Giant cell tumor of the small bones, particularly the carpal bones of the hand, is exceedingly rare. We present a case report of giant cell tumor of the capitate in a 24 year-old female with 10 years postoperative follow-up. Although carpal bones are extremely unusual location, orthopedic surgeons should always keep in mind that differential diagnosis must include giant cell tumor of bone whenever an expansile osteolytic lesion with well-defined but nonsclerotic margins is identified in a young adult with closed physes. Giant cell tumor of bone (GCTOB) is defined as a benign but locally aggressive primary bone tumor which generally involves the meta-epiphyseal region of long bones, mostly around the knee joint and distal radius of skeletally mature individuals . ClinicaA 24-year-old female patient with a 2 × 2 cm wide mild swelling on the dorsum of her left hand, which was painful especially during dorsiflexion and strong grip, was admitted to the orthopedic department. The pain and swelling appeared during her third trimester of pregnancy, persisted for nearly 4 months up to the first admission to the orthopedic department, and she had a 2-month-old baby at the first clinical evaluation. There was no past medical history of trauma or previous treatment. Physical examination revealed the swelling and tenderness on the dorsum of the hand in the area above the carpometacarpal joints. Routine laboratory blood test results were within normal limits. Plain roentgenograms showed a lytic lesion that involved the capitate almost totally except the proximal pole but surrounding bones were normal . MagnetiAt the 6-month follow-up clinical visit, she had no pain; flexion and extension of the operated wrist were 30° each, and 20° of radial and 15° of ulnar deviation could be achieved. The graft was incorporated with the third and fourth metacarpal bones, as well as the surrounding carpal bones . The conAt the 10-year follow-up clinical visit, she had no pain. Quick-DASH score was measured as 27.3 points. Mayo wrist score was 75 points. Gartland and Werley score was 7. The control plain roentgenogram and MRI were obtained, and no local recurrence was detected  and 5B.Giant cell tumor of bone is still considered by many of the orthopedic surgeons, as a disease that is difficult to treat due to a high incidence of local recurrence and potential to metastasize to lungs or mediastinal nodes. Although it is one of the common primary tumors of the human skeleton and has been discussed widely in the orthopedic literature, controversies regarding the most effective methods of treatment and prevention of its recurrence still continue. The clinical behavior is benign in the majority of the cases; however, metastases in the form of benign pulmonary implants rather than classical metastatic lesions associated with malignant tumors can be diagnosed in 2% of the cases. Giant cell tumor of the small bones, particularly the carpal bones of the hand, is exceedingly rare. We present a case of primary GCTOB of the capitate in a 24-year-old female patient with 10-year postoperative clinical follow-up results.Intralesional resection and curettage, adjuvants, grafting, filling the defect with bone cement, marginal or wide resection, and even amputation have been discussed as the treatment options in such patients , 5. AdjuThe multicentric disease incidence is less than 1%, therefore a systemic testing in an asymptomatic individual is not routinely advised. A preoperative chest CT and a scintigraphic bone survey are the clinical tools in case of any requirement for a systemic testing. Our patient did not have any clinical signs of disseminated disease preoperatively. Furthermore, the morbidity to her or to her unborn child would be much higher than the potential benefit of such a procedure. Therefore, we did not perform a bone survey preoperatively. After the birth of her child, our patient was breastfeeding and wanted to avoid radioactive injection until she stopped breastfeeding. We performed a bone scintigraphy at the 6-month follow-up visit which revealed no pathologic findings indicating any other focus.In conclusion, although carpal bones are extremely unusual location, orthopedic surgeons should always keep in mind that the differential diagnosis leading the physician to the most appropriate treatment must include GCTOB whenever an expansile osteolytic lesion with well-defined but nonsclerotic margins is identified in a young adult with closed physes.There are not any conflicts of interest regarding preparation, submission and publication of this paper.


Choledochal cysts are rare but serious bile duct abnormalities are found in young children, usually during the first year of life. Choledochal cysts are rare congenital abnormalities usually found in infants and children. They require urgent surgical intervention due to a 10% risk of cholangiocarcinoma.A six-year-old female of Asian descent born full term by spontaneous vaginal delivery with no past medical or surgical history presented to the ED with right-sided abdominal pain that started five days prior to presentation. The patient described the pain as sharp, intermittent, and located in the right upper quadrant and epigastric region of the abdomen without any aggravating or alleviating factors. She had a decreased appetite, constipation, and fatigue. However, she and her family denied nausea, vomiting, changes in stool or urine color, fevers, or weight loss. The patient was seen by her pediatrician earlier that day and had been sent to the ED for evaluation of possible appendicitis.Her physical examination revealed the following vital signs: pulse rate of 138 beats per minute; respiration rate of 20 breaths per minute; temperature of 35.9 degrees Celsius orally; oxygen saturation of 98% on room air; and weight of 22.6kg. The patient was alert, well appearing, and in no apparent distress. The head, eyes, ears, nose, and throat exam was unremarkable. The heart sounds were normal and the lungs were clear. The abdomen was soft, with normal bowel sounds, and mild tenderness in the right upper quadrant with no rebound, guarding, or radiation. No masses or hernias were appreciated. The spleen and liver were normal in size. No lymphadenopathy was appreciated. Gait was normal with mild abdominal discomfort appreciated when the child was asked to jump. Skin was normal with no rashes or jaundice. The neurologic exam was within normal limits.The patient’s urinalysis was normal, and an ultrasound was performed at the bedside using a low frequency (2–6 MHz), curvilinear probe oriented in a transverse then sagittal plane fanning superiorly then inferiorly, medially then laterally along the child’s right upper quadrant along her subcostal margin. The point-of-care ultrasound (POCUS) demonstrated what initially appeared to be a distended gallbladder with shadowing stones . HoweverAfter the POCUS was performed the patient was transferred to the children’s hospital for surgical management and an magnetic resonance imaging of the abdomen that showed findings similar to the ultrasound. The CBD cyst measured 6.7×4.8×8.0cm and extended from the porta hepatis to the pancreatic head. There were multiple small stones in the cyst but no solid components. The extrahepatic portal vein was mildly deviated to the left due to a mass effect. There was mild gallbladder dilatation with stones. The remainder of the study was negative. These results were consistent with a Todani type Ic bile duct cyst. The patient underwent open resection of the choledochal cyst, cholecystectomy, and a hepaticoduodenostomy biliary bypass. The patient tolerated the procedure well, was extubated shortly after surgery, and was discharged home six days after surgery.Final pathology report showed that the cystic tissue had rough fibrous connective tissue and friable mucosa consistent with reactive changes. The gallbladder tissue was smooth with a congested dark red serosal surface consistent with chronic cholecystitis. At the two-month follow up, the patient had regained her appetite, was doing very well, and was pain free.While choledochal cysts are most commonly found in children under the age of 10, up to 20% are diagnosed at adulthood.6Choledochal cysts are generally classified into five subtypes by the Todani classification developed in 1977. Since then, several other classification systems have been developed, but Todani’s is still widely accepted. Type 1 cysts are extrahepatic cysts in the CBD. These are further subdivided into types a-c. A type 1a cyst consists of diffuse CBD dilatation, a type 1b cyst has focal segmental dilatation, and a type 1c has fusiform dilatation of the CBD as in our patient. Type 2 cysts are extrahepatic duct diverticula. Type 3 cysts are intraduodenal or intrapancreatic ductal dilatations. Type 4 cysts are multiple bile duct cysts and type 5 cysts are intrahepatic cysts also referred to as Caroli disease.3There is no definite explanation for the pathogenesis of these cysts; however, multiple studies suggest they may be formed due to prolonged reflux of pancreatic enzymes and bile stasis leading to chronic inflammation.2Malignant changes in the epithelium of the bile duct can occur even after cyst excision, sometimes years after cyst removal. These patients therefore need to be followed for recurrent symptoms. Some of these malignant transformations have been seen in areas distant from the CBD cyst.10Classic findings include jaundice, pain, and an abdominal mass; however, less than 20% of patients will have all three findings. Classic findings are more common at a younger age with 85% of children having at least two of the three findings and only 25% of adults having two out of three findings. Laboratory results including liver enzymes are generally normal.4Because of the lack of radiation, abdominal ultrasound should be the primary imaging modality used in young children with right upper quadrant pain presenting to the ED. Ultrasound has been shown to be superior to computed tomography (CT) in identifying gallbladder pathology and avoids exposing the patient to unnecessary radiation. Emergency bedside ultrasound by trained physicians has both a sensitivity and specificity of greater than 88% for detecting gallbladder pathology.Historically, cystenterostomy was considered the best surgical treatment for patients with choledochal cysts. However, this approach was found to be associated with a high risk of malignancy in the remaining cyst wall with up to 30% of adults developing malignancy after cyst removal.Because a choledochal cyst is a serious condition in which a delay in diagnosis can lead to a worse clinical outcome, young patients suspected of having this condition should undergo an abdominal ultrasound and if a choledochal cyst is found, the patient should have early surgical removal in order to avoid complications and prevent malignancy. Thus, emergency point-of-care ultrasound as a first-line diagnostic tool may prove to be a life-saving measure in detecting rare but potentially fatal pediatric abnormalities such as a choledochal cyst.


