We report an isolated giant solid macronodular tuberculoma in an 8-year-old boy. A large-space-occupying lesion in the right lobe with nodular surface and hard consistency mimicked liver malignancy. This case is unusual as the ultrasonography, computed tomography scan, and aspiration cytology were all suggestive of a malignant tumor. Laparotomy confirmed a 15 × 10 cm nodular tumor present in the right lobe of liver. The segments 5, 6, 7, and 8 were excised. The histopathology revealed tuberculosis. Liver is a rare site for tuberculosis. Isolated2An 8-year-old boy presented with history of intermittent low-grade fever, and loss of appetite and weight of six months duration. The child was immunized with BCG vaccine. The child had protein energy malnutrition with nontender hepatomegaly. The laboratory findings showed Hb, 9 gm%; TLC, 16,800/cu mm; DLC of neutrophils, 83%, lymphocytes, 12%, eosinophils, 2%, monocytes, 1%; and the ESR, 10 mm. The renal and liver functions were normal. Montoux skin test showed 15 mm induration. The chest and abdomen X-rays were unremarkable. Ultrasound examination showed a hyperechoic solitary 15 × 15 cm lesion occupying the right hepatic lobe. Contrast enhanced computed tomography (CECT) scans  revealedThe abdomen was explored by a roof-top skin incision. A 15 × 10 cm size nodular tumor was seen involving the entire anatomical right lobe of the liver . There wMacroscopically, a large mass of 13 × 10 × 10 cm size with solid areas and foci of necrosis was seen replacing the normal liver tissue. In addition, an 8 × 5 cm size tumor tissue was infiltrating the capsule and forming nodular surface. The gallbladder was seen adherent to the undersurface with 1 cm wall thickness. The cut surface was homogenously white. The histology revealed large areas of caseous necrosis and clusters of epitheliod cells and scattered Langerhan's giant cells. Polymerase chain reaction (PCR) analysis of tumor tissue was positive for Mycobacterium tuberculosis. The patient was subsequently treated with antitubercular therapy and is under follow-up.Tuberculosis of liver is uncommon and it iHepatic macronodular tuberculoma is not uncommonly misdiagnosed as a liver tumor. On ultrasonography, the tuberculoma presented in our case as a hyperechoic lesion in contrast to round hypoechoic mass which is usually seen in this condition. The CECT showed the lesion replacing the entire anatomical right lobe with enhancement resembling an infiltrative tumor. To add to the confusion, FNAC was suggestive of hepatoblastoma.et al,[The main stay of treatment is antitubercular drug therapy. However in the literature, hepatectomy has been done in some cases7 as a paet al, treated Isolated giant solid macronodular tuberculoma has a pseudotumor appearance and mimics malignant primary or secondary liver tumors. Keeping in view the large size of mass and extra pulmonary localization, surgical enucleation along with antitubercular drug therapy could be more effective in the treatment of such cases.


Cystic lesions of the pancreas are relatively uncommon.We describe the case of a young man with acomplex cystic mass located within the head of thepancreas. The patient underwent exploration withresection of the mass. Pathology revealed a ciliatedepithelial cyst, a rare cystic lesion of the pancreas.


The combination of neurofibromatosis and liposarcoma is very rare. We present a case of a dedifferentiated liposarcoma in the forearm, as a complication in a patient with neurofibromatosis type 1.A Caucasian man with neurofibromatosis type 1 presented at our clinic complaining of a slow growing swelling on his left forearm over a period of one and a half years. Clinical examination and history pointed to malignancy. Radiological examination inclusive of magnetic resonance imaging and positron emission tomography confirmed our suspicion. A final diagnosis of dedifferentiated high-grade liposarcoma with axillary lymph node metastases was established after a pathological examination of a tumour biopsy. The consulting tumour board recommended either an elbow exarticulation or an accurate radical local resection including the metastatic axillary lymph nodes. Fortunately, we were able to perform an R-zero resection and the forearm could be saved. The treatment was completed with postoperative radiotherapy of the left forearm's operative bed, the left axillary and the supraclavicular regions. The patient decided against adjuvant chemotherapy.Liposarcoma complicating neurofibromatosis type 1 is a very rare combination. Up to now, only five cases have been reported in the literature. We are adding a new case to this short list to stress the importance of early recognition. It is the first known case with this disease combination in an upper extremity. Liposarcoma is usually treated by surgery followed by radiotherapy. The role of chemotherapy is controversial and should be based on a decision made on a case-by-case basis. Soft-tissue sarcomas in adults associated with a clinically identified genetic disease represent 2.8% of all cases . NeurofiA 41-year-old Caucasian man, known to have generalized NF1 since the age of 21, presented at our clinic complaining of a swelling in his left forearm. He reported that his complaint started 1.5 years previously, when he noticed a slow-growing swelling. The patient was assured that the swelling was a simple lipoma that could be electively resectioned. The patient's history revealed no preceding trauma or inflammation. The swelling was not painful. His family history revealed no similar conditions, but his father and grandmother were operated on for bowel carcinoma. According to the physical examination, the patient had generalized cutaneous neurofibromas all over his body and some papillomas in his mouth. He is of average build and was of normal health and without any other systemic diseases. Local examination showed a hard, lemon-sized, non-movable tumour in the ventral aspect of the left middle forearm. The skin was not affected. The range of movement of the left forearm and hand were free, as was the range of movement at the wrist.Radiological examination started with X-ray imaging of the left forearm. It showed a soft tissue tumour with no bone affection. Ultrasonography showed a 91 × 52 × 50 mm inhomogeneous condensed tumour with a well-defined border. Contrast-enhanced magnetic resonance imaging (MRI) showed a 95 × 55 × 49 mm well-defined, highly inhomogeneous tumour with liquid and fat equivalent parts. It displaced surrounding tissue  pT2a liposarcoma with left axillary lymph-node metastases. This correlated with stage IV disease, on the staging system of the American Joint Committee on Cancer.The wounds healed primarly, with no motor, sensory or vascular complications Figure . After sAmbulant, adjuvant radiotherapy commenced 6 weeks later. The total dose of radiotherapy was determined by normal tissue tolerance. External-beam radiotherapy  was given to the left forearm region and to the supraclavicular region with a total dosage of 59.4 Gy. To protect the brachial plexus, the total dosage for the left axillary region was reduced to 50.4 Gy. After extensive discussion with the patient concerning adjuvant chemotherapy, he decided against it for fear of side effects. He has been followed-up and screened continuously every 3 months for possible further malignant transformations or local recurrence.Liposarcomas are classified into five subtypes according to the World Health Organization: well-differentiated, dedifferentiated, myxoid, pleomorphic and mixed type. Dedifferentiated liposarcomas account for 10% of cases; they occur in the retroperitoneum three times more often than in the extremities . NeoplasLiposarcoma complicating NF1 is a rare occurrence; until now, only five cases have been reported in the literature -8]. Our. Our8]. Most commonly, a soft-tissue sarcoma presents itself as an asymptomatic mass. The differential diagnosis of a soft-tissue mass includes malignant lesions, desmoids and benign lesions. Our case indicates the importance of considering soft-tissue swelling and growths as malignant until the reverse is proven.In general, limb-sparing surgery is preferred to achieve local tumour control with minimal morbidity. Both the surgeon and the pathologist should thoroughly document surgical margins, by evaluating a resected specimen.The recommended treatment for liposarcoma is a radical local excision of the tumour, while trying to preserve the limb. It should be followed by radiotherapy to enhance local control. The effectiveness of adjuvant external beam radiotherapy has been shown in several retrospective and three prospective randomized trials that compared surgery alone to surgery in combination with radiation .Adjuvant chemotherapy treatment of localized dedifferentiated liposarcomas of extremities is controversial because no sufficient and convincing data are available. However, soft-tissue sarcomas are a heterogeneous group. Most published studies include soft-tissue sarcomas without discrimination of the histological type, localization or tumour size. In an Italian randomized cooperative trial, patients with high-grade or recurrent extremity sarcoma showed a better overall survival rate with adjuvant chemotherapy . The recAmputation for sarcomas of extremities should only be considered in cases of extensive soft-tissue mass, skin involvement or recurrence prior to adjuvant radiation .0 resection was possible. The treatment was completed with postoperative radiotherapy. Due to the large tumour size, histopathological findings and lymph-node metastases, we recommended adjuvant chemotherapy, which the patient decided against.In our case, there were axillary metastases, but the decision not to amputate was taken intra-operatively after assuring that an RConcerning the treatment of soft tissue sarcoma, local control rates of 85% to 90% have been achieved with a combination therapy of surgery and radiation . DiscussDespite its rarity, we present this case to stress the importance of liposarcoma as a potential complication in neurofibromatosis. This emphasizes the relevance of an early detection of malignancy in increased swelling in patients with NF1. Keeping this in mind could save patients from major surgery and tumour complications.Concerning the treatment, we recommend early intensive investigations and an interdisciplinary approach, such as a tumour board, regarding surgery, radiotherapy, chemotherapy and further treatment. The patient should present for follow-up regularly.NF1: neurofibromatosis type 1; MRI: magnetic resonance imaging.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.MDS, MYAS, SFW, JP and BFEZ all analyzed and interpreted the patient data regarding the NF1 and liposarcoma. MDS carried out the operation on the patient and was the main contributor in the writing of the manuscript. All authors read and approved the final manuscript.


