Histiocytosis represents a group of rare disorders characterized by nonneoplastic proliferation of histiocytes and solitary cutaneous reticulohistiocytosis (SCR) is a form of non-Langerhans histiocytosis. SCR consists of small papule, usually single, varying in color from yellow to brownish-red, more frequent in young adults, and uncommon in childhood. We report a case of SCR in an 11-year-old child and emphasize a unique dermoscopy pattern of this lesion and its correlation with clinical and histopathological aspects in the diagnosis. Initially described by Zak in 1959, solitary cutaneous reticulohistiocytosis (SCR) is a form of reticulohistiocytosis that is a rare presentation of non-Langerhans cell histiocytosis . Still,  Recently, some authors have reviewed a high number of similar cases and proposed the name solitary epithelioid histiocytoma instead of the archaic “reticulohistiocytoma” . It is more common in young adults and slightly more predominant in men . The aimAn 11-year-old male was taken to a primary care because his mother noticed a lesion painful to touch on his neck that appeared 30 days previously; the lesion had been gradually growing. There was no history of obesity or dyslipidemia. The examination revealed a well-defined papule of firm consistency, 6.5 mm in diameter, erythematous, and nonexudative Figures . There w Dermoscopy under nonpolarized light showed a well-defined central white-grayish area and white-pinkish streaks situated at the periphery, without dilated vessels . An exciSCR is characterized by an exophytic neoformation with rapid growth that has become a well-delimited papule or nodule, with a smooth surface of 0.3 to 2 centimeter in diameter. The lesions are of firm consistency and variable color, ranging from yellow to red-brownish . Pediatr Reticulohistiocytosis can also present as diffuse cutaneous reticulohistiocytosis and multicentric reticulohistiocytosis (MR) . The las The histopathological study was done objecting to exclude possible differential diagnosis. SCR differs from conventional granulomatous inflammation by being free of well-formed spherical granulomas and the presence of large epithelioid histiocytes with eosinophilic “glassy” cytoplasm . The lasThis lesion can be difficult to distinguish clinical and histopathological from solitary juvenile xanthogranuloma: however, the last classically contains lipids in the histiocytes and Touton-type histiocytic giant cells , both no In its turn, dermoscopy of SCR, previously described only twice in the literature, can have an auxiliary role in its diagnosis. The dermoscopic patterns reported were different from the one observed in our patient. One study showed dotted vessel and light-brown globules on a yellow background and the other a uniformly yellow central area and a pink-orange color in the periphery . The sec Other differential diagnoses include nodular tenosynovitis, fibrolipoma, Spitz's nevus, mastocytoma, keratoacanthoma, Hashimoto, and Pritzker's disease and pyogenic granuloma , 3. Thes Therefore, this case reinforces this new dermoscopy finding and the use of dermoscopy in nonpigmented skin disorders evaluation and its importance as an adjuvant in diagnosing non-Langerhans cell histiocytosis, contributing to exclude potential differential diagnosis when used together with histopathology.


Urinary bladder carcinoma is the second most common cancer of the urinary system. The recurrence rate in the upper urinary system (UUS) for urothelial cancers is around 3% following radical cystectomy. The followup generally consists of imaging studies and urinary cytology, although there are no prospective data on the frequency, the mode, and the duration of followup. In patients carefully selected according to risk factors, kidney-sparing minimally invasive methods  appear as contemporary alternatives for low-grade and low-stage primary UUS. In this paper, we present the patient who underwent radical cystectomy with urinary diversion ureterocutaneostomy, was diagnosed with widespread bilateral UUS tumors and recurrent tumor at the urostomy site at active followup, for which he was given local Bacillus Calmette-Guérin (BCG) and cryotherapy, and was followed by disease-free for 2 years thereafter. Urinary bladder cancer is the second most common cancer of the urinary system and is responsible from 3% to 5% of all cancer-related mortality . More thRadical cystectomy, which is considered the most effective treatment option for invasive bladder cancer, is curative in only half of the patients. The remaining local recurrences are common, the majority of which are distant metastases. Most of these recurrences appear in the first 2 years, following surgery . The ratIn this paper, we present the patient who underwent radical cystectomy ureterocutaneostomy, was diagnosed with widespread bilateral UUS tumor and recurrent tumor at the urostomy site at active followup, for which he was given local Bacillus Calmette-Guérin (BCG) and cryotherapy, and was followed disease-free for 2 years thereafter. A 54-year-old male patient underwent radical cystoprostatectomy, ureterocutaneostomy (patient preference), and bilateral iliac lymph node dissection following a positive test result of transurethral resection-bladder (TUR-B) pathology for a low-grade urothelial carcinoma with muscle invasion. Perioperative ureter lower end frozen examination revealed no tumor at the lower ends of both ureters. The tumor's pathological stage was pT2N0M0  reactive lymph nodes). He began and routine followup after the operation. Urinary cytology was class 2 at the postoperative 3rd-month control and class 4 at the 6th month; his urinary cytology was repeated, and the test result was reported as class 5. Furthermore, his physical examination revealed a hyperemic and edematous area that was tuberous at the site of the urostomy . The patAn excisional biopsy was taken from the suspicious hyperemic lesion at the urostomy site. Bilateral ureterorenoscopy was performed. Multiple tumors smaller than 0.5 cm were detected in both ureters, and a punch biopsy was taken . The pathological examination of the sample tissues revealed urothelial carcinoma, cutaneostomy skin excisional biopsy, in situ carcinoma right, and left suspicious ureteral lesions. A local therapy was planned as he had bilateral ureteric recurrences that involved the urostomy site, and the patient preferred the local therapy. With these findings, he was given BCG 81 mg diluted in a 50 cc isotonic saline solution and given in 25 cc to the right and left ureters each from a height of 40 cm as intraureteral chemotherapy every second week for a total of 3 courses. A dermatology consultation was obtained for the tumoral lesion at the cutaneostomy, and 4 courses of cryotherapy with 21-day intervals were conducted on this site as the initial therapy. Cryotherapy is a technique that employs intensely low temperatures to eliminate the diseased tissues. For this purpose, solid carbon dioxide (dry ice) at −78.5°C or liquid nitrogen at temperatures up to −190°C are used. The gas that is to be used in the freezing process is passed through the probe and causes the probe to cool excessively. When the gas used in the cooling process is pushed toward the end of the probe, the volume of the gas instantly expands, and as it absorbs heat from the environment, the probe end is cooled. The cell death is provided by the transformation of the pure water in and out of the cell into ice crystals. According to these principles, the patient underwent 4 courses of cryotherapy of 30–70 seconds with a double cooling-thawing cycle, and it was observed that the tumoral lesions at the cutaneostomy site regressed to skin level. At the mid-term evaluation, it was decided to continue the cryotherapy. After observing that the patient's lesion completely recovered as a result of 9 courses of cryotherapy, a few punch biopsies were taken from the cutaneostomy region . The pathological examination of the punch biopsies was negative for tumoral lesions. In addition, urinary cytology was observed as class 2, and the flexible ureterorenoscopy was also negative for a tumoral presence on both sides of the UUS. The patient was enrolled in active followup. His later urinary cytological examinations were also consistent with class 2, and endoscopies were negative for tumors . He has Survival after recurrences in the UUS following radical cystectomy is generally disappointing. The rate of survival for more than 3 years has been reported as 0%–25%. Thus, the main priority of the UUS followup after cystectomy is to diagnose the recurrences as early as possible to allow for an effective treatment. Diagnosis of the cancer recurrence before the symptoms develop is very important. Followup generally consists of urinary cytology and imaging modalities. One of the controversial topics regarding cytology, which is commonly used for followup following radical cystectomy, is the positivity of cytology before any other positive finding appears. There is limited information in the literature regarding this issue. Raj et al. detected uroepitheleal recurrence at a median of 2.1 years after surgery in 57 56.4%) of 101 patients [.4% of 10The other modality in oncological followup is imaging which is usually applied in the form of intravenous urography (IVU) or computerized tomography (CT). IVU and CT can only diagnose 0%–55% of UUS recurrences. Although no method is superior to another in the diagnosis of the UUS tumors, CT has the advantage of showing retroperitoneal lesions, and organ recurrences better. The diagnostic power of CT is related with the localization of the lesion at UUS and its size. For example, its diagnostic power is around 78%–94% in lesions located at the renal pelvis, whereas it is only 17%–53% in ureteric localizations. The chance of detecting small (<2 mm) lesions by CT is also low [By the very nature of urothelial cancer, all local and distant recurrences other than “new” tumors originating from the remaining uroepithelium following radical cystectomy are considered systemic disease. The only current treatment modality that has been shown to boost survival in UUS recurrences is nephroureterectomy. Regional lymph node involvement has been reported at between 32% and 83% in those undergoing nephroureterectomy for UUS recurrence after cystectomy. Adjuvant chemotherapy application also has limited benefit following lymph node dissection and nephroureterectomy in patients with lymph node involvement. Unfortunately, the long-term disease-free survival rate is below 5% in those patients. Thus, kidney-sparing minimally invasive methods  seem to be current alternatives for low-grade, low-stage primary UUS tumors in patients selected carefully based on risk factors [After minimally invasive or nephroureterectomy therapies, the actual main determinants of prognosis are the stage, grade, localization, and size of the tumor. One of the most important factors determining the prognosis in UUS transitional cell carcinomas is the tumor grade . Large hIn conclusion, recurrent UUS urothelial tumors following radical cystectomy can be treated by systemic and local therapies in cases in which surgical therapy is not an option. The localization, grade, and size of the recurrent tumor should certainly be taken into consideration in that decision. In addition, alternative treatment modalities such as locally-administered drug instillation (BCG) and cryotherapy should be considered in localized recurrent urinary system urothelial tumors.


