Myxoid variant of chondrosarcoma is an uncommon potentially lethal malignant tumor which is even rare in pediatric age group. In the present paper, we report one such case of intermediate grade myxoid chondrosarcoma of left side of maxilla in a 12-year-old girl. The present case had a firm, painless, and lobulated growth in premolar-molar region which was associated with bicortical expansion. Maxillofacial imaging showed ill-defined radiolucency with displaced maxillary molars. Osteolytic changes were evident with the alveolus and walls of maxillary sinus. Owing to the age of the patient, surgical excision was selected as the modality of management followed by postoperative radiotherapy. This report encompasses the entire gamut of clinicopathological, radiological, and treatment modalities employed for chondrosarcoma. Chondrosarcoma is an uncommon, slowly enlarging, malignant tumor which has its origin from cartilaginous tissue or bone derived from chondroid precursors, resulting in abnormal bone and/or cartilage growth . It reprIn this report, we present a case of a 12-year-old girl with myxoid chondrosarcoma involving maxilla and review the clinical presentation, histopathology, and treatment of the same.A 12-year-old girl was referred to the Department of Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences, in January 2015 for evaluation of painless growth on the left side of her maxilla. The patient and her mother had noticed the mass approximately 4 months earlier. The medical and family histories were unremarkable.There was facial asymmetry caused by a mass within the left buccal area .There was no cervical lymphadenopathy. Intraoral examination revealed the presence of a lobular maxillary growth measuring approximately 4.0 × 3.0 cm in size extending from the second premolar to the maxillary tuberosity in buccopalatal aspect of left side. The regional teeth were displaced and mobile .On palpation, it was firm and slightly tender and was associated with expansion of both cortical plates. Egg shell crackling was evident over some areas of buccal cortical plate.Radiological examination showed radiolucency displacing the molars along with resorption of roots .Water's view showed destruction of floor of maxillary sinus with complete haziness of the sinus and ill-defined borders. Superior displacement of impacted third molar was also seen .Computed Tomography (CT) imaging showed an irregular soft tissue mass causing osteolytic destruction of upper left maxillary alveolus, floor, medial wall, and lateral wall of left maxillary sinus Figures  and 6.Since the lesion was aggressive, malignant neoplasms were considered in differential diagnosis. Salivary gland malignancies like mucoepidermoid carcinoma and adenoid cystic carcinoma were primarily considered as they occur commonly on palate. Both of these lesions do not cause bicortical expansion which was present in our case. Carcinoma of maxillary sinus was also included in differential diagnosis although it is typically a disease of adults and is associated with habit history. Malignant mesenchymal tumors like osteosarcoma and chondrosarcoma, though rare in craniofacial region, were considered in differential diagnosis. Another group of lesions like Hodgkin's and non-Hodgkin's lymphoma can present as mass in the palate with ulceration but are seldom reported. Moreover, lymphomas most frequently present as cervical lymphadenopathy which was absent in the present case.Incisional biopsy was performed under local anesthesia, and the specimen was subjected to histopathologic evaluation. Microscopic examination revealed a hypercellular connective tissue stroma comprising abundant cartilage, a lobulated growth pattern with round and oval cells in lacunae showing nuclear pleomorphism, nuclear atypia, and hyperchromasia. Mitotic activity was mild and at places large plump chondroblasts and binucleated chondrocytes were seen. Large loose basophilic areas were seen in connective tissue suggestive of myxoid stroma. The final diagnosis was made as intermediate grade myxoid chondrosarcoma of left maxilla.Under general anesthesia, degloving incision was given in left maxillary buccal vestibule and surgical excision of tumor was done .The surgical defect was closed with medicated gauze pack placed under palatal surgical splint. Posthealing palatal obturator was fabricated to prevent contamination. The removed mass was firm and rubbery in consistency and was sent for histopathologic evaluation which confirmed the preoperative diagnosis .The patient was then subjected to postoperative radiotherapy because of the inadequate removal of tumor as maxillectomy was not performed considering the age of the patient. The patient is under followup and after 10 months she is disease-free with no signs of recurrence.Chondrosarcoma was considered to be a variant of osteosarcoma before 1930 when Pheimeister first described it as a separate entity . It can Chondrosarcoma has been considered to be a malignant tumor histogenetically derived from mature cartilaginous tissue. Since maxilla is a bone of exclusive membranous ossification, the possibility of chondrosarcoma is difficult to explain. However, it is thought to arise from vestigial cartilage remnants in periodontal ligament, cartilage found in incisive papilla, foci of cartilage from cartilaginous nasal capsule, and paraseptal cartilage. Thus, it explains the notion that chondrosarcoma in maxilla is derived from cartilaginous differentiation of primitive mesenchymal cells rather than from embryonic cartilaginous nests .Unlike the expanding high grade chondrosarcoma of the long bones presenting with excruciating pain, the chondrosarcoma of head and neck tends to be painless on presentation. The common reported symptoms are swelling/mass (68%), nasal obstruction (32%), epistaxis (32%), and tooth mobility (24%) . ProgresA thorough radiological examination including periapical radiograph and panoramic radiograph as well as CT scan may provide clues to diagnosis. The conventional radiographic findings usually include irregular intramedullary radiolucencies interspersed with punctuate radiopacities, expansion and destruction of the cortical plates, PDL spaces widening, or even sunburst appearance at the periphery , 3, 16. Diagnosis can only be established by histopathologic examination. Lichtenstein and Jaffe established a histopathological diagnostic criterion for chondrosarcoma. Histologically, chondrosarcoma can be classified according to the microscopic appearance into conventional, clear cell, myxoid, mesenchymal, and dedifferentiated . ChondroBecause of the rarity of chondrosarcoma of the jaw, there are no established evidence based treatment protocols . ChondroFollowup at regular intervals with repeated investigations may be necessary due to high recurrence rate and distant metastasis . Local rMyxoid chondrosarcoma is a rare entity in head and neck region of patients in pediatric age group. Early and accurate diagnosis of this tumor helps in formulating a proper treatment plan. Considering patient characteristics, the nature of tumor, and high recurrence rate, a proper treatment modality must be chosen. Long term regular followup is mandatory for such tumors.


In practice, small bowel cancer is a rare entity. The most common histologic subtype is adenocarcinoma. Adenocarcinoma of the small bowel (SBA) is challenging to diagnose, often presents at a late stage and has a poor prognosis. The treatment of early-stage SBA is surgical resection. No standard protocol has been established for unresectable or metastatic disease.We report here on a 26-year-old man with SBA in the jejunum, lacking specific symptoms and with a delay of 6 months in diagnosis. The diagnosis was finally achieved with a combination of balloon-assisted enteroscopy, computed tomography scans, positron emission computed tomography scans and the values of carcino-embryonic antigen and carbohydrate antigen 19-9. The patient underwent segmental intestine with lymph node resection, followed by eight cycles of FOLFOX palliative chemotherapy with good tolerance. As of the 11-month postoperative follow-up, there has been no evidence of recurrent disease.This case is reported to arouse a clinical suspicion of SBA in patients with abdominal pain of unknown cause. We also provided evidence in this case of a response to palliative chemotherapy with FOLFOX. Because the incidence of SBA is very low, there is a need for further studies to evaluate the possible application of newer investigative agents and strategies to obtain a better outcome within the framework of international collaborations. Small bowel cancer is a rare malignancy that comprises less than 5 % of all gastrointestinal malignancies. The estimated annual incidence is 0.3–2.0 cases per 100,000 persons, with a higher prevalence rates in the black population than the white, and has been recently increasing [Small bowel cancer has four common histological types: adenocarcinoma 30–40 %), carcinoid tumour 35–42 %), lymphoma (15–20 %), and sarcoma (10–15 %) [0 %, carc–42 %, lyHere, we report on a 26-year-old man with SBA in the jejunum, without specific symptoms. He was diagnosed until he had an incomplete small bowel obstruction, with a delay of 6 months in diagnosis. Segmental intestine with lymph node resection was performed, followed by eight cycles of FOLFOX palliative chemotherapy. The patient was doing well as of his last follow-up.The patient was male, 26 years old and had no specific underlying or family disease. Six months ago, he experienced an episodic attack of distending pain in his left lower quadrant, nausea and vomiting; he was treated with oral drugs at a local hospital. However, his symptoms were not completely relieved, and were later aggravated. A normal abdominal X-ray suggested incomplete small bowel obstruction. He was admitted to our hospital.18F-FDP in many stiffening intestinal segments and also in many retroperitoneal swollen lymph nodes, indicating hypermetabolism disease, with a high possibility of a malignant disease  at 29.17 ng/ml and carbohydrate antigen 19-9 (CA 19-9) at 970.3 U/ml. Abdominal computed tomography (CT) scans showed many swollen lymph nodes adjacent to the abdominal aorta in the retroperitoneal space . The mass involved the entire wall of the small intestine and directly invaded the neighbouring mesentery. There were many enlarged lymph nodes around the superior mesenteric vein and the first and second jejunal arteries in the involved mesentery. There was no evidence of metastatic lesions in the peritoneum or liver during intraoperative inspection of all quadrants of the abdominal cavity. We performed a radical resection with 40 cm of the jejunum and the involved mesentery, vessels and lymph nodes Fig. . PatholoWhereas the small bowel represents 75 % of the length of the digestive tract and 90 % of the absorptive mucosal surface area, tumour of the small bowel is rarer than other gastrointestinal malignancies. The possible explanations include the high levels of IgA and the more rapid transit in the small bowel compared to the large bowel. Little bacteria and more sensitivity to stress in the small bowel also contribute to the low tumour incidence , in this18F-FDG is related to tumour size, infiltration and lymph node metastasis; the higher the uptake of 18F-FDG, the higher the tumour invasiveness [The symptoms of SBA are initially nonspecific abdominal discomfort; diagnosis is delayed and usually in the context of emergency involving an occlusion (40 %) or bleeding (24 %) , which isiveness . Gastrossiveness . Howeversiveness . A baselsiveness . In thisp = 0.025). Ecker et al. [p < 0.001). As for the Asian population, Mizyshima et al. [p = 0.008). Several chemotherapy drugs have also been evaluated in the treatment of metastatic SBA. Zaanan et al. [Surgical resection with clear margins and regional lymph node resection remains the treatment of choice in localized SBA; indeed, it is often required even in metastatic SBA due to the high probability of obstruction or severe haemorrhage . To dater et al.  have shoa et al.  showed tn et al.  have shon et al. , 20. Newn et al. . From lin et al. . In viewWe report a rare case of jejunum adenocarcinoma in a young man in China. Diagnosis of SBA remains a challenge. A physician’s suspicion and awareness is crucial in patients with abdominal pain of unknown cause. Patients with delayed diagnosis often have a poorer prognosis. Surgery remains the primary treatment. In this case, we noticed a response to palliative chemotherapy with FOLFOX. Because the incidence of SBA is very low, there is a need for further studies to evaluate the possible application of newer investigative agents and strategies to obtain a better outcome within the framework of international collaborations.CA 19-9, carbohydrate antigen 19-9; CEA, carcino-embryonic antigen; CT, computed tomography; DBE, double-balloon enteroscopy; ERCC1, excision repair cross-complementing gene 1; PET, positron emission tomography; SBA, adenocarcinoma of the small bowel; TS, thymidylate synthase


