A cholesterol granuloma (CG) is usually found in the middle ear, papilla, orbits, petrous apex, and choroid plexus, but is highly uncommon in the skull. In spite of benign clinicopathological lesions, bone erosion can be seen occasionally in the patient with CG. The optimal treatment strategy is radical surgery, but complete excision is usually impossible due to anatomical restrictions and a risk of injury to the key structures located nearby. Here, we report a patient with CGs in the suprasellar and sellar regions who was successfully treated with Java brucea and Chinese herbal medicine.A 31-year-old man presenting with progressive decreased vision in both eyes was analyzed.A skull magnetic resonance imaging (MRI) scan showed a low-density tumor in the uprasellar and sellar regions and histopathological examination revealed a CG.The patient was referred the surgery and radiotherapy. In the meantime, brucea soft capsules and herbal medicine combined were administered to him.The related clinical symptoms and signs resolved significantly after several months, as his therapy progressed. The patient showed no sign of recurrence during the treatment period. Furthermore, he was still alive and disease-free at 37 months of follow-up visit.Overall, brucea soft capsules and a Chinese herbal formula treatment combined could be beneficial in improving the patient's quality of life with CG in the skull. The majority of researchers have proposed a theory of airway obstruction in the cells. A benign tumor is a cystic lesion that is formed as a result of a giant cell's response to cholesterol crystals and metabolized blood byproducts.,9 In addition, there are several case reports of intracranial CGs related to familial hypercholesterolemia and high serum lipid levels. Although radical surgery is the primary treatment and results in long-term survival, an endoscopic approach or radiotherapy is also recommended. However, the efficacy of these treatments cannot be guaranteed due to the rarity of this disease and the high risks of recurrence, which are described in the current report. No therapeutic regimens have been established for CGs.A cholesterol granuloma (CG) is an infrequent intracranial neoplasm that is typically located in the middle ear, papilla, orbits, petrous apex, and choroid plexus. The role of CHM on the following aspects of cancer therapy has been extensively explored: prevention of tumorigenesis, alleviation of adverse effects, enhancement of efficacy of conventional therapy, reduction of tumor recurrence and metastasis, and improvement of a patient's quality of life. However, the potential role of this formula in cancer therapy has not yet been clearly addressed by modern science. In addition, Brucea javanica in CHM is characterized as an antipyretic and detoxifying plant that is distributed throughout South East Asia and South China. Its fruits have potent antimalarial, anti-inflammatory, and antiviral effects with low toxicity and have also been widely used in the treatment of lung, prostate, and gastrointestinal cancers. Increasing attention has been paid to the remarkable antitumor activity of B. javanica. Current pharmacological research has identified the main anti-tumor ingredients in B. javanica to be tetracyclic triterpene quassinoids.,13 Nonetheless, the detailed mechanisms of the effects of B. javanica on neoplasms, especially those of the brain, have never been explored.In recent years, Chinese herbal medicine (CHM) has increasingly proven to be effective and popular in the management of patients with neoplasms, particularly in patients who exhibit resistance, complications, and severe side effects of conventional treatment for several cancer types.Here, we report a case involving a 31-year-old, recurrence-free survivor of CGs in the suprasellar and sellar regions who was treated with brucea soft capsules and a Chinese herbal formula.2In March 2012, a 31-year-old man presented to a local hospital for progressive decreased vision in both eyes, along with dizziness, headache, nausea, and vomiting. An eye examination revealed that the vision in his left eye was 0.15 and that in his right eye was hand motion at 1 m. He did not have a genetic predisposition to familial hypercholesterolemia or hyperlipidemia and did not have a history of traumatic brain injury or a cerebral hemorrhage. Craniopharyngioma was suspected from the results of a skull magnetic resonance imaging (MRI) scan. In April 2012, he underwent a neoplasm resection. A histological examination of the surgical specimen showed a CG, which was contradictory to the MRI findings  practice, he was diagnosed with a spleen deficiency and phlegm stagnation. Therefore, the therapeutic principle was to invigorate the spleen and remove phlegm. We prescribed a decoction by combining syndrome differentiation and disease differentiation, with 15 g of radix codonopsis preparata, 10 g of pericarpium citri reticulatae, 10 g of Rhizoma Pinellinae Praeparata, 30 g of poria cocos, 15 g of fructus aurantii immaturus, 10 g of caulis bambusae in taeniam, 15 g of vinegar rhizoma zedoariae, 15 g of rhizoma ligustici wallichii, 15 g of gastrodia elata, 15 g of grassleaf sweelflag rhizome, 15 g of Chinese taxillus twig, 20 g of Oldenlandia diffusa, 5 g of scorpio, 6 g of centipede, 20 g of Coicis semen, and 6 g of Radix Glycyrrhizae Preparata. The concoction was boiled in water and administered once a day. He followed this course of treatment for 28 days. After 3 courses of treatment, the therapeutic principle remained to invigorate the spleen and remove phlegm.On January 11, 2013, the patient came in for a follow-up visit and told us that the pain in his left lower extremity had alleviated, but he still had nausea, headache, absence of poor binocular vision, and feeble limbs. His pulse was rough and he had a slightly purple tongue with stasis macules. In Traditional CM (TCM) practice, he was diagnosed with stasis of blood and phlegm. A decoction was prepared with 15 g of Angelica Dahurica, 3 g of taxus chinensis, 15 g of pericarpium citri reticulatae, 15 g of Rhizoma Pinellinae Praeparata, 30 g of poria cocos, 20 g of Coicis semen, 15 g of rhizoma ligustici wallichii, 15 g of salt cortex eucommiae, 5 g of safflower, 15 g of Parasitic loranthus, 30 g of Radix Fici Simplicissimae, 6 g of scorpion, 6 g of centipede, 15 g of vinegar rhizoma zedoariae, and 20 g of Oldenlandia diffusa. The decoction was administered once a day for about 6 months, according to a therapeutic principle for dissolving phlegm and activating blood stasis.On August 2, 2013, the patient was admitted to our oncology department for memory deterioration, fatigue, and lethargy. His Karnofsky score was 40 and he was incapable of looking after himself. His MMSE  score, which detects changes in cognitive skills, was 14 (less than 17 points indicates severe cognitive impairment). His orientation, registration, attention, calculation, recall, language, and praxis were markedly reduced. An MRI scan of the skull revealed that the size of lesion was bigger than before  to remove phlegm and blood stasis and without replacement of the therapeutic principle. His symptoms disappeared gradually, with no recurrence during the treatment period.In May 2014, a brain MRI scan showed that the lesion was decreasing in size Fig. . Thereaf3 However, CGs in the suprasellar and sellar regions are uncommon; hence, there is very little literature on them. Computed tomography and MRI results suggest that they become enlarged by repeated hemorrhages and reparative tissue responses within the pituitary adenoma or are distinct forms of craniopharyngioma. The most suggestive symptoms of CGs in the suprasellar and sellar regions are not observable symptoms such as severe progressive headache, vomiting, vision loss, and drowsiness. Therefore, a final diagnosis relies on intraoperative findings and postoperative histopathology. CGs most commonly occur in men, with a male-to-female incidence ratio of 3:1, and among middle-aged patients.,15CGs located in the central nervous system are rare and are mostly associated with the petrous apex in the intracranial site.–19 At present, they are thought to occur as a result of long-term chronic inflammation, infection, and surgical trauma history. However, CGs in the skull that do not originate from the petrous apex are pathologically distinct from CGs deriving from the petrous apex, which have no relevant association with inflammation and infection. This suggests that the risk factors differ among intracranial CGs from different sources. Previous case reports indicate that patients diagnosed with familial hypercholesterolemia or hyperlipidemia had asymptomatic manifestations, while intracranial CGs were not found to be associated with familial hypercholesterolemia or hyperlipidemia. In this case report, the patient did not have a history of a traumatic brain injury or cerebral hemorrhage. Furthermore, the pathogenesis of CG is unclear and speculative to date; however, most hypotheses suggest that an airway obstruction followed by drainage obstruction leads to the rupture of blood vessels and a hemorrhage. In this circumstance, red blood cell metabolic product accumulation may contribute to the formation of cholesterol crystals provoking a foreign-body giant cell reaction.–19,21 A CG in the skull may occur as a consequence of a hemorrhage into the diploe of the bone.CGs are cystic lesions formed from metabolism of blood byproducts and foreign-body giant cell responses to a large quantity of cholesterol crystals.–20 In spite of a benign clinicopathological entity, bone erosion can be seen occasionally and enlarged lesions compressing adjacent tissue structures may cause a series of symptoms and signs, including a headache, nausea, vomiting, declining eyesight, and loss in memory. An optimal treatment strategy for these symptomatic cases is a total tumor resection, which would help lead to a definitive diagnosis based on the postoperative pathological results.,24A CG is essentially a benign lesion, and because of a lack of typical distinguishing radiographic features, the treatment strategy is controversial. For patients who are asymptomatic, who have no abnormal findings following a physical examination of the nervous system, or who are in a stable condition, a long-term follow-up using imaging tests is recommended.,14 Studies by Brackmann and Toh also reported that the incidence of postoperative recurrence was 14.7% in 34 patients with CG. In the other 17 case reports, a study by Hoa et al found that 41% of patients that underwent surgery had to undergo a second surgery.In general, the chances of a tumor recurrence in the cases with complete excision are rare, but complete excision is usually impossible due to anatomical restrictions and a risk of injury to the key structures located nearby. Currently, although open surgery is still common, most strategies use endoscopic techniques to remove the tumor, which is likely to reduce the risk but may also decrease the recurrence rate.Our case report showed that the patient relapsed after undergoing surgery, conformal radiotherapy, and gamma knife radiosurgery, which may have been induced by the nidus of deficiency of dermal layers and complex anatomical structures of tumor location.The patient declined the above conventional therapies and opted for a traditional CM treatment. Due to financial constraints, he could not afford any western medicine therapies. During the period of outpatient treatment, the clinical symptoms and signs disappeared progressively. In addition, the lesion size also gradually narrowed. These results demonstrated the usefulness of decoction and Java brucea fruit soft capsule synergistic effects, further indicating that TCM played a vital role in the recovery of the patient.In summary, a systematic review of the holistic treatment period suggests that a patient may obtain very good curative effects with TCM alone. First, we should emphasize a combination of tonification and purgation as well as a treatment regime for improving the body's resistance to eliminate pathogenic factors. The advantages of a TCM therapy for cancer are a holistic concept and treatment based on syndrome differentiation. Thereby, according to the therapeutic principles, we regard the local tumor lesions and the whole body as significant in the treatment of cancer. Second, the therapeutic principles of syndrome differentiation and disease differentiation should also be combined. We can use several antitumor herbal medicines, according to the location and characteristics of the tumor cells. Naturally occurring substances found in CHM are promising candidates that exert effective tumor chemoprevention and chemotherapeutic properties.,11,27,28 For example, Radix Astragali, the main herb in our formula, is widely used as an immunomodulating agent in the treatment of many types of cancer.–31 Total Astragalus saponins extracted from Radix Astragali may inhibit cell growth of various cancer cell lines via regulation of cell proliferation and apoptosis.,33 In the colon, Astragalus saponins is likely to attenuate tumor cell growth through downregulation of vascular endothelial growth factor (VEGF) production, which modulates mammalian target of rapamycin and Cyclooxygenase 2 signaling. Coicis semen possesses antitumor and immune-enhancing properties, such as promoting T lymphocyte proliferation. Moreover, modern medicine research has established that coix seed emulsion from Coisis semen combined with gemcitabine had a much greater antitumor effect than the effect of either agent alone in pancreatic cancer through abrogation of nuclear factor-kappa B signaling. Another 2 components (Zedoary and Oldenlandia diffusa) also exhibit potential anticancer effects and restore the sensitivity of MCF-7/ADR (doxorubicin-resistant MCF-7 breast cancer cells) and A549/Taxol cells, modulating the multidrug resistance phenotype and the function of P-glycoprotein in human breast cancer cells.,37Despite the limited data, we can speculate that some components  in CHM may contribute to its efficacy in treatment of a CG. A large number of modern studies have revealed the anti-cancer mechanisms of CHM. Furthermore, centipede and gecko, 2 types of traditional CM with remarkable antineoplastic activity, have been reported to induce cell cycle arrest and the apoptosis of cancer cells.,40In this case report, other ingredients of CHM, including a scorpion, centipede, and gecko, have also been identified as effective anticancer drugs as prescriptions or formulas. They are classified as medical insects of well-known TCM. For example, a scorpion has been used in TCM to treat chronic neurological disorders, such as neuropathic pain, paralysis and epilepsy, for thousands of years. In the latest research, polypeptide extract from scorpion venom (PESV) may inhibit the angiogenesis of Lewis lung carcinomas (LCCs) by decreasing the level of VIII, alpha-SMA, DII4, and Notch1 in the tumor microenvironment.B. javanica include antitumor activity, low toxicity, and enhancement of immunity.,13A review of the complete therapy course of this case demonstrates that Brucea soft capsules play a key role in the process of recovery. It has been reported that the advantages of B. javanica oil (BJO), extracted from dry fruit of CHM, is a complex mixture of fatty acids and their derivatives. Its main components are oleic acid and linoleic acid. Modern pharmacological research has demonstrated that tetracyclic triterpene quassinoids are the main antitumor ingredients in B. javanica, which may induce cancer cell death by various mechanisms, including the induction of apoptosis, regulation of the cell cycle, reversal of multidrug resistance, and a reduction in cell proliferation by reducing the expression of the Bcl-2 gene.,13,41–45 A report showed that B. javanica may inhibit Ehrlich ascites cancer cells in mice and ascites hepatoma cells in vitro.B. javanica is becoming increasingly popular in the treatment of lung, prostate, and gastrointestinal cancers and glioma, as well as in the reduction of intracranial pressure, it is not known whether these mechanisms involve a CG in the brain.Although B. javanica may exert efficiency, as pharmacokinetic studies have shown that approximately 90% of lipophilic emulsion particles with a diameter of 1 μm can cross the blood–brain barrier rapidly, enter the brain or cerebral tissue, and reach the location of lesion or metastasis,,48 finally producing an effective concentration in the brain.,50 Nonetheless, we have to admit that there is no direct evidence to explain the efficacy of B. javanica and the CM in the treatment of a CG.We speculate that However, TCM is mainly applied as complementary Chinese traditional patent medicine in the treatment of cancer and it has not been generalized to be applied to the treatment of malignant tumors. Furthermore, we believe that traditional CHM may contribute to the improvement of patient's quality of life and may be a good antineoplastic agent for benign tumors, especially cerebral tumors.4This case report shows that CGs in the suprasellar and sellar regions are rare, and a novel combination of a Java brucea fruit soft capsule and Chinese herbal decoction may have an antineoplastic effect with an excellent safety profile, which merits more attention.


