Tracheal diverticulum, defined as a benign outpouching of the tracheal wall, is rarely diagnosed in clinical practice. It can be congenital or acquired in origin, and most cases are asymptomatic, typically being diagnosed postmortem. We report a case of a 69-year-old woman who was hospitalized after presenting with fever, fatigue, pleuritic chest pain, and a right neck mass complicated by dysphagia. Her medical history was significant: pulmonary emphysema ; bronchiectasis; and thyroidectomy. On physical examination, she presented diminished breath sounds and muffled heart sounds, with a systolic murmur. Laboratory tests revealed elevated inflammatory markers, a CT scan showed an air-filled, multilocular mass in the right tracheal wall, and magnetic resonance imaging confirmed the CT findings. Fiberoptic bronchoscopy failed to reveal any abnormalities. Nevertheless, the patient was diagnosed with tracheal diverticulum. The treatment approach was conservative, consisting mainly of antibiotics. After showing clinical improvement, the patient was discharged. Concerning etiology, tracheal diverticula can represent congenital anomalies of the tracheobronchial tree or acquired outpouchings from a weakened tracheal wall, the two conditions differing mainly in relation to the site of implantation and the histological features of the wall. Congenital tracheal diverticula are usually smaller and feature a narrower communication with the trachea than do those that are acquired.  The former are frequently right-sided, occurring 4-5 cm below the vocal cords or a few centimeters above the carina, and are histologically similar to the tracheal wall, comprising respiratory epithelia, smooth muscle, and cartilage, whereas acquired tracheal diverticula are composed exclusively of respiratory epithelia. The lack of cartilage in the acquired form is thought to be due to its origin, because it is caused by increased intra-luminal pressure or by the weakening of the structures after surgical procedures, resulting in evagination of the mucous membrane through vulnerable points in the trachea. Therefore, acquired tracheal diverticula can appear at any level, although they typically occur along the right posterolateral wall near the thoracic inlet.A tracheal diverticulum is a benign outpouching of the tracheal wall that is rarely diagnosed in routine clinical practice, and there are few reports of cases in the literature. Tracheal diverticula can be single or multiple-9 and,,,,-10 th wall.,,11 Coina,,,-15 andures,, resulti,,,, Therefol wall,,17 neinlet.,,8 In most cases, the diagnosis is made on the basis of features observed on X-rays, on CT scans, during bronchoscopy, or in autopsies. Consequently, the reported incidence varies depending on the diagnostic tool used. For example, in a postmortem study, the incidence was estimated to be approximately 1%, compared with 0.3% in children diagnosed through bronchoscopy. However, in a study employing cervical CT, Buterbaugh & Erly estimated that paratracheal air cyst  occurs in approximately 3.7% of the population.Tracheal diverticula are usually asymptomatic, and their frequency can therefore be underestimated.,,18 Inscans,,,17 duhoscopy,,16 oropy.,, Howeverulation. Because the diverticula usually act as reservoirs for respiratory secretions, they are sometimes associated with chronic cough and can become infected. Although less common, dyspnea, dysphagia, dysphonia, recurrent nerve paralysis, cervical neck swelling, hematemesis, and hemoptysis have been described in patients with tracheal diverticula. Tracheal diverticulum can also be associated with abnormal pulmonary function and obstructive lung disease,(-) mainly emphysema, although no relationship between tracheal diverticulum and alpha-1-antitrypsin deficiency has been described to date.Although infrequent and nonspecific, symptoms can develop in individuals with tracheal diverticulum. Because-,,,,14 Alicula.,,12 Trdisease,-9 maiysema,, althougIn establishing a diagnosis of tracheal diverticulum, CT plays a fundamental role, providing information concerning the location, origin, and size of the lesion, thus helping distinguish between the congenital and acquired forms. Fiberoptic bronchoscopy, although useful, can yield false-negative results, because it often misses the communication point with the trachea.  Conservative management with antibiotics, mucolytics, and physiotherapy can be appropriate for asymptomatic, elderly, or debilitated patients. Here, we describe the case of a patient presenting with symptoms attributed to a tracheal diverticulum. Various approaches to the treatment of tracheal diverticulum have been described, including surgical resection, endoscopic cauterization, and conservative measures. Most tracheal diverticula are managed conservatively. Surgery is generally reserved for larger diverticula or truly symptomatic presentations with recurrent infections.,,13 Conts.,,,14 HeA 69-year-old woman presented to the emergency room with a one-week history of fever, fatigue, and pleuritic chest pain. After clinical examination, she was discharged on a one-week course of amoxicillin-clavulanate and azithromycin. Despite the antibiotic therapy, she showed no clinical improvement over the following days, and, rather than getting better, she noticed a painless right neck mass complicated by dysphagia. In addition, detailed history-taking revealed a two-month history of hoarseness with no other associated complaint. Consequently, she was admitted to the hospital.Her medical history was significant: pulmonary emphysema secondary to alpha-1 antitrypsin deficiency (PiZZ phenotype); bronchiectasis; recurrent pneumonia (at least two episodes per year); a thyroid neoplasm treated surgically (by thyroidectomy) in 2001; hypertension; and a herpes zoster infection. She reported no alcohol abuse or history of smoking. Her usual medications included levothyroxine, valsartan, hydrochlorothiazide, and bisoprolol. On physical examination, she was afebrile with apparently normal skin. Chest auscultation revealed muffled heart sounds with an apical systolic murmur and diminished breath sounds. The remainder of the examination was unremarkable.Laboratory tests revealed elevated inflammatory markers  and mild hyponatremia (132 mmol/L). A chest X-ray (at admission) showed a hypertransparent area in the upper mediastinum , and a CAfter a 14-day course of meropenem and vancomycin, the patient showed clinical improvement. Her inflammatory markers returned to normal values, and she was discharged from the hospital.  Tracheal diverticula are usually reported after the development of complications or in postmortem examinations.  The largest case series, reported by Goo et al., consisted of 64 confirmed cases.The scarcity of reports on tracheal diverticulum is due partly to its rarity and partly to the nonspecific nature of its symptoms, which tends to hinder the diagnosis.-,,,,14 Tr et al., consistHere, we have reported a case of a tracheal diverticulum associated with respiratory tract infection, a right cervical mass, dysphagia and a two-month history of hoarseness. The patient had a history of recurrent respiratory infections and chronic pulmonary disease, specifically emphysema, which is known to be associated with tracheal diverticulum. However, to our knowledge, this is the first report of alpha-1 antitrypsin deficiency in a patient with tracheal diverticulum. It seems obvious that this was a case of acquired tracheal diverticulum, given the presence of emphysema and the history of thyroidectomy, which could have created weak points in the cervical anatomy, increasing the propensity to develop diverticula. In addition, although we did not perform a histological examination to confirm this hypothesis, the location of the tracheal diverticulum was that most often reported for the acquired form.,,8 In the case presented here, the patient received conservative treatment. Her history of recurrent infection (and consequent antibiotic courses) was probably responsible for the lack of response to the initial treatment and the subsequent requirement to switch to broad-spectrum antibiotics. Although the definitive diagnosis was infected tracheal diverticulum, the CT and MRI, while still showing the air cyst, indicated resolution of the infection, because they were both performed after at least 10 days of treatment with antibiotics. The fiberoptic bronchoscopy missed the point of communication with the trachea and was not very helpful in the diagnosis, as has been previously reported. The treatment approach to tracheal diverticulum varies according to the age of the patient, the clinical presentation, and the presence of comorbidities. Surgical resection is typically reserved for younger, highly symptomatic patients, whereas older patients, especially those with comorbidities, are treated conservatively. In the In conclusion, tracheal diverticula are mostly asymptomatic and frequently go undiagnosed. When symptomatic, the approach to treatment should be tailored to the patient. In many cases, as in the one reported here, conservative treatment is indicated, although a surgical approach can be considered in patients who do not respond to clinical treatment.


