Oral lesions in neonates represent a wide range of diseases often creating apprehension and anxiety among parents. Early examination and prompt diagnosis can aid in prudent management and serve as baseline against the future course of the disease. The present review aims to enlist and describe the diagnostic features of commonly encountered oral lesions in neonates.How to cite this article: Patil S, Rao RS, Majumdar B, Jafer M, Maralingannavar M, Sukumaran A. Oral Lesions in Neonates. Int J Clin Pediatr Dent 2016;9(2):131-138. The diseases of the oral cavity comprise an important arena of the pediatric specialty, yet many are misdiagnosed or left untreated due to lack of resources and parental education. Although the lesions are usually confined to the oral cavity, they might provide certain clues to the underlying more serious systemic conditions. A broad spectrum of diseases manifest with oral features in the neonates , majorit1 They are postulated to arise from the dental lamina. They appear as small, multiple, nodular, and white to creamish lesions on the crests of the maxillary and mandibular dental ridges. Histopathology reveals they are keratin-filled true cysts. Treatment is not indicated as they self-resolute.23The gingival cysts are frequently observed in newborns (13.8%) with no gender predilection.12 They are apparently entrapped epithelial remnants. These are clinically asymptomatic and appear as nodules in the mid-palatal raphe region along the line of fusion. Treatment is not indicated.23They are nonodontogenic, keratin-filled cysts with prevalence of 35.2% with no gender predilection.12 They are apparently derivatives of palatal salivary gland structures. They clinically appear as numerous nodules along the junction of the hard and soft palate. Treatment is not indicated.23They are keratin-filled cysts with prevalence of 47.4% with no gender predilection.4 Their origin may be from degenerative cystic changes in the reduced enamel epithelium or from the remnants of the dental lamina.34 The patho-genesis involves impediment of eruption by overlying dense fibrotic mucosa.2 These clinically present as bluish, dome-shaped, translucent, compressible swelling within the mucosa, overlying the erupting tooth. Diagnosis is aided by fine needle aspiration biopsy (FNAB). Treatment includes marsupialization or surgical extraction.34Eruption cyst (EC) in neonates is a rarity. Clark et al have reported six cases of EC in neonates, while Bodner et al have reported two cases.5 Common oral locations include floor of the mouth and the submental region (23.3%).6 These are clinically asymptomatic, slow growing cysts and diagnosed when enlarged. It poses respiratory distress and feeding difficulty in neonates. Diagnosis is based on prenatal/natal ultrasonography (USG), magnetic resonance imaging (MRI)/computed tomography (CT), FNAB, and histopathology, ruling out ranula, dermoid cyst, teratoma, heterotopic gastrointestinal cyst, duplication foregut cyst, and lymphatic malformation. Histologically, an epidermoid cyst is lined by only epidermis and a dermoid cyst shows presence of adnexal glands in addition. Treatment includes surgical enucle-ation. Recurrence is rare.5They are rare benign developmental disorders with an incidence of 7% in the head and neck region. Approximately 30 cases have been reported in neonates.7 The causative organisms include Staphylococcus aureus (most common), group B Streptococcus , and Gram-negative organisms (Escherichia coli and 78Klebsiella pneumonia). The involvement of maxilla is approximately 4% and the initial clinical presentations include acute onset of fever followed by edema and redness of cheek, swelling of eyelids with conjunctivitis, and unilateral nasal discharge.9 The features of chronic osteomyelitis is seldom manifested in new-borns. Diagnosis is based on positive blood cultures and tests .8 Treatment includes empirical regimen of antimicrobial drugs along with or without surgical intervention. Prognosis is poor and morbidity is high.7It is a relatively rare infection with high mortality rate, seen in the neonatal period. The incidence is estimated to be 1 to 7 per 1,000 hospital admissions with a predilection for males (1.6:1) and preterm newborns. Common risk factors include iatrogenic, catheterization, prolonged hospital-ization, parenteral nutrition status, ventilatory support, and nosocomial infections.10It was first reported by Hass and Batignani in the mid-1930s. The incidence ranges from 1 in 3,000 to 20,000 live births. The orolabial lesions are caused by herpes simplex virus (HSV)1, while genital lesions are by both HSV1 and HSV2. The transmission occurs during the time of parturition and is facilitated by the status of maternal antibody, maternal infection, i.e., primary or recurrent, duration of rupture of membranes, integrity of mucocutaneous barriers, and mode of delivery, i.e., cesarean or normal.11 Diagnostic modalities include serological tests, polymerase chain reaction amplification analysis of cerebrospinal fluid (CSF), and viral cultures. Treatment and prophylactic measures involve antiviral therapy with acyclovir.10 Prognosis of SEM infection is good , but 70% of infants with skin, eye, and mouth disease progress either to central nervous system or disseminated disease, both having a higher fatality or permanent sequelae.11The incubation period varies from 4 to 21 days after delivery, with symptoms appearing between 6 and 21 days. The eruptions commonly involve the mouth, scalp, face, soles of the feet, and palms of the hand. Characteristically, vesicular eruptions appear as single unit or in clusters, measuring about 1 to 3 mm in diameter, which often ulcerate within a few days. The manifestations vary according to the type of infection . Other cCandida can be vertical or due to external contaminations. The most common opportunistic Candida species include Candida albicans (75%) followed by Candida glabrata, Candida krusei, Candida tropicalis, and Candida parapsilosis. The risk factors comprise immature immune system, prolonged catheterization, prolonged hospital stay, etc. Oral manifestations include white plaques on oral mucosa, composed of hyphae, epithelial cells, and necrotic tissues. The prominent systemic features include meningitis, endophthalmitis, cardiovascular manifestations, and urinary tract infections.12 Diagnosis is confirmed by fungal cultures in blood, urine, and CSF. The colonization of oral mucosa by Candida organism plays a decisive role in development of invasive candidiasis; hence, as a prophylactic measure, maintenance of oral hygiene is believed to be an important preventive measure.13Disseminated or invasive candidiasis is the second most common cause of mortality with a reported incidence of 2 to 20% in preterm newborns. The transmission of 14 It can be of two types: Extravasation and retention mucoceles, the former affecting the lower lip most frequently. Extravasation type often affects the younger age group and results due to trauma.1415 Clinically, it presents as bluish (depending on the proximity to the surface), translucent, and fluctuant swelling which may cause mechanical obstruction during feeding.14 Diagnosis can be confirmed by FNAB and histopathological evaluation. Conventional treatment includes surgical excision.15Mucocele commonly arises due to alterations in the minor salivary glands, occurring in approximately 2.7% of patients under the age of one.16 Treatment includes observation for asymptomatic cases, aspiration, cryo-surgery, marsupialization, or surgical excision with or without sublingual gland depending upon the variant .17Ranulas are a rarity in newborns, presenting as a swelling in the floor of the mouth and are commonly caused by extravasation of mucin than retention cyst. The incidence is estimated to be approximately 0.74%. Clinical features show marked similarity to that of a mucocele. Diagnosis can be arrived with the aid of FNAB, MRI, and histopathological assessment.18 Clinically, the lesion appears ulcerated, unifocal/multifocal, and occasionally painful, frequently occurring on the ventral surface of tongue in the midline region. Other sites include lip, palate, gingiva, vestibular mucosa, and floor of the mouth. Diagnosis is confirmed by clinical examination and histopathology to rule out other possible cause of ulcerations caused by bacterial or fungal infections, immunologic diseases, and neoplasia. Treatment includes dental extraction, cortico-steroids, teething rings, oral disinfectants, smoothing the incisal edges, and use of protective dental appliances.20Riga-Fede disease (RFD) is a rare benign reactive mucosal disease first identified and later described by Riga (1881) and Fede (1890) respectively. The most contributory factor postulated is trauma. It is commonly associated with natal/neonatal teeth in newborns and other disorders like Riley-Day syndrome, Lesch-Nyhan syndrome, Tourette’s syndrome, and cerebral palsy. Dominguez-Cruz et al categorized RFD into “precocious RFD”  and “late RFD” .21Recently, Kiat-Amnuay and Bouquot reported a case of breastfeeding keratosis, nonresponsive to antifungal drugs, in a 2-month-old child. History elicited from parents revealed unusual habit of active lip sucking habit in-between the feeding sessions. Cytopathology revealed no mycotic structures. With diminution of habit, the lesion regressed by the 4th week with no recurrence.22 It is caused due to transplacental passage of maternal immunoglobulin G autoantibodies (mainly class 4) against transmembrane glycoprotein desmoglein 3 (Dsg3). It is characterized by multiple cutaneous, mucosal, or mucocutaneous ulcerations soon after birth. Diagnosis is confirmed by histopathology and immunofluorescence. The symptoms spontaneously resolve within 2 to 3 weeks.22It is a rare vesiculobullous disease in neonates. Rucco et al first described the lesion in 1975 and till date more than 21 cases have been documented.23 Various predisposing factors include child-bearing age, gestational hypertension, and infant birth weight. Kasabach-Merritt syndrome has been associated with extensive hemangiomas in infants.24 They are usually present at birth but tend to develop few weeks after. The natural course of hemangioma follows a rapid proliferating phase (0-1 year), involuting phase (1-5 years), and involuted phase (5-10 years). Clinically, it manifests as rapidly growing macule followed by regression into spotted pigments. Diagnosis is confirmed by history, FNAC, MRI, and/color Doppler USG, histopathology, and immunohistochemistry (Glucose transporter 1) ruling out other vascular malformations.25 Treatment guidelines are based on the stage of the lesion and includes drugs , lasers , and surgical corrections. Complete resolution occurs in 