This manuscript reports on a patient with a metastatic gastrointestinal stromal tumor (GIST) refractory to standard first-line treatment, who underwent a gallium-68 scan based on pre-clinical data of somatostatin receptor (SSTR) expression in such tumors. The gallium-68 DOTATATE scan determined significant somatostatin receptor avidity as hypothesized, suggesting that this imaging modality may be used as an option for diagnostic and follow-up purposes in GIST patients. In addition, peptide receptor-mediated radiotherapy (177Lu-PPRT) via SSTR may provide a novel treatment strategy in carefully selected SSTR-avid GIST patients with thyrosine kinase inhibitor (TKI)-resistant tumors such as this case, and this warrants further investigation in novel clinical trial concepts. This manuscript reports on a patient with a metastatic gastrointestinal stromal tumor (GIST) refractory to standard first-line treatment, who underwent a gallium-68 scan based on pre-clinical data of somatostatin receptor (SSTR) expression in such tumors. The gallium-68 DOTATATE scan determined significant somatostatin receptor avidity as hypothesized, suggesting that this imaging modality may be used as an option for diagnostic and follow-up purposes in GIST patients. This is significant, as it may provide a new target-specific diagnostic option similar to the case of neuroendocrine tumors. In addition, the tumor was noted to be radiosensitive, and peptide receptor-mediated radiotherapy (177Lu-PPRT) via SSTR may provide a novel treatment strategy in carefully selected SSTR-avid GIST patients with thyrosine kinase inhibitor (TKI)-resistant tumors such as this case, which undoubtedly warrants further investigation. Hereby, we report on this interesting patient's case.The patient is a 35-year-old male who was in his usual state of health until the summer of  2016, when he started to complain of worsening upper abdominal pain. This led to a visit to the emergency department (ED), and he had a computed tomography (CT) scan of the abdomen and pelvis done, which showed an incidental 3.4 cm rounded hypoattenuation in the right hepatic lobe. A [18F] fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) scan reported a fluorodeoxyglucose (FDG)-avid right retropharyngeal lymph node, hepatic dome lesion, and two osseous lesions in the lumbar vertebra L4 and left proximal sacral ala consistent with hypermetabolic malignancy. Differential considerations included lymphoma, metastatic disease from unknown primary, and less likely primary hepatic malignancy with metastasis.The patient then underwent a liver biopsy, which reported spindle cell tumor, with equivocal succinate dehydrogenase B (SDHB) expression in the tumor cells; the ERG stain highlighted endothelial cells but was negative for tumor cells, and the mitotic count was 9/50 high power field. The tumor cells were positive for CD117 (KIT) and DOG1, and negative for SOX10, HMB-45, Melan A, desmin, SMA, CD31, ERG, synaptophysin, chromogranin, keratins AE1/AE3, Cam 5.2, arginase, Hep-Par 1, PAX-8, p63, CD138, and CD43. Evaluation of pathology at the National Institutes of Health reported a highly epithelioid neoplasm consistent with succinate dehydrogenase (SDH)-deficient gastrointestinal stromal tumor (GIST). The tumor cells were positive for KIT and SDHA, and negative for SDHB. Next-generation sequencing of the tumor  showed no mutations in their panel, including KIT and platelet-derived growth factor A (PDGFRA). We discussed the option of pursuing germline genetic testing for genes associated with SDH-deficient tumors by way of a next-generation sequencing multi-gene panel. After our discussion and given the patient's young age, he elected to pursue Invitae's Hereditary Paraganglioma-Pheochromocytoma Panel . The genes included on this panel were: MAX, NF1, RET, SDHA, SDHAF2, SDHB, SDHC, SDHD, TMEM127, and VHL, and the results showed no germline alterations.We considered the patient to have Stage IV SDH-deficient GIST metastatic to liver and spine, KIT and PDGFRA wild-type, and as a suitable candidate for palliative systemic therapy in order to improve his survival and quality of life. Upper endoscopy was not performed as there was no evidence on imaging of lesions and would not have altered the treatment plan. We discussed that ‘wild-type’ GISTs are usually highly resistant to tyrosine kinase inhibitors (TKIs) but may convey a relatively indolent course . A trialThe patient also received palliative fractionated radiation to liver and head and neck  from late 2016 through early 2017, concomitant with regorafenib use. A follow-up 18F-FDG PET/CT scan in March 2017 showed an interval decrease in the FDG uptake in the right parapharyngeal mass and right hepatic lobe metastatic lesion, suggestive of partial treatment response status post interval radiation therapy. However, there was a moderate interval increase in the FDG uptake in the multiple osseous metastatic lesions. No new metastatic lesions were noted. After a multidisciplinary meeting and discussion, and given stable disease per response evaluation criteria in solid tumors (RECIST) criteria, the patient continued taking regorafenib accordingly. He was planned for future enrollment in an immune checkpoint inhibitor-based clinical trial .Given some pre-clinical data regarding the expression of somatostatin receptors (SSTR) in GISTs as a potential target for a therapeutic strategy -5, the p Notably, the 18F-FDG PET/CT scan showed a completely matched finding with glucose hypermetabolism of the liver and bone metastases as noted in the gallium-68 DOTATATE scan  overexpression of SSTRs has enabled personalized ‘theranostic’ advances using radiolabeled somatostatin analogues; SSTRs targeting with 177Lu-DOTATATE peptide receptor-mediated radiotherapy (177Lu-PPRT) has demonstrated efficacy and short-term safety, and could be considered for advanced NET patients with disease that express SSRTs and is otherwise refractory to medical therapy .Gastrointestinal stromal tumors have been reported to express somatostatin receptors and bind radiolabeled somatostatin analogs, with some authors considering the possibility of using such receptors as a new prognostic biomarker and potential therapeutic strategy -5; howevPeptide receptor-mediated diagnostics  and radiotherapy (177Lu-PPRT) via SSTR targeting may provide a novel treatment strategy in carefully selected SSTR-avid GIST patients with TKI-resistant tumors such as this case. In the era of precision medicine and biomarkers, future theranostic studies may consider the inclusion of PRRT with or without TKI in appropriately selected patients; this warrants further investigation in prospective trials.


Regenerative endodontic treatment was performed on a mature maxillary premolar diagnosed as chronic pulpitis. The root canals were chemomechanically prepared and placed intracanal medicaments at the first appointment. Then 2 weeks later, a blood clot was created in the canals, over which mineral trioxide aggregate was placed. At 6-month follow-up, cementum-like tissue seemed to be formed in the root canal along with nearly recovered pulp vitality. At 12-month recall, the radiographic results revealed evidence of root wall thickening. At 30-month recall, no periapical lesion was found. This case report indicates that regenerative endodontic treatment for the mature premolar is feasible. More cases are needed for further validation. Regenerative endodontics is the use of biologically based procedures designed to replace damaged structures, including dentin and root structures, as well as cells of the pulp-dentin complex . It showTraditionally, for pulpitis or apical periodontitis, root canal treatment (RCT) is the most common treatment method. However, RCT results in complete removal of pulp tissues, which means loss of a warning system, immunoresponse and formation of dentin as active defense mechanisms against invading toxins and bacteria, and cease of root development in the cases of young patients. Moreover, in some special cases, the absence of an apical constriction makes RCT problematic. Apexification also has some disadvantages such as variability of treatment time, patient compliance, and increased risk of tooth fracture, which may do not promote the continued development of the root and just “closed” the open apex by a calcific barrier. In contrast, the goal of regenerative endodontics is to induce biologic replacement of dental tissues and regenerate a functional and healthy pulp-dentin complex. So, regenerative endodontic treatment may be a good alternative to conventional endodontic therapies, especially for immature permanent teeth.To date, more and more case reports and case series showed the feasibility of regenerative endodontic treatment –5; howevA 15-year-old girl in good health presented to the Department of Endodontics, Wuhan University Hospital of Stomatology, in November, 2014, with a chief complaint of cold water pain on her left upper posterior tooth for the last 5 days. Three months earlier, she had caries filled in the same region. Intraoral examination revealed that tooth #13 had an existing distal occlusal composite restoration. Tooth #13 showed sensitivity to pulp test and no sensitivity to palpation and percussion. Radiographic examination showed distal a filling shadow close to the pulp and a fully developed root and closed apex . On the An informed consent was obtained from the patient and her parent for regenerative endodontic treatment. An access cavity preparation was performed after local anesthesia with 2% lidocaine and rubber dam isolation. The canal was irrigated copiously with 5.25% sodium hypochlorite and 17% EDTA. The canal was partially dried with sterile paper points and then dusted with a mixture powder of ciprofloxacin and metronidazole. The tooth was then temporized with zinc oxide eugenol cement.At 2-week follow-up, the patient was asymptomatic. The tooth was not sensitive to percussion and palpation. After local anesthesia by using 2% lidocaine and rubber dam isolation, the temporary restoration was removed. The antibiotic mixture was completely removed with 5.25% sodium hypochlorite. The apical foramen was enlarged up to 0.6 mm with a size #60 hand file (K-file). Seventeen percent EDTA was used as a final irrigating agent and left in the canal for about 1 minute. Then, the canal was dried with sterile paper points. A size #25 K-file was introduced into the root canal to irritate the periapical tissue and to create some bleeding into the root canal. The mineral trioxide aggregate (MTA) was placed approximately 2 mm below the cementoenamel junction. The tooth was restored with glass ionomer cement .At 3-month recall, the patient was asymptomatic. The tooth was not sensitive to percussion or palpation and not responsive to pulp testing. The radiograph showed nearly a normal periodontal ligament space . The tooAt 6-month follow-up, tooth #13 regained pulp sensibility and responded positively to the electric pulp tester (EPT) and Endo-Ice at a similar extent as the control tooth. The radiographic results showed narrowing of the canal space with radiopaque shadows .At 12-month recall, there was no pain on percussion and palpation. Tooth #13 was normally responsive to Endo-Ice and EPT. The radiographic results revealed evidence of root wall thickening .At 30-month recall, tooth #13 still showed normal pulp vitality compared to the control tooth, and no periapical lesion was found on the X-ray film . The recAge of thirteen to fifteen years is the period of a premolar maturation, during which the apex is gradually closed. In this case, the patient was 15 years old. The X-ray showed that the apex was fully developed. Furthermore, during the regenerative endodontic treatment, a #15 K-file was used to probe the apical foramen and an obvious sense of friction was found, so we judged the tooth in this case belongs to mature permanent tooth. Apical bleeding was induced into the root canal, leading to a suitable environment for pulp regeneration with an enrichment of host endogenous stem cells and growth factors in a bioactive scaffold. The new-grown tissue was not a pulp tissue revealed by the calcified shadows in the root canal. Instead, it might be a newly generated cementum-like tissue termed herein “intracanal cementum” as reported in relevant literature .The concept of regenerating pulpal tissue was promulgated by the classic studies of Nygaard-Ostby in 1961. His early research revealed tissue repair  without histologic evidence of regeneration of the pulp-dentin complex, while a newly mineralized tissue appeared to be cementum was evident on some dentinal walls. The second case series 10 years later showed histologic evidence of an ingrowth of vascularized fibrous connective tissue in the most of the teeth. Wang et al.  analyzedIt is believed that stem cells play an important role in histogenesis as well as pulp regeneration. To our knowledge, at least five types of postnatal mesenchymal stem cells can differentiate into odontoblast-like cells based upon the studies of recent years, including dental pulp stem cells (DPSCs), stem cells of human exfoliated deciduous teeth (SHED), dental follicle progenitor cells (DFPCs), stem cells of the apical papilla (SCAP), and bone marrow-derived mesenchymal stem cells (BMMSCs). Promisingly, studies in vivo have shown that transplantation of stem cells can yield ectopic dental pulp-like tissues in tooth slices or fragments. However, no clinical trials of stem cell transplantation have been reported to date. It has been adopted by the American Dental Association (ADA) to induce apical bleeding into the root canal in immature permanent teeth with necrotic pulps which have been extirpated in January 2011 . The evoScaffold is thought of as an indispensable element for pulp/dentin regeneration. In this report, sterile blood clot induced into the root canal also acted as the 3-dimensional scaffold  for tissClinical regenerative endodontics has been focused on immature teeth because they have a greater chance of pulp tissue regeneration. It is believed that immature teeth with open apices allow more stem cells to migrate into root canals, and more stem cells found near immature root apices have been shown to possess a great regeneration potential in pulp regeneration . MoreoveIn conclusion, the present case demonstrates the resolution of clinical signs and symptoms with cementum-like tissue formed in the root canal and pulp vitality nearly recovered in the mature permanent premolar with pulpitis after regenerative endodontic treatment. Current regenerative procedures successfully produce root development, but still no evidence is there to reestablish a real pulp tissue. Higher level of evidence with large-scale investigations and randomized controlled clinical trials is still needed. Anyway, it might be possible that regenerative endodontic treatment could be widely used on mature teeth in the future and become an alternative to conventional endodontic therapies.