Primary liver liposarcoma is a rare disease. The knowledge of the clinical course, management, and prognosis of primary liver liposarcoma are all limited because of its rarity. Twelve cases of primary liposarcoma of the liver have been previously reported. We present the thirteenth case, which occurred in an adult male patient. A 42-year-old male patient came to our outpatient department with complaints of pain abdomen, mass per abdomen, and weight loss. Ultrasonography showed a mass arising from the the left lobe of liver. CT abdomen showed a heterogenous enhancing mass from left lobe of liver with multiple cystic and necrotic areas compressing the stomach and spleen with no evidence of metastasis. Differential diagnosis included adenoma and primary malignancy. Exploratory laparotomy and resection were done. HPE was found to be pleomorphic liposarcoma of liver. Virchow first described a malignant tumor of fatty tissue arising in the lower extremity in 1857 . LiposarFurthermore, most of the articles describing liver liposarcoma concentrate only on histopathological and imaging studies. The clinical course and prognosis of primary liver sarcoma are rarely mentioned. Hence we report a case of liposarcoma liver in detail.A 42-year-old male patient had history of pain abdomen which he attributed to a mass per abdomen noticed since 15 days. Pain was intermittent, dull aching variety with symptom-free intervals. He also complained of weight loss. On examination, a mass of size approximately 15 × 10 cm was felt occupying the epigastrium and left hypochondrium. All the blood tests were normal. Chest X ray revealed elevation of left hemidiaphragm and Ultrasonography revealed a large heterogenous mass lesion of size around 18 × 15 cm arising from the liver occupying the epigastrium, left hypochondrium extending up to splenic hilum. Liver function tests were normal. CT abdomen showed a large lobulated, well-defined, heterogeneously enhancing mass lesion of size 18 × 14 × 13 cm from the left lobe of liver with multiple cystic, necrotic areas and compressing the stomach and spleen . Upper GDifferential diagnosis of a primary hepatic adenoma and carcinoma was made. There were no risk factors for malignancy. AFP levels were normal. FNAC was not attempted due to risk of tumor seeding and haemorrhage. Metastatic workup was done and no metastases was identified. CT Chest, pelvis was normal. During laparotomy, mass was arising from liver . The lefEn bloc resection of the tumor mass and extended left lateral hepatectomy with resection of the part of left hemi diaphragm and upper part of spleen was done. Diaphragmatic rent was closed with mesh and splenorrhaphy was done . An ICD was also put in the left pleural space. Specimen was sent for histopathological department for examination. Grossly, cut section of the tumor showed a soft fleshy, friable mass with extensive foci of haemorrhage and necrosis .Microscopy showed a tumor with sheets of large pleomorphic cells with vesicular hyperchromatic nuclei showing plenty of mitosis, occasional lipoblasts, and thick capsule with tumor infiltration suggestive of pleomorphic liposarcoma . DiaphraImmunohistochemistryTest result-NEGATIVE for S 100, CK, and EMA. Postoperative course was uneventful. The patient tolerated normal activity and enteral feeds. Chest tube was removed and discharged and he was referred to oncology department. Clinical stage: Stage III [T2b N0 M0 G3] as per AJCC staging. And hence the patient was put on adjuvant chemoradiotherapy and now is free of recurrence.Primary tumors arising from the liver are common. The differential diagnosis of primary hepatic mass should include Benign and Malignant tumors. epithelial origin, mesenchymal origin, mixed origin, others.Classifications on the basis of cell origin include Primary hepatic sarcomas are rare accounting for 1-2% of all primary malignant tumors of liver. Among these, angiosarcoma and hemangioendothelioma are most common . Liposar the stage of the differentiation of lipoblasts, based on relative amounts of lipid in the cells and myxoid material in the extracellular spaces, and  the overall degree of cellularity and cellular pleomorphism.There have been many attempts to classify liposarcomas depending on a combination of two basic histological aspects of the tumor:Primary hepatic liposarcoma is extremely rare although liposarcoma is one of the common soft tissue malignancies which occurs usually in the extremities and retroperitoneum . Early dAbdominal ultrasonography usually is a good tool to do preoperative screening and postoperative followup. Computed tomography is still the best tool to evaluate the resectability of liver liposarcoma before surgery. Contrast enhancement depends on the level of differentiation. Little enhancement is noted in well-differentiated liposarcomas, and more with round cell, pleomorphic, and dedifferentiated subtypes. Corresponding heterogeneity with regards to contrast enhancement is seen in Myxoid variety . Other fWorld Health Organization (WHO) Divides Primary Hepatic Liposarcomas into Four Subtypes Myxoid liposarcoma: it is the most common type in pediatric age group. It is Intermediate grade but its round-cell variant is high grade in nature and can metastasize.Well-differentiated liposarcoma: it is the most common subtype (50% of liposarcomas) and includes atypical lipoma. It is low grade . There is minimal risk of dedifferentiation.Dedifferentiated liposarcoma: it is most common with retroperitoneal lesions. High-grade sarcoma arising in association with well-differentiated liposarcoma.Pleomorphic liposarcoma: it is the rarest type (5–10% of liposarcomas). High grade in nature and may mimic MFH or even carcinoma or melanoma. There is very high chance of local recurrence and metastasis. A number of cytogenetic correlations also have been made with liposarcoma. Well-differentiated liposarcomas have been associated with abnormalities derived from the q13–15 region of chromosome 12. Such abnormalities also are found in dedifferentiated liposarcoma. Perhaps, genetic association is best characterized for myxoid liposarcoma. This represents a translocation between two chromosomes. In myxoid liposarcoma, the translocation is between chromosomes 12 and 16. The result is a gene called TLS-CHOP which is an oncogene. This particular translocation is highly specific for myxoid liposarcoma and therefore is diagnostic of this tumor .Surgical curative resection with clear margins remains the mainstay of treatment except in cases of advanced liposarcoma with metastasis where palliative treatment can be given. But inspite of complete R0 resection, there is a high chance of recurrence particularly in pleomorphic variety. The role of radiotherapy is not well defined. Chemotherapy for high-grade liposarcoma has been tried with low success rates. Patient prognosis depends on histological subtype, grading, and tumor necrosis. The 5-year survival rate of patients who have undergone curative resection or radiation therapy is approximately 50% . There is higher incidence in adult females with 7 cases as opposed to 3 in male adults and 3 involving children. There is no predilection for lobar involvement with 5 cases affecting each of the right and left lobes equally. It can present at any age ranging from 2-year baby to 86-year-old adult. Myxoid variety appears to be commonest as HPE studies have not been mentioned in all of the previous reported cases. Resection is the predominant mode of treatment as other modalities are still under evaluation. Myxoid liposarcoma carries poor prognosis.Ours is the 13th case involving the left lobe for which left lateral lobectomy was done with HPE showing pleomorphic liposarcoma. The patient is still on followup and is tumor free till now. Based on the previous reports, The following predictions can be drawn about primary pleomorphic liposarcoma of liver.Primary hepatic liposarcomas should be considered in differential diagnosis of liver tumors and computed tomography is helpful in evaluation of the tumor like any other visceral soft tissue sarcoma. Moreover, pleomorphic variety has a high metastatic potential compared to other histological variants. Neo adjuvant radiotherapy may be tried for high-grade tumors if diagnosed beforehand keeping in mind its occurrence. Although multimodality treatments combining chemoradiation have been put forward to achieve long-term survival, surgical resection still is the best means to achieve survival with other modalities serving a supplementary benefit.


Rhabdomyosarcoma (RMS) is a high-grade, malignant mesenchymal neoplasm. These tumors represent the most common soft tissue sarcomas of children and adolescents. RMS is uncommon on the lip and it is rarely seen in adults. Here, we report a rare case of primary RMS, embryonal type, occurring on the upper lip in a 27-year-old female. Rhabdomyosarcoma (RMS), a malignant soft tissue neoplasm of skeletal muscle, was first described by Weber in 1854. It is the most common soft tissue sarcoma of childhood, accounting for 10% to 20% of all malignant solid tumors [We report a rare case of primary RMS, embryonal type, occurring on the upper lip in a 27-year-old female.A 27-year-old female was referred for evaluation of reddish in color, erythematous, nodular lesion on the upper lip. Physical examination of the patient revealed a painful mass, firm in consistency, measuring about 0.7 × 0.5 cm. No lesions were present on the mucosal surface and the mass did not cross the midline of face. The mass simulated a vascular lesion and was clinically diagnosed as a hemangioma. There was no lymphadenopathy. The remainder of the systemic examination was normal.An excisional biopsy was performed under local anesthesia. Material was excised and examined histopathologically. Light microscopy examination of hematoxylin and eosin stained sections showed small round cell tumor morphology. Tumor cells appeared round to oval, with hyperchromatic nuclei, scanty pale cytoplasm, and inconspicuous nucleoli . The hisImmunohistochemical tests were performed with antibodies against vimentin, myogenin, myo-D1, desmin, muscle-specific actin, chromogranin, CD99, EMA, S 100, HMB 45, and Pan CK. In our case, among these markers, vimentin, myo-D1, muscle-specific actin, and myogenin revealed strong positive staining Figures , whereasRMS is a rare malignant lesion more common in children . The incRMS occurs most often in the head and neck region, genitourinary tract, retroperitoneum, and extremities . The orbThe head and neck RMSs are divided into two categories: parameningeal and nonparameningeal. The parameningeal type includes middle ear, paranasal sinus, nose, nasopharynx, mastoid, and pterygopalatine fossa RMSs, while the nonparameningeal type consists of scalp, orbit, oropharynx, oral cavity, larynx, and parotid gland RMSs . Oral RMThe prognosis and clinical behavior of the tumor also partially depend on the histologic subtype. Multiple classification systems have been proposed for subclassifying these tumors. The most recent classification system, the “International Classification of Rhabdomyosarcoma,” was created by the Intergroup Rhabdomyosarcoma Study . AccordiRMS can be mistaken clinically for hemangioma, neuroblastoma, hematoma, and other sarcomas . Our patEarly diagnosis is important. An early diagnosis of RMS and appropriate treatment can be highly effective. Treatment options include excision, chemotherapy, and radiotherapy. When the tumor can be totally removed, as in our patient, surgical excision is the most effective choice. If the tumor is huge and total excision is not possible, then a biopsy should be done for diagnosis. After diagnosis, chemotherapy is administered, thereby permitting localized control by a second surgery and/or radiotherapy .


