Pituicytoma is a rare neoplasm of the neurohypophysis. To the best of our knowledge there have been no reports of pituicytoma in which long-term magnetic resonance imaging observation was performed. We calculated the doubling time of the tumor volume and described the growth pattern of a pituicytoma.A 52-year-old Japanese man with a history of decreased libido was found to have a sellar and suprasellar mass. He underwent transsphenoidal surgery, but only a small specimen was obtained because of intraoperative bleeding. The tentative histological diagnosis was schwannoma. He noticed bitemporal hemianopsia 7 years later. A follow-up magnetic resonance imaging disclosed a tumor volume doubling time of 3830 days. Transcranial gross-total tumor resection was performed. The lesion consisted of elongated and plump tumor cells that were arranged in a fascicular or storiform pattern and were positive for S-100 protein and focally positive for glial fibrillary acidic protein. The final histological diagnosis was pituicytoma.Pituicytoma is a slow-growing tumor, but the growth rate may change during follow-up. Pituicytoma is a rare neoplasm in adults. It corresponds to a low-grade astrocytoma of the neurohypophysis that presumably arises from pituicytes of the stalk and posterior lobe of the pituitary gland,2. This A 52-year-old Japanese man presented with a 1-year history of decreased libido. He was referred to our institution for evaluation of a possible pituitary tumor. Laboratory tests were all within normal limits except for a low free testosterone level. A visual field defect in his upper right quadrant was found in a neuro-ophthalmologic examination. Magnetic resonance imaging (MRI) revealed a 20mm mass that was isointense on T1-weighted MRI and hyperintense on T2-weighted MRI. The lesion was homogeneously enhanced with gadolinium  and cytokeratin. The patient’s molecular immunology Borstel-1 (MIB-1) proliferation index was less than 2%. The tentative histological diagnosis was schwannoma. Hydrocortisone and levothyroxine sodium hydrate were administered postoperatively. The visual field testing did not show any change from his preoperative testing. We recommended a second transcranial surgery or radiotherapy, but the patient refused both proposed treatments. Therefore, careful observation has subsequently been performed with yearly MRI. This follow-up imaging showed quite slow growth in the first 5 years after surgery, with a tumor volume doubling time (TVDT) of 20,267 days. Progressive bitemporal hemianopsia occurred at 7 years after surgery and MRI revealed apparent tumor progression during the previous 2 years , and periodic acid-Schiff (PAS). The patient’s MIB-1 index was 1% Figure. All thePituicytoma is a very rare tumor of the adult neurohypophysis with only about 50 reported cases. SeveralThe neuroimaging characteristics of pituicytomas are nonspecific. Pituicytomas have been described to be located within the sellar, the suprasellar region or both. AlthougIn previous reports, the most common symptoms at presentation of pituicytoma have been headache (38.9%) followed by visual field defect 31.5%). Only one patient presented with diabetes insipidus, despite pituicytomas arising from the posterior pituitary gland or infundibulum. Nakasu %. Only oSurgery is the main treatment for pituicytoma. Tumor rThe natural history of pituicytomas is unknown. We perfPituicytoma is an extremely rare tumor of the neurohypophysis. To the best of our knowledge this is the first report of the TVDT of pituicytoma. Pituicytoma is a slow-growing tumor, but may enlarge rapidly without malignant change. The relatively slow growth of pituicytoma and the possible change in growth rate during follow up should be recognized in determining the most appropriate treatment approach.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.YK drafted and edited the manuscript. JH, HM, YT and TH contributed to the writing of the manuscript. All authors read and approved the final manuscript.


Palatal swellings are rare in children and the incidence differs from that of the adult counterparts. When the palatal swellings do arise in children, they usually are palatal abscess from periapical region, and few cases like pleomorphic adenoma in young adults have also been reported. But inflammatory fibrosis of palate in children is a rare occurrence. Inflammatory fibrosis is formation of excess fibrous connective tissue in an organ or tissue, as a reparative or reactive process. This report describes an unusual case of iatrogenic inflammatory fibrosis on the palate due to extraction of tooth number 22 in a 13-year-old female patient. The patient presented with a single large well-circumscribed oval palatal swelling that was soft, fluctuant, not fixed, and nontender. Surgical excision of the lesion was done and it was sent for histopathological assessment. The biopsy showed fibrous tissue with collagen fibers, spindle shaped fibroblasts, neovascularization, RBCs, chronic inflammatory cells, and traces of salivary gland and nerve tissue.  Rapidly growing, aggressive palatal swellings are relatively rare in children when compared to adults. Among all the palatal swellings, pleomorphic adenoma is the most frequently encountered lesion in young adults . Cases oA 13-year-old female patient reported to the Department of Pediatric Dentistry, Panineeya Dental College, Hyderabad with a complaint of swelling in the palate region for the last 15 days. When detailed history was obtained, patient gave no history of systemic disease or allergies. Patient presented with congenitally missing tooth number 21. She observed a swelling for which she reported to an undisclosed private dental office where tooth number 22 was extracted. The nodular swelling on the buccal aspect of tooth number 22 disappeared and a swelling on the palatal aspect appeared within two days of extraction and rapidly increased to the present size, for which the patient reported to our institution.Patient presented with a 4.5 × 2.7 × 0.8 cm linear swelling, oval in shape, towards the left side extending from the palatal aspect of tooth number 21 to tooth number 26 . The sweIt was observed that there was no difference in the size of the swelling, even after one week, so enucleation of the lesion was planned under general anaesthesia (GA). Complete haematological tests along with a radiograph of chest PA view were ordered as a preoperative protocol and the case was posted for treatment under GA. Nasotracheal intubation was done and nerve block with 2% lignocaine was given around the lesion. Crevicular incision was performed around the gingival margin on the palatal aspect extending from the regions of 16 to 26, anteroposteriorly. A full thickness mucoperiosteal flap was raised and complete dissection of the lesion was done separating it from the palatal mucosa . Wound cThe excised specimen was sent for biopsy and microscopy revealed fibrous connective tissue consisting of plump, spindle shaped fibroblasts neovascularization with extravasated red blood cells. It also showed infiltrate of chronic inflammatory cells with no evidence of salivary gland tissue or nerve tissue, thus suggestive of inflammatory fibrosis . The patDamage to the surrounding soft tissues is easily inflicted during negligently performed local anesthetic technique and extraction procedures. In this present case, it could have been any of the two. More serious complications are caused when deeper structures are traumatized when the procedure is done without good knowledge of technique and the anatomy of the tissues. These complications can appear during or after the procedure. The complications may range from infection inflammation trauma to nerves resulting in variable nerve dysfunctions .Inflammatory fibrosis manifests as a postextraction complication caused by possible localized iatrogenic trauma to the soft tissues, deregulating the wound healing process at either the proliferative or remodeling stages. It may also be caused if the irritant persists in the tissues continually during the process of healing. Fibrosis can occur with or without inflammation .Fibrosis is similar to the process of scarring, which involves immigration, proliferation of fibroblasts, and also extracellular matrix deposition by these fibroblasts, which is followed by collagen synthesis. Researchers have suggested that NLRP3 inflammasome is a key cellular sensor that results in generation of an inflammatory response. This inflammasome mediates the activation and recruitment of inflammatory cells to the site of injury as an initial response. Many observations suggest that tissue remodeling and fibrosis are similar, but a delicate alteration in the biosynthetic pathway of reconstruction of extracellular matrix may affect the balance .Complications resulting from rapid palatal injection of local anesthetic solutions, particularly those containing a vasoconstrictor, have been reported, which include ischemia, allergic reactions, epithelial desquamations, traumatic injuries, ulcerations, fibrosis, and also necrosis .Here in the present case, the clinical, radiographic, and histological features were correlated to arrive at a final diagnosis of iatrogenic inflammatory fibrosis.Though a rare occurrence, inflammatory fibrosis of hard palate may result as a complication of tooth extraction due to iatrogenic factors. So a thorough knowledge of the clinical, radiographic, and histological features of fibrosis is essential for a proper diagnosis. In spite of the fact that the complications are sometimes inevitable, comprehensive knowledge about the technique and anatomy is necessary for preventing iatrogenic challenges during tooth extraction.


