Epithelioid hemangioma is a rare vascular tumor found in the penis. It is essential to avoid misdiagnosis with Peyronie's disease and penile cancer, as management differs significantly.We present a case of epithelioid hemangioma of the penis in a 50-year-old Caucasian man. We also review the literature to evaluate the incidence of benign vascular anomalies of the penis and their management.Epithelioid hemangioma of the penis should be considered in the differential diagnosis of patients presenting with painful penile lumps. A thorough histological and immunohistochemical examination is required to make the diagnosis. Optimal management is complete local excision and periodic physical examination for local recurrence. The differential diagnoses of painful lumps on the penis include Peyronie's disease and penile phlebothrombosis. Epithelioid hemangioma is a rare vascular tumor that is characterized by capillary vessels lined by epithelioid endothelial cells and accompanied by an inflammatory cell infiltrate -4. It shA 50-year-old Caucasian man presented to our facility with a painful nodule on the dorsum of his penis, which had developed over the last six months. It became more painful over time and interfered with his sexual activity. Our patient reported no erectile dysfunction or penile deviation. His medical history was unremarkable. A physical examination revealed a 5 mm tender, firm nodule at the mid shaft of the penis dorsally. There was no inguinal lymphadenopathy. A penile ultrasound scan demonstrated a well circumscribed lesion (6 × 8 mm) over the dorsal aspect of the penis within the subcutaneous tissue, superficial to the corpus cavernosum Figure . There wEpithelioid hemangioma, first described in 1969, is a rare vascular lesion that typically arises on the head and distal extremities. The pathogenesis is not fully understood and it is unclear whether it represents a benign vascular neoplasm or a reactive process to a preceding trauma . EpithelMacroscopically, the epithelioid hemangioma forms an inflammatory red to brown nodule affecting the cutaneous tissue of the head, neck and digits. Microscopically, endothelial cells are arranged in nests surrounded by immature vessels and eosinophil cell infiltrate. The characteristic feature of epithelioid hemangioma is the epithelioid appearance of the endothelial cells, with large nuclei, prominent nucleoli and abundant eosinophilic cytoplasm. The lesion is also characterized by low mitotic index and absent nuclear atypia . Two varBartonella henselae bacteria, and affects immune compromised patients. It is characterized by proliferative blood vessels in a myxoid or hyaline matrix and heavy infiltration of neutrophils and bacilli [Differential diagnoses of epithelioid hemangioma include epithelioid hemangioendothelioma, epithelioid hemangiosarcoma, Kimura's disease and bacillary angiomatosis. Epithelioid hemangioendothelioma is a borderline malignant tumor that has the tendency to recur and metastasize. It is characterized by epithelioid endothelial cells embedded in a hyaline connective tissue matrix with nuclear atypia, and absence of eosinophil infiltrates . Epithel bacilli .Management of epithelioid hemangioma of the penis includes taking a detailed history of trauma during sexual intercourse and erectile function. Clinical examination usually reveals a solitary, painful, well circumscribed nodule on the dorsum of the penile shaft with no lymphadenopathy or penile deformity. Clinical investigations include full blood count to exclude eosinophilia, ultrasound scan, color Doppler and MRI scans of the penis and the pelvis if indicated . TreatmeThis case study demonstrates the importance of making the correct diagnosis of painful penile lumps. Awareness of epithelioid hemangioma is important for urologists and should be included in the differential diagnosis of painful penile lumps. A thorough clinical and radiological evaluation is essential to make the diagnosis. Optimal management appears to be local excision and periodic physical examination for local recurrence.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.MI analyzed and interpreted and wrote the original draft. SD and AF performed the histological examination and were major contributors in drafting the manuscript. RN made a major contribution to writing the manuscript and editing the final version of the paper and figures and was the consultant urologist responsible for the case. All authors read and approved the final manuscript.


Primary Non-Hodgkin's Lymphoma of the cranial scalp and skull vault is a rare disease. We are describing a case of the same in a 50-year-old man. He was presented with a diffuse swelling in the left side scalp since 4 months of duration and progressively enlarging in size. On local Examination of the scalp, there was a diffuse swelling in the left parietal and occipital region of scalp. Imaging showed diffuse infiltration of the skull vault with extracranial soft tissue masses. Further investigations with CT scan chest, abdomen, and pelvis did not reveal any other evidence of systemic lymphoma. Biopsy of one of the scalp masses showed a small to intermediate cell B-cell lymphoma. Other nine previously reported cases of primary skull vault lymphoma were reviewed. Primary Non-Hodgkin's Lymphoma of the skull with extra- and intracranial extension without systemic or skeletal manifestation in a nonimmunocompromised patient is extremely rare. Till date, only nine such cases have been reported in the literature and in none was the lesion located in the midline . A 50 years male, with 4 months duration of a diffuse swelling in the left side scalp. On local Examination Diffuse swelling in the left parietal and occipital scalp more than 10 × 10 cm, irregular surface, skin over the swelling normal, patchy loss of hair, no tenderness, no transparency or translucency, no pulsation . On gene Computed tomographic examination showed Swelling (soft tissue opacity) in the left Parietal region, the surrounding parietal and occipital bones shows bony erosions with cortical thickening and periosteal reaction withmotheaten pattern of destruction.There is associated component of subdural collection Figures  and 4. T The patient was treated with surgery with partial removal of the scalp lesion followed by 6 cycles of chemotherapy with injection cyclophosphamide, doxorubicin, vincristine, and tab. predonisolone. (CHOP regimen) and showed good response with regression of the cutaneous lesions. Local adjuvant External beam Radiotherapy of 36 Gy @ 2 Gy per fraction in 18 fraction for a period of 3 weeks, is planned to be given to the left scalp region was given with 9 MeV electrons.Most primary cutaneous B-cell lymphomas (PCLs) have been reported involving the head and neck region and therefore PCL of the scalp needs to be differentiated from primary malignant Non-Hodgkin's lymphoma of cranial vault which is more frequently associated with intracranial  extension . Other iMost PCLs are hyperdense on unenhanced CT and show marked enhancement on postcontrast studies. Magnetic resonance imaging is important for evaluating local and regional spread to see involvement of bone marrow, leptomeninges, or dural venous sinuses .Gallium scanning can rule out or confirm extracutaneous involvement and the presence or absence of activity in cases of gallium avid lymphomas is helpful in indicating the nature of residual soft tissue masses following chemotherapy/radiotherapy. Skin is the second most common site of extranodal lymphoma. Among them, 65% are T-cell lymphomas , 25% B-cell lymphomas, and about 10% rare variants or nonclassifiable lymphomas. Only 15 to 25% of cutaneous lymphomas show extracutaneous manifestations at time of diagnosis. The prognosis is relatively good, since the average survival time from diagnosis is 12 to 14 years . We are


