A 61-year-old woman was referred to our hospital with a mass in the left proglossis. The lesion was excised with a provisional diagnosis of hemangioma. The mass was well-demarcated and easily dissected with an ultrasonic surgical aspirator. The histopathologic diagnosis was angiomyolipoma arising in the tongue. There were no signs of recurrence at followup at 18 months. Angiomyolipoma is a benign tumor that is histologically composed of groups of mature adipose tissue intermixed with convoluted thick-walled blood vessels, interlacing bundles, and irregularly arranged sheets of smooth muscle, with the kidney as the most frequent site of involvement. Extrarenal angiomyolipoma can occur in organs such as the liver, lung, uterus, and skin. Oral and maxillofacial cases are rare. Only two instances of this tumor arising in the tongue have previously been reported , 2. ThisA 61-year-old woman was referred to our hospital with a mass in the left proglossis that was painless, but had enlarged slowly for 5 years. There were no clinical signs or family history of tuberous sclerosis. The mass measured 20 mm × 20 mm and was soft and dome shaped with a dark violet-colored surface . The lesOnly two cases of angiomyolipoma arising in the tongue have previously been reported. Koizumi et al.  reportedAngiomyolipoma could be considered a hamartoma, but there is no consensus that these lesions are a single entity. Ide et al.  reportedOral angiomyolipomas are sharply demarcated and either completely or partially encapsulated. Previously, recurrence has not been documented. In our case, the mass was well-demarcated and easily dissected with an ultrasonic surgical aspirator. The patient has remained free of recurrence 18 months after excision. In particular, tongue cancer and hemangioma are tumors with many blood vessels in the proposed area of surgical excision. For preservation of the nervous system and avoidance of bleeding, an ultrasonic surgical aspirator is effective in the resection of these tongue tumors –5. In ou


Cystosarcoma of the seminal vesicle is a very rare malignant tumor; in the literature only four cases are reported. We present a case of cystosarcoma phyllodes arising in the right seminal vesicle of a 49-year-old man without any urinary symptom but with persistent constipation. Ultrasound examination showed a mass at the right superior base of the prostate subsequently studied with CT and MRI. The patient underwent vesiculectomy; his postoperative course was uneventful. The patient is still well, without evidence of recurrent disease. The seminal vesicle is involved more frequently by tumors originating elsewhere, particularly prostatic carcinoma. Primary malignant seminal vesicle neoplasms are extremely uncommon: in addition to carcinomas and even more rare pure sarcomas, there is a distinctive group of mixed epithelial-stromal tumors that includes the cystosarcoma phyllodes reported in this case, exhaustively studied with ultrasound, computed tomography, and magnetic resonance.A 49-year-old man was admitted with two months persistent constipation, incoercible with medical therapy. He did not report any urinary symptom, only a mild erectile dysfunction. On digital rectal examination his prostate was regular in size and consistency but with an extrinsic compression on the right-posterior wall by a mass. Transabdominal ultrasonography showed a localized cystic mass of about 7,3 × 5 cm, probably of the right seminal vesicle, characterized by multiple endoluminal septa. Transrectal US confirmed the origin of the lesion from the right seminal vesicle without infiltration of rectum, bladder, or prostate .Routine blood exams, including PSA and prostatic acid phosphatase, were normal.Magnetic resonance (MR) was performed and reported a 56 × 63 × 59 mm lesion of the right seminal vesicle with a fluid content and endoluminal central solid tissue caracterized by a sepimentated structure with enhancement after Gadolinium-DTPA. On T1 weighted images, some hyperintensities in small cavities, caused probably by past hemorrhages, were observed. Prostate and bladder were normal, without signs of infiltration. No local adenopathies were found .Colonoscopy confirmed a delayed fecal transit through the rectum and cystoscopy showed compression on the vesical neck without any alteration of the mucosa.Computed tomography (CT) staging was performed without any abnormalities of thoracic and abdominal organs; lesion of the right seminal vesicle was confirmed .US guided needle biopsy was performed and it was negative for atypical cells.The patient underwent right seminal vesiculectomy, with section of ipsilateral vas deferens and the saving of prostate, bladder, and rectum.On gross examination the specimen consisted of a distorted and dilated seminal vesicle of 5 × 5 × 5 cm, with an intact and smooth external surface. On serial sectioning, in particular of the central mass of hard consistence, the lesion was characterized of necrotic-haemorragic areas with pseudocysts. Histologic examination demonstrated a biphasic tumor: one part with ischaemic necrosis, the other without necrosis characterized by an epithelial matrix mainly cystic delimited by addensed stroma  with atypic cells and a variable grade of mitosis. The proliferation index Ki 67 MIB1 clone was inhomogeneous with foci of high proliferation, in particular near the necrotic areas and associated with squamous metaplasia. The final histological diagnosis was cystosarcoma phyllodes of the right seminal vesicle.Patient's recovery was uncomplicated, so after one week he was discharged.Clinicians decided jointly for a strict clinical and CT follow up. Actually, after 14 months, the patient is still alive and makes his periodic clinical-strumental-laboratoristic controls without evidence of disease on chest and abdominal-pelvic CT.Reported primary malignant seminal vesicle neoplasms include a spectrum of carcinomas, sarcomas, and an uncommon group of tumors with mixed epithelial and stromal components.Although rare, adenocarcinoma is the most common primary histotype. Because involvement of seminal vesicle by prostatic adenocarcinoma is a common occurrence , since 1956 Dalgaard and Giertsen applied strict criteria to diagnose primary neoplasms: the lesion must be a papillary or anaplastic carcinoma that is primarily localized in the seminal vesicle in absence of other primary carcinoma in the region  [Sarcomas are even rarer than those of epithelial origin. In the most conclusive documentation Schned et al. reviewed 11 cases of primary sarcoma of the seminal vesicle . Many ofThe third histotype is a rare group of tumors that contain both an epithelial and a stromal component and have been called epithelial-stromal or phyllodes tumors. Phyllodes tumors usually arise in the female breast and display a mixture of variably cellular stroma and benign glandular elements. The density and cytologic features of the stroma determine whether the tumor is a fibroadenoma, low-grade phyllodes tumor, or high-grade phyllodes tumor (cystosarcoma phyllodes). Phyllodes tumors with varying degrees of malignant potential have been reported in the prostate, including cystosarcoma phyllodes. Adenofibroma and adenosarcoma of the female genital tract are histologically similar to phyllodes tumors and are considered of müllerian origin .In the seminal vesicle a range of epithelial-stromal neoplasms that is analogous to phyllodes tumors in the breast and prostate has been reported; they space from benign cystoadenoma and cystomyoma to cystosarcoma that is at the malignant end on the range of phyllodes tumors in the seminal vesicle.In 1993 Fain et al. described the first case of cystosarcoma phyllodes of the seminal vesicle . Since tUnlike previous cases, the patient subject of this report did not show any urogenital symptoms, and the only complaint was recently arisen constipation. Abdominal ultrasound first showed the existence of a pelvic mass with possible origin from the seminal vesicle, as confirmed by subsequent transrectal ultrasound. The lesion was also documented by CT , however, as part of a staging to exclude metastases. Of course, MRI better explained the locoregional extension and hypothesized the possible phyllodes nature of the tumor. Like in Laurila's case and differently from Fain and Abe, the lesion was not solid but with a cystic component. On MRI the absence of infiltration of the adjacent structures obviously could not push the diagnosis up to define the high degree of malignancy and, therefore, the sarcomatous nature of the lesion. In our case, however, even the cytological examination did not show atypical cells, thus orienting the surgery to a simple vesiculectomy. Followup showed no recurrence, thus justifying the surgical choice that was made.


Periosteal chondroma is a rare benign hyaline cartilage neoplasm that occurs most commonly in the metaphases of long tubular bones. We present a unique case of periosteal chondroma arising in the proximal phalanx of the left index finger in a 12-year-old boy. Physical examination revealed a slightly protuberant, subcutaneous mass. Plain radiographs and computed tomography scans showed a periosteal lesion producing saucerization of the cortex and subjacent cortical sclerosis, without internal matrix calcification. On magnetic resonance imaging, the lesion exhibited intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Contrast-enhanced fat-suppressed T1-weighted images demonstrated peripheral and septal enhancement. The patient underwent a marginal excision with curettage of the underlying bone cortex. Histological examination confirmed the diagnosis of periosteal chondroma. There has been no evidence of local recurrence eight months after surgery. Periosteal chondroma can protrude into the subcutaneous soft tissue causing a palpable mass. Recognition of the typical radiological features can lead to an accurate diagnosis of this rare condition. Periosteal chondroma, also known as juxtacortical chondroma, is a rare benign cartilaginous neoplasm of bone surface that occurs predominantly in the metaphases of long tubular bones, particularly, the proximal humerus and distal femur. The small tubular bones are also common sites. It presents as a swelling or palpable mass that may be painful in children and young adults, with a slight male predominance . HistoloA 12-year-old boy presented with a 1-year history of a slow-growing, painless mass in the radial aspect of the proximal phalanx of the left index finger. The patient's past medical history was unremarkable. Physical examination revealed a 2 cm, firm, immobile, nontender, subcutaneous mass . There wPlain radiographs revealed a discernible soft tissue lesion with saucerization and sclerosis of the underlying cortex . ComputeThe operative procedure was carried out under general anesthesia with tourniquet control. A zigzag incision was made on the volar aspect of the left index finger. The mass was adherent to the periosteum of the proximal phalanx and extended into the bone cortex. It was completely excised together with the overlying peritoneum, and the underlying bone cortex was curetted. There was no sign of invasion into the medullar cavity. Bone graft was not done. Histologically, the tumor was well demarcated and surrounded by a periosteum-like fibrous capsule. The tumor consisted of hyaline cartilage with clusters of bland chondrocytes . BinucleThe postoperative course was uneventful, and the patient is doing well without evidence of local recurrence eight months after surgery.Surface-based bone tumors may present as palpable subcutaneous masses in the hands or feet, as in our case. In fact, periosteal chondromas involving finger phalanges were confused with primary subcutaneous or skin tumors at initial presentation , 4. Clinisocitrate dehydrogenase 1 (IDH1) mutations have been identified in 71% of cases [Periosteal chondroma is much less common than enchondroma, accounting for less than 2% of all chondromas . It is uof cases . HistoloPlain radiographs often show a discernible soft tissue mass with underlying cortical saucerization or scalloping, subjacent cortical sclerosis, and overhanging margins . CT may Differential diagnosis of the current case includes soft tissue chondroma and periosteal chondrosarcoma. Soft tissue chondroma occurs most commonly in the fingers and typically affects adults between 30 and 60 years of age . RadiogrPeriosteal chondroma is usually treated with surgical excision. Local recurrence is extremely uncommon  and is aIn summary, we have described a unique case of periosteal chondroma of the proximal phalanx in the left index finger manifesting as a subcutaneous mass in an adolescent boy. Knowledge of the characteristic imaging features can lead to an accurate diagnosis of periosteal chondroma, thereby avoiding unnecessary radical surgery.