We describe a case of recurrent metastatic malignant ameloblastoma to the lungs with hypercalcaemia in a 47-year-old man. The first lung metastasis was resected nine years after the initial primary, and the tumour recurred with extensive pulmonary metastases 21 years after the primary tumour was resected. This case presented with malignancy-associated hypercalcaemia, likely due to paraneoplastic syndrome, which is exceedingly unusual in association with malignant ameloblastoma. He was successfully treated with carboplatin/paclitaxel and showed the longest survival and stable disease, from the diagnosis of recurrent metastasis, recorded as a case report. This regimen is reasonably well tolerated and can be repeated safely. Ameloblastoma is the second most common odontogenic tumour that mostly involves the mandible and maxilla. It is a slow-growing locally invasive epithelial tumour with a high recurrence rate (50%–72%) and rare metastasis (<2%). Histopathologically, metastasising ameloblastoma shows no specific features different from non-metastatic ameloblastoma, which makes it impossible to predict its clinical behaviour. Metastasis usually follows multiple recurrences and frequently occurs in the lungs (≥75%) and cervical lymph nodes, usually many years after the primary tumour –4. ExtenBecause metastatic ameloblastoma is rare, there is little information in the literature to guide the treatment plan, and the evidence is mainly derived from case reports. Here, we describe a case of mandibular ameloblastoma with recurrent extensive pulmonary metastasis controlled effectively with carboplatin/paclitaxel, achieving long-term partial remission. This case is also interesting because hypercalcaemia is rarely reported in metastasising ameloblastoma, and the absence of other causes suggested a paraneoplastic aetiology.In March 2010, a 47-year-old male presented to the Lung Clinic at Princess Margaret Hospital, University Health Network, Toronto, Canada, with occasional haemoptysis. His past history was significant due to a resection of a left-sided mandibular ameloblastoma with subsequent hip bone graft in 1989. After being asymptomatic for nine years, he had developed a lung metastasis and had undergone a wedge resection of the right-sided solitary pulmonary metastasis in 1998. Subsequently, he was followed for approximately three years with serial chest x-rays and was discharged, being disease-free at that time. He had a recurrence a second time in 2010 when he was symptomatic with occasional haemoptysis from pulmonary metastases.A clinical examination was unremarkable, except for alopecia and a scar on the left mandible from the previous tumour resection. The whole-body PET/CT scan and bone scan revealed multiple bilateral pulmonary metastases  with no The patient’s situation was also complicated with asymptomatic hypercalcaemia (3.53 mmol/L), likely as part of paraneoplastic syndrome, which was managed initially by intravenous fluids and pamidronate therapy and subsequent therapies administered every 3–4 weeks.The pulmonary metastases were surgically unresectable and were not amenable to radiotherapy due to the large radiation fields required to encompass the tumours. After a case discussion in our multidisciplinary tumour board, the patient commenced treatment on carboplatin/paclitaxel. Soon after treatment initiation, haemoptysis disappeared, and his calcium was stabilised. A chest radiograph and CT scan taken after three cycles showed disease response , and theApproximately three years after starting chemotherapy, he is generally feeling quite well (ECOG = 0–1) and is clinically asymptomatic. After a long interval without treatment, his lung disease is stable on follow-up CT imaging and his calcium level is normal. We continue to follow him with intermittent CT scans and would re-institute carboplatin/paclitaxel were there to be a relapse or progressive disease.Metastatic ameloblastoma is rare, and metastasis is often a strikingly late event after the primary occurance. As a result, the treatment of metastatic ameloblastoma is elusive. There is inadequate evidence in the literature to guide the treatment plan, and treatment decisions are mainly taken from case reports.For lung metastases, pulmonary metastasectomy with maximum preservation of viable lung tissue remains the mainstay of treatment, and the role of cheomotherapy and/or radiation is yet to be defined. Based on the available data from published case reports, chemotherapy at the physician’s discretion has been the treatment of choice when radical resection could not be achieved. There is no single-agent or combination chemotherapy regimen that can be recommended for palliation in patients with unresectable metastases. Different palliative chemotherapy regimens are reported to have reduced the tumour size and improved symptoms  1–5].–5.1–5].et al in a patient with bilateral pulmonary metastases, who interestingly remained asymptomatic and did not require any treatment [With these rare tumour subtypes, chemotherapy options are limited by a lack of experience and variable efficacy as well as non-optimal treatment results. Only very few reports exist in the literature on the use of platinum-based treatment in this indication , 5, 6. Hreatment .A rare feature of our case was that a good clinical response was achieved with chemotherapy only. It highlights the benefit of single modality chemotherapy treatment when surgical resection or radiotherapy is not feasible. This case is also interesting because only a few cases of metastasising ameloblastoma with malignancy-associated hypercalcaemia have been reported , 8–10. IThis report may help to guide physicians to choose a systemic treatment for patients with metastatic and/or disseminated ameloblastoma. This regimen is reasonably safe, well tolerated, easy to administer, and, more importantly, can be repeated, as being used in ovarian cancer. The efficacy for this particular regimen warrants further reports from similar cases. However, in the absence of any proven effective chemotherapy and due to perceived poor prognosis of metastatic ameloblastoma, systemic chemotherapy using carboplatin plus paclitaxel should be considered a treatment option.The authors declare no conflicts of interest for this manuscript.


Sir,A 70-year-old male presented with complaints of bleeding per rectum since last 6 month. The patient complained of abdominal pain and nausea. He had a history of altered bowel habit and tenesmus. The patient was hemodynemically stable and afebrile. Physical examination showed no sign of peritonitis. Routine blood chemistry was normal. Per-rectal examination revealed circumferential growth of approximately 5 cm from the anal verge. Histopathological examination was suggestive of adenocarcinoma. The patient was subjected to CT scan abdomen which revealed the contrast enhancing lesion in the rectum with hepatodiaphragmatic interposition of the colonic loop Figures  and 2. TTransposition of loop of large intestines in between diaphragm and liver surface on plain X-ray chest or abdomen is known as chilaiditi sign. Physical examination is usually normal except interposition of loop in chilaiditi sign. Incidence is around 0.1-1%. Symptoms such as nausea, abdominal pain, Chilaidi


We report a case of gastric malignant schwannoma presenting with gastrointestinal bleeding.A 70-year-old Japanese man presented with gastrointestinal bleeding to our hospital. Gastrointestinal endoscopy revealed a protruding lesion in the gastric body. Hematoxylin and eosin staining of biopsy specimens from this lesion revealed sheets of spindle cells. Immunohistochemistry revealed that these cells were positive for S-100 protein and negative for c-Kit and smooth muscle actin. Because mitosis was diffusely visible, this tumor was diagnosed as a gastric malignant schwannoma. Distal gastrectomy with lymph node dissection was performed and the patient's postoperative course was uneventful. However, five months after the surgery, he died from multiple liver metastases.Cases of gastric malignant schwannoma have rarely been reported. The efficacy of surgical resection and postoperative prognosis continues to remain unclear and should be investigated further. Schwannomas are neurogenic tumors that originate from different organs as well as other areas throughout the body. Gastric schwannomas are rare; however, if they do occur in the gastrointestinal tract, the most common site is the stomach. Gastric schwannomas represent 0.2% of all gastric neoplasms . GastroiSchwannomas are generally benign. Complete surgical removal is sufficient treatment for a benign gastric schwannoma because of excellent postoperative prognosis. Gastric malignant schwannomas are extremely rare and only a few cases have been reported ,5. We prA 70-year-old Japanese man with melena that began five days before admission was admitted to our hospital. He complained of abdominal discomfort and epigastralgia. Five years before, he had undergone a right upper lobectomy for lung cancer (T1b N0 M0 Stage IA). Physical examination revealed no abnormal findings associated with the abdomen except a surgical scar on the right side of his chest. Evaluation of laboratory data on admission revealed that his hemoglobin level was 7.0 g/dL and hematocrit value was 23.1%. Upper gastrointestinal endoscopy revealed a distinctly protruding lesion (diameter: 5 cm) at the lesser curvature of the middle third of the gastric body  reported gastrointestinal bleeding as the first symptom and 42% presented with abdominal pain [Bruneton nal pain . Gastroiet al. reported that there is a high expression rate of platelet-derived growth factor receptor (PDGFR) and c-kit in vestibular schwannoma [® (imatinib mesylate)may have relevant therapeutic applications for this kind of tumor. From these results, molecular therapy for gastric schwannoma may become an additional treatment modality and deserves further examination.Gastric malignant schwannomas can be distinguished from benign schwannomas on the basis of histological examination of the resected specimens, not by clinical symptoms or imaging studies. The treatment strategy for gastric schwannoma is, therefore, the same regardless of whether the tumor is malignant or benign. Surgical resection is the only possible treatment for gastric schwannoma ,14. The hwannoma . They coGastric malignant schwannomas are extremely rare, and only a few cases have been reported. Given the paucity of the currently available published literature, the efficacy of surgical resection and postoperative prognosis for such cases warrants further study.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.All authors were actively involved in direct patient care and have read and approved the manuscript. MT is the principal author and was involved in the collection of data. AK contributed to writing the manuscript. MT, KY and KS were involved in the collection of relevant literature and proof read the manuscript.


