Retroperitoneal Schwannomas are uncommonly found in the retroperitoneum and few of them show malignant transformation and invasion. Local recurrence are common in malignant Schwannomas with very few reports of tumor distinct differentiation at recurrences.We report here a rare case of retroperitoneal schwannoma with multiple origins from retroperitoneum and pelvic wall. Pathological examination confirmed the case as a schwannoma with malignant transformation. Radical dissection of the tumors along with the sacrifice of adjacent sigmoid colon and left kidney failed to provide a cure for this patient. Due to tumor recurrence, a second and a third surgery of radical excision were performed 6 months and 17 months later after the first surgery, respectively. Histopathologic analysis identified that the recurrent tumors were different from the original schwannoma because of their smooth muscle-like differentiation.Malignant schwannomas are uncommon sarcomas with a high incidence of local recurrence. Distinct immunohistochemical staining results of the tumors at recurrence indicate their potential of smooth-muscle like differentiation. Radical excision of the tumors may provide benefit for their local recurrences. Schwannomas are a rare variant of peripheral nerve sheath tumors that seldomly develop to malignancy. In the absence of Recklinghausen's disease, these masses rarely occur in the retroperitoneum, which has a reported incidence of only 0.5-5% of all schwannomas ,2. SchwaA large mass in the left lower quadrant of the abdomen was found in a 51 year old male patient during physical examination and confirmed by computer tomography. The patient has no history of any cancer and no family history of neurofibromatosis. Lab tests results including blood routine, urine routine, serum chemistry, as well as examinations of several serum tumor markers such as Carcinoembryonic antigen (CEA), α-fetoprotin (AFP) and Carbohydrate antigen 19.9 (CA19.9) were all within normal ranges. Computed tomography scan confirmed a 15.0 × 12.3 × 10.0-cm enhancing heterogeneous mass with left kidney invasion arising from retroperitoneal space . All specimens from the three surgical resection were negative for CK, EMA, CD117 and SMA staining. Interestingly, the spindle cells in the first resected specimen were positive for S-100 Fig.  but negaMost previously reported cases of retroperitoneal schwannomas were solitary tumors except for a few reports of multiple tumors cases . Our casVery few Schwannomas were reported to undergo malignant transformation and invade adjacent viscera, including colon and kidney . AlthougSchwannomas have been reported to be coexisted with focal smooth muscle differentiation . ControvMalignant schwannomas are aggressive tumors that act as high-grade sarcomas with a high incidence of local recurrence or distant metastasis . RecurreRadical excision is considered to be the best way to treat retroperitoneal neural sheath tumors, however, considerable controversy exists concerning the soft tissue margins that are negative of tumor invasion . Some auMalignant schwannomas are uncommon sarcomas with a high incidence of local recurrence. Distinct immunohistochemical staining results of the tumors at recurrence indicate their potential of smooth-muscle like differentiation. Radical excision of the tumors may provide benefit for their local recurrences.Written informed consents were obtained from the patient for publication of this case report and accompanying images. Copies of the written consent are available for review upon request.The authors declare that they have no competing interests.WHY wrote the initial draft. LZQ and WHY contributed equally to this work. TLS is the guarantor. All authors read and approved the final manuscript.This study was partly supported by National Basic Research Program of China .Fig S1. Recurrent schwannoma. Schwannoma recurred at the retroperitoneal space 6 months later after the first surgery as indicated by arrow.Click here for fileFig S2. Tumor invading colon. Pathological findings showed the tumor invasion to the colon seromuscular layer. .Click here for fileFig S3. Tumor invading kidney. Pathological findings showed the tumor invasion to renal capsule. .Click here for file


Reoperation as a result of increased intracranial pressure (ICP) associated with cyst formation in an intracranial tumor resection cavity is a rare clinical condition. We report two cases of reoperation as a result of raised ICP associated with cyst formation in the tumor resection cavity, one arising after glioma resection and the other after meningioma resection. In both cases, a “valve”-like structure was noted intraoperatively in the roof region of the tumor resection cavity. Surgical resection of the “valve”-like structure led to slow regression over several months after the reoperation rather than to immediate disappearance of the cyst. Both cases illustrate that the “valve”-like structure formed in the roof region of the tumor resection cavity may be responsible for cyst formation. Surgical resection of it provides good long-term outcomes in such patients though short-term outcomes are unsatisfactory; we speculate that if the resection of the cortical tissue around the “valve”-like structure is enough wide, its return may be avoided. Raised intracranial pressure (ICP) is common in patients undergoing intracranial tumor resection. Reoperation as a result of raised ICP is an important prognostic factor, often resulting in a poor outcome. Raised ICP associated with intracranial tumor resection frequently arises as a result of hemorrhage in the tumor resection cavity, peritumoral cerebral contusion, cerebral edema, and/or hemorrhage at adjacent or remote sites –3. In coA 44-year-old female patient with a 1-year history of paroxysmal dizziness presented with an exacerbation of dizziness and nausea for 5 days. Physical examination revealed that she had poor memory and computation abilities without other focal neurological signs. A magnetic resonance imaging (MRI) scan of her head revealed a large zone of slightly elongated T1 or shortened T2 signal in her right temporal lobe. After administration of contrast agent, the lesion showed patchy heterogeneous enhancement or ring enhancement Figures . A diagnHowever, 3 days after surgery, she developed somnolence, mydriasis (pupillary diameter of 4.0 mm), disappearance of the light reflex in her right eye, and left limb paralysis. She had a Glasgow Coma Scale (GCS) score of 7. The patient received 250 ml of 20% mannitol and 40 mg of furosemide immediately to lower ICP. A computed tomography (CT) scan of her head revealed a hypodense area in the tumor resection cavity in the right temporal lobe, which led to deformation and dislocation of the surrounding tissue and the cerebral ventricle. Therefore, cyst formation in the tumor resection cavity was indicated . EmergenFive days after the reoperation, the patient again developed symptoms of high ICP and cerebral hernia. Repeat CT showed a recommencement of effusion in the tumor resection cavity and resealing of the roof region of the tumor resection cavity, suggesting possible reformation of the “valve”-like structure . A seconOne week later, a CT rescan of her head demonstrated that there was still effusion in the tumor resection cavity, and it was possible that the “valve”-like structure had reformed again . But becA 60-year-old women with a 2-month history of decreased memory presented with an exacerbation and nonfluent speech over the previous month. Physical examination revealed that she had incomplete motor aphasia without other focal neurological signs. An MRI scan of her head revealed a gourd-like area in the left frontotemporal region that spanned the anterior and middle cranial fossa. This abnormal area had a well-demarcated boundary, appearing as a slightly hypointense signal on the T1-weighted image, and as mixed isointense, slightly hyperintense and hypointense signals on the T2-weighted image. The left cerebral ventricle had become narrow as a result of compression. After contrast administration, the lesion showed heterogeneous enhancement Figures . A diagnPostoperatively, the patient's overall condition was good. However, her condition deteriorated 6 days after the operation. She developed somnolence, mydriasis of her left eye, right limb paralysis, and pathological reflex and had a GCS score of 7, suggesting the formation of a cerebral hernia. To lower ICP, the patient was given 250 ml of 20% mannitol immediately. An emergency CT scan of her head showed a patchy mixed density (mainly hypodensity) area in the tumor resection cavity adjacent to the temporal lobe. The ipsilateral cerebral ventricle was deformed as a result of compression, and the midline structure had shifted toward the right side, suggesting cyst formation in the tumor resection cavity. A band-shaped hyperintense shadow was noted in the intracranial subdural space, in which some shadows of gas density were scattered . EmergenOne week later, a CT rescan of her head revealed return of effusion in the tumor resection cavity, and it was possible that the “valve”-like structure had reformed again. But the roof region of the tumor resection cavity had become wider than before , and cyst fenestration by means of stereotactic or endoscopic techniques –19. For In case 1, postoperative CT reexamination revealed the opening and resealing of the roof region of the tumor resection cavity, suggesting possible disappearance and reformation of the “valve”-like structure (as shown by the arrows in In conclusion, we describe two cases of reoperation as a result of raised ICP owing to cyst formation in the tumor cavity following intracranial tumor resection. We hypothesize that the presence of a “valve”-like structure in the roof region of the tumor resection cavity is responsible for cyst formation in the cavity. Surgical resection of this and marsupialization of the cortex provide good long-term outcomes in such patients though short-term outcomes are unsatisfactory, and we speculate that if the resection of the cortical tissue around the “valve”-like structure is wide enough, the problem may be avoided.


