Idiopathic omental bleeding is a rare cause of acute abdomen, with only a few reported cases. It usually presents with abdominal pain and may be life-threatening. As it rarely occurs, it may not be considered initially during patient presentation.A 35-year-old male came to our emergency department with abdominal pain present for around 5 to 6 hours. The patient complained of left upper quadrant abdominal pain after eating breakfast. The only associated symptom was 3 episodes of vomiting up food. Physical examination revealed mild left upper quadrant abdominal tenderness without muscle guarding or rebounding pain. Blood examination showed leukocytosis with neutrophil predominance and C reactive protein elevation. The pain was persistent and relief was not obtained by medication.Computed tomography showed a large lobular-contour homogenous slightly hyperdense lesion without enhancement along the greater curvature of the stomach in the lesser sac. A surgeon was consulted and laparotomy was suggested. Hematoma was found at Morrison pouch, subsplenic fossa, and lesser sac under operation.Laparotomy and ligation for hemostasis.The patient was discharged with stable condition after 7 days of hospitalization.This diagnosis should be considered in patients presenting with epigastric pain and vomiting after eating while in the emergency department because this disease might be life-threatening. This case highlights 2 important learning points. First, idiopathic omental bleeding could occur after eating in patients without underlying disease or trauma history, and this disease should be taken into consideration when acute abdomen occurs. Second, emergent laparotomy is indicated if the cause of acute abdomen is not clear. As it rarely occurs, it may not be considered initially during patient presentation. Here, we report a case visiting the emergency department because of abdominal pain after eating breakfast, and idiopathic omental bleeding was diagnosed. After, we contacted the regulations of institutional review board of the Kaohsiung Medical University Hospital, there was no need for ethical approval for this case report article. Informed consent was obtained from the patient.Idiopathic omental bleeding is a rare cause of acute abdomen, with only a few reported cases.2A 35-year-old male without any systemic disease and denying any medication use came to our emergency department with abdominal pain present for around 5 to 6 hours. When he arrived at emergency department, his consciousness was clear and vital signs showed body temperature 36.9° Celsius, blood pressure 112/73 mm Hg, with heart beat 102 per minute. The patient complained of left upper quadrant abdominal pain after eating breakfast. The only associated symptom was 3 episodes of vomiting up food. Physical examination revealed mild left upper quadrant abdominal tenderness without muscle guarding or rebounding pain. Blood examination showed leukocytosis  and C reactive protein 5.59 mg/L, with normal renal and liver function. The pain was persistent and relief was not obtained by medication, then computed tomography was done, which showed a large lobular-contour homogenous slightly hyperdense lesion without enhancement along the greater curvature of the stomach in the lesser sac (Fig. 3 trauma, aneurysm,–3 coagulopathy, or vasculitis. Idiopathic omental bleeding is a rare cause. Omental bleeding often presents as abdominal pain, especially over the epigastric area, and is accompanied with nausea, vomiting, diarrhea, or even unstable hemodynamics. Some patients suffer just after a meal; the reason could be due to increased visceral blood flow after ingesting food. A larger meal increases the visceral blood flow and results in vessel rupture. The management of omental bleeding includes laparotomy or laparoscopy with omentectomy or simple vessel ligation, and transcatheter arterial embolization.–9 In recent years, more minimally invasive surgery has been used such as transcatheter arterial embolization or laparoscopy.Omental bleeding results from rupture of omental vessels, and it could be caused by tumor, Men are likely to suffer more than women from this condition.–8,11–15 The reasons why there are more Japanese patients and why men are more likely than women to experience this condition are still unknown.In this case, the patient presented with symptoms of epigastric pain and vomiting after eating breakfast. No comorbidity was known before, and no trauma history or coagulopathy was noted. Emergent laparotomy was done instead of laparoscopy or transcatheter arterial embolization under the impression of massive intraperitoneal hemorrhage, with cause to be determined. Pathological examination of specimen revealed hemorrhage and showed no evidence of vasculitis, thrombosis, or malignancy. Idiopathic omental bleeding was thus diagnosed. In a review of the literature, idiopathic omental bleeding occurs more frequently in Japan than in other countries, and the occurrence of idiopathic omental bleeding ranges from young to old patients.In conclusion, idiopathic omentum hemorrhage is a rare cause of acute abdomen which sometimes occurs after eating, while laparotomy with ligation and transcatheter artery embolization can be used to rule out malignancy and aneurysm. This diagnosis should be considered in patients presenting with epigastric pain and vomiting after eating while in the emergency department because this disease might be life-threatening. This case highlights 2 important learning points. First, idiopathic omental bleeding could occur after eating in patients without underlying disease or trauma history, and this disease should be taken into consideration when acute abdomen occurs. Second, emergent laparotomy is indicated if the cause of acute abdomen is not clear.


Osteochondroma of mandibular condyle is a rare benign tumor.This case report described clinical, radiographic features, differential diagnosis, histopathologic correlation and treatment of condylar osteochondroma.Conebeam computed tomography (CBCT) is an alternative modality to CT or MRI that should be performed in all cases of suspected osteochondroma of the mandibular condyle. However, it is rarely found in maxillofacial area. Mandibular osteochondromas occur in coronoid process, condyle, ramus, body, angle, and symphysis regions -5. MandiConebeam computed tomography (CBCT) is an acceptable alternative for the evaluation of mandibular condyle . Treatme21).A 29 years old female presented with facial asymmetry, pain in the left temporomandibular joint (TMJ) and headache. Her past medical history revealed that she had a trauma to her chin 15 years ago and from that time on, a slowly progressing facial asymmetry and limitation in the mouth opening began. The clinical examination revealed an obvious facial asymmetry with the chin point deviated to the right. Non tender bony hard swelling on left TMJ was found, including reduced jaw movement, unilateral posterior crossbite on the right side, open bite on the left side and limited mouth opening (28 mm). Clicking sound was observed on opening and closing the mouth . CBCT showed a large bony mass arising from the left mandibular condyle extending anteriorly, posteriorly, medially and superiorly to the temporal bone. The lesion density was continuous with the structures of the mandibular condyle .Panoramic radiographic examination showed an irregular radiopaque lesion in association with the left condylar head. It had similar density to the adjacent bone. Postero-anterior (PA) skull showed a well defined bony overgrowth extending medially from the left condyle, facial asymmetry and deviation of mandible to the right side .Surgical treatment plan called condylectomy and extraoral vertical ramus osteotomy were performed under general anesthesia. Histopathologic examination revealed small and large cancellous bones covered in some parts by cartilaginous cap. This finding was consistent with osteochondroma, which was the final diagnosis of this lesion  with slight deviation. For the correction of the midline deviation and occlusion, adjunctive orthodontic treatment was suggested.3Although osteochondromas are one of the most common benign bone tumors, they are relatively rare in the maxillofacial region. Early investigation and diagnosis are essential in order to provide proper treatment, which may affect the patient’s quality of life. Condylar osteochondromas are usually situated on the anteromedial surface of the condylar head , howeverPanoramic radiograph is mainly used for screening purposes, however, the high rate of false-positive results for TMJ pathology evaluation suggests that if the clinical finding is positive, more advanced techniques such as CT and/or Magnetic Resonance Imaging (MRI) are indicated, even if the panoramic findings are negative. CBCT is an acceptable alternative to medical CT for the evaluation of osseous abnormalities of the mandibular condyle with almost equal high sensitivity and specificity . CBCT ovOsteochondroma should be differentiated from lesions involving mandibular condyles or TMJ complex. Condylar hyperplasia mimics osteochondroma clinically, however, they are different on radiographic findings. Condylar hyperplasia shows a proportionate growth of the involved condyle as a whole, with elongation of the neck of condyle. Osteochondroma, on the other hand, shows an exophytic growth from condyle. Conventional radiographs are difficult to differentiate osteomas from osteochondroma. Osteomas of the condyle may grow as a sessile or pedunculated mass from condyle . MultiplTreatment for osteochondroma sometimes requires adjuvant orthognathic correction . ImpropeOsteochondroma of the mandibular condyle is a rare benign tumor. However, it should be considered in the differential diagnosis of bony masses in the TMJ region. Panoramic and/or other conventional radiographs can be considered as screening modalities. CBCT is an alternative modality to CT or MRI that should be performed in all cases of suspected osteochondroma of the mandibular condyle.


A 54-year-old otherwise healthy Caucasian male was referred to us for further management of an enlarging left heterogeneous peri-renal mass. The patient had been initially followed with serial imaging by his primary care physician, who had been monitoring the mass since it was first detected 2 years earlier, when it was 2.9cm in size. Most recent CT scan showed a 4.7 cm mass, located posteriorly, near the renal hilum, apparently peri-renal (arising from retroperitoneum). Axial PET/CT showed mild increased FDG uptake with standardized uptake value measurements of up to 2.8, which could represent malignancy or inflammatory process . It was Gross examination of the surgical specimen revealed a well-circumscribed mass displaying fibrous and fatty cut surfaces. Microscopic examination revealed a proliferation of spindle cells with features of reactive myofibroblasts and fibroblasts interspersed with lobules of adipocytes, many of which contained multiple vacuoles, characteristic of pseudolipoblasts. Foamy macrophages and infiltrates of lymphocytes and plasma cells were present throughout the tumor. Based on the morphologic features, the differential diagnosis included well-differentiated liposarcoma, inflammatory myofibroblastic tumor, angiomyolipoma, an IgG4-related sclerosing lesion, and inflammatory pseudotumor. Immunohistochemical stains showed that the myofibrobasts were positive for CD34, vimentin, and smooth muscle actin and were negative for melan-A, HMB-45, ALK, and bcl-2. IgG4 staining did not reveal an excessive number of IgG4-positive plasma cells. Fluorescent in situ hybridization revealed no amplification of the MDM2 gene locus, ruling out the possibility of well-differentiated liposarcoma. The overall findings were most consistent with inflammatory pseudotumor . PostopeThis type of lesion is rarely encountered –8, but iIn conclusion, inflammatory pseudotumor of the kidney represents an extremely rare neoplasm of uncertain biological potential, which the clinician should keep in mind in the differential diagnosis of an enlarging renal mass with non specific features on diagnostic imaging and inconclusive biopsy results.


