Metastasis to the internal auditory canal from breast carcinoma is extremely rare and difficult to diagnose. It radiologically mimics vestibular schwannoma and can occur as a first manifestation of systemic relapse after a long disease-free interval in patients previously treated for early breast cancer. The diagnosis is usually made retrospectively and the optimal management of such metastasis following complete resection remains undefined. The most common lesion within the internal auditory canal is vestibular schwannoma accounting for approximately 90% of all cases in this area. Metastatic tumours are extremely rare. Here we report just such a case, radiologically mimicking a schwannoma and representing the first clinical recurrence of breast carcinoma after a 13-year interval, in order to raise awareness and highlight the difficulties in pre-operative diagnosis.A 66-year-old woman presented with rapidly deteriorating left-sided hearing loss, vertigo and mild intermittent dull ache in her left ear of 2 months' duration, followed by a left-sided lower motor neurone facial nerve weakness. She recalled 2 or 3 similar episodes of vertigo 2 years previously that resolved spontaneously. Thirteen years before, she had been diagnosed with invasive lobular adenocarcinoma of her right breast, treated by simple mastectomy and 5 years of adjuvant tamoxifen. 2 years later, she underwent prophylactic contralateral mastectomy. Regular follow-up had shown no evidence of disease recurrence. On present admission, physical examination revealed absent left corneal reflex and ipsilateral lower motor neurone facial nerve dysfunction (House Brackmann grade 6). The Unterberger's stepping test was to the left, Romberg was unsteady and Hitzelberger sign was positive. Pure tone audiometry showed left-sided high frequency sensorineural hearing loss. MRI revealed a 1.1 × 0.3 cm intracanalicular mass within the left internal auditory canal which enhanced with gadolinum, consistent with a schwannoma (Figure It did not extend into the cerebellopontine cistern and the cerebellopontine angle appeared normal. The lesion was excised via a translabyrinthine approach. Intra-operatively, it resembled a vestibular schwannoma, albeit unusually vascular. Temporal bone and adjacent structures were uninvolved. Histology showed, rather than schwannoma, a metastatic adenocarcinoma infiltrating the nerve sheath that had suffered extensive axonal loss Figure . No schwThe vast majority of lesions within the internal auditory canal are benign tumors, of which vestibular schwannomas account for approximately 90%. Vestibular schwannomas are benign slow growing tumors and tinnitus is the most common initial symptom. Other common symptoms include vertigo and progressive unilateral hearing loss. Facial nerve palsy is considered a late manifestation. Metastases to the normal internal auditory canal are extremely rare. Only very few cases have ever been reported. Two of these were from breast ,2. MarquEven though our MRI findings were consistent with a vestibular schwannoma, the clinical history of rapidly deteriorating sensorineural hearing loss, notably unaccompanied by tinnitus, rapidly succeeded by severe facial nerve palsy might have raised suspicion of an alternative diagnosis. Severe, unremitting pain localized to the mastoid and retromastoid areas has been noted to be a characteristic sign of metastasis to the internal auditory canal .Pre-operative diagnosis of such metastasis is often difficult as there are no distinctive features on MR imaging that will help to differentiate them from the more common benign lesions. The majority of schwannomas are homogeneous, isointense in signal compared to gray matter on both T1- and T2-weighted images and enhances strongly following gadolinum. Bilateral metastases have been known to mimic neurofibromatosis type 2 .Thus, the diagnosis of internal auditory canal metastasis is usually made retrospectively following surgical removal of the tumor. Immunohistochemistry is useful in identifying the tissue of origin as such metastasis can be the first sign of an undiagnosed malignancy ,5 as welThe optimal management of such metastases from a breast primary following complete resection is hard to define. In the 2 similar previous cases reported in the literature, where isolated metastasis to both the internal auditory canal and the cerebellopontine angle occurred 16 and 5 years following initial treatment for breast cancer respectively, surgical resection was noted to be complete and both went on to receive post-operative radiotherapy remaining in remission with follow-up of 3 and 18 months respectively [In conclusion, although internal auditory canal metastases are extremely rare, it should form part of the differential diagnosis when patients present with rapidly progressive and painful deficits of the seventh and eighth cranial nerves. Difficulties will still remain in distinguishing between a metastasis and a benign tumor once MR imaging reveals the presence of a lesion in the internal auditory canal.The authors declare that they have no competing interests.SWL, AD and PM were involved in the preparation of the manuscript. SWL performed the literature search. AD carried out the histological analysis and provided the histological slides. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Adrenal cysts are rare clinical entities that can present as acute abdomen through rupture and internal hemorrhage as well as chronic symptoms such as gastrointestinal disturbances. A 20-year-old girl presented to our hospital with a 4-years history of abdominal pain and diarrhea. Ultrasound of the abdomen revealed a cystic area measuring 10 × 10 cm between the spleen and left kidney. Computed tomography scan showed a large cystic, homogeneous mass measuring 12.8 × 9.5 × 9.4 cm in the left hypochondrium with most likely origin from the left adrenal gland. Limited work up for hormone hypersecretion was negative. The patient was then encountered in the emergency room with an acute abdomen secondary to intracystic hemorrhage. A laparotomy with left adrenalectomy was performed. Final pathology showed a benign adrenal endothelial cyst. Post-operatively, the patient's long standing complaints of diarrhea and abdominal pain completely resolved. Surgical resection appears a safe and reasonable management strategy in a patient with intracystic hemorrhage of adrenal cyst. Adrenal cysts are rarely encountered clinical entities. Their incidence has been reported from 0.06%-0.18% in autopsy series . HoweverWe report here the case of a 20-years-old girl who presented to our institution with acute and chronic morbidity resulting from a giant non-functioning left adrenal cyst. She was managed with surgical intervention. We have also reviewed the indications for surgical intervention in a patient with an adrenal cyst.A 20-year-old Pakistani girl from Karachi presented to our hospital with a 4-years history of abdominal pain and diarrhea. She had been having up to 10 episodes of loose stools per day associated with abdominal heaviness and tenesmus. In view of her chronic symptoms, she had been empirically prescribed anti-tuberculous therapy in the past due to suspicion of abdominal tuberculosis. Her physical examination was unremarkable.Helicobacter pylori associated gastritis. Ultrasound of the abdomen revealed a cystic area measuring 10 cm × 10 cm between the spleen and left kidney.Laboratory investigations showed an increased erythrocyte sedimentation rate  while lipase, amylase, liver function tests, electrolytes and a stool detailed report (DR) were all within normal range. In view of her normal laboratory parameters, she next underwent an upper gastrointestinal endoscopy and a colonoscopy to further evaluate her chronic diarrhea. Patchy erythema in the ascending and transverse colon along with mild antral erythema in the stomach were noted. Biopsy of different parts of the digestive tract revealed chronic non-specific inflammation in the duodenum, ileum, ascending and descending colon with mild chronic Computed tomography (CT) scan showed a large cystic, homogeneous mass in the left hypochondrium with most likely origin from the left adrenal gland Figure . The masWhile the work up was in progress, the patient was encountered in the emergency room of the hospital with one day history of excruciating abdominal pain. On examination, she had an acute abdomen which was exquisitely tender in the left upper quadrant with a vaguely palpable mass in the umbilical area. Surgical intervention was planned in view of the quickly decreasing hematocrit. Multiple blood transfusions were given and a CT scan was emergently performed which revealed a left adrenal gland cyst with internal hemorrhage Figure . ModeratAfter stabilization, the patient was taken to the operation theatre where a laparotomy with left adrenalectomy was undertaken. Histopathological examination of the specimen showed cystic tissue with no definite lining and fibro-collagenous wall exhibiting areas of hemorrhage and congestion. Immunohistochemical staining for CD31 was positive; confirming the diagnosis of a benign adrenal endothelial cyst.The post-operative hospital course of the patient was unremarkable and she was discharged after a week. She has been maintaining regular follow-ups in the clinic and her long standing complaints of diarrhea and abdominal pain have completely resolved.Adrenal cysts are generally rare and around 600 cases of adrenal cysts have been reported so far ,4. ApproAdrenal cysts may be categorized as any of the four major types including pseudocysts (39%), epithelial (9%), parasitic  or endothelial cysts 45%) ,5 Endoth% ,5 EndoAdrenal cysts larger than 10 cm are rare ,7. GiantThe management of the patient with an adrenal cyst includes the battery of history taking, physical examination complemented by appropriate laboratory investigations to rule out a functioning lesion. CT scan and aspiration of the cyst may be performed for better characterization of the lesion .Most of the adrenal cysts are asymptomatic and encountered as "incidentalomas" . AdrenalIntervention in the form of excision or aspiration for an adrenal cyst is indicated if the cysts are symptomatic, rapidly expanding, producing endocrine abnormalities, hemorrhagic, when malignancy can not be ruled out unequivocally or if their size exceeds 5 cm ,10. Our In summary, follow-up of patients with asymptomatic adrenal cysts is needed to document the incidence of conversion of the cyst to a symptomatic form and occurrence of hemorrhage in such cysts. The documentation of such risks will help in providing an evidence based justification for surgical intervention in the management of asymptomatic adrenal cysts. Acute complications arising in benign adrenal cysts can be safely managed by surgical excision.Written, informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the consent form is available for review by the Editor-in-Chief of the journal.The authors declare that they have no competing interests.SA and TS collected the data, helped in its interpretation and drafted the manuscript. MRK conceived the study, helped in the interpretation of the data, drafted the manuscript and provided overall supervision in the project.