To the best of our knowledge, the association between air travel and intra-tumoral hemorrhage in pediatric populations has never been described previously.We report the case of a two-and-a-half-year-old Caucasian, Iranian boy with a hemorrhaging brain tumor. He had a posterior fossa midline mass and severe hydrocephalus. He had been shunted for hydrocephalus four weeks earlier and was subsequently referred to our center for further treatment. The hemorrhage occurred in an infra-tentorial ependymoma, precipitated by an approximately 700-mile air journey at a maximum altitude of 25,000 feet.A pre-existing intra-cranial mass lesion diminishes the ability of the brain to accommodate the mild environmental disturbances caused by hypercarbia, increased venous pressure and reduced cerebral blood flow during long air journeys. This is supported by a literature review, based on our current knowledge of physiological changes during air travel. Hemorrhage into brain neoplasms is a relatively uncommon but not a rare occurrence with obvious relevance to the neurosurgeon. In general, about 5% to 10% of all brain tumors develop hemorrhage of some type. The tissue type of the tumor itself is clearly related to its propensity to bleed, as metastatic lesions are known to carry a high risk of hemorrhage. Of the primary brain tumors, glioblastoma appears to be the most common source of intra-cerebral hemorrhage. Oligodendrogliomas, astrocytomas, ependymomas and medulloblastomas have also been associated with intra-cranial hemorrhage. Less commonly, benign tumors such as pituitary adenomas and meningiomas have also been demonstrated to bleed [Several pathophysiological factors have been described to account for spontaneous hemorrhage within brain tumors, including coagulation defects and vascular abnormalities . HoweverTo the best of our knowledge, two adult cases of hemorrhage within brain tumors after air travel have been described before . The assA two-and-a-half-year-old Caucasian boy with posterior fossa midline mass and severe hydrocephalus was brought to our emergency room immediately after completing a 700-mile air flight. He was generally well before the flight suffering from moderate ataxic gait and lower cranial nerve involvement. About 40 minutes into the flight, he had developed severe headache and retractable vomiting leading to rapid onset loss of consciousness. He had been shunted for hydrocephalus four weeks earlier and was subsequently referred to our center for further treatment. Brain computed tomography (CT) and magnetic resonance imaging (MRI) were performed before referral, which had demonstrated satisfactory decompression of the hydrocephalus without hemorrhage signal inside the tumor bed Figure .On admission, he was unconscious, unable to follow commands, but able to localize painful stimuli. He had apneustic breathing but bilateral reactive pupils were retained. Over the next few hours, he developed severe hypoxia that necessitated mechanical ventilation. A brain ultrasound confirmed normal-sized ventricles but without any new information about the posterior fossa mass. Given the fact that cerebrospinal fluid shunting had been carried out several weeks earlier, upward herniation was assumed an unlikely event. He was admitted to the pediatric intensive care unit (PICU) and revealed that he was given high-dose dexamethasone and supportive therapy with the initial diagnosis of brain stem compression due to the tumor mass. Three days after admission, his condition had not changed and he underwent resection of the tumor through a midline sub-occipital approach.During the operation, the posterior fossa was very tense through the exposed field. There was blood-tinged cerebellum in the midline with a small subdural clot. The tumor was soft, reddish-gray, amenable to suction and highly vascular containing a large area of hemorrhage Figures  and 3. IChildren with posterior fossa ependymomas most often have slowly evolving signs and/or symptoms of intra-cranial hypertension or cerebellar dysfunction. However, there are rare occasions where the tumor can lead to a severe illness. Hemorrhage into these tumors is not rare and might present as apoplexy -7. The mHowever, the pathophysiological mechanisms by which air travel could predispose the tumors to bleed are not fully-understood. Decreased barometric pressure, hypoxemia, and local hemostatic abnormalities are well-known physiological changes during air travel.Commercial airplanes cruising at typical altitudes of 30,000 to 40,000 feet partially pressurize their cabins to the atmospheric pressures found at 5000 to 8000 feet, or 552 to 632 mmHg. Due to the resultant decrease in the partial pressure of oxygen in the inspired air, blood oxygen saturation levels of as low as 85% may be reached . Due to Additionally, local tissue ischemia may be a manifestation of decreased perfusion due to hypovolemia. The most commonly reported in-flight malady is syncope. Venous pooling of blood in the lower extremities as a result of prolonged sitting combined with dehydration from low cabin humidity and poor fluid intake have been reported to contribute to intra-vascular volume depletion. However, cerebral vasculature may be able to compensate for this through normal autoregulatory mechanisms, which are lacking in the tumor vascular structure .An alternative hypothesis concerns the role of decreased cabin pressure resulting in an increase in tumor venous pressure due to transmission of mildly increased intra-abdominal pressure through the inferior vena cava and cranial dural sinuses. At a cabin pressure of 575 mmHg, gas expands to 132% of its baseline volume at sea level . Expansi2 in commercial flights. Cabin air undergoes a degree of recycling as well as exchange with atmospheric air. This process leads to an increasing inspired fraction of CO2 levels in aircraft cabins during flight. US federal aviation law specifies a CO2 level of less than 0.5% in the cabin air [Another mechanism may be related to increased levels of inspired COabin air . Howeverabin air ,10 and c2, oxygen levels and interior pressure. Therefore, it seems reasonable to assume that these physiological changes pose an additional risk of hemorrhage into brain tumors in decompensated individuals.The sudden onset of neurological deficits in our patient, who had previously been well and with a functioning shunt, suggest bleeding in the pre-existing intra-cranial tumor, which was confirmed intra-operatively. The possible mechanisms of bleeding in the highly vascular and potentially hemorrhage-prone tumor in our patient during flight can be more than a coincidence and might be related to fluctuation of cabin CO2 may be considered for these patients during air travel. In spite of all the suggested mechanisms, we believe that in order to offer thorough guidelines for patient care during flight, further studies need to be carried out with respect to the effects of air travel on health.Although obviously rare, this case together with previously described cases suggest that it is reasonable to caution patients with a known intra-cranial mass lesion about the possible risks of commercial flight. Prophylactic medications such as steroid agents, acetazolamide, and supplementary OThe authors declare that they have no competing interests.AM, NB and FN managed our patient and collected and interpreted our patient data regarding the disease and the possible mechanism of hemorrhage during flight. ME helped during management and was a major contributor in writing the manuscript. MM performed the histological examination of the tumor sample. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's parents 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.


Jejuno-jejunal invagination is a rare condition and is usually caused by a benign lesion. We describe the case of a patient with a jejunal epithelioid sarcoma. Epithelioid sarcoma is a rare histologic subtype of sarcoma and few cases have been published.A 70-year-old Caucasian man presented with vomiting and anemia. A jejuno-jejunal invagination was diagnosed and the patient underwent surgery. An epithelioid sarcoma of the wall of the jejunum was found on the invaginated ansa.To the best of our knowledge, an epithelioid sarcoma has never been reported to arise at the wall of the proximal jejunum or to present with jejuno-jejunal invagination. Adult jejuno-jejunal invagination is unusual  and it pEpithelioid sarcoma (ES) is a distinct clinicopathologic entity. This tumor is a relatively rare soft tissue neoplasm of unknown histogenesis. It is usually a slow-growing tumor and mostly occurs in the distal extremities of young adults. Both local recurrence and metastasis are common . An aggrStaphylococcus aureus infection of a hip prosthesis in the Orthopaedic Surgery Department, was found to have anemia. His skin was pale, blood pressure was 90/60 mmHg, hemoglobin (Hb) had dropped to 9.4 g/dl  but his mean corpuscular volume was normal.A 70-year-old Caucasian man, who was being treated for a A few days later, the patient complained of nausea and vomiting after meals; his Hb had decreased to 7.6 g/dl and he was given a blood transfusion. A fecal occult blood test was positive, an abdominal X-ray was unremarkable showing no air fluid levels, and an endoscopic examination of his stomach was inconclusive, showing only food remains. Bilious postprandial vomiting ensued and melena appeared. The patient's Hb level continued to fall, and repeated blood transfusions were required. A new endoscopic examination of his stomach was scheduled to evaluate his duodenum, but no pathology was found. Total colonoscopy, including visualization of the terminal ileum, was performed but found no lesions. The patient developed severe vomiting.An abdominal computed tomography (CT) scan was carried out, revealing one thickened ansa in the proximal jejunum, which suggested an invagination. There was also intense intravenous contrast uptake at this location Figure .The patient underwent laparotomy and, during surgery, it was discovered that in fact a jejuno-jejunal invagination was present at the location of an intestinal tumor. Reduction was impossible and resection was performed, followed by an end-to-lateral mechanic anastomosis with CEEA 25 Figure .In the anatomopathological examination, a malignant neoplasm was found. It had undifferentiated characteristics, large cells with bizarre nuclei and abundant granulocytic infiltrate. Histochemical markers revealed epithelioid features Table  of an unSerum tumor marker levels for carcinoembryonic antigen (CEA) were normal, but CA 125 was elevated . Both the thoraco-abdominopelvic CT scan performed with intravenous contrast and the positron emission tomography (PET), performed 1 month after surgery revealed no remaining or new lesions.Less than 3% of all gastrointestinal invaginations occur in adult patients and the most common location on the small bowel is at its distal end, either ileo-ileal or ileo-colic. Principal symptoms are diffuse abdominal pain, nausea, vomiting and interruption of stool and gas emissions. Melena and hematochezia may be present.Clinical presentation may be acute, with complete mechanical obstruction, eventually with strangulating injury, or chronic, with relapsing abdominal pain, relieved by spontaneous reduction. In some instances, the condition has been present for months or years at the time of diagnosis. Frequently, the diagnosis is made intra-operatively, on the occasion of urgent exploratory laparotomy performed for obstruction, hemorrhage or perforation.The abdominal CT scan has both the highest sensitivity and specificity in this situation. Longitudinal images are likened to a 'sandwich' and transverse ones to 'bulls' eyes' or 'doughnuts'.It has been estimated that 80 to 90% of all intestinal invaginations occur at the location of a structural lesion of the bowel wall and 14% of those are malignant tumors. Even though it is the longest segment of the digestive system, small bowel tumors represent no more than 3% of all gastrointestinal neoplasms . Only 2%Undifferentiated tumors are those that lack microscopic features of tissue differentiation. Further study of these lesions has been enhanced in recent years by increasingly available immunohistochemical assays, which often allow some differentiation to be established .Since there is no specific marker, the rather challenging diagnosis of ES was reached in our patient by combining the evidence and ruling out more frequent candidates. Epithelioid differentiation was established by the presence of low molecular weight cytokeratins, namely CK 8, CK 18 and CK 19 which cause CAM 5.2 antibody positivity, and by a mixture of several keratins signaled by the AE 1/AE 3 antibody .ES is a rare soft tissue sarcoma with a known tendency for local recurrence, originally described by Enzinger in 1970 [Lately, an aggressive subtype of ES has increasingly been recognized, the 'proximal-type/axial-type' ,8 descriLocal surgical resection is the single consistently proposed treatment and it need not include lymphadenectomy, since this has not been shown to influence prognosis . The docThis is an extremely unusual clinical case where a rare tumor, an epithelioid sarcoma , was found at the proximal jejunum, a location where it had not previously been described. Furthermore, it presented with jejuno-jejunal invagination, which is also uncommon.CT: computed tomography; CEA: carcinoembryonic antigen; ES: epithelioid sarcoma; Hb: hemoglobin; JI: jejunum invagination; PET: positron emission tomography; UT: undifferentiated tumor.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.AB performed the pre-operative study, took part in the surgery, followed the patient, reviewed the literature and was a major contributor in writing the manuscript. HB performed the surgery and reviewed the manuscript. CP participated in the literature review. FM reviewed the final text. All authors read and approved the final manuscript.