A 61-year-old female presented with night sweats following a resection for non-Hodgkin’s lymphoma of splenium corporis callosi. A positron emission tomography-computed tomography scan demonstrated that original lymphoma activity remained. A new ascending colon mass was identified simultaneously, which was diagnosed as an adenocarcinoma following the surgery. To the best of our knowledge, this is the first case to report a coexistence of primary central nervous system non-Hodgkin’s lymphoma and colorectal adenocarcinoma. The case poses a difficult clinical challenge. Primary central nervous system non-Hodgkin’s lymphoma (PCNSNHL) is rare and accounts for 0.8–1.89% of intracranial tumors  in December 2011 with a five-day history of night sweats following a resection for non-Hodgkin’s lymphoma of splenium corporis callosi. One month previously, the patient underwent contrast-enhanced cranial magnetic resonance imaging for dizziness, which indicated a splenium corporis callosi mass. Thus, the patient underwent splenium corporis callosi mass resection. Frozen pathology revealed lymphoma and immunohistochemistry identified cells that were CD19(+++), Bcl-2(+), Bcl-6(+), CD23(−), CD5 , CD10(+), CD20(+), CD43 , CK (pan)(−), glial fibrillary acidic protein(−), Ki-67 (60% positive), CD2 , neuron-specific enolase (−), CD79a(+), multiple myeloma oncogene 1(+), CD3(+) and cyclin D1(+), thereby confirming the presence of B cell lymphoma. The post-operative recovery was good, but five days prior to admission, the patient experienced night sweats. Following admission, a positron emission tomography-computed tomography (PET-CT) scan was performed. The results indicated that tumor activity remained following the non-Hodgkin’s lymphoma of splenium corporis callosi resection, and an ascending colon mass was identified. Electronic colonoscopy was performed in order to identify the pathological characteristics of the ascending colon mass . Biopsy Due to the aggravating abdominal discomfort, a PET-CT scan was performed again in April 2012. The scan indicated the possibility of primary intestinal malignancy with hepatic multiple metastases and left lower lung metastasis. Biopsy under electronic colonoscope revealed an ascending colon adenocarcinoma  and 2B. et al (Synchronous carcinomas are defined as multiple separate neoplasms that are diagnosed at the same time or within a six-month period of identifying the primary lesion. The gross and histological criteria of synchronous carcinomas, described by Warren and Gates in 1932 (et al  reportedet al (All the previously mentioned studies had a colorectal neoplasm and lymphoma in the same site. By contrast, the present study described the case of an elderly female with coexisting PCNSNHL and colorectal adenocarcinoma for the first time, with lymphoma in the cranial cavity and adenocarcinoma in the intestinal cavity. No hepatic or pulmonary metastases were observed in the first PET-CT scan , and theet al . PCNSNHLThe development of a malignancy, including colorectal neoplasm and lymphoma involves oncogenes and associated genes. The genes that are associated with colorectal neoplasm and lymphoma have been identified to include C-myc, Bcl-2 and survivin –17. C-myIn addition, common drugs in the chemotherapy regimen for PCNSNHL are cyclophosphamide, doxorubicin, vincristine and prednisone, while those in the chemotherapy regimen for colorectal neoplasm are 5-fluorouracil, capecitabine and antitumor platinum complexes. The two groups of drugs rarely overlap with each other. Therefore, further research is required to identify how to optimize the chemotherapy regimen in patients with coexisting PCNSNHL and colorectal adenocarcinoma. C-myc, Bcl-2 and survivin may offer breakthrough treatments for this disease in the future.


A chronic fungal infection in tropical regions, chromoblastomycosis is caused by dematiaceous fungi, the form-family of Fungi Imperfecti, usually affecting one lower limb at the site of a trauma but sometimes involving other areas of the body including head & neck. In this article, we report the case of a rare primary chromoblastomycosis of the palate and chest in a 27-year-old man who was successfully treated with surgical resection and combined drug therapy, and eventually free tissue transfer reconstructive surgical procedure to cure the palatine defect. Moreover, intact cell mediated immunity was revealed. Imaging studies showed the extent of mass growth and the involvement of surrounding bone. The mass was resected sacrificing the involved soft tissue and bone, and the palatal defect was covered by means of local tissue, only to fail. The patient received Amphotericin B and Itraconazole according to a protocol provided by clinical mycologists of the department of infectious diseases , 9. FinaThe patient underwent surgery once the necessary tests were run and the patency of the ulnar artery and deep palmar arch was confirmed preoperatively. The flap was dissected on the nondominant limb in a distal to proximal direction on its radial artery pedicle and venae comitantes. After preparation of the Facial vessels as the recipient vessels, the flap was harvested and transplanted. The nasal lining was restored by split thickness skin graft. The patient received postoperative care and was discharged after the donor site dressing and immobilizing splint were removed, and scheduled for several office visits.Cladosporium type of sporulation was noted.The histological finding in the biopsy specimen was that of a granulomatous reaction characterized by formation of pseudotubercles containing giant cells, and a focal round cell infiltration in the superficial portions of the specimen. The fungi appeared in clusters of brown, spherical cells with thick, dark cell walls and coarsely granular pigmented protoplasm. The cultural characteristics were also studied. The colonies produced black, slow growing, heaped-up colonies and the The last specimens obtained before the final reconstructive procedure showed eosinophil rich acute inflammation without any fungal infection. Cultures obtained as the reference method were all negative.Cladophialophoracarrionii, Fonsecaeapedrosoi, F.compacta, Phialophoraverrucosa, and Rhinocladiella aquaspersa (4 Usually the disease process remains localized to one lower extremity, however, there are reports of various clinical involvements, even in the central nervous system, with or without associated skin lesions. Metastases through the blood stream are rare, but have been documented (Chromoblastomycosis usually begins on one lower extremity. The small lesions may resemble common warts . The cicuaspersa , 5. The uaspersa .There iscumented . The invDespite medical and surgical therapy, cure of chromoblastomycosis infection is difficult and recurrences are frequent as in our case. As yet, no controlled therapeutic trials have been reported, so there is no medication or combination of medications considered as treatment of choice. Antifungals are needed to be given for at least 6-12 months, often combined with physical treatments such as surgery, cryotherapy and thermotherapy. Cure rates range from 15% to 80% .The essential pathologic changes are characterized by a granulomatous reaction  and the The oral cavity contents perform important functions including speech, mastication, deglutition, maintenance of oronasal competence, salivation, and early digestion. Hence, oral cavity reconstruction should aim to restore both form and function. The palate divides the upper airway into two parts, oral and nasal, allowing speech and aiding in deglutition. The oral cavity reconstruction has been revolutionized by microvascular surgery . The rec


The occurrence of Langerhans Cell Histiocytosis (LCH) in a patient with lymphoma is an indication of a probable relationship between them. The two conditions have similarities both clinically and histopathologically. Occurrence of these two conditions in the same patient, particularly not simultaneously, is rare. According to different management and treatment of these conditions, exact histopathologic evaluation and even using immunohistochemistery (IHC) can prevent misdiagnosis. In this report, a 10 year old boy presented who afflicted with LCH 3 years after diagnosis and treatment of mixed cellularity Hodgkin lymphoma. Langerhans Cell Histiocytosis (LCH) comprises a group of diseases determined with proliferation of Langerhans cells.4So presentation of LCH after Hodgkin Lymphoma is rare and generally has been the subject of isolated case reports.A boy, now 10 years old, presented six years ago (in 2003) with cervical and submandibular lymphadenopathy without hepatosplenomegally and lymph node enlargement in other parts of the body. Concurrent systemic signs (B symptoms) were not found. Complete blood count, erythrocyte sedimentation rate, liver function tests, chest X- ray and bone marrow examination were all normal. Biopsy was performed from one of the enlarged cervical nodes (measuring 2x2x2 cm). In histopathologic examination, in a background of plasma cells, eosinophils and lymphocytes, some Reed- Sternberg cells (classic or mononuclear forms) with prominent large eosinophilic nucleoli were seen .Diagnosis of Hodgkin lymphoma (mixed cellularity type) was made and the patient was treated with six alternative cycles of ABVD  and MOPP  chemotherapy. He responded to this regimen but 1 year later, an asymptomatic mediastinal mass was detected in chest X- ray. Sono- guided biopsy revealed relapse of Hodgkin Lymphoma. The patient underwent treatment with three cycles of chemotherapy with CEP  and involved field radio-therapy. He responded favorably and was symptom free till 2007.In January 2007, the patient presented with a swelling in his scalp. In skull radiography, an osteolytic lesion in a fairly round shape with the greatest diameter of 3.5 cm was seen on the left side . In boneThese cells depicted acidophilic cytoplasm and lobulated indented nuclei, some with longitudinal clefts. Eosinophils, neutrophils, multinuclear giant cells and foamy macrophages were seen in the background. In addition, some fibrotic bands existed in this background. The histological diagnosis was LCH which was confirmed by IHC staining . Unfortunately, CD1a marker was not available for IHC study. Previous slides of patient’s lymph node were reexamined, confirming the diagnosis of mixed cellularity Hodgkin Lymphoma. In IHC staining, classic and mononuclear Reed- Sternberg cells reacted with CD15 and CD30 and were negative for S100. CD3 was positive in back-ground lymphocytes while CD20 was negative.In this way, morphologic and IHC findings confirmed the diagnosis of LCH following Hodgkin Lymphoma.Overall, the occurrence of lymphoma and LCH in the same individual is not common. More-over, the association of LCH and Hodgkin Lymphoma is rare.56LCH has a complex relationship with malignant lymphoma. It can occur before, after or simultaneously with Hodgkin Lymphoma.7Concurrent occurrence of these diseases and even a report indicating simultaneous nodular sclerosis Hodgkin’s disease, LCH and multiple myeloma without past history of radiotherapy and chemotherapy can make the occurrence of LCH following radiotherapy and chemotherapy questionable.8The time interval between LCH occurrence and previous lymphoma is variable. Intervals of 1 to 33 years have been reported in the literature.This condition should be considered in the differential diagnosis of recurrent lymphoma. Differentiation of the two diseases is very crucial because of their far different management. Immunohistochemistry can be helpful in such circumstances.In concurrent occurrence of these diseases, Langerhans cells are smaller than regular ones in histopathologic examination. Abnormal neoplastic proliferation of stromal cells is a response to Hodgkin lymphoma microenvironment. Smaller size of these cells makes differential diagnosis more difficult.2It is interesting that differentiation of these diseases, particularly in the simultaneous from, is considered a pitfall even in PET (Positron Emission Tomography) imaging because both of them show increased uptake in this technique.Although rare, the probable occurrence LCH following Hodgkin lymphoma should be kept in mind. Exact evaluation of histopathologic slides and IHC are helpful in making the correct diagnosis.