The coexistence of glial high grade tumors  and cerebral aneurysms is common but the association with optic glioma is rare. The treatment of these associated lesions is problematic.A 36-year-old white woman presented to our institution with recurrent attacks of headache. Her preoperative radiological studies revealed a lesion of her left optic nerve with extension to the optic chiasma, an aneurysmatic dilatation of the left carotid bifurcation, a second aneurysm on the left of her middle cerebral artery, and a third one on her right anterior cerebral artery in the A2 tract. A left pterional approach was used to remove the tumor and clip the three aneurysmatic dilatations in a single stage.We report this unusual case of optic glioma associated to multiples aneurysms and review the pertinent literature. An adequate knowledge of this association is mandatory to plan the correct approach to avoid complications. Optic pathway gliomas (OPGs) are predominantly classified as pilocytic astrocytomas: World Health Organization (WHO) Grade 1 [The incidence of cerebral aneurysm with brain tumor has been documented (2.5 to 4.0 %) . The treA 36-year-old white woman presented to our institution with recurrent attacks of headache. She reported initial visual impairment in her left eye that was gradually worsening. A neurological examination showed left amaurosis, confirmed by a visual field test, associated to a severe optic atrophy at fundus oculi. No other deficits were disclosed and all routine laboratory findings were normal.A magnetic resonance imaging (MRI) study of her brain revealed a lesion of her left optic nerve 22×13 mm) with extension to the optic chiasma and a suspect aneurysmatic dilatation (6×5 mm) of the left carotid bifurcation , glioma 27.5 to 38 %), pituitary adenoma (11 to 20.6 %), and with a lesser frequency lymphoma, craniopharyngioma, chordoma, epidermoid tumor, dermoid tumor, and choroid plexus adenoma [ to 38 %, to 44 %,The association of brain tumors with cerebral aneurysms raises the question of whether a causal relationship exists. Several hypotheses have been proposed to explain the possible association.An increase in the directional blood flow due to a higher blood supply to a meningioma or malignant glioma may induce secondary changes in the arterial wall and thus facilitate the formation of aneurysms . The rolIn aneurysms that are within or adjacent to a brain tumor, histopathological examination for infiltration of the aneurysm wall from neoplastic cells has been demonstrated , 5. DeveIn postoperative treatments for tumors, the destructive effects of irradiation on blood vessels are well known but rare; only 21 cases have been reported in the literature . RadiatiIntratumoral, subdural or subarachnoid hemorrhage (SAH) may occur in primary brain tumors. Spontaneous SAH is not common in malignant cerebral tumors, but the presence of aneurysms must therefore be investigated if it occurs . The proIf the aneurysm is unruptured, the treatment options include conservative management, surgical clipping and tumor excision either simultaneously or sequentially, or endovascular coiling followed by tumor removal , 13. CliThe presence of an incidental aneurysm close to or embedded within a tumor makes the surgical excision of the tumor hazardous. The lesional resection can be performed following endovascular coil embolization of the aneurysms to reduce the risk of intraoperative rupture and to enable total tumor removal . In caseThe rate of aneurysm rupture during the intraoperative period must be dealt with by taking precautions and even more so when there is a comorbidity, such as a neoplasia, which can increase difficulties, extend, and potentially complicate the procedure. In these cases, the perioperative anesthetic management can have a significant effect on global neurological results by monitoring many factors, including the induction of anesthesia, the presence or absence of burst suppression, use of volatile agents/muscle relaxants, hemodynamic parameters, and temperature. In any case, these parameters must be assisted by intraoperative neurophysiological monitoring with EEG and evoked potentials .In the literature, all cases of cerebral aneurysm associated with optic glioma referred to patients with a history of treatment with radiotherapy , while iWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Objective. Meningiomas are benign primary meningeal tumors and are seen rare in children and adolescents. Clinical Presentation and Intervention. A 15-year-old Turkish boy reported a 1-month history of headache and blurred vision in both eyes. His visual acuity was 0.3 in both eyes with papilledema. Magnetic resonance imaging showed a 77 × 97 × 77 mm intracranial-extra-axial frontal lesion which compresses the chiasm. He was diagnosed with intracranial meningioma and referred to neurosurgery clinic. Conclusion. Ophthalmologists should be aware of the fact that papilledema and low vision can be caused by an intracranial tumor which compresses optic chiasm. Meningiomas are benign primary meningeal tumors and are seen rare in children and adolescents. These tumors arise from meninges, covering the brain and spinal cord, and therefore can occur in any number of locations. The diagnosis may be incidental or in response to a workup for ophthalmological or neurological symptoms. Even though they are slow-growing benign tumors, significant morbidity may result from compression of the oculomotor nerve, anterior visual pathways, or trigeminal nerve. Tumor expansion may lead to visual loss . The purA healthy 15-year-old Turkish boy presented with one-month history of headache and visual impairment in both eyes. He visited the neurology department of a hospital one week before, but the results of general physical examination were unremarkable. It was suggested that he visit an ophthalmologist because of his visual disturbance. His best-corrected visual acuity (BCVA) was 0.3 in both eyes. There was papilledema on funduscopic examination . MagnetiMeningiomas occur most commonly in the fifth decade of life with female preponderance, accounting for approximately 15–20% of primary intracranial tumors , 4. We pFrequent symptoms of meningioma are headache and visual disturbance . DiagnosAggressive surgical treatment is the treatment of choice in most cases which allows complete excision of the tumor in about 70–80% of cases. Kotecha et al. have stated that extent of initial surgical resection is also the strongest independent prognostic factor for children and adolescent meningiomas [Most pediatric meningiomas are WHO grade I (80.6%) with WHO grade II accounting for 10.4% and grade III for 8.1% . The patWith this case report we aimed to point out that papilledema and low vision can be caused by an intracranial tumor which compresses optic chiasm.


Multiple pigmented masses, likely melanomas, were detected peri-anally. Thoracic radiography, cytological examination of the pleural fluid and a fine needle aspirate of a thoracic mass led to a presumptive diagnosis of malignant melanoma and this was confirmed at post mortem examination. Further metastatic spread to the central nervous system and right guttural pouch was also identified. In conclusion this case manifests the potential malignant behaviour of equine melanomas, and a review of proposed therapies for melanoma treatment highlights the therapeutic options and current areas of research.A 15 year-old grey Thoroughbred gelding presented for investigation of chronic weight loss and recent onset of respiratory difficulty. Clinical examination confirmed tachypnoea with increased respiratory effort. Thoracic ultrasound examination detected pleural effusion. The dyspnoea was related to the large volume of pleural effusion and, following  Melanin is a pigment produced by melanocytes in the basal layer of the epidermis. It is proposed that, in grey horses, a disturbance in melanin metabolism and transfer associated with progressive greying of the hair, due to increasing age, results in intra-cellular accumulation of pigment. Excess pigment deposition then stimulates formation of new melanoblasts or increased melanoblast activity resulting in focal areas of overproduction and neoplastic transformation of melanocytes. MelanocAlthough it has been stated that 66% of equine melanomas may become malignant, resultsThe following report describes a case of malignant melanoma with the discussion focussing on available treatment modalities and therapeutic and preventative measures currently being developed.A 15 year-old grey Thoroughbred gelding was referred to the University College Dublin Veterinary Hospital (UCDVH) for investigation of respiratory difficulty of three weeks duration. The horse had a history of insidious weight loss over the past year and had recently developed depression, inappetance, pyrexia and pectoral oedema. Pigmented peri-anal masses, likely melanomas, had been noted since purchase three years ago. Recent treatment by the referring veterinarian included a combination of antibiotics, non-steroidal anti-inflammatories and bronchodilators.On presentation, the horse was quiet, alert and responsive with a body condition score of 3.5/9. Clinical examination revealed tachypnoea (30 breaths/min) and increased respiratory effort. Mucous membranes appeared pink, slightly tacky and capillary refill time was 3 seconds. Multiple pigmented masses, likely melanomas (approximately 1.5 cm diameter) were detected peri-anally. A small, firm, well circumscribed mass was palpable in the right parotid region. Upon auscultation, there were bilaterally increased lung sounds in the dorsal lung fields and reduced vesicular sounds bilaterally in the ventral lung fields. As the horse was exhibiting respiratory difficulty a rebreathing examination was not performed. Based on the clinical evidence of hypovolaemia, an intravenous catheter was placed and treatment begun with intravenous fluids . A maintenance rate was administered until further diagnostic evaluation had been performed.9/L, reference range 4.4 – 9.0 × 109/L; neutrophil count 12.8 × 109/L, reference range 2.2-5.8 × 109/L). Serum biochemistry revealed total hyperbilirubinaemia . Thoracic ultrasonography revealed a large volume of hypoechoic fluid present in the pleural cavity to the level of the tuber ischii bilaterally.Arterial blood gas analysis parameters were within reference ranges. Haematology revealed a mild neutrophilic inflammatory response ; 25 litres of proteinaceous serosanguinous fluid was slowly drained. Repeat thoracic ultrasonography revealed a soft tissue structure extending from ICS 6-13 on the left side of the thorax. The structure extended ventrally from the dorsal extent of the thoracic cavity. Radiographic examination of the lung fields on the left side of the horse confirmed the location of the soft tissue opacity. The structure was superimposed over the mid-thoracic vertebral bodies and was therefore estimated to be 12 cm in dorsoventral distance  were seen on cytospin examination Figure . The finAt post mortem examination large multifocal to coalescing black firm nodular masses were observed expanding and distending the mediastinum and extending multifocally throughout the pleural lining of the intercostal spaces and diaphragmatic surface. Similar masses were present in the right guttural pouch adjacent to the internal carotid artery and within the right submandibular salivary gland. A solitary black nodule was noted on the dural surface of the spinal cord in the region of T13 and within the meninges between the rostral border of the cerebellum and the dorsal aspect of the midbrain. Histological sections of perianal skin, lung tissue, pleura, brain, spinal cord and oesophagus revealed multinodular, unencapsulated, infiltrative, densely cellular, expansile neoplasms composed of spindle to epithelioid cells arranged in nests and sheets. Neoplastic cells exhibited marked pleomorphism and contained round to oval nuclei, single prominent basophilic nucleoli and eosinophilic cytoplasm containing variable amounts of melanin. Mitotic figures ranged from 2 – 5 per high powered field. Numerous tumour cell emboli were noted in lymphatics within the interlobular septae of the lung. This confirmed the diagnosis of malignant melanoma.The horse described in this report had multiple small perianal masses consistent with the benign melanomas reported in approximately 80% of aged grey horses. Until cTraditionally, equine melanomas were classified based on their growth patterns into three groups: benign melanomas which grow slowly for years without metastasis, malignant transformation of a previously benign melanoma and malignant melanoma from the outset. A laterAccording to the classification system described by Valentine the case described in the present report clinically represented dermal melanomatosis i.e. multiple peri-anal lesions in an aged horse. HoweverIn contrast to reports indicating that cases of equine melanoma rarely have clinical signs referable to metastases, despite a high metastatic rate being detected at necropsy, euthanaBy the time a definitive diagnosis in this case had been made, disease progression was too advanced to offer any reasonable treatment options. However the external melanomas were present for a number of years and earlier therapeutic options might have been possible.2 laser excision and cryosurgery are often curative in cases of small well-demarcated dermal melanomas[Sharp surgical excision, COelanomas. Howeverelanomas. Cisplatelanomas. Implantelanomas. Cisplat2-receptor antagonist, has been reported to have anti-neoplastic properties that may improve survival in patients with melanoma. Its mechanisms of action are multifactorial with histamine reported to be a potential growth factor for melanoma cells, breast and colon cancer cell lines[Cimetidine, a histamine Hll lines; involvell lines. Cimetidll lines. Goetz[ll lines reportedll lines.Tumour cells express antigens recognisable as non-self by the immune system. These antigens are weakly immunogenic. CurrentAs the mechanisms of secondary immunosuppression are investigated it should become possible to target specific immunological functions. Heinzerling et al. injectedIn the United States there is a DNA plasmid vaccine, encoding human tyrosinase (HuTyr), licensed for the treatment of canine melanoma. This xenogenic vaccine utilises the 92% homology of human and canine tyrosinase to produce a tyrosinase-specific anti-tumour response. The equine tyrosinase sequence has a 90% homology to the human sequence therefore cross-reactivity of the HuTyr DNA vaccine is an area warranting further research.While the heritability of melanoma (0.36) implies a strong genetic basis for prevalence, the mode of inheritance is inconclusive. Rieder In conclusion, veterinarians should recognise that dermal melanomas can indeed have life-threatening consequences. As a profession we are responsible for improving client awareness of the risk of malignant transformation of these ‘benign’ cutaneous tumours.The authors declare that they have no competing interestsLM drafted the manuscript, VD supervised clinical work-up, HM carried out the diagnostic imaging, SP and PO’B carried out the clinical pathology and SC carried out the post mortem examination. All authors read and approved the final manuscript.


