Condyloma acuminatum caused by Human Papillomavirus is the most commonly occurring sexually transmitted infection in the anogenital region. Buschke-Löwenstein tumor (BLT) known also as giant condyloma acuminatum is a rare disease. The disease, for which the most important treatment method is the surgical excision, differs from normal condyloma acuminatum cases with its high degree of malignancy. The purpose of this paper is to present the case that reached huge dimensions in the perianal region and that was treated with wide resection in the literature. Condyloma acuminatum is a disease in which Human Papillomavirus (HPV) is active, that shows epithelial overgrowth. It is most commonly seen in genital, anal, and perianal regions. It is the most common sexually transmitted infection of anorectal region . IncidenIncubation period of HPV that causes condyloma acuminatum is 1–6 months. Giant condyloma acuminatum known also as Buschke-Löwenstein tumor (BLT), is a slow growing, although histopathologically benign, clinically malignant rare disease. The most important treatment method is the excision of the mass. To determine the margins of the mass, degree of invasion, lymph node involvement, and whether the case is primary or recurrence before the surgery shall identify the method of surgical treatment.The purpose of this paper is to present a BLT case that reached huge dimensions covering all perianal region and extending into anal channel and developed due to condyloma acuminatum.53-year-old-male patient was applied with the complaint of palpable mass that originated 10 years ago and gradually enlarged, causing discharge with unpleasant odor, recently causing gas-fecal incontinence. His history did not reveal any characteristics. In the examination of the patient, 20 × 20 cm mass was observed which was covered with exudate with unpleasant odor, shaped like broccoli, and grew towards scrotum and penis root covering all perianal region beginning from anal channel . ColonosCondyloma acuminatum is a benign disease caused by Human Papillomavirus that is sexually transmitted and that can cause malignant transformation. In HPV transmission homosexuality, bad genital hygiene, chronic genital infections, and polygamy can be considered as risk factors. BLT is a rarely seen form which develops by the overgrowth of condyloma acuminatum and has a high risk of malignant transformation . BLT is Most efficient treatment method especially during the early period of disease is a surgical excision . SystemiEarly surgical resection in the treatment of condyloma acuminatum prevents the development of BLT. It is necessary to determine histopathologically whether a malignant transformation occurred, or whether the anal sphincter muscles and rectum are invaded with radiological and endoscopic imaging in BLT cases before the surgery for determining the surgical method.


A 65-year-old female had a history of tuberculosis of the left greater trochanter 30 years ago. She underwent 6 months of chemotherapy after which the disease healed completely. Currently she presented to us with pain and swelling on the lateral aspect of left hip of 2-month duration. Clinical and radiological findings were suggestive of a recurrence. Biopsy was conclusive for tuberculosis. She was successfully treated with debridement and curettage with chemotherapy for 1 year. Recurrent tuberculosis of the greater trochanter is rare and should be aggressively treated. Primary tubercular involvement of the greater trochanter and its overlying bursa is rare and accounts for 1-2% of all musculoskeletal tuberculosis . Newer d Tubercular lesions are known to recur in people with poor immune function, especially elderly. We describe a 65-year-old lady with primary tuberculosis of the left greater trochanter and its overlying bursa treated successfully by chemotherapy, who presented to us with recurrent disease after 30 years. Excision of the bursa, curettage of the lytic lesion and antitubercular chemotherapy was curative. At 2-year followup, patient were asymptomatic and the disease had completely healed.  65-year-old lady presented to us with a history of pain and swelling on the lateral aspect of left hip of 2-month duration. Both pain and swelling were gradual in onset and progressive in nature. Pain was constant, dull aching type, increasing on weight bearing and partially relieved with analgesics. There was no history of trauma, fever, or other constitutional symptoms. She did not have any other comorbid illness.  Thirty years back patient had pain and swelling on the lateral aspect of left thigh along with a discharging sinus. She was diagnosed to have tuberculosis of the left trochanteric bursa based on the clinical and radiological findings. Short course antitubercular chemotherapy for 6 months was curative and the patient was asymptomatic since then.General physical examination was unremarkable. On local examination, there was a fluctuant swelling measuring about 8 × 4 cm on the lateral aspect of the left hip, overlying the greater trochanter, with a dimple of healed sinus adherent to it . There w3) and differential counts . Erythrocyte sedimentation rate was high (50 mm in 1st hour). Liver functions, renal functions, and blood sugar levels were normal. Chest X-ray was normal. X-ray of the pelvis with both hips showed a lytic lesion of the left greater trochanter with sharp margins suggestive of benign tumour or infection  with normal total counts  for 12 months. She was followed up regularly and, at each followup, progressive improvement was noted clinically, hematologically and radiologically. At 3-year followup, the disease had completely healed; the patient was totally asymptomatic and walking with a normal, pain-free gait. Repeat MRI of the pelvis was done at 2 years and it showed subsidence of the marrow edema in the trochanter and resolution of swelling, consistent with healing.Patient was started on Category I antitubercular chemotherapy (2HHip is the second most frequent site of osteoarticular tuberculosis after the spine . The disThe patient presents with pain with or without swelling on the lateral aspect of the hip overlying the greater trochanter. Chronic, untreated cases may present with discharging sinus on the lateral aspect of the hip; however, in our case, pain and increasing swelling over the greater trochanter were the presenting complaints. There was evidence of healed dimple scar over the swelling. Involvement of hip joint is very rare. Fever and other constitutional symptoms may be present in up to 30% of the cases . RadiogrA review of literature shows a few case reports and case series of primary tuberculosis of the greater trochanter , 3, 5–11Tuberculosis is known to recur in patients with poor immune status like in the elderly. Sastre et al. have reported a case of reactivation of trochanteric tuberculosis after previous surgical drainage done in the prechemotherapy era. They achieved a good result with wide excision and curettage of the bone along with chemotherapy for 9 months . YamamotOur case demonstrates that an old healed tubercular lesion can recur, especially in the elderly, in whom the immune status is waning. MRI is useful in delineating the extent of the lesion especially in sites of rare affection like the greater trochanter and also guides in surgical planning. MRI may also be useful to monitor the response to the antitubercular chemotherapy in such cases. Total excision of the lesion along with antitubercular chemotherapy may be associated with lesser recurrence rates as compared to chemotherapy alone.


Schwannoma, or neurilemmoma, is a benign neoplasm of Schwann cells that is extremely rare in the soft palate. Herein we present a case of a soft palate schwannoma presenting with an ulcerated surface and purplish colour in a 12 year-old girl. This report also introduces a successful surgical technique for coverage of the defect left by surgery. A neurilemmoma is a benign, encapsulated tumour that arises from a nerve sheath. One-fourth of extracranial schwannomas occur in the head and neck area. Only 1% of schwannomas present in the oral cavity . An oralHistologically, neurilemmomas contain two main tissue regions: Antoni A and Antoni B . MalignaThe aim of the present study is to report the case of a 12-year-old female patient with an ulcerated mass in her soft palate, and to discuss the clinical picture, histopathology, and immunohistochemistry, as well as the method of surgery and its follow-up for 6 months postoperatively.A 12-year-old female patient presented without any systemic problems. She had noticed a bulging in her soft palate three months earlier. The patient’s parents reported an increase in the size of the bulge two weeks previously. On intraoral examination, a mass with an ulcerated surface was noted in the soft palate. The lesion extended from the hard palate to near the uvula on the right side, was 3 cm at its largest diameter, and had an ugly appearance. The patient reported no pain, bleeding, or difficulty in swallowing or breathing .® was fixed between the two edges of the tissue and then sutures were placed in normal mucosa far away at the edge of the lesion. Microscopically, the lesion was encapsulated and consisted of Antoni A tissue with Antoni type B regions. The Antoni A tissue included Verocay bodies and was marked by spindle-shaped Schwann cells palisaded around the amorphous eosinophilic area. Numerous blood vessels were observed between these areas . Only 1% of this type of tumour occurs in the jaw . A lesio3, but in this case the patient’s tumour had grown to roughly 6 cm3. Although these tumours are of nervous origin, the patient experiences no pain, but pressure from the tumour on an adjacent nerve may present as paraesthesia. There was no pain or paraesthesia in the present case. A neurilemmoma presents as a submucosal nodule with normal surface coloration. The present lesion was a painless mass that was purple in coloration and had an ulcerated surface. Schwannomas usually do not become as large as 2 cmMalignant changes in untreated neurilemommas have been reported only rarely . ConservThe clinical differential diagnosis for soft tissue masses in the submucosa are: traumatic neuroma, neurofibroma, mucosal neuroma, haemangioma, mucocele, fibromas, lipomas, and salivary gland tumours . The cliSince soft palate surgeries can affect swallowing and speech, we propose a surgical technique which leaves less of a defect in the palate.