The small intestine is the third in frequency intraperitoneal organ which is injured after blunt trauma of the abdomen. In most of the cases, this type of injuries is accompanied by other injuries, which make it more difficult to diagnose. Failure of diagnosis and delay in treating these injuries significantly increase the morbidity and mortality of these patients. Abdominal visceral injuries after flipping the handlebar of the bike are common in children. Such injuries can cause injury to both solid and hollow abdominal viscera. Unlike children, adults' abdominal visceral injuries after flipping the bike's handlebar are extremely rare. A 25-year-old man was admitted to our department due to progressively abdominal pain after an accident with the handlebar of his bike. The subsequent CT scan after per os administration of contrast medium revealed the presence of free intraperitoneal contrast. It is a rare case of jejunal perforation after flipping the handlebar of the bicycle which was treated by partial removal of the injured part of jejunum and end-to-end anastomosis. To the best of our knowledge this is the first time we describe such an injury with this mechanism to an adult. Intra abdominal organ injuries caused by a stroke of bike handlebars are well documented in children. Flipping the bicycle's handlebars in the abdomen is common in children and can cause a variety of injuries such as traumatic rupture of solid organ , rupture of hollow organs , posttraumatic hernias of the abdominal wall, and even injuries of intra-abdominal vessels  –7. ApartThe abdomen is the third most common anatomical area of the body which undergoes blunt injuries, and 75% of these injuries are due to road-traffic accidents . AlthougIsolated lesions of the jejunum secondary to blunt trauma of the abdomen are very rare injuries, and few reports exist in the literature in the form of case reports –14.Injuries from the bicycle's handlebar are very rare in adults, and an indication is the absence of literature on such injuries. This fact can be attributed both to differences in behavior between adults and children  and anatomical differences. The main difference is that the most powerful abdominal wall of adult partly protects intra abdominal viscera from such injuries.Here, we present a rare case of an adult with isolated rupture of jejunum after injury by the bicycle's handle bar.A 25-year-old man was admitted to the emergency department after falling off his bicycle. He was hit by the bicycle's handle bar into the left side of the abdomen. The clinical examination revealed a fit young man who had only a scratch (abrasion) on the abdominal wall left of the umbilicus. Hemodynamically he was normal and alert and referred to intense pain at the abrasion site. The abdomen was soft, without signs of peritoneal irritation while sensitivity was only at the point of the abrasion. Laboratory tests, including white blood cells, liver enzymes, and amylase, were normal. The abdominal X-ray in upright (standing) position did not reveal the presence of free intraperitoneal air. Abdominal ultrasound did not reveal any solid abdominal organ injury nor the presence of free intraperitoneal fluid. The pain was attributed to hematoma of the rectus abdominis muscle pricey below the abrasion which was revealed by ultrasound.The pain of the young man was gradually worsening and was mostly described diffusely throughout the whole abdomen. The abdomen remained soft and tender without signs of peritoneal irritation. We proceeded to the administration of per os contrast material and CT abdomen. The CT scan revealed the presence of sufficient amount of free intraperitoneal contrast but did not allow the clarification of the exact point of escape. The free contrast material was detected at the left side of the abdomen, at the area of the descending colon but mainly in the pelvis . The intThe patient was taken to the operating room for exploratory laparotomy immediately after the CT scan . Intraoperatively, fecal peritonitis due to isolated rupture of jejunum 30 cm from the ligament of Treitz was revealed. The rupture was at the center of an extensive jejunum serous layer fissure giving the picture of “blow out” perforation. At the jejunal mesentery there was minimal bruising. Multiple washings of the peritoneal cavity were performed with normal saline, and the restoration of jejunal injury was done with partial resection and end-to-end anastomosis .The postoperative course of the patient was uncomplicated, and he was discharged on the 6th postoperative day. 9 days later he returned with clinical and radiological signs of ileus that led us to the operating room 48 hours later due to deterioration of his clinical picture. The cause of the ileum was adhesions, so we proceeded to lysis of adhesions. The anastomosis was normal without leakage. Five days later the patient was discharged, and a year later he is still free of symptoms.The lesions of the small intestine and even if it is the third in frequency site of injury after blunt abdominal trauma do not exceed 5% of all abdominal injuries . AlthougThe energy transferred to the injury site in the abdominal wall from the handlebar due to its small diameter acts as a javelin releasing the energy of injury to a small area of the abdominal wall. This, in combination with the relatively weak abdominal wall in children, puts the underlying viscera of the abdominal wall in danger. Both the stronger abdominal wall of adults and the less numerous strokes by bicycle make this mechanism of injury to the abdominal organs rare in adults.In our patient, this transfer of energy through the abdominal wall led to pressure on the initial part of jejunum. The extensive serous lesion in the vicinity of the jejunum rupture leads to the conclusion that probably at the time of injury this part of the small intestine was full of content, and the transfer of energy from the injury resulted in a significant increase of the intraluminal pressure leading to a “burst” of the bowel.The diagnosis of lesions of the small intestine after blunt trauma is often particularly difficult as the signs and symptoms of peritonitis appear in a later time. The clinical examination is not reliable in the diagnosis of these lesions as the classical triad of rupture of the small intestine  is present only in 30% of patients with rupture of the small intestine . The preOur patient was not the exception to the rule as both the initial clinical examination and abdominal X-ray in a standing position gave no signs of a possible ruptured hollow organ. The clinical examination is particularly useful and sensitive diagnostic test if repeated in small periods of time because the patient will develop signs of irritation of the peritoneum progressively.For the diagnosis of rupture of the small intestine, the diagnostic peritoneal lavage (DPL) and the focused abdominal sonography for trauma (FAST) have been used .Nowadays, the investigation of choice for early diagnosis of lesions of the small intestine is a CT scan with contrast administration per os. As for the clinical examination, so as for the FAST, the sensitivity of the method is increased if there is enough time given for free intraperitoneal fluid to be concentrated in sufficient quantity so as to be detected with FAST. The CT shows sensitivity and specificity of 92% and 94%, respectively, in the evaluation of the patient with blunt abdominal trauma, and most importantly it displays negative predictive accuracy of 100% which enables us to exclude early any possible lesions of the small intestine  and thusThe main disadvantage of CT is that, for its execution, the patient has to be hemodynamically stable. The general condition of the young man in our case gave us the option to move to CT, and the examination was performed approximately two hours after per os administration of contrast. Although it was not possible to pinpoint the source of leak of contrast from the gastrointestinal tract, the recognition of the presence of free intraperitoneal contrast was an absolute indication to proceed to exploratory laparotomy directly. Free intraperitoneal air was not observed.Although there is no consensus in the literature regarding the effects of delay in treatment of traumatic rupture of the small intestine, the widely accepted position is that the sooner treated, the lower the morbidity for the patient . FailureBoth the rarity of rupture of the small intestine and the inherent difficulties in diagnosis of these kinds of injuries make the need of the physician to have a high index of suspicion imperative, based on the mechanism of injury. The presentation of the above case aims to raise awareness of doctors regarding the possibility of rupture of the small intestine in adults following abdominal injury with the bicycle's handlebar. Knowledge of this rare mechanism of injury takes on added value as more and more adults use bicycles.


Plasmacytoma is an extremely rare and discrete solitary mass of neoplastic monoclonal plasma cells. Extramedullary plasmacytoma (EMP) tends to occur during the fifth and seventh decades of life and is rarely diagnosed in younger patients. Only four cases of EMP have been previously reported in relatively young patients. Here we report a 15-year-old patient presenting with long-term nasal obstruction, who was found to have EMP of the nasopharynx. The patient was treated with surgery followed by radiotherapy with a satisfactory outcome. To the best of our knowledge, this study describes the the youngest individual with nasopharyngeal EMP to be reported in the literature. Plasmacytoma is an extremely rare and discrete solitary mass of neoplastic monoclonal plasma cells, which was first described by Schridde in 1905 . While oA 15-year-old male was referred to the Department of Otolaryngology, Cathay General Hospital  due to intermittent epistaxis lasting for 2 weeks. In addition, the patient reported a 3-year history of persistent nasal obstruction. A physical examination revealed an extremely large tumor in the center of the nasopharynx that bled easily when touched. Computed tomography revealed a mass occupying almost the entire nasopharyngeal space without involvement of the bony structures . SurgicaPlasmacytomas have been classified into 3 subtypes. The most common type is multiple myeloma, which is usually a disseminated disease and is characterized by abnormal M protein. The other 2 types, solitary plasmacytoma of the bone and EMP of the soft tissue, are considerably less common. EMPs present in <5% of plasma cell neoplasms and often >80%) originate in the head and neck region . EMPs re0% originet al proposed a pathological grading system based on the multiple myeloma grading criteria; tumors classified into low, intermediate and high grades, which have been found to correlate closely with outcomes. The study recommended the use of adjuvant chemotherapy in patients with higher-grade disease (et al, it was found that radiotherapy was quite effective and safe for patients with EMP in the head and neck region. Moreover, radiotherapy combined with surgery produced an improved outcome, as determined by survival rates (The etiology of this disease remains unknown, but factors such as viral pathogenesis and chronic irritation from inhaled irritants have been previously indicated –14. Radi disease . A radia disease . Irradiaal rates . Althougal rates . Follow-al rates ,8.A literature search revealed no publications supporting the use of surgery alone to treat EMP. In the current case, although the tumor was well defined and thus completely excised, and the patient recovered from the surgery smoothly, subsequent irradiation was recommended. Only four cases of EMP have been previously reported in relatively young patients. To the best of our knowledge, the present case is the youngest case of nasopharyngeal EMP to be reported in the literature.


Familial progressive hyperpigmentation (FPH) is a rare genodermatosis characterized by hyperpigmented patches in the skin and mucous membranes, present in early infancy, and increase in size and number with age. The genetic basis for FPH remains unknown. We report an unusual case of familial progressive hypermelanosis in a 17-year-old male patient with family history, who presented with a peculiar progressive oral pigmentation disorder. Diagnosis was confirmed by a series of hematological, biochemical, and histopathological investigations. Our paper stresses the need for the dentist to be aware of the systemic conditions that can also manifest in the oral cavity. Familial progressive hyperpigmentation (FPH) is a rare genodermatosis first reported by Chernosky et al. in 1971 . This coThough such cases have been previously reported in dermatology, no such case has been reported in dental literature even though there are significant oral findings in these patients.α and β MSH, T3 T4 TSH, and Cortisol levels to ascertain the cause for the hyperpigmentation. Hematology and blood chemistry did not reveal any abnormalities. After an opinion from the dermatologist, an initial diagnosis of familial progressive hyperpigmentation (FPH) was made. The patient was then scheduled for an oral incisional biopsy under local anaesthesia. Light microscopic examination of H&E sections taken from the edge of the hyperpigmented areas displayed strong basilar and suprabasilar hyperpigmentation. Numerous melanophages seen as dark brown pigment in the subepithelial layers were also noted. Edge of the tissue from the apparently normal appearing gingiva showed only a slight basal hyperpigmentation but virtually no melanophages in the connective tissue. Further, presence of melanin in the section was confirmed by bleaching using hydrogen peroxide and to rule out the possibility of hemosiderin pigment. Also, Masson-Fontana stained sections showed an increase in the number of melanocytes in the basal and suprabasal cell layers .Familial progressive hyperpigmentation is a distinctive, dominantly inherited genodermatosis, characterized by patches of hyperpigmentation present at birth, which increase in size and number with age . ClinicaOral mucus membrane is characterized by a mottled appearance . FrequenHematological and biochemical investigations, including hormone  levels are generally found normal in these subjects .No known dental treatment is documented in previous literature. There is also no literature on the malignant potential of these lesions or any other pathological change. The treatment is based solely on cosmetic purposes. The cosmetic oral treatment including depigmentation procedure of the gingiva can be carried out. As this patient was not concerned about aesthetics, no such treatment was carried out. Since there is no literature available on the prognosis of these lesions, it is recommended to keep these lesions under periodic evaluation.