Entamoeba histolytica with engulfed erythrocytes complicated by hemorrhagic cyst. If an intra-abdominal tumor is present and colitis is observed, amebic intra-abdominal tumor should be considered among the differential diagnoses.We report a rare case of huge amebic intra-abdominal tumor with asymptomatic amebic colitis. This appears to represent the first report of amebic intra-abdominal tumor. A 31-year-old woman presented to a local doctor with only a sensation of abdominal fullness. Abdominal computed tomography (CT) showed a huge intra-abdominal tumor in the left abdominal cavity, and she was referred to our hospital. Colonofiberscopy for detailed examination showed multiple slight, discrete ulcers in the cecum. Ameboid trophozoites were identified from biopsy specimens, and asymptomatic amebic colitis was diagnosed. Oral metronidazole (MTZ) was administered at 1500 mg/day for 10 days. CT 14 days after starting MTZ showed no change in the intra-abdominal tumor, and resection of the tumor was therefore performed. Pathological examination revealed  Entamoeba histolytica causes amebic colitis, which often presents as cramping abdominal pain and bloody diarrhea. While the majority of E. histolytica infections may be asymptomatic, approximately 10 % of amebic infections develop to invasive disease. Approximately 1 % of cases of invasive amebic disease develop extraintestinal disease through the bloodstream, affecting tissues such as the liver [E. histolytica infection may result in severe and potentially fatal illness, but no case reports appear to have described amebic intra-abdominal tumors.Infection by he liver , lungs [he liver –5, periche liver , 7, braihe liver –10, and he liver , 12. Inv3; C-reactive protein, 1.006 mg/dl). CT revealed a multicystic tumor measuring 270 × 100 × 120 mm, continuous with the greater curvature of the stomach  showed a huge intra-abdominal tumor in the left abdominal cavity. She was referred to our hospital for detailed examination and treatment. Physical examination revealed a palpable, slightly hard mass with smooth surface in the left abdomen. The patient had never been overseas. Laboratory examination showed no marked abnormalities . Doctors diagnosing E. histolytica are required to report the case to a public health department within 7 days of diagnosis. According to the report of the National Institute of Infectious Disease, the number of cases of E. histolytica infection has been increasing annually, particularly since 2000, and this has been attributed to an increase in sexually transmitted cases. The number of E. histolytica cases was reported as 1047 cases in 2013. The major reported cities in 2013 were Tokyo, with 188 cases, and Osaka, with 106 cases. Given that registration of E. histolytica cases is obligatory in Japan, the breakdown of causes of infection was reported in 2012 as unknown in 51.9 % and sexually transmitted in 34.1 % [Amebiasis is a parasitic infection caused by the intestinal protozoan  disease –17. In JE. histolytica is reportedly asymptomatic in approximately 90 % of cases. However, 4–10 % of initially asymptomatic individuals infected with E. histolytica develop symptomatic amebiasis over the course of the following year. E. histolytica can cause invasive intestinal and extraintestinal infections, which may occasionally result in severe and potentially fatal illness. The most common manifestation of invasive amebiasis is colitis, typically presenting as a several-week history of cramping abdominal pain, weight loss, and bloody diarrhea. Common sites of extraintestinal lesions are the liver and lungs, while rare case reports have described infection of the pericardium, brain, and skin. A search of PubMed using a combination of key words such as “Entamoeba histolytica”, “amebiasis,” and “intraabdominal tumor” through December 31, 2014 yielded no reports of amebic intra-abdominal tumor. Likewise, no mention of amebic intra-abdominal tumor was found in various reviews of E. histolytica infection [Infection with nfection –15, 19. In this case, diagnosis of the intra-abdominal tumor by imaging alone was very difficult. Differential diagnoses for intra-abdominal tumor include cystic mesothelioma, omental cyst, cystic lymphangioma, liposarcoma, and gastrointestinal stromal tumor. In these cases, surgical excision is usually indicated for diagnosis and treatment , 21.E. histolytica [E. histolytica would need to be considered among the differential diagnoses, and removal should be performed in such a manner as to avoid damaging the tumor.Many reports have suggested that extraintestinal amebiasis spreads hematogenously , 22. Shatolytica . In thisE. histolytica infection has been MTZ for 10–14 days  or tinidazole for 3 days (2 g/day), followed by a 7-day course of paromomycin (25–35 mg/kg daily in three divided doses) to eliminate colonization [E. histolytica has been seen to date.In some reports and reviews, a typical treatment regimen for nization , 14, 19.nization . AlthougNo standard treatment strategy for amebic intra-abdominal tumor has yet been established. We might have achieved cure with MTZ treatment alone, using the treatment strategy for amebic liver abscess , 24, 25,E. histolytica infection and warrants colonofiberscopy. When amebic colitis is observed, amebic intra-abdominal tumor should be considered as a differential diagnosis.Intra-abdominal tumor may represent asymptomatic Written informed consent for publication of this case report and the accompanying images was obtained from the patient. A copy of the written consent is available for review by the Editor in Chief of this journal.