Brunner’s gland hamartoma is a rare tumor, predominantly found in the fifth to sixth decades of life. Generally, it is a single pedunculated polyp, rarely larger than 5 cm. Asymptomatic cases are found incidentally, but cases with a large polyp tend to have gastrointestinal bleeding and/or obstructive symptoms. Polyp size increases in a time-dependent manner, however, the growth mechanism is unknown. We report a Japanese male case in his mid-twenties with an over 6 cm sized polyp.A 26-year-old man presented black stools and anemia. Endoscopic examination revealed a large pedunculated polyp at gastroduodenal junction. The polyp, subsequently resected by distal gastrectomy, was lobulated with random surface erosions and sized 6.4 × 3 cm. Histological examination revealed that the polyp arose from duodenal mucosa and was composed of hyperplastic Brunner’s glands in lobules separated by fibromuscular septa, associated with lymphocytic infiltrate and lymphoid follicles. No evidence of malignancy was found. Thus, the lesion was diagnosed as Brunner’s gland hamartoma. Further immunohistochemical studies indicated that gastric foveolar metaplasia is associated with surface epithelium covering upper two thirds of the polyp, showing immunohistochemical positivity for mucin 5 AC (MUC5AC). Below the metaplastic surface epithelium, Brunner’s glands had high proliferative activity (MIB-1 labeling index: 7.9%). The similar staining pattern was observed at surface erosive sites (MIB-1 labeling index in Brunner’s glands: 9%). On the other hand, surface epithelium in the lower side of the polyp still preserved intestinal nature, containing CDX2-positive nuclei and MUC2-positive goblet cells. Brunner’s glands below the surface epithelium with intestinal characteristics showed low proliferative activity (MIB-1 labeling index: 0.77%).Proliferative activity of Brunner’s glands was high at the sites with surface erosion and also below the epithelium showing gastric foveolar metaplasia. As gastric foveolar metaplasia occurs along with a mucosal repair process in the duodenum, mucosal damages underlay the hamartomatous proliferation of Brunner’s glands and eventually resulted in a formation of large polypoid mass in this case. Brunner’s gland hamartoma is a rare tumor-like lesion, predominantly seen in the fifth to sixth decades of life. This lesion is generally a single pedunculated polyp, with an average size of 2 cm, rarely larger than 5 cm, and locates in the first portion of duodenum. Its patWe experienced a 26 year-old male case with an over 6 cm sized polyp at gastroduodenal junction, investigated histological and immunohistochemical characteristics of the lesion, and report here.2). His body temperature was 36.7°C, blood pressure was 137/77 mmHg and radial pulse rate was 80 beats/min and regular. Complete blood count showed the red blood cell count of 326 × 104/μl, hemoglobin concentration of 8.6 g/dl (reference range: 13.5 to 17.6 g/dl), and mean corpuscular volume of 87 fl. Serum chemistry showed that hemoglobin A1c was 4.2% . Endoscopic examination of the upper digestive tract revealed a large pedunculated polyp arising from gastroduodenal junction, close to pyloric ring on the side between minor curvature and anterior wall  have been reported mentioning their unusually large polyp size, 5.5 cm examined histologically and 7 cm observed by endoscopy.The major disadvantage having a large polyp is that a benign lesion may be misdiagnosed and over-treated as malignancy. In the past, a 60-year-old male case was reported that Brunner’s gland hyperplasia forming a 5.5 cm polyp at duodenal bulb was treated by duodenocephalopancreatectomy. When a In our immunohistochemical study, proliferative activity of Brunner’s glands was high beneath the epithelium showing gastric foveolar metaplasia. Gastric foveolar metaplasia seems to be a common finding in Brunner’s gland hamartoma, and alset al., recently reported histology and mucin expression in Brunner’s gland hamartoma and hyperplasia[Kim, erplasia. They sherplasia.et al., demonstrated hyperacidic state in patients with Brunner’s gland hamartoma[Considering possible causes of mucosal damage, mechanical stimuli, Helicobacter pylori infection, and hyperacidic environment in duodenum have been suggested. The latter two have been postulated to be involved in the development of Brunner’s gland hamartoma,12. Heliamartoma.In summary, we report a case of large Brunner’s gland hamartoma in a young (26-year-old) patient. Our immunohistochemical results suggest that mucosal damage underlies the hamartomatous proliferation of Brunner’s glands.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Series Editor of this journal.MUC: Mucin; HE: Hematoxylin and eosin.The authors declare that they have no competing interests.MA collected and analyzed the data, and was involved in drafting the manuscript. ST did clinical aspects of this study including surgical treatment. KH helped designing this study. RK guided us for pathological diagnosis and conception. HK revised the manuscript critically for important intellectual content and supported financially. All authors read and approved of the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/14/14/prepub


We are reporting a case of hemoperitoneum followed by early post partum collapse due to bleeding from a ruptured vessel on the surface of an undiagnosed uterine pseudo tumor. There are literature reports of spontaneous hemoperitoneum from bleeding of superficial vessels over lying myomas during pregnancy but a case of rupture of a blood vessel on a uterine pseudo tumor leading to isolated hemoperitoneum in the immediate postpartum period is a rare event. We are presenting the literature review and some aspects of the management of this case. The importance of having a high index of suspicion in cases of hemoperitoeum occurring immediately after delivery especially in a low income setting where radiologic imaging techniques like magnetic resonance imaging (MRI); which is the most sensitive diagnostic tool in cases of ruptured vessels are rare is highlighted. Postpartum hemorrhage (PPH) remains the most important cause of maternal death in both the developed and the low-income countries . Severe A 34 year-old Gravida 5, Para 1 was received at the Douala General Hospital with a 39 weeks gestation calculated from the last menstrual period for antenatal evaluation. Her medical records showed two induced abortions by dilatation and curettage. Her antenatal visits had been uneventful. After this last visit the patient was sent home but returned five days later to our maternity where she was diagnosed to be in labour and admitted into the labour room. She later on had a normal vaginal delivery of a life born female baby weighing 3250gm with APGAR score of 9 and 10 at the first and fifth minute respectively. Delivery of the placenta by controlled cord traction was initially unsuccessful so the Crede Maneuver was employed. The membranes and the placenta were complete and the uterus was well contracted. The estimated blood loss was about 250ml. She was hemo-dynamically stable immediately after delivery.However, an hour after delivery the patient started complaining of weakness, dizziness and shortness of breath. She became agitated with signs of hypovolemic shock. Immediate resuscitative measures were started. Her lung fields were clear. The abdomen was full and a slightly tender at the hypogastric region. The uterus was about 20 week's size (level of the umbilicus) and well contracted. On vaginal examination, there was slight vaginal bleeding but no lacerations or tears. A digital exploration of the uterine cavity did not reveal clots, placenta debris or a uterine defect suggestive of uterine rupture. The clinical diagnosis of a hemoperitoneum was made.Her hemoglobin level dropped to 7g/dl as compared to 11.2g/dl on admission 75 minutes after delivery so she was resuscitated with intravenous macromolecules and transfused 1000ml of whole blood as initial emergency measures. Furthermore, a two way Foley's catheter was also inserted in the urinary bladder. Her coagulation profile and platelet count were normal. Ultrasonography revealed an intra abdominal fluid collection. The uterus was enlarged but there was no evidence of retained products of conception. There were no adnexal masses. An ultrasonograhic guided abdominal paracentesis, confirmed the presence of a hemoperitoneum.A consent form was duely signed by the patient's relatives and 45 minutes later she underwent an exploratory laparotomy after she had been stabilized. Per-operatively, two liters of blood was suctioned from the peritoneal cavity. The uterus was well contracted with no evidence rupture. However, there was a firm, well vascularized mass at the uterine fundus measuring 6,0 cm x 5,0 cm with two large bleeding vessels on its surface. A portion of omentum was adherent to the mass . The oth® Ethicon France). She remained stable after transfusion of 1000ml of blood per-operatively. The post operative period was uneventful and she was discharged from hospital on the fifth postoperative day with her newborn. The histologic analysis of the resected mass revealed a few granulomatous, collagenous and fibrous tissues with areas of calcification. The patient was reviewed two weeks after discharge from the hospital. Her general condition was satisfactory and the serum beta hCG assay was 15 IU/L.The mass was resected with a small infraction of the uterine cavity since the mass was mainly subserous and a small portion intra-mural . The sitPostpartum collapse due to severe PPH is a life threatening condition if resuscitative and therapeutic measures are not promptly instituted. Often when the patient is well evaluated the cause of PPH can quickly be elucidated as this is usually due to uterine atony, genital lacerations, or consumptive coagulopathy . HoweverAt laparotomy, a highly vascularized uterine pseudo tumor was diagnosed with ruptured vessels on its surface. One is tempted to attribute this rupture to the Crede Maneuver and uterine message which were used during the management of the third stage of labor. The occurrence of hemoperitoneum which is probably linked to carrying out of the above procedures in the presence of an undiagnosed highly vascularized serosal uterine mass emphasizes the fact that pressure on the uterus should be exerted with caution during the management of third stage of labor.Choriocarcinoma presenting with metastasis can be associated with vascular masses protruding on the surface of the uterus or other organs can be a rare cause of hemoperitoneum in the postpartum period . HistoloIn cases of postpartum collapse the existence of life threatening hemoperitoneum with minimal vaginal bleeding should be excluded. A high index of suspicion of this clinical entity is imperative so as not to delay diagnosis and management. Bleeding can be stopped by carrying out an exploratory laparotomy even in a low income setting.


