic monozygotic monochorionic diamniotic twin that implants itself and grows within the body of its normal karyotypically identical sibling [1]. It is a rare anomaly (around 200 published cases in English literature [2]), which can be differentiated from a retroperitoneal teratoma by the presence of a calcified vertebral axis and limb buds within the mass.We report a case of prenatally diagnosed FIF residing in the left retroperitoneum and associated with ipsilateral testicular atrophy. Possible causative embryological events are also discussed.An asymptomatic 2-week-old male neonate was brought to us with an antenatal diagnosis of intra-abdominal cystic mass. He was born at term to a 25-year-old primigravida mother by caesarean section in another hospital, indications being cephalo-pelvic disproportion and fetal distress. It was a non-consanguineous marriage and there was no family history of twins. The new-born weighed 2.2 Kgs and had normal Apgar scores. Antenatal ultrasonography done during the third trimester had shown a spherical fluid-filled cystic mass with 42 mm diameter and 38ml volume having internal ellipsoid calcific and soft tissue areas. The possibility of FIF was considered.Clinical examination revealed a cystic spherical mass, 4 cm in diameter, in the left hypo-chondrium and lumbar regions. The left testis could not be palpated in the hemiscrotum or inguinal region. Postnatal ultrasound of the abdomen done on day 11 of life demonstrated a thick walled cystic sac with multiple internal ossified contents in the left hypochondrium and lumbar regions. Plain X-Rays of the abdomen were non-contributory. Serum AFP and βhCG were within normal range for age. He underwent exploratory laparotomy through a left upper transverse incision on day16 of life. There was a left sided retroperitoneal cystic mass which was excised after reflecting the left colon medially. No definite vascular pedicle or sac was identified. Postoperative X-ray of the excised specimen showed organized axial skeletal elements . Chromosomal analysis was not performed. Gross examination of the specimen revealed a single globular soft tissue mass measuring 3 x 2 x 2cms (fig 2). The external wall was well encapsulated and had a corrugated skin surface. Sections from the above showed epidermis with appendages. The underlying tissues showed a primitive limb like area with cartilagenous tissue and enchondrial ossification. It was surrounded by skeletal muscle bundles. Interconnecting areas of hyaline cartilage which gave the appearance of vertebral bodies were also found . The above features were consistent with a diagnosis of FIF.He was readmitted at the age of 6 months for definitive management of left sided non palpable undescended testis. Pre-operative ultrasound had not revealed any testis in left hemiscrotum or inguinal region. At laparoscopy, the vas deferens was seen entering the left deep ring; however testicular vessels were not visualized. Left inguinal exploration revealed a nubbin representing left atrophic testis that was excised. The parents did not opt for placement of testicular prosthesis at that time. The child has been followed up for 2.5 years and is thriving well; with no features of recurrence on serial abdominal ultrasonography and serum AFP is within normal limits. FIF was defined by Willis in 1935 as “a mass containing a vertebral axis often associated with other organs or limbs around this axis” [1]. Since then, the presence of a vertebral axis in a fetiform mass has been considered pathognomonic of FIF. It must be differentiated from a retroperitoneal mature teratoma (RMT) which has an accumulation of pluripotential cells without organogenesis or vertebral segmentation [1]. Some authors consider the two entities as part of a spectrum that includes conjoined symmetric twins; fetus-in-fetu; embryonic vestigial inclusion; and fetiform teratoma [3].Demography: The incidence of FIF is 1: 500 000 live births with a slight male preponderance [4]. Besides the retroperitoneum which is the most common site of occurrence, it has also been described in the cranial cavity, oral cavity, mediastinum, lung, sacrococcygeal region, kidneys, intra-abdominal and scrotum [4-6].Clinical presentation and diagnosis: The clinical presentation is either an incidental mass or with symptoms due to compression of adjoining structures in the abdominal, thoracic or cranial cavities [4].Demonstration of metameric segmentation of its spinal axis on imaging modalities usually clinches the diagnosis. However, non-visualization of the vertebral axis on plain film of the abdomen or on CT scan does not exclude FIF, as the non-calcified vertebrae may be radiolucent, but will definitely be demonstrated on histopathology [4].Prenatal diagnosis of FIF is possible in about 15% of reported cases (as in our case) [5]. Features suggestive of FIF on imaging have been described as early as 16 weeks of gestation [7]. Prenatal MRI can also be useful. Serum markers like AFP and βhCG may be normal or marginally elevated . The most important differential diagnoses to be