A case of 14-year-old girl is reported who presented with features of tuberculous subacute intestinal obstruction. Exploratory laparotomy revealed a urachal cyst associated with pseudomyxoma peritonei (PMP). Histopathology confirmed a moderately differentiated mucin secreting adenocarcinoma of urachal cyst associated with PMP. The adenocarcinoma of urachal cyst associated with PMP is further reviewed. Urachal cysts may occur at any level in the urachal remnant and may include the entire urachus. The cyst may or may not communicate with the cavity of urinary bladder. The urachal remnants are usually lined by transitional type epithelium, but focal mucinous glandular metaplasia is often seen and may provide morphological basis for the development of intestinal-type mucinous neoplasms.2 Pseudom9/L with 45% lymphocytes, ESR 86, normal renal and liver function tests, serum albumen 2.8 g%, and normal urine analysis. Her chest X-ray was normal and plain abdominal radiographs showed occasional gas fluid levels with some dilated small bowel loops. Abdominopelvic ultrasound revealed 1.6 cm gall stone in neck of gall bladder, normal pelvic organs and a 13 × 8 cm debrinous collection in the cul-de-sac. She responded well to conservative treatment and was discharged on antituberculous medications. She was readmitted in January 2007 with subacute bowel obstruction. There was tenderness and a vaguely palpable mass in the lower abdomen and bowel sounds were diminished. Her laboratory investigations were same as the first admission. Repeat ultrasound suggested a 16 × 10 cm collection seen in hypogastrium extending toward both sides of the midline and some increase in the previously reported pelvic collection (15 × 10 cm). Laparoscopy employing open technique was performed to obtain tissue diagnosis and drain the collections, but camera entered in a pool of mucoid collection. The procedure was converted to laparotomy through lower midline incision. A well-defined cyst (8 × 10 cm) filled with mucoid material was found in the extra peritoneal tissues in the midline attached to the urinary bladder. Upon opening the peritoneum, the same mucoid material was found in the pelvis and peritoneal cavity. A loop of distal ileum was stuck to the peritoneum over the posterior aspect of the cyst wall resulting in kinking, possibly causing recurrent subacute obstruction. The appendix, abdominal viscera, and pelvic organs were normal. Appendicectomy was performed and whole mucoid material was evacuated from the peritoneal cavity. The cyst and subjacent part of the dome of urinary bladder were excised [A 14-year-old girl was admitted in December 2006 with lower abdominal pain, frequent vomiting, abdominal distension, and constipation of 6 days duration. Interrogations revealed history of recurrent abdominal pain, low-grade fever, and loss of weight during past 7 months. On examination, she was undernourished and pale. There was deep tenderness in the left lower abdomen. No viscera were palpable and bowel sounds were exaggerated. Rectal examination revealed a boggy nontender swelling in relation to anterior rectal wall. Clinical diagnosis of subacute small bowel obstruction due to abdominal tuberculosis was made. Conservative management with nasogastric decompression, intravenous fluids, and intake-output monitoring was initiated. Laboratory investigations disclosed hemoglobin 9.2 g%, white cell count 8.8 × 10 excised . Cholecyet al. reported first case of mucinous adenocarcinoma in a urachal cyst producing PMP.[1134Urachal cysts are one of the sequelae of the vestigial remnants of the embryological structure connecting allantois to the bladder apex. The cystic remnants are not uncommon and although may remain asymptomatic, they may present with mass lesions in the lower abdomen or with urinary symptoms including mucusuria. Adenocarcinomatous change in such cystic remnant accounts for 0.17-0.34% of all bladder cancers. Immunohi11cing PMP. In additing PMP.1 We did n PMP.1134 Our caseTo the best of our knowledge, this is the youngest age for urachal cyst adenocarcinoma associated with PMP. The mucinous adenocarcinoma found in the cystic remnant of urachus had no communication with urinary bladder and serum tumor markers were normal.


Sir,An inflammatory fibroid polyp (IFP) is a rare benign, nonneoplastic, polypoid lesion of the gastrointestinal tract. A 66-year-old hypertensive and diabetic woman was referred to us for the evaluation of severe iron deficiency anemia. Clinically she was obese, pale, with stable vital signs, and physical examination revealed no abnormalities. Laboratory data were unremarkable except for a hemoglobin level of 62 g/L; upper endoscopy was normal. Colonoscopy revealed a 3-cm sessile, polypoid lesion in the cecum, and biopsy was performed . A CT scMicroscopically, the lesion was a polypoidal mass of fibromuscular and inflammatory tissue covered by colonic mucosa. The latter was continuous with the underlying tissue and had focal ulceration and granulation tissue formation. The lesion was composed of a highly vascular tissue with bland fibroblast-like cells and an inflammatory infiltrate of lymphocytes, eosinophils, and plasma cells. In some areas, the inflammation was dense with the formation of reactive lymphoid follicles .et al., 17 have been treated surgically. Different techniques have been described for the endoscopic removal of the polyp including the one using the clip-and-cut technique.[Colonic IFP is rare and there have only been a total of 44 cases, including our case, reported in the literature.–3 Out ofIn our case, a large polypoid lesion was found in the cecum during colonoscopy done as a part of the diagnostic work-up for iron deficiency anemia. IFPs originate primarily in the mucosa and submucosa, but they can, in rare instances, extend to the muscular layer. In this patient, the IFP was predominantly in the mucosa without any extension to the muscular layer, and hence, we decided to remove this by colonoscopy and the snare polypectomy technique. Follow-up colonoscopies done three months and a year later showed no residual lesions or recurrence. As the IFP is a benign polyp and its recurrence is very rare, we believe that its endoscopic removal is an appropriate treatment modality. With wide use of colonoscopy, more such cases of IFP will probably be identified, and awareness of such condition among physicians will help to avoid surgery and resection.


Fetus in fetu is a rare condition that has been defined as the presence of one of the twins in the body of the other. It is most frequently located in retroperitoneal area; however, it has been reported in other locations as well. This report presents two cases of “fetus in fetu” cases: one located in the retroperitoneal area and the other in the sacrococcygeal area. Fetus in fetu (FIF) is a rare congenital anomaly. It is a condition in which malformed and parasitic fetus is located in the body of its twin. The anomaly was first defined in early nineteenth century by Meckel.2 DespiteA 10-day-old female newborn, born to a 28-year-old mother at the forty-first week through normal delivery as the fourth live birth was referred to our hospital with a prediagnosis of abdominal mass. Upon physical examination, a mass with a size of nearly 10 × 15 cm was detected at the right upper quadrant of the abdomen.The computerized abdominal tomography showed a multilobed heterogeneous mass lesion with a size of 10 × 7 × 6 cm in the retroperitoneal area .The tumor markers of the patient  and VMA creatinine ratio were normal.During the operation, a mass with a size of 10 × 15 cm was found at the retroperitoneal area. Upon the incision of the capsule, we found a fetal head, a trunk and an arm and two leg-like structures representing the extremities along with nearly 200 cc of serohemorragic fluid. The fetus, except for its ventral side, was covered by vernix caseosa . The masPathological studies revealed noncalcified vertebral bodies on the midline of the fetus, extending at cranial to caudal direction in the sagittal plane. The microscopic evaluation revealed skin, skin extensions, glial tissue, striated muscle, mature cartilage, peripheral nerve, lung tissue, bone and bone marrow tissues in the capsule, which were mostly lined with multifold epithelium, and at some locations, single-layered epithelium was found.The postoperative period of the patient was free of complications. The patient who was followed-up with ultrasound and α-feto-protein estimations is currently 4 years of age and has no complaints.A 3600-g, 28-day-old male term baby, born through spontaneous vaginal delivery to a mother of 29 years of age in the first pregnancy, presented to our hospital with a lump at the deeper part of the buttocks that was noticed by his mother incidentally on the third week of the birth. On physical examination, the physical appearance of the baby was normal. There was a semimobile mass of 8 × 8 cm, which could only be noticed by deep palpation. The direct radiography revealed a bony structure in the sacrum area. The abdominal ultrasound and α-FP levels were normal.During the operation, following the incision of the capsule of the mass, which presented adherence to some locations on the subcutaneous tissue, drainage of a yellowish fluid was observed. In the capsule, there was a hairy trunk with a size of 5-6 cm and two extremities, which had fingers and nails at the ends. The mass was totally removed along with the coccyx .Pathological examination demonstrated skin, skin extensions, bone, bone marrow, fat tissue, venous structures, striated muscle and peripheral nerve sections. The postoperative period of the patient was uneventful. The patient is currently 5 years of age and is being periodically followed up with checkups on the α-FP levels and ultrasound and has no problems.Fetus in fetu malformation has been defined as the existence of a parasitic, monozygotic, diamniotic fetus in the body of its twin. Preceded by Willis in 1935, in 1954, Lord claimed the presence of a vertebral column and extremities and organs located at appropriate places around it as the basic diagnostic for FIF. These criteria are still, to a wide extent, valid today.16–9 HowevFetus in fetu most frequently (80%) inhabits the retroperitoneal region. However, there have been few reports of FIF location in the head, sacrum, scrotum and the mouth. Despite the requirement of the presence of a vertebral column for diagnosis, there are reports of the cases without a vertebral column.Fetus in fetu is considered as a benign condition. Consequently, some researchers have stated that to facilitate the excision, it is possible to leave some sections of the capsule in its place. Nevertheless, in one case, the mass has been reported to recur as a yolk sac tumor after 4 months. This has been attributed to the presence of immature tissues in the small areas and the remnants of the capsule of the mass.In summary, FIF is considered as a benign condition, while the potentially malignant characteristics of teratoma constitute the basis of the discussion. This argument may lead to differences in the follow-up and treatment of such cases. Although there is a consensus on FIF being a benign condition, considering the reports of malignant recurrences, as stated above, there is a need for the total removal of the mass including its capsule. In addition, we consider the evaluation of the postoperative tumor markers and periodical ultrasound examinations is an appropriate approach.