The hydatid cyst is a frequent pathology in Morocco. All localizations are possible. However, renal hydatid cyst is still rare; it constitutes about 2.5 % of all localizations. We report 4 cases admitted at the Department of Pediatric Surgery of the University Hospital of Fes in the period running from February 2004 to January 2008. The four patients were of ages ranging from 8 to 11 years old. Two of them had double localization in the kidney and liver. The imaging was the diagnostic tool of choice. The patients benefited from surgical treatment; two were treated using standard surgery while laparoscopic surgery was used in the next two. Anti-parasitic medication was associated in the post-surgery stage for a period of six months. The evolution was good for all the patients. Echinococcosis or hydatid cyst disease of the kidney is extremely rare in children and constitutes only 2-4% of all cases of hydatid disease. Its diagnosis is easy and mainly based on ultrasound and CT-scan. The treatment is mainly surgical, by open surgery or by laparoscopic management. Here, we present 4 cases; 2, with only renal localization, were managed laparoscopically and the others by conventional surgery. The follow-up showed no residual disease.Observation 1An 8-year-old girl, without any noticeable medical history, was admitted into our hospital. The clinical profile consists haemoptysis sputum and without hydatid vomica or any other signs. She was admitted in pediatric department where she underwent phthisiologic investigations that were all negative. The biological assessment was normal. The clinical examination showed an apyretic patient with rattle at auscultation, the abdomen was supple without any hepatosplenomegaly or lumbar contact. The thoracic x-ray found a left basal site; hence the patient was initially treated using an antibiotherapy that improved the symptomatology. Abdominal ultrasound demonstrated a lowed polar renal cyst, while the abdominal CT-scan confirmed the hydatid character of the cyst  and 2. TObservation 2A 10-year-old girl was admitted with recurring abdominal pains. The examination found a hepatomegaly with two entities of solid palpable masse without pain. A left lumbar sensitivity was also found without any urinary signs. The biological assessment was normal. The ultrasound found a hepatic hydatidosis (two cysts of 65× 47 mm and 70× 51 mm) and a renal localization (63× 51 mm) . The patObservation 33. The ultrasound and the CT-scan of the abdomen revealed two hepatic hydatid cysts (80×70 mm and 66× 58 mm) including one that has already ruptured. A RHC of type 3 (67×54 mm) was also found in the left kidney.The patient was urgently operated on to remove the ruptured hepatic cyst. She developed a cutaneous rush with hypotension. The cure of the renal cyst was differed 2 months later to reduce the time of the intervention considering the anaphylactic shock developed, and to avoid sowing the retroperitoine. The patient favorably evolved under treatment, using corticosteroid and antiparasitic therapy, and she has received albendozale-based medical treatment for six months. The follow up is for three years.An 11-year-old girl was treated for pulmonary tuberculosis when she was 3 years old; then operated on to remove a hepatic hydatid cyst while she was 8 years old. The patient was admitted at emergency department for an acute abdomen following an abdominal contusion. The examination found a febrile and vomiting patient with abdominal pain. The palpation objectified a painful hepatic mass with matity of the sides. The biological assessment found a hyperleukocytosis at 13000 elements/mmObservation 4A 10 year old boy was admitted for left lumbar pain and hematuria. The examination found a left lumbar mass. The ultrasound and CT-scan of the abdomen confirmed type 3 renal hydatid cyst. The patient was managed by cœlioscopy, after injection of 30% NaCl solution, the germinative membrane was removed, a resection of the neighboring tissues was also realized, the fluid content of the cyst was aspirated and the cavity was filled with 30% NaCl solution. The patient has received albendazol-based medical treatment for six months. The evolution is good within a follow up of one year.The RHC is the third localization of the hydatid cyst after liver and lungs. The RHC represents about 2.5% of the whole localizations and most often unilateral and unique, however cases of multiple and even bilateral were reported ,2. HydatThe renal localization is discovered while investigating known hydatidosis extensions. In case of a large cyst, signs of compression of closer organs might appear, and would manifest in terms of dyspnea, abdominal swelling, dyspepsia and constipation. The radiological investigations allow clarifying the diagnosis and provide the most interesting evidences for hydatidosis diagnosis. The X-ray allows displaying of a thin arc-shaped calcification that is characteristic of hydatid cyst compared to heterogeneous and more or less diffused calcifications. The diagnosis of hydatid cyst using ultrasound is more reliable and it is specific up-to 80%. This technique provides an accurate size of the cyst, its topography, its structure, and diagnosing any associated abdominal lesions.According to Gharbi and al, the hydatid cystic disease is classified in five distinguishable ultrasonographic types . And theThe immunological study contributes to introduce the diagnosis; and it consists of immunoelectrophoresis, indirect immunofluorescence and ELISA. This assessment approach is reliable in more than 70% of cases ,9. The bIn the epidemiological context, the radiological and biological data allow preparing the diagnosis in all cases. Nevertheless, the differential diagnosis is established with other origins of renal masses such simple cyst, calcified hematoma, cystic nephroblastoma and abscess of kidney ,5,7.Considering the insufficiencies of medical treatment used especially in cases of small cysts (lower than 30 mm), and the potential risk of interventional radiology, the treatment of RHC remains surgical. The choice of the treatment approach depends on three basic elements: the volume of the mass; the relation of this mass with neighboring tissues and the extra-renal and abdominal localization of another hydatid cyst. Therefore, the pure lombotomy is the most used approach, followed by the median means reserved to RHC associating extra-renal visceral localization. In the cases with double localization, we used the laparotomy.At present, the coelioscopy is increasingly used as it provides the same outcome, less morbidity and a better esthetic result but only some studies were published. We use it in two cases, when the localization was only renal, using a retroperitoneal access with good results. Current literature indicates that laparoscopic surgery is safe, and gives further support to minimally invasive treatment of this condition, as reported in the literature in other organs. Once the cystic lesion is displayed, the sterilization has been achieved using parasiticidal such salted hypertonic serum at 30‰. The surgical treatment is achieved including an essential stage consisting of the cystectomy considering the ablation of the hydatid membrane and possibly small vesicles. The pericysticectomy is generally limited to the resection of the external casual part “the resection of the prominent dome”. A systematic shell does not allow opening the residual cavity and reduce the hemorrhagic risk ,5. The pThe renal hydatid cyst in children constitutes a very rare localization. It has variable and polymorph symptomatology whish is rarely specific. The RHC has to be evoked in all renal cystic lesions, especially in endemic regions of the earth. The surgical approach remains the treatment of choice; particularly using laparoscopy and the resection should be mostly conservative.The authors declare that they have no competing interestsAll the authors contributed at the diagnosis of this disease, in the treatment, and the follow-up of the patients.


Calcifying aponeurotic fibroma (CAF) was originally described by Keasbey in 1953 as juvenile aponeurotic fibroma, most commonly occurring in the palms of the hands and soles of the feet in children and adolescents. It usually presents as a firm, painless mass without preceding trauma. We report a case of this rare condition with an unusual presentation in a 60-year-old woman affecting the dorsal surface of the foot. It is a relatively benign condition with a good prognosis following complete surgical excision. It may have a slightly increased incidence in males. The accurate diagnosis is based only on histology but it is essential to differentiate it from other sinister lesions such as fibrosarcoma that may lead to amputation. Calcifying aponeurotic fibroma (CAF) is a rare, locally aggressive fibroblastic lesion occurring primarily in the palms of the hands and soles of the feet in young children and adolescents under 20 years of age . ClinicaA 60-year-old woman in good general condition with no history of any trauma exhibited a palpable mass on the dorsal surface of the right foot. The lesion slowly enlarged over 12 years. Physical examination revealed a 4.5 × 4.5 cm, hard, painless, immobile mass; it was well defined, round with ulceration at the end . Radiogr Calcifying aponeurotic fibroma (CAF) was first described by Keasbey in 1953 as “juvenile aponeurotic fibroma” occurring in the palms and soles of the children , 3. The Clinical features such as the patient's age, site of lesion and calcific stippling on plain radiographs are suggestive of CAF but they are not diagnostic; several conditions share similar clinical features including infantile and juvenile forms of fibromatosis, a fibrous hamartoma of infancy, the monophasic fibrous subtype of synovial sarcoma, and a chondroma of soft parts.aponeurotic has been used because there is a subtle transition from fibrous connective tissue to fibrocartilage as tendons, aponeuroses, and ligaments insert into bone through Sharpey fibers, and the location of many of these tumors suggests an aponeurotic origin [Histologically, CAF is comprised of varying degrees of fibrous connective tissue arranged in a fascicular pattern. The lesion is bland in appearance and composed of plump spindle cells with round to ovoid nuclei with indistinct cell borders. The nuclei may be arranged in a palisading fashion. Extension of the fibrous connective tissue into the adjacent surrounding tissue is not uncommon . In addic origin . Malignac origin . Given aRecurrence is common especially in infants and children. However, local re-excision can be performed with a favourable prognosis.In summary, CAF is a relatively rare benign soft tissue tumour occurring in children and young adults. It usually presents as a firm, painless mass in the soles and hands without preceding trauma. It may have a slightly increased incidence in males. The accurate diagnosis is based only on histology but it is essential to differentiate it from other sinister lesions such as fibrosarcoma that may lead to amputation. In our case, the presentation was unusual as the lesion appeared to develop in the dorsal surface of the foot and occured in a 60-year-old female.None identified.


Elastofibroma dorsi (ED) is a soft tissue tumor found in the subscapular region. The pathogenesis of ED is unclear, but may involve a regenerative or reactive hyperproliferation due to mechanical microtrauma. Magnetic resonance imaging (MRI) is preferred to diagnose ED and complete excision is curative. When bilateral, subscapular masses are identified in the elderly patient and MRI characteristics are typical, biopsy and excision can be avoided. Symptomatic EDs should be excised, and recurrence is rare. Three hundred and thirty cases of ED have been reported since 1980. Fourteen case series and 43 isolated case reports involved 263 women and 67 men (F:M ratio = 3.9:1), with a mean age of 62 years (range 6–94 years). Bilateral ED was present in 164 patients and unilateral ED in 157. The reported prevalence in the elderly population ranges from a minimum of 2% to a maximum of 24%. Elastofibroma dorsi (ED) is a benign, slow-growing fibroelastic tumor that was first described by Jarvi and Saxen in 1961. EDs typi3Three hundred and thirty cases of symptomatic ED have been reported in the last 30 years. A comprehensive review of all isolated reports and case series, published since 1980, affirms that EDs are diagnosed almost exclusively in persons over the age of 40, with sporadic reports of ED arising in children and adolescents as young as 6 years. and as hWe report our experience treating an illustrative case of ED and provide a discussion of the significance of physical exam and imaging in the diagnosis of these tumors in order to avoid surgery.A 55-year-old male machinist with no significant medical or surgical history presented with a right subscapular mass causing mild discomfort. He denied debilitating pain, recent trauma, or weight loss. Physical examination revealed a small, 4 cm mass, inferior to the right scapular spine. Laboratory findings were unremarkable. Computed tomography (CT) imaging of the chest with contrast revealed an 8×2.1 cm soft tissue mass, similar in density to muscle, that was located superficial to the ribs and deep to the serratus anterior and lower subscapularis muscles. The lesion was slightly inhomogenous, non-enhancing and contained strands of fatty tissue. A much smaller (1×1.5 cm) contralateral lesion was also noted at that time. Histopathology of samples obtained by core biopsy and a subsequent incisional biopsy revealed normal muscle and adipose tissue and no further intervention was performed.The patient returned 2 years later with increasing discomfort and limited range of motion on the right side. MRI revealed a mass below the body of the scapula, which was isointense to muscle and contained interspersed signals similar to fat, with moderate diffuse enhancement seen on post-gadolinium imaging . ED was The resected specimen consisted of a single, irregular, pink-red fragment of soft tissue that measured 10×6×2.5 cm and weighed 81 g. The cut surface varied from pink to white in color and was soft to rubbery in consistency with focal cystic degeneration . HistopaFirst described by Jarvi and Saxen in 1961, ED is a benign soft tissue tumor located in the subscapular and infrascapular region between the thoracic wall, serratus anterior, and lattisimus dorsi muscle.[et al. speculated that ED may be the result of a physiologic aging process, rather than abnormal elastogenesis or degeneration, based on the discovery of “pre-elastofibroma changes” in their autopsy series. These changes are defined by a weakly elastinophilic material that does not exhibit definite elastic tissue formation.[et al. have reported a familial predisposition for ED, noting that 32% of their cases occurred within a single family.[2The etiology of ED is not fully understood, but most believe that ED results from degeneration of collagen due to repeated mechanical friction between the chest wall and scapular tip, while others have suggested that it may be the cause of a reactive hyperproliferation of fibroblastic tissue rather than a degenerative process.7 Geibel ormation. Additionormation. Nagaminee family. To date, family.210et al. performed a CT study of 258 asymptomatic elderly patients and identified ED in 2% of the patients.[et al. (n = 170),[et al. found ED in 24% of females and 11% of males in people over 55 years of age in a large autopsy series involving 235 cases.[et al. reported that ED occurred in 13% and pre-elastofibroma changes in 81% among autopsies performed on 100 patients.[et al. reported incidental findings of ED in 12 out of 15 patients, nine of whom were diagnosed by CT/MR imaging for symptoms of ED on the contralateral side, and three were diagnosed during surgery for an unrelated thoracic disease.[Historically, ED has been regarded as rare tumors occurring predominantly in the elderly. Brandser n = 170), the liteAn understanding of the classic imaging features of ED is vital to make a presumptive diagnosis and eliminate the need for biopsy or unnecessary surgical resection. MR is the imaging modality of choice in diagnosing ED and typically demonstrates a well-defined, moderately inhomogenous mass with no associated soft tissue edema. On T1-weighted MRI, EDs are isointense with skeletal muscle, which explains how these tumors are often diagnostically overlooked. T1- and T2-weighted images both show interspersed linear and curvilinear, hyperintense areas representing fat.411 Fat s43473Macroscopically, elastofibromas appear as an irregular, poorly defined, unencapsulated, fibroelastic mass with firm, rubbery consistency. Cut surface reveals strands of white and yellow tissue representing adipose tissue intermingled with fibroelastic tissue in a “checkerboard” pattern. Histolog34611et al. suggested an algorithm for the diagnosis and treatment of a subscapular elastofibromal mass,[Excision may be offered to symptomatic patients, with curative marginal resection proving to be sufficient and is preferred over wide or radical resection. Because mal mass, which comal mass,. In the All patients who underwent a marginal R0 resection (negative macroscopic and microscopic margins) were free of disease at follow-up and experienced no loss in range of motion.671020 Th67104et al.[In conclusion, our case report initially confirmed how CT imaging and general lack of awareness of this mass can lead to a missed diagnosis despite biopsy. Fortunately, on second evaluation by following the protocol set forth by Muratori et al. in which