Solitary plasmacytoma of the liver is a very rare and aggressive form of plasma cell dyscrasia. To the best of our knowledge, very few cases have been reported without systemic disease. We reported a rare case of hepatic solitary plasmacytoma that successfully responded to fractionated stereotactic radiotherapy.A 64-year-old white French man had monoclonal gammopathy of the immune globulin G lambda type; he developed a cholestasis and cytolysis with the discovery of a subscapular nodule. A biopsy showed plasma cells and, for several reasons, the decision was made to use the fractionated stereotactic radiotherapy strategy. After 20 months, he is asymptomatic and the immune globulin G component has completely disappeared.We suggest considering Cyberknife® radiosurgery as an option for the treatment of hepatic solitary plasmacytoma. Solitary plasmacytoma (SP) is a rare form of plasma cell dyscrasia with a single bone (SBP) or extramedullary location (EMP). It accounts for 3 to 5% of all plasma cell neoplasms . Almost Radiotherapy is the treatment of choice for EMP, with excellent response rates of approximately 86% . Fractio18fluorodeoxyglucose (18FDG) revealed an unusual hypermetabolic nodule, with maximum standardized uptake value (SUVmax) at 16. An ultrasound-guided biopsy showed numerous plasma cells  lambda type (IgG = 1 g/L) with normal bone X-rays. He had no other significant comorbidities, except for diabetes and hypertension. Two years after the diagnosis of monoclonal gammopathy, he developed cholestasis 10N  and cytolysis 4N . Ultrasounds revealed a 4-cm subcapsular nodule involving segment VI of his liver. Magnetic resonance imaging (MRI) revealed multiple signal anomalies, with hemangiomas and benign cysts and a slightly hyperintense nodule on the T2-weighted image Fig.  and T1-wlls Fig.  with a slls Fig. . A full 18FDG PET-CT revealed a stable disease, and subsequent assessments showed a partial response of 50% and 75% at month 12 and month 18, respectively (Fig. max also decreased to 8.2 at month 12 and 4.8 at month 18. Twenty months after irradiation, he is still asymptomatic with a normal biological liver function and IgG lambda M component has completely disappeared (Fig. In February 2015, our patient received 30 Gy in five consecutive fractions of 6 Gy, a dose that may be considered biologically equivalent to 40 Gy delivered in 2 Gy per fraction. The tolerance was excellent without acute toxicity. At month 3, ely Fig. . SUVmax red Fig. . No signWe describe a very good partial response of a very rare form of hepatic EMP with fractionated stereotactic radiotherapy. The diagnosis was made according to the recently updated recommendations , and difet al. reported a plasmacytoma of the clivus extending to the foramen magnum treated by fractionated stereotactic radiotherapy with a complete and durable response on MRI at 12 months [et al. reported the case of a 49-year-old man with SP of the bone, with radiotherapy as first-line treatment and radiosurgery for the treatment of local relapse with disappearance of bone lesion [Radiation therapy is the best option for patients with localized EMP over systemic chemotherapy. Recommendations include a radiotherapy dose of 40 Gy in 20 fractions for tumors <5 cm and up to 50 Gy in 25 fractions for tumors ≥5 cm with at least a 2-cm margin encompassing the primary tumor . Other a2 months . Theilere lesion . Other ce lesion , and spie lesion . To the This case shows that stereotactic radiotherapy could be highly effective in localized liver plasmacytoma. The Cyberknife® technology, which combines high precision and surrounding tissue protection, could be an alternative to conventional radiotherapy in some cases , 12. Due


Gastric lipomatosis is characterized by multiple gastric lipomas or a diffuse gastric infiltration of the submucosal or subserosal layer by the adipose tissue; diffuse-type gastric lipomatosis is an extremely rare condition. Here, we present the case of a patient with gastric lipomatosis treated by total gastrectomy.A 54-year-old man diagnosed with gastric submucosal tumor in 2008 was referred to our hospital for further examination and treatment in September 2016. Upper gastrointestinal endoscopy revealed a submucosal tumor with an associated ulcer on the anterior wall of the lower body of the stomach. A compressing mass was observed on the anterior wall of the greater curvature and the posterior wall of the stomach. Following a biopsy of the submucosal tumor and ulcer, lipoma without malignancy was diagnosed by microscopy. A giant gastric lipoma was suspected because endoscopic ultrasound revealed a high-echoic lesion on the antral wall that extended to the stomach. Therefore, total gastrectomy was performed, and gastric lipomatosis was confirmed by a histological examination of the resected specimen.Surgical treatment is a highly effective treatment for symptomatic gastric lipomatosis with extensive involvement or multiple lipomas and can be used for patient diagnosis. Gastrointestinal (GI) lipomatosis is characterized by multiple, small, and asymptomatic lipomas, which are one of the most common submucosal tumors (SMTs) of the GI tract , 2. AlthOur patient was a 54-year-old man who was originally diagnosed with a gastric SMT in 2008. He underwent an annual follow-up by upper GI endoscopy at another hospital but was referred to our hospital for further examination and treatment in September 2016, during which his main clinical symptoms were epigastric soreness, general malaise, and melena. He had an unremarkable family history.On admission, he measured 161.6 cm tall and weighed 58 kg and his pulse was 115 beats/min, and blood pressure was 69/43 mmHg. There were no significant findings on abdominal examination, but laboratory analysis revealed a hemoglobin level of 5.6 g/dl. Other hematological and biochemical parameters were within normal limits. Chest X-ray, electrocardiography, and echocardiography results were normal. On admission, because he had advanced anemia and low blood pressure, he received blood transfusion (480 ml). On upper GI endoscopy, an SMT was identified with an associated ulcer on the anterior wall of the lower body of the stomach Fig. . There wWe diagnosed lipoma without malignancy based on the biopsy of the SMT and ulcer. Endoscopic ultrasound (EUS) confirmed a high-echoic submucosal lesion in the antral wall that extended to the stomach body Fig. , and comBased on our findings, we suspected a giant gastric lipoma and proceeded to perform a standard total gastrectomy. We considered the execution of resection of the stomach, but we decided to perform total gastrectomy because the range of the tumor was unclear and the risk of recurrence could not be determined. The specimen was opened along the greater curvature, revealing a mucosal surface that was smooth and diffusely elevated by the submucosal mass, but with no involvement of the lesser curvature Fig. . There wGastric lipomatosis was confirmed by a histological examination of the resected specimen. Microscopy revealed adipocyte proliferation without nuclear atypia and mature adipocytes replacing the submucosal and muscle layers of the stomach. Lipomatosis was present only in the fundic gland zone, and there was no intestinal metaplasia or atrophic gastritis. Multiple hyperplastic polyps were observed on the mucosa overlying the area of diffuse lipomatosis. Immunostaining was negative for MDM2, CDK4, and p16. Moreover, there was no evidence of malignancy in the fatty lesion.The patient recovered well following surgery and was discharged on the postoperative day 14. At the latest follow-up, he was continuing to do well and showed no evidence of recurrence in other organs.Gastric lipomas are characterized by smooth, sharply marginated, and oval or spherical submucosal masses comprising well-differentiated adipose tissues surrounded by a fibrous capsule –4. In coApproximately, 90–95% of lipomas are submucosal, and the rest are subserosal . Most gaCT is an excellent diagnostic tool because it allows the diagnosis of lipoma based on tumor fat density, precluding the need for an endoscopic biopsy. Indeed, a homogeneous mass with a fat density ranging between − 70 and − 120 Hounsfield units is considered pathognomonic of gastric lipoma . HistoloAlthough conservative treatment is preferred for asymptomatic solitary lipomas, surgical intervention should be considered for symptomatic lipomas associated with ulcers or non-fatty elements. Endoscopic polypectomy is an option for submucosal lesions that are smaller than 3 cm, but larger broad-based tumors have a higher risk of perforation using this approach. In our case, we decided to treat the patient by total gastrectomy for three main reasons: first, a large and symptomatic lipoma was present at surgery; second, although biopsy suggested lipoma, we could not completely exclude malignancy; and third, anastomotic leakage and tumor recurrence were possible if partial resection was performed.Eight reports of gastric lipomatosis exist in the literature, of which five describe a detailed pathology Table  2, 5, 66, 8–12. We performed total gastrectomy for a large and ulcerated gastric lipoma in a patient with anemia. Gastric lipomatosis was confirmed by CT and EUS, which should be considered essential for diagnosis. We believe that surgery is an appropriate treatment when gastric lipomatosis is symptomatic or when there is an extensive gastric involvement or multiple gastric lipomas. This approach can also be used to confirm the diagnosis.


Mesenchymal hamartoma (MH) is not an uncommon tumor of the liver in the age group of 2–10 years. It is the second most common benign liver tumor in children. Previously considered a developmental anomaly, newer insights into other theories of origin including toxic-metabolic, ischemic, and a true neoplastic process are in progress. Previous understanding of a purely benign nature of the tumor is being overridden by a real malignant transformation. Complete excision of the tumor with clear margins is recommended to achieve a long term cure. A thorough understanding of the natural history of these tumors and skillful surgical treatment are indispensable elements of care. Mesenchymal tumors of the liver are a common occurrence in the pediatric age group and are third in order following Hepatoblastoma and HCC. Mesenchymal hamartoma (MH) is the second most common benign liver tumor (next to Hemangioma) in the age group of 5–10 yrs and constitutes 30% of benign liver tumors and 5–8% of all the liver tumors in children [A 4-year-old girl was incidentally detected to have a right upper quadrant (RUQ) mass during work-up for diarrheal illness which has since resolved. Mother denies any history of pain, jaundice, fever, or weight loss. Developmental milestones were normal. Physical exam was notable for an active child, with a firm mass from liver. Work-up revealed a normal hemogram, liver, and renal function tests. Alpha-feto protein level was 83 ng/ml. Viral markers for Hepatitis B and Hepatitis C were negative. Sonogram of the abdomen was notable for an avascular hypoechoic liver mass with septations with no mural nodules. MDCT of the liver  was notaMH is considered a ductal plate malformation, wherein mesenchymal rests become isolated from the normal portal triad architecture and differentiate independently , 4. The Grossly, mesenchymal hamartoma is a well circumscribed, unencapsulated mass that can be very large with a soft, myxoid, and cystic cut surface . The tumβ-HCG) or liver function test that is specific for a diagnosis of MH. Normal laboratory parameters are useful in excluding other diagnoses. The usual imaging finding is a large, well-defined, heterogeneous solitary mass containing cysts of varying sizes, ranging from a few millimeters to more than 15 cm. The characteristic ultrasonography findings are multiple echogenic cysts with thin septa. On a noncontrast CT the stromal elements appear hypoattenuating and the cystic components are of near water attenuation. The mesenchymal component enhances with contrast administration [About three-quarters of MH occur in the right lobe of the liver. The rest are found in the left lobe or involve both lobes. Up to 20% of MH are pedunculated, arising from the inferior surface of the liver. Painless RUQ mass noticed by the mother or an incidental imaging finding is the usual presentation. Mechanical compression of adjacent viscera causing pain, vomiting, jaundice, or poor weight gain is described. There is no tumor marker , an aggressive liver tumor with a median survival of less than 1.5 years , 7. UES The practice of watchful waiting, enucleation, and marsupialization is strongly discouraged for the above-mentioned reasons , 6, 7, 9The overall mortality after liver resection for primary liver malignancies in children is 3.7% . In seriParental involvement in treatment decisions, heightened awareness of malignant transformation, and an expert surgical management are essential elements of high value care in treating these tumors.