70% cases but around 40 to 50% of the cases show permanent changes in the skin, such as telangi-ectases, stippled scarring, anetoderma, hypopigmentation, fibro-fatty residua, etc., without any disfigurement.26Hemangiomas are most common pediatric vascular benign neoplasms with 2 to 3 and 22 to 30% prevalence in neonates and underweight preterm newborns, respectively, with a female predilection (3:1-5:1). It commonly involves the head and neck region (60%) apart from trunk (25%) and extremities (15%). Common oral locations include lips, buccal mucosa, tongue, and rarely the palate and uvula.2427 Incomplete development; ectopic deposition of lymph tissues; congenital obstruction or sequestration of the primitive lymphatic channels; and role of vascular endothelial growth factor (VEGFR)-2 and 3 are suggested modes of etiopathogenesis. Histologically, it can be categorized into simplex form, cavernous, cystic and benign lymphangioendothelioma. Oral sites include the dorsum of tongue, lips, buccal mucosa, soft palate, and floor of the mouth in the descending order of preference. Clinically, it is a slow, progressive lesion with superficial blue-black or red hemorrhagic elevated nodules, the deeper lesions presenting as soft, diffuse growths with normal color and cystic forms manifesting as soft, painless fluid-filled lesions, characteristically located in the neck. Oral manifestations include macroglossia, sialorrhea, dysphagia, cosmetic abnormalities, ulcerations, deformity of jaws, and difficulty in speech and mastication and feeding problems. Other features include respiratory distress, infection and fever, and sudden exaggeration. Diagnosis is confirmed by clinical examination, MRI/CT/color Doppler USG, and histopathology as well as immunohistochem-istry lymphatic markers, such as D2-40, Prox-1, factor VIII-associated antigen, CD-31, LYVE-1, podoplanin, and VEGFR-3. Prenatal diagnosis can be aided by chromosomal analysis of chromosomes 13, 18, 21, X, and Y. Treatment modalities include surgery, cryotherapy, electrocautery, sclerotherapy, steroids, embolization, and ligation, laser surgery , radiofrequency tissue ablation technique, and radiation therapy. Recurrence is high, 39% in case of tongue, followed by hypopharynx and larynx.27Lymphangiomas are benign neoplasms of the lymphatic channels with 50% of cases noted at birth and 90% developing before the age of 2. The prevalence is 1-3/10,000 live births, affecting both the genders equally, involving 75% of the head and neck region followed by trunk, abdomen, and extremities.28 Another variant, congenital self-healing reticu-lohistiocytosis/Hashimoto-Pritzker, is present at birth and shows complete involution within 2 to 3 months. Characteristic features include erythematous vesiculo-pustules with/without crusting and eczematous scaling with respect to skin.29 Oral manifestations include pete-chiae, lytic bone lesions involving posterior mandible, and pain and swelling of gingiva corresponding with accumulation of Langerhans cells. Other sites presenting with lytic lesions include skull, femur, pelvis, and vertebrae. Systemic findings may include hepatomegaly, splenomegaly, pulmonary affection, pancytopenia, central nervous system involvement, diabetes insipidus, etc., depending upon the severity. Diagnosis is confirmed by histopathology and immunohistochemistry (CD1a and/or S100) and complete liver and blood chemistry profile with CT/MRI to evaluate the extent of systemic involvement. Possible differentials include seborrheic dermatitis, lytic lesions of jaws, leukemia, lymphoma, and metastatic tumors.28 Treatment modalities include surgical intervention, chemotherapy, and radiotherapy. Prognosis depends upon the age and extent of systemic involvement.2829Langerhans cell histiocytosis X (LCH) constitutes a wide group of disorders, sharing the histiocyte as the common cell of origin. Langerhans cell histiocytosis X occurs at a frequency of 1 in 200,000 children under 15 years with a male predilection. It is classified as eosinophilic granu-loma, Hand-Schuller-Christian disease (between 3 and 6 years of age), and Letterer-Siwe disease (under 2 years of age).3031 The tumor shows a female predilection (8:1-10:1 ratio) with an estimated incidence of 0.0006%.32 The various etiology proposed includes odontogenic, neurogenic, myoblastic, endocrino-logic, fibroblastic, or histiocytic origin.31 The lesion occurs three times more commonly in the maxilla than mandible, frequently involving the alveolar ridge near the canine region. Clinical presentation includes lobular or ovoid, sessile or pedunculated swelling of various sizes, covered by a smooth normal/reddish mucosal surface. Larger lesions cause mechanical obstruction in feeding and respiration in neonates. Diagnosis is confirmed by USG, CT/MRI, and histopathology, which appears similar to other granular cell tumors in adults, but is distinguished based on its exclusive origin from the neonatal gingiva, the scattered presence of odontogenic epithelium, lack of interstitial cells with angulate bodies, and the more elaborate vasculature.30 Other possible differential diagnosis includes dermoid cysts, teratoma, hemangioma, lymphatic malformations, rhabdomyosarcoma, and melanotic neuroectodermal tumors of infancy (MNTI). Treatment includes complete surgical excision with no reported cases of recurrence.31It is one of the rare benign tumors of oral cavity first described by Neumann in 1871.3334Melanotic neuroectodermal tumor of infancy is a rare pigmented benign neoplasm. It is seen in the first 6 months of life with a male predilection. It originates from the neural crest cells. It commonly presents in the craniofacial region (92.8%), maxilla (61.4%), skull (15.7%), mandible (6.4%), the brain (5.7%), and the genitals. Oral sites include tongue, palate, buccal mucosa, and floor of the mouth. Clinically, it is characterized by painless, nonulcerative, expansile, rapidly growing, pigmented, and locally aggressive behavior. Diagnosis is based on clinical assessment, CT/MRI, and histopathology. Microscopically, it presents as a biphasic tumor, comprising neuroblast-like round cells and melanocytic cells. Differential diagnosis includes Ewing’s sarcoma, desmoplastic small round cell tumor, rhabdomyosar-coma, peripheral neuroepithelioma, neuroblastoma, peripheral primitive neuroectodermal tumor, lym-phoma, and malignant melanoma. Treatment modalities include surgical excision, chemotherapy, and radiotherapy alone or combined. High recurrence (10-15%), metastases (3%), and malignant transformation rate (6.5%) are reported.35Epignathus or pharyngeal teratoma is an exceptionally rare form of teratoma attached to the base of the skull, usually the hard palate or mandible. It frequently occurs in females (3:1 ratio) with an incidence of approximately 1 in 35,000 to 200,000 live births. Teratomas are derived from the pleuripotent cells of one or more of the three germ layers. It presents as a unidirectional growth protruding through the oral cavity with rare intracranial extension and in association with cleft palate and bifid tongue or nose. Other manifestations include elevated maternal serum alpha-fetoprotein, mechanical feeding, airway obstruction, and fetal death. Diagnosis is confirmed with clinical examination, USG, and CT/MRI excluding hemangioma, lymphangioma, dermoid cyst, sincipital encephalocele and other benign or malignant soft-tissue masses of neonates. Prognosis is poor and mortality rate is high in both fetal life and neonates.36 Oral choris-toma can include salivary gland, cartilaginous, osseous, lingual thyroid, sebaceous, glial, gastric, and respiratory mucosa.37 Clinically, it presents as asymptomatic, large masses, causing obstruction in feeding and respiration in neonates. Diagnosis is aided by clinical examination, imaging, and histopathology, ruling out other similar oral neonatal lesions like mucocele, lymphatic malformation, venous malformation, and dermoid cyst. Treatment includes complete surgical excision. No recurrence is reported.36Choristomas are histologically normal tissue, presenting in its nonnative location. Oral choristomas are exception-ally rare aberrant developmental disorders with a male predilection. In the head and neck region, the most frequent locations include the tongue , floor of mouth, pharynx, and hypopharynx.39 It is a rare salivary gland neoplasm of epithelial origin, with approximately 30 reported cases. The neoplasm resembles the developmental phase of the salivary glands. It is noted as a swelling of variable sizes involving the parotid followed by the submandibular gland. Facial nerve palsy may be present in cases of parotid gland involvement. Treatment includes surgical excision. Local recurrence is reported. Chemotherapy and radiotherapy are contraindicated. Prognosis is favorable.3839Sialoblastoma was coined by Taylor (1988).40It is benign neoplasm of the salivary gland, present at birth but manifests later. It commonly affects females (3:1). Its natural course includes the proliferative followed by involution phase. Clinically, it manifests as multiple, rapidly growing parotid mass, often along with the presence of cutaneous lesion (infantile hemangioma). Diagnosis is aided by imaging and histopathology. Other newborn lesions involving the parotid gland include sialoblastoma, congenital infantile fibrosarcoma, solitary infantile myofibromatosis, and vascular malformations. Surgical resection carries risk of facial nerve damage.41 In another review of 60 years by Campbell et al (1987) only one case of rhabdomyosarcoma (tongue) was observed. Such cases require prompt diagnosis and multimodal management for a disease-free survival.42In a 40-year review of solid malignant neoplasm in neonates by Hasen Xue et al (1995) it was revealed that malignant neoplasms are extremely rare in newborns and involvement of oral tissues even rarer. The majority of cases involved head and neck followed by trunk and extremities. Oral cavity involvement was seen in only two cases: Malignant melanoma  and spindle cell sarcoma (tongue).43The most common cause of neonatal deaths is often associated with preterm birth and its related complications. In brief, the effects of premature birth on oral tissues mainly include dilacerations of crown from endotracheal intubation, distortions of dental arches, enamel opacity, and enamel hypoplasia, increase in height of the palate, delay in eruption of the primary dentition, and growth of the permanent dentition.Neonates presenting with intraoral lesions mandate precise diagnosis, management, and parental reassurances and counseling. A thorough evaluation and substantial knowledge can aid in diagnosis of easily recognizable as well as rare abnormalities affecting the oral tissues in neonates.