We reported a very rare case with placentomegaly and markedly-dilated chorionic vessels. A 23-year-old Japanese pregnant woman was referred to our hospital at 32 weeks of gestation because of suspected dilatation of the umbilical vein. Ultrasound revealed fetal growth restriction with no fetal anomalies. The placenta was thick. The umbilical cord had two arteries and one vein, and marginal insertion of the umbilical cord in the placenta was suspected. A lot of remarkably tortuous tubular structures were observed on the surface of the placenta. Slow blood flow, indemonstrable with color Doppler, was observed within them. Labor started suddenly and progressed very rapidly at 33 weeks of gestation. A female infant weighing 1524 g was delivered. The infant had no malformations. However, she showed hypotension, anemia and DIC and required blood transfusion. The placenta was very large, weighing 1416 g. On the fetal surface, numerous dilated and tortuous vessels were observed, arising from a vein that was connected to the umbilical vein. These venous channels were dilated and tortuous and led into the placenta. In conclusion, prenatal diagnosis of placentomegaly and markedly-dilated chorionic vessels requires assessment of growth, anemia and DIC of the fetus and the newborn infant. Placentomegaly and dilation of chorionic vessels are rare anomalies of the placenta. There have been limited papers that reported on anomalies of the chorionic vessels, although venous anomaly of those is clinically important because it may threaten the life of the fetus. Recently, placental mesenchymal dysplasia (PMD) has been reported as a benign entity of the placenta . Her blood pressure was 149/92 mmHg; urinary protein, 2+; and her lower legs were edematous.Obstetric abdominal ultrasound revealed a fetus in cephalic presentation with an estimated fetal weight of 1498 g (−1.7 standard deviation), an amniotic fluid index of 10.6 cm, resistance index of the umbilical artery of 0.65, resistance index of the middle cerebral artery of 0.87, peak systolic velocity of the middle cerebral artery of 60.2 cm/s (<1.5 MoM). No fetal anomalies were found. The placenta was thick and located on the posterior uterine wall. The umbilical cord had two arteries and one vein, and marginal insertion of the umbilical cord in the placenta was suspected. A lot of remarkably tortuous tubular structures were observed on the surface of the placenta Figure . TransvaThe patient was admitted to our hospital for management of PIH. Although her condition of PIH was stable, labor started suddenly and progressed very rapidly at 33 weeks of gestation. A female infant weighing 1524 g was delivered vaginally with an Apgar scores of 8 and 9 at 1 and 5 min, respectively.The infant had no malformations. She was admitted to the NICU for a preterm infant without incubation and oxygen supply. However, her blood pressure was 39/21 mmHg; hemoglobin content, 10.1 mg/dl; platelet count, 71000/μl; fibrinogen, 49.2 mg/dl; FDP, 21.0 μg/ml; and D-D, 8.8 μg/ml. Because these data met the criteria of neonatal DIC, she required blood transfusion and administration of dopamine hydrochloride. Her general condition gradually recovered and she was transferred to a nearby hospital from her parents’ home on the 32nd day after birth.The placenta was very large, weighing 1416 g. On the fetal surface, numerous dilated and tortuous vessels were observed, arising from a vein that was connected to the umbilical vein Figure .Figure 4Histologic examination revealed necrosis in the decidua. The villi were normally formed and hydropic villi were not observed Figure . Part ofWe have found the only one previous report of a case with placentomegaly and dilation of the chorionic vessels of the placenta exactly like ours (Lee et al. The chorionic vessels are supposedly formed by the branching of the umbilical vessels (Lee et al. Sander described that the cause of FGR might be the diversion of blood away from the maternal intervillous space and that fetal anemia might be a result of a microangiopathic process occurring within the aberrant placental vasculature Sander . In addiIn conclusion, we reported a very rare case with placentomegaly and markedly-dilated chorionic vessels. Prenatal diagnosis of this condition using ultrasound and MRI requires assessment of growth, anemia and DIC of the fetus and the newborn infant.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.


Small bowel neuroendocrine tumors (NETs) are frequently characterized by a strong propensity to metastasize to the liver, mesentery, and peritoneum. However, only a few extra-abdominal metastatic sites have been reported in the published literature. The present paper implicates that primary small bowel NETs may unusually metastasize to the inguinal lymph nodes. Furthermore, we discuss the formidable diagnostic and therapeutic challenges associated with the metastatic NETs. Small bowel neuroendocrine tumors (NETs) are the most common malignancies of the small intestine. They are mostly indolent tumors , yet resistant to cytotoxic chemotherapy -2 and, iA 66-year-old male was diagnosed with a Stage IIIB small bowel NET three years previously. He underwent exploratory laparotomy and small bowel segmental resection, along with mesenteric resection of the mass. The tumor measured 2.3 cm in its greatest dimension. It involved the full thickness of the bowel wall. It was present in the mesentery, having a perineural invasion, with foci suspicious for lymphovascular invasion. However, after the curative resection, the proximal and distal margins of the small bowel wall were clear and free of tumor. Since then, the patient has been followed with annual imaging by staggered computed tomography and octreotide scintigraphy every six months. The disease had been in a deep remission without specific therapy. His chromogranin A (CGA), urinary 5-hydroxyindoleacetic acid (5-HIAA), and neurokinin A (NKA) remained within normal limits throughout, and there was no clinical evidence of recurrence until his current presentation.The patient presented to our institution with night sweats and a weight loss of 20 lbs over the last three months. He denied fever, abdominal pain, diarrhea, flushing, constipation, and fatigue. His physical examination was unremarkable. On admission, laboratory studies revealed 5-HIAA 6.1 mg/24 hr (< 8) and CGA 36 ng/mL (< 93). Informed patient consent was obtained prior to treatment. No identifying patient information is contained in this paper.Computed tomography (CT) through the lower pelvis showed an enlarged right inguinal lymph node adjacent to the right common femoral vein Figure .The patient subsequently underwent an octreotide scintigraphy. An axial image was obtained from a single-photon emission computed tomography (SPECT) acquisition through the pelvis 24 hours following the intravenous injection of 5.9 mCi Indium-111 pentetreotide , a somatostatin analog. Abnormally increased radiotracer uptake was identified in the right anterior lower pelvis corresponding to the enlarged right inguinal lymph node seen on the CT scan  , 3-4. HoThe correct identification of inguinal metastasis from small bowel NETs is difficult to ascertain, as these metastases are deemed clinically asymptomatic and diagnostic modalities do not necessarily demonstrate unique features distinguishing the lesion as primary small bowel malignancy. Therefore, the diagnosis is largely reliant on CGA, 5-HIAA, and circulating NKA, which are used as major laboratory diagnostic tests. However, our patient was unique in this regard as his CGA and 5-HIAA levels were within regular limits, and he was eventually diagnosed by octreotide scintigraphy and consistent histopathologic analysis of the lesion. Therefore, the results of biochemical markers for NETs may often be misleading or confusing . The octreotide scintigraphy (111In-Pentetreotide) is a useful adjunct and likely the most commonly used diagnostic imaging modality for NETs. Recently, the 68Ga–tetraazacyclododecane tetraacetic acid–octreotate (68Ga-DOTATATE) PET/CT has been evaluated for the diagnosis and workup of NETs. It was equivalent or superior to 111In-Pentetreotide imaging in numerous studies and had no considerable adverse events -8. Haug,In terms of management of metastatic NETs, the PROMID study  showed tSmall bowel primary NETs can metastasize to inguinal lymph nodes, which may become a diagnostic and therapeutic predicament for clinicians treating this disease. Knowledge regarding such unusual metastatic sites of NETs is of paramount importance in order to diagnose cases early, monitor tumor progression, and to institute effective treatment. Furthermore, the present paper adds evidence to the previous studies that imaging modalities employed for monitoring purpose in cases with metastatic NETs may have higher sensitivity and specificity than biochemical markers.


Osteoma is a benign bone-forming tumor that usually arises in the craniofacial bones and rarely in the long bones. Clavicular involvement is extremely rare. We report a 51-year-old woman with osteoma of the left clavicle. Radiograph of the left shoulder showed a well-defined lobulated blastic mass in the proximal and mid-portion of the left clavicle. Bone scintigraphy was performed 4 hours after an intravenous injection of Tc-99m hydroxymethylene diphosphonate (HMDP). Whole-body image showed a focus of intensely increased uptake in the clavicle. Single photon emission computed tomography / computed tomography (SPECT/CT) images were also acquired and clearly showed intense uptake at the tumor site. Integrated SPECT/CT imaging supplies both functional and anatomic information about bone the SPECT imaging improves sensitivity compared with planar imaging, the CT imaging provides precise localization of the abnormal uptake, and information on the shape and structure of the abnormalities improves the specificity of the diagnosis. Osteoma is a benign bone-forming tumor and clavicular involvement is extremely rare. We report a case of clavicular osteoma undergoing bone scintigraphy who demonstrated intense uptake in the clavicle, for which further single photon emission computed tomography / computed tomography (SPECT/CT) imaging was performed to characterize and localize the lesion.The present case was a 51-year-old woman who presented with a left clavicular mass. The tumor had grown very slowly since the age of 21 years when the lesion was detected incidentally on plain chest X-ray. Radiograph of the left shoulder showed a 70×35 mm, well-defined lobulated blastic mass in the proximal and mid-portion of the left clavicle. Bone scintigraphy was performed 4 hours after an intravenous injection of Tc-99m hydroxymethylene diphosphonate (HMDP). Whole-body image showed a focus of intensely increased uptake in the clavicle . SPECT/COsteoma is a benign ostogenic tumor that usually arises in the craniofacial bones and rarely in the long bones , 2. Clav


In rare cases, echo findings of degenerative valve disease is similar to valvular mass.A 56-year-old woman was evaluated for palpitation. Echocardiography revealed an 8- mm mass on the anterior mitral leaflet with minimal mitral insufficiency. Resection of the valve tumor was attempted to prevent a possible embolism. However, the lesion was not a tumor, but an aneurysm-like bulge on the anterior leaflet without chorda elongation. Triangular resection and ring annuloplasty were performed. The patient’s postoperative course was uneventful. Pathological examination revealeddegenerative disease.This case illustrates that a valvular mass that looks like a tumor by echocardiography may actually be degenerative regardless of the presence of mitral insufficiency. When a mass is observed on the mitral valve by echocardiography, infectious vegetation and various types of valve tumors are generally suspected –6. HowevA 56-year-old woman with no infectious history was evaluated for palpitation. She had regular pulse rhythm and no heart murmur. Electrocardiography, Holter, electrocardiography, and chest X-ray findings were normal. Transthoracic echocardiography revealed an 8- × 8-mm mass on the posterior side of the anterior mitral leaflet with minimal mitral insufficiency Fig. . The lefWhen a mass is found on the mitral valve by echocardiography, an infectious vegetation is usually suspected first. Various types of valve tumors may be suspected less frequently. Primary cardiac tumors are uncommon, accounting for 0.021 % among 1 million autopsies . DespiteIn contrast, degenerative mitral valve disease, such that caused by fibroelastic deficiency, is a common disorder affecting approximately 2 % of the population . DegenerIn conclusion, an aneurysm-like bulge on the leaflet without major regurgitation was misdiagnosed as a valve tumor in this case; the patient actually had degenerative disease. Our assumption that degenerative disease should coexist with regurgitation led to misdiagnosis. Our experience serves to remind clinicians that when a valvular mass looks like a tumor by echocardiography, it may instead be a degenerative change, even without mitral insufficiency.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 ethics committee of our institution approved to publish this case report.


