Hematemesis caused by intragastric rupture of a splenic artery aneurysm, is an exceptional and potentially lethal emergency.A 36 years old woman, mother of seven children presented with hematemesis. The gastric endoscopy revealed a bleeding polypoid lesion leading to a surgical management. The operative discovery of a complicated splenic artery aneurysm, led to its resection with splenectomy and gastric suture.Intragastric rupture of a splenic artery aneurysm is an exceptional emergency which urgent diagnosis and management can avoid a potential lethal evolution. Splenic artery aneurysm (SAA) is the most frequent visceral artery aneurysm  and the third most common site of intra-abdominal aneurysm after aorta and iliac arteries ,2. Its iA 36 years old woman, mother of seven children, was admitted in the emergencies for hematemesis. Two episodes 10 days and 2 days before admission were reported, accompanied with epigastric pain. The gastric endoscopy found a polypoid-bleeding lesion. Biological tests and abdominal ultrasonography were normal. A laparotomy for haemostasis was made. An examination of the gastric mucosa after gastrotomy did not find the lesion described in fibroscopy. However a splenic artery aneurysm was individualized. It was adherent to the posterior side of the stomach from which it was released. The diagnosis of SAA fistulation through the posterior wall of the stomach was made. This 2-4 cm diameter aneurysm was sacciforme, multiple and joining the spleen hilum  , especiaThe SAA diagnosis is difficult cause only 17% of all patients are symptomatic ,7. TheseThe SAA rupture causes 25% average mortality , about 7The intragastric rupture of a spelnic artery aneurysm is exceptional. Its presentation as a digestive bleeding is an emergency which urgent management can avoid a potential lethal evolution.Written informed consent was obtained from the patient for publication of this case report and accompanying images.The authors declare that they have no competing interests.AO, KA and KM operated on the patient. KHI took the photos. HE participated in following up. All authors participated in writing the case report. All authors read and approved the final manuscript.


Gynecological surgery, as radical hysterectomy or pelvic and aortic lymphadenectomy, accounts for more than 50% of iatrogenic injuries. In premenopausal women, an hysterectomy with ovarian sparing and concomitant lateral ovarian transposition is frequently performed. However, the fate of the retained ovary is complicated by the residual ovarian syndrome (ROS) and one of the most common postoperative complications of the lymphadenectomy procedure is the lymphocele, with an average incidence of 22–48.5%. The differential diagnosis of a postoperative fluid collection includes, in addition to a lymphocele, urinoma, hematoma, seroma or abscess and the computed tomography (CT) findings alone is not enough.We describe a patient, affected by ROS concomitant with a asymptomatic lymphocele, initially confused with an aortic lymph nodes relapse, after abdominal radical hysterectomy. The patient was subjected to a surgical approach, included a diagnostic open laparoscopy and laparotomy with sovraombelico-pubic incision, wide opening of the pelvic peritoneum and retroperitoneum. Examination of the mass revealed, macroscopically, a ovary with multiloculated cystic masses filled with clear or yellow serous fluid and the layers were composed by flat or cuboidal mesothelial cells.The tribute of this case illustrates the atypical appearance with uncertain aetiology after complex imaging. Gynecologist and radiologist should acquaint with the appearance of fluid collection  in gynecologic oncology follow-up to properly differentiated from tumor recurrence. Gynecological surgery, as radical hysterectomy or pelvic and aortic lymphadenectomy, accounts for more than 50% of iatrogenic injuries ,2, such We describe a case of ROS concomitant with a pregress asymptomatic lymphocele, in a 37-year-old woman who developed an abdominopelvic mass, initially confused with a recurrence in the aortic lymph nodes, 12 years after abdominal radical hysterectomy for cervical cancer.A 37-year-old woman was admitted to our Institute with suspected an abdominopelvic mass, without univocal interpretation, considering the peculiarity of the onset and of the radiological appearance.Twelve years earlier, the patient was treated with radical abdominal hysterectomy. Whertheim-Meigs radical hysterectomy, systematic pelvic and aortic lymphadenectomy with conservation and lateral transposition of the right ovary for stage IB1 cervical cancer. One of 47 pelvic lymph nodes removed was positive. Adjuvant external radiotherapy was administered for a total of 4500 cGy. At the end of treatment, the patient developed asymptomatic aortic lymphocele, measuring 4 cm in diameter and it was untreated. The follow-up was negative until December 2006 when the patient exhibited dyspareunia, lower abdominal and back pain. The first examinations carried out, ultrasonography and computed tomography (CT) showed an irregular loculated cystic mass measuring 8 × 7 cm, located in aortic area. The serum level of CA125 was found increased to 89 U/mL and there was a slow and progressive elevation.These symptoms worsened and the first diagnosis was confirmed by subsequent several imaging studies. In March 2007, the patient underwent to further abdominal and pelvic CT scan that explained a pelvic mass with complex features; pelvic MRI confirmed a cystic pelvic mass of 18 × 8 cm size but with a solid component figure . The patLymphadenectomy plays an important role in the management of gynecological malignancies for the assessment of lymph node status. In premenopausal women, an hysterectomy with ovarian sparing and concomitant lateral ovarian transposition is frequently performed.However, the fate of the retained ovary could be complicated by the residual ovarian syndrome (ROS): it consists of recurrent or chronic pelvic pain (71–77%), disturbance of the urinary tract (33%), dyspareunia (67%), pelvic mass on bimanual examination (14–25%), as a single or a cluster of symptoms. The interval between hysterectomy and the appearance of symptoms surgery for the residual adnexal disease syndrome range from 4 months to 26 years. Over 50% of the women presented within 5 years, and 75% within 10 years. It is estimated that at least 2.85% of patients will develop ROS and require surgery for it following hysterectomy ,10. In lAll at once, one of the most common postoperative complications of the lymphadenectomy procedure is the lymphocele, with an average incidence of 22–48.5% . About aet al. [In this case, the presence of a small, asymptomatic lymphocele was diagnosed 6 weeks after surgical procedure by CT scan. Considering that most of the small lymphocysts regress spontaneously, a conservative approach was opted. Remarkably, in this report the lymphocyst preserved the same aspects, either for the size and the location, until 12 years later, when a CT showed irregular cystic pelvic mass, mimicking malignant recurrent ovarian/lymphonodal lesion. Although late relapse for cervical cancer after the fifth years is very rare, estimated about 04–7.5%, one third of it had lymph node metastasis and the CT scan is helpful for early diagnosis [et al. , lymphocThis case emphasizes that the gynecologist and radiologist should acquaint with the appearance of transposed ovaries and their abnormalities, to properly differentiated from other possible entities, such as peritoneal metastases, urinomas, seroma, hematoma, abscess, cystic neoplasm; the report also strongly supports the evidence that more close radiological examinations in this setting of patients are required in order to promptly exclude tumor recurrence.The author(s) declare that they have no competing interests.MP Conceived of the study. Carried out the design of the study, participated in the sequence alignment and drafted the manuscript. NM Participated in the study's design and coordination. Gave final approval of the version to be published. CM. Carried out the analysis and interpretation of data. Helped to draft the manuscript. FE Participated in the study's design and coordination. Performed the statistical analysis. MI Helped to draft the manuscript. Participated in the design. LM Carried out the acquisition of data. Participated in the design. PBP Gave final approval of the version to be published and revised the manuscript.All authors read and approved the manuscript.