considered are teratoma and meconium pseudocyst; both of which will also show calcifications on plain radiography [4]. Besides the above mentioned conditions, intussusception, Wilms’ tumour, neuroblastoma and retroperitoneal lymphadenopathy should also be excluded [10].Difference between FIF and RMT: Table 1 delineates the various differences between FIF and RMT. A basic point to remember is that unlike teratoma, FIF is not a true tumour.Pathology: Detailed and meticulous gross as well as histopathological examination of the excised specimen is the gold standard for diagnosing FIF. The different organs seen in order of frequency are vertebral column (91%), limbs (82.5%), CNS (55.8%), gastrointestinal tract (45%), vessels (40%), and genitourinary tract (26.5%). Hence the vertebral axis may be absent in as much as 9% of cases [4].Treatment and follow up: Complete surgical excision is the treatment of choice as malignant recurrence has been reported when the membrane was left behind [9]. For the same reasons, these patients should be kept under close follow up with serial ultrasounds and serum tumour markers. Good surgical acumen is needed as injury to the bile duct has also been described during excision of FIF [11].Theories of originIncluded twin theory: This is the most commonly accepted theory of origin of FIF. The supporters of this theory regard FIF as a rare form of monozygotic twinning whereby an aberrant asymmetric twin becomes internalized in the other twin thus acting endoparasitically. Developing from a single ovum, they usually share the same sex, blood group and exactly the same and normal karyotype [4]. This is further strengthened by demonstration of trisomy 21 in both the host as well as FIF by Lee et al [13].Supporting this school of thought are Spencer's observations that FIF and teratomas are both part of a spectrum of defective conjoint twinning. Both may coexist and there may be multiple foetuses in FIF. He proposed a primary cardiac malformation in the aetiogenesis of FIF with secondary anencephaly [3].Beaudoin's [6] theory of defective implantation during the second week of development resulting in the invasion of a second embryo (that becomes a homunculus) into the extra-embryonic mesenchyme of the host foetus or autosite, instead of the uterine wall, appears plausible.The absence of normal umbilical vessels and a definite vascular connection explain the growth retardation and arrest of organ differentiation in almost all cases of FIF [1].The presence of an axial skeleton implies development of the included fetus past the primitive streak stage when the notochord is formed, a stage thought to be too developed for formation of a teratoma [4].Fetiform teratoma theory: Willis nurtured the theory that teratomas were derived from embryonic pleuripotential cells associated with the primitive streak, which escaped organizer influence to form a true neoplasm, which may later exhibit benign or malignant characteristics [1]. However, concomitant presence of FIF with mature or immature teratoma in several instances implies a common embryological origin [14]. Supporters of this theory believe that FIF represents a well- differentiated, highly-organized or fetiform teratoma [8].Association of FIF with ipsilateral atrophic testis: The normal descent of testis is known to occur during late gestation. Any retroperitoneal mass lesion during fetal life can hinder the descent or vascularity of the testis resulting in cryptorchidism or anorchia respectively. Since the FIF in our case was small it affected only the ipsilateral testis. The testicular atrophy could have resulted from extrinsic compression of the testicular vessels by the FIF, since the testicular vessels could not be identified during laparoscopy. Moreover, the FIF may have been larger to begin with producing pressure effects, and regressed later to its small size. Pelvic or large retroperitoneal FIF have been reported to cause bilateral testicular maldescent [15]. However, to the best of our knowledge, testicular atrophy associated with retroperitoneal FIF has not been reported till date in English literature.To conclude, with improvement in imaging modalities, more cases of FIF are being diagnosed preoperatively and even prenatally (as in our case). The association of FIF with ipsilateral testicular atrophy was also noteworthy. Source of Support: NilConflict of Interest: None