A four-year-old boy presented with constipation and mild abdominal distention for one year. Radiologic investigations showed a multiloculated cystic lesion in the caudate lobe of liver with focal calcification in the wall. The child underwent laparotomy with marsupialization of the cystic lesion. Histopathologic examination showed mature teratoma of liver.  Teratomas are germ cell tumors occurring most commonly in ovaries or testis. Liver is an extremely rare site for teratoma, constituting less than 1% of all teratomas [1]. An extensive review of literature yielded less than 50 cases of primary hepatic teratomas [2]. Teratomas have distinctive imaging characteristics allowing an accurate pre-operative diagnosis in majority of cases. In certain instances, radiologic diagnosis may not be very apparent, and histologic examination renders the definite diagnosis along with assessment of immature component, the latter being important for further management [3]. This case is being presented for rarity and the difficulty in radiologic diagnosis in this patient.A 4-year boy was brought with complaints of constipation, loss of appetite, mild abdominal distension, and intermittent fever for the last one year. Physical examination revealed pallor. There was no icterus or cyanosis. On abdominal examination, mild distension was noted. Liver was palpable extending up to the right lumbar region; it was firm, non-tender with smooth surface. Spleen was not palpable. Routine investigations revealed anemia (hemoglobin 10.5g/dl). Other hematological and biochemical investigations, including liver function tests were within reference ranges. Ultrasonography (USG) of abdomen showed hepatomegaly with a multiloculated round cystic lesion in the caudate lobe. The lesion measured 4.3x4.5x4cm and showed internal septation. No calcification or hyperechoic foci were seen. Contrast-enhanced computed tomography (CECT) scan also showed a well-defined contrast enhancing multiloculated cystic lesion involving the caudate lobe of liver. The lesion measured 43.8x43x41mm and showed multiple septations and calcification . Hydatid serology (IgG by ELISA) was negative. Intra-operatively a multiloculated cyst 4 cm in diameter was seen in the caudate lobe of liver. The cyst contained clear fluid with calcification in the wall. Partial excision of the lesion and marsupialization was performed. Histopathology showed mature teratoma composed of mature elements including skin, bone, glial tissue, tooth enamel and pulp, lymphoid aggregates and choroid plexus . Immature component was not seen in any of the sections examined. Postoperative alpha-fetoprotein (0.82 ng/ml) and beta–human chorionic gonadotrophin (1.2 mIU/L) performed were within reference ranges. The child is doing well one year after surgery and follow-up USG did not reveal any residual mass/recurrence.Most hepatic teratomas are encountered in patients less than 3 years of age. In pediatric patients, teratomas account for less than 1% of all hepatic neoplasms [2]. Majority of these tumors are discovered incidentally due to site-specific mass effect. Tumors in liver cause abdominal distension, nausea and vomiting due to compression of adjacent structures. Hepatic teratomas have been reported more commonly in female patients and involve right lobe of liver in many cases [2]. Our patient was a boy and had the lesion in caudate lobe of liver. Ultrasonography (USG) of teratoma shows hypo- or anechoic component representing cystic portion and hyperechoic foci denoting calcifications or macroscopic fat. Fat-fluid levels, due to presence of sebum, are considered pathognomonic of teratoma [4]. On CT scan, calcifications are seen as hyperattenuating and macroscopic fat as hypoattenuating foci within a cystic cavity in a teratoma. CT scan also permits characterization of fluid as sebum, serous or complex [5]. Occasionally, there may be absence of calcification, making the radiologic diagnosis difficult [7]. A minority of teratomas do not demonstrate sebum-filled cystic cavity [7]. Few cases of mature teratoma have none to minimal fat on radiologic studies [7]. In our patient also, USG and CT scan did not show fat in the wall of the cystic cavity or sebum in it. The presence of a cystic lesion in the liver with calcification in the wall of the cyst resembled the radiologic findings of a non-calcified hydatid cyst, hence this impression was considered in our differentials. A definitive diagnosis of mature teratoma is possible by histologic examination alone. Histologically, teratomas contain variable amounts of bone, hair, skin, sebum, fat, muscle, neural tissue and rarely pancreatic and thyroidal tissue. Teratomas can be categorized as benign or malignant on the basis of their histopathological features [2]. Hence, surgical resection is the mainstay of treatment, since the presence of immature tissue of any germ layer adversely affects the prognosis [3]. In our case, no immature component was found and the patient has been doing well with no residual mass. However, the risk of recurrence looms large since the child underwent marsupialization of the cyst. Hence, regular follow-up at three or six month intervals, including ultrasound examination, is being performed.Source of Support: NilConflict of Interest: None declared


Plasma cell granuloma is a pathological entity reported in nearly every organ system; however, intracranial cases remain rare. In the current case report, we present a case of intracranial plasma cell granuloma with the longest known follow-up period in the literature. Medical follow-up over 14 years, detailing four recurrences following the patient’s initial presentation and management, is presented. The patient’s treatment course consisted of three craniotomies, 3,600-cGy fractionated radiation and two courses of glucocorticoid therapy. In addition to disease surveillance using clinical examination and imaging, this case represents the first description of the clinical utility of analyzing changes in an inflammatory blood marker, the erythrocyte sedimentation rate, which coincided with recurrence and response to therapy. Plasma cell granuloma is a rare entity describing a non-neoplastic lesion featuring histological proliferation of polyclonal plasma cells, lymphocytes, neutrophils, eosinophils and histiocytes in a fibrotic background . While tA 55-year-old Caucasian female with a history of hypertension, chronic otitis and mastoiditis presented to an outside institution with a three-week history of bitemporal frontal headaches and left-sided hearing loss. On examination, the patient was awake and alert but was noted to have difficulty with speech. Bilateral papilledema was identified by fundoscopy. The remainder of the exam was nonfocal and without further neurological deficits. A computed tomography with contrast revealed a 5×5-cm heterogeneously enhancing mass in the left temporal lobe with a large amount of associated left hemisphere edema and left-to-right shift. The patient underwent surgery for further management.Pathological analysis of a subtotal resection demonstrated perivascular and intraparenchymal collections of lymphocytes and plasma cells set within a densely fibrotic background. Neurons and reactive astrocytes were entrapped within the inflammatory lesion. The lymphocytes and plasma cells appeared small and mature with no histological evidence of lymphoma or myeloma. There was no evidence of vasculitis or amyloid deposits on the routine stains. Immunohistochemical studies revealed the presence of κ  and λ light chains, confirming the polyclonal nature of the plasma cell infiltrate, along with a mixed population of T and B cells, consistent with an inflammatory process. Stains for microorganisms and Epstein-Barr virus were negative.Further work-up included a bone marrow biopsy, serum electrophoreses  and β-2 microglobulin, which were all within normal limits. A final diagnosis of intracranial plasma cell granuloma was made.The patient’s course was punctuated by several recurrences over a 14-year follow-up period. The first recurrence in the left temporal region was detected by surveillance magnetic resonance imaging (MRI) at three years and treated with another surgical resection and 3,600-cGy adjuvant radiation therapy fractionated over four weeks. A second recurrence was again detected by surveillance MRI at seven years and treated with a third resection of a 3×5-cm mass. Pathology was again consistent with recurrent plasma cell granuloma. One month later, the patient presented to an ophthalmologist with decreasing vision in the left eye. A small blind spot progressed to complete loss of vision out of the left eye over the next eight months. Two months later, the patient noted decreasing vision in the right eye and was referred to Wake Forest University School of Medicine for further management.Now at nine-years post-diagnosis, work-up at our facility, including MRI imaging and erythrocyte sedimentation rate (ESR) measurement , revealeTwelve-years following the initial diagnosis and 1.5 years after steroid treatment, a surveillance MRI demonstrated a new contralateral peripherally enhancing mass surrounded by vasogenic edema in the right temporal lobe . Of noteFourteen years following the initial diagnosis and two years following the patient’s latest course of prednisone, a repeat brain MRI revealed a near complete response . The sedThe number of reported intracranial cases of plasma cell granuloma reviewed in the literature is ~50 –5. The pHistopathological analysis remains the gold standard for achieving the diagnosis of plasma cell granuloma. Tissue sections in the present patient contained a perivascular infiltrate of lymphocytes and polyclonal plasma cells, which is characteristic of plasma cell granulomas ,6,7. A sMonitoring for response to therapy and recurrences traditionally relies on clinical exam and surveillance imaging. To the best of our knowledge, this case represents the first time ESR has been reported to rise and fall in concert with disease recurrence, presence and resolution. Rising ESR values appeared to be specific to the disease and were not the result of surgical intervention, as these recurrences were treated with steroids. Further, the decline in the ESR appeared to be specific to disease activity rather than the result of a systemic immune suppression, as the values correlated with imaging changes. The literature reports elevation of inflammatory markers, ESR and CRP, in patients with plasma cell granulomas; however, the marker levels were analyzed at diagnosis and not serially followed, with only one case series describing a decrease in ESR following surgical management of pulmonary plasma cell granulomas –10. TrenThis unique case of a plasma cell granuloma was treated for four recurrences over the course of 14 years. Each treatment resulted in a complete, lengthy, but unsustained response. Relapses and responses of the disease were detected by imaging and ESR, which may prove supplemental to imaging studies for evaluating disease activity.


The aim of this report was to describe the clinical signs, diagnostic approach, treatment and outcome in the case of a tiger with a deformity of the paw.Panthera tigris) was presented with lameness of the left thoracic limb. A deformity involving the first and second metacarpal bones, and a soft tissue separation between the second and third metacarpal bones of the left front paw were observed. The second digit constantly struck the ground during locomotion. Based on the physical and radiographic evaluations, a diagnosis of ectrodactyly was made. A soft tissue reconstruction of the cleft with excision of both the second digit and distal portion of the second metacarpal bone was performed. Marked improvement of the locomotion was observed after surgical treatment, although the tiger showed a low degree of lameness probably associated with the discrepancy in length between the thoracic limbs.A 1.5-year-old tiger (This report shows a rare deformity in an exotic feline that it is compatible to ectrodactyly. Reconstructive surgery of the cleft resulted in significant improvement of limb function. There are several types of congenital hand anomalies in human patients and a variety of classification systems ,2. AccorEctrodactyly has been described in dogs and domestic cats but is considered rare -9. In geThe purpose of the case reported here is to describe the clinical signs, diagnostic approach, treatment and outcome in the case of a tiger with a deformity of the paw.Panthera tigris) was admitted to the Veterinary Hospital of the School of Veterinary Medicine and Animal Science (Unesp Botucatu) with a history of left thoracic limb lameness that had started to worsen approximately five months previous to admission. In addition, the tiger had avoided scratching with this paw. According to the owner, the tiger had a deformity in the left paw which had been noticed since birth, and this limb had always been lame. No treatment had been performed. He was the only cub born in a litter. Two other litters from the same parents showed no evidence of deformity. The tiger was kept in captivity in a large area with seven more tigers. The owner is authorized by federal agency to raise the tigers, and all animals are submitted to training program.A 1.5-year-old, 150 kg, intact male tiger , accomplished by the software ThermaCAM Quick Report, was used to evaluate both paws and shoulders. Mean temperatures of the second and third digits of the left paw were 29°C and 31°C, respectively  anesthesia, the tiger was positioned in right lateral recumbency and the left paw area was clipped and aseptically prepared for surgery. After clipping it was possible to identify one extra claw, which was located on the mediolateral region of the third metacarpal bone Figure d. Two seIn dogs and domestic cats, ectrodactyly has been considered a highly heterogeneous disorder with different sites of soft tissue separation and a variety of abnormalities ,8,10. ThA supernumerary digit constituted only by the distal phalanx and connected to the fourth digit by cutaneous tissue was observed in a dog with ectrodactyly . In the In the majority of the reported canine ectrodactyly cases, the cause was unknown ,8,10,15.There is no specific management or treatment strategy for congenital anomalies, but the primary goals are to prevent progression of the condition and to improve quality of life. In case of minor lesions of ectrodactyly that do not affect limb function no treatment is required; however, reconstruction is necessary in severe cases ,7-9,12. Ulnar osteotomy or ostectomy, partial or pancarpal arthrodesis, use of orthopedic wire around adjacent bones, bone lengthening and soft tissue reconstruction are some procedures reported in dogs for treatment of ectrodactyly ,7-9,12. This report shows a rare deformity in an exotic feline that it is compatible to ectrodactyly. Reconstructive surgery of the cleft resulted in significant improvement of limb function.Consent was obtained from the owner of the tiger for publication of this case report and any accompanying images.SCR and RSV performed the surgical procedure and prepared the manuscript, VMVM performed the radiographic examination, CRRN performed the thermographic examination, CRT and GDPS carried out the clinical examination and prepared the tiger to surgery, KL reviewed the literature. All authors have read and approved the manuscript.Movie 1. Observe the lameness of the left thoracic limb in a tiger with ectrodactyly in the left front paw before the surgery.Click here for fileMovie 2. Observe the marked improvement of the locomotion after 10 days after surgery.Click here for file