A rare complication of chronic pancreatitis is the formation of single or multiple mediastinal pseudocysts, which are fueled from the pancreas through anatomical openings of the diaphragm. We present a rare case with a difficult diagnosis, treatment and potentially catastrophic complications.A 53-year-old Caucasian man was referred to our hospital for further investigation and treatment of a large heterogeneous mass situated in the posterior mediastinum, and bilateral pleural effusions which had developed after recent multiple episodes of pancreatitis. He had a history of chronic alcoholism. Laboratory and imaging modalities established the diagnosis of a pancreatic mediastinal pseudocyst.Despite successful initial conservative treatment, our patient had a relapse and underwent emergency surgical intervention due to internal hemorrhage. We present his diagnostic and imaging workup, along with the multidisciplinary intervention, and a literature review referring to the diagnosis and treatment of mediastinal pancreatic pseudocysts. One of the most common complications of chronic pancreatitis is the development of pseudocysts due to stenosis or disruption of the pancreatic duct. These can be numerous and their size varies from a few centimeters to 30cm in some cases. They are rich in enzymes and are held together by fibrous and granulomatous tissue, hence the term pseudocyst. In some cases they can invade adjacent organs, such as the liver ,2 and spWe herein present a patient with a history of alcohol abuse who was referred to our hospital for further investigation and treatment of a mass in the posterior mediastinum, and bilateral pleural effusions, which had developed after recent multiple episodes of pancreatitis.A 53-year-old Caucasian man with a past medical history of recurrent pancreatitis for the last 18 months, depression, alcohol and tobacco abuse, was referred to our hospital after a 10-day hospitalization in a pulmonary clinic, where he was admitted due to dyspnea and two episodes of hemoptysis. An extensive workup had already been performed, including bronchoscopy, gastroscopy, chest and upper abdomen computed tomography (CT) scans. A diagnostic paracentesis had already been carried out and fluid samples were sent for further analysis. His upper gastrointestinal endoscopy and bronchoscopy did not show any remarkable findings, and his pleural fluid was plenteous in protein and amylase. His cytology reports were negative for malignancy and his pleural fluid adenosine deaminase levels showed no evidence of mycobacterial infection Table . After ath postoperative day.Two months after his discharge he was readmitted with clinical signs of respiratory distress and bilateral pleural effusion was visible on his radiology chest imaging. The results from his serum blood and pleural fluid laboratory tests were similar to his first admission. As similar findings were identified on his chest and abdomen CT scan compared to the images from his last admission, a decision for surgical intervention was made. Upon completion of the preoperative diagnostic workup he was transferred to the general surgery ward. He was on a triple antibiotic regimen  and was scheduled for elective surgery. On the fourth hospitalization day he suffered from nausea, vomiting and abdominal pain. His physical exam showed that his abdomen was rigid, with noted pain on the upper abdomen and guarding. His laboratory tests showed a significant drop in his hemoglobin level and his vital signs revealed borderline tachycardia. After resuscitation with fluids and blood transfusions, a CT scan of his abdomen was performed where an extended hematoma at the lesser sac was identified with no active bleeding. Subsequently, he underwent an elective embolization of the splenic artery followed by an emergency laparotomy. Intraoperatively, a sizable hematoma was found at the lesser sac, pushing his stomach anteriorly. Due to chronic inflammation his pancreas was fibrous and hard. The splenic vein was thrombosed and splenomegaly with left-sided portal hypertension was present. A distal pancreatectomy with splenectomy was performed; his post-operative course was uneventful and he was discharged on the 11Tumors that are most commonly located in the posterior mediastinum are of esophageal and nervous origin. Hernias, aortic aneurysms and duplication cysts can also be found in this anatomic area. Some cases of extramedullary hematopoiesis  and pancComputed tomography and magnetic resonance imaging are the most commonly used imaging modalities to reveal the size, location and possible communications of the pseudocysts with the pancreas. Furthermore, magnetic resonance computed pancreatography in conjunction with esophageal retrograde cholangiopancreatography can unveil strictures and disruption of the pancreatic duct. A transesophageal fine needle aspiration can be performed when a differential diagnosis problem is raised, but the patient’s medical history and CT imaging study are usually adequate for the diagnosis to be established.The management of a mediastinal pancreatic pseudocyst is a difficult task. Relapses are common and procedural complications are many. At the moment there are no guidelines addressing this problem. A literature review revealed only a few scant reports of spontaneous resolution ,12, but Conservative treatment with strict diet, enzyme supplementation and complete abstinence from alcohol is indicated to all stable patients. In addition, bromhexine hydrochloride and somatostatin analogues have been used in a few cases -15. SomaIn certain cases, minimally invasive procedures can resolve the problem and help patients to avoid surgery. Patients with pancreatic duct disruption and stenosis can be treated with the placement of stents or with naso-pancreatic drainage, in order to restore the duct patency and seize the pseudocyst fuelling. For other patients with large abdominal pseudocysts that communicate with the mediastinum, CT-guided abdominal percutaneous drainage may be the optimal treatment -20. In oMediastinal pancreatic pseudocyst is a rare complication of alcohol related pancreatitis, with potentially catastrophic complications and a difficult treatment course. A multidisciplinary approach is mandatory for achieving an optimal outcome.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.


Repair of contaminated abdominal wall defect in a geriatric patient is a challenge for the surgeon. We present the case of the oldest patient (105-years old) to successfully undergo a single-stage repair of a contaminated abdominal wall defect with a Permacol™ implant.A 105-year-old Caucasian woman presented to our emergency room with a clinical and radiological diagnosis of small bowel obstruction due to prior operative adhesions. She underwent laparotomy with small bowel resection and primary closure of her abdomen. There was total eventration of her bowel through the suture line 9 days after surgery. She underwent a second laparotomy that revealed no signs of peritonitis or turbid fluid. Her abdomen was closed with a 15×10cm Permacol™ implant sutured sublay with prolene sutures. Her postoperative period was unremarkable. After a follow-up period of 3 years and 2 months, there was no sign of recurrent hernia or wound contamination.We suggest that Permacol™ mesh can be considered an efficient alternative to primary closure or synthetic mesh in geriatric patients with contaminated abdominal wall defects. The reconstruction of an abdominal wall defect or the repair of a large ventral hernia is a challenge for surgeons. In the repair of clean ventral hernia, the use of synthetic mesh can lead to a 50% reduction in hernia recurrence . HoweverPermacol™ contains non-reconstructed porcine dermal collagen that has been stabilized against degradation by collagenase while retaining its elastin content and flexibility . Recent A 105-year-old Caucasian woman was admitted to our department complaining of diffuse abdominal pain with recurrent vomiting for a day. Her past surgical history included the repair of an incarcerated umbilical hernia 3 weeks prior and an open cholecystectomy 13 years before. Her past medical history included ischemic heart disease, atrial fibrillation with a cardiac pacemaker and hypertension. Despite her age, she was clear-minded, and she managed to fulfill her daily activities in her own home with the help of a nursing assistant. On physical examination her abdomen was distended and tympanic with tenderness in the postoperative scar near her umbilicus. A computed tomography of her abdomen demonstrated small bowel obstruction. A midline laparotomy through the previous scar revealed numerous adhesions of the small bowel. During adhesiolysis, one small bowel loop was opened and a resection with primary anastomosis was created. Her abdominal fascia was closed with polydioxanone loop and her skin was closed with tension nylon sutures.There was a total eventration of her bowel through the suture line 9 days after surgery. She underwent a second laparotomy that revealed necrosis in the fascia edges. No signs of peritonitis or turbid fluid in peritoneal lavage were observed. Due to the fascial necrosis the field was believed to be contaminated. As a result, fascial edges were resected and instead of using a regular synthetic mesh, we decided to close her abdomen with a 15×10cm Permacol™ implant (Covidien) sutured sublay with prolene sutures. Her abdominal skin was closed with several single nylon sutures, leaving an interval of a few centimeters between one suture and the next, due to contamination. After the second surgery, the postoperative period was devoid of complications. As part of the conservative treatment approach, she was gradually returned to oral nutrition that was accompanied by normal bowel movements. Her abdominal skin was closed with close nylon sutures 7 days after the second surgery, and she reported feeling well, with no fever. Her abdomen was soft and non-tender without any signs of surgical site infection. Discharged later that day, she returned to her house as clear-minded and functional as she was prior to her admission to hospital.During a follow-up period of 3 years and 2 months, there was no sign of either recurrent hernia or wound contamination. The patient reported that she felt good, and she had no complaints of abdominal pain. She died, 3.5 years after surgery, at the age of 108 of cardiac arrest unrelated to the abdominal surgery. For clarification, since the report is retrospective and obviously we cannot call the patient for a follow-up examination, all the data for the follow-up was collected from medical records, as the patient was hospitalized several times due to other reasons, not related to the surgery, and underwent physical examination by a doctor.Permacol™ is a porcine-derived acellular dermal sheet composed predominantly of type I collagen 93 to 95%). During the manufacturing process the cellular components are removed and the collagen of the dermis is treated with hexamethylene diisocyanate (HMDI) to increase the degree of cross-linking 3 to 95%.,11. In ain vivo studies evaluating the different biologic meshes reported that Permacol™ is a safe prosthetic material for ventral hernia repair, supporting hernia healing by strengthening the damaged tissue [et al. [et al. [The use of Permacol™ in hernia repair was first proposed in 1984 . Subsequd tissue ,14. Cate [et al.  reported [et al.  reportedet al. [in vitro and in vivo study of collagen meshes  to the polytetrafluoroethylene mesh, Preclude®, in contaminated surgical fields. They reported that the collagen bioprostheses failed to show any bacterial adhesion or bacterial clearance benefits. In addition, Rosen et al. [™, AlloDerm®, Biodesign, XenMatrix™ and BioA) did not include Permacol™, and in our case the use of Permacol™ with a follow up of approximately 3 years revealed no signs of hernia recurrence, this finding still raises the question of the long-term efficacy of Permacol™. For clarification, recently studies report favorable outcomes with synthetic mesh in a contaminated ventral hernia [In spite of such promising results, the use of Permacol™ in contaminated surgical fields is still controversial. In fact, recent reports have cast doubt on those results. García-Pumarino et al.  reportedn et al.  reportedl hernia . HoweverWhile the general issue of abdominal wall repair in the presence of contamination is controversial, it becomes even more complicated for geriatric patients, who often have multiple comorbidities. This situation precludes the use of a two-stage surgical procedure with geriatric patients, in whom the potential increase in operative risk is unacceptable. Moreover, the high rates of pulmonary diseases in these patients rule out the use of a direct suture, which will increase intra-abdominal pressure, thereby influencing respiratory dynamics .Based on the literature reviewed here, we decided in our case of a 105-year-old patient with bowel eventration to repair her abdominal wall defect with Permacol™ mesh. Over the course of a follow-up period of 3 years and 2 months, we did not observe any sign of recurrent hernia or long-term infectious complications. In addition to the surgical technique of using a biological mesh, we must mention that it was a combination of better perioperative care and preoperative preparation  that were the basis of the successful treatment.The repair of a contaminated abdominal wall defect in a geriatric patient is a challenge for the surgeon. Due to their high cost and the fear of postoperative complications, many surgeons decide not to use a biological mesh in a geriatric patient. We present the case of the oldest, to the best of our knowledge, patient (105-years old) to have successfully undergone a single-stage repair using a Permacol™ implant. We suggest that Permacol™ mesh can be considered an efficient alternative to primary closure or synthetic mesh in geriatric patients with contaminated abdominal wall defects.Written informed consent was obtained from the patient’s next-of-kin 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.