Paraganglioma is a rare but highly vascular tumor of the anterior mediastinum. Surgical resection is a challenge owing to the close proximity to vital structures including the heart, trachea and great vessels. Preoperative embolization has been reported once to facilitate surgical treatment.We report a case of anterior mediastinal paraganglioma that was embolized preoperatively, and was resected without the need for cardiopulmonary bypass and without major bleeding complications.We make a case to further the role of preoperative embolization in the treatment of mediastinal paragangliomas. Pheochromocytomas located outside of the adrenal glands are referred to as paragangliomas . CompletA 50-year-old patient had been having recurrent headaches, and right upper and lower extremity weakness, which was worked up. Thoracic surgery was consulted after finding a 4.3 × 5.7 × 8.7-cm mass in the antero-superior mediastinum; see Figure A CT-guided biopsy of the mediastinal mass was performed using a 19-gauge needle. No complications were encountered. Pathologic examination revealed findings typical of a paraganglioma. Nests of cells with uniform bland nuclei and abundant pink granular cytoplasm in an organoid pattern were seen. Chromogranin and S-100 staining of the sustentacular cells was strongly positive.An interventional radiology consultation was obtained for an angiogram and possible embolization before undertaking surgical resection of the tumor. This revealed the proximal great vessels were widely patent without significant luminal irregularity or stenosis. However, there was a mild mass effect with splaying of proximal left common carotid and left subclavian arteries by the underlying mass. Two main branches of the left thyrocervical trunk were supplying the large hypervascular mass in the left cervical region extending to the aortic arch. The tumor demonstrated marked hypervascularity with multiple dilated and ectatic outflow veins. There was another small arterial branch arising from left inferior thyroidal artery. Selective embolization of the two main feeding vessels from the left thyrocervical trunk was performed. There was minimal vascularity of the tumor following embolotherapy.The patient was taken to the operating room 24 h later for definitive resection using median sternotomy. The tumor originated between the left subclavian and left common carotid arteries. It was sharply dissected away from the mediastinal pleura, but the pleural cavity was entered. It was dissected from the pericardium and great vessels with relative ease without major blood loss. Although we were ready for the possibility, cardiopulmonary bypass was not needed. The tumor extended along the left common carotid and internal jugular veins into the neck, with an anatomic plane allowing safe dissection. Final pathology revealed an encapsulated paraganglioma. Hemostasis was adequate, and there no major intraoperative or postoperative bleeding problems. Our patient had an uneventful postoperative recovery and continues to do well 6 months postoperatively.Pheochromocytomas are neuroendocrine tumors originating from enterochromaffin cells in the adrenal medulla or sympathetic ganglia that secrete catecholamines . ParaganThe incidence of malignancy in extra-adrenal paragangliomas has been reported between 21% and 76% . After eOur case was that of a biopsy proven anterior mediastinal paraganglioma. The surgery of anterior and middle mediastinal paragangliomas is challenging because of their close proximity to the central airways, heart and great vessels, making complete resection difficult. Preoperative embolization is an established technique to reduce operative blood loss in head and neck tumors, and has been described for mediastinal paragangliomas as well . The hypWritten 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.None of the authors have any personal or financial competing interests to report.All authors made substantive intellectual contributions this case report, including acquisition of data, interpretation of the case report and drafting/editing of the manuscript, and have given final approval of the version to be published.M.S. is a 5th year general surgery resident.


A ten-year old male child, weighing 20 kg, was admitted through emergency with abdominal fullness and pain. There was a history of sustaining a trivial injury to abdomen two months back following which he developed mild abdominal pain. Intensity of pain increased gradually and became unbearable, along with abdominal distention. There was single episode of bleeding per rectum and off and on fever during this period with no other associated symptoms like vomiting and constipation. Past medical and family history was unremarkable.Examination showed pale, anxious, thin built child with heart rate 120/min, respiratory rate 24 breaths/min, and temperature 101° F. Abdomen was protuberant, firm and severely tender. Digital rectal examination revealed a firm mass palpable on anterior aspect of rectal wall with mobile overlying mucosa, finger stall stained with blood.Despite the history of trauma, signs and symptoms were more in favor of abdominal tuberculosis, with the differential of post traumatic infected haematoma, and sub acute or delayed presentation of infections like appendicitis and enteric fever. His haemoglobin was 7.8 g/dl, total leukocytes 14200/cmm, neutrophils 83%, ESR 10mm in 1st hour. Ultrasound abdomen showed moderate amount of fluid in abdomino-pelvic cavity. CT scan showed thick omentum, matted gut loops with lymphadenopathy and fluid collection in the peritoneal cavity (Fig. Omental spread of diseases ranges from inflammation, infection, to malignancy. Malignancy can be either primary tumor of omentum, or spread from the adjacent or remote areas. The different patterns of omental involvement include seedlings, localized or diffuse infiltration of omental fat by soft tissue density material. The resulting thickened solid omentum is called as omental caking .Thick caking is an indicator of advanced stage of any disease. It is often documented in adult population. Metastatic peritoneal tumors most often originate from the ovary, stomach, pancreas, colon, uterus, and bladder. Haematogenous metastases from malignant melanoma, as well as breast and lung carcinoma, are also common. In developing countries it is also found to be associated with fibrotic type of peritoneal tuberculosis. In paediatric population it is uncommon though reported in cases of rhabdomyosarcoma and lymphoma. Mucinous adenocarcinoma of colon itself is a rare entity in paediatric population, and has an aggressive course, but omental caking is infrequently reported with this type of cancer , 5, 6, 7Computed tomography is a good diagnostic modality in cases of omental pathologies. In the normal anatomy, omentum looks like bands of fatty tissue with some fine blood vessels while in cases of ascites it appears as thin fatty layer. Soft deposits can appear as seeding. Omental caking is actually a radiological sign which on CT scan can be easily identified as diffuse haziness, or a mass like effect. The ascitic fluid encased in the thickened omentum appears as cystic spaces .In our patient CT scan showed, thickened omentum almost occupying the whole of abdomen pushing the matted thick walled gut loops towards one side with ascites. These findings are very much suggestive of advanced pathology especially secondary to malignancy but since such pathology hardly documented in cases of paediatric population our provisional diagnosis was tuberculosis. CT scan findings along with the relevant clinical and demographic data can be of great help in making a diagnosis and also in planning the management of the patients with omental pathology. Source of Support: NilConflict of Interest: None declared


The ingestion of non-food items in children is a relatively common event, often unwitnessed, unknown, and unreported. For those children brought in for medical evaluation, less than 10% require intervention, and only 1% require surgery. This, however, is not the case for magnet ingestion. Magnets, in plurality, can become attracted to one another through intestinal walls, causing a variety of surgical emergencies.We present a case of unwitnessed multiple magnet ingestion in a 5 year-old boy who presented to the emergency department with the atypical chief complaint of neck pain. The diagnostic work-up including a neck magnetic resonance imaging (MRI) potentially led to bowel perforations managed definitely by a subsequent exploratory laparotomy. The child had an uneventful postoperative recovery and was discharged to home upon surgical recovery.Institutions should make all possible efforts to attempt to prevent such potential life-threatening circumstances. We propose a screening tool that can further enhance the care of children who cannot or do not report unwitnessed magnetic ingestion prior to MRI evaluation. Children are prone to ingest many non-food objects that will often pass uneventfully through their digestive system. Magnets in plurality, however, are often attracted to each other even through intestinal walls and multiple reports of pressure necrosis, bowel perforation, volvulus, intestinal fistulas, and obstruction have been documented in the literature -4. With A five-year-old boy presented to the emergency department with neck pain. Per the parent’s report, the child had been unattended in a room in the home watching television when he began to complain of acute onset posterior neck pain. There was no reported history of trauma. There was no history of fever, sore throat, or headache. The child was administered acetaminophen orally, with no relief of symptoms. The child was then brought to the emergency department, where a thorough evaluation was performed due to continued pain and refusal to move the neck. The past medical history was significant for right-sided congenital muscular torticollis, bilateral developmental dysplasia of the hip, and mild gross and fine motor delay. The torticollis was treated with physical therapy and had resolved prior to this visit. The child’s hip dysplasia was treated with a Pavlik harness and had significantly improved at the time of the most recent radiographic examination, one year prior.Initial evaluation revealed a healthy-appearing child in no acute distress. His vital signs were stable. Examination of the mouth showed the oropharynx to be clear. Eye exam was normal. Abdominal examination was normal. The child had focal tenderness to palpation over the midline of the entire cervical spine. He was noted to resist range of motion of the neck in all directions, but there was no asymmetry of motion noted. Neurologic examination of the cranial nerves and extremities was normal.Laboratory studies, including C-reactive protein, were normal. CT scan of the neck was normal. Lumbar puncture was performed in the emergency department and was negative. Throat culture was negative. The child received anti-inflammatory medication and narcotics in the emergency department without resolution of the neck pain. The decision was made by the Pediatric service to admit the child to the hospital and obtain a magnetic resonance imaging (MRI) scan (1.5 Tesla) under moderate conscious sedation, given the child’s young age. MRI of the brain and cervical spine was performed and the patient was kept in the inpatient ward for pain control and observation. The MRI was reported as normal that evening. Orthopaedics was then consulted for further evaluation. The child was placed in a soft collar for comfort overnight.The following morning, the child’s neck pain was noted to be improving, but he was now complaining of severe abdominal pain and refusal to eat. Plain radiographs of the abdomen were obtained which demonstrated pneumoperitoneum and 11 small round metallic objects in the left upper quadrant of the abdomen  published in their Morbidity & Mortality Weekly Report a review of three select cases summarizing the 20 known cases of magnet ingestion identified by the Consumer Product Safety Commission (CPSC) from 2003–2006. Of these 20 cases, one resulted in death and the other 19 required gastrointestinal surgery. Ages of children ranged from 10 months to 11 years, 6 months . Boys accounted for 80% of cases. Two of the three cases outlined in this review presented with the chief complaint of stomach pain and vomiting. The third presented after the child self-reported swallowing the building block toy to his mother. At the time of initial presentation and after radiographic confirmation, it was believed that the child had only swallowed one magnet. The family was reassured this object should pass uneventfully. However, even after the same child represented a few days later having also swallowed a small metal ball, this family was again told to monitor stools, as the objects should pass. The following day, the mother read about a death following magnet ingestion, a specialist was consulted, and two 10 mm disc-shaped magnets and a 10 mm steel ball was removed from the small intestines and the affected bowel was resected. This review highlighted a potential grave consequence of magnet ingestion [In 2009, Avolio and Martucciello published a radiographic case report in the New England Journal of Medicine highlighting the cases of a nine-year-old boy who ingested 23 magnets and a 13-year-old developmentally delayed boy who ingested 15 magnets. The nine-year-old child presented four days after ingestion with clinical signs of intestinal perforation and peritonitis while the 13-year-old presented 10 days after ingestion with