Blunt traumatic abdominal wall disruptions associated with evisceration  are very rare. We describe a case of large traumatic abdominal wall disruption with bowel evisceration and complete transection of jejunum and sigmoid colon that occurred after a 30-year-old male sustained run over injury to abdomen. Abdominal exploration and primary end to end jejuno-jejunal and colo-colic anastomosis were done. Staged management of giant abdominal wall defect was performed without any plastic reconstruction with good clinical outcome. Traumatic abdominal wall hernia (TAWH) associated with blunt injury mechanism is very rare, with an approximate prevalence of 0.2%–1% in majority of reported series. Various A 30-year-old male presented to emergency department after being involved in run over injury by truck. Examination revealed complete avulsion of skin and subcutaneous tissue from bilateral inguinal region up to bilateral nipples. Upon reflection of avulsed skin, a full thickness defect of size 25 × 20 cm with complete loss of sheath, muscle, and peritoneum was noted in anterior abdominal wall. Through the defect, intestines were protruding out. Tyre marks were present over whole of the avulsed skin. Other positive finding on the physical examination included wound in lateral aspect of left thigh approximately 10 × 5 cm in size. The bowel was easily reduced and saline-soaked gauze was used for temporary coverage over the wound.After resuscitation with intravenous fluids and blood components, patient was taken to the operating room for exploratory laparotomy. Exploration of abdominal cavity was done through the defect. There was complete transection of jejunum about 2.5 feet distal to duodenojejunal flexure and mesentery at that level was incompletely transected with bleeding . There wAfter abdominal wash out, patient underwent primary end to end jejuno-jejunal and colo-colic anastomosis in single layer. After abdominal wound debridement, defect was covered temporarily with urobag (urine collecting bag) by taking continuous sutures with margin of defect and urobag . This wath, second stage operation was planned which involved excision of whole necrosed skin and removal of the urobag. We found that whole of the defect was covered with healthy granulation tissue. Two vicryl meshes of 15 × 15 cm size were used to give the strength to the granulation tissue [On day 12n tissue .th, split skin grafting was done over healthy granulation tissue that was taken up very well [Later on vicryl meshes got infected and were removed. Infected wound was managed with saline dressing and antibiotics. Patient’s wound was well covered with healthy granulation tissue with no cough impulse. Therefore, we decided for skin grafting of wound. On day 37ery well .The patient was discharged from the hospital 7 weeks after the initial injury and did well in follow-up at 2 months, both from cosmetic and functional perspective. Further, there was no evidence of hernia at the site of the traumatic defect.The anterior abdominal wall is a complex fasciomuscular structure that poses a challenge to the reconstructive surgeons. Defects produced from infection, herniation, tumor extirpation, or trauma are among the most often encountered.The reported incidence of all abdominal wall injuries following blunt trauma in about 9%. TAWHs arAEs constitute an extreme form of TAWHs with the main difference between the two being the amount of force that is focally delivered to the abdominal wall tissues as well as the anatomic location of the force application .et al.,[Dennis et al., describeet al.,. Of noteet al.[Our case report describes a case of grade VI injury, an exceedingly rare finding with staged management of giant abdominal wall defect. A case with grade VI injury was also described by McDaniel et al.Regardless of the presence of any associated injuries, prompt surgical repair of the TAWH and/or AEs is required.,4 At timStaged management of patients with giant abdominal wall defect without the use of permanent mesh results in a safe and consistent approach for both initial and definitive management with low morbidity and no technique related mortality. AbsorbabPolypropylene mesh has been used for temporary closure but has been associated with infection, mesh extrusion, and enteric fistula formation. Fistula rates of 12%–50% have been reported when prostheses are used for acute management.While these infectious complications appear to occur less frequently with the use of absorbable material, these meshes finally lead to an incisional hernia, requiring repair with non-absorbable mesh after a period of 6–12 months. Nevertheless, in the complex situation requiring a temporary abdominal wall closure, use of absorbable mesh material is common.The use of plastic materials (intravenous fluid bags or urine collection bags used as Bogota bag) for closure has been reported by many institutions. The appeLarge, full thickness defects require treatment with dressing and nutritional support. From 7 to 20 days from the onset of treatment, exposed viscera become densely adherent to granulation tissue upon which skin graft can be placed. For large abdominal wall defect, which cannot be primarily closed, this technique is safe and has a satisfactory outcome.In literature, various complications of TAWH include wound infection, abdominal compartment syndrome leading to multiple organ dysfunction, enteric fistula formation. Most important late complication is development of ventral hernia. In our case, only wound infection was seen and during a short-term follow-up of 2 months no hernia was observed.Definitive closure in such cases is done about 6–12 months later when a planned ventral hernia is operated. Various techniques for repair include component separation method, prosthetic mesh, and flap repair.This report describes a case of grade VI injury  which is an exceedingly rare finding along with staged management of giant abdominal wall defect without any plastic reconstruction, without any hernia at the site of injury and with both satisfactory cosmetic and functional outcomes.


Background. Soft tissue sarcoma with a hemorrhagic component that cannot be easily diagnosed by needle biopsy is defined here as soft tissue sarcoma with telangiectatic changes (STST). Methods. We retrospectively reviewed clinicopathological data of STST from 14 out of 784 patients  with soft tissue sarcoma. Results. Tumors were found mostly in the lower leg. Histological diagnoses were undifferentiated pleomorphic sarcoma (n = 5), synovial sarcoma (n = 5), epithelioid sarcoma (n = 2), and malignant peripheral nerve sheath tumor and fibrosarcoma (n = 1). No history of trauma to the tumor site was recorded in any patient. Needle aspiration transiently reduced the tumor volume, but subsequent recovery of tumor size was observed in all cases. Out of 14 patients, 9 presented with a painful mass. MRI characteristics included intratumoral nodules (64.3%). The local recurrence rate was 14.3%, and the 2-year event-free survival rate was poorer (50%) than that of most sarcomas. Conclusions. STST is unique in its clinicopathological presentation. Painful hematomas without a trauma history, intratumoral nodules within a large hemorrhagic component, and subsequent recovery of tumor size after aspiration are indicative of the presence of STST. Needle biopsies are useful for histological diagnosis, since most soft tissue sarcomas are solid. However, small segments of soft tissue sarcoma cannot be diagnosed by needle biopsy because the tumor contains a large, fluid-filled hemorrhagic component. This phenomenon is generally not well appreciated, resulting in delayed diagnosis and poor prognosis . We defiWe retrospectively reviewed 764 cases of soft tissue sarcoma treated in our hospital between 1984 and 2006. Among these patients, 14 (1.8%) developed soft tissue sarcoma of the extremities, which presented with a significant hemorrhagic mass on MRI prior to the initiation of chemotherapy.The mean age of these patients was 35.9 years (range: 18–66 years). The male to female ratio was 1.8 : 1. The mean follow-up period was 6 years (range: 1–19 years) after the diagnosis of STST.Of these 14 patients, 7 developed lung metastases, 2 developed lymph node metastases, and 1 developed subcutaneous metastases. Seven patients had died of exacerbation of lung metastases. Information was reviewed from medical records detailing demographic characteristics, clinical presentation of the primary tumor, imaging characteristics, local recurrence of the primary tumor site, treatment procedure of the primary site and any lung metastasis, the diagnostic procedure, and oncological outcome. The clinical features of STST were subsequently analyzed.No history of trauma to the tumor site was recorded in any patient. The primary complaints were swelling (14 cases), pain (9 cases), and local inflammation (7 cases). Most tumors were located in the thigh (7 cases), followed by the lower thigh (3 cases), buttocks (2 cases), and knee and neck (1 case each).All cases were categorized as high-grade sarcomas, with histological diagnoses of undifferentiated pleomorphic sarcoma , synovial sarcoma (5 cases), epithelioid sarcoma (2 cases), and malignant peripheral nerve sheath tumor (MPNST) and fibrosarcoma (1 case each) . Tumor s∗), although the size of tumor nodules varied in each case. Four out of 10 cases contained fluid-fluid levels (MRI was performed in 10 out of 14 patients (71%). All tumors were observed to contain blood in over 70% of the tumor area. Tumor nodules on the side of the blood-filled mass were observed in all cases , ∗, althd levels , #.Fine-needle aspiration was performed in 5 patients, resulting in a diagnosis of malignancy in only 1 patient. Needle aspiration temporarily reduces tumor volume, but subsequent recovery of the tumor size was observed in all cases. Core needle biopsies were performed in 6 patients; cytological diagnosis is a sensitivity of 57.1%, but histological diagnosis is a sensitivity of 28.6%. Open biopsies were performed in 10 patients because an accurate diagnosis could not be determined by needle biopsy in 8 cases, and small size precluded needle biopsy in the remaining 2 cases. Incisional and excisional biopsies were performed in 6 and 4 patients, respectively, with a sensitivity of 100% . The meaWide resection of tumors with limb-sparing surgery was performed in 11 cases, and amputation was performed in 3 cases, resulting in wide-margin tumor resection in all cases. Local recurrence was observed in 2 cases (14%) and was not related to biopsy procedures and surgery . The ratWeiss and Enzinger reported on this rare subset of tumors in their 1978 review of 200 cases of MFH , 4. In oMost high-grade STSTs often present as a painless, gradually enlarging mass . In our In our study, repeated puncture of the masses misdiagnosed as hematomas led to a delay of STST diagnosis and treatment. Therefore, subsequent recovery of tumor size after aspiration is an important clue to the presence of STST , 7, 8.In imaging, chronically expanding hematomas have been shown to have large central collections of heterogeneous signal material in both T1- and T2-weighted MRI series . Unlike It is clinically and radiologically impossible to differentiate chronic hematomas from sarcomas; therefore, biopsies must be performed. Since STSTs tend to be misdiagnosed as hematomas as a result of imaging results, tumor aspiration is initially performed in most cases. In this study, fine-needle aspiration resulted in a diagnosis of malignancy in only 1 out of 5 patients. Another study reported a similar diagnostic rate of aspiration-biopsy cytology, that is, 1 out of 6 patients . The lowSternheim et al. reported a relatively high local recurrence rate of 30% [STST is a rare and unique clinicopathological entity. STSTs present with characteristic MR imaging patterns, but precise differentiation from benign neoplasms is challenging. However, reduction in size after aspiration and subsequent rapid recovery of tumor size are suggestive to the clinician of the possible presence of STST, and cytological and pathological analyses should be performed through repeated aspiration and needle biopsies. In the instance that no malignancy is observed by needle biopsy, incisional and excisional biopsy should be performed to precisely diagnose STST. STSTs present with aggressive biological behavior and hemorrhagic changes, even at the metastatic lesions; therefore, prompt excision of the metastatic lesions could improve overall outcomes.