Paraganglioma is an extra site of pheochromocytoma. Paraganglioma in the bladder is a very rare disease accounting for 0.06% of all bladder tumors.A 77-year-old Japanese man was referred to our department for the further examination of a bladder tumor detected on preoperative computed tomography of his gastric cancer. Cystoscopy revealed a submucosal tumor in the upper area of his bladder, so transurethral resection of the bladder tumor was performed. During transurethral resection of the bladder tumor, his blood pressure sharply increased, and a pathological examination showed paraganglioma in his bladder. Postoperative I-123-metaiodobenzylguanidine scintigraphy detected a higher intake of his bladder tumor. Laboratory examinations showed a slightly increased noradrenaline level of 530 pg/ml and reduced platelet count at 167,000/μL. Based on the progression of his gastric cancer, no additional therapy was performed on his bladder tumor. Eight months after surgery, he died from aspiration pneumonitis.Here we report a rare case of paraganglioma in the bladder. We discuss paraganglioma based on previous studies. Paraganglioma is an extra site of pheochromocytoma from the adrenal gland. Paraganglioma is reported to account for 18% of pheochromocytomas, and 10% of cases occur in the bladder. Paraganglioma in the bladder is a very rare disease and accounts for 0.06% of all bladder tumors .We performed transurethral resection of bladder tumor (TUR-Bt) on a mass unexpectedly detected on preoperative computed tomography (CT) of a patient’s gastric cancer, and his arterial blood pressure was abnormally elevated during the procedure. Postoperatively, the tumor was diagnosed as paraganglioma. Here we report a rare case of paraganglioma in the bladder.A 77-year-old Japanese man was referred to our department for treatment of a bladder mass (26 mm in diameter) detected on preoperative CT of his gastric cancer. He had no remarkable medical history except for gastric cancer and hypertension. The stage of gastric cancer was T1b(SM)N0M0. A laboratory examination showed almost normal values except for a low platelet count of 167,000/μL. Urinary cytology showed class II. A CT revealed a 26-mm bladder tumor in the upper region of his bladder Fig. .Fig. 1CoBased on these findings, TUR-Bt was performed for his bladder tumor. His usual blood pressure was around 120/80 mmHg with olmesartan medoxomil/azelnidipine intake. At the time of starting transurethral resection (TUR), his blood pressure was elevated as 240 mmHg in his systolic blood pressure. In the procedure of TUR, no active bleeding was observed.Hematoxylin and eosin staining showed Fig  polygonaParaganglioma is a rare neuroendocrine neoplasm which tends to develop in the extra-adrenal glands. Paraganglioma in the bladder is extremely rare and accounts for 0.06% of all bladder tumors , 2.et al. reported that the symptoms of paraganglioma in the bladder were macroscopic hematuria, hypertension, and hypertension seizure at urination [et al. examined 234 Japanese cases and found that 41.3% had macroscopic hematuria, 33.2% hypertension, and 23.0% hypertension seizure at urination. Only 1.4% showed all three symptoms, and 10.6% showed none of these symptoms [Das rination . YamamotMRI and MIBG scintigraphy have been reported useful for a diagnosis. In a previous report, MRI T1-WI showed low intensity, while T2-WI showed high intensity, but not all cases show this pattern . In factRegarding laboratory findings, 88% of cases of paraganglioma show elevated levels of urine metanephrine and serum catecholamine . In bladParaganglioma in the bladder can be benign or malignant, but its histopathological diagnosis is difficult. The diagnosis of benign or malignant status depends on the degree of invasion, lymph node metastasis, and distant metastasis. Our patient had T1b(SM)N0M0 gastric cancer and no previous study showed a correlation between gastric cancer and paraganglioma. Partial cystectomy has been recommended, but TUR-Bt might be an option in cases in which the tumor has not invaded the surrounding fat , 11.We describe the case of a patient whose blood pressure became extremely elevated during TUR-Bt, and a pathological examination showed paraganglioma of the bladder. Here we report a rare case of paraganglioma in the bladder.


We report here a case of giant vulval condyloma in a two-year-old infant infected by her “baby sitter” without sexual abuse. Treated by surgical excision coupled with electrocoagulation, it was noted a rapid recurrence two weeks after treatment requiring a second electrocoagulation session. More than a year later, no lesion was noted, thus demonstrating therapeutic success. The unavailability of imiquimod in our context requires a systematic use of invasive treatment regardless of the age of the patient. Adult’s anogenital condylomas are among the most frequent sexually transmitted diseases (STDs) . These aThe case is about a female infant of two years brought into consultation in July 2015 by her mother because of a vulvar, asymptomatic lesions evolving for about 06 weeks, with a progressive and rapid increase in size. No prior treatment had been made before her admission. Clinical examination showed a vegetative tumor with a verrucous surface of 3 cm by 1.5 cm on the lower half of the cutaneous part of the large left lip . ExaminaCondylomas are subsequent to an infection of the keratinocytes by HPV, a DNA virus. In adults, transmission is essentially sexual. In children, three modes of transmission exist: perinatal (in utero and during delivery), horizontal (self- and hetero-inoculation known as “innocent”) and in sexual abuse . TherefoThe interest of our observation lies in the rarity of giant condylomas in infants, the therapeutic method used successfully, the absence of recurrence after more than one year, the non-sexual contamination of these condylomas in an immunocompetent patient. Moreover, this study shows the necessity to make available the therapeutic means less or not invasive for the management of these cases. It is also important to ensure the medical supervision of house workers because the health of the whole family depends on it.The authors declare no competing interests.