Long-term exposure of colonic mucosa to urinary content and its association with increased risk of infection, mechanical and biochemical irritation, and malignancy have been described in the literature. Existing case reports and studies depict the low but distinct risk of malignancy in gastrointestinal segments which come in contact with urinary content as a result of surgical correction of urinary tract abnormalities. However, these reports are largely limited to colonic adenocarcinoma and urothelial cell carcinoma. Late urointestinal carcinoma in patients with ileal incorporation into the urinary tract has also been reported. To the best of our knowledge, however, there is only one case report documenting neuroendocrine (NE) cell hyperplasia in colonic mucosa after long-term cystoplasty. Our case is the first to describe microcarcinoids and diffuse NE hyperplasia occurring in a patient with congenital anorectal anomalies, resulting in long-term exposure of colonic mucosa to fecal stream and urinary content. This case, in conjunction with the reported cases in the literature, raises the distinct possibility of an association between exposure of colonic mucosa to urine and long-term development of malignancy, including NE neoplasms. Gastrointestinal segments are commonly utilized for urinary tract reconstruction when the creation of a conduit or bladder replacement is indicated , 2. LongA 29-year-old male presented to our tertiary facility with imperforate anus and associated urinary incontinence. The patient had a history of multiple congenital abnormalities detected at birth, including atrial septal defect (ASD), persistent left-sided superior vena cava, cardiac conduction abnormalities, Wolff-Parkinson-White (WPW) syndrome, and vertebral anomalies. The gastrointestinal and genitourinary abnormalities were comprised of malformations including imperforate anus with the rectum terminating to the left and above the sphincteric complex, a connection between the rectum and bladder, and left vesicoureteral reflux.He underwent open cardiac surgery for repair of the ASD and ablation of the WPW foci. Also, shortly after birth, the patient underwent surgery during which a loop transverse colostomy was created and an anoplasty was attempted unsuccessfully. Subsequently at the age of 26, a posterior sagittal anorectoplasty could not be completed due to technical difficulties. For the past several years, the patient had stool from the proximal portion of his colostomy and urine from the distal nonfunctional limb with persistent exposure of both colostomy limbs to urine and fecal material.On physical examination, a left upper quadrant colostomy and imperforate anus were confirmed. MRI demonstrated the abnormalities stated above and suggested a mass near the colovesicular fistula . EndoscoThe specimen consisted of a segment of rectum containing the colovesicular fistula and a segment of sigmoid colon submitted separately, measuring 8.2 cm and 6.8 cm in length, respectively. Examination of initial representative sections revealed the incidental finding of neuroendocrine cell hyperplasia, after which the entire rectal specimen was submitted for microscopic evaluation. Histologic sections of the rectum and sigmoid demonstrated multiple microscopic foci of neuroendocrine cell hyperplasia with rare foci of microcarcinoids, the largest of which measured 5 mm in greatest dimension. These foci involved the mucosa and submucosa and were composed of small clusters of medium-sized cells with small round to oval nuclei containing fine chromatin with a salt and pepper appearance Figures . The mitReview of the literature demonstrates a risk of malignancy in gastrointestinal segments exposed to urine following surgical correction of urinary tract abnormalities –5, 7. LaWhile the physiopathologic mechanism is not well known, it has been postulated that contact among urine, feces, urothelium, and colonic epithelium at the anastomotic site of ureterosigmoidostomies activates fecal carcinogens , 13. AlsNeuroendocrine cell hyperplasia (NEH) is a well-established entity in the lung and in the upper gastrointestinal tract, particularly stomach  and pancWhile the association of NEH with certain entities such as inflammatory bowel disease and diversion colitis is well documented , 17, 18,Review of the literature demonstrates that few cases have been reported exhibiting the occurrence of different types of malignancy in association with long-term exposure of colonic mucosa with urinary content. Our case shows development of NEH and microcarcinoids in association with long-term exposure of colonic mucosa to urinary content. While uncommon, the reported cases establish the possibility of development of malignancy including NE neoplasms in the urointestinal tract postoperatively. Thus, one may recommend long-term follow-up of those patients who have undergone a surgical procedure exposing intestinal mucosa to urinary contents with or without fecal stream.


An incidental finding of a testicular mass in young male population is always a case of great concern for the patient and controversy for the physician. Differential diagnosis ranges from acute scrotum (notably testicular torsion), to acute inflammation and infection, all the way to testicular tumors. We present a case of an incidental finding of a painless testicular solid mass in a 19-year-old male patient, with an end pathological result of paradidymis  following orchiectomy. To the best of our knowledge, this is the first case of its kind to be reported in the literature. Finally at the level of the tail of the epididymis, we have the caudal vas aberrans of Haller (∗). Pathologies and cases involving these appendages are quite rare and almost always involve a presentation of an acute scrotal mass.A testicular appendage is a vestigial residual of the Wolffian (mesonephric) duct or the Mullerian (paramesonephric) duct. A Mullerian-inhibiting substance produced during fetal growth causes the degradation of the Mullerian duct, in a craniocaudal fashion . There aβ-HCG, and lactate dehydrogenase, LDH) were also negative. Ultrasound of the scrotum paradoxically revealed a swelling of the left epididymis and the testicle with hypervascularization signals on Doppler ultrasound suggestive of epididymitis.We describe a case of a healthy 19-year-old male patient, presenting to the urology clinic for an incidental finding of a painless left scrotal mass. Clinical history goes back to a couple of days before, where the patient first noticed a mass while taking a shower. The patient denies recent scrotal trauma, unprotected sexual intercourse, penile discharge, urinary symptoms, fever, or chills. Physical exam revealed a 3-4 cm scrotal mass, attached to the left testicle at the level of the epididymis. The mass was painless to palpation and mobile with the testicle. No inguinal hernia or inguinal lymph nodes were detected during the physical exam. Both testicles were of normal size and position. Cremasteric reflex was present bilaterally. No signs of inflammation, edema, erythema, or infection were observed. Blood and urine exams were within normal ranges, including hemoglobin, Hb, hematocrit, Hct, white blood cells, WBC, C-reactive protein, CRP, negative red blood cells, RBC, and white blood cells, WBC, in urine and negative urine culture. Tumor markers . Two weeks later, physical exam showed similar findings to the one done two weeks ago, and testicular ultrasound showed a 3 cm testicular swelling, with similar Doppler findings.18F-FDG PET-CT, showing a hypermetabolic lesion of the left testicle, with iliac and para-aortic lymphadenopathy.This atypical presentation of a painless scrotal mass in a young male adult, with negative tumor markers and ultrasound suggestive of epididymitis in the absence of any inflammatory signs or symptoms, with no signs of improvement with a course of antibiotics, as well as the risk of malignant lesion, put a remarkable amount of stress on the patient and the treating team, resulting in a decision to go for surgical testicular exploration via an inguinal incision due to the risk of testicular malignancy. Metastatic workup was composed of fluorine-18-fluorodeoxyglucose positron emission tomography During surgery, the left testicle was delivered via an inguinal incision. Dissection of the mass off the testicle was tried, but due to the adherent nature of the mass to the testicle itself, increasing the risk of malignancy, the final decision was made to undergo a total left radical orchiectomy. Patient was discharged the following day.Pathology report showed a normal testicle (6.5 × 4 × 3.7 cm), spermatic cord, and an epididymis containing an indurated whitish lesion, measuring 3.5 × 2 × 1.6 cm. No histological anomalies of the testicle were noted. A significant inflammatory remnant of the epididymis was reported, with microabscess in vestigial remnants , cannot give a clear contribution for the diagnosis of organ of Giraldes, leaving surgical exploration and eventually orchiectomy a must-do approach. Our case represents a rare entity in the literature, of a solid scrotal mass, with no other associated symptoms, ending up with surgical exploration and orchiectomy for the suspicion of testicular cancer, with an end result of organ of Giraldes. We believe that solid masses, even in the absence of supporting diagnostic measures, should be managed by surgical exploration and confirmation of absence of malignancy by pathology.In our opinion, the classic approach to scrotal masses in young male population, including physical exam, scrotal ultrasound, and tumor markers (AFP,


Intense FDG accumulation was also observed in the left internal iliac region. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy were performed under the diagnosis of LGESS with lymph node metastasis. However, postoperative histological examination proved that the tumor was ESN without lymph node metastasis. Since mitotic figure is no longer included in the diagnostic criteria of ESN or LGESS, ESN could exhibit high cellularity and high proliferative activity as observed in this case. Therefore, DW-MRI or FDG-PET is not useful in the differentiation of ESN from LGESS.Preoperative differentiation of benign endometrial stromal nodule (ESN) from malignant low-grade endometrial sarcoma (LGESS) is challenging, because it requires histological evaluation of the tumor-myometrium interface, which is difficult to obtain in conventional endometrial curettage. A 72-year-old postmenopausal woman presented with 5-year history of persistent vaginal bleeding. Histological examination of the endometrial curettage specimen revealed hyperplasia of apparently normal endometrial stromal cells. T2-weighted magnetic resonance imaging (T2W-MRI) showed polypoid tumor occupying the entire uterine cavity. The tumor exhibited high signal intensity in diffusion-weighted MRI (DW-MRI) and intense accumulation of  Endometrial stromal tumor (EST) of the uterus is a rare neoplasm, whose annual incidence is estimated to be 2 per million . AccordiESN is a benign tumor that is mainly composed of cells resembling normal proliferative-phase endometrial stromal cells . As long18F-fluorodeoxyglucose (FDG) in positron emission tomography (PET) [LGESS has been reported to exhibit high signal intensity in diffusion-weighted magnetic resonance imaging (DW-MRI) and intense accumulation of hy (PET) –6. SinceHere, we present a case of ESN that exhibited high signal intensity in DW-MRI and intense FDG accumulation in FDG-PET. The cells resembling normal endometrial stromal cells were densely distributed in the endometrial curettage specimens. These findings led to the misdiagnosis of LGESS and total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy were performed. Postoperative histological evaluation proved that the tumor was ESN without lymph node metastasis.A 72-year-old, para 2, gravida 3, postmenopausal woman (menopause at the age of 52) consulted our hospital due to abnormal vaginal bleeding persistent for 5 years. Her final Pap smear test at the age of 66 had been negative. On the vaginal inspection, large blood clots were retained in the vaginal cavity with small amount of bleeding still continuing from the cervical os. Bimanual pelvic examination showed retroflexed uterus that was enlarged to man's fist size. Transvaginal ultrasonography delineated heterogeneous endometrium thickened to 24.7 mm. The boundary between the endometrium and the myometrium appeared smooth. Both Pap smear test and endometrial cytology proved to be negative. Laboratory data revealed moderate anemia (hemoglobin: 8.2 g/dL). The examined tumor markers were all within the normal ranges . Microscopically, uniform