Dear Sir,Cysticercosis is a systemic parasitic disease caused by the larval form of Taenia solium. Cysticercus can be found in any part of the body including the subcutaneous tissues, skeletal muscles, eye, heart, liver, lungs, and peritoneum. Solitary cysticercosis of the parotid gland is rare entity and only few cases have been reported in English literature.[1-3] We report a case of cysticercosis within the parotid gland which was clinically misdiagnosed as parotid gland tumor.A 13-year-old girl presented with slowly growing painless mass at right preauricular region for the past one year. There was no history of fever, pain, or weight loss. Local examination revealed a rounded 2 cm x2 cm sized, soft-to-firm non-tender mass. The overlying skin showed no signs of inflammation. No cervical lymphadenopathy was noted. Routine blood count including absolute eosinophil count; biochemistry and urine analysis were within normal limits. The clinical diagnosis was that of a parotid gland tumor. FNAC yielded few drops of clear fluid with granular particles. The smears were air dried and stained with May-Grunwald-Giemsa (MGG) stain. On cytology, fragments of bluish fibrillary material with interspersed small nuclei were seen . Fair number of lymphocytes, palisading histiocytes, and degenerated cells in dirty granular background were noted. No eosinophil, granuloma, giant cells or atypical cells were seen. A diagnosis of cysticercosis of parotid gland was made. The patient was advised antihelminthic therapy which resulted in complete resolution of the parotid swellingSigns and symptoms of cysticercosis depend on the site of involvement and the stage of evolution. However, the most common presentation is swelling at the affected site. It is commonly misdiagnosed as soft-tissue tumor. In our case, the preoperative diagnosis was a parotid tumor and radiological imaging was in plan but FNAC changed our management plan. In previously reported cases, cysticercosis of parotid presented as mild swelling, or masquerading as a salivary gland neoplasm or with features resembling acute parotitis.[1-5] Sometime, cysticercosis of parotid gland is secondary involvement in case of disseminated cysticercosis.Definitive diagnosis can be made on FNAC or open biopsy. FNAC is now being increasingly accepted as a reliable, out-patient diagnostic procedure for preoperative diagnosis and may even obviate the need for open biopsy as in our case. In conclusion, cysticercosis should be considered in the differential diagnosis of parotid lump in endemic area with FNAC as the diagnostic tool.Source of Support: NilConflict of Interest: None declared


Primitive neuroectodermal tumors (PNETs) are rare tumors of uncertain histogenesis that occur predominantly in children and young adults. The current study reports a case of PNET in a 60-year-old female, which presented clinically as an intraspinal tumor, causing symptoms of lower back pain, numbness and pain in the right lower extremity. The patient underwent tumorectomy. Following primary therapy, the symptoms of spinal cord compression were relieved. The patient underwent several courses of radiotherapy following surgery but refused to continue with chemotherapy. After a further four months, the tumors recurred and the patient succumbed to the disease. Primitive neuroectodermal tumors (PNETs) are extremely rare tumors which typically arise from multipotent progenitor cells and are considered to be of neuroectodermal derivation . Since tThe present study reports the case of an otherwise healthy 60-year-old female with extradural PNET extending into the lumbar cavity, which caused symptoms of nerve root compression. Few such presentations have been reported previously . WrittenA 60-year-old female was admitted to Shanghai Tenth People’s Hospital Affiliated to Tongji University  due to a one-year history of increasing lower back pain, worsening numbness and pain on the back of the right thigh. The patient did not smoke or consume alcohol, and was suffering from diabetes, which was managed by a controlled diet. Initially, the patient’s blood pressure was 130/80 mmHg , with a regular pulse of 80 beats/min  and a respiratory rate of 18 breaths/min . The patient was afebrile. On physical examination, hypoesthesia was detected on the back of the thigh and the knee jerk reflex was found to be reduced. In the straight leg raising test an angle of 30° was achieved. The results of all laboratory tests, including complete blood count, renal, bone, hepatic, and coagulation profiles, lactate dehydrogenase, carcinoembryonic antigen, α-fetoprotein, carbohydrate antigen (CA) 19-9 and CA12-5 levels, were normal. Computed tomography (CT) imaging of the lumbar spine revealed a 4.9×2.1×1.8 cm mass with ill-defined margins from the L2–L3 vertebrae . The lesThe patient subsequently underwent intraspinal neoplasm resection. Following a half laminectomy of vertebrae L2 and L3, the 4.9×2.1×1.8 cm ill-defined mass was revealed. The tumor was adhered to the right L2 nerve root and extended into right lumbar cavity through the dilated intervertebral foramen between L2 and L3. Following the complete removal of the mass, the L2 nerve root was dissociated. L3 nerve root activity was improved and all resection margins were free from tumor cells. Macroscopically, the outer surface of the resected mass was white, irregular, firm, and marked with several prominences, and the cut section revealed irregular, ulcerated and necrotic tissue. Postoperatively, the patient showed partial improvement of the deficits; lower back and right thigh pain was alleviated and a significant improvement was achieved in the straight leg raising test, when compared with that observed preoperatively.Immunohistochemical evaluation of CD99 expression revealed characteristic reactivity on the tumor cell membranes. Histopathological examination of the mass revealed that the tumor cells had small round or oval morphology, strong staining for neuron specific enolase (NSE), fine chromatin, indistinct nucleoli and signs of mitosis. Homer-Wright rosettes were observed, composed of tumor cells surrounding a central region of filamentous fibers combined with necrotic blood vessel and tumor tissue. This led to a diagnosis of PNET.Focal radiation therapy to the spinal cord (L1–L5)  was administered over a period of six weeks, however, chemotherapy was refused. Four months following surgery and radiotherapy, the tumors recurred and the patient succumbed to the disease four months later.PNETs may be classified as central (cPNET) or peripheral (pPNET), and both types have poor prognoses . pPNET rPrimary spinal PNETs are now more frequently diagnosed due to the improvement of histological techniques, particularly immunohistochemistry. Initially, these cases were diagnosed as astrocytoma, neurofibroma or ependymoma dependent upon on the location of the tumor in relation to the dura . NeurofipPNET is a highly aggressive cancer associated with poor prognosis. Surgical excision cannot remove the lesion completely, leading to a postoperative recurrence rate of 90%. The current recommended treatment for pPNET is a combined therapy including surgery, high-dose local radiotherapy and chemotherapy .Although primary PNETs may be indicated by radiological features, immunohistochemical evaluation following surgery is required to confirm the diagnosis. Histological examination must be conducted in every suspected case to diagnose this type of tumor. The current study illustrates a unique case of intraspinal PNET that does not match the typical age distribution for this condition; few similar cases have been previously reported –8. RadioDespite improvements in surgical techniques and adjuvant chemotherapy, the prognosis of this malignancy remains poor. Further research into the molecular pathogenesis of PNET and its potential application in immunotherapy is crucial for the development of more effective treatments for this condition.


Primary small cell neuroendocrine carcinoma (SNEC) of paranasal sinuses is an extremely rare malignant tumor known for its aggressive clinical behavior.n = 19) and computerized tomography (CT) and MRI (n = 18) were retrospectively studied. CT and MRI were undertaken to investigate tumor features.Nineteen patients with SNEC in paranasal sinuses by magnetic resonance imaging (MRI) (n = 6), maxillary sinus (n = 4), and bilateral sphenoid sinus (n = 9). All lesions showed a symmetry or ‘pigeon’ pattern in the bilateral sphenoid sinus (n = 9). On CT scan, the lesions showed to be isodense (n = 3) or mild hyper-dense (n = 15). Bone changes included bony absorption or sclerosis (n = 3) and moth-eaten bone destruction (n = 16). Mild cystic components were visible in five patients with SNEC. There was no evidence of calcification in any of the SNEC tumors. The lesions were isointense on T1WI and isointense (n = 6) or mild hyper-intense on T2WI (n = 13). The lesions showed mild or moderate homogeneous enhancement after the administration of a contrast agent. The aggressive nature of the tumors was demonstrated by invasion of adjacent structures, which showed involvement of the nasal cavity (n = 17), orbits (n = 15), pterygopalatine fossa (n = 9), ethmoidal sinus and sphenoid (n = 5), clivus ossis occipitalis (n = 2), cavernous sinus and internal carotid canal (n = 5), optic canal (n = 3), jugular fossa (n = 2), anterior fossa (n = 2), apex partis petrosae ossis temporalis (n = 3), meninges (n = 2), temporal fossa and infratemporal fossa (n = 4), and pharyngonasal cavity and parapharyngeal space (n = 3). There was evidence of distant metastasis in five (lung) and one (liver) of the tumors. Fifteen patients  expired within 5 years of the initial diagnosis, and the other patients are currently still alive.The lesions were located in the ethmoidal sinus (A tumor exhibiting mild or moderate homogeneous enhancement together with a symmetry or ‘pigeon’ pattern in the bilateral ethmoidal sinus may be considered as specific MRI features. Primary small cell neuroendocrine carcinoma (SNEC) of paranasal sinuses is an extremely rare malignant tumor known for its aggressive clinical behavior ,2. MoreoA search of pathology records and PACS system identified 19 patients {Chinese, 84% (16/19) of patients were diagnosed by biopsy} with SNEC in paranasal sinuses who were hospitalized at Subei People’s Hospital, Yangzhou, China from January 2006 to September 2014. Eighteen patients underwent CT, and all patients underwent MRI examination. Details of the patients’ age, gender, tumor location, and clinical symptoms are recorded.All examinations were performed on a multidetector computed tomography (MDCT) scanner . The parameters of the CT scanner are 250 mAs, 120 kVp, a rotation time of 0.75 s, a pitch of 1.204, a 25-cm field of view, a matrix size of 512 × 512, a slice thickness of 1.5 mm, and a detector configuration of 64 × 0.625 mm.n = 5) or 3.0 T (n = 14) MR scanner  on patient for head imaging. Before contrast injection, standard brain protocol was applied: unenhanced axial T1-weighted images, axial, coronal and sagittal T2-weighted images, and axial fluid attenuated inversion recovery sequences were obtained. The parameters of the MRI scanner are a 23-cm field of view, a matrix size of 256 × 162, and a slice thickness of 4 mm. T1-weighted spin echo (SE) images were obtained in the axial plane (repetition time/echo time (TR/TE), 279/2.3 ms, two excitations). T2-weighted fast SE images  and T2-weighted short-time inversion recovery (STIR) in the axial and coronal planes were obtained before injecting the contrast material. After the intravenous administration of gadopentetate dimeglumin . Fat-saturated T1-weighted SE images were obtained in the axial, coronal, and sagittal planes with the same parameters that were used before Gd-DTPA injection. Eleven