Background. Torsion of greater omentum is a quite uncommon cause of acute abdomen. It can be primary or secondary but in both cases omentum twists upon itself and causes omental segmentary or diffuse necrosis. Symptoms are unspecific and preoperative diagnosis is difficult. The widespread and increasing use of computer tomography (CT) in differential diagnosis of acute abdomen can be useful for making a specific diagnosis. Objectives. This work aims to describe primary omental torsion in order to help avoid misdiagnosis, especially with acute appendicitis, which is eventually based solely on a physical examination. Case Report. We present a case of primary omental torsion in a young man and discuss contemporary methods in diagnosis and management of the condition. Conclusions. When a right diagnosis has been posed, possible treatments for omental torsion and necrosis are two: conservative or surgical. Conservative treatment had been rarely carried out because of frequent and important sequelae just like abdominal abscesses. Nowadays, surgical treatment, laparoscopic or laparotomic, is preferred because it is a safe method in diagnosis and management of this condition. Torsion of the greater omentum can be either primary or secondary. Primary torsion of the greater omentum, first reported by Eitel in 1899, occurs when the omentum twists upon itself, with the formation of a narrow neck in the absence of associated intra-abdominal pathology . Since t3/μL) and CRP was 1.4 mg/dL. An ultrasound scan showed, in correspondence with the right paraumbilical region, an oval hyperechoic region bounded by a hypoechoic rib with a small fluid district. This finding was situated immediately behind the rear surface of the abdominal wall and was not of unique interpretation, possible for herniation of bowel loop or intussusception. An abdominal computed tomography (CT) scan  but CRP was increased (8.4 mg/dL). Therefore, we decided to perform an explorative laparoscopy, which revealed a large necrotic area in the abdomen and a widespread hemorrhagic infarction. We subsequentially decided to perform a midline laparotomy. Omentum appeared widely necrotic, involving both the right and left sides, by a torsion that occurred at its superior point of attachment to the transverse colon (The patient was observed with conservative management. After 12 hours, we noticed an increase in abdominal rebound tenderness and guarding. Laboratory tests showed a decreased leukocytosis (neutrophils 7.74 × 10se colon . HemorrhOmental infarction, with or without torsion, is a rare cause of acute abdominal pain, which makes it a difficult and unusual diagnosis to make. When compared with appendicitis, torsion has an incidence of 0.0016% to 0.37%, which is a ratio of less than 4 cases per 1000 cases of appendicitis , 9.Omental torsion can present in 2 ways. In primary torsion, anatomic malformations such as a bifid or accessory omentum cause a spontaneous torsion; sudden movements, violent exercise, and hyperperistalsis have been implicated as precipitating factors. Obesity is also a well-documented risk linked to primary torsion, with one study documenting that almost 70% of patients with omental infarction were obese . It is pThe primary symptom associated with omental torsion is pain, which is frequently localized in the right lower quadrant of the abdomen. The onset of pain is usually sudden and does not radiate to the abdominal wall . In manyThe great majority of cases of omental torsion and infarction reported in the literature were segmental involving the right side of the omentum , 15. LefDifferential diagnosis should include appendicitis, cholecystitis, cecal diverticulitis, perforated duodenal ulcer, abdominal wall hematoma, and intestinal obstruction , 17. In Two treatments are predominant: early laparoscopic surgical intervention and conservative medical treatment. Conservative treatment for omental infarction varies among physicians and includes all or part of the following: oral analgesics, anti-inflammatory drugs, and prophylactic antibiotics , 27. ComOmental torsion is a very rare condition, which can create problems in differential diagnosis of the acute abdomen especially with acute appendicitis. No one can rule out the fact that the previous episode of acute appendicitis accused by the patient three months earlier was actually a first symptom of a partial omental torsion and then resolved spontaneously; moreover, at the time of the intervention, the appendix was retrieved healthy. Approaching this kind of patients on the basis of the past history and physical examination only applying an Alvarado Score –21 can bCT and ultrasound scans are very useful in order to diagnose a suspect omental torsion, and the right approach to the disease, in our opinion, is surely surgical. Laparoscopy has been decided to explore the entire abdomen cavity. A single classic iliac laparotomic access usually used for appendectomy in our case probably would give rise to a potentially fatal outcome, based on a dramatic diagnostic error.


There was no fever,abdominal pain, or bowel complaints. He denied smoking or drinking abuse. There was notany kind of disease in patient's past or family medical history. He had been treatedwith spironolactone years before, with no previous investigation, and it was suspendedby the occurrence of gynecomastia. On admission, he was clinically in good condition,and presenting an important abdominal distention without tenderness, and bowel soundspreserved. The rest of the examination was unremarkable. Admission laboratory testsshowed no abnormalities. An abdominal computerized tomography revealed a mass occupyingall regions in the abdominal cavity, showing no apparent origin. The patient underwentexploratory laparotomy that showed a mass weighing approximately 30 kilograms , whose o,,Histologically, teratomas are classified as mature or immature, and the mature type,which was described in this case, has the most common occurrence,Migratory property of the germ cells may explain the ocurrence of teratomas inextragonadal sites. The retroperitoneal account for approximately 5% of teratomas andare responsible for less than 10% of the retroperitoneal neoplasms. In theretroperitoneal space, teratomas have a predilection for the upper pole of the kidneyand are frequently located on the left side,,This type of tumor can affect both children and adults, exhibiting different behaviorbetween the two groups. With higher incidence in the retroperitoneal region in children,less than 20% of patients develop these tumors by the age of thirty, though the patientin this case was in the fourth decade of life at diagnosis. Considering gender,teratomas at a retroperitoneal location affect approximately twice as many women thanmen,,,,,Most of the patients are asymptomatic and when the tumor compresses adjacent structures,due to its growth, it can bring pain, bloating, nausea and vomiting. Malignant teratomastend to progress more quickly and occur more frequently in adults than in children, withincidences of 26% and 10%, respectivelyPinson et al