Lobular capillary haemangioma (LCH), previously known as pyogenic granuloma, is a benign vascular lesion commonly found within the oral and nasal cavity. However, it is rarely encountered within the trachea, where presenting features include recurrent haemoptysis, cough, and wheeze. We here describe a case of a 7 mm tracheal LCH in a 56-year-old woman, which was successfully resected at interventional bronchoscopy using biopsy forceps. Clinicians should be aware of tracheal LCH in the differential diagnosis for recurrent haemoptysis. Tracheal tumours represent only 2% of all upper respiratory tract tumours . Those iA 56-year-old Caucasian woman was referred to our institution with several episodes of mild haemoptysis over the preceding three months. She denied associated chest pain, exertional dyspnoea, dysphagia, syncope, weight loss, anorexia, fever, and rigors. There was no history of airway instrumentation or foreign body aspiration. Her medical background included laparoscopic sterilisation, oesophagitis, meningitis, and hypertension. She was a nonsmoker and consumed alcohol within normal limits.1 3.50 L and FVC 3.85 L. Computed tomography (CT) scanning (Physical examination was unremarkable and routine blood investigations and chest radiograph were normal. Pulmonary function was satisfactory with FEVscanning  demonstrHistological examination  of the sTracheal tumours account for less than 2% of all upper respiratory tract tumours  and are Lobular capillary haemangioma is a benign lesion characterised microscopically by a distinctive lobular arrangement of capillaries in an oedematous, fibroblastic stoma , 3, 6. TThe surface epithelium is often ulcerated, predisposing to invasion by microorganisms. Commonly found on the lip, nose, oral cavity, and tongue , 4, occuAlthough the precise aetiological mechanisms accounting for LCH are not yet fully ascertained, traumatic insults, hormonal imbalances during pregnancy, viral and bacterial infections, microscopic arteriovenous malformations, angiogenic growth factors, and cytogenetic abnormalities have been proposed as causative factors.Chest radiography and computed tomography findings may be inconclusive, and thus bronchoscopy with biopsy plays a key role in diagnosis of tracheal LCH, whilst additionally affording the opportunity for therapeutic intervention. Endoscopic appearances are nonspecific and may mimic adenoma, carcinoma, or carcinoid tumour. For this reason, decision for surgical resection should be avoided until a definitive histopathological diagnosis is established.The extent and size of the lesion, as well as patient age and comorbidities, require consideration prior to any therapeutic intervention for LCH. Despite their benign nature, local recurrence is common and thus surgical excision remains the treatment of choice. Nevertheless, mucocutaneous LCH is also amenable to various nonsurgical techniques including snare electrocautery, cryotherapy, YAG laser therapy, and plaque radiation. In the present case, we were able to safely remove the culprit lesion with biopsy forceps alone and with minimal bleeding owing to its small vascular pedicle.To our knowledge, there are only 14 reports of tracheal LCH in English medical literature to date . Irani eIn conclusion, LCH is a benign lesion rarely found within the trachea. Common presenting features may include recurrent haemoptysis, cough, and wheeze. Symptomatic lesions are usually amenable to direct evaluation and removal via interventional bronchoscopic techniques.