Cancerous cells are known to metastasize to different ocular structures. This happens especially to the choroid in males with lung cancer and females with breast cancer. However, we observed two cases of cancerous metastasis to the optic canal region. Both cases showed only a progressive decrease in vision without any other remarkable ophthalmological symptoms or abnormalities in the affected eye.Two females, a 60-year-old and a 73-year-old, came to our hospital because of progressive loss of vision. These patients showed no remarkable symptoms or signs in their eyes except visual acuity loss. Several ophthalmoscopic examinations, such as slit lamp microscopy and fundoscopy, showed no abnormal changes in their affected eye but magnetic resonance imaging indicated a massive legion around the optic nerve.It is possible for cancer to metastasize to the optic canal region and the existence of primary tumors should be considered. Primary and secondary orbital tumors, including intraorbital and optic nerve tumors, are uncommon observations in daily medical practice. The primary orbital tumors are solitary fibrous tumors, rhabdomyosarcomas, meningiomas, gliomas and others. Secondary orbital tumors include post-transplantation lymphoproliferative disorders and metastatic rhabdomyosarcomas . PrimaryCase 1: A 60-year-old woman came to our hospital after experiencing a progressive decrease in vision in her left eye of several months duration. Her medical history was not significant except for having diabetes mellitus. The cause of the progressive decrease in vision could not be determined. At her first visit to our hospital, the visual acuity in her right eye was 6/6 but the vision in her left eye had decreased to <6/60. We performed a visual field test and confirmed the visual field loss in her left eye. All ophthalmological tests were normal; e.g., a slit lamp examination did not indicate cornea, pupil or lens abnormalities and a fundoscopic examination, and fluorescent fundus angiography showed no remarkable changes such as optic atrophy or retinal ischemic changes. However, magnetic resonance imaging (MRI) showed a massive lesion in the optic nerve area (Figure Case 2: A 73-year-old female noted a decrease in the visual acuity of her right eye for a month. She had no remarkable medical history that could cause such a progressive decrease in vision. Her visual acuity in the right eye was counting fingers, and there was a central scotoma in her right visual field with no abnormal changes observed with a slit lamp examination and fundoscopic examination. Her left eye was completely normal. We considered the existence of an orbital tumor and examined her with MRI. MRI showed one mass restricted to the optic nerve region and another mass located between the occipital lobes (Figure Both of our cases were secondary tumors as a result of metastases from either a primary breast cancer or lung cancer. We suggest that the growth of the tumor in the optic canal exerted pressure on the optic nerve, which led to the progressive decrease in vision. This was supported by the stationary state and recovery of visual field or visual acuity after surgical removal of the metastatic tumor. Thus, we concluded that the tumor in both patients was secondary and the immunohistochemical staining suggested that the primary cancer was in the breast in Patient 1 and in the lung in Patient 2. PET-CT body scans confirmed the immunohistochemical findings.We presented our findings on two patients whose only sign and symptom was a progressive decrease in vision. Histopathological examinations of the excised tissues suggested that the retrobulbar tumors were metastases from breast cancer in one patient and lung cancer in the other patient. PET-CT body scans confirmed not only the location of the primary cancer but also the location of the metastatic area. Thus, our examinations of these two patients led not only to stopping the loss of vision but also determining the location of the life-threatening cancer.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 Executive Editor, Editor-in-Chief of this journal.MRI: Magnetic resonance imaging; PET-CT: Positron emission tomography–computed tomography; TTF-1: Thyroid transcription factor 1.The authors have declared that no competing interests exist.HT carried out the patient interaction and diagnosis, drafting of the manuscript, final approval of the manuscript. KI carried out the pathological examination. KM carried out the patient interaction and diagnosis, neurosurgical treatment, final approval of the manuscript. NN carried out the patient interaction and diagnosis, neurosurgical treatment, final approval of the manuscript. TT carried out the patient interaction and diagnosis, neurosurgical treatment, final approval of the manuscript. NF carried out the patient interaction and diagnosis, final approval of the manuscript. All authors read and approved the final manuscript.