Certain nasal neoplasms, such as ectopic menigioma, present as nasal polyps, together with similar symptoms. The present study reports the diagnosis and treatment of ectopic meningioma in the bilateral nasal olfactory cleft in order to improve the diagnosis and treatment of ectopic meningioma in the nasal cavity. By retrospectively analyzing the clinical data and reviewing the associated literature, a detailed introduction to the clinical manifestation, diagnosis and treatment of ectopic meningioma of the nasal cavity was ascertained. The tumor was removed from the sinus by functional endoscopy surgery. Regular follow-up appointments were scheduled every three months, with no evidence of recurrence to date. The olfactory recovery and nasal ventilation were normal subsequent to surgery. Meningiomas are infrequently occurring tumors with unpredictable clinical behavior. A clear understanding of the etiology and appropriate diagnostic and management principles may aid in overcoming the challenges of treating primary extracranial meningiomas. Primary and secondary ectopic meningiomas are rare lesions . In addiMeningiomas account for 10–15% of all intracranial tumors , but priExtracranial meningiomas of the sinonasal tract are rare tumors that are frequently misdiagnosed, resulting in inappropriate clinical management. Primary extracranial meningiomas are likely to arise from the transformation of embryonic arachnoid cell remnants of ectopic meningocytes, which are derived from pluripotent mesenchymal cells. The diagnosis of extracranial primary meningiomas requires confirmation by computed tomography (CT) to exclude the presence of an intracranial mass or any underlying bony erosion of the skull base . TreatmeA 60-year-old female presented to the Otolaryngology Department of the Shanghai Pudong New Area Gongli Hospital  with hyposmia that had been present for a six-month period, without rhinorrhea or epistaxis. Clinical examination did not identify a nasal obstruction, and the patient did not possess a history of headaches or visual problems. Endoscopy identified the presence of a neoplasm in the bilateral olfactory cleft, with the nasal polyp morphology necessitating a radiological examination.A magnetic resonance imaging (MRI) examination in the Radiology Department of Shanghai Pudong New Area Gongli Hospital revealed sphenoid sinusitis on the left side of the olfactory cleft and a high-density shadow in the bilateral olfactory cleft five months prior to presenting at the Otolaryngology Department, where a CT scan of the paranasal sinus was conducted. Radiological examination of the nasal cavity prior to surgery identified the presence of soft tissue shadows in the bilateral olfactory cleft area and sinusitis in the left side of the sphenoid. MRI and CT scans of the orbit and nasal cavity revealed that the soft tissue mass was situated exclusively in the bilateral olfactory cleft region and did not invade other sinuses or the orbit .The histopathological appearance of the lesion was meningothelial, a common tumor type in which the cells present in a lobulated arrangement and are spaced along collagen fibers. The tumor cells also varied in size. They demonstrated a high nucleocytoplasmic ratio and a marginal oval nucleus, with nucleoli discernable in each cell. Fibroblasts were arranged in a matrix rich in collagen and crosslinking reticular fibers. Spiral structures were visible and did not contain psammoma bodies. Mitosis was inconspicuous, and no necrosis was observed  and 3.Immunohistochemical examination identified the presence of the epithelial membrane antigen expression. However, the immunoreactivity was focal and generally weak, identifying only a small number of positive cells in the sample examined. Other epithelial markers were also identified, including the S-100 protein in the nucleus and the cytoplasm. Isolated tumor cells were stained for the expression of Ki-67 in the nucleus.The tumor was excised from the sinus by functional endoscopy surgery. The patient continues to experience disease-free survival seven months subsequent to surgery. Post-operative nasal endoscopic examination revealed no residual mass. Follow-up visits were scheduled every three months, with no evidence of recurrence to date. The patient’s olfactory recovery and nasal ventilation were normal subsequent to surgery.The present patient presented with a benign primary ectopic meningioma. Meningiomas of the nasal cavity, particularly in the olfactory cleft, are rare. Primary ectopic meningiomas are challenging to diagnose, partly due to the infrequency of their presentation and often being confused with nasal polyps. However, primary ectopic meningiomas tend to be aggressive. Definitive diagnosis requires histological examination. Anosmia is among the first symptoms associated with ectopic meningioma, although patients also present with headaches or visual problems . EndoscoPrimary extracranial meningiomas of the head and neck are rare, with the majority presenting at secondary locations relative to the primary intracranial tumor. Primary extracranial meningiomas account for 1–2% of all meningiomas and are generally associated with a favorable prognosis. Subsequent to the diagnosis of a meningioma, it is necessary to exclude meningioma of the neuraxis or a primary central meningioma .The most frequent extracranial sites reported for primary meningioma are the nasal cavity, paranasal sinuses, cranial bones, middle ear, scalp and soft tissues of the face and neck, and the parotid gland . The larThe etiopathogenesis of extracranial meningiomas involves the migration of arachnoid cells derived from the neural crest. However, additional mechanisms have been proposed. For example, extracranial meningiomas may potentially originate from: i) Arachnoid cells of nerve sheaths emerging from the skull foramina; ii) pacchionian bodies that have been displaced or entrapped in an extracranial location during embryological development; iii) arachnoid islets that have been displaced due to trauma or cerebral hypertension; and iv) undifferentiated mesenchymal cells .et al ; atypical with frequent mitosis (Grade II); and anaplastic with invasion (Grade III). However, Zulch  suggesteet al . Acc. Accet aet al .Radical surgical resection has been associated with a good prognosis in patients with meningioma, but the benefit of adjunctive post-operative radiotherapy has not yet been established . RadiothNovel techniques available for meningioma management include proton irradiation and stereotactic radiosurgery using a gamma knife. Incomplete tumor removal, atypical or malignant tumors, nucleolar prominence, more than two visible mitotic events per 10 high-power fields and a heterogeneous contrast enhancement on CT are associated with increased rates of recurrence .Meningiomas are infrequently occurring tumors with unpredictable clinical behavior. A clear understanding of the etiology and the appropriate principles for the diagnosis and management of these lesions may aid in overcoming the difficulty of treating primary extracranial meningiomas. The present case revealed that CT and immunohistochemical examination are important for the diagnosis of ectopic meningioma of the nasal cavity and that tumor resection presents the optimum treatment for meningiomas.


Background: Cystadenoma is an extremely rare benign tumor of the seminal vesicle. Diagnosis of these tumors and differential diagnosis from malignant ones may be challenging since most of the time symptoms do not occur. Management of these tumors remains debatable due to the limited data in the literature. We present the first robot-assisted laparoscopic excision of a cystadenoma of the seminal vesicle.Case Presentation: A 48-year-old man presented with diminished ejaculate volume and a 3.5 cm right seminal vesicle mass, which increased its size at 6 cm after the 3-month period. Transrectal ultrasound-guided biopsy revealed no malignancy. Robot-assisted laparoscopic excision of the tumor was performed. Port placement was the same as robot-assisted radical prostatectomy. Operative time and estimated blood loss were 240 minutes and 200 mL, respectively. Patient was discharged on postoperative day 3 without any complications. Final histopathologic examination revealed cystadenoma of the seminal vesicle.Conclusion: Surgical intervention may be considered when a cystadenoma of the seminal vesicle is diagnosed and symptoms or tumor growth occurs. Robot-assisted laparoscopic excision is an alternative in the management of these rare tumors. Cystadenoma is an extremely rare benign tumor of the seminal vesicle with only 15 cases reported so far in the English literature. The management for these tumors remains debatable since the reports in the literature are limited; nevertheless, surgical intervention is usually needed when symptoms or increasing size occurs. Various approaches have been proposed for the treatment of these tumors until today. We present the first robot-assisted laparoscopic excision of a cystadenoma of the seminal vesicle.P1 In our case, the only complaint of the patient was decreased ejaculate volume.A 48-year-old man presented with diminished ejaculate volume lasting for several years. The patient underwent transrectal ultrasonography (TRUS), which identified a 3.5 cm solid mass with cystic and solid areas arising from the right seminal vesicle . These tThe patient underwent a digital rectal examination with no specific findings. MRI was then planned, which revealed a 3.5 cm complex cystic mass arising from the right seminal vesicle. To exclude malignancy, a TRUS biopsy of the tumor was planned, but due to the patient's refusal, close follow-up was scheduled.2 but they may require more radical procedures. Due to the above-mentioned reasons, a TRUS biopsy of the mass was arranged with a pathology report of the specimen revealing no malignancy but being inconclusive of the type of the tumor.After 3 months, a new MRI revealed a growth of the tumor from 3.5 cm to 6 cm. Although benign tumors of the seminal vesicles do occur more frequently, the mass has increased its size in a short follow-up period, and therefore, malignancy had to be excluded to plan the therapeutic strategy for the patient. Primary malignant tumors are extremely difficult to diagnose,Management of benign tumors of the seminal vesicle remains debatable due to the limited data in the literature. Nevertheless, the presence of symptoms, which often relates to the tumor size, seems to be the trigger point for surgical intervention in most cases reported. The robot-assisted laparoscopic approach was chosen for the surgical excision of the tumor with the use of a four-arm Da Vinci Si system. Preoperatively, a 4.8F Double-J catheter was placed into the right ureter for easier ureteral identification. Port configuration was similar to transperitoneal robot-assisted radical prostatectomy. The peritoneum was incised over the seminal vesicle, as in the Montsouris technique. Right vas deferens was identified, dissected, and divided. Weck clips were used to control the vessels avoiding thermal damage to the ureter. There were severe adhesions blocking the posterior side of the seminal vesicle. The right seminal vesicle was dissected out carefully with the athermal technique. Then, the anterior aspect of the seminal vesicle was exposed. Once the specimen was freed, it was taken out through a 12 mm assistant port within a 10 mm organ retrieval bag . A frozeThe postoperative period was uneventful, and the patient was discharged on postoperative day 3. The final pathology report revealed a benign cystadenoma of the right seminal vesicle .The patient was followed for a 1-year period. During this period, he had normal erections, effective sexual intercourse, and complained for no other symptom except ejaculate volume, which remained diminished in the follow-up period.3 There are limited and sparse data for the use of minimal invasive techniques in seminal vesicle cystadenoma excision. The only available data so far in the literature come from Zhu and colleagues, who performed a laparoscopic excision of an 8.8 cm left seminal vesicle cystadenoma.4 They reported 125 minutes surgery time and 120 mL estimated blood loss. The patient was free of symptoms for a 10-month follow-up period. To our knowledge, no robot-assisted laparoscopic excision of cystadenoma of the seminal vesicle has been reported so far. Robotic assistance eases resection with the advantage of articulated robotic arms and 7 degrees of freedom of robotic instruments. This aids in precise dissection and in avoiding any injury to adjacent organs. Both 0° and 30° lenses can be used during the procedure. In our case, a 30° lens was used in the upward position during the posterior dissection that improved view and offered optimal exposure of the tumor and the seminal vesicle. An intraoperative biopsy may be mandatory after tumor excision, especially if the preoperative biopsy was inconclusive, since a possible malignant pathology in the frozen section specimen can lead to a more radical procedure. In conclusion, cystadenoma of the seminal vesicle is a rare entity and a surgical intervention may be considered in the case of symptoms or tumor growth. Robot-assisted laparoscopic excision can be an alternative in the surgical management of these rare tumors.Due to the rarity of these tumors, no standard surgical approach can be concluded. Various open surgical techniques have been described in the literature, including transperineal, transvesical, paravesical, retrovesical, and transcoccygeal approaches.