small cells with scanty cytoplasm and oval nuclei that resembled normal endometrial stromal cells were densely distributed in the endometrial curettage specimens. Since the tumor-myometrium interface was not contained in the specimens, the tentative pathological diagnosis was LGESS or ESN. T2-weighted magnetic resonance imaging (T2W-MRI) delineated polypoid tumor occupying the entire uterine cavity. Boundary between the tumor and the thinned myometrium appeared smooth, but minimal invasion into the myometrium could not be ruled out Figures . In DW-MNo postoperative adjuvant therapy was offered. The patient has been followed up in the outpatient clinic without any sign of recurrence as of one year after the surgery.Preoperative differentiation between ESN and LGESS by histological examination of the specimens obtained from conventional endometrial curettage is extremely difficult, because the tumor-myometrium interface is unlikely to be contained in these specimens . AlthougDW-MRI and FDG-PET have become widely recognized as powerful tools to differentiate malignant from benign tumor. In DW-MRI, signal intensity is inversely related to the degree of microscopic water diffusion in the tissue, which is mainly restricted by the high cellularity. FDG-PET visualizes the accumulation sites of FDG  that was systemically administered. The cells with high metabolic and/or high proliferative activity predominantly take up FDG. Since most of malignant tumors have high cellularity and are composed of highly proliferative cells, they generally exhibit high signal intensity in DW-MRI and intense FDG accumulation in FDG-PET.Like other malignant tumors, LGESS has been demonstrated to show high signal intensity in DW-MRI and high FDG accumulation in FDG-PET –6. SinceConsistent with the findings observed in DW-MRI and FDG-PET, histological examination of the present ESN demonstrated high cellularity with frequent mitotic figures as indicated by numerous Ki-67-positive cells (3 mitotic figures/10 high-power fields). Since it has been demonstrated that proliferative activity of EST does not influence the prognosis , mitoticIn conclusion, we here present a case of benign ESN that exhibited high signal intensity in DW-MRI and intense FDG accumulation in FDG-PET, both of which are characteristic features for malignant tumors. These findings are not surprising because mitotic figure in the tumor is not included in the diagnostic criteria of ESN or LGESS. Therefore, DW-MRI or FDG-PET is not useful in the differentiation of ESN from LGESS, which, for the present, only can be made by histological evaluation of the tumor-myometrium interface.


Primary vaginal leiomyosarcomas are uncommon, especially those growing outside the vagina.Out of all malignant vaginal neoplasms, leiomyosarcomas account for about 2%. Reports in the literature mostly concern the pathology of these tumors; few reports have been published that discuss how to surgically remove them.A 69-year-old Chinese woman presented with a mass in her buttocks that had been present for more than four months. Computed tomography demonstrated a mass of approximately 12.0×9.5×8.0cm in her retroperitoneal space. We resected the tumor via a posterior incision, and resected part of her sacrum and coccyx. The resected tumor was diagnosed by its pathological features as a leiomyosarcoma. Our patient received adjuvant chemotherapy after surgery. She was free of disease at a one-year follow-up and her general condition is good.We report a rare case of a primary vaginal leiomyosarcoma that was resected through an approach that has not, to the best of our knowledge, been previously reported. This case report adds valuable knowledge to the sparse available literature on the surgical treatment of vaginal leiomyosarcomas. Vaginal leiomyosarcomas are rare tumors. Primary vaginal leiomyosarcomas comprise less than 2% of all malignant vaginal neoplasms ,2. The mA 69-year-old Chinese woman presented with a progressively enlarging mass in her left buttock that was first noted four months earlier. Menopause had occurred when she was 46 years of age. She had a history of two vaginal spontaneous deliveries and one abortion. She had no family history of cancer or other diseases. On physical examination, we detected a spherical mass close to her uterine rectal nest, and she was referred to the Department of General Surgery at our hospital. Combined with the results of a needle biopsy, the mass was believed to have a smooth muscle origin, and surgery was scheduled.On computed tomography, a mass sized approximately 11.2×9.0cm was detected in her uterine rectal nest. We found varied density and low density shadows and a calcified separating strip. The edges of the lesion and separation showed obvious enhancement with enhanced scanning. The lesion was completely encapsulated. Her uterus, vagina, rectum and bladder pressure changed due to the tumor. There was no obvious pelvic lymph node enlargement and no pelvic effusion . Based on the histopathological and immunohistochemical results, the tumor was diagnosed as a high grade leiomyosarcoma Figure .Figure 3Our patient received adjuvant chemotherapy after surgery. She was free of disease at a one-year follow-up and her general condition is good.Smooth muscle is a component of many tissues and organs. As a result, leiomyosarcoma can arise at almost any anatomic site . The aveet al. reported the case of a 39-year-old woman who presented with a vaginal mass and underwent resection. A histopathological examination revealed atypical leiomyoma of the vagina with definite risk of recurrence. Eleven months later, she presented with a recurrent vaginal mass and underwent exploratory laparotomy with total abdominal hysterectomy and a bilateral salpingo-oophorectomy, plus resection of the recurrent tumor and a partial vaginectomy [et al. reported a case of stage IV primary vaginal leiomyosarcoma with metastases to the lung and left breast. The prognostic factors included age, tumor size, histological grade, mitotic count, tumor injury, and treatment modality [et al. reported the case of a 25-year-old south Indian woman who received treatment with surgery, radiation, and chemotherapy [There have been few cases reported in the literature that discuss surgical treatment. Khosla inectomy . Gong etmodality . Sahu etotherapy . SurgicaThere is no clear preoperative diagnostic criteria for vaginal leiomyosarcomas; diagnosis should be made based on their immunohistochemical features. The gold standard for diagnosis is histology . PrimaryWritten informed consent was obtained from our 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.


Intracranial malignant solitary fibrous tumor (MSFT) is extremely rare. The authors report a case of MSFT of the right occipital lobe with a rapid recurrence and bilateral lung, multiple bone metastasis.The patient was a 25-year-old male presenting with headache, nausea and visual disturbances without obvious cause. Three times right-side occipital craniotomies were performed and two times postoperative conformal radiotherapy were administered within one year. 4 months after the third time of right-side occipital craniotomy, the patient felt right chest pain and neck pain. Positron emission tomography/computed tomography (PET/CT) showed tumor recurrence of the right occipital lobe and bilateral lung metastasis, multiple bone metastasis including: vertebrae, libs, the left iliac wing, sacrum, the right ischium and upper parts of both femurs. Ultrasound guided puncture biopsy of left-side back of the neck and CT guided puncture biopsy of the third lumbar vertebra were performed. General sample showed grayish white or grayish red with irregular shape. Histopathologically, the tumor was composed of areas of alternating hypercellularity and hypocellularity with spindle-shaped cells, which arranged as fascicular, storiform pattern or patternless pattern, with intervening irregular eosinophilic collagen bundles. Some areas showed hemangiopericytoma-like perivascular pattern and perivascular hyalinization. Tumor cells were pleomorphic with mitotic counts of more than 4 per 10 high power fields and showed coagulative necrosis. Immunohistochemically, tumor cells were diffusely positive for vimentin and CD99, focal positive for CD34, bcl-2 and Actin. Ki-67 labelling index was more than 40 %. The final pathological diagnosis was MSFT of the right occipital lobe, metastatic MSFT of left-side back of the neck and the third lumbar vertebra.The MSFT of the right occipital lobe with recurrence and bilateral lung, multiple bone metastasis is extremely rare. Although intracranial MSFT is extremely rare, it should be considered in the differential diagnosis. Definite diagnosis depended mainly on pathological morphology and immunohistochemistry. The prognosis of MSFT is poor due to recurrence and metastasis. Complete resection of intracranial MSFT is difficult, and carful follow-up is needed. Solitary fibrous tumor (SFT) is a rare spindle cell tumor of mesenchymal origin and was first differentiated from mesothelioma in 1931 as primary neoplasms of the pleura . MeanwhiA 25-year-old male was referred to our hospital with progressive right chest pain and neck pain on March 2014, 4 months after the third time of right-side occipital craniotomy. Initially, he presented with headache, nausea and visual disturbances without obvious cause on December 2012. Magnetic resonance imaging (MRI) revealed intracranial tumor apoplexy of right occipital lobe at local hospital. First right-side occipital craniotomy was performed on 22th December 2012. Postoperation histopathology revealed spindle cell tumor, anaplastic meningioma was a preferred diagnosis. Then he complained of repeat headaches. Follow-up MRI showed a recurrence of tumor in the same location. The second and third open surgery was performed successively on 21th November 2013 and 31th December 2013. Postoperative conformal radiotherapy was administered for two times at doses of 54Gy and 46Gy on13th March 2013 and 17th January 2014, respectively. All these treatments were performed at local hospital. After he was admitted to our hospital, positron emission tomography/computed tomography (PET/CT) showed tumor recurrence of the right occipital lobe Fig. , severalAlthough SFT occurs mainly in the mediastinum and visceral pleura, in accordance with previous studies, approximately 30 % of SFT arise in any extrathoracic locations, including the CNS . Since tSFT in the CNS most occurred in the posterior fossa and spine as well as along spinal nerve rootlets . HoweverMSFT showed rapid local recurrence and distant metastasis. Based on the new World Health Organization (WHO) classification of tumors of the CNS published in 2007 and WHO classification of tumors of soft tissue and bone published in 2013, necessary criterions suggestive of the malignant potential of SFTs include hypercellularity, more than 4 mitoses/10 HPFs, variable cytological atypia, tumor necrosis, and/or infilitrative margins, among which mitoses seem to be most prognostic . Some paMost intracranial SFT seem to demonstrate a dural attachment and are usually mistaken for meningioma either radiologically and surgically. Intra-parenchymal non-dural-based SFTs are extremely rare in cranial compartment. As in the current case, first postoperation histopathology revealed a spindle cell tumor, tend to be anaplastic meningioma. Therefore, it is possible that the real frequency of CNS MSFT has been underestimated.Clinical and imaging features of CNS SFTs are relatively nonspecific and resemble to both meningiomas and hemangiopericytomas, which makes preoperative diagnosis difficult. Definite diagnosis mainly depends on careful examination of histological and immunohistochemical features. WHO classification for tumors of soft tissue treats hemangiopericytoma and SFT as a continuous spectrum of neoplasia, and many lesions that were called hemangiopericytomas prior to 1990 could now be called SFT , 15, 19.Surgery is the preferred treatment and achieves excellent local control for SFT, however, complete resection of intracranial MSFT is difficult. The prognosis is most likely dependent upon the extent of complete resection rather than histologic grading , 3, 15. In conclusion,the authors report here a rare case of MSFT of the right occipital lobe with a rapid recurrence and bilateral lungs, multible bone metastasis. Although intracranial MSFT is extremely rare, it should be considered in the differential diagnosis of tumors in CNS, and carful follow-up is needed. Definite diagnosis depended mainly on pathological morphology and immunohistochemistry.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.