Primary aorto enteric fistula is a very rare but life threatening condition. We report a case of primary aorto enteric fistula in a 62-year-old man whose diagnosis was only made at laparotomy. A high index of suspicion along with a good history and physical exam is critical for making a successful diagnosis. Surgical exploration is warranted if other investigation is not conclusive. Aorto enteric fistula (AEF) is a rare life threatening complication of aortic surgery. It occurs in 0.3-4% of patients who underwent open AAA repair. Primary fistula formation between the aorta and the duodenum is however considerably rarer with an incidence rate at autopsy of 0.04% to 0.07%. We report a case of primary AEF in a 62-year-old man whose diagnosis was only made at laparotomy.9/L and a CRP of 21 mg/L. He has a strong history of ischaemic heart disease with three previous episode of myocardial infarction, the last one being over one year ago. An urgent CT scan of the abdomen and pelvis were organised to rule out a malignant cause of abdominal pain. Patient has no further episode of rectal bleeding and clinically appeared well. The following day, patient collapsed while walking to the toilet. His pulse rate was 110/min with a systolic pressure of 80 mmHg. CT scan early in the day showed a 5 cm infrarenal AAA. , abdominal pain (32%) and a pulsatile abdominal mass (25%) [%, abdomiIn this case the initial abdominal ultrasound scan measured the aorta at 2.6 cm. By definition, this is not aneusymal. The subsequent CT scan measured it at 5 cm. It is difficult to explain the large discrepancy of size. It could be due to operator error or it could be rapid expansion of the anerusym following the initial scan. Also there is always the slight discrepancy in measurement of size between ultrasound and CT. If the initial scan has picked up an AAA, a CT would certainly follow rapidly as the patient presented with abdominal pain. This might help to reach the diagnosis earlier.AEF should be considered in all patients with GI bleeding and a history of AAA or previous aortic revascularisation with prosthetic graft. A high index of suspicion is the key. Although diagnostic tests cannot entirely eliminate the possibility of AEF, endoscopy is commonly employed followed by CT scan and angiography. Over 90% of AEF are within the reach of endoscopy. Also endoscopy are usually easily accessible in most hospital and can exclude other causes of upper GI bleed. With the continual improvement in CT imaging, it has fast becoming the preferred diagnostic test especially if endoscopy failed to demonstrate the cause. Loss of the aneurysmal wall or the fat plane between the aorta and the duodenum or air in the retroperitoneum is highly suggestive of AEF. Angiography defines arterial anatomy and may be useful especially in patients with previous aortic reconstruction. However very few primary AEF are diagnosed with angiography.Exploratory laparotomy is indicated for patients with suspected AEF and unremitting gastrointestinal bleeding. The mortality rate of untreated AEF is 100%. Surgical intervention is mandatory for survival and successful outcome. With appropriate treatment, survival rates varying from 18% to 93% has been reported . Post opSurgical repair of the AAA and fistula is the standard treatment. In cases of primary AEF with minimal infection, anatomic in situ AAA repair with Dacron and primary repair of the bowel and placement of omentum between the bowel and the prosthetic graft is preferred. In cases of gross infection and contamination, extensive debridement and extra anatomic bypass graft is advocated. Harvesting the patient's superficial femoral vein and using it as graft or specially prepared homograft has also been used in infected cases. In this case, collatamp sheet which are gentamicin impreganated collagen sponge was used to wrap around the Dacron graft followed by placement of omentum acting as a barrier to prevent infection. Intra operative cultures should be taken and antibiotic treatment tailored to the culture and sensitivities. If cultures are negative, empiric antibiotics to cover the most likely contaminating organism are usually recommended for 7-10 days.Primary AEF is a very rare cause of GI bleeding and abdominal pain. However mortality rate is high if the diagnosis is missed. A high index of suspicion along with good history and physical exam is critical for making a successful diagnosis. Surgical exploration is warranted with continued bleeding and high index of suspicion even if OGD and CT scan is not diagnostic.AAA: abdominal aortic anerusym; AEF: aorto enteric fistula; GI: gastro intestinal; OGD: oesophagogastroduodenoscopy.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-chief of this journal.The author declares that they have no no competing interests.


Granular cell tumours of the abdominal wall are extremely rare: less than 10 have been reported in the worldwide medical literature. We report this interesting case, review the relevant literature on this tumour and discuss surgical abdominal wall reconstruction options.® mesh. Histopathological examination of the surgical specimen showed it to be a granular cell tumour.A 70 year old lady presented with a left abdominal mass. This was thought to be a soft tissue sarcoma on CT imaging prior to surgical excision. En-bloc surgical resection was performed. Surgical reconstruction of the abdominal wall defect was performed using Permacol®) which appeared to work well in this situation.Although rare, granular cell tumours can present as an abdominal wall mass. It is important that clinicians are aware of their existence. The closure of large defects, after surgical resection of abdominal wall tumours, is a surgical challenge. We used a new biosynthetic procine mesh (Permacol Granular cell tumours (GCT) are rare neural tumours characterized by large granular appearing eosinophilic cells. GCTs were initially considered to be of striated muscle origin by Abrikossoff who described a tumour arising from the tongue in 1926 . Most GCWe describe a new case of a GCT arising from the abdominal wall muscles in a 70 year old lady. We briefly review the medical literature on this tumour and discuss the surgical abdominal wall reconstruction options pertinent to this case.A 70 year old lady was referred urgently to the colorectal clinic with a palpable abdominal mass. She presented to her General Practitioner (GP) with left sided abdominal pain, diarrhoea and weight loss. Her GP found a suspicious left sided abdominal mass on examination and referred her urgently under the two week colorectal cancer rule. Her past medical history included hypertension, chronic obstructive airways disease and appendicectomy. She also had a previous total abdominal hysterectomy and bilateral salpingo-oopherectomy for large uterine fibroids.® mesh . The Permacol® mesh was sutured to the posterior leaf of the rectus sheath medially and the internal oblique laterally using a slow absorbing polydioxanone suture. The remaining external oblique muscle was closed over the mesh and the subcutaneous tissue and skin were closed in a standard fashion.On examination in the outpatient clinic a 10 × 7 cm firm, fixed lump was found in the left iliac fossa area of the abdomen. Urgent colonoscopic examination revealed mild sigmoid diverticular disease with no evidence of colonic malignancy. Computer Tomography was preformed Figure . At surgThe surgical specimen measured 11 × 7 × 4 cm. In the centre of the specimen, there was a 4 cm whitish solid tumour. The tumour consisted of relatively large cells with granular eosinophilic cytoplasm and small pleomorphic nuclei with occasional nucleoli Figure . No consThis patient has been reviewed in the outpatient clinic and is currently alive and well five months after surgery.GCTs typically present as a small, poorly circumscribed, painless, non-ulcerating nodule. The tumours can arise from virtually any anatomical site; the most common sites are the head and neck , the chest wall and the arm. They are mainly located in the dermis or the subcutaneous tissue (66% of cases) and less frequently submucosa, smooth muscle or striated muscle. They also can arise in the internal organs: larynx, bronchus, stomach, anogenital region and bile ducts. They arThe histopathological differential diagnosis can include rhabdomyoma (contains cross-striations and glycogen); hibernoma and fibroxanthoma (contain lipid droplets); and reactive changes with surgical trauma (associated with inflammatory elements and areas of necrosis). A common site for a rhabdomyoma is the heart, which is helpful in the differential diagnosis. GCTs can also be mistaken for squamous cell carcinoma due to marked acanthosis and pseudoepitheliomatous hyperplasia. Immunohistochemistry is essential for the correct diagnosis . Most GCPatients with completely resected benign lesions are usually cured. Excluding malignant tumours, recurrence is rare . Therefore the prognosis for these tumours appears to be favourable. There is no role for adjuvant therapy with radiotherapy or chemotherapy.Malignant GCTs are encountered in only 2% of cases . Only arExtensive abdominal wall defects like the one encountered here are a surgical challenge . The optThe ideal material for the repair of abdominal wall defects would provide strength, flexibility, host tissue incorporation, and infection resistance. There is a wide variety of mesh material available for abdominal wall reconstruction . Complic®) to close the large abdominal wall defect and this appeared to be ideal for this particular situation.Although rare, GCTs can present as an abdominal wall mass. It is important that clinicians are aware of their existence. The closure of large defects, after surgical resection of abdominal wall tumours, is a surgical challenge. We used a new biosynthetic porcine mesh (PermacolThe author(s) declare that they have no competing interests.AC wrote the draft of the manuscript; EG assisted in the surgical procedure, performed the literature research and revised the manuscript; NS examined the surgical specimen, wrote the pathological report and helped with revising the manuscript; SR performed the surgical procedure and revised the manuscript for intellectual content.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.


Malignant small cell neuroendocrine tumors of the pelvi-calyceal system are rare, and even more uncommon is their occurrence with concomitant transitional cell carcinoma, in the same renal unit. We present such a case for its unique presentation. Although most small cell carcinomas arise in the tracheobronchial tree, they are increasingly being reported in extra-pulmonary sites like the esophagus, cervix, parotid and in the genitourinary tract like the prostate and bladder.et al.,[Capella et al., reportedA 55-year-old gentleman had right loin pain for six months. He had no lower urinary tract symptoms (LUTS), fever or hematuria. On evaluation he was found to have microscopic hematuria and positive urine cytology. An ultrasound revealed right hydroureteronephrosis and a middle calyceal lesion with perinephric stranding.A computed tomography (CT) scan revealed a small 15×15 mm pelvi-calyceal lesion, along with a mid-ureteric thickening  and seveA working diagnosis of TCC was made and he underwent a right retrograde pyelogram, a ureterorenoscopy followed by right open nephroureterectomy with a bladder cuff.Retrograde pyelogram (RGP) showed a complete cutoff of contrast at the mid-ureter with inability of glide wire to be negotiated beyond it . UreteroIntraoperatively the mid-ureter was densely adherent to the retroperitoneum and there were large interaortocaval and pre-caval nodes, which were also removed.On gross examination, the kidney showed a well-defined tumour in the interpolar region  measurinRenal pelvis was infiltrated by the tumor which was composed of dispersed single cells and sheets of small to medium-sized cells with round, hyperchromatic mitotically active nuclei and scant eosinophilic cytoplasm . There wThe wall of the ureter was infiltrated by tumor as described above with areas of necrosis. There were nests of polygonal cells with vesicular nuclei, prominent nucleoli and clear cytoplasm . Hilar vSeparately sent interaortocaval lymph nodes showed reactive hyperplasia and no tumor. Immunohistochemical markers showed cytoplasmic positivity for neuron specific enolase (NSE) and synaptophysin  in the sPrimary malignant small cell neuroendocrine tumors comprise a group of highly malignant tumors, which hitherto are difficult to characterize, both clinically and histologically.Neuroendocrine tumors in the urinary tract have been described in the literature and they range from carcinoid tumors to small cell carcinomas. These tumors are more common in the renal pelvis, even though there are reports of neuroendocrine tumors occurring in the renal parenchyma, ureter and urinary bladder. The hist4This particular patient had a tumor in the renal pelvis with a small satellite tumor adjacent to it and another in the ureter, both showing histological and immunohistochemical features of neuroendocrine origin. In addition, the tumor in the ureter contained focal nests of high-grade urothelial carcinoma. To our knowledge, this is the first case in the literature of multicentric high-grade neuroendocrine tumor in the urothelial tract with concomitant high-grade urothelial carcinoma of the ureter.It is well known that the kidney can be the site of tumors with endocrine-paracrine differentiation. Tumors of the diffuse endocrine system collectively known as carcinoids, have been reported.9 It is, The key to the diagnosis of the small cell component is ultrastructure demonstration of secretory neuroendocrine granules and immunohistochemistry for synaptophysin and neuron-specifice enolase.Due to the rarity of genitourinary small cell neuroendocrine neoplasms, there are no well-defined protocols for adjuvant therapy. The discussion at the multidisciplinary meeting was that gemcitabine and carboplatin would be offered for six cycles for this patient. There have been studies proving the use of carboplatinum, etoposide and vincristine for small cell carcinoma of the lung. It is re