Modified MVTx (MMVTx), the liver is not transplanted . This teet al,  in dogs et al, . With inet al,  so that et al, . In spitet al, ,5,6. HerIn June 2009, a 30-year-old man was presented to the surgery clinic of a general hospital with painless right abdominal mass without any other problems. He underwent laparotomy where the surgeon found an inoperable mass that involved retroperineal area around ascending and transverse colon; then, he only performed an incisional biopsy and referred the patient to our center. The pathologic diagnosis was “desmoids tumor.” At presentation to our center, he developed transient hematochesia. Colonoscopy revealed multiple polyps of “familial adenomatous polyposis” type which involved the entire colon. Whole body spiral computed tomography (CT) demonstrated no signs of distant metastasis . The patAfter the operation, he lost the follow-up, but 10 months later, in May 2010, he returned to our clinic in Namazi Hospital with a large abdominal mass and over 12 kg weight loss because of severe loss of appetite. Abdominal CT revealed recurrence of the tumor with involvement of all abdominal organs except for the left kidney and liver. No signs of distant metastasis were found in the imaging studies. After discussion about unresectability of his tumor with him and his family, we decided to perform an elective MMVTx for him.Donor operationen bloc stomach, duodenum with pancreas and spleen and whole small intestine) was harvested using these steps: transecting of the esophago-gastric junction and terminal ileum by separate linear staplers; separating the splenic ligaments; and dissecting all retroperitoneal adhesions of the stomach, pancreaticoduodenal complex and small intestine. The arterial inflow of this complex graft was superior mesenteric and celiac arteries on a common patch of the aorta; the venous outflow of the graft was through the portal vein, immediately superior to upper border of the pancreas  since 48 hours before his brain death was confirmed. He was only receiving 5 µg/kg/min dopamine as a vasoactive agent. His blood group was the same as the recipient. We used a long midline incision for exposing the heart and abdominal viscera. After complete dissection of abdominal organs including the arterial branches of celiac trunk and canulating the infra-renal aorta and inferior mesenteric vein, cold irrigation was started by University of Wisconsin (UW) solution. For removal of the liver, the hepatic artery was transected just after the origin of the gastro-duodenal artery and portal vein was transected just above the upper border of the pancreas. After removal of the liver and kidneys, the complex modified multivisceral graft , inferior vena cava and aorta were meticulously dissected free from the tumor. The superior and inferior mesenteric arteries and left renal artery and other minor branches of aorta were transligated. After finishing tumor dissection, gastro-esophageal junction, the ileo-rectal anastomosis site and common bile duct were transected, portal vein was clamped, and tumor was completely removed from the abdominal cavity. Hepatic artery remained intact to perfuse the liver during the rest of operation.Implantation was done through the following steps. End-to-side anastomosis of the donor aortic patch to the anterior side of aorta; end-to-end anastomosis of the graft and native portal vein; after reperfusion of the organs, anastomosis of the native esophagus to graft stomach; graft terminal ileum to the native rectal remnant by endoluminal staplers; and, end-to-side anastomosis of native bile duct to a Roux-en-Y loop of the graft and constructing a protecting loop ileostomy, 45 cm proximal to the ileo-rectal anastomosis in the left side of abdomen. Pyloroplasty was performed for enhancing the gastric emptying. Abdominal cavity was drained externally by two Jackson-Pratt type drains. Abdominal wall was repaired in two layers without any problem. Total duration of operation was nine hours including four hours for tumor resection. The total cold ischemia time of the graft was six hours; the total warm ischemia time was 76 minutes.Immunosuppression®, Berlex Laboratories, Montville, NJ, USA)  and 1000 mg methylprednisolone   were used for the induction of immunosuppression. Maintenance immunosuppression was started on day one by tacrolimus  that increased to 6 mg/day for a target serum level of 12 ng/mL. Oral prednisolone started on day four (50 mg/day) and gradually decreased to 20 mg/day during next three weeks.Alemtuzumab  and also amphotericin and ganciclovir were continued for two weeks. Drains were removed after 10 days when the lymphatic drainage was less than 100 mL/day. After day seven, gastric biopsy with upper gastro-intestinal endoscopy and direct biopsy of the ileostomy site was done three times per week for detecting acute rejections. Only one episode of acute cellular rejection was observed after three weeks which was treated by three-day methylprednisolone pulse therapy. The blood sugar of the patient was <140 mg/dL without any need for insulin therapy. Diet was started after seven days and the patient was discharged from hospital 28 days after the operation with oral medications .®, Genentech, Roche Pharmaceuticals, San Francisco, CA, USA).Ten days later, he returned back to hospital because of severe abdominal pain and tenderness and underwent exploratory laparotomy. The cause of pain was the strangulation of the terminal ileum  through an internal hernia. The ischemic segment was resected and the anastomoses were revised with a new ileostomy. He was discharged for the second time from the hospital seven days later, and now, after three months of the operation, he is on oral diet and in a good condition except for an episode of cytomegalovirus gastritis which is under treatment by valganciclovir (Valcyte


Noncardiac causes should be kept in the differential while evaluating ST elevation on EKG. Rarely abdominal pathologies like acute pancreatitis can present with ST elevation in the inferior leads. Once acute coronary syndrome is ruled out by emergent cardiac catheterization alternative diagnosis should be sorted. Abdominal pathologies, like acute pancreatitis and acute cholecystitis, can present with ST elevation in the inferior leads. Treating the underlying condition would result in resolution of these EKG changes. Chest pain accounts for around 6 million annual visits to emergency department (ED) in the United States (US) . Electro56-year-old lady with a history of hypertension, dyslipidemia, and gallstones presented to the emergency department (ED) with severe stinging, nonradiating, midsternal chest pain ongoing for 45 minutes. She experienced nausea, vomiting, and diaphoresis. She denied palpitations, orthopnea, or paroxysmal nocturnal dyspnea. On physical exam she was hypotensive with BP of 80/50 mmHg and a heart rate of 117 bpm. Her lungs were clear and cardiac exam showed normal heart sounds with no murmurs or rubs. She had mild epigastric tenderness, but there was no guarding or rigidity and bowel sounds were heard. 12-lead electrocardiogram (EKG) showed 2 mm ST elevation in leads II, III, and AVF, with reciprocal changes in leads I and AVL . With th28-year-old gentleman, with no significant past medical history, was transferred from outside hospital with diagnosis of STEMI. He had presented to the outside facility with severe, sharp, stabbing, midsternal chest pain and epigastric pain radiating to his axilla and back. His social history was significant for daily alcohol use with an average of 5-6 beers/day. He admitted to binge drinking one day prior to admission. EKG at the outside facility showed ST segment elevation in leads II, III, AVF, V5, and V6 . He had A 43-year-old lady with history of hypertension, gastroesophageal reflux, and morbid obesity presented to the ED with severe knife-like chest pain and abdominal pain which started one hour prior to presentation. On physical exam her BP was 200/100 mmHg, HR was 96 bpm, RR was 22 breaths, and temperature was 100.5 F. She was alert but looked pale and diaphoretic. On cardiac exam there were no murmurs. Abdominal exam revealed positive murphy sign and right upper quadrant tenderness. EKG showed ST segment elevation in leads II, III, and AVF with reciprocal changes in the lateral leads . Her troIt is imperative to rule out cardiac ischemia in patients who present with chest pain and ST segment elevation on EKG. Emergent cardiac catheterization is the standard of care. However, once a cardiac etiology is ruled out other diagnosis should be sought.A 2.3% incidence of alternative conditions mimicking STEMI is found in patients referred for primary percutaneous coronary intervention (PCI) .Abdominal etiologies like pancreatitis and cholecystitis can also cause troponin elevation. Release of pancreatic proteolytic enzymes causing transient myonecrosis and coronary vasospasm has been the hypothesized pathophysiologic mechanism . VariousThe electrocardiographic changes in patients with acute cholecystitis and pancreatitis which have been reported are mostly transient , 10–12. We did not perform echocardiogram in ED for our cases as emergent left heart catheterization was performed based on clinical presentation, EKG findings, and elevated troponins. However, echocardiogram can be helpful to improve the diagnostic specificity in selected cases. In patients having atypical chest pain, with ST elevation on EKG and/or troponin elevation where there is a clinical dilemma whether these patients need urgent catheterization or initial conservative management, echocardiographic assessment of ventricular function and wall motion abnormalities can help in further management. Absent wall motion abnormalities in patient with ongoing chest pain puts acute ST segment elevation myocardial infarction very low on differential. However, this must be balanced against the time delay necessary to obtain transthoracic echocardiogram and potential for ongoing myocardial injury.Physicians should therefore consider intra-abdominal etiologies when faced with transient inferior ST segment elevations in patient without significant coronary disease.