Smooth muscle tumors (SMTs) of the pleura are exceptionally rare. At present and to the best of these authors' knowledge, there are only 17 cases reported in the literature. We describe a case of a 51-year-old woman who complained of left sided pleuritic chest pain. Further, computed tomography (CT) revealed a left sided localized pleural-based mass involving the 9th rib. She underwent an interventional radiology guided percutaneous core biopsy of the lesion, which disclosed a “Smooth Muscle Tumor of Undetermined Malignant Potential (SMT-UMP).” A video-assisted thoracoscopic surgery (VATS) was performed for diagnosis and treatment purposes. Resections of the pleural-based mass and 9th rib were performed. SMT-UMP was the definitive diagnosis.  Intrathoracic smooth muscle tumors are uncommon in the respiratory tract (upper and lower respiratory tract). They are seen occasionally in the gastrointestinal tract and commonly seen in the urogenital system –3. HowevA 51-year-old woman presented to the emergency department with persistent posterior left sided chest discomfort. Patient had nonspecific symptoms for over one year. Upon admission patient was noted to have a normal EKG findings; X-Ray of the chest was unremarkable. She underwent a CT which revealed a pleural-based mass 3.3 cm × 2.0 cm of the left lower lobe involving the 9th rib posteriorly, in She was further treated with complete resection of the pleural-based mass and the 9th rib by video-assisted thoracoscopic surgery (VATS). The final pathology examination revealed a well-capsulated SMT-UMP of pleural origin measuring 3.5 × 3.0 × 2.4 cm with no evidence of rib involvement by the tumor, in SMT-UMP originating in the pleura are rare. They tend to have a female predominance (12 out of 18 patients) as per current literature review. Patient's age ranges from 21 to 73 years old (mean 42.7). Leiomyosarcomas (LMS) were found mainly in older patients and SMT of UMP on the other hand tend to happen in younger patients. Our case illustrates that SMT-UMP can present in a relatively older age.SMTs can be found incidentally on imaging studies done for unrelated issues or they can cause symptoms usually related to tumor size (the largest one has been reported as at least 21 cm) and location. In our case a middle aged women presented with nonspecific pleuritic chest pain where fatal conditions need to be ruled out. These patients should undergo a thorough history and physical examination. Radiological studies should be performed with chest X-ray (CXR), computed tomography, and magnetic resonance imaging that helps identify location, size, and radiological structure of the tumor .Pleural tumors tend to grow locally toward the intrathoracic cavity . There iConfirmation of diagnosis is always made with tissue sample and histological examination. A CT-guided biopsy can be performed, but it has the potential to seed the tissues directly in its path . If surgPrimary pleural tumors are rare since 75% of pleural tumors represent metastatic disease . The difImmunohistochemical staining for smooth muscle actin and desmin provides a definitive diagnosis of smooth muscle origin.In our patient, microscopic examination showed proliferation of bland spindle cells with elongated nuclei, eosinophilic cytoplasm, and rare mitotic figures. Focal areas of increased cellularity and atypia were present, but no necrosis was identified, in Even when smooth muscle tumors of the pleura appear benign, well-encapsulated, smooth, and without evidence of necrosis and show rare mitotic activity they can possess malignant potential and present as or transform in LMS; see Primary and preferred treatment is surgical resection if feasible which can be performed using minimally invasive surgery such as VATS, if after surgical resection there are positive margins to consider reresection (preferable option) versus observation (watch and wait approach) of the remaining disease with serial imaging studies during follow-up . Smooth The prognosis appears to be good if the tumor is excised completely with negative margins, but routine follow-up should not be neglected. Due to the rarity of this entity and relative short follow-ups the behavior of this tumor cannot be properly evaluated.Primary SMTs of the pleura are infrequent tumors and should be considered as a differential diagnosis when approaching a pleural mass. It seems to develop from the vascular smooth muscle cells. SMT-UMP tends to affect younger patients and LMS to tends to affect older patients. However, SMT-UMP can present in older patients as in our case. They appear to grow locally and invade nearby structures but there is not yet a single case reporting distant metastasis (the present case was not the exception). Tissue diagnosis and accurate histopathological evaluation are required. Although these tumors seem to possess low malignant potential they can be life threatening  and should be treated as such with appropriate surgical management and close follow-up.


Uterine tumors resembling ovarian sex cord tumors (UTROSCT) are rare uterine neoplasms. These tumors are usually benign, displaying a nodular or polypoid growth pattern; common occurrence is observed at the 4th to 6th decade of life. This entity is divided according to clinical behavior and pathological typical findings including different immunohistochemical staining. Traditionally type I tumors show a predominant endometrial stromal pattern with less than 50% ovarian sex cord component. This type has been shown to behave more aggressively with a decreased disease free survival period. Type II tumors, the classical UTROSCT, are less invasive but have the tendency to recur. We report a case of a 57-year-old patient presenting with postmenopausal bleeding. Hysteroscopic polypectomy showed the diagnosis of UTROSCT. This case presents a less morbid minimally invasive treatment plan and exemplifies that in patients where low malignant potential exists and their will is taken into consideration such management is both crucial and correct. Uterine tumors resembling ovarian sex cord tumor (UTROSCT) is an extremely rare type of uterine neoplasm and its clinical characteristics are not fully understood. To date, only 77 cases have been reported in the English literature –3. GomesThis classification is critical due to the fact that the two types of tumors resemble each other histologically and yet differ significantly in terms of clinical behavior and genetic features, thus requiring different clinical approaches .Since the initial report in 1976, a distinct separation between the two subtypes has been formed. Until recent years, this categorization was solemnly clinically based .Recently the classification has been reframed based on several immunohistochemical markers, including Calretinin, CD99, Inhibin, and Melan .Type I ESTCLE shows a predominant endometrial stromal pattern, with usually less than 50% ovarian sex cord pattern. Such tumors typically express Calretinin immunohistochemical marker. This tumor also contains unique genetic features and a characteristic translocation. These findings are absent in Type II tumor .Type I is known to have a significantly higher malignant potential and the outcome is contingent upon grade and stage of the underlying stromal neoplasm .Type II also known as classical URTOSCT is considered to be of low malignant potential secondary to occasional recurrence, although they typically exhibit benign biological behavior. A positive Calretinin, as well as another positive staining by Inhibin, CD 99 or Melan A, is to be obtained in order to reach the diagnosis of this specific type , 8. UTROA 57-year-old Caucasian woman presented with postmenopausal bleeding (PMB) and hot flushes was admitted to our department. Initial workup included physical examination and transvaginal sonography with no pathological findings.∗8∗2.5 mm. On microscopic examination, fragments of uterine wall infiltrated by malignant nonpleomorphic tumor cells with pale chromatin small nucleoli minor variations in their round to oval nuclear contour and rare mitosis. The cytoplasm of tumor cells is mostly scant but some epithelioid cells with abundant foamy cytoplasm are seen. These neoplastic cells form different patterns of growth: ovarian sex cord tumors, including solid areas, glomeruloid structures, and small nests  was performed and pathologic examination revealed syncytial metaplasia. Consequently, the patient experienced a few more episodes of bleeding; therefore hysteroscopy was performed revealing normal appearing endometrium with an endometrial polyp. Eventually, polypectomy was performed. On gross examination there was an elastic pale grey mass measuring 9ll nests .On immunohistochemistry tumor cells were positive for Calretinin , MART-1,Due to the rare histological result of the polypectomy a computerized tomography (CT) was done and showed no abnormality. No other imaging studies were performed.Pathological results correlated with a neoplasm of low malignant potential (subtype 1). Taking into account the patient's age and personal preference she underwent laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy without the additional omentectomy and regional lymph node dissection.No further macroscopic abnormal finding was observed in the operative field. Upon final pathological review, the uterus showed an inactive endometrium with focal ulceration, fibrin, and giant cell reaction consistent with previous polypectomy. No residual tumor was documented. An unremarkable cervix and lower uterine segments were observed; furthermore bilateral ovaries with atrophic changes and inclusion cysts as well as bilateral benign fallopian tube were described. Today, three years after the initial treatment the patient is being followed up with no evidence of recurrence.We present here an additional case report of UTROSCT. It is of utmost importance to bring forward every such patient in order to reveal the unknown complexity of this intriguing entity.UTROSCT are rare uterine neoplasms. The differential diagnosis includes leiomyoma, endometrial polyp, and malignant neoplasm of the uterus . The initial morphologic description in the literature failed to describe whether UTROSCT represents a variant within the spectrum of endometrial stromal tumors (ESTs), which may rarely exhibit areas of sex cord-like differentiation or whether it is a distinct uterine neoplasm unrelated to ESTs . The neoThe most significant information from recently conducted studies concerns the immunophenotype of these lesions, especially of UTROSCT. Out of the plethora of the immunohistochemical stains, a panel of 4 stains, including Calretinin, Inhibin, CD99, and Melan A, seemed to be the most characteristic sex cord markers. Positivity for Calretinin and at least for one more of the other above-mentioned markers confirms the diagnosis of UTROSCT. Endometrial stromal tumors with sex cord-like elements, on the other hand, usually express only one of these sex cord markers, mostly Calretinin . In our Hysterectomy with or without bilateral salpingo-oophorectomy is usually the treatment for UTROSCT . UTROSCTThe decision to remove the adnexa is based on the clinical status, tumor histological type, and the age of the patient. Our patient was 57 years old, with postmenopausal bleeding, and therefore, bilateral salpingectomy was performed. However, owing to the uncertain malignant potential of UTROSCT, while fertility sparing surgery in young patients could seem safe, the risks of recurrence are precipitating the need for close follow-up.To date there are no recommendations for adjuvant chemotherapy or radiotherapy . AlthougIn this case report, a description of a patient with classical subtype UTROSCT was presented. We believe that the distinction between the two subtypes is fundamental for both gynecooncologists and the gynecopathologists in order to prevent overtreatment and supply adequate care for those rare patients.This subclassification can be performed readily by requesting immunostaining in all subsequent pathological results. By doing so, treatment is proportionate and tailored on an individual basis. We also urge that the importance of bringing forward such similar cases in the future thus strengthens our clinical practice and management.