Adult Wilms tumor  is a rare, but well-described renal neoplasm. Although inferior vena cava tumor thrombosis is present in up to 10% of Wilms tumors in childhood, only few cases of this clinical manifestation in adults have been reported. To the best of our knowledge, this is the first case of adult WT infiltrating into inferior vena cava (IVC) with concomitant distal deep vein thrombosis.A 28-year-old male patient with gross hematuria and right flank pain was diagnosed with right kidney tumor penetrating to IVC. Preoperatively, acute distal thrombosis in inferior vena cava and lower extremities veins occurred. Right radical nephrectomy with tumor thrombectomy via cavotomy was performed. In order to prevent pulmonary embolism, IVC was ligated below left renal vein level. Histopathological examination revealed a triphasic nephroblastoma without anaplastic features. Postoperatively, patient was diagnosed with metastatic liver disease, which was treated with two lines of chemotherapy followed by radiotherapy with achievement of complete response.Adult WT occurs usually in young patients, under 40 years of age. Neoadjuvant chemotherapy proved to be effective in children, resulting with tumor shrinkage and venous tumor thrombus regression. Therefore, percutaneous biopsy should be always considered in young patients presenting with renal tumor invading venous system. IVC ligation is a safe treatment option in the event of complete inferior vena cava occlusion due to distal thrombosis concomitant to tumor thrombus, provided collateral venous pathways are well-developed. Wilms tumor  is the most common renal neoplasm in children, but can rarely occur in adults, with an incidence of 0.2 per million (70 newly diagnosed cases yearly in Europe) . In the In this report, we discuss the first case of an adult patient with Wilms tumor infiltrating into inferior vena cava with concomitant distal deep vein thrombosis.A 28-year-old male was admitted to the emergency department with right flank pain and gross hematuria. Ultrasound revealed 8 cm right renal mass. Ambulatory computed tomography (CT) scan showed a 7.8 × 6.8 × 8.5 cm, contrast-enhancing tumor in the right kidney with IVC thrombus extending to the level of hepatic veins. Fig.  ElectiveOn gross examination the tumor was 9 cm large, white, solid/cystic, with soft cut-surface, unencapsulated, but infiltrating adipose tissue. Histopathological examination revealed a triphasic nephroblastoma composed predominantly of blastema and non-specific spindle cell stroma with minor epithelioid component. Fig.  No featuAt follow-up visit after 3 months, the patient presented with mild lower limbs edema. On abdominal CT scan, more than 20 liver metastases were identified  protocols, utilized in North America, stresses the importance of primary surgical treatment with the emphasis on precise pathological evaluation before chemotherapy and radiotherapy . In EuroBoth aforementioned groups (COG and SIOP) agreed that patients with WT infiltrating IVC and right atrium of the heart would benefit from preoperative chemotherapy. Majority of tumor thrombi respond to neoadjuvant treatment , 10. TumPercutaneous needle core biopsy under ultrasound or CT guidance is a safe and accurate procedure. Post-biopsy complication rate is low (1%), with incidental cases of tumor seeding along biopsy tract .According to the data from EUROCARE study, median age at the presentation of adult Wilms tumor is 34 years . EggenerIn pediatric patients, the introduction of adjuvant chemotherapy is recommended within 1–2 weeks post nephrectomy . In adulIVC thrombosis is uncommon and usually associated with malignant disease, congenital IVC malformations, or untreated IVC filter , 21. TumSymptoms of acute IVC thrombosis may vary with severity, from mild  to life-threatening . If intrahepatic IVC or renal veins are involved, patient may present symptoms of renal congestion and Budd–Chiari syndrome  –25. PatiTumors involving more than half of IVC circumference,Complete chronic IVC obstruction in the absence of venostasis clinical symptoms,High risk of postoperative pulmonary embolism due to residual irresectable bland thrombus, andSuccessful thrombectomy complicated by vascular intima layer damage causing increased risk of new clot development.Several factors, such as degree, level, and duration of venous obstruction, presence of collateral vessels should be evaluated before the treatment to determine the feasibility and extent of the surgery. Resection of IVC is not required as long as tumor and bland thrombi are completely removed . HoweverPostoperative morbidity after IVC interruption is minimal, provided the presence of chronic obstruction . HoweverPatients presenting with clinical symptoms of IVC obstruction, with insufficient venous collaterals or intraoperative dissection of preexisting collaterals, should be considered for IVC reconstruction with application of polytetrafluoroethylene (PTFE) graft, bovine pericardium, or autologous vein graft  , 30.p < 0.001) without distal thrombosis [In our patient, due to complete IVC obstruction by tumor thrombus accompanied by bland thrombus reaching below the IVC bifurcation, and in the absence of clinically significant venostasis symptoms, we decided to perform complete IVC ligation below left renal vein level, with no postoperative complication. However, according to Ayyathurai et al. , patientrombosis .In the series of Blute et al., 40 of 160 patients (25%) underwent IVC interruption. In this group, 23 patients (14.4%) had IVC ligated, 4 (2.5%) had IVC filter placed for co-existing bland thrombus and 13 patients (8.1%) had IVC segmentally resected due to venous wall infiltration .The main indicators for IVC interruption are the presence of bland thrombus and the degree of venous occlusion , 31.Adult Wilms tumors are rare but occur usually in young adults. Neoadjuvant chemotherapy proved to be effective in children, resulting in tumor shrinkage and venous tumor thrombus regression. As such, image-guided percutaneous core biopsy is strongly advised in all young adults, under 40 years of age, presenting with renal tumor and venous system invasion.Inferior vena cava ligation is a safe treatment option in case of complete and chronic vena cava inferior occlusion due to complete distal thrombosis concomitant to tumor thrombus, provided that collateral pathways are well developed. Primary IVC reconstruction should remain the surgical strategy of first choice in patients presenting with clinical symptoms of IVC obstruction, with insufficient venous collaterals or intraoperative dissection of preexisting collaterals.


Segmental testicular infarction is a very rare condition, which can mimic a testicular torsion or testicular cancer. Correct diagnosis is difficult but it is important to avoid unnecessary radical treatment.We report a clinical case of a 36-year-old white man who presented at our emergency department with subacute testicular pain. A urine analysis, Doppler ultrasound, surgical exploration, blood analysis, and magnetic resonance imaging were performed to diagnose his condition, to exclude a testicular torsion, and to raise confidence in its non-malignancy. He was treated conservatively. At follow-up, a few months after the incident, he no longer had complaints. Ultrasonography showed remaining hypo-echogenicity of the left upper pole, indicating a sequel of ischemia.Segmental testicular infarction is a rare condition which can be easily confused with a testicular torsion or a testicular tumor. This case report can be helpful in recognizing and diagnosing this condition. Making the right diagnosis is important since it can prevent an unnecessary radical treatment. Segmental testicular infarction is a very rare condition which can be diagnostically challenging. The etiology and pathophysiology are not well understood. Patients are mostly affected between the second and fourth decade . It can A 36-year-old white man with no relevant medical history presented to our emergency department (ED) with severe left scrotal pain.3/mm3; 83% neutrophils). Viral epididymitis was suspected and therapy with oral anti-inflammatory drugs was started. He was advised to wear tight underpants and could return home.Left testicular discomfort had been present for a month, and the pain had worsened in the past few hours. A scrotal examination revealed a painful and lightly swollen upper pole of his left testicle. He experienced no fever or dysuria and urine analysis was normal. Blood analysis showed a slightly elevated C-reactive protein , creatine kinase (368 U/L), lactate dehydrogenase , and white blood cell count  and CRP (16.4 mg/L) had risen further. A color Doppler ultrasound evaluation revealed a reduced vascularization of his left testicle .A month after the operation a contrast-enhanced magnetic resonance imaging (MRI) was performed. T2-weighted images showed a heterogenic hypointensity in the upper part of his left testicle , alpha fetoprotein (AFP), and LDH. Except for a slightly elevated LDH (698 U/L), the results were in the normal range. These results increased confidence in the diagnosis of segmental testicular infarction and made the hypothesis of testicular cancer less likely.At follow-up a few months after the incident, our patient no longer had complaints although ultrasonography showed a remaining hypo-echogenicity of the left upper pole, indicating a sequel of the ischemia Fig. .Fig. 3UlIn Table In contrast to infarction of the entire testicle, segmental testicular infarction is rare and in 70% of cases no underlying cause is observed. The most common underlying cause is thought to be epididymo-orchitis . This coThe pathophysiology of segmental testicular infarction is not completely understood; however, some mechanisms have been proposed. The testicle has a triple arterial blood supply: the testicular artery arising from the abdominal aorta, the cremasteric artery, and the artery of ductus deferens . In someet al. [Segmental testicular infarction is most frequently accompanied by acute scrotal pain and swelling. Our patient presented with a rather atypical subacute onset of testicular pain, but swelling was present. Gianfrilli et al.  states tet al. .An important differential diagnosis with segmental testicular infarction is a testicular tumor. Tumor markers are elevated in 60% of cases of testicular cancer. In our case we determined tumor markers β-HCG, LDH, and AFP to diminish doubts about malignancy. Only LDH was slightly elevated probably due to tissue loss caused by the segmental infarction. One must remark that a negative marker level does not prove the absence of a tumor and additional examinations are advised. Examination possibilities are: color Doppler ultrasound, contrast-enhanced ultrasonography (CEUS), and MRI . Ultrasoet al. presenting the ultrasounds of 19 cases of segmental testicular infarction showed a hypoechoic lesion in 74%, mixed echogenicity in 21%, and a hyperechoic lesion in 5% of the cases [A case study of Madaan he cases . The leshe cases .et al. described six out of seven testicular tumors smaller than 1.6 cm to be hypovascular on color Doppler ultrasonography [If a focal lesion is seen which is markedly less vascularized than the surrounding normal tissue, shows no mass effect, nor signs of infiltration of vascular structures or scrotal tunics , it is lnography .When a discrepancy between clinical and ultrasonographical signs is present, MRI can provide extra information , 11. T2-Two approaches are possible in the management of segmental testicular infarction: a surgical approach or a conservative approach. Because the clinical and radiological presentation of testicular tumors and segmental testicular infarction can be similar , segmentet al. even suggest that any hypoechoic testicular lesion should be considered malignant unless proven otherwise and consider infarction to be a clear-cut indication for partial orchiectomy [et al. advocate that reassuring imaging combined with negative tumor markers is sufficient for the diagnosis of segmental testicular infarction; therefore claiming that conservative follow-up, by means of watchful waiting, is reasonable [Exclusion of testicular tumor or abscess is not always possible with MRI . Therefohiectomy . In contasonable .In our case a surgical exploration was carried out to rule out a testicular torsion. After the exploration, a conservative approach was selected because the blood tests and imaging were reassuring.Segmental testicular infarction is a rare condition which can be easily confused with a testicular torsion or a testicular tumor. In cases similar to the one described by us, a partial or radical orchiectomy was often performed because they feared a testicular tumor. Making the right diagnosis is important in preventing this unnecessary radical treatment.In our opinion a color Doppler sonography, followed by blood tests and MRI is sufficient for diagnosis. When followed by watchful waiting, we consider this approach justifiable and safe.