volvulus and intestinal occlusion. Both were taken to surgery for open exploration and removal. The authors recommended early intervention following magnet ingestion [Others believe that multiple magnet ingestion can be safely, but closely observed and that surgical exploration should be performed only if the child begins to demonstrate these worrisome findings or, if serial radiographic examinations show an unchanged position of two or more magnets side-by-side ,16,17. IAnother often agreed upon criteria for nonsurgical management of magnet ingestion is solitary magnet consumption. Many physicians feel that a solitary magnet poses very little threat to the child and can be allowed to pass spontaneously; however, this practice could prove devastating. On plane radiographs, it can be difficult to discern if the magnet is truly solitary or stuck to multiple magnets in series. A case of bowel perforation from a presumed solitary magnet treated non-surgically at the Mayo Clinic has been documented, and the authors warn against this practice .In 2009, Siddaiah-Subramanya and Borzi presented three cases of magnet ingestion. All three of their cases presented with the initial chief complaint of abdominal pain and vomiting. The history of magnet ingestion was not obtained, so radiographs were not initially ordered and the children were treated symptomatically for gastroenteritis. The first case detailed an 11-year-old autistic child who required laparotomy to remove multiple magnets in adjacent loops of small bowel. This child had areas of small bowel necrosis and 13 perforations. The second case was a four-year-old child who had swallowed multiple magnetic rings. Laparoscopy and subsequent laparotomy were used to repair the small bowel and caecum perforations. The final case was five years old, and laparotomy revealed a perforation of the jejunum secondary to pressure necrosis from multiple magnets. The authors recommended more stringent regulations on the use of magnets in toys, especially for those younger than five years old, and increased awareness in medical providers of the harmful consequences of magnetic toy ingestion [Our patient did not present initially with stomach pain and vomiting but with the chief complaint of neck pain. This initial presenting complaint is not documented elsewhere in the literature. Possibly, this pain was secondary to the magnets passing through the esophagus, and stomach pain and vomiting would have presented in the following few days. The differential diagnosis for isolated neck pain in the pediatric patient is broad, with possible causes ranging from acute trauma to infectious etiologies. Therefore, the work-up of these patients is often extensive and may include advanced imaging studies, such as MRI. Children, under the age of eight years often require a general anesthetic for these studies, thereby disabling their ability to alert providers of an evolving injury during the study. To our knowledge, the case presented here is the first to document bowel perforation following magnetic resonance imaging. Although we cannot definitely identify the MRI as the causative agent for bowel perforation, this case may represent a rare complication of advanced imaging studies and should draw attention to the possibility of complications resulting from unwitnessed foreign body ingestion.The differential diagnosis of acute onset neck pain in a child is large, and the workup often involves advanced imaging studies such as MRIs. This case potentially highlights a rare but potential life-threatening complication of magnetic resonance imaging. Health care providers treating children with vague pains must be aware of this potential complication and take all steps necessary to identify an unknown ingested foreign body that can potentially react with the MRI equipment.2, a thorough written and verbal screening was performed on all children prior to entering the MRI examination room, and a written ‘Patient History Questionnaire’ was completed by the parents. This questionnaire specifically addressed the presence of any implanted metallic devices, including cardiac stents, defibrillators, and orthopaedic implants. Following administration of the written questionnaire, a verbal screening was performed by the technician, addressing any concerning answers on the written survey.Previously at our institutionFollowing this event, a new screening protocol has been instituted. Children and their parents are still asked to complete the written and verbal screenings. In addition, all children are now required to change into a hospital gown and are then screened using a hand-held Ferromagnetic detection scanner . Testing at our institution has shown that this ferromagnetic screening tool is able to identify small magnets commonly used in children’s games and toys in both living and cadaveric models. This additional safety precaution has been presented in hopes it will be replicated by other institutions.A release of information with obtained and signed by the patient’s mother.The authors declare that they have no competing interests.The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.JRB and EAE were involved in the care of this patient. JRB, EAE, and EWE designed the case report. JRB drafted the first version of the manuscript. EAE and EWE critically revised this paper. All authors contributed and approved the final version of the manuscript.


Heterotopic ossification (HO) is the ectopic development of normal bone within soft tissue that can occur after traumatic injury. It is uncommon and may be missed or misdiagnosed, which can lead to complications. We report the case of an 84-year-old male with a previous history of a laparotomy who underwent resection of an intra-abdominal tumor through a midline incision. On postoperative day six, the patient was taken to the operating room, as succus was draining from the incision. Upon re-exploration, sharp bone-like material was found in the wound directly adjacent to an enterotomy. Pathology confirmed mature lamellar bone and the diagnosis of HO. This is the first report of postoperative intestinal perforation secondary to HO in a midline wound. We report this case to encourage accurate reporting of HO and its morbidity and complications for the benefit of appropriate surgical planning and epidemiologic tracking of outcomes. Heterotopic ossification is the ectopic development of normal bone within soft tissue. In the setting of traumatic injury, such as surgery, it may be referred to as myositis ossificans traumatica and carries the eponyms of Rider's bones and Shooter's bones when found in the adductor muscles and deltoid muscles, respectively. The underlying etiology is unknown but commonly occurs following operations, central nervous system injury, musculoskeletal injuries, burns, vasculopathies, and arthropathies , 2. MorbNo true estimate of the incidence heterotopic ossification exists and underscoring is rarity, especially in the abdominal surgery cohort. Select case series of three, eleven, and twenty-three patients combined with isolated case reports provide the majority of our understanding of this condition –7, highlAn 84-year-old man was worked up as an outpatient for tachycardia and hypertension. An abdominal CT scan demonstrated a para-aortic mass, suspicious for a neuroendocrine tumor. Biopsies were positive for synaptophysin and CD117, and the patient was initially treated with octreotide for a presumed carcinoid tumor. Further work-up revealed serum metanephrines to be twenty times normal levels. This along with subsequent episodes of hypertension, chest pain, electrocardiography changes and repeated non-ST elevation myocardial infarctions led to a change in diagnosis to pheochromocytoma or paraganglioma. The patient was appropriately resuscitated and started on a non-selective alpha-blocker, phenoxybenzamine, followed by a beta-blocker. The patient's medical history was significant for an abdominal operation two years prior for a sigmoid diverticular bleed. At that time, he had a midline abdominal incision, bowel resection, end colostomy, and a rectal pouch. In the ensuing two years, he found that his colostomy was malpositioned, located on a skin crease, and, therefore, he had difficulty with stoma hygiene. Under our care, the patient was taken operating room for an exploratory laparotomy, tumor resection, and stoma revision.Upon abdominal exploration, lysis of adhesions resulted in several serosal tears that were repaired primarily. One large tear required a partial small bowel resection and primary hand-sewn anastomosis. The tumor was encountered adherent to the aorta and carefully resected. The end colostomy was resited, and careful exploration of the abdominal cavity ensured no missed enterotomies. The fascia was closed with two types of absorbable suture, and the skin was closed with staples. On postoperative day five, he was noted to have leakage of serosanguinous fluid from the midline wound. Some staples were removed from the skin, and the wound was packed. In the interim, the colostomy had regained function. On postoperative day six, succus was found to be draining from the inferior portion of the wound, and the patient was taken back to the operating room for a re-exploration with a pre-operative diagnosis of anastomotic leak or failure of enterotomy repair.Upon re-exploration, the remaining staples were removed. The inferior portion of the midline wound was opened first, as it was draining succus. We quickly identified, immediately under the fascia, an enterotomy that was draining succus. This area was oversewn in two layers. The remainder of the wound was opened, and a thorough exploration of the abdominal cavity did not reveal any other evidence of leakage or perforation. All previous anastomosis and enterotomy repairs were intact. During that search, a hard 3 mm × 1 cm irregularly shaped lesion with a sharp point was encountered along the inferior portion of the midline wound directly adjacent to the noted enterotomy . The remMicroscopically, the two specimens were found to be normal, mature lamellar bone . There wA thorough search of the literature revealed several reports regarding the presence and treatment of heterotopic ossification in a diversity of locations in association with a variety of traumatic injuries , 5, 7–16Reports of heterotopic ossification specifically within abdominal wall can be found in the literature dating back to the 1940s  with a sFocusing solely on abdominal heterotopic ossification, one of the earliest case series conducted in 1975 looked at heterotopic ossification in 23 abdominal incisions. They found a male preponderance (79% versus 21%) with an average age of 55. They noted the possibility of reabsorption and disappearance in some patients but urged removal if symptomatic and cautioned against mistaking it for a malignant lesion . Male prThere are two proposed mechanisms for the development of heterotopic ossification in abdominal wounds. The first is that heterotopic ossification develops from liberated bone fragments from the periosteum or perichondrium of either the xiphoid process or symphysis pubis that are deposited within and along an incision. This theory is supported by the fact that all reported cases have been associated with midline laparotomy wounds and none have been reported within transverse incisions . The secan inciting event, such as trauma, but can be as trivial as a few torn muscle fibers, an inductive signaling pathway, most probably secreted from injured cells in the form of protein, supply of mesenchymal cells that are somewhat totipotent so that they differentiate into osteoblasts and chondroblasts under the appropriate signal, an appropriate environment conducive to production of heterotopic bone. Signals for osteoblast and chondroblast differentiation from mesenchymal cells may include bone morphogenetic protein-2 (BMP-2) as heterotopic ossification has been seen in patients receiving recombinant human bone morphogenetic protein-2 (rhBMP-2) for orthopedic procedures . AlthougRegardless of the underlying etiology, management of a mass believed to be heterotopic ossification must take several factors into account. First, one must differentiate between benign heterotopic ossification and the possibility of a malignancy . If the This case of postoperative intestinal perforation secondary to heterotopic ossification in a midline abdominal wound serves to demonstrate several important points. First, the preoperative evaluation and imaging of patients that have had previous operations should not only focus on the intra-abdominal pathology in question, but also include the possibility of heterotopic ossification in a previously operated wound. Second, close attention to the wound edges during fascial closure to ensure the absence of heterotopic ossification may prevent a similar occurrence. Finally, keeping an open mind when needing to reoperate in the immediate postoperative period will allow one to think of rare and remote possibilities such as the one we experienced instead of the more common (anastomotic leak). The surgeon should be alert to the possibility of heterotopic ossification, especially within a previously operated wound and be prepared for the difficulties it may cause during re-opening of an incision, during the operation itself, at closure of the wound and, if not removed, also in the postoperative setting. An institutional IRB was obtained for publication of this case report along with accompanying images. A copy of the documentation is available for review by the Editor of this journal upon request.