Congenital and perinatal primary brain neoplasms are extremely rare. Brainstem neoplasms in the perinatal and neonatal period are typically of high-grade nature and have poor prognoses with survival rates of less than 2 years from diagnosis. Herein, we report an unusual case of congenital anaplastic oligodendroglioma that arose in the pons and was detected as diffuse pontine glioma on in utero imaging studies during prenatal evaluation at 26 weeks' gestation. A male infant was delivered at 36.4 weeks of gestation via Cesarean section who developed progressive dyspnea shortly after birth. Magnetic resonance imaging (MRI) studies of his head showed the expansile, poorly demarcated mass in the pons with minimal heterogeneous enhancement and severe communicating hydrocephalus. Despite aggressive management, including dexamethasone treatment, the infant expired on the third day of postnatal life. On postmortem examination cut sections through the brainstem and cerebellum disclosed the neoplasm that infiltrated the entire pons, extended into the midbrain, medulla, cerebellar peduncles, and caudal diencephalon. Histological sections demonstrated an anaplastic oligodendroglioma infiltrating the pons, 4th ventricle, midbrain, medulla, cerebellar white matter, posterior thalamus, and occipital white matter. The pathological features of the lesion distinguish it from previous reports in which spontaneous regression of pontine gliomas occurred and argue in favor of establishing a tissue diagnosis to plan for aggressive versus conservative management. Congenital and perinatal primary brain neoplasms are extremely rare as the incidences range from 1 to 30 cases per million . BrainstA 33-year-old G6 P3 woman presented for prenatal evaluation at 26 weeks of gestation. Past medical history was noncontributory. Fetal US examination revealed findings consistent with macrocephaly, triventricular hydrocephalus, and small cerebellar hemispheres, but no evidence of spina bifida. Fetal MRI detected an expanding, poorly demarcated brainstem mass that was centered in the pons, extended into the midbrain, medulla, and cerebellar peduncles, and associated with dilated ventricles. A presumptive diagnosis of diffuse pontine glioma was made. Cesarean section at 36 weeks and 4 days produced a 3415-gram male infant who had Apgar scores of 7 and 9 at 1 and 5 minutes after birth, respectively. Head circumference was 41.2 cm . Shortly after birth, the infant developed progressive dyspnea. He was intubated and transferred to the neonatal intensive care unit. MRI studies of his head again showed the expansile, poorly demarcated mass in the pons with minimal heterogenous enhancement and severe communicating hydrocephalus . NeurosuPostmortem examination revealed a full-term, well developed male infant with macrocephaly. Karyotype revealed normal male, 46 XY. The general autopsy findings showed large size for stated gestational age male neonate weighing 3239 g with expected weight of 2383 ± 373 g. Examination of the internal organs was unremarkable except for signs of moderate stress-induced thymic involution, as evident by cortical lymphocyte depletion on histologic examination.The fixed brain weighed 537 gms . Small intra-arachnoid hemorrhages surrounded the ventrolateral surfaces of the brainstem and cerebellum and the right superior parietal region. The brain was diffusely swollen and had early encephalomalacia with pressure necrosis of all cranial nerves. In addition, severe hydrocephalus  involving the lateral and third ventricles resulted in extreme thinning of the cortex and compression of subcortical nuclei. Recent infarcts were present in the distribution of both middle and posterior cerebral arteries. The brainstem was occupied by a large tumor with variegated appearance and soft somewhat gelatinous consistency, showing multiple hemorrhagic areas . Cut secHistological sections stained with Luxol Fast Blue-Hematoxylin and Eosin demonstrated an anaplastic oligodendroglioma infiltrating the pons, 4th ventricle, midbrain, medulla, cerebellar white matter, posterior thalamus, and occipital white matter . CytologOligodendroglioma is the third most common glioma, accounting for 2–5% of primary brain tumors, 5–18% of all glial neoplasms, and less than 1% of pediatric central nervous system neoplasms. Prevalence rates are difficult to determine due to lack of standardized morphologic criteria and immunohistochemical or molecular biomarkers. Most oligodendrogliomas are diagnosed in adults, with peak incidences in the fourth or fifth decade. In adults, anaplastic oligodendrogliomas are detected later, with peak incidences in the sixth or seventh decade .Oligodendroglial neoplasms in children arise 4–10 times more often in supratentorial brain structures, compared to infratentorial lesions . CerebelThe prognostic significance of brain tumor classifications and grading has been difficult to evaluate due to periodic updating, changing grading criteria, and low interrater reproducibility even among specialized pediatric pathologists. The most widely used histological classification system of brain tumors is that of the World Health Organization (WHO). However, classifying high-grade gliomas by histological features can be challenging, leading to limited reproducibility and significant interobserver variability. In addition, despite similar histological terminology, adult and pediatric high-grade gliomas differ in terms of prognosis .An alternative classification system appears to be more practical. The Sainte-Anne (SA) classification has been reported as a simpler and more standardized grading system with more reproducibility than the WHO system. It encompasses more tumor grades or subtypes, oligodendroglioma grades A and B, as well as the malignant glioneuronal tumor (MGNT).It is highly unusual for oligodendrogliomas to be diagnosed in children. The peak incidence is between 6 and 12 years of age. In addition, pediatric oligodendrogliomas appear to be genetically distinct from tumors of adults, rarely exhibiting 1p/19q codeletions.Oligodendrogliomas are even more rarely seen in fetuses comprising just 0.5–1.5% of brain tumors diagnosed during infancy . The preSeveral reports have been published describing expansile brainstem mass lesions in neonates, in which the typical clinical and radiographic findings of diffuse glioma resolved spontaneously , 10–12. We present an unusual and rare example of an anaplastic pontine oligodendroglioma arising in a fetus that was detected by fetal US and MRI and confirmed by neonatal US/MRI and autopsy. The extensive degree to which the neoplasm infiltrated the brainstem, destroying major respiratory and autonomic centers, together with its aggressive growth leading to obstructive hydrocephalus, respiratory failure, and hemorrhage accounts for the malignant clinical course. The pathological features of the lesion distinguish it from previous reports in which spontaneous regression of pontine gliomas occurred and argue in favor of establishing a tissue diagnosis to plan for aggressive versus conservative management.


Serinus canaria) with a history of an oval mass in the left wing for several months was examined. Radiographs showed a radio-opaque mass. Upon the bird’s owner request, the canary was euthanatized and submitted for necropsy. The histopathologic examination revealed numerous trabeculae consisting of both woven and lamellar bone covered by one to several rows of normal osteoblasts. The trabeculae were closely packed, having only small intertrabecular spaces which contained proliferating osteoblasts, sinusoids and myeloid tissue. Based on clinical, radiographic, and histopathologic findings, the mass was diagnosed as extraskeletal osteoma. To the best of authors’ knowledge, extraskeletal osteoma has not been reported in in avian species so far, and this is the first report of osteoma tumor in the birds. However, benign tumors of bones are extremely rare in the birds, osteoma should be considered as a differential diagnosis in the birds with bone lesions. Osteoma is an uncommon bone tumor in avian species and other animals. A 2-year-old male canary ( A number of authors describe the osteoma as a hamartoma, a benign focal overgrowth of mature cells native to the organ, without the normal architecture of the surrounding tissue, while others consider them as the sclerotic end stage of fibrous dysplasia.3Central, peripheral, and extraskeletal osteoma are three variants of osteoma. Central osteomas arise from endosteum, peripheral osteomas arise from periosteum and extraskeletal soft-tissue osteomas usually develop within a muscle.4-7 Mandible, maxilla, nasal sinuses, and bones of the face and cranium are the most common sites of involvement in domestic animals.2These uncommon tumors appear in all domestic species, however, they are more often recognized in horses, cattle, sheep, dogs and cats.Anas platyrhynchos) and a budgerigar were reported (Melopsittacus undulatus).8 In a 10-year survey, with 2281 necropsy examinations of domestic fowl, only a single case of osteoma was observed.9 In a study of 351 cases of tumors in broiler chickens , only two cases of osteoma were reported.10 Hahn et al. reported two cases of osteoma in a barred owl (Strix varia)11 and in 2011, a suspected case of osteoma was described in an eclectus parrot (Eclectus roratus).12 Cardoso et al. observed a case of osteoma in a blue-fronted Amazon parrot (Amazona aestiva).13 Osteomas are extremely rare tumors in the birds and to the best of our knowledge, the extraskeletal type of osteoma has not been previously reported in avian species. This report describes a case of extraskeletal osteoma in a canary (Serinus canaria) for the first time.Bone-forming tumors such as osteomas are extremely rare in free-living and captive birds. In a study of 383 cases of neoplasms in 69 avian species, three cases of osteoma in two domestic ducks (Serinus canaria) was referred to the veterinary teaching Department of Clinical Sciences, Shahrekord University with a history of an oval mass in the left wing, near the forearm region for several months. On physical examination, the mass was firm, well circumscribed, and measured approximately 12×8×6 mm  can be used.In conclusion, although, benign tumors of bones are extremely rare in the birds, osteoma should be considered as a differential diagnosis in birds with bone lesions. To make a more accurate diagnosis, the clinical and radio-graphic appearance, as well as the pathologic characteristics of osteoma should be considered.