We present a case of the rare combination of unilateral ovarian leiomyoma, uterine leiomyoma, and goblet cell carcinoid tumor of the appendix in a premenopausal woman who presented with right iliac pain. Immunohistochemistry study for desmin (muscle marker) and chromogranin and synaptophysin (neuroendocrine markers) confirmed immunophenotyping origin. Interestingly, both tumors showed positive reaction for estrogen receptor. To our knowledge, such a combination has not been reported previously in the literature. In this paper, the pathogenesis and differential diagnosis of both types of tumors are discussed. Ovarian leiomyoma is one of the rarest tumors of the ovary and accounts for 0.5 to 1% of all benign ovarian tumors , 3. MostBoth carcinoid tumor and ovarian leiomyoma are included in the differential diagnosis of right abdominal pain. In this paper, we are reporting a rare combination of ovarian leiomyoma, uterine leiomyoma, and goblet cell carcinoid of the appendix in a 52-year-old premenopausal woman; to our knowledge, this association has not been reported in the medical literature.A 52-year-old premenopausal female presented at the emergency department with acute right-lower abdominal pain for one-month duration that was aggravated in the four days before admission. Examination of the abdomen revealed right iliac fossa tenderness, associated with rebound and guarding. The clinical findings were consistent with acute appendicitis. One year earlier, she had a full colonoscopy that showed a single colonic polyp, diagnosed microscopically as tubular adenoma. Four years ago, she had antral gastric biopsy which revealed mild chronic antral gastritis.During her admission, an ultrasound of the abdomen and pelvis was performed and showed retrocecal appendix with early signs of inflammation  and a 9 × 4.6 cm uterus with a small hypoechoic fundal interstitial fibroid. A 2.5 × 2.9 cm right adnexal solid mass was also seen, with no follicles within and good vascularity. It showed intimate relation to both the right lateral uterine wall and the right ovary. A differential diagnosis of either a subserosal fibroid or a complicated ovarian cyst was suggested.However, she was urgently taken to the operating room for emergent laparoscopic appendectomy. On exploring the abdominal cavity, minimal fluid was found in the peritoneum. The right ovary was noted to have a 5 × 3 cm hard mass, separated from the uterus, not adherent to or infiltrating the surroundings . The lefGrossly, a 5 × 2.5 × 2 cm right ovary with attached 5 × 1 × 0.7 cm fallopian tube was received. The cut surface of the right ovary was solid and white with whorled appearance. Microscopically, it showed a normal ovarian tissue with spindle cell tumor. The tumor cells were arranged in interlacing bundles with eosinophilic cytoplasm and cigar-shaped nuclei; no significant mitosis or pleomorphism was seen Figures . The tumAdditionally, a 6.5 × 1.5 × 1 cm specimen of lusterless appendix was received for histopathological examination. Microscopically, the appendix showed a tumor in the distal portion, measuring 8 mm in maximum dimension . The tumLeiomyoma arising in the ovary is considered a rare type of benign tumor compared to other leiomyomas in the female genital tract. The size of ovarian leiomyoma is usually very small—millimeters or a few centimeters in diameter. In our case the tumor measured 5 cm in maximum dimension and was easily visible on ultrasound. Malignant potential is suspected if the tumor is huge, despite its benign microscopic picture . Most ofUsually the presentation of ovarian leiomyoma occurs in the premenopausal, childbearing years. This is also the common age for developing uterine leiomyoma. However, postmenopausal patients represent approximately 16% of cases , 7. TherOvarian leiomyomas are mainly asymptomatic and are discovered accidentally during imaging or operation for uterine leiomyoma or other pathologies . The patLeiomyoma of the ovary may not always present asymptomatically or with abdominal pain. A rare presentation was reported by Kurai et al.  who repoThe histogenesis of ovarian leiomyoma is not well known. Some theories hypothesize that the tumor may originate from hilar blood vessels, smooth muscle metaplasia of ovarian stroma, or smooth muscle-like theca externa cells . Its assThe presence of normal ovarian tissue beside the tumor confirms the ovarian origin of the tumor and excludes tumors of other origins, such as leiomyoma of broad ligament or a subserous leiomyoma that grew large and lost its attachments to the uterus (wandering leiomyoma) . Despiteα-smooth muscle actin and h-caldesmon. Sometimes it may be difficult to differentiate between ovarian leiomyoma and ovarian fibroma, but Lerwill et al. [Apart from leiomyoma there are other ovarian tumors that show a spindle cell microscopic appearance. Fibroma is the most common ovarian spindle cell neoplasm, but other neoplasms of the sex cord-stromal group may contain spindle cells and the differential diagnoses may include thecoma, granulosa cell tumor, Sertoli-Leydig cell tumor, sclerosing stromal tumor, and signet-ring stromal tumor . Howeverl et al.  concludel et al. .On the other hand, goblet cell carcinoid of the appendix was first described as a separate entity in 1974 . In geneTo our knowledge there is no case report describing an association between goblet cell carcinoid tumor of the appendix and leiomyoma of the ovary or leiomyomas in general. A single case of carcinoid tumor of the appendix was reported in a patient with endometrial cancer and uterine myoma .The association of a rare goblet cell carcinoid tumor of the appendix with ovarian leiomyoma has not been reported in the literature. Both tumors are of uncertain histogenesis, but the shared presence of estrogen receptors may indicate that both tumors are hormone dependent. Despite its rarity, ovarian leiomyoma should be considered in the differential diagnosis of acute abdomen and other spindle cell tumors of the ovary. Extensive sampling, along with appropriate immunohistochemistry studies, should be performed to confirm diagnosis.


Partial lung resection was performed by video-assisted thoracoscopic surgery. In the second patient, a nodular lesion was incidentally identified in the lower lobe of the left lung during a health check-up. Partial lung resection was again performed by video-assisted thoracoscopic surgery. The postoperative course in both cases was uneventful, and no recurrences have been observed as of 44 months and 41 months postoperatively, respectively. To the best of our knowledge, malignant transformation has been reported both with the squamous type and the mixed type of solitary papilloma of the lung. The glandular variant has shown no tendency toward local recurrence after local excision and has no apparent malignant potential. Local excision is thus recommended for solitary glandular papilloma in order to preserve pulmonary function.Solitary papilloma of the lung is thought to be a rare benign epithelial tumor, and complete surgical resection is currently the standard treatment for this pathology. However, some cases of papilloma have reportedly shown malignant potential. We report two cases of solitary glandular papilloma of the peripheral lung that were treated by thoracoscopic partial resection. The first patient presented with a nodular lesion in the lower lobe of the left lung that was detected on  Solitpilloma) . Of thespilloma) ,4-7. Thetwo packs of cigarettes daily for 40 years was noted to have an abnormal lesion in the left lung on chest computed tomography (CT) performed as follow-up after treatment for laryngeal cancer. He was therefore referred to our department. The previous laryngeal cancer had shown complete clinical response after chemoradiotherapy and the patient had no respiratory symptoms. Laboratory data were unremarkable, and serum tumor marker levels were all within normal limits. Chest CT revealed a solitary pulmonary nodule 0.8 × 0.8 cm in size in segment 9 of the left lung (Figure was comprised of a fibrovascular core and papillomatous fronds lined by pseudostratified columnar epithelium (Figure In January 2010, a 64-year-old man with a smoking history of was comprised of a fibrovascular core and papillomatous fronds lined by pseudostratified columnar epithelium (Figure In August 2010, a 73-year-old woman with no smoking history was noted to have an abnormal lesion in the left lung during a health check-up and was thus referred to our department. She had no relevant past history and no respiratory symptoms. Laboratory data were unremarkable, and serum levels of tumor markers were all within normal limits. Chest CT revealed a solitary pulmonary nodule with air and solid components 1.0 × 0.8 cm in size in segment 9 of the left lung (Figure two types, multiple and solitary. Multiple papillomas, representing papillomatosis, are usually related to infection with papillomavirus, most often occurring in children and young adults, and involving both the upper and lower respiratory tracts. Solitary papillomas are rarer and predominantly affect adults [et al. reviewed 14 cases of solitary pulmonary papillomas, describing 13 as central endobronchial papillomas and only 1 as a peripheral bronchiolar papilloma [a central endobronchial papilloma often causes a persistent, paroxysmal and/or productive cough. Screening for lung cancer using chest radiography has recently gained popularity among healthy people in Japan, so opportunities to discover asymptomatic peripheral papillomas may increase. Pulmonary papillomas are histologically divided into three categories: squamous cell, glandular and mixed types [Pulmonary papillomas can be classified according to the number of lesions, location or histology . With ret adults -11. Accoapilloma . The majed types ,12. Squaed types . PeripheIn both of our cases, the patient was successfully treated by local excision. To the best of our knowledge, malignant transformation has only been reported with the squamous variant . The glaWritten informed consent was obtained from the patient for the publication of this case presentation and accompanying images. A copy of the written consent is available for the review by the Editor-in-Chief of this journal.CT: Computed tomography; VATS: Video-assisted thoracoscopic surgery.The authors declare that they have no competing interests.the surgery. TH carried out the pathological examination. All authors approved the final manuscript.KK and HH wrote the manuscript. KK, HH and MH performed


Focal laryngeal candidiasis is not reported widely and is very infrequently recognized clinically. This disease is rare and may occur after pulmonary, pharyngeal and esophageal candidiasis or as part of disseminated disease. It is also secondary to inhaled steroid therapy which is usually mild and has been reported in 10-15 percent of patients taking these medications. In this study, we introduced a rare case of laryngeal candidiasis in a 79-year-old immunocompromised male presented with 17 months of progressive hoarseness. In video laryngoscopy a white, vegetative mass on anterior one-third of right vocal cord mimicking laryngeal carcinoma. The histopathological examination showed laryngeal mucosal with keratosis, degenerating necrotic epithelial cell aggregates containing hyphea and candida albicans. In immunocompromised patients, the diagnosis of laryngeal candidiasis should be considered in any patients with laryngeal symptoms Respiratory fungal infections should be considered in immunocompromised patients who have received either long-term steroid treatment, broad-spectrum anti-microbial therapy or have a non-resolving underlying chronic disease. In other words, respiratory fungal infections are relatively prevalent conditions -3. HowevFew cases were reported previously. We report a case of laryngeal candidiasis with an unusual mimicking laryngeal carcinoma to describe the clinical and histological features of this condition and highlight the role of early diagnosis and treatment.A 79-year – old man presented to the E.N.T clinic at Ayatollah Rouhani Hospital of Babol, Iran, with 17 months of progressive hoarseness. He was panegyrist whose voice was getting worse during the eulogy. We referred him to speech therapy clinic video laryngoscopy. During video laryngoscopy, a white, vegetative mass on anterior one-third of right vocal cord was shown. At first glance, it mimicked laryngeal carcinoma, so the decision for surgery was made by the surgeons. Under anesthesia, biopsy of the lesion was carried out to rule out malignancy. Histopathological examination revealed laryngeal mucosal with keratosis, degenerating necrotic epithelial cell aggregates containing hyphea and Candida albicans.The patient was treated with 200 mg of oral itraconazole once daily for 2 weeks. Video laryngoscopy after 2 weeks showed an improvement of the right vocal cord on the affected area. Laryngeal fungal infections must be considered in the different diagnosis of chronic laryngitis . A numbeThey can also develop in people with diabetes or in people who have long – term irritation resulting from dentures. Laryngeal candidiasis always expands from oral cavity or due to oral trash and it may result in the involvement of esophagus , 9, 15. The most common symptom of laryngeal candidiasis is hoarseness, and dysphagia however, stridor and respiratory distress are reported infrequently , 16. A n