Myelolipomas are uncommon, benign tumors composed of mature adipose tissue and hematopoietic elements. They mostly occur in the adrenal glands, but extra-adrenal myelolipomas have also been reported in other locations such as the presacral region, retroperitoneum, pelvis and mediastinum. Here, we present a case of an extra-adrenal myelolipoma in a rare site: the renal parenchyma. To the best of our knowledge, it is only the third case reported in this unusual location.We report a case of primary myelolipoma occurring in the kidney of a 55-year-old Moroccan man. We describe the radiological and clinicopathologic features of this unusual tumor with a review of the literature, and we discuss differential diagnosis of retroperitoneal myelolipomas.This case is noteworthy because the tumor site was unusual. Although renal myelolipoma is rare, it should be considered in the differential diagnosis of lesions in this site. Myelolipoma is a relatively uncommon, benign mesenchymal tumor composed of mature adipose tissue admixed with benign mature hematopoietic elements in varying proportions. The most common site of involvement is the adrenal gland. The occurrence in extra-adrenal sites is quite rare with an incidence of 0.4% at autopsy . Extra-aA 55-year-old Moroccan man, with insulin-dependent type II diabetes, presented with right flank pain. A physical examination did not reveal any other abnormalities, such as hepatosplenomegaly or lymphadenopathy. Laboratory tests  revealed no abnormal findings. Ultrasonography (US) of his right kidney showed hydronephrosis. The patient underwent a left retrograde pyelography which confirmed hydronephrosis caused by calyceal and pelvic lithiasis and revealed a non-functional right kidney. Computed tomography (CT) of his abdomen and pelvis showed a relatively well-circumscribed parenchymal mass of fat density, measuring 10cm in diameter, with no involvement of the perinephric adipose Figure . HistoloMyelolipoma is a relatively uncommon benign tumor, composed of mature adipose tissue and hematopoietic elements. Myelolipoma is most frequently found in the adrenal gland, but it may occur in the pelvis, retroperitoneal space or even in the chest. Extra-adrenal myelolipomas occur in women more often than in men and more often in middle-aged to older patients .The exact pathogenesis of myelolipoma is not clear at present. Most theories involve the development and differentiation of either ectopic adrenal rests or hematopoietic stem cell rests in response to a triggering stimulus, particularly endocrine dysfunction . Other rBoth adrenal and extra-adrenal myelolipomas are typically asymptomatic. They tend to be incidentally discovered during radiological investigation of symptoms unrelated to myelolipoma. However, some patients with myelolipoma complain of abdominal or flank pain, possibly related to intratumoral or peritumoral hemorrhage, tumor infarction or mechanical compression from tumor bulk . BecauseIf a definite diagnosis is needed, a fine-needle biopsy is indicated either under US or CT guidance, although one should consider the possibility of a ruptured mass or the development of hemorrhage. The biopsy can show adipose tissue and a variable amount of hematopoietic elements, raising the differential diagnosis of extramedullary hematopoiesis and extra-adrenal myelolipoma. It must be noted that it is also often difficult to label a retroperitoneal neoplasm benign based on biopsy, because both benign and malignant tumors can share similar characteristics.Grossly, extra-adrenal myelolipoma is a solitary circumscribed mass ranging in size from a few centimeters to 27cm . The tumth decade, with no sex predominance. Retroperitoneal liposarcomas are often asymptomatic until the tumor has exceeded 20cm in diameter and may be found incidentally. In renal localization, liposarcomas are rare with few cases reported in the literature [When the diagnosis of retroperitoneal myelolipoma is considered, it should be differentiated from other fat-containing retroperitoneal tumors, of which liposarcoma is the most common. Liposarcoma involves middle-aged adults with a peak incidence in the 6terature . MacroscAngiomyolipoma is a benign mesenchymal tumor usually occurring in the kidney. It comprises 2.0% to 6.4% of all renal tumors; however, it represents one of the most common benign renal lesions . It can Also considered in the differential diagnosis are reactive extramedullary hematopoietic ‘tumors’ that usually occur in the context of myeloproliferative disorders or chronic hemolytic anemia . Both reRetroperitoneal myelolipomas should also be differentiated from other lesions that contain adipose tissue and hematopoietic elements, such as teratomas. Histology of the latter shows tissue elements from all the three germ layers.The usual natural history of extra-adrenal myelolipoma is benign although they may enlarge and bleed. Some reports have shown stable lesions with follow up from 3 to 62 months . Small aIn conclusion, our case is noteworthy because the tumor location was extremely rare. Despite its rarity, renal myelolipoma should be known and mentioned in case of adipose-containing tumor. Management options for extra-adrenal myelolipoma include conservative and surgical approaches depending upon the certainty of the diagnosis and the progression of the patient’s symptoms. It is generally impossible to distinguish this entity from other retroperitoneal tumors by radiographic differentiation. So the final diagnosis should depend on pathological features of the surgically removed sample.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: Computed tomography; MRI: Magnetic resonance imaging; US: Ultrasonography.The authors declare that they have no competing interests.MG retrieved clinical information, wrote the manuscript and performed the literature review. KZ first identified this case, proposed the study and revised the manuscript for important intellectual content. AJ acquired photomicrographs. FZ and ZB provided valuable insight during manuscript preparation. NM supervised the entire case. All authors read and approved the final manuscript.


While umbilical hernias frequently occur during pregnancy, the few reported cases of uterine or fibroid incarceration in ventral hernias during pregnancy all involved incisional abdominal wall defects from prior laparotomies and Cesarean sections; none involved umbilical hernias. We discuss the case of a 42-year-old well-developed, well-nourished grand multiparous woman (G8P7) with a huge umbilical hernia containing a 38-week gravid uterus, as well as her management and the avoidance of known complications that have occurred in similar incisional hernia cases. Successful pregnancy outcomes can occur in cases of pregnancies in ventral hernias, even in resourcepoor settings that have Cesarean section capabilities. While umbilical hernias frequently occur during pregnancy, the few reported cases of uterine or fibroid incarceration in ventral hernias during pregnancy all involved incisional abdominal wall defects from prior laparotomies and Cesarean sections; none involved umbilical hernias . Given tA 42-year-old well-developed, well-nourished grand multiparous woman (G8P7) with a huge umbilical hernia  presenteOn examination, she had normal vital signs and an unremarkable heart and lung exam. Abdominal examination revealed a huge protruding mass through the umbilical region with a 5-cm X 5-cm ulceration of the overlying skin. The uterus could be felt subcutaneously with a complete lack of overlying abdominal wall fascia and musculature. The fetus lay in a longitudinal position with the fetal head at the uterine fundus in the most dependent part of the umbilical hernia. Laboratory examinations were normal. Ultrasonography showed a full-term  fetus with a normal heart rate, no gross congenital abnormalities, and the placenta in the upper uterine segment. Since uterine contractions were observed, the patient was prepared for emergency surgery.Under general anesthesia, the skin over the umbilical mass was incised. This exposed the subcutaneous uterus . The redUmbilical hernias  are present in about 15% of pregnant West African women . The ratFinding a gravid uterus in an anterior abdominal wall hernia is rare, and is usually found, as in this case, in multiparous patients ,5. The pComplicationsMultiple complications have been reported in association with pregnancies in anterior abdominal wall defects. The only previously reported complication that occurred in our patient was excessive stretching of the skin, causing ulceration due to friction between the hernia sac and other parts of the patient’s body and clothing.Other reported complications, many of which can threaten the mother or fetus, include incarceration, miscarriage, premature labor, intrauterine hemorrhage, intrauterine growth retardation, intrauterine death, rupture of the lower uterine segment, ruptured abdominal wall, and death .Herniorrhaphy during C-SectionIt has been suggested that the laxity of the abdominal wall and the presence of an enlarged, hypertrophied uterus could weaken a repair. Despite these theoretical concerns, herniorrhaphy has been successfully performed as part of the Caesarean section with no increase in wound infection rates and no recurrences . As in sFollow-upOur patient’s repair was intact at follow-up >1 year after surgery; the baby was healthy and developing normally.Advanced pregnancies developing in ventral hernias can pose multiple risks. Yet even in resource-poor settings, successful pregnancy outcomes can occur in such cases, including the rare situation of a pregnancy in an umbilical hernia, if Cesarean section capabilities exist.There are no financial or competing interests associated with this manuscript. This manuscript has not been submitted elsewhere.All authors participated in vital aspects of producing this article and approve the final version for publication.


Epidural spinal myelolipoma was diagnosed in an 11.5-year-old castrated male Husky-cross that was evaluated at the veterinary teaching hospital due to progressive thoracolumbar spinal hyperaesthesia and mild proprioceptive pelvic limb ataxia. A focal, ill-defined mildly inhomogenous extradural mass lesion was detected by MRI. The dog was euthanized. At necropsy an extradurally located reddish mass of about 2.5 cm in diameter was present in the vertebral canal. The mass was identified histopathologically as an epidural myelolipoma. Myelolipomas are benign tumors consisting of mature fat interspersed with haematopoietic elements resembling bone marrow. Extraadrenal myelolipomas are suspected to arise from uncommitted mesenchymal cells. Their occurrence is thought to be influenced by haematopoietic growths factors, which mediate the recruitment of pluripotent haematopoietic stem cells . They arIn most cases there is no clinical relevance of this haematopoietic proliferation, but large tumors may cause clinical signs as a result of a mass effect . Albeit Epidural myelolipomas have previously been described in a Siberian husky  and in aAn 11.5-year-old castrated male Husky-cross was evaluated because of a 3 week history of thoracolumbar spinal hyperaesthesia. Treatment with phenylbutazone and prednisolone for 2 weeks by the referring veterinarian did not improve clinical signs.At the time of initial admission to the veterinary teaching hospital, general physical examination only confirmed the thoracolumbar spinal hyperaesthesia. Haematological parameters and radiographs of the vertebral column were unremarkable. Treatment with gabapentin and metamizol  was initiated.Three days after initial presentation, the hyperaesthesia progressively worsened and the dog was presented again. As compared to initial presentation, the neurological examination revealed that the thoracolumbar spinal hyperaesthesia had progressed and was severe. Additional mild proprioceptive ataxia in the pelvic limbs was consistent with a T3-L3 spinal cord segments localisation. MRI was obtained under general anesthesia using a 3.0 tesla scanner  Figures , 2, 3. AT2-weighted sagittal MR images showed a heterogenous epidural mass, hyperintense compared to spinal cord parenchyma, but hypointense compared to CSF/epidural fat signal. The mass was extending from the cranial aspect of the first lumbar vertebral body to the cranial aspect of the second lumbar vertebral body and compressing the spinal cord Figure . The T1-Differential diagnoses for the MRI findings of this dog were idiopathic epidural fat inflammation, epidural lipoma and epidural myelolipoma.Based on the MRI findings, the progression of clinical signs and the unknown prognosis the owners elected euthanasia. At necropsy, an extradurally located reddish mass of about 2.5 cm in diameter was present in the vertebral canal at the level of the vertebrae L1 to L2. There were no morphological changes of the vertebral body. Histologically, the mass in the vertebral canal was poorly demarcated by a discontinuous fibrous capsule and consisted predominantly of mature adipocytes and cell rich areas. The latter were composed of haematopoietic cells of the myeloid, erythroid and megakaryocytic lineage in proportions equivalent to normal mature bone marrow Figures  &5. In amyelo-, for marrow, lipo for fat and oma meaning tumor or mass) is a benign tumor-like lesion composed of mature adipose (fat) tissue and haematopoietic (blood-forming) elements in various proportions [MRI was especially useful in determining the underlying cause of the clinical manifestations and source of the dog´s thoracolumbar spinal hyperaesthesia and proprioceptive ataxia. Particularly the fat suppression sequence, because the hypointensity seen on this sequence is most compatible with the lesion being predominantly composed of adipose tissue, lead to the suspicion, that the diagnosis could be lipoma or myelolipoma. SPAIR is chemically selective and in comparison to a chemically non-selective fat suppression technique such as STIR (short T1 inversion recovery) only the fatty tissue is inverted, which is an advantage of this technique. It is useful in cases where water-based tissue lesions may have a T1 similar to that of lipids, because the non-selective scheme of STIR, in which the inversion pulse affects all tissues, can provide misleading results. Myelolipoma , a male Alaskan Malamute (13 years), and the presented male Husky-cross (11.5 years) and therefore with a close genetic ancestry. Together with the Samoyed these breeds descend from the original sled dog. The lesion sites were also similar, namely at the level of L1 and L2, and from Th13 to L3 in the Alaskan Malamute and Husky-cross, and in the Siberian husky, respectively.Myelolipoma can occur epidurally and cause signs of proprioceptive ataxia and spinal hyperaesthesia. MRI is particularly useful to determine the underlying cause of this myelopathy. Particularly the fat suppression sequence is beneficial to identify the mass as adipose tissue, which predominates this lesion. Myelolipoma should be a differential diagnosis in cases of extradural spinal cord compression.Everything performed was wanted and approved by the owner of the dog and no experimental research has been performed.The authors declare that they have no competing interests.MVH performed the clinical workup of the patient and drafted the manuscript. DCL performed the diagnostic imaging. CL and VH carried out the post-mortem examination. VMS was involved in the clinical workup and drafting the manuscript. All authors read and approved the final manuscript.