Granulocytic sarcoma (GS) is a form of acute myeloid leukemia (AML), also known as extramedullary myeloid tumor or chloroma. It forms a solid malignant tumor consisting of myelocytes or granulocytes and is typically located in bone while occurrence in other parts of the body is rare.We reported a 40-year-old male patient who had jaundice, highly elevated bilirubin, and a mass highly suspicious of pancreatic head carcinoma. We performed surgery and the pathology and immunohistochemistry suggested GS; however the blood test and the bone marrow infiltration showed no evidence of AML. In our review of the published reports of GS, we only found six reports of the GS in the pancreas, and we suggested that immunohistochemical staining should be used to accurately differentiate GS from other pancreatic cancer and other types of leukemia.The accurate diagnosis of GS is necessary for determining prognosis and deciding appropriate therapy. Granulocytic sarcoma (GS), also called extramedulary myeloblastoma or chloroma, is a rare solid tumor composed of immature myeloid cells . The tumThe patient was a 40-year-old man. He had no significant past medical history. He initially went to the outside hospital on Jan 20, 2009, with the symptom of jaundice and weight loss of 5 Kg in one month. He described that his skin and sclera got yellow and gradually got worse in one month. He denied fever, chills, nausea, or vomiting. His physical examination at the time was only yellow skin and sclera. His routine laboratory test only showed the elevated total bilirubin and direct bilirubin. MRCP of the other hospital showed the malignant tumor in the distal common bile duct.3, platelets: 142 × 103/mm3, AST: 114U/L, ALT: 250U/L, total bilirubin: 43.2 μmol/L, direct bilirubin: 35.2 μmol/L, serum creatinine:80 μmol/L,AFP:1.7ng/L,CA19-9:13.1U/L . A CT scan  revealed a low-density mass at the pancreatic head  and, less often inv (16)  -7. Both ; 21 and,In the differential diagnosis, the most important diseases to be considered were non-Hodgkin lymphomas of the lymhoblastic type, Burkitt lymphoma, large-cell lymphoma and small round cell tumors . DiagnosFor the treatment of the GS, radiation therapy or surgical resection had been found less effective than chemotherapy on improving the disease-free interval or disease-free survival ,3. ThereThe patient has given their consent for the case report to be published. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors have neither financial nor non-financial competing interests to declare in relation to this manuscript.All authors read and approved the final manuscript. YFR and DYJ: Operating team and drafted the manuscript; DSW, WHL and TTK: operating team, post-operating care and helped in drafting the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/10/80/prepub


Liposarcomas are classified into four subtypes, with different malignancy potential and characteristic imaging appearances. Well-differentiated liposarcomas have imaging characteristics similar to those of benign lipomas, however they can be usually distinguished from lipomas because of the larger size and broader fibrous septa, with a more nodular appearance.This paper presents a case of atypical lipoma (well-differentiated liposarcoma) of the pelvis, leading to partial involvement of the sciatic nerve. In our case, computed tomography (CT) showed a low-density lesion. In magnetic resonance imaging (MRI), T1 and T2-weighted sequences revealed a fatty appearance with signal loss on fat saturation pulse sequences.The lesion was successfully resected and no other similar lesions have been found within one year of follow-up. Liposarcoma, a malignant tumor of mesenchymal origin, is one of the most common primary neoplasms in the retroperitoneum . HistoloA 60-year old woman was admitted to the outpatient department of our hospital due to deep pain of the pelvis and distal lumbar spine. Progressive pain of the posterior right leg also developed. Neurological examination revealed a reduction of strength of the right leg and incomplete paresis of the right tibial and common peroneal nerve (both branches of the sciatic nerve). The patellar reflexes were evocable on both sides, the Achilles tendon reflex was positive on the left side but absent contralaterally. Additionally, a hypoaesthesia of the S1 dermatome was detected on the right leg. The clinical picture was therefore that of a partial impairment of the right sciatic nerve. Initially, a local irritation of the sacral spinal nerve 1 was suspected, however a magnetic resonance imaging (MRI) showed the presence of a massive tumor in the right pelvis. An extension of the MRI to the whole pelvis revealed a lipomatous appearance and the presence of septa Figure . The diaThe lesion presented high signal intensities on T1-weighted sequences Figure  and a coAfter surgical removal of the tumor, the histopathology confirmed the diagnosis of a well-differentiated liposarcoma Figure . Nearly We present a case of well-differentiated liposarcoma  in the pelvis with incomplete involvement of the sciatic nerve. About 16–18% of all malignant soft-tissue tumors in the general population are liposarcomas , which aBest to our knowledge, this is the first description of a case with paresis of a nerve as clinical manifestation of a lipomatous lesion. Local compression in the sciatic foramen due to the hudge size of the tumor caused impairment of the nerve.The presented massive pelvic tumor demonstrated typical imaging findings of a lipomatous lesion. In CT imaging, the neoplasm showed a low density reaching -100 HE, except for the septa, which showed densities of soft tissue. MRI also enables a precise diagnosis of the tumor and the adjacent anatomic structures. Fat tissue demonstrates a short T1 and a relatively