Ewing's sarcoma/peripheral primitive neuroectodermal tumor is a small, round, and blue cell malignancy that occurs most often in bone and soft tissues of children and young adults. The intraspinal manifestation of the disease is rare, and when present, this is often misdiagnosed with other varieties of primary spinal tumors. Fine-needle aspiration cytology (FNAC) plays important role in the early diagnosis of these cases. We report such a case of Ewing's sarcoma of thoracic spine with extension into the intradural space, which was initially suspected to be a case of metastatic lesion in an 18-year-old boy. Ewing's sarcoma family of tumors are a group of small round-cell neoplasms, which include Ewing's sarcoma (EWS), primitive neuroectodermal tumor (PNET), Askins tumor, PNET of the bone, and extraosseous Ewing's sarcoma (ESS) . Ewing'sAn 18-year-old boy was admitted to Neurosurgery Ward of RNT Medical College, Udaipur Rajasthan, with chief complaints of progressively increasing dullaching pain in the lower back and both limbs and tenderness at D7, D8 vertebral region. There was a history of loss of appetite and malaise. The patient was thin built and on general examination there was a mild pallor. Systemic examination did not reveal any abnormalities except weakness (power 3/5) in both lower limbs and decrease in sensation of touch.Investigation revealed haemoglobin 9 gm.%, total leukocyte count 8200 cells/mm cu with 70% polymorphs and 26% lymphocytes. Erythrocyte sedimentation rate was 60 mm at the end of 1 hour. The urine examination and bone marrow examination did not reveal any abnormality. Tuberculin test was negative. Chest radiograph was normal. CT scan  of the sThe soft tissue component was seen involving the thecal sac, lamina, and spinous process of D7 and causing compression and displacement of spinal cord anteriorly. MRI of the spine  reveals James Ewing described the first case of ES in 1921 . Ewing'sES and pPNET both are the two ends of the spectrum which differ in morphology as well as neuronal differentiation. This family of tumors share common cytogenetic and molecular changes which involve the translocation of Ewing's sarcoma gene on chromosome 22 (22q12) onto chromosome 11 (11q24). The tumor also shares expression of glycoprotein surface antigen mic2/CD99 .Differential diagnosis includes round-cell tumors like metastatic neuroblastoma, rhabdomyosarcoma, and non-Hodgkin lymphoma (NHL). Skeletal Ewing's sarcoma is known to have a 5-year survival of 75%. The EES and pPNET on the other hand have 38% survival .FNAC is a very economic and quick procedure in the diagnosis of Ewing's sarcoma family of tumors. Accurate diagnosis can be made in deep seated tumor as in our case by adequate material under radiological guidance. FNAC is also useful in long term followup .


Primary ectopic meningiomas occurring in the mediastinal region are extremely rare. So far, only five cases of primary mediastinal meningioma have been reported in the literatures. The imaging characteristics and the clinicopathological significance of mediastinal psammomatous meningioma have not been detailed. Here, we report the case of a 42-year-old male with primary posterior mediastinal psammomatous meningioma. The clinical features, imaging, and pathological findings are carefully analyzed, and the relevant literatures were reviewed. Derived from the meningothelial cells capping the arachniod villi, meningioma is a common neoplasm of the central nervous system (CNS) . Most meA 42-year-old Chinese male was admitted for a 6-year history of dysphagia lusoria. His past medical history was unremarkable. At admission, general conditions were satisfactory, and a physical examination of the thorax was normal. Routine laboratory tests were within normal values, but a chest radiograph revealed a large mass with calcification in the mediastinum. Esophagus barium opacification showed that the middle and inferior segment of the esophagus was compressed by the mass Figure . A compuThe patient underwent surgical resection of the mediastinal tumor through the right thorax incision. During the operation, the tumor was located in the posterior mediastinum. It was found to have extended under the bronchial bifurcation. Based on this surgical finding, the mass was in close relationship with the esophagus and pericardium; the esophagus was obviously compressed and displaced. The tumor was a clearly demarcated encapsulated solid mass with brown-gray color and off-white cut surface. After being routinely fixed with 10% formaldehyde and embedded in paraffin, the tumor sample was processed, and 4-μm-thick tissue sections were obtained. The hematoxylin and eosin (H-E) staining (Figure Meningiomas are usually clinically indolent and morphologically heterogeneous tumors; they may exhibit a variety of different histologic patterns ,2. PrimaImaging features of ectopic meningioma are varied among different histopathogenical types. Fibrous meningioma, malignant meningioma, and angioblastic meningioma located in the mediastinum had been reported in the previous literature ,7. The cA definite diagnosis can only be made upon histopathological and immunohistochemical findings. In this case, H-E staining showed that the tumor is composed of elongated spindle cells and collagen fibers, the common features of meningioma -9. The fIn summary, primary meningioma of the posterior mediastinum is extremely rare; they need to be differentiated from other tumor masses. Radiological imaging is useful in preoperative diagnosis and surgical planning, but the ultimate diagnosis has to be confirmed by histopathological examination.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. This case report was performed in compliance with the Helsinki Declaration.


Taurodontism is a morphologic feature of generally multi-rooted teeth with large pulp chambers and shortened roots. A case of endodontic treatment in a 24-year-old male with the chief complaint of swelling and pain in the right mandibular region is described. Periapical lesion was present in the radiographic examination of hypertaurodont second mandibular molar.Four root canals were detected with an endodontic microscope. The canals were prepared and obturated with lateral condensation technique in the second appointment. The patient was asymptomatic in the 18-month follow-up. The term “taurodontism” was first introduced in 1908 and is defined as a morphologic change of generally multi-rooted teeth with large pulp chamber which its pulpal floor and furcation is apically displaced.A 24-year-old male patient with a non-contributory medical history was referred to Shiraz University of Medical Sciences Department of Endodontics. The chief complaint of the patient was swelling in the right mandibular region. Clinical examination revealeda deep amalgam restoration in the right mandibular second molar and a firm swelling in submandibular region. Performing vitality tests, complete necrosis was confirmed. Preoperative radiograph showed a priapical radiolucency of the mentioned tooth. The tooth revealed the characteristics of hypertarodontia in the radiograph. After aIndividual canal instrumentation was performed with ProTaper  rotary Ni-Ti files, S1to F2. Canals were irrigated with 2.5%sodium hypochlorite. Calcium hydroxide paste with normal saline was placed as an intracanal medicament with a lentulospiral and the access cavity was sealed with a temporary filling material  and AH-26sealer . Access cavity was sealed with the same temporary filling material and the patient was referred for final restoration . The pat5 Females had higher prevalence of taurodontism than men and mandibular second molar was the most affected tooth.5Clinically, a taurodont cannot be differentiated from a normal tooth because its body and roots lie below the alveolar margin.8The radiographic feature of taurodontism is extension of the pulp chamber into the elongated body of the tooth, shortened roots and root canals, and location of furcation near the root apices.6Prevalence of taurodontism has been reported to be 5.5% in the south of Iranwith67% of taurodonts being hypotaurodont, 31% mesotaurodont, and 2% hypertaurodonts.6 present case can be classified as hypertaurodont with four short root canals.As for difficulty of finding and preparingthe canals of this tooth,the use of magnification was crucial. Taurodontism complicates the endodontic procedure due to an abnormal root canal system that may disturb the location of the root orifices, thereby increasing the difficulty of instrumentation and obturation.9 The complexity of root canal system in taurodonts makes sufficient instrumentation nearly impossible; therefore, sodium hypochlorite can improve root canal cleaning because of its ability to dissolve the remaining pulp tissues.10According to the mentioned classification,Proper clinical and radiographic examination is a key factor forsuccessful endodontic treatment. Endodontic treatment of taurodonts is often challenging and needs more time than usual treatment. Careful evaluation for detecting additional canals is crucial due to potential of an abnormal root canal system.