Non-Hodgkin's lymphomas (NHLs) are a group of malignant disorders that can arise from any part of the lymphatic system. However, extra-nodal lymphomas are uncommon accounting for around 6-18% of NHLs. Among extra-nodal involvement, the gastrointestinal (GI) tract is the commonest system in around one out of three cases, the majority of which are low-grade MALT (Mucosa Associated Lymphoid Tumors). Stomach is the commonest organ with 50-75% of all GI NHL arising from the stomach; however, diffuse large B-cell variants are uncommon.1We report a case of high-grade, diffuse large B-cell lymphoma of stomach in a 35-year-old female with disseminated skin involvement at presentation.2, Doxorubicin 50 mg/m2 and Vincristine 1.4 mg/m2 each on Day 1, plus Prednisolone 100 mg on Days 1 to 5. She achieved major partial remission at the end of four cycles for the stomach and skin lesions.The patient presented with history of abdominal pain and multiple swellings over the neck and upper limbs for two months. Examination showed multiple subcutaneous nodules over the face, neck, shoulder, thorax and abdomen  and the et al.et al.n = 266). To the best of our knowledge, it is the third reported case. The outcome is not defined in this subset. However, as the current evidence suggests that there is only minimal role of surgery and the mainstay of therapy is CHOP/CHOP-like regimens, the patient was offered CHOP and she showed a good response to therapy. The current case report reconfirms that chemotherapy without surgery can achieve good results even in advanced high-grade gastric lymphomas.The differential diagnosis in the present case includes disseminated lymphoma, (Stage IV) with stomach and skin involvement. However, as per the definition of primary gastric lymphoma, the patient had a primary lesion in the stomach, without systemic/peripheral adenopathy.


Acute necrotising fasciitis is a life-threatening condition, which requires urgent surgical intervention. Surgical debridement is invariably associated with large areas of tissue loss.We present a 58-year old woman with a past history of cervical carcinoma who presented with necrotising fasciitis of the perineum and upper thighs with associated pubic bone osteomyelitis. Following extensive debridement, a Vacuum Assisted Closure (VAC) system was applied to the large residual defect to facilitate skin graft application and optimise wound healing.This case demonstrates the successful management of a complex and potentially lethal wound of the perineum with debridement, skin grafting and the VAC system. Necrotising fasciitis (NF) is a devastating soft tissue infection characterised by widespread necrosis of the fascia and subcutaneous tissue. We describe a 58-year old woman who presented with NF of the perineum and thighs which were treated successfully with surgical debridement, broad-spectrum antibiotics, and skin grafting. We emphasise the advantageous use of the vacuum assisted closure (VAC) device which successfully expedited wound healing.A 58-year old woman presented to the gynaecology out-patient department with a 1-day history of increasing bilateral hip and suprapubic pain. She had a past history of carcinoma of the cervix 12-years prior to this admission, which was treated with a total abdominal hysterectomy, bilateral salpingo-oophorectomy with adjuvant radio- and chemotherapy. She developed a colo-vaginal fistula and bilateral ureteric obstruction 2-years ago due to complex pelvic sepsis, which was managed by fashioning a defunctioning loop colostomy and an ileal-conduit urostomy. However, the patient was otherwise well with no other significant medical problems.9/litre, erythrocyte sedimentation rate of 109 mm/hour and a C-reactive protein of 357 mg/L. She was treated conservatively with analgesia, fluid resuscitation and intravenous antibiotics  which were administered 3-times per day. On the second day post-admission, her condition deteriorated significantly and she was transferred to the high dependency unit (HDU) with septicaemic shock with a pulse rate of 110/min, blood pressure of 70/43 mmHg, and an oxygen saturation of 94% on 2 litres/min of oxygen therapy.On examination, the patient was dehydrated and pyrexic (38.6°C). Her blood pressure was 101/56 mmHg and pulse rate was 92/min. Abdominal examination revealed deep suprapubic tenderness with erythema of the perineum and inner thighs. Bowel sounds were normal. Initial haematological investigations demonstrated a haemoglobin level of 12.8 g/dl, white cell count of 19.1 × 10An urgent magnetic resonance imaging (MRI) scan of the pelvis revealed extensive oedema of the urethra, vagina and rectum with fluid collections within the proximal thigh adductors bilaterally which contained an air/fluid level within the pubic symphysis with extension into the retropubic space and superior to the urethra Figure . SubsequHistopathological assessment of a 20 cm × 7.5 cm ellipse of skin showed necrosis of the skin, dermis and subcutaneous fat with evidence of focal inflammation and pus within all tissue layers. Gram staining confirmed gram-positive cocci extending from the surface of the skin into the deep fatty tissue and arranged in chains, suggestive of streptococcal necrotising fasciitis. Cultures of swabs taken from the perineal wound isolated viridans group streptococci, coagulase negative staphylococci, enterococci and mixed anaerobes. The patient underwent repeated exploration and debridement of the wound in theatre under general anaesthesia on days five, seven, nine, twelve and fourteen post-admission.The wound was suitable for VAC dressing  from day-9 after initial debridement Figure . Owing tOn day-36, a repeat MRI was performed to investigate persistent bilateral groin sinuses. This demonstrated extensive oedema of all the muscle groups around the pelvis, most marked in the region of the obturators and the adductor muscles in the proximal thigh and bone marrow oedema in the symphysis pubis suggestive of osteomyelitis. Biopsy of the symphysis pubis corroborated the presence of osteomyelitis with collections of acute inflammatory cells and some reactive debris in the marrow space in combination with viable and necrotic bone. A gram stain showed some gram-positive organisms similar to those seen on the original biopsy, suggesting a residual nidus of infection in necrotic bone. The patient remained on long-term antibiotic therapy with continued application of the VAC dressing system as further surgical intervention was deemed inappropriate Figure . VAC theNecrotising fasciitis is a rare, life-threatening soft tissue infection, associated with rapidly progressive inflammation and necrosis of subcutaneous fascial tissues, with or without involvement of underlying muscle ,2. PoromNecrotising fasciitis affects the extremities more frequently than central areas and is classified according to speed of onset and aggressiveness ranging from type 1, a slow evolving process initiated by polymicrobial infection associated with less fulminant systemic complications; to the more aggressive type-2 which is associated with multi-organ failure . MortaliGross fascial necrosis detected at the time of surgical intercession is the gold standard for identifying NF. The 'finger test', which can be performed at the bedside, is based on the discovery of underlying fascial dehiscence. It involves blunt dissection with a probe or digit down to the deep fascia, through an iatrogenic or spontaneous wound. The diagnosis of NF is established if there is effortless dissection of subcutaneous tissue from the deep fascia .Gram-positive group A streptococcus, haemolytic streptococci and staphylococcus aureus; gram-negative enterobacteriaceae, escherichia coli, klebsiella spp and proteus spp; anaerobes including peptostreptococcus, clostridia and bacteroides; fungi such as candida, and acid fast bacteria have all been implicated in the pathogenesis of necrotising fasciitis . HoweverIntravenous antibiotic administration must not be delayed if necrotising fasciitis is suspected clinically. The antibiotic must have broad-spectrum properties and be effective against gram-positive organisms, gram-negative rods and anaerobes. Carboxypenicillin, carbapenam, clindamycin and metronidazole have been used successfully in various combinations to treat NF. Intensive nutritional supplementation, haemodynamic and analgesic support are all important for improving survival. Some studies have shown a reduction in the morbidity and mortality with the use of adjunctive therapies such as intravenous immunoglobin and hyperbaric oxygen .et al (2003) reported a mortality rate of 6% for surgery conducted within 24-hours compared to a rate of 24% if performed between 24 and 48 hours . Cir. Cir6].  3-weeks .NF associated with underlying osteomyelitis is extremely uncommon with only one previous case report of scalp necrotising fasciitis with aspergillus osteomyelitis of the skull . AlthougThe authors declare that they have no competing interests.SK Involved in the literature review, manuscript preparation and manuscript editing.MEOD Involved in the conception of the report, literature review, manuscript preparation, manuscript editing and manuscript submission.KK Involved in the manuscript editing and manuscript review.GD Involved in the manuscript editing and manuscript review.PDC Involved in the manuscript editing and manuscript review.JL Involved in the conception of the report, manuscript editing and manuscript review.All authors have read and approved the final manuscript.