Early and accurate detection of bone tumors and their staging are important since some of them are highly malignant. Intraoperative pathological consultation in bone tumors and tumor-like conditions is quite complex; however, it allows improvement in prognosis and limb salvage. Present study was conducted on 52 patients who underwent surgical procedure after clinical and radiological diagnosis of bone tumors/tumor-like conditions. Fresh unfixed tissue was quickly inspected grossly, followed by preparation of imprint smears and frozen section which were evaluated by two pathologists separately and compared subsequently with reports of paraffin-embedded sections. Clinical reasons for intraoperative consultation were to make diagnosis in 65.4% of cases and to determine resection margin status in 21.1% while in 13.5% of cases, it was for both indications. Diagnostic yield of imprint smears was 87.8%  and of frozen section was 90.2%  while paraffin sections could diagnose specific tumors in 95.1% . Although frozen section had better sensitivity (88.2%), it had less specificity (94.7%) as compared to imprint smears . Imprint cytology and frozen section together provide a quick, safe, and reliable intraoperative provisional tissue diagnosis in skeletal tumors and tumor-like conditions. Bone tumors are infrequent but their detection is important since some of them are highly malignant. Incidence of sarcomas of the bone is about 8 to 9 per million population per year . ClinicaCurrently, intraoperative consultation is considered as an integral part of surgical pathology and provides a rapid intraoperative diagnosis leading to timely and proper management of the patients . In contInterpretation of intraoperative pathological consultation is a complex process that requires specialized histomorphologic knowledge which must be complemented by clinical, laboratory, and radiographic information . AccuratThe present prospective study was conducted on 52 patients undergoing surgery  for bone tumors and tumor-like lesions from November 2009 to September 2011. For each case, detailed history, clinical, and radiological data were recorded. Fresh unfixed tissue specimen taken intraoperatively was wrapped in a wet gauze piece and quickly brought to tissue service laboratory of department of pathology. A careful and quick gross examination of the specimen was performed, followed by preparation of imprint smears and frozen sections.Direct imprints were prepared by pressing the microglass slide gently against the freshly cut surface of specimen. Gliding movement was avoided. Air-dried and wet-fixed smears were prepared and stained by May Grünwald Giemsa (MGG) and hematoxylin and eosin (H&E), respectively . After pFrozen section and imprint smears were evaluated simultaneously, but by independent observers. The results were communicated immediately to the operating surgeon verbally or in written format. Turnaround time between tissue accession and conveying of report was noted. The results of imprint smears and frozen section techniques were later compared with paraffin-embedded sections prepared from the resection specimen, which were considered as gold standard.K) was applied to observations of imprint cytology and frozen section to find the respective agreement with final histopathology report. K value more than 0.75 was considered to give excellent significance.For statistical purpose, all malignant lesions were taken as positive and all benign lesions were taken as negative. Sensitivity, specificity, diagnostic accuracy, and total predictive value of each technique were calculated using descriptive statistics. Kappa test of agreement  or pain and swelling (36.6%). Most commonly affected bones were femur (34.6%), humerus (17.4%), tibia (11.5%), and sacrum (9.6%). Radiological diagnosis was benign in 22 cases (42.3%), malignant in 29 cases (55.7%), and inconclusive in 1 case (2.0%).Clinical reasons for requesting an intraoperative pathological consultation were to make a diagnosis  and to determine the adequacy of resection margins , and in 7 cases (13.5%) it was required for both these purposes. For 18 cases, where the consultation was done for resection margin status, a total of 30 biopsies were evaluated. Previous tissue diagnosis was not available in majority of the cases (69.2%).Imprint smears were diagnostic in 87.8% cases (36 out of 41 cases) while the diagnostic yield of frozen section was 90.2% (37 out of 41 cases). The diagnostic yield of paraffin-embedded sections was 95.1% of cases (39 out of 41 cases). Among the 39 cases diagnosed on gold standard paraffin-embedded sections, there were 18 malignant neoplasms (46.15%), 18 benign neoplasms (46.15%), and 3 nonneoplastic lesions (7.7%). On imprint cytology, there were 13 malignant neoplasms (36.1%), 22 benign neoplasms (61.1%), and one nonneoplastic lesion (2.8%) while on frozen section, diagnosis of malignant neoplasm was made in 16 cases (43.2%), benign neoplasm in 19 cases (51.4%), and nonneoplastic lesion in 2 cases (5.4%). The diagnoses given by each technique and their correlation with paraffin-embedded sections are given in The concordance rate between diagnoses of imprint cytology and paraffin-embedded sections was 88.9% (32 out of 36 cases). There were 4 false negative cases (11.1%) but no false positive result on imprint was seen. The concordance rate between diagnoses of frozen sections and paraffin-embedded sections was 91.7% (33 out of 36 cases). The discordance in 3 cases (8.3%) was due to one false positive case (2.77%) and 2 false negative cases (5.55%) on frozen section.While assessing the adequacy of resection margin, imprint smears gave 2 false positive results and frozen section gave one false positive result. There was no false negative case with both techniques.The statistical result of imprint smears and frozen sections for distinguishing malignant from benign lesions as well for determining the adequacy of resection margins is given in The range of turnaround time for intraoperative pathological consultation was 5 to 35 minutes with average turnaround time of 18.7 minutes. In 75% of cases, turnaround time was less than or equal to 20 minutes.The diagnosis and management of primary musculoskeletal lesions are complex and associated with significant issues involving biopsy technique, treatment protocol, and postbiopsy management. The pitfalls can be overcome by utilizing a multidisciplinary approach to correlate clinical, radiological, and pathological information. Correct intraoperative histological assessment of bone lesions is crucial to select an appropriate surgical procedure and avoid under- and overtreatment of the patient.Frequent reasons for requesting an intraoperative pathological consultation are to make or confirm a diagnosis, to determine the adequacy of resection margins, and to ascertain if the biopsy specimen is sufficient for making a definite diagnosis. Less commonly, it can also be employed to determine the extent of disease spread locally and beyond the local resection field, to assess an unsuspected finding at the time of operation, and to determine the presence or absence of residual or recurrent tumor after previous surgery . IntraopIntraoperative pathological consultation can be done by techniques such as frozen section and cytology , each having its own advantages and limitations. The diagnostic yield of imprint smears obtained in the present study (87.8%) parallels the diagnostic yield observed in study by Wisanuyotin et al.  while itThe concordance rate between diagnoses of imprint cytology and paraffin-embedded sections in the present study was 88.9% which is lower compared to 94.9% reported in another study . SensitiIn terms of tumor typing, imprint smears correctly categorized all the malignant tumors into 4 major categories: malignant small round cell tumor, sarcoma, non-Hodgkin's lymphoma (NHL), and metastatic tumor. However, type specific diagnoses were possible to make in 76.9% of cases. The subtyping of sarcoma cases was difficult on imprint smears in the present study as the presence of osteoid or chondroid differentiation was not appreciated. Wisanuyotin et al. [The diagnostic yield of frozen section was 90.2%; sampling errors were attributed to all 4 inconclusive cases. Almost similar diagnostic yield (93.4%) has been reported by Shah et al. . InterprFrozen section accurately typed 86.66% of malignant cases in terms of type of malignancy into 4 main categories: malignant small round cell tumor, sarcoma, NHL, and metastatic tumor. The sarcoma category could not be subtyped in all the cases as the respective differentiation was not recognized. In a study by Estrada-Villaseñor et al. , specifiWhile determining the adequacy of resection margin, both imprint smears and frozen section techniques showed high diagnostic accuracy. Positive predictive value of imprint smears was quite low unlike that of frozen section. Surgical resection limits were revised in the cases reported as positive that is involved by the tumor. High negative predictive value by both techniques indicated that the surgery should be considered complete as the resection margins given negative by frozen section and imprint smears are expected to be negative on paraffin-embedded sections.In the present study, better diagnostic yield was seen with frozen section compared to imprint smears. It was 2.4% more compared to imprint smears. However, difficulty was encountered while sectioning tissue from myxoid lesions. Paraffin-embedded section further improved diagnostic yield by 4.9%.Frozen section was found to be superior to imprint smears and had better sensitivity but less specificity than imprint smears in making diagnosis. Frozen section diagnosed 7.1% more malignant cases in comparison to imprint cytology. False-negative results were less frequent on the frozen section compared to imprint evaluations. This may be due to better architectural details of frozen section. Imprint smears had advantages of being relatively inexpensive  and less time consuming with rapid turnaround time. Imprints also gave better morphological details.However, it is stated that attempt to make type specific intraoperative microscopic diagnosis of bone lesions is not necessary; distinguishing benign from primary malignant tumor and metastatic tumor is usually sufficient for correct management.The turnaround time should be given due importance while providing intraoperative pathological consultation. Average turnaround time was less than 20 minutes. This was in accordance with observations of other workers , 7. In tIn conclusion, both frozen sections and imprint cytology provide a quick, safe, and reliable intraoperative provisional tissue diagnosis, especially to distinguish malignant from benign lesions. These techniques also provide reasonable assessment of adequacy of surgical resection limits, thus helping the surgeon to plan further treatment accordingly. Imprint cytology and frozen section complement each other in ensuring rapid tissue diagnosis. Intraoperative pathological consultation (frozen section and imprint cytology together) proves to be a valuable addition to the armamentarium in evaluating musculoskeletal tumors.


Introduction. Internal hernias are often misdiagnosed because of their rarity, with subsequent significant morbidity. Case Presentation. A 61-year-old Japanese man with no history of surgery was referred for intermittent abdominal pain. CT suggested the presence of a transmesocolic internal hernia. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We found internal herniation of the small intestine loop through a defect in the transverse mesocolon, without any strangulation of the small intestine. We were able to complete the operation laparoscopically. The patient's postoperative course was uneventful and the patient was discharged on postoperative day 6. Discussion. Transmesocolic hernia of the transverse colon is very rare. Transmesocolic hernia of the sigmoid colon accounts for 60% of all other mesocolic hernias. Paraduodenal hernias are difficult to distinguish from internal mesocolic transverse hernias. We can rule out paraduodenal hernias with CT. Conclusion. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We report a case of a transmesocolic hernia of the transverse colon with intestinal obstruction that was diagnosed preoperatively and for which laparoscopic surgery was performed. Transmesocolic hernia is an extremely rare type of internal hernia . The repTransmesocolic hernia of the transverse colon is very rare. Transmesocolic hernia of the sigmoid colon accounts for 60% of all other mesocolic hernias .Ordinarily, hernias develop in a preexisting anatomical orifice such as the foramen of Winslow . CongeniInternal abdominal hernia has a nonspecific and intermittent clinical presentation; therefore, presurgical diagnosis is rare . Its diaWe report a case of a transmesocolic hernia of the transverse colon with intestinal obstruction that was diagnosed preoperatively and for which laparoscopic surgery was performed.A 61-year-old Japanese man was admitted to our hospital with intermittent abdominal pain. He had no past history of abdominal surgery. His vital signs were stable. On examination, the abdomen was soft and nontender. Laboratory investigation measurements on admission were normal. An abdominal radiograph showed the air-fluid levels in the upper quadrant with no free air under the dome of the diaphragm . An enhaThese findings suggested the presence of an internal hernia excluding paraduodenal hernias. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia.We chose to treat the obstruction laparoscopically with a four-trocar approach. Intraoperatively, we found internal herniation of the small intestine loop through a defect in the transverse mesocolon, without any strangulation of the small intestine . The herThe patient's postoperative course was uneventful and the patient was discharged on postoperative day 6. At the 1-year follow-up examination, no clinical or radiographic evidence of the internal hernia was observed.An internal hernia is defined as the protrusion of viscus through a normal or abnormal opening within the confines of the abdominal cavity . These hA transmesocolic hernia is difficult to diagnose preoperatively and often requires resection of the affected intestine , 5. WhilInternal hernias are often misdiagnosed because of their rarity, with subsequent significant morbidity. Paraduodenal hernias are difficult to distinguish from internal mesocolic transverse hernias. Paraduodenal hernias originate at the fossa of Landzert, which is located immediately lateral to the fourth segment of the duodenum and behind the IMV and ascending left colic artery. We can rule out paraduodenal hernias with CT. CT is the gold standard test to diagnose internal abdominal hernia. CT findings may include displacement of the mesenteric trunk toward the hernia, elongation, grouping and engorgement of the mesenteric vessels, abnormal encapsulation of intestinal loops in the peritoneal cavity, stasis, and absence of intraluminal contrast progression associated with distension content , 11. HowThere are few reported cases of laparoscopic repair of internal transmesocolic hernia . LaparosThe internal transmesocolic hernia is a rare intestinal obstruction that should be considered in cases of recurrent abdominal pain and obstruction without any history of surgical intervention, external hernia, or inflammatory disease. As in our case, the early diagnosis can reduce complications such as obstruction, necrosis, and perforation. Surgical intervention is the treatment of choice, particularly in asymptomatic cases, because it reduces the urgent surgery and complications associated with hernia. The laparoscopic approach, although more difficult to perform as an emergency procedure, is considered for cases such as ours, because it can reduce morbidity, postoperative pain, and length of hospital stay.