Coccydynia in adult patients is not uncommon and is frequently neglected. Coccydynia is mostly associated with fall on buttocks. In long-standing cases, coccydynia can be debilitating. Rarely coccydynia can be due to more sinister causes and surgeons should be aware of all differential diagnosis. We present a case of an elderly female who presented with a complaint of pain over coccyx which was not subsiding with conventional treatment methods. Biopsy was done and a diagnosis of sclerosing epitheloid fibrosarcoma was made. We describe an unusual case of coccydynia secondary to this tumour with the histopathology finding and surgical management. Sclerosing epithelioid fibrosarcoma (SEF) is an uncommon but aggressive sarcoma . It is aClinical historyA 77-year-old female presented to our outpatient department with a history of coccydynia for the past three months. The patient was initially thought of a simple coccydynia and was started on conservative treatment for coccydynia. However, the patient's symptoms were not relived and she complained of increasing pain which was present during the night also. On physical examination, an ill-defined mass of 10 x 8 cm approximately, hard in consistency was noticed in the coccygeal region. The mass was found to be fixed to the underlying structures and immobile. On per rectal examination, the mass could be felt in the left posterior quadrant which was hard in consistency and surface was found to be lobulated. The patient had no history of constitutional symptoms. Plain X-ray of the pelvis showed an ill-defined shadow of the mass with a corresponding destruction of the coccyx. Contrast computed tomography (CT) of abdomen and pelvis revealed a heterogenous lesion of soft tissue density in the midline and left paramedian region of the coccyx  measuring 8.4 x 8.9 cm as seen in Figure Based on the appearance and location, the differential diagnosis included chordoma or a soft tissue sarcoma. The chest radiograph was normal. Biopsy was done, which showed diagnosis to be sclerosing epithelioid sarcoma. Positron emission tomography (PET) scan was done which showed no metastasis.Operative detailsFollowing pre-anesthesia clearance, bowel was prepared to prevent fecal contamination in case of an unlikely event of a rectal perforation. In the prone position, the buttocks were retracted laterally with adhesive tape to expose the gluteal cleft. The coccygeal and anal regions were prepared with povidone-iodine. Lateral fluoroscopic image was used to locate the S3 level as shown in Figure A midline vertical incision is made from S3 till few centimeters caudal to the palpable mass. The tumor mass was separated from the surrounding tissues taking healthy margins circumferentially and separating it from skin and fascia laterally and from recto-sacral fascia ventrally taking care of the rectum. The tumor was removed en-bloc as seen in Figure However, sacral nerves were spared. Hemostasis was secured and the wound was closed in layers over a drain. The patient is symptom-free at two years follow-up.Pathological examinationThe resected specimen was of 12.5 x 8.5 x 7.5 cm and was submitted for pathological examination. The cut section was grey-white with minimal hemorrhages. Microscopic examination showed round to oval spindle-shaped epitheloid cells with mild pleomorphism embedded in eosinophilic collagenous bands of different thickness as seen in Figure Cells were arranged in files, cords, nests, vague whorled patterns, and sheets. Scant mitosis was seen without the presence of necrosis. Resection margins were free of infiltration. Immunohistochemistry was positive for vimentin and negative for other markers . The pathology examination was consistent with sclerosing epithelioid fibrosarcoma.Sclerosing epithelioid fibrosarcoma is a very rare mesenchymal tumor, which mainly affects patients of middle age with equal gender predisposition. It was first described by Meis Kindblom and grouped under low-grade fibrosarcomas . Being vOur patient was elderly female with a relatively rapid onset of symptoms (three months). SEF typically involves the extremities or the torso and presents as a deep tissue mass . The avaPathognomic histology finding includes epithelioid cells arranged in cords and nests in a background of dense collagenous extracellular matrix. SEF is likely to be mistaken for benign soft tissue lesions in lieu of their usual bland appearance including nodular fasciitis, fibrous histiocytoma, ossifying myositis or the hyalinizing leiomyoma. However, in lesions that demonstrate greater cytological atypia, the epithelioid appearance can lead to an improper diagnosis of metastatic carcinoma. With regard to intraosseous SEF, the dense collagenous matrix associated with the lesion can be misinterpreted as osteoid, leading to misdiagnosis as osteosarcoma -10.Electronic microscopy reveals cells of ovoid or angular configuration, with fine chromatin, and well-formed nucleoli. The cytoplasm has characteristics similar to those of fibroblasts, with abundant rough endoplasmic reticulum. Immunohistochemical study is confirmatory. This study must include the determination of cytokeratins, epithelial membrane antigen, common leukocyte antigen, muscle-specific actin, protein S-100, neurospecific enolase, desmin, and vimentin. The most characteristic is vimentin which is positive in our case.Due to the rarity of the condition no standard treatment protocols have been advocated. Moreover, preoperative or postoperative radiation as used in other soft tissue sarcomas also should be considered in cases which cannot be excised with clear margins.To our knowledge, this is the first case of coccygeal sclerosing epithelioid fibrosarcoma. Due to lack of literature reporting SEF in coccyx region, it is not uncommon to confuse these tumors with chordoma arising from sacrum and surgeon should always keep in mind a differential diagnosis of SEF in tumors arising from coccyx.Sclerosing epithelioid fibrosarcoma is histologically low-grade sarcoma but clinically aggressive tumor. A differential diagnosis of SFE should be made in tumors arising from coccyx. All cases of coccydynia should not be treated as idiopathic and clinical; radiological examination should be done in all patients.


Specifically in neck level IIb, the expected normal anatomy does not contain any vital structures and consequently it might direct a surgeon to perform rapid surgical dissection of tissues. Therefore aberrant anatomy of the vessels in the patients may be overlooked during neck dissection. Unexpected and potentially devastating injuries can be avoided by respecting the possible aberrant anatomy in any level of the neck. In this case report, a 74-year-old man was presented with laryngeal carcinoma who was treated with laryngectomy and bilateral neck dissection. During the left side neck dissection, tortuous internal carotid artery imitating a metastatic mass was unexpectedly encountered in level IIb. As in this case, surgeons should keep in mind possible aberrant anatomy during the neck dissection and perform surgery staying in surgical principles to be safe for an unforeseen and potential dangerous injuries.  Specifically in neck level IIb, the expected normal anatomy does not contain any vital structures and consequently it might direct a surgeon to perform rapid surgical dissection of tissues. Therefore aberrant anatomy of the vessels may be overlooked during neck dissection. Unexpected and potentially devastating injuries can be avoided by respecting the potential unexpected anatomy of the neck .In this presentation, a male patient with tortuous internal carotid artery (ICA) which was mimicking a metastatic mass in neck level IIb was reported and the importance of anatomic variations was emphasized.A 74-year-old man was admitted to our clinic with dysphonia and dyspnea. In laryngoscopic examination, an ulcerovegetating mass was seen in laryngeal surface of epiglottis, left ventricular fold, and left vocal fold. The mass exceeds the midline and extends to the right side of the laryngeal surface of epiglottis. On the left side, the movement of arytenoid could not be observed. Histopathologic examination of the biopsy specimen was evaluated as squamous cell carcinoma of the larynx. MR imaging showed a mass with contrast enhancement in the larynx. Total laryngectomy and functional neck dissection for both sides of the neck were planned. During the neck dissection on the left side, though there was a lymphadenopathy in level IIa, it was decided to add the level IIb to the dissection. During the dissection of level IIb, we detected a mass embedded into lymphoadipose tissue by palpation. Though the mass was pulsatile, careful dissection was performed and it was understood that the pulsatile mass was a continuation of the tortuous internal carotid artery mimicking a metastatic mass at the first glance . The angAberrant routes of the extracranial ICA are widely known and not unusual anatomic variations, but their clinical effect is underestimated. In the literature, it is possible to read previously reported several anatomic variations of ICAs. Prominent parapharyngeal ICA anomalies can be found in up to 5% of the general population and may place the artery into close correlation with the pharyngeal wall, where it is at risk of damage particularly during surgical interventions , 3. TortThere are two provoking factors that appear to play a role in the development of ICA aberrations: age-related degenerative changes in the vessel wall and embryological maldevelopment, as well as the combination of both . BecauseAnomalies that are located anatomically in an important region and have a major risk for complications should be recognized by radiologists in the preoperative imaging taken before the surgery and the surgeon should be warned for such anomalies. In fact, the surgeon should review the imaging to guarantee him/herself despite the report of the radiologist. MRI was taken for our patient before the surgery but neither the radiologist nor we paid attention for this anomaly in the images. Briefly, preoperative imaging is an important tool for surgeons while planning the surgery.ICA anomalies are noteworthy because when ICA is tortuous, the vessel lacks a definitive muscular layer and will be softer than normal . Also, r