Acute vascular emergencies can arise from direct traumatic injury to the vessel or be spontaneous (non-traumatic).The vascular injuries can also be divided into two categories: arteial injury and venous injury.Most of them are life-treatening emergencies, sice they may cause an important ipovolemic shock or severe ischemia in their end organ and require prompt diagnosis and treatment.In the different clinical scenarios, the correct diagnostic approach to vascular injuries isn’t firmly established and advantages of one imaging technique over the other are not obvious.Ultrasound (US) is an easy accessible, safe and non-invasive diagnostic modality but Computed Tomography (CT) with multiphasic imaging study is an accurate modality to evaluate the abdominal vascular injuries therefore can be considered the primary imaging modality in vascular emergencies.The aim of this review article is to illustrate the different imaging options for the diagnosis of abdominal vascular emergencies, including traumatic and non traumatic vessel injuries, focusing of US and CT modalities. Acute vascular emergencies can arise from direct traumatic injury to the vessel or be spontaneous (non-traumatic).The vascular injuries can also be divided into two categories: arteial injury and venous injury.The findings of various types of vessel injury include laceration with active hemorrage, occlusion, and, for arteries formation of psedoaneurysm and dissection.Most of them are life-treatening emergencies, sice they may cause an important ipovolemic shock or severe ischemia in their end organ and require prompt diagnosis and treatment.In the different clinical scenarios, the correct diagnostic approach to vascular injuries isn’t firmly established and advantages of one imaging technique over the other are not obvious.Ultrasound (US) is an easy accessible, safe and non-invasive diagnostic modality and is presently cosidered with the use of Doppler duplex sonography, the first-line examination for evaluation of vascular injuries .Computed Tomography (CT) with multiphasic imaging study is an accurate modality to evaluate the abdominal vascular injuries, quick to perform, non-invasive, readily avaible and able to visualize other anatomical regions simultaneously . CertainThe aim of this review article is to illustrate the different imaging options for the diagnosis of abdominal vascular emergencies, including traumatic and non traumatic vessel injuries, focusing of US and CT modalities.Traumatic aortic injury following blunt (nonpenetrating) trauma is a rare but potentially lethal injury. Recent autopsy series have shown the incidence of abdominal aortic injuries ranging from 12 to 15%; abdominIntimal disruption is the most common type of blunt aortic damage observed, with the distal intimal flap often dissected by the blood flow, leading to thrombosis .Occasionally, frank transection and disruption of the aorta with exsanguinating hemorrhage may happen,8,9.Injuries are typically limited in length. The anatomic location of abdominal aortic injury is usually infrarenal because the suprarenal abdominal aorta is better protected by the lower bony thorax. The most frequent sites of injury are at the level of the inferior mesenteric artery (33%), near the renal arteries (24%), and between the inferior mesenteric artery and bifurcation (19%) .A high index of clinical suspicion is therefore essential because rapid diagnosis and treatment are crucial for a successful outcome in a patient with arterial injury that is potentially life- or limb-threatening. The triad of blunt abdominal trauma, acute lower extremity arterial insufficiency, and lower extremity paralysis could suggest the diagnosis .Among hemodynamically unstable patients, few investigations can actually be instituted. Ultrasonography has been proposed as a useful screening tool for the detection of intraabdominal fluid ; howeverHemodynamically stable patients and patients who respond to initial resuscitation measures require instead further diagnostic evaluation. MDCT has recently become the modality of choice for a comprehensive evaluation of patients with acute vascular disease after blunt trauma, completely replacing in the past years angiography, traditionally considered the gold standard, as a diagnostic tool .Compared to conventional angiography, MDCT indeed has many advantages; it is fast, minimally invasive, and readily available in most large trauma centers. In addition, it is capable of documenting associated abdominal injuries and extrinsic lesions impacting the vasculature can be seen directly. There is still the disadvantage of the need for intravenous contrast, but on the other hand, it can be used as the final diagnostic test on which definite treatment, whether open surgery or endo-vascular stent grafting, in cases of hemodynamically stable patients with intimal injuries or dissections and preserved flow through the vessel, can be planned ,15.Direct signs of abdominal aortic injury include the presence of a large intraluminal flap, intramural hematoma, focal intimal injury, pseudoaneurysm formation, or active extravasation of contrast material; indirect findings of abdominal aortic injury include the presence of retroperitoneal hematoma as well as surrounding retroperitoneal or mesenteric stranding .The finding of frank rupture of the aorta with exsanguinating hemorrhage is extremely uncommon among those patients reaching the hospital alive, and clearly represents an indication to urgent surgical repair.Given the frequent association of abdominal aortic injury and other solid organ and osseous injuries, it is particularly important to include the abdominal aorta in a CT search pattern in patients with severe traumatic injuries. Close inspection of the aorta is particularly important in patients with atherosclerosis, hypertension, or Marfan’s disease, as the intima tears more easily in patients with these conditions ,18.Most renal artery pseudoaneurysms or dissections result from penetrating injuries, many of which are iatrogenic  . Th. ThFindianeurysm ,41.Acute or type B aortic dissection is a life-threatening condition and must be diagnosed and treated promptly.An aortic dissection arises from a tear in the intima which results in a separation of the aortic wall layers with infiltration of bleeding and the danger of aortic rupture. Various genetic disorders of connective tissue promote degeneration of the aortic media, most notably Marfan syndrome. Risk factors for aortic dissection are nicotine abuse, arterial hypertension, age and male gender. The clinical course and symptoms of aortic dissection are very dependent on the section of the aorta affected and the manifestations are manifold. Acute aortic dissection is in 80 % of cases first manifested as sudden extremely severe pain. The diagnostics and subsequent course control can be achieved by a variety of imaging procedures but the modality of choice is CT . FindingAortoenteric fistula is a rare but potentially fatal entity, presents a significant challenge to radiologists in diagnosis, largely because of its subtle and nonspecific imaging findings. Primary aortoenteric fistulas are a complication of atherosclerotic aortic aneurysms, whereas secondary aortoenteric fistulas are a complication of aortic reconstructive surgery ; the secMost fistulas involve the duodenum, most commonly its third and fourth portions. Symptoms include abdominal pain, hematemesis, and melena.Primary aortoenteric fistulas may pose a diagnostic dilemma for the clinician, especially in the absence of gastrointestinal tract bleeding. Uppergastrointestinal- tract endoscopy may help rule out other causes of bleeding but rarely helps diagnose a fistula. Typical CT findings Figure , which cPatients with lower INR are out of therapeutic effect being at risk of thrombosis, whilst an INR >5 increases the risk of bleeding more than 30% per year . Due to It may occur spontaneously or result from minor trauma and may affect any organ system.Given the technical difficulty to identify by US the bleeding site and selectively bind the target vessel, an accurate iter based on a multiphasic CT examination has been widely accepted as an optimal strategy.The bleeding site was defined as a non homogeneous density area (hematoma) with an attenuation value of 50-80 HU in non-contrast scan, whilst active constrast medium extravasation was defined as high-attenuation shapes on arterial phase that initially appeared like a jet or fountain with a tapered edge and after was confirmed on venous and late phases, where the contrast-enhanced blood was mixed with the fresh and clotted blood already present within the hematoma.Renal hemorrhage may occur in suburothelial, intraparenchymal, subcapsular, or perinephric locations, or in a combination of these . Acute hHowever, an additional examination with contrast- enhanced CT should always be performed to exclude other pathologic renal conditions that may cause hemorrhage and may require specific therapy. The presence of perinephric hemorrhage is confirmed by bridging septa of the perinephric fat, which determine the location of bleeding.Renal angiomyolipoma (AML) is one of the most frequent causes of subcapsular and perinephric heamorrhage in adults. AML is a relatively rare benign tumor  composed of fat, muscle tissue and vascular elements in various proportions .The small-sized lesions are usually asymptomatic and are often an incidental diagnostic finding. Larger lesions may be clinically because, in 40% of cases, they tend to rupture with subsequent bleeding .Therefore a correct diagnostic approach is important in order to guide the surgical approach. Emergency US is often the first diagnostic test to be