long T2 relaxation and therefore appears hyperintense on T1-weighted and intermediately isointense to hyperintense on T2-weighted fast-spin-echo and gradient-echo images. The presented case showed the characteristics of a benign lipoma on both CT and MR imaging . LipomasInterestingly, only well-differentiated liposarcomas are predominantly fatty. The other histological subtypes usually demonstrate less than 25% or no fat tissue . Its sigPleomorphic and round cell liposarcomas are high-grade sarcomas, consisting of only small (or no) amounts of fat tissue. Both tumors show a heterogeneous appearance, also occurring in other malignant soft tissue tumors.Preoperative diagnosis of the subtype has an impact on the surgical planning . If the In conclusion, well-differentiated liposarcomas present imaging characteristics similar to benign lipomas because both lesions consist of large amounts of fat tissue (more than 75%). However, a differentiation is usually possible because well-differentiated liposarcomas generally demonstrate a larger size and broader fibrous septa with a more nodular appearance compared to benign lipomas. Neurological symptoms as clinical manifestation of a well-differentiated liposarcoma are firstly described in this case.The authors declare that they have no competing interests.AH conceived the study. JB did research the literature review. AH, MG and JB prepared the manuscript. WAK edit and coordinated the manuscript.All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Late gadolinium enhanced (LGE) cardiovascular magnetic resonance (CMR) has proven to be the gold standard for viability assessment. LGE CMR is also useful for identifying the nature of cardiac masses or lesions. We report a case of a rare primary cystic tumor of the atrioventricular node, in which CMR proved to be valuable. Although primary cystic tumor of the atrioventricular node is very rare and classified as benign , it may The patient, a 42-year old female, was referred for CMR with suspected atrial myxoma and the confirmation was needed for pre-surgical evaluation. She presented with episodes of syncope, mitral valve prolapse and suspected atrial myxoma. She had four successful pregnancies, however, developed shortness of breath about 1 month after the birth of her fourth infant. An electrocardiogram (ECG) was performed with results indicating sinus rhythm with first degree AV block and PR interval of nearly 400 ms, an LV ejection fraction (EF) of 50%, mildly dilated left ventricle (LV = 58 mm and 42 mm), left atrial enlargement and mitral regurgitation. Two weeks after the ECG study, the patient was admitted to the hospital due to recurrent syncope and a repeated ECG showed abnormal AV node function and the subsequently had a dual chamber pacemaker implanted. About a month after the implantation, the patient had persistent swelling and yellowish discharge due to infection in the peripherally inserted central catheter (PICC) line and the pacemaker had to be removed. An echocardiogram revealed a myxomatous mass in the right atrium. The patient was then scheduled for surgery to remove the mass, with CMR preceding the surgery for confirmation of the right atrial myxoma .The patient was scanned in a 1.5 T clinical scanner  using a 4-element phased array coil and gated by a 4-lead electrocardiogram (ECG). Two doses of gadopentetate dimeglumine  were injected  using a Spectrus power injector . The protocol used is as follows: (1) sagittal localizer using fast spoiled grass (fSPGR); (2) long axis localizer using Fast Imaging Employing Steady State Acquisition (FIESTA); (3) short axis using FIESTA; (4) perfusion imaging using fast gradient echo-echo train (FGRE-ET); (5) cine radial views using FIESTA; (6) Late Gadolinium Enhancement (LGE) approximately 10 minutes post-intravenous injection. All acquisitions, except for the perfusion study, were performed with breath-holding and the entire exam was accomplished in 45 minutes. The data was analyzed and quantified using Advantage Workstation  and MASS Analysis Plus software .2, located in the right atrium (RA) on the atrial-septal wall immediately above the medial leaflet of the tricuspid valve. Furthermore, there were no changes in the size of the mass during systole and diastole phases. LGE revealed an-enhancing mass (Figure The standard imaging sequences revealed a hypointense cardiac mass Figure , measuris Figure  with lefs Figure , with si2 between the coronary sinus and the tricuspid valve annulus. The tricuspid valve was preserved and the roof of the coronary sinus was protected. The surgical area was patched using pericardial patch and the atrial septal defect was also closed. It was noted that the patient was in heart block postoperatively. A few days following the resection, the patient received a new dual chamber pacemaker. The patient made a full and uneventful recovery.A surgical sternotomy and excision of the atrial tumor was performed and findings include an atrial-septal defect and a golf ball size tumor measuring 2 × 3 cmA sample of the tumor was sent for pathology investigation. The specimen had a large amount of orange/brown thickened debris which was then sent to microbiology for aerobic, bacterial and fungal studies. The histology report indicated that the tumor was filled with abundant brown amorphous material. It consisted of multiple cysts Figure  of variaWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.The authors declare that they have no competing interests.TT acquired the MR images and carried out data analysis. VS is the surgeon responsible for removing the tumor. XW performed and analyzed the histopathology of the tumor. JG and BDR aided in the analysis of the MRI and the diagnosis of the tumor. All authors read and approved the final manuscript.