cases had time-signal intensity curve (TIC) examination.MR examination was performed with a 1.5 T  with SNEC in paranasal sinuses. The mean age at diagnosis was (46.7 ± 7.6) years (range from 26 to 63 years). Headache, vision loss, hyposmia, yellow nasal discharge, and exophthalmos were found in 17, 12, 11, 11, and 7 out of 19 patients, respectively.n = 9, Figure n = 6, Figure n = 4). All lesions showed a symmetry or ‘pigeon’ pattern in the bilateral sphenoid sinus  or mild hyper-dense (n = 15). Bone changes included bony absorption or sclerosis (n = 3) and moth-eaten bone destruction (n = 16). Mild cystic components were visible in five patients with SNEC. There was no evidence of calcification in any of the SNEC tumors.On CT scan, the lesions showed to be isodense (1WI and isointense (n = 6) or mild hyper-intense on T2WI (n = 13). The lesions showed mild or moderate homogeneous enhancement after the administration of a contrast agent. TIC showed plateau type in 11 cases. The aggressive nature of the tumors was demonstrated by invasion of adjacent structures, which showed involvement of the nasal cavity (n = 17), orbits (n = 15), pterygopalatine fossa (n = 9), ethmoidal sinus and sphenoid (n = 5), clivus ossis occipitalis (n = 2), cavernous sinus and internal carotid canal (n = 5), optic canal (n = 3), jugular fossa (n = 2), anterior fossa (n = 2), apex partis petrosae ossis temporalis (n = 3), meninges (n = 2), temporal fossa and infratemporal fossa (n = 4), and pharyngonasal cavity and parapharyngeal space (n = 3). There was evidence of distant metastasis in five (lung) and one (liver) of the tumors.The lesions were isointense on TMacroscopic examination reveals sheets, cords, or ribbons of small cells with little cytoplasm. Scattered areas of necrosis may be observed, and the typical crush artefact of neoplastic cells is often visible. Hemorrhage (hemosiderin deposition) was visible only in two patients with SNEC. Immunochemistry staining demonstrated that Syn, CK, CgA100, and NSE were positive in 18, 17, 16, and 16 cases, respectively.In this study, all of the 19 patients with SNECs underwent surgery, radiotherapy, or chemotherapy, of which all patients were able to be followed up from 13 to 167 months. Fifteen patients (78.9%) expired within 5 years of the initial diagnosis, and the other patients are currently still alive.SNEC occurs mainly in the lungs and accounts for approximately 20% of primary lung carcinomas . Less thSNEC in paranasal sinuses has been described to affect primarily adults without gender differences . The aven = 5) and liver (n = 1), which is coincidence with the prior reports.No particular risk factor for the tumor occurring in elderly patients has been identified . ClinicaSurgery, radiotherapy, or chemotherapy therapeutic methods either alone or in combinations are used by various head and neck oncologists . A groupCalcification (0/19) and hemorrhaging (2/19) are rare in SNEC, and accordingly, these features were not present radiologically or pathologically in the current study. In addition, bony destruction has been a common imaging feature of SNEC in previous studies. In the current study, bony erosion was frequently observed in paranasal sinuses and sclerosis was rare . Radiolo2WI or enhanced T1WI [SNEC in paranasal sinuses shows rare necrosis or hemorrhage on pathology, which is coincidence with the homogeneous signal on Tced T1WI . Primaryced T1WI . This inIn our study, nine cases distributed a symmetry or ‘pigeon’ pattern in the bilateral ethmoidal sinus. The characteristics were only found in the SNEC and may be considered as specific MRI features. A tumor exhibits features, for example, the lesions were located in the sphenoid sinus and distributed a symmetry or ‘pigeon’ pattern. MRI showed that the tumor grows invasively, with mild or moderate homogeneous enhancement, except for the typical imaging findings of squamous cell carcinoma, lymphoma, and adenoid cystic carcinoma, so we considered the possibility of SNEC .2WI are the hallmarks. ACC affects a broad age range, but it is uncommon before the age of 20 years and the peak incidence is in the fifth decade. The imaging features of sinonasal ACC may be observed with a combination of bony erosion and sclerosis on CT and intermediate or high signal intensity on T2WI. Lymphoma usually demonstrates bony erosion or infiltration of the sinonasal cavities and orbits without calcification [1WI and T2WI and homogeneously contrast enhancement on postcontrast CT or MRI. ONB is an aggressive neuroendocrine tumor located highly in the nasal cavity. It affects a wide range with peaks in the second and fifth or sixth decade. Peripheral areas of cystic degeneration and calcific foci are radiologic features associated with ONB.The differential diagnosis of SNEC in paranasal sinuses includes inverted papilloma (IP), squamous cell carcinoma (SCC), adenocarcinoma, adenoid cystic carcinoma (ACC), lymphoma, and olfactory neuroblastoma (ONB). Those tumors have similar radiologic findings such as soft tissue mass, bony destruction, and different patterns of enhancement. IP has a typically ‘lobulated’ or ‘cerebriform’ configuration on CT and MRI and may contain hyper-dense foci . SCC of fication . It exhiThe present study had certain limitations. Firstly, a small number of patients were included owing to the rarity of SNEC, and secondly, 84% (16/19) of patients were diagnosed by biopsy. Therefore, further multicenter cooperation on the radiological diagnosis of SNEC is required.In conclusion, SNEC is a rare and aggressive malignancy. CT or MRI accurately demonstrates the location and extent range of SNEC; however, SNEC may exhibit certain imaging features that are similar to other tumors in the head and neck regions. The present study indicated that a tumor exhibiting mild to moderate homogeneous enhancement together with a symmetry or ‘pigeon’ pattern in the bilateral ethmoidal sinus may be considered as specific MRI features.


Primary gastrointestinal lymphoma is a rare entity, commonly involving stomach, small bowel, and colorectum. The usual location for small bowel B cell lymphoma is distal ileum due to abundant lymphoid tissue. We are reporting the case of a 53-year-old lady presumptively diagnosed as Crohn's disease on clinical and radiological grounds but histopathologically proven to be an unusual variant of isolated primary non-Hodgkin's lymphoma. Gastrointestinal (GI) lymphomas may clinically be confused with other GI tumours as well as with inflammatory bowel disease. About 5% of all lymphomas primarily involve the GI tract. The small intestine is the site of origin of about 15–25% of primary GI lymphomas, with stomach being the most common site affected. GI lymphomas arise from the lymphoid tissue within the wall of small intestine which is abundant in the ileum. Primary GI lymphoma is usually localized to a single segment of the intestine, with multicentricity seen in 15–20% of cases [We report the rare case of a 53-year-old lady presenting with features, which was clinic-radiologically diagnosed to be jejunal stricture secondary to Crohn's disease (CD) on the basis of clinical and radiological features and was reported to be a case of non-Hodgkin's lymphoma (NHL) of B cell type (uncommon in jejunum) on histological evaluation. Our report emphasizes the importance of considering lymphoma in the differential diagnosis of jejunal stricture presenting with small bowel obstruction.A 53-year-old lady presented to us with chief complaint of left-sided abdominal pain associated with multiple episodes of bilious vomiting over duration of 3 months. She had episodes of diarrhoea for the initial week of onset of symptoms which had improved with oral antibiotics. There was no history indicative of immunosuppression. The general physical and abdominal examinations of the patient were within normal limits. Her blood parameters were within normal limits. Ultrasonography of abdomen revealed evidence of concentric wall thickening of small bowel loops in the left lumbar and paraumbilical region measuring approximately 9 mm with loss of wall stratification. Contrast Enhanced Computed Tomography (CECT) abdomen showed stricture with thick enhancing walls in proximal jejunum measuring 4 cm in length with surrounding fat stranding and dilated proximal and collapsed distal bowel loops. A focal area of proximal jejunum was also thickened. It also showed evidence of hyperemia with dilated mesenteric vessels. These features were suggestive of inflammatory pathology, with a differential diagnosis of Crohn's disease or chronic infectious process such as tuberculosis. Colonoscopy was unremarkable.She was thereafter planned for surgery. Intraoperatively there was a jejunal stricture present at approximately 1.5 feet distal to duodenojejunal flexure with surrounding fibrosis and mesentery and transverse colon adhered to the segment with associated mesenteric lymphadenopathy Figures .The histopathology report showed diagnosis of non-Hodgkin's lymphoma of B cell type. Immunohistochemistry was positive for CD20, CD3, and LCA and was negative for CD117 and Pan CK. The postoperative period of the patient was uneventful and the patient was given the chemotherapy based on R-CHOP regimen .Primary gastrointestinal non-Hodgkin's lymphomas (PGINHL) are one of the rare lymphoproliferative neoplasms arising from lymphatic tissue below the mucosal membrane of the gastrointestinal tract (GIT), accounting for less than 5% of GIT lymphomas . The criPGINHL is usually associated with haemorrhage and perforation and rarely with stricture formation. Although stricture formation might be one of the predictable complications of PGINHL, it has not been reported in previous studies; in a prospective trial of 56 patients with intestinal lymphoma, there were no reported cases of bowel stricture [The main modality of treatment for intestinal lymphoma is chemotherapy. Surgical intervention is usually reserved for complicated lymphomas like in obstruction or perforation. The most common chemotherapeutic regimen includes R-CHOP for B cell lymphoma.Intestinal lymphomas may masquerade as Crohn's disease or chronic infectious disorders. On the other hand, there may be some causal association between the two pathologies, although so far it is unclear. Hence a differential diagnosis of lymphoma should always be considered while dealing with such patients. Endoscopy with deep biopsies followed by immunophenotypic studies should be considered as a part of evaluation so as to reach to a definite diagnosis and timely intervention.