Mucinous cystic neoplasms arise in the ovary and various extra-ovarian sites. While their pathogenesis remains conjectural, their similarities suggest a common pathway of development. There have been rare reports involving the mesentery as a primary tumour site.A cystic mass of uncertain origin was demonstrated radiologically in a 22 year old female with chronic abdominal pain. At laparotomy, the mass was fixed within the colonic mesentery. Histology demonstrated a benign mucinous cystadenoma.We review the literature on mucinous cystic neoplasms of the mesentery and report on the pathogenesis, biologic behavior, diagnosis and treatment of similar extra-ovarian tumors. We propose an updated classification of mesenteric cysts and cystic tumors.Mucinous cystic neoplasms of the mesentery present almost exclusively in women and must be considered in the differential diagnosis of mesenteric tumors. Only full histological examination of a mucinous cystic neoplasm can exclude a borderline or malignant component. An updated classification of mesenteric cysts and cystic tumors is proposed. Cysts of the mesentery, retroperitoneum and omentum present with similar incidence in both sexes, varying between 1:260,000 and 1:27,000 in adults and 1:20,000 in children. They are usually incidental, or present with unspecific and chronic symptoms involving abdominal pain, distention, a palpable mass, gastrointestinal and urinary obstruction . Acute mα-smooth muscle actin and desmin) [Mucinous cystic neoplasms (MCNs) arise in the ovary and various extra-ovarian sites, predominantly but not exclusively ,12-16 in desmin) -22. Alth desmin) -27, the  desmin) -30 and t desmin) ,32 and m desmin) -35 parat desmin) -41, lung desmin) -44breast desmin) -47, sple desmin) ,48,49 bo desmin)  and the A 22 year old white-Caucasian female, with otherwise unremarkable history, presented with chronic, left sided, vague abdominal pain. There were no abnormal findings on clinical examination. Ultrasound (US), computerized tomography (CT) and magnetic resonance (MR) scans Fig.  demonstrThere are thirteen documented cases of mesenteric MCNs in the literature prior to this report Table . Five ofThe origin of extra-ovarian MCNs has been sporadically attributed to implanted or ectopic ovarian tissue , supernuAccording to the WHO classification (ICD 10), MCNs are divided into benign adenomas, borderline tumours, non-invasive (in situ) and invasive carcinomas. The malignant potential of all MCNs is supported by observations of malignant transformation of benign neoplasms during long term follow up ,51. OtheWhen differentiating mucinous from non mucinous neoplasms and non neoplastic cysts and evaluating their malignant potential, the following features may have a positive predictive but not pathognomonic value: Patient age and tumour size ,74, multNone of the recognized classifications of mesenteric cysts -85, has There is no definitive diagnostic test. Radiological examinations may suggest the origin of a cyst, but cannot exclude the malignant potential of an MCN ,84,96-99Mucinous cystic neoplasms of the mesentery present almost exclusively in women and must be considered in the differential diagnosis of mesenteric tumors. Whilst there are no pathognomonic diagnostic criteria, a mesenteric cyst should be approached as potentially malignant especially in adults. Only complete excision and full histological examination of a mucinous cystic neoplasm can exclude a borderline or malignant component. We propose an updated classification of mesenteric cysts.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 journalThe authors declare that they have no competing interests.GM and AT were involved in the treatment of the patient, study design and drafting of the manuscript. GM also reviewed literature, prepared the tables and figures and edited the final version. PP and IP collected case details and helped in the literature search and drafting of the manuscript. All authors read and approved the final manuscript.Cysts of lymphatic origin• Simple lymphatic cyst• LymphangiomaCysts of mesothelial origin• Simple mesothelial cyst• Benign cystic mesothelioma• Malignant cystic mesotheliomaCysts of enteric origin• Enteric duplication cyst• Enteric cystMucinous cystic neoplasms• Mucinous cystadenoma• Borderline malignant mucinous cystic neoplasm• Mucinous cystadenocarcinomaCysts of urogenital originMiscellaneous neoplasms• Mature cystic teratoma• Neuroendocrine carcinoma• Cystic spindle cell tumorNon – neoplastic cysts• Hydatid cyst• Tuberculous cystNon – pancreatic pseudocysts• Haematoma• Abscess


Nodular fasciitis (NF) is a benign myofibroblastic proliferation in soft tissue. The most common sites are extremities, followed by the trunk and head and neck region. It is infrequently seen in the post-auricular region of pinna.We present here an interesting case of a young male who had a swelling in the post-auricular region; on cytology, it was diagnosed as pleomorphic adenoma; however, biopsy revealed characteristic morphology of NF.The case highlights the potential pitfall of cytology in diagnosing NF, especially because of unusual site and morphologic overlap. These leasciitis. It is exasciitis.4We report here an interesting case of an adolescent boy who presented with a swelling in the post-auricular region; and on cytology, it was diagnosed as pleomorphic adenoma (PA); however, the histological diagnosis of classical NF was a surprise. The case is presented to highlight the diagnostic pitfall of cytology.A 16-year-old adolescent boy presented with a swelling in the post-auricular region, slowly increasing in size for the past 6 weeks. On examination, the swelling was nontender, nonfluctuant, smooth, soft to firm with well-defined margins and measuring 1.5 cm in diameter. Clinical diagnosis of sebaceous cyst was considered, and the patient was referred for fine needle aspiration cytology (FNAC).FNA smears showed moderate cellularity comprising of predominantly dissociated round-to-plasmacytoid cells with central-to-eccentric nuclei, occasional binucleated cells, and few spindle cells. A fair number of spherical and linear deep magenta–colored stromal fragments surrounded by similar cells were also seen. The background was pale mucoid. There was no pleomorphism and necrosis; however, occasional typical mitosis was noticed . A cytolSubsequently, total excision of the mass was performed for histological correlation. Gross examination showed a well-circumscribed, unencapsulated gray-white soft tissue mass measuring 1.5×1 cm in size. Histologically, the lesion comprised of proliferating but uniform-appearing plump fibroblasts arranged loosely in short fascicles, bundles, and vague storiform patterns. The background stroma was variably collagenous. Few mitotic figures and extravasated red blood cells were also noted . In viewA panel of immunohistochemical (IHC) markers for cytokeratin (CK), epithelial membrane antigen (EMA), S-100, smooth muscle actin (SMA), and vimentin (Vim) was performed by Avidin-Biotin complex (ABC) method. On IHC study, CK, EMA, and S-100 were negative, and SMA and Vim were focally expressed, thus confirming the diagnosis of NF.FNA smears reviewed after histological diagnosis of NF for the overlapping features of NF and PA  were fouet al. studied clinico-pathological features in the largest series of 50 cases of NF in the region of external ear, including 28 dermal variants. In the auricular area, it occurs most often in young patients.[Nodular fasciitis is a relatively common soft tissue tumor; it occurs more frequently than most other tumors or tumorlike lesions of fibrous tissue that develop in adults. Althoughpatients. Usually,et al. further supported its cytological diagnosis.[Dahl and Ackerman first documented the correlation between FNAC and histologically confirmed cases of NF. Aydin etiagnosis. Morpholoiagnosis. The commiagnosis. The presiagnosis.. On reviiagnosis.-1c. In ciagnosis., in addiiagnosis..Spontaneous regression is known to occur in NF even without excision. Local recurrences are more frequent in these cases because of the difficulty in obtaining complete surgical excision around the ear; rarely, frequent recurrences may transform the lesion to fibrosarcoma.To conclude, preoperative cytological diagnosis of NF is important to avoid unnecessary surgery in most cases. Although site and overlapping morphology can mislead the cytologist, leading to a diagnostic pitfall, a careful evaluation of certain morphological features may help in making a definitive diagnosis of NF.Authors do not have competing interests in this case.DJ, assistant professor, collected the literature and helped in drafting of the manuscript.NK, professor, helped in the histological evaluation of the case.SJ, professor, helped in the final revision and approval of the version for publication.All authors read and approved the final manuscript.


Empyema of gallbladder is generally a rare disease and it is even rarer in the traditional African population where incidence of cholelithiasis is much lower compared with the Caucasian population. This is a presentation to highlight massive empyema of the gallbladder in a 58 year old woman who had no prior history of gallstone disease and who was treated with open cholecystectomy. The outcome was successful and she was followed up for a year. Empyema of the gall bladder received extensive attention in the early twentieth century but has since been seldom discussed -3. Untilnd of January 2007 with 4 days history of an insidious onset of right hypochondrial colicky abdominal pain which progressed and became generalized a day prior to admission. It was associated with anorexia, nausea and one episode of non - bilious, projectile vomiting. She had dyspepsia and early satiety a couple of days prior to the onset of abdominal pain. Although she also had low grade fever there were no chills and rigor. She was never fat intolerant and had not suffered previous jaundice. She is Para 3 + 0 3 alive woman last menstrual period was 12 years ago. She neither drink alcohol nor smoke cigerratte.A 58-year-old woman, a University Lecturer of Yoruba ethnicity in Nigeria. She weighed 52 kg and 1.55 m in heght. She presented on 2Physical examination essentially revealed an exhausted, dehydrated, tachycardic  woman in painful distress with a Blood Pressure of 140/100 mmHg. There was a firm, tender, irregularly surfaced globular abdominal mass measuring 20 cm lengthwise and extending from her right hypochondrium to the iliac fossa. Its upper limit was tucked under the rib cage and could not be reached. Although bowel sounds were hypoactive, there was no clinically demonstrable ascites.Clinical diagnosis of infected mucocoele or empyema of the gallbladder was entertained with a differential diagnosis of infected hepatic cyst. Ultrasonography and Computerized axial tomography respectively reported mucocoele and empyema of the gallbladder with impacted stone at the neck. Her haematocrit was 39% and except for a mild azotaemia (urea level of 6.3 mmol/L), possibly due to dehydration, the electrolytes were within normal limits. Electrocardiogram showed occasional supraventricular ectopic beat.She was adequately resuscitated with intravenous fluid and antibiotics and analgesic (intravenous ceftriaxone and intramuscular petazocine). She then had an emergency exploratory laparotomy and retrograde cholecystectomy. Operative findings included minimal serous ascites, massively distended and oedematous gallbladder measuring about 24 cm in longitudinal diameter , 2. WithGallstone pathology and the recognition that it might result in fatal complications was widely discussed during the renaissance in several treatises . Some ofThe relatively short duration of symptoms, the low incidence of gallstone disease in our environment and the rarity of empyema of the gallbladder in general coupled with the fact the patient was a very enlightened person who could not have neglected her disease state made the clinical diagnosis slightly difficult in this case and much reliance had to be placed on the physical appearance and the location of the swelling in the abdomen.Performing emergency cholecystectomy on an inflamed and oedematous gallbladder with surrounding tissue oedema and adhesion is generally known to be fraught with danger of bleeding and iatrogenic injuries to structures in the triangle of Calot given the regularity and notoriety of the anatomical anomalies and variations of the extrahepatic ducts and vessels. The sheer size of the gallbladder in the case, rather than compound the problem, was found to be helpful to dissection and the operation in that the colon, duodenum and omentum were to some extent pushed down and out of the way. The splaying out occasioned by the displacement resulted in a wide triangle and the inflammatory oedema further assisted in identifying the tissue planes . AdoptioThis report highlighted that gallstone diseases complicated by empyema could present without the known typical chronic clinical features of cholelithiasis that usually antedate the presentation. Absence of chronicity was in this case supported by the distensibility of the gallbladder to the enormous size encountered. The sheer size coupled with the presence of inflammatory oedematous tissue rather than compound the usual danger of operating in the condition favourably modulated the emergency open cholecystectomy offered the patient.