A 23-year-old woman with an alveolar soft-part sarcoma of her calf with pulmonary metastases unresponsive to chemotherapy is described. Interferon (IFN) alpha-2b induced an impressive tumour response still ongoing after IFN treatment had to be stopped because of a psychosis. An explanation of this effect is still speculative. Alveolar soft-part sarcoma (ASPS), a rare soft tissue sarcoma in young adults, preferentially presents as a quite large, painless tumour mass in the lower extremities. The microscopic picture shows an organoid nest-like arrangement of large polygonal cells, surrounded by thin-walled vascular channels. Mitotic figures are scarce. Central degeneration with loss of cohesion in the nests often provides a pseudoalveolar pattern. The cells contain varying amounts of glycogen and ‘diagnostic’ PAS-positive diastase-resistant crystalline material. Frequently, numerous multiple arteriovenous shunts are seen in the tumour , across We describe a 24-year-old woman with chemoresistant ASPS showing a still ongoing good partial response to interferon (IFN) alpha-2b.A 24-year-old woman presented in June 2000 with a fast-growing, tender swelling of her right calf without systemic complaints. Magnetic resonance imaging (MRI) showed a tumour of the gastrocnemius muscle around the right fibula of 5.5 × 8 cm without invasion of surrounding structures. Incision biopsy of the tumour (July 2000) revealed the characteristic histological pattern of ASPS with diastase-resistant PAS-positive accumulations of crystalline material identified in the cytoplasm. The cells showed immunoreactivity for vimentin, desmin and for S-100 protein. Other muscle markers , melanoma markers , and epithelial markers  were negative. Isolated limb perfusion was considered, but the thorax computed tomography (CT) scan revealed multiple, pulmonary metastases on both sides that were not resectable. Computed tomography scans of abdomen and brain were normal.6 IU s.c. day−1), was started, resulting in a gradual softening of the primary tumour. After 3 months, the dose was increased to 5 × 106 IU s.c.day−1, and after a further 3 months, a good partial regression of the pulmonary metastases (After treatment with three courses of intensive chemotherapy according to the SIOP-MTT-98 study for metastatic malignant soft tissue sarcomas of childhood, the lung metastases (Figure 1Atastases  and tumotastases  was confPrimary conservative surgery is the mainstay of therapy of ASPS, eventually preceded by isolated limb perfusion in case of questionable resectability or followed by local radiation. The ASPS of the patient in this case report was clearly progressive during a 4 months lasting treatment with three combination chemotherapy schemes and two periods of single-agent treatment. In an ultimate effort to inhibit the progressive growth of this well-vascularised tumour, treatment with the relatively weak and nonspecific angiogenesis inhibitor IFN alpha-2b was initiated. After a 6 months lasting period of stable disease, this treatment resulted in an impressive partial regression of primary tumour and lung metastases. Although treatment had to be stopped because of an acute psychotic syndrome, interpreted as side effects of the interferon, the remission now lasts for 14 months, while the patient has recovered from her psychosis. A comparable observation has recently been described in an 8-year-old boy (The explanation for regression of ASPS after IFN alpha treatment is still speculative. Growth inhibition may be mediated by IFN alpha-receptors shown to be present in most solid tumours in childhood  or by mo


Lichen planus is an immune mediated inflammatory lesion involving skin and mucosal sites including oral mucosa, vulva and rarely vagina. Lichen planus occurring at mucosal sites has been shown to be associated with squamous cell carcinoma in a proportion of cases. To the best of our knowledge, no case of lichen planus of uterine cervix has been reported in the available literature.A 45-year-old female underwent vaginal hysterectomy for uterine prolapse. The resected specimen showed a bluish-colored area in the non-dependent part of the ectocervix. Microscopic sections from this area showed dense lymphocytic infiltrate at the junction of mucosa and submucosa causing disruption of the basal cell layer. On immunohistochemical examination there was predominance of CD8+ T lymphocytes at the junction with scattered CD4+ T lymphocytes, characteristic of lichen planus. Based on the history and negative serum antibody titers, other differential diagnoses including lupus erythematosus and drug reaction were excluded. The patient did not have any cutaneous or oral lesions of lichen planus.Lichen planus of uterine cervix is a hitherto unreported entity, and is worth studying considering the premalignant potential of lichen planus at other mucosal sites. Lichen planus is chronic inflammatory mucocutaneous disease with an immunologic etiopathogenesis ,2. It moWe report the first case of cervical lichen planus with histopathological and immunohistochemical confirmation. Since cervical cancer is one of the commoner cancers in females, report of lichen planus, a pre-neoplastic condition, becomes important. More such cases need to be reported to delineate the biologic significance of the lesion at this site.A 45-year-old Indian female presented to the gynecologist with a six-month history of a mass descending down the vagina. She was post menopausal for the last three years and there was no relevant medical or surgical history. Local examination revealed second-degree uterine prolapse with cystocoele and rectocoele. Cervix showed a bluish-colored area measuring 2.5 × 3 cm in size. This area was not related to the most dependent part of cervix. Vulva and vagina were unremarkable. Routine cervical smear was reported as atrophic smear with inflammation. Pre-operative biochemical investigations were unremarkable and she underwent vaginal hysterectomy.On gross examination, a bluish discolored area without ulceration measuring 2.5 × 3 × 3 cm in size was seen in the uterine cervix Figure . EndometLichen planus is a chronic immune-mediated mucocutaneous disease with characteristic violaceous polygonal flat-topped papules and plaques. It occurs mainly on flexor surfaces of extremities and trunk, though can also involve scalp, nails, oral and genital mucosa . GenitalThe pathogenesis of lichen planus is not certain, though many studies have supported an immunologic mechanism. The role of T lymphocytes has been emphasized with cytotoxic activity of the CD8+ve subset of T lymphocytes responsible for keratinocyte damage ,2. In ouMalignant transformation of cutaneous lesions of lichen planus has been reported in less than 1% of cases . SimilarThe gross appearance of cervical lesion needs to be differentiated from congestion due to prolapse of uterus. Congestion occurs as bluish-brown discoloration on the dependent portion of the cervix whereas lichen planus has no such preference. Histologic examination differentiates between congestion and lichen planus, since congestion does not exhibit the band-like infiltrate observed in lichen planus with destruction of the overlying epithelium. Characteristic localization of T-cell subsets using Immunohistochemistry for CD4 and CD8 further resolves the matter. Other lesions, like involvement in systemic lupus erythematosus and drug reactions were excluded with the history and negative serologic findings.Cervical lichen planus is a hitherto unreported entity. We report the first case of lichen planus of uterine cervix confirmed by histopathology and immunohistochemistry. Since squamous cell carcinoma has been reported in long-standing lesions of mucosal lichen planus, existence of lichen planus in uterine cervix needs to be identified and more cases must be added to the literature in order to assist in the further study on this subject.Written consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review from the journal's Editor-in-Chief.The authors declare that they have no competing interests.RG was involved in drafting the manuscript and conducting a literature search. BB and SS were involved in signing out the case on histopathology and helped in literature review. IY was the gynecologist in-charge of the day-to-day care of the patient. KG helped in signing out of the case and finalizing the manuscript. MK assisted in critical evaluation of the manuscript and approved its final form.