Dentigerous cysts, commonly encountered in the practice of dentistry, are benign odontogenic cysts associated with crowns of unerupted and/or impacted permanent teeth. They frequently occur during the second and third decades of life. Treat-ment modalities range from enucleation to marsupialization, which may be influenced by the age of the patient, severity of impaction, and root form of associated tooth/teeth. The purpose of this report is to describe the successful outcome of con-servative surgical management of a large dentigerous cyst associated with an impacted mandibular second premolar in a young patient. Maxillary and mandibular premolars have also been associated with dentigerous cysts.7 Dentigerous cysts have also been reported in association with impacted deciduous teeth.9Dentigerous cyst or follicular cyst is an odontogenic cyst associated with the crown of an impacted, embedded, unerupted or developing tooth. The cyst which encloses the crown of an unerupted tooth is attached to the cervical region of the tooth. It is the second most common type of odontogenic cysts accounting for 14% to 24% of all jaw cysts.10 The usual radiographic feature is characterized by a symmetric, well-defined, usually unilocular radiolucent lesion surrounding the crown of an unerupted tooth. Generally there is a distinct, dense periphery of reactive bone (condensing osteitis) with a radiolucent center. These cysts can also manifest as multilocular entities and occasionally may be associated with resorption of the roots of adjacent erupted teeth.13Clinically, patients with dentigerous cysts are generally asymptomatic. They are often described as an incidental radiographic finding on routine radiographs or when films are obtained to determine why a tooth has failed to erupt or when an acute inflammation or infective exacerbation occurs.2 marsupialization,5 and decompression of the cyst via fenestration.6Dentigerous cysts are generally treated by surgical means. The most common surgical modalities used are total enucleation,This case study describes a conservative surgical approach combined with routine orthodontic treatment of a dentigerous cyst associated with a mandibular second premolar in an adolescent.An 11-year-old female was referred by her dentist in Community Medical Center to the Orthodontic Section, Department of Dentistry, Hamad Medical Corporation, Doha, Qatar, with the chief complaint of a swelling on the left side of her lower jaw since three months earlier. The swelling had been growing slowly over the period and was associated with no pain or discharge. The overall general physical health of the patient was good with nonspecific general medical history, without any contraindication to dental treatment.The extraoral examination revealed a symmetrical orthognathic facial profile with no signs of neurological deficit in the lower half of the face. There was no sign of any regional lymphadenopathy. Intraoral examination revealed a mixed stage of dentition, bilateral Class I molar relationships and Class I incisors. A hard, non-tender, non-fluctuant swelling of 2.5 × 2 cm was evident in the lower left vestibule, extending from the distal surface of the left permanent canine to the distal surface of ipsilateral first permanent molar. The swelling was associated with expansion of buccal and lingual cortical plates and covered by healthy-appearing and freely-moving mucosa. The teeth adjacent to the swelling were quite firm and not associated with any decay. A panoramic radiographic examination (OPG) revealed the presence of all the permanent teeth without any decayed or supernumerary teeth. There was a well-circumscribed unilocular radiolucent lesion in the body of the mandible on the left side, which was associated with the crown of a vertically impacted second premolar. The root of the impacted second bicuspid was developed approximately up to half of its usual length and the apex was quite wide open. The cystic structure appeared to have originated from the second bicuspid with inferior and distal displacement of the same tooth. The corresponding deciduous tooth (second molar) was still present with normal crown and roots.A clinical diagnosis of a dentigerous cyst involving the crown of the impacted left mandibular second bicuspid was made with the differential diagnosis of an inflammatory cyst, a keratocyst and a unilocular ameloblastoma.Aims and objectivesConsidering the age of the patient, her occlusal status, size of the cyst, position, and developmental stage of the root of the involved tooth a conservative treatment modality was decided upon. The main objectives of the treatment were clinical and radiographic elimination of the pathologic entity and to bring the involved permanent tooth into its proper position.Treatment planExtraction of the left mandibular second deciduous molar and decompression of the cyst through the extraction socket.Histopathologic examination of the cystic lining.Trans-lingual arch to hold the permanent first molars bilaterally in their current position and to maintain the space for unerupted left bicuspids.Follow-up of the progress of eruption of the impacted second bicuspid with periodic radiographs.Fitting of a fixed orthodontic appliance for final alignment of teeth in due course if needed.Treatment progressThe left second deciduous molar was extracted under local anesthesia  and the socket was used to establish a communication between the cyst cavity and the oral cavity. An incisional biopsy was obtained from the cyst wall for histopathologic examination, which confirmed the initial diagnosis of a dentigerous cyst without evidence of any dysplastic changes. A BIPP (bismuth iodoform paraffin paste) gauze pack was inserted into the cyst cavity and secured with a suture. One week after surgery, the pack was removed and repacking was done with another BIPP gauze pack, which was kept in place for another week. Two weeks after surgery, the patient was sent back to an orthodontist for the fabrication of trans-lingual arch and for further follow-up.However, the patient could not return for further follow-up and treatment as she was out of the country. She reported eight months after the initial surgery and at this stage the clinical examination revealed inadequate space for the unerupted second premolar. The panoramic view (OPG) showed a favorable change in the position of the impacted premolar with increasedradiopacity of cystic lesion, suggesting osteogenesis. A fixed14The aim of treatment for dentigerous cysts is complete elimination of pathology and maintenance of dentition with minimal surgical intervention. Recently-defined criteria for selecting the treatment modality refer to the cyst size and location of the cyst, patient age, dentition involved, stage of root development, position of the involved tooth in the jaw and its relation to the adjacent teeth, and involvement of adjacent vital structures.14 This approach is favored in cases involving impaction of a single tooth, such as a wisdom tooth in an adult, which has no function; however, it is not often in the patient’s best interests. In particular, extractions of associated teeth in children may have functional, esthetic, and psychological consequences. Thus a conservative surgical approach was chosen for this patient, which consisted of the removal of one deciduous tooth and an incisional biopsy for histological examination, considered essential to confirm the diagnosis. Many authors have emphasized the importance of maintaining the opening between the cyst and the oral cavity artificially not only to heal the cystic lesion but also to prevent the formation of a fibrous scar which can impair eruption of the involved teeth.10 However, in this case no such attempt was made to maintain the patency of the cyst opening into the oral cavity except for keeping the surgical pack in place for only two weeks. This finding supports the hypothesis that simple decompression of the cyst and further root development would allow for the spontaneous relocation of the associated tooth.Surgical treatment of dentigerous cysts usually includes enucleation of the lesion along with the removal of associated teeth.7 the optimal timing for the initiation of surgical treatment of a cyst-associated tooth is when the tooth has the ability to erupt. Radiographically the roots of these teeth should show at least 2/3 of root formation with an open apex. Although optimal timing correlates with the 2/3 of root development, in this case the radiograph showed approximately 1/2 of root development. The decision was made to administer treatment at this stage considering the initial position of the involved tooth in relation to the lower border of the mandible and to allow for further root development by an early release of intra-cystic pressure.According to Miyawaki et al,6 However in this case an early initiation of orthodontic treatment was essential as there was inadequate space for the impacted second premolar due to drifting of adjacent teeth into the extraction site of the second deciduous molar.It has also been well-documented by many authors in different case studies that complex orthodontic treatment can be avoided by maintaining the space in the arch for underlying involved tooth.It took a total of 37 months to finish the treatment, which emphasizes the importance of close supervision by the operators. The result also highlights the potential for healing of the cystic lesion after its decompression, particularly in young children. As revealed by the panoramic view, there was complete radiologic healing of the cystic lesion, including the filling of cystic cavity with normal trabecular bone at the end of the treatment .This case report presents a number of points which are noteworthy:A simple and conservative surgical approach should be preferred for a large dentigerous cyst in an adolescent in the mixed dentition period. This not only preserves the function and esthetic values but also prevents the child from psycho-social trauma due to tooth loss.The capacity to regenerate bone is greater among children than among adults and teeth with open apices have great eruptive potential. Thus, large dentigerous cysts in children can be treated differently and conservative treatment with tooth preservation should always be considered.This case report also provides a commentary on the optimal timing to initiate surgical treatment of a cyst-associated tooth. It supports the concept of initiation of treatment when radiographic analysis of the roots and apex of these teeth shows at least 1/2 - 2/3 of root formation with an open apex.A panoramic (OPG) film is a common and reliable tool for the diagnosis and assessment of progress in healing of a mandibular dentigerous cyst along with the change in the position of the associated tooth.However, this conservative approach does require close cooperation on the part of both the patient and the dental practitioners in order to monitor the healing of the lesion and change in the position of the involved tooth. The result can be the elimination of pathology and maintenance of the dentition.


A case of a 63-year-old man with small bowel ischemia six weeks after transplantation surgery is presented. Plain abdominal radiograph obtained several days after ingestion of barium shows the sign of prolonged barium coating indicating severe mucosal damage. Abdominal CT scan demonstrates small bowel wall thickening as well as pockets of peritoneal fluid collections. Most critically, CT allows visualization of subtle traces of dense barium within the dependent portions of this fluid indicating bowel perforation. Recipients of transplants are a unique group of patients that pose a diagnostic dilemma when their recovery is complicated. Graft-versus-host disease (GVHD) is a potential life-threatening complication usually seen with bone marrow transplantation but has been seen with other organ transplants where immunocompetent cells are introduced into the immunosuppresed host , 2. ProlA 63-year-old man presented six weeks after right orthotopic lung transplantation with abdominal pain suggesting an intra-abdominal catastrophe. Plain abdominal radiograph  demonstrA subsequent abdominal CT scan  again deWith the evidence for bowel perforation, he went emergently for exploratory laparotomy. Intraoperatively, his peritoneal cavity was grossly soiled with succus entericus as well as fresh CT contrast. Examination of the bowel revealed two discrete perforations in the distal two feet of ileum. In addition, the remainder of the small bowel, cecum, and ascending colon showed blotchy and dusky areas which blanched with bowel wall thickening. Blotchy hematomas were identified throughout the mesentery. Grossly, these findings suggested ischemia which was confirmed on histologic examination with mucosal necrosis. The diseased small and large bowel were resected, and a right lower quadrant ileostomy and left upper quadrant mucus fistula were created.Transplant recipients are a unique subset of patients that pose a diagnostic dilemma for the referring clinician as well as the radiologist. As in this patient, the constellation of symptoms including oropharyngeal dysphagia, renal failure, and abdominal pain six weeks after transplant surgery combined with radiographic findings of initially fluid filled nondilated small bowel but persistent barium coating  and subsequent evidence of perforation by abdominal CT scan posed the diagnosis of GVHD or possibly opportunistic infection. The time interval since transplant (six weeks) was compatible with GVHD.GVHD is usually seen with bone marrow transplantation which may be used in the treatment of a variety of hematological disorders and malignancies. GVHD has also been seen with other organ transplants such as liver, small bowel, or heart transplant and even with blood transfusion , 2, 4. IGVHD is a systemic disease when immunocompetent lymphoid tissue in the foreign donor graft mounts a reaction against the host and may involve a variety of organs most commonly the skin, liver, and gastrointestinal tract –6. GraftPatients with GVHD may complain of difficulty swallowing due to pharyngeal or esophageal pathology. Oral or pharyngeal abnormalities may occur due to functional problems, such as poor bolus control, abnormal pharyngeal retention, or abnormal mucous production or due to structural lesions, such as scarring and strictures. Esophageal abnormalities may also result in difficulty swallowing either in the form of structural lesions, such as strictures, webs, and mucosal inflammation (esophagitis), or functional abnormalities, such as weak peristalsis or incoordinate contractions  . Intestinal involvement manifests as diffuse inflammation followed by ulceration, which may be quite extensive and eventually resulting in submucosal fibrosis and stricture formation . These pRadiological features of GVHD include bowel lumen narrowing, mucosal fold thickening and nodularity or effacement, and bowel wall thickening, a constellation producing a characteristic featureless or “ribbon” bowel , 8–10. LIt may be difficult to differentiate clinically or radiologically GVHD involvement from other pathology, which may involve the intestines related to the patient therapy . InfectiThis case highlights the value of interpreting imaging studies with the knowledge of prior studies. The recognition of the three-day time interval between the ingestion of the barium and the abdominal radiograph was crucial to the observation of prolonged barium coating. The case also discusses complications commonly considered in the post-operative course of transplant patients, including rejection, opportunistic infection, and GVHD. Furthermore, it emphasises that this patient population is at risk for additional complications that may not be directly attributable to the aforementioned problems. The etiology for this patient's bowel ischemia is uncertain. The radiological findings in this case suggest that observation of prolonged barium mucosal coating heralds severe mucosal damage. This in turn indicates a need for a close monitoring of the patient as it progresses to complete bowel wall perforation.