Ameloblastic fibroodontoma is a benign mixed odontogenic neoplasm considered in patients with asymptomatic swelling and unerupted teeth that exhibit histologic features between ameloblastic fibroma and complex odontoma. Radiographically, this lesion appears as radiolucency admixed with focal radio opaque masses of irregular shapes and sizes. This lesion is confirmed by the presence of proliferating odontogenic epithelium, ectomesenchyme, and dental hard tissue formation on pathological analysis supplementing clinical and radiographic findings. As this tumour is less commonly seen in routine clinical practice, ameloblastic fibroodontoma with detailed orofacial features and periodic approach to its diagnosis is discussed. This paper reports a case of ameloblastic fibroodontoma of the mandible in a 6-year-old male patient with an uncommon case presentation and review of the literature. Odontogenic tumours are a diverse group of diseases ranging from simple hamartomas to neoplasms with metastatic potential . AmeloblWe present a case of ameloblastic fibroodontoma (AFO) in a 6-year-old male patient with distinctive orofacial manifestations, radiographic findings, histopathological report, and differential diagnosis with treatment to add to the existing knowledge.A 6-year-old male patient reported to the dental hospital with a chief complaint of swelling on the right side of face since 1 month. History revealed a slow growing and nontender swelling. Medical, personal, and family history was noncontributory. The patient was well oriented with stable vital signs. On extraoral examination, mild facial asymmetry due to swelling in the right body of mandibular region, with ill-defined margins, was evident. On palpation the swelling was asymptomatic and hard in consistency. Skin over the swelling was normal with no evidence of secondary changes. Restricted temporomandibular joint (TMJ) movements and palpable lymph nodes were evident.On intraoral examination, obliteration of the buccal sulcus in molar region with buccal and lingual osseous cortical expansion was apparent . On palpBased on clinicoradiographical findings, a provisional diagnosis of complex odontoma was made. The patient underwent enucleation of the lesion and curettage under general anesthesia. Tooth attached to the follicle around the lesion was removed. The cavity was irrigated carefully and the debris was detached. The flap was repositioned in the same location and suturing was done with vicryl 3.0 suture material Figures .Surgical specimen was fixed in 10% formalin and subjected to pathological analysis. On gross examination the specimen consisted of a hard tissue mass with a soft tissue attachment. Routine histopathological examination revealed strands and islands of odontogenic epithelium with peripheral palisading nuclei resembling ameloblast-like cells and loosely arranged central cells, identical to stellate reticulum, embedded in a myxoid cell-rich stroma resembling the dental papilla. Dentin and enamel were also present Figures . CorrelaAmeloblastic fibroodontoma has been conventionally classified as a benign mixed odontogenic tumour with limited cases documented in literature. This lesion is reported in approximately 0.3% to 1.7% of odontogenic tumours among different locations with 4.6% accounting to total number of paediatric cases. Children or teenagers with a mean age of 8–12 years are commonly affected with no obvious gender or anatomic site predilection. This lesion is frequently seen in the posterior border of the mandible (2.4 : 1) as in the present case .Debate exists concerning the histogenesis of the ameloblastic fibroodontoma as a mixed odontogenic neoplasm. Previously, concept stated this lesion to be continuum of differentiation from ameloblastic fibroma to complex odontoma. However, the recent literature stated that ameloblastic fibroodontoma as a discrete entity but it can be histologically indistinguishable from immature complex odontoma due to the presence of abundant dental hard tissue formation . AccordiPatients present with swelling, unerupted tooth, rapid destruction, and cortical plate expansion. This case also presented with marked intraoral and extraoral swelling resulting in the obliteration of molar buccal sulcus and cortical plate expansion. World Health Organization (WHO) also described this well encapsulated tumour to be a benign odontogenic neoplasm admixed in primitive ectomesenchymal tissue exhibiting varying degrees of inductive changes and dental hard tissue formation , 12.Radiographically, this tumour varies from a unilocular or multilocular mixed radio-lucent radiopaque lesion with irregular size and shape to complete radio opacity as in the current case consistent with odontoma formation , 14. HisDifferential diagnosis of ameloblastic fibroodontoma includes odontoma, ameloblastoma, ameloblastic fibroma, odontoameloblastoma, calcifying epithelial odontogenic tumour, calcifying epithelial odontogenic cyst, and adenomatoid odontogenic tumour. These clinical conditions can be clearly differentiated from ameloblastic fibroodontoma based on radiographs due to the presence of dental hard tissue (enamel and dentin), clinical findings, and prognosis that also supplemented our case diagnosis . AmeloblA case of ameloblastic fibroodontoma is rare and unacquainted to a clinician due to underreported number of cases in literature. This article presents an exceptional case report of ameloblastic fibroodontoma (AFO) with emphasis on diagnostic criteria thus emphasizing to all the readers its importance. Treatment of this lesion involves a complete surgical enucleation with removal of associated tooth. Additional cases need to be conveyed into certification so as to have a strong understanding concerning various aspects of this disease.


In the appropriate clinical setting, certain aspects of extranodal abdominallymphoma, as revealed by current cross-sectional imaging techniques, should beconsidered potentially diagnostic and can hasten the diagnosis. In addition,diagnostic imaging in the context of biopsy-proven lymphoma can accurately stagethe disease for its appropriate treatment. The purpose of this article was toillustrate the various imaging aspects of extranodal lymphoma in theabdomen. The exception isthe spleen, where it is classified as extranodal in non-Hodgkin lymphoma (NHL) andnodal in Hodgkin lymphoma.Lymphomas are classified as primary extranodal when there is no nodal involvement orwhen there is minimal lymph node involvement and the extranodal component isdominant,3. Secondary involvement, such as advanced disease,is significantly more common. The extranodal form is more commonin NHL, occurring in 25% of cases. On computed tomography (CT), a lymphoma usuallypresents with slightly less density than does the parenchyma of the organinvolved. It often showslittle contrast uptake.Heterogeneous enhancement can be seen in large masses, due to areas of centralnecrosis. Unless previously treated, lymphomas do not typically presentcalcifications.Extranodal involvement occurs in 40% of patients with lymphoma. Primary splenic lymphoma is rare.Diffuse infiltration is the most common form of presentation, often resulting inhomogeneous splenomegaly, although the spleen can also be of normal size. In suchcases, functional imaging methods, such as FDG-PET/CT, facilitate thediagnosis. Solitarymasses and multifocal lymphomatous nodules are hypointense on CT, with littlecontrast uptake  is the most common abdominal site of primaryextranodal lymphoma, the stomach being the segment most often affectedric wall , usuallyric wall . PrimaryThe small intestine is the second most common GIT site affected by lymphoma, thedistal ileum being the segment most often affected. Primary lymphoma accounts forover 50% of cases. Lymphoma of the small intestine can present as a polypoid mass,multiple nodules, or (asymmetric or concentric) thickening of the intestinal wall.It typically promotes aneurysmal dilation of the intestinal loop . The priOne important clinical condition that can occur in the context of GIT lymphoma isperforation as the tumor recedes during chemotherapy, which is mainly associatedwith lymphomas that invade the intestinal wall and respond well to chemotherapy.. Lymphoma of the colon can manifest as a bulky polypoidgrowth, which is the most common pattern and can cause invaginations. Incontrast-enhanced imaging studies, it can also present as an infiltrative mass,thickening of the haustra (.The colon is the third place most common site affected by GIT lymphoma. The cecum andrectum are the sites most often involved haustra , andmuc,5, bilaterally in 50% of those cases. The morphological patternsinclude well-defined homogeneous masses (.The adrenal glands are involved in about 4% of all cases of NHLs masses , small n (, can mimicpapillary renal cell carcinoma due to the pattern of homogeneous hypovascularimpregnation (In advanced cases of nodal lymphoma, renal involvement is relatively common. Primaryrenal lymphoma is extremely rare. In 60% of cases, it manifests as multiple,bilateral, homogeneous nodules, with discrete and sometimes progressiveimpregnation . Diffuse . Renal megnation . Contiguegnation . Perirenegnation . In mild.Increased mesenteric density is most commonly seen after treatment. The patterns of involvementinclude peritoneal nodules (.Lymphoma is the most common cause of masses and nodules in the mesenteric lymphnodes, which are most often associated with GIT lymphoma. Such changes areradiologically indistinguishable from those occurring in peritonealcarcinomatosis nodules  and adi. It is aserious and relatively common complication, occurring in 2-5% of such patients, andis particularly common after treatment with cyclosporine,5. Itsincidence peaks in the first year after transplantation, and it can affect virtuallyany organ. Isolated lymph node involvement is less common, occurring in only 20% ofcases.There is a high incidence of NHL in immunocompromised transplantrecipientsExtranodal lymphoma can simulate other neoplasms or inflammatory conditions. Theradiologist plays a crucial role in the noninvasive management of the disease. Inaddition to raising suspicion of the diagnosis, the role of the radiologist includesobtaining material via percutaneous biopsy, facilitating the staging, assessing theresponse to or complications of treatment, and identifying recurrence orrelapse.


We highlight an unusual case of familial adenomatous polyposis (FAP) presenting initially with gout, jaundice and a periampullary carcinoma. This case may be of interest to clinicians involved in the diagnosis and management of FAP and follow-up of patients after surgical resection. Familial adenomatous polyposis (FAP) is a precancerous syndrome of autosomal dominant inheritance, affecting approximately one in 10,000 individuals and characterized by multiple colorectal adenomas as well as extracolonic manifestations . AdvanceA 33-year-old male presented with an inflamed right first metatarsophalangeal joint of 24 hours duration, with no history of trauma. He had no significant medical history, but on questioning revealed a three-month history of intermittent pruritus and dark urine. There was no history of a change in bowel habit or bleeding per rectum and no family history of polyps or colorectal cancer.Laboratory tests were largely unremarkable, apart from a serum uric acid of 0.44 mmol/L, gamma-glutamyl transferase test (GGT) 1878 U/L, alkaline phosphatase test (ALP) 1143 U/L, aspartate aminotransferase (AST) 426 U/L, 615 78 U/L, and a bilirubin of 72 mmol/L. A diagnosis of gout was made and managed with a simple analgesic. An upper abdominal ultrasound showed common bile duct dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) subsequently demonstrated an intraluminal lesion at the duodenal ampulla of Vater and biopsies demonstrated a villous adenoma  scan of the abdomen confirmed the ampullary mass, with no evidence of metastatic spread Figure .On referral to a tertiary institution, acute gout had resolved, but the patient had become mildly jaundiced. Colonoscopy and biopsy revealed hundreds of pedunculated and sessile tubulovillous and tubular adenomas involving the colon and rectum to the anorectal junction.Radical pancreaticoduodenectomy and cholecystectomy were performed due to the high chance of underlying malignancy. Histology revealed an adenocarcinoma arising from a villous adenoma at the duodenal ampulla and multiple duodenal adenomas, highlighting the limitations of ampullary polyp biopsy. Three months later, the patient was readmitted and underwent total colectomy and ileorectal anastomosis. A pelvic pouch procedure had been planned, but the pancreaticoduodenectomy made it not possible to bring the terminal ileum down to the pelvic floor for reconstruction.The patient made a good recovery from this operation and was discharged home on the tenth postoperative day. At four year follow-up, there was no recurrence of the periampullary carcinoma and the patient's rectal polyps were well controlled with six-monthly sigmoidoscopic ablation thereafter.To our knowledge, this is the first case of FAP presenting with gout and jaundice reported in the literature. The presence of gout may have been mere coincidence or precipitated by hyperuricemia caused by increased nucleotide catabolism due to underlying malignancy . This caUpper GIT manifestations of FAP will affect up to 100% of patients, and their occurrence may be related to the carcinogenic properties of bile . The incUpper GIT screening is advocated by most centers, due to the high incidence and increasing severity of duodenal adenomatosis with age . EndoscoFor malignant duodenal polyps, pancreas-sparing duodenectomy or pancreaticoduodenectomy are recognized options . Our patThis case highlights an unusual presentation of familial adenomatous polyposis (FAP) presenting with gout and jaundice, and with upper gastrointestinal tract (GIT) disease requiring treatment before lower GIT disease. Pancreaticoduodenectomy was performed and the mass was found to be malignant despite the original ampullary polyp biopsy demonstrating adenoma. This case may be of interest to clinicians in the diagnosis and management of FAP, in particular, the unusual presentation, and the inaccuracy of ampullary polyp biopsy in detecting underlying malignancy in high-risk patients.