A 22-year-old female in her third trimester of pregnancy was referred to our department for sudden loss of vision with a painful blind eye. It was diagnosed as retinoblastoma clinically and radiologically. Histopathology and immunohistochemistry confirmed the diagnosis. This case is one of its kind because retinoblastoma occurring during pregnancy had not been reported in literature so far. Retinoblastoma is the most common intraocular tumor in childhood; occurring before the age of two years and rarely after the age of four years. Literature review shows only 23 cases in adults Table 1Table 1. A 22-year-old female in third trimester of pregnancy was referred to our department from the obstetrics ward for sudden loss of vision in right eye. Her visual acuity was ‘no perception of light’. She had no history of trauma, surgery or use of spectacles. On the slit-lamp examination, findings were circumcorneal congestion, keratic precipitates, shallow anterior chamber with aqueous cells Figs.  and 2, aOn contrast enhanced computed tomography (CECT) of orbit, a contrast enhanced mass at posterior pole with absence of calcification was reported . The patHistopathological examination showed small round cells with hyperchromatic nuclei arranged in cords along with undifferentiated cells. Occasional rosettes and areas of necrosis were found . CalcifiShe received chemotherapy with carboplatin, vincristin, etoposide for six months and radiotherapy of 200cGy for four weeks to orbit. Although this was a case of non-hereditary retinoblastoma (due to age), contralateral eye of the patient, her first degree relatives and her newborn child were checked for ocular disease and found normal. Patient was followed for one year. By the end of one year CECT-orbit showed infiltration up to the orbital apex. She refused further treatment and died after four years probably due to metastatic complications, exact details are not available.Retinoblastoma is a rare tumor in adults. Literature review shows only 23 cases of retinoblastoma above 20 years. Table 1Table 1 ROn literature review through journals, cross references from cases and Pubmed search, we came to the some conclusions:Age of presentation of retinoblastoma in adults was 20-74 years. Oldest patient was a 74-year-old female reported by Finlay . Most coet al. reported one case which was presented six months post-partum.[No case was reported in the pregnancy although Takahashi t-partum. This 26 Clinical presentation is also different in adults as majority of them presented with diminution or loss of vision. Flashes, floaters, photopsia were also presenting features. Very few presented with leucocoria or squint which are commoner presentations in children. On indirect ophthalmoscopy, retinal detachment was the most common finding followed by vitreous hemorrhage, which may be non-resolving.Majority of the tumors were differentiated showing rosettes (17 cases). Completely undifferentiated tumors needing immunohistochemistry were few (four cases). Detailed histopathological findings have not been mentioned in two cases. Though calcification is supposed to be one of the criteria for diagnosis of retinoblastoma, it was never seen in adult cases including our case.Retinocytoma is a benign tumor of retina. It has got the same genetic characteristics and hereditary pattern as retinoblastoma. Singh and colleague had stated that malignant transformation rate of retinocytoma is four per cent. It is unnd and 3rd trimester, even though there are less chances of teratogenic effect, low birth weight, intra-uterine growth retardation, intra-uterine death and post-natal problems are common.[In a normal person, circulating mutagens are known to bind to cell and deactivate the retinoblastoma protein. If the patient has only one working copy, deactivation of this gene may affect cellular signaling and results in retinoblastoma. In pregnancy, the patient may have excessive circulating mutagens which may be responsible for retinoblastoma. Immunosue common. ChemotheDiagnostic dilemma often exists as retinoblastoma is not expected in adults. In such a situation, differential diagnoses are- amelanotic melanoma, metastatic carcinoma, lymphoma, leukemia, endophthalmitis, panophthalmitis and inflammatory diseases of retina. DiagnosiIn developed countries, five-year disease-free survival rate is 90-95%. These survivors have substantially increased risk of death from non-retinoblastoma malignancy pinealoblastoma, tri-lateral retinoblastoma, bony and soft tissue sarcomas. This risk is 20% in 25 years.Perhaps this is the only case of adult retinoblastoma presenting during pregnancy in literature. If in future, more cases are presented this way, it would highlight the relationship between pregnancy and retinoblastoma.


Bithalamic gliomas are extremely rare tumors of central nervous system. Although they are usually benign in nature, their outcome is poor because of the involvement of thalamic nuclei and inadequate surgical excision. Surgery is usually done to get tissue for diagnosis. Role of radiotherapy and chemotherapy is questionable. They are unique in their metabolic and neuroradiological properties. We report herein a 6-year-old male of bithalamic astrocytoma (WHO grade 2) who presented with raised intracranial pressure and tremors in right upper limb. The child had a very huge bithalamic mass which was debulked through the interhemispheric transcallosal approach in order to reduce the mass effect. He had a stormy post-operative course to recover gradually. Bilateral thalamic glioma are rare tumors of brain. Though they are benign in nature but their outcome is poor in comparison to unilateral thalamic glioma. They grow slowly and present with huge size involving nuclei of thalamus. Surgery had a limited role like biopsy, management of hydrocephalus and decompression if there is significant mass effect. Radiotherapy also is not much effective. We present a boy of six year with bithalamic glioma.A 6-year-old male who presented with complaints of tremors in right upper limb for two months which did not increase in frequency or severity over this period. He had history of occasional holocranial headache for two months. There was no memory or behavioral changes or compromise of school performance. Systemic examination was normal and neurological examination revealed no gross deficit except blurred margins of optic disc. Contrast enhanced CT scan showed large defined isodense mass lesion involving the bithalamic region with continuity in midline. Lateral ventricles were enlarged anteriorly and posteriorly to the mass. There was no enhancement on contrast.MR of head showed huge bithalamic lesion, of size about 7 cm × 7 cm × 5 cm interconnected with massa intermedia without any gap in between, occupying whole of the third ventricle, except a part anteriorly. It was uniformly isointense on T1 weighted and, hyperintense on T2 and FLAIR weighted images, with no contrast enhancement.There was no restriction to diffusion weighted images. Extent of lesion was up to midbrain, infiltrating bilateral cerebral peduncles reaching to left medial and posterior temporal and medial occipital lobes. Lateral ventricles were dilated with periventricular lucency and no perilesional edema was present Figures –5. MR spAs the mass was very bulky and ventricles were also obstructed, a decision to debulk (and not only biopsy) was taken in order to reduce the mass effect in supratentorial compartment. He was planned for surgery with interhemispheric and transcallosal approach. Lateral ventricles were distorted. A possible tumor decompression was done and a decompression of about 30% was acheived. Intraoperatively