Chylous ascites is an uncommon finding which is usually associated with recent abdominal/oncologic or retroperitoneal surgery. It is not usually seen in cases of acute obstruction.A patient who had previously undergone a laparoscopy-assisted distal gastrectomy with Roux-en-Y reconstruction for early gastric cancer presented with acute abdominal pain and epigastric fullness. Computed tomography suggested small bowel obstruction due to volvulus. We were able to reduce the volvulus and close a Petersen’s hernia without resecting the bowel; a large amount of chylous ascites was an incidental finding.We present a case of chylous ascites occurring in a setting of small bowel obstruction due to Petersen’s hernia, 3 years after successful distal gastrectomy for early gastric cancer, with no evidence of tumor recurrence. A large amount of ascites can accompany bowel obstruction with nonviable bowel loops . AscitesAn 85-year-old man presented to our hospital with a 5-h history of abdominal pain and distention. He attended the outpatient department at our hospital for regular checkups but had been asymptomatic until he visited out emergency department. At age 82 years, he had undergone laparoscopy-assisted distal gastrectomy with Roux-en-Y reconstruction for early gastric cancer. An antecolic isoperistaltic gastrojejunostomy was performed using an endoscopic linear stapler. A serosubmucosal single-layer hand-sewn anastomosis (Jourdan’s) was performed through a small abdominal incision for Y reconstruction. The mesentery of the Y loop was closed using nonabsorbable braided polyester (3-0) interrupted sutures, while the Petersen’s defect was not closed. Pathology revealed a stage IB (T2N0M0) tumor; the resection stumps were negative. His postoperative course had been unremarkable. Computed tomography (CT) performed 1.5 months prior to admission showed no evidence of tumor recurrence and no ascites. The patient had no other relevant medical history.Physical examination on arrival showed focal tenderness and distention in the epigastrium. His body temperature was 36.4 °C.9 cells/L  and a C-reactive protein (CRP) level of 16.2 nmol/L . A contrast-enhanced abdominal CT scan  count of 8.7 × 10Intraoperatively, a massive amount of milky fluid was observed in the peritoneal cavity, and approximately 1 L was removed Fig. . The greThe patient’s postoperative course was uneventful. The color of the ascites changed from milky to light yellow, and the TG levels decreased to 21 mg/dL on postoperative day 4. The patient was not required to eat a fat-restricted diet during hospitalization and was discharged from the hospital 16 days after surgery. He underwent a physical examination and CT scan in the outpatient department 10 months after discharge from the hospital. There was no evidence of ascites Fig. .Fig. 4CTChylous ascites typically develops due to congestion of the lymphatic system. Malignancy—particularly lymphoma—is a relatively common cause of chylous ascites in adults . MetastaIn the present case, an abdominal CT scan showed a dilated colon and severe ascites with a whorl-like appearance of the SMA and mesentery, findings generally suggesting small bowel obstruction from volvulus , 8, whicWe identified eight case reports of chylous ascites with bowel obstruction in the English language literature Table . ChylousThe abdominal CT scan showed that there was an intestinal obstruction and large amounts of ascites. These findings sometimes indicate strangulated obstruction. Our case was interesting in that the physical examination and laboratory tests did not match the severity of the problem as shown on CT. It is difficult to explain this discrepancy, and it is difficult to prove accurately what caused the chylous ascites. This situation is very rare. The absence of bowel ischemia suggests that the arteriovenous system was patent while lymphatic channels were occluded in this case. This vascular patency may explain the discrepancy between the laboratory values and physical findings and the imaging findings, and the fact that no previous cases have reported the requirement for an enterectomy. The obstruction of the lymphatic system resulted in the extravasation of chylous fluid . Pre- anWe present a case of chylous ascites associated with intestinal obstruction from volvulus due to a Petersen’s hernia. Detecting the presence of chylous ascites in small bowel obstruction is important, because the therapeutic strategy may differ depending on it. The presence of chylous ascites with intestinal obstruction may represent a particular situation in which the arteriovenous system is patent, and more conservative therapy may be appropriate.Written informed consent was obtained from the patient’s family for the publication of this case report and any accompanying images. A copy of the written consent is available for review from the Editor-in-Chief of this journal.CRP, C-reactive protein; CT, computed tomography; HU, Hounsfield Units; SMA, superior mesenteric artery; TG, triglycerides; WBC, white blood cell count


Ulceration in a blind loop can lead to massive gastrointestinal tract (GIT) bleeding. A 13-year old girl presented with symptomatic melena requiring repeated blood transfusion since childhood. She was an operated case of small bowel atresia in neonatal life. Her upper and lower gastrointestinal endoscopies were normal. Operation showed presence of multiple ulcers in two blind loops (parts of previous side to side anastomosis) and at the anastomotic site. She underwent resection and end-to-end anastomosis of the small bowel leading to complete resolution of melena and anemia. A 13-year old girl presented with history of intermittent melena and bleeding per rectum requiring multiple blood transfusions since the age of 5 year. She was an operated case of small bowel atresia at day-2 of life. She was vitally stable but markedly pale. There were no significant findings on clinical examination. Her Meckel’s and RBC tagged scans were normal. Her upper and lower gastrointestinal flexible endoscopies were reported as normal. A CT scan of abdomen and pelvis showed presence of solitary dilated small bowel loop with air-fluid level near the central abdomen. At the time of presentation her hemoglobin was 2.7 gm %. She was transfused with three units of blood. After optimization she underwent operation. At exploration after extensive adhesiolysis two blind loops close to the side-to-side anastomosis found in the proximal ileum . Enteroscopy performed through the blind loops revealed presence of a large circumferential anastomotic ulcer and multiple ulcers in both blind loops. The rest of the small bowel was normal. Resection of both blind loops and side-to-side anastomosis was done. Following resection end-to-end anastomosis of proximal and distal small bowel was performed. Postoperative course remained uneventful. Histopathology confirmed the presence of anastomotic ulcer with severe submucosal inflammation and reactive lymphoid hyperplasia. At one year follow up; she is asymptomatic with no history of melena and bleeding per rectum with hemoglobin level of 13 gm/dl without any need of blood transfusion.Melena and bleeding per rectum is often a challenging condition as to the diagnosis and treatment. These patients frequently need extensive evaluation by imaging studies to establish diagnosis for its effective treatment. Flexible gastrointestinal endoscopy, technetium nuclear scan, GIT contrast studies, CT scans, CT angiography, and RBC tag studies are various options that can pick the source of GIT bleed. Capsule endoscopy is a non-invasive tool to visualise mucosal surface of small bowel. However, this capsule is very large in size and it is difficult for a child to swallow. Diagnostic laparoscopy or exploratory laparotomy is one of the options in cases where the imaging studies and endoscopic evaluation fail to fetch diagnosis. Source of bleeding like Meckel’s diverticulum, duplication cyst, and vascular malformations etc. can be found. If no anatomic lesions are identified, one can perform peroperative small bowel enteroscopy to inspect small bowel mucosa.[1-5]Blind loop syndrome is a well known problem and it usually presents with diarrhea, abdominal pain and fever. It can lead to malabsorption, steatorrhea and deficiency of fat soluble vitamins.[5] However, presence of ulcers in the blind loops along with anastomotic ulcerations is extremely uncommon.[1-3] In our patient all the investigations could not direct us for the diagnosis however, exploration revealed the source of bleeding. To conclude, blind loops may grow to a significant length and may become symptomatic as happened in the index case.Source of Support: NilConflict of Interest: None declared


We describe the case of a 44-year-old woman with primary Burkitt lymphoma of the heart who presented with abdominal bloating and epigastric discomfort secondary to tamponade physiology caused by a large pericardial effusion. The pericardial fluid contained a large number of highly atypical lymphocytes with moderate basophilic cytoplasm, rare punched-out vacuoles, a vesicular nuclear chromatin, large nucleolus, and marginated chromatin that by FISH were positive for the 8;14 translocation. She had no other sites of disease. She was treated with four alternating cycles of modified CODOX-M and IVAC in combination with rituximab and remains in remission more than 5 years since diagnosis. Primary cardiac tumors are rare. Most of them are benign with myxoma being the most frequent histologic type –3. PrimaDiffuse large B cell lymphoma is the most common histologic type of cardiac lymphoma. Primary cardiac Burkitt lymphoma (BL) has been reported very rarely. In our review of the literature we identified 4 cases in adults. Kuroda et al. reported the case of a 79-year-old female with cardiac BL in the form of a left ventricular mass and a massive pericardial effusion. Diagnosis was made by pericardiocentesis that showed large B cells that had an t8;22) translocation. The patient initially went into remission with chemotherapy with CVP  but relapsed in the brain and eventually succumbed to her disease . Fatimi ;22 transIn the literature we identified 3 more pediatric cases. Chalabreysse et al. in 2002 described a case of primary BL as part of their review of the only 35 cases of primary cardiac lymphoma published to that date . It was We herein report the case of a 44-year-old woman with primary BL of the heart. This is only the fifth reported case in an immunocompetent adult.A previously healthy 44-year-old woman presented to the emergency room with early satiety, abdominal bloating, and epigastric discomfort that had started about a week ago. A right upper quadrant ultrasound was done followed by a CT of the abdomen and pelvis. The CT scan showed a partially visualized large pericardial effusion. There was no lymphadenopathy. She then underwent an echocardiogram that showed a hyperdynamic left ventricle systolic function with large circumferential pericardial effusion with tamponade physiology. She was taken to the cath lab where a pericardiocentesis was performed and a total of 730 cc of sanguineous fluid was drained and a pericardial drain was placed. The pericardial fluid contained 65,000 WBCs with the differential showing 6% polys, 1% lymphocytes, 1% monocyte, and 92% highly atypical lymphocytes with moderate basophilic cytoplasm, rare punched-out vacuoles. Most of the large atypical cells had a vesicular nuclear chromatin, some with large nucleolus and marginated chromatin. A hematoxylin and eosin (H&E) stained cell block preparation is shown in For staging she underwent a bone marrow biopsy that was negative for lymphomatous involvement and a CT of the torso that showed a decreased, now small pericardial effusion, stable small bilateral pleural effusions, a 2.6 cm lobulated soft-tissue lesion in the right atrium, and no evidence of lymphadenopathy. A cardiac MRI revealed on T1- and T2-weighted images a broad base, isointense structure measuring 3 cm × 1 cm arising from the lateral wall adjacent to the atrioventricular junction of the right atrium . ConnectPrimary cardiac lymphomas are extremely rare but unlike most other cardiac tumors fast growing and potentially curable , 17–19. Our patient presented with abdominal and epigastric discomfort, which were most likely manifestations of visceral congestion secondary to elevated right heart filling pressures associated with cardiac tamponade.Certain radiographic characteristics might point towards a lymphoma , 21. TheStaging procedures should be similar to the other systemic lymphomas as heart involvement is usually secondary rather than the only location. Infection with HIV needs to be ruled out as part of the initial workup as extranodal involvement in general and heart involvement in particular are more common in HIV related lymphomas . Even thIn summary primary cardiac Burkitt lymphoma is an extremely rare and very fast growing tumor of the heart. Suspicion should be high though as cure can be achieved with multiagent chemotherapy.