Solitary necrotic nodule of the liver is a rare lesion, with similar radiologic findings to those of hepatic metastases or other liver masses.We here report a case of a 30-year-old male with hepatic solitary necrotic nodule discovered after an episode of acute abdominal pain and high grade fever. Routine laboratory data revealed leukocytosis and abnormal liver function. The imaging features of the lesion suggested malignancy or liver adenoma. The patient underwent surgical resection of segments V and VI. Histology was compatible with solitary necrotic nodule and localized vein thrombosis at the periphery.Solitary necrotic nodule of the liver is a benign lesion which can mimic liver malignancies. Abdominal imaging and liver biopsy are often equivocal. In such circumstances liver resection is mandatory to exclude HCC or other malignant liver lesions. A 30-year-old Caucasian male with, no prior medical history, presented at the Emergency Department with acute right upper quadrant pain, high grade fever (38.5 C) and vomit.Laboratory tests revealed marked leukocytosis (WBC: 19810/ml) and abnormal liver function tests . Serology profile for hepatitis B or C was negative. A previous history of alcohol abuse was not documented.Abdominal US revealed a 7 cm hyperechoic lesion at the right liver lobe.Computed tomography demonstrated a single lesion, located in segments V and VI, with hemorrhagic features. After contrast administration the lesion appeared to be encapsulated with peripheral enhancement, a necrotic core and contrast wash out at the venous phase. These findings were suspicious for adenoma or HCC although fever and leukocytosis suggested a possible infectious process. No dilatation of the intra- or the extra-hepatic biliary ducts was noted. A lateral displacement of the gallbladder was documented Figure .The patient was admitted and initially treated with systemic broad spectrum antibiotics. However blood cultures and antibodies for Echinococcus and Entamoeba histolytica were negative.Tumor markers including CA 19-9, a-Fetoprotein and CEA were within normal range.A CT-guided core-needle biopsy was performed and revealed numerous lymphocytes and necrotic material but not atypia. Gram stain and Tissue cultures were negative.The patient was treated with intravenous antibiotics for 7 days until fever subsides with complete white cell count normalization and followed by CT scan two weeks later. Due to high suspicion for a malignant process, anatomic liver resection including segments V and VI was performed. Intraoperatively, the liver had a normal appearance and a solid mass, well encapsulated without gallbladder invasion was identified.Pathology was associated with hemorrhagic infarct and extensive hepatocellular necrosis, due to sinusoidal portal vein thrombosis. Furthermore hepatoportal sclerosis and non-cirrhotic portal vein fibrosis was identified. An eosinophil granular matter combined with calcifications, cholesterol, foam cells, and some inflammatory cells was noted.The patient had an uneventful course, discharged the 6th postoperative day and remains well 6 months postoperatively.Solitary necrotic nodule (SNN) of the liver is a rare benign lesion first reported in 1983 by Shepherd and Lee [In the majority of cases, this condition is clinically silent, and often the patients complain of nonspecific symptoms such as right upper quadrant pain. SNNs are usually first detected incidentally at US examination .Lobular shape, well-delineated margin, and close proximity to the hepatic inflow structures, are suggestive of SNN, but are nondiagnostic. SNN usually appears as a well-defined lesion with no enhancement on contrast CT or MRI ,4, althoIn our case reported, patient presented with a history of high grade fever and leukocytosis suggested an infectious process. CT findings were associated with a single lesion enhanced peripherally after contrast infusion with venous wash out. A necrotic center with intralesional bleeding was also identified. In this situation diagnosis of HCC or adenoma is possible and difficult to exclude even with needle core biopsy.The etiology of SNN is still uncertain. Sclerotic evolution of small hemangiomas because of the finding of a "feeding vessel" or trauma with or without previous parasitic infestation -9 is sugSurgical resection is strongly recommended by our team in agreement with the literature ,10,11 duSNN of the liver is a lesion without malignant potential. Nevertheless it can mimic HCC, metastasis, abscess or non-specific disease both clinically as well as imaging-wise. Therefore it is important to exclude hepatic malignancy.Although the behavior of this lesion is benign diagnosis is usually uncertain making surgical resection imperative.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.SD, DK, AS and CD analyzed and interpreted the patient data. CT and IP interpreted the computed tomography image. All authors read and approved the final manuscript.


Inflammatory eosinophilic pseudotumor of the bladder is a rare inflammatory bladder disease. The etiology and pathophysiology of this condition are still unclear. Few case reports have described inflammatory eosinophilic pseudotumor of the bladder in adults or children. Although benign, this disease is occasionally clinically aggressive and locally invasive, thus open surgical removal or complete transurethral resection is recommended.We present the case of a biopsy-proven inflammatory eosinophilic pseudotumor of the bladder in a previously healthy 16-year-old male adolescent with 2-month history of frequent micturition and dysuria with no significant apparent causative factors. The tumor regressed after a 6-week course of glucocorticosteroids.To the best of our knowledge, our case is a rare case of inflammatory eosinophilic pseudotumor of the bladder treated with complete conservative management. Due to its glucocorticosteroid-sensitive nature, we postulate that this disease belongs to a subgroup of eosinophilic disorders. Inflammatory eosinophilic pseudotumor (IEPT) of the bladder is a rare, benign and proliferative lesion of the submucosal stroma . The firIn September 2005, a previously healthy 16-year-old boy was admitted to a local hospital with 2-month history of frequent micturition and dysuria, but no apparent causative factors. The patient had no known history of drug allergies. Physical examination revealed a palpable suprapubic mass. Urine analysis showed no evidence of infection. An ultrasound examination revealed a bladder mass. Computed tomography (CT) of the abdomen and pelvis revealed a solid homogeneic mass involving the wall of the dome and two lateral walls of the urinary bladder; the average thickness of the bladder wall was 1.9 cm Figure . CT scan3 (0.05×109/l). The biochemistry tests did not show any abnormalities. Blood sedimentation rate was 11 mm/h and the level of serum C-reactive protein was 3.20 g/l. Serum levels of immunoglobulin (Ig)E, IgG, IgM and IgA1 were in the normal range. Occurrences of the lesion in other parts of the patient's body were excluded by physical examination and auxiliary examinations.Cystoscopy revealed homogeneic evagination of a solid submucosal mass at the dome, and two lateral walls of the bladder, but the mucosa on the tumor surface had integrity with no hemorrhagic spots. The patient was then transferred to our hospital. Results of a magnetic resonance imaging (MRI) scan were the same as the previous CT scan. Urodynamics indicated an unstable bladder with a volume of 70 ml. Reflection of the detrusor muscle was normal, as was coordination with the external sphincter, with no obstruction. Six tissue specimens were procured by transurethral resection on cystoscopy. The pathology report on the tissue biopsies indicated chronic inflammatory change with no evidence of malignancy, and a large quantity of eosinophilic cell suffusion infiltration accompanied by spindle cell proliferation. The blood count showed 1% eosinophil granulocytes, with an absolute value of 500/mmPrednisone, a glucocorticosteroid, was administered orally (20 mg/day), along with 200 mg  of ranitidine to treat vomiting symptoms after the MRI scan. Two weeks later, the symptoms and frequency of dysuria had subsided and an ultrasound check showed that the average thickness of the bladder wall had decreased from 1.9 cm to 1.2 cm. The patient was discharged. Four weeks later, the average thickness of the bladder wall had further decreased from 1.2 cm to 0.8 cm. After 6 weeks of glucocorticosteroid therapy, the patient completely recovered, was asymptomatic and had a normal bladder. A follow-up 3 years later revealed an asymptomatic patient and ultrasonic inspection and cystoscopy showed no evidence of disease recurrence.IEPT of the bladder is a benign proliferative lesion of the submucosal stroma, also regarded as a rare and poorly understood form of allergic cystitis, that is, eosinophilic cystitis . ManifesCurrent treatment modalities include transurethral resection of the bladder lesion along with nonspecific medical therapy, such as nonsteroidal anti-inflammatory agents, steroids or antihistamines. Although benign, this disease is at times clinically aggressive and locally invasive ,4. The pThe etiology of IEPT of the bladder is unclear -3. CausaIt is generally thought that IEPT belongs to the inflammatory pseudotumour (IPT) disease group . BecauseAs the pathology test results show in Figure To the best of our knowledge, this case of an inflammatory pseudotumor of the bladder is one of only a few cases reported in the literature that have been treated with complete conservative management . AccordiBCG: Bacille Calmette-Guerin; CT: computed tomography; IEPT: inflammatory eosinophilic pseudotumor; Ig: immunoglobulin; IL: interleukin; IPT: inflammatory pseudotumour; MRI: magnetic resonance imaging; TH: T helper;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.YL and DX managed the patient and reviewed the literature. YG and JR were the main writers of the manuscript. CM, XZ and CQ moderated the manuscript. All authors read and approved the final manuscript.


Patient. A 62-year-old man presented with effort dyspnea, non-productive cough and weakness of 4 month duration. He had no findings on physical examination.Discussion. Chest X-ray revealed a large mass in the left anterior mediastinum. Computerized tomography of the chest showed a well-delineated homogeneous mediastinal mass with fat-equivalent density and a small pleural effusion. Fiberoptic bronchoscopy revealed narrowing of the left main bronchus, secondary to external compression. The bronchial mucosa was normal and brush cytology was negative. A CT-guided fine needle aspiration (FNA) of the mass yielded fragments of cells embedded in myxoid background material and closely packed atypical lipoblasts, compatible with liposarcoma. The patient underwent a left lateral thoracotomy and margibnal resection of the mass. The histopathological examination confirmed the diagnosis of mixed-type liposarcoma, consisted of myxoid and pleomorphic liposarcoma. Postoperative two-field radiation therapy was delivered to the mediastinum for a total midplane dose of 40 Gy. After a disease-free interval of 8 months the disease recurred in the mediastinum and pleura. Palliative chemotherapy achieved a short duration partial response but the patient succumbed to local recurrence 2 years after the diagnosis.