Primary non-Hodgkin's lymphoma of the small and large bowel presenting as a perforated viscus entity with peritonitis is extremely rare. A thorough literature review did not reveal any cases where primary lymphoma of the jejunum presented with perforation and peritonitis synchronously with primary lymphoma of the descending colon.This report concerns a 64-year-old Caucasian woman admitted with severe abdominal pain and fever. An emergency laparotomy revealed a large mass with perforation in the proximal jejunum with intense mesenteric thickening and lymphadenopathy. The descending colon was edematous and covered with fibrinous exudate. Histopathological examination of the resected segment of jejunum revealed a T cell non-Hodgkin's lymphoma. On post-operative day 10, a computed tomography scan of our patient's abdomen and pelvis showed leakage of contrast into the pelvis. Re-exploration revealed perforation of the descending colon. The histopathology of the resected colon also showed T cell non-Hodgkin's lymphoma. Her post-operative course was complicated by acute renal and respiratory failure. The patient died on post-operative day 21.Lymphoma of the small intestine has been reported to have a poor prognosis. The synchronous occurrence of lesions in the small intestine or colon is unusual, and impacts the prognosis adversely. Early diagnosis and treatment are important to improve the prognosis of bowel perforation in patients with non-Hodgkin's lymphoma. Despite the fact that the small bowel represents 75% of the length and over 90% of the mucosal surface of the intestinal tract, malignant tumors of the small bowel account for less than 1% of intestinal malignances and primary lymphomas of the small intestine are rare .T cell lymphomas (TCL) have higher incidence rates in Asia than in Western countries . These tA thorough literature review using Medline did not reveal any previously reported cases where primary lymphoma of the jejunum had presented with perforation and peritonitis synchronously with a primary lymphoma of the descending colon.A 64-year-old Caucasian woman presented to our emergency room with severe abdominal pain of four days duration, associated with fever and chills in the last 24 hours. Our patient had an eight-month history of vague abdominal pain, anemia, weight loss, and change in bowel habits. She underwent extensive investigation for non-specific abdominal pain and no pathology was found. This investigation included blood tests, esophagogastroduodunoscopy, colonoscopy, and a computed tomography (CT) scan of the abdomen and pelvis. Her surgical history was significant for a donor left nephrectomy.A physical examination conducted in the emergency room revealed she was in acute distress, with a distended abdomen and peritonitis. The laboratory test results showed a white blood cell (WBC) count of 15,700/mm^3, neutrophils 87%, lymphocytes 6%, Na 137 mEq/L, K 3.5 mEq/L, Cr 1.2 mg/dL, and albumin 2.3 g/dL. A CT scan of the abdomen and pelvis showed a large collection of contrast media in the left upper quadrant associated with multiple small pockets of air, suggestive of perforation most likely in the proximal small bowel  were found in the left upper quadrant of the peritoneal cavity. Upon exploration we found a perforated tumor in the proximal jejunum measuring 8 × 5 cm in size, positioned 10 cm from the ligament of Treitz Figure . The proResults of a mesenteric lymph node sample sent for intra-operative consultation revealed probable lymphoma. The segments of resected small intestine had a combined length of 22 cm, and a circumference of 8 cm. A 5 cm-long area of transmural bowel necrosis with perforation was present. The adjacent bowel wall was inflamed and thickened. No grossly discerned mass was noted. Light microscopic findings, immunohistochemical staining and testing for T cell gene rearrangement indicated a T cell non-Hodgkin's lymphoma extending through the full thickness of the bowel wall with an area of transmural necrosis and gross perforation Figures , 4, 5.After the operation, our patient was transferred to our intensive care unit in a stable condition. On post-operative day one, she was extubated and started on total parenteral nutrition. Then, two days later, due to respiratory distress our patient was reintubated and started on enteral tube feeding, after which she had bowel movements and was doing relatively well. On post-operative day 9, her clinical condition began to deteriorate and she was diagnosed with sepsis. A repeat CT scan of the abdomen and pelvis revealed leakage into the abdominal cavity Figure . Urgent The resected segment of colon had the same clinical and pathological features of the jejunum. After the second laparatomy our patient's condition continued to deteriorate, with respiratory and renal failure. Subsequently, her family decided to pursue palliative care only, and our patient died after withdrawal of care.et al. have also found T cell lymphomas in patients with a long history of celiac disease in the small bowel and ulcerative colitis in the colon [Our report describes an unusual case of simultaneous small and large bowel non-Hodgkin's lymphoma with synchronous perforation. Tumors of the small intestine are infrequent; only 3% to 6% of gastrointestinal tumors and 1% of gastrointestinal malignances arise from the small bowel . They arhe colon . The colhe colon  analyzedhe colon  reportedThe typical patient is in their fifth or sixth decade of life. The most common presenting symptoms include abdominal pain, altered bowel habits and weight loss that in some patients had persisted for months before a diagnosis was made. Other symptoms include bleeding, obstruction, perforation, and intussusceptions. No sex predominance exists. Some patients remain asymptomatic until intestinal perforation. At diagnosis the lymphoma was bulky in 65% of patients, reaching over 10 cm in 45% of cases, implying a delay in diagnosis with a possibly adverse effect on prognosis. The lack of specific complaints and the rarity of intestinal obstruction probably account for the delays in diagnosis. Early diagnosis and systemic chemotherapy may prevent the occurrence of perforation and the need for surgery.Proposal of the Revised European and American Lymphoma (REAL) classification in 1994 generated new interest in T cell lymphomas. According to this classification, peripheral T cell lymphomas (PTCLs) are a subset of T cell lymphomas . PTCL isTreatment generally includes surgery, radiation, therapy, and chemotherapy. In the treatment of high-grade intestinal T cell non-Hodgkin's lymphoma or anaplastic large cell type lymphoma, a multimodality approach is superior to surgery or chemotherapy alone. Prognostic factors include the stage at presentation, the presence of perforation, tumor resectability, histological subtype, and the use of multimodality therapy. Perforated lymphomas usually have higher tumor staging and poorer prognosis.The clinical evolution of T cell lymphoma is aggressive, and the five-year survival rate is 25% . The morSurgeons should always be alert for the possibility of multiple sites of malignancy during laparotomy. T cell non-Hodgkin's lymphoma is a rapidly progressive malignancy that may present with surgical complications. Poor prognostic factors include advanced age, late stage disease, and a poor performance status, as well as delay and contraindication of chemotherapy. The prognosis of synchronous primary lymphoma in the small and large bowel correlates better with the depth of invasion, tumor size, and lymphadenopathy. In our patient the prognosis was always poor, especially because of the complicated post-operative course with a second perforation in the descending colon. We speculate that our patient's outcome may have been different if the lesion in the descending colon was diagnosed in the first setting and if chemotherapy had been feasible in the early post-operative course.Written informed consent was obtained from the patient's next-of-kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors read and approved the final manuscript. MD reviewed the literature and participated in writing the abstract, introduction, and discussion sections. FB participated in writing the case report and prepared the figures. AL wrote the pathology section and prepared the pathology figures.


Urothelial carcinoma (UC) of the renal pelvis has been rarely shown to metastasize to the skin. Tumor seeding from iatrogenic procedures is a source of spreading of UC to the skin. We herein present a case of primary UC of the renal pelvis with spreading to the skin from a percutaneous nephrostomy tract. The most common sites of metastatic disease from urologic malignancies include the regional lymph nodes, liver, lung, and bone . UrothelA 76-year-old male presented with a history of solitary right kidney after a left nephrectomy for a nonfunctional kidney. He developed low grade stage Ta UC in the right renal pelvis that was initially diagnosed in 2002 with multiple recurrences as well as migration to the ureter and bladder. This was previously managed with endoscopic fulguration of the tumor periodically as he was inconsistent in his followup. He then presented in June 2012 with acute renal failure due to ureteral obstruction from the tumor. A percutaneous nephrostomy (PCN) was placed emergently by interventional radiology. He underwent an endoscopic procedure in September 2012, but due to large tumor volume he was unable to be completely treated at that last visit. His PCN was kept in place to attempt percutaneous management of his tumor at his next visit.The patient was taken back to the operating room in November 2012 for the planned percutaneous fulguration. The case was started from a retrograde ureteroscopic approach to ablate the portions of the kidney that we felt would be easier managed ureteroscopically. We had fulgurated portions of the mid and lower pole when anesthesia staff noted that the patient was tachycardic and hypotensive (60s/40s), and the case was stopped to resuscitate the patient. During the evaluation, his PCN was pulled out and was found on the operating room floor. After the patient became more stable, we used a flexible cystoscope to place a right ureteral stent under fluoroscopic guidance. We were never able to commence the percutaneous portion of the procedure, and the patient was transferred to the surgical intensive care unit. He recovered from his urosepsis without sequelae and was able to be discharged home. Histopathologic evaluation of the upper pole lesion revealed a high grade urothelial carcinoma involving the collecting ducts. At his follow-up visit a few weeks later, the patient was noted to have a soft tissue mass at the previous percutaneous nephrostomy tract site . He alsoCutaneous metastasis of UC is an extremely rare condition, especially in the case of UC of the renal pelvis , 5. It iIatrogenic procedures have been known to cause spreading of tumor to the skin, even in the face of low grade UC. Procedures such as partial cystectomy, suprapubic cystotomy, pyelotomy, and laparoscopy have all been reported to cause seeding of tumor to the skin , 7. TherSquamous differentiation occurs in about 20% of urothelial carcinoma of the bladder with varying proportions. The frequency of squamous differentiation increases with grade and stage. It has been reported that these tumors have less favorable response to therapy than pure urothelial carcinoma . Since tIn our case, there were likely 2 main causes of tumor seeding. The first is the duration of the PCN for 5 months. The second is the inadequate and insufficient resection of his extensive tumor which was limited by his deterioration in the OR. Our case illustrates that awareness of this rare complication is particularly relevant to those with multiple recurrences of UC managed with PCN. This case illustrates the importance of limiting the duration of use of PCN in these patients. Additionally, this case shows cause for resection of nephrostomy tract in patients with a PCN in place for an extended period of time.