Primary angiosarcoma of the spleen is a rare mesenchymal malignant tumor of vascular origin often with a poor prognosis, due to its high metastatic potential. This disease often presents with atraumatic rupture and lethal hemorrhage.We report a case of a 65-year-old man who presented with abdominal pain, anemia, thrombocytopenia, and palpable abdominal mass with unstable blood pressure. Laparotomy revealed a huge actively bleeding spleen, thus splenectomy was performed. Some liver metastasis foci were also found during the procedure. Histopathology diagnosis of the removed spleen was primary splenic angiosarcoma. The patient was discharged on the 10th day post operation with no complication.Splenic angiosarcoma should be considered one of the differential diagnoses in patients with spleen parenchymal lesions. Definitive diagnosis requires laparotomy followed by splenectomy. In the majority of the patients with spleen angiosarcoma, metastatic diseases have already occurred at the time of laparotomy, so splenectomy is an approach more for diagnostic purpose rather than curative purpose. Primary angiosarcoma of the spleen is an extremely rare malignancy, the pathogenesis of which is unknown, with high metastatic potential and a very poor prognosis. This aggressive disease usually presents in adults in their sixth to seventh decade. The reported median survival rates range from 4.4 to 14 months. These m9/l), but it did not reach disseminated intravascular coagulopathy. Results of other laboratory examinations had not been reported to us before the operation due to the emergency. Abdominal ultrasonography showed an enlarged spleen filled with irregular nodules, multiple hepatic solid lesions and moderate accumulation of peritoneal fluid. Abdominal paracentesis was performed with blood fluid aspirated from the peritoneal cavity. These findings were further confirmed by an abdominal computed tomography scan , the hemodynamic status of the patient became stable. Peripheral blood count revealed anemia (hemoglobin 10.0 g/dl) and thrombocytopenia  × 2.5 cm (depth) in the lower pole of spleen. Two liters of blood had been collected from the peritoneal cavity. Splenectomy was performed. During the procedure, the patient received 4 units of concentrated red blood cells and 2 units of fresh frozen plasma.The spleen was 1,650 g in weight, 19 cm × 16 cm × 11 cm in size, with nodular appearance and bleeding. The pathology diagnosis of the excised spleen was angiosarcoma originating from the spleen Figure. ImmunohAngiosarcoma originated from the spleen is an extremely rare malignant tumor, which affects 0.14 to 0.25 per million people. People Although the pathogenesis of this tumor is not clear, ionizing radiation, arsenic, vinyl chloride and chemotherapy for lymphoma have been implicated as causative factors,19, and Clinical presentation of splenic angiosarcoma is variable. Left upper abdominal pain is the most common symptom. Other cLaboratory examination can find cytopenia, leukocytosis, thrombocytosis and elevated erythrocyte sedimentation rate. Anemia and thrombocytopenia are presented in more than 50% cases,11.Imaging examinations are helpful for the differential diagnosis, although lacking accuracy. The most common ultrasonography findings are splenomegaly and ill-defined solid and cystic masses in the spleen with heterogeneous echotexture,23. The Biopsy is contraindicated in splenic angiosarcoma because of high risk of rupture. Histologic studies can therefore only be made after splenectomy. Microscopic examinations reveal freely anastomosing papillary and classical characteristic vascular channels lined by masses of endothelial cells. ImmunohThis tumor has a high incidence of early metastasis, as reflected in the reported rates of between 69% and 100%, with the most common sites being in the liver, lungs, bones or bone marrow, lymph nodes, gastrointestinal tract, brain and adrenal glands,5,29. OuOur case died 6 months after the surgery. Primary splenic angiosarcomas are very aggressive neoplasms, with a median survival of 5 months irrespective of treatment. Neuhauser and colleagues reported that 93% of patients died with disseminated tumor within 29 months, but it Splenic angiosarcoma is very rare but has a poor prognosis. It may cause secondary spontaneous rupture, resulting in fatal hemorrhage, which should be paid sufficient attention. Immediate surgery is necessary but the outcome is still unsatisfactory. Attempts should be made to improve the outcome by developing new techniques.Written informed consent was obtained from the patient for publication of this report and any accompanying images.The authors declare that they have no competing interests.Y-FD and FZ participated in the clinical management of the patient and wrote the manuscript. YJ and C-XW carried out the pathological examination. Y-FD and FZ were involved in the final editing. All authors approved the final manuscript.


Colonic-duodenal fistulas are rare, and may be secondary to benign or malignant conditions. Malignant duodenocolonic fistulas may also develop in patients with right colon or hepatic flexure carcinoma or duodenal malignancy. The sigmoido-duodenal malignant fistula is exceptional and, to our knowledge, only two previous cases have been reported. The first case was treated in our Institution in 1981 and published by Russello  in the lAn 84-year-old white male was observed in our department. He came to his general practitioner with anaemia. He had an eight month history of diarrhoea and constipation, poor appetite, weight loss, nausea and vomiting. Blood tests revealed: a) two tumour markers outside normal range: CEA: 18 ng/ml e CA 19-9: 121U/ml; b) severe anaemia: Hb=7,0 gr/dl, RBC=3,23 mil/uL, Ferritin=4 ng/ml. The colonscopy revealed an ulcerated tumor about 25 cm from the anal verge obstructing the sigmoid lumen and not allowing the passage of the instrument. The fistula was not identified at by endoscopy. The CT scan of the abdomen did not show the fistula and did not highlight any local spread or distant metastasis. The neoplastic lesion of the sigma of about 8 cm in length and 6 cm in thickness with tight luminal eccentric stenosis and dilatation of the colon upstream was highlighted (Figure


Pneumoperitoneum in the presence of acute abdominal pain is well recognised as an indication for laparotomy. We present a case of acute abdominal pain in the presence of an incidental pneumoperitoneum secondary to the rupture of pneumatosis intestinalis. We will discuss the importance of clinical context in the diagnosis and management of pneumoperitoneum and pneumatosis intestinalis. Pneumatosis intestinalis (PI) is when there is bowel gas in the wall of the intestine. It could be primary when it is asymptomatic, or secondary to serious conditions such as bowel ischaemia.Pneumoperitoneum secondary to rupture of primary PI can be managed conservatively. Hence one should be aware of this rare but important condition.A 91-year-old female presented to the accident and emergency department with a 12 hour history of severe right upper quadrant pain. She reported several similar previous episodes over the last year. On examination she was found to be tender in the right upper quadrant with localised guarding, but no evidence of generalised peritonism. Her initial blood tests demonstrated raised inflammatory markers and normal arterial blood gas and lactate measurements. An initial working diagnosis of acute calculus cholecystitis was formulated and management instigated.Subsequently a routine erect chest x-ray was performed that demonstrated a large volume of free gas under the right hemi-diaphragm . In viewPneumatosis intestinalis (PI) is defined as the presence of gas within the bowel wall . It was Three major pathogenic theories have been proposed for the formation of PI: mechanical, bacterial and biomechanical . The mecThe management of PI is entirely dependent on the aetiology responsible for its presence and the severity of symptoms. In the case of incidental discovery and benign presentation conservative management is indicated. Treatment of symptomatic PI in the absence of an acute intra abdominal emergency includes the use of antibiotics, elemental diet and oxygen therapy . In the Our patient presented a more problematic clinical picture in which an acute surgical abdomen was complicated with the presence of a pneumoperitoneum and pre existing PI. This presents as diagnostic conundrum in which the surgeon must evaluate the suspected pathology of both the pneumoperitoneum and the abdominal pain. Knechtle suggested several clinical features that may predict the need for surgical exploration in cases of PI . These iPneumatosis intestinalis is a clinical finding that can be associated with a pneumoperitoneum. It is a condition that can be incidental or indicate significant intra abdominal pathology. In this case an emergency laparotomy was avoided despite the presence of significant intra peritoneal gas in a patient with acute abdominal pain as the patient did not have features of peritonism or metabolic disturbance. This decision was further strengthened in view of the historical nature of the PI. For this reason this case highlights the importance of the application of sound clinical judgement in the context of the patient in front of you, not simply an isolated image presented to you.


We describe a case of unusual gastric band migration outcome. A 54 years old female was submitted to laparoscopic adjustable gastric band in September 2001. In September 2009 she developed access-port infection which needed drainage and access-port removal. Three months later in December 2009 the patient was investigated due to abdominal pain and abdominal distention. X-rays and Abdomen CT revealed migrated gastric band which is completely intraluminal with its connecting tube, causing transient distal small bowel obstruction and subsequently comes out per-rectum. Band erosion and intragastric migration is a late complication that frequently needs surgical removal. There are few reported cases in the literature of migrated gastric band removal by endoscopy. However according to my knowledge, this is the first reported case of migrated gastric band coming out per rectum without need for surgical or enoscoipic removal. Laparoscopic adjustable gastric band (LAGB) is the most frequent bariatric surgery performed worldwide . It is a2) was submitted for laparoscopic adjustable gastric band in September 2001. Her comorbidities include non-insulin dependent diabetes and hypertension. The post-operative course reported to be straightforward with no immediate complications. However she started to be followed up in other hospital with no available documented data about reduction in weight in the few years after the surgery.A 54 years old female patient  = 41.2 kg/cmAt September 2009, she presented to the emergency department complaining of fever, periumblical pain and swelling. On examination there is superficial periumblical swelling and tenderness. Blood tests revealed leukocytosis. Abdominal contrast enhanced CT scan showed 6.5 X 4.5cm fluid collection surrounding the access port . Under g®) and contrast enhanced abdomen CT scan performed later. It showed resolution of bowel dilatation with the band and its connecting tube noted at transverse / descending colon (Three months later, the patient presented again to the emergency department with colicky abdominal pain and abdominal distention. Supine and erect abdomen x-ray revealed small bowel dilatation and multiple air-fluid levels . Interesng colon . Few houng colon . Per recLaparoscopic adjustable gastric band is the least invasive bariatric surgery, which has the advantage of preserving the anatomy of gastrointestinal tract . Access There are few reported cases in the literature of unusual gastric bands migration outcome like intra colic penetration , 9 and sBand migration is a major complication of LAGB that can be due to early or late erosion. Early erosion thought to be related gastric wall damage during the initial operation. Late erosion takes place over a long period of time; usually after two years. It is the result of a destructive process and an effective self-healing of the gastric wall , 8. LateAccess-Port infection is frequently seen as complication of inadequate asepsis during puncturing the port. It is usually necessitates disconnection and removal of the port. It is important to exclude any associated gastric band erosion since most of the patients are asymptomatic. If the migrated band left with the tube not connected to the port, it can leads to further erosion of stomach or bowel , 9. Furt