tumor was very firm, moderately vascular which was not yielding to suction and to CUSA easily. It was so tough that the excision was probably causing trauma to bilateral thalamic nuclei on account of energetic movement of the hands and instruments. The squash was suggestive of low grade glioma. Considering the total excision impossible, an external ventricular drainage catheter was placed in right ventricle and wound was closed following a good hemostasis. Patient was put on elective ventilation in postoperative period, but it was soon weaned off. The patient deteriorated in sensorium and breathing within 6 h, elective ventilation was again required. Post-operatively the child had a stormy course in the ICU. He remained dependant on the ventilator and continued as unconscious for three weeks. He improved gradually and started opening eyes and was weaned off from the ventilator in further three weeks time. CT scan suggested an operative site cavity and an increase in size of lateral ventricles Figures  and 8.As he had high grade fever and CSF culture showed coagulase negative staphalococcus aureus growth, shunt was not done and ommaya reservoir was placed in right frontal region.Owing to prolonged need of ventilator, tracheostomy was done. Regular aspiration of CSF was done under aseptic condition for two weeks with coverage of antibiotics according to sensitivity A biventricular shunt was done with y connector with medium pressure chhabra chamber. Patient improved after shunt. Within few days, ventilator was weaned off and decannulation was done. His histopathology showed a moderately cellular tumor composed of mild anisomorphic cells embedded in fibrillary matrix. Tumor cells displayed mild hyperchromasia and pleomorphism. Mitotic figures or endothelial proliferation or necrosis were not seen. Immunohistochemistry revealed tumor cells positive for GFAP. MIB index was low. Synaptophysin positive ganglionic cells were few. KI 67 index was < 2%. Impression was fibrillary astrocytoma (WHO Grade 2). Patient is being discharged on Ryle’s tube and planned for radiotherapy after two months. At the time of discharge, the child was conscious, following commands, breathing spontaneously, tracheostomy site healthy and had started accepting orally.Thalamic gliomas are rare tumors of brain accounting about 1-1.5% of all brain tumors. Twenty-five percentage of this is reported in people of age less than 15 years. In one study incidence was reported to be 0.84 -5.2% of all intracranial tumors.[2Bilateral thalamic tumors are different from their counterparts presenting as unilateral thalamic gliomas. These have poor prognosis in spite of benign histopathology.2 There aAge of presentation varies from 3 months to 70 years,5 but is Presentation is also quite typical, symptoms and signs are mild even though the patients may have large tumors. Raised iOn CT scan, these tumors appear as bilateral symmetrical isodense nonenhancing lesions, with little or no mass effect. MRI is the best radiological investigation in which the lesion appears as hypo to iso intense on T1 weighted images and hyperintense on T2 weighted images with no enhancement on contrast, respecting the grey white boundaries and confined to thalamus. Hydrocephalus is usually mild, but in our case was significant hydrocephalus with periventricular lucency. It was obviously because of the obstruction of the third ventricle and compression of the bodies of the lateral ventricle. Differential diagnosis to be kept in thalamic region are vascular lesions, other tumors , infections . MR spectOwing to diffuse and bilateral involvement of thalamus, surgical excision is difficult and no case of radical removal has been reported,–3510 so 3511111Bilateral thalamic glioma are rare neoplasms. They are different from unilateral neoplasm, with respect to neuroradiological and metabolic aspect and prognosis. Even though they are benign, prognosis is poor, which may be because of bilateral involvement of thalamic nuclei. Even large bithalamic gliomas may present with minimal symptoms. An obstructive hydrocephalus because of compression of the third ventricle and bodies of the lateral ventricle may cause dilatation of ventricles proximal and distal to the mass. Post-operative course after debulking may be stormy.


We present the first reported case of a craniopharyngioma as a second primary tumor in a patient with acromegaly due to a growth hormone (GH)-secreting pituitary adenoma. The patient was lost for follow-up for 18 years after trans-sphenoidal pituitary surgery for a GH-secreting pituitary adenoma. She presented with headaches and decreased visual acuity, and showed unsuppressed GH in an oral glucose load test with high IGF-1 levels. Brain MRI showed a suprasellar cystic mass and the patient underwent surgery for cyst drainage resulting in postoperative improvement in her vision. Biopsy of the mass confirmed the diagnosis of a craniopharyngioma. We stress the need for close follow-up of patients with acromegaly with adequate control of GH and IGF-1 levels. Craniopharyngiomas are rare, mainly sellar/parasellar, epithelial tumors, arising along the path of the craniopharyngeal duct, with an as yet undescribed pathogenesis. Their overall incidence is around 0.13 cases per 100 000 person-years5The simultaneous occurrence of both a craniopharyngioma and a GH-secreting pituitary adenoma has not been reported previously in the literature. Cases of the coexistence of craniopharyngioma with prolactinomaTwo theories on the pathogenesis of craniopharyngiomas are that they arise from neoplastic transformation of embryonic squamous cell rests of the involuted craniopharyngeal duct,14Acromegaly is known to be associated with high levels of IGF-1, which through activation of the IGF-1 receptor, results in cell proliferation and growth advantage, whereas the associated IGFBP3 bioactivity promotes an apoptotic advantage.Figure 2).A 41-year-old woman presented to our university hospital emergency department in 2007 with complaints of occipital headache of increasing intensity and worsening blurred vision in her left eye for the last seven months prior to her visit. Recently, she had also noticed that her menstrual periods were becoming irregular. The patient had a history of acromegaly treated with trans-sphenoidal resection of a pituitary tumor in 1989. She was also known to have primary infertility for which she had not sought any medical help. She had been lost to follow-up since her surgery until this visit. On examination, she was found to have acromegalic features and a left eye temporal visual field defect on confrontation and visual field mapping. An x-ray of her skull revealed thickened calvaria with a wide, double-floored sella. An MRI of her brain revealed a multiloculated cystic mass seen in the suprasellar region with extension more to the left side, causing a mass effect on the surrounding structures without midline shift or hydrocephalus . Six months after presentation, she was still being followed up at the endocrine and the neurosurgery clinics for further management.In the two months since her first visit, the patient had noticed a significant decrease in her left eye vision with an ability only to perceive light. On examination, her right eye was found to have a new temporal visual field defect. At that time, endocrine testing revealed hypogonadotropic hypogonadism with a serum prolactin level that was mildly elevated at 45 ng/mL. She was also found to have central hypothyroidism. Her GH was not suppressed even after an oral glucose load test. The baseline GH was 17.3 ng/mL; it became 13.0 ng/mL and 10.3 ng/mL at one and two hours. The