carried out and enables to assume the presence of a neoplasm with a reported sensitivity of 13-30% while identifying both the haemorrhage and the tumor, as compared to a reported sensitivity of 71% for the CT scan ,51. In cAcute Mesenteric Ischemia (AMI) is a vascular emergency with comparable urgency to myocardial infarction or apoplexy.AMI is the cause of acute abdomen in up to 10% of patients aged over 70. The following are predisposing risk factors: heart failure, atrial fibrillation, coronary heart disease, arterial hypertension, and peripheral arterial occlusion . One of The mortality rate of acute mesenteric ischemia (AMI) is 50% to 70% and has remained at this high level for decades . The reaThis is often caused by the time-consuming use of inappropriate diagnostic procedures.In acute mesenteric ischemia, due to distension of the intestinal loops, US should not be used for examination. However, Color Doppler US of mesenteric circulation has become a method which can be carried out in most patients. An experienced US operator can identify the celiac tripod and the superior mesenteric artery in 80-90% of patients  Figure .When acute occlusive mesenteric ischemia is suspected, biphasic contrast-enhanced CT with three dimensional multiplanar reconstruction ( MPR-CT) is the diagnostic tool of choice. CTA is more specific and will often demonstrate the site of embolic occlusion as a central filling defect within the SMA or may show an abrupt point where the artery is not opacified, with poor or absent collaterals Figure .Similar findings of arterial nonopacification are usually present in cases of SMA thrombosis, and there may be accompanying vascular calcifications at the origins of the celiac, SMA, and/or IMA along with well-formed collaterals .CT may demonstrate bowel dilatation and wall thickening, as well as ascites and mesenteric edema in the early stages of AMI, whereas pneumatosis, pneumoperitoneum, and intravascular gas are seen in later stages. In cases of embolic occlusion, other abdominal organs such as the kidneys may show evidence of infarction.Visceral artery aneurysms (VAAs) are the intra abdominal aneurysms that affect the celiac artery, the superior and inferior mesenteric arteries, and the renal arteries and their branches.VAAs involve the splenic artery in 60%–80% of cases Figure , the hepTrue renal artery aneurysms (RAAs) are rare and traditionally have not been included in reviews of VAA because they have different clinical manifestations and are frequently associated with hypertension.The advent of interventional procedures in the liver has made traumatic intrahepatic aneurysm the most frequently encountered VAA at some institutions .The study by Stanley et al  reportedThe routine use of CT and US has led to the increased diagnosis of both symptomatic and asymptomatic VAAs. CT is powerful tools for diagnosis and treatment planning in patients with ruptured VAA. In fact, Increasingly faster speed and higher spatial resolution make CT a first-line imaging modality for patients who present to the emergency department with a suspicion of visceral aneurysms rupture. When a VAA ruptures, intraperitoneal or retroperitoneal hemorrhage or hematoma in a visceral organ or in the course of a visceral artery can be seen at CT. Although to our knowledge no reliable sign to suggest an impending rupture has been reported, rapid size increase in a known VAA may be predictive .Iliac artery aneurysms are rare, accounting for less than 2% of abdominal aneurysms. Common iliac artery is most commonly involved ( 70%), whereas internal iliac artery is involved in 25%. Iliac artery aneurysms are bilateral in approximately 30% cases. External iliac artery is very rare . Those tIn acute, Doppler ultrasonography allows a good detection of the iliac arteries in normal weight patients; however, at present, CT angiography is the most accurate technique to identify and accurately depicts the extravasation of contrast medium in case of aneurysm rupture.Venous injuries are usually present in the setting of penetrating trauma; however, they are an uncommon imaging finding, likely because of the comorbid trauma-related injuries that either result in death or cause hemodynamic instability requiring immediate surgical intervention before imaging .Modern multidetector CT scanners are able to provide superior image detail of venous trauma.However, venous opacification, even during the portal venous phase, is often less than that of the arterial structures during the arterial phase because of hemodilution of the contrast material and its elimination by the kidneys. This lessened venous opacification may create inherent and unavoidable limits in the evaluation of the venous structures. Therefore, it is imperative for the radiologist to understand that although current imaging protocols are not designed specifically to evaluate the venous system, venous injuries may nevertheless be identified, with the potential for important alteration of management .Venous injuries can be identified at CT by finding either direct or indirect signs of the injury. Direct signs of vascular injury are diagnostic and include thrombosis and/or occlusion, avulsion and/or complete tear, rupture and active extravasation. Indirect signs of venous injury, such as perivascular hematoma, fat stranding, and vessel wall irregularity, are indeterminate findings because a venous injury may or may not be present. These indirect signs can often be seen in association with other adjacent injuries.The Inferior Vena Cava (IVC) injury are associated with high morbidity and mortality rates. Investigators have reported that more than one-third of patients with an IVC injury die before reaching the hospital, and in-hospital mortality is greater than 60% [than 60% . Given tthan 60% . Few to A common imaging pitfall is mixing of unenhanced blood with contrast material, which can simulate a thrombosis or vessel injury .Risk factors for acute venous occlusion range from prolonged immobilization to hypercoagulability syndromes, trauma, and malignancy. Acute occlusion of the pelvic veins and the inferior vena cava, often due to extension from the femoropopliteal system, represents a major risk for pulmonary embolism.Acute pelvic vein and inferior vena cava occlusion Isolated pelvic vein occlusion is uncommon in an emergency situation and has been reported mainly as a complication in the postpartum period. Furthermore, thrombosis of the pelvic veins, including the internal iliac veins, can be seen in women with pelvic inflammatory disease and in men with involvement of the prostatic plexus; more frequently, however, acute occlusion of the pelvic veins and the inferior vena cava (IVC) are due to extension from the femoro-popliteal system.Pelvic vein occlusion should be suspected in patients with abdominal pain, a unilateral pelvic mass, uterine infection and fever that fails to respond to appropriate treatment .The utilization of US has a great importance for the diagnosis of venous occlusion. In the presence of thrombus, the vein is distended and incompressible, sharp definition of the venous wall is lost and the presence of echogenic material inside the lumen may be observed. Very fresh thrombus may be nearly anechoic and consequently not openly perceptible . Color fColor flow Doppler imaging is necessary for the evaluation of pelvic vessels but is often limited due to the intrinsic difficulty in plainly outlining the pelvic structures; US imaging in general is also strictly dependent on the technical expertise of the investigator and restricted by patient’s obesity and bowel gas .Both CT scanning and MR imaging can accurately provide the diagnosis of pelvic vein thrombosis. CT venography requires the application of IV contrast agent and is thus contraindicated in patients with renal failure. Pregnancy is another exclusion criterion for CT imaging; however, at present, Contrast-enhanced CT remains the examination of choice for acute pelvic vein and inferior vena cava occlusion .Venography has long been considered the gold standard for identifying proximal venous occlusion because it allows a complete work-up of the lower limb up to the IVC. It is generally a safe procedure and is often indispensable in case of failure of sonography and in the absence of CT or MR facilities .Acute mesenteric vein occlusion Initially illustrated by Warren and Eberhard in 1935, acute mesenteric vein occlusion is an exceptional and distinctive type of intestinal ischemia. Often idiopathic, precipitating factors could be liver cirrhosis, portal hypertension, neoplasm, intra-abdominal inflammatory diseases, trauma, and hypercoagulable states. Symptoms can be varied and include poorly localized abdominal pain, a change in bowel habits, nausea, vomiting, melena, bloody diarrhea, and ultimately circulatory collapse [collapse .As mortality rates for acute mesenteric vein occlusion can be as high as 80%, timely diagnosis is crucial .US and CT imaging are both possible imaging tools in the detection of acute venous occlusion. Contrast-enhanced CT has a sensitivity of 90% and is currently considered the examination of choice ; in factCurrently, with widely available MDCT technology, the first-line assessment of vascular injury in trauma patients is CTA, instead ultrasound is more used in the non traumatic vascular injuries, but CT is still preferable because the ultrasound has limitations as abdominal distension and obesity, which often do not allow to make the diagnosis. The CTA affords a rapid, accurate, non invasive method of detecting vascular injury and appropriately triaging patients to receive the requisite intervention, when necessary.The authors have no conflict of interest.