Sunitinib was developed as a molecular-targeted drug to treat advanced renal cell carcinoma. It is not yet known whether liver damage occurs in patients with liver metastases of renal cell carcinoma after sunitinib administration. Here, we report the case of a patient with an inoperable massive liver metastasis of renal cell carcinoma for whom sunitinib administration was dramatically effective with no obvious evidence of liver damage. As a result, the liver metastasis could be resected. We emphasize the dramatic reduction in liver metastasis with sunitinib treatment, and the histopathological effects of sunitinib on the non-tumorous liver parenchyma.A 54-year-old Japanese woman was diagnosed with right renal cell carcinoma and underwent right nephrectomy 12 years earlier. She presented to a local clinic with right abdominal pain. A computed tomography scan showed a massive liver metastasis occupying her right hepatic lobe, and she was referred to our hospital for treatment. The diagnosis was not only liver metastasis, but also left renal metastasis. Oral administration of tyrosine kinase inhibitor sunitinib was started. Adverse events due to sunitinib included liver dysfunction, thrombocytopenia, and decreased hemoglobin, but she completed eight courses with the help of drug holidays and dose adjustments. Post-treatment computed tomography showed a dramatic reduction in size of her liver metastasis, enabling right lobectomy of her liver. Histopathological findings showed no obvious liver damage due to chemotherapy in non-cancerous parenchymal areas.With the availability of sunitinib, some patients with potentially unresectable massive liver metastases of renal cell carcinoma may be able to undergo major hepatectomy curatively and safely with little histopathological damage to non-tumorous liver parenchyma, thus improving their prognosis. Following the introduction of new anticancer agents in recent years, multimodal therapy incorporating surgical resection for metastatic liver cancer has been reported to be effective. HoweverWe emphasize the dramatic reduction in liver metastasis with sunitinib treatment, and the histopathological effects of sunitinib on the non-tumorous liver parenchyma.A 54-year-old Japanese woman was diagnosed with right renal cell carcinoma, and she underwent right nephrectomy in the Department of Urologic Surgery at our hospital. The size of her tumor was 80mm. A diagnosis of T2N0M0 Stage II was made based on histopathological findings. The histological subtype of the renal cell carcinoma was clear cell. After 12 years she began to feel right abdominal pain and was examined at a local clinic. A computed tomography (CT) scan showed a massive liver metastasis occupying her right hepatic lobe, as well as a left renal metastasis. She was referred to the Department of Urologic Surgery at our hospital for treatment, and oral sunitinib was started. A pre-treatment abdominal CT showed a massive liver metastasis measuring 22cm × 17cm in her right hepatic lobe, and a left renal metastasis of which the largest diameter was 4cm. Neither ascites nor lymph node metastases were present Figure .Immunohistopathology showed that her tumor was CD10(+), cytokeratin (CK)7(+), and CK20(-), and a diagnosis of renal cell carcinoma liver metastasis was made. Hematoxylin and eosin staining of her non-tumorous liver tissue showed no sinusoidal dilatation, with a Rubbia-Brandt score of 0, and the nonalcoholic fatty liver disease (NAFLD) activity score was 1, with no obvious steatohepatitis Figure .The patient’s postoperative course was uneventful, and she was discharged after 13 days. Radiofrequency ablation was performed on her left renal metastasis at 1 month after discharge. At the time of writing, 1 year after surgery, no recurrence has been observed in either her liver or her left kidney.et al.[et al.[Multiple liver metastases are frequently seen when renal cell carcinoma metastasizes to the liver; the frequency of solitary metastasis is 2% to 4%. For thiet al. performel.[et al. performeThe frequency of adverse events during sunitinib treatment tends to be higher in Japanese patients than in Western patients, and druet al.[et al.[Multimodal therapy incorporating new anticancer agents for metastatic liver cancer is highly effective for liver metastases of colon cancer in particular but, at the same time, the liver damage caused by regimens including oxaliplatin or irinotecan means that caution is required during surgical hepatectomy. To investigate whether liver damage occurred during the use of sunitinib in the present patient, histopathological evaluation of sinusoidal dilatation in non-tumorous liver tissue was carried out by scoring according to the method of Rubbia-Brandt et al., and thel.[et al.. The livThere are very few reports of patients with massive liver metastases in whom liver metastasis resection has been performed after sunitinib administration. Although this means that it is still unclear whether sunitinib causes liver damage, in the present case, sunitinib was dramatically effective, enabling hepatectomy to be performed with no complications. Hepatectomy can also be regarded as a valuable tool from an oncological standpoint. The present histopathological results for the effects of sunitinib on the non-tumorous liver tissue might not be the same in all cases; further investigations involving a greater number of cases are required.In conclusion, with the availability of sunitinib, some patients with potentially unresectable massive liver metastases of renal cell carcinoma may be able to undergo major hepatectomy curatively and safely with little histopathological damage to non-tumorous liver parenchyma, thus improving their prognosis.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.HN and TT designed the manuscript; SM wrote the manuscript; GW, HN, and TT performed the operation; NI, TF, and SM cared for the patient; and TS and NU made the pathological diagnosis. GW, supervised and approved the final manuscript. All authors read and approved the final manuscript.


Multiple primary neoplasms are defined as multiple occurrences of malignant neoplasms of differing histological origin in the same individual. The present study describes the case of a 46-year-old male who suffered from two synchronous primary malignant neoplasms, an osteoclastoma of the left femoral trochanter and an anaplastic astrocytoma of the the Sylvian fissure area in the brain. At the 6-month follow-up, the patient presented no problems following the aggressive treatment, including surgical resection, radiation therapy and chemotherapy. To the best of our knowledge, this is the first study in the medical literature of such a presentation. Multiple primary neoplasms are defined as cases of two or more simultaneous abnormal growths of tissue, which are presumed to be of separate origin in one person. The neoplasms may be histologically similar or different and may be identified in the same or different sites . With thOsteoclastoma and anaplastic astrocytoma are relatively common malignant neoplasms in their respective fields. Synchronous osteoclastoma and anaplastic astrocytoma in the same individual, however, has not been previously reported. The present study describes the case of a 46-year-old male patient with synchronous primary malignant tumors of the femoral trochanter and brain.A 46-year-old male presented to the Department of Orthopedics, The First Affiliated Hospital of Nanchang University Medical School  with a complaint of intermittent pain in the left hip for six months and aggravation of this symptom one month previous to admittance. The medical and family history of the patient was not significant. The general physical examination was normal, with the exception of limited movement and percussion pain in the left hip. A central nervous system examination revealed normal mental capabilities, a functioning motor and sensory system and no neck rigidity. All the cranial nerves were intact. X-ray and computed tomography CT;  of the lMultiple primary malignant tumors in an individual are relatively rare. In a review of the literature on multiple primary malignant neoplasms, the overall incidence of multiple primary malignancies has been recorded as 0.73–11.7% .et al(In 1889, Billroth  publisheet al also claThe pathogenesis of multiple primary neoplasms remains unclear, but previous studies ,8 have iIn the patient of the present study, the malignant features were histopathologically proven in each tumor. Each tumor was pathologically categorized as a separate type. The tumor that was detected in the left femoral trochanter was an osteoclastoma and the tumor in the brain was an anaplastic astrocytoma. These findings may also support the fact that these two neoplasms occurred in a random and synchronous manner.Osteoclastoma is one of the most obscure and discussed bone tumors, and the histogenesis of the tumor is uncertain as the histology does not predict the clinical outcome. The World Health Organization has classified osteoclastoma as ‘an aggressive, potentially malignant lesion’ . PreviouAstrocytoma is the most common neuroglial tumor, but is more commonly located in the cerebrum, leptomeninges and spinal cord, and is usually present with other associated focal neurological signs and symptoms . The deset al(Proverbially, the early diagnosis of malignancy prior to the appearance of clinical symptoms is important, and screening procedures, including pathological and imaging examinations, should be emphasized as soon as possible. Furthermore, the possibility of a second or third malignant lesion should be considered for patients with primary cancer. The prognosis of patients with multiple primary malignant tumors may be determined independently by the stage of each malignancy. A study by Di Martino et al identifiThe patient in the present study suffered from synchronous appearance of osteoclastoma and anaplastic astrocytoma, which is rare and previously unreported in the medical literature.


The etiology of Inflammatory myofibroblastic tumor(IMT) is contentious. In this study, we used computed tomography (CT) to examine tonsillar IMT and further analyzed the etiology of this entity.We presented CT features of left tonsillar IMT and reviewed the English-language literature published between 1984 and 2011.To our knowledge, there are only six published cases of tonsillar IMT including the present case. Two patients were asymptomatic at initial presentation. Two patients were taking immunosuppressants, and one was pregnant and in an immunomodulated state. CT of our patient revealed a 2.6 × 1.8 cm irregular soft tissue mass between the left tonsil and the base of the tongue. It did not invade surrounding structures and was not enhanced on contrast-enhanced imaging.Tonsillar IMT may be a benign tumor. We suggest that preoperative recognition of tonsillar IMT by CT may be important to avoid unnecessary expanded surgery. Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal tumor. The etiTonsillar IMT is rare; we reviewed the English-literature regarding tonsillar IMT and only five previous reports covered this topic-13. Two A 51-year-old woman presented with a 3-year history of a progressively enlarging mass in the left palatine tonsil. The mass had been approximately 0.5 × 0.5 cm during a routine check-up 3 years previously. The patient denied sore throat, fever, malaise, dysphagia, and dyspnea. The patient had no history of generalized immune deficiency, leukemia, malignant disease, diabetes mellitus, or use of immunosuppressive drugs, including corticosteroids. The patient also denied alcohol and tobacco abuse and any previous surgery or trauma. The patient had not visited a doctor for evaluation of the mass. Six months prior to presentation, the patient felt a dry itch in her throat and the mass had progressively enlarged. In June 2011, the patient presented to our department. Physical examination showed a 2.5 × 2 cm irregular mass in the upper pole of the left palatine tonsil. There was no adenopathy. The rest of the physical examination results were normal. CT of the pharynx showed a 2.6 × 1.8 cm irregular soft tissue mass between the left tonsil and the base of the tongue Figure  with no On June 17, 2011, the mass and left tonsil were excised completely under general anesthesia without any complications Figure . PatholoIMT may occur at nearly every site of the body, includiAlthough debate exists as to whether IMT is a pseudotumor or a neoplasm, the concept of IMT as a neoplasm was recently solidified  with theMagill et al. mentioned that CT confirmed the presence of an enlarged right tonsil along with right-sided nodes, but did not supply any CT imaging. Here, wIMTs arising in mesenteric, omental, peritoneal, pelvic, and retroperitoneal sites, and the2 laser, seems to be an effective treatment based on the outcome of four tonsillar IMTs[The optimal treatment for IMTs at other sites is still controversial, but excision of the tonsils with IMT, either by tonsillectomy or excision with a COllar IMTs-12. TreaWritten 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.IMT: Inflammatory myofibroblastic tumor; CT: Computed tomography; EBV: Epstein-Barr virus; HIV: Human immunodeficiency virus; USG: Ultrasonography; IHC: Immunohistochemical; PCR: Polymerase chain reaction.http://www.textcheck.com/certificate/nSTlESThe English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: The authors declare that they have no competing interests.Yun-Zhen Luo designed the manuscript. Li-Bo Dai and Xing-Mei Luo aided in the surgery and collected the materials. Shui-Hong Zhou performed the surgery and wrote the manuscript. J un Fan did the laboratory examination. Ling-Xiang Ruan analysed the imaging of CT. All authors read and approved the final manuscript.