Renal cell carcinoma (RCC) uncommonly metastasizes to the ureter and rarely to the contralateral ureter. We describe the presentation of 2 successive contralateral ureteric metastases from RCC in our institution. The first represents the only reported metachronous ureteric deposit on adjuvant sorafenib after laparoscopic radical nephrectomy for RCC. The other presented with a synchronous lesion after radiological work-up. Both lesions were treated with endoscopic excision and laser ablation with preservation of the renal unit and no local recurrence. We report these cases and discuss the literature. Ureteric metastasis from renal cell carcinoma (RCC) is a rare finding; ipsilateral lesions are the most reported in literature with over 50 reported to date. We describe the presentation and management of two very different cases of contralateral ureteric metastases. The majority of literature describes surgical excision of these lesions. We outline a novel treatment of these rare lesions with endoscopic biopsy and laser ablation in order to preserve renal function and reduce morbidity.54-year-old male presented in 2010 with painless visible haematuria. No significant past medical history was reported other than hypercholesterolaemia. Ultrasound revealed a left renal mass; however, CT scan demonstrated in addition to the 56 mm left renal mass an 8 mm right pelviureteric junction stone in the lower pole moiety of a partial duplex kidney joining in the proximal third of the ureter .There was no evidence of metastatic disease and accordingly he underwent right flexible ureteroscopy laser lithotripsy of calculus and stent insertion. Four weeks later flexible cystoscopy with removal of stent and laparoscopic radical nephrectomy were performed. Pathology revealed a pT1b Fuhrman grade 3 Leibovich score 4 intermediate risk clear cell carcinoma with complete excision. He was recruited to the SORCE adjuvant trial in view of his intermediate risk  [μm fibre at 10 W and the specimen removed using a 1.9 French ZeroTip Nitinol basket. The ureter was secured with a 6 French 24 cm stent into his lower pole moiety. Recovery was complicated by readmission 7 days after procedure with further haematuria and decline in renal function necessitating temporary nephrostomy into both moieties due to clot obstruction distally. The nephrostomies were removed after a further week and stent was removed at ureteroscopic surveillance 3 months later. Histology confirmed metastatic clear cell cancer. The patient was unblinded from SORCE trial and had been receiving sorafenib at the time of development of his ureteric metastasis which was subsequently discontinued.He presented 14 months later with visible haematuria and a reduced eGFR of 46. CT-IVU demonstrated a 9 mm enhancing soft tissue lesion obstructing the lower pole moiety of the right kidney partial duplex at a similar position to his previous PUJ calculus . FlexiblThe patient went on to develop a solitary metastasis in lung treated with wedge excision 10 months later; however, he remains free of ureteric recurrence 13 months following excision on no systemic therapy.51-year-old female presented in 2012 with visible haematuria and right sided abdominal pain on a background of recurrent urinary tract infections. Significant past medical history includes hypertension and a subarachnoid haemorrhage in 2006 with full recovery. Ultrasound identified right hydronephrosis in an atrophic kidney and a left renal mass lesion. Staging CT confirmed a 96 mm left renal lesion and a solid obstructing 16 mm intraluminal lesion in the lower third right ureter with no evidence of pulmonary metastases or distant disease Figures , and 5. Ureteroscopy confirmed a pedunculated vascular smooth solid lesion identical in appearance to the previous ureteric renal cell metastasis experienced in our unit. Holmium laser excision was performed using the same technique described above. A 6 French 24 cm stent was inserted following excision. Baseline eGFR was 48, DMSA renogram confirmed 9% differential function on the right side, and histology of the lesion revealed metastatic clear cell carcinoma.The patient was commenced on systemic sunitinib and at 6 months has no evidence of local right ureteric recurrence, no distant disease, and a 10 mm reduction in the primary tumour size. Ureteroscopy has demonstrated no stricturing at the site of metastasectomy to suggest a preexisting condition.The ureter is an unusual source of metastases with the majority from a nonurological origin. Breast and gastric carcinomas are the commonest nonurologic metastases and bladder and prostate are the commonest urologic metastases . RCC typThe influence of retrograde ureteroscopy with stent insertion or local inflammatory response related to endoscopic stone removal in the first case described above is unclear however because of the location of subsequent metastasis is likely to be relevant. The authors hypothesize that this could be either through reflux or through haematogenous spread as described in the literature –5. PatieIt is well accepted that complete metastasectomy of RCC improves patient survival . The majIn conclusion contralateral ureteral metastases from RCC are a rare occurrence. We describe how novel endoscopic treatment can preserve renal function and reduce morbidity in these complicated patients with metastatic disease. In addition we describe a case where contralateral renal cell ureteric metastasis occurred whilst on adjuvant tyrosine kinase therapy.


Glioblastoma represents 15%-20% of all intracranial tumors and approximately 50% of gliomas in adults. Although capable of arising anywhere in the central nervous system, these tumors mainly present as a frontotemporal lesion (63%) of the cerebral cortex. But, intraventricular glioblastoma is rare and only few cases have been reported in the literature. We report a case of 40-year-old woman who had a headache, vomiting and visual disturbances that persisted for four weeks. Magnetic resonance imaging showed an intraventricular lesion with inhomogeneous enhancement and infiltrative borders. These characteristics are consistent with other differential diagnoses: carcinomas, ependymomas and choroid plexus papillomas. The patient underwent a stereotactic biopsy allowed the final diagnosis of intra ventricular glioblastoma.


Primary tumors of the paratesticular region are rare, with paratesticular sarcomas constituting a major proportion of these tumors, particularly in the elderly. The paratesticular region consists of mesothelial, various epithelial and mesenchymal cells and may therefore give rise to a number of tumors with various behaviors. Defining the association between the paratesticular mass and the testicle, and differentiation between benign and malignant masses using radiology is challenging, therefore the mass is usually considered to be malignant and radical orchiectomy with high ligation is performed. The present study reports the cases of seven patients with tumors of the paratesticular region and presents the clinical and significant histological features of the tumors. In total, two patients suffered from dedifferentiated liposarcoma (DDLS), two exhibited leiomyosarcoma, two exhibited low-grade fibromyxoid sarcoma and one case of undifferentiated pleomorphic sarcoma was identified. Radical orchiectomy with high ligation was performed in five cases; simple orchiectomy was performed in one case and excisional biopsy was performed in the remaining case. A leiomyosarcomatous and epithelial membrane antigen (EMA) positive whorl pattern was observed during microscopy in the two DDLS cases. Additionally, one of the low-grade fibromyxoid sarcoma patients exhibited pleomorphism and mitosis in focal areas. To the best of our knowledge, the present study is the second time low-grade fibromyxoid sarcoma cases with paratesticular localization have been reported in the literature. Of the seven cases, four patients succumbed to the disease, one patient is living with the disorder and the two cases of DDLS are living without the disease. Paratesticular sarcomas are often aggressive and a multidisciplinary approach is required for the diagnosis and treatment of these tumors. As the paratesticular region contains various structures, including the epididymis, spermatic cord, tunica vaginalis and strong fat-ligament-muscle supporting tissues, it may give rise to a number tumor types with various behaviors . Tumor vThe majority of the masses within the scrotum in adults are of testicular origin. Paratesticular masses account for 2–3% and sarcomas account for ~30% of all scrotal masses –4. The mDetermining the association between the paratesticular mass and the testicle, and differentiation between benign and malignant masses using radiology is challenging, therefore the lesions are usually considered to be malignant and radical orchiectomy with high ligation is used. The prognosis is often poor, as recurrence and metastasis are common, and the mechanism and outcome of regional lymph node resection, radiotherapy and chemotherapy is unclear. The present study reports seven cases of paratesticular sarcoma and emphasizes the significant clinical and histological features.Seven cases of paratesticular sarcoma diagnosed at the Pathology Department of the Istanbul Education and Research Hospital  are retrospectively investigated. Hematoxylin and eosin and immunohistochemical staining of the cases were reevaluated and accurately diagnosed according to the recent World Health Organization classification . The cliThe clinical features are summarized in Cases three and four exhibited nodular, well-delineated tumors with surgical border invasion. Microscopy revealed the histology to be similar in the two cases, with the prominent features consisting of a collagen and myxoid zone, mixed with bland spindle-like fibroblastic cells and a whorl pattern, and arcades of curvilinear blood vessels  and 7. TThe masses in cases five and six were well-circumscribed and nodular, with long bundles that were parallel or perpendicular to each other. The cell cytoplasm was strongly eosinophilic and the nuclei were generally spindle shaped, with one blunt end. Mitosis was not frequent, with 1–3 mitoses per 10 high power fields. Necrosis was observed in focal areas and pleomorphism was moderate. Immunohistochemical staining for smooth muscle actin and desmin yielded a positive result. The two cases were diagnosed as LMS.Macroscopically, the mass in case seven had infiltrative borders, and, microscopically, was rich in spindle cells, with small bundles and storiform patterns. The tissue also contained large pleomorphic cells, with large eosinophilic cytoplasm in certain areas. Immunohistochemical staining yielded a positive result for vimentin only. This case was diagnosed as undifferentiated pleomorphic sarcoma.Paratesticular sarcomas are rare and account for ~2% of all soft tissue sarcomas ,10. No cThe histological features of the three cases diagnosed with LMS and undifferentiated pleomorphic sarcoma were typical and created no diagnostic problems. However, the two DDLS cases exhibited extremely rare histological features.Although the LMS and whorl patterns observed in the DDLS cases is not common, they have been described in previous studies –13. Leioet al (A further feature of the DDLS cases was the dominant spindle cell liposarcoma as a homologous component. The denomination of spindle cell liposarcoma remains controversial; certain authors use spindle-cell neoplasm or spindle cell lipoma-like neoplasm , and theet al . The autLow-grade fibromyxoid sarcoma is a relatively rare sarcoma –17. The The accepted treatment for paratesticular masses is radical inguinal orchiectomy, including the surrounding soft tissues. No consensus with regard to regional lymph node excision has been reached, radiotherapy and chemotherapy. In the current study, radical orchiectomy with high ligation was performed for the seven cases. Simple orchiectomy and excisional biopsy were conducted for the two cases with fibromyxoid sarcoma. The two patients with fibromyxoid sarcoma succumbed to the disease within 22 and 43 months, respectively, as there was residual mass and the patients did not accept additional treatment. This emphasizes the importance of radical surgical treatments. No recurrence or metastasis was observed in the two cases of liposarcoma and the improved prognosis of liposarcoma compared with the other sarcomas, or the short clinical follow-up durations may have had an effect on this finding. As four of the seven cases succumbed to the disease and one remains alive with the sarcoma demonstrates the requirement for a multidisciplinary approach to the treatment of paratesticular sarcomas.In conclusion, the paratesticular region consists of complex structures that can develop various neoplastic formations and patterns. Sarcomas comprise a significant part of paratesticular masses and may exhibit an aggressive clinical course. In older patients, paratesticular sarcomas must be considered for the differential diagnosis of scrotal masses, which do not exhibit a clear association with the testes. Furthermore, clinicians and patients must be informed about the high probability of local recurrence and distant metastasis in paratesticular sarcomas.