Liposarcoma of the esophagus is very rare. We experienced a huge (27.5 × 11.6 cm) liposarcoma of the esophagus. A 73-year-old man presented with severe dyspnea requiring emergency tracheal intubation. Computed tomography and esophagogastroduodenoscopy showed a large submucosal tumor arising from the esophageal entrance and extending intraluminally to the lower esophagus. We successfully performed endoscopic submucosal dissection (ESD) and esophagotomy to remove the tumor, which preserved swallowing and phonation. The final diagnosis by histopathologic and immunohistologic examination was well-differentiated liposarcoma of the esophagus. Treatment by the combination of ESD and esophagotomy can be performed even for a very large tumor. This method preserves deglutition with a lower risk of recurrent laryngeal nerve paralysis than that with esophagectomy. Liposarcoma of the gastrointestinal tract is rare, with a reported incidence at autopsy of 0.1 to 5.8 %. It is particularly rare in the esophagus, accounting for 1.2 to 1.5 % of all gastrointestinal liposarcomas [The most common presenting symptom of esophageal submucosal tumors is dysphagia. However, we saw a patient with esophageal liposarcoma who presented with severe dyspnea. Previously reported liposarcomas of the esophagus had been treated with various surgical methods, including simple resection by the transcervical, transthoracic, or transabdominal route. However, such approaches are invasive and expensive. The first report of endoscopic resection of the esophageal liposarcoma was reported in 2007, with endoscopic submucosal dissection (ESD) first reported in 2013 .We report a huge liposarcoma of the esophagus that compressed the airway and was successfully resected by combined ESD and esophagotomy.A 73-year-old man was brought to the emergency room with severe dyspnea. His height was 170 cm and weight 78 kg. He had a history of hypertension and atrial fibrillation and had undergone surgery for a subarachnoid hemorrhage 20 years earlier.Several hours before presentation, he had temporary difficulty in swallowing which resolved after drinking some water. However, he suddenly had difficulty breathing and called emergency medical services. On arrival at the emergency room, he was given oxygen and a bronchodilator, which failed to improve the dyspnea. Computed tomography (CT) showed a giant intraluminal tumor from the pyriform sinus into the thoracic esophagus Fig. . The tumEsophagogastroduodenoscopy (EGD) showed the stalk of the tumor at the esophageal entrance, having a surface covered with a smooth mucous membrane Fig. . These fOur treatment strategy for this huge esophageal tumor was designed to achieve curative resection while preserving swallowing and phonation. It appeared that a minimally invasive method without resecting the esophagus was possible because the tumor had a stalk that was confirmed by EGD, that is, it was a pedunculated submucosal tumor.ESD was selected as main treatment Figs. and 3b. Since the tumor was too large to retrieve through the mouth, we made an oblique skin incision at the left neck Fig. , followeThe postoperative course was uneventful. The patient had no difficulty swallowing and tolerated oral intake well. There were no signs suggestive of recurrent laryngeal nerve paralysis. After 41 months of postoperative follow-up, the patient remained in good condition with no evidence of recurrence.The excised specimen consisted of a 27.5 × 11.6-cm branched polypoid mass Fig. b with a Liposarcoma is the most common soft tissue malignant tumor in adults and usually occurs in the retroperitoneum, deep soft tissues of the trunk, or lower extremities. It is very rare in the gastrointestinal tract, especially in the esophagus . In PubMOur patient, conversely, complained of severe dyspnea resulting from compression of the membranous portion of the trachea by the huge tumor. Therefore, tracheotomy was required for airway management. None of the patients with esophageal liposarcoma reported in the literature had similar airway compression. There are, however, reports of sudden asphyxia due to pedunculated polyps of the esophagus or pharynx .Since tumor resection is the only curative treatment for liposarcoma , 8, suchLiposarcoma originates from a primitive mesenchymal cell and usually arises from the esophageal mucosa and submucosa , 10. AccGenerally, the aggressiveness of soft tissue sarcoma differs depending on histologic type. Enzinger reported that the patients with well-differentiated liposarcoma in various organs had the highest 5-year survival and the lowest local recurrence rate . But theWe successfully treated a large esophageal liposarcoma by combining ESD and esophagotomy. We think this combined method is safety and less invasive than esophagectomy, but only as long as the base of the stalk is confirmed by EGD to be in the cervical esophagus. This method can theoretically be performed regardless of the tumor size. Moreover, this method enables preservation of deglutition so that the patient can resume oral intake. Such a combined procedure also carries a lower risk of recurrent laryngeal nerve paralysis than dose esophagectomy.


A 44-year-old right-handed male construction worker presented with a slow-growing, firm, soft-tissue mass at the palm between the middle and ring finger metacarpals heads. The mass was causing pain, morning stiffness, and interference with work.What is the differential diagnosis of a slow-growing hand mass?What is the role of radiographic imaging in diagnosing hand masses?What is the role of occupation and repetitive trauma in the development of this lesion?What anatomic structures should be avoided intraoperatively during excision of the mass?Benign lesions can arise from all tissue types in the hand—skin, fat, muscle, nerve, vessel, and more. The most common benign soft-tissue tumors of the hand are ganglion cysts and giant cell tumors of the tendon sheath. Ganglion cysts are more prevalent in women, and 70% occur between the second and fourth decades of life. Giant cell tumors of the tendon sheath are the second most common tumors seen in the hand. These tumors are slow-growing and may be asymptomatic unless the lesion occurs in proximity to the digital nerves, resulting in a sensory deficit.For most patients with simple subcutaneous hand masses, imaging will not alter management, as excision and pathology are the criterion standards for diagnosis. However, imaging provides clues for diagnosis and may guide excision. Imaging may demonstrate tissue type, mass encapsulation, invasion, and proximity to surrounding anatomic structures. There are a variety of imaging modalities available for the assessment of hand masses. In the basic hand radiograph, 3 views are obtained: anterior-posterior, oblique, and lateral. Standard radiography determines whether or not the lesion developed from the osseous elements as well as the presence of subcutaneous calcifications.Based on clinical presentation, the mass was thought to be a giant cell tumor of the tendon sheath. However, the final pathology report described it as densely fibrotic tissue with chronic inflammation. The lesion measured 4.3 × 3 × 1 cm. The gross appearance of the mass was flesh-colored, smooth, and homogeneous. The inflammation and fibrosis found on pathology may be explained by the pathophysiology of work-related musculoskeletal disorders of the hand and wrist. Basic science studies in animal and human models suggest that inflammatory changes are more prevalent than degenerative changes in overuse injuries; these inflammatory and proliferative changes appear early before overt signs of tissue injury or tendinopathy.Definitive treatment of most hand masses is excision. The common and proper neurovascular structures were identified and protected during the dissection of the mass. In the hand, arteries run volar to nerves in the palm and dorsal to the nerves in the digits. The superficial and deep palmar arterial arches give off the common digital arteries in the central palm and proper digital arteries at the metacarpophalangeal joint level. The mass in question was located at the transition between these structures.The hand is a highly utilized appendage that can give rise to various benign masses. Based on clinical examination, hand masses have a broad differential diagnosis that may ultimately have an uncommon pathology, such as fibrotic tissue. A number of diagnostic imaging modalities can be utilized in assessing hand masses. Ultimately, surgical excision is indicated for treatment and diagnosis. During excision, impeccable attention to anatomy is essential to preserve normal structure and function.


To present a rare case of a conjunctival hypertrophic scar presenting as eyelid mass after surgical treatment of a chalazion.A 74-year-old man visited our clinic with severe ocular discomfort and excessive lacrimation since several months in his left eye accompanied by itching of the upper eyelid. Examination of the anterior segment revealed a 6 mm  × 8 mm  round, immobile, hard, mushroom-shaped protruding mass on the tarsal conjunctiva of his left eye. There was no associated pigmentation, ulceration, or tenderness. Excisional biopsy of the benign conjunctival tumor was performed using radiofrequency electrosurgical systems. The region of the excised conjunctiva was well-healed on postoperative day 14, and there was no recurrence until 1 year post-surgery. Histopathological examination demonstrated thick interlacing collagenous fibrous bundles oriented in random directions and fibroblastic proliferation. Immunohistochemical staining revealed that spindle-shaped fibroblasts were positive for CD34 and negative for smooth muscle actin. The excessive collagenous tissue was stained blue by Masson trichrome stain. These findings were consistent with a hypertrophic scar of the conjunctiva.This short report demonstrates that a hypertrophic scar of the conjunctiva can develop after surgery of a chalazion and cause severe ocular discomfort and excessive lacrimation. These lesions can be easily removed using simple excision. Hypertrophic scars of conjunctival tissues following ocular surgery do not develop commonly  × 8 mm  round, immobile, hard, mushroom-shaped protruding mass on the tarsal conjunctiva of his left eye. There was no associated pigmentation, ulceration, or tenderness Fig. a. ExcisiOn microscopic examination, the lesion was composed of spindle-shaped fibroblasts and collagenous stroma (hematoxylin & eosin stain, 40×, Fig. Conjunctival hypertrophic scars following ophthalmic surgery are rare (Lyu et al. Differential diagnosis includes keloid and angiofibroma. Keloid is less cellular and has thicker collagen fibers. Angiofibroma is characterized by small vessel dilatation and concentric perifollicular fibrosis. The histologic features of the present case are compatible with hypertrophic scar.The eyelids are dynamic and complex structures. The primary function of eyelid is to protect the ocular surface via cleansing and lubrication of eyes. They serve as both a physical and immunological barrier, which constitutes a crucial defense mechanism (Lin et al. This case report demonstrated that a hypertrophic scar of the conjunctiva can develop after surgical treatment for a chalazion and cause severe ocular discomfort and excessive lacrimation. These lesions can be easily removed using simple excision.