Primary diffuse large B cell lymphoma (DLBCL) of the uterus is rare, and primary DLBCL arising from a uterine leiomyoma (collision tumor) has not been reported in the literature.We describe the clinical, histological, immunohistochemical, and molecular features of primary DLBCL arising from a leiomyoma in the uterine corpus. A 73-year-old female patient had a uterine mass for 23 years. An ultrasound scan revealed marked enlargement of the uterus, measuring 18.2 × 13 × 16.3 cm, with a 17.6 × 10.9 × 11.6 cm hypoechoic mass in the uterine corpus. The tumors consisted of medium- to large-sized cells exhibiting a diffuse pattern of growth with a well-circumscribed leiomyoma. The neoplastic cells strongly expressed CD79α, CD20 and PAX5. Molecular analyses indicated clonal B-cell receptor gene rearrangement.To the best of our knowledge, no previous cases of primary DLBCL arising from a leiomyoma have been reported. It is necessary to differentiate a diagnosis of primary DLBCL arising from a leiomyoma from that of leiomyoma with florid reactive lymphocytic infiltration (lymphoma-like lesion). Careful analysis of clinical, histological, immunophenotypic, and genetic features is required to establish the correct diagnosis. Primary lymphoma of the uterus is rare and diffuse large B cell lymphoma (DLBCL) is the most common histological subtype , 2. Howe9 /L, a hemoglobin level of 123 g/L, and a platelet count of 186×109/L. The Pap smear results showed moderate inflammation and no other abnormalities. Intraoperatively, a well-defined intramural myoma was observed in the anterior wall of the uterine fundus (The surgeon opened the uterus but did not collect a sample during the surgery for generation of frozen sections), and hysterectomy and bilateral adnexectomy were performed. The postoperative course of the patient was uneventful. The patient underwent no further examination or treatment due to economic reasons. At the most recent follow-up (13 months after the diagnosis), the patient was alive and did not report any discomfort.A 73-year-old woman had a uterine mass for 23 years without abnormal vaginal bleeding or discharge. A sonographic examination performed 23 years prior showed a myomatous mass that measured approximately 7 cm . The patient did not complain of discomfort and did not undergo a Pap smear or medical treatment during this 23-year period. One year ago, the patient underwent a gynecological B ultrasound examination, which revealed that the uterine mass had enlarged since the previous sonogram . The more recent ultrasound scan revealed marked enlargement of the uterus, measuring 18.2 × 13 × 16.3 cm, with a 17.6 × 10.9 × 11.6 cm hypoechoic mass in uterine corpus. This mass was nonhomogeneous and had irregular borders. The cervical thickness was 2 cm and had homogeneous echogenicity. The endometrial thickness was 3 mm. Bilateral adnexa were not clearly delineated. The mass was diagnosed as a leiomyoma by ultrasound. Laboratory tests revealed that the serum CA-153 level was 39.93 U/ml (high), the β2-microglobulin level was 3.24 mg/L (high), and the serum lactate dehydrogenase level and other biochemical test results were normal. The complete blood cell count revealed a white blood cell count of 6.4×10On gross examination, the uterine corpus was completely replaced by a whorled intramural single mass with a diameter of 17 cm, and the cut surface appeared yellowish with focal hemorrhage, without any necrosis or calcification. The endometrium was smooth and had a thickness of 3 mm. The cervix and bilateral adnexa displayed no abnormalities. The mass was sampled by examining 2 sections /cm. Histological examination of the formalin-fixed, paraffin-embedded sections revealed a marked, predominantly lymphocytic infiltrate involving a well-circumscribed leiomyoma, and a few lymphocytes extended into the adjacent myometrium with an intravascular tumor thrombus. Within the leiomyoma without any mitosis or necrosis, the lymphoid infiltrate was diffuse, and there were only a few recognizable whorled bundles and fascicles of smooth-muscle cells Fig. . The lymThe tumor was ultimately diagnosed as a stage IE (Ann Arbor) primary DLBCL of the activated B-cell-like (ABC) subtype arising from the uterine leiomyoma (collision tumor).Although infiltration of the uterus during the course of malignant lymphoma is not rare, few malignant lymphomas originate in the uterus. In a study with a large number of cases, it was reported that malignant lymphomas originating in the uterus accounted for 0.5 % of all extranodal lymphomas and that they were most common in the cervical region. The histological type of these tumors was DLBCL , 2. EvenOne peculiarity of this case was the coexistence of DLBCL and leiomyoma. In previous reports, cases of primary T-cell lymphoma arising from a leiomyoma of the uterus was described, and these tumors expressed T-cell antigens CD3 and CD8) and markers of cytotoxicity (TIA and granzyme) and exhibited monoclonal rearrangement of the T-cell receptor based on molecular analyses [ and CD8 The most important differential diagnoses in this case included leiomyoma with heavy lymphocytic infiltration and massive lymphoid infiltration simulating lymphoma (lymphoma-like lesion) –7. RegarBecause our case had a history of 23 years, it may be hypothesized that the DLBCL evolved as a result of progression from a polyclonal inflammatory population concomitant with the development of a leiomyoma with lymphocytic infiltration or massive lymphoid infiltration, resulting in a collision tumor. However, there is a lack of strong evidence supporting this assumption.We report the first documented case of DLBCL concurrent with leiomyoma in the uterus. Although these findings could be purely coincidental, it should be considered that there might be a causal relationship between DLBCL and leiomyoma with lymphocytic infiltration. We could not exclude the possibility that the leiomyoma induced a lymphoid reaction with an extranodal lymphoma, representing the final event of progression of the inflammatory reaction.Written informed consent was obtained from the patients for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