Rhomboid glossitis (RG), first described by Brocq in 1914, is an uncommon benign abnormality of the tongue, most frequently affecting men. His etiology is unknown, although it has been proposed that it may be derived from chronic candidiasis, or that it may be of embryological, inflammatory, or even immunological origin. It appears as a rounded or rhomboid painless plaque with well-defined margin, intense reddish or pinkish in colour due to atrophy or depapillation, and firm to palpation. The diagnosis of rhomboid glossitis is largely based on clinical examination, though histopathological studies of biopsies may be required if clinical appearance does not allow other possible diagnoses to be ruled out. No treatment is required for asymptomatic cases. We report a case of a female patient aged 24 years, consulted for a painless plaque in dorsum of the tongue. Clinical examination indicated an erythematous plaque, located anterior to the lingual “V” in left paramedial position, elongated and slightly fissured, about 2 x 0.5 cm in size. Candida culture tested positive. The lesion was thus diagnosed as RG with presence of C. albicans. Treatment was with fluconazole for 2 weeks at 50 mg per day. A complete disappearance of the lesion was noted. After 12 months follow-up, no recurrence was reported.


Imatinib, a tyrosine kinase inhibitor, is a major therapeutic option for the management of unresectable aggressive fibromatosis. Unfortunately, for most patients of low or very low average income countries, surgery often is the first treatment option. This is related to unavailability of chemotherapy or targeted therapy, and to a lack of financial resources or surgeons’ lack of knowledge of other therapeutic options.In 2010, a 26-year-old Moroccan man was referred to our oncology and radiotherapy center by his surgeon for the management of a recurrent tumor of his right subscapularis muscle. Before his assessment in our center, two resections were performed by his surgeon after performing an incision biopsy and magnetic resonance imaging. Postoperative magnetic resonance imaging was performed and showed a right axillary nodule size 2.1cm regarding a collection with a residual tumor. We decided to administer imatinib 400mg daily by mouth. Clinical and magnetic resonance imaging evaluation were performed regularly and reported a stable tumor. We reported no adverse side effects to imatinib regarding Common Terminology Criteria for Adverse Events grading.Recurrences are high during aggressive fibromatosis management. Systemic treatment with imatinib for unresectable or recurrent tumors with positive c-KIT could be the best therapeutic option. In our case report, the patient was stabilized with imatinib for 30 months and he had a very good quality of life. Longtime disease stabilization with imatinib mesylate has been reported in different series of patients with relapsing desmoid tumors, with 1-year progression-free survival rates close to 60 to 70% [Imatinib, a tyrosine kinase inhibitor, is a major therapeutic option for the management of unresectable aggressive fibromatosis (AF) or desmoid tumors . These t0 to 70% . UnfortuIn 2010, a 26-year-old Moroccan man was referred to our oncology and radiotherapy center for management of recurrent tumor of his right subscapularis. No pathological medical or surgical history was reported and no alcohol or tobacco habits. One year before, he had presented to his surgeon with a subscapularis tumor which had appeared gradually and increased in size during 6 months without associated pain or other symptoms. A physical examination reported a mass size 10cm, palpated in his right subscapularis region. A first resection was realized. Histopathological analysis demonstrated spindle-shaped cells with no identifiable nuclear pleomorphism or mitotic activity. There was no necrosis. A benign tumor with spindle-shaped cells is suspected. On immunohistochemical analysis, the cells stained positive for anti-smooth muscle actin, favoring a smooth muscle origin. The diagnostic of AF was retained. Unfortunately, the mass recurred within a period of 10 months and continued to increase in size reaching 13cm on a computed tomography scan and magnetic resonance imaging  as a selective tyrosine kinase inhibitor targeting Bcr-Abl fusion protein in chronic myelogenous leukemia, multiple class 3 receptor tyrosine kinases including PDGFR-α and PDGFR-β, as well as the c-KIT subtype [Mace  subtype .This agent blocks ligand-activated receptor phosphorylation and mitogen-activated kinase activation and proliferation, resulting in the inhibition of cellular growth and proliferation. Complete or even partial responses are documented in the literature in approximately 10 to 23% of patients treated with imatinib. Our patient has been treated with imatinib for 24 months. The mean follow-up time in the literature varied from 12 to 19.7 months . HoweverThe aggressiveness of desmoid tumors is related to their frequent recurrences despite surgical resection with clear margins. Surgery of tumors located in the subscapularis is almost R1  and recurrences or progression are evident. Systemic treatment with imatinib for unresectable or recurrent tumors with positive c-KIT could be the best therapeutic option. In our case report, the patient was stabilized with imatinib for 30 months and had a very good quality of life.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Lipomas are benign tumors of mature adipose tissue which can occur in subcutaneous, intramuscular, intermuscular, parosteal, and intraosseous compartments. Parosteal lipoma is a rare type of lipoma, accounting for less than 0.1% of primary bone neoplasms and 0.3% of all lipomas. Parosteal lipomas commonly arise in the femur and extremities. Around 150 cases have been reported in English literature with scapula being a rare site of involvement. They are known to be associated with underlying bony changes like focal cortical hyperostosis, pressure erosion of the underlying bone, and bowing deformity or with underlying osteochondroma. We report a rare case of a parosteal lipoma arising in the scapula with a bony excrescence in a 38-year-old male. A 38-year-old male presented with complains of a painless swelling gradually increasing in size over the left side of upper back for 3 years. There was no history of any neurological deficit or fever. On clinical examination, an approximately 6 × 5 cm sized mass was palpated adjacent to inferior margin of left scapula. The swelling was soft, nontender, and easily compressible with no evidence of increased local temperature. Distal pulse and neurological examination were normal.Plain radiograph of left shoulder joint revealed an irregular osseous protuberance seen contiguous with inferior part of lateral border of left scapula with overlying well-circumscribed radiolucent lesion .To characterize the lesion and define the compression of adjacent neurovascular bundle, plain and contrast enhanced magnetic resonance imaging (MRI) was performed on 3T Achieva Philips MRI scanner which revealed a well-defined, multilobulated, and juxtacortical bony excrescence measuring 2 × 1.7 cm in size adjacent to inferior margin of left scapula showing no contiguity with marrow space of scapula differentiating it from an osteochondroma. There was overlying 4.5 × 5.5 × 6.0 cm  well-defined T1 and T2 hyperintense lesion, which was suppressed on fat saturated imaging Figures . There wThe patient refused complete excision of mass which is treatment of choice.Lipomas are the most common benign mesenchymal tumors that usually arise in soft tissues. Parosteal lipoma is a rare benign tumor of adipose tissue arising from mesenchymal cells of periosteum . InitialThere are various ways in which a parosteal lipoma occurs depending on degree of chondroid modulation and endochondral ossification . The focOn radiographs, a parosteal lipoma is a well-defined area of lucency located adjacent to a long bone. Parosteal lipomas may have underlying bony alterations, mostly hyperostotic reactive changes presenting as fine linear densities, calcification, cortical thickening or undulation or frank excrescences of bone, cortical bowing (in patients with growing bones), or smooth cortical erosions, or underlying osteochondroma .On computed tomography, parosteal lipomas have fat density lesion with an osseous lobulated component adherent to the surface of the adjacent bone. Osseous excrescences may be present, but they lack the contiguity of the marrow space with the underlying bone differentiating them from an osteochondroma. Computed tomography characterizes degree of septation and defines relationship of mass with underlying cortex which is important for surgical planning .On MRI, the tumor is identified as a juxtacortical mass with signal intensity identical to that of fat, regardless of pulse sequence with occasional low-signal-intensity strands on T1 in the lesion, corresponding to fibrovascular strands that are commonly found in lipomatous lesions. These strands can be differentiated from those of well-differentiated liposarcoma, as these are thin and lack postcontrast enhancement . T1 and In our case, bony protuberance and surrounding juxtacortical benign lipoma were seen in the inferior surface of the left scapula, with underlying cortical hyperostosis, suggestive of the typical findings of parosteal lipoma well appreciated in MR imaging. The exclusion of medullary continuity between bony protuberance and the adjacent bone, which is the differential diagnostic clue from osteochondroma, was also well appreciated in the precontrast T1-weighted images. Additionally, no findings related with nerve compression were detected in MR imaging, providing confidence to the clinical examination results.Complete excision of the mass is treatment of choice. Prognosis is good with no recurrence postoperatively. Majority of parosteal lipomas have been reported to have no malignant potential and thus can be followed conservatively.Parosteal lipoma is a rare benign mesenchymal primary tumor arising from periosteum. Imaging plays an important role in diagnosis, characterization of the lesion with MRI evaluating the effect of the tumor on the neurovascular bundle and associated muscle atrophy.


Dear Editor,A 76-year-old female patient with a previous history of surgically resected rectal cancerfor seven years was admitted for diagnostic investigation of bilateral and symmetricaldorsal masses. She reported chronic pain in the thoracic spine. At clinical examination,the masses were solid, mobile, located subcutaneously and inferiorly to the scapulae. Compute. It is a benign fibroelastic tumor inferiorly locatedin the infrascapular region, between the scapula and the thoracic wall deeply to theserratus and latissimus dorsi muscles, possibly inserting into the periosteum of theposterior ribs. Coincidentally such type of tumor has been detected at CT in up to 2% ofelderly patients,2. It is most frequently found in elderly women  in the age range between 65 and 70 years at the moment of thediagnosis.ED is a slow growing soft tissue pseudotumor incidentally diagnosed during routineimaging studies, that may also cause chronic scapular pain. Other reportedsites include deltoid muscle, axillae, ischial tuberosity, olecranon, hands and feet,among others. It is alsocharacterized by symptoms absence at early phases. With the disease progression, thereis an increase in the mass volume, possibly limiting the upper limb motion, principallyin the upward movements of the arm which require sliding of the scapula in relation tothe thoracic wall. Such a movement may cause pain. Macroscopically, ED is characterized by an ill defined masswith fibrous tissue and internal adipose tissue. Histopathological analysis demonstratesnon-encapsulated hypocellular mass composed of benign fibroblasts, eosinophilic collagenbundles and apparently fragmented elastic fibers, with groups of interposed matureadipocytes,3,6.Unilateral masses are slightly more prevalent at the right side, but up to 60% of EDs arebilateral-11, CT may be diagnostic in cases wherethe lesion presents as an infrascapular or subscapular ill defined, non-encapsulatedsoft parts mass, isoattenuating to the muscles (fibrous tissue), interspersed with fatattenuation strips or lines. Homogeneity may be observed in cases of smallermasses,3. MRI is the method of choice for the diagnosis anddemonstrates an expansile, solid, ill defined, non encapsulated and heterogeneous mass,with predominance of isosignal in relation to the muscles (fibrous tissue) and,typically, intermingled with hypersignal lines on T1- and T2-weighted sequences (fattissue). Recently, reportsabout ED detection at positron emission tomography were published in the literature.Mild or moderate fluorodeoxyglucose uptake was frequently observed and should not beinterpreted as a malignant finding.In cases of asymptomatic lesions, there is no need for excision. Surgical resection inindicated in cases were pain and discomfort are present.Although in most cases of thoracic investigation magnetic resonance imaging (MRI) isindicated to evaluate extrapulmonary lesions, and CT remains reserved for investigationof parenchymal diseases