Heterotopic gastric mucosa has been described at various locations of the body; however, the polyp composed of heterotopic gastric mucosa in the small intestine is rare.A 15-year-old boy visited us for investigation of recurrent episodes of melena. Capsule endoscopy (CE) revealed a polypoid tumor in the ileum, with an active nearby hemorrhage. Contrast-enhanced computed tomography (CECT) showed a tumor in the right quadrant of the abdomen, with a diameter of about 18 × 14 mm.The patient was diagnosed with polypoid gastric heterotopia.We performed an operation to resect the lesion.The patient recovered smoothly after surgery and was discharged on postoperative day 7 and followed up for 3 months. He has not experienced gastrointestinal intestinal (GI) symptoms up to now.Giant polypoid gastric heterotopia in the small intestine is extremely rare, which can express as an occasional finding with or without symptoms. Surgical resection is the preferred therapy when symptoms appear. Here, we reported a case of a boy who was diagnosed with a giant polyp in ileum composed of heterotopic gastric mucosa. To our knowledge, this is the first case that reveals a giant polypoid gastric heterotopia in the small intestine.Heterotopic gastric mucosa (HGM) has been described at various locations of the body, including all levels of the gastrointestinal tract.2A 15-year-old boy visited us for investigation of intermittent episodes of melena for a week. The patient had no history of alimentary tract hemorrhage, infection, trauma, or medication history. Hematological examination showed a hemoglobin (Hb) value of 7.5 g/dL. Esophagogastroduodenoscopy (EGD) and colonoscopy revealed negative result. Capsule endoscopy (CE) demonstrated a polypoid tumor of about 2 cm in diameter in the ileum, with an active nearby hemorrhage Fig. . Macrosc3,7 Poindecker reported the first case of HGM in 1912. Subsequently, many cases of small intestinal HGM have been reported. The incidence of HGM in the esophagus varies widely from 0.1% to 13.8%, and that of HGM in duodenal varies from 0.5% to 8.9%. HGM usually presents as an “inlet patch” in the proximal esophagus, as polypoid masses in rectum, or as nodular tumors in the duodenum.,11 Polypoid lesions composed of gastric mucosa in the small intestine are rare. The vast majority of reported cases occur as small metaplastic nodules or polyps in duodenum in association with other disease processes.,13HGM of the small intestine is a congenital disorder with a variable clinical presentation. It may occur in the duodenum, esophagus, colon, and most commonly occurs in ileum in Meckel's diverticulum (MD) and gastrointestinal duplications.–18 It also can cause failure to thrive because of the chronic abdominal pain associated with recurrent episodes of vomiting and diarrhea. Our case was unique in that the lesion appeared as a giant polyp composed of heterotopic gastric mucosa in the small intestine. Polypoid gastric heterotopia is normally present sporadic, small in dimension and with no symptoms. The clinical feature depends on the size of the polypoid gastric heterotopia. It can cause intestinal and airway obstruction.,21 However, giant polypoid gastric heterotopia in small intestine caused gastrointestinal bleeding has not been reported yet. The natural history of polypoid gastric heterotopia is deficient in clearness and currently there are no available guidelines for surveillance or treatment. The mechanism for the development of polypoid gastric heterotopia in the small intestine remains to be seen. There are various theories that are used to explain the etiology. (1) It occurs between the fourth and seventh week of fetal development due to an erroneous differentiation of the pluripotent stem cells of the endodermis. (2) It occurs due to a failure in the descent of the proximal intestine. (3) It is the result of an anomalous regeneration under inflammatory conditions, such as gastric metaplasia in Barrett's esophagus.,23 4) It occurs due to Cdx2 modify the expression of molecules. Cdx2 stimulates markers of enterocyte differentiation. Null mutation of Cdx2 lead to the development of ectopic lesions with a gastric phenotype in the midgut endoderm. The study present that mice in which Cdx2 gene had been inactivated developed multiple intestinal polyp-like lesions in the mouse esophagus and stomach.HGM can cause intestinal perforation, gastrointestinal bleeding, and intestinal obstruction. Tc-99m pertechnetate scan may be useful depending upon the location and size of the heterotopic tissue. The final diagnosis depends on the histological results from surgical specimens.The clinical diagnosis of polypoid gastric heterotopia may be difficult before surgery due to its rarity and urgent presentation. It is often discovered during laparotomy and confirmed upon pathologic examination post-operatively. There are no endoscopically distinctive features of polypoid gastric heterotopia in the intestine. It is difficult to differentiate polypoid gastric heterotopia in the intestine from other intestinal diseases, such as GIST, hemangioma, adenoma, or inversion of intestinal diverticulum. History-taking and physical examination are required, which help to suspect the potential diseases involved. Cross-sectional imaging such as CECT should be done as well, followed by the latest enteroscopy, capsule endoscopy, and deep enteroscopy according to the patient's conditions. CE is a viable and safe option.4We are presenting a rare case with giant polypoid gastric heterotopia in the ileum. We should pay attention to diagnosis of polypoid gastric heterotopia. Endoscopy combined with histopathologic examination is definitely a mandatory method in clinical diagnosis. Surgical resection is the preferred therapy when symptoms appear.


Pott’s puffy tumour is characterized by a fluctuate swelling of the frontal region as a result of osteomyelitis of the frontal bone. This inflammatory lesion may propagate endocranially, resulting in acute meningitis, epidural abscess, subdural empyema, cavernous sinus trombophlebitis, cerebritis, and frontal lobe abscess of the brain.We present an unusual case of a 33-year-old man suffering from Pott’s puffy tumour whose condition was further complicated by a draining epidural-cutaneous fistula and an epidural abscess. We confirmed the diagnosis by contrast-enhanced computed tomography scanning and magnetic resonance imaging of the head. After intense antibiotic treatment, we performed a combined endoscopic and external surgical approach with drainage of abscesses, evacuation of pus and bone sequestrate and excision of fistulous lesion. The treatment was prolonged with four weeks’ antibiotic administration.Subperiosteal abscess of the frontal bone is an extremely rare complication of frontal sinusitis. This lesion may propagate endocranially, resulting in dangerous intracranial inflammatory lesions. Early diagnosis, medication and surgical therapy are very important in reducing morbidity and mortality. Pott’s puffy tumour (PPT), originally described by Sir Percival Pott, surgeon from the London, in 1760, is diagnosed as a subperiosteal abscess of the anterior wall of the frontal sinus originating from osteomyelitis of the frontal bone . Althoug9/L. A contrast-enhanced computed tomograpy (CT) scanning with coronal, sagittal and axial reconstructions was performed. The CT scan showed the presence of an osteomyelitis of the frontal bone with destruction of the anterior and posterior frontal sinus wall. A subperiosteal (3.60x1.96 cm) and an epidural abscess that were connected to each other through a fistulous canal were seen. CT scan also showed bilateral extensive opacification of the anterior ethmoid cells and frontal recess and an extensive pneumatization of the left middle turbinate  2.0 g, two times daily; metronidazole  0.5 g, three times daily; amoxicillin-clavulanate  1.2 g, three times daily] were administered for 2 weeks to control the active disease. Two days after the start of antibiotic therapy, the patient was afebrile and without secretion from the fistula. Surgical treatment included a combined endoscopic and external approach. The patient underwent bilateral endoscopic anterior ethmoidectomy and left-sided lateral resection of the concha bullosa under general anaesthesia. The surgery was continued by external approach performed by a neurosurgeon and rhinologist. We performed a craniotomy using the bicoronal approach. After the surgical drainage of the epidural abscess and debridement of the osteomyelitic focus, the fistulous canal and inflamed mucosa of the frontal sinus were removed. The granulation tissue overlying the dura mater was carefully excised. No defect of on the dura was found. At the end, bony defects were successfully reconstructed using a temporal muscle flap. Histopathological examination of the excised tissue showed chronic non-specific granulation with bony sequestration and foreign body giant cell reaction. The treatment was continued with 2 weeks of intravenous and 4 weeks of oral antibiotics. The patient’s post-operative course was uneventful. He had a complete recovery and after 7 years of follow-up, there has been no recurrence.The bacterial cultures taken from the frontal fistulous canal grew PPT is very rare complication of frontal sinusitis in the age of antibiotics. It is found mainly in adolescents. According to the world English-language literature, only 30-40 cases of adult patients with PPT were reported between 1990 and 2016 . PPT is Intranasal cocaine abuse is also an important cause of PPT. Inhaled cocaine compromises local blood circulation and, potentially, can destroy bony structures of the nose/paranasal sinuses . The sevEarly diagnosis of PPT is based on rhinological findings and radiological imaging. This rare but grave clinical entity can be misdiagnosed with benign or malignant neoplasms, soft-tissue and skin infections, and infected haematoma of the frontal area. Contrast-enhanced CT is the most adequate imaging method for the diagnosis of PPT . CT is tStaphylococcus aureus, the most involved bacteria in the nasal/paranasal chronic inflammatory process. Therefore, antibiotics must be used to cover streptococci and anaerobes. Finally, the antimicrobial treatment should be adapted to the results of bacteriological analysis (Osteomyelitis of the frontal bone, commonly associated with intracranial complications, requires swift management. Antibiotic therapy is of crucial importance. It is necessary to deal with analysis ,6. It isanalysis ,6. The uanalysis ,5. Surgianalysis .