Epidermoid cysts are slow-growing, benign tumor which account for less than 1% of all intraspinal tumors and epidermoid cyst with Atypical Hyperplasia is very rare. Surgical resection is the standard treatment of the tumor, but recurrence is not uncommon after incomplete resection. Inappropriate treatment can lead to repeated recurrent. Here, we reported a case of repeated recurrent epidermoid cyst with atypical hyperplasia treated with radiotherapy after surgery.A 40-year-old female presenting with intraspinal epidermoid cyst showed incomplete paraplegia in lower limbs.Back pain reappeared 19 months later after surgical treatment. The patient suffered marked weakness in both limbs, along with obvious muscle atrophy and sensation deficiency of warmth and pain in left lower limb. MRI demonstrated a cystic mass with solid content and peripheral strengthen in enhanced scan.Extended excision with intraoperative local chemotherapy and postoperative radiotherapy was performed and a dramatic reversal of symptoms was gained 4 weeks after surgery, with a total dose of 46 Gy. Postoperative pathological examination revealed epidermoid cyst with mild to moderate atypical hyperplasia.No acute side effects of the treatment were reported. Back pain obviously alleviated within 48 hours after surgery, while weakness and numbness of the lower limbs gradually improved and nearly disappeared in the 3-monthly follow-up visit. Until now, no recurrence is found during the 5-years follow-up.Our study highlights that incomplete excision has led to repeated recurrent epidermoid cyst, but its complete removal with adjuvant radiotherapy has achieved remission of symptoms. Atypical hyperplasia discovered by pathological examination reminds us the possibility of malignant transformation and ensures the necessity of adequate treatment. We describe a 40-year-old female with a recurrent intraspinal epidermoid cyst and incomplete paraplegia. The lesion was unusually located in the centrums of L2–L3 and had atypical osseous destruction imaging.Epidermoid cysts are slow-growing, benign tumor which account for < 1% of all intraspinal tumors. An intraspinal epidermoid cyst can be of either congenital or acquired origin; congenital lesions are usually associated with spinal dysraphisms such as syringomyelia, dermal sinus, and spinal bifida, while repeated lumbar puncture is the most common etiology for acquired epidermoid cysts.22.1The study was reviewed and approved by the Ethics Committee of the Changzheng Hospital, Second Military Medical University. Informed consent was obtained from the patient.2.2A 40-year-old female visited our center in August 2011 due to the severe weakness and numbness of lower limbs along with continuous back pain. Treatment history of the patient dated from 2008, when she accepted a surgery for an epidermoid cyst and psoas abscess in L2 with the symptoms of pain in back and left lower limb. With back pain and numbness of left lower limb, she was treated with reopening of previous surgical incision and re-excision of the cyst with posterior fixation in 14 months after the first surgery. However, back pain reappeared and catavertebral lump was found 19 months later. So she had the surgical treatment for the third time in April 2011, but the result was unsatisfied. She had no history of back injury and never underwent lumbar puncture before the first treatment  were used for reconstruction Fig. . Intraop2.6The final histological diagnosis was an epidermoid cyst with mild to moderate atypical hyperplasia, while the tofukasu-like tissue was confirmed to be keratinized tissue Fig. .3 Epidermoid cysts within the neuraxis are rare and most of them are usually located in the intracranial region, accounting for < 1% of all intraspinal tumors.,3,6 Pathogenesis of the tumor can be traced back to 2 possible origins: congenital or acquired. Congenital epidermoid cysts which account the vast majority of the tumor attribute to anomalous implantation of ectodermal cells during closure of the neural tube between the third and fifth week of embryonic life.,8 While acquired epidermoid cysts are thought to be the result of displacement of epithelial tissue secondary to previous lumbar puncture or trauma.–14 As for the patient, she did not have any trauma or lumbar puncture before her first surgery, so the tumor may be congenital one. However, other spinal abnormalities were also not found.An epidermoid cyst was first described by Cruveilhier and named “tumors perlees” (pearly tumors) in 1835.,16 First, this case had 3 times repeated recurrences history and the patient received 4 treatments during 2008 and 2011. Recurrence of the epidermoid cyst is very rare and repeated recurrences in spine have not been reported yet. Only surgery was performed in the first 3 treatments, but the tumor recurrence occurred a few months later after operations. In 2011, surgery combined with radiotherapy was used to treat the third recurrence of the epidermoid cyst, in order to avoid recurrence. Second, epidermoid cyst is a benign tumor with indolent characteristic in general, while the pathological diagnosis of this case was an epidermoid cyst with atypical hyperplasia, suggesting that epidermoid cyst might have some malignant biological characteristics which required more aggressive treatment besides surgery. According to the follow-up study, the symptom of this patient almost disappeared and no recurrence occurred >5 years after radiotherapy.In this case, some new clinical characteristics should be noticed compared to other reported epidermoid cysts in spine.,5,18 The typical imaging findings of intraspinal epidermoid cyst are hypointense on T1-weighted images and hyperintense on T2-weighted images which are consistent with the signal of the cerebrospinal fluid.–21 Almost all the intraspinal epidermoid cysts in the literature were intradural and enlarged in the type of swelling growth, but the recurrent case was located in the centrum and increased in invasive growth which was a signal for possible malignant transformation. Imaging studies of the patient showed that lytic imaging of bone and the content of the cyst with solid change seemed to be abnormal.Epidermoid cysts always remain asymptomatic for a relatively long period until the lesions infringe the nerves or spinal cord, along with cyst rupture which is another vital trigger. Pain and neurologic deficits such as numbness, weakness, and paralysis with long duration are the most common symptoms which are nonspecific.,19,21–23 In the treatment history of the patient, psoas abscess and catavertebral lump once occurred and were thought to be the result of cyst rupture and response of surrounding tissue to the cyst content. The difference was that psoas abscess might be the result of spontaneous rupture, while a catavertebral lump was more likely caused by intraoperative spillage of the cyst content.Histologically, epidermoid cysts consist of lined stratified squamous epithelium supported by an outer layer of collagenous tissue. Desquamation of keratin from the epithelial lining produces soft white material rich in cholesterol crystals. The content of the cyst contains considerable fat and little cholesterol which may produce a vigorous inflammatory reaction when the cysts rupture.,23–25 But the goal is really hard to achieve because of the intimate adherence between the capsule and spinal cord, so subtotal excision is more often to be adopted and leaves the possibility of recurrence which may occur and quickly become symptomatic shortly after surgery.,22,24,26 Metastatic lesions of the epidermoid cyst were never reported, while malignant transformation was very rare but there were still few intracranial cases with malignant transformation reported.–31 The recurrent lesion of our case was the result of 3-time subtotal excisions and had some notable changes such as soluble osseous destruction, invasive growth, and solid changes of the cyst content. These changes suggest the possibility of malignant transformation, although it was not supported by the final pathological examination. But mild to moderate atypical hyperplasia let us confirm the necessity of adequate treatment and also reminded us the close follow-up of the patient.In spite of benign and indolent characteristic of a epidermoid cyst, complete excision is still the goal we pursue for the symptomatic lesions while asymptomatic lesions can be kept on conservative observation. Given that the patient had received 3 surgeries and relapsed for 3 times, we decided to adopt extended excision of the lesion with adjuvant therapies of intraoperative local chemotherapy and postoperative radiotherapy. The results were inspiring that complications of chemotherapy and radiotherapy did not appear, pain and neurologic deficit recovered well, and no recurrence has been found until now.Symptomatic recurrent lesions can be surgically treated once more but tumor excision becomes harder by formation of scar tissue resulting from the previous interventions. Even so, surgery is the most effective and curable method to remove oppression and relieve symptom for the spinal lesions. Radiotherapy once used for a repeatedly recurrent epidermoid cyst in the spine and received a relatively good result of controlling tumor growth and alleviating pain, while chemotherapy was considered useless and had never been used.4An epidermoid cyst is a rare benign tumor which can occur and cause severe neurological deficits. Complete excision is the standard treatment but is hard to reach, so recurrences after subtotal excision are not uncommon. Special attention should be paid to the treatment for recurrent lesions because repeated recurrence may lead to malignant transformation. Complete excision at the utmost with the help of postoperative radiotherapy can serve as an ideal choice.


Mycoplasma hominis, a well known cause of neonatal infection, has been reported as a pathogen in urogenital infections in adults; however, central nervous system (CNS) infections are rare. We report here the first case of M. hominis meningitis in China, post neurosurgical treatment for an intracerebral haemorrhage in a 71-year-old male.M. hominis meningitis after neurosurgical treatment and was successfully treated with combined azithromycin and minocycline therapy of 2 weeks duration, despite delayed treatment because the Gram stain of cerebrospinal fluid (CSF) yielded no visible organisms. The diagnosis required 16S rDNA sequencing analysis of the cultured isolate from CSF. Literature review of M. hominis CNS infections yielded 19 cases . Delay in diagnosis and initial treatment failure was evident in all cases. With appropriate microbiological testing, antibiotic therapy (ranging from 5 days to 12 weeks) and often, multiple surgical interventions, almost all the patients improved immediately.We describe a 71-year-old man who developed M. hominis together with the challenges prompted by rare infectious diseases in particular for developing countries laboratories with limited diagnostic resources.Both our patient findings and the literature review, highlighted the pathogenic potential of The online version of this article (doi:10.1186/s12879-016-1885-4) contains supplementary material, which is available to authorized users. Mycoplasma hominis, initially described as pleuropneumonia-like organism, is a commensal of the human oral cavity, respiratory tract, and genitourinary tract [M. hominis, which does not possess a cell wall and hence is not identifiable by Gram staining of clinical specimens, is difficult to detect [M. hominis which is fastidious in nature, is both resource- and time-consuming because specialized media and incubation conditions are required. Direct 16S rDNA PCR amplification/sequencing on clinical specimens may be performed but sensitivity is moderate at best, and not all laboratories perform this test [M. hominis infections is thus probably underestimated and delayed diagnosis leads to delayed treatment with suboptimal outcomes [ry tract –3. Howevry tract , 4–7, hao detect , 9. Culthis test , 3, 8. Toutcomes .M. hominis are rare in patients other than neonates. To the best of our knowledge, only 19 cases of such infections have been reported in the English literature  following neurosurgical intervention for cerebral haemorrhage. This is the first reported case of meningitis in an adult caused by M. hominis from China.CNS infections due to The patient was a 71-year-old man with a history of hypertension for 2 years who suddenly developed aphasia, and right-sided weakness and numbness while lifting water and was sent to the local hospital immediately on 21 September 2014. A cerebral computed tomography (CT) scan identified a cerebral hemorrhage rupturing into the ventricular system. He underwent craniotomy and evacuation of the hematoma. One week after the surgery, the patient developed hospital-acquired pneumonia, which was complicated by respiratory failure despite treatment with broad-spectrum antibiotics of imipenem.The patient was soon transferred to the medical intensive care unit (MICU) of Peking Union Medical College Hospital (PUMCH) on October 14. On admission, he was febrile, comatose (Glasgow Coma Score of 9), dyspneic, and hypotensive. Mechanical ventilation was started after endotracheal intubation.2O, 1201 x 106/L red cells, 201 x 106/L white cells (79 % polymorphonuclear forms), an undetectable glucose concentration, protein 2.32 g/L, and chloride 128 mmol/L. No organisms were seen on Gram stain of the CSF. A cerebral CT showed an extensive left temporal hematoma and moderate lateral ventricle enlargement  and vancomycin (1.0 g intravenously q12h) was initiated for hospital-acquired pneumonia. A lumbar puncture showed an opening pressure > 33 cmHent Fig. .Fig. 1CoAcinetobacter baumannii, which was only susceptible to cefoperazone/sulbactam, and intermediately susceptible to tigecycline and minocycline. A follow-up chest CT scan revealed a thick-walled cavity in the right lower lobe  obe Fig. . As a reobe Fig. .Fig. 2Th2. On October 30, cultures revealed non-hemolytic, semi-translucent pinpoint colonies on sheep blood agar plate after 4 days of incubation under anaerobic conditions  were used, i.e. the MALDI Biotyper (Bruker) and VITEK MS IVD (bioMérieux) as instructed by the manufacturer. The spectra were analyzed by using the MALDI Biotyper database library V.3.3.1.2 and the VITEK® MS IVD v2.0 database respectively. Both MALDI Biotyper and VITEK MS IVD consistently yielded no identifying profile and assigned “no identification” to this isolate.http://www.ncbi.nlm.nih.gov/blast). By querying 16S rDNA sequences against those in the GenBank database, the isolate best matched with 3 M. hominis reference strains  with an identity of 100 % (1385/1385), followed by Mycoplasma equirhinis, with an identity of 97 % (1314/1353). All M. hominis 16S rDNA nucleotide sequences available in GenBank till 2015 (n = 10) are summarized in Additional file Bacterial DNA was obtained from isolates by using QIAamp DNA minikit  following the manufacturer’s instructions starting from 200 μL of bacterial pellet suspension about 2-3 McFarland followed by a series of extracting steps with different reagents. Amplification of the 16S rDNA gene was performed by broad-range bacterial polymerase chain reaction (PCR) assay using the universal primers: 27 F (5’-AGAGTTTGATCCTGGCTCAG-3’) and 1522R (5’-AAGGAGGTGATCCAGCCGCA-3’) as described before , 12. PurM. hominis, which was susceptible to doxycycline, and intermediately suscepible to azithromycin by the bioMérieux® SA Mycoplasma IST2 kit . Combination therapy with azithromycin (0.5 g qd) and minocycline (100 mg q12h) was then started  [n = 4) [n = 1) [n = 1) [A PubMed search was performed using the following key words: “al flora . By carena Table . Of thes n = 13) , 14–23,  [n = 4) –26, spin [n = 1) ,  require ad-hoc antibiotic treatment [M. hominis at present. Nevertheless, the organism is generally considered to be susceptible to tetracyclines, lincosamides, streptogramins and quinolones, but not to the macrolides although tetracyclines-resistant M. hominis has been reported [M. hominis, do possess reasonable CSF penetration [M. hominis is warranted. However, surgical drainage and debridement remain the key to recovery, since patients may respond to surgical treatment alone [In all previously published case studies of py alone . Infectireatment , 34. Thereported , 35–37. etration . Becausent alone .A. baumannii was also isolated from the lower respiratory tract possibly due to nosocomial infection. Persistent fever despite various antibiotic treatment with meropenem, vancomycin, and cefoperazone/sulbactam, as well as the satisfactory response to azithromycin and minocycline, strongly suggested that M. hominis, rather than A. baumannii was the primary pathogen in our patient.In our case, initial treatment with meropenem and vancomycin showed little efficiency since a low-grade fever still persisted (as shown in Fig. M. hominis may be increasing, presenting a diagnostic and therapeutic challenge to clinicians. We reported here the first case of meningitis caused by M. hominis in an adult in China, who was successfully treated with azithromycin and minocycline. The pathogenic potential of M. hominis, the need for early diagnosis, and the importance of initial appropriate chemotherapy must be highlighted also in developing countries, where the challenges in diagnostic capacity for clinical laboratories are greater.The prevalence of brain infections caused by