Since disc sequestration that mimics a tumor is rare and sometimes presents with an atypical appearance upon magnetic resonance imaging (MRI), it is often confused with other more common epidural and intradural neoplasms, particularly neurinoma. Open surgery is necessary due to the difficult of achieving a definitive diagnosis using computed tomography, MRI, and gadolinium- enhanced MRI prior to operation. Herein, we describe the use of coronal MR images of 3D fast-field echo with water selective excitation in the diagnosis of disc sequestration mimicking a tumor.Two patients were admitted to our hospital with back pain, radiating pain, and hypoesthesia in the right lower limb. MRI revealed tumor-like masses in the lateral recess of L3 and posterior to the body of L4. The initial diagnosis indicated disc sequestration mimicking a tumor and neurinoma. The coronal MR images of 3D fast-field echo with water selective excitation showed a clear boundary between the tumor-like mass and the nerve root. Moreover, the mass was also completely separated from the dura. Therefore, neurinoma was excluded as a possible diagnosis prior to operation. Surgical excision to perform removal of the gross mass was performed in one patient. The histopathological diagnosis was consistent with the 3D fast-field echo with water-selective excitation MRI. Another patient was successfully treated by minimally invasive endoscopic surgery.Disc sequestration that mimics a tumor is difficult to diagnose preoperatively. As a non–invasive strategy, coronal MR images of 3D fast-field echo with water selective excitation is a helpful imaging tool for differentiating between diagnosis of disc sequestration that mimics a tumor and neurinoma prior to operation. If the disc fragment of mimicking tumor can be identified prior to operation, open surgery may not be necessary for all patients. Minimally invasive endoscopic surgery also is an alternative strategy. Disc sequestration is defined as the migration of a herniated disc fragment into the epidural space such that it is completely separated from the parent disc . MagnetiA 57-year-old man with a 10-year history of intermittent pain of the lower back and a 7-month history of intermittent pain of the right lower limb was admitted to our clinic. He complained of increased pain and hypoesthesia of the right lower limb that had started 1 month prior. Physical examination revealed that the pain was located in the distribution of L4 and weakness of the left extensor digitorum longus. Using a 10-cm visual analog scale (VAS), the patient reported the intensity of his leg pain to be 7/10, with an Oswestry disability index (ODI) score of 70. Negative Lasegue’s sign was shown bilaterally on the lower limbs. T1-weighted images (T1WI) of MRI revealed a tumor-like mass with signal intensity posterior to the body of L4 Fig. . But, thA 63-year-old male was admitted to our hospital with back pain and radiating pain in the right lower limb that persisted for 3 months. Upon admission, his neurological examination revealed hypoesthesia of L3 and L4 in the right lower limb. Meanwhile, the patient presented a score of 6 on the VAS and a score of 64 on ODI. A negative Lasegue’s sign was observed on the bilateral limbs. T2-weighted images (T2WI) in the axial planes revealed a dumbbell mass in the lateral recess Fig. . Gd MRI Sequence development was conducted on a 3.0 T whole-body scanner  with a spine coil. Conventional axial T2 fast spin echo (4180/102) (repetition time ms/echo time ms), sagittal T2 fast spin echo (2200/120), and sagittal T1 fast spin echo (460/20) were used to acquire the original images. Then, 3D coronal CUBE-MRN sequence was acquired using the following acquisition parameters for a 1 mm-thick section without an overlapping section gap: a repetition time of 2000 ms, echo time of 32 ms, 352 × 256 matrix, 32 cm file of view, 20°flip angle, and 2 signal-intensity acquisitions. Original coronal fast spin echo images were acquired. We set the imaging plane to be parallel to the longitudinal axis of the lumbar spinal cord and centered on the level of the L3 vertebral body. The coronal image was reconstructed using maximum intensity projection and volume rendering technique on ADW version 4.6 software.Disc sequestration is defined as the migration of a herniated disc fragment into the epidural space such that it is completely separated from the parent disc . Far migLike the previous reports, we were also unable to make a definitive diagnosis for the present cases depending on CT, MRI, and gadolinium-enhanced MRI before operation because of uncharacteristic radiological appearance. However, within this study we have demonstrated that the use of the coronal MR images of 3D fast-field echo with water selective excitation (3D MRI) was capable to differentiating a sequestered disc fragment from other neoplasms prior to operation.A series of literatures –22 with In 2017, Takano et al.  successfUnlike discography, 3D MRI is a non–invasive imaging examination modality. Compared to conventional MRI, 3D MRI can display the whole view of the nerve root, including the extraforaminal region . MeanwhiSince the disc fragment appeared similar to a neurinoma on T1WI and T2WI of MRI in the present cases, neurinoma was speculated prior to operation by us. However, 3D MRI showed a clear boundary between the mass and nerve root. Moreover, the authors found that the mass was also completely separated from the dura in the 3D MRI view. As a result, we excluded neurinoma as a possible diagnosis prior to operation, and minimally invasive endoscopic surgery was performed in the patient. Postoperatively, histopathology confirmed that the mass was consistent with a degenerated intervertebral disc.This case report indicates that 3D MRI as a non–invasive imaging examination is a helpful tool for differentiating between an epidural disc fragment that mimicked a tumor and neurinoma prior to operation. If the disc fragment of mimicking tumor can be identified prior to operation, open surgery may not be necessary for all patients. Further verification for the usefulness and deficiency of 3D MRI on differentiating the disc of mimicking tumor ought to be considered using larger sample size in future study.


Gastrointestinal tract cancers are highly lethal malignancies with early metastatic dissemination. Chemotherapy is therefore of crucial importance in advanced cancer for obtaining palliation of symptoms and improving survival. However, there is no universal standard chemotherapy regimen for the treatment of gastroesophageal cancer. Also, complete remission is an uncommon outcome in advanced gastroesophageal cancers treated with chemotherapy; and where encountered, the response is not sustained. We present a 65 year-old patient who presented with advanced gastric adenocarcinoma. She had histopathologically proven liver metastases. She was treated with chemotherapy comprising of six cycles of Docetaxel, Oxaliplatin and Capecitabine (DOX). She showed complete remission with disappearance of local as well as liver lesions, and achieved disease free status for 9 months. This is the first known sustained Complete Response in a case of advanced gastric carcinoma with DOX combination regimen. Cancers of the upper gastrointestinal (GI) tract are highly lethal malignancies with propensity for early metastatic dissemination . Gastric2 followed by oxaliplatin 50 mg/m2 on days 1 and 8, with capecitabine 625 mg/m2 BID from days 1 to 14, in 21-day cycles. The protocol was well tolerated by the patient except for grade 2 hematologic toxicity, which responded to blood product transfusions, erythropoietin and G-CSF. Patient also experienced diarrhea, managed with supportive therapy. A thorough workup done was after 3 and 6 cycles of chemotherapy to evaluate the response. Investigations at the end of 6 cycles of chemotherapy (November 2007) showed decreased gastric lesion, with a wall thickness of 8 mm on CT abdomen  and elevated alkaline phosphatase levels (310 U/L). Esophagogastroduodenoscopy (EGD) showed large ulcerated lesion at the fundus, extending into the esophagus. CECT abdomen showed mass lesion in gastric cardia extending to involve the gastroesophageal junction and fundus, with compression of fat planes and wall thickness of 44 mm. There were multiple space occupying lesions (SOLs) in the right lobe of liver, the largest measuring 4.3 x 3.1 cm . Tissue  abdomen ; the par abdomen . This paPalliative systemic chemotherapy is more beneficial as compared to supportive care alone for patients with advanced gastric cancer . CytotoxWith this background, we modified the efficacious, albeit toxic DCF regimen, by replacing cisplatin with oxaliplatin and 5FU with capecitabine, to make it more tolerable and easier to administer while maintaining efficacy. The rationale for combining docetaxel with capecitabine is the synergism between the two, as docetaxel upregulates thymidine phosphorylase enzyme in the tumor cells. This enzyme is responsible for conversion of capecitabine to its active metabolite, 5-FU that kills cancer cells . DOX reg


Herein we describe the case of an elderly diabetic gentleman presenting with a two-week history of dyspnea and nonproductive cough, found to have a large left anterolateral chest wall mass. Further characterization through computed tomography (CT) of the chest revealed a soft tissue mass in the left anterior lower hemithorax found to be hepatocellular carcinoma (HCC). The liver, spleen, and pancreas were unremarkable. Diagnostic labs were unremarkable. The patient had no history of hepatitis, alcohol abuse, or illicit substance use. Pathological examination and immunohistochemical staining of the chest mass biopsy were consistent with metastatic hepatocellular carcinoma (HCC). The patient opted to pursue no further medical intervention and expired two weeks later. To the authors' knowledge, this is one of very few descriptions of isolated hepatocellular carcinoma found in the absence of a primary liver lesion and classical risk factors for hepatocarcinogenesis. This case highlights that HCC may present independently of liver lesions seen on imaging in a patient without clear signs or symptoms of liver. HCC should be considered in cases of isolated tumors with unclear primaries as ectopic carcinogenesis and occult primary malignancy are possibilities. Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, estimated to be responsible for over one million cancer deaths annually . ImportaThe clinical presentations of HCC are highly variable. One case describes a patient presenting with oral pain and who was found to have HCC metastasized to the jaw . HoweverAn 82-year-old man with a past medical history of diabetes mellitus presented to the hospital with a two-week history of worsening shortness of breath, cough, and pain on the left anterolateral chest wall. Prior to this, the patient was only taking metformin for diabetes. He would visit his primary care physician yearly and had no previous lab abnormalities on routine examination. He was a former tobacco user but had no history of alcohol, or illicit substance use.He was hemodynamically stable with an oxygen saturation of 90% on room air. Physical examination revealed decreased breath sounds of his left lower lung fields and exquisite tenderness to palpation of his left anterior chest wall with no crepitus. This area was mildly indurated.μL) with normal liver enzymes and basic metabolic panel. HIV and hepatitis screening panels were negative. A chest radiograph revealed a dense opacity at the periphery of the left lung base concerning for a mass. Further characterization through computed tomography (CT) of the abdomen and thorax with contrast demonstrated a 10 × 13.3 cm soft tissue mass in the left anterior lower hemithorax, extending from the left anterior sixth rib to the external oblique muscle and left pericardium (Laboratory examinations showed a mild leukocytosis (11,700/icardium . Furthericardium . A biopsWe have presented herein the unusual case of a gentleman with HCC presenting as a solitary lesion in the left anterolateral chest wall. On their own, chest wall tumors themselves are quite rare in the American and European populations .Reports of HCC in the absence of a culprit primary liver lesion are exquisitely rare, especially as a first presentation of the disease , 4, 9. HAn alternative possibility is that the malignant lesion arose from ectopic hepatocellular tissue. Ectopic liver is found infrequently and has been reported to be found in structures near the liver, omentum, retroperitoneum, and thorax . EctopicA final explanation is that the patient had developed NAFLD with an accompanying noncirrhotic liver. In this patient, the only salient risk factor for HCC was diabetes mellitus, which is known to predispose to the development of NAFLD. Furthermore, NAFLD itself may provoke hepatic carcinogenesis even in the absence of liver cirrhosis . Among tFurther work is needed to clinically and pathologically distinguish ectopic liver giving rise to HCC from isolated metastases of occult HCC lesions. It is possible that patients with ectopic HCC may have better long-term prognosis . Such a This case demonstrates that HCC may present independently of clear liver lesions on radiographic imaging, even in a patient without clear signs or symptoms of liver disease or multiple risk factors for malignancy. Although it is impossible to say which particular insult may lead to hepatocarcinogenesis, a systematic approach to diagnosing and treating risk factors—such as hepatitis, illicit substance abuse, and obesity—should be adopted. We propose that clinicians encountering the exceptional cases of isolated malignant lesions without detectable lesions in the native organ, such as the liver, attempt to distinguish ectopic carcinogenesis from occult primary lesions with metastases.