Ameloblastic fibro-odontoma is a rare, benign, asymptomatic tumor. The term ameloblastic fibro-odontoma was first used by Hooker in 1967 as a separate lesion from ameloblastic odontoma.This case report describes an eleven years old female with large ameloblastic fibro-odontoma in the right maxillary sinus.There is a low potential for recurrence after complete Enucleation of ameloblastic fibro-odontoma, but due to the risk of ameloblastic sarcoma after recurrence, the surgery should be perfect along with a careful follow up.  Ameloblastic fibro-odontoma (AFO) is a very rare, benign, asymptomatic, slow growing, expansile mixed odontogenic tumor . OdontogRadiographically, AFO presents as a well-defined radiolucency containing radiopaque areas . The aimAn 11-year-old girl was referred to the Department of Oral and Maxillofacial Surgery, Mashhad Dental School, Iran for evaluation of a facial swelling of 6 months duration. There was no history of systemic disease and trauma. The extra oral examin- ation revealed an asymptomatic swelling on the right side of the maxilla without signs and symptoms of inflammation.Intra-orally, a bony hard bulge was palpable in the maxillary vestibule. A full complement of the teeth with the exception of missing second molar was marked able. Oral mucosa was normal and tooth mobility was not seen. Radiographically, computerized tomography scan (CT) showed a well-defined, radiolucent lesion in the maxillary sinus which contained several radiopaque materials of varying sizes and shapes .The panoramic view showed a very large lesion which the maxillary second molar had been involved . As the clinical and radiological presentations alone could not show a definitive diagnosis, incisional biopsy was performed. Specimen was sent to the department of oral and maxillofacial pathology. Pathologist reported: this lesion is lobulated in general configuration and is surrounded by a fibrous capsule.The tumor mass is composed predominantly of a primitive appearing myxoid connective tissue similar to dental pulp. The epithelial component has been compared microsco- pically to the dental lamina that proliferates from oral epithelium in the early stages of the tooth developments. Some foci contain enamel and dentin similar to compound and complex odontoma .These findings were consistent with diagnosis of ameloblastic fibro-odontoma.After a final histological diagnosis, the patient was submitted for surgical excision and enucleation of the lesion. The patient was taken to the operation room, under general anesthesia an incision was made intraorally. A full thickness mucoperiosteal flap from second incisor to the tuberosity was reflected. After bone removal of the sinus wall, access to the lesion was completed. The lesion and the impacted second molar were enucleated Finally, histopathological examination of the last specimen confirmed the diagnosis of AFO. Postoperatively, after twelve months, no evidence of residual or recurrent disease was found ,5.There are different concepts about the nature of AFO in the literature. Regezi demonstrated that AFO is a derivative of the ameloblastic fibroma . SlootweThe pathologically and radiologically differential diagnosis of AFO are included: ameloblastoma, odontogenic myxoma, dentinogerous cyst, odontogenic keratocyst, central giant cell granuloma, histocytosis-X group of lesions, calcifying odontogenic cyst, calcifying epithelial odontogenic tumor, adenomatoid odontogenic tumor and immature odontoma .There is controversy over the management of AFO. According to the literature, conservative surgical excision is an accepted treatment for this lesion. In most cases, the impacted tooth associated with the tumor is removed at the same time . There is a low potential for recurrence. According to Boxberger, in almost all cases recurrences were related to incomplete removal of the lesion at the time of the initial surgery.Ameloblastic fibro-odontoma (AFO) is a very rare, benign, asymptomatic, slow growing, expansile mixed odontogenic tumor. Note that this tumor is encapsulated, treatment plan is surgical excision. Despite the little potential of this lesion to locally recur, due to a low risk for ameloblastic sarcoma, a careful follow up is recommended.


The growing teratoma syndrome (GTS) is defined as a detection of an enlarged mass during or after chemotherapy treatment for germ cell tumor. We report a case of an 18-year-old girl treated for growing teratoma syndrome after chemotherapy for malignant germ cell tumor of the ovary associated with peritoneal gliomatosis. Chemotherapy induced normalisation of alpha-fetoprotein rate whereas there was an enlargement of the mass. Subsequent complete resection was performed, and the patient remained in good control for 60 months. This clinical picture suggested the diagnosis of “GTS”. This syndrome can lead to confusion with progression or relapse of a germ cell tumour because of increase in tumour volume during chemotherapy, so it is important to recognize it. The growing teratoma syndrome (GTS) is defined as a detection of a benign enlarged mass during or after chemotherapy treatment for germ cell tumor. The diagnosis is based on three criteria : increasThis entity was first described by Logothetis et al. in 1982 [This syndrome occurs in 1.9 to 7.6% of testicular nonseminomatous germ cell tumors , but it We report a case of an 18-year-old girl treated for growing teratoma syndrome after chemotherapy for malignant germ cell tumor of the ovary associated with peritoneal gliomatosis.An18-year-old girl, with no previous health problems, no previous pregnancy, an age of first menstruation of 13 years, presented with a 5-month history of abdominal pain and increased abdominal volume. Physical examination revealed a huge abdominopelvic mass, and ultrasound and CT scan revealed an abdominopelvic mass of 22 × 18 cm in diameter, starting from the right ovary, without lymphadenopathy or liver metastasis. Preoperative tumor markers were high with an alpha-fetoprotein (AFP) rate of 210 ng/mL , beta-human chorionic gonadotrophin at a normal rate (2.45 mu/mL), Ca 125 rate of 30 u/mL , and lacticodehydrogenase was at 326 u/L . Laparotomy revealed a huge right ovarian mass with multiple peritoneal granules measuring between 0.2 and 0.5 cm. A total hysterectomy, oophorectomy, and omentectomy were performed. Histological examination of the ovarian mass (weight = 1880 g) revealed a teratomatous tumor, with grade 2 immature areas, showing neuroepithelial elements. The contra lateral ovary was not involved.Peritoneal granulations consisted of a mature glial tissue. Examination of peritoneal fluid did not reveal suspicious lesions. Postoperatively, the rate of AFP was 76.98 ng/mL. The patient had an immature teratoma on histopathology. The histopathological specimen analyzed did not show aspects of yolk-sac and/or embryonal carcinoma. The coexistence of an elevated AFP and immature teratoma concluded to a diagnosis of a nonseminomatous ovarian germ cell tumor. 2 on day 1 and etoposide 120 mg/m2 on days 1-2-3, every 21 days, was administered for 6 cycles with normalization of AFP from the 4th cycle ; other markers were still unremarkable. Moreover postchemotherapy pelvic CT (6 months after surgery) revealed a voluminous pelvic mass 25 × 21 × 11.5 cm containing calcifications and fatty areas. A second laparotomy was performed, revealing a huge abdominopelvic mass and multiple peritoneal implants, and the surgical procedure had consisted of an optimal cytoreduction. Surgical pathology consisted of benign mature teratoma with no neuroectodermal component  if the tumor is of grade 2 or 3. Second aggressive debulking is limited to patients having a growing teratoma syndrome after immature teratoma .Immature ovarian teratomas are associated with gliomatosis peritonei, a favorable prognostic finding if composed of completely mature tissues.The peritoneal gliomatosis (PG) is a very rare entity, defined by the implantation of glial tissue in the peritoneal cavity, omentum, and abdominal lymph nodes. PG occurs almost exclusively in combination with an ovarian teratoma, whatever its grade . Two theories have been proposed regarding the pathogenesis of PG. One of them postulates that the PG is derived from teratoma associated with the relocation of cells from the primary tumor through the capsular defect  or by lymphogenous metastatic spread . The oth Molecular studies have been performed to better understand the relationship between an ovarian teratoma and PG. Best et al.  performeBy performing the same molecular analysis, Kwan et al.  concludeThe association of GTS and PG was previously described by Shefren et al. , who repA review of the literature, reported by Chou et al. , had fouTreatment of PG is the complete surgical resection, which has two objectives: confirmation of diagnosis and therefore the exclusion of malignancy, but also the prevention of malignant transformation of residual lesions. Complete excision is often impossible, given the extent of the lesions, hence the importance of close monitoring of residual lesions, using imaging such as CT scans. The presence of a PG at the initial laparotomy may be predictive of the occurrence of a GTS after chemotherapy of a germ cell tumor of the ovary , hence t