Benign multicystic peritoneal mesothelioma (BMPM) is a rare disease arising from the peritoneal mesothelium. Here, we report a 57-year-old woman admitted to our unit with an incisional hernia fifteen years later following her first operation due to BMPM. Computerized tomography demonstrated a cystic appearing mass with intraabdominal extension in hernia sac. The patient underwent en bloc resection of the mass and hernia repair. An immunohistochemical analysis of the mass confirmed the recurrence of BMPM. Our case supports that BMPM has slowly progressive nature and can recur with complicated incisional hernia long time after primary resection. Diagnosis and long-term followup are crucial for clarifying the characteristics of this disease. Benign multicystic peritoneal mesothelioma  is a very rare multilocular cystic tumor arises from the peritoneal mesothelium , 2. The We herein describe the late recurrence of BMPM complicated with incisional hernia fifteen years later following her first abdominal operation due to BMPM.A 57-year-old woman presented to our unit with an incisional hernia due to enlarged abdominal mass surrounded to the umbilicus fifteen years later following her first abdominal operation. She had a past medical history of BMPM originated from mesentery of appendix with extension to the ascending colon and she underwent right hemicolectomy. Since then, she was followed up four times a year in first two years then a year basis after 2 years of her operation. She did not go annual followup after 10 years. She reported abdominal discomfort and distension fifteen years later following her first operation. She attributed this to her incisional hernia at the site of midline incision. These had progressively worsened in size as had her symptoms. Her physical examination revealed painful palpable abdominal mass about 4 cm in size around the umbilicus and incisional hernia that lays 10 mm above and below her umbilicus and 30 mm diameter. Computed tomography (CT) examination demonstrated an intraperitoneal hypodense cystic mass surrounded to umbilicus and extended between the great curvature of the stomach, spleen, and tail of pancreas and extending caudally to the upper margin of the pelvis and pressure over the adjacent organs resulted with hernia from midline incision scar . She undMacroscopic examination of large cystic mass containing multiple smaller cystic spaces was shown in Multicystic mesothelioma of the peritoneum was first described by Plaut in 1928, but the mesothelial nature was confirmed with electron microscopy by Mennemeyer and Smith in 1979 .  The disease is an exceedingly rare medical entity, which renders its origin, pathogenesis, diagnosis, and therapy challenging , 4. BMPMThe pathogenesis of BMPM is unclear and there is some controvercy regarding its neoplastic or reactive nature , 2, 8. MMost patients are diagnosed incidentally during physical examination or surgery for other reasons. The clinical findings of benign multicystic mesotheliomas are nonspecific and include nausea, vomiting, and abdominal pain. Safioleas et al.  also havHistologically, BMPM is a localized tumor arising from mesothelial cells. The tumor is composed of a multiple mesothelial-lined cystic structure. Surgery is the only effective treatment. Aggressive surgical approaches including cytoreductive surgery with peritonectomy are recommended , 11. ComPrognosis of BMPM was reported differently. Weiss and Tavassoli reported that the prognosis was excellent and only death was occurred in a patient who refused the surgery . Beside In conclusion, recognition of BMPM is difficult and it can be recur as an incisional hernia. Recurrence of disease and uncertainty of biological behaviors indicate the necessity of proper long-term followup of patients with BMPM. In addition to this, complete cytoreductive surgery seems to be the proper management of this disease.


Ectopic cervical thymoma is rare and is often misdiagnosed as a thyroid tumor or other malignancy. Ectopic thymic tissue can be found along the entire thymic descent path during embryogenesis. However, a thymoma arising from such ectopic thymic tissue is extremely rare. Herein we report a patient with ectopic cervical thymoma and myasthenia gravis (MG) and discuss the management. Ectopic cervical thymomas are very rare and often present as palpable neck masses. Ectopic cervical thymoma presenting in patients with MG is even rarer and only two other cases have been reported in the literature ,2. The dA 58-year-old woman presented to our Neurology department with ptosis that had persisted for 4 months. A physical examination revealed a palpable cervical mass. Repetitive nerve stimulation testing revealed abnormally decreasing responses and the acetylcholine receptor antibody titer in the patient's serum was elevated . Other laboratory examinations were unremarkable, including thyroid function tests and tests for autoimmune diseases. She was diagnosed with MG and received pyridostigmine treatment 180 mg/day). Computed tomography (CT) of her chest revealed one well- circumscribed, homogeneous mass of soft tissue measuring 2.6 × 2.5 × 1.6 cm at the lower pole of the left thyroid gland  or present as local symptoms (30% to 40%) or associated systemic parathymic disease syndromes (30% to 50%). When there are local symptoms, vague chest pain, shortness of breath, and cough are the common complaints. When there are systemic parathymic disease syndromes, MG is the most commonly associated disease (30%-50%) . RelativMost ectopic cervical thymomas misdiagnosed as thyroid tumors were removed simply by a neck incision, because the exact diagnosis was made after postoperative histopathology. For ectopic cervical thymomas with MG, extended thymectomy seems to be the treatment of choice, like mediastinal thymomas. Of the two other case reports of ectopic cervical thymoma with MG in the literature, one received extended thymectomy and the other received simple resection of the ectopic cervical thymoma. The one received extended thymectomy achieved complete remission and the one received simple resection of the ectopic cervical thymoma achieved pharmacological remission during the long-term follow-up. Although our patient achieved only pharmacologic remission at a six-month follow-up, but the outcome of extended thymectomy improved gradually and took 3 years to achieve plateau . Long-teFor ectopic thymomas with capsule invasion, adjuvant radiotherapy may be considered to reduce local recurrence rates as the general rule in mediastinal thymomas. However, the number of patients in this subgroup was limited, so more cases collection is required to confirm the result.Although the condition is rare, clinicians must bear in mind that ectopic cervical thymomas might be associated with MG. Extended thymectomy can offer a good result for these patients.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.THW carried out the manuscript and collected references. JSJ reported pathological findings and took the pathologic pictures. TWH and HC helped to draft the manuscript. THW and SCL underwent this operation. All authors read and approved the final manuscript.