Colonoscopy is a commonly performed procedure for diagnosis and treatment of large bowel diseases. Recognized complications include bleeding and perforation. Splenic injury during colonoscopy is a rare complication. We report a case of a 73-year-old woman who presented with left-sided abdominal pain after colonoscopy with finding of splenic injury on CT scan. She was managed conservatively. We discuss the diagnostic and therapeutic approach to colonoscopic splenic injury. Approximately 14 million colonoscopies are performed in the US every year . A rare When a patient presents with abdominal pain following colonoscopy, the main concern is that of colonic perforation . CT scanA 73-year-old woman underwent a screening colonoscopy that was initially reported as uneventful. Her medical history included atrial fibrillation treated successfully with radioablation. She was not on anticoagulation at the time of her exam. In her late 40s she underwent a total hysterectomy. Her medications included aspirin 81 mg daily.Colonoscopy was done under moderate sedation with 75 mcg of fentanyl and 5 mg of midazolam given intravenously. The colonoscope was advanced to the cecum without difficulty. The exam was normal except for pandiverticulosis. The nurses' notes indicated that the patient had mild left-sided abdominal pain shortly after the procedure. This improved after passing gas and she was considered suitable for discharge.Five hours after the procedure she called the endoscopist reporting increasing left-sided abdominal pain. There was no associated nausea, vomiting, fever, chills, dyspnea, or left shoulder pain. She was reevaluated in the endoscopist's office. On exam her vital signs were normal and there was moderate left-sided abdominal tenderness. There was no rebound or guarding. Concern for colonic perforation prompted a CT scan of the abdomen and pelvis, done without intravenous contrast. The study revealed high density perisplenic fluid consistent with blood, tracking in the left paracolic gutter , with noSplenic injury is a rare complication of colonoscopy and is usually not a diagnostic consideration in patients who present with abdominal pain after the procedure. Since the first case report by Wherry et al., in 1974, around 100 cases have been reported –7. The iThe mechanism of injury is presumably due to downwards traction on the splenocolic ligament or on adhesions around the spleen during colonoscopic manipulation causing a tear in the splenic capsule , 6, 8–10Patients with splenic injury during colonoscopy usually present within 24 to 48 hours, but presentation can be delayed for up to 10 days after the procedure , 8, 10. CT of the abdomen is the most reliable diagnostic tool for stable patients , 9, 13. The American Association of Surgeons for Trauma (AAST) Splenic Injury Grading Scale is used to grade splenic injuries based on CT scan findings  4]. Tre. Tre4]. An estimated 85% of patients with blunt splenic injury in the past decade were managed nonoperatively . In patiSurgical management is indicated in patients who fail conservative treatment and splenic artery embolization. The standard approach is open exploration. Laparoscopic surgery, which may be technically more demanding and more time consuming, is reserved for select patients with minimal hemorrhage and who are hemodynamically stable , 19. AttIn patients presenting with abdominal pain following colonoscopy, perforation is the primary concern. CT without contrast is recommended as the first diagnostic test. Splenic injury is so rare that it is almost never considered until diagnosis by CT imaging or laparotomy. This test, done without contrast, is sufficient to rule out colonic perforation and for evaluation of most splenic injuries. The scan can be repeated with IV contrast if necessary to obtain more anatomic information or to document active bleeding. Management is initially nonsurgical, which is successful in most patients. If it fails and the patient is hemodynamically stable, splenic artery embolization is the next step. Surgery is indicated, usually by open technique, when the patient is unstable or if bleeding continues after embolization attempt.


Myoepithelial carcinoma (MEC) is a rare salivary gland tumor. Its long-term prognosis remains unknown because of the paucity of reported cases with long-term follow-up. Although some case series exist, the clinical features of MEC vary considerably depending on the site of origin. Therefore, accumulation of these rare cases is important.Case 1: An 89-year-old man presented with a 10-year history of a mass originating from the right parotid gland and involving the neck. The mass grew rapidly for 3 months, reaching approximately 8 cm. There was no facial paralysis. MEC ex pleomorphic adenoma (PA) was suspected. Superficial parotid gland resection was performed in 2013; the tumor grade was pT3N0M0, and the resection margins were free of carcinoma. Because of several high-risk factors for metastasis , radiotherapy and chemotherapy were recommended as adjuvant therapy. Although the patient refused adjuvant therapy, he was recurrence-free at 36 months after surgery.Case 2: A 54-year-old woman presented with a >10-year history of a right submandibular mass, which grew rapidly for 1 year, reaching approximately 6 cm. Preoperative diagnosis was PA of the right submandibular gland. Submandibular gland resection was performed in 2013. Pathological analysis revealed invasive MEC ex PA, pT3N0M0; in addition, the carcinoma portion had an extra capsule and had invaded the platysma muscle close to the margin. An MIB1 index of 40 % and mutant p53 protein positivity indicated a high risk for metastasis. Additional resection and right neck dissection revealed no residual carcinoma. The patient refused adjuvant chemotherapy. One year after surgery, metastasis to the right pulmonary hilar node and both lungs were detected. Chemotherapy prevented recurrent growth of the lesion and extended survival. The patient was alive with cancer 30 months after the first surgery.High expression of the Ki67 labeling index might reflect prognosis of these cases. Chemotherapy for distant metastasis was effective, as expected. Further accumulation of cases and long follow-up data are needed to elucidate the pathophysiology and prognosis of MEC ex PA. Myoepithelial carcinoma (MEC) is a rare salivary gland tumor, accounting for 0.1–0.45 % of all salivary gland tumors . MEC genWe present two cases of MEC ex pleomorphic adenoma (PA) of the major salivary gland. The prognosis of these cases was reflected by an unusually high Ki67 labeling index. We also summarize the risk factors for MEC ex PA with a mini-review of the literature.Case 1: An 89-year-old man presented to us in 2013 with a 10-year history of a mass originating from the right parotid and involving the neck. The mass grew rapidly for 3 months before the patient was examined. At presentation, the diameter of this rubbery hard mass was approximately 8 cm. There was no facial paralysis. Computed tomography (CT) showed an irregular mass of the right parotid gland with partially defined margins and no lymph node metastases Fig. . Magneti2, cisplatin 50 mg/m2, and adriamycin 50 mg/m2 were intermittently initiated [Case 2: A 54-year-old woman presented to us in 2013 with a >10-year history of right submandibular lesion. The growth of the mass was slightly faster 1 year before presentation. At presentation, the elastic hard mass was approximately 6 cm in diameter, and there was no facial paralysis. MRI showed an irregular mass in the right submandibular gland with partially defined margins Fig. . There wWe experienced two cases of MEC ex PA of the major salivary gland. The MEC in Case 2 presented with a clinically aggressive behavior compared to Case 1, which was also indicated by the MIB1 index score. However, chemotherapy for Case 2 could contribute to an improvement in the quality of life in the future, for example, prevention from dyspnea or pleural effusion, and extended survival.Precise preoperative diagnosis of MEC ex PA is almost impossible, and risk factors for prognosis remain uncertain . SymptomPathological analysis is performed to identify risk factors and plan adjuvant therapies. However, specific risk factors and the efficacy of postoperative therapy for MEC ex PA remain unknown. Past reports and reviews have suggested candidate markers to predict the prognosis of MEC Table . MECs orA list of the treatment modality and outcomes in the MEC of the salivary gland from previous articles is summarized in Table Although the efficacy of radiation therapy for MEC ex PA remains unknown, adjuvant radiotherapy with or without chemotherapy is suggested for high-grade malignancies with residual tumor/close margin, neural/perineural invasion, soft-tissue extension, lymph node involvement, or lymphatic/vascular invasion, as well as after salvage surgery for recurrent tumors , 19. MorWe reported two rare cases of MEC ex PA originating in the major salivary gland. High expression of the Ki67 labeling index might reflect prognosis of these cases, and chemotherapy for distant metastasis was effective, as expected. Further accumulation of cases and long follow-up data are needed to elucidate the pathophysiology and prognosis of MEC. We will continue to follow these patients to obtain long-term survival data.