Metastases of solid tumors to the pituitary gland are often asymptomatic or appereas as with diabetes insipid us. Pituitary metastases more commonly affect the posterior lobe and the infundibulum than the anterior lobe. The presentation with an acute adrenal insufficiency is a rare event. A 69-year-old men presented with vomiting, low blood pressure and hypoglycemia. Hormonal exploration confirmed a hypopituitarism. Appropriate therapy was initiated urgently. The hypothalamic-pituitary MRI showed a pituitary hypertrophy, a nodular thickening of the pituitary stalk. The chest X Rays revealed pulmonary opacity. Computed tomography scan of the chest showed a multiples tumors with mediastinal lymphadenopathy. Bronchoscopy and biopsy demonstrated a pulmonary adenocarcinoma. Hence we concluded to a lung cancer with multiple pituitary and adrenal gland metastases. This case emphasizes the need for an etiological investigation of acute adrenal insufficiency after treatment of acute phase. Pituitary tumors are the most frequent intracranial neoplasm, affecting 11000 of the worldwide population , 3. We rA 69-year-old patient active smoker with history of type 2 diabetes mellitus presented with signs of acute adrenal insufficiency; vomiting, low blood pressure and hypoglycemia, associated to a polyuro polydipsic syndrom. Assessment of pituitary function revealed hypopituitarism and an insipidus diabetes; serum cortisol level of 12.6 ng/mL , Free T4 level of 6.8 pg/mL , thyroid stimulating hormone level of 0.005mUI/mL , total testosterone level of 0.025 ng/mL , follicle stimulating hormone level of 0.5 IU/mL , luteinizing hormon level of 0.1IU/L  and low urine osmolarity. A hormone replacement therapy was indicated urgently. In the first 12 hours after admission, a magnetic resonance imaging was performed and demonstrated an inhomogeneous pituitary hypertrophy, with convexity of the sellar diaphragm, a nodular thickening of the pituitary stalk, and a loss of high intensity signal from the posterior pituitary . The ophIn front of the deterioration of the general condition, tobacco intoxication, the imagery founds and the very high level of carcinoembryonic antigen (CEA) at 197µg/L, hypothalamic and pituitary metastasis was suspected. The computary tomography scan of the Chest, Abdomen and Pelvis revealed a mass in the upper right lobe with mediastinal lymph nodes, liver and bilateral adrenal metastases . A biopsConsent: a written informed consent was obtained from the patient for the publication of this paper and the accompanying images.Authors of reports on large autopsy series have stated that pituitary metastases occur in between 1 and 3.6% of patients with malignant tumors, if one considers autopsy series in which both the pituitary and surrounding sella turcica have been evaluated, however, rates of metastasis as high as 27% have been reported to occur in this area . Zoli etBreast and lung carcinomas represent the most frequent tumors that metastasis on a normal pituitary or on a pituitary adenoma. Other primary tumors have been reported, such as prostate, renal cell, gastrointestinal cancers, lymphoma, leukemia, thyroid carcinoma, and plasmocytoma , 4.The majority of pituitary metastases are clinically silent. Only 7% of pituitary metastases were symptomatic. Among symptomatic patients, diabetes insipidus is the most frequently reported finding, with a variable incidence ranging from 29% to 81%. Other symptoms are essentially represented by ophthalmoplegia, headache/pain, vomiting, visual field defects, decreased consciousness, and anterior pituitary dysfunction [The explanation for metastatic tumor localization to pituitary is not well understood. In patients with metastasis to the pituitary gland, four pathways for metastatic spread to this gland have been identified, as follows: Direct blood-borne metastasis to the posterior lobe with subsequent expansion; Blood-borne metastasis to the pituitary stalk with growth into the anterior and posterior pituitary lobes; Blood-borne metastasis to the clivus, dorsum sellae, or cavernous sinus, which then spreads into the pituitary gland; Leptomeningeal spread with involvement of the pituitary capsule.However, in patients with metastasis to a pituitary adenoma, the metastasis often takes the path of the arterial blood supply of the adenoma, the blood supply from capsular arteries originating in the internal carotid artery. Functionally, diabetes insipidus is an expression of stalk-posterior pituitary damage, and frequently it manifests at early stages, whereas anterior pituitary insufficiency may be a subsequent manifestation . On an oMRI is the preferred technique to demonstrate pituitary metastases . HoweverTreatment, mostly palliative, depends on symptoms. It is usually limited and includes palliative radiotherapy, hormone replacement therapy when indicated and/or chemotherapy for the primary cancer. Surgical exploration and decompression, alone or combined with radiation, is often necessary when suprasellar extension causes progressive deterioration in vision and/ or pain .The prognosis of metastatic cancer to pituitary adenoma is grim, as most patients already have widespread metastases at the time of diagnosis. The mean survival after the development of pituitary metastasis is only six months, with an overall 1-year mortality rate of more than 90% . Our patDespite the fact that pituitary metastasis are rare, they must be evoked on the presence of pituitary involvement, sudden onset of adrenal insufficiency, even in the absence of a neoplastic history. Pituitary tumor and / or metastasis should be taken in account in differential diagnosis.


Concomitant pituitary adenoma (PA) and Rathke's cleft cyst (RCC) are rare. In some cases, such PA is known to produce pituitary hormones. A 53-year-old man was admitted to our hospital with a diagnosis of lacunar infarction in the left basal ganglia. Magnetic resonance imaging (MRI) incidentally showed a suprasellar mass with radiographic features of RCC. When he consulted with a neurosurgical outpatient clinic, acromegaly was suspected based on his appearance. A diagnosis of growth hormone- (GH-) producing PA was confirmed from hormonal examinations and additional MRI. Retrospectively, initial MR images also showed intrasellar mass that is compatible with the diagnosis of PA other than suprasellar RCC. The patient underwent endonasal-endoscopic removal of the PA. Since we judged that the RCC of the patient was asymptomatic, only the PA was completely removed. The postoperative course of the patient was uneventful and GH levels gradually normalized. Only 40 cases of PA with concomitant RCC have been reported to date, including 13 cases of GH-producing PA. In those 13 cases, RCC tended to be located in the sella turcica, and suprasellar RCC like this case appears rare. In a few cases, concomitant RCCs were fenestrated, but GH levels normalized postoperatively as in the cases without RCC fenestration. If radiographic imaging shows typical RCC, and PA is not obvious at first glance, the possibility of concomitant PA still needs to be considered. In terms of treatment, removal of the RCC is not needed to achieve hormone normalization. The relationship between pituitary adenoma (PA) and Rathke's cleft cyst (RCC) is controversial. The origin of RCC is generally considered to be derived from remnants of Rathke's pouch. PA is also formed by proliferation of the anterior wall of Rathke's pouch. They have a possibility to be derived from a common ancestry . It has μIU/mL, FT3 of 3.2 pg/mL, FT4 of 1.8 ng/mL, serum cortisol of 14.5 μg/dL, and serum prolactin of 17.5 ng/mL.A 53-year-old man had high height from the cradle and also realized his protruding chin. He presented to our hospital with slight paralysis of the right upper extremity. His height was 181 cm that was within the limits of 2 standard deviations. Head MRI showed left lacunar infarction of the basal ganglia, as well as a suprasellar mass. The suprasellar mass was hyperintense on T1-weighted MR image  and alsoPituitary insufficiency is common at presentation of RCC; however pituitary function status was normal in this case .A 75 g oral glucose tolerance test failed to suppress GH to <1 ng/mL. Nadir GH during this test was 8.3 ng·mL. In conjunction with the findings from Gd-enhanced MRI, a diagnosis of GH-producing PA was made Figures . At thisRemoval of the PA using an endonasal-endoscopic approach was performed. Intraoperatively, the margin between the normal pituitary gland and adenoma was clear . We idenPostoperative course of the patient was uneventful other than diabetes insipidus, which was well controlled by medication. GH and somatomedin C levels gradually improved until 7 days postoperatively. We decided to observe the RCC conservatively without additional surgery. The patient was discharged from our hospital on foot with no neurological sequelae.Diabetes insipidus was treated by administered medication for 6 months. Pituitary function and visual field were not disturbed for 6 months. Hormonal laboratory testing 12 weeks after the operation showed GH of 0.3 ng/mL and somatomedin C levels of 131 ng/mL. At the 6-month follow-up time point, he has made satisfactory progress without recurrence.A great variety of lesions such as sarcoidosis, intrasellar schwannoma, and gangliocytoma can coexist with pituitary adenomas and are referred to as collision sellar lesions . HoweverRCC usually appears hyperintense on T1-weighted imaging. However, RCC existing concomitant with PA is known to present with variable intensity on T1-weighted imaging, since it tends to be complicated by hemorrhage in the cyst . In suchWhen a nonenhanced cyst is demonstrated in cases of PA detected by MRI, the possibility of accompanying RCC should be considered. As for differential diagnosis, RCC usually demonstrates no contrast enhancement of the cyst wall as referred to above and displayed no calcification unlike craniopharyngioma. These radiographic characteristics are helpful in the differential diagnosis of craniopharyngioma.As for treatments, there is no need to fenestrate RCCs as far as they are asymptomatic. In reported cases of GH-producing PA and concomitant RCC, fenestration of the RCC and surgical biopsy of the cyst wall were performed for 61% . HoweverIn the present case, the appearance of the patient suggested acromegaly and guided us to a diagnosis of RCC with concomitant PA. If the PA in this patient had been nonfunctional, correct diagnosis of the concomitant PA would have been much more difficult. This case offers a reminder that although rare, RCC can accompany PA. We recommend performing contrast-enhanced MRI routinely on suspicion of RCC.