The differential diagnosis of cystic adnexal masses includes various pathologies, some placed extragonadally. Herein, we present two different cases of omental ovarian dermoid tumours that were diagnosed using ultrasonography and removed with surgery. The greater part of the omental teratomas appear to have developed from self-amputation of cysts in the ovary, followed by their re-implantation into the omentum. Omental teratomas can be located in the pelvis, where they might be mistaken for an adnexal mass, an upper abdominal mass, or a periumbilical mass. The location of omental teratomas might slightly change from one examination to another. In such cases, preoperative diagnostic imaging methods may not provide adequate information to physicians. Gynecologists should always keep in mind the possibility of intraabdominal ovarian parasitic cystic teratomas in the differential diagnosis of suspicious adnexal masses during surgery. Awareness among gynecologic surgeons of such masses may help prevent misdiagnosis, delayed surgery, or the use of wrong surgical approaches. Although teratomas are rarely encountered in the omentum, parasitic dermoid cysts are often localized in the omentum. Lebert first described omental dermoid cysts in 1734. These cysts are usually observed among reproductive-age women, although they can also be found in young girls and elderly women in certain cases. An examination of the current literature showed that there have been only 31 cases of omental teratomas described to date, and three of these cases had both dermoid cysts in the ovaries and teratomas in the omentum. In this report, we present two patients with teratomas in the omentum, one a woman aged 34 years, and the other a postmenopausal woman aged 74 years; both patients’ dermoid cysts were surgically treated with ovarian cystectomy.In contrast to dermoid cysts, which are also known as mature cystic teratomas and represent a frequently observed type of ovarian tumour, parasitic ovarian dermoid tumours tend to be highly uncommon, accounting for only 0.4% of teratomas in the ovariesOur first case was a nulliparous woman aged 34 years who had been married for six months, and was initially admitted to another centre because of symptoms of severe pelvic pain. A cystic mass was identified in the patient’s right adnexal area after an ultrasonographic (USG) assessment was conducted, and she was subsequently referred to the Gaziantep University Faculty of Medicine, Department of Gynecology and Obstetrics. The USG performed at our centre identified a 10 cm cystic mass in the right adnexal area with internal echogenic focus. The left ovary and uterus were normal, and the patient had a regular menstrual cycle. Preoperative assessment of cancer antigens (CA) 125 and 19-9 indicated values within normal range. Laparotomy was performed in January 2015 based on a preliminary diagnosis of ovarian dermoid cyst. The left ovary and oviduct were visible in a perioperative examination, but the right ovary and oviduct could not be observed. In the fundus of the uterus, we observed a 10 cm dermoid cyst surrounded by the omentum that had adhered to the uterus wall . After pOur second case was a postmenopausal woman aged 74 years who was initially admitted at another centre because of severe pelvic pain. After a dermoid cyst was suspected in the patient’s magnetic resonance ımaging (MRI) evaluation, she was referred to the Gaziantep University Faculty of Medicine, Department of Gynecology and Obstetrics. USG performed at our centre revealed atrophy in the uterus and bilateral ovaries. Preoperative assessment of CA 125 indicated normal values and CA 19-9 was 62 U/mL. A laparotomy was performed in February 2015 based on a preliminary diagnosis of ovarian dermoid cyst. A perioperative examination revealed an atrophic left ovary and oviduct, but the right ovary and oviduct could not be seen. The omentum was adhered to the abdomen, and contained a 5 cm dermoid cyst . The der. The underlying mechanism for the development of teratomas in the omentum has not yet been clarified; however, there are three theories on the possible cause for these cysts’ occurrence and their diverse locations:Teratomas generally develop from germs cells within the gonads. In the early stages of embryonic development, germs cells inside the yolk sack move towards the genital ridge by migrating along the hindgut. These germ cells, which are totipotent, develop into various types of tissues. The cells’ movement over the hindgut also indicates why teratomas can occur in a variety of locations1. Omental teratomas might develop from germ cells that, for one reason or another, may have been displaced.2. Omental teratomas might develop within a supernumerary ovary..3. Omental teratomas might develop due to the self-amputation of a dermoid cyst in the ovary, and then become re-implanted into the omentum. The omentum, which assumes an important role in the inflammatory defence mechanism of the intra-abdominal area, is the most common target for the cysts’ re-implantation. In both of our cases, the dermoid cysts lacked any visible blood supply and vascularization, which suggests that they might have become detached from the ovary through self-amputation as a result of torsion. Although the clinical picture of parasitic dermoid cysts normally includes abdominal pain, it may also be associated with uncommon signs such as distension in the abdomen. The only symptoms observed in our patients were severe pelvic pain. Teratomas of the omentum normally appear as palpable round and mobile masses in the abdomen. They can be located in the pelvis, where they might be mistaken for an adnexal mass, an upper abdominal mass, or a periumbilical mass. The location of omental teratomas might slightly change from one examination to another. One of our patients exhibited a mobile and palpable mass in the right pelvic area during her physical examination, whereas the other patient’s physical examination revealed no abnormal findings. A preoperative diagnosis of omental teratoma is often difficult. Diagnosis can be established using computerized tomography, MRI, and USG. However, a definite diagnosis usually requires histopathologic examination, which helps distinguish immature from mature teratomas. Although omental teratomas are benign tumours in the majority of cases, a number of malignant omental teratomas have also been reported(. Only three cases of immature teratoma have been reported in the English literature. Immature teratomas, which are also known as nongerminomatous germ cell tumours, consist of primitive neuroectodermal, endodermal or mesodermal tissue. They have a higher susceptibility to metastasis compared with mature teratomas. In addition, age, sex, and location of the tumor can affect their aggressive behavior. The management of these patients, including early stage disease, is chemotherapy after surgery has been performed. The bleomycin-etoposide-platinum combination is the most recommended protocol for all stages of nonseminomatous germ cell tumours. Standard treatment involves laparoscopy and laparotomy, with tumour excision accompanied by partial omentectomy; this is sufficient in most cases. The treatment approach against omental teratomas is determined based on the tumour’s level of maturity, with full surgical excision providing adequate treatment against mature teratomas.Of the three mechanisms listed above, the third is likely to have been the underlying cause in our two cases. The dermoid cysts in our cases could have detached from their initial location after losing their blood supply, and then moved to another location where they re-vascularized and gained a new blood supply. There is also the possibility that previous surgical treatments might have left ovarian tissue remains that later became parasiticIn conclusion, the greater part of the omental teratomas in our patients appear to have developed from the self-amputation of adnexal cysts in the ovary, followed by reimplantation into the omentum. Although ultrasonography and computerized tomography might aid diagnosis, determining the exact location of intraabdominal ovarian parasitic cystic teratomas with these methods can prove to be challenging. For this reason, color flow Doppler is often used to assist localization. In the event that laparotomic exploration reveals a unilateral lack of adnexa in a patient, the abdominal cavity should be explored for tumors that might have self-amputated and re-implanted in this area. In patients with such unusual unilateral absence of adnexa, gynecologic surgeons should consider the possibility of parasitic dermoid cysts that have re-localized in extragonadal areas during differential diagnosis. Awareness among gynecologic surgeons of such masses may help prevent misdiagnosis, delayed surgery, or the use of wrong surgical approaches.


Chronic intestinal pseudo-obstruction (CIPO) is a rare clinical syndrome in veterinary medicine characterized by severe intestinal dysmotility without evidence of mechanical occlusion of the intestinal lumen. The exact pathogenesis of CIPO is unknown.A 1-year-old male Miniature Bull Terrier dog was presented with a history of chronic weight loss, regurgitation, lethargy, vomiting and diarrhea. The dog was submitted for exploratory laparotomy. A full thickness intestinal biopsy was taken and a CIPO was suspected. The clinical condition deteriorated and the dog was euthanized. At gross examination the small intestine was severely dilated. Histologically severe fibrosis of the submucosa and severe atrophy of the tunica muscularis were present in small intestine and colon. Immunohistochemical examination with a panel of antibodies for gastro-intestinal neuromuscular disease-associated antigens revealed a severely reduced expression of alpha-smooth muscle actin in the tunica muscularis.This case report describes the gross, histological and immunohistochemical findings of CIPO affecting a 1-year-old Miniature Bull Terrier; on the basis of these findings a myopathic form of CIPO is hypothesized in this case. Chronic intestinal pseudo-obstruction (CIPO) is a rare clinical syndrome in veterinary medicine characterized by severe intestinal dysmotility without evidence of mechanical occlusion of the intestinal lumen. In the veterinary literature, few cases of CIPO affecting dogs, horses and cats have been reported –10. In hIn dogs, most cases have been related to an idiopathic fibrosing enteropathy or fibrosing gastrointestinal leiomyositis, or less frequently to dysautonomia –10, 13. A 1-year-old male Miniature Bull Terrier dog was presented with a 2-month history of chronic weight loss, regurgitation, lethargy, vomiting and diarrhoea. The dog received prokinetic treatment, antiemetics, antimicrobial agents, and intravenous fluid therapy, without significant clinical improvement. Abdominal radiographs revealed marked small intestinal dilation. On exploratory laparotomy, the small intestine was not obstructed but appeared markedly distended and a full-thickness biopsy of the jejunum was taken. Histological examination revealed severe atrophy of the tunica muscularis and fibrosis of the tunica submucosa and a diagnosis of CIPO or neuromuscular disorder was suspected. Following the histopathological examination, the dog was unsuccessfully treated with glucocorticoids. Due to the persistent clinical signs of dysmotility, the dog’s clinical condition severely deteriorated thus euthanasia was elected.®Plus slides and an avidin–biotin–peroxidase-complex (ABC) technique with diaminobenzidine as the chromogen was performed. A panel of antibodies to the following antigens was used: alpha-smooth muscle actin (α-SMA) , CD3 , CD79a , CD117 , glial fibrillary acid protein (GFAP) , neurofilaments , neuron specific enolase (NSE) , S-100 , and synaptophysin . Appropriate negative and positive controls including gastrointestinal tissue sections of an healthy dog were used for the immunohistochemical analyses. The specificity of the different antibodies was evaluated considering the information available in the datasheet for each antibody. Moreover, the specificity and cross-reactivity of the antibodies were evaluated based on published studies [At necropsy the dog appeared dehydrated, in poor nutritional condition and with minimal body fat amounts. The small intestine was severely dilated and filled by a variable amount of grey-greenish fluid Fig. . The eso studies –19.Fig. Histological findings for duodenum, jejunum, ileum, cecum, colon and rectum consisted of severe diffuse atrophy of the tunica muscularis and severe locally-extensive to diffuse fibrosis of tunica submucosa as demonstrated by Masson’s trichrome stain Fig. a–d. SimiIn veterinary medicine, most of the reported cases of canine CIPO were histologically characterized by fibrosis and muscular atrophy of the gastro-intestinal tract along with variable inflammation centred on the tunica muscularis (leiomyositis) , 5, 7, 8In human medicine, immunohistochemistry is used in order to discriminate between different forms of CIPO: myopathic, neuropathic and those caused by abnormalities of the interstitial cells of Cajal, by means of a panel of antibodies able to identify which neurointerstitial-muscular component is involved , 12, 21.Neuropathy was not considered in our case due to the lack of enteric nervous plexus inflammation and the absence of neuronal degeneration. Additionally, the dog did not exhibit clinical signs consistent with dysautonomia. The clinical, histopathological and immunohistochemical findings of this rare case diagnosed with CIPO is consistent with enteric myopathy and intestinal fibrosis and could be referred to a myopathic form of GINMDs. In another CIPO case affecting a Pug, there was also a marked segmental loss of α-SMA expression in the intestinal muscular layer . These fIn conclusion, the present case report describes the first CIPO case described in a Miniature Bull Terrier and highlights the importance of immunohistochemical examination in order to characterize the type of GINMDS and add new information about the underlying pathogenic mechanisms. Further studies at the genetic level are necessary to explain if loss of α-SMA expression is associated with a specific genetic disorder.