We report a case of acinar cell carcinoma of the pancreas with colon involvement that was difficult to distinguish from primary colon cancer. A 60-year-old man was admitted with a 1-month history of diarrhea. Contrast-enhanced computed tomography (CT) revealed a large tumor (10.6 × 11.6 cm) at the splenic flexure of the colon. Colonoscopy showed completely round ulcerative lesions, and biopsy revealed poorly differentiated adenocarcinoma. Left hemicolectomy, resection of the jejunum and pancreas body and tail, and splenectomy were performed based on a diagnosis of descending colon cancer , and surgery was considered to be curative. Diagnosis was subsequently confirmed as moderately differentiated acinar cell carcinoma of the pancreas by immunohistochemical staining . Multiple liver metastases with portal thrombosis were found 8 weeks postoperatively. Despite combination chemotherapy with oral S-1 and gemcitabine, the patient died of hepatic failure with no effect of chemotherapy 14 weeks postoperatively. Correct diagnosis was difficult to determine preoperatively from the clinical, CT, and colonoscopy findings. Moreover, the disease was extremely aggressive even after curative resection. Physicians should consider pancreatic cancer in the differential diagnosis of similar cases. Acinar cell carcinoma of the pancreas (ACC) is a rare malignant epithelial tumor representing 1-2% of all exocrine pancreatic neoplasms [μL , a hemoglobin level of 5.8 g/dL , and a platelet count of 32.0 × 104/μL . Serum carbohydrate antigen 19.9 (CA19–9) was 48.9 U/L , carcinoembryonic antigen (CEA) was 45.1 ng/mL , Span-1 was 36.0 U/mL , and soluble interleukin-2 receptor was (s-IL-2 R) measured as high as 1137 U/mL . Serum aspirate aminotransferase, alanine aminotransferase, and amylase were within the normal range.A 60-year-old man with no remarkable past history was admitted to our hospital in October 2011 with a 1-month history of diarrhea and nonspecific lower abdominal pain. He also complained of losing 25 kg within the previous 2 months. He did not regularly drink alcohol and had no history of acute pancreatitis or trauma. On admission, a hard mass, approximately 15 cm in size, with an irregular surface was palpable in the left abdomen. Initial laboratory tests revealed a white blood cell count of 23,960/2 on days 1 and 8 of each 21-day cycle) was administered. However, the patient died of hepatic failure 14 weeks after surgery, with no effect of chemotherapy observed.Contrast-enhanced computed tomography (CT) showed a large tumor (10.6 × 11.6 cm) at the splenic flexure of the colon with an irregularly thickened wall . ColonosCommonly referred clinical symptoms of ACC are upper abdominal pain, weight loss, nausea, and vomiting , 2. In oAccording to the initial symptoms of diarrhea, lower abdominal pain, and body weight loss, as well as the finding of the palpable mass in the left abdomen, colorectal cancer was considered the most probable diagnosis. In addition, CT showed a large, well-defined tumor mainly at the splenic flexure of the colon in contact with a part of the pancreas tail. Round ulcerative lesions of about 20 cm, detected by colonoscopy inside the colon, were an atypical finding of colon cancer. s-IL-2 R levels were as high as 1137 U/mL. We therefore suspected malignant lymphoma in addition to colon cancer, despite the fact that primary colonic lymphoma is rare , and we Gross examination revealed an annular constricting mass that appeared to be growing into the wall of the colon from the outside and pushing onto the mucosa, resulting in focal areas of ulceration. No heterotopic pancreatic tissue was seen in the colon. Tumor cells were negative for both CK20 and CDX2, specific markers of adenocarcinoma of intestinal origin. Taken together, moderately differentiated ACC with multiple organ involvement was diagnosed.It is rare to find colon involvement in pancreatic cancer . The mosReports from a few small case series have indicated that, compared with ductal cell carcinoma, ACC is considered to have good prognosis if completely resected , 10, 11.Production of AFP has been reported as a possible marker of ACC . In the No optimal strategy has yet been determined for patients with synchronous or recurrent liver metastasis from ACC. It has been reported that gemcitabine is not sufficiently efficacious against this cancer, despite its wide use as a standard agent for the treatment of pancreatic adenocarcinoma . Some ca


Carcinoid tumors are neuroendocrine neoplasms derived from the enterochromaffin cells. Central nervous system involvement is rare and has been reported either as metastases to the brain and spine or primary tumors involving the sacrococcygeal spine. We report the first case of a primary carcinoid tumor of the cervical spine.A 50-year-old African-American woman presented with a 4-month history of numbness, paresthesias, and mild left-hand weakness. Magnetic resonance imaging of her cervical spine revealed a homogenously enhancing extradural mass, indenting the cervical cord and expanding the left neural foramen at C7–T1. A C7 corpectomy, en bloc resection of the tumor, and anterior C6–T1 fusion were performed to decompress the spinal cord and nerves and provide stability. Postoperative histopathologic examination and immunohistochemical analysis were consistent with carcinoid tumor. There has been no recurrence at the 6-year follow-up visit.Primary cervical carcinoid tumor is extremely rare, but should be included in the differential diagnosis of enhancing expansile extradural masses compressing the spinal cord and nerves. Surgical resection may provide a definitive cure. Carcinoids are the most common neuroendocrine tumors, derivinA 50-year-old African-American woman presented with a 4-month history of pain, paresthesias, and mild weakness in her left upper extremity. Her past medical history was significant for hypertension and borderline diabetes mellitus. Her family history was positive for breast cancer (sister), prostate cancer (father), and ovarian cancer . The patient had a five-pack-year history of smoking cigarettes, but had stopped smoking 7 years prior to presentation. Her review of systems was negative for any hormonal imbalance. A neurological examination revealed hypesthesia and mild weakness in her left C8 spinal nerve distribution, as well as mild hyperreflexia and a Babinski’s sign in the left lower extremity. Preoperative laboratory tests  showed borderline anemia, hypokalemia, and hypoalbuminemia .T1-weighted magnetic resonance imaging (MRI) of the cervical spine  revealed sheet-like proliferation of neuroendocrine tumor cells in a trabecular pattern and no mitoses or necrosis Figure , suggestExtensive postoperative work-up, including octreotide and technetium scintigraphy, as well as positron emission tomography scanning, failed to reveal any other carcinoid lesions elsewhere in the body. At the 6-year follow-up visit, the patient remains asymptomatic, with no evidence of local tumor recurrence Figure , nor anyCarcinoid tumors arise from enterochromaffin cells and have an incidence of 0.28 to 0.8 per 100,000 per year-8,13-15.There have been several reports of carcinoid metastases to the cervical spine. A 51-year-old man with a history of gastric carcinoid and multiple endocrine neoplasias presented with symptoms of myelopathy, and a cervical MRI revealed an osteoblastic tumor arising from the posterior arch of C2, compressing the spinal cord. The authors performed a surgical removal of the tumor, followed by radiation. AnotherOur patient presented with similar symptoms of myelopathy and radiculopathy. The MRI confirmed the presence of an extradural tumor compressing the spinal cord and left C7 spinal nerve. However, there was no clinical or radiological evidence of a primary tumor that would make metastasis likely, and there were no signs of hormonal imbalance to suggest a neuroendocrine tumor. Therefore, the surgical intervention was started with a wide differential diagnosis in mind and with the decision of total versus partial resection to be made based on intraoperative findings, that is, the amount of tumor involvement with the neural elements. Because the tumor could be relatively easily separated from the dura of the spinal cord and nerve, we performed a gross total resection, at the cost of removing a large portion of the C7 vertebral body. This, in turn, created the need for instrumented stabilization of the lower cervical spine: a C6–T1 fixation. Because there has been no local recurrence at the 6-year follow-up visit, we conclude that the surgical resection was curative. Moreover, because there has been no other manifestation of carcinoid tumor in this patient, it is probable that the cervical involvement was primary, not a metastasis from common sites, such as the gastrointestinal tract or bronchi.Primary cervical carcinoid tumor is a rare entity, but should be included in the differential diagnosis of enhancing expansile extradural masses compressing the spinal cord and nerves. Surgical intervention should aim at gross total resection, because it may provide a definitive cure. Spinal instrumentation may be needed to provide stability following tumor resection.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.GT performed the operation, all authors discussed and analyzed the patient data; MN and DS were major contributors in writing the manuscript; all authors have read and approved the final manuscript.


An intracranial germinoma is a tumor that is sensitive to radiotherapy. As medulla oblongata germinomas are extremely rare, determining an accurate preoperative diagnosis is challenging. Two cases of medulla oblongata lesions were surgically treated, and a postoperative diagnosis of germinoma was determined in both of the cases. The tumor in one patient completely resolved after a treatment course consisting of surgical intervention, radiotherapy and chemotherapy; the other patient, who did not receive any type of adjuvant treatment after surgery, suffered from tumor relapse and died from pneumonia 8 months following surgery. A preoperative diagnosis of medulla oblongata germinoma is difficult because of the lack of specific clinical signs and symptoms. If the correct diagnosis is reached, patients can have a favorable prognosis with proper evaluation and treatment. An invasive operation can potentially lesion and impair the function of the medulla oblongata, which is fatal to the patient. Intracranial germinomas constitute 50 to 60% of central nervous system germ cell tumors and are commonly found in the suprasellar, basal ganglia, and pineal midline structures of the brain . MedullaA 14-year-old male patient presented with right facial numbness and gait instability lasting 6 months. The neurological examination upon admission revealed right-sided deficits in cranial nerves V, VIII and IX. The magnetic resonance imaging (MRI) showed a lesion in the dorsal region of the medulla oblongata  ,4,11. WiThere is currently no standard treatment regimen for intracranial germinoma. We know that germinomas are sensitive to radiotherapy. One series reported that patients who were treated with radiotherapy for intracranial germinoma had 10-year survival rates of 90% ,7. ConsiExperimental radiotherapy is the preferred treatment option for intracranial germinoma originating in the pineal, suprasellar or basal ganglia regions. However, because primary medullary germinoma is extremely rare, it is challenging to correctly diagnose this disease preoperatively based on the clinical presentation and imaging reports. In all of the reported cases of patients with primary medullary germinoma who underwent surgery, 86.7% 13/15) had a favorable prognosis  had a fa,11-14. FPrimary medullary germinoma is extremely rare. A preoperative diagnosis is difficult due to the absence of specific clinical features. With proper evaluation and treatment of this disease, patients can have favorable prognoses.Written informed consent was obtained from the patient reported in case 1, and from the father of the patient in case 2 for the publication of this report.AFP: Alpha-fetoprotein; hCG: Human chorionic gonadotropin; CSF: Cerebrospinal fluid; CSI: Craniospinal irradiation; CT: Computer tomography; MRI: Magnetic resonance imaging; PEB: Cisplafin, etoposide and bleomycin; T1WI: T1-weighted imaging.The authors declare that they have no competing interests.SYH made substantial contributions to the study conception and design and the acquisition of the data. DL and SYH also drafted the manuscript and revised its final form. JF, LW, ZW and JTZ were involved in the analysis and interpretation of the data. LWZ contributed to the interpretation of the data and gave the final approval for the version to be published. All of the authors read and approved the final manuscript.