We report a case of isolated, unilateral avulsion of the vastus lateralis tendon from its insertion at the patella. This was diagnosed by magnetic resonance imaging, and underwent successful surgical repair.A healthy 32-year-old national level power lifter presented with an isolated avulsion of the vastus lateralis tendon. After a failed course of conservative therapy he underwent surgical repair and a graded physical therapy programme. One year later he returned to full training with no evidence of re-rupture.This is the first reported case of an isolated vastus lateralis avulsion. Our experience suggests that magnetic resonance imaging is invaluable in the diagnosis of this condition and that surgical repair provides a good outcome in high demand patients. Quadriceps tendon rupture is a well recognized, debilitating condition, often requiring surgical intervention to restore normal knee function -5.The vastus lateralis is one of the four muscles that make up the quadriceps mass. It arises from the inter-trochanteric line, base of the greater trochanter and lateral linea aspera and inserts into the superior-lateral pole of the patella as a distinct tendinous entity ,7.Quadriceps tendon rupture is thought to primarily manifest in tendons with a pre-existing degenerate ultrastructure. This is typically as a consequence of metabolic diseases such as chronic renal failure, systemic lupus erythematosus (SLE), and diabetes ,3-5,8. IQuadriceps tendon rupture is uncommon and may be unilateral, bilateral, complete or partial -12. BilaWe describe the first reported case of an isolated vastus lateralis avulsion which was suspected clinically, diagnosed by MRI and underwent surgical repair.A 32-year-old, Australian Caucasian man who was a national competing power lifter was referred to our specialist sports clinic 8 weeks after experiencing sudden intractable pain in his left knee, accompanied by a loud popping sound, whilst leg pressing 300 kg. Weight bearing and extension of his left leg were subsequently limited as a result of pain. Prior to attending our clinic, he had been managed non-operatively by his General Practitioner and a Physiotherapist, who had provided him with a knee brace for support. Despite this, he suffered continued pain and weakness, but denied any locking, giving way or instability.He was a non-smoker, with no past medical problems and expressly denied using systemic steroids. He had not previously experienced any knee problems. Clinical examination revealed left quadriceps wasting in comparison to the contra-lateral leg with a palpable gap over the superior-lateral aspect of his patella. Knee flexion, in particular squatting, evoked pain and accentuated the gap. This also further demarcated the prominent, retracted vastus lateralis muscle belly . A normaBlood tests showed no evidence of haematological or metabolic abnormality.Anterior-posterior, lateral and skyline patella radiographs of the knee showed no diagnostic irregularity and no evidence of femoral trochlea dysplasia or variation in patella height or tilt. MRI demonstrated a complete and isolated avulsion of the vastus lateralis component of the quadriceps tendon in the osteotendinous region at its patella insertion . The patIntra-operative findings confirmed an avulsion of vastus lateralis with a residual stump of osteotendinous tissue still attached to the patella . The remPost operatively the knee was immobilized in an extension brace restricting movement from 0-45° for six weeks with protected weight bearing . At thisClinical diagnosis of quadriceps tendon rupture is not always straightforward, and imaging is often required for confirmation ,10. StanSurgical repair is widely recommended for cases of complete rupture to prevent long term functional impairment ,8,11-13.While isolated vastus lateralis avulsion has not been described, Bikkina et al.  and LewiOur case illustrates that partial quadriceps tendon rupture may occur purely due to excessive mechanical forces and in this scenario appears to yield good results with surgical repair even in high demand individuals.This is the first reported case of an isolated avulsion of the vastus lateralis tendon. For an elite athlete this is a potentially debilitating condition and may be overlooked by clinicians because of the integrity of the vast proportion of the Quadriceps tendon. This case report raises awareness of this condition and indicates that surgical repair is successful in expediting recovery in high demand individuals.


Cutaneous neoplasms including sebaceous tumors, keratoacanthomas, and basal cell carcinomas with sebaceous differentiation can be markers of internal malignancy associated with the Muir-Torre Syndrome (MTS). We report a 56-year-old man with a diagnosis of hereditary nonpolyposis colorectal cancer (HNPCC) and ureteral transitional cell carcinoma who subsequently developed two sebaceous gland neoplasms and several keratoacanthomas, leading to the diagnosis of MTS. Our case highlights the clinical advantages of immunohistochemistry (IHC) in identifying mutations in the mismatch repair (MMR) genes responsible for both HNPCC and MTS. The importance of continued clinical suspicion in the dermatological assessment of patients with sebaceous neoplasms is emphasized. Usually diagnosed clinically by the synchronous or metachronous manifestation of a sebaceous neoplasm and visceral malignancy, most commonly colon cancer, MTS was first described by Muir et al. in 1967 and subsequently by Torre in 1968 . Later, Although MTS is a rare, autosomal genodermatosis, the serious but curable nature of its associated cancers makes early identification paramount. In such, cutaneous neoplasms can serve as visible markers of internal malignancy. The most important of these being sebaceous adenoma, a relatively rare but benign tumor that presents as yellow papules or nodules and acts as the most specific marker of MTS , 5.Our patient first presented with a change in bowel caliber and fatigue. During his interview, a significant family history of cancer was identified with five of his ten siblings diagnosed with a variety of cancers. Specifically, a sister diagnosed with colon cancer, a brother diagnosed with kidney cancer, another brother diagnosed with two colon cancers, a third brother diagnosed with two colon cancers and skin cancer, and a fourth brother diagnosed with two colon cancers, ureter cancer, and skin cancer. Additionally, his father was diagnosed with colon cancer in his late forties and his paternal uncle was diagnosed with colon cancer. With a presentation and family history consistent with HNPCC, he was initially evaluated with a pelvic-computed tomography (CT) scan. After visualization of a 3.5 × 5.5 cm mass near the ileocecal valve, an endoscopy-guided biopsy of the mass was performed. Pathology characterized the mass as an adenocarcinoma with moderate differentiation. A subtotal colectomy followed which confirmed the biopsy results. No serosal invasion or lymph node involvement was noted. Following the colectomy, he elected to pursue research-based testing of the MSH2 and MLH1 genes, the most common MMR proteins implicated in HNPCC [A year later, he noticed hematuria and a lower abdominal mass. A pelvic CT was ordered which showed right hydroureteronephrosis, but no external mass. This was followed up with an intravenous pyelogram (IVP) and urinary cytology. The IVP confirmed the hydroureteronephrosis and cytologic examination showed numerous small, atypical cells with a high nuclear-cytoplasmic ratio highly suspicious for malignancy. A low-grade urothelial carcinoma was found in the right ureter and a right nephroureterectomy was performed. With no results forthcoming in the research-based testing of MMR genes and a growing concern for other family members, he decided to pursue clinical genetic testing. DNA sequencing for both MSH2 and MLH1 was undertaken. However, no explainable mutation was discovered and uncertainty remained. The patient presented to our dermatology clinic with concerns of a flesh-colored papule on his left cheek. Surgical excision and skin biopsy were performed and identified a sebaceous adenoma. With the presentation of this sebaceous neoplasm and his history of visceral malignancy, a new diagnosis of MTS was made. The following year, a similar lesion was removed from his chin and biopsy identified a keratoacanthoma. Still without the identity of the causative mutation, he decided to pursue additional clinical genetic testing utilizing new Southern blotting technology in the screening of MSH2 and MLH1. This study finally identified a deletion of exons 1 through 7 in the MSH2 gene. With an explanation for his personal cancers and family history, genetic testing was offered to his extended family. Since the mutation has been identified, he has undergone regular colonoscopies, urinary cytologic analysis, dermatologic assessment, and monitoring of carcinoembryonic antigen (CEA). Colonoscopy and urinary cytology have been negative and CEA levels have been stable. Subsequent biopsies of a variety of skin papules have confirmed a sebaceous carcinoma and a second keratoacanthoma .Although MTS generally presents as a sebaceous neoplasm plus colorectal adenocarcinoma, a secondary diagnostic criterion includes multiple keratoacanthomas associated with visceral neoplasms and a family history of MTS . The intCancer surveillance and early identification of these tumors are important for the implementation of proper treatment regimens. Because sebaceous tumors can serve as visible markers of internal malignancy in MTS, a detailed dermatologic exam is important in these patients. Sebaceous hyperplasia and solitary keratoacanthoma, relatively common findings in the general population, are not considered markers of MTS, but all other sebaceous neoplasms, including sebaceous adenoma, sebaceoma, and carcinoma, are considered highly specific markers of MTS . Sebaceous adenoma, the most common lesion in MTS, presents as tan or yellow neoplasms that contain a spectrum of cells ranging from germinative or basaloid to fully mature sebocytes. Pleomorphism is exceptional in cases of sebaceous adenoma . SebaceoWhenever multiple sebaceous tumors are identified involving any site or any sebaceous tumor is discovered outside of the head and neck region, especially in a young person <50 years), a thorough work-up for MTS is necessary. The initial test should be IHC, using antibodies to bind specific cellular antigens, to determine the presence or absence of MMR proteins [0 years, MMR genes encode proteins that recognize and remove improper genomic insertions and deletions, and nucleotide mismatches that arise during DNA replication and recombination. Collectively these genes maintain the integrity of the genome and prevent mutations from accumulating. In MTS, individuals are born with one defective copy of an MMR gene and acquire a second somatic mutation in the other allele during their lifetime . InteresThe first mutations identified in MTS involved the MMR genes MSH2 and MLH1, the same genes known to cause HNPCC. This insight has led MTS to be considered a phenotypic variant of HNPCC , 8. SubsIHC, assessing MSH2, MLH1, and MSH6 activity, and microsatellite instability (MSI) analysis are currently the two main screening tests for MTS. Using a combination of these tests, most cases of MTS should be identified after a thorough clinical examination and family history. The recent advances in IHC and MSI analysis have made the diagnosis of MTS much simpler.Although screening MMR genes for mutations can detect MTS genotypes, the protracted nature of these tests and the fact that not all causative mutations are known make these mutation screenings a poor first diagnostic choice. The shortcomings in mutation screenings are highlighted by the difficulty our patient had in identifying a mutation and the many years before this technique obtained clear results. Because early diagnosis of MTS is essential for both the patient and their extended family, we believe that mutational screenings are not the best initial diagnostic approach. We agree with recent proposals to use IHC as the initial screening test assaying MSH2, MLH1, and if both of these are negative MSH6 . MSI anaIt is the responsibility of dermatologists to carry a strong suspicion when evaluating sebaceous tumors, especially those with an unusual presentation. The proper tests and early detection of malignancies will hopefully allow patients with MTS to reach normal life expectancies.