Primary mediastinal goiters (PMG) are very uncommon; few cases were reported in the literature.We report here two cases of mediastinal goiters that met all criteria of PMG. Transternal approach was necessary for complete removal and pathological diagnoses confirmed their adenomatous goiter nature. The rarity of their occurrence, their clinical characteristics and surgical management were discussed.PMG is part of the differential diagnoses of mediastinal masses. Safe excision is ensured through transthoracic approach. Ectopic goiters are very rare, they can be found from the tongue to the diaphragm. Ectopic location is related to the embryologic descent of the thyroid gland.The majority of ectopic thyroid tissues (90%) are found in the base of the tongue. The rest (10%) may lie in the larynx, trachea, esophagus, mediastinum and heart.PMG is a diagnostic challenge, which is frequently made after excision, often through transthoracic approach. Our objective is to report our modalities in the management of this very rare mediastinal disease through two cases of PMG from a total of 152 intrathoracic goiters operated in our department during 10 years from January 2004 to December 2013.A 50 year old woman presented with a five month history of palpitations. No cough, dyspnea or dysphagia were noted. She was clinically euthyroid. Physical examination showed an obese patient without cervical abnormalities. A chest X-ray Figure  revealedThe tumor was completely resected through a total median sternotomy Figure . There wA 55 year old man was referred to our department for surgical management of a substernal goiter. He had a 7 year history of a slowly growing anterior neck mass, associated during the last year with a dry cough, shortness of breath, dyspnea, dysphonia, palpitations and sweating. He was followed by an endocrinologist for hyperthyroidism, for which he was placed on neomercazole for thyroid suppression. Physical examination showed an enlargement of the thyroid gland; it was bilateral, irregular and non adherent. The inferior pole of the goiters left lobe was not palpated because of its extension through the thoracic inlet. Chest X-ray showed that upper mediastinum was enlarged and the trachea right deviated. An ultrasound examination of the neck had revealed a multinodular goiter which the left lobe extends inside the thorax. CT scan of the chest Figure  demonstrPrimary mediastinal goiters are considered in Rives classification established in 1947 Rives . Only upIn our first case, the patient had a PMG. In the second case, the separation of the mediastinal goiter from the substernal part of the cervical thyroid and its blood supply exclusively from mediastinal vessels were clearly visible intraoperatively; the patient had an exceptional association between a primary and secondary MG, it’s the first case described in the literature.The primordial thyroid gland is first identifiable during the fourth week of gestation on the tongue; it begins its descent during the fifth week to reach its final position, anterior to the trachea, in the eighth week. Ectopic thyroid tissue may occur at any point along this pathway. In rare conditions, the totality or part of thyroid tissue may descend into the thorax drawn by the caudal migration of the heart. Few cases of ectopic thyroid were reported to lie in the mediastinum, the trachea, the esophagus, the thymus and the heart (Spinner et al. Symptoms related to PMG are often those indicating a compression of adjacent structures, such as dysphagia, dyspnea, hoarseness or superior vena cava syndrome. Thyrotoxicosis was rarely described. The majority of patients with PMG are asymptomatic; their tumors were reported as incidental findings on chest roentgenogram or chest CT scan (Shah et al. Plain chest roentgenogram shows the shadow of mediastinal mass in 70%, presence of calcifications is highly suggestive. The sensivity of ultrasound in the evaluation of PMG is poor. However, in substernal position CT scan and MRI are very effective. Chest CT scan provides information pointing toward the thyroid nature of the mediastinal mass (Senac & Giron Although rare, ectopic thyroid tissue might be malignant. Therefore iodine containing contrast medium might delay further possibility of radioiodine treatment, I123 scan or MRI might be a reasonable alternative to CT scan. This should be taken into consideration, when thoracic mass is detected by X-ray.Thyroid scintigraphy is not accurately used in the diagnosis of mediastinal masses. When performed, it’s effective for differential diagnosis of other mediastinal tumors including lymphadenopathy, thymoma, teratoma, bronchogenic cysts and primary tracheal or esophageal tumors.In our two patients CT was sufficient to suggest the diagnosis of MG. MRI was performed in the first case to better plan the surgical technique.Surgical resection is the gold standard in the treatment of PMG. Its role is both diagnostic and therapeutic; it allows ensuring the diagnostic by providing tissue for histological study, it also allows to rule out malignancy and to remove compression of adjacent structures, such as trachea and heart to prevent the risk of tracheomalacia and heart rhythm disorders. The risk of postoperative tracheomalacia and consequent tracheostomy is slightly increased but occurs very rarely, it’s especially seen in long standing and large goiters with tracheal compression. In our second patient, the trachea was compressed severely, but after the removal of the two masses, it regained its normal aspect and position without chondromalacia.Resection is often achieved through median sternotomy or thoracotomy to ensure all vessels supplying the mass are adequately ligated. Thoracotomy is potentially required when the mediastinal mass is lateralized to the left or the right side. In the first case, the goiter was lateralized to the left, but we preferred sternotomy because the mass had an intimate contact with the heart and great vessels. The combination of cervical incision and sternotomy is useful in excision of mediastinal masses associated with cervical goiter (Tang et al. Thoracoscopy has been described as a new technique in resection of mediastinal masses (Grondin et al. In conclusion, we reported two cases of PMG that highlight the need to keep in mind that ectopic goiter, although rare, is part of the differential diagnoses of mediastinal masses. Transthoracic approach is mandatory for safe excision. The precise histological diagnosis of PMG is often obtained after surgical excision of the tumor.


Introduction. Femoral hernias are at high risk of strangulation due to the narrow femoral canal and femoral ring. This can lead to symptoms of obstruction or strangulation requiring emergency surgery and possible bowel resection. To our knowledge, there is only one previous published report of bilateral strangulated femoral hernia. We present our case of this phenomenon. Case Report. An 86-year-old woman presented with symptoms of small bowel obstruction. Examination revealed two tender lumps in the area of the femoral triangle. CT scan revealed bilateral femoral hernias. Both hernias were repaired and a small bowel resection on the right side was performed with side to side anastomosis. She made an uneventful recovery. Conclusion. Bilateral femoral hernias are a rare occurrence with only one reported case of bilateral strangulation. Our case highlights the importance of meticulous history taking and clinical examination as any delay in diagnosis will increase the risk of mortality and morbidity for the patient. Hernias should always be considered as a cause if one presents with symptoms of abdominal pain or obstruction. A femoral hernia is a protrusion of a viscous through the femoral canal due to a defect in the femoral ring. It is the third commonest hernia with 20% occurring in females compared to 5% in men. This hernia is more prevalent in parous elderly women and found on the right side. Femoral hernias descend through the femoral ring then femoral canal and exit via the saphenous opening. The femoral ring is bounded anteriorly by the inguinal ligament, posteriorly by the iliopectineal ligament, medially by the lacunar ligament, and laterally by the femoral vein. They are the most likely to become strangulated due to the narrow femoral canal and rigid femoral ring. Strangulation may lead to bowel resection which has been shown to have increased mortality and morbidity . The aetClinical features of a femoral hernia may be the sensation of a lump in the groin but may cause a dragging sensation. Symptoms of colicky pain may persist due to incarceration and develop with vomiting due to obstruction or strangulation of small bowel. On examination the hernia can be identified below and lateral to the pubic tubercle; it may be generally irreducible and may be tender , 4. A feAn eighty-six-year-old woman from a nursing home presented to the Accident and Emergency Department with absolute constipation for three days, constant abdominal pain, distension, and vomiting. It was also noted that the patient had lost twenty-five kilograms in weight in approximately three to four months and reduced appetite. Her past medical history included a sliding hiatus hernia, diverticular disease, dementia and multiple deep vein thrombosis, and pulmonary embolism for which she was on warfarin.On examination the patient appeared comfortable at rest. She had abdominal distension and tenderness particularly in the lower half of the abdomen with no evidence of peritonism, no palpable masses, and no organomegaly. Examination of the groin revealed two well circumscribed lumps in the region of the femoral triangle. They were tender to palpation. There was no change in the colour or temperature of the overlying skin. There were no audible bowel sounds or bruit over the lumps.9/L, white cell count 23 109/L, creatinine 65 μmol/L, complement reactive protein 45 mg/L, lactate 3.2, INR 2.7, sodium 127 mmol/L, potassium 4.4 mmol/L, urea 7.7 mmol/L, serum glucose 4.5 mmol/L, amylase 29 μ/L, bilirubin 4 μmol/L, albumin 18 g/L, alkaline phosphatase 320 μ/L, alanine transaminase 19 μ/L, adjusted calcium 2.38 mmol/L, haemoglobin 109 g/L, and platelets 285 109/L.Blood tests showed neutrophils 21 10In view of this patient's significant weight loss a CT abdomen and pelvis was organised to exclude the possibility of malignancy contributing to the clinical picture of bowel obstruction Figures , and 3. McEvedy's approach was preferred bilaterally in order to gain access to the peritoneal cavity if necessary. There was a small knuckle of ischaemic gangrenous bowel strangulated at the right femoral hernia. Left femoral hernia contained a small loop of strangulated small bowel which was still viable. The ischaemic bowel was resected and a side to side anastomosis was performed using a linear stapler device. Prolene interrupted sutures were used to close the hernia defects. The patient was admitted to intensive care postoperatively and discharged to the ward after 2 days. She made a full recovery and was discharged home within one week.Bilateral femoral hernias are very rare occurrence. We have found just over a dozen reported cases of bilateral femoral hernia in the literature with only one reported case of bilateral strangulated hernia , 7.The operation was performed through bilateral McEvedy's approach using a small oblique incision 3 cm above the pubic tubercle extending to the lateral border of the rectus muscle. This was used due to the emergency nature of the operation so that the abdominal cavity could be accessed, which proved useful for resecting part of the small bowel from the right sided femoral hernia. The defect was repaired with interrupted prolene sutures. Although the operation was delayed for about six hours in order to correct the INR, we feel that this was probably not responsible for the state of small bowel ischaemia encountered during the procedure as the patient presented late with symptoms and signs of bowel obstruction for three days.In our experience, high McEvedy's approach is generally preferred in the emergency setting as this provides good access to the peritoneal cavity allowing easier evaluation of the small and large bowel and facilitates adequate resection if necessary . Repair Laparoscopic approaches have been shown to have lower recurrence rate and postoperative pain compared to open techniques. However laparoscopy requires more time, specialised skill and is more expensive .In conclusion, this case report of a rare phenomenon of bilateral strangulated femoral hernias reinforces the importance of femoral hernias due to their high risk of strangulation. One should be vigilant in patients presenting with gastrointestinal symptoms, especially in case of suggestive of small or large bowel obstruction. Elderly frail patients especially with obstructed femoral hernias may present with atypical symptoms of abdominal pain, nausea, and vomiting. Therefore, meticulous clinical examination including thorough examination of both inguinal areas, complemented by appropriate haematological and radiological investigations, is essential in the diagnosis of these hernias. Any delay or failure to reach this diagnosis would result in a significantly increased risk of morbidity and mortality for the patient.