The hypospadias is the most common urogenital anomaly of male neonates but the prenatal diagnosis of this is often missed before birth. We present the prenatal diagnosis of a severe penoscrotal hypospadias using 2D and 3D ultrasounds. 3D sonography allowed us the best evaluation of the genitals and their anatomical relations. This ample detailed study allowed us to show the findings to the parents and the pediatric surgeon and to configure the best information about the prognosis and surgical treatment. Hypospadias is a congenital anomaly in the development of the urethra, in which the urethral meatus is abnormally positioned with a ventral opening in the surface of the penis .Despite hypospadias being the most common congenital defect of the male external genitalia, it is often missed on prenatal ultrasound. Most diagnosed cases are severe forms, those associated with other anomalies or those with a family history of hypospadias.We present a case of a severe penoscrotal hypospadias diagnosed prenatally using 2D and 3D ultrasound, which was crucial for an accurate diagnosis and proper parental advice.A 26-year-old woman, primigravida, with no significant past medical history was referred to our Prenatal Diagnosis Unit because in the 21-week ultrasound the sex was not clearly differentiated. Due to the ambiguity of the genitalia, a fetal karyotype in maternal blood was requested and it revealed a normal male karyotype (46XY). We performed a detailed fetal examination using ultrasound equipment Epiq 7  with abdominal probes C5-1 and xMATRIX 6-1.The fetal biometric measurements correlated with his estimated gestational age and showed no fetal anatomic abnormality except in the external genitalia.In the external genitalia a shortened penis is observed with a ventral angulation between the two scrotal folds. The two testicles were properly descended into the scrotum . 3D ultrThe remaining ultrasounds performed during pregnancy showed no other relevant findings except for a fetal weight at the lower limit.The patient was admitted at 37th week of gestation for a hypertension study. At 37 + 1 weeks a male of 2100 grams (percentile <3) was delivered by an induced vaginal delivery. The newborn was admitted to the Neonatal Unit because of low weight for gestational age. The exploration of the external genitalia confirmed the diagnosis of severe hypospadias with the urethral meatus at the base of the penis, almost interscrotal, a severe curvature, and a bifid scrotum with the testes in the bag, without other associated anomalies .We present a case of hypospadias where the surface rendering and multiplanar mode allowed us to ascertain its severity and the perineal anatomical relationships, in order to advise parents on the expected surgical outcomes.Hypospadias is one of the most common congenital anomalies, with an estimated prevalence between 0.2 and 4.1 per 1000 live births of both sexes . The incThe severity of hypospadias is graded upon the position of the urinary meatus and the extent of ventral penile angulation. Severity rises as the distance of the displaced urethral opening increases from the normal position at the tip of the glans and with increasing penile curvature. Hypospadias is classified into three grades, depending on the location of the meatus: first degree/mild , second degree/moderate (in the penile shaft) and third-degree/severe .The exact etiology of the disorder remains unknown. It seems that the origin of hypospadias is multifactorial; several risk factors have been identified such as genetic predisposition, placental insufficiency, and substances that interfere with natural hormones, endocrine disruptors –6.Up to 40% of hypospadiac fetuses have associated upper urinary tract anomalies. Cryptorchidism and inguinal hernias are the most common extragenital anomalies, which are found in 7–10% of all hypospadias cases [In 5–10% of cases there are extragenital malformations such as heart defects, cleft palate, neural tube defects, and anorectal malformations. It has also been described in the context of various syndromes, such as XXY, XXXXY, trisomies 13 and 18, Fraser syndrome, the Smith-Lemli-Opitz, Opitz-Frias Wolf-Hirschhorn, and (4p−) [Attention should be paid in detecting abnormalities in the external genitalia during second trimester ultrasound. Conventional sonographic criteria for the diagnosis of hypospadias are a small penis, with a blunted bulbous tip and two parallel echogenic lines at the top, representing the lateral folds of the foreskin. This was called by Meizner  the “tulHowever, in certain cases, especially when the testicles are undescended, it is difficult to distinguish between external female genitalia and severe hypospadias. So ambiguous genitalia would be included as main differential diagnosis, congenital adrenal hyperplasia being its primary cause. The sonographic findings of these virilized female fetuses are a clitoromegaly, which can mimic a penis, and enlarged adrenal glands bilaterally with discoid morphology . This diThe sonographic visualization of the fetal micturition is also important for its role in the diagnosis of hypospadias . In a noAlthough 2D ultrasound is still the gold standard for diagnosing fetal genital abnormalities, prenatal diagnosis using 3D has been reported previously , 12. A d3D ultrasounds are a very interesting tool for diagnosis and clinical evaluation in prenatal diagnosis of hypospadias.


A 36-year-old Hispanic female diagnosed with non-classical congenital adrenal hyperplasia and salt wasting disorder on chronic exogenous steroids presented to our emergency department with excruciating bilateral flank pain, 10/10 in intensity, associated with nausea, vomiting, and generalised weakness. On examination, the patient was in hypovolemic shock with BP of 65/45 mmHg, MAP 52 mmhg, and HR 110 b/min. She was resuscitated with intravenous fluids and intravenous corticosteroids. Physical examination was otherwise unremarkable. Haematology and serum chemistry were non-contributory. The patient had been on high dosages of narcotic analgesics due to persistent abdominal pain, which infrequently required hospitalisations. Current and serial contrast computed tomography scans over the past few years revealed progressive growth of the tumour  with conAdrenal myelolipomas are rare, benign, and biochemically inactive tumours often diagnosed inadvertently when radiological investigations are performed for other medical conditions. They were first described in 1905 by Gierke as a mass lesion of the adrenal gland comprising a mixture of adipocytes and haematopoietic cells . FemalesSmall tumours should be managed by annual radiological screening in an outpatient setting; large tumours of a size greater than 7 cm should be removed, as they carry a potential risk of malignancy and retropeitoneal haemorrhage due to spontaneous rupture . In our


Introduction. Single-step apexification procedures using mineral trioxide aggregate (MTA) have been reported as favorable treatment options for teeth with an open apex, posing greater benefits compared to the other available medicaments. However, controlled apical placement of MTA is a challenging procedure to perform using orthograde approach. This case series describes the outcome of the unintentional extrusion of MTA into periradicular tissues during apexification, in three separate cases. Methods. Three adult patients reported to the Department of Conservative Dentistry and Endodontics for the management of maxillary incisors with open apices. After isolation, conventional access, and cleaning and shaping procedures, one-step MTA apexification was performed. On subsequent radiographs, a considerable amount of MTA was seen to be extruded in all the three cases. Results. During follow-up examination the teeth were seen to be asymptomatic in all cases and radiographically demonstrated repair of the periapical lesion. Conclusion. The results of these cases suggest that extrusion of MTA into the periapical tissues does not cause any detrimental effect, which could be attributed to the biologic properties of MTA. The conventional school of thought regarding the clinical treatment of a traumatized or an infected immature vital tooth is preserving the vitality by apexogenesis or revascularization so as to allow complete root formation. However, such teeth with nonvital pulps require a hard-tissue apical barrier for the completion of the root filling , 2.Earlier, intracanal medicaments were used over several appointments to treat cases with open apices, with the hope of creating a barrier over which gutta-percha could eventually be placed. The treatment could be prolonged to a year, with little evidence of an apical barrier, resulting in thinner and brittle roots which are more susceptible to fracture .Mineral trioxide aggregate (MTA) has evolved as a material of choice for apexification owing to its properties of better biocompatibility, good sealability, ability to promote dental pulp, and periradicular tissue regeneration. Moreover, it can also harden in the presence of moisture . ApexifiHowever, MTA has been known to exhibit certain shortcomings, which include long setting time, the potential to discolour teeth, technique sensitivity, and high cost , 7. AlsoThe lack of normal apical constriction of the root canal in teeth with open apices complicates the procedures for apexification. The wide apical foramen requires a large volume of filling material that may extrude into the periradicular tissues. This produces undesirable tissue inflammation, neurotoxic effects, and foreign body reaction . OverfilThis case series describes the outcomes of unintentional extrusion of MTA into the periradicular tissues during apexification, in three separate cases.A 29-year-old female patient reported to the Department of Conservative Dentistry and Endodontics for endodontic retreatment of the right maxillary lateral incisor. The chief complaint was pain with tooth #12. She presented with a history of root canal treatment with the same tooth 2 years back. Medical history was not contributory. On clinical examination, the tooth was tender to percussion. A localized, erythematous swelling could be appreciated on the buccal mucosa surrounding the tooth. Radiographically, tooth #12 showed periapical rarefaction measuring approximately 2 mm (width) × 4 mm (height), with a resorbed apex . A diagnFollowing placement of the rubber dam, endodontic access cavity was modified and the gutta-percha was removed using xylene  and ProFile rotary instruments. The canal was instrumented with K-files up to size #50, irrigated with 5.25% NaOCl , and dressed with calcium hydroxide . The entire length of a size #40 Lentulo spiral  was coated with the paste, introduced into the canal to the working length, and then rotated at 500 rpm using a handpiece mounted on a speed and torque control machine . After ten days, the tenderness had disappeared, and no soft tissue swelling, erythema, or canal exudate were seen. The temporary restoration was then removed under rubber dam isolation and local anaesthesia, and the calcium hydroxide dressing was flushed out using alternating irrigation with 5.25% NaOCl and 17% EDTA  together with gentle filing with a size of 50 K file. Since no exudate was found on the blotted paper points test, a one-step apexification procedure with MTA was performed. MTA  was manipulated according to the manufacturer's instructions, carried to the apical 4 mm of the canal using an MTA carrier, and then condensed with measured endodontic pluggers under an operating dental microscope . Radiograph taken during the procedure displayed considerable extrusion of the MTA into the periradicular tissues . No atteAt the following appointment the cotton pellet was removed; the setting of MTA and other clinical signs and symptoms were verified. The remaining pulp space was backfilled with thermoplasticized gutta-percha  and AH Plus sealer  by using warm vertical condensation technique. The tooth was restored with a composite resin  and the patient was informed regarding the possible need for surgical intervention. On the 1-month recall visit, the patient reported no episodes of discomfort and/or swelling . PeriapiA 30-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with the complaint of pain associated with the left maxillary central incisor (tooth #21). She presented with a history of trauma to tooth #21, about 18–20 years ago. Tenderness on palpation was noted in the vestibule area. Radiographic examination revealed open apex of tooth #21 associated with a large periapical lesion of about 8 mm in diameter . The tooOne week later, the canal of tooth #21 was irrigated alternately with 5.25% NaOCl  and 17% EDTA  and dried with sterile paper points. A one-step MTA  apexification was performed as described in Case 1. Despite adequate precautions ensured during MTA placement, there was some extrusion of MTA  into theA 17-year-old male patient reported to the Department of Conservative Dentistry and Endodontics with aesthetic concerns resulting from the discolouration of the maxillary right central incisor. The medical history was noncontributory. The patient's history included a traumatic injury in that region 5-6 years back. Extraoral examination revealed normal soft tissue structures with no apparent pathosis. On intraoral examination, a sinus tract was located in association with the maxillary right anterior region. Evaluation of periapical radiographs showed a large radiolucent lesion with well-defined margins around the root of tooth #11 along with an open apex and root resorption . The tooAt the first visit, root canal treatment was initiated on tooth #11 under rubber dam isolation, and the access cavity was prepared. Necrotic pulp tissue was extirpated, and the working length was estimated as being 1 mm short of the radiographic apex. The drainage of pus was noted. The cleaning shaping procedures were performed as described earlier. A calcium hydroxide paste  was placed using a size #40 Lentulo spiral  to the working length and then rotated at 500 rpm using a handpiece mounted on a speed and torque control machine , as an intracanal medicament for one week. Sterile cotton pellets were placed into the access cavity before sealing it with temporary filling material . When the patient reported back after 1 week, the tooth was seen to be asymptomatic. The tooth was reopened, and calcium hydroxide paste was removed. The canals were irrigated alternately with 5.25% NaOCl  and 17% EDTA  with a final rinse with normal saline solution and dried with sterile paper points. MTA apexification was performed as described earlier, but unintentionally a considerable amount of MTA was seen to have extruded into the periapical region, when checked on periapical radiograph . A moistAt the one-month follow-up appointment , the tooThe low cytotoxic potential of MTA explains its wide range of applications in endodontics . It has For the present case series, undesirably so, during apexification procedure, an appreciable amount of MTA was extruded into the apical lesion. It may be contemplated that the wide apical foramen might have resulted in the dislodgement of MTA through it, or it might have been pushed actively beyond apical foramen as a result of condensation pressure during placement. The healing outcomes of these three cases were very similar and favorable as compared to the materials that contain paraformaldehyde, calcium hydroxide, and/or eugenol. The outcomes of these present cases mirrored the results from animal studies as well .In this case series, calcium hydroxide was used as an intracanal medicament before MTA placement to allow adequate disinfection of the root canal without the risk of compromised root strength. Researchers have proved that calcium hydroxide pastes do not significantly affect the sealability of MTA . In contThe studies on the effectiveness of intracanal placement techniques of calcium hydroxide state that the most effective delivery of calcium hydroxide was achieved when the paste carriers were introduced to working length . TherefoOn the other hand, the use of calcium hydroxide as an intracanal medicament prior to MTA apexification has been related to the extrusion of the MTA material . TherefoAlthough MTA is a nontoxic material, it should be restricted to the root canal space, and the condensation pressure is required to be considerably reduced in order to prevent MTA from being pushed beyond the apex . A resorIt was demonstrated in this case series that there were no undue complications when MTA was applied as a root canal filling and extruded into the periradicular lesion associated with necrotic pulps. The teeth were continuously asymptomatic for the entire duration after the MTA filling was extruded. There was no complete resorption of the filling material, although gradual periradicular healing and slight resorption of extruded material were observed. Osseous repair was also noted. Indeed, the absence of clinical and radiographic symptoms justified the initial nonsurgical approach.The clinical findings of the present cases imply evidence that MTA favors the apexification and periapical healing, even though a considerable amount of this material had unintentionally been extruded. The follow-up observations at 3- and 6-month intervals support the fact that the extruded material does not act as a hindrance for the healing of periapical tissues. The present case series also reinforces the importance of cautious placement of MTA apical plugs and does not recommend intentional overfilling of MTA into the periapical lesion in any clinical scenario. Revascularization procedures can be considered for such cases to obtain biological healing of the periradicular tissues, which would thereby eliminate the likelihood of material extrusion.