A 38-year-old man was diagnosed with malignant peripheral nerve sheath tumour of the maxilla. He was treated with total maxillectomy. Histopathological examination of the resected specimen revealed a close resection margin. The tumour was of high grade with an MIB-1 labelling index of almost 60%. At six weeks following the surgery, he developed local tumour relapse. The patient succumbed to the disease at five months from the time of diagnosis. The present report underlines the locally aggressive nature of malignant peripheral nerve sheath tumour of the maxilla which necessitates an early therapeutic intervention. A complete resection with clear margins is the most important prognostic factor for malignant peripheral nerve sheath tumour in the head and neck region. Adjuvant radiotherapy may be considered to improve the local control. Future research may demarcate the role of targeted therapy for patients with malignant peripheral nerve sheath tumour. Malignant peripheral nerve sheath tumours (MPNSTs) encompass a cluster of tumours which arise from the peripheral nerves or display differentiation along various elements of the nerve sheath, namely, Schwann cells, perineural fibroblasts, or fibroblasts . An origA 38-year-old man presented with an 8-month history of pain in the left cheek, bleeding from the left nostril, and nasal blockage. He had noticed a swelling over the left cheek and dorsum of the nose which progressed over a period of 6 months. He had also noticed an ulcer on the left upper alveolus which progressed over a period of 2 months. He had a 10-year history of tobacco consumption. A contrast enhanced computed tomography (CECT) of the paranasal sinuses (PNS) was performed which revealed a mass lesion in the left maxillary sinus. He had undergone a surgery for the removal of mass in the left maxillary antrum and nasal cavity by Caldwell Luc approach. Histopathological examination of the resected mass was reported as angiofibroma. After remaining asymptomatic for 5 months, the patient presented with the similar complaints as before for duration of one month. The patient was now evaluated in our multidisciplinary clinic by a team of head and neck surgeon, radiation oncologist, and a medical oncologist. Physical examination revealed swelling of 8 × 6 cm size over the left cheek involving the nasolabial fold. There was no abnormality seen on the overlying skin. No sensory deficit was seen in the region of the trigeminal nerve distribution. Oral cavity examination revealed a polypoidal friable mass lesion arising from the left upper alveolus. A similar mass lesion was seen filling the left nasal cavity. A bulge was seen in the region of the hard palate with prominent overlying vessels. The patient did not have any signs of neurofibromatosis.Magnetic resonance imaging (MRI) of the PNS and neck was performed which revealed an ill-defined soft-tissue mass lesion in the left maxillary sinus. The lesion showed isointense and hyperintense appearance on T1- and T2-weighted images, respectively. A few hypointense areas were noted in the mass lesion suggestive of spicules of destroyed bone. There was no haemorrhage or necrosis seen within the lesion. The mass lesion showed contiguous extension to the left nasal cavity with destruction of the middle and inferior turbinate. Cranially, the lesion was seen reaching till the left ethmoid sinus with destruction of air cells. Caudally, the lesion was extending to the hard palate with destruction of the floor of the maxillary antrum. The anterior wall of the maxilla was destroyed with extension of the mass lesion into subcutaneous plane of the premaxillary area. The posterior wall of the maxillary antrum was destroyed at places with extension of the mass lesion into retromaxillary fat pad. Infiltration of the left maxillary alveolar arch by the lesion was seen. The mass lesion demonstrated restricted diffusion on the diffusion-weighted images. There was no intraorbital or intracranial extension. No significant cervical lymphadenopathy was seen. A CECT of the PNS was also performed which showed a mass lesion measuring 7.6 × 4.7 cm in the left maxillary sinus extending to the ethmoidal air cells, nasal cavity, pterygomaxillary fissure, and pterygopalatine fossa. Irregularity of the left pterygoid plates was seen. Destruction of the left palatine bone and maxillary alveolar process in the region of premolars and molars was seen with eroded buccal and palatal cortices. Chest radiograph demonstrated normal lung fields.A biopsy of the mass lesion was performed. Histopathological examination of the biopsied specimen revealed features of malignant mesenchymal tumor. The tumour cells demonstrated immunopositivity for vimentin and immunonegativity for cytokeratin, epithelial membrane antigen, desmin, myogenin, and smooth muscle actin (SMA). Subsequently, the patient underwent a total left maxillectomy. Peroperative findings revealed a proliferative growth in the left maxilla and nasal cavity reaching up to nasopharynx and infratemporal fossa. Gross examination of the resected specimen revealed a tumour measuring 8 × 3 × 5 cm. There were also separately lying pieces of tumour tissue collectively measuring 4 × 3 × 2 cm. The tumour was lying close to the right lateral mucosal margin and 0.5 cm from the nearest bony resected margin. On microscopic examination, the right lateral mucosal resection margin was 0.3 cm. The remaining mucosal and bony resected margins were free of tumour. Spindle-shaped atypical cells with a high mitotic activity (15/10 hpf) were seen on histopathological examination . No necr99mTc-methylene diphosphonate planar (MDP) bone scintigraphy with single photon emission computed tomography-computed tomography (SPECT-CT) was performed. There were no skeletal metastases evident on the scan. Adjuvant radiotherapy was planned for the patient. However, at six weeks subsequent to the surgery, he presented with a mass lesion in the oral cavity at the maxillectomy site  [Minovi et al.  reportedBagan et al.  describeThe survival meta-analyses by Kolberg et al.  reportedThe present report underlines the locally aggressive nature of MPNST of the maxilla which necessitates an early therapeutic intervention. A complete resection with clear margins is the most important prognostic factor for MPNST in the head and neck region. Despite the conflicting reports, adjuvant radiotherapy may be considered to improve the local control. Future research may demarcate the role of targeted therapy for patients with MPNST.


Pulmonary sclerosing hemangioma (PSH) is a rare benign tumor of the lungs. These tumors are composed of cuboidal surface cells and polygonal stromal cells and show four histological manifestations: hemorrhagic, papillary, solid, and sclerotic. PSH predominantly affects asymptomatic middle-aged women. The tumor often occurs at the intralobar site, and less commonly in the bronchus and mediastinum. PSH is easy to be misdiagnosed preoperatively. In this study, we present in detail the treatment procedures followed for two atypical cases of PSH. Case 1 was a 62-year-old woman bearing a tumor for 15 years. The tumor lesion was found to be located in the oblique fissure of the left lung. PSH was confirmed by surgical resection and postoperative pathological diagnosis. There was no sign of recurrence and metastasis 1.5 years after surgery. Case 2 was a 54-year-old woman diagnosed with bilateral multiple nodules by physical examination. This patient was diagnosed with definite PSH through computed tomography-guided percutaneous lung biopsy. Surgical resection was not performed. The patient also showed no sign of enlarged tumor and metastasis after 2 years of follow-up. Although PSH can be cured by surgical resection, the findings in our cases indicate that surgical resection need not be considered the preferred course of treatment. If PSH is diagnosed before surgery, the patients may survive while bearing the tumor. Pulmonary sclerosing hemangioma (PSH) is an uncommon benign tumor, which was first described by Liebow and Hubbell in 1956-7. DefinThe patient was an asymptomatic 62-year-old woman diagnosed with a tumor in the left hilum of the lung in 1995, who had refused to undergo treatment . A chest radiograph obtained in 1999 indicated multiple abnormal nodular shadows in the left hilar field; the shadows were approximately 2.5 cm × 3 cm in size, which, in combination with the patient’s description of the original tumor size, indicated that the tumor had not enlarged in sized. A chest radiograph obtained in 2001 showed a slight increase in the lesion size. The tumor measured about 7 cm × 8 cm in 2009 Figure.A 54-year-old woman underwent chest CT as a part of physical examination. Round-shaped nodular shadows were observed in the medial and lateral segments of the middle lobe of the right lung and the basal segment of the left lower lobe, with diameters of 2.5 cm, 0.9 cm, and 0.8 cm, respectively. No tumors were observed in the periphery, and point-like calcification was observed in the two nodules in the middle lobe of the right lung Figure. The resPSH is a rare benign neoplasm of the lung. The origin of PSH has remained controversial despite extensive studies by many investigators. PSH can occur in any individual in the age group of 4 to 70 years, 9]. P. P9]. PSPSH is mainly composed of two types of cells: cuboidal surface cells that tend to differentiate into type II pneumocytes, and polygonal stromal cells that have considerable multilineage differentiation potential. In the Imaging data for the first case indicated a gradual increase in the lesion size, but the patient did not experience any special discomfort. To date there has been no report of a patient bearing a tumor for 15 years in the oblique fissure area of the lungs. In our first patient, there was no sign of lung and lymph-node metastasis, suggesting that PSH may be showing benign biological characteristics, such as poor growth, non-invasiveness, and nonmetastasis. However, there was evidence indicating that PSH is accompanied by lung or lymph-node metastasis and the etiology of PSH is still unclear, while metastasis of this tumor has no effect on patient survival, [5]. IIn the second patient, the CT scan showed round-shaped nodular shadows in the middle lobe of the right lung and in the lateral and basal segments of the left lower lobe, with diameters of 2.5 cm, 0.9 cm, and 0.8 cm, respectively. In addition, the periphery was clear and point-like calcification was observed in the two nodules in the middle lobe of the right lung. CT-guided percutaneous lung biopsy was performed only on the nodule in the medial segment of the middle lobe of the right lung. On the basis of the clinical features and the pathological results, this patient was diagnosed with bilateral multiple PSH, which can coexist with lung cancer or can even occur in the same cancerous lesion,13. A siSurgical resection is currently widely used for treating PSH, and no study has reported distant metastasis and the effect of surgical resection on patient survival. However, PSH predominantly affects middle-aged individuals whose lung function may be bad, and the misdiagnosis rate by intraoperative frozen-section assessment is high, resulting in unnecessary extensive surgical procedures and discomfort for the patients. We therefore suggest that surgical resection should not be considered the preferred strategy for treating single or multiple PSH in the intralobar sites or oblique fissure. If PSH is diagnosed before surgery, and the lesion has no effect on the patient’s respiratory function, the patients can survive bearing the tumor.Written informed consent was obtained from the patients 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.CT: computed tomography; PSH: pulmonary sclerosing hemangioma.The authors declare that they have no competing interests.CH carried out the molecular genetic studies, participated in the sequence alignment and drafted the manuscript. HYF carried out the immunoassays. YL participated in the sequence alignment. XQH and LR participated in the design of the study and performed the statistical analysis. WZ conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