Atypical hepatocellular neoplasm (AHN) is an adenoma-like hepatic tumor that even occurs in noncirrhotic liver of males (any age) or females ≥50 years old, or associates focal atypical features.In this article, 2 unusual cases diagnosed in elderly cirrhotic patients, unrelated to steroids, are presented.The first case was incidentally diagnosed in an 83-year-old female. During laparoscopic surgery for cholecystectomy, hemoperitoneum was installed and laparotomy was necessary to remove a 70-mm nodular encapsulated hepatic tumor that was microscopically composed by hepatocyte-like cells with clear cytoplasm, arranged in 1- to 2-cell-thick plates and intermingled with areas of peliosis, negative for alpha fetoprotein (αFP), p53, and keratin 7, with low Ki67 index and intact reticulin framework. The second case was incidentally diagnosed at ultrasound examination in a 66-year-old male. The surgical specimen was a 50-mm solid multinodular tumor that microscopically consisted of 3-cell-thick plates of hepatocyte-like cells with acinar, pseudoglandular, and trabecular architecture, intermingled with peliotic areas, without nuclear atypia and disintegrated reticulin framework. Both of the cases occurred in cirrhotic liver. The tumor cells were marked by AE1/AE3 keratin, displayed a Ki67 index < 5% and were negative for αFP, p53, and keratin 7. No recurrences or any other disorder occurred 6 months after surgery.In cirrhotic liver, adenomas with peliosis that do not satisfy all the diagnosis criteria synthesized in the article should be considered AHNs and differential diagnosis includes hepatocellular carcinoma but also focal nodular hyperplasia, regenerative nodules, and dysplastic nodules. This histological entity is not yet included in the WHO Classification list. Further careful examination leaded to modified diagnosis: one of the cases was classified as AHNs and the other one was considered well-differentiated hepatocellular carcinoma (HCC). Besides the clinicopathologic characteristics of the cases, the criteria of differential diagnosis of HA versus AHN and HCC were presented with illustrative pictures. Consent of the patients was obtained for surgical intervention and publication of these cases.An 83-year-old nonalcoholic female, with 6 months history of lithiasic cholecystitis, was admitted to the hospital with severe right upper quadrant and epigastric pain, nausea, vomiting, and scleral jaundice. Emergent laparoscopic cholecystectomy was decided. Before surgical intervention, ultrasound examination was performed and a hepatic hemangioma of the V, VI, and VII segments of the liver was suspected.Her past medical history included nonoperated acute pancreatitis (10 years before) and hepatitis B-related Laennec's atrophic cirrhosis . Five years ago, she was also diagnosed with a right breast neuroendocrine invasive tumor in pT2N0 stage; right mastectomy was performed, without any postoperative oncologic therapy. No recurrences or metastases were suspected. The gynecologic examination revealed no modifications.At the current admission, blood tests did not show significant disorders except slight anemia (hemoglobin 10.40 g/dL and hematocrit 29.90%), lymphopenia (18.50%), and slight elevated aspartate aminotransferase and alanine transaminase .During laparoscopic surgery, exploration of the peritoneal cavity revealed hemoperitoneum. Laparotomy was performed and the distended gallbladder was removed. The peritoneal hemorrhage occurred as a result of rupture of a 75-mm diameter nodular tumor that was relatively well defined and involved the segments 5, 6, and 7 of the liver.Gross examination of the surgical specimen showed a 75 mm × 70 mm × 55 mm encapsulated nodular tumor, with a 25 × 20 ruptured bleeding area. On cut section, the gray-colored tumor had a soft consistency and presented multiple hemorrhagic areas Figure . The livBased on the above findings, the initial diagnosis was HA with clear cell features and peliosis. Based on the patient's age  and occurrence of the tumor in the setting of cirrhosis Table , the finA 66-year-old nonalcoholic male was admitted at the hospital with severe diffuse abdominal pain. His past medical history included primary hypertension and chronic B hepatitis, without Delta virus. Hepatitis was diagnosed 20 years before and was not treated with any drugs, except hepatoprotective pills. Two years ago, hepatitis-related Laennec atrophic cirrhosis was diagnosed. At the current admission, with no therapy, there were no signs of decompensated cirrhosis.Physical examination did not reveal significant disorders, except a slight abdominal wall contraction. Ultrasound examination showed a 35 mm solid hepatic nodule in the sixth liver segment. Blood tests did not show significant disorders except slight anemia (hemoglobin 12.00 g/dL and hematocrit 35.20%), and lymphocytosis (46.00%). Transaminases were within normal limits  as well as total bilirubin (0.40 mg/dL).Based on these examinations, laparotomy was decided, and the sixth segment of the liver that embedded a well-defined encapsulated tumor was removed.Gross examination of the surgical specimen revealed a 35 mm × 30 mm × 38 mm round encapsulated tumor, surrounded by hepatic parenchyma. On cut section, the tumor had a multinodular solid aspect, was green-yellow in color, soft in consistency, and presented multiple small hemorrhagic areas Figure . The livUnder microscope, the encapsulated tumor was shown to be composed by multiple nodules separated by connective bands. Within the nodules, hepatocyte-like cells that displayed tubular or glandular-like, acinar and solid-trabecular arrangement of the tumor cells with clear component was noted. No atypical nuclei were identified; the reticulin framework was disintegrated Figure . The tumBased on the microscopic aspect, the initial diagnosis was HA with mixed components, including trabecular and acinar structures. Based on the patient's gender , the multinodular aspect, 3 hepatocyte-like cells thick plates, many pseudoacini, disintegrated reticulin framework Figure  and asso9 especially in males.10 Despite their apparently benign morphology, AHNs can recur and metastasize and it is likely that malignization of HA is rather an incorrect diagnosed AHNs.11 To prevent bleeding and/or consequences of malignant behavior, surgical excision of adenomatous lesions larger than 5 cm is recommended in females, and in males, removal of any tumor nodules, respectively.6HAs and adenoma-like tumors such as AHNs are incidentally discovered during computed-tomography, ultrasound, or magnetic resonance imaging (MRI) examinations. In HAs larger than 70 mm in diameter, spontaneous rupture, intraperitoneal bleeding, and even malignant transformation in HCC can occur,12 but the large peliotic areas can also indicate a high risk for bleeding and during ultrasound examination the tumor can be misconstrued as hemangiomas, such as in this case. Microscopically, in contrast to hemangiomas, the peliotic areas do not display endothelial-lined walls. Although HAs of the left hepatic lobe are more predisposed to rupture,12 in this case, the spontaneous bleeding occurred in a tumor that involved the fifth, sixth, and seventh segments of the right-inferior part of the liver.In our first case, the risk factors for rupture and/or bleeding in a cirrhotic liver was the diameter that was higher than 70 mm,15 Type 1 HA occurs in patients with a median age of 45 years and is characterized by: 4 to 5 cm nodules composed by proliferation of hepatocyte-like cells, a rich inflammatory stroma with ductular reaction, marked sinusoidal dilatation, and thick-walled arteries. In males with alcoholic cirrhosis, a serum amyloid-A positive inflammatory HA was recently described.10 Type 2 HA is usually asymptomatic and occurs almost exclusively in women below 45 years, about 90% of them having a history of contraceptives use. Microscopically, the nodules with a median diameter of 4 cm are composed by hepatocyte-like cells with excessive lipid accumulation in their cytoplasm and can occur on the background of a steatotic liver.10 The third type occurs more frequently in young males, is usually associated with male hormones consumption, and the diameter is larger than 15 cm. Microscopically, it is characterized by proliferation of hepatocyte-like cells that can present nuclear atypia and pseudoacinar structures.15 Type 4 HA is more frequent in females that can present a history of contraceptives use, the diameter is around 4 cm, can be unique or multiple, and occurs in patients younger than 45 years.10Based on genetic and pathologic features, 4 major subtypes of HAs are known, with specific histologic features and clinical behavior: inflammatory type (type 1 ∼40–55% of the cases), hepatocyte nuclear factor (HNF-1α)-inactivated (type 2 ∼15–50%) HA, β-catenin-mutated HA (type 3 ∼10–18%), and unclassified HA (type 4 ∼10–30%).10 but its occurrence in an 83-year-old female and development in the background of hepatitis B-related liver cirrhosis indicated an AHN,11 based on the criteria synthesized in Table 11 However, its occurrence in a male with liver cirrhosis and disintegrated reticulin framework asserted for HCC.11The clinicopathologic characteristics of the first case presented in this article suggested a type 2 HA, an HNF 1-α-mutated subtype,16 whereas peliosis should be differentiated from an associated-cavernous hemangioma  type.17 However, both steatotic and peliotic adenomas shows, according to Lewin et al17, hyperintense signal on T1- and T2-weighted images and moderate enhancement at the arterial phase. The steatotic adenomas are usually smaller than 7 cm in diameter, compared to the peliotic type than can be larger.17 At contrasting MRI, no delayed enhancement is observed in steatotic type, whereas the peliotic-type adenomas can display persistent enhancement at the portal and delayed phase.17 In the present study, both cases were peliotic lesions. In first case, due to large peliotic areas, the ultrasonography revealed the suspicion of hemangioma that was removed due to acute hemoperitoneum. The second case showed, at ultrasonography, a nodule larger than 3.5 cm occurring in the setting of cirrhosis; this was the reason why it was surgically removed without any supplementary investigations.Regarding the preoperative diagnosis, ultrasonography, computed tomography, and MRI examinations are commonly used but differential diagnosis of HA versus HCC is very difficult. Biopsy is necessary for diagnostic confidence and adenomas larger than 4 to 5 cm, in male patients and/or patients with cirrhosis, should be surgically resected.This article showed 2 unusual cases that highlights the difficulties of diagnosis of tumors with peliosis developed in the setting of cirrhosis. The complex differential diagnosis should be based on the clinicopathologic background, histological aspect, reticulin stain, immunoprofile, and cytogenetic analysis of chromosomal abnormalities. The AHN is a histological entity that should be included and codified in the World Health Organization Classification system.


A 27-year-old female presented with a history of a right chest wall tumor at 3 years of age. At that time, the tumor was surgically resected and diagnosed as Ewing’s sarcoma (EWS), and postoperative chemoradiotherapy was administered. The patient remained disease-free for 25 years. At age 27, chest computed tomography revealed a mass adjacent to the anterolateral thoracic wall. After surgery, the diagnosis was primitive neuroectodermal tumor (PNET). She died of the disease 10 months later. PNET and EWS were integrated into a single item in the 2002 WHO classification; thus, they are considered clinically and pathologically identical. The morphologic, immunohistochemical, and molecular biological characteristics of both specimens showed that the second tumor was a local recurrence of Ewing’s sarcoma family of tumors (ESFT). Our case is the longest duration local recurrence reported. Long-term recurrences of ESFT and patients with recurrent ESFT have a poor prognosis; thus, long-term follow-up is necessary. Tumors of Ewing’s sarcoma family of tumors (ESFT) are malignant tumors that originate in the central and peripheral nervous systems and soft tissues in children and adolescents. The prognosis is generally poor. However, recent treatment outcomes of ESFT have improved with the use of multimodal therapy . AdvancePNET and Ewing’s sarcoma (EWS) were integrated into a single item in the 2002 WHO classification; thus, they are considered clinically and pathologically identical. Late relapses are seldom described. We report a patient with an ESFT who had a recurrence 25 years after initial surgery and postoperative chemoradiation.A patient presented to us with a remote history of treatment for a right chest wall tumor. At 3 years of age, she was noted to have a very large chest wall tumor in the right thoracic cavity Figure  without At 27 years of age, she was referred to our institution with the chief complaint of chest pain. Her chest X-ray demonstrated a well-defined, round mass in the right upper lung field. A computed tomography (CT) scan of the chest revealed a distinct mass adjacent to the anterolateral thoracic wall Figure , and metAs either radiation-induced sarcoma or a local recurrence of EWS was suspected, we performed extirpation of the tumor and chest wall (the left second to the fourth ribs), partial resection of the right lung, and reconstruction of the chest wall Figure . Intraopin situ hybridization analysis using a EWSR1 break-apart probe identified the rearranged EWSR1 gene in both cases. Thus, histopathologically, the tumor was diagnosed as a PNET. Four cycles of VDC  chemotherapy and two cycles of IE  and high-dose L-PAM  and radiotherapy of left thigh bone for a total dose of 30 Gy was administered after the second operation. She had recurrences in the right chest wall and upper middle lobe and metastases in the skull, rib, vertebrae, ilium, and thigh bone. She died of carcinomatous lymphangiosis 10 months after the second surgery.Pathologic findings were identical to those of the original chest wall tumor, with small round cells and extensive necrosis Figure . The speIn 1921, James Ewing reported a rare type of sarcoma in children, adolescents, and young adults that is a highly malignant tumor of the bone and soft tissue, composed of small round cells . SeparatPathologically, EWS/PNET is composed of small, round, uniform cells with characteristic small-sized rosette formation. These tumors, both with a poor prognosis, were described as separate entities in the small round cell tumor group in the second version of the WHO classification published in 1993. However, with recent improvements in molecular biology, a translocation   specific to both EWS and PNET has been identified, and the EWS-FLI-1 fused gene was identified at the cleavage site of this translocation. They therefore were subsequently integrated into a single item (Ewing’s sarcoma/PNET) in the WHO classification, published in 2007 . The ESFThe most useful immunohistologic reagent for the diagnosis of ESFT is the monoclonal antibody CD99, which recognizes a cell surface protein. Specimens stain strongly positive with the CD99 antibody in more than 90% to 95% of cases of reported ESFT.Chest wall ESFT tumors are rare, have a high rate of local recurrence, and frequently are metastatic at presentation. In a report of 84 thoracic PNET cases by Biswas et al., patient age ranged from 3 to 40 years (mean age = 15 years) and tumor diameter ranged from 1.6 to 20.0 cm (mean diameter = 9.0 cm). It occurred most commonly in the ribs (54%), the scapula (25%), and the chest wall (14%), with a male predominance 70%). Twenty-seven (32%) patients had metastatic disease at diagnosis. An independent prognostic factor for PNET is the presence of metastatic disease [0%. TwentThe morphologic, immunohistochemical, and molecular biological characteristics from both specimens supported that the second tumor was a local recurrence of an ESFT. Several prior studies established that the longest time until recurrence of ESFT was 19 years [We report a case of locally recurrent ESFT 25 years after initial treatment. To our knowledge, no case with such late local relapse as our case has been reported to date.We report a rare case of chest wall ESFT in a 27-year-old female. A right thoracic recurrence was surgically resected 25 years after the primary tumor, but the patient died of the disease 10 months after surgery. Our case suggests that patients with ESFT should undergo lifetime surveillance. Generally, it is difficult to detect recurrence from clinical symptom of the patients. Patients should be under observation using periodical CT, bone scintigraphy, or PET periodically.Written informed consent was obtained from the patient for publication of this case report and any accompanying images.