The hepatic teratoma is a very rare entity of which only 25 cases have been published so far. In our case the hepatic teratoma is associated with peritoneal gliomatosis, which is an indicator for an ongoing peritoneal spread of a teratoma. Wall calcifications and the homogeneity as well as the well defined border misled the radiologist to the diagnosis of an echinococcal cyst, which is the most common differential diagnosis, however the hepatic teratoma has to be taking into consideration when dealing with unclear hepatic cysts, although it is very rare. In November 2008, a 59-year-old, Swiss Caucasian woman presented to her family physician with mild abdominal pain. No significant events were documented in this previously healthy woman's medical history besides a left sided oophorectomy in 1960 for a teratoma and a hysterectomy in 1982 for unknown indication after three uncomplicated pregnancies. She had no history of trauma and was taking no medication at the time of presentation.The general practitioner performed abdominal ultrasound and found an anechoic, well delineated lesion of the right liver, 13 cm (centimeters) in diameter. For further evaluation the patient was referred to our hospital where computed tomography (CT) revealed a homogenous, hypodense, well delineated lesion of the right liver with a diameter of 13 cm and small calcifications in the lesion's wall (Figure Intraoperative findings included a large cystic lesion adjacent to the liver without hepatic infiltration as well as multifocal peritoneal thickening combined with white superficial spots on the peritoneum Figure . The cysA large, cystic, well encapsulated, firm-elastic lesion with a diameter of 16 centimeter was macroscopically described by the pathologist and smooth muscle, adipose tissue, hyaline cartilage, thyroid tissue, respiratory epithelium, calcifications and cholesterol crystals were found microscopically Figure . The finCystic liver lesions are frequent findings in diagnostic imaging and can be of either neoplastic or non-neoplastic origin. We have reported the case of an unusual appearance of a hepatic teratoma in an adult woman combined with peritoneal gliomatosis, which is a very rare, atypical finding. Up to our knowledge of current literature, a total of twenty-five cases of hepatic teratomas have been published so far , howeverIn our case, the well encapsulated, homogenous, cystic lesion with wall calcifications misled the radiologist initially to the false diagnosis of an echinococcal cyst. Additionally, the intraoperative finding of peritoneal gliomatosis could not be detected on the CT images. Gliomatosis peritonei is thought to be genetically unrelated to the associated teratoma and might be derived from non-teratomatous cells, such as through metaplasia of submesothelial cells . HoweverThe key differential diagnoses include the amebic abscess and echinococcal cysts as well as a necrotic metastases, however, in our case the patient had not visited any countries with endemic occurrence of Amoebiasis or Echinococcosis and further on the results of the laboratory examinations were negative for these parasitic disease patterns. A necrotic metastases was ruled out by histopathology.We conclude from this reported case that the finding of an unclear, cystic liver lesion and multifocal peritoneal thickening can, although very rarely, represent a hepatic teratoma with associated gliomatosis peritonei and has therefore be taken into consideration as a possible differential diagnosis especially in patients after oophorectomy for a teratoma.Institutional review board approval was granted based on a general waiver, taking into account that patients have the possibility to choose if their data can be used for retrospective investigations. 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.CK: Image reconstruction, Manuscript writing, SL: Manuscript Editing, Idea, MD: Histology workup, SB: Manuscript Editing, Surgical feedback, PS: Manuscript Editing. All authors have read and approved the final manuscript.


A synovial sarcoma (SS) is an aggressive soft tissue tumor that classically occurs in the extremities near, but rarely within large joints, in young adults. Variable symptoms and clinical manifestations may be encountered and a definite diagnosis should depend on pathological results. This poses certain difficulties in arriving at a prompt diagnosis and appropriate treatment.We report the case of a 68-year-old woman patient who presented an inguinal mass with swelling and pain in the right lower limb. She underwent surgery, and later received systematic intravenous chemotherapy. The pathological studies, especially the specific chromosomal translocation of a t , confirmed the diagnosis as a synovial sarcoma. To the best of our knowledge, this is the first report of a monophasic synovial sarcoma in the inguinal region.Besides making the readership aware of the rarity of location and age of this present case, this report distinctly highlights the great value of a molecular analysis of an SYT associated genetic alteration in the diagnosis of synovial sarcoma occurring at rare sites especially when immunochemical results are equivocal. A synovial sarcoma (SS) is an aggressive soft tissue tumor, which mainly occurs in the para-articular region of extremities with a predilection of lower limb. It usually develops in adolescents and young adults between the age of 15 and 40 years . The detInguinal synovial sarcomas are rare findings with only one case report in the English literature . Here weA 68-year-old woman was admitted with a complaint of swelling and pain in her right lower limb. She had felt a progressive swelling and pain for more than two months without any obvious cause. Subsequently, she was referred to a vascular surgery clinic where a mass was found in the right inguinal area by physical examination. The mass was like a goose-egg in shape, hard, fixed and couldn't disappear under pressure. A Doppler ultrasonic vessel examination suggested that there were small blood clots and reduced blood flow in the veins of the right lower limb. Correspondingly, CT and CT angiography (CTA) scans were conducted which displayed a mass in her right inguinal area with involvement of the femoral vein Figure , 2. The A surgical excision was performed which revealed a tumor located in the right inguinal region with adhesion to the right femoral vein and artery. The tumor was completely resected with negative margin. Grossly, the specimen was 8 cm × 6 cm × 4.5 cm in size and the cut surface was firm and white-to-tan. Microscopic appearances were monomorphic, highly cellular composed of plump, spindled cells growing in short fascicles. The tumor cells had ovoid nuclei and minimal cytoplasm with frequent mitotic activity and atypical nuclei Figure . ImmunohFor personal reasons, the patient refused to receive any chemotherapy after the operation. Unfortunately, lung and spleen metastasis were found 15 months after operation in a routine postoperative follow-up. The patient was referred to the oncology department where she received systemic intravenous chemotherapy . However, the patient responded poorly to the treatment and finally died 9 months later due to an initially poor and subsequently rapidly worsening condition.Synovial sarcomas are uncommon soft tissue tumors accounting for 5-10% of the soft tissue sarcomas. They usually develop in children and young adults and approximately 95% of SSs occur in the extremities. They can metastasize distantly, especially to the lung and lymph node [Two major histologic subtypes exist: monophasic and biphasic synovial sarcomas. The classical SS has a biphasic appearance with a mixture of epithelial and spindle cells in varying proportions. The monophasic SS consisting solely of sarcomatous components is often diagnostically challenging. Synovial sarcomas typically occur in patients between the age of 15 and 40 years, rarely in the elderly. Patients commonly present with a palpable mass or swelling, associated with pain in almost half of the patients. The most common sites include the lower extremities (60%), with a special predilection for the knee area; the upper extremities (23%); the head and neck region (9%), particularly in the retropharyngeal and parapharyngeal areas; and the trunk (8.1%), most commonly involving the abdominal wall or retroperitoneum et al meIn our case, heavily stained nucleus, mitotic activity and atypical spindle-shaped cells with an increase in nucleus to cytoplasm ratio were observed under the light microscope. A panel of immunohistochemical staining was done for differential diagnosis. The spindle cells were positive for epithelial membrane antigen (EMA), calretinin, cytokeratin (CK), vimentin (VIM) and proliferating cell nuclear antigen (PCNA), but negative for smooth muscle actin(SMA), muscle specific actin(MSA), CD117 and S100. These findings helped to exclude the presence of a leiomyosarcoma, malignant peripheral nerve sheath tumor(MPNST), gastrointestinal stromal tumor(GIST). Despite of a panel of immunohistochemical staining results, however, to distinguish between sarcomatoid mesothelioma and synovial sarcoma was extremely difficult because both types of tumors share the same immunostaining results. They show an overlap in their respective immumostaining spectrum of EMA, calretinin, vimentin and S-100. To date, there exist no ideal immunohistochemical markers to reliably diagnose the SS and make an unequivocal distinction. The gold standard applied in order to confirm the diagnosis of SS is to detect the specific t translocation,20 at moSurgery is the mainstay treatment. Chemotherapy and radiation therapy should be considered as additional treatment options or may be utilized in cases of relapse. Prognosis is poor with local recurrence and metastases in almost 50% of the patient . MetastaCurrently, with known genetic alterations in SSs, new therapies targeting DNA or protein are under investigation. Vaccine of SYT-SSX junction peptide was tested in a pilot study . Recent In conclusion, this is the first report of a monophasic synovial sarcoma in the inguinal region. We report this unusual case because of the tumor location and patient's old age. The case illustrates possible differential diagnoses before the treatment. It also highlights the value of molecular analysis in ascertaining the diagnosis of a synovial sarcoma at a rare site, especially when immunohistochemical results are equivocal.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.JX performed surgery on the patient and participated in designing the report and also was involved in data acquisition and interpretation, writing initial drafts and subsequent revisions and undertook review of literature on topic. JW made a substantial contribution regarding conception of report, made many suggestions regarding pathological issues contained in the report and undertook review of pertinent literature on topic. XW made a substantial contribution regarding pathological molecular analysis. LC made a substantially contributed to the concept of this case report, supervised the work and drafts of the case report prepared by the first and second authors. All authors read and approved the final version of the article to be submitted for publication.