T-cell prolymphocytic leukaemia is a rare condition that constitutes around 2% of cases of small lymphocytic leukaemia in adults. It follows an aggressive clinical course with a poor prognosis.We report a 55-year-old male who was diagnosed with T-cell prolymphocytic leukaemia following investigations for microscopic haematuria. Splenomegaly was identified on a plain abdominal radiograph and intravenous urography, thus triggering further investigations and diagnosis.Our case-report serves to remind us of the need to bear in mind other possible pathologies outwith our own area of expertise when interpreting results of any kind. This is perhaps increasingly important in the current era of increasing sub-specialisation throughout medicine. T-cell prolymphocytic leukemia (T-PLL) is a mature post-thymic T-cell malignancy with distinct clinical and laboratory features. T-PLL is a rare condition that constitutes around 2% of cases of small lymphocytic leukaemia in adults. It follows an aggressive clinical course with a poor prognosis. Median age is 65 years and it affects men slightly more often than women . Main diA 55-year-old Caucasian male smoker with a history of industrial exposure to urothelial carcinogens was referred for assessment of microscopic haematuria and lower urinary tract symptoms. The patient admitted to feeling increasingly tired for over 6 months and had shingles in the distribution of the maxillary division of the right trigeminal nerve. Abdominal examination revealed fullness in the left hypochondrium and the left lumbar region.Flexible cystoscopy revealed normal bladder urothelium. A control film of the intravenous urogram failed to demonstrate any areas of abnormal calcification but revealed a soft tissue shadowing in the left hypochondrium extending down to the left iliac crest. Subsequent contrast films of the IVU demonstrated bilateral prompt nephrograms with normal sized renal outlines and normal pelvicalyceal filling bilaterally. The left renal pelvis was, however, pushed medially and the pelvicalyceal system compressed by an extrinsic mass which was thought to represent an enlarged spleen. A renal ultrasound scan performed as part of investigations for microscopic haematuria, revealed normal anatomy and architecture of the kidneys, but no comment was made regarding any other intra-abdominal organs.9/L) with a predominance of lymphocytes, macrocytic anaemia  and thrombocytopenia (Platelet Count 39 × 109/L). Spherocytes, smear cells and red cells with polychromasia were identified on peripheral smear. A diagnosis of T-cell prolymphocytic leukaemia was established following confirmation on bone marrow aspirate. He was treated with a 12 week course of CAMPATH chemotherapy.Full blood count demonstrated leucocytosis  at some stage during their illness . HoweverThere is no known association between haematuria or lower urinary tract symptoms and T-PLL. It is, however, crucial to analyse and interpret the available information in its entirety. Our case-report serves to remind us of the need to bear in mind other possible pathologies outwith our own area of expertise when interpreting results of any kind. This is perhaps increasingly important in the current era of increasing sub-specialisation throughout medicine.IVU: intravenous urography; KUB: plain abdominal radiograph; MCV: mean corpuscular volume; T-PLL: T-cell prolymphocytic leukaemia; WBC: white cell count.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.IP investigated the patient for microscopic haematuria, identified the soft tissue shadow on plain radiograph and IVU and organised for haematological referral. GL organised for further investigations, established the diagnosis of T-PLL and commenced the patient on appropriate chemotherapy. SP was a major contributor in preparing the manuscript and obtained patient consent. All authors read and approved the final manuscript.


Very little data about the conservative treatment of early stage glassy cell cervical cancer have been reported.A 30-year old patient, nulligravida was admitted to the Gynecologic Oncology Unit of the Catholic University of Campobasso for irregular post-coital vaginal bleeding. The patients was staged as having FIGO stage IB1 (tumor diameter = 2 cm) squamous cervical cancer. After extensive counseling of the patient and her family, laparoscopic pelvic lymphadenectomy and cold knife conization were performed. The final diagnosis was FIGO Stage IB1 glassy cell carcinoma. Currently, after a follow-up of 38 months, she has no evidence of disease.We reported a case of early stage glassy cell cancer patient, who was conservatively treated by conization and laparoscopic pelvic lymphadenectomy. Over the past decade, the treatment of cervical cancer has evolved registering a gradual abandonment of radical surgery in favor of more conservative approaches: this becomes even more relevant considering that approximately 15% of all cervical cancers, and 45% of surgically treated stage IB cervical cancers occur in women < 40 years of age  has gainper se seems not to be a relevant factor [Among the strict criteria employed in the selection of cases who can potentially be offered uterus preserving approaches, tumor histology t factor , with tht factor ,6, and ct factor ,8. In pat factor  in the ut factor , endowedt factor .To our knowledge, only three cases of glassy cell carcinomas undergoing conservative treatment by laparoscopic pelvic lymphadenectomy and radical vaginal trachelectomy have been reported .Here, we report the case of a stage IB1 cervical glassy cell carcinoma patient, who was safely treated with cold knife conization plus laparoscopic pelvic lymphadenectomy.A 30-year old patient, nulligravida was admitted in March 2005, to the Gynecologic Oncology Unit of the Catholic University of Campobasso, for irregular post-coital vaginal bleeding. Her medical history was unremarkable. Her gynecological history was negative with menarche at the age of 12 years, and regular menses until 6 months before the occurrence of the symptoms.Gynaecological examination revealed a normal size uterus, and no adnexal masses. A circumscribed, ulcerated lesion (maximum diameter = 2 cm) was documented in the posterior esocervix. Parametria and vagina appeared uninvolved. Colposcopy-guided biopsy and curettage of endocervical canal were performed revealing an invasive squamous cell cervical carcinoma with areas of poor differentiation. Transabdominal and transvaginal ultrasound examination documented the presence of a normal size uterus showing normal echogenicity with the exception of a vascularized hypoechogenic area (18 × 14 × 11 mm) located in the cervix.Staging evaluation including chest X-ray, total body CT scan, and pelvic magnetic resonance imaging (MRI) documented the presence of a tumor mass (maximum diameter = 2 cm) located in the uterine cervix, and no enlarged lymph nodes. Examination under anesthesia revealed an ulcerated lesion of maximum diameter of 2 cm, without vaginal and parametrial involvement. Squamous cell carcinoma antigen levels were negative. The patient was staged as having FIGO stage IB1 cervical cancer.After extensive counseling of the patient and her family, she opted for a conservative approach. Open laparoscopy was carried out: peritoneal washing and a careful inspection of the adnexae and intra abdominal organs was performed. Systematic pelvic lymphadenectomy was performed up to internal iliac lymph nodes, and they returned as negative at frozen section examination. Several biopsies of the vaginal walls were obtained; these were negative for disease on frozen section. A cold knife conization was performed, and frozen section analysis showed that the lateral and deep margins of the tissue specimen were uninvolved. The biopsy of the endocervical canal also resulted negative at frozen section.At definitive pathological examination, a nodular lesion of maximum diameter of 2.0 cm (width extension) located in the cone , was detected. Microscopic examination revealed a tumor composed of nests of large cells with large eosinophilic cytoplasm presenting a ground-glass appearance Figure . Cell meCervical stenosis was documented after 21 months since surgery, and was easily managed by cannulation of the cervical canal under anesthesia.per se should not be considered a contraindication to conservative treatment, some concerns have been raised for rare histological types such as adenosquamous, neuroendocrine or glassy cell carcinomas. In particular, conservatively treated neuroendocrine and adenosquamous tumors have been reported to carry out a very unfavorable prognosis [We report a case of early stage glassy cell cancer in a patient, who was conservatively treated by conization and laparoscopic pelvic lymphadenectomy. Indeed, among the fertility preservation approaches to early stage cervical carcinoma, RVT has gained much attention because of the recognized oncologic efficacy and safety. Intra- and postoperative complications have been reported to be approximately 4% and 12% of cases, respectively , and everognosis ,6. On thrognosis . No caseDespite the extensive counseling about the possibility to perform trachelectomy or adjuvant treatment after final diagnosis, our patient decided only to undergo strict follow-up procedures, and is currently without evidence of disease after 38 months since initial diagnosis.We report a case of an early stage glassy cell cervical carcinoma patient, who was successfully treated with conization and laparoscopic pelvic lymphadenectomy. Given the rarity of this tumor histological type, and the paucity of data about its natural history, which has been reported to be similar to other histological types only with the employment of multimodal treatment strategies , cautionThe authors declare that they have no competing interests.GF conceived of the study, participated in its design and drafting. VS participated in the design of the study and collected the clinical data. MP participated in the design of the study and collected the clinical data. AC carried out the histopathological evaluation. GS conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Spontaneous rupture of uterus in unscarred uterus prior to onset of labor in third trimester is extremely rare and to our knowledge, very few cases have been reported so far.A 26-year-old third gravida women with 32 weeks pregnancy presented with pre-labor rupture uterus with extrusion of intact amniotic sac from the rent in uterine fundus.Rupture uterus can present in third trimester even before labor and should be kept in differential diagnosis of pregnancy with abdominal pain of any degree with fetal demise. Spontaneous rupture of uterus has been reported many times in pregnant women mainly during labor, due to external injuries and in scarred uterus. However, spontaneous rupture in unscarred uterus prior to onset of labor in third trimester is extremely rare -3.A 26-year-old pregnant women of Asian Indian origin was referred to the obstetric casualty by the general practitioner with a provisional diagnosis of placental abruption in view of abdominal pain, pallor and inability to find fetal heart. The women had insidious onset of pain for 12 hrs, and with reduced fetal movements for the same duration. The woman was third gravida with 32 weeks gestation, with previous two normal deliveries and an uneventful antenatal period. Her dating and anomaly scan were normal. There was also no history of trauma, any diagnostic or therapeutic intrauterine intervention, vaginal bleeding or labor pains. She had no significant past medical, surgical history or gynecological history.On examination, she was pale with respiratory rate of 28 per minute, pulse rate of 110 per minute and blood pressure of 90/60 mmHg. On abdominal examination, uterus measured 30 weeks, with mild abdominal tenderness and no increased tone. The uterine wall felt thin but with regular outline and no fetal part was palpable. Fetal heart could not be localized. Speculum examination showed no vaginal bleeding and there was marked tenderness on internal examination and cervix was uneffaced and os admitted tip of finger.Ultrasound scan revealed fetal demise. An intact amniotic sac with fetus and normal volume of amniotic fluid, without any echogenecity to suggest blood, was seen lying outside the uterus. Uterus was deviated towards left iliac fossa. Diagnosis of rupture uterus with fetal demise was made and the woman was prepared for laparotomy. Blood investigations revealed hemoglobin of 7.7 gm% with no evidence of coagulopathy.After resuscitation with intravenous fluids, the patient was taken for surgery. Emergency exploratory laparotomy was done with consent for hysterectomy or uterine repair with tubal sterilization under intravenous antibiotic cover. An intact amniotic sac with fetus was found along with 1.5 liter of haemoperitoneum. Membranes were ruptured and male stillborn fetus (weight 2.2 kilograms) was delivered with breech extraction. The amniotic fluid was clear, and placenta was lying outside the uterus and appeared complete and normal. There was a 3 inch tear on the right side of the uterine fundus, 2 cm anterior to the cornua. The myometrium adjacent to this was relatively thin. There was no evidence of couvelier uterus. The tear was repaired by suturing the uterus in double layer. Bilateral tubal ligation was done. She received one unit of blood during intra-operative and three during the postoperative period. Her postoperative period was uneventful and was discharged after eight days.Rupture of unscarred uterus is a rare event involving 1:16,000 deliveries . The proTo our knowledge, this is the fourth reported case of pre-labor silent rupture uterus in third trimester in an unscarred uterus. In one of the reported cases, rupture uterus was found behind the cornual structures and was diagnosed on laparotomy done for deteriorating maternal condition after vaginal delivery of the stillborn baby by forceps . The secApart from pre-labor uterine rupture in an unscarred uterus, this case had a subacute onset. The fetus along with the amniotic sac had silently extruded through the rent in uterus making the diagnosis of rupture uterus difficult clinically, as uterine contour was falsely preserved due to intact amniotic sac. There was no placenta accreta, couvelaire uterus, any signs of placental abruption or history of connective tissue disorder like Ehler Danlos syndrome . It thusThis case re-emphasizes that rupture uterus can present in many different ways and high suspicion is required for timely intervention to prevent maternal morbidity and mortality.