Bizarre leiomyomas of the scrotum are rare benign tumors that are often misdiagnosed. In this study, we present a case of bizarre leiomyoma of the scrotum in a 53-year-old male. The patient presented with a painless scrotal mass that was insidious in the right side of the scrotum with no sudden increase in size. Definitive preoperative diagnosis could not be established; however, following surgical resection of the tumor, a diagnosis of bizarre leiomyoma of the scrotum was determined by pathological examination. The patient was followed up six months following resection and no problems were reported. This is the first reported case of bizarre leiomyoma of the scrotum in China. A supplementary review of previously published cases and literature is also presented. Leiomyomas are benign tumors that originate from smooth muscle, which have been identified throughout the genitourinary tract . FollowiA 53-year-old male presented to his physician with a painless scrotal mass located on the right side, which the patient had first observed 2–3 months previously. The mass had remained stable in size during that period. The patient was admitted to Department of Urology, Peking University Shenzhen Hospital,  for further examination on April 13, 2012, and was determined to be asymptomatic with a normal appetite and no weight changes. The patient did not exhibit any urinary, respiratory, cardiovascular or constitutional symptoms and had not previously undergone surgery. There was no prior history of trauma, inflammation or infection and no significant urological past history. Physical examination revealed the patient was a well-developed and well-nourished male. The patient was afebrile with a heart rate of 92 beats per min, a temperature of 36.5°C, blood pressure of 129/73 mmHg and respiratory rate of 18 breaths per min. The chest was clear to percussion and auscultation, and no masses were palpable on abdominal examination. Physical examination identified a firm, elastic, non-tender mass on the right side of the scrotum, located near the testis. The mass was ~1.0 cm in diameter and no tenderness or erythema was observed. The lesion was not fixed to the skin or adjacent deeper tissue, and no warmth or discharge was noted. Testes on both sides were normal on palpation with no inguinal lymphadenopathy observed.9/l, with 53.0% granulocytes. Concentrations of glucose, urea nitrogen and serum creatine were 4.87 mmol/l, 9.11 mmol/l and 107.3 μmol/l, respectively. Liver function tests and serum electrolytes were recorded to be within normal limits. The serum levels of certain tumor markers, such as α-fetoprotein and β-human chorionic gonadotropin, were observed to be normal. Following examination by a radiologist, the mass was diagnosed as a sebaceous cyst.Laboratory examination revealed that the patient’s hemoglobin concentration was 142 g/l and white blood cell count was 5.84×10A right percutaneous mass excision was performed on April 17, 2012. The tumor was dissected from the tunica dartos and no invasion of adjacent tissue was observed. The tumor was a solid, well-circumscribed, 1.2×1.0×0.8 cm-sized, oval mass that originated from the tunica dartos, which was independent of the testis, epididymis and funiculus spermaticus. The pathological report revealed clear surgical margins of the tumor. Microscopically, the mass consisted of irregularly shaped cells, with certain tumor cells exhibiting bizarre nuclei and demonstrating focal lymphocytic infiltration into the stroma . ImmunohBizarre leiomyomas of the scrotum are extremely rare; only 14 cases have been reported previously –9. In thPreviously reported cases tend to be asymptomatic and painless in nature; therefore, patients may not seek medical consultation for prolonged periods of time, sometimes decades, by which time the tumors may have grown large enough to become cosmetically undesirable or to cause ulceration of the overlying skin. Of the 14 cases, 12 bizarre leiomyomas of the scrotum are solitary, subcutaneous tumors ranged from 0.5 to 10 cm in diameter . They usUltrasound scans can provide useful information with regard to scrotal mass diagnosis. However, it is difficult to reliably identify malignant scrotal masses on the basis of sonographic features alone. Resection of the mass may be required, as preoperative and intraoperative findings may not be effective in excluding malignancy. However, the frozen section procedure is helpful when discriminating between malignant and benign lesions .The following four pathological features are used to grade scrotal smooth muscle tumors: i) size ≥5 cm in dimension; ii) infiltrating margin; iii) ≥5 mitotic figures per 10 high-power fields; and iv) moderate cytological atypia. Tumors with only one of the aforementioned features are considered benign; those fulfilling two of the criteria are diagnosed as atypical or bizarre leiomyomas; and tumors exhibiting three to four of these criteria are classified as leiomyosarcomas . ImmunohIn conclusion, to our knowledge, only a small number of cases of bizarre leiomyomas of the scrotum have been reported in the literature thus far. This case report highlights diagnostic and treatment issues associated with this rare tumor type. Histologically, the tumor behaves differently to conventional leiomyomas and leiomyosarcomas; therefore, definitive diagnosis is established by pathological evaluation. Correct diagnosis is important to avoid overdiagnosis and unnecessary clinical treatment.


Introduction. Crossed renal ectopia is a congenital anomaly which usually goes unnoticed as most cases are asymptomatic. The majority, 90% of these are fused. Case Presentation. We report an unusual presentation of a case of crossed renal ectopia without fusion. Our patient is a 16-year-old adolescent male, previously fit and healthy, who presented with acute onset of abdominal pain. The clinical suspicion was that of an abdominal aortic aneurysm. Computed tomography with intravenous contrast revealed nonfused crossed renal ectopia. Conclusion. Although renal ectopia is an uncommon cause of acute abdominal pain, there should be an index of clinical suspicion in previously healthy individuals presenting with acute abdominal pain. Renal ectopia as the cause of abdominal pain is a diagnosis of exclusion after other possible causes have been excluded. Most cases remain undiagnosed because they remain asymptomatic . From 20A 16-year-old adolescent male presented with acute abdominal pain of unknown cause. This was the first time the patient presents with abdominal pain. Based on the clinical examination, a diagnosis of abdominal aortic aneurysm was suspected. The patient had no background medical history. Initial blood investigations were normal. Serum urea and creatinine were normal. Chest X-ray and abdominal X-rays were normal. Computed tomography (CT) scan was requested to evaluate for the cause. CT scan revealed crossed ectopic left kidney without fusion to the right kidney. Both kidneys showed normal renal parenchymal enhancement . The lefSeparate conventional intravenous urography (IVU) was not performed because the diagnosis was conclusive on CT scan.Most cases of crossed renal ectopia are asymptomatic and are noted incidentally during autopsy, screening tests, or during investigation for unrelated causes , 3. Of tThere are other tests which can be used to investigative renal ectopia. Radioisotope scans have been used . BelekarWhereas our patient had no other explanation for the acute abdominal pain, all the other reported cases of crossed renal ectopia without fusion presenting with abdominal pain had other explanations. These include ipsilateral ureteral carcinoma , nonfuncRenal tract congenital anomalies should be suspected in previously asymptomatic patients who present with acute abdominal pain. Even though not common, the ectopic kidney varieties should be thought of. In our case, we conclude that a single temporary episode of left urinary pathway obstruction caused the severe colic.


First branchial cleft anomalies are uncommon, accounting for less than 10% of all branchial abnormalities. Their rare occurrence and varied presentation have frequently led to misdiagnosis and inadequate and inappropriate treatment of these conditions leading to repeated recurrences and secondary infection. In this paper, a case of 11-year girl with type 2 first branchial cleft defect is described. She first presented with a nonhealing ulcer of upper neck from childhood. Diagnosis had previously been missed and treated as tubercular ulcer. We confirmed the correct diagnosis by history and computerized tomography fistulogram. The lesion was completely excised with no further recurrence. First branchial cleft anomalies are a special group of congenital malformations of head and neck. The incidence of these lesions is quite low, accounting for fewer than 10% of all branchial cleft anomalies, and often involves the external auditory canal structures . A wide An 11-year girl presented to our department with a nonhealing ulcer in right upper neck and intermittent right ear discharge. The neck ulcer first developed when she was 2 years old and initially started as a swelling which ruptured and formed a fistula with a surrounding ulcer. She had had numerous incision and drainage procedures performed for recurrent infections. She also complained of one more recurrent swelling behind right ear for the same duration.On examination, there was small cutaneous opening in the right submandibular region surrounded by a 2.5 × 2 cm size ulcer with granulation tissue. The surrounding area was fibrosed and scarred due to repeated surgeries and infection . Ear exaFistulogram revealed tract starting from skin of right submandibular region ending blindly in the deeper part of parotid gland. Contrast-enhanced computed tomography (CT) showed loss of tissue planes with mild diffuse thickening of submandibular and parotid region. No definite tract could be visualized. As both fistulogram and CT were in conclusive for definitive diagnosis, a CT fistulogram was planned. CT fistulogram was done according to the technique described by Whetstone et al. . The fisComplete resection of the fistula tract was performed. Wide exposure of the facial nerve was achieved using modified Blair incision and superficial parotidectomy. During surgical exploration, the fistulous tract was traversing through the parotid gland and noted to run medial to the main trunk of facial nerve. The upper end of the tract was found to be bifurcating, one end ending in floor of EAC at the level of bony cartilaginous portion and the other end going to retroauricular region and ending in a small cyst. The aural end of the tract was thick and containing cartilage while the cervical end was entrapped within the fibrous tissue Figures  and 6.The tract was completely excised with a small cuff of EAC cartilage and skin along with the small tract to retroauricular area and surrounding granulation tissue and scar tissue . The main branches of facial nerve could be preserved except for marginal mandibular branch, which was embedded in the inflammatory mass of fibrotic tissue that was sacrificed. The defect in EAC was repaired and EAC was packed to prevent stenosis of the ear canal. The skin defect was closed by cervical advancement flap as the primary closure was not possible. The postoperative recovery was uneventful. Histological examination of the excised fistula confirmed that it was lined by squamous epithelium with adnexal structures and cartilage. Thus, the findings of surgical exploration and histopathology confirmed the diagnosis of type 2 defect of first branchial cleft. The patient is asymptomatic with no further recurrence after surgery.During the 4th week of human embryological development, 6 pairs of branchial arches appear which are separated by 5 clefts externally and 5 pouches internally. By the seventh week of development, the arches fuse and clefts are obliterated. The structures derived from the first branchial cleft are cavum conchae, the EAC and the external layer of the tympanic membrane .Arnot , in 1971Patients with branchial cleft anomalies most commonly present with swelling in the cervical region (35%), parotid 35%, or periauriclar (24%) region . First bImaging studies are useful in aiding diagnosis. CT scan can confirm the diagnosis by showing the tract near the external auditory canal . A fistuIn first branchial cleft duplication anomalies, misdiagnosis is very common when one is not aware of the possibility of this condition. Triglia et al. noted a delay of 3.5 years between the time of initial presentation and that when adequate treatment was received, with almost 50% of patients having a history of unsuccessful treatment . The resType 1 cyst can be removed while still keeping the epidermal skin of the meatus intact via a retroauricular incision. Work  recommenThe first branchial cleft malformation may be unrecognized or mistaken for other inflammatory lesions in the periauricular and cervical region. Surgical treatment might then be inadequate leading to recurrence or secondary infection. Complete removal without complications depends on a good understanding of regional embryogenesis, an awareness of the different anatomical presentations, and readiness to identify and protect the facial nerve during resection of the tract. CT fistulogram can be instrumental in minimizing the surgical complications by establishing a definite diagnosis and directing the treatment plan.