The spontaneous rupture of a parathyroid adenoma accompanied by extracapsular hemorrhage is a rare, potentially fatal, condition and is a cervicomediastinal surgical emergency.This report describes an atypical two-step spontaneous rupture of an asymptomatic parathyroid adenoma in a 56-year-old Caucasian woman who presented with a painful mass in the right side of her neck.Based on this case report and similar cases reported in the medical literature, a diagnosis of extracapsular parathyroid hemorrhage should be considered when a non-traumatic sudden neck swelling coexists with hypercalcemia and regional ecchymosis. Hypercalcemia is the most common clinical sign of a parathyroid adenoma . HemorrhPatients usually present with a palpable lateral neck mass with signs of ecchymosis, appearing slowly 24 to 48 hours after the sudden onset of neck discomfort, dysphagia, dyspnea, or hoarseness ,24. SuchThis case report describes a patient who experienced a two-step spontaneous rupture (with extracapsular bleeding) of a large (probably long-standing) asymptomatic parathyroid adenoma. To the best of our knowledge, this is the first report of such an atypical modality of parathyroid adenoma rupture.In April 2007, a 56-year-old Caucasian woman with a painful, right-sided neck mass presented to a private practitioner. Ultrasound (US) suggested a clinical diagnosis of subacute thyroiditis, which was not supported by subsequent laboratory tests . Two days later, the patient had an exacerbation of the latero-cervical pain which prompted a repeat US of the neck, which revealed an iso-echoic lesion (51.3 mm in size), apparently included within an enlarged right thyroid lobe (83.5 mm). The lesion was interpreted as an intrathyroid hematoma Figure  and the The patient was referred to the Special Surgical Pathology Department at Padova University Hospital, where computed tomography (CT) showed a laterocervical hemorrhagic lesion, extending from the lateral neck to the right prevertebral/paratracheal spaces Figure ; a distiGross section of the surgical specimen revealed a three-layered lesion consisting of peripheral areas of  hemorrhagic material, invading a more internal, compact  zone around the core of the specimen, which consisted of necrotic parathyroid remnants Figure . MultiplA 9-month follow-up including clinical evaluation, serology and US, revealed no clinical abnormalities.Spontaneous neck hemorrhage is a rare, frightening surgical emergency, usually resulting from the traumatic rupture of vessels or from generally spontaneous thyroid or parathyroid extraglandular bleeding. A parathyroid intra- and extracapsular hemorrhage is a serious, potentially fatal, complication of parathyroid gland enlargement due to hyperplasia, adenoma or cancer. The physiopathological mechanisms behind such non-traumatic bleeding are not known. They probably stem from an imbalance between cell growth and blood supply, a situation prone to the onset of necrotic-hemorrhagic foci, which may ultimately spread outside the glandular structure; this mechanism has been considered similar to the apoplexy seen in other endocrine neoplasia .et al., however, a clinical triad consisting of acute neck swelling, hypercalcemia, and neck and/or chest ecchymosis strongly point to this clinical hypothesis [Capps first documented a fatal case of spontaneous massive parathyroid hemorrhage with cervical/mediastinal infarction in 1934, which was only assessed at post-mortem examination . To datepothesis . Table 1The differential diagnosis of non-traumatic lateral-neck bleeding involves thyroid lesions, cyst or nodular goiter, subacute thyroiditis, and parathyroid conditions, such as adenoma, hyperplasia or cancer ,14,24. AIn our patient, the clinical history of a bland presentation, quiescent interval and final emergency, and the pathological features of the resected mass are both consistent with a spontaneous rupture of a parathyroid adenoma in two successive stages. As described in many other parenchymal organs here too we can assume that an initial episode of paucisymptomatic intracapsular bleeding progressed to a capsular rupture resulting in a massive cervical and/or mediastinal infarction.This case should alert physicians that parathyroid extracapsular hemorrhage needs to be considered among the list of non-traumatic surgical neck emergencies and, in line with the current literature, any neck swelling, variably associated with "mass" symptoms such as dysphagia and/or dyspnoea, in association with hypercalcemia and regional ecchymosis, should strongly point to this clinical hypothesis.The authors declare that they have no competing interests.All authors of this paper have participated directly in the planning, execution, or analysis of the study, and have read and approved the final version submitted.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.


Intussusception of the large bowel is a rare clinical entity. In adults, this pathology is usually associated with a malignant lead point and often requires operative management. Reported is the case of an 83-year-old female who was recently diagnosed with superficial bladder cancer (T1) treated by partial cystectomy. She presented 3 months post-operatively with an isolated mucosal metastasis of the transverse colon causing intussusception and large bowel obstruction. The patient was successfully treated by colonic resection with primary anastomosis. Histology was significant for a pedunculated sarcomatoid bladder carcinoma originating from the colonic mucosa with incomplete invasion of the bowel wall. An isolated mucosal metastasis of this variety has not been reported in the literature to date. Metastatic disease from a primary genitourinary neoplasm has a typical pattern, with involvement of lymph nodes in the pelvis, liver, lung, bone, and adrenal glands. Histologic evaluation most commonly demonstrates transitional cell carcinoma, and less often squamous cell carcinoma. A sarcomatoid variant of bladder cancer is an extremely rare clinical entity with a reported incidence of only 0.31% . PresentAn 83-year-old white female presented to the Emergency Department with a four-week history of progressively worsening epigastric abdominal pain and a four-day history of obstipation. Her past medical history was significant for hypertension and bladder cancer diagnosed 3 months prior to presentation, treated by partial cystectomy. Her pathology at that time was significant for a superficial bladder tumor with sarcomatoid features (T1), and was closely followed medical oncology. She had not received adjuvant therapy. The patient presented with persistent nausea without vomiting, fevers or chills, chest pain or shortness of breath. Her oral intake was decreased over the prior two weeks, worsening to complete food intolerance. She had no urinary complaints at presentation and denied any night sweats or weight loss. She had a 70-pack-year smoking history and drank alcohol on occasion.On physical exam the patient appeared cachectic and uncomfortable but in no acute distress. She was afebrile, with a normal blood pressure but was slightly tachycardiac with a heart rate of 110 beats per minute. She was tachypnic with a respiratory rate of 23 breaths per minute with an oxygen saturation of 96% on room air. Her heart and lung exam was unremarkable, but her abdomen was grossly distended with hyperactive bowel sounds. She was tender primarily in the epigastrum with fullness in that region. There was no rebound tenderness, and she was voluntarily guarding in all four quadrants. No organomegaly was appreciated. Her lower midline cystectomy scar was noted. Rectal exam was not significant for any palpable masses and fecal occult blood testing was negative. Laboratory values were within normal limits and her chest X-ray was unremarkable.A computed tomography scan of her abdomen with intravenous contrast demonstrated evidence of intussusception at the transverse colon with a 2 × 2 cm lead point characterized as a soft tissue density. There was appreciable thickening of the descending colon as well as para-aortic lymph nodes measuring 7-10 mm . The patIn the operating room a rigid proctoscopy was performed demonstrating normal mucosa up to 20 cm. The patient was prepped in standard surgical fashion and a midline incision was made. Evaluation of the proximal transverse colon revealed an intussusception involving a 6-8 cm segment. The remaining colon appeared normal without appreciable masses or thickening. A sleeve colectomy containing the segment was initially performed and opened in the operating room. No serosal involvement of the specimen was noted. Within the colon, a 2 × 5 cm pedunculated hard mass appeared to arise from the mucosa. Frozen section assessment was unable to determine a pathologic origin for the submitted tissue, including whether cells had a benign or malignant appearance. Due to the high suspicion for an underlying malignant process, a completion right hemicolectomy was performed. There was no evidence of metastatic disease on any serosal surfaces, nor within the liver. The remainder of the operation was uneventful, and the patient extubated and taken to the recovery room. She was monitored in the intensive care unit for 24 hours. Her diet was advance postoperative day three and she was discharged to subacute rehabilitation on post-operative day seven.Pathologic assessment of the resection specimen was remarkable for a mucosal-based lesion without gross invasion of the colonic wall. Twenty-five lymph nodes were included with the specimen, all negative for metastatic disease. Histological evaluation revealed a mucosal lesion, sarcomatoid in appearance, with incomplete invasion of the colonic wall and no serosal involvement -4. CompaIntussusception in adult patients is relatively rare, representing only 5% of all cases of intussusception and less than 5% of all cases of bowel obstruction . IncidenAnatomic locations of intussusception include entero-enteric, colo-colic, and ileo-colic, and the differential diagnosis for the underlying etiology can be made upon location alone. Small bowel intussusception can be due to adhesions, Meckel's diverticulum, inflammatory bowel disease, lymphoma, primary malignancy or metastatic disease, as opposed to large bowel intussusception, which is due to an underlying malignancy in the majority of cases.Clinical presentation of adult intussusception is typically significant for signs and symptoms of bowel obstruction. The diagnosis is radiologic, with imaging modalities that can be diagnostic or ancillary including plain radiographs, ultrasound, computed tomography scan, and endoscopy. Surgical management of adult intussusception is mandatory, with specific operative intervention tailored to anatomic location and etiology. If the diagnosis of a benign etiology is definitive, distal to proximal reduction can be safely performed followed by limited resection with primary anastamosis . HoweverAlthough bladder cancers can disseminate hematogenously or lymphatically, superficial tumors (T1) rarely metastasize. When metastatic disease is present, it is most frequently in the pelvic lymph nodes, liver, lungs, or bone , with noTransitional cell carcinomas of the genitourinary tract with sarcomatoid differentiation are extremely rare, representing tumors with both epithelial and non-epithelial components. Although debate exists as to the pathogenesis and nomenclature of such tumors,  they tenA metastatic lesion in the transverse colon, with an atypical invasive pattern, is an unexpected finding following complete resection of a superficial bladder carcinoma. This pathology mandates volume resuscitation and surgical management in a timely fashion. The aggressive nature of sarcomatoid bladder carcinoma presents a challenging clinical situation even after R0 resection has been performed. Reported is the unique case of a superficial sarcomatoid bladder carcinoma with an isolated metastatic lesion to the transverse colon causing intussusception and large bowel obstruction.