Solid and cystic tumor (SCT) of the pancreas predominantly Occurs in women, and the occurrence in men is extremely rare. We experienced a male case of SCT. A 38-year-old man was admitted with the complaint of upper abdominal pain. CT scan showed the presence of a mass in the head of the pancreas. The mass was composed of high density areas and low density areas. Ultrasonograms revealed the mass being composed of high echoic areas and low echoic areas. The mass .was hypovascular on angiography. SCT was suspected and pancreaticoduodenectomy was performed. The cut surface of the tumor showed mainly cystic degenerative areas containing dark red hemorrhagic materials. Microscopically, there were solid areas in the periphery and pseudopapillary areas in the center. No metastasis was found in the removed lymph nodes. The tumor cells were not stained by Grimelius' silver stain. The tumor cells were positive for alpha-l-antitrypsin (AAT) and neuron-specific enolase (NSE). Pancreatic hormones such as insulin, glucagon, and somatostatin were all negative. Electron micrograph showed that tumor cells were rich in mitochondria. Zymogen granules and neurosecretory granules were not detected. Estrogen receptor (ER) and progesterone receptor (PR) were both negative.


Iatrogenic fornix rupture caused during retrograde manipulation of the ureter is a rather rare or rarely diagnosed phenomenon. A 22 year-old female patient presented with a fornix rupture following endoscopic ureteral stone extraction under uretero-renoscopy, the rupture having become symptomatic two days later. The fornix rupture, a special form of the obstructive nephropathy, presents a rather rare and/or rarely diagnosed phenomenon. We report of a 22 year old female patient who was transfered to us after suspicion of a fornix rupture two days after receiving ureterorenoscopic extraction of an ureteral stone.An ureterorenoscopy with extraction of an ureteral stone was performed on a 22 year old female patient after two unsuccessful attempts of extracorporeal shock wave lithotripsy. Dilatation of the upper urinary tract as well as peri- or intrarenal urinary extravasation did not exist before endoscopic stone removal.On the postoperative abdominal plain radiograph a perirenal sickle-shaped contrast medium paravasation was shown Fig. . During On the second postoperative day the patient developed progredient symptoms with flankpain spraying into the right upper and lower abdomen. Therefore she was transfered to our clinic for further diagnostics and therapy.Escherichia coli was detected in the urine culture. In the abdominal CT scan the previously sonographically diagnosed paravasation was found without signs of abscess formation (Fig. An urinary tract infection with ion Fig. . A conseEvery supravesical obstruction might be a possible reason for developing a fornix rupture. The most common causes are obstruent ureter stones. 2–3% of all colics caused by stones are supposed to be followed by a fornix rupture . The secThe iatrogenic caused fornix rupture through retrograde ureter manipulation is a rather rare or rarely diagnosed phenomenon, because after disobstruction of the upper urinary tract the rupture remains mostly asymptomatic. The urinary extravasation will be reabsorbed through the lymphatic system in the perirenal fat .Requirement for a mild process, which justifies a conservative treatment, is the sterility of the urine. On the other hand, if the urine is infected, the risk of febrile to septic pyelonephritis with perirenal formation of an abscess increases dramatically. Approximately 10% of all perirenal abscesses are caused by urinay extravasation due to fornix ruptures . In thesRegular postoperative sonographic controls are absolutely necessary to diagnose an urinary extravasation in time to induce an appropriate therapy, especially if additive febrile symptomatic has become evident. Even in the case of a non-dilated upper urinary tract with a correct placement of the ureterstent after endoscopic uretermanipulation, this approach is recommended as well.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The author declares that they have no competing interests.AB analyzed and interpreted the patient data, and was the major contributor in writing the manuscript. He approved the final manuscript.


Skeletal muscle metastases from tumors are a rare occurrence and can present difficult management decisions. We report here on a patient that had been previously treated for squamous cell laryngeal cancer with surgical resection and adjuvant systemic chemotherapy that presented with a metastasis to the rectus abdominis muscle without evidence of recurrent disease at the primary site. After a metastatic workup with PET/CT scan suggested this to be an isolated lesion, surgical excision with negative margins was performed based upon limited treatment options secondary to the location of the tumor and his favorable prognosis suggested by his pathological staging at the time of the initial resection. Here we discuss the incidence of distant metastases from laryngeal cancer and appropriate screening methods. Additionally, skeletal muscle metastases and treatment considerations are discussed. Skeletal muscle metastases from cancer occur rarely and there are no clear guidelines for appropriate work-up and management of these lesions. Specifically, soft muscle metastases to the abdominal region provide exceptionally difficult treatment decisions based on location. While these can occur following percutaneous or surgical procedures in patients with head and neck cancers, it is extremely rare that one should occur in a patient without a history of any such procedures. Soft tissue metastases to muscle and skin generally represent undiscovered disease elsewhere and an overall poor prognosis. The case presented here occurred in a patient that had been successfully treated and had no signs of other recurrence on clinical exam or imaging studies. Therefore, this case presented a rare and difficult treatment strategy.A 52-year-old male with a history of laryngeal cancer was found on routine physical examination to have a 2 cm subcutaneous nodule in the left mid-abdomen approximately 2 cm superior and 4 cm lateral to the umbilicus. The mass was non-mobile and slightly tender to palpation. There was no erythema, induration, or cutaneous changes. The lesion had been asymptomatic and the patient had not been aware of this finding. Computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast was performed, with the only pertinent finding being the mass localized within left rectus abdominis muscle Figure . This raThe patient's history was significant for a squamous cell carcinoma of the larynx, treated operatively seven months prior to this presentation with a total laryngectomy and bilateral selective neck dissections of levels 2 through 4. The patient had also received adjuvant chemotherapy and local radiation. Pathology revealed a moderately to poorly differentiated squamous cell cancer of the larynx, pathologic stage T3N2bMx, with involvement of 2 out of 60 lymph nodes in the surgical specimen. The patient had been followed regularly by his primary care physician, otolaryngologist, and medical oncologist with no evidence of a local recurrence until the point of presentation. Of note, the patient did not have a history of a trans-abdominal feeding tube or any instrumentation of his abdominal wall.Based upon the patient's above history, physical examination and CT scan appearance of the mass a fine needle biopsy was performed that revealed a moderately differentiated squamous cell carcinoma. Restaging of the patient's cancer was done by positron emission tomography/computed tomography (PET/CT) scan, which demonstrated significant fluorodeoxyglucose (FDG) uptake to the left rectus muscle with no evidence of focal uptake in the neck or elsewhere Figure . On CT, Given the finding of the isolated metastasis and the location of the mass, which limited the option of radiation treatment secondary to the high risk of radiation induced enteritis, the decision was made to proceed with surgical excision. Complete surgical excision of the lesion with minimal loss of fascia allowing for primary closure. The tumor at pathology was a 4.5 × 3.5 × 2.5 cm metastatic intramuscular squamous cell carcinoma. Histology from the original bilateral neck dissection Figure  was reviLaryngeal cancer is the second most common type of head and neck malignancy, accounting for 25-45% of all head and neck tumors ,2. SquamMost commonly abdominal wall metastases for head and neck cancers, including laryngeal, occur after percutaneous, laparoscopic, or incisional procedures. Metastatic disease at the site of a percutaneous endoscopic gastrostomy (PEG) tube placement is known to occur with many different types of head and neck cancers -6, most Distant metastases from head and neck cancer occur in 11-26% of patients ,11, thouWhereas squamous cell carcinoma of the larynx has similar metastatic patterns to head and neck cancer in general, the incidence of metastases may be slightly lower . Few repScreening for distant metastases in head and neck cancers, and laryngeal cancer more specifically, is currently not well established. According to one study, a CT scan of the thorax is the single most important study that can be done . There aThe treatment options for distant soft tissue metastases from all cancers are highly individualized as there is little published data. Perhaps the largest study published regarding distant soft tissue metastases included 30 new patients and a review of 91 case reports . This stThis paper describes a case of a laryngeal cancer metastatic to the rectus muscle following appropriate treatment for the primary tumor. There are few described cases of distant soft tissue metastases in the literature, and therefore no evidence based guidelines exists for these occurrences. Whereas soft tissue metastases for all cancers are generally a sign of widespread disease and therefore a poor prognostic indicator, we used PET/CT to define this as an isolated lesion. The patient underwent surgical excision of the lesion with negative margins. At this point, given the low incidence of isolated soft tissue metastasis in the literature, we recommend complete whole body physical examination as an adjunct to routine follow up for head and neck cancers; however, we advocate the use of PET/CT scanning if evidence of metastatic disease is found. Treatment options need to be individualized based upon the adequacy of the initial treatment regimen, disease free interval, location of the metastasis, and the patient's cardiopulmonary risk and performance status.PET/CT: Positron emission tomography/computed tomography; FDG: Fluorodeoxyglucose; PEG: Percutaneous endoscopic gastrostomy; MRI: Magnetic resonance imaging.The authors declare that they have no competing interests.RK - Manuscript design, collection of data and figures, literature review, drafting of manuscript, critical revision. BZ - Conception and manuscript design, critical revision, administrative support and supervision. AT - Conception and manuscript design, critical revision, administrative support and supervision, final approval. All authors have read and approved the final manuscriptThe authors of this report attempted to contact the patient or next of kin and were unable to contact the patient at the current contact information. He is no longer followed by the surgical clinic. Therefore, consent was unable to be obtained.