Duodenal adenocarcinoma (ADC) represents only 0.3% of gastrointestinal neoplasms. With the frequency being higher between the ages of 40 and 60, it is predominantly located in the second part of the duodenum and around the periampullary region. Symptoms are nonspecific, so the majority of patients present with advanced disease. Neoadjuvant chemotherapy is a therapeutic option that has not been well studied. The global literature includes only isolated reports on this subject. This is why we are presenting the following case: a 60-year-old female patient with a locally advanced, inoperable duodenal ADC received neoadjuvant chemotherapy. Having presented a favourable response as observed in the post-neoadjuvant extension studies, a pancreaticoduodenectomy was performed without any perioperative complications and with satisfactory progress. The final biopsy reported a complete pathological response. After being monitored for 34 months, the patient was free from locoregional and distant metastatic disease. During the last weeks of monitoring, she developed a second primary breast tumour, which has been corroborated by immunohistochemistry. Adenocarcinoma is the most common malignant tumour of the digestive tract. It is a major cause of morbidity and mortality around the world. The small intestine comprises 75% of the entire length of the gastrointestinal tract and 90% of its mucosal surface. However, it is an uncommon place to develop cancer; fewer than 5% of gastrointestinal cancers are found here. The main histological types of cancer in the small intestine are adenocarcinoma, neuroendocrine tumours, lymphomas and gastrointestinal stromal tumours. The first two histological types comprise 80% of cases with a very similar ratio. In the United States of America, the annual incidence is 5,300 cases with a mortality rate of 1,100 deaths per year. These data have remained stable during the last 15 years; in Europe, according to EUROCARE, there are 3,600 cases each year with an estimated incidence of 5.7 cases per 1 million people . In VeneThe main therapeutic option is surgery. The type of surgical resection depends on the size and location of the tumour. Pancreaticoduodenectomies or segmental resections are the most common procedures , 5. Due As a result, CT is commonly used in duodenal adenocarcinomas (ADCs). Neoadjuvant CT is one option. Current scientific evidence that supports this treatment method is based on retrospective studies or anecdotal experiences. There are very few published cases. In view of this fact, we are presenting the case of a female patient with a locally advanced duodenal ADC who received neoadjuvant CT with a positive result.A 60-year-old female patient reported the onset of her present illness roughly 6 months ago. Her illness was characterised by abdominal pain in the epigastrium without irradiation but with a moderate intensity that was partially relieved by ingesting NSAIDs. During the same time she lost about 20 kg. Presenting with these symptoms, the patient visited a physician who suggested an abdominal ultrasound. This exam reported a tumour on the head of the pancreas measuring 72.9 × 59.9 with irregular edges. Later, an upper gastrointestinal endoscopy showed an infiltrating duodenal tumour in the second part of the duodenum with gastroduodenal extrinsic compression. A sample of the duodenal tumour was taken, which showed moderate chronic duodenitis and reactive lymphoid hyperplasia. With this clinical picture in mind, the patient was referred to the Instituto de Oncología Dr ‘Luis Razetti’ (IOLR).Her family history showed that she had a sister who had breast cancer at the age of 40. She said that she had not had any significant pathological or surgical history. The physical examination showed that the patient was in good general health and afebrile with an Eastern Cooperative Oncology Group (ECOG) Performance Status of 0. Her neck showed no adenopathies; the abdomen was soft and palpable without pain and there was no sign of tumours; the rectal examination showed a lesion-free normotonic sphincter. At the IOLR Digestive Tract Service, an upper gastrointestinal endoscopic ultrasound was requested. It showed a mucosa with an infiltrative appearance in the second and third parts of the duodenum. It also showed a conglomerate retroperitoneal lymph node involving the second and third parts of the duodenum. In addition, there were numerous adenopathies in the peri-aortic/caval region and in the hepatic hilum. The pancreas showed moderate adipose infiltration without any tumour. The inferior vena cava showed compression from the designated lesion without infiltration. A biopsy from the second and third part of the duodenum was taken and sent to create a cell block, the histopathological reports of which showed a carcinoma that was poorly differentiated from the duodenum . An immuExtension studies were made: a chest CT, where there was no evidence of any images with metastasis, and an abdominal and pelvic CT that showed hypodense images, irregular edges adjacent to the second and third parts of the duodenum, and irregular enhancement after the administration of contrast. In addition, a conglomerate lymph node was found in the interaortocaval region without any liver metastasis; CA 19.9 and carcinoembryonic antigen levels were within the reference ranges  and 3. IAfter the neoadjuvant CT, the following restaging studies took place: (1) Abdominal and pelvic CT: solid duodenal SOL measuring 4 mm with highlighted enhancement after administering intravenous contrast but no metastatic lesions; para-aortic lymph nodes measuring less than 5 mm. (2) Chest CT: no metastatic lesions. (3) Upper gastrointestinal endoscopy: duodenal bulb without lesions progressing to the third part of the duodenum where there was evidence of completely normal papilla; no infiltration or compression of the mucosa was seen. There were no lesions in the duodenum. (4) Upper gastrointestinal endoscopic ultrasound: a nonconcentric, hypoechoic lesion with imprecise edges between the second and third parts of the duodenum, with minimum extramural extension toward the distal end of the lesion; local inflammatory changes with perilesional adenopathies and in the hepatic hilum that appear to be benign; pancreas with moderate adipose infiltration not showing any tumours; inflammatory changes around the vena cava; and no evidence of extrinsic compression by a primary lesion as evidenced in the previous study.In view of the positive response observed in the extension studies, a pancreaticoduodenectomy was planned. The intraoperative findings were a lesion-free peritoneal cavity and liver. In the second and third parts of the duodenum, a diffuse thickening with loose adhesions to the retroperitoneum and without any interaortocaval adenopathies was palpable. The pancreaticoduodenectomy was performed without any immediate or late complications. The patient was discharged on the fifth postoperative day. The final biopsy was a sample from the pancreaticoduodenectomy: the duodenum showed moderate chronic infiltration with areas of ulceration and no evidence of neoplasm; the head of the pancreas showed mild chronic inflammation and foci of interstitial fibrosis, 12 lymph nodes with nonspecific reactive follicular hyperplasia and adipose infiltration, but these were negative for malignancy; the gallbladder showed chronic cholecystitis, cholesterolosis and three lymph nodes with nonspecific reactive paracortical hyperplasia in the hepatic pedicle without any evidence of neoplasm.Six weeks after the surgery, the case was discussed again with the Internal Medical Oncology Service. It was decided together that the patient would be monitored via physical examinations every 3 months for 2 years, and then every 6 months until the fifth year. She would also undergo imaging and endoscopic studies on an annual basis. At present, the patient has been free from locoregional or distant metastatic disease for 34 months. Recently, she developed a right breast ductal adenocarcinoma, with immunohistochemistry ER + PR + HER2 − Ki−67 15% T1NxM0. She is waiting for a surgical appointment at the IOLR’s Breast Care Service.Duodenal ADC was first described in 1746 by Hamburger. It represents only 0.3% of gastrointestinal neoplasms and occurs in 45% of cases in the third and fourth parts of the duodenum. It is found most frequently in males aged 40–60. Furthermore, duodenal ADC is still a fatal disease, even though it can be removed surgically . OccurreDuodenal ADCs usually affect a short segment. They feature progressive annular growth and often lead to delayed stenosis and ulceration. The symptoms are nonspecific and resemble those of a duodenal ulcer. For this reason, most patients present with an advanced disease. The staging of this type of lesion is done through studies that assess locoregional extension, such as an endoscopic ultrasound; and those that assess locoregional and distant metastatic extensions, such as a tomography of the chest, abdomen and pelvis .The treatment of choice for duodenal malignant neoplasms is surgery. It is defined as a resection of the entire tumour with lesion-free margins in the absence of metastatic disease. This can be carried out either through a pancreaticoduodenectomy or via a segmental duodenal resection. The type of pancreaticoduodenectomy that is usually indicated for tumours of the first and second parts of the duodenum, or the duodenal resection for distal tumours to the superior mesenteric vein, is usually performed for healing purposes. In cases when surgery is not possible, or if the patient condition contraindicates surgery, there are intestinal bypass or CT procedures that act as palliative treatment .According to the literature, at the time of diagnosis, only between 40% and 70% of patients were able to receive curative surgical treatment. Overall survival after 5 years is 25–35%. This number is directly related to lymphatic compromise, tumour location, transmural invasion and histologic classification. A much poorer prognosis is noted in those who are not candidates for surgery –16. Our The role of neoadjuvant therapy for patients with unresectable, locally advanced duodenal ADCs has not been well studied. It is unknown whether this represents a potential rescue treatment for a selected subset of patients with this type of cancer. In 2015, the National Cancer Institute in the United States established palliative measures, CT or chemoradiotherapy (CRT) as recommended treatments for patients who were not candidates for surgical resection, along with a monitoring of any complications. It also considered that there were new treatment methods being studied that essentially consisted of combinations of new drugs. However, radical surgery was not recommended.et al [et al [The first recorded use of neoadjuvant CT was in 1994, when Coia et al . In anotl [et al , the vall [et al .et al [Currently, no selection criteria have been approved for patients with duodenal cancer receiving neoadjuvant treatment. The choice of treatment depends on the preference of the medical oncologist. Such criteria are often similar to those used in colorectal or pancreatic carcinoma , 20. Ouret al . After aet al , 21, 22.Cancer treatment has evolved significantly in the last decades. It is becoming more and more specific for each patient. Consensus meetings or those attended by large groups of experts make recommendations based on highly statistical studies, but there are cases that escape conventionally published standards . At presWe can conclude that in patients with duodenal ADC, neoadjuvant CT is a therapeutic option for a subset of inoperable patients as it can decrease the tumour size and lead to surgical resection with negative oncological margins.