Carcinoma ex pleomorphic adenoma (CXPA) is an aggressive salivary gland malignancy and rare in minor salivary gland. A soft palate CXPA initially presenting as direct cavernous sinus (CS) invasion is very rare.A 60-year-old male had a 3-month history of a small soft palatal mass with progressing left cheek numbness, proptosis, and disturbed vision. Biopsy of soft palatal tumor showed pleomorphic adenoma. Magnetic resonance imaging showed a tumor involving left maxilla, and extended from pterygopalatine fossa, inferior orbital fissure to CS. Excision of tumor revealed CXPA. Adjuvant concomitant chemo-radiation therapy (CCRT) was given. The tumor recurred 5 months later in left CS which was re-treated with CCRT. The disease status was stable at 2 years after the diagnosis of CXPA.We present this case to emphasize that patients with symptoms such as facial numbness, proptosis and disturbed vision should be carefully investigated for lesions invading CS by perineural spread. Carcinoma ex-pleomorphic adenoma (CXPA) is a rare, aggressive, poorly understood malignancy that usually develops in a primary or recurrent pleomorphic adenoma (PA) . The patnd division of trigeminal nerve, proptosis, and disturbed visual acuity at the level of counting fingers. He also had left esotropia which was due to traumatic left abducens nerve palsy by saw dust 10 months ago. Biopsy of the tumor revealed PA.A 60-year-old male visited our hospital for left cheek numbness for 3 months. A painless soft palatal mass was noticed and became more prominent recently Figure . PhysicaComputed tomography of head and neck showed asymmetry with some bulging contour at palatal region. Magnetic resonance imaging (MRI) arranged revealed irregular soft tissue mass involving left maxilla, and extended from pterygopalatine fossa, inferior orbital fissure to CS with bony destruction of the skull base Figure . We perfst CCRT. Follow-up MRI revealed the tumor recurred at left CS. CCRT for the recurrence was implemented and the disease has been in a stable condition. However, the vision in his left eye was completely loss after the 2nd CCRT.Five months later, the patient complained of deteriorated visual acuity to the level of light sensation. The functions of CN III and V2 were similar to that after 1th~8th decades of life [According to the World Health Organization histological classification published in 2005, malignant changes in the PA include three different types: CXPA, carcinosarcoma, and metastasizing PA ,4. CXPA  of life . The timThe imaging findings of CXPA are usually nonspecific and difficultly identified from those of other benign and malignant salivary gland tumors . PA showThere are controversies on the treatment of CXPA in salivary gland. The incidence of positive margins, perineural invasion, facial nerve involvement, and lymph node metastasis in CXPA is higher than other malignancies of the parotid gland. Post-operative adjuvant radiation could effectively eradicate residual deposits of microscopic disease . CXPA alCXPA in the minor salivary gland with direct CS invasion was very rarely met. Our case is exceptional because the size of tumor in soft palate was small and not growing into the oral cavity. Instead, it spreads extensively through PPF and directly into the CS. It illustrates an atypical clinical presentation of the CXPA and the difficulty in its management.The authors declare that they have no competing interests.CHH and HSF conceived the idea for the manuscript, conducted a literature search, and drafted the manuscript. HSF performed surgery, obtained images and critically revised the manuscript. LLY provided and reviewed pathological images. CSC obtained radiological images used in the manuscript. CIH and LCT critically revised 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 accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Vulvar fibroadenomas are sporadic lesions informed in the literature and a controversy about origin has been discussed widely. We report a case of a 19 years old woman with a large slow growing mass in the right labia majora with the final diagnosis of fibroadenoma with mammary tissue surrounding it and positive hormone receptors. In this case, we support the origin in ectopic mammary tissue. Vulvar lesions in general are infrequent. Malignant neoplasms represent no >5% of gynecological cancers, are more frequent at advanced ages, the most common tumors are epithelial, and among these, epidermoid carcinoma comprises 80% . MesenchAt present, controversy exists regarding the histological origin of these lesions. The debate includes the postulation of ectopic mammary tissue-derived lesions, of cutaneous apocrine glands, and mammary-like anogenital glands, the latter the most recent of the theories.,3,5,7,10Examples of benign and malignant mammary-type anogenital tumors have been reported sporadically. These tumors are morphologically similar to their mammary counterparts. Among benign lesions are included fibrocystic disease-like changes, intraductal papillomas, fibroadenomas, and phyllodes tumors, while malignant lesions mentioned comprise ductal, lobular, and mucinous adenocarciomas. ,4,7,9 WeAn 18-year-old nulligravida Mexican female was referred to our institution in November 2006 complaining of a vulvar tumor of progressive growth for the previous 12 months. Previous medical and familial history was not contributory to the present illness. Physical examination revealed a 12 × 5-cm tumor located on the right labia majora  scan reported no masses or retroperitoneal lymph node enlargements.Patient was programmed for wide tumor excision on January 8, 2007. During surgery, the tumor was found as firm, not adhered to adjacent structures, and well circumscribed. Frozen section of the lesion was performed and was reported as benign mesenchymal neoplasm. Primary vulvar-incision closure was performed, and the patient evolved adequately and was discharged 24 h after the surgery. Final pathologic report was ectopic mammary gland-originated fibroadenoma. The patient has been followed up for 17 months and is free of new lesions at present.Grossly a well delimited multilobular mass with a skin ellipse was received. The measures of the mass was 7 × 4 × 4 cms. Cut surface shows a lobulated white firm mass without necrosis or hemorrhage located in the dermis and subcutaneous tissue no related to skin. Microscopically a fibroepithelial neoplasm with well defined borders was seen; collagenized stroma with more cellular areas around ducts lined by one line of epithelial cells without atypia supported by a layer of myoepithelial cells Fig . Next toIn 2006, Atwal published a case of previously documented supernumerary mammary tissue-originated vulvar fibroadenoma, describing a lesion that histopathologically mimicked a fibroadenoma with positive estrogenic receptors by immunohistochemistry and with healthy mammary tissue surrounding the lesion. The presCarter in 2008 presented an analysis of 18 reports of prior cases of vulvar fibroepithelial neoplasms, showing an average patient age at moment of diagnosis and surgical extirpation of 38.7 years , average tumor size was 3.0 cm . Difference in tumor size and age at diagnosis of phyllodes tumor and fibroadenoma was not significant. Two cases of bilaterality were reported: one of fibroadenoma, and the other, phyllodes tumor. [Although in the majority of cases ectopic mammary-tissue origin is assumed, only two cases were documented of lesion- or peripheral-associated mammary tissue, these being phyllodes tumors. In no case does the study describe mammary-like anogenital glands. Lack of documentation on vulvar lesion-adjacent tissue can be a limitation for determining reliable lesion histogenesis. The well-circumscribed nature of the lesion permits its simple excision, which implies the need for a more extensive resection for adequate histological review of the surrounding tissue.We conclude that mammary-type vulvar fibroepithelial-lesion histogenesis remains uncertain. The debate will continue until adequate study is conducted of vulvar lesion-surrounding tissue; its clinical presentation and subsequent behavior are comparable with its counterpart in breast. We should consider in a reserved fashion the publication of Atwal et al.  with regOur case increases the number of cases that support the origin in ectopic mammary tissue since we were able to find normal mammarian tissue surrounding the neoplasm and has positive for estrogen and progesterone receptors.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.DCL was responsible for the design and writing of the manuscript. DPM was responsible for the pathologic evaluation and writing of the manuscript. HV was responsible for the literature and case review. CH was responsible for the literature review and writing of the manuscript. LC was responsible for the manuscript completion and critical review. MHL was responsible for the coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