Primary hepatic carcinoids are rare tumors that are often diagnosed at a locally advanced stage. Their primary nature can only be ascertained after thorough investigations and long-term follow-up to exclude another primary origin. As with secondary neuroendocrine liver tumors, surgical resection remains the mainstay of therapy. Despite their large size and often central location liver resection is often feasible, offering long-term survival and cure to most patients. In selected patients liver transplantation appears to be a good indication for tumors not amenable to liver resection. An aggressive surgical attitude is therefore warranted. We report a large and unusually fast-growing liver carcinoid that appeared only marginally resectable in a patient who remains free of disease four years after surgery. With less than 100 reports in the literature little is known of primary hepatic carcinoids. They often present as large centrally situated liver masses, characteristics that may discourage attempts at resection. Data is scarce on the outcome of surgical treatment but these tumors seem to be associated with a favorable prognosis, justifying an aggressive surgical approach. Presented here is a patient with a giant primary liver carcinoid that appeared only marginally resectable, who remains disease free four years after surgical resection.A 52-year-old female complained of fatigue and intermittent fever of one-year duration. There was no history of liver failure, hematemesis, flushing, or diarrhea. She had undergone a previous appendectomy. Abdominal ultrasound revealed a heterogeneous 8 cm right lobe focal liver lesion. Contrast enhanced CT performed one month later showed a solid 15 cm liver mass with a hypodense core that was suggestive of an atypical hemangioma. The patient came to our attention two months after the initial ultrasound with palpable hepatomegaly. MR showed a hypervascularized solitary liver lesion measuring 20 cm . MalignaDuring laparotomy thorough exploration of the abdominal cavity, small bowel, and mesentery was performed before proceeding to an extended right hepatectomy. The resected specimen weighed 2.2 kg and was almost entirely occupied by a 22 cm solid mass with a large central cystic component. Microscopically the tumor displayed a trabecular and pseudoglandular pattern and a highly vascular stroma. Tumor cells were uniform and displayed rare mitoses (<1 per mm³). At immunohistochemical examination tumor cells stained positive with chromogranin A and synaptophysin antibodies and were negative for hepatocyte, AFP, and CD56 antibodies. 10% nuclear reactivity for Ki-67 was present. There was intense expression of somatostatin subtypes I and II receptors but not subtype V.111-DTPA-octreotide scan, EUS of the pancreas, thyroid US and Tc-scintigraphy, and small bowel barium study failed to find a primary neuroendocrine tumor. Review of the pathology of the previous appendectomy was also noncontributive. Postoperative screening for recurrence and detection of a possible primary tumor has included abdominal MR, chest X-ray, and serum chromogranin A assay every 6 months. Octreotide and FDG-PET scan are scheduled yearly. At 48-month follow-up the patient shows no signs of liver recurrence or appearance of a primary tumor or secondary extrahepatic tumor. She is asymptomatic and fully functional.Final diagnosis was a well-differentiated nonsecreting neuroendocrine tumor. Further investigations including InCarcinoid tumors also known as well-differentiated neuroendocrine tumors (NET) derive from neuroectodermal cells that are dispersed throughout the digestive tract but are also found in organs such as the adrenals, bronchi, thymus, thyroid, and paravertebral ganglia. Fifty-four percent of carcinoids occur within the gastrointestinal tract, mostly in the appendix and small bowel (16.7% and 44.7% resp.) but also in the rectum (19.6%), colon (10.6%), and stomach 7.2%) [% [2].The 2010 World Health Organization carcinoid and pancreatic neuroendocrine tumor grading system takes into account the number of mitoses per 10 high power microscopic fields or the percentage of tumor cells that immunolabel positively for Ki-67 antigen. These measures reflect the rate of proliferation and correlate with prognosis. Carcinoids are classified into three types: (1) well-differentiated tumors of low grade malignancy with an indolent development and a good prognosis, (2) moderately differentiated or intermediate grade neoplasms, and (3) poorly differentiated or high grade epithelial neoplasms that carry a poor prognosis .Less than 100 patients with primary hepatic carcinoid tumors (PHCT) have been reported, mostly as single cases . The twoAscertaining that a carcinoid liver tumor is a primary rather than a secondary deposit is challenging. A single large centrally situated tumor is suggestive of a primary tumor whereas neuroendocrine liver metastases present typically as multiple diffuse liver masses . The panThe best practice for neuroendocrine tumors metastatic to the liver remains surgical resection of both the primary tumor and liver metastases whenever possible. Recent publications indicate an advantage for aggressive liver surgery for locally advanced and metastatic NET in terms of duration and quality of life . SurgicaBecause there are only sporadic reports, there are currently no established standards for the treatment of PHCT. Primary hepatic carcinoids are associated with a resectability rate of 70%, a 74–78% 5-year survival rate, and an 18% 5-year recurrence rate . Better In patients with unresectable disease a variety of palliative options exist but data on these is very limited. Systemic 5-fluorouracil downstaged disease in 1 of 3 patients . HepaticIn conclusion primary hepatic carcinoid tumors are rare and their primary nature can only be ascertained after thorough investigations and long-term follow-up to exclude another primary origin. Their large size and often central situation within the liver should not deter surgeons from attempting resection because long-term survival and cure can be expected. In selected patients not amenable to partial liver resection liver transplantation can be considered.


Surgicel™ is an oxidized cellulose preparation that is widely applied in neurosurgery due to its hemostatic effect and good tissue compatibility. Tumor-like lesions induced by Surgicel® application in cerebral surgery have been rarely reported, especially for intracranial hemorrhage debridement surgery in patients with hypertension.en bloc resection of the lesion, the patient was diagnosed with a Surgicel™-related intracranial giant-cell granuloma by histopathology.This case report describes a rare case in which Surgicel™ application led to a foreign body reaction, contributing to the development of an intracranial giant-cell granuloma. A 49-year-old female hypertensive patient was diagnosed with intracranial hemorrhage. She was treated with debridement surgery that employed Surgicel™ application. Although a satisfactory hemostatic effect was achieved, the patient was diagnosed with epilepsy 6 months later. Subsequent magnetic resonance imaging revealed an intracranial space-occupying lesion. After undergoing Application of Surgicel™ during intracranial hemorrhage debridement surgery may be associated with a risk of granuloma development due to formation of a tumor-like space-occupying lesion in the surgery bed. Even a low risk of tumor development implies a need for caution when applying Surgicel™, especially when solely used to achieve a hemostatic effect. In recent years, absorbable hemostatic materials have emerged as standard tools in neurosurgery. Covering the neurosurgical bed with hemostatic material helps to prevent hematoma due to wound bleeding. As one of the most widely applied absorbable hemostatic materials, Surgicel™  is an oxidized cellulose preparation manufactured by Ethicon Inc. of Johnson & Johnson Medical Limited. Extensive clinical evidence has shown that the application of Surgicel™ during cerebral surgery rapidly promotes blood clotting and effectively controls bleeding. Moreover, Surgicel™ has been demonstrated to display superior tissue compatibility compared to other resorbable hemostatic agents-3.A few cases of Surgicel™-induced foreign body reactions have been reported, all of which involved organs outside the nervous system; specifically, giant cell granulomas developed in surgical beds of the cardiac, renal, and adrenal gland tissues-6. To thA 49-year-old female with a 5-year history of hypertension was hospitalized for grand mal seizures. Six months prior to hospitalization, the patient had been diagnosed with right basal ganglia hemorrhage via computed tomography (CT) scan Figure A and undMagnetic resonance imaging (MRI) studies showed an irregularly shaped lesion in the right frontal temporal lobe and basal ganglia, with a mixed signal Figure B includiThe space-occupying lesion was surgically resected. The titanium plate was removed, and the frontotemporal lesion and related dural adhesions were visually identified. The gross appearance of the lesion included pale coloration, rough surface, poor blood supply, and clear boundaries. The bottom of the lesion was tightly adhered to the lateral ventricle. Under microscopic guidance, the lesion was completely resected. The patient’s postoperative recovery was unremarkable. A CT scan 5 days after surgery showed complete lesion exenteration.Pathological analysis indicated a foreign body response, as evidenced by substantial amounts of foam-like cells distributed throughout the lesion. The presence of gliosis led to the final diagnosis of a giant-cell granuloma caused by Surgicel™ application Figure . The patThe formation of surgical beds is unavoidable during neurosurgery, and the normal soft structure of the brain has insufficient strength to support the new vasculature. Traditionally, hemostasis had been achieved during surgery by electrical stimulation. However, this method can cause some vessels to sink into the brain tissue, making coagulation more difficult, or can liquefy the brain tissue, causing irreparable injury. The devet al. reported a case of Surgicel™-related granuloma in a laparoscopic kidney tumor resection surgery that was misdiagnosed as tumor recurrence[et al.[Surgicel™ is an oxidized cellulose polymer, with polyglucuronic glucuronide as its effective functional unit. Blood absorption initiates within 1 day after its application, but complete absorption requires 4 to 8 weeks,9,10. In[et al..A similar immune-related mechanism may have contributed, at least in part, to the Surgicel™-related granuloma observed in the brain of our patient. However, a Surgicel™-related granuloma in the brain will have distinctive features from those involving other organs because the blood–brain barrier functions to prohibit giant cell infiltration and assembly in the brain. To addret al. reported that the clinical manifestations of two Surgicel™-related granulomas occurring after brain tumor resection were similar to those of other intracranial space-occupying lesions[et al. formed within 1 and 3 months after surgery, respectively. In contrast, Ito et al. reported three cases of Surgicel™-related granuloma formation in brain that occurred within the time span of 13 to 21 months[Sandhu  lesions. The tim lesions. The two1 months. Hence, Another intriguing feature of Surgicel™-related granulomas is the fact that they are commonly misdiagnosed as brain tumors, particularly in cases of granuloma forming after cerebral tumor resection. In two previous cases, the Surgicel™-related granuloma manifested as a space-occupying lesion with heterogeneous density by CT scan,14 and mTo confirm the MRS-based tumor diagnosis, histopathologic analysis of the resected lesion was performed. Hematoxylin-eosin (HE) staining of the unabsorbed Surgicel™ substance showed mild eosinophil infiltration (indicated by blue or lavender coloration). Because the blood clot around the unabsorbed Surgicel™ was gradually absorbed, the Surgicel™ was left in place. The blood clot appeared in the HE-stained lesion sections as a ‘ghostly’ fiber surrounding the Surgicel™ substance, and no tissue accumulation was observed surrounding the Surgicel™. Notably, numerous multinucleated giant cells were found around these fibers. The patAlthough low, the risk of developing Surgicel™-related granuloma after surgery indicates a need for caution in applying Surgicel™, especially when it is used solely for the purpose of achieving a hemostatic effect. However, the risk of granuloma may be reduced by removing the unabsorbed Surgicel™ after the hemostatic effect has been achieved, or by reducing the amount of Surgicel™ applied. When a tumor-like space-occupying lesion is observed in the intracranial surgery bed after surgery employing Surgicel, the rare possibility of Surgicel™-related granuloma should be considered.Written informed consent was obtained from the patient for publication of this case report and accompanying images. Copies of the written consent are available for review upon request.Cho: choline; CT: computed tomography; HE: hematoxylin-eosin; MRI: magntic resonance imaging; MRS: magnetic resonance spectroscopy; NAA: N-acetylaspartate.The authors declare that they have no competing interests.