Arterial aneurysms (AA) can be classified as true aneurysms, characterized by the persistence of all three layers of the arterial wall with progressive dilation and wall thinning; arterial pseudoaneurysms (APAs) are characterized by a tear in the vessel wall and a periarterial hematoma formation. They could occur due to a visceral, retroperitoneal, or peripheral origin. Most AA/APA are usually found incidentally, and it is imperative to be vigilant in order to diagnose and manage them due to their potentially life-threatening complications. We present a case of a 35-year-old woman presenting with right-sided abdominal pain mimicking renal colic with an initial misdiagnosis of ureteral calculus. Post-cystoscopy, a misdiagnosis was confirmed, and subsequently, the patient had a right retroperitoneal mass excision. The histopathology report concluded the calcified retroperitoneal mass to be pseudoaneurysm. Such pitfalls in diagnosis are essential to be shared with the larger medical community for increased vigilance and optimal management of pseudoaneurysms. There are no known reported data on the incidence of retroperitoneal arterial aneurysms and arterial pseudoaneurysms (AA/APA). However, visceral artery aneurysms (VAA) and visceral artery pseudoaneurysms (VAPA) are relatively rare, with a reported incidence of 0.01 to 0.2% in routine autopsies [A 35-year-old woman with no past medical and surgical history presented to the emergency department with severe colicky right flank pain radiating to right lower quadrant. The patient reported that the pain started two weeks previously and had been worsening since the last few days.A complete history was taken and physical exam performed, along with comprehensive laboratory and radiological evaluation. Elevated white blood cell (WBC) count with borderline renal function was noted, and an abdominal computed tomography (CT) was done without intravenous contrast Figure . This deAfter the diagnosis was made, the patient was admitted to the urology service, actively resuscitated with fluids, given pain medication, and observed. She deteriorated during the course of admission with increasing fever, chills, and worsening pain. We obtained repeat blood work along with the cultures from blood and urine, and the patient was immediately taken to the operating room for cystoscopy, retrograde ureterography, and ureteral stenting as a temporary measure of managing obstructive uropathy. The patient was taken to the operating room where cystoscopy revealed orthotopic ureteral orifices with unremarkable bladder architecture. An intraoperative stent was placed, and fluoroscopic examination revealed the presence of extra-ureteral lesion with calcification and the absence of any filling defect. The ureter ran medial to the calcification, and the J stent was left in situ. She was informed of her findings and was advised to have further investigation and management by excisional biopsy. However, the patient left the hospital against medical advice.She returned to the emergency room after three months, complaining of persisting right flank pain that was on and off, and was subsequently re-admitted to the urology service. Repeat CT scan confirmed the persistence of the mass. She consented for diagnostic laparoscopy and possible excisional biopsy of the mass. She was subsequently taken to the operating room where a laparoscopic evaluation was done, and the right retroperitoneal mass was noted Figure , which wThe patient was transferred to the post-anesthesia care unit (PACU) and was given optimal postoperative care.The specimen was dissected, and on removal, we noted an ellipsoid mass with a thick capsule which was beige in color, with a septae compartmentalizing a darker center. The proximal end had a indurated pellet of uncertain composition. We sent it for further histopathological exam which reported right retroperitoneal mass with changes consistent with pseudoaneurysm wall Figure . The spePseudoaneurysm, false aneurysm, pulsatile hematoma, and communicating hematoma are synonymous terms and may be used interchangeably. Pathologically, the wall of the arterial pseudoaneurysm has been breached; the external wall of the aneurysmal sac consists of arterial layers with perivascular tissue, blood clot and/or layers of reactive fibrosis and might undergo further changes with time, like calcification . RetropeVAA, VAPA, and retroperitoneal aneurysms most commonly involve celiac trunk, the superior, inferior mesenteric, renal arteries, and their branches. The pathogenesis of pseudoaneurysm is poorly established and may be associated with aforementioned risk factors, but sometimes might be idiopathic as in our case where the young female patient did not have the aforementioned associations. Clinical presentation of individual VAA/VAPAs differs depending on anatomic location, size, and organ associations. Though often asymptomatic , the incDespite recent advances in surgical techniques and diagnostic tools, management of visceral artery aneurysms remains extremely challenging. There is no consensus on the optimal management of VAPA and retroperitoneal aneurysms (surgery v/s endovascular procedure) -9 due toVAA/VAPA and retroperitoneal aneurysms commonly can be treated with endovascular intervention (covered stent and coiled embolization) or operative repair that consists of exclusion of the aneurysmal sac from the systemic circulation while ideally preserving distal blood flow. Current literature indicates that open and endovascular approaches have similar rates of technical and clinical success. However, it should be duly noted that the endovascular approach has resulted in rupture of pseudoaneurysm and bleeding which has been reported . In caseFrom our search of literature, we were unable to delineate the exact or approximate distribution percentage of retroperitoneal or VAPAs and the frequency of their occurrence and hence, their rarity and importance of awareness and vigilance, although with an increasing number of reported cases, they might be present more and could often be missed during diagnosis. Our case is unique and multivariate, featuring a misdiagnosis of ureteral calculi, and later, an intraoperative diagnosis of a vascular mass. We confirmed the diagnosis to be a pseudoaneurysm. Our report clearly demonstrates the low threshold for prudence with regards to VAA, VAPA, and retroperitoneal aneurysms in our day-to-day differentials. Through this, we would like to emphasize the importance of vigilance in our day-to-day practice of this diagnosis.


We describe a rare case of retroperitoneal endometriotic cyst infiltrated in the iliopsoas incidentally found in a patient with acute back pain. Endometriosis at the pelvic peritoneum, including the Douglas pouch, has been reported often; there are few reports of cystic endometriosis in the retroperitoneal cavity. Today there are various theories regarding how endometriosis occurs. By pathological findings and lesion sites of the present case, we concluded that the endometrial tissues in the menstrual blood might metastasize lymphatically and implant and form the retroperitoneal cyst.  An endometriotic lesion occurs frequently in the ovary, pelvic peritoneum, and Douglas pouch but rarely at other sites. In recent years, an endometriotic lesion that occurs at an atypical site has been defined as scarcity endometriosis in Japan. We describe a case of a retroperitoneal endometriotic cyst that infiltrated the iliopsoas and was incidentally found in a patient with acute back pain. Here, we describe the patient's clinical course and pathological findings and discuss the pathogenic mechanisms.The patient was a 43-year-old, gravida 0, para 0, woman with a history of leiomyomectomy at the age of 28 years. She felt sudden pain between the left lower abdomen and lower back 3 days before her first visit, and she took analgesic drugs; however, the pain persisted. Originally, she did not have additional menstrual disorders and the lumbar backache was not related to menstruation cycle. The computed tomography (CT) scan showed enlargement of the uterus, which led us to suspect uterine sarcoma and para-aortic lymph node metastasis that infiltrated the iliopsoas. She was referred to our hospital for a detailed examination. Her abdomen was enlarged 5 cm above the umbilicus, and we recognized the left costovertebral angle knock pain. The transvaginal ultrasonogram showed a great mass with echo-free space in the uterus, and we suspected uterine fibroma. The serum levels of CA-125 and CA-19-9 were increased to 514.3 U/mL and 299.2 U/mL, respectively. However, the levels of CEA and lactate dehydrogenase were within normal ranges. The pelvic magnetic resonance imaging scan showed adenomyosis of the uterus and a mass lesion measuring 19 × 15 × 7 cm on the left side of the uterus with many cystic and hemorrhagic cavities. The mass had low-intensity enhancement on T1-weighted and T2-weighted images, and it did not have decreased diffusion. The bilocular cystic mass with hemorrhaging was found in the retroperitoneal cavity. The retroperitoneal cyst was 5.3 × 2.7 × 4.0 cm and did not have solid parts, and it had high-intensity enhancement on T1-weighted and T2-weighted images with shading. Therefore, we diagnosed the patient as having endometriotic cysts. Using contrast-enhanced CT, we found that this bilocular cystic mass was located caudally from the left renal hilus. The cranial cystic wall was relatively thick; however, it did not have solid parts Figures . The cysGross findings showed a 22-cm mass at the uterine corpus. Poorly marginated adenomyosis existed in the left side of the uterus . The retThe mass of the uterine corpus was associated with bleeding, and hyalinizing and eosinophilic spindle cells grew with a fascicle-like structure. Adenomyotic tissues existed in the surrounding area. The retroperitoneal cyst had exfoliated epithelia, and most cystic walls were fibrous tissues with bleeding and hemosiderosis. However, we recognized the endometrium-like tissues and endometrial stromata with CD10 expression .Atypical endometriosis that occurs at sites other than female genitals has been defined as scarcity endometriosis, which develops at various sites, such as the intestine, bladder, urinary duct, diaphragm, chest cavity, and abdominal wall. Various symptoms occur depending on the original site and invasion depth. Intestinal endometriosis occurs most frequently among those with scarcity endometriosis, and the common sites are the rectum and sigmoid colon . AlthougThere are various theories regarding how endometriosis occurs, such as the implantation theory, coelomic metaplasia theory, embryonic residual theory, hematogenous dissemination theory, and lymphatic dissemination theory , 6. Thes