Hemangioblastomas are highly vascular tumors that can arise within the central nervous system as well as other organ systems within the body. They can arise sporadically or as part of von Hippel-Lindau syndrome. Those arising in critical locations within the central nervous system can be difficult to resect surgically and therefore pose a significant challenge and result in morbidity and even mortality. Hemangioblastomas express high levels of vascular endothelial growth factor that drives angiogenesis and tumor progression. We hypothesized that bevacizumab through its inhibitory effect on vascular endothelial growth factor will result in hemangioblastoma tumor regression as well as a meaningful clinical response.We present the case of a 51-year-old Caucasian man with surgically unresectable cervical cord hemangioblastoma presenting with progressive weakness leading to quadriparesis. He was treated with bevacizumab and his follow up magnetic resonance imaging scans showed marked tumor regression. After only six cycles of intravenous bevacizumab (10mg/kg every two weeks), he started ambulating after being wheelchair bound. He is currently still receiving treatment almost two years after initiation of bevacizumab.We have shown for the first time that bevacizumab can result in significant tumor regression and a sustained clinical improvement in a patient with an otherwise unresectable spinal cord hemangioblastoma. This novel approach can be immensely useful for patients with difficult to resect hemangioblastomas or those with multiple lesions such as in von Hippel-Lindau syndrome. Central nervous system (CNS) hemangioblastomas are highly vascular tumors that commonly arise in the brain and less commonly in the spinal cord . DespiteGiven their high levels of VEGF expression, blocking the VEGF pathway would be an appealing target for controlling angiogenesis and subsequently tumor growth. Bevacizumab is a humanized monoclonal antibody that binds to the VEGF protein and inhibits its interaction with the VEGF receptor . It is, A 51-year-old Caucasian man with a four-year history of left hand pain, dysesthesia and weakness that progressed over the subsequent year to involve the left upper extremity presented to our clinic. He was initially diagnosed with Raynaud’s disease and treated with nifedipine. His pain continued to worsen and later progressed to involve bilateral upper extremities all the way up to the elbows. Over the subsequent two to three years he developed progressive right upper extremity as well as bilateral lower extremity weakness. Neurologic examination revealed quadriparesis and impaired sensation to all modalities over bilateral upper extremities up to the elbows and bilateral lower extremities up to a few inches below the waistline.He underwent a magnetic resonance imaging (MRI) of the brain and cervical spine which showed a 2.7 × 1.1 × 1.5cm avidly enhancing intramedullary lesion at C2-C4 with a cervical cord syrinx, marked cord edema and expansion, extending from the medulla through T3. He was taken to the operating room and an attempt at surgical resection was unsuccessful due to the lack of a defined surgical plane and the high vascularity of the tumor mass. A biopsy was performed which confirmed the diagnosis of hemangioblastoma. The syrinx was not entered or drained during this procedure. The patient refused testing for von Hippel-Lindau disease but no other hemangioblastomas were seen on whole neuraxis scanning and fundoscopic examination. Postoperatively he continued to deteriorate to the extent that he became wheelchair bound. Oral dexamethasone (16mg daily) was initiated approximately one week postoperatively because of increasing arm weakness and he showed minimal improvement. The improvement was short-lived and dexamethasone was subsequently tapered over the ensuing two to three weeks.Bevacizumab was started after obtaining appropriate informed consent. The patient was given a 10mg/kg infusion every two weeks  and an MRI of the cervical spine was obtained. The MRI revealed significant improvement in the T2 signal change surrounding the enhancing component and a decrease in the size of enhancing disease from 2.7 × 1.0 × 1.5cm to 2.2 × 1.0 × 1.5cm  [VHL function results in deregulated HIF activity and overexpression of VEGF leading to hemangioblastomas [The molecular pathogenesis of hemangioblastomas is not fully understood; however, in VHL disease the genetic mutation had been previously elucidated. The disease is linked to a mutation of the n (pVHL) . This prlastomas . Since Vlastomas . Bevacizlastomas . Intravilastomas ,10.Current treatment options for patients with CNS hemangioblastomas include surgical resection as well as adjuvant stereotactic radiosurgery for incompletely resected or recurrent lesions ,14. AlthDevelopment of a systemic approach would, therefore, offer an attractive alternative for patients with surgically unresectable hemangioblastomas, those with medical comorbidities that may preclude surgery as well as patients with multiple hemangioblastomas as can be seen with the VHL complex. We have shown that the systemic infusion of bevacizumab can result in hemangioblastoma tumor regression as well as a sustained and meaningful clinical improvement. This effect may potentially be attributed to a decrease in vascular permeability and subsequent improvement of edema, regression of angiogenesis or a combination of both. Further studies are needed to define better the role of bevacizumab in the treatment of this challenging disease.Only one case report was found in a Medline search  that showed retinal hemangioblastomas may respond favorably to intravitreal bevacizumab . To the 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.CNS: central nervous system; HIF: hypoxia-inducible factor; PDGF: platelet-derived growth factor; pVHL: von Hippel-Lindau protein; US FDA: United States Food and Drug Administration; VEGF: vascular endothelial growth factor; VHL: von Hippel-Lindau..The author declares that he has no competing interests


Testicular lymphoma was first reported by Malassez and Curling in 1866. Primary testicular lymphoma constitutes only 1 - 7% of all testicular neoplasms and less than 1% of all non Hodgkin lymphoma. The authors report a new case of primary testicular lymphoma and highlight its diagnostic and therapeutic challenge. We report the case of a 26-year old man without a particular past medical history, who presented with a painful right testicular swelling that he has noticed for several weeks. Radiological findings consisted in multiple hypoechoic masses that corresponded in histological examination to a diffuse intratubular lymphomatous infiltration situated away from the spermatic cord, the epididymis, ductuli efferentes and rete testis. Immunohistochemical study showed positivity for leukocytic common antigen (CD45), B-cell marker (CD20) and bcl 6. The patient underwent full staging for lymphoma showing no evidence of extra-testicular involvement by lymphoma and no lymph nodes. The diagnosis of stage I primary testicular large B-cell lymphoma of germinal center B-cell-like group was made. The patient is now treated by chemotherapy. Primary testicular lymphoma is a rare tumour whose diagnosis is based on histological findings. There are non consensual etiological or predisposing factors. Treatment modalities consist in surgical excision, chemotherapy and radiation therapy but the accurate procedures are not standardized. Factors that have been linked to more favorable outcomes include younger patient age, localized disease, presence of sclerosis at pathologic analysis, smaller tumour size, lower histological tumor grade and lack of epididymal or spermatic cord involvement.Testicular lymphoma; Germinal center; B-cell Primary testicular lymphoma is a rare tumor accounting for 1% of all testicular non Hodgkin lymphoma [We report the case of a 26-year old man without a particular past medical history, who presented with a painful right testicular swelling that he has noticed for several weeks. There was no reported history of trauma, night sweets, fever or chills. Scrotal examination revealed a firm and enlarged testis with a homolateral hydrocele. The remainder of the clinical examination was noncontributory. The ultra-sound examination showed an enlarged, heterogeneous testis with multiple hypoechoic masses . LaboratTesticular lymphoma was first reported by Malassez and Curling in 1866 ,3. PrimaHistopathological differentiation of testicular lymphomas from germinal tumors is usually a challenge but these lymphomas generally appear more lobulated with well defined borders at ultra-sound examination . Other c


Dear SirEventration of diaphragm is a well known entity that may present at any age. Most of the cases are diagnosed in first decade of life. The usual clinical presentation is that of respiratory distress and recurrent respiratory tract infections; however unusual presentations have also been reported [1]. The objective of this report is to highlight a rare possibility of small bowel obstruction in settings of ineffective or incomplete separation of abdominal and thoracic cavities by diaphragm. A case of left sided eventration of diaphragm presenting with small bowel obstruction is being reported.A 6-month-old infant presented to our institution with complaints of abdominal distension, bilious vomiting, non passage of stool, and irritability for two days. The past medical history was insignificant. On general physical examination the patient was vitally stable. Abdominal examination revealed mildly distended and tender abdomen in all quadrants with absent bowel sounds. A digital rectal examination revealed only mucous in the rectum. Laboratory investigations were within normal limits. Abdominal radiographs, in supine and erect postures, delineated intestinal air shadows moving up into the left hemithorax and air fluid levels respectively . An exploratory laparotomy was performed that revealed few loops of small and large bowel adherent with each other and also with the eventration, causing small bowel obstruction at the level of distal ileum. Adhesiolysis relieved the obstruction following which plication of the diaphragm was performed. Ladd’s procedure was added for the associated malrotation. Patient had an uneventful postoperative recovery. He has a follow up of 6 months and doing well.Eventration of diaphragm is an abnormal elevation of the dome of diaphragm; usually unilateral and left sided, but isolated right sided and bilateral involvements have also been reported. The lesion may be congenital or acquired as to the etiology. Embryologically, a failure of myoblastic migration to diaphragm or of its innervation, during 7th week of gestation, results in a thin and hypoplastic diaphragm on the involved side [2].During the same period of development the physiologically herniated bowel start returning to the abdominal cavity. The eventration of diaphragm impairs the process of normal rotation and fixation as happens in case of congenital diaphragmatic hernia; thus resulting in association of malrotation as found in our case. Acquired eventration always develops due to phrenic nerve palsy in conditions such as obstructed labor, surgery (iatrogenic) etc .The treatment can be delayed in asymptomatic patients. At times patients with eventration of diaphragm may present with life threatening complications necessitating urgent surgical intervention. These conditions are acute gastric volvulus, severe respiratory distress, and intestinal obstruction. The management includes plication of the eventration and the management of the complications, as done in case reported here . It is assumed that the associated malrotation and malfixation of intestine caused recurrent episodes of partial intestinal volvulus and ischemia, resulting in inflammation and adhesions between intestinal loops and the diaphragm.Few cases of intestinal obstruction after spontaneous rupture of congenital eventration of diaphragm have been reported in literature; three cases of intestinal obstruction after plication of diaphragm have also been documented .Small bowel obstruction as a sole presentation of eventration of diaphragm in pediatric patients is a very rare event. The treating physician and surgeon must keep this possibility in mind.Source of Support: NilConflict of Interest: None declared