Resection of a retrocaval paraganglioma is technically challenging due to limited tumor accessibility and proximity to the vena cava.A large, malignant paraganglioma was found behind the retrohepatic segment of the inferior vena cava of a 60-year-old male. During resection of this rare paraganglioma, the left lateral lobe of the liver, a portion of the caudate lobe of the liver, and the gallbladder were also removed. Unfortunately, the patient died six months after surgery due to hepatic metastasis.This case demonstrates that a partial hepatectomy may be necessary to improve tumor accessibility during resection of a retrocaval paraganglioma, particularly if the tumor is proximal to the vena cava. Furthermore, palliative treatments may help prevent tumor recurrence and metastasis of malignant paragangliomas. Paragangliomas, also known as extra-adrenal pheochromocytomas, are rare. Moreover, they are usually benign, catecholamine-secreting tumors that arise from chromaffin cells of the sympathetic ganglia . AlthougHere, a rare malignant paraganglioma located behind the retrohepatic segment of the inferior vena cava (IVC) is described. By performing a partial hepatectomy, the retrocaval tumor was successfully resected without bypass of the vena cava.A 60-year-old man presented with a 2-month history of persistent right epigastric pain and a weight loss of 9 kg, without fever, headaches, palpitations, and sweating attacks. His two brothers had previously died of esophageal cancer and gastric cancer. At a local hospital, a computed tomography (CT) scan without using contrast medium revealed a large retroperitoneal mass that was characterized by a non-homogeneous appearance and slightly low density. Magnetic resonance imaging showed both hypo- and hyper-signal intensities on T1-weighted images, whereas only hyper-signal intensity was observed on T2-weighted images. Compression of the hepatic segment of the IVC was also observed. Due to the complex anatomy of the tumor region and the need for resection, the patient was referred to a tertiary unit for further oncological and surgical assessment.Upon admission, the patient denied any history of hypertension or any other cardiovascular disease. A general physical examination findings were normal. The patient’s blood pressure varied at normal level (110-130/69-86 mmHg). Blood and urine analyses, liver and kidney function, and clotting time, were also normal.The patient’s fasting blood glucose level was 7.34 mmol/L (reference range: 3.9–6.11 mmol/L) and glycosylated hemoglobin level was 7.2 mg/ dL. Serum levels of tumor markers, including carcinoembryonic antigen, alpha-fe-toprotein, and carbohydrate, were normal. Preoperative levels of adrenocorticotropic hormone were assayed at various time points: 15.98 pg/mL at 0:00, 20.25 pg/mL at 8:00, and 14.40 pg/mL at 16:00. Plasma renin activity was 1.30 ng/mL (0.05–2.86 in the lying position), angiotensin II was 31.50 pg/mL , aldosterone was 91.00 pg/mL , and serum levels of cortisol were 7.95 μg/dL at 0:00, 14.53 μg/dL at 8:00, and 6.44 μg/dL at 16:00. Levels of vanillylmandelic acid and urine volume after 24 h were 31.41 mg (1.4–6.5 mg) and 2.05 L, respectively.Ultrasonography revealed a 7.4 cm × 4.5 cm well-demarcated solid mass with mixed echoes  located between the upper abdominal IVC and the aortic artery Figure A. The hePrior to undergoing a laparotomy, the patient completed 3-day volume expansion therapy with artificial colloid solution. During surgical exploration, a generous right subcostal incision was made. The mass of interest was found behind the retrohepatic portion of the IVC. The adjacent lymph nodes were not swollen. Compression of the IVC was observed, with the hepatic hilum lifted in an anterior direction Figure A. The tuIntraoperatively, there was two sharp changes in hemodynamic status of the patients observed during manipulation of the tumour (blood pressure rose to 150-160/90-100 mmHg), which was treated with nicardipine hydrochloride and sodium nitroprusside. Esmolol hydrochloride was used to decrease the heart rate. After the tumor was resected, the blood pressure dropped to 70/50 mmHg and norepinephrine was pumped continuously one half hour. Blood pressure rose and steadied at 110/85 mmHg in the end.The resected tumor (8 cm × 6 cm × 4 cm) was solid, nodular, and encapsulated. On the tumor surface, many tortuous vessels and some localized necrotic tissue were observed Figure D. Macros2, vincristine 1.4 mg/m2, and dacarbazine 600 mg/m2 on Day 1 and dacarbaine 600 mg/m2 on Day 2; every 21 to 28 days) was recommended; however, the patient refused. During the follow-up period, the patient’s initial symptoms of paraganglioma rapidly disappeared. However, 3 months later, ultrasonography revealed hepatic metastasis (Figure By 3 days after surgery, the patient undergone closed thoracic drainage for the right side of massive pleural effusion and aerothorax with the obviously compression of the right lung. The closed thoracic drainage tube was removed on postoperative day 18 and the patient was discharged on postoperative day 21. Postoperative adjuvant chemotherapy CVD-protocol (cyclophosphamide 750 mg/mParagangliomas can develop anywhere along the midline of the retroperitoneum. The exact incidence of retroperitoneal paragangliomas is unknown, although males are typically affected more frequently than females. In addition, most patients are diagnosed between 30 and 45 years of age . Clinicaet al. [et al. [Based on an increase in the level of urine vanillylmandelic acid after 24 h and sharp fluctuation of intraoperative blood pressure, the normotensive paraganlioma is functional in the present case. Prior to the resection of pheochromocytoma or paraganglioma, alpha blocker is still recommended. However, the effect has never been tested in a randomized clinical trial. The necessity of preoperative alpha blocker remains uncertain for the normotensive or asymptomatic pheochromocytom . Shao etet al.  consider [et al.  also rep [et al. .Conventional treatment for paragangliomas typically involves complete surgical excision, while surgical debulking is considered a mainstay of palliative therapy for malignant paragangliomas . In someAlthough paragangliomas are usually benign, 30–50% of all retroperitoneal paragangliomas are malignant . No defien bloc resection was performed to remove the affected surrounding hepatic lobe and diaphragm tissue, it did not extend the life of the patient. Had the malignant nature of the tumor been identified, then the pharmacologic control of symptoms, targeted methods, and systemic antineoplastic therapy could have been applied [Although  applied . The mos applied . In cont applied .Here, we report an extremely rare case of malignant paraganglioma, in which the tumor was located behind the retrohepatic segment of the IVC. The paraganglioma was successfully resected, along with the left lateral lobe and caudate lobe of the liver. This case demonstrates that a partial hepatectomy can improve tumor accessibility, particularly if the tumor is proximal to the vena cava. In addition, palliative treatments may help prevent postoperative tumor recurrence and metastasis.Written informed consent was obtained from the patient for publication of this case report and any accompanying images prior to his death. A copy of the written consent is available for review by the Editor of this journal.The authors declare that they have no competing interests.CJ and XW prepared the manuscript and performed the literature search; CD and XB corrected and revised the manuscript; CD, CJ, YX, and YZ treated and observed the patient; XW provided the radiographic and ultrasound images; and SP and FX performed the histopathological and immunohistochemical examinations. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/13/49/prepub