Ameloblastomas are tumors arising from the odontogenic epithelium. Despite There are significant anatomic, histopathologic, and radiologic differences between desmoplastic ameloblastomas and the classic type.A 45-year-old lady presented with a painless hard swelling in the anterior part of the lower jaw of 6 months’ duration. Clinical examination revealed a bony hard swelling arising from the lower jaw, with the intraoral examination showing a large, hard, nontender mass on the anterior mandible, covered by red, intact, and mobile mucosa. The lesion extended from the right premolar region to the left canine region. No lymphadenopathy or fistulae were present. The involved teeth were vital and slightly displaced lingually. The past medical history was unremarkable.A frontal radiograph of the mandible revealed a diffuse, ill-defined, predominantly radioopaque lesion interspersed with fine radiolucent areas, producing a honeycomb appearance; this arose from the body of the mandible in the region of the right incisors, canine, and premolars .A plain CT scan clearly showed the internal characteristics and extent of the lesion. It revealed a solid, expansile, ill-defined, radiodense mass intermixed with radiolucent areas, arising from the anterior part of the body of the mandible and extending from the right incisor to the right premolar region, as well as across the symphysis. The lamina dura of the affected teeth and the buccal and lingual cortices were destroyed Figures  and 3.Based on the radiological appearances, the diagnostic possibility of either a fibro-osseous mass or an ameloblastoma (desmoplastic variant) was suggested. The patient underwent an incisional biopsy, which showed a desmoplastic ameloblastoma. A right hemimandibulectomy across the midline was then performed with a transitional prosthesis.The desmoplastic ameloblastoma is a rare and infrequent tumor, characterized histologically by marked stromal desmoplasia. The commThe majority of desmoplastic ameloblastomas occur in the mandible, commonly in the anterior part. The clasRadiographically, a desmoplastic ameloblastoma is seen either as an ill-defined mass containing osteolytic and sclerotic areas or as multifocal radiodense flecks within a radiolucent background, resembling a honeycomb. This is because of the infiltration of the tumor cells into the adjacent marrow spaces, with simultaneous vigorous osteoblastic activity. The tumoMRI shows heterogeneous low to intermediate signal intensity on T1W images, heterogeneous high signal intensity on T2W images, and strong enhancement on post-gadolinium T1W images. MRI can On histopathology, desmoplastic ameloblastoma reveals small areas and thin cords of odontogenic epithelium distributed between dense, fibrous connective tissue. Regions As it is almost impossible to find the exact interface between the lesion and normal bone, it is difficult to cure these tumors surgically. Since deThus, desmoplastic ameloblastoma should always be considered in the differential diagnosis of a mixed radiodense-radiolucent lesion with diffuse borders in the anterior premolar region of the jaws. Other possibilities include fibro-osseous lesions like cemento-ossifying fibroma, cementoma (intermediate stage), osteitis, cementoblastoma, fibrous dysplasia, calcifying odontogenic cyst, etc. A definitive diagnosis prior to surgery requires histopathology, to aid proper surgical management.


This study documents the first reported case of a rapidly growing (volar) thenar eminence ganglion arising form the first carpometacarpal joint, masquerading as a sarcoma. The discussion informs the hand surgeon on the evidence regarding the unusual presenting features.An 85 year old left hand dominant female presented with a six week history of rapidly growing lump on the thenar eminence. Clinical examination revealed a non-tender large lobulated mobile swelling measuring 5 × 4 cm and involving the whole thenar eminence.Ganglia may present from the thenar eminence and are a source of diagnostic confusion. A rapidly expanding (volar) thenar eminence ganglion is a rare entity that may easily be confused with malignant soft tissue tumors. To our knowledge this the first reported case in the literature, both in site of (thenar eminence) and its unusually rapid expansion (5 × 4 cm in 6 weeks).An 85 year old left hand dominant female presented with a six week history of rapidly growing lump on the thenar eminence. Clinical examination revealed a non-tender large lobulated mobile swelling measuring 5 × 4 cm and involving the whole thenar eminence. A sarcoma was initially suspected. Plain X-ray figure  revealedIn an effort to increase the rigor of our study by reducing retrieval bias, the structured search is being reported. This was performed using the search-construct " AND Ganglion)" across the following databases: Pubmed EMBASE, AMED, CINAHL.While dorsal and wrist ganglia are common in the upper limb, our literature search retrieved only one other article describing a volar wrist ganglion. Our case is materially different since Chiu and Aschermann reported a slowly enlarging ganglion arising from the wrist whereas the case reported here derived from the first carpometacarpal joint, expanded volarly, and rapid expanded over six weeks to the reported dimensions. Chiu and Aschermann (1993) reported an 'extensive review of the literature' to claim the first report of a ganglion presenting as a thenar mass. However they did not report a reproducible literature e search strategy to substantiate their claim.Our patient presented at an atypical 85 years of age, in an atypical volar position and in an atypical rate of growth. Such a presentation may lead the unsuspecting clinician to disregard the possibility of this diagnosis when examining a thenar eminence lump. Conversely although soft tissue sarcomas of the hand are uncommon, the most frequent presentation is a painless soft tissue mass in the thenar eminence. The clinical confusion with sarcomas may prevent diagnostic aspiration, due to fears about seeding the tumor. This distinction between the two pathological entities is paramount due to the differences between operative resection, and the distinctly worse prognosis for palmar sarcomas compared to similar lesions elsewhere in an extremity.Ganglia may present from the thenar eminence and are a source of diagnostic confusion. Documentation of an occurrence of thenar ganglion may alert the hand surgeon to consider its possibility in planning diagnostic and operative procedures, and avoid patients' undue anxiety.The authors declare that they have no competing interests.AM, and SG contributed towards retrieval of data. EA performed the literature meta-search and was a major contributor in writing the manuscript. MK was essential for delivering a clinical perspective and critically reviewing the manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Malignant gastrointestinal stromal tumor (GIST) is a rare type of sarcoma that is found in the digestive system, most often in the wall of the stomach. Multiple GISTs are extremely rare and usually associated with type 1 neurofibromatosis and familial GIST.We report here a case of a 70-year-old woman who reported pain in the abdomen, loss of appetite, and weight loss for six months. Ultrasound examination showed a small bowel mass along with multiple peritoneal deposits and a mass within the liver. Barium studies were suggestive of a neoplastic pathology of the distal ileum. A differential diagnosis of adenocarcinoma/lymphoma with metastases was entertained. Perioperative findings showed two large growths arising from the jejunum and the distal ileum, along with multiple smaller nodules on the serosal surface and adjoining mesentery of the involved bowel segments. Segmental resection of the involved portions of the intestine was performed. Histopathological features were consistent with those of multicentric malignant GIST-not otherwise specified (GIST-NOS). Follow-up examination three months after surgery showed no evidence of recurrence. Gastrointestinal stromal tumors (GISTs), formerly classified as leiomyomas or leiomyosarcomas, are mesenchymal tumors of the gastrointestinal tract (GIT). GISTs are now defined as spindle cell, epithelioid, or occasionally, pleomorphic mesenchymal tumors of the gastrointestinal tract, which express the KIT protein CD117) detected by immunohistochemistry and which lack smooth muscle or Schwann cells as seen in electron microscopy.[17 detect1A 70 year old woman presented with pain in the abdomen, especially over the right flank and lumbar region, a feeling of mass in the abdomen, and weight loss for six months, with gradual increase in pain and loss of appetite since two months. There were no cutaneous lesions or any familial history.Clinical examination revealed two irregular, palpable, nonpulsatile, abdominal masses in the upper abdomen measuring 8 × 6 cm and 6 × 5 cm, over the hypogastrium and right hypochondrium-epigastrium region, respectively. Laboratory investigations revealed anemia with hemoglobin (Hb) = 9.0 g%; total and differential leukocyte counts were within normal limits. Biochemistry showed random blood sugar = 114 mg%, urea = 32 mg%, creatinine = 0.8 mg%, total bilirubin = 0.8 mg%, total protein = 5.3 mg%, Alanine Aminotransferase = 31 IU/L, Aspartate Aminotransferase = 42 IU/L, Alkaline Phosphatase = 467 IU/L, and serum. amylase = 97 IU/L.Ultrasound examination showed a small bowel mass along with multiple peritoneal deposits and a solid mass within the liver. The mass measured 8.5 × 2 cm with a cystic center and a thick echogenic wall. Focal, asymmetrical, circumferential, heterogeneous thickening of the small intestinal wall was also noted. The findings of a barium enema were normal, whereas a barium meal follow-through examination was suggestive of neoplastic pathology of the distal ileum. Fine needle aspiration from the liver mass was inconclusive. The patient underwent exploratory laparotomy and perioperatively, two large growths were seen to arise from the jejunum and distal ileum with multiple smaller nodules in the mesentery; resection of the involved segments of the intestine was done. The liver was also found to be enlarged, raising the suspicion of metastasis, but no biopsy was performed.The resected segment of the jejunum measured 8.0 cm in length and 1.8 cm in diameter, along with a large encapsulated, nodular, exophytic mass measuring 13 × 10 × 9 cm arising from the jejunal wall . The cutA large, encapsulated, soft mass measuring 6 × 5 × 5 cm was seen in the mesentery of the ileum . MultiplMicrosections from the jejunal mass showed a highly cellular tumor arising from the muscle layer of the intestine and composed of spindle cells arranged in fascicles . The celSections from the mesenteric tumor nodules showed similar histomorphology with pleomorphic nuclei, necrosis, and high mitotic activity (> 50 mitoses per 50 high-power fields).Immunohistochemical staining was positive for CD34, vimentin, and CD117, weakly positive for smooth muscle actin (SMA), and negative for desmin and S100.Based on the findings of gross examination, histopathology, and immunohistochemistry, a diagnosis of multiple malignant GIST-NOS was made.The differential diagnosis of spindle cell tumors of gastrointestinal tract consists of GIST-NOS, leiomyoma, schwannoma, and fibromatosis. Moreover, the scenario becomes complex because of the smooth muscle and/or neural features that can also be found in GISTs. GISTs are rare but are nevertheless the most common mesenchymal neoplasms of the GIT and are thought to arise from the interstitial cells of Cajal—the intestinal pacemaker cells. GIST mos14However, these tumors can be defined better on immunohistochemistry: c-kit is positive only in GISTs; SMA is positive in leiomyomas, fibromatosis, and GISTs (30–40%); desmin is positive in leiomyomas but very rarely in GISTs and fibromatosis; S-100 is negative in fibromatosis and very rarely positive in GISTs or leiomyomas, but positive in schwannomas.The incidence of GISTs is estimated to be 10–20 cases per million, and they usually occur in patients who are older than 50 years.[Mesenteric GISTs are rare and may arise as primary lesions or as a result of metastatic spread. Usually metastatic, mesenteric GISTs are multiple and may simulate peritoneal carcinomatosis. In the study by Miettinen et al., the average size of mesenteric GISTs was reported to be 16.5 cm.[Clinical symptoms are related to the size and location of the GISTs. Most pathologists use a combination of tumor size and mitotic rate to assess the malignant potential of these tumors. Features favoring malignancy are: size > 5 cm, mitotic rate > 5/50 hpf, high cellularity, nuclear pleomorphism, and necrosis. In general, malignant GISTs are larger, more cellular, and more mitotically active. GISTs that are smaller than 5 cm with ≤ 5 mitoses per 50 consecutive high-power fields are considered to be benign with a low risk for metastasis. Tumors larger than 10 cm with more than five mitoses per 50 high-power fields are considered to be malignant. All tumors falling between these two extremes are considered to be of uncertain malignant potential with intermediate risk for metastasis. Tumors with > 50 mitoses per 50 high-power fields are considered to be highly malignant with an aggressive clinical behavior. The liver and the peritoneum are the most common sites of spread in malignant GISTs.The immunohistochemical marker, c-Kit CD117) identifies tumors originating from the pacemaker cells of Cajal and seems to be the most specific diagnostic marker currently available.17 identiOmental and mesenteric GISTs are typically positive for CD117, and less consistently, for CD34. They often show alpha-smooth muscle actin reactivity but are virtually negative for desmin and S-100 protein. The presGISTs mostly metastasize within the abdomen. In one study of 83 patients, the common site of metastasis was the liver in 38 patients (46%) and the peritoneum in 34 patients (41%). Other siThe usual treatment of such tumors is surgical excision, although recently, treatment targeted toward inhibiting the mutant KIT gene by imatinib mesylate, a tyrosine kinase-inhibitor, has also been very successful in recurrent cases.A recent review noted that patient survival after primary surgical resection of GISTs ranges from 48–80% at five years.[Therefore, the treatment of choice for malignant GISTs should be surgical resection, along with imatinib mesylate therapy, and a close follow-up by imaging techniques for recurrences.