Malignant fibrous histiocytoma (MFH) is a rare tumor that mostly involves adults aged 50 to 70. The most common anatomic location is the lower extremities. MFH of the retroperitoneum usually manifests late in its course and may be initially mistaken with other more common diagnosis. Here, the authors describe a 60-year-old man that was brought to the emergency department with a chief complaint of periumbilical abdominal pain. Our patient presented with symptoms consistent with a symptomatic aortic aneurysm, but a mass was encountered during surgery. In such circumstances the diagnosis of malignant sarcoma must be kept in mind and attempts at full resection with tumor-free margins are necessary. Malignant fibrous histiocytoma (MFH) was first described in 1961 by Kauffman and Stout as a histiocytic tumor with storiform growth in children . VariousThis rare tumor mostly involves adults aged 50 to 70, with a slight tendency towards male gender. The most common anatomic location is the lower extremities and the most common presentation is a growing painless soft tissue lump. Here we present the case of a 60-year-old man who came to the emergency department with a complaint of abdominal pain.A 60-year-old man was brought to the emergency department with a chief complaint of periumbilical abdominal pain. He suffered from abdominal pain for two weeks but it was significantly increased in the three days prior to admission. The pain radiated to the back and no accompanying signs or symptoms were present. It was described as a constant pain without any alleviating or exacerbating factors. The patient was a heavy smoker without any history of previous surgery or drug use.The patient showed stable vital signs and a nuisance general appearance. No objective signs of weight loss or cachexia were observed. The physical exam was normal in the head and neck, chest, and extremities. In the abdomen a pulsatile mass was palpated in the periumbilical region. Routine laboratory tests revealed mild normocytic normochromic anemia, normal ESR and CRP, and liver function and diagnostic tests within normal limits.Due to the pulsatile nature of the mass a CT angiography of the abdomen was ordered to look for vascular pathology. The tomography revealed a 5-by-4 cm pseudoaneurysm with hematoma formation in the infrarenal aorta alongside diffuse dilation of the infrarenal inferior vena cava with extension into both common iliac veins , and theDuring surgery a pulsatile mass 20 by 20 cm in diameter with surrounding hematoma was observed in left zones 1 and 2. Upon further investigation a huge retroperitoneal mass 11 by 8 by 6 cm in diameter with apparent local invasion to the aorta and the inferior vena cava was found. En bloc resection was attempted along with involved vascular segments. The abdominal aorta was reconstructed using 16 mm-by-8 mm Dacron bifurcated graft, while the IVC was ligated below the renal veins but perhaps because of chronic process of disease no lower extremity edema happened and the patient was discharged after a week.Pathologic evaluation of the specimen showed an undifferentiated pleomorphic sarcoma  with a histologic grade according to French Federation of Cancer Centers Sarcoma Group III  . There wMalignant fibrous histiocytoma is a sarcoma of mesenchymal origin affecting soft tissues of the body, particularly the extremities and retroperitoneum, yet it has been reported in almost all parts of the body –7. The tRetroperitoneal and intra-abdominal tumors may present with constitutional symptoms, including fever, malaise, and weight loss , 10. TheAlthough the best imaging modality for evaluation of the tumor is Magnetic Resonance Imaging (MRI), for intra-abdominal masses usually this is not the initial step. Generally, retroperitoneal undifferentiated pleomorphic sarcomas manifest as heterogeneous masses with areas of hemorrhage and necrosis and occasionally focal or diffuse coarse calcifications. While invasion of the abdominal musculature is a well-recognized phenomenon, the renal veins, or inferior vena cava, are not invaded , 12. In One must bear in mind that the pathological diagnosis of MFH/UPS is a diagnosis of exclusion. In order to rule out a pleomorphic nonmesenchymal neoplasm resembling a pleomorphic sarcoma, pleomorphic sarcoma as a result of dedifferentiation, and pleomorphic sarcoma with a specific line of differentiation, a combination of sampling and immunohistochemistry should be used.Microscopically, UPS has a highly variable morphologic pattern and shows storiform to haphazardly arranged pleomorphic areas. In immunohistochemistry they show features of fibroblasts/myofibroblasts .The current treatment of choice for primary MFH/UPS is wide surgical resection aiming at tumor-free margins. While adjuvant radiotherapy has become an integral part of treatment, the role of chemotherapy is still controversial in these tumors –15.MFH/UPS of the retroperitoneum usually manifests late in its course and may be initially mistaken with other more common diagnoses. Our patient presented with symptoms consistent with a symptomatic aortic aneurysm, but a mass was encountered during surgery. In such circumstances the diagnosis of malignant sarcoma must be kept in mind and attempts at full resection with tumor-free margins are necessary.