Congenital simple hamartoma of retinal pigment epithelium (CSHRPE) is a rare, asymptomatic, and incidentally detected benign lesion. However, it is very important to do the differential diagnosis from other pigmented retinal lesions. Its clinical presentation and imaging findings are very helpful in doing this differentiation. This paper presents clinical and imaging findings of a 56-year-old woman with incidentally detected CSHRPE. The lesion was small, heavily pigmented, well circumscribed, and slightly elevated. Optical coherence tomography (OCT) scanning was diagnostic and showed an elevated retina at the site of the lesion, increased optical reflectivity on its inner surface, optical shadowing of deeper structures, and clearly cut tumor margins. Ocular ultrasonography, fluorescein angiography, and fundus autofluorescence imaging which is firstly described in this report did not show any characteristic finding. The lterature .We report ophthalmoscopic and imaging findings of a case with congenital simple hamartoma of retinal pigment epithelium (CSRPEH). To the best of our knowledge, although fluorescein angiography (FA) and optical coherence tomography (OCT) characteristics had already been described –7, this A 56-year-old woman presented for a routine eye examination had been told to have a nevus in the back of her right eye and referred to the “Retina Department” of our hospital. The patient was completely asymptomatic. The visual acuity was 20/20 in both eyes. Biomicroscopic findings and intraocular pressure were completely normal. Dilated fundus examination revealed a heavily pigmented, small, well-circumscribed, and slightly elevated lesion located superonasal to the fovea and temporal to the optic disc . There w Examination and imaging findings of the left eye were completely normal.CSRPEH is a heavily pigmented, well circumscribed and nodular benign tumor usually located adjacent to the foveola or more rarely at the foveal center. This lesion involving the full-thickness retina may be associated by retinal traction, exudation, dilated feeding and draining retinal vessels and pigmented vitreous cells , 8. NoneCSRPEH is asymptomatic and detected incidentally in most of cases as in ours. Because it does not grow and remains stationary, the visual prognosis is good especially for lesions located extrafoveally .Ocular ultrasonography demonstrates an echogenic and nodular mass with moderate to high internal reflectivity and without shadowing , 5. UltrFluorescein angiography of CSRPEH shows nonfluorescence throughout the angiogram as in our case. Late hyperfluorescence which is not observed in our case may be seen in few cases , 6.OCT findings of CSRPEH were first described by Shields et al. in 2004 . OCT scaFundus autofluorescence findings of this rare lesion had not been described before and were not characteristic. Because FAF is known to originate from the lipofuscin and the content of CSHRPE is melanin, a blockage of background autofluorescence at the site of heavily pigmented lesion was observed.Varied pigmented lesions such as congenital hypertrophy of the RPE, hyperplasia of RPE, intraretinal foreign body, adenoma and adenocarcinoma of the RPE, combined hamartoma of retina and RPE should be considered in the differential diagnosis of CSRPEH –6. Clini


Parahiatal hernia is an extremely rare subtype of hiatal hernia, which in turn is a type of diaphragmatic hernia in adults, and only a few cases have been reported to date. We report the case of a patient who suffered from gastric incarceration through an anatomically separate diaphragmatic defect, immediately lateral to a structurally normal esophageal hiatus, that developed after treatment of a malignant mesothelioma.A 70-year-old Japanese man, who had undergone treatment for a left malignant pleural mesothelioma a year ago at another hospital, was referred to our institution following a 4-day history of epigastric pain. Esophagogastroscopy demonstrated a normal esophagogastric junction, with remarkable stenosis and active gastric ulcer of the gastric body. Histopathological examination of the gastric biopsy specimen confirmed a gastric ulcer. Furthermore, computed tomography revealed a large fluid-filled structure in the retrocardiac space. On the basis of preoperative data, we decided to attempt laparoscopic repair for the gastric volvulus. During surgery, gastric and omental herniation was observed within a peritoneal lined defect immediately lateral to the esophageal hiatus. Dissection near the esophageal hiatus revealed a discrete extrahiatal defect 3cm in diameter immediately adjacent to the left crus of the diaphragm. The parahiatal defect was closed using interrupted nonabsorbable heavy suture. The patient’s postoperative course was uneventful, and anastomotic leakage was not observed at postoperative barium swallowing.Although preoperative diagnosis of parahiatal hernia is difficult, a laparoscopic approach can be a useful therapeutic procedure not only for paraesophageal hernia but also for parahiatal hernia. Parahiatal hernia is an extremely rare subtype of hiatal hernia, which in turn is a type of diaphragmatic hernia in adults. Parahiatal hernia is characterized by the presence of a diaphragmatic hernia defect immediately adjacent to an anatomically normal esophageal hiatus. Few cases of laparoscopic repair for parahiatal hernia have been reported to date . Here weA 70-year-old Japanese man was referred to our institution following a 4-day history of epigastric pain. He also complained of acute dysphagia and frequent episodes of severe vomiting. He had been diagnosed with a left malignant pleural mesothelioma and for the past year he had been treated at another hospital. At that time, a chest roentgenogram obtained before treatment for malignant mesothelioma revealed no elevation of the diaphragm. At the current admission, his body mass index was 18.3, and he appeared slightly emaciated. Decreased breath sounds and dullness on percussion of the left lower hemithorax were noted. His white blood cell count was 8100/uL, and his C-reactive protein level was 3.16mg/dL.A chest roentgenogram revealed elevation of the left hemidiaphragm Figure . EsophagAfter general anesthesia induction and carbon dioxide insufflation of the abdominal cavity, laparoscopic exploration was performed. The standard approach for laparoscopic distal gastrectomy employed at our institution was used for this patient. A total of six ports were placed in the abdomen Figure , and no During surgery, gastric and omental herniation through a peritoneal-lined defect immediately lateral to the esophageal hiatus was observed Figure a. This pDissection near the esophageal hiatus revealed a discrete 3-cm diameter, extrahiatal defect immediately adjacent to the left crus of the diaphragm. The hernia sac was present within this defect, which had invaginated into the left retrocardiac space. Closure of the parahiatal defect was performed using monofilament absorbable suture (0 PDS™ [polydioxanone] II) Figure d. SimultThe patient’s postoperative course was uneventful, and anastomotic leakage was not observed during a postoperative barium swallowing. The patient resumed oral intake of food 5 days after surgery, and he was discharged from our hospital 29 days after surgery.et al. [The most generally accepted nomenclature of hiatus hernia includes four categories: Type I (sliding hernia) which accounts for approximately 95% of cases of hiatal hernia, Type II  which accounts for approximately 5% of cases of hiatal hernias, and Type III which is a combination of both Type I and II. Type IV, parahiatal hernia, is also gaining widespread acceptance in the literature. Parahiatal hernia (Type IV) is differentiated from the foregoing three types (Types I to III) of hernia by the presence of a separate extrahiatal diaphragmatic defect with intervening normal crural muscle ,3. Howevet al.  reportedParahiatal hernia is characterized by the presence of a separate extrahiatal diaphragmatic defect with intervening normal crural muscle. Moreover, the hiatus is structurally normal and both crural muscles are intact ,8. In ouet al. described that chronically increased intra-abdominal pressure (IAP) leads to both morphological and biochemical adaptations of the costal diaphragm [Incomplete obliteration of the embryonic pleuroperitoneal canal, resulting in a persistent pneumoenteric recess, has been theorized to explain the etiology of naturally occurring primary parahiatal hernias . Althougiaphragm . Chroniciaphragm ,13. Becaet al. [et al. [On the one hand, laparoscopic repair for paraesophageal hernia has become widely recognized ,15. On tet al.  reported [et al.  reportedWe experienced an extremely rare case of parahiatal hernia that developed after treatment of a malignant mesothelioma and was successfully treated by laparoscopic surgery. Although the preoperative diagnosis of parahiatal hernia is difficult, a laparoscopic approach can be a useful therapeutic procedure, not only for paraesophageal hernia but also for parahiatal hernia.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.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. KM contributed to writing the manuscript. TI and GH were involved in the collection of relevant literature and proof read the manuscript.


Choriocarcinoma usually arises in the uterus and gonads. Primary choriocarcinoma (PCC) in an extragenital organ is rare. When it occurs in the gastrointestinal tract, the stomach is the most common site. Only 12 cases of PCC of the colon have been reported in the world literature. Most cases were associated with adenocarcinoma. We report the case of a 36-year-old man with PCC of the colon and review the clinical characteristics of previously documented cases. Choriocarcinoma is a highly malignant tumor of trophoblastic cells that most often arises in the female genital tract. It is considered to be pertinent to molar pregnancy, normal or ectopic pregnancy and abortion. When it occurs in male patients, the testis is the most common site. Choriocarcinoma of extragenital origin is found in the retroperitoneum or the mediastinum, or intracalvarium. Primary choriocarcinoma (PCC) originating in the colon is extremely rare and the prognosis is usually poor.A 36-year-old male patient visited the local hospital for the chief complaint of discomfort of the upper abdomen. An appendectomy was performed under the clinical diagnosis of acute appendicitis. During the operation, a tumor was observed in the colon. The operation was aborted because of an inability to remove the tumor. Two days later, a computed tomographic (CT) scan of the abdomen revealed the mass arising from the ascending colon. The regional enlarged lymph nodes and metastases in the liver were noted Figure .The patient was transferred to our hospital for treatment. Tumor markers, including carcinoembryonic antigen, cancer antigen 19–9 (CA 19–9) and CA 125, were in the normal range. His serum beta human chorionic growth hormone (β-HCG) level was 3.38 mIU/ml. A colonoscopy revealed a yellow tumor in the colon (Figure Systemic chemotherapy using bleomycin, etoposide and platinum was performed. Chemotherapy engaging etoposide phosphate 100 mg, cisplatin 30 mg, bleomycin 18 mg was initiated. The β-hCG level increased from 3.38 to 10,000 mIU/ml after the first course of chemotherapy, and CT showed another mass in the liver. After three cycles of chemotherapy, his β-hCG level remained high. Because of the progression of disease, the patient and his family abandoned other alternative regimens of chemotherapy.Choriocarcinoma most commonly arises in trophoblastic tissue following gestational events such as molar pregnancy, normal or ectopic pregnancy, and abortion. When the tumor occurs in men, the gonads are the most common sites. Choriocarcinoma of extragenital origin has been reported in the retroperitoneum , mediastThe pathogenesis of primary extragenital choriocarcinoma is controversial. Several hypotheses have been proposed, including that it develops from retained primordial germ cells that migrated abnormally during embryonic development ; metastaThe preoperative diagnosis of PCC of the colon is poor. In our case, the patient was assessed as having metastatic colonic cancer. An endoscopic biopsy supported this possibility because of an insufficient specimen. However, on postoperative biopsy, he was re-diagnosed with PCC of the colon. The diagnosis of primary extragenital choriocarcinoma should firstly rule out any abnormal findings in the uterus or genitalia. The presence of cytotrophoblast and syncytiotrophoblast on biopsy, the presence of β-hCG immunoreactive cells, and elevation of serum β-hCG level confirm the diagnosis.et al. found that resection followed by adjuvant chemotherapy was the best treatment of PCC of the lung [et al.[The majority of patients with gastric choriocarcinoma are treated surgically. Umemori the lung . For patthe lung . The cheg [et al. – their The correlation between the β-hCG level and the effectiveness of treatment has not been detailed in most previous reported cases. β-hCG did not decrease to normal levels after surgery, implying that micrometastatic disease existed . The redThe prognosis of PCC of the colon is poor. In our analysis of the literature, the median survival time was less than 1 year. PCC of the colon is usually not identified until the tumor has generalized metastasis. The great majority of patients die from liver failure.Written informed consent was obtained from the patient for publication of this manuscript.β-HCG: beta human chorionic growth hormone; CA: cancer antigen; CT: computed tomography; PCC: primary choriocarcinoma.The authors declare that they have no competing interests.Jing-Tao Wu and Lun Jiang proposed the study. Jing-Tao Wu, Lun Jiang and Xin Peng - wrote the manuscript. Lun Jiang and Xin Peng contributed equally to this work. All authors read and approved the final manuscript.