We describe a patient in whom an early carcinoma of the duodenum was able to be resectedendoscopically. A 77-year-old man presented with epigastric pain. Upper gastrointestinalendoscopy revealed a mass in the duodenum, and the patient was admitted. A whitish nodularaggregated lesion, measuring 20 mm in diameter, was found in the second portion of theduodenum. Examination of a biopsy specimen showed a Group III tubular adenoma. Endoscopic ultrasonography showed that the lesion was confined to the mucosa. The large sizeof the lesion suggested the possibility of malignancy. Endoscopic mucosal resection wastherefore performed. Histopathologically, the diagnosis was carcinoma in adenoma. Thedepth of invasion was mucosal. We conclude that endoscopic muosal resection can be usedto treat mucosal lesions arising in the duodenum.


Sigmoid colon cancer metachronous metastases commonly occur in the liver and lungs with sporadic reports also to the spleen, stomach, thyroid gland, abdominal wall and upper urinary tract. This is a rare case of metachronous metastases invading the mesorectum and the abdominal wall.A 72-year-old female underwent sigmoidectomy for stage I (T2N0 M0) sigmoid colon cancer in May 2008. In June 2009, an abdominal computed tomography scan revealed a tumor 2 cm in size at the lower anterior mesorectum and a second mass 2 cm in size at the anterior abdominal wall midline. Total colonoscopy showed no mucosal lesion. The serum carcinoembryonic antigen level was normal. A biopsy of the mesorectum tumor showed similar histologic characteristics with the primary tumor. Since no other site of recurrence was identified, an abdominoperineal resection was attempted. During the operation and after the removal of the incision recurrence, sinus bradycardia and signs of myocardial ischemia were noticed. A loop transverse colostomy was immediately perfomed and the operation was terminated. Postoperative cardiologic examination revealed an acute myocardium infract. Chemo-radiation of the mesorectum tumor and re-evaluation for surgical excision was decided.Metachronous metastasis of the mesorectum from sigmoid colon cancer is extremely rare. Although patterns of lymphatic spread from rectal cancer to sigmoid colon have recently been demonstrated, there is no evidence of metachronous mesorectum invasion from sigmoid colon cancer. This could be the issue for future trials. Colon cancer as one of the most commonly diagnosed cancers around the world has an improved prognosis due to the development of diagnostic and therapeutic procedures. Overall survival however, can be seriously shortened, mostly in the presence of distant metastasis during follow-up. Liver is the commonest site of metachronous metastases in approximately one fourth of the patients, followed by the lungs . SporadiA 72-year-old female was admitted to hospital suffering from fatigue, weight loss and rectal bleeding. Total colonoscopy demonstrated adenocarcinoma of the sigmoid colon at 25 cm from the anal verge. A chest x-ray was normal. No sites of distant metastasis were reported on abdominal computed tomography (CT) scan. The serum carcinoembryonic antigen level was normal. The patient underwent sigmoidectomy in May 2008. During the operation, the left ovary was fixed at the site of the sigmoid colon cancer and was removed en block. Thorough macroscopic examination of the liver and rest of the abdomen showed no sign of metastatic disease. Histopathological examination of the specimen revealed a moderately differentiated mucus-producing adenocarcinoma, 3 cm in diameter located 5 cm from the peripheral surgical margin figure . The tumRecurrence after curative resection of colon adenocarcinoma is a major determinant of survival and it seems to increase as the primary tumor stage advance. In this case, a sigmoid adenocarcinoma is infiltrating 2/3 of muscularis propria with four lymph nodes harvested free of metastatic disease. According to TNM classification this is a stage I (TIN0 M0) colon cancer but with inadequate lymph node evaluation -8. Even This case is important in showing that metachronous metastasis of the mesorectum from sigmoid colon cancer is possible, probably due to downward lymphatic cancer spread. Perhaps, there is a need of a more thorough investigation of the mesorectum region in sigmoid colon cancer during preoperative imaging. There is no similar report published in the literature.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.JK first noticed this rare case report and wrote the main manuscript. GF revised the manuscript for important intellectual content. AM has been involved in drafting the manuscript. AZS performed histological examination of the specimens. SR has given final approval of the version to be published.


We herein report two cases showing long-term complete remission (CR) in response to S-1 monotherapy. Case 1 was a 65-year-old male diagnosed with an advanced poorly differentiated adenocarcinoma of the stomach with paraaortic lymph node metastases, which disappeared after S-1 monotherapy. Subsequently a total gastrectomy was performed, and histological CR was evident. His progress is presently uneventful without recurrence 50 months after surgery. Case 2 was a 59-year-old female who underwent a total gastrectomy with a jejunal pouch. The resected tumor was a medullary type poorly differentiated adenocarcinoma infiltrating the serosa and involving the regional lymph nodes. One year after surgery, endoscopy revealed a recurrent tumor in the jejunal pouch. After the administration of S-1, this recurrent tumor completely disappeared, and she has since maintained CR for 39 months. These cases suggest that a subgroup of patients with advanced gastric cancer may attain CR with S-1 monotherapy. S-1 is an oral antitumor agent that exploits the biochemical modulation of 5-fluorouracil (FU) pharmacokinetics. S-1 contains tegafur, gemistat and otastat potassium. Gemistat inhibits 5-FU degradation and maintains prolonged 5-FU concentrations. Otastat potassium alleviates the gastrointestinal toxicity induced in the host by 5-FU.,3 Howeve®, Taiho Pharmaceutical Co., Ltd.) at a dose of 120 mg/day was administrated orally for four weeks, followed by a two-week period of no treatment (4-week regimen). This therapeutic schedule was thereafter repeated four times. No adverse events were observed during the S-1 therapy. With the regimen, the gastric cancer remarkably decreased in size and the paraaortic lymph node metastases disappeared. A total gastrectomy with regional lymph node dissection was performed, and the removed specimen showed a scar in the cardia  in the upper corpus. Exfoliative cytology of the peritoneal lavage fluid during the operation was positive for adenocarcinoma (CY1). There was no metastasis to the liver. Microscopically, the tumor was a medullary type poorly differentiated adenocarcinoma with lymphoid stroma, infiltrating through the serosa (pT3) and involving regional lymph nodes . Based on the surgical findings, the tumor was diagnosed as stage IV , [This report documents two cases of advanced (stage IV) gastric cancer showing long-term CR to S-1 monotherapy; In case 1, CR was histologically verified in the surgically resected stomach, and in case 2 this was presented for a suture line recurrence in the jejunal pouch.In phase II studies of S-1 in patients with advanced gastric cancer, the overall response rate has been approximately 40–50%.,3 A retrFew reports have documented advanced gastric cancer with long-term remission after neoadjuvant chemotherapy with S-1 alone; two patients with advanced or metastatic gastric cancer, who responded to S-1 monotherapy and demonstrated clinical CR for about 4 years.,9 In anoKimura et al. devised an alternative dosing regimen for S-1, i.e. 2-week regimen, and conducted a retrospective study to evaluate the efficacy and feasibility of this schedule in comparison with the 4-week regimen. In theirJejunal pouch recurrence after gastrectomy for gastric cancer has rarely been described.,14 InterIn conclusion, the two documented cases of advanced gastric cancer showed long-term CR in response to S-1 monotherapy. At present, a standard neoadjuvant strategy for advanced gastric cancer has not been established, but oral intake S-1, which is desirable in the outpatient setting because of its feasibility and mild toxicity, might prove to be considered as a possible alternative chemotherapeutic regimen for such patients, but we definitely need large randomized controlled trial.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.Hiroyuki Mitomi: pathological examination for this case. Ichiro Kishimoto: surgeon and clinical follow-up for the patient. Akifumi Amemiya, chief surgeon for the patients. Goro Kaneda, assistant surgeon for the patients. Ken Adachi, chief gastroenterologist for preoperative examinations of the patient. Takuya Shimoda, assistant gastroenterologist for preoperative examinations of the patient. Masakazu Takigawa: chief radiologist for radiological examinations of the patient. Naoshi Fukui: conclusive discusser for the case. Yasuo Ohkura: main consultant for pathological findings of the case.