Ultrasound (US), Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are widely used in the clinical diagnosis of parotid gland tumors and their efficacy in identifying benign lesions is well documented. However, problems arise when facing some malignant lesions. Only few cases of salivary gland low grade malignant tumors have been previously reported in the literature complete with the radiological features.We here describe a case of epithelial-myoepithelial carcinoma (EMC) of the parotid gland, a low grade malignant tumor, with spread to an intraparotid lymph node and with CT and MRI findings mimicking a benign lesion.All the images revealed sharply outlined profiles and a homogeneous enhancement of the nodule, suggesting a benign tumor and demonstrating that a radiological evaluation of the lesion alone may be unsatisfactory and misleading in the diagnosis of salivary gland tumours, especially in the case of low grade malignant tumors, such as EMC. Nowadays different imaging techniques offer optimal visualization of the parenchyma and of the tumors of the parotid gland. Ultrasound (US) imaging is the first-line technique in the radiological study of parotid lesions because it is an easy, quick, repeatable and non-invasive procedure. Moreover, since the parotid gland is superficial and easily accessible to the ultrasound transducer (even up to 12 MHz [Contrast-enhanced computed tomography (CT) is the second choice radiological approach: it allows both assessment of the lesion and adequate exploration of the deeper gland parenchyma and offers highly defined spatial resolution along with a panoramic overview of the entire head-neck region.Magnetic Resonance Imaging (MRI) is mandatory, representing a valid alternative to CT or a complementary approach to better assess the lesion. Compared to CT, MRI offers a much higher contrast resolution, but it is inadequate to evaluate the presence of calcifications.CT and MRI can usually assume the benignancy or malignancy of a focal lesion based on simple elements of radiological findings. Benign lesions are usually small in size, well circumscribed, and have a regular morphology, as in the case of pleomorphic adenoma and Warthin's tumour. The characteristic radiological features of these lesions are represented by well defined margins, the presence of a capsule, and by bright signal intensity on T2-weighted MR images. Intralesional calcifications, easily detected by US and CT, are another element of benignancy.Malignant tumors are usually medium to large in size (over 3 cm in diameter), present undefined margins and a typical heterogeneous echo pattern because of the frequent presence of necrotic areas. MRI can show multiple round high signal intensity areas on T2WI or a large very high signal intensity area on T1WI.Epithelial-myoepithelial carcinoma (EMC) is extremely rare compared to other carcinomas, and is considered a low malignancy neoplasm.In the present report we describe a case of this unusual parotid gland neoplasia, radiologically simulating a benign lesion.In December 2005, an 81-year-old woman came to the attention of the othorinolaryngology surgeon complaining of a painless, nodular, firm mass of the left parotid gland arisen a few months before. The patient underwent a fine needle aspiration cytology (FNAC) and 3 samples were sent to Department of Pathology. Although the CT scans suggested a benign lesion, the finding of atypical cells indicated a malignant tumor. Thus, the patient underwent a total parotidectomy with a complete excision of the lesion.Axial contrast-enhanced CT scan Fig.  showed aAll the images revealed sharply outlined profiles, suggesting a benign lesion.Grossly, the parotid gland contained a well circumscribed gray-white nodule, partially plurinodular in structure, firm on the cut surface and 2.2 cm in diameter.Histologically, the tumor was characterized by a biphasic cell population represented by myoepithelial and ductal cells. The myoepithelial cells were large, polygonal, with clear-staining cytoplasm and irregularly shaped nuclei. The ductal elements were composed of cuboidal cells with eosinophilic cytoplasm and uniform, round voluminous nuclei. The cells appeared to grow in sheets with an organoid pattern. Atypia was mild or absent. Mitotic figure count was very low. Moreover, spread to an intraparotid lymph node was observed Fig. . A diagnUS, CT and MRI are widely used in the diagnosis of parotid gland tumors. In particular CT and MRI are useful in the detection of salivary gland tumors and in assessing their extent . IrregulSalivary gland tumors are 12-times more frequent in the parotid gland than in the submaxillary gland, a difference that can not be explained only on the basis of gland size. Most parotid gland lesions are benign 83%) and are largely represented by mixed-type tumors . CT and 3% and arInitially reported by Donath et al. , EMC ariTo our knowledge, diagnostic imaging findings of EMC have been previously reported only few times -14.In the report by Witterick et al. , the manIn the report by Silvers et al. , a case More recently, Tas et al.  reportedIn our case of parotid EMC all the images revealed sharply outlined profiles and a slight enhancement of the nodule, suggesting a benign tumor and demonstrating that a radiological evaluation of the lesion alone may be unsatisfactory and misleading in the diagnosis of salivary gland tumours, especially in the case of low grade malignant tumors, such as EMC. A FNAC of the lesion is always recommendable.The author(s) declare that they have no competing interests.AF, MN, AC, SD and IP participated equally in the design of the paper and in the study of the radiological data. LM, SL and FDN participated in the study of macroscopic and microscopic features of the lesion, in the design of the study and in the drafting of the manuscript. ZCDR was involved in the drafting of the manuscript. SL revised critically the final version of the manuscript. All authors read and approved the final manuscript.


The diagnosis of spontaneous pneumomediastinum in an acute hospital setting can present as a challenge. We present a case of 32 year Caucasian male with gradual swelling of his face and neck with increasing hoarseness of voice. He was treated for anaphylaxis with little improvement. He underwent a video-assisted thoracoscopic surgery procedure (VATS) with a definite diagnosis of sub pleural bleb. Spontaneous pneumomediastinum is an uncommon benign condition, which should be diagnosed with the high degree of suspicion .We present a 34 year old Caucasian male, who worked as a plumber. He was admitted for the third time in four weeks with gradual worsening of the swelling of his left eye, face and neck. He suffered with increasing hoarseness of voice on this occasion. He had no significant past medical and family history. He was a non smoker and drank alcohol socially. He was taking no regular medications.He was treated on these presentations for anaphylaxis with little improvement. His earlier serial chest X rays and CT scan of the chest were uneventful. He had an uneventful recovery on previous occasions and eventually discharged home.On this occasion he was unable to open his eyes but had palpable surgical emphysema on the face, neck and chest. His physical examination revealed a clear chest. His routine haematology and biochemistry results were normal. His repeat CT thorax revealed pneumomediatinum Figure . His barHe underwent a video-assisted thoracoscopic surgery (VATS) procedure with a definite diagnosis of sub pleural bleb. There were no further untoward complications.Spontaneous pneumomediastinum presents with non specific signs and symptoms but certain modern and less invasive techniques can be used to aid early diagnosis . Such adThe authors declare that they have no competing interests.SQ collected the data and drafted the manuscript. AT provided the supervision for writing this manuscript. All authors read and approved the manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal


Many conditions present as groin swellings, in both the elective and emergency setting. The management of these conditions varies widely, thus a prompt and accurate diagnosis is important.A 27 year old female presented with an acute painful swelling in her right groin. A preliminary diagnosis of an incarcerated femoral hernia led to urgent surgical exploration. Histology of the excised tissue showed appearances consistent with endometriosis.Endometriosis is an unusual cause of an acute groin mass, which should be considered as a differential diagnosis in women of childbearing age. Endometriosis is a condition in which foci of endometrial glandular tissues are found beyond the uterine cavity. It affects approximately 12% of women and commonly involves the ovaries, rectovaginal pouch and the pelvic peritoneum. Rarely, foci of endometriosis have been found in bowel, the umbilicus, abdominal surgical scars and in the lungs.In many cases endometriosis is asymptomatic. However, the commonest presenting symptom is of cyclical pelvic pain. At affected sites outside the pelvis cyclical bleeding may also be noticed. Laparoscopic evaluation of the abdominal cavity is often used to distinguish endometriosis from other conditions causing chronic pelvic pain such as chronic pelvic inflammatory disease, pelvic congestion syndrome and interstitial cystitis.Suppression of ovarian function for six months has been shown to reduce endometriosis-associated pain. Combined oral contraceptives, danazol, gestrinone, medroxyprogesterone acetate and GnRH agonists are equally effective but have differing side effect profiles and costs . SurgicaAlthough first reported in the British Medical Journal in 1949 , endometA 27 year old nulliparous white Caucasian woman presented to the surgical admissions unit with a two day history of an acutely painful swelling in her right groin. The swelling was tender to touch, and her pain was made worse by lying down.The patient was previously fit and well, a non-smoker, and her past medical history included irritable bowel syndrome and lactose intolerance. Her current medication was a combined oral contraceptive pill.On examination a tender, 5 × 2 cm, non-compressible, non-reducible ovoid swelling in the right groin was noted and a diagnosis of either an incarcerated femoral hernia or an enlarged lymph node was made.Surgical exploration of the groin was carried out the same day under general anaesthetic. On incising the skin and subcutaneous fat, the operating surgeon was able to palpate the mass deep to the superficial inguinal ring. On opening external oblique to access the inguinal canal, a hard inflammatory mass was found at the insertion of the round ligament into the pubic tubercle . There wThe patient made an uncomplicated recovery from her operation and was discharged home the following day.Histology of the excised tissue reported fibroadipose tissue showing foci of endometrial type glandular epithelium and stroma which stained positive with anti-CD 10 antibody  and 3. TOn subsequent outpatient review the surgical wound had healed without complications and the patient had no further symptoms.The differential diagnosis of a swelling in the groin is broad. Common causes are inguinal or femoral herniae, enlarged lymph nodes, swellings arising from structures within the skin such as lipomata and sebaceous cysts, and vascular pathology such as saphena varix and femoral artery aneurysms. Ectopic and incompletely descended testes may also be located in the groin.This case illustrates an unusual cause of an acute painful groin swelling in a young woman - endometriosis. The timely diagnosis of this condition allowed optimal patient management. It acts as a reminder that although common conditions will form the mainstay of our surgical practice we must be also be alert to the more extra-ordinary presentations.