Cerebellar hemangioblastomas are rare tumors of the neuraxis. Only seven cases of hemangioblastoma associated with a cerebral aneurysm have been reported. We report a case of a patient who presented with acute onset headache as a result of subarachnoid hemorrhage (SAH) and hydrocephalus. Radiographic workup revealed a hemangioblastoma with an intratumoral aneurysm. Preoperative cerebral angiography was performed for both embolization as well as characterization of the aneurysm. The patient underwent a suboccipital craniotomy for tumor resection. The patient’s postoperative course was unexpectedly complicated by delayed ischemic neurologic deficit secondary to flow-limiting left internal carotid artery vasospasm. We present a case report, review of the literature, and management considerations for patients who present with tumors and an associated ruptured aneurysm. Hemangioblastomas account for approximately 7 to 10% of tumors arising in the posterior fossa and can develop sporadically or in association with Von Hippel-Lindau disease (VHL). Despite the highly vascularized nature of the tumor, clinical presentation with spontaneous subarachnoid hemorrhage (SAH) is rare . We repoA 70-year-old male presented to the hospital with complaints of severe headache, confusion, and gait instability. He became progressively obtunded in the emergency department. A non-contrast computed tomography (CT) of the head demonstrated diffuse SAH and ventriculomegaly Figure . The patHemangioblastomas are highly vascularized tumors that occur due to sporadic development or as a result of VHL. Sporadic cases represent over 70% of hemangioblastomas, which are most often discovered in the posterior cerebellum or cerebellar vermis -2,4. ThePresenting neurologic deficits are typically caused by direct tumor compression or tumor hemorrhage. Clinical manifestations depend on the location and nature of the lesion, but common signs and symptoms arising from lesions of the cerebellar region include obstructive hydrocephalus, headache, ataxia, and nausea ,4. In thManagement of cerebellar hemangioblastomas uniquely encompasses nuances of both tumor and vascular malformation resection. The primary treatment modality is surgical resection while radiation therapy is reserved for unresectable tumors. Preoperative embolization is often completed to reduce bleeding risk and facilitate tumor resection, but some studies found no reduction in operative complications and rather an increased risk of postoperative morbidity and mortality . The decVasospasm and DIND following tumor resection are rare. Proposed mechanisms of vasospasm following aneurysmal bleeding include smooth muscle constriction secondary to increased calcium release, dysregulation of vasoconstrictors and vasodilators, and vascular remodeling. Vigilant monitoring can prevent significant morbidity and mortality after aneurysmal SAH (aSAH) but typically does not apply to tumor resection. One case reported by Prontera, et al. documented vasospasm of the anterior inferior cerebellar artery 12 days after resection of a medullary hemangioblastoma . Though Hemangioblastoma presenting with aneurysmal SAH is atypical. Preoperative embolization of the tumor in similar cases is warranted for the reduction of intraoperative bleeding and has been supported with previously described good outcomes. The few similar cases available for review encourage the initiation of an institution’s aSAH management protocol to prevent vasospasm and DIND, although the true risk remains uncharacterized. In the case of neurologic decline in circumstances such as these, it is imperative that early diagnosis and treatment must include vascular imaging and measures to prevent DIND once further hemorrhage has been excluded.


Some patients with thymoma present with a very large mass in the thoracic cavity. Although the most effective treatment for thymoma is surgical resection, it is difficult to perform because of the size of the tumor and the infiltration of tumor into the surrounding organs and vessels. We report a patient with a giant thymoma that was completely resected via a median sternotomy and left anterolateral thoracotomy.A 63-year-old woman presented with a mass in the left thoracic cavity that was incidentally found on a chest X-ray. Chest computed tomography revealed a giant mass (16 × 10 cm) touching the chest wall and diaphragm and pressed against the heart and left upper pulmonary lobe. Complete resection was performed via a median sternotomy and left anterolateral thoracotomy. The tumor was histologically diagnosed as a WHO type B2 thymoma, Masaoka stage II.Giant thymomas tend to grow expansively without invasion into surrounding organs and vessels. Surgical resection that employs an adequate approach must be considered, regardless of the size of the tumor. Thymic epithelial neoplasms are commonly located in the anterior mediastinum. The tumors typically show slow-growing behavior. Patients present with various clinical signs and symptoms that are associated with expansion of the tumor; the most effective treatment modality is surgery . Giant tA 63-year-old woman was seen at a local hospital for chest bruising secondary to an accident. Chest radiography revealed an abnormal shadow in the left middle and lower lung fields Fig. . The finA 16-cm anterolateral incision was made in the fifth intercostal space. The tumor occupied approximately half of the left pleural cavity Fig. . It was The resected specimen was 16.5 × 11.8 × 7 cm, and showed a well encapsulated tumor with lobules separated by fibrous bands Fig. . MicroscThymomas account for approximately 20% to 25% of all mediastinal masses in individuals of all ages and 47% of all mediastinal masses in adults , 5–14. TSurgical resection is generally accepted to be the most effective treatment for thymoma, and complete resection is an important prognostic indicator of long-term outcome . Large sA median sternotomy is the standard procedure for resecting a thymoma of normal size, but the procedure is controversial for giant thymoma Table . A clamsSome thymoma patients develop MG after thymectomy (“post-thymectomy MG”) regardless of whether or not they have a history or signs or symptoms of MG. Post-thymectomy MG develops in 1.0% to 28% of thymoma patients who have undergone thymectomy –23. PrevWe reported a rare case of giant thymoma that was successfully resected via median sternotomy and left anterolateral thoracotomy. Giant thymomas tend to be low-grade tumors that do not infiltrate adjacent organs and vessels. For successful treatment of giant thymoma, curative surgical resection must be considered, regardless of tumor size.


Pseudo-Meigs' syndrome is used to describe cases of ascites and/or pleural effusion associated with ovarian neoplasms other than benign tumors, which improve after removal of the ovarian lesion. We present three cases of pseudo-Meigs' syndrome secondary to ovarian metastasis from colorectal cancer. In case 1, the patient has severe dyspnea and hypoxia due to massive right pleural effusion; therefore preoperative thoracic drainage was needed. In case 2, the patient needed paracentesis every two or three days to improve abdominal distension. After two courses of 5-fluorouracil, levofolinate, and oxaliplatin (mFOLFOX6), her ascites could be controlled by diuretics without aspiration and her general condition improved. Then she underwent operation. In case 3, the patient developed a massive pleural effusion and ascites coincident with a rapid enlargement of ovarian tumor after resection and adjuvant chemotherapy for rectal cancer. In all cases, pleural effusions and/or ascites resolved and general conditions and daily activities of the patients improved after oophorectomy. They are all currently in good health without recurrence of pleural effusion or ascites. In patients with suspected pseudo-Meigs' syndrome secondary to ovarian metastasis of colorectal cancer, operation including oophorectomy may reduce pleural effusions and/or ascites and improve the general condition. Meigs and Cass reported 7 cases of nonmalignant ascites and/or pleural effusion associated with benign ovarian tumors that improved after removal of the ovarian lesion . ThereafA 48-year-old woman was admitted to the local clinic with vomiting. She was diagnosed with bilateral ovarian tumors. Right pleural effusion rapidly increased. She had severe dyspnea and was transferred to our hospital. Her abdomen was distended, and an abdominal mass was palpated. Laboratory tests showed anemia and elevated serum tumor marker levels . A chest X-ray showed a right pleural effusion. The cytology of the pleural effusion was class II. Colonoscopy identified a type 2 tumor in the sigmoid colon and a biopsy specimen from the tumor histopathologically showed a moderately differentiated adenocarcinoma. Contrast-enhanced CT scan displayed wall thickening of sigmoid colon and a huge intrapelvic tumor Figures . Her dysA 33-year-old woman was admitted to previous hospital with constipation and abdominal distension, and an intrapelvic tumor was identified. Colonoscopy and CT scan revealed ascending colon cancer, bilateral ovarian tumors, and peritoneal dissemination. She needed repeated paracentesis to improve dyspnea and severe abdominal distension. She was then referred to our hospital. Laboratory tests showed anemia, malnutrition, and elevated levels of tumor markers . Colonoscopy showed a type 3 tumor in the ascending colon, and a biopsy specimen revealed well-differentiated adenocarcinoma. CT scan displayed bilateral pleural effusion, massive ascites, wall thickening of the ascending colon with enhancement, and bilateral cystic ovarian tumors that were about 20 cm in diameter Figures . There wA 27-year-old woman was diagnosed with rectal cancer and underwent low anterior resection with lymphadenectomy, and R0 operation was achieved. Histopathological examination of the specimen revealed type 2 well-differentiated adenocarcinoma that was staged T4N2M0 and pathological stage IIIc according to the International Union Against Cancer TNM Classification of Malignant Tumors (7th Edition). KRAS mutation testing revealed the KRAS Q61H mutation. She underwent transvaginal oocyte retrieval from bilateral ovaries due to her hope for pregnancy. Subsequently, she received 8 courses of adjuvant chemotherapy with capecitabine and oxaliplatin (XELOX) for 6 months. After the therapy, follow-up CT scan showed no evidence of recurrence of rectal carcinoma. However, 3 months later, the patient felt abdominal distension, and CT scan revealed an ovarian tumor and right pleural effusion . LaboratClinical and histological findings are summarized in Ovarian metastasis from colorectal cancer is not commonly encountered by oncologists. Women with colon cancer reportedly developed metastasis to the ovary in 4.0% to 30.8% of cases , 6. MetaFormer studies suggested that there are three possible routes of metastasis for colon cancer to the ovary: the lymphatic vessels, blood vessels, and peritoneal dissemination. Sato et al.  and TomiWith regard to the etiology of ascites, Graffner et al.  proposedIt may be difficult to distinguish between metastasis to the ovary from colon cancer and primary ovarian carcinoma. Loy et al.  reportedPatients with metastatic colon cancer to the ovary are known to have poor prognoses. Terada et al.  reportedIn the present report, after operation, including oophorectomy, patients were discharged from our hospital without evidence of recurrent pleural effusion or ascites. When the patients with malignant ovarian neoplasms suffer from ascites and/or pleural effusion, it is essential to rule out pleural dissemination and carcinomatous peritonitis, make a diagnosis of pseudo-Meigs' syndrome, and consider operations including oophorectomy, which possibly reduce pleural effusion and/or ascites and improve the general condition of the patient. Further studies are warranted to elucidate etiology and efficacy of palliative operation for pseudo-Meigs' syndrome.