IGF-1 level of 1006 ng/mL along with the unsuppressed GH confirmed the previous diagnosis of acromegaly. She underwent a left pterional craniotomy with subfrontal approach under microscopic guidance to obtain a tissue diagnosis and drain the cystic tumor. She developed transient diabetes insipidus postoperatively, but her vision improved significantly following surgery. She received perioperative stress doses of steroids, which were tapered rapidly afterwards. The patient was also started on L-thyroxine replacement therapy. Tissues obtained from surgery confirmed the diagnosis of a craniopharyngioma  have been previously described in case reports or small case series. The most common presentation of collision sellar lesions is the presence of a simultaneous pituitary adenoma with a Rathke cyst. A previous case report exists of simultaneous GH-secreting pituitary micro-adenoma with a Rathke cleft cyst, causing compression of the optic chiasm with resultant visual field defects.27In a study of the nationwide Swedish cancer family registry, meningioma was reported as the most frequent second primary tumor in individuals with a previous diagnosis of a first primary tumor of pituitary or parathyroid adenomas.3031Acromegaly has been arguably associated with an increased risk for several tumors with the strongest association reported with colorectal carcinoma.33Our patient had evidently suffered from uncontrolled acromegaly for several years with elevated GH and IGF-1 levels. Given the close anatomic proximity of the GH-secreting pituitary macroadenoma and the suprasellar craniopharyngioma in this patient, it would be reasonable to assume that the paracrine effects of the GH/IGF-1 axis would have been exaggerated. There is a paucity of literature investigating the tumorigenic effects of the GH/IGF-1 axis on brain tumors and craniophayngiomas, in particular, due to the rarity of this occurrence. Though rare, this complication of acromegaly might have been potentially prevented or detected earlier if the patient had maintained closer follow-up after her trans-sphenoidal pituitary resection. Better biochemical control of her acromegaly might have prevented the emergence of the craniopharyngioma. It is debatable whether the patient’s clinical picture and biochemical evidence of acromegaly were the result of GHRH secretion from the suprasellar craniopharyngioma. A possible scenario is that she had a craniopharyngioma at time of initial presentation, which was too small to be detected by the radiological studies done at that point of time. However, we have no proof that this was the case. Additionally, if the GH excess was the result of GHRH, it would have resulted in pituitary GH-secreting cell hyperplasia, rather than a distinct pituitary adenoma, which is the case in our patient. She first underwent trans-sphenoidal surgery for the GH-secreting pituitary adenoma, which did not result in adequate control of her disease. After an interval of several years without follow-up, she presented with the second pathology. It is worth noting that in a series of 121 cases of craniopharyngioma in children, none presented with acromegaly. In fact, craniopharyngioma mostly presents with hormone deficiency syndromes, with the sole exception of the expected elevation in serum prolactin levels.In summary, we report a patient with uncontrolled acromegaly who presented with headache and visual field defects due to a suprasellar craniopharyngioma. She had central hypothyroidism and hypogonadotrophic hypogonadism. To our knowledge, this is the first reported case in the literature.


A 24-year-old man presented with dysuria and voiding frequency. Cystoscopy revealed a smooth surfaced nodular mass in the trigonal region. Transurethral insisional biopsy of the mass was done. Histopathological and immunohistochemical examination revealed benign prostatic tissue situated ectopically. The term ectopic prostate has been applied to the lesions arising distant from the prostate, although this term has also been used to refer to small foci of prostatic tissue in the region of the bladder trigone and the seminal vesicles.The finding of ectopic prostatic tissue in the bladder is unusual although there are few case reports in the literature.–4 In the2A 24-year-old man presented with history of dysuria and voiding frequency of 3 months duration, took antibiotherapy for urinary tract infection. Physical examination did not present abnormality. Hematological and biochemical investigations were within normal limits. Both X-ray and intravenous pyelogram were normal, microscopic hematuria was detected on urine cytologic examination. On the basis of the clinical suspicion of tuberculosis (symptoms and microscopic hematuria) urine acid-fast bacilli (AFB) investigation was performed. Urine examination yielded neither positive AFB smears nor positive AFB culture.2 solid looking nodular tumoral mass on the midline of the trigonal region. The tumor had smooth surface covered with shiny mucosa. Complete transurethral resection of the tumor was done. Postoperative course was uneventful.Ultrasonography revealed any properties. Cystoscopy showed a 0.5 × 0.5 cmHistopathological examination revealed prostatic glands with secretion in the lumen. Immunohistochemical markers study was done to reveal ectopic prostatic tissue, prostate-specific antigen (PSA) and prostatic acid phosphatase (PAP) were applied to paraffin sections using commercially available reagents. Immunohistochemistry staining done on ectopic tissue revealed PSA and PAP positivity. A diagnosis of ectopic prostate was confirmed Figures , 2. PresHistorically, the first evidence of ectopic prostatic tissue was in the form of a group of glands located in the submucosa of the neck of the bladder, which they called the subcervical glandular group. Subsequently other authors also reported this finding.2 The mos2et al. histologically, two types of lesions were observed, the polypoid located in various sites of the bladder wall and the flat lesion found in the bladder neck. Both lesions shared in common a prostatic-type and transitional surface epithelium while prostatic-type glands were prominent in the polypoid lesion. Prostatic differentiation of the lesion in the presented case was confirmed by immunohistochemical staining. The glandular cells were strongly positive for PSA and PAP as it was reported in previous researches.[The other modes of presentations are bladder outlet obstruction and urinary tract infection. Histological, histochemical, and ultrastructural characteristics resemble the prostate.2 In the searches.5On the basis of specific findings, some authors considered the metaplasia as the most reliable histogenetic aspect. Another A mesodermal proliferation divides cloaca into bladder and rectum, the anterior portion of the bladder further develops into the urethra, which at 3 months gestation extends tubular outgrowths that eventually form the encircling prostate gland. In this case, cells capable of differentiating into prostatic tissue would have traveled with the bladder after division from the bladder, later forming a prostate gland locus.5The development of clinically significant prostatic tissue in this area in the postpubertal adults should therefore not be unexpected, albeit rare. The location of the lesion and the presence of vascular congestion correlate well with the clinical findings of dysuria, pollaciuria, and microscopic hematuria. The lesion is histologically and clinically benign. Local persistence or recurrence, however, may result from incomplete removal. There is no report of malignant transformation of ectopic prostatic tissue in the literature.