Osteomas are benign, slow-growing osteogenic tumors commonly occurring in the craniofacial bones. Osteomas are characterized by the proliferation of compact and/or cancellous bone. It can be of a central, peripheral, or extraskeletal type. The peripheral type arises from the periosteum and is rarely seen in the mandible. The lingual surface and lower border of the body are the most common locations of these lesions. They are usually asymptomatic and can be discovered in routine clinical and radiographic examination. In this paper, we presented a large solitary peripheral osteoma located in the buccal surface of the left posterior mandible and causing facial deformity in a 37-year-old woman. Radiographic examination by computed tomography revealed radiopacity with a well-circumscribed, pedunculated mass approximately 3 cm in size. The osteoma was removed surgically, and no recurrence has been observed. An osteoma is a benign osteogenic tumor characterized by compact or cancellous bone proliferation. It may be classified as peripheral, central, or extraskeletal. A peripheral osteoma arises from the periosteum, a central osteoma from the endosteum, and an extraskeletal osteoma in the soft tissue –4. The pOsteomas are found mainly in the craniofacial bones. A peripheral osteoma (PO) occurs most frequently in the paranasal sinuses. Other locations include the orbital wall, temporal bone, pterygoid processes, and external ear canal , 4, 6–8.Patients with osteomas should be evaluated for Gardner's syndrome (GS). This syndrome is an autosomal dominant disease characterized by gastrointestinal polyps, multiple osteomas, skin and soft tissue tumors, and multiple impacted or supernumerary teeth. Intestinal polyps are predominantly adenomas and may progress to malignancy in almost 100% of patients . BecauseThe purpose of this paper is to present a large peripheral osteoma originating from the buccal surface of the mandible and causing asymmetry in a 37-year-old woman.A 37-year-old woman was referred to the Oral Diagnosis and Radiology Department with a complaint of facial and intraoral swelling on the posterior buccal aspect the left-side mandible. She had been aware of the slow but steady increase in the size of the lesion over the past six years. The lesion was not associated with pain, and there was no problem with mouth-opening or chewing. She had no previous facial trauma, and her medical history was not contributory. Clinical examination revealed extraoral swelling on the left side . The regμ thickness and slides were stained with hematoxylin and eosin. The histopathologic diagnosis confirmed the clinical diagnosis of peripheral osteoma. Microscopic examination of the specimen revealed a hard mass consisting entirely of dense lameller compact bone (The patient presented for a postoperative visit and suture removal a week later, and the healing was progressing normally. There were no postoperative complications. The surgical specimen was submitted for histopathological examination. Tissue specimens were fixed in 10% formaldehyde and then decalcified in 8% formic acid solution. They were processed routinely and paraffin embedded. Tissue blocks were cut with 6 act bone . The patOsteomas real prevalence is unknown. Sondergaard et al.  in theirThe lingual surface and lower border of the body are the most common locations of mandibular lesions , 13–16. The exact etiology and pathogenesis of peripheral osteoma is unknown. Neoplastic and reactive causes have been suggested as possible etiologic factors. Kaplan et al. , 3 and WClinically, peripheral osteoma appears as an unilateral and well-circumscribed mass ranging from 10 to 40 mm in diameter , 9. LesiRadiographic findings: panoramic radiography or computed tomography is used for imaging; however, as demonstrated in this case, the CT is the best imaging modality for determining the location and real extension of the lesion , 17, 19.Differential diagnosis: peripheral osteoma should be differentiated from several pathologic entities, such as exostoses, osteoblastoma, and osteoid osteoma, late-stage central ossifying fibroma, or complex odontoma. Exostoses are bony excrescences that usually stop growing after puberty, differentiating them from osteomas , 20. TheOsteoblastomas and osteoid osteomas are more frequently painful and grow more rapidly than peripheral osteomas , 5. A coRemoval of an asymptomatic peripheral osteoma is not generally necessary. Surgical intervention is indicated only if it becomes large enough to cause facial asymmetry and functional impairment , 17, 18.We have presented a case of a large osteoma on the buccal surface of the mandibular body. The lesion had grown slowly for six years and caused intraoral swelling and facial asymmetry. Following histological diagnosis, surgical excision was done. Recurrence of peripheral osteoma after surgical excision is extremely rare. However, it is appropriate to provide both periodic clinical and radiographic followup after surgical excision of a peripheral osteoma.


Dear Editor,Abdominal cocoon or sclerosing encapsulating peritonitis is a rare condition of unknown cause in which intestinal obstruction results from the encasement of variable lengths of bowel by a dense fibrocollagenous membrane that gives the appearance of a cocoon. This condition is not often suspected preoperatively, and therefore the diagnosis is usually made at laparotomy . The abdA 30 year old male presented with pain left lower abdomen and vomiting of 3 days duration. He had similar episodes of pain and vomiting in the past that were managed conservatively, with a diagnosis of subacute intestinal obstruction (SAIO). On examination he was thin built and looked undernourished. His vitals were normal and he had mild pallor with Hb of 10.9 with no lymphadenopathy. Abdomen was distended, with a sausage shaped intra-abdominal lump felt in left umbilical region, size 6x4cm, with concavity towards midline. Margins of the lump were ill defined, soft in consistency, non-pulsatile, mobile. Bowel sounds were not present and there was no shifting dullness. Hernial sites and per rectal examination was normal. The patient had no previous history of hepatic disease, abdominal surgery, peritoneal dialysis, ventriculoperitoneal and peritoneovenous shunting. Additionally, no clinical features of connective tissue disease could be identified. A family history of chest tuberculosis was, however, positive. Plain radiograph abdomen showed multiple air and fluid levels in the erect position. Chest radiographs were however normal without any evidence of pulmonary tuberculosis. Ultrasound abdomen showed gas filled loops of small bowel, suggestive of small bowel loop obstruction. A CECT (contrast enhanced computed tomography) abdomen showed gut wall thickening Diagnosis of acute intestinal obstruction was made. Exploratory laparotomy was done. The whole of small bowel was adhered together like a cocoon  and 3 frAbdominal cocoon is a rare disease, characterized by a thick fibrotic membrane that wraps the small bowel in a concertina-like fashion. Terms such as sclerosing peritonitis , encapsu


The flexor digitorum accessorius longus (FDAL) is a rare muscular occurrence in the lower extremity. In this case study and review of the literature the cause of tarsal tunnel syndrome by a flexor digitorum accessorius longus is described with emphasis on clinical testing methods, diagnostic imaging and both non-surgical and surgical management. A 52 year old male presented with pain and paraesthesia in his left foot and ankle. Tinel’s sign was exhibited clinically as well as severe bilateral pes planus. Inverted style custom foot orthoses failed to reduce the patient’s symptoms over a six month period. Magnetic resonance imaging (MRI) confirmed the presence of a FDAL muscle within the tarsal tunnel. The patient was subsequently referred to a podiatric surgeon for decompression and excision of the accessory muscle. Follow up at 18 months revealed resolution of pain and return to normal activities however, some plantar paraesthesia remained. A literature search was conducted across several major scientific databases. Further information was sought with citation tracking, reference checking, reviewing unpublished data and seeking expert opinion. The search yielded sixteen research papers pertaining to the FDAL muscle. Six of these papers described the FDAL as the cause of TTS in the form of case studies and were included in the review. Pain and paraesthesia were described as the pertinent symptoms and indicative of neural pathology, as was a Tinel’s sign. MRI was preferred for diagnostic purposes due to the ability to detect space-occupying lesions within the tarsal tunnel. In some cases FDAL was diagnosed intra-operatively. Surgical decompression via excision of the accessory muscle was described with a reportedly high success rate. Practitioners treating the foot and ankle should have a degree of suspicion for the presence of an accessory muscle particularly when interpreting MRI films as part of the diagnostic work-up for TTS.


Extraskeletal chondroma is a benign cartilaginous tumor that occurs predominantly in the soft tissues near small joints of the hands and feet. There are rare reports of the lesion in other sites, such as the head, neck, trunk, oral cavity, larynx, and pharynx. We present a case of an axillary mass in a 15-year-old girl who underwent MRI examination and resection, with the ultimate diagnosis of an extraskeletal chondroma, in order to expand the differential diagnosis of an axillary soft tissue mass in an adolescent. Extraskeletal chondroma, also referred to as chondroma of soft parts , is a beWe present a case of an axillary mass in a 15-year-old girl who underwent magnetic resonance imaging (MRI) examination and resection, with the ultimate diagnosis of an extraskeletal chondroma, in order to expand the differential diagnosis of an axillary soft tissue mass in an adolescent.An otherwise healthy 15-year-old girl was referred by her clinician to our hospital for imaging of a mass in the right axilla. The mass was slowly growing over the prior 6 months. Physical examination revealed a 5 cm painless, nonmobile, palpable firm lesion in the right axilla. The girl denied tenderness, erythema, or fluctuance. The patient recalls no antecedent traumatic event and has no pertinent medical or surgical history. Her laboratory tests include white blood cell count, erythrocyte sedimentation rate, and C-reactive protein, all of which were normal. Frontal and lateral radiographic views of the chest were normal. MRI was subsequently requested to define the lesion location and to evaluate for any specific imaging characteristics that might propose a diagnosis. MRI showed a well-defined, well-circumscribed, 4 × 5 × 6 cm in diameter solid mass within the subcutaneous fat of the right axilla. The mass was slightly hyperintense to muscle on T1-weighted images  and homoFollowing biopsy and frozen section analysis, the patient underwent full excision of the lesion. The excised mass was well demarcated, multilobulated, measuring 7 × 6.5 × 4.2 cm and weighing 75.9 grams. The cut surface was firm, grayish white, with focal gelatinous areas . Upon miSoft tissue masses of the axilla in children are not uncommon and encompass a wide variety of lesions including both benign and malignant lesions. Most commonly encountered are benign lesions that include enlarged inflammatory or infectious lymph nodes, posttraumatic hematoma, soft tissue abscess, vascular malformation, lipoma, myofibroma, and less commonly accessory breast tissue or fibroadenoma from axillary breast tissue in teens. Schwannoma, myofibroma, and myositis ossificans are additional rare considerations . Maligna Accessory breast tissue is often asymptomatic, but occasionally it can produce symptoms related to hormonal influences and can be mistaken for a neoplasm . It can  Solitary myofibroma is a single lesion within skin, subcutaneous tissue, muscle, or bone in infant or young children. Myofibromas are frequently confused with both benign and malignant tumors . MyositiThe differential diagnosis from histology includes well-differentiated extraskeletal chondrosarcoma, extraskeletal myxoid chondrosarcoma, and mesenchymal chondrosarcoma. Well-differentiated extraskeletal chondrosarcoma shows abnormal mitoses, atypism, and necrosis. Extraskeletal myxoid chondrosarcoma is less differentiated, especially in the peripheral portion of the tumor. Mesenchymal chondrosarcoma is another chondroid lesion with a characteristic dimorphic pattern composed of well-differentiated cartilage surrounded by small, undifferentiated tumor cells. Our case showed the typical pattern of chondroma without atypia or mitosis and, therefore, was easily diagnosed as a chondroma.Extraskeletal chondroma is a relatively rare, benign, slow-growing soft tissue tumor that usually occurs in the soft tissues about the joints of the hands and feet  and usua To our knowledge this is the first report case of an extraskeletal chondroma of the axilla in an adolescent confirmed by histopathology to undergo MRI evaluation. Only one other case of extraskeletal chondroma located in the axilla has been reported in a child in the literature . When a