The prevalence of primary cardiac tumour ranges from 0.0017-0.28% and papillary fibroelastoma is rare but not uncommon benign cardiac neoplasm. Currently, with the advent of higher-resolution imaging technology especially transoesophageal echocardiography such cases being recognized frequently. The clinical presentation of these tumours varies from asymptomatic to severe ischaemic or embolic complications. We herein, present a 50-year-old female patient with a papillary fibroelastoma of the aortic valve arising from the endocardium of the right coronary cusp very close to the commissure between the right and non-coronary cusps. The patient presented with angina-like chest pain and was investigated using echocardiography and CT angiographic modalities in addition to the usual investigations. The differential diagnosis considered was a thrombus, myxoma, Lambl's excrescence and infective vegetation. The surgical management included a prompt resection of the tumour on cardiopulmonary bypass avoiding injury to the aortic valve. The patient recovered well. A review of the literature suggests that the cardiac papillary fibroelastoma is a rare but potentially treatable cause of embolic stroke and other fatal complications, therefore, a strong suspicion; appropriate use of imaging modality, preoperative anticoagulation and urgent surgical resection is warranted. Also, possibility of this diagnosis should be kept in mind while managing cardiac or valvular tumours. Although the prevalence of primary cardiac tumors ranges from 0.0017-0.28%, the papillary fibroelastomas (PFE) are second most common benign neoplasm of the cardiac valves after myxomas . CurrentA 50-year-old female presented to our hospital for evaluation of chest pain. She had history of recurrent, vague, central chest pain with radiation to inter-scapular area. The pain was compressive and mild in nature and was not associated with effort. The clinical examination and routine blood laboratory investigations were unremarkable. The electrocardiography including stress test was also inconclusive. The chest x ray was normal. A 2-D and transoesophageal echocardiography (TEE) revealed presence of an echodense supra valvular, pedunculated, spherical mass of 1.2 × 1 cm in size about 1.2 cm above the aortic annulus Figure . HoweverIn view of the possibility of embolism and unknown nature of the pathology, the patient was taken for urgent surgical resection under standard cardiopulmonary bypass at systemic hypothermia (32 degree Celsius) and systemic heparinisation. The ascending aortic and right atrial cannulation was done before institution of cardiopulmonary bypass. The aortic cross clamp was applied and heart was arrested using antegrade blood cardioplegia via the root. Subsequently, a transverse aortotomy was performed proximal to the aortic root. On exploration a 1 × 1 cm pedunculated tumor mass was found to be attached to the right coronary cusp very close to the commissure between the right and non-coronary cusp of the aortic valve. The tumor mass was firm, glistening, friable and looked filamentous on gross examination Figure . The aorth day.Histopathology examination of the resected tumor revealed a papillary proliferation including few fibroblasts, collagen and elastic fibers, covered with hyperplastic endothelial cells. These features confirmed the diagnosis of papillary fibroelastoma Figure . The posCardiac papillary fibroelastomas are classified as primary benign endocardial tumours arising from the normal component of the endocardium like fibrous tissue, elastic fibers or smooth muscle cells. Characteristically they have a short pedicle and multiple papillary fronds similar to a sea anemone . They ofThe origin of PFE is unclear and various possible causes have been mentioned in the literature. They have been considered as hamartomas, organized thrombi, iatrogenic  or inflammatory foci due to unusual endocardial responses to infection or hemodynamic trauma . HoweverClinical presentation of PFE's varies from asymptomatic to severe thromboembolic complications, myocardial ischemia, infarction and stroke. However, pulmonary embolism, congestive heart failure, near-syncope, ventricular fibrillation and sudden death have also been reported -10. EmboIn our patient, the atypical vague chest discomfort and pain could have been due to the partial, intermittent obstruction or limitation of blood flow through the right coronary artery orifice in the aortic root due to the strategic location and variable mobility of the tumour mass during various phases of cardiac cycle Figure  and 3. TThe diagnosis is usually made by 2-dimentional or transoesophageal echocardiography. Recently, 3-D echocardiography, magnetic resonance imaging and multislice spiral computed tomography have also been used for better delineation of similar tumors ,8. TypicDespite the benign nature of this tumour, it carries very high risk of embolic complications including neurological deficit. The fragile nature and frond-like papillary tissues of the tumour itself is prone to thromboembolism -7. ThereLaw 'et al' have done a review of the English language literature using 'Pub Med'  to identify previously published cases of PFE from 1997 up to 2008 [Cardiac PFE's are not uncommon tumours and should be considered in the differential diagnosis of cardiac masses. A strong suspicion, appropriate use of imaging modality, pre operative anticoagulation and urgent resection of the tumour is not only life saving but also avoids tumour-related vascular, embolic or neurological complications.The authors declare that they have no competing interests.All authors have contributed in case management, manuscript preparation and image acquisition.Written informed consent was obtained from the patient for publication of this case report and any accompanying image. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


A rare case of aneurysmal bone cyst (ABC) located in the mandibular condyle in a 10-year-old boy is presented. The patient came to our attention for a sudden swelling in the right temporomandibular region, the mouth opening was not reduced.A rapid growing mass, depicting soft tissue invasion, in the right condyle of the mandible was found. Clinically and radiographically it resembled to a malignant lesion. The surgical excision of the mandibular condyle allowed a complete removal of the lesion. The histological examination revealed a pseudocystic expanding osteolytic lesion containing blood-filled space separated by connective tissue and many osteoclastic giant cells, which was a conventional vascular ABC.The ABC is an infrequent bone lesion which can only be found very rarely at the craniofacial skeleton. There have been described about 160 cases of ABC originated in the molar region or in upper maxilla and even more rare is the location of this cyst in the mandibular condyle. Only 6 cases were reported in the literature to date.A complete surgical resection of this osteolytic lesion is the treatment of choice considering its high recurrence rate. The condyle was not replaced with any graft. Therefore a functional device was used after surgery to overcome the lack of the condyle and to stimulate the growth of the ramus. The aneurysmal bone cysts are benign neoformations which can affect all the skeleton bones. More than half occur in the metaphysic of long bones  and between 12 and 30% in the spine. ABC occurs very rarely in the jaws, about 160 cases have been reported and two thirds were located in mandible  and one third in the maxilla . An aneu, and 1111].The aneurysmal bone cyst of the jaw is a pseudocystic lesion. It is a rapidly growing and destructive bone lesion characterized by replacement of the normal bone with fibro-osseous tissue containing blood-filled sinusoidal or cavernous spaces. However an unusual solid, focally hemorrhagic variant has recently been reported . The solThe etiology of ABC is unclear and controversial. One theory states that trauma causes an inciting injury to periosteal vessels, thus initiating the development of ABC . HoweverHistologically the ABC is considered a pseudocyst due to the absence of an epithelial wall. The ABC is an expanding osteolytic lesion containing blood-filled spaces of variable size, separated by connective tissue by bone trabeculae or osteoid tissue and many osteoclastic giant cells. The lesion does not have any clinical or radiological specificity. Recurrence has been reported confirming the aggressive behaviour of this lesion .A 10-year-old male patient presented with a painless mass in the right temporomandibular region. The swelling was evident since one month and it was hard and sensitive to palpation. The patient was able to open widely; the mandible could move in all axes without any limitation. The lesion caused facial asymmetry. There was no paresthesia in the area innervated by the right mandibular nerve or by the right facial nerve. The boy did not have any previous trauma in the swollen region . Even Written informed consent was obtained from the patient and patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this Journal.The authors declare that they have no competing interests.SP, GG and PFA performed the surgery and carried out the case study. PFA and RB wrote the article. AM reviewed scientific literature for this mandibular cyst. All the authors have read and approved the manuscript.