A minority of intra-abdominal desmoid tumors is associated with Gardner’s syndrome in which desmoid tumors become an important cause of morbidity and mortality if they are surgically unresectable.Here, we report two cases of intestinal perforation during chemotherapy in patients with Gardner’s syndrome-associated intra-abdominal desmoids. One female and one male patients who developed inoperable desmoids were given the chemotherapeutic regimen of doxorubicin plus dacarbazine, followed by meloxicam. Significant tumor regression was observed clinically. However, intestinal perforation happened in both patients. They were subjected to emergency surgery, follow-up management, and survived up to now.The doxorubicin plus dacarbazine chemotherapy is an effective treatment for intra-abdominal demoid tumors in patients with Gardner’s syndrome. On the other hand, given severe adverse events might occur, clinicians should pay more attention that tumor quick regression may cause intestinal perforation in which urgent surgical intervention is necessary. Desmoid tumors (aggressive fibromatosis) are rare, locally aggressive, benign fibroblastic tumors, accounting for ~0.03 % of all neoplasms. Although desmoid tumors (DTs) are histologically benign and without any metastatic potential, they are locally aggressive with a tendency to invade nearby structures and recur after resection. The etiology of these tumors is still controversial, but antecedent trauma including surgery, endocrine, and genetic factors seem to be implicated. Most desmoids are sporadic, but some are in association with familial adenomatous polyposis (FAP), also known as Gardner’s syndrome.Although desmoid tumors can arise at any body site, the desmoids in Gardner’s syndrome usually arise in the abdomen and are a major cause of morbidity and mortality in patients who undergone prophylactic colonic surgery , 2. DesmIn 2009, a 35-year-old woman (patient 1) was diagnosed as FAP, inherited from her father, with numerous adenomatous polyps at the surface of colon. She did not suffer from osteomas of the skull, thyroid cancer, and epidermoid cysts. The patient received prophylactic colectomy. The patient presented with abdominal bloating and self-palpable left abdominal mass in September 2012 Fig . Laparot2 daily) plus DTIC (150 mg/m2 daily) throughout 4 days of drip intravenous infusion every 28 days, followed by meloxicam (10 mg/m2). The abdominal bloating was relieved after 1 cycle of chemotherapy. At the end of the second cycle of chemotherapy, the patient felt abdominal pain and fever. X-ray imaging displayed a little shadow of free gas below the right diaphragm  after the operation. The lesion remains without tumor progression till now  discussion indicated that the tumors were unresectable. On Oct 11th 2012, the patient was administrated with systemic chemotherapy: doxorubicin  plus DTIC (150 mg/m2 daily) throughout 4 days of drip intravenous infusion every 28 days, followed by meloxicam (10 mg/m2) on May 24th 2014. After 3 cycles of chemotherapy, abdominal pain symptoms of the patient were disappeared. After 5 cycles of chemotherapy, the patient displayed abdominal pain and high fever with elevated amount of neutrophils. CT scan showed intestinal perforation which was not detected by the X-ray  in abdomen and a desmoid tumor on the left abdominal wall as evidenced by CT scan in April 2014 Fig . After M-ray Fig  and the About 10 % of Gardner’s syndrome patients develop mesenteric desmoids . In cont2 DOX and 600–700 mg/m2 DTIC per cycle) up to 10–11 times [Choosing optimal therapy for patients with Gardner’s syndrome is difficult because the diagnosis is rare and no randomized and prospective trials for different treatment approaches are available. In addition, the evaluation of efficacy is problematic given that desmoids have a variable natural history, with some tumors showing spontaneous regression in the absence of treatment. Therefore, the treatment plans have to consider that the growth of DT can be highly variable with growing, stabilization, and even regression. Nonsteroidal anti-inflammatory drugs (NSAIDs) and antiestrogens may be used as first-line therapies for an unresectable tumor . However11 times .In conclusion, we reported two cases of unresectable intra-abdominal desmoid tumors associated with Gardner’s syndrome. Our study provides further evidence of the remarkable efficacy of the DOX-DTIC regimen. However, the drastic regression of tumor upon DOX-DTIC treatment resulted in the perforation of implicated intestine. Even if there is no evidence of intestinal perforation in X-ray imaging during the management of intra-abdominal desmoids complicating Gardner’s syndrome, oncologists should be aware of the possibility of perforation when the patients have high fever and abdominal pain. MDT discussion and team work may be helpful. The modality of DOX-DTIC-meloxicam requires further study on a clinical trial basis. We are also trying a sequential chemotherapeutic regimen of DTIC followed by doxorubicin plus NASID. New results are expected in the near future.DOX, doxorubicin; DTIC, dacarbazine; DTs, desmoid tumors; FAP, familial adenomatous polyposis; MDT, multidisciplinary team; NSAIDs, nonsteroidal anti-inflammatory drugs