The MRI showed mix attenuation mass of 19.7 x 16.8 x 13.7cms arising from right side of uterus extending up to epigastrium, with cystic and solid components and ascitic fluid. Resection of mass with abdominal hysterectomy with bilateral salphingo oophrectomy was done. No local or abdominal organ metastases were seen. Histopathology showed left broad ligament leiomyoma weighing 4000 grams with cystic degeneration.Fibroids are smooth muscle benign tumors; most commonly arise from uterus but may also rise from extra uterine sites like broad ligament. This case report of broad ligament myoma with extensive cystic degeneration is presented for its rarity and diagnostic challenges as they mimic pelvic adenexal tumors. Mrs. X, 43 years old pConclusion: Huge broad ligament leiomyoma with cystic degeneration and abdominal ascites may cause diagnostic dilemma with ovarian malignancy. This differential diagnosis must be considered before surgery. This is a case report of huge leiomyoma with massive cystic degeneration resulting in diagnostic confusion with ovarian malignancy on clinical evaluation and radiological findings. Fig.1Leiomyomas are commonly found in 20 – 30% of uterine tumors with typical sonological appearance.Mrs. X para 5+2, asymptomatic, hypertensive obese woman with previous cesarean deliveries and tubal ligation (09 years back), presented with ultrasound (U/S) showing an ovarian tumor of huge dimensions. She was regularly menstruating, had no urinary, bowel, sexual or weight related complaints. She got the ultrasound done as her abdomen was increasing in size. She had consulted many gynecologists to avoid surgery. Abdominal examination revealed a hard mass extending from pelvis up to xiphisternum and laterally extending into the flanks, shifting dullness was not present. On pelvic examination the uterus was difficult to identify separately from the mass; it was non-tender, fixed and all the fornices were full with hard solid palpable nodules. There was no palpable lymphadenopathy.4 levels were normal. ultrasound on 14-06-2013 reported, a large cystic cum solid multiseptate mass extending from right side of uterus up to the right hypochondrium of about 19.7 x 16.8 x 13.7cm. Color Doppler showed low resistant vascularity in thin parts. R.I was 0.43.The CA 125, Carcino Embryonic Antigen (CEA), serum alpha foeto protein HEHigh resistant vascularity was found in left ovary measuring 5.8 x 4.0 cm, free fluid in cul-de-sac and para colic gutters, with no abdominal visceral involvement. MRI on 19-06-2013 showed a well defined left adenexal mass of mixed attenuation predominantly cystic, extending up to the level mid pole of the kidney anteriorly. It measured 14.0 x 20.0 x 20.0 cm in anteroposterior, transverse and craniocaudal dimensions. After anesthesia fitness the surgery was planned. On laprotomy a transverse rectus cutting abdominal incision was given. About 500 ml straw colored fluid was aspirated from abdominal cavity.On opening the peritoneum the appearance of the tumor was as if the guts were adherent to the anterior surface of the tumor. The mass was arising from the pelvis and extending up to xiphisternum with lateral extensions to both the para colic gutters. It had solid cum cystic consistency and multiple cysts were filled with straw colored fluid. Normal sized uterus was attached to the lower right lateral pole of the mass with a normal looking right and left ovary. Left lateral extension of the mass was encroaching into the retroperitoneum, the pedicle of the tumor was arising from the left lateral uterine border extending into broad ligament.The mass was removed and subtotal hysterectomy was done due to adherence of bladder with the lower uterine segment. Surrounding structures like anterior surface of bladder, intestines, liver and diaphragm were normal looking. Para aortic lymph nodes were not palpable. After securing homeostasis, abdomen was closed in layers.Histopathology Report: A large cyst about 19.5 x 16.5 x 6cm in dimension; weighing 4000grams with solid areas measuring 9.5 x 9.3cm was reported. The cut surface was grey white with whorled appearance. This multilocular cyst contained yellow serous fluid. Secretory endometrium, unremarkable ovaries and fallopian tubes. No evidence of malignancy. Cytology of fluid showed no malignant cells. Immunohistochemical markers showed Caldesmon - Positive in spindle cells.2 The commonest type of degeneration is hyaline seen in 60% of patients.3Uterine leiomyoma can undergo cystic degeneration and is said to be found in 4% of all types of degenerations.Usually uterine leiomyoma does not present a clinical and sonological diagnostic challenge. However, when fibroids undergo massive cystic degeneration they may present clinical and sonologic diagnostic difficulties. In this case report the asymptomatic presentation, with a huge palpable mass and ultrasound appearance of extensive tumor with solid cum cystic areas, presence of peritoneal free fluid mimicking Pseudo-Meig's syndrome, raised the suspicious of ovarian malignancy.4 levels however were <70 pmol/L.The patient’s normal readings of CA 125, CEA and alpha fetoprotein levels; being non-specific tumor markers could not be banked upon. Serum HE3,4MRI is a useful diagnostic tool; Leiomyomas with cystic degeneration typically show decreased T1W and high signal intensity on T2-weighted images, and the cystic areas do not show enhancement on contrast image.5 Knowledge of unusual presentation of the benign degenerated fibroids is essential to the clinicians; to help differentiate benign from malignant tumor entities.6 Intraoperative finding of ascites with the huge tumor mimicked ovarian malignancy. However, the attachment of the tumor to the lateral border of uterus along with bridging vessel sign (vessels bridging the mass and myometrial tissue seen in Intraoperatively the irregular shape, solid cum cystic appearance and the left lateral extension of the mass caused difficulty in distinguishing from retroperitoneal malignant encroachment of tumor. Preoperative identification of feeding or draining vessels arising from the myometrium could be helpful in distinguishing an intraligamentary leiomyoma from a retroperitoneal tumor.Huge broad ligament leiomyoma with cystic degeneration may present diagnostic difficulties in differentiating ovarian malignancies even on ultrasound and MRI. This differential diagnosis must be considered prior to surgical management.


Burkitt’s lymphoma is a highly aggressive lymphoma. The endemic form is present with Epstein - Barr virus. The most common sites are the mandible, facial bones, kidneys, gastrointestinal tract, ovaries, breast and extra-nodal sites. We present the first reported case of a primary Burkitt’s lymphoma of the postnasal space occurring in an elderly Caucasian male.A 72-year-old Caucasian male farmer presented with a 6-week history of a productive cough and a painless left sided cervical swelling. Examination of the neck revealed a 5 cm by 5 cm hard mass in the left anterior triangle. A CT scan of the head and neck showed a soft tissue swelling in the postnasal space. Histology of the postnasal space mass showed squamous mucosa infiltrated by a high grade lymphoma.in situ hybridisation confirmed the tumour to be Epstein - Barr virus Ribonucleic acid negative suggesting this was a rare sporadic form of the tumour presenting in a location that is atypical for the clinical subtype and age of the patient.Immunohistochemical staining and This is the first reported case of sporadic Burkitt’s lymphoma of the postnasal space of an elderly Caucasian male in the absence of Epstein - Barr virus or human immunodeficiency virus infection and further serves to illustrate the diversity of histological subtypes of malignancies that may develop at this concealed site. Burkitt’s lymphoma is a highly aggressive lymphoma that appears to occur in three histologically and phenotypically identical but clinically distinct forms; endemic, sporadic and immunodeficiency-associated. The endemic form is present with Epstein - Barr virus (EBV) in nearly all cases. It is most commonly found in children with a male preponderance .The most common sites are the mandible, facial bones, kidneys, gastrointestinal tract, ovaries, breast and extra-nodal sites. Sporadic Burkitt’s is found worldwide with the abdomen being most commonly involved. EBV is involved in up to 30% of cases -3.Cases have also been reported in which a Burkitt’s-like lymphoma is associated with HIV -4, congeWe present the first reported case of a primary Burkitt’s lymphoma of the postnasal space occurring in an elderly Caucasian male.All treatments were given according to standard accepted guidelines in accordance with the hospital R&D and ethical review committees, patient consent was obtained prior to publication. A 72-year-old Caucasian male farmer presented with a 6-week history of productive cough and painless left sided cervical swelling. He had given up smoking cigarettes fifteen years previously. Examination of the neck revealed a 5 cm by 5 cm hard mass in the left anterior triangle by the angle of the mandible with no other palpable masses.Fibre-optic naso-endoscopy revealed a 3 cm by 3 cm mass extending from his left Eustachian cushion towards the midline. History and examination were otherwise unremarkable.A CT scan of the head and neck showed a soft tissue swelling in the postnasal space, with extensive lymphadenopathy along the carotid sheath and deep to the sternomastoid Figure . The lowEndoscopically directed biopsies of the postnasal space mass and a fine needle aspirate (FNA) of the neck lump were performed under general anaesthesia. And on microscopy showed atypical lymphoid cells on a background of foamy macrophages and cellular debris.Histology of the postnasal space mass showed squamous mucosa infiltrated by a high grade lymphoma comprising a mono-morphic population of tightly packed, medium sized lymphoid cells exhibiting a very high mitotic rate along with numerous characteristic “starry sky” macrophages Figures , 4 and 5in situ hybridisation for Epstein - Barr virus (EBV) revealed the tumour to be EBV Ribonucleic acid (RNA) negative, EBNA2  negative and LMP1  negative, confirming there was no previous infection with the Epstein Barr Virus. Human immunodeficiency virus (HIV) serology was negative confirming that the lymphoma was not HIV-associated.Immunohistochemical staining and The patient was treated with a CODOX-M chemotherapy regime  and remains in remission after five years.Both sporadic and endemic forms of Burkitt’s lymphoma present primarily in childhood . An abdoPreferred sites for sporadic Burkitt’s include the bowel, the ovaries, the mesentery and retroperitoneal lymph nodes . A signiIt is not clear why this particular patient had sporadic nasopharyngeal Burkitt’s lymphoma in this highly atypical site. To our knowledge, this is the first reported case in the world literature of Burkitt’s lymphoma in an elderly Caucasian male.This case is unusual as it is a sporadic tumour in an elderly presenting at a site favoured by endemic paediatric tumours.In addition, this is the first reported case of sporadic Burkitt’s lymphoma of the postnasal space of an elderly Caucasian male in the absence of EBV or HIV infection and further serves to illustrate the diversity of histological subtypes of malignancies that may develop at this concealed site.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors contributed to conception and design, carried out the literature research, manuscript preparation and manuscript review. All authors have read and approved the final version of the manuscript.