Malignant peripheral nerve sheath tumors of the scalp are rare lesions of the nervous system. Only 14 cases have been reported to date. The field of neurosurgery has struggled with diagnosing and treating these tumors. In this report, we present two cases of giant malignant peripheral nerve sheath tumors of the scalp and retrospectively analyze the clinical features, imaging findings, pathological features, and prognoses of these two patients. Each underwent microsurgery and radiotherapy. In addition, based on a literature review, we discuss the diagnostic and therapeutic strategies used to treat these unusual lesions. Malignant peripheral nerve sheath tumors of the scalp are rare neoplasms of the nervous system. These tumors are considered to be a subcategory of soft tissue sarcomas, because they arise from a peripheral nerve or nerve sheath cells and show divergent differentiation potentials -3. A varCase 1 was a 35-year-old male patient. The patient came to our hospital with swelling on the back of his head, which he reported had existed for 18 years. He had undergone four operations in another hospital during the past 18 years, and it had been five years since the most recent operation. The pathologic analysis was evaluated as malignant schwannoma  after the fourth operation. On local examination, we observed a firm, non-compressible, non-tender, non-pulsatile swelling that measured approximately 10 × 9 cm in the occipital region. The middle part of the mass was necrotic with a sickening stench . After excising the large mass, the scalp defect was approximately 12 × 12 cm. Reconstruction was completed using a latissimus dorsi myocutaneous flap with a muscle cuff along with the vascular pedicle , non-tender, non-compressible, firm to fluctuant swelling measuring approximately 10 × 10 cm in the occipital region  may be related to previous radiation at the tumor site [Malignant peripheral nerve sheath tumor (MPNST) is a malignant spindle-cell tumor arising from a peripheral nerve or showing a peripheral nerve differentiation. MPNST is a rare tumor with an incidence of approximately 0.01% in the general population ,3, with mor site ,19,20.Theoretically, MPNST of the scalp can originate from any site on the scalp. Of the 16 reported cases . In tumors arising from sarcomatous degeneration of a benign neurofibroma, growth is relatively slow at the beginning and then becomes rapid in the last several months, suggesting malignant transformation in a relatively and previously benign tumor [The initial clinical features of MPNST of the scalp are generally atypical. Most patients present with a gradually increasing swelling in the scalp (cutaneous or subcutaneous) -18. On lgn tumor ,19. Hemogn tumor . SymptomAlthough MPNSTs of the scalp generally lack specificity on imaging features at the early stage, CT or MRI scans are useful for demonstrating the relationship with surrounding structures. They may display high, equal, or low densities when the CT scans are enhanced. On MRI scans, MPNSTs of the scalp are often hypointense or isointense in T1-weighted series and hyperintense in T2-weighted and Flair sections . EnhanciPathological diagnosis is the gold standard for diagnosing MPNST of the scalp. Most examples of MPNST show differentiation toward Schwann cells, but MPNSTs that exhibit perineurial cells and endoneurial fibroblasts have also been reported . AlthougThe current treatment of these highly malignant tumors does not guarantee an optimistic prognosis. Surgery and local radiation therapy are currently administered to treat the disease -18,22,23As reported, surgical excision followed by adjuvant radiotherapy can improve local control ,23. ThusIn conclusion, in this paper, we have described two cases of MPNSTs of the scalp. The diagnosis of MPNST of the scalp is based on integrating clinical, imaging, histopathological, and immunohistochemical findings. Considering the high malignance and invasive growth of MPNST of the scalp, radical excision with wide margins (≥2 cm), histologic control of resection borders, and adjuvant radiation should be considered standard treatment.Written informed consents were obtained from the patients for publication of this Case report and any accompanying images. Copies of the written consent are available for review by the Editor-in-Chief of this journal.CT: computed tomography; Flair: fluid-attenuated inversion recovery; H&E: hematoxylin and eosin; MPNST: malignant peripheral nerve sheath tumor; MRI: magnetic resonance imaging; MRV: magnetic resonance venography; 3-D CT: three-dimensional computed tomography.The authors declare that they have no competing interests.JW wrote the initial draft. SO, ZG and YW were the neurosurgeons of the patients. DX performed the pathological examination. All authors read and approved the final manuscript.


Lymphoepithelial carcinoma of the maxillary sinus is a very rare malignancy and it can be difficult to make a pre-operative diagnosis.A 72-year-old Caucasian woman presented to our facility with an isolated right-side epistaxis that had been present for three months, with the results of a computed tomography scan showing a soft tissue mass in the right maxillary sinus with an impacted tooth. The results of a transnasal endoscopic biopsy were compatible with a lymphoepithelial carcinoma, following which our patient underwent a radical excision of the mass. The final histology results revealed lymphoepithelial carcinoma of the maxillary sinus with negative assays for Epstein-Barr virus. Our patient was given post-operative external radiotherapy and has remained disease-free at three-year follow-up.This report details the diagnosis and management of a case of lymphoepithelial carcinoma of the maxillary sinus, which is a very rare malignant tumor with very little mention in the literature. Only a strong suspicion with systematic use of various patho-immunological tests helps to arrive at a definitive diagnosis by excluding other better-known tumors. A majority of malignant tumors of the paranasal sinuses occur in the maxillary sinus ,2. AmongA 72-year-old Caucasian woman presented to our facility with an isolated right-side epistaxis that had been present for three months without other associated otolaryngological, ophthalmological or neurological symptoms. There was no history of trauma or chronic sinonasal infections. Ten years prior to the incident, our patient was diagnosed as having breast cancer and was treated with surgery and chemoradiotherapy. The results of a physical examination were normal except for a thread of blood coming out of the right middle meatus. A neck examination revealed no palpable lymph nodes. Routine laboratory investigation results were normal. A paranasal sinus (PNS) computed tomography (CT) scan showed expansion of the right maxillary sinus by a homogenous soft tissue mass without calcification, occupying the entire sinus cavity. The sinus walls were intact with no bony erosion. There was an impacted tooth visible inside the mass Figure . Other sHistopathological examination Figure  revealedet al. the presence or absence of Epstein-Barr virus in the lymphoepithelial carcinoma of the maxillary sinus does not have any prognostic importance [Lymphoepithelial carcinoma of the maxillary sinus is a very rare malignant tumor and was described for the first time by Schminke and Regaud in 1921 . The lymportance .The lymphoepithelial carcinoma developing from the maxillary sinus can present as an aggressive tumor with signs of local invasion to nerves, orbit, or the rhinopharynx . In geneBecause of the limited number of cases, there is no standardized treatment policy reported to date for lymphoepithelial carcinoma of the maxillary sinus . The iniLymphoepithelial carcinoma of the maxillary sinus is a very rare malignant tumor with little mention in the literature. Its pre-operative diagnosis is difficult and the final definitive diagnosis is established by histopathological examination and immunohistochemical studies. The treatment consists of surgery and radiotherapy with the possibility of achieving acceptable cure rates. A strong suspicion and systematic use of various immunological tests helps to arrive at a definitive diagnosis by excluding other better-known tumors.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 with the Editor-in-Chief of this journal.The authors declare that they have no competing interests in the preparation of this article.DM, collection of data, manuscript preparation; AJ, collection of data, manuscript preparation; MP, manuscript preparation, analysis; SK, manuscript preparation, analysis. SK was the major contributor to writing the manuscript. All authors read and approved the final manuscript.