Neuromyelitis optica is a demyelinating disease of the central nervous system with various patterns of brain lesions. Corpus callosum may be involved in both multiple sclerosis and neuromyelitis optica. Previous case reports have demonstrated that callosal lesions in neuromyelitis optica are usually large and edematous and have a heterogeneous intensity showing a “marbled pattern” in the acute phase. Their size and intensity may reduce with time or disappear in the chronic stages.In this report, we describe a case of a 25-year-old Caucasian man with neuromyelitis optica who presented clinically with optic neuritis and myelitis. His brain magnetic resonance imaging demonstrated linear enhancement of the corpus callosum. Brain images with contrast agent added also showed linear ependymal layer enhancement of the lateral ventricles, which has been reported in this disease previously.Linear enhancement of corpus callosum in magnetic resonance imaging with contrast agent could help in diagnosing neuromyelitis optica and differentiating it from other demyelinating disease, especially multiple sclerosis. Neuromyelitis optica (NMO) is a severe demyelinating disease of the central nervous system characterized by optic neuritis and transverse myelitis. The etiology is unknown, but anti-aquaporin 4 (AQP4) receptor immunoglobulin G (IgG) antibody plays an important role in the pathogenesis of the disease. Based on 2006 criteria, diagnosis of NMO requires the presence of optic neuritis and myelitis plus the presence of at least two of the following three characteristics : (1) a cSeveral studies and case series have shown different patterns of brain involvement in NMO, which include those in the periaqueductal, hypothalamic and periventricular regions, as well as extensive lesions in the cerebral white matter. The corpus callosum has been reported to be involved in NMO in a pattern different from that of MS, such as large edematous lesions or involvement of the callosal edge in a linear pattern. Linear enhancement of the ventricular ependyma has been reported previously as having a “pencil-thin” appearance , 4. In tOur patient was a 25-year-old Caucasian Iranian man who was referred to our center in 2010 for further evaluation of paraparesis and urinary incontinence. There was no significant point in his past medical or familial medical history. He was well until 2008, when he developed blurred vision in his right eye and was admitted to a local center with the clinical impression of optic neuritis. He received intravenous methylprednisolone 1000mg for 5 days without a good response. Two months later he experienced optic neuritis in his left eye, but he had a good recovery after receiving intravenous methylprednisolone. According to his medical records, his physical examination was normal at that time, with the exception of mild optic atrophy of the right eye. Brain MRI was performed, which revealed some hyperintense T2-weighted lesions around the ventricles, with linear callosal involvement. The lesion was nicely enhanced in a linear pattern in a T1-weighted image with contrast agent  beta 1a three times per week. Six months later he developed another episode of optic neuritis in his left eye, and he had a less than 50 % recovery with intravenous steroids and plasmapheresis. After 1 year, he developed paraparesis and urinary incontinence while receiving IFN beta 1a three times per week. He was admitted to a local hospital and received intravenous methylprednisolone 1000mg/day for 5 days. He responded to this therapy and was able to walk in 4 weeks. At that stage, the patient was referred to our center to escalate the disease-modifying therapy.A neurologic examination of the patient revealed bilateral optic atrophy, weakness of both lower limbs (grade 4/5) and bilateral Babinski sign. Although we did not perform detailed neuropsychological tests, the patient did not show any apparent decrease in cognition or any other signs or symptoms of callosal involvement. New MRI showed a longitudinal cord lesion extending more than four vertebral segments without any enhancement. Regarding episodes of optic neuritis, longitudinal extensive spinal cord lesion and atypical callosal involvement, anti-AQP4 was checked, and the result was positive. Other laboratory tests, such as anti-nuclear antibody and anti-phospholipid antibody, for collagen vascular diseases were negative. The patient was diagnosed with NMO, and azathioprine was started for him at a dose of 50mg/day with a gradual increase to 150mg/day.NMO is one of the most important mimics of MS. Although NMO has distinct immunopathogenesis and treatment options, both NMO and MS may have similar clinical presentations and imaging features. It is very important to differentiate NMO and MS, especially in patients with both optic nerve and spinal cord involvement, as some MS therapies can exacerbate NMO. MRI may play an important role in differentiating these two entities.Spinal cord lesions extending over three or more vertebral segments are typical imaging findings in NMO. These longitudinal extensive cord lesions are not specific and can be observed in patients with MS or acute disseminated encephalomyelitis.Brain MRI scans are usually normal or demonstrate non-specific T2-weighted hyperintense abnormalities. These non-specific small hyperintensities are usually asymptomatic and located in the subcortical or deep white matter area.Authors of recent case series have reported different patterns of brain involvement in NMO, especially in areas with high AQP4 expression. Diencephalic lesions surrounding the third ventricles and cerebral aqueduct, which include the thalamus, hypothalamus and anterior border of the midbrain, have been reported in NMO. These lesions frequently are asymptomatic, but syndromes of inappropriate anti-diuretic hormone secretion, narcolepsy and hypothermia are some of the clinical manifestations related to these lesions. Lesions located in the dorsal brain stem adjacent to the fourth ventricle  represent one of the most specific brain MRI abnormalities in patients with NMO and may cause intractable hiccups and vomiting .arch bridge sign [NMO may involve the corpus callosum in the acute phase with large edematous lesions and heterogeneous intensity, higher in the rim and lower in the core of the lesions (in a “marbled pattern”). Callosal lesions may involve the complete thickness of splenium in a unique pattern that is called an dge sign , 6. MS tExtensive, confluent, hemispheric, T2-weighted lesions mimicking tumors are more frequent in the pediatric population. These lesions differ from those observed in regions of high AQP4 expression and are likely related to vasogenic edema and sometimes look like “spilled ink” on MRI scans. Such large lesions may follow the white matter tracts without severe mass effect and may cause hemiparesis, encephalopathy and visual field defects , 5, 6.Different patterns of enhancement have been reported to be typical for NMO, such as multiple patchy enhancements with blurred margins in adjacent regions (cloud-like pattern) or linear enhancement of the ependymal surface of the lateral ventricular caps (pencil-thin appearance). Ito and colleagues showed a cloud-like pattern in 90% of their patients with NMO who had contrast-enhanced lesions visualized by MRI .Our patient presented with recurrent optic neuritis and myelitis, which raised the possibility of a diagnosis of NMO or MS. Involvement of the corpus callosum misled the clinician to diagnose the patient with MS and to start MS therapy. Although linear involvement of the corpus callosum and pencil-thin-appearing enhancement of ventricular caps in a patient with optic neuritis could have raised the possibility of NMO, it was ignored at first, and the diagnosis was delayed until the patient developed a longitudinal extensive cord lesion.To the best of our knowledge, this is the first case report of linear callosal enhancement visualized by MRI. Another interesting neuroimaging feature of this patient is the simultaneous enhancement of the corpus callosum and ventricular surfaces in both the frontal and occipital horns.Special types of enhancement previously reported in the literature and the pattern we present in this case report can assist clinicians in differentiating NMO from MS at an early stage and prevent inappropriate treatments. We suggest that clinicians pay special attention to brain MRI of patients who present with optic neuritis and have a poor response to steroids, as well as of patients with extensive cord lesions with atypical brain involvement.Written informed consent was obtained from the patient for publication of this case and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Congenital segmental dilatation of colon (CSDC) is a rare malformation in neonates. A single segmental dilatation of colon is mentioned in the available case reports. Not a single case of multiple CSDC is reported hitherto. We report a case of multiple CSDC associated with cleft lip and palate, and rectal atresia. Congenital segmental dilatation of colon is a rare entity being described mostly in children. It is even rarer in neonates. Some of these patients also have association with anorectal malformations [1]. We report the first case of multiple CSDC in a neonate presenting as neonatal intestinal obstruction. The patient also had associated cleft lip and palate, and rectal atresia. To the best of our knowledge, such a malformation in association with cleft lip and palate, and rectal atresia has not been reported till date.A 3-day-old male neonate, weighing 2.2 kg, presented with failure to pass meconium, abdominal distension, and bilious emesis since birth. The neonate was a product of consanguineous marriage. He was born by spontaneous vaginal delivery at term in a private hospital. The patient had no history of perinatal problems. The maternal history of polyhydramnios was present.The baby was offered first feed within a few hours of the birth, which was not tolerated. On worsening of the clinical condition over next three days, the baby was referred to our hospital as a case of neonatal intestinal obstruction. In our nursery emergency, the patient was examined and found to have the cleft lip and palate. General physical examination was essentially unremarkable. Abdominal examination revealed visible bowel loops and abdominal distension. On rectal examination, we could not negotiate thermometer beyond 1.5 cm of rectum from the anal verge. Abdominal radiograph showed a big gas shadow in the right abdomen . A large gas filled bowel loop was noted in the right abdomen on ultrasonography.A differential diagnosis of rectal atresia resulting in colonic dilatation and/ or associated congenital pouch colon was kept in mind. Exploratory laparotomy was performed after optimization of the patient. There was a CSDC at the level of ascending colon. The colon on either side of the segmental dilatation was of normal caliber and the transition to huge dilatation was abrupt. The segmental dilatation of the colon lacked teniae coli, haustrations, and appendices epiploicae. The mesocolic vessels were dilated and tortuous . Moreover, there was an out-pouching of the colon present just next to the segmental dilatation . The transverse colon was normal followed by another similar segmental dilatation of colon at the level of descending colon. The sigmoid colon distal to the second segmental dilatation was of normal caliber and continued behind urinary bladder. Both the CSDC along with that out-pouching were resected and end to end colocolic anastomoses performed. A proximal ileostomy was also fashioned. The proximal CSDC had meconium and gas in it whereas the distal CSDC had more meconium and negligible air contained in it. Before performing distal colocolic anastomosis, a rectal diaphragm was confirmed by passing a nelaton tube through the lumen of sigmoid colon to the rectum. The immediate postoperative recovery was uneventful. On second postoperative day, the ileostomy started moving. The patient was allowed orally on 4th postoperative day. However, a night before the planned discharge the patient aspirated milk. The patient was mechanically ventilated for 4 days during which he developed full blown sepsis. His platelets count dropped to 22000/microliter. Blood culture yielded pseudomonas. The antibiotics were changed according to the culture and sensitivity. Platelets and fresh frozen plasma were transfused. The patient developed petechiae and bruises on all over his body and succumbed to sepsis on 10th postoperative day. The histopathology of the resected CSDC revealed colonic tissue with normal ganglion cells. Swenson and Rathauser were first to report their observation on segmental dilatation of colon in a child in 1959 [2]. Since then many case reports on this anomaly were reported in children. There is a paucity of neonatal case reports in literature. Mahadevaiah et al, have reviewed the literature in 2011 and found only 9 cases of CSDC reported in neonates [3]. The presence of segmental dilatation in neonates supports the congenital nature of this poorly understood malformation [3].CSDC has been reported in association with anorectal malformations, congenital pouch colon, duplex appendix, duplication of cecum, vesical exstrophy, malrotation, duodenal atresia, Meckel’s diverticulum, meningomyelocele, hydrops gallbladder, colonic atresia, and