According to his medical history, one year prior to admittance the patient was treated for anemia. At the time, he presented positive fecal occult blood test. Endoscopy and contrast exams were normal and no weight loss or changes in bowel movements were noticed. In the six months prior to admittance, the patient felt sporadic pain in the anal canal that ceased with the use of NSAID suppositories. After 30 days, he sought medical attendance and underwent proctosigmoidoscopy and colonoscopy, along with biopsy of lesions in the anal canal and cecum. The patient was then diagnosed with poorly differentiated carcinoma of the canal and well differentiated tubular adenocarcinoma of the cecum. At the time, a lump began forming in the root of the thigh, just below the inguinal fold. The patient was refered to Sírio-Libanês Hospital in São Paulo, Brazil, for surgical treatment of the colon lesion and clinical treatment of the anal canal lesion , as he rAnatomopathological findings of the anal canal revealed an amelanotic malignant melanoma with extensive infiltration and presence of ulcerations and necrosis ; right iFindings on the colon lesion revealed a segment of the left colon had histological stage II invasive tubular adenocarcinoma, a presence of 20% of mucous membrane, diffuse and extensive infiltration of the colon wall up to the peripheral adipose tissue, ulcerous lesion with irregular areas and necrosis, discreet fibrosis and inflammatory infiltration, and absence of vascular or peri-neural invasion. The anatomopathological examination of surgical borders revealed absence of neoplasm. Assessment of mesocolic lymph nodes exhibited reactive lymphoid hyperplasia with no metastasis (0/13). th day prior to hospitalization, there was a new episode of bleeding, which led to hospitalization. A new abdominal tomography showed multiple adenomegalies in the paraaortic, paracaval, inguinal, and bilateral perirectal lymph nodes. It also revealed a heterogenic mass with imprecise limits, compatible with ganglion conglomerates of mesenteric origin, next to the hepatic angle of the colon; presence of a soft tissue mass in the anal canal, extending to the ischiorectal fossa towards the perineal border, predominantly on the left, with no dividing plane with the elevator muscle of the anus. Due to the bleeding and ulceration, a colonostomy was performed and local radiotherapy began. After the third session of 300 rads in each there was significant improvement of the bleeding, which stopped after the fourth session. There was clinical improvement and the patient is currently undergoing monitoring.The patient refused surgical treatment on the anal canal and neglected follow-up. After two months, he returned with exophytic lesion and bleeding, along with significant loss of weight and pain. In the 30 days before hospitalization he presented important anal bleeding with spontaneous remission. In the 6,,,Malignant anorectal melanoma was first described by Moore in 1857,,,,The prognosis is poor since the survival rate is low,,,,,The early signs and symptoms are similar to other colorectal diseases, being most frequent anal bleeding, local pain, changes in bowel habits, and in many times, the growth of lumps in the region,,,,The incidence is greater in women,Resection is the treatment of choice among the authors depending on the size of the lesion. The level of infiltration and presence of metastases are some of the factors considered when choosing the extension of resection,,,,Many authors believe that the origin of these tumors is in the dentate line, where melanocytes have been detected,,The Breslow classification is best used to classify the depth of the tumor,Many authors classify anorectal melanomas in stages; the most common being: stage I - in situ; stage II - regional spread ; stage III - metastasis,The metastasis areas can be arranged according to its frequency: lungs, bones, liver, brain and gastrointestinal tract,,The early diagnosis is essential to improve the prognosis of such an aggressive disease. Survival rates vary from 6-12% for five yearsSome factors can worsen the prognosis such as late diagnosis, ulceration, rich mucous vascularization, and aggressive nature of the tumors. ,,,,Since the most common complaints are enterorrhagia and anal bleeding, it is essential to perform a proctosigmoidoscopy and biopsyThe malignant anorectal melanoma presents early metastases,For some authors,The great majority of authors did not show significant difference in survival rate in patients referred to abdominoperineal resection and local excision Another aspect is that patients without compromised lymph nodes who are refered to abdominoperineal resection have a more favorable prognosis when compared to cases with compromised lymph nodesRegarding adjuvant treatments, literature contests the success of radiotherapy , as well as the lack of clarity of chemotherapy successIn conclusion, studies show the highly aggressive nature of the tumor, and the difficulty in early diagnosis and initial clinical staging. The prognosis is poor and patients face challenging metastases


Masses of the round ligament of the uterus are uncommon. Leiomyomas are the most common of them, followed by mesothelial cysts and in some cases endometriosis. The exact incidence is not known, but most cases are frequently encountered during the fertility age. Leiomyomas are benign tumors, which can present as hernias, lymph nodes, or other inguinal masses. Surgical excision is the appropriate treatment. We are presenting a case of a 47-year-old female patient who was admitted to the hospital with a left inguinal mass. Our patient underwent surgery, and a leiomyoma of the round ligament was found. Leiomyomas are the most frequent tumors of the round ligament of the uterus. In most cases, they present as inguinal masses in women of reproductive age. They can be mistaken for hernias or lymph nodes. Except from inguinal locations, abdominal and vulvar locations have been reported , 2. Afte2 presented with a huge painless mass in the left inguinal region, complaining of sensation of pressure and discomfort in the area. No other symptoms were mentioned. Initially, an inguinal hernia was suspected; however, magnetic resonance imaging (MRI) was recommended. MRI revealed a soft tissue mass of 19 × 6 × 2.5 centimeters (cm), without any pathological lymph nodes. The mass is clearly visible in both coronal and sagittal T2-weighted images.  of 26 kg/m images. . The pat images. . The pat images. .Various malignant and benign masses can be found in the inguinal canal. They can affect patients of both genders from 13 to 70 years of age . In the The most frequently found tumors of the round ligament are leiomyomas. Over 50% of leiomyomas are found in the extraperitoneal portion of the round ligament and most commonly occur in the right side for unknown reasons . UsuallyLeiomyomas of the round ligament can be a possible but rare etiology of the inguinal mass and can be mistaken for an inguinal hernia or lymphadenopathy. Firstly, MRI and, if not possible, a CAT scan can assist when there is diagnostic dilemma, but eventually, surgical exploration provides therapy and defines the exact nature of the mass.


While intussusception is rarely seen in adults, it is typically obstructive in nature when it does occur. Even less commonly seen is transient intussusception, which occurs without a radiological lead point or any evidence of bowel obstruction. Such findings consist of a “target pattern” seen on computed tomography (CT) but are incidental and do not require any surgical intervention. We report the case of a 31-year-old female who presented to the emergency department with abdominal pain, vomiting, and diarrhea. CT imaging revealed transient intussusception, a benign finding that is not well established in emergency medicine literature. In emergency medicine (EM), abdominal pain is a common complaint. The etiology of abdominal pain is vast and we are constantly faced with multiple diagnostic challenges. This case highlights a presentation of abdominal pain with a diagnostic imaging dilemma: a relatively benign exam with an unusual finding on computed tomography (CT). Intussusception, often considered a surgical emergency, is a common pediatric diagnosis but rarely seen in adults. We discuss the case of an incidental finding of adult intussusception on CT imaging. With the increasing use of CT in patients with abdominal pain, we are likely to see more of this transient and benign finding in the emergency department (ED). Although it has been discussed in surgical and radiological literature,A 31-year-old Caucasian female with history significant for chronic recurrent pancreatitis, endometriosis, anxiety, depression, and previous cholecystectomy presented to the ED with abdominal pain for two days. She described the pain as constant, stabbing, and localized to both lower quadrants without radiation. She also complained of non-bloody, bilious emesis “too numerous to count” with non-bloody diarrhea. She denied any fever, dysuria, or vaginal bleeding or discharge. On presentation, her vital signs were normal but she appeared anxious and in moderate distress. Her abdominal examination revealed a soft, non-distended abdomen with normoactive bowel sounds. She was diffusely tender to palpation without rebound or guarding. There was no palpable mass, evidence of McBurney’s point tenderness, or Rovsing’s sign. The remainder of her physical examination was unremarkable.Review of the patient’s laboratory tests, including complete blood count, basic metabolic panel, liver function tests, lipase, and urinalysis revealed no significant abnormalities. Human chorionic gonadotropin urine test was negative. The patient was given intravenous normal saline, ketorolac, ondansetron, and lorazepam for symptomatic control but she later noted only mild pain relief. A contrast-enhanced CT of the abdomen and pelvis was obtained and showed normal kidneys, pancreas, and appendix. There was no free air, free fluid, biliary dilatation, or pericolic inflammatory change. Stool was present in the right colon with fluid in the small bowel representing mild constipation. An incidental finding of a jejunal short segment intussusception in the left upper quadrant was seen without any evidence of bowel obstruction see . FollowiIntussusception, the telescoping of one portion of the intestine into a contiguous segment, is a clinical entity that has been well described in children. It is a common cause of abdominal pain in the pediatric population and is usually idiopathic. However, intestinal intussusception is rare in adults, accounting for just 5% of all intussusceptions.4What do we already know about this clinical entity?Intussusception is the telescoping of one segment of the intestine into an adjoining section. It is the most common surgical emergency in the pediatric population but a rare occurrence in adults.What makes this presentation of disease reportable?Unlike classic intussusception, transient intussusception is visualized on computed tomography (CT) as a “target pattern” without bowel obstruction and requires no further management.What is the major learning point?Adult transient intussusception is an incidental radiographic finding and should not prompt any surgical intervention.How might this improve emergency medicine practice?With the increasing use of CT imaging in patients with abdominal pain, knowledge of this benign and transient finding will lead to timely recognition and disposition.In the absence of an inciting factor such as an organic lesion as in this case, a transient non-obstructing intussusception without a lead point was identified. Although most often idiopathic, this type of intussusception has been seen in some patients with celiac or Crohn’s disease. It does not require surgical intervention and will resolve on its own.Despite being operator dependent, ultrasound is currently considered the imaging diagnostic modality of choice in children.6In this case, the classic “target pattern” was clearly visualized on the coronal sections of the CT images of the abdomen and pelvis, and the patient was monitored in the ED with complete resolution of her symptoms. On reevaluation, abdominal examination revealed normoactive bowel sounds and a non-distended, soft abdomen without any tenderness to palpation. There were no palpable masses or evidence of rigidity, rebound, or guarding. Coupled with the patient’s clinical presentation and our discussion with the radiologist, the patient was discharged home and instructed to follow up with her PCP and established gastroenterologist. A follow-up telephone call was attempted five days after discharge; however, the contact phone number provided by the patient was found to be invalid.Review of her chart later revealed five additional ED visits also for abdominal pain. The first of these five other visits occurred only two months after her initial presentation. Two subsequent CTs performed on her did not demonstrate any target pattern, bowel obstruction, or other acute abnormality. She was discharged home in improved condition on all visits. These ensuing visits and CT images further support the transient nature of the intussusception seen initially.In conclusion, this case demonstrates a unique finding not well documented in the EM literature. Unlike obstructive intussusception with a lead point, transient non-obstructing intussusception can present as an incidental finding that should not prompt emergent surgical evaluation in the ED.