Invasive methods currently applied to the respiratory tract may result in impaired movement of the cricoarytenoid joint with hoarseness and immobility of the vocal ligament. Hoarseness after tracheal intubation is reported as a high incidence in patients who receive general anaesthesia. In most cases, the symptoms are temporary and improve within several days. We report this case for emphasizing that early diagnosis of arytenoid cartilage dislocation is important even in nontraumatic cases.We present the case of a 19-year-old Caucasian male who developed arytenoid cartilage dislocation associated with uneventful endotracheal intubation and anesthesia.Arytenoid subluxation should be considered whenever any of the symptoms mentioned occur following endolaryngeal manipulation, and they become persistent, as recovery becomes difficult if appropriate treatment is not started immediately. Endotracheal intubation, laryngoscopy, bronchoscopy, and other invasive methods, which are often applied to the respiratory tract, may result in injuries of the airway. These complications include submucosal hemorrhage, granuloma formation, subglottic edema or laryngitis, impaired movement of one or both vocal folds caused by recurrent laryngeal nerve damage, and cricoarytenoid joint dysfunction, and may be characterized by hoarseness or stridor ,2.Hoarseness is a common postoperative complication and reported as an incidence between 14.4% and 50% of patients. Prolonged or permanent hoarseness may occur in 1% of patients [Due to the non-sensitive symptomatology, diagnosis of the cricoarytenoid injury can be delayed, and recovery becomes difficult if appropriate treatment is not started early. The symptoms are temporary and improve within several days in most cases. In the case of persistent hoarseness, specialists should consider arytenoid cartilage dislocation. Fortunately this is a rare event, the frequency related to direct laryngoscopy has been reported to be 0.023% [In this report, we present a case of arytenoid cartilage dislocation caused by an apparently straightforward tracheal intubation and anesthesia.-1), rocuronium (0.6 mg.kg-1), and remifentanyl (0.5 mcg.kg-1) intravenously. Complete muscle relaxation was provided before insertion of the tube. At the visualisation of larynx with direct laringoscopy (Macintosh 4 laryngoscope blade) the epiglottis was short but the glottis was Grade II (Cormack-Lahene). On the first attempt, a 8.0-mm endotracheal tube was smoothly inserted into the trachea without difficulty and fixed at the middle. The patient did not cough during the intubation. During the four hour operative procedure, anesthesia was maintained with nitrous oxide, oxygen, isoflurane, remifentanyl (0.25 mcg.kg-1.min-1) and rocuronium. The surgery was uneventful. After the operation, the endotracheal tube cuff was deflated and removed without any difficulty, severe coughing and vomiting did not occur at this period. On the first day, the patient complained of moderate hoarseness. He was discharged on the second day and still complained of persistant hoarseness on the 6th day. He had no symptoms other than hoarseness. On the 6th day after the operation, fiberoptic laryngoscopy was performed by an otorhinolaryngologist and revealed anteromedial dislocation of the left arytenoid cartilage . Physical examination revealed a class 2 airway. Mallampati Intubation Score and other airway measurements were normal. After securing intravenous access and beginning standard monitoring, anesthesia was induced with thiopental (8 mg.kgInjuries of the larynx are a well known complication of anesthesia and range from moderate to severe. Incidence of hoarseness is common, varying between 14.4 and 50%. Most cases are temporary and improve within several days ,4. If hoResearch has been done to investigate the mechanism of arytenoid dislocation. The preferred theories are incomplete neuromuscular blockage, motor reactions during endotracheal intubation, or direct trauma to the cricoarytenoid joints leading to joint cavity hemorrhage or serosynovitis. After this, pathological process can be followed by adhesion of articular surfaces or periarticular structures that fix the arytenoid in an abnormal position. Delay in diagnosis and treatment can consequently lead vocal fold immobility to occur. Typical subluxation leads to the arytenoid cartilage shifting in an anterior-medial or a posterior-lateral direction . In thisThe primary symptom is persistent hoarseness in adults and respiratory compromise in pediatric and neonatal cases . Some syReported occurrences of arytenoid cartilage subluxation are rare. Several risk factors leading to laryngeal injury have been identified in the literature . It has In our patient, the cause of arytenoid cartilage dislocation was unclear, the intubation was not traumatic. In the literature, a case has reported as a complications of the uneventful and apparently straightforward endotracheal intubation and anesthesia . Mencke Recovery from arytenoid cartilage dislocation is difficult if appropriate treatment is delayed . Early tThe authors declare that they have no competing interests.NS participated in the patient's management, drafted the manuscript. HO and NU performed the case management. ZD participated in drafting of manuscript. AK participated in the patient's diagnosis and management. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's 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 presentation of the bronchogenic cyst is variable, making pre-operative diagnosis difficult. Majority of them are either asymptomatic or discovered incidentally. The most common presenting symptoms are cough, fever and dyspnea. We discuss the case of a large bronchogenic cyst in the posterior mediastinum causing oesophageal compression and impinging on the left atrium. The patient presented with dysphagia and back pain and was extensively investigated by various physicians before being diagnosed as having bronchogenic cyst. We concluded that the backache was due to stretching of nerves in the parietal pleura. This case demonstrates the need for detailed investigations prior to treatment of patients with such symptom complex as a bronchogenic cyst may be the cause of such symptoms. Bronchogenic cyst, though rare, is the most common primary cyst of the mediastinum and accounts for 6.3% of primary mediastinal masses and 34% of the cysts. Two-thirds of the patients are asymptomatic. This case presented with dysphagia and back pain which is a rare and clinically confusing presentation for this entity. A thorough review of literature showed very few cases with such rare presentation.A 35-year-old female patient presented with a history of dull, aching pain in the inter-scapular region and dysphagia for solid diet of one-month duration. Patient was evaluated by a medical gastro-enterologist; Barium swallow, Oesophago-gastro-duodenoscopy (OGD) and USG abdomen were done apart from the routine investigations. Hematology was unremarkable, except, raised ESR of 72 mm/first hr. An ultrasonography of the abdomen showed solitary 2.5 cm large gall bladder calculi. An OGD revealed normal oesophageal mucosa with signs of extrinsic compression over anterior oesophageal wall and mild gastritis. Barium swallow showed large extrinsic compression anteriorly on mid-oesophagus causing narrowing of the region  possiblyPatient was referred to a cardiologist for evaluation prior to cholecystectomy. A 2D-echocardiography showed normal heart with a large cystic structure, situated behind LA, with mild tricuspid regurgitation.The patient was admitted in the cardio-thoracic unit. Chest X-ray showed well defined round mass lesion with superior displacement of bilateral principle bronchi. X-ray of vertebral column showed no abnormality. Post-contrast helical chest CT scan showed a 9.5 × 6.5 × 6 cm well defined homogenous cystic lesion having attenuation values of 0-20 HU beginning at the carina and extending downwards in the middle mediastinum . It causPatient was taken for a planned surgery. A sixth space postero-lateral thoracotomy was done. A large smooth walled cystic lesion of 9.5 × 6.5 × 6 cm was found in the infra-carinal region of the middle mediastinum . There wth post-operative day after suture removal. Histological evaluation confirmed the diagnosis of bronchogenic cyst [The tumour was found to be displaying the two principle bronchi behind the left atrium pushing the latter anteriorly. The tumour extended almost equally on either side of the midline and was found compressing the mid-oesophagus posteriorly. Right vagus was firmly adhering to the lesion as it ran over the tumour wall. An attempt was made to dissect the cyst from the surrounding structures but was abandoned due to dense adhesions and immense vascularity. A milky white fluid on needle aspiration established the cystic nature of the tumour. A major portion of the cyst wall was excised and representative tissue was sent for histopathological examination. The remaining portion of the cyst was ablated with electrocautery. Thorax was closed and two drains were left in the thoracic cavity. The patient was extubated on the OT Table and had an uneventful recovery and was discharged on the 10nic cyst .Bronchogenic tumours are rare tumours in the mediastinum. These are the most common primary cysts. Of the mediastinal bronchogenic cysts, 79% are located in the middle mediastinum, 17% in the posterior mediastinum, and three per cent in the anterior mediastinum.[They originate as sequestration from the ventral foregut, the antecedent of the tracheo-bronchial tree. The cyst may lie within the lung parenchyma or the mediastinum. The cyst wall is composed of cartilage, mucous glands, smooth muscles and fibrous tissue with the pathognomic inner layer of ciliated respiratory epithelium. Almost 75% cases are asymptomatic. Symptoms vary with age at presentation and up to a large extent depend upon the size and location of cyst. Common symptoms are chest pain 22%), dyspnea 12%), cough (7%), stridor (7%), respiratory compromises due to tracheal/ bronchial compression and recurrent pneumonia (10%).[2%, cough2%, dyspnThe presented case is rare in terms of mode of presentation which was dull backache and dysphagia. Backache in these tumours is caused by stretching of the nerves supplying the parietal pleura. Dysphagi2Appropriate treatment of patients with bronchogenic cysts depends on the patient's age and symptoms at presentation. Symptomatic cysts should be resected (either at thoracotomy or by means of video-assisted thoracoscopy) regardless of patient age unless surgical risks are unacceptably high. It is generally recommended that asymptomatic cysts in young patients be removed because of the low surgical risk and the potential risk of late complications  such as infection, hemorrhage, or neoplasia within the cyst. Conservative (watch-and-wait) treatment has been advocated in asymptomatic adults or other high-risk patients. Percutaneous catheter drainage or sterile alcohol ablation has been performed in selected cases. In such patients, radiologic diagnosis is of great importance as tissue confirmation will not be obtained.Intra-operative findings demand special attention to avoid injury to the vagus, the tracheo-bronchial tree, pericardium and the oesophagus. Minimal possible damage to oesophageal layers has been recommended and is logical. Ablation of the cyst rules out the possibility of recurrence which, though unusual, have been reported. Thoracoscopic/videoscopic resection of broncThis case study highlights dysphagia and back pain as unusual, presenting symptoms of mediastinal bronchogenic cysts, and emphasises the importance of contrast-enhanced chest CT scan in dealing with all thoracic tumours. Surgical option should be exercised as a definitive procedure in all cases to avoid development of complications.


We discuss a rare presentation of an unusual case of endometrioma.A 40-year-old Caucasian woman presented with subacute abdominal pain and a suprapubic mass. A final diagnosis was made after the mass was resected and histopathology confirmed an endometrioma originating from an urachal remnant. Select imaging studies and histopathology are presented in this case report.While endometriomata are well known to arise from abdominal scars, the condition described in this case report is a rare example of an endometrioma arising from the urachus. A review of the pathological complications of the urachus is also included. Endometriosis is defined as the presence of endometrial type glands and stroma outside the uterus. The areas usually affected are the fallopian tubes, ovaries, uterine ligaments, ureters and bladder . The terA 40-year-old Caucasian woman presented to the emergency room with a six-month history of progressive lower abdominal pain. She had failed to visit a doctor sooner for fear that she may have a malignancy. Her medical history was notable for hysterectomy and unilateral salpingo-oophorectomy five years prior to presentation to treat endometriosis. Her obstetric history was remarkable for three lower segment caesarean sections, all via a suprapubic (Pfannenstiel) incision. Hormone replacement therapy had been instituted four years previously following the onset of symptoms of oestrogen insufficiency.A physical examination at the emergency room revealed a 3-cm poorly defined, tender suprapubic mass extending to her umbilicus. The overlying skin was normal and the mass appeared to be tethered to the abdominal wall. No urinary symptoms were present and her urine analysis was clear. Contrast computed tomography of her abdomen and pelvis demonstrated a 3.3-cm lower abdominal mass intimately related to the dome of the bladder in a position that was typical of urachus Figure . FlexiblA percutaneous trucut (16G) biopsy, which only showed the presence of fibromuscular tissue, proved to be of no help. An open exploration of this urachal mass was performed through a laparotomy incision. No technical problems were experienced intraoperatively. The fibrous mass was distinct and easily separated from the bladder. Wide local excision was performed, but removal of a cuff of bladder was found unnecessary. Histopathological analysis concluded the mass to be a benign endometrioma arising from the urachus. The patient's recovery has been excellent without any recurrence of the pain she previously experienced.An embryologic structure, the urachus is the canal joining the fetal urinary bladder to the allantois. The urachus, when obliterated normally, forms the median umbilical ligament. Persistent remnants are uncommon but may still manifest clinically as a vesicocutaneous fistula, urachal cyst or umbilical sinus. The presence of urothelium within the persistent urachus has been reported to result in malignant transformation.A recent article in the American Journal of Surgery retrospectively examined abdominal wall endometriomas and found that the mean age of presentation was at 29.4 years. Presenting symptoms were noted to include abdominal mass, cyclical and non-cyclical pain with dysmenorrhea ,4. AlthoAs demonstrated in our patient, however, endometriosis may masquerade as a tumour arising from the urachus . EndometThis case report illustrates a rare presentation of urachal endometrioma. Accurate final diagnosis can only be accomplished after surgical excision and histopathological examination of the mass. Malignant transformation has been described in abdominal wall endometriosis and radical excision is the mainstay of 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.KB, SC and RF wrote and proofread the manuscript. ND and TC performed pathological work and research. They also contributed in writing the manuscript. All authors read and approved the final manuscript.