We report the case of a patient with a benign multicystic peritoneal mesothelioma and describe its appearance on computed tomography scans and ultrasonography, in correlation with gross clinical and pathological findings.A 72-year-old Caucasian woman presented to our emergency department with acute abdomen signs and symptoms. A clinical examination revealed a painful palpable mass in her left abdomen. Abdominal ultrasonography and computed tomography demonstrated the presence of a large cystic mass in her left upper abdomen, adjacent to her left hemidiaphragm. The lower border of the mass extended to the upper margin of her pelvis. A complete resection of the lesion was performed. Pathological analysis showed a benign multicystic peritoneal mesothelioma.Benign multicystic peritoneal mesothelioma is a rare lesion with a non-specific appearance on imaging. Its diagnosis always requires pathological analysis. Benign multicystic peritoneal mesothelioma is an uncommon lesion arising from the peritoneal mesothelium. It is often diffuse and shows a marked predilection for the surfaces of the pelvic viscera -8. In ouA 72-year-old Caucasian woman was admitted to our surgical department having experienced diffuse abdominal pain and discomfort, nausea and vomiting for the previous two days. Her medical history included diabetes mellitus and arterial hypertension, for which she was on medication. She had no relevant family history and did not smoke or drink alcohol.On physical examination, she showed signs of acute abdomen and a palpable painful mass in her left abdomen was noted. She was tachycardic and laboratory tests showed a white blood cell count of 13,000 cells per cubic millimeter. Her chest and abdominal radiographs did not reveal any abnormalities.An ultrasonography (US) examination demonstrated a complex cystic mass with internal septa, without increased vascularity. The source organ could not be identified Figure .Computed tomography (CT) examination demonstrated a large 18.7 × 13.2 × 22cm, intra-peritoneal hypodense mass in her upper left abdomen, lying between the great curvature of the stomach, the spleen and the tail of the pancreas, and extending caudally to the upper margin of the pelvis, causing pressure over the adjacent organs. The mass demonstrated no internal septa and no enhancement after the intravenous administration of a contrast medium. No abnormal lymphadenopathy was present Figure .She underwent an urgent operation and the multicystic mass was found to occupy her entire left abdomen, adherent to the spleen. A complete resection of the lesion and splenectomy were performed. She had an uneventful post-operative recovery and a post-splenectomy prophylaxis was used.Gross examination of the specimen showed a large gelatinous cystic mass containing multiple smaller cystic spaces. Her immunohistochemical stains were positive for calretinin and cytokeratins, confirming the mesothelial origin of the mass. The final diagnosis was benign multicystic peritoneal mesothelioma. Figures  and 6.Six months post-operatively, she had experienced no recurrence and was free of symptoms.Mesotheliomas are mesenchymal neoplasms originating from the serous lining of the pleural, pericardial or peritoneal space. Multicystic peritoneal mesothelioma involves the peritoneum or extra-peritoneal space, omentum, pelvic or abdominal viscera. It most commonly arises from the pelvic surfaces of the peritoneum and has benign or indolent biologic behavior. Multicystic mesothelioma of the peritoneum was first described in 1979 by Mennemeyer and Smith and since then approximately 130 cases have been described in the literature. It is an intermediate-grade tumor, among the benign adenomatoid tumors of the peritoneum and the more common malignant asbestos-related peritoneal mesothelioma. It is not related to prior asbestos exposure and may recur locally .On histological examination, the mesothelial cells lining the cysts may vary from flattened and endothelial-like to cuboidal. The thin-walled cysts may be filled with eosinophilic, serous fluid. Inflammatory cells and fibrous elements may be found within the stroma between the cysts. Foci of mesothelial hyperplasia may also be present .It is usually large at the time of diagnosis . Multifocality, free floating cysts and unilocular cysts have been reported .It commonly occurs in young to middle-aged women . The presenting symptoms are chronic or intermittent lower abdominal or pelvic pain, tenderness, or distension with an abdominal or pelvic mass and, rarely, dyspareunia, constipation and urinary hesitancy and/or frequency. Women with this lesion often have a history of prior pelvic surgery, endometriosis or pelvic inflammatory disease -3,5,7-10The pathogenesis of benign multicystic peritoneal mesothelioma is unclear and there is some controversy regarding its neoplastic and reactive nature ,6. The fUS demonstrates multiseptated anechoic cysts. The fluid within the cysts is generally anechoic, but the cysts may contain echoes from debris or hemorrhage. The number and complexity of septations, as well as the size of the cysts, are quite variable. Calcification has not been described in multicystic mesothelioma. CT provides more information about the location and extent of the mass, and demonstrates a well-defined, low-attenuation mass with non-calcified septa. The septa become enhanced following intravenous administration of a contrast material. Magnetic resonance imaging (MRI) provides additional coronal and sagittal planes. The watery serous content has low signal intensity on T1-weighted images and intermediate-to-high signal intensity on T2-weighted images. Septal enhancement has been reported [The differential diagnosis includes lymphangioma, other mesenteric and/or omental cysts, cystic teratoma, pseudomyxoma peritonei, cystic smooth muscle tumors, visceral cysts, cystic mucinous neoplasms of the pancreas, non-pancreatic pseudocysts, endometriosis, cystic adenomatoid tumor and cystic mesonephric duct remnants. When multicystic mesothelioma is located solely in the pelvis in women, tubo-ovarian abscess, hydrosalpinx, cystic ovarian neoplasms  and cystic forms of endosalpingiosis should be considered in the differential diagnosis. Lymphangiomas often occur in younger patients and can be identified if they contain predominantly chylous fluid and microscopically lymphoid aggregates and smooth muscle in their walls. Mesenteric cysts are generally unilocular and contain serous secretions, with no discernible wall or internal septa. Teratomas contain fat and calcification. Pseudomyxoma peritonei can be distinguished when there is co-existing omental