Background. Intestinal obstruction in pregnancy is uncommon. The condition is associated with significant maternal and fetal mortality. The delay in diagnosis is due to nonspecific symptoms and a disinclination to carry out radiologic investigations in pregnancy. Case. A 39-year-old lady at 32 weeks of gestation presented with abdominal pain and nausea. Her symptoms worsened during admission. A computed tomography (CT) scan showed dilated small bowel loops suggestive of intestinal obstruction. She eventually underwent a laparotomy as conservative measures failed. Conclusion. A high index of clinical suspicion is required to diagnose intestinal obstruction in pregnancy. Prompt diagnosis should be made and the appropriate treatment instituted. Surgical intervention should be performed if necessary as further delay only results in increased morbidity and mortality. A 39-year-old patient, para 1, presented at 32 weeks' gestation with colicky abdominal pain and nausea. She had no fever, vomiting, constipation, or urinary symptoms. Her pregnancy had been uneventful and she had no prior medical or surgical history.On admission, she was afebrile with normal pulse and blood pressure. The uterus was soft and there were no palpable contractions. She had epigastric tenderness, but normal bowel sounds. CTG was reassuring with irregular uterine activity but the cervix was closed. Full blood count, liver and renal panel were normal.The working diagnosis was threatened preterm labour versus intestinal colic. She was commenced on IV fluids, antiemetics, antispasmodics, analgesia, and oral nifedipine for tocolysis. Fetal lung maturation was induced with dexamethasone. The initial abdominal ultrasound was normal. Over the next 24 hours, she developed fever with increasing abdominal pain, distension and started vomiting large amounts of bilious fluid. Surgical referral suggested subacute intestinal obstruction and she was managed conservatively with nasogastric suctioning, IV fluids, and antibiotics. A computed tomography (CT) scan with contrast showed nonspecific mild dilatation of the distal jejunal loops and proximal ileum .Over the next 72 hours, her symptoms worsened with high volumes of nasogastric aspirate. A subsequent laparotomy confirmed a mesenteric band constricting the distal ileum, with proximal small bowel dilatation and collapsed distal ileum. The mesenteric band was lysed and the bowel retrogradely decompressed. The abdomen was closed with loop PDS. She recovered well and went home a week later. At 39 weeks, she went into labour and had an uneventful vaginal delivery. She delivered a healthy baby boy weighing 3200 gm and with Apgar scores of 9 and 9 at 1 minute and 5 minutes of life, respectively. Intestinal obstruction (IO) in pregnancy is rare at 1 in 2500 . Often, Adhesions are the commonest cause of IO in pregnancy and account for more than half the causes found at laparotomy. The incidence and complication rates increase with gestational age, particularly in the third trimester. The risk of gestational IO increases as the uterus enlarges. Other causes include volvulus 23%), intussusception (5%), hernia (3%), carcinoma (1%), appendicitis (1%), and idiopathic “ileus” (8%) [%, intussThe diagnosis of IO in pregnancy is difficult. Signs of acute abdomen may not be as prominent in the pregnant abdomen when compared to the nonpregnant one , due to Our patient presented with generalised abdominal pain and nausea which progressed to vomiting and abdominal distension, indicating an obstructive pathology. She had no previous surgical history to suspect adhesions as a cause for intestinal obstruction. In suspected intestinal obstruction, CT, rather than MRI, has recently emerged as the diagnostic modality of choice. In contrast to MRI, CT involves ionizing radiation, whereas MRI requires gadolinium contrast, with an uncertain safety profile in pregnancy. However, CT is justified in our case as the risks of radiation are outweighed by the maternal-fetal risks of missing the diagnosis.Management of IO in pregnancy is similar to nonpregnancy. Clinical suspicion is vital and joint management between surgeons and obstetricians is crucial. The basis of treatment is timely surgery, minimising delays in decision. The initial treatment consists of nasogastric aspiration with aggressive IV fluids to correct electrolyte disturbances. CT with contrast gives the most diagnostic information on the level and cause of obstruction.Failure of conservative treatment and demonstration of complete obstruction on CT are indications for early surgery as persistence will contribute to an increase in mortality and morbidity. Perinatal death from hypoxia secondary to maternal hypovolaemia, sepsis, and peritonitis has been reported . MaternaIf fetal distress is present or if there is inadequate exposure at laparotomy, delivery by caesarean section should precede the relief of obstruction. There was also a potential dilemma that the primary abdominal incision closure would not be possible, therefore exposing the fetus to risks of ensuing sepsis and peritonitis, necessitating an early caesarean section. Fortunately, after retrograde decompression of the small bowel, closure was possible. IO in pregnancy is rare. A high degree of suspicion is crucial, especially in patients with previous abdominal surgery. The high morbidity and mortality rates meant that radiological investigations and surgery should not be delayed. An additional learning point from this case would be that in an obstetric patient without any surgical history who presents with abdominal pain, one should always consider rarer surgical causes other than merely obstetric or gynaecological causes of pain.


Appendiceal cystadenoma, the most common type of what has been generally termed ‘mucocele’ of the appendix, has unique clinical characteristics. In this study, three similar clinical manifestations of appendiceal cystadenoma are presented, with different subsequent management and diverse prognostic outcomes relating to the characteristics of the disease, the wishes of the patients, the medical workers and social factors. In this study, we provide details of three cases of appendiceal cystadenomas. Appendiceal cystadenoma has unique clinical characteristics. It is a rare disease, accounting for 0.6% of appendectomy specimens , with anA 79-year-old man with no notable medical or surgical history presented with a four-day-long history of distending pain in the right side of the abdomen. There was no palpable mass and no guarding or rebound tenderness was observed. Ultrasound showed a pathologic mass, 4 cm in diameter in the right side of the abdomen and the echo of the normal appendix was not displayed. Biochemistry laboratory results were within normal range. At surgery, a smooth mass was noted at the base of the appendix that continued into the cecum at the ileocecal junction. The tumor was not observed to be involved with the appendix, which, up to the base, was hard and encapsulated with no adhesions to the surrounding tissue. The frozen section of the mass was consistent with appendiceal cystadenoma. An appendectomy was performed. When the specimens were cut yellowish jelly-like mucinous material was observed . The patA 70-year-old woman was in good health until a large abdominal mass was detected in her right lower quadrant upon routine physical examination. Physical and laboratory examinations were within the normal range, but the patient had a raised carcinoembryonic antigen (CEA) level of 6.64 ng/ml. Ultrasound found a pathologic mass, which was consistent with appendiceal mucocele. The patient underwent a diagnostic laparoscopy. Intraoperatively, dense adhesions were not encountered in the right lower quadrant, but the capsule wall ruptured with an outflow of yellowish jelly-like mucus . The patA 73-year-old female presented with a 1-month history of a distended abdomen, without nausea and vomiting. A computed tomography (CT) scan was obtained and revealed abnormal appendix enhancement, which was partially thickened at the surface of the liver and peritoneum. At this point, surgical options were discussed and the patient underwent diagnostic laparoscopy. Operative findings included diffusely light yellow nodules located at the surface of the liver and peritoneum without ascites . There wIn China, appendiceal cystadenoma has its own characteristics . LocatedThis study presents one case of a successful and complete resection, one case of intraoperative rupture due to the appearance of postoperative secondary PMP ascites, and one case of PMP nodal type. Three types of PMP, namely PMP ascites type, nodular type and mixed type –11 have Ultrasound is both pervasive and commonplace in China. When finding the right lower quadrant filled with fluid, ultrasound Doctors often consider appendix abscess rather than appendiceal cystadenoma. At this time a personal medical history should be taken to determine whether the patient has experienced pain in the past and how severe the pain has become. Even if the intraoperative pathological diagnosis is appendiceal cystadenoma, clinicians still prefer to believe that it is an appendiceal cyst, as this is more common. This results in: i) PMP: an appendix with an abscess requires a few months of conservative treatment before surgery. If the puncture fluid is mucus, the rupture caused by intervention may lead to PMP. Delayed surgery causes it to develop into secondary PMP. Case 3 presents a similar situation, since it is difficult to eliminate the minimal residual disease by chemotherapy and surgery. If the patient has a poorer prognosis, this disease produces canceration, which is more common in younger individuals and requires surgery as early as possible. ii) Rupture of PMP: assumption that the cause is a small cyst may lead to rupture of the PMP during surgery. Case 2 presents a similar situation.Health care reform in China has reached a critical point. This economy has a large population and any small problem will be multiplied by the sheer size of the population and become exacerbated. Misunderstandings and treatment errors can result in a different prognosis of the same disease, which may result in an unreasonable allocation of medical resources.With the global economy in distress, more direct and convenient high economic cost measures should be taken. Healthcare should be promoted in rural communities, particularly to the elderly. The grassroots level hospital is the first step in treating appendiceal disease and primary care doctors are a main force. They must therefore deepen their knowledge and increase their awareness of such presentations as described here. The difficulty of surgery will not increase, in comparison to treating appendicitis, if the treatment is not delayed. It may significantly affect prevention, treatment and amelioration of prognosis; it is therefore essential to understand the clinical manifestations of appendiceal mucinous tumor and its comprehensive pathological features, and to master the timely processing and proper disposal of the tumor. Finally, early diagnosis has important clinical significance as it can be complicated by malignant transformation, volvulus, intestinal necrosis, obstruction, intussusception, secondary infection, bleeding, PMP and even thrombosis of the iliac vein –14. Doct