Extramedullary adrenal plasmacytoma (EMP) involving the adrenal glands is rarely encountered clinicaly. We report a A 47-year-old male who presented with bilateral adrenal incidentalomas. After confirming EMP, the patient received two consecutive autologous hematopoietic stem cell transplants (HSCT) using high-dose melphalan. Following HSCT, a serial follow-up helical CT revealed a substantial decrease in the size of both adrenal masses. Serial periodic serum protein and urine electrophoresis and immunofixation showed abrogation of a previously noted monoclonal band. At 50 months follow-up the patient was alive and well. Our patient is the first with EMP to have received an autologous HSCT, which may prove to have a role in therapy due to the immunological effect of the infused donor marrow T-lymphocytes against the clonal proliferation of abnormal plasma cells in extrammedullary sites. This case indicates that an EMP should be added to the differential diagnosis of adrenal incidentalomas. Plasmacytomas are tumors that arise in different locations due to the ubiquitous tissue distribution of plasma cells. They are a clonal proliferation of atypical plasma cells that exhibit a localized osseous or extraosseous (extramedullary) growth pattern.12/L, WBC 6.1×109/L, serum creatinine 87 μmol/L  serum calcium 1.95-2.25 g/L , serum albumin 35 g/L , serum phosphorus 0.57-1.27 mmol/L , alkaline phosphatase 64-96 U/L , total proteins 109 g/L , and urine total protein of 1.22 g/L. The hormonal profile consisted of 24-hour urine normetanephrines of 2.88 μmol/day , urine metanephrines of 0 μmol/day , urine 3-methoxy-tyramine 1.34 μmol/day , synthetic ACTH stimulation testing revealed a normal adrenal cortical reserve , urine cortisol of 45 μg/day , urine aldosterone <33 nmol/day , supine renin of 2.17 μg/L/h , and serum dehydroepiandrosterone sulfate of 0.7 μmol/L . Imaging data consisted of an ultrasound of the abdomen/pelvis (not shown) that revealed large bilateral adrenal masses, a CT of the abdomen  followed by two cycles of etoposide, dexamethasone, Ara-C and cisplatinum (EDAP). A follow-up CT scan showed no change in the size of the bilateral adrenal lesions nor was there a change in the immunological studies of serum and urine. Two years following initial presentation the patient received two consecutive autologous hematopoietic stem cell transplantation (HSCT) procedures using high dose melphalan. Starting 6 months pos-HSCT through a last follow-up at 50 months, serial periodic serum protein electrophoresis and immunofixation showed abrogation of a previously noted monoclonal band. Urine electrophoresis and urine immunofixation also turned out to be negative for Bence-Jones proteins. A last CT scan of the abdomen done at 47 month follow-up  revealedThe diagnosis in our case was based on the findings of a plasma cell tumor in an extramedullary site detected on adrenal imaging, the tissue diagnosis, the relevant immunological analysis of serum and urine, flow cytometry of the adrenal tumor, the absence of mutiple myeloma on bone marrow examination and the absence of skeletal lesions, coupled with the long-term follow-up data. An EMP is a rare malignant tumor. Fewer than 3% of all plasma cell proliferative disorders are EMPs.3Extramedullary plasmacytoma involving the adrenal gland is unusual. It has been reported in 4 other cases previously. 6In contrast to previously reported cases, our case is dintinct in presenting with bilateral incidentalomas that were much larger, producing IgG kappa light chain, followed-up for a longer time period without surgical intervention but received chemotherapy that was considered a failure and had then undergone two consecutive autologous HSCT procedures. Following the first HSCT patient demonstrated a partial reduction of the adrenal masses and an improvement in protein electrophoresis. Considering these responses, a second HSCT procedure was undertaken that was temporally related to a significant reduction in the tumor size and resolution of the abnormal findings in serum and urine electrophoresis. These responses remained sustained without maintenance therapy. Because a biopsy was not performed from the contralateral left adrenal mass, we cannot definitely state that our patient indeed had bilateral plasmacytomas. However, the imaging findings, the follow-up data and the regression in the size similar to that of the right adrenal plasmacytoma following HSCT is highly suggestive of a bilateral process.The role of HSCT in the management of EMPs is not defined. For the last 20 years autologus and allogeneic HSCT have been used to advantage in patients with multiple myeloma.7In conclusion, although the frequency of diagnosis of adrenal incidentaloma has increased with the increased use of contemporary imaging modalities, the definitive diagnosis of such lesions should rest on a combination of clinical and pertinent laboratory criteria coupled with cytological/histological criteria. Thorough investigations will lead to the diagnosis of most unusual adrenal lesions, which can have an enormous impact on treatment, quality of life and on eventual outcome. EMP should be considered among the differential diagnoses of adrenal incidentalomas.


We report the development of acute lymphoblastic leukemia in a patient in whom temozolomide was used for the treatment of a brain tumor. Unlike that of other alkylating agents, the leukemogenic potential of temozolomide is considered to be very low, and very rarely are such cases reported.A 26-year-old Pakistani man who was treated for glioblastoma with temozolomide in an adjuvant setting was diagnosed to have acute lymphoblastic leukemia one year after stopping temozolomide.Temozolomide is a highly active agent, used in the management of high-grade brain neoplasms. The agent is generally regarded to be safe, with an acceptable safety profile. Very few cases of myelodysplasia associated with temozolomide use have been reported. We report here the first case of acute lymphoblastic leukemia, which developed in a young man about one year after he finished taking temozolomide. This should provide further insight into a possible toxicity profile of this alkylating agent. This finding should be of interest to physicians in general and to medical oncologists in particular. Survival rates from aggressive, relapsed, refractory, or high-grade brain tumors are generally poor, with the median survival for some being less than one year . With in2). He showed an excellent response to concurrent chemoradiotherapy, with a complete disappearance of the recurred lesion. He was given a total of six cycles of TMZ . He completed chemotherapy in January 2008 and remained well, without evidence of recurrence, on surveillance MRI scans. He recently came in complaining of easy bruisability; blood counts revealed an elevated white blood cell count  and thrombocytopenia . Bone-marrow aspirate revealed diffuse infiltration with blast cells consistent with acute leukemia. Peripheral blood flow cytometry on immunophenotyping with five-color cytomics (fc500 Beckman Coulter flow cytometer) showed this population of cells with bright reactivity with Pan-T-markers . Positivity of this population with Tdt was also very prominent, so immunophenotypic results were consistent with precursor-T-acute lymphoblastic leukemia (Pre-T-ALL). Bone marrow cytogenetics revealed a normal karyotype and negative Philadelphia chromosome. He is currently undergoing treatment.A 26-year-old Pakistani man presented with history of new-onset seizures. Magnetic resonance imaging (MRI) of the brain revealed a contrast-enhancing lesion in the right frontoparietal region with compressions and a shift of the midline. The mass was resected in August 2007 and confirmed to be a mixed glioma with components of both astrocytoma and oligodendroglioma, WHO grade II. About six weeks after surgery, the patient was brought back with a new history of seizures. An MRI examination revealed a gross local recurrence at the site of the previous surgery, which was infiltrating within the sulci of the brain matter. Based on the clinical behavior and surgical unresectability of the tumor, he was treated with concurrent chemoradiation therapy . MTIC degrades to a highly reactive cation that methylates guanines in DNA at the O6 position, causing base-pair mismatch. Unsuccessful cycles of mismatch repair eventually lead to breaks and permanent nicks in the daughter strand, preventing mitotic division, and the cell undergoes apoptosis ,8. The aet al.  publisheTMZ has unequivocally shown its therapeutic potential in randomized clinical trials as an effective, relatively safe, and generally well-tolerated therapy for aggressive CNS neoplasms, resulting in better overall survival. Because it is a relatively new and unique alkylating agent, the short-term and long-term data regarding safety, especially leukemogenic potential, must have further time to mature. Although the association is unlikely to be a random finding, the association between TMZ and treatment-related leukemia deserves further study.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.Both authors declare no conflict of interest with reference to material published.AJS wrote the manuscript, searched the literature, and aided in patient coordination. NM wrote the manuscript and searched the literature. Both authors read and approved the final manuscript.


Neurocysticercosis is rare in Western Europe and a high degree of physician awareness is necessary for diagnosis. We describe a case of Neurocysticercosis with a single brain lesion acquired in Germany in which only surgical removal and subsequent histological examination allowed diagnosis whereas diagnostic investigation yielded no pathological findings. Neurocysticercosis (NCC) is the most common CNS parasitosis worldwide. It is caused by infection with eggs of the tapeworm Taenia solium, found in undercooked pork, affecting the gut initially and spreading haematogenously . SuffereA 69-year-old German patient presented with a first generalized epileptic seizure. He grew up on a farm with pigs. His travel history revealed no trips to foreign countries.On examination the patient was afebrile, fully conscious, orientated and showed no neurological abnormalities. MRI disclosed a solitary cystic lesion with gadolinium enhancement in the left temporal lobe surrounded by a perifocal edema Figure . EEG shoThe patient received an antiparasitic treatment with albendazole 800 mg/d in combination with dexamethasone 4 mg every 8 h for 4 weeks and remained seizure-free under anticonvulsant therapy with lamotrigine 100 mg/d.The differential diagnosis of a solitary cystic cerebral lesion on CT or MRI includes abscess, tubercle, metastasis and glioblastoma. Parasitic CNS infections and subacute cerebrovascular events should also be considered. The clinical picture of NCC is variable with seizures, focal neurological signs, and intracranial hypertension depending on the amount and localization of the cysts . AccordiCNS: central nervous system; CSF: cerebrospinal fluid; CT: computed tomography; EEG: electroencephalography; EITB: enzyme-linked immunoelectrotransfer blot; MRI: magnetic resonance imaging; NCC: neurocysticercosis.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.FL, JS, ES, JB and FT were major contributors in writing the manuscript. KF and HM performed the histological examination of the brain biopsy. PS performed the analysis of CT and MRT scans. All authors read and approved the final manuscript.