Metallic phosphides are extremely toxic pesticides that are regulated in their usage. Information concerning the impact of metallic phosphides on human health is abundant. Data regarding the clinical pathology of phosphide poisoning in humans or domestic and wild animals is largely incomplete with only a few cases of metallic phosphide poisoning being reported every year, especially in humans. For the majority of cases reported in dogs the data are vague or incomplete. Here we report a complete and detailed description of pathological changes in a case of intentional metallic phosphide poisoning in a dog including an exhaustive examination of the brain.A 1 year old, male, Belgian Shepherd crossbreed dog with a clean medical history and no observed clinical signs prior to death, was submitted for post mortem examination. The dog was found dead by the owner. Near the body a suspect mix of bread, fat and a blackish powder was found. The owner announced the authorities and submitted the animal and the possible bait for forensic examination. At necropsy, multisystemic necrotic and degenerative lesions were observed. Histological exam confirmed the presence of necrotic and degenerative lesions of variable severity in all of the examined organs. The toxicological forensic examination revealed the presence of the phosphine gas in the gastric content and the bait.Metallic phosphide poisoning is a rarely reported entity, since the diagnosis of intentional poisoning with these compounds is a great challenge for forensic pathologists and toxicologists. To our knowledge, this is the first study describing the lesions completely in veterinary forensic toxicology. We assume that the toxic shows systemic endotheliotropism and damage of the endothelial cells responsible for the hemorrhagic lesions and for the secondary ischemic necrosis in various organs. This report will contribute to a better understanding of the pathogenesis in cases of acute metallic phosphide exposure in animals. Metallic phosphides are effective rodenticides and insecticides widely used for over 100 years for the control of pests and to protect grain . Due to Because of their extensive use as high efficient grain fumigant and rodenticide, low price and permissive legislation over the past two decades, a dramatic increase of human casualties following accidental or suicidal ingestion of phosphide pesticides was observed in developing countries as India and Iran –7. Even Here we describe the detailed post mortem, histopathological and toxicological findings from a dog that died following metallic phosphide poisoning.. The owner went to work in the morning, left the dog in the yard, and found him dead approximately 7 h later. Near the body there was a suspect mix of bread, fat and a blackish powder  stain. From the brain 5 coronal sections were made, starting from the frontal lobe to the cerebellum as previously recommended . Thus, sGross postmortem examination revealed multisystemic necrotic, haemorrhagic and degenerative lesions. In the proximal digestive tract  a partially digested, haemorrhagic material was observed as a result of hematemesis. The stomach mucosa was severely congested, presenting in the fundic and pyloric regions multiple, acute erosions and approximately 200 ml of digested blood Fig. . The livDuring the post mortem examination, samples of gastric content and urine were collected and submitted along with the presumptive bait for toxicological examination to the national reference laboratory of the National Sanitary Veterinary and Food Safety Agency of Romania in Cluj-Napoca. The silver nitrate test was used for the identification of the phosphine gas from the mix of bread, fat and a blackish powder as well as from the gastric content .The predominant histopathologic finding in the stomach was severe congestion in the lamina propria and submucosa Fig.  and supeThe toxicological examination confirmed the presence of the phosphine gas in the gastric content and in the bait. The urine was tested negative for the presence of phosphines.3-known as phosphorus trihydride or hydrogen phosphide) liberated in contact with water and hydrochloric acid from the stomach [The current report describes pathological and toxicological findings in an intentional poisoning with metallic phosphides in a dog. Poisoning with metallic phosphides in dogs can be accidental by direct ingestion of bait for different pests or by eating tissues of metallic phosphide-poisoned animals or it can be intentional. The forensic necropsy report has to be complete and clear and needs to contain all the information that may be relevant to a court case. The toxicity of these compounds is mainly due to the phosphine gases  signs, respiratory signs and cardiovascular signs . These s3 inhibits cytochrome c oxidase which leads to mitochondrial dysfunction, a decrease of ATP (Adenosine triphosphate) production followed by metabolic shutdown and multiorgan dysfunction [The exact mechanism of action of the metallic phosphides is yet not known, but it was showed that PHfunction . Metallifunction . As a refunction , 5. In oMetallic phosphide poisoning is reported sporadically in veterinary medicine. We describe here the gross and histopathological lesions associated with acute metallic phosphide exposure in a dog, showing that the toxic is mainly responsible for systemic acute necrotizing and hemorrhagic type of lesions, mainly targeting endothelial cells with secondary ischemic necrosis in the affected tissues.


Background. Gestational choriocarcinoma (GC) is a recognized clinicopathological subtype of gestational trophoblastic neoplasia that usually metastasizes hematogenously to highly vascular organs like the lung, liver, and brain. However, orbital metastasis to the choroid and lacrimal gland is a rare occurrence. Case Presentation. A 21-year-old female presented with headache and left orbital swelling one year after resection of a complete hydatidiform mole followed by adjuvant methotrexate chemotherapy. A metastatic imaging screening revealed multiple metastases in the lungs, brain, and adrenal gland, in addition to the choroid and lacrimal gland. Based on her modified WHO risk factors scoring she was started on chemotherapy and whole brain radiotherapy, which resulted in a complete response. At two-year follow-up, serum b-HCG level was with normal limits; imaging surveillance was uneventful. Conclusion. We present the first case of lacrimal gland metastasis in a young girl from GC relapse. Gestational Trophoblastic Disease (GTD) is a spectrum of diseases characterized by abnormal proliferation of trophoblasts . There aThe term Gestational Trophoblastic Neoplasia (GTN) is reserved for the last four in this subgroup as these have a propensity for progression, invasion, and metastasis any may potentially lead to death if untreated . GTN comGestational choriocarcinoma is a malignant disease with marked trophoblastic hyperplasia resulting in direct invasion into the myometrium and endometrium. About 50% of these occur following a hydatidiform mole, with an incidence of 25% each after abortion or tubal pregnancy .Metastasis develops in about 4% of patients following the surgical evacuation of a molar pregnancy; however, the incidence is higher in nonmolar pregnancies .Metastasis of GC to the orbit is a very rare presentation in the literature, which was recently reviewed . We presA 21-year-old female G1P0 had a termination of her first pregnancy by suction evacuation of a complete hydatidiform mole one year ago. During her preoperative and postsuction follow-up, she had persistently elevated serum level  of beta-human chorionic gonadotropin (b-HCG). She was labeled as GTN-stage I and received methotrexate (MTX) chemotherapy according to WHO score of low risk. Eventual normalization of serum b-HCG was achieved after eight cycles of chemotherapy; she was followed up every 4–6 weeks with pelvic ultrasound scan and serum b-HCG level.She presented with a 4-week history of headache and progressive left periorbital fullness with blurred vision. Her vitals and general physical and genital examination were within normal; there was no abdominal swelling or vaginal bleeding.An ophthalmological examination showed the fullness over the left upper lid and mild ptosis . The visRoutine laboratory blood investigations were within normal; however, b-HCG was grossly elevated . Metastatic work-up included computed tomographic (CT) studies of the brain, chest, abdomen, and pelvis, which showed multiple hemorrhagic brain lesions, multiple lung nodules, and a small suspected metastatic lesion in the left adrenal gland. There were endometrial infiltrating uterine mass and cystic right adnexal lesion identified as a locoregional recurrence. Magnetic resonance imaging (MRI) scan of the brain revealed multiple small hemorrhagic metastases demonstrated on susceptibility-weighted imaging (SWI) .Orbital MRI scan demonstrated a marginally exophytic lesion in the left eye at the level of choroid adjacent to the optic disc appearing hyperintense to gray matter on T1-weighted images . There wGiven the significant disease burden, history of GC, and uterine and systemic imaging findings, the patient was diagnosed as recurrent GC. Based on the modified WHO prognostic scoring system adopted by FIGO for GTN , the patThe patient was started on EMA-CO chemotherapy regimen . Additionally, the patient was also started on high-dose dexamethasone to reduce cerebral edema exerted by the brain metastasis and received whole brain radiation. She tolerated the treatment well with eventual normalization of her b-HCG, and metastatic imaging scans surveillance was negative for 2-year follow-up.Ocular metastases, also known as uveal metastasis, occur in about 9 to 10% of all systemic cancer –9. The mChoriocarcinoma has shown metastasis to the orbit, particularly retinal choroid predominantly reported from the male pathological counterparts, testicular choriocarcinoma , 15. A fUnlike metastatic ocular diseases of other primaries, choriocarcinoma has an affinity for hemorrhage and need an expedited MRI evaluation for diagnosis and management planning. One of the differential diagnoses, which were entertained, was malignant melanoma, which has similar characteristics in T1-MRI scan as a hyperintense lesion. However, they tend to show a characteristic collar button shape and are more exophytic than our study. Radiological appearances of T1-MRI scan of a hyperintense choroidal lesion in the absence of calcification, particularly in the scenarios of other metastasis, helped in the decision-making.Lacrimal gland metastasis from malignancy is a rarity in itself. Although a site-specific percentage of lacrimal gland metastatic infiltration could not be found, even among the cases with orbital metastasis, mention of lacrimal gland involvement has been few and far between. The common primary tumors metastasizing to the lacrimal glands include esophageal, breast, and renal malignancies . To the The International Federation of Gynecology and Obstetrics (FIGO) developed an adapted staging system for GTN, which incorporated the World Health Organization risk factor scoring system for GTN and the previous FIGO anatomical scoring . AccordiTraditionally, the treatment for metastatic GC is first and foremost chemotherapy. Patients with a low-risk disease (score <7) are treated with single-agent therapy, usually methotrexate. Patients classified as having high-risk (score >7) are treated with multiple chemotherapy agents with or without radiation or surgery . Recent This is the same applied to orbital GC metastases with EMA/CO chemotherapy regimen without  or with Visual impairment and orbital swelling due to orbital metastasis in a patient with GC are rare occurrence and require a high index of suspicion. We emphasize the need of brain and orbital MRI scan in addition to local and systemic radiological evaluation and serum level of b-HCG for assessing the disease burden in all patients with advanced GC for early diagnosis and management planning.