This case series illustrates the clinical presentation and radiological findings of two patients in whom the diagnosis of a Giant Colonic Diverticulum (GCD) was histologically confirmed. We also discuss the pathogenesis and differential diagnosis.In one case, the patient had no previous large bowel symptoms and intra operatively no other colonic diverticula were found. Both were treated with surgical resection.The preoperative diagnosis of GCD is made radiographically, and the importance of the early recognition of radiological findings, especially in asymptomatic disease, is emphasised. A Giant Colonic Diverticulum (GCD) is a rare complication of colonic diverticulosis, a frequently occurring condition most often found in the sigmoid colon. This infrequent complication can easily be misinterpreted and is described only occasionally in the literature making it an interesting diagnostic problem both clinically and radiologically.The preoperative diagnosis of GCD is made on plain abdominal radiography with findings of a large, smoothly marginated, round or oval, homogenous radiolucency in the abdomen that may contain an air-fluid level . This maImportance of these findings and their early recognition is even greater in the absence of gastrointestinal complaints in view of the potential complications of perforation, obstruction or a volvulus, which occur in 10 to 19 per cent of cases . In addiThe recommended treatment is excision of the diverticulum in continuity with the involved colonic segment.An 82-year-old Caucasian man was admitted with a 1-week history of worsening left upper quadrant pain. Apart from a 1-day history of constipation, he denied any previous bowel symptoms. His past medical history included sero-positive rheumatoid arthritis, chronic renal impairment secondary to gold injections, atrial fibrillation, chronic obstructive airways disease and previous right hip fracture.On examination he was found to have a distended abdomen, with tenderness and resonant percussion note in the epigastrium and left upper quadrant. Blood results were unremarkable.An initial plain abdominal radiograph showed a large air filled cyst. [Figure Exploratory laparotomy was performed at which a large air filled cyst was found, adherent to sigmoid colon and bladder and containing only gas, no urine, fluid or faeces. No communication with the bowel or bladder lumen was demonstrated. The large bowel was otherwise free from diverticular disease. Excision of the cyst was performed.Histology of the cyst showed muscularis mucosa and faecal material in granulation tissue within the lining of the cyst wall, making the cyst a type 1 giant colonic diverticulum or pseudodiverticulum [Table A 52-year-old Caucasian man with a longstanding history of Gastro-oesophageal reflux disease was under routine care in Gastroenterology clinic. He described a 5 week history of a mobile left upper abdominal mass associated with episodic pain and bloating worst after meals. He had experienced no weight loss and had regular bowel habit.Over the next four months the patient developed worsening discomfort, alteration in bowel habit described as increased frequency of loose motions, and weight loss. Plain abdominal radiograph demonstrated a homogenous radiolucent oval structure in the left upper quadrant. Surgical referral and a contrast enhanced C.T scan were arranged.The intra-venous and oral contrast enhanced CT scan demonstrated a large 12 cm gas filled structure in the left upper abdomen that appeared to be arising from the top of the sigmoid colon. There was no mural or intra-luminal enhancement, and this was associated with mild underlying wall thickening at the neck, and thought to represent a giant sigmoid diverticulum. [Figure Due to ongoing symptoms, the decision was made to perform an elective laparoscopy and sigmoid colectomy.Pathologic examination demonstrated a cystic structure with a smooth lining, 11 cm in maximum diameter, with a wall thickness of 0.6-1 cm. There was no mucosa, and the wall was composed of dense fibrous tissue with foreign body reaction and acute and chronic inflammation. This made the cyst a type 1 giant colonic diverticulum or pseudodiverticulum. Diverticular disease was identified in the attached colon. The patient made an uneventful recovery.The incidence of colonic diverticulosis is difficult to measure, as most patients remain asymptomatic. Studies show that up to 35 per cent of the population has colonic diverticulosis by age 65 . ApproxiGiant colonic diverticulum is a rare complication of this common disease with fewer than 150 cases reported in the literature. It affects men and women equally, occurs most commonly in patients 60-80 years of age, affecting the sigmoid colon in over 90% of cases .Hughes and Greene first reported this condition in 1953. Several theories have been proposed to explain its pathogenesis; the most widely accepted theory attributes the progressive dilatation to inflammation narrowing the diverticular ostium, creating a "ball-valve" mechanism, allowing air to enter the diverticulum, but not to return to the colonic lumen . Other tClinical presentation of GCD is very variable ranging from the asymptomatic patient, to patients presenting with an acute abdomen. Most patients however report abdominal pain, either acute or chronic. The other symptoms are less common and also non-specific, including fever, nausea, vomiting, constipation, diarrhoea, and haemorrhage . PhysicaPlain abdominal radiographs demonstrate a large, oval radiolucency, typically in the left lower quadrant, which may contain an air-fluid level in 25% of cases. A barium enema demonstrates the relation of the diverticulum to the bowel and results in the opacification of the diverticulum in 60% of patients . When coThe role of CT scanning has greatly increased and at present it is considered by many to be the diagnostic procedure of choice. On CT the GCD appears as a smooth-walled gas-containing structure  adjacent to the sigmoid colon . The marSeveral MRI studies have demonstrated its efficacy in the diagnosis of diverticulitis and its associated complications including Giant Colonic Diverticula . HeverhaCorrect interpretation of radiological findings can exclude several important differentials. Duplication cysts are found in the lateral colon or on the posterior rectum but rarely on the sigmoid colon. A Meckel's diverticulum affects young children, in whom it is located in the distal ileum, and when complicated will specifically demonstrate the teardrop or blind-ending sac shape on ultrasound. When a mass with ring enhancement is observed in the female pelvic cavity, it is necessary to consider tubo-ovarian abscess, or a large uterine tumour, (which may contain gas if there is a fistula with the colonic lumen) as differential diagnoses. The most common appearance of tubo-ovarian abscess is that of a tubular, septate, cystic mass with uniform wall thickness and loss of fat planes between the mass and adjacent pelvic organs. On CT, a GCD is commonly gas-filled and oval whereas duplication cysts are usually fluid filled and fusiform.Treatment ranges from conservative management to surgical intervention, because of the risk of complications surgical resection is felt by some to be the preferred management in all cases .The above illustrated cases demonstrate the efficacy of radiological findings in the diagnosis of Giant Colonic Diverticula in the appropriate clinical setting. The possibility should always be considered with such unusual radiological findings and rarity of the condition.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.GC: First/Main author, responsible for literature review. MK: Second author, responsible for reviewing and reporting imaging and supervising first author. Both authors read and approved the final manuscript.


Primary adenocarcinoma of the urinary bladder is not common. Though penile metastases from transitional cell carcinoma are reported, such metastases from adenocarcinoma of urinary bladder is unknown. We report a 55-year-old male having penile metastasis from primary mucinous adenocarcinoma of bladder. Primary adenocarcinoma constitutes 0.5-2% of all urinary bladder malignancies and mucinous adenocarcinoma constitutes around 15% of them.[1A 55-year-old male, chronic smoker, presented with recurrent episodes of painless hematuria for two months. He had undergone cystolithotomy five years back. Physical examination revealed an infraumbilical scar with induration. On cystoscopy, a broad-based solid growth was seen at the dome of the bladder extending onto the anterior bladder wall. Rest of the bladder mucosa and ureteral orifices appeared normal. Biopsy of the growth suggested mucinous adenocarcinoma of the urinary bladder. Computed tomography revealed a growth involving the dome and anterior wall of the bladder extending extravesically and involving the rectus muscles . Chest XSix months later the patient presented with pain in the penile shaft. On examination, a nodule was felt in the corporal body. Fine needle aspiration biopsy of the nodule revealed metastasis from mucinous adenocarcinoma . Repeat Primary adenocarcinomas of the bladder are not common tumors. They are commonly reported in cases of extrophy bladder, enterocystoplasty and in endemic areas of bilharziasis.–5 Severaet al. classified vesical adenocarcinoma into (1) enteric (papillary), (2) mucinous, (3) signet ring, (4) adenocarcinoma not otherwise classified and (5) mixed.[et al., in their large series of 192 patients with vesical adenocarcinoma, had mucinous variety in 14.6% of their cases.[5Grignon 5) mixed. Zaghloulillary),  mucinousr cases.5Penile metastases occur in very rare cases. The primary site is the urinary bladder in 30-35%, prostate in 30%, rectosigmoid in 13%, kidneys in 8-10% and testes in 5%.[Malignant neoplastic lesions spread to the corpora cavernosa by direct extension, retrograde venous or lymphatic transport and arterial embolism. ThrombosPenile metastases indicate advanced disease with an average survival of 3.9 months from the time of diagnosis. Total peThe uniqueness of the present case is it being a rare variety of bladder cancer and later presenting as penile metastasis. Since the tumor had extravesical spread and had infiltrated abdominal wall muscles, we feel retrograde venous spread as the cause for penile metastasis. The aggressive tumor behavior resulted in rapid progression of the disease and eventual mortality.