Background: in endemic areas, neurocysticercosis appears mainly as a single, large, spherical and non-enhancing intracranial cyst. Case presentation: an atypical case of neurocysticercosis (NCC) in a French Caucasian, without history of travel to endemic areas, was confirmed by histology and molecular speciation. Imaging was atypical, showing several hook-bearing scolices visible in the cyst, while the serology employed was non-contributary. Conclusions: NCC should be considered when multiple taeniid scolices are observed within the same cystic lesion. Taenia solium. The infection predominates in less developed countries where NCC is the most frequent cause of parasitic infections of the human central nervous system. Clinical symptoms vary according to localization, viability, number and size of the cyst(s) and the extent of the inflammatory reaction. Seizures, increased intracranial pressure and focal neurological deficits are the most common clinical manifestations.Neurocysticercosis (NCC) is a pleomorphic taeniid parasitic infection, acquired via carriers of the adult intestinal tapeworm, A 69-year-old Caucasian man, from the Burgundy region of France, presented with symptoms of asthenia and headache of a two-year duration. There was neither fever nor seizure and no history of travel. The full blood cell count was unremarkable. Computerized tomography (CT) scans indicated a diffuse right frontal lobe lesion. Magnetic resonance imaging (MRI) with gadolinium injection demonstrated a right frontal tumor on the cerebrifalx, the lateral right ventricular floor and the corpus callosum, with an extending process to the right but not to the left lobe. The lesion measured c. 40 × 30 mm, surrounded by a ring of gadolinium enhancement and a peripheral edema. The MRI revealed some internal necrotic or cystic septations including fluid. No other cystic lesion and no sign of recent hemorrhage were found in the brain.Cysticercus cellulosae, the most common cysticercus observed in humans. But other cysticercus such as Taenia saginata, Taenia crassiceps, Echinococcus multilocularis, Cenurosis were discussed.The first hypothesis was a primitive glial tumor and the lesion was resected. Macroscopically, the cystic lesion appeared like a bunch of grapes, the tissue fragments having a yellow appearance, surrounded with a discontinuous band of cerebral tissue. However immuno-histochemical analyses with tumor related markers , S100 protein, EMA, vimentine and synaptophysine) were negative. Finally histological observations excluded a cerebral tumor but highlighted a cystic cavity lined with a fibrotic and inflammatory wall scattered with calcifications and macrophages . InteresEchinococcus granulosus in serum  was weakly positive whereas a similar assay for T. solium  was negative. However, based on clinical, radiographical and histological features, the diagnosis of NCC was retained and the patient received both surgical resection of the cyst and albendazole therapy , which was well tolerated.Surprisingly, commercially available Enzyme-Linked Immunosorbent Assay (ELISA) designed to detect antiparasite antibody to E. granulosus ELISA became negative seven months after the lesion was resected.At the final follow-up consultation, the patient was asymptomatic with no recurrence of symptoms. Repeated MRI revealed the persistence of right frontal lesions up to one year after the diagnosis, reflecting sequellar and non-evolutive lesions. T. solium and not E. granulosus, as might have been inferred from the serology.Molecular identification was retrospectively carried out using previously described PCR protocols (i.e. parasite microscopic observation) allow unequivocal diagnosis of NCC. Major criteria  strongly suggest the diagnosis but cannot be used alone to confirm the disease, further their value is closely related to their sensitivity/specificity, which, if insufficient may, as in this case, suggest a misdiagnosis of the species involved. This is where the more specific PCR based diagnostic procedures employed here present an advantage  are considered to be nonspecific. Finally, epidemiological criteria refer to circumstantial evidence that favors a cysticercosis/neurocysticercosis diagnosis.Accurate diagnosis of NCC is based on the combination of clinical, epidemiological, radiographic, histological and serologic criteria  assay, contributing to the diagnosis of NCC as a major criteria .The molecular characterization of Guidelines have been proposed for the management of NCC .In fine, NCC must be considered in patients with atypical clinical and neuro-imaging presentations, regardless of travel to endemic areas. In this case, anatomopathological examination and molecular tools were crucial for the diagnosis (i) showing atypical form of NCC with the presence of several larvae in a unique cerebral cystic cavity and (ii) unequivocal PCR-based speciation of the parasite involved.


Desmoid tumors are rare lesions without any metastatic potential but a strong tendency to invade locally and to recur. These tumors are associated with women of fertile age, especially during and after pregnancy.The case of a desmoid tumor of the anterior abdominal wall in a 40-year-old Caucasian man with no relevant family history is presented, describing its appearance on computed tomography and ultrasonography. The patient, who presented with a painless mass in the left anterolateral abdomen, had a history of previous urgent abdominal surgery after a shotgun injury two years earlier. Radical resection of the affected abdominal wall musculature was performed, and the defect was reconstructed with polypropylene mesh.The diagnosis of desmoid tumor should be strongly considered even in male patients with an abdominal mass and a history of previous abdominal surgery. The goal of its treatment is complete tumor excision and avoidance of the development of complications such as hernia. Desmoid tumors are histologically benign neoplasms with a strong tendency to recur locally after resection and account for 0.03% of all neoplasms and 3% of all soft tissue tumors. These tumors have an intermediate biological behavior between benign fibrous lesions and fibrosarcomas. They occur usually between the ages of 25 and 40 years with a strong prevalence among women in the fertile age group. The most common site of predilection is the anterior abdominal wall, with an incidence of 50% -8.We present the case of this rare medical entity in a 40-year-old man with history of abdominal surgery and describe its appearance on computed tomography (CT) and ultrasonography.A 40-year-old Caucasian man presented to the emergency department with a painless mass in the left anterolateral abdomen. During a physical examination, the mass was firm, nontender and fixed to the abdominal wall. The patient stated that the mass was gradually increasing in size. He had no relevant family history and did not smoke, drink alcohol or take any medications. Analyzed blood parameters were within the normal range, and tumor marker results were negative. The patient had a history of previous urgent abdominal surgery for traumatic rupture of the left colonic flexure and part of the small bowel after a shotgun injury two years earlier.An ultrasound examination was performed and demonstrated a large mass of heterogeneous echogenicity with smooth, sharply defined margins in the left anterolateral abdominal wall Figure . PreoperRadical resection of the affected abdominal wall musculature down to the peritoneum was performed to include a peripheral margin of 3 cm of healthy tissue. The defect was reconstructed with polypropylene mesh. Macroscopically, the lesion had a firm, gritty texture. On the cut surface, it was glistening white and coarsely trabeculated, resembling scar tissue Figure .The postoperative course was uneventful, and the patient was discharged on the sixth postoperative day. The patient remained well at three years of follow-up with no evidence of tumor recurrence or development of incisional hernia.Desmoid tumor, also known as aggressive fibromatosis, is a rare tumor. Approximately 3.7 new cases occur per one million persons per year and develop mostly as an extracolonic manifestation of familial adenomatous polyposis (FAP) -8. They They can be divided into five subgroups: extraabdominal, intraabdominal, multiple, multiple familial and as part of Gardner's syndrome. Extraabdominal desmoid tumors have a wide distribution; the shoulder girdle, trunk and lower extremities are most commonly involved. Abdominal desmoids, which may occur in the abdominal wall, mesentery or retroperitoneum, have an increased incidence in individuals with Gardner syndrome. The histologic findings in these lesions are identical ,5,6,8.Abdominal wall desmoid tumors arise from musculoaponeurotic structures of the abdominal wall, especially the rectus and internal oblique muscles and their fascial coverings, and occasionally cross the midline. Less commonly, they originate from the external oblique muscle and the transversalis muscle or fascia .The commonest groups associated with these tumors are young women during or after pregnancy. The fibroblast has been shown to exhibit a proliferative response to estrogen. Women with desmoid tumors have regression of their lesions after attaining menopause -9.There is a well-known association in patients with a history of abdominal or pelvic surgery. This tumor is also associated with trauma, estrogen therapy, FAP and Gardner syndrome ,4-6. In Abdominal desmoid tumor usually presents as a mass that is sometimes associated with pain and weight loss . Most ofThe differential diagnoses for rectus abdominis lesions include acute hematoma, fibrosarcoma, lymphoma, rhabdomyosarcoma, liposarcoma, leiomyosarcoma, neurofibroma, benign fibrous tumor and primitive neuroectodermal tumor .Histologically, desmoid tumors consist of elongated fibroblasts and myofibroblasts characterized by elongated, tapered cytoplasm; elongated, vesicular, typical-appearing nuclei; and multiple small nucleoli. The cells are linearly arranged and are surrounded and separated from each other by collagen -4,6. TheOn ultrasonography, desmoid tumors appear as well-defined lesions with variable echogenicity. The lateral borders may appear ill defined or irregular ,7.The CT appearance of desmoid tumors depends on their composition. They may appear homogeneous or heterogeneous and hypo-, iso-, or hyperintense compared with the attenuation of muscles. The degree of enhancement after the intravenous administration of contrast medium is variable ,5,7,8. IMagnetic resonance imaging (MRI) features of desmoid tumors also show wide variability depending on the stage they are imaged. Characteristic MRI findings include poor margination, low signal intensity on T1-weighted images and heterogeneity on T2-weighted images, and variable contrast enhancement. Low T2 signal intensity bands are characteristic and represent foci of high concentrations of collagen deposition ,7.Definitive diagnosis must be established with histopathologic analysis .Wide local excision followed by reconstruction of the defect is the treatment of choice. Full-thickness resection of the tumor-containing abdominal wall with a grossly negative margin has to be performed when the lesion closely approximates or involves the peritoneum. Intraperitoneal organs or adjacent bony structures involved by tumor must be resected as well. Incomplete tumor removal or involved excision margins may lead to local recurrence -6.The recurrence rate of desmoid tumors is 20% to 77% depending on the location, extent and completeness of the initial resection. Abdominal wall desmoid tumors have a significantly lower recurrence rate. Their recurrence is 20% to 30% and usually becomes evident within six months after excision or in connection with subsequent gestations or deliveries. Metastatic disease has not been reported with desmoid tumor ,3,4,6-8.Radiation therapy is used in patients with inoperable tumors, local recurrences or incompletely excised lesions. Chemotherapy and endocrine therapy have also been used to treat desmoid tumors in patients in whom resection is technically impossible because of a widespread tumor infiltration ,2,4,5.The combination of features, such as the history of previous surgery, the age and sex of the patient, the location of the mass within the anterior abdominal wall and the imaging features, make desmoid tumor a strong primary diagnostic consideration even if it is a rare entity and especially in men. The treatment approach remains aggressive and includes complete surgical resection. Repair of abdominal wall defects can be sufficiently achieved with prosthetic mesh reconstruction with excellent functional results.CT: computed tomography; FAP: familial adenomatous polyposis; 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.XP performed the chart review and manuscript preparation. AE and EA carried out the operation. LP was the pathologist who examined the specimen. TC participated in manuscript preparation. All authors read and approved the final manuscript.