Restoration of the lateral ankle after distal fibulectomy is a difficult reconstructive procedure. Many surgical techniques have been proposed. This report shows another fibular reconstructive option with promising outcome.We report the case of a 30-year-old woman who presented with a solitary mass located in the lateral aspect of the ankle. The mass had grown rapidly for 2 months and caused increasing pain. Physical examination showed a 3.0 cm diameter tender, nonmobile hard mass in the lateral malleolus. Radiographs showed an osteolytic lesion involving the lateral cortex at the distal fibula. After incisional biopsy, pathologic examination found a well-differentiated intramedullary osteosarcoma. Neoadjuvant chemotherapy with doxorubicin was provided for 3 months prior to definitive surgical treatment. Magnetic resonance imaging showed persistent tumor in the biopsy site. After distal fibulectomy and wide resection, split tibialis posterior tendon transfer to the remaining peroneus brevis restored the stability of the ankle. The pain resolved within 3 months. The ankle was stable and no recurrence of the cancer was found at a 7 year follow-up.Reconstruction following distal fibulectomy and surrounding soft tissue resection responds favorably to split tibialis posterior transfer to the remaining peroneus brevis suggesting that this technique can provide a good and functional outcome.The online version of this article (10.1186/s13104-017-3097-4) contains supplementary material, which is available to authorized users. Osteosarcoma is the most common non-hematologic primary bone tumor. The peak incidence of 44.77% is in the second decade of life and the most common site is the knee region . OsteosaDistal fibulectomy, however, can lead to ankle joint instability and progressive valgus deformity . ReconstA 30-year-old Thai woman had had right ankle pain for 2 months and had a history of mild injury of the right ankle. Her ankle was swollen, especially on the lateral malleolus. Physical examination revealed a tender mass at the right lateral malleolus. Results of vascular, neurologic, and dermatologic examinations of the lower extremities were normal Fig. .Fig. 1PrRadiographs showed an eccentric osteolytic lesion in the distal fibula Fig. a. An incAfter chemotherapy, magnetic resonance imaging (MRI) was performed in order to evaluate the extension of disease and guide for definite tumor removal. The images revealed a 2.4 × 1.6 × 2 cm mass above the removed bone in the fibula, indicating a poor response to chemotherapy and persistent tumor. The tumor involved underneath the peroneus longus and brevis tendons  avoiding of scar tissue during tendon reconstruction (2) avoiding ankle and subtalar joint arthrofibrosis that may occur in late stage procedure. It is important for a step of balancing medial and lateral stability of the hindfoot. The excellent functional score results at the mid-term follow-up confirm that ankle ligament reconstruction following distal fibula resection is an alternative treatment for malignant bone tumors that require wide resection of the bone and surrounding soft tissue. However, longer-term follow-up and a larger number of case series are needed to confirm these results.In conclusion, the method of ankle ligament reconstruction after distal fibula and surrounding soft tissue resection described in this study is an option in cases where metal fixation or bone grafting are not required.Additional file 1. Care checklist.


A traumatic non-anastomotic pseudoaneurysm is a rare complication of an axillofemoral bypass graft. Fewer than 20 cases have been reported in the literature. Our case is unusual in that we report a double localization of this complication.We report the case of a 60-year-old Arabic male patient who was diagnosed with two hematomas in the trajectory of his axillofemoral bypass secondary to a traumatism. The diagnosis of a non-anastomotic pseudoaneurysm was retained considering the results of a computed tomography angiography scan, which showed the double localization of the pseudoaneurysm. Surgical management consisted of flattening the pseudoaneurysm along with the interposition of a prosthetic segment. There were no postoperative complications and our patient was well 3 years after discharge.Non-anastomotic pseudoaneurysm is a rarely described complication of a axillofemoral bypass graft. To the best of our knowledge, a double localization has not been described in the literature before. Minimally invasive techniques as a treatment option are being widely used as an alternative to open repair. In 1963 Blaisdell and Hall were the first to describe an axillofemoral bypass graft (AFBG); it has since become one of the commonly used surgical techniques. It is routinely used for lower extremity occlusive disease in selected situations. Its major indications are a hostile abdomen, multiple previous abdominal surgeries, a prohibitive risk from general anesthesia, and severely sick patients [The most commonly known complications of this technique are thrombosis and infection. Other complications, such as postoperative axillary anastomosis disruption, have also been reported. According to some retrospective studies, postoperative axillary anastomosis disruption can occur in 5% of the cases , especiaOur case report not only describes a traumatic PSA at the mid-shape of an AFBG but also adds to the literature an unusual case with a double localization.A 60-year-old Arabic male patient presented to our emergency department with pulsating masses in his right torso 5 days after a traumatism secondary to a cart accident. A review of his medical chart revealed that he had undergone an AFBG about 2 months earlier for lower limb revascularization. The indication for the AFBG was an occlusion in his primitive iliac artery, diagnosed by Doppler ultrasonography and computed tomography (CT) angiography. At that time, AFBG was chosen as the treatment of choice because of our patient’s low ventricular ejection fraction (35%) in addition to several comorbidities, including diabetes (type 2 diabetes mellitus treated with insulin) and high blood pressure (for which he was being treated), and his long history of tobacco use (active smoker for about 40 years). Revascularization was performed using an 8-mm, reinforced, thin-walled, fluorinated ethylene-propylene-ringed, expanded polytetrafluoroethylene (ePTFE) graft.2. Echocardiography showed a ventricular ejection fraction of 40%. Consequently, our patient underwent urgent operative repair. The surgical treatment involved flattening the PSAs and the interposition of a prosthetic segment (Figs. During the current admission, we found two masses along the side of the AFBG of about 6 cm and 4 cm each. On examination, these masses were painful and tender. The first mass was located at the level of the nipple line, while the second was located at the level of the umbilical line. The overlying skin was tense and blanched. Doppler ultrasonography demonstrated that his left femoral pulse and left distal extremity pulses were absent with monophasic flow. The strength and sensation in his left leg were intact. There were no signs of compartment syndrome. There was a left anterolateral midrib fracture deep to the hematoma. CT of his chest with intravenous contrast showed two non-anastomotic PSAs in the trajectory of the AFBG graft Fig. . His hemnt Figs. . On compAn AFBG is a routine surgical technique used to revascularize the lower limb. It can be done alone or in conjunction with a femoro-femoral bypass. One of the most interesting benefits of this technique is that it avoids aortic clamping and is associated with low rates of morbidity and mortality when compared with traditional aortobifemoral graft surgery. It also has the advantage that it does not necessarily require general anesthesia . AFBG isDespite its benefits, authors have reported lower patency rates for AFBG, estimated to be around 35–71% at 5 years . This peet al. in 1992 [et al. [ et al. [Non-anastomotic PSA is an extremely rare complication. We found few cases reported in our literature review, and none reported more than one localization, which makes our report unusual. The first case of post-traumatic non-anastomotic PSA was described by Buche  in 1992 ; they re [et al.  and Krug[ et al.  each des[ et al. , 17, 18.Ultrasonography is considered a reliable tool to diagnose non-anastomotic PSA; however, its main flaw is that it is an operator-dependent procedure . CT angiet al. were the first to describe this technique in 2008 [With regards the treatment and management of this complication, surgical open repair has had excellent outcomes in the first reported cases of non-anastomotic PSA –15, and  in 2008 . Since t in 2008 . The mos in 2008 . In our Routine follow-up of these grafts after placement is recommended by most authors, even after a successful repair. Our patient is still attending follow-up appointments.A non-anastomotic PSA is a rarely described complication of AFBG; traumatism is the most common etiology. With the advent of new imaging methods, diagnosis of PSA has become easier. Surgery is the standard of care for this entity; however, minimally invasive techniques are being widely used as an alternative to open repair.