Streptococcus parasanguinis, along with a review of the literature. This case demonstrates the importance of early diagnosis and aggressive surgical treatment of aortoenteric fistulae and recognizing infectious aortitis as a potential etiology. Primary aortoenteric fistula is a rare cause of upper gastrointestinal bleed but can lead to significant mortality if the diagnosis is delayed. Aortitis, characterized by inflammation of the aortic wall, is a rare cause of aortoenteric fistula. We present a case report of a 72-year-old male patient with infectious aortoenteric fistula secondary to Streptococcus parasanguinis. Early recognition and urgent surgical repair lead to a favorable outcome.Primary aortoenteric fistula (PAEF) is a direct communication between the aorta and the intestinal lumen without prior reconstructive procedures on the abdominal aorta. Although rare with an estimated prevalence of 0.07% , PAEF isA 72-year-old male presented with chief complains of acute onset abdominal pain, back pain, and hematemesis. The patient reported vomiting around 2 ounces of blood followed by an episode of melena. He reported chills, fatigue, diaphoresis, and subjective fevers for the last week. He denied chest pain, shortness of breath, or cough. His past medical history was significant for a right lower lobe stage IB non-small cell lung cancer treated with radiation therapy currently in remission and polyangiitis obliterans with resultant upper and lower limb amputations. Physical examination revealed a temperature of 99.5 F, with a regular pulse rate of 74/min and a blood pressure of 136/83 mmHg. Abdominal exam elicited mild diffuse tenderness without guarding. Laboratory investigation was significant for anemia with hemoglobin of 8 g/dL. Inflammatory markers were elevated with a C-reactive protein of 12.6 mg/dL and erythrocyte sedimentation rate of 110 mm/h. No coagulopathy or thrombocytopenia was noted. Blood cultures were not drawn. Esophagogastroduodenoscopy (EGD) revealed a large pulsating bulge in the second portion of the duodenum. A 15 mm ulcer with an adherent clot was also visualized in the same region without active bleeding . Urgent  Streptococcus parasanguinis and antibiotics were deescalated appropriately. Acid-fast bacilli and fungal stains were negative. Surgical pathology revealed intense chronic active inflammation with the presence of necrotizing granulomas , defined as an abnormal connection between the aorta and the gastrointestinal tract, is a rare cause of upper gastrointestinal bleeding but can lead to significant morbidity and mortality if not promptly recognized. Two types of AEFs are described, primary aortoenteric fistula arising de novo between the aorta and the bowel or secondary aortoenteric fistula (SAEF) occurring after aortic reconstruction surgery. SAEF is far more common .The “herald bleed” is a common presentation of AEF that needs to be recognized early in order to prevent a later catastrophic hemorrhage. The diagnosis of PAEF is elusive as the classic triad of gastrointestinal bleeding, abdominal pain, and palpable mass is only found in 11% of patients  and uppe Streptococcus parasanguinis, a member of the viridans group, is associated with a variety of infections, mycotic aneurysm is uncommon. In our case, the source of infection was unknown.Aortitis, characterized by inflammation of the aortic wall , is an uTherapy of infected aneurysms relies mainly on a combination of antibiotic therapy, surgical debridement, and, if possible, revascularization . Timing Early diagnosis and aggressive surgical treatment of an AEF are vital to achieve a positive outcome. Aortitis is a rare cause of AEF that should be considered based on clinical, imaging, and surgical findings. Infectious aortitis, as seen in this case, should be considered as an etiology of aortitis in cases with suggestive history and radiological findings.


Malignant melanoma (MM) in the female genital tract accounts for less than 2% of all melanomas, and the vast majority associated occur in the vulva and vagina. Primary MM of the uterine cervix is extremely rare and its prognosis is very poor. We report a case of primary MM of the cervix with dissemination throughout the vaginal wall. A 66-year-old woman presented with postmenopausal bleeding. Gynecologic examination demonstrated a 2 cm polypoid blackish-pigmented tumor on the cervix with multiple small blackish-pigmented lesions throughout the vaginal wall. Cervical Pap smear cytology showed malignant melanoma. MRI and PET/CT did not detect any distant or lymph node metastases. She underwent radical hysterectomy, pelvic lymphadenectomy, and total vaginectomy. The pathological diagnosis was FIGO stage IIIA primary cervical MM. She received adjuvant chemotherapy with 6 courses of dacarbazine, but 6 months later, multiple lung metastases were detected. Despite 4 courses of anti-PD-1 antibody (nivolumab) treatment, she died of the disease 13 months after surgery. Malignant melanoma (MM) is a common neoplasm of the skin and mucous membranes. Less than 2% of all MMs occur in the female genital tract , and the～8.0). She underwent radical hysterectomy, bilateral salpingooophorectomy, pelvic lymphadenectomy, and total vaginectomy (A 66-year-old woman presented with postmenopausal bleeding. Gynecologic examination and colposcopic findings revealed a 2 cm polypoid blackish-pigmented tumor in the cervix, and multiple small blackish-pigmented lesions were found throughout the vaginal wall, spreading to the lower third of the vagina . Cervicainectomy  without inectomy . The tumPrimary MM of the cervix is a rare entity. The incidence of genital tract melanomas has been reported to be 1.6 cases per 1 million females . Most caNorris and Taylor  proposedThere is no consensus regarding standard management for primary cervical MM due to its rarity. The most common treatment based on the literature is surgery, including radical hysterectomy coupled with pelvic lymphadenectomy for stage I-II disease or pelvic exenteration for advanced cases . In our


Mucin-producing cholangiocarcinoma (MPCC) is an uncommon tumour that is clinically characterized by mucin-hypersecretion. Because the initial symptoms of MPCC may be attributed to the viscus mucobilia, the primary tumour mass may potentially be unrecognizable. We report an interesting case of curatively resected occult MPCC in situ.A 70-year-old man was referred to our hospital with increased levels of biliary enzymes. Multidetector row computed tomography (MDCT) demonstrated a diffuse dilatation of the entire biliary system without evidence of tumour mass. Additionally, there were numerous variably sized cysts throughout the liver. The cyst of S4 was the largest, followed by that of S1, which connected with the right hepatic duct. Endoscopic retrograde cholangiography showed intrabiliary mucus, predominantly in the left hepatic duct, but failed to show a communication of both cysts with the bile duct. We clinically suspected that minute MPCC was present within the S1 cyst and performed left hepatectomy, caudate lobectomy, and resection of the extrahepatic bile duct. Macroscopically, papillary adenocarcinoma in situ was present in the S1 cyst, and a final diagnosis of MPCC originating from the bile duct of the caudate lobe was made.For MPCC, in practice, we should consider the possibility that this tumour can be occult. In this complicated setting, demonstrating the communication to the responsible dilated duct is a clue to the diagnosis. Multidirectional MDCT images succeeded in specifically demonstrating this communication, which is insensitive to the presence of excessive mucobilia. Some cholangiocarcinomas secrete excessive mucus into the biliary system –4, causiHere, we report a rare case with occult MPCC in situ that was resected with tumour-free margins. Lack of radiological evidence of a gross tumour and the presence of multiple liver cysts complicated the preoperative tumour diagnosis, thereby making surgical management difficult.A 70-year-old man had visited a local physician and had increased levels of biliary enzymes at medical check-up: serum aspartate aminotransferase (72 IU/l), alanine aminotransferase 212 IU/l), alkaline phosphatase (555 IU/l), gamma glutamyl transpeptidase (218 IU/l), and total bilirubin (0.4 mg/dL). He had undergone open cholecystectomy 23 years ago. Magnetic resonance cholangiopancreatography (MRCP) revealed a diffuse dilatation of the entire biliary system and bilateral multiple cysts in the liver  revealed extensive dilatation of the entire bile duct without evidence of tumour mass or stricture. Among the liver cysts, there were two major adjacent cysts in S1 (33.1 mm in size) and S4 (74.7 mm in size). The former was evidently connected with the right hepatic duct, whereas the latter was not Fig. . DuodenoThe above radiological findings strongly suggested the presence of minute/occult MPCC. For the surgical management, we focused on two radiologic findings: first, the S1 cyst connected to the bile duct, suggesting a primary diseased site; second, mucus was found predominantly in the left hepatic duct, suggesting that the largest S4 cyst should also be resected. Therefore, we planned to perform left hepatectomy, caudate lobectomy, and extrahepatic bile duct resection with dissection of regional lymph nodes. During surgery, because the two cysts adhered to the middle hepatic vein, liver transection was carefully advanced to avoid rupture. We resected the two cysts en bloc without explosion. The operation time was 484 min, and blood loss was 913 ml. The patient’s postoperative course was uneventful, except for minor bile leakage, and he was discharged 16 days after the surgery.Macroscopically, the S1 cystic lesion, filled with mucus, connected with the right hepatic duct via the two bile ducts of the right caudate lobe (B1r), the luminal surface of which showed a fine granular pattern Fig. a, b. MicMPCC was first reported by Chou et al.  in 1976;Yang et al.  showed tMPCC exhibits two representative morphologies: ductectatic type and cystic type. The former is defined as a papillary tumour in the dilated intrahepatic bile duct branch that shows disproportional enlargement, and the latter is defined as a papillary tumour within a large liver cyst that communicates with the biliary system . NotablyIn the present case, we hypothesized that the occult MPCC was associated with any of the liver cysts (a variation of cystic type MPCC). As the communication between the S1 cyst and the hepatic duct was clearly demonstrated on CT images, the S1 cyst was specified as the target region. Additionally, biopsy samples from the bile duct were all negative for cancer, indicating that the tumour was confined to the cyst and the communication. Based on this limited information, we planned left hepatectomy, caudate lobectomy, and extrahepatic bile duct resection to maximize the chance of R0 resection.The clinical impact of the remnant carcinoma in situ at the ductal remains a matter of debate; however, our recent study clearly demonstrates the growing nature of the foci, the risk of local disease relapse, and a deteriorating impact on postoperative survival . These bOccult MPCC is uncommon and complicated. MDCT is a leading diagnostic modality in which a communication between the cystic lesion and the biliary system is the key finding to specify the disease site. Although an optimal approach for occult MPCC has not been fully addressed, this case report provides a simple MDCT-based diagnostic approach and surgical management for this challenging scenario.