Cerebellar liponeurocytomas were recognized in the 2000 WHO 3rd edition of CNS tumors as a distinct grade I pathological entity, a tumor with a more favorable prognosis than medulloblastoma. But reports of long-term recurrences and some possible aggressive behavior led to an upgrade on the latest WHO 4th edition of CNS tumors. The case of a 64-year-old female patient is reported in this paper. More than 30 cases of this lately recognized pathological entity have been reported to date. The diagnostic, radiological, and pathological features associated with this tumor are discussed through a literature review. The cerebellar liponeurocytoma was first included in the 2000 World Health Organisation's (WHO) 3rd edition of Central Nervous System (CNS) tumors' classification as a separate grade I entity. Thanks to a better recognition and longer follow-up, evidences of a possible tumor recurrence were growing. Rates of recurrences were estimated to 60% during follow-up, with some cases presenting even an aggressive behavior –3. This Through this case report we reviewed the literature for a better understanding of this pathology and the controversy around, with a listing of published cases of cerebellar liponeurocytoma.A 64-year-old woman, with a 10-year history of Parkinson's disease, was admitted to our department for a 7-month clinical course of progressive worsening, right-sided weakness, and signs of increased intracranial pressure.On examination, her consciousness was clear, and, beside the Parkinson's related tremor, she had a mild right hemiparesia (3/5) with a right Babinski sign and hyperreflexia on the right side. Ocular investigations showed bilateral papilledema and horizontal nystagmus.MRI scan showed a 60 × 40 × 42 mm heterogeneous, enhancing lesion of the right cerebellum extending to the CPA (cerebellopontine angle), causing mass effect and mild hydrocephalous.On T1-weighted images  the massIrregular enhancement was noted after gadolinium administration . There wThe patient underwent surgery through a retrosigmoid approach. It discovered a soft grey tumor, with yellowish areas, and globally well circumscribed. The anterior part of the tumor was encasing cranial nerves and was infiltrative toward the brainstem, which only allowed for near total removal. No cerebrospinal fluid shunt was decided.Pathological examination with immunohistochemical study revealed a tumor with astrocytic and neuronal differentiation (GFAP-NSE-synaptophysin positive) in which some focal areas of lipomatous differentiation were identified; the MIB-1 index was <1%; there was no cellular immaturity or necrosis, concluding on a cerebellar liponeurocytoma (WHO grade II) .The postoperative course was free of complications and the patient was discharged from hospital to the postoperative care unit for physical rehabilitation. No adjuvant therapy was decided.At two-year follow-up, the patient's condition was fair with no motor deficit and better autonomy (Karnofsky index improved from 40 to 70%).TP53 mutation, absent in the later), which comforts the definition of cerebellar LNC as a separate pathological entity [The cerebellar liponeurocytoma (LNC), as defined by the WHO, is a “rare, well differentiated neurocytic tumor of the cerebellum that arises in adults and typically shows focal or regional lipomatous differentiation. It has a low proliferative potential and a more favorable prognosis especially when compared to medulloblastoma (MDB), from which it needs to be distinguished” , 5. In al entity . The assThe cerebellar liponeurocytoma was first described in 1978, in a 44-year-old patient. Bechtel et al. named it “lipomatous medulloblastoma” and pointed to its better prognosis , lipidizRelying on a Pubmed research of Medline's database , we found 36 effective cases of pure cerebellar liponeurocytoma reported till now . ControvEpidemiological analysis places cerebellar LNC as a tumor of adulthood (fourth and fifth decades), with mean age of 49 years (range from 32 to 74 years). The sex ratio, based on our review, shows a clear female prevalence (1 : 1.8). Giordana et al. and Sharma et al. reported cases of childhood onset, but these are more likely MDB with lipidized cells than lipomatous MDB , 16.It is a tumor of the cerebellar hemispheres; location on the vermis is not unusual and so is the extension to the CPA, and was reported by many authors –19. Two On MRI scan, these tumors are globally heterogeneous, iso-, or hypointense on T1-weighted images, with areas of high signal intensity. These areas turn hypointense on fat suppression sequences, which may be very suggestive although there is no specific radiological behavior. Contrast enhancement is usually present and reported as irregular and heterogeneous; on T2-weighted images, the solid component is slightly hyperintense with focal pronounced hyperintense areas corresponding to fat. Some cystic components may be present, but usually no edema is reported .One case of central tumor hemorrhage was reported on radiological findings .Typically, cerebellar LNC is a glioneuronal tumor with lipidized neoplastic cells that resemble mature adipocytes. These are interspersed throughout the lesion. Areas of neuronal differentiation are usually positive for immunochemistry neuronal markers . Reactivity for GFAP was also described –25. No mProliferation index, as measured by Ki-67/MIB-1, is usually low <5%) in most published cases % in most, 20, 23,To date, no specific genetic marker has been clearly identified. However, in their recently published paper, Anghileri et al. found a significantly positive overexpression of two possible markers: NEUROG1 and FABP4 . FurtherOptimum treatment modality is still a matter of debate. If all recommend surgery as the initial management, postoperative radiotherapy does not make the unanimity. In fact, the lack in understanding the tumor's biological behavior led to various therapeutic approaches.The strong belief of it being a benign tumor often led surgeons not to choose adjuvant therapies whatever the extent of resection was. Moreover, the absence of histopathological patterns of malignancy comforted this attitude . FurtherThe efficacy and the need for postoperative radiotherapy are still unclear. The scarcity of the tumor does not allow structured studies, and radiotherapy was used in many ways  with different follow-up periods which makes literature very inhomogeneous. In fact, it seems not to prevent early recurrence . The plaManagement of recurrence is also debatable, but radiotherapy following reoperation seems to be more appropriate especially when secondary aggressive features are observed.Our patient did not receive postoperative radiotherapy based on the belief that radiotherapy is to be a recurrence modality management after reoperation as for Cacciola et al. .To date, the longest survival time recorded is of 18 years in two patients , 18; botAll this data analysis makes the prognosis and the evolution of this tumor still unpredictable. Its management is more debatable but all agree on a large surgical removal and a long follow-up. Adjuvant radiotherapy may be indicated if subtotal removal was performed or only on relapse after reoperation.This paper represents an up-to-date literature review of all published cases of cerebellar liponeurocytoma.


Introduction. A peritoneal inclusion cyst is a very rare mesenteric cyst of mesothelial origin usually asymptomatic. A rare case of an 82-year-old white Caucasian female with a femoral hernia containing a large peritoneal inclusion cyst, mimicking strangulated hernia, is presented herein. Case Presentation. The patient was admitted to our hospital suffering from a palpable groin mass on the right, which became painful and caused great discomfort for the last hours. Physical examination revealed a tender and tense, irreducible groin mass. An inguinal operative approach was selected and the mass was found protruding through the femoral ring. After careful dissection it turned out to be a large unilocular cyst, containing serous fluid, probably originating from the peritoneum. McVay procedure was used to reapproximate the femoral ring. Histologic examination showed a peritoneal inclusion cyst. Discussion. Peritoneal inclusion cysts are usually asymptomatic but occasionally present with various, nonspecific symptoms according to their size. Our case highlights that high index of clinical suspicion and careful exploration during repair of a hernia is mandatory in order to reach the correct diagnosis about hernia's contents. A peritoneal inclusion cyst is a very rare mesenteric cyst of mesothelial origin occurring in the peritoneal cavity, mostly affecting women in the reproductive age. Unilocular peritoneal inclusion cysts are usually asymptomatic, but occasionally present with various, nonspecific symptoms, which makes correct preoperative diagnosis difficult . They maAn 82-year-old white Caucasian female was admitted to our hospital suffering from a palpable groin mass on the right, which appeared two days ago, but for the last hours before admission it became painful and caused great discomfort. The mass was tender and tense on physical examination measuring at least 8 cm on diameter, and it was not reducible. The initial differential diagnosis was either a strangulated femoral or groin hernia. She had no history of other hernias and her laboratory findings were within normal range. Also no history of previous surgery, endometriosis, or pelvic inflammatory disease existed. An inguinal approach was selected and after opening the skin and subcutaneous fat the mass was found protruding through the femoral ring. Our initial thought was that it was a bulge of abdominal contents covered by peritoneum, but after careful dissection it turned out to be a large unilocular cyst, containing serous fluid, probably originating from the peritoneum. Frozen section was negative for malignancy and cyst excision was easily performed. McVay procedure was used to reapproximate the femoral ring. The patient's postoperative course was uneventful, and she was discharged on the first postoperative day. The histologic examination of the cyst showed a fibrous wall of variable thickness with inflammatory and hemorrhagic infiltrations. Its inner surface was almost completely covered with hemorrhagic tissue and fibrin, lacking epithelial lining. Focally, the presence of a few mesothelial cells in a linear pattern was noted . The immPeritoneal inclusion cysts are very rare and only about 900 cases are reported in the literature . Those cA femoral hernia usually presents as a tender, nonreducible swelling, situated below, and lateral to the pubic tubercle. The differential diagnoses include inguinal hernia, lipoma, saphena varix, enlarged lymph nodes, femoral artery aneurysm, sarcoma, obturator hernia, psoas abscess, psoas bursa, and in males, ectopic testis. Different contents in femoral hernias have been reported in the literature, such as appendix, small intestine, omentum, bladder, Meckel's diverticulum, ectopic testis, adnexa, and stomach . WheneveIn conclusion, high index of clinical suspicion and careful exploration during repair of a femoral hernia is mandatory in order to reach the correct diagnosis about the contents of the hernia.


Segmental Odontomaxillary Dysplasia (SOD) is an uncommon, nonhereditary, recently recognized developmental disorder affecting the upper jaw and related dental components. It is a rare condition of uncertain etiology that results in painless unilateral expansion of the posterior dentoalveolar complex, gingival hyperplasia, lack of one or both premolars in the affected area, delayed eruption of adjacent teeth and malformations of the primary molars. Radiographically, the affected bone is thickened and irregular in outline, with coarse trabecular pattern that is vertically oriented resulting in a relatively radiopaque granular appearance. Only a few cases have been reported in the English literature. Considering the rarity of the condition, we report a case of SOD in a pediatric patient who was followed up over a period of over two years. The clinical, radiographic, and histologic features are presented along with a review of the literature. The diagnosis of SOD is mainly based on clinical and radiographic presentation but may be augmented by histological findings. Clinically SOD is characterized by unilateral enlargement of posterior segment of maxilla, enlargement of gingiva, and ipsilateral dental anomolies. The age of the patient at presentation is variable but the condition is usually discovered during childhood with most common complaints being missing teeth, abnormal spacing, and delayed eruption. This condition is slightly more common in males than females. No tendency for its occurrence in any specific ethnic group has been reported. Histologically, the affected bone consists of immature bone with irregular trabeculae of woven appearance with resting or reversal lines without osteoblastic or osteoclastic rimming [Hemimaxillofacial dysplasia (HD) was first recognized by Miles et al. in 1987 in a report of two cases . Danfort rimming . Radiogr rimming .A four-and-a-half-year-old male was referred to the department of pediatric dentistry by a general dental practitioner for evaluation of a painless left maxillary expansile lesion. The patient was otherwise asymptomatic. The major concern was the delayed eruption of primary and permanent teeth in this quadrant. The patient was otherwise healthy with a noncontributory medical history. On clinical examination, the patient revealed mild facial asymmetry caused by an increase in fullness of the left upper lip and cheek. Ipsilateral erythema with increased facial hair of the skin and a scar in the nasolabial region was also seen. Intraoral examination demonstrated buccolingual expansion of maxillary left arch with gingival overgrowth since the age of 3. The left maxillary primary molars exhibited delayed eruption. The gingiva adjacent to primary canine was thickened and appeared red and edematous. The patient was asymptomatic and his oral hygiene was good. His chief complaint was that of delayed eruption of his primary teeth in the same quadrant, especially in the canine and molar area. His left maxillary alveolus was widened with gingival hyperplasia.y-axis  was introduced in 2004 by Welsch and Stein [Hemimaxillofacial dysplasia (HMD) was first recognized in 2 cases by Miles in 1987 which is characterized by unilateral maxillary enlargement, gingival hyperplasia, facial asymmetry, ipsilateral dental abnormalities, unusual radiographic bone pattern, and facial hypertrichosis . The acrnd Stein . They reThe prevalence of this condition is not well established since the literature largely consists of case reports. According to a previous literature review, 27 cases of SOD/HMD had been published from 1987 to 2000 , 7–10. 1Clinically, SOD usually presents as a non-progressive facial asymmetry, ipsilateral gingivo-dento-alveolar maxillary involvement which can extend from the canine to tuberosity area . Facial SOD may go unrecognized or misdiagnosed because some conditions like fibrous dysplasia and regional odontodysplasia (ROD) shows similarities to SOD, but they can be differentiated from SOD . ROD disTreatment of SOD remains unknown as the management protocol in most case reports has not been discussed to date. Once diagnosed, SOD seems to remain stable and may or may not require surgical intervention. So the primary goal of the treatment is to retain the deciduous teeth, thus facilitating eruption of the permanent teeth so that occlusion can be restored . UsuallySOD is a rare condition. Since it affects children care should be taken to accurately diagnose the condition to reassure the patient and offer the best treatment options. The diagnosis of SOD is primarily based on the clinical and radiographic findings. Treatment may be limited to retaining the primary teeth and enhancing the eruption of the permanent teeth, if possible, to restore occlusion in that quadrant.