Alveolar soft-part sarcomas are rare, slow-growing tumors that metastasize commonly via vascular routes to the lungs, bones, lymph nodes and brain, causing morbidity and mortality. To the best of our knowledge, this is the first case describing metastasis to the liver reported from Nigeria.A 57-year-old man of the Urhobo ethnic group of Nigeria presented with a persistent mass in his left calf. It was initially diagnosed as soft-tissue sarcoma, and its associated systemic effects lead to his death before a histological diagnosis could be obtained.Alveolar soft-part sarcoma with metastasis to the liver can occur in our region (northeast Africa), and a high index of suspicion is required to make an early diagnosis, followed by prompt surgical excision with clear margins in order to prevent mortality. Alveolar soft-part sarcoma (ASPS) is an extremely rare, vascular soft-tissue sarcoma affecting predominantly adolescents and young adults .Accounting for less than 1% of soft tissue sarcomas, ASPS occurs commonly in the lower extremities (44%) and the head and neck 27%). Of the head and neck cases, 25% occur in the tongue [7%. Of thBecause it has close clinical and imaging resemblance to common benign vascular tumors such as hemangioma, there is danger of misdiagnosis and, therefore, inadequate or delayed treatment. ASPS often involves the extremities of adolescents and young adults. Although the origin of ASPS is still unknown, recent cytogenetic studies revealed chromosomal rearrangements at t resulting in the ASPL-TFE3 fusion gene. Because women have an extra X-chromosome, their likelihood of developing an X autosomal translocation is theoretically double that of men. Thus, this extra X-chromosome is a possible explanation for the preponderance of ASPS in women .et al. on the epidemiology of soft-tissue sarcomas in Jos, north central Nigeria, ASPS was found in only 3 (1.4%) of the 216 soft-tissue sarcomas studied over a period of 10 years [Literature on ASPS is scant, especially in Nigeria and neighboring countries. In work done by Mandong 10 years .ASPS is a slow growing tumor, which runs an indolent course with a poor prognosis, which metastasizes late to the lungs, bones, lymph nodes and brain ,7. MetasOur case shows the fast metastatic potential of this tumor. Although it is most common among women and in the young to early middle-age group, it can occur in men into the sixth decade of life.Because of the rapidity of metastasis with consequent mortality, a high index of suspicion is required to make a definitive diagnosis.A 57-year-old man of the Urhobo ethnic group of Nigeria presented to our hospital in January 2009 with an eight-month history of a persistent left calf swelling and one-week history of generalized body swelling. He had already undergone an excision of the swelling in another hospital five months prior to presentation, although no histologic report or statement on the margins of excision were available from this hospital. The swelling was recurred three weeks after the first excision and our patient sought help for his condition from traditional healers before presenting to our hospital.The swelling was tender and he had difficulty moving his left leg. He was not diabetic or hypertensive. He had no other swelling.Examination revealed a middle-aged man in painful distress with a solitary lymph node in the left inguinal region and non-pitting pedal edema in the affected limb. There was a fungating mass measuring 6×8 cm on the left calf. There was a wound with everted edges on the mass, which was bleeding on contact.The surgeons made a provisional diagnosis of recurrent soft-tissue sarcoma. An abdominal ultrasound showed multiple hepatic metastases about 3 cm in greatest diameter. Random blood sugar (RBS) was 16.1 mmol/L, fasting blood sugar (FBS) was 10.6 mmol/L, and packed cell volume (PCV) was 27%. Chest and left leg X-rays were normal. Our patient could not afford a computed tomography (CT) scan.He was admitted, transfused with a unit of blood and placed on subcutaneous soluble insulin, intravenous ciprofloxacin, metronidazole and ibuprofen tablets with daily wound dressing using Eusol.One week later, the clinical condition of our patient deteriorated and he died following efforts at resuscitation. Surgeons delayed making a histological diagnosis. The reason given was that our patient presented with delirium and hyperglycemia, was thought to have diabetes mellitus and was unfit for excision biopsy. Therefore, the physicians were asked to review and metabolically stabilize our patient for surgery. The pathologists were asked to review him two days before his death, during which a biopsy of the leg swelling was taken for histology. Because of the rapidity of events leading to his death we were not able to obtain clinical photographs of the site of the lesion.Five days after his death, a histology report was obtained as alveolar soft-part sarcoma with metastasis to the liver. Our patient's relatives declined an autopsy. Macroscopic features were a grayish-white tissue measuring 2×3 cm with overlying skin and a tiny grayish-white inguinal node biopsy tissue preserved in 10% formalin.Microscopy showed oval to polygonal cells with eosinophilic cytoplasm delineated by thin fibrovascular septae which separated the tumor cells into an organoid or nest-like pattern of arrangement with evidence of vascular invasion Figures  and 2. TSarcomas are rare malignant tumors, arising from connective tissues and mostly found in the extremities , with ASIt was first described as a separate disease entity in 1952 [ASPS is a slow-growing tumor, which runs an indolent course with a poor prognosis, and metastasizes late to the lungs, bones lymph nodes and brain ,7. ReporHistologically, ASPS is characterized by the presence of organoid nests of polygonal tumor cells encompassed by a dense capillary vasculature Figures  and 2. TASPL), located at 17q25, to the C-terminal region of the transcription factor E3 (TFE3), located at Xp11. Two alternative fusion junctions have been observed resulting in the expression of two distinct fusion transcripts, ASPL-TFE3 type 1 and type 2 [Recent cytogenetic studies show that ASPS exhibits a conserved abnormality in the form of an unbalanced translocation der(17)tp11;q25), which fuses the N-terminal region of the alveolar soft-part locus gene (5, which d type 2 .et al. observed that ASPS accounted for only 1.4% of total soft-tissue sarcomas diagnosed over a period of 10 years [ASPS is a rare tumor. In a report on epidemiology of soft-tissue sarcoma in Jos, Nigeria, Mandong 10 years . This is10 years .et al. suggest that ASPS is a variant of rhabdomyosarcoma [Reports in other parts of the world have also show that ASPS is rare and of unknown histogenesis. Joyama osarcoma .Our patient had metastases to the liver presenting with features of diabetes mellitus, the first such case reported in Nigeria.Although spontaneous regression has been reported , surgicaOur case shows the ignorance of some health practitioners, especially those in peripheral hospitals, about the need for histologic reports of any mass excised from a patient. Medical doctors in the developing world must inculcate evidence-based medicine in the management of patients. The role of the pathologist in patient management cannot be overemphasized as the incidence of cancers gradually increases worldwide, including Africa. Although radiologic diagnosis maybe helpful, it may be limited in the typing of tumors for effective treatment. Hospitals should therefore be equipped with histologic and cytologic diagnostic tools for early detection of malignancies and to reduce morbidity and mortality.ASPS with metastasis to the liver does occur in Nigeria. A high index of suspicion is required to make an early diagnosis. After this, a prompt surgical excision with clear margins should be done in order to avoid fatal outcomes.Written and informed consent for the publication of this report and any accompanying images was obtained from the daughter of our patient. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.OAS conceived the report and prepared the histologic slides and manuscript. AAA performed the literature search and prepared the manuscript. ANM read the slides. GOE reviewed the final manuscript. ARV performed the literature search. BMM reviewed the final manuscript. All authors have read and approved the final manuscript.


Endosalpingiosis describes the ectopic growth of Fallopian tube epithelium. Pathology confirms the presence of a tube-like epithelium containing three types of cells: ciliated, columnar cells; non-ciliated, columnar secretory mucous cells; and intercalary cells.We report the case of a woman with umbilical endosalpingiosis and examine the nature and characteristics of cutaneous endosalpingiosis by reviewing and combining the other four cases existing in the international literature.A 50-year-old Caucasian, Greek woman presented with a pale brown nodule in her umbilicus. The nodule was asymptomatic, with no cyclical discomfort or variation in size. Her personal medical, surgical and gynecologic history was uneventful. An excision within healthy margins was performed under local anesthesia. A cystic formation measuring 2.7×1.7×1 cm was removed. Histological examination confirmed umbilical endosalpingiosis.Umbilical endosalpingiosis is a very rare manifestation of the non-neoplasmatic disorders of the Müllerian system. It appears with cyclic symptoms of pain and swelling of the umbilicus, but not always. The disease is diagnosed using pathologic findings and surgical excision is the definitive treatment. Endosalpingiosis is a rare clinical entity that describes the ectopic growth of Fallopian tube epithelium . EndosalWe report the case of an adult woman with umbilical endosalpingiosis and elucidate the nature and characteristics of cutaneous endosalpingiosis by reviewing and combining the four cases existing in the international literature.A 50-year-old Caucasian, Greek woman presented with a pale brown nodule in her umbilicus. The nodule was asymptomatic, with no cyclical discomfort or variation in size. Her personal medical, surgical and gynecologic history was uneventful. An excision within healthy margins was performed under local anesthesia. A cystic formation measuring 2.7×1.7×1 cm was removed. There were no signs of malignancy and no evidence of endometrial component in her surrounding tissue. Pathologic examination showed a unilocular cyst with papillary projections into the lumen Figures . Immunohet al. in 1930. Under that term, the author designated any unusual growth and invasion of tubal epithelium in tubal stumps, in subjects who had undergone previous salpingectomy or tubal sterilization , melanoma, suture granuloma, pyogenic granuloma, desmoid tumor, sarcoma, lymphoma, endometriosis, and endosalpingiosis. Of course, the final diagnosis should be made by pathology .In the international literature, this is the fifth case of umbilical endosalpingiosis. The other four cases refer to patients with previous medical history of gynecologic procedures ,19,20, wUmbilical endosalpingiosis is a very rare manifestation of the non-neoplasmatic disorders of the Müllerian system. Normally, it appears with cyclic symptoms of pain and swelling of the umbilicus, but not always. The disease is diagnosed using pathologic findings and surgical excision is the definitive treatment.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.TSP analyzed and interpreted the patient data and drafted the manuscript. KS received the patient in our out-patient department and was the principal surgeon. NM received the patient in our out-patient department, was the auxillary surgeon and drafted the manuscript. GK performed the pathological examination and was a major contributor in writing the manuscript. AC performed the pathological examination. STP was responsible for the overall treatment of the patient and corrected the manuscript. All authors read and approved the final manuscript.


Intrahepatic sarcomatoid cholangiocarcinoma is a rare but an aggressive variant of cholangiocarcinoma with a very poor prognosis. We report the first caucasian patient who presented with a rapidly enlarging liver mass requiring hepatic resection. Detailed histopathological analyses including immunohistochemistry and electron microscopy confirmed sarcomatoid cholangiocarcinoma. The patient had early onset disease recurrence within 5 weeks of surgery. Here we demonstrate that combination chemotherapy with gemcitabine and cisplatin is a potential treatment option in patients with advanced sarcomatous cholangiocarcinoma. The patient achieved sustained partial remission with combination chemotherapy and remains alive and well more than 29 months since initial surgery. Sarcomatoid changes of epithelial neoplasms are rare but found occasionally in renal cell carcinoma, squamous cell carcinoma , and adenocarcinoma of the lung . In the A 60-year-old Caucasian woman presented with an acute onset right upper abdominal pain and a rapidly enlarging upper abdominal mass. She had a previous history of resected early-stage melanoma. Clinical examination revealed tender hepatomegaly, and a contrasted computed tomography (CT) scan of the thorax, abdomen, and pelvis showed a large solitary heterogeneous mass in segment V1 of the liver with evidence of intratumoural bleeding . She proThe tumour measured 15 × 11 × 20 cm and cut section revealed massive necrosis and haemorrhage consistent with the preoperative CT scan . The tum2 on days 1 and 8) and cisplatin (60 mg per m2 on day 1) chemotherapy in a 21-day cycle which she tolerated well with minimal side effects. Patient received a total of six cycles of chemotherapy and a restaging CT scan at the end of 6 cycles confirmed partial response (A postoperative contrasted CT scan at 5 weeks confirmed rapid onset disease recurrence with multiple peritoneal deposits and multifocal liver metastasis . Patientresponse . Apart fSarcomatoid cholangiocarcinoma is an uncommon variant of intrahepatic cholangiocarcinoma and in the previously reported series, the sarcomatoid component exhibited mainly spindle cell morphology. To the best of our knowledge osteoid differentiation and osteosarcoma like features in a sarcomatoid cholangiocarcinoma are very rare. Here, we describe the first case of such an entity in a Caucasian patient along with ultrastructural features. Sarcomatoid transformation has been reported to occur in a hepatocellular carcinoma previously treated with transcatheter arterial chemo embolisation regimes . HoweverAggressive biology is highlighted by the fact that our patient had an early onset rapid recurrence of disease within a few weeks of surgery. The rapid recurrence is also indicative of early microscopic metastatic seedlings prior to surgery. In view of widespread recurrence, further surgical intervention was not performed and the patient proceeded to palliative chemotherapy. Kaibori et al. reviewed sixteen cases of sarcomatous cholangiocarcinomas previously reported in the literature. Seven patients had not had surgery and all had died within five months of diagnosis. Nine patients had liver resection but four of these patients died within seven months of surgery . The surIn conclusion, we have demonstrated that combination chemotherapy with gemcitabine and cisplatin is a potential treatment option in patients with advanced sarcomatous cholangiocarcinoma. Review of previous reports suggests that radical surgery is the treatment of choice in those with limited disease. However, the role of adjuvant chemotherapy is unknown. As the prognosis of this tumour type is very poor, and the amount of reported clinical data is limited, our report raises the need to consider the potential benefit of adjuvant gemcitabine/cisplatin chemotherapy in patients with resected intrahepatic sarcomatoid cholangiocarcinoma.