A 48-year-old woman presented with unilateral hearing loss and tinnitus for three years associated with middle ear effusion. Previous treatments, including antibiotics, corticoids, and transtympanic tube, were ineffective. Otomicroscopy showed a greyish retrotympanic mass associated with middle ear effusion. High resolution CT scan of the mastoid was in favor of chronic oto-mastoiditis without any evidence of tegmen dehiscence. Surgical exploration revealed a polypoid greyish mass filling the tympanic cavity. Histological examination postoperatively revealed a meningothelial meningioma. Postoperative magnetic resonance imaging (MRI) was obtained and showed a large skull base meningioma, extending from the clivus anteriorly to the porus acusticus posteriorly with middle ear invasion. After discussion with the multidisciplinary tumor board, it was managed by stereotactic radiotherapy due to the high surgical associated neurovascular risks. In conclusion, middle ear meningioma, although still a rare presentation, should be suspected in the presence of atypical chronic OME. Otitis media with effusion (OME) secondary to skull base meningioma is a rare condition and only few cases are reported in the literature . In unilIn this paper, we present a case of a large skull base meningioma mimicking chronic OME. We also discuss its histological pattern, imaging characteristics, and the therapeutic modalities.A 48-year-old woman was referred to our tertiary care center for persistent right OME. Her main complaint was unilateral hearing loss associated with tinnitus. For the past three years, she has received multiple antibiotics courses without benefit. Transtympanic ventilation tube was inserted and spontaneously expulsed. She denied history of acute otitis media, chronic otorrhea, or vertigo.Otomicroscopic examination of the left ear was normal. On the right side, the tympanic membrane (TM) was intact, slightly erythematous, and bulging. We decided to put a subannular tympanic tube under local anesthesia. However, after elevating the tympanomeatal flap, we noticed a greyish mass filling the mesotympanic cavity resembling cholesteatoma. The tube was inserted and the patient was scheduled for canal wall up mastoidectomy. Flexible nasopharyngoscopy examination was normal and there were no neurological deficits.Audiometric studies showed a conductive hearing loss with an airbone gap of 30 dB HL. Axial high-resolution temporal bone CT scan demonstrated homogenous opacity of the mastoid and tympanic cavities without bone erosions .Intraoperatively, a multilobulated greyish mass was filling the tympanic cavity and extending posteriorly to the antrum. The ossicular chain was intact and completely engulfed by the lesion rendering complete excision impossible. TM healing was excellent at 1 month postoperatively and there was no CSF otorrhea.Histologic studies confirmed the diagnosis of meningothelial meningioma. The lesion had an infiltrative growth pattern with whorled and nested neoplastic cells that display indistinct cell borders and round to oval nuclei with fine chromatin. Characteristic psammoma bodies and nuclear inclusions were also found .MRI was then performed postoperatively and demonstrated a large skull base meningioma measuring 7 cm and extending from the clivus anteriorly to the porus acusticus posteriorly . ExtensiA neurosurgical consultation was then solicited in addition to the radiooncology team. After discussion in the multidisciplinary tumor board, complete excision was judged to be difficult with high risks of neurovascular injuries and the resultant postoperative functional disabilities. So stereotactic radiation therapy was decided for this patient.Meningiomas are benign tumors, slow-growing originating from the arachnoid villi of the meninges . Two forExtracranial meningioma accounts for less than two percent of meningiomas . It was ME extension of meningioma follows multiple pathways: the tegmen tympani, posterior fossa, the jugular foramen, and the internal auditory canal . The preMRI is the best imaging modality for the diagnosis of meningioma and typically shows an enhancing, dural-based, soft tissue mass with a characteristic enhanced dural tails. CT scan might show hyperostotic reactions  as well Glomus tumors and ceruminomas. However, the histological pattern is quite characteristic.Microscopically they consist of small nests separated by strands of dense connective tissue. Each nest consists of polygonal cells with faintly acidophilic cytoplasm. Cell borders are typically indistinct resulting in a syncytial growth pattern. Nuclei are typically round or oval and contain inconspicuous nucleoli. There is no polymorphism, mitotic activity, nor tumor necrosis. Occasionally one may observe psammoma bodies. Immunohistochemical profiles include staining with EMA and vimentin. Histologically the differential diagnosis includes The treatment of choice for meningioma is surgical excision with an overall survival rate of 85%, 75%, and 70% at 5, 10, and 15 years, respectively . HoweverIn conclusion, ME meningioma, although still a rare presentation, should be suspected in the presence of atypical chronic OME. MRI or biopsy through TM paracentesis, if possible, is advised to avoid unnecessary delay of diagnosis.


Polypoid cystitis is a benign exophytic mucosal lesion of the bladder. Differentiating it from papillary transitional cell carcinoma is difficult due to their similar characteristics. Although indwelling catheter is the main well-known cause of polypoid cystitis, some case reports unrelated to catheterization have been described. However, the radiological findings of polypoid cystitis have rarely been reported. We hereby describe polypoid cystitis in a 20-year-old man without a history of catheterization along with the computed tomographic findings. Catheter-associated polypoid cystitis is a well-recognized condition that mimics bladder cancer 2]. Howe. Howe2].A 20-year-old man complaining of dysuria and straining on voiding for 6 months and gross hematuria for one month was admitted to our hospital. Serum urea, creatinine, electrolyte, white blood cells and hemoglobin values were normal. Urinalysis showed 20-29 RBC/HPF and 20-29 WBC/HPF. Urine culture and urine cytology were negative. Pre-contrast Computed tomoyraphy (CT) revealed no mass in the bladder. However, post-contrast CT demonstrated an intraluminal protruding polypoid lesion 1.5 cm in diameter on the posterior wall of the urinary bladder near the bladder neck. The lesion was homogeneously enhanced and no evidence of muscle layer invasion was observed . The radPolypoid cystitis is a form of chronic cystitis characterized by an exophytic inflammatory lesion of the bladder mucosa . FriedmaThe enhancement pattern of polypoid cystitis is not well known. In our patient, the mass was homogeneously enhanced. Kim et al.  did not As described by Kim et al.  and ChoiIn summary, when a polypoid lesion in the urinary bladder is observed in a patient without a history of catheterization, polypoid cystitis must be considered as a differential diagnosis, especially in stalked lesions without evidence of bladder wall invasion.


Introduction. Leiomyoma is a benign vascular tumor affecting the greater saphenous vein rarely. Proper histopathological examination sets the diagnosis after complete and wide surgical excision along with a normal portion of the GSV. Case Presentation. A 36-year-old woman was admitted to our hospital complaining of a dull ache on her right groin for the last three months, along with a palpable mass on the mentioned area. An ultrasound (U/S) scan revealed a solid mass measuring 3 × 2 cm. After wide surgical excision, pathological examination revealed a leiomyoma of the GSV. Discussion. Benign and mostly malignant tumors arising from the GSV are reported in the literature before. Diagnostic modalities and clinical examination cannot set a correct diagnosis preoperatively due to no specific characteristics of these tumors. Possible sarcomatous behaviour has to be kept in mind when treating tumors arising from a vessel wall and wide surgical excision as negative margins should be attempted. Leiomyomas of deep soft tissue, other than the retroperitoneum and pelvis, including leiomyomas arising in vessels are rare. Leiomyomas arising from veins may be luminal or attached to the vessel wall. We wish to report a case of leiomyoma of the greater saphenous vein that was attached to the vessel wall and clinically presented as inguinal lymphadenopathy treated successfully in our hospital.The patient is a 36-year-old woman who was admitted to the hospital complaining of a dull ache in the right inguinal area. On physical examination a firm mass was palpated in that area. Imaging with ultrasound (U/S) scan examination revealed a solid mass measuring 3 × 2 cm . Fine neLeiomyomas are benign soft tissue tumors that, although very common in other locations, rarely occur in the retroperitoneum, deep soft tissues, and vessel walls. The first case of greater saphenous vein leiomyoma was described by Deweese et al. in 1950 –4. Clini


Introduction. Spontaneous splenic hematoma or splenic rupture due to CMV infection in immunocompetent adults is rare and life-threatening. Case Report. Herein we report a rare case of spontaneous splenic hematoma and hemoperitoneum due to CMV infection in a 23-year-old Caucasian male in whom conservative management was successful. Conclusion. Spontaneous splenic hematoma and spontaneous splenic rupture are extremely rare conditions during primary CMV infection. Though rare, they must be always considered by the operating surgeon, because any misinterpretation may result in unfavorable outcomes. Human cytomegalovirus is a member of the herpes family of viruses and undergoes latency after primary infection , 2. The  A 23-year-old Caucasian male was admitted to the emergency department of our hospital due to severe left upper quadrant abdominal pain. His medical history was free, and no recent trauma was reported. Clinical examination revealed no pyrexia, heart rate at 90 per minute, and normal blood pressure. Upon physical examination, upper abdominal tenderness was revealed. On auscultation, abdominal sounds were present. Rectal examination showed an empty rectum.3, hemoglobin 14,2 g/dl, platelets 278000/mm3, c-reactive protein 17 mg/dl, Tbil 1,9 mg/dl, Dbil 0,28, ast 27 IU/L, alt 42 IU/L, and creatinine and electrolytes were normal. An abdominal ultrasound showed splenomegaly  and free fluid in the left iliac fossa and in pelvis  , 8. ClinThe mechanism for the spontaneous hematoma and the splenic rupture is not yet fully clear. However, it seems that it consists in increased intrasplenic tension caused by cellular hyperplasia and vascular occlusion caused by reticular endothelial hyperplasia. This leads to subcapsular hemorrhage, formation of subcapsular hematoma, and rupture of the splenic capsule .Spontaneous subcapsular splenic hematoma with hemoperitoneum, splenic contusions-lacerations, and complete spontaneous splenic rupture are rare and life-threatening complications of primary CMV infection in young immunocompetent adults. To our knowledge, only few reports on splenic “surgical” involvement during primary CMV infection treated conservatively have been published to date.In order to explore this, we conducted a PubMed search using the key words “splenic hematoma,” “CMV infection,” “conservative management,” and “splenic rupture.” We found only five cases, including our case, of “surgical” splenic involvement during primary CMV infection in immunocompetent adults. These patients were treated successfully with nonoperative management , 12 Tab.In case of hemodynamic instability, it is obvious that splenectomy is the treatment of choice. When, however, the patient is hemodynamically stable, as in our case, the non-operative management is a safe option with the patient under close monitoring and surgical supervision –15. ReceIn conclusion, the diagnosis of splenic hematoma or splenic rupture due to CMV infection in young immunocompetent individuals can be very difficult and requires a high suspicion and a lot of awareness on the part of the surgeon. These conditions must be always considered when dealing with left upper abdominal pain in young immunocompetent adults in order to prevent the dramatic consequences of a missed diagnosis.