Solitary central osteomas of jaw are extremely rare lesions with only few previously documented cases. This paper reports a case of large solitary central osteoma involving mandible symphysis- parasymphysis region in an elderly female patient. A brief review of similar cases reported in the literature is also provided in this paper. Key words:Osteomas, osteogenic,bone, tumor, jaw, mandible. Osteomas are rare benign lesions characterized by proliferation of compact and/or cancellous bone. Three variants of ostemoa have been described in literature - peripheral , central , and extra-skeletal. The peripheral osteoma arises from periosteum and presents as peripheral mass attached to the cortical plate, whereas the central variants are extremely rare and arises within the bone, developing from endosteum. Extra-skeletal soft tissue osteomas are usually seen within muscles .Multiple osteomas may present as part of Gardner’s syndrome, an autosomal dominant disease characterized by gastrointestinal polyps, soft tissue tumors, and multiple impacted or supernumerary teeth. Solitary osteomas in oral and maxillofacial region, often involve the skull bone, the frontal bone (sinus) being the site of predilection . SolitarA 75 year old female reported to our clinic with complaint of painless intraoral swelling over the lower anterior jaw, causing difficulty in speech and interference in tongue movements. The patient had first noticed the swelling five years earlier. No history of facial trauma was reported. The patient was under medication for hypertension for the past fifteen years. She gave a history of cardiac surgery five years back and was subsequently on anti-platelet therapy. History of multiple teeth extractions over a period of time was given, of which no record was available. On examination a non-tender bony hard swelling was present over mandible alveolus, extending across the midline from 32 to 44 region, measuring about 5 cm x 3 cm. The swelling extended lingually to the tip of the tongue. The mucosa overlying the swelling was normal. Patient was partially edentulous with poor oral hygiene. Mandibular left canine and premolar teeth present over lateral aspect of the swelling exhibited grade III mobility. Other mandibular anterior teeth were missing.Orthopantamogram (OPG) showed a radiopaque lesion in mandible anterior region, extending from the crest of the alveolar ridge upto the inferior border of the mandible, superoinferiorly and measuring about 5 cm in its greatest dimension. The lesion had well defined margins and could be demarcated from the surrounding normal bone. A mandibular occlusal radiograph showed radiopaque mass expanding the buccal and lingual cortices Fig. . Based oFor management of the lesion, both option of complete excision under general anesthesia and a conservative approach by recontouring of the jaw under local anesthesia was discussed with the patient, physician and anesthesiologist. Considering her age, medically compromised status and non-malignant, non-infiltrative nature of the lesion conservative surgical management was preferred choice after consensus. After attaining adequate regional anesthesia, a crestal incision was place over the alveolar bone and envelop flap raised, exposing the bony mass. The lesion appeared more yellowish and could be easily differentiated from the surrounding normal bone. The mandibular right canine and first premolar were extracted. The excess hard tissue overlying the alveolar ridge was contoured. The flap was approximated and sutured Fig. . The excet al. ; with an age range of 13-67 years . Smallerpression . On radipression  presentepression  had irreManagement of osteoma depends on its presentation. Smaller asymptomatic SCO generally does not require any treatment. Surgical intervention is indicated for lesions which are large, symptomatic, and painful or causes functional impairment. Excision is usually simple in pedinculated peripheral osteomas. Larger central variants require wider area of bone resection, thus increasing the surgical risks and postoperative complications. Recurrence is unlikely. In the present case lesion was managed conservatively by surgical recontouring of the anterior mandible with functionally and aesthetically favorable outcome.Due to the rarity of reported cases in literature, this paper puts forth the ninth case of SCO of mandible. Unlike the other eight cases our case presented in geriatric patient and was located in anterior mandible crossing the midline.