We report a rare case of a ‘giant ganglion’ with 24 × 10 × 12 cm dimensions originating from the semimembranosus tendon. The patient presented with chronic pain and a palpable mass in his left calf located between the superior aspect of the popliteal fossa and the distal third of the calf. MRI revealed the mass to be a ganglion in close relation to the semimembranosus muscle at its attachment to the tibia. The patient was operated on and had complete resolution of symptoms postoperatively. To the best of our knowledge there are no other case reports in the literature of ganglion cysts of similar size arising from the tendon of semimembranosus. A brief review of the literature is included. A ganglion is best described as a cyst filled with colloid material met within the vicinity of a joint or tendon sheath. They most commonly occur on the dorsal aspect of the wrist . PopliteA 50-year-old Caucasian male presented to clinic with a mass in his left popliteal fossa and calf which had been increasing in size over the past six months. This had been associated with intermittent pain in the popliteal fossa. The patient also, felt the mass to be aesthetically displeasing.Physical examination revealed a non-tender swelling extending from the superior aspect of the popliteal fossa to the junction of the middle and distal third of the calf. The mass was cystic in consistency and transilluminated with a well defined margin. Flexion at the knee was restricted due to the size of the swelling. The ankle had an uncompromised range of movement  and 2.Full blood count and inflammatory markers were normal. X-rays of the knee and tibia were normal. An ultrasound scan of the mass revealed the cystic nature of the swelling. A provisional diagnosis of a Baker’s cyst was made. An MRI of the knee and leg was obtained which revealed a large cystic lesion measuring 24 × 10 × 12 ;cm in the posteromedial aspect of the knee and calf. The lesion was reported to have multiple septae and was closely related to the semimembranosus muscle  and 3b. At surgery the swelling was found to be originating within the superficial posterior compartment of the leg without any communication with the knee joint or proximal tibio-fibular joint. The fluid inside the cyst was found to be mucinous. A definitive capsule was identified and the cyst was excised with its capsule.Histology revealed the mass to be a ganglion . The ganThe patient had an uneventful recovery with complete resolution of all symptoms  and 5b.A ganglion is a term applied to a cyst filled with colloid material which is met within the vicinity of a joint or tendon sheath. The commonest variety-the carpal ganglion-is met with a smooth, rounded, or oval swelling on the dorsal aspect of the carpus, usually towards its radial side. Ganglia are thought to arise from cystic degeneration in a tendon sheath or joint capsule usually in middle aged males . PreviouOther theories for the development of popliteal cysts suggest that these cysts may be the result of a lack of support from surrounding structures which leads to a gradual disturbance in the mechanics of movement and the production of excess fluid in a synovial membrane . A herniLarge synovial cysts have been reported in patients with rheumatoid arthritis and a Baker’s cyst is a common finding in patients over 50 years old. However, it is very rare for a ganglion to reach a size of 24 × 10 × 12 ;cm and we have not found any case reports similar to this.The differential diagnosis of ganglia in the calf and popliteal fossa can be demanding. Differentials such as a Baker’s cyst, haematomas, lipomas and a deep vein thrombosis must be excluded. Ultrasound can be used however is not adequate to visualise associated structures. MRI is the most accurate imaging modality and is best used for planning the surgical excision . Althoug


Spontaneous scar dehiscence of a previous repaired urinary bladder rupture is described in a 5 yr old girl approximately 4 yrs after the original repair, she presented at the hospital with the chief complain of pain and distension of the abdomen. No underlying aetiology could be related to the event, her blood urea and creatinine levels were found to be raised. A diagnostic peritoneal tap showed non bloody straw colour urine in the peritoneal cavity. Emergent laparotomy was carried out and the site of scar dehiscence was closed in layers. Delayed scar dehiscence in bladder rupture is rare unlike that of the uterine dehiscence which is seen more commonly in association with some underlying pathology or in some cases may be iatrogenic following radiotherapy. But spontaneous or idiopathic bladder scar dehiscence is even more uncommon, only 2 cased being documented. I present a case of spontaneous scar dehiscence of a repaired bladder rupture after 4 yrs in a 5 yr old girl in Delhi.Presenting complain – A 5 yr old Indian girl presented at the hospital with the chief complain of pain and distension of the abdomen. She complained of pain for last 4 days, the pain was continuous in nature and diffusely involved the whole abdomen but was more so in the umbilical and the hypo-gastric regions, pain was non-radiating, was relieved on lying still and aggravated on movement. No predisposing cause of the pain could be found and the girl's mother said that she complained of stomach pain suddenly. The pain had gradually increased in intensity over time. Abdominal distension developed about 2 days after she complained of pain. She also complained of multiple episodes of vomiting (about 15 per day), the vomitus was greenish yellow in colour, non bloody, odourless and copious in amount. She complained of burning micturation as well and described an increase in pain during urination. She also complained of loss of appetite and mild constipation but denied any fever or cough. Past history – Her mother described that she had developed similar kind of features 4 yrs back when a ceiling fan had fallen on her stomach, she was hospitalized and was diagnosed as a case of intrauterine rupture of urinary bladder. Exploratory laparotomy was performed and bladder rupture was repaired. The post operative recovery was uneventful with no further complains.Birth history – She was a full term normal spontaneous vaginal delivery, her development milestones and vaccination status are up to date.The girl was conscious and alert and was in pain.Height-103 cms, Weight-28 kgsVital signs as follows: temp-98.8^F, pulse-126/min, RR-28/min, BP-100/70 mm Hg.Abdominal exam-previous operative scar, abdomen distended, diffuse tenderness over whole abdomen, no rigidity, no guarding, liver and spleen impalpable, shifting dullness and fluid thrill were found to be present, bowel sounds were absent.Examination of rest of the systems was uneventful.Hb-12.5 gm%, TLC-14000, Na-130 mEq/L, K-6.5, Urea-210 mg/dl, creatinine-2.4 mg/dl, bilirubin-0.6(direct-0.3)mg/dl, AST-85 iu, ALT-49 iu.X-ray abdomen erect showed diffuse ground glass appearance in the abdomen Fig. . No air Abdominal ultrasound showed intraperitoneal fluid collection.Diagnostic peritoneal tapping revealed a non bloody straw colour fluid which was found to be urine. The collected urine was found to be sterile.IVP or cystogram were not undertaken as the peritoneal tap and ultrasound confirmed the presence of urine in the abdomen, in case of doubt i definetely recommend these tests.The patient was catherized and put on intravenous ceftriaxone and metronidazole pre-operatively and was continued on the same for a period of 5 days. Emergent exploratory laparatomy was performed; intraperitoneal rupture of the bladder as a result of scar dehiscence of the previous bladder rupture repair was found located on the dome of the bladder and was repaired in layers. About two litres of urine was drained out of the peritoneal cavity. The rest of the bladder was found to be absolutely normal. The girl's recovery was fast and uncomplicated; her blood urea and creatinine levels were in the normal range in just two days after the operation. Subsequently she was discharged on oral antibiotics and dietary supplements with advice for regular follow up.The fore mentioned case is only the third to be reported till date, the first one being in 1992 in UK . HencefoStudying at all the three documented cases closely brings out some interesting facts, to enumerate firstly in all the three documented cases spontaneous bladder scar ruptures occurred about 3 to 4 years after the original bladder repair was carried out, in the earlier two cases exactly after 3 yrs, my case had the greatest time gap-that of 4 years. Secondly both my case and that reported in Nepal involved children (I don't have the details of the one reported in UK). In my view as bladder is subjected to tremendous pressure variations throughout the day, spontaneous scar dehiscence is likely as a result. It can be pointed out that children are on an even higher risk because because they are not as "toilet trained" as adults are, especially children who avoid voiding and hold urine for long periods of time. The above observations reinforce the need for proper patient education and that of regular follow up in cases of bladder rupture, at-least up to a minimum of 5 years after the primary repair procedure is carried out and more so in cases of bladder rupture involving children.It seems that bladder scar dehiscence is more common in children and that too within 4 yrs of the primary repair. Bladder rupture can be easily diagnosed early with a detailed history and imaging techniques like USG and AXR, confirmed by a cystogram or diagnostic peritoneal tapping. Most of the cases are not infected but should be put on IV antibiotics nevertheless. A surgical repair or the bladder should be done immediately on confirmation instead of trying to manage the case conservatively. Augmentation cystoplasty or urinary diversion should be considered in recurrent cases. I would also like to emphasize the need of proper education and toilet training for children as well as regular follow up after a primary bladder rupture repair, more so in the beginning 3 to 4 yrs of surgery.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The author declares that they have no competing interests.AS collected, analyzed and interpreted the patient data regarding the scar dehiscence of a previous repaired urinary bladder rupture. AS has been involved in drafting the manuscript or revising and has given final approval of the version to be published.