Eccrine porocarcinoma is a rare malignancy of the eccrine sweat gland. It is usually found frequently on the lower extremities, and it affects both sexes equally usually in the sixth to seventh decade. In our case, we present a 42-year-old male patient with a recurring exophytic tumor on the right lower extremity without local extension. The initial tumor was biopsied, excised and diagnosed as an eccrine poroma. The tumor then recurred 6 years later, was re-excised, reconstructed with a soleus muscle flap and diagnosed as an eccrine porocarcinoma. Eccrine porocarcinoma (EPC), a rare malignant sweat gland tumor, representing only 0.005% of epithelial cutaneous neoplasms. The first reported case, in 1963, was attributed to Pinkus and Mehregan . These lA 42-year-old male presented with an exophytic mass on the right lower extremity that had developed over the last 6 years. The patient denied any type of trauma to the area or insect bites. The mass had been previously excised and pathology showed a benign poroma. The laboratory work-up for this patient was within normal limits.On physical exam, there were no lymphadenopathy in the inguinal, axillary or clavicular areas were noted. The tumor itself measured 3.0 × 2.0 cm with a width of 0.6 cm Figure . Pink exThe macroscopic examination of the specimen showed an exophytic mass measuring 3 cm in diameter. Microscopically, the specimen displayed malignant eosinophilic lobular masses with eosinophilic polyhedral fusiform cells that contained variable cytoplasm, hyperchromatic nuclei, distinct nucleoli and indistinct cell boundaries Figure . There wThe final pathology report stated the specimen was a porocarcinoma in situ with clear surgical margins. During the 6 month and 1 year post-op follow up, the wound had healed without any complications or recurrence Figure . The phyEccrine porocarcinoma (EPC) is more common in elderly patients and most cases occur in the sixth to seventh decade of life. In our case, we presented a male in his early 40 s and with time, has become malignant from a previous benign poroma. Men and women are usually equally affected, and prevalence varies in both sex in diverse studies -14. ApprTheorectically, eccrine porocarcinoma progresses from benign to malignant. This is supported clinically by long histories, mean 8.5 years and recent onset of rapid growth in longstanding cases. Only a period of 6 years duration was noted in our case. Histological reports of dysplasia and malignant change in benign variants, including eccrine poroma and hidroacanthoma simplex support this theory .The pathogenesis and roles of possible pre-invasive precursors of this lesion is still unknown . It seemTreatment of choice for EPC is total surgical excision with broad tumor margins and regional lymph node disection if involved. There is still insufficient literature data on cryosurgery and electrosurgery in order to accurately assess indication and tumor recurrence . ChemothIt is important to have this diagnosis as a differential for cutaneous lesions due to the malignant nature of the tumor if left unattended. EPC must be considered in the differential diagnosis of patients older than fifty years with long standing tumors in the limbs and head - including basal cell carcinoma, Paget's disease, melanoma and metastatic cancer. EPC has been documented to occur even in the nail fold of the toe mimicking an ingrown toe nail. Biopsy is indicated and, even with a previous diagnosis of EP, one must be attentive to risk of malignancy in the future or if it is a recurrence . EPC is Eccrine porocarcinoma (EPC), a rare malignant sweat gland tumor, representing only 0.005% of epithelial cutaneous neoplasms. Being only 0.005% of all cutaneous neoplasms makes this diagnosis intricate, but not impractical if more literature is provided of this rare pathology. The treatment is a multidisciplinary effort that consists of a pathologist and surgeon. And if treated in the early stage, surgery can be curative. EPC is a rare malignancy of the eccrine sweat glands but yet curable if accurately diagnosed and properly treated. Due to the limited amount of literature and cases documented, it is important to have a basic knowledge of this disease process as a differential diagnosis when dealing with cutaneous lesions.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.Non-financial competing interest: The authors declare that they have no competing interests.OC wrote the article and participated in the collection of data in the literature review. NC performed the surgical procedure and acted as preceptor for the project. AE performed the microscopic analysis of the surgical specimen and provided the pathological slides with description. BR performed originally surgery and acted as preceptor and gave final approval for publication. AA acted as preceptor and gave final approval for publication. All of the authors have read and approved the final manuscript.


A 66-year-old man presented with a symptomatic, mobile, 2.5-cm right forehead mass. Exploration for excision revealed a friable mass with invasion into the frontal bone. Magnetic resonance imaging revealed an intracranial mass. Positron emission tomographic scan indicated an additional lesion in the left lung. Lung mass pathology demonstrated identical immunohistochemical staining pattern to the frontal mass, suggesting a metastatic squamous cell carcinoma to the cranium with a primary pulmonary lesion.What is the differential diagnosis of a subcutaneous mass and what is the common presentation of cutaneous metastases?What is the incidence of cutaneous involvement as the initial presentation of metastatic disease?When should preoperative imagining be considered?What is the suggested treatment and prognosis of cutaneous metastasis?2. Often the lesions appear near the anatomical site of the primary tumor but can be found anywhere in the body.2,2,2A systematic approach to evaluating subcutaneous masses can help determine an appropriate differential diagnosis. One approach is to divide the possible diagnoses into categories such as mesenchymal tumors , skin appendage lesions , metastatic tumors , other tumors or tumorlike lesions , and inflammatory lesions .The prevalence of cutaneous metastases of visceral tumors amounts to roughly 2% of all skin tumors.2,2,3In isolated cases, subcutaneous masses may represent a more complex diagnosis requiring further work-up before undergoing surgical excision. In general, small subcutaneous nodules do not require preoperative imagining. However, lesions that are firm, adherent to underlying tissue, or symptoms suggesting involvement of adjacent structures should be further evaluated with imaging prior to surgical intervention.1Cutaneous metastases are a poor prognostic indicator, with an average survival time after diagnosis of approximately 3 to 6 months.


CYP21A2 identified a compound heterozygosity consisting of p.I173N and p.Q319*. The patient has been treated with dexamethasone 0.5 mg once daily and fludrocortisone 0.1 mg once daily. As subject has been raised as a male, additional operation such as oophoro-hysterectomy is under consideration. Patients with congenital adrenal hyperplasia should be screened for incidental adrenal masses to avoid unnecessary surgical procedures.Adrenal myelolipoma is an uncommon, non-functioning tumor composed of variable amounts of mature adipose tissue and scattered islands of hematopoietic elements, including erythroid, myeloid, lymphoid series, and megakaryocytes. Diagnosis of adrenal myelolipomas based on radiologic imaging, such as ultrasonography, CT or MRI is effective in more than 90% of cases. It should be differentiated from other fat-containing adrenal masses such as teratoma, lipoma and liposarcoma. The optimal treatment depends on the size and symptoms of the tumor. Surgical treatment is usually not necessary for asymptomatic adrenal myelolipomas smaller than 4 cm. In contrast, symptomatic, complicated, and hormonally active myelolipomas larger than 7 cm should be surgically removed. This report present a 50-year old adult raised as a male with giant adrenal myelolipomas manifested as adrenal masses, which was misdiagnosed with liposarcoma by radiologic examination. The patient has been raised as male despite of ambiguous genitalia and thorough investigation was not performed because of poor socioeconomic status. Physical examination showed short stature (<3rd percentile), hyperpigmentation, and micropenis without palpable gonads. There were uterus and ovary in pelvic cavity on abdominopelvic CT. ACTH stimulation test showed adrenal insufficiency. Steroid replacement was initiated before bilateral adrenalectomy. The histologic findings revealed myelolipomas, and endocrine and molecular investigation lead to the diagnosis of 21-hydroxylase deficiency. Karyotype was 46,XX and mutation analysis of