A 75-year-old man underwent elective biological aortic valve replacement. Two weeks aftersurgery, transthoracic echocardiography (TTE) showed a small pericardial effusion. On thefollowing day, the patient suffered from syncope. A repeated TTE revealed a "giant"echo-dense mass (90x80 mm) occupying the entire right atrium and severely limitingtricuspid valve inflow. Although the initial differential diagnosis included thedevelopment of an intracavitary process, the rapidly-growing mass with a characteristicecho‑lucent layer at its atrial aspect  (arrows) led to the final diagnosis of a pericardial hematoma mimicking a hugeatrial mass. Emergency surgical exploration confirmed the diagnosis.


Duplication of the gallbladder is a rare congenital anomaly of the gallbladder, with an estimated prevalence of 1–3 per 3800 individuals. Unless properly diagnosed preoperatively, it can lead to biliary tract injuries and postoperative complications which may require reoperative surgeries. While previously reported cases have been treated with conventional laparoscopic cholecystectomy (LC), treatment with single incision laparoscopic surgery (SILS) has not been reported yet. We herein present the case of a 58-year-old female with gallbladder duplication who was successfully treated with SILS cholecystectomy. Duplication of the gallbladder is a very rare congenital entity seen in 1–3 patients among every 10.000 patients diagnosed with gallbladder anomalies . ApproprThe gold standard treatment for benign gallbladder disorders is laparoscopic cholecystectomy (LC). Recent developments in laparoscopic techniques have allowed the procedure to be performed safely through a single incision. However, to date, only 20 cases of gallbladder duplication have been reported and all cases were managed via the conventional LC . The manA 58-year-old Caucasian female was admitted to our general surgery department, with complaints of dyspepsia and intermittent epigastric pain. Except for right upper quadrant pain and tenderness that was present on palpation, all other physical examination findings were normal. Laboratory results including liver function tests were found to be within normal limits. Upper abdominal ultrasound imaging revealed 2 separate gallbladders lying side by side . In one Following a 2-cm incision, a SILS port with three 5-mm ports  was placed through the umbilicus. Two separate gallbladders were observed at laparoscopic exploration, using a camera of 5-mm and 30° . By usinAlthough congenital anomalies of the biliary system are frequent, gallbladder duplication is a relatively uncommon anomaly. In a case series, published by Harlaftis et al. in 1977, 207 duplicated and 8 triple gallbladders were reported. Accordingly, anatomic variations of gallbladder duplications were classified based on the location and number of cystic ducts. Type 1 includes gallbladder duplication separated with a septum and two separate gallbladders that fuse in the neck to form a single cystic duct; type 2 includes accessory gallbladders with two different cystic ducts .The symptoms and signs of gallbladder duplication are similar to those of patients with a single gallbladder. There is no scientific evidence to associate the anomaly with increased cholecystitis or malignancy. When diagnosed incidentally, prophylactic cholecystectomy is not required . NeverthSimilar to other biliary disorders, surgical resection of the duplicated gallbladders is warranted in symptomatic patients . ResectiWith increased surgical experience and technical improvements in laparoscopy, SILS has been introduced. It is accepted as a less invasive alternative to conventional laparoscopic surgery. Numerous studies have shown single incision laparoscopic cholecystectomy to be an applicable, safe, and effective surgical method. Advocates have recommended it for noncomplicated gallbladder diseases –17 due tOver the past 5 years the SILS technique has been successfully incorporated into the treatment algorithm for noncomplicated biliary disorders at our center. With our experience extending beyond the learning curve, we attempted SILS for the treatment of a duplicated gallbladder case. To the best of our knowledge this is the first report describing SILS for duplicated gallbladder in the medical literature. We believe that, with appropriate preoperative imaging diagnosis, it is feasible and safe to perform this technique as conventional LC in noncomplicated gallbladder duplications.