facial defects . Their association with rectal atresia is however not reported hitherto.The common symptom in children is constipation; however, in neonates the presentation is usually with neonatal intestinal obstruction . Their preoperative diagnosis is not formed in most of the reported cases. These children are often suspected for Hirschsprung’s disease and thus investigated on these lines. Ganglion cells are always present in these patients which differentiate them from those of Hirschsprung’s disease. Rarely, it may present with perforation peritonitis, and volvulus of the sigmoid colon . In neonates, CSDC is usually found as an incidental finding; in few cases where it was associated with anorectal malformation, it had simulated congenital pouch colon [1]. We also expected congenital pouch colon as it has been reported in association with rectal atresia [11].The cardinal features of CSDC include a single large dilatation of colon that lacks teniae coli, haustrations, and appendices epiploicae; and have abundant serosal blood vasculature. The normal colon on both sides of the segmental dilatation abruptly transitioned to the segmental dilatation . It usually involves left colon but right colon may be involved. On account of these features, it has got extraordinary resemblance with congenital pouch colon. However, congenital pouch colon is always associated with anorectal malformations, which is not true for CSDC. The presence of normal colon distal to the segmental dilatation and absence of fistulous communication between CSDC and urogenital tract separates them from congenital pouch colon .The etiology of CSDC is largely based on speculations. Intrauterine vascular accident, failure of or defective organogenesis, strangulation of intestine in the umbilical ring, and defective muscular development are few of proposed theories . In the index case, a small out-pouching of colon was also present just next to the first CSDC; this out-pouching might be a developmental error or it could be secondary to the vascular insult during intrauterine life. This out-pouch may have grown later to its present size of CSDC.Management of this anomaly depends upon the clinical condition of the patient, presentation, surgeon’s experience of dealing such malformations, and association with other malformations. The definitive surgery is resection of the involved segment and end to end anastomosis [8]. In case of critically sick patients, an ileostomy can be fashioned without excision of the segmental dilatation [8]. Other option is resection of the segmental dilatation and colostomy. In case of associated anorectal malformations, stoma formation is always recommended to buy time for anorectoplasty in the second stage. In case of associated congenital pouch colon, both of the lesions can be resected with end ileostomy. . In the index case, a covering ileostomy was also fashioned on account of multiple colonic anastomoses and rectal atresia.Source of Support: NilConflict of Interest: None


Dear Sir,Sacrococcygeal teratoma (SCT) is usually found in the newborn period and now frequently being diagnosed prenatally on fetal ultrasound. Majority of the cases are found during the first few days of life, with less than 10% being diagnosed beyond the age of two year. Females are ten times more likely to be affected then males.[1] We herein report a case of benign and infected sacrococcygeal teratoma in a 13-year-old girl.Patient presented with complaints of fever for five days and swelling in sacrococcygeal region. The swelling was present since birth. There was history of occasional urinary retention. She had no significant change in bowel habits. She was a student of sixth grade. She was born at home with uneventful antenatal and postnatal period. On examination, she had stable vital signs, pallor, febrile, bilateral chest was clear. Abdominal examination was normal. On local examination, there was a firm, tender and irregular mass of 10cm -12 cm in size in the sacral region . On per rectal examination a tender mass was palpable extending into presacral space, and finger could be insinuated above the swelling. Laboratory investigations showed hemoglobin level 8 g/dl. Rest of the tests were within normal limits. X-ray pelvis showed calcification. On ultrasonography of abdomen and pelvis, there was a mass of mixed echogenicity with cystic lesions in presacral space. CECT scan abdomen showed a multicystic lesion in pre-sacrococcygeal region containing foci of calcification with posterior extension up to skin . On the basis of clinical and radiology diagnosis of sacrococcygeal teratoma type II was made. After preoperative optimization the patient underwent surgical excision of tumor in toto in prone position through perineal approach. Tumor contained pus (which was drained), along with cystic and solid elements. Post operative period was uneventful. Histopathological examination confirmed the diagnosis of mature sacrococcygeal teratoma. Postoperative alpha fetoprotein and ultrasound examination were normal. The patient is doing fine on follow-up.SCT is the most common congenital tumor occuring in 1 in 35000 live births. Teratomas are classified as mature, immature, and malignant depending upon histopathological findings. The propensity of malignant changes increases with age. Approximately 8% of SCTs are malignant at birth; by the age of 6 months, 40 % to 80% are malignant.[4] Presence of yolk sac tumor or other malignant component is main reason of malignant transformation of a SCT. It can be speculated in our case that the absenec of these malignant components may be a reason of non transformation to malignancy. Prognosis is excellent for mature teratoma, but malignant cases have a tendency to recur and metastasize. Regular follow up is required to detect early recurrence. We are following up our patient for last two years and found no recurrence.Source of Support: NilConflict of Interest: None declared


Here, we report the case of a 62-year-old man with neuroblastoma, which is extremely rare in adults. His tumor was resected, but it recurred four months later. Radiotherapy reduced tumor size, and the patient remained in good health three years after surgical tumor removal. The residual tumor and the treatments administered to this patient were evaluated. We have also reviewed the literature. Neuroblastoma is one of the most common tumors in children, but it is incredibly rare in adults. The disease in adults differs from that in children with respect to tumor markers, treatment, and prognosis. An adult case of neuroblastoma generally has a poor prognosis, and no standard therapy has been established. In general, adult neuroblastoma is only minimally responsive to current therapeutic schemes.131I-metaiodobenzylguanidine (MIBG) scintigraphy did not reveal any MIBG accumulation.A left adrenal mass was discovered in a 62-year-old male patient during evaluation for mild epigastralgia that had lasted for several days. He also had a 1-year history of mild hypertension, which was not treated. The patient denied having headaches, palpitations, or excessive/inappropriate perspiration. His physical examination was unremarkable, and no cushingoid features, petechiae, or abdominal striae were detected. Serum electrolytes, blood urea nitrogen, creatinine, and a complete blood count were normal. Pertinent adrenal serum and urine chemistries were also normal, except for a slight elevation in serum norepinephrine. An abdominal X-ray revealed an irregular mass with calcification just above the left kidney. Computed tomography (CT) confirmed the presence of a 7 × 6 cm mass containing sporadic calcification that was located in the left suprarenal position above the left kidney . The masThe patient underwent a left adrenalectomy and a splenectomy that was performed via a thoracoabdominal incision. The mass was partially encapsulated, but the inferior and posterior portions were strongly adherent to adjacent tissues. Gross inspection showed that the tumor measured 8.5 × 5 × 4 cm and 115 g. The cut surface revealed a grayish solid portion and a dark reddish necrotic portion. Histopathologically, the tumor was composed of eosinophilic filamentous tissues and small round cells with hyperchromatic nuclei and scant cytoplasms . ImmunohFour months after surgical removal of the tumor, CT revealed a recurrent abdominal mass that was 12 × 9 cm in size . The patThree years after surgery, the patient remains well without any metastases. The mass has decreased to 20% of its original size, with the central necrotic portion of the tumor measuring larger and the peripheral parenchymal portion measuring smaller . Serum NNeuroblastoma is a relatively common solid tumor in children, comprising about 8% of all childhood cancers . Over 90A literature review revealed that there have been 190 adolescent and adult cases of neuroblastoma described from 1987 to 2014 –7, with Neuroblastoma in adolescents and adults has been reported to lack MYCN oncogene amplification, which occurs in 20–30% of younger children. Elevation of catecholamine metabolite secretions, including urinary vanillylmandelic acid (VMA), homovanillic acid (HVA), and dopamine, occurs in as many as 90% of pediatric patients  but is gThe majority of neuroblastomas are irregularly shaped, lobulated, and unencapsulated on CT and MRI imaging. They also sometimes invade adjacent organs or encase adjacent vessels. Neuroblastomas tend to be nonhomogeneous because of tumor necrosis and hemorrhage. They also contain calcifications in approximately 85% of cases, as determined using CT imaging [The rarity of neuroblastomas in adolescents has led to the lack of systematic trials for chemotherapeutic agents, either alone or as a part of combination therapy. CYVADIC  and James (cyclophosphamide and vincristine) regimens have been administered to adults, but these protocols have not been analyzed because of limited data. Castleberry et al.  claimed Spontaneous maturation and tumor regression have been documented at a much higher rate in patients with neuroblastoma than those with any other type of tumor , 11. Neu


Retinal artery occlusion can be the first indicator of a significant cardiovascular disorder and the need for treatment. We present the case of a 69-year-old man with a cilioretinal artery occlusion and retinal ischemia. Retinal imaging, in particular fundus autofluorescence, highlighted an intraluminal hyperautofluorescent lesion which led to the diagnosis of retinal emboli. Subsequently a severe, previously undiagnosed carotid occlusive disease was discovered. The patient underwent prompt endarterectomy. Retinal artery occlusion and retinal ischemia can be the first signs of a significant and symptomatic cardiovascular disorder and indicators of an urgent need for treatment. We show a case of a patient who presented with visual complaints and was found to have two focal areas of retinal whitening. Due to a complicated systemic history, his presentation led initially to a workup by the urgent care clinic for infectious retinitis and septic emboli. However, after exclusion of an infectious origin, the intraluminal hyperautofluorescent plaques in the macular arterioles were detected on retinal imaging, which led to the correct diagnosis of retinal emboli and associated retinal ischemia. These specific features led to the finding of severe, previously undiagnosed carotid occlusive disease. The patient underwent prompt endarterectomy, thus preventing further events.A 69-year-old male awoke with a “foggy spot the size of a pencil eraser” in the center of his vision of the right eye. His ocular history was unremarkable. His medical history was notable for hypertension and hyperlipidemia, which were treated with Amlodipine 5 mg and Simvastatin 40 mg once a day. He admitted ethanol abuse (about 1 bottle of bourbon per day). In addition, he reported a recent episode of cough and night sweats. He also complained of green sputum and chills.At presentation to the urgent care clinic, his best corrected visual acuity was 20/20 OU and the anterior segment was unremarkable. Ophthalmoscopy revealed two parafoveal white retinal lesions . No vitrOne month after presentation, the whitish lesions were nearly invisible. On FAF and IR, the hypoautofluorescent and hyporeflective lesions were still visible but were fading  and SD-ORetinal artery occlusions and retinal ischemia can be the first signs of cardiovascular disorders. The case presented here demonstrates that retinal imaging can be crucial for the detection and diagnosis of a cardiovascular disease leading to immediate important therapy.i.e., proximal, larger vessel involvement may lead to retinal artery occlusions, affecting all inner retinal layers. Small microvasculature thromboembolic events of the capillary network in turn cause localized ischemic lesions, limited to particular retinal layers [The retinal blood vessels are responsible for the blood supply of the inner retinal layers, whereas the outer retina is nourished by the choroidal vascular system, with the outer plexiform layer acting as a watershed zone ,2. Retinl layers ,4,8. Howl layers . This prl layers . Howeverl layers . This inl layers . The usel layers ,11.In summary, retinal imaging can reveal characteristic findings of retinal ischemia and embolic plaques. This may help to identify patients with cardiovascular diseases in need of life-saving intervention.