Primary intrathoracic chondrosarcomas are rare tumors. The present study reports three cases of primary intrathoracic chondrosarcomas in two males and one female aged between 45 and 64 years. Clinically, one case presented with cough and blood sputum, while the other two cases of primary intrathoracic chondrosarcoma were found incidently during a routine health examination. Radiologically, the chondrosarcomas presented as large masses with intratumoral calcification. Chondrosarcoma should be distinguished from other calcified pulmonary lesions. In this study, all three cases underwent surgical treatment, and in one case, the surgery was accompanied by radiotherapy. To date, all patients have been followed up for between two and three years and are alive. Accounting for approximately one-quarter of all primary osseous sarcomas, chondrosarcoma is the second most common type of primary sarcoma of bone. Although chondrosarcoma only occasionally originates within the lungs and bronchi, it is the most common type of primary malignancy of the chest wall . ChondroA 52-year-old female presented to the First Affiliated Hospital of Soochow University  with an intermittent cough and bloody sputum that had persisted for four months. A chest roentgenogram revealed a homogeneous, round, well-defined shadow in the left lung . ComputeA 64-year-old male presented with a slightly hyperdense mass with rounded boundaries on the right lower lung, which had been incidentally diagnosed during a routine health examination. . A CT scA 45-year-old male presented with a round mass on the left lung. The mass was homogeneously hypodense (near the density of water) and 6×5 cm in size on CT images . The masPrimary chest chondrosarcomas, including those arising from the chest wall  and lungs or bronchi, are uncommon . PrimaryThe natural history of primary intrathoracic chondrosarcoma is similar to that of skeletal chondrosarcoma. Chondrosarcomas usually occur in individuals >30 years old, with a male predominance . Patientet al , primary lung cancer and other intrathoracic sarcomas ,13. PH iIn conclusion, primary intrathoracic chondrosarcoma is a rare, malignant tumor that originates from the chest and may involve the chest wall, lungs or bronchi. Radiologically, primary intrathoracic chondrosarcomas usually occur as large masses with intratumoral calcification. Although histological analysis is always required for a definite diagnosis, imaging is important for analyzing the tumor. It may also be useful to pay careful attention to the imaging features of the tumor and its clinical manifestations for the diagnosis.


Physicians are educated with the classical teaching that symptomatic patients with Meckel's diverticulum (MD) most often present with painless rectal bleeding. However, a review of the literature reveals that young patients with MD will most commonly present with signs of intestinal obstruction, an etiology not frequency considered in patients presenting to the emergency department with obstruction. We present two cases of intestinal obstruction diagnosed in our emergency department, with Meckel's diverticulum being the etiology. An 18-month-old male with a past medical history significant for constipation and reflux presented to our pediatric emergency department with an approximately 5-hour history of lethargy, intermittent crying, and abdominal pain. The parents denied fever, vomiting, or abdominal distension but reported a decrease in oral intake and urine output. He had not stooled that day and had no prior surgical history.Upon arrival to the emergency department (ED), the patient was afebrile with a rectal temperature of 98.2°F, heart rate of 129 bpm, blood pressure of 115/71, respiratory rate of 28, and oxygen saturation of 100% on room air. On physical exam, he was notably lethargic and pale, with sunken eyes and dry mucus membranes. He had periods of wakefulness, during which he appeared uncomfortable. He was intermittently tachycardic. The abdominal exam was notable for decreased bowel sounds and moderate distension with diffuse tenderness to palpation.Intravenous access was obtained and the patient was given a 20 mL/kg normal saline bolus. Laboratory studies drawn were notable for a leukocytosis of 26,000 with a neutrophilic predominance and thrombocytosis. The chemistry obtained was grossly normal.Intussusception was high on our differential diagnosis. Multiple-view abdominal plain films and an ultrasound of the abdomen were requested.The supine abdominal plain film  revealedThe patient received a second 20 mL/kg saline bolus for persistent tachycardia and a pediatric fleet enema which did not produce significant stool. The patient developed worsening abdominal tenderness and bilious emesis and appeared obtunded, increasing our concern for an acute obstructive process. Intravenous piperacillin-tazobactam was empirically administered to the patient, given that a third 20 mL/kg normal saline bolus was administered, and a nasogastric tube was placed. A pediatric surgery consult was obtained and a noncontrast CT scan of the abdomen and pelvis was performed. The CT scan revealed a distal small bowel obstruction with evidence of ischemia and significant ascites.A diagnostic laparoscopy and subsequent exploratory laparotomy revealed a congenital band extending from Meckel's diverticulum to the root of the mesentery, with thickened loops of dilated and ischemic bowel strangulated within this space . SignifiA 3-month-old full-term male with no prior medical history was referred to our pediatric emergency department after presenting to an outside institution with voluminous emesis and dehydration. Abdominal plain films were suspicious for malrotation . There hOn presentation to our pediatric ED, the patient was afebrile, with a pulse of 123 bpm, blood pressure 103/57 mmHg, respiratory rate of 26, and oxygen saturation of 100% on room air. On physical exam, the patient was alert, active, and playful and in no acute distress. He had dry lips, but his skin was warm and with brisk capillary refill. His abdomen was soft, nontender, and nondistended and without hepatosplenomegaly. He had a normal testicular and inguinal exam.An abdominal ultrasound revealed multiple air filled loops of bowel within the mid-abdomen, with no evidence of intussusception. An upper GI series and barium enema were subsequently performed, revealing an abnormal position of the duodenum without the expected course of contrast to the left upper quadrant, suggesting the possibility of malrotation without volvulus.Pediatric surgery was consulted, and the patient was taken to the operating room for diagnostic laparoscopy. Surgical evaluation revealed Meckel's diverticulum with a congenital band, causing an extra-luminal obstruction of the adjacent bowel—the cause of his vomiting. Ironically, the patient did also have a malrotation, without volvulus or obstruction from the Ladd's bands that were present; however this abnormal anatomy was not the cause of the patient's symptoms.The congenital band and Meckel's diverticulum were resected to resolve the obstruction, without loss of bowel. Ladd's procedure was also performed to correct the malrotation. Final pathology report revealed Meckel's diverticulum without perforation lined by small intestinal and gastric antral mucosa showing active inflammation and reactive changes, with a nodule of pancreatic tissue in its wall.The differential diagnosis for a child with vomiting is broad and ranges from relatively benign conditions such as gastroenteritis to life-threatening causes such as volvulus. While the physical exam, laboratory studies, and imaging can often elucidate the cause of vomiting, it is sometimes incumbent upon the pediatric emergency medicine physician to recognize a surgical abdomen that requires an intraoperative evaluation for formal diagnosis and intervention.Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract, with an incidence of 2–4% in the general population . Meckel'Most children with Meckel's diverticulum are asymptomatic. Complications of Meckel's diverticulum are seen more frequently in those who present at a younger age and in male patients , 4. The The etiologies of obstruction in children with symptomatic Meckel's diverticula include intussusception, volvulus, Littre's hernia, omphalomesenteric band, and diverticulitis –4. PediaClassically, one should suspect Meckel's diverticulum in children who present with painless lower gastrointestinal bleeding without evidence of infectious gastroenteritis or inflammatory bowel disease. MD may also be suspected in children with recurrent intussusception, as it may serve as a lead point. MD is also in the differential for right lower quadrant pain, especially in those patients with a previous appendectomy .There are classically three diagnostic modalities in the evaluation of a patient with suspected Meckel's diverticulum. Meckel's scan is a nuclear medicine study that uses technetium 99m pertechnetate, which detects gastric mucosa, to identify ectopic gastric mucosa , 5. Its Our patients presented with evolving obstructive processes. To be clear, in the setting of a suspected obstructive process, the aforementioned imaging modalities are superfluous. Upright and decubitus abdominal radiographs to assess the patient for the presence of air-fluid levels, with computer aided tomography of the abdomen and pelvis with oral and intravenous contrast, may be necessary to identify the obstruction.For the pediatric patient who presents with evidence of an obstructive process, there are a number of important aspects of management that should be addressed early. Intravenous access should be obtained immediately, and aggressive fluid resuscitation should be considered. A nasogastric tube should be placed for continuous suction and the patient made NPO. Any electrolyte abnormalities should be corrected, and a surgical consult should be obtained promptly. One can consider the empiric use of antibiotics with broad Gram-negative and anaerobic coverage, and some studies suggest the use of proton pump inhibitors . PerhapsThe first patient in our series became progressively lethargic and obtunded. This is likely due to the release of inflammatory mediators as part of a SIRS response to strangulated tissue, as was evident by his tachycardia, tachypnea, and leukocytosis . PreviouIn addition to Meckel's diverticulum, the second patient in our series was noted to have malrotation. The association between malrotation and other congenital gastrointestinal anomalies has been well reported. In one study, Meckel's diverticulum was the 2nd most common anomaly found with malrotation, behind duodenal atresia .Both of our patients required resection of MD and associated bands to relieve their respective obstructive processes.Meckel's diverticulum is occasionally found incidentally during abdominal surgery. Resection of incidental MD is generally not recommended, although this is an area of controversy and there may be exceptions , 3, 10. Younger children with Meckel's diverticulum are more likely to be symptomatic than older children. While the classical association of MD with painless rectal bleeding is still taught, obstruction is the more common presenting symptom in pediatric patients. Our case series identified two patients with different clinical presentations of obstruction, both of whom were found to have complications of MD. Small bowel obstruction is relatively uncommon in pediatrics, and our cases highlight the importance of early recognition and management to minimize morbidity and mortality. We strongly recommend early, urgent consultation with a pediatric surgeon in setting of suspected small bowel obstruction.