Chronic wounds and scar tissues are prone to skin cancer. In 1828, Jean-Nicholas Marjolin described the occurrence of tumours in post-traumatic scar tissue. He did not, however, identify the warty ulcers he described as malignant. It was Dupuytren, who about two years later, noted that these lesions were cancerous. The eponym was bestowed by Da Costa in 1903. Marjolin’s ulcer no longer refers only to carcinomas secondary to burns and is classified as a malignancy that arises from previously traumatised, chronically inflamed, or scarred skin. It has been reported in relation to osteomyelitis, venous stasis ulcer, tropical ulcers, chronic decubitus ulcer, frostbite, pilonidal sinus, vaccination site, urinary fistula, hidradenitis suppurativa, skin graft donor site, gunshot wounds, puncture wounds, dog bites, and lupus rash. Early arising Marjolin’s ulcer has rarely been described in literature. In this case report, we present the CT appearances of Marjolin’s ulcer in the left gluteal region of a young man. A 37-year-old, Chinese man had a 3-month history of intermittent low grade fever and a painful, non-healing ulcer in the left gluteal region. The left gluteal ulcer initially started as a pimple-like swelling 9 years ago. Later, it ruptured and slowly increased in size. The patient had sought treatment from numerous General Practitioners, who only prescribed oral antibiotics and daily dressing. Three months prior to admission, the ulcer begun to enlarge and was increasingly painful. No symptom suggestive of tuberculosis, however, was present. There was no history of discharging sinus. There was also no associated numbness or weakness in the left lower limb. He denied history of weight loss or high risk behaviour, such as, drug abuse or sexual promiscuity. He was not a known diabetic or immunologically compromised. He was also not taking any immune-modulating medication. His past medical history was completely uneventful.Physical examination revealed a mildly pale, febrile young male with a temperature of 37.5 degree Celsius. Examination of the gluteal region revealed a 4 x 4 cm ulcerated, infected, bad-smelling lesion in the left gluteal fold. The ulcer had a fungating edge with a fixed base and its depth was about 4-5 cm. Mild tenderness was noted on palpation. No neurological deficit was detected in the left lower limb. Palpable left superficial inguinal lymphadenopathy was found consistent with secondary involvement of inguinal lymph nodes. The rest of the systemic examination showed no abnormal findings. Laboratory evaluation revealed mild anaemia with haemoglobin count of 10.4 g/L and a mildly raised white blood cell count of 11,900/ul. The erythrocyte sedimentation rate (ESR) was not elevated. Serology confirmed he was negative for retrovirus as well as Hepatitis B and C viruses. No bacterial cultures were performed from the ulcer here.Pelvic radiograph  demonstrIncisional biopsy of the lesion was performed, and histopathological examination confirmed an invasive, well-differentiated squamous cell carcinoma surrounded by acute inflammation. Wide surgical excision and debridement with distal flap reconstruction and split-thickness skin graft was performed. This confirmed invasion into the ischial tuberosity (which was osteotomised), cartilage, ligaments, and fibromuscular tissue as well as metastasis to the inguinal nodes. The hamstring muscle was not involved and the left sciatic nerve was preserved. The anus and rectum appeared free of tumour involvement. Post-operative recovery was uneventful. Post-operative radiotherapy was given to the primary and draining nodal sites, with a generous margin, because of the ill-defined extension of the tumour. So far, follow-up has not demonstrated any recurrent disease.While malignancy does not usually arise in ulcers in the developed world, this complication is not rare in developing countries . MarjoliThe precise mechanism by which chronic ulcers (wounds) develop malignancy is not known. A variety of causes including chronic irritation and infection (with resulting degeneration and regeneration), decreased vascularity and weakened epithelium, and elevated expression of proto-oncogenes  , howeveThe essential imaging features of Marjolin’s ulcer are bone destruction, soft tissue mass, and periosteal reaction , which wStaging of SCCs are based on their size, where T0 lesions are in situ, T1 lesions are less than 2 cm in diameter, T2 lesions are 2-4 cm in diameter, T3 lesions are greater than 4 cm in diameter, and T4 lesions are invasive of muscle or bone [Preventive care is very important in the management of Marjolin’s ulcer. In all wounds, infection should be treated early, adequate drainage should be provided when necessary, and culture results should be used to choose appropriate antibiotics. In general, recurring ulcers should be excised even if they are not malignant, and skin grafts or flaps should be used for coverage to facilitate complete healing as quickly as possible. Wide local excision, with a margin of at least 1 cm of healthy tissue, should be performed in cases of Marjolin’s ulcer. Regional lymph node dissection is indicated whenever nodes are palpable . Non-surLong-term follow-up is recommended in all cases of Marjolin’s ulcer because of the possibility of recurrence, metastasis, and other lesions . Most reAlthough Marjolin’s ulcers can originate from any long-standing ulcer or region of chronic inflammation, this report has described the unusual development of a metastasising SCC in a chronic, non-healing ulcer in the left gluteal region of a young man. Despite the patient’s young age and apparent good health, the tumour followed an aggressive, metastatic course. Therefore, chronic, non-healing ulcer should be followed carefully to enable the early detection of SCC.


Retained surgical instrument or sponge following an intra-abdominal surgery is a potentially dangerous medico-legal problem. The condition may manifest either as asymptomatic or severe gastrointestinal complications. Transmural migration of gossypiboma is a rare entity that may lead to bowel or visceral perforation, obstruction and/or fistula formation. Transmural migration of an intra-abdominal gossypiboma has been reported to occur in stomach, ileum, colon, bladder, vagina and diaphragm. To our knowledge, this is the fifth case reported in the medical literature. However, we report the first case of the largest gossypiboma to date: a surgical gas compress measuring 20 × 20 cm which was successfully treated endoscopically.A 52-year-old woman with obstructive jaundice was referred to our clinic. She had a medical history of cholecystectomy and T-tube drainage for choledocholithiasis a year previously. Abdominal ultrasonography and computed tomography revealed a mass located into the stomach which was compatible with gastric carcinoma. On the gastroscopy, a surgical gas compress that had totally migrated into the stomach was observed. The compress was successfully removed by gastroscopy through the esophagus. The recovery of the patient was uneventful.Transmural migration of gossypiboma into the stomach should be considered in the differential diagnosis of any postoperative patient with obstructive jaundice symptoms. Endoscopy may be feasible for both diagnosis and treatment even though the size of gossypiboma is large. However, surgery should be considered in case of fixed reaction or incomplete migration of gossypiboma located into the stomach. Gossypiboma is the term used to describe a retained non-absorbable surgical material that is composed of cotton matrix which leads to serious surgical complications for both patient and surgeon . The inc3μL) and cholestatic enzymes; aspartate aminotransferase (AST): 51 U/L, alanine aminotransferase (ALT): 37 U/L, alkaline phospatase (ALP): 143 U/L, gamma glutamyl transferase (GGT): 120 U/L and amylase: 220 U/L. Plain abdominal radiography and ultrasonography (USG) were unremarkable. The preliminary diagnosis was acute pancreatitis until abdominal computed tomography (CT) revealed a 10×8 cm mass located in the stomach which was compatible with a gastric carcinoma. However, we suspected a gossypiboma in the differential diagnosis due to the medical history of patient. Gastroscopy was performed for diagnosis and treatment. A written informed consent including surgical risks was obtained from the patient. The procedure was performed under sedation in the operation room with regards to possible urgent surgical intervention. On the gastroscopy, a large surgical gas compress which totally migrated and filled two thirds of the stomach was observed  may usually be helpful for diagnosis. Basically, a “whorl-like” mass imaging on plain X-ray is usually enough for diagnosis. In addition, imaging of a hyperechogenic mass with hypoechoic rim on USG or a rounded mass with a dense central part and enhancing wall on CT are the basic signs of gossypiboma ,10. HoweGossypiboma should be removed as soon as possible to avoid further surgical complications and legal problems . AlthougIt is notable that prevention should be discussed instead of treatment modalities. Patients undergoing emergency surgery, those with high body mass index, lengthy operations, inexperienced staff or unexpected change in surgical procedure are major risk factors for retained surgical materials ,8. SimplTransmural migration of gossypiboma into the stomach should be considered in the differential diagnosis of any postoperative patient with obstructive jaundice symptoms. Endoscopy may be feasible for both diagnosis and treatment even though the size of gossypiboma is large. However, surgery should be considered in case of fixed reaction or incomplete migration of gossypiboma located into the stomach.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.AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phospatase; GGT: Gamma glutamyl transferase; USG: Ultrasonography; CT: Computed tomography; MR: Magnetic resonance.The authors declare that they have no competing interests.AS, SY participated in acquisition of data and drafting the manuscript. HK, BS participated in revising critically the manuscript and giving the final approval of the version to be published. All authors read and approved the final manuscript.