Fibrolipomas are a rare subtype of lipomas. We describe a case of a man suffering from subcutaneous penile fibrolipoma, who three months earlier has been submitted to an augmentative phalloplasty due to aesthetic dysmorphophobia. After six months from the excision of the mass, the penile elongation and penile enlargement were stable, and the patient was satisfied with his sexual intercourse and sexual life. To our knowledge, this is the first reported penile subcutaneous fibrolipoma case in the literature. The diagnostics and surgical features of this case are discussed. As described in literature, penis size is an issue of social relevance , 2.Some men who were considered normal may request augmentation surgery as a result of an altered perception of the size of the organ (penile dysmorphophobia); in this case, dysmorphophobia may represent a functional problem  or aesthetic problem  –5. Most In these patients, a simple operative procedure can be used to enlarge the volume of the penis by autologous fat transfer; at the same time, the penis can be lengthened by the release of the suspension ligament below the symphysis, so defined “augmentative phalloplasty” –10.We describe a case of subcutaneous fibrolipoma in a man submitted in the previous three months to augmentative phalloplasty due to aesthetic dysmorphophobia, to the knowledge of the researchers this is the first case reported in the literature.We describe the case of a 54-year-old man who presented small penis. After urological consult, he agreed to undergo an augmentative phalloplasty resulting in penis elongation and enlargement. The procedure was performed on April 2012 under general anaesthesia. After skin incision at the base of the penis, a dissection of the ligament suspensory of penis below the symphysis was done, extracting the corpus cavernosus, and anchoring the tunica albuginea at the periost. At the root of the phallus, the skin was elongated by V-Y plasty.Following that, the sovrapubic liposuction was performed. Fractions of fat were centrifuged, purified of serum and oil, and put into 2 mL syringes.Incision with a scalpel at the stretched preputium between the two forceps was done.By inserting and pulling back the Coleman Cobra cannula, a purified body fat was transplanted from the penis root upwards, positioning longitudinal steri strips at the end of surgery. Overall 40 mL of purified fat cells was transferred.At the end of procedure, the patient obtained an increase of 4 cm in length and 2,5 cm in circumference. Before surgery, the length of the penis in flaccid state was 4,5 cm, immediately after surgery the length of the penis increased to 8,5 cm. Before augmentation with autologous fat transfer, the circumference of the penis in flaccid state was 8 cm, after augmentation with autologous fat transfer the circumference of the penis was 10,5 cm.Patient was advised to refrain from sexual activity for 5 weeks after the surgery.Three months later, the man was found to have a subcutaneous dorsal penile mass. This mass caused pain during erection and difficulty in having a sexual intercourse because of the limited penile extension during erection such as trapped penis .During penile examination, a mass of approximately 6 × 6 × 4 cm was palpated at the basis of penis, at the level of the proximal third of the penile shaft, on the dorsal surface of the organ. On palpation, the mass was firm in consistency, painless, and mobile under the palpating finger.No abnormalities were detected in the glans and other organs. The patient did not complain about any other medical problems. Ultrasonography of the mass was performed using B-mode equipment  and a linear 8.0 MHz transducer . Ultrasonography showed a structure with a loss of homogenous echogenicity with multiple hyperechoic areas. We waited further six months after surgery to assess the possible spontaneous retraction of the mass, but no changes were observed so we decided to remove it. Under general anesthesia, an infrapubic incision at the base of penis was performed to excise the mass; it was dissected from the lateral subcutaneous tissue easily, but it was very difficult to dissect it from the below penile neurovascular bundle.The mass (6 × 6 × 4 cm) had an elastic texture and was enclosed by a smooth, shining, and vascular capsule . On the The excised tissue was sent for histological examination.Tissue samples of the mass were fixed in 10% buffered formalin and processed for paraffin embedding as standard procedure.The sections were deparaffinised, dehydrated, and stained with haematoxylin and eosin. Microscopic histopathological examination of the mass demonstrated adipose tissue with diffusely distributed mature adipocytes and septa of fibrous connective tissue with proliferating fibroblast .On the basis of these clinical and histologic findings, a diagnosis was made of a subcutaneous fibrolipoma of penis.There were no postoperative complications. After six months from the second surgery, the penile elongation and penile enlargement were stable, and the patient was satisfied with his sexual intercourse and sexual life.The satisfaction of surgical outcome was also assessed at 12 months following the surgery by directly asking the patients “are you satisfied with the result of your surgery?” The patient was satisfied with the outcome of the surgery.At the 12th month, during the postoperative follow-up visit, the patient reported a normal erectile function; overall, the ED domain score was 25, and the Rigiscan test revealed a good number of nocturnal penile erections (3-4 a night), with a normal duration and a good rigidity both at the base and at the tip of penis (>70%). An artificial erection, induced with the administration of 10 mcg of prostaglandin E, ruled out the presence of any curvature.To the best of the authors' knowledge, this is the first report of subcutaneous penile fibrolipoma in man. Fibrolipoma is a histological variant of lipoma, the aetiology of this condition is not well understood, usually in other organs this lesion is an uncommon benign tumour , 12. The consistency of the fibrolipoma can be soft or firm depending on the amount of fibrous tissue, and the treatment is usually an excision .The condition can occur in the oral cavity, subcutaneous tissue, colon, trachea, larynx, parotid gland, and spermatic cord as a slow growing lesion .As reported in the literature, in men affected by aesthetic dysmorphophobia, a simple operative procedure can be used to enlarge the volume of the penis by autologous fat transfer. At the same time, the penis can be lengthened by the release of the suspension ligament below the symphysis, so defined as “augmentative phalloplasty” –10.Probably bleeding and lymphorrhoea after surgery, together with the amount of fat transferred, could play a role in the aetiology of penile fibrolipoma such as in our case.In our opinion, it could be useful to perform sovrapubic liposuction, autologous fat transfer, and dissection of suspension ligament separately, so to reduce the amount of bleeding.We suggest even to use a compressive bandage on the sovrapubic area for 4–6 weeks and to reduce the amount of fat transferred during the procedure.For the diagnosis of the lesion, we effectuated only clinical palpation and ultrasonography.In addition to that in the patient's preoperative diagnosis, a magnetic resonance imaging (MRI) should be performed.As reported in the literature, MRI could be very useful not only for the diagnosis of all kinds of lipomas, but also for the connection with the neighboring structures . In our patient, surgical resection of the mass was technically difficult because of the near connection with penile neurovascular bundle and the adherences to it. Most probably, the MRI could have helped us to provide better understanding of the involvement of local structures. Augmentative phalloplasty with autologous fat transfer and section of the suspension ligament below the symphysis is a generally safe and effective procedure.Occasional complications are possible even with a meticulous observation of the steps of the operation.Further investigation is warranted to clarify the aetiology of this subcutaneous penile fibrolipoma after augmentative phalloplasty.The complete resection of the mass, consisting in surgical excision with capsular dissection, should be performed but it is not always easy.MRI increases the accuracy of diagnosis and helps to determine the best surgical approach.


Melanoacanthoma (MA) has been described in the oral mucosa as a solitary lesion or, occasionally, as multiple lesions. MA mainly affects dark skinned patients and grows rapidly, showing a plane or slightly raised appearance and a brown to black color. The differential diagnosis includes oral nevi, amalgam tattoos, and melanomas. We report here the case of a 58-year-old black woman who presented multiple pigmented lesions on the hard palate.Based on the differential diagnosis of melanoma, a punch biopsy (4 mm in diameter) was performed. The material was fixed in 10% formalin, embedded in paraffin, and stained with hematoxylin-eosin or submitted to immunohistochemical analysis. Immunohistochemistry using antibodies against protein S-100, melan-A, HMB-45, MCM-2, MCM-5, Ki-67 and geminin was performed. Immunohistochemical analysis revealed strong cytoplasmic immunoreactivity of dendritic melanocytes for proteinS-100, HMB-45 and melan-A.Positive staining for proliferative markers  was only observed in basal and suprabasal epithelial cells, confirming the reactive etiology of the lesion. The diagnosis was oral Melanoacanthoma (MA).The patient has been followed up for 30 months and shows no clinical alterations. MA should be included in the differential diagnosis of pigmented lesions of the oral cavity. In an attempt to better define the melanoepithelioma types 1 and 2 described by Bloch (1937), Mishima & Pinkus (1960) were the first to use the term melanoacanthoma (MA) [The first report of oral MA was published by Schneider and coworkers 1981) . Since t1 . SinceThe objectives of the present study were to report a case of multifocal MA in the hard palate and to highlight the main differential diagnoses and immunohistochemical findings.sic). The patient used a removable upper denture and had noted the presence of black-brownish spots on the hard palate 3 months ago. The spots had increased in size during this period and presented discrete itching when touched by the tongue.A 58-year-old black woman sought the Stomatology Outpatient Clinic of the São José dos Campos Dental School in March 2008 because of a “blood stain on the roof of her mouth” . This type of melanoma can also exhibit a dense subepithelial lymphocytic infiltrate ,13-15.According to Goode et al. 1983) , the inf3 , the iThe present histopathological findings showing no sign of malignancy agree with reports in the literature. Although some investigators emphasize the frequent occurrence of a heterogeneous inflammatory infiltrate in cases of MA , the preImmunohistochemical analysis was performed in order to better understand the etiology and behavior of MA. For this purpose, specific markers of cellular elements that might be compromised during the genesis of the disease and cell proliferation markers were used. Epithelial cells stained positive for protein S-100, demonstrating the involvement of cells of neuroectoderm origin in the etiology of MA . ProteinNo neoplastic progression of melanocytic lesions has been observed in the cases reported in the literature. Regression of the lesions within a period of 2 to 6 months after diagnosis has been reported after removal of the local irritating agent or after excisional and/or incisional biopsy . In contAccording to Carlos-Bregni et al. (2007) , since MThe immunohistochemical features of the case reported here demonstrate the importance of the application of an immunohistochemical panel to better understand the etiopathogenesis of pigmented lesions.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.LFCSC, VHF, LAGC and JDA examined the patient. LFCSC and VHF carried out the biopsy. JDA drafted the manuscript. RDC and AAHB participated in the design of the manuscript. AAHB performed the histological examination. RDC performed de immunohistochemistry. LACG conceived the manuscript, and participated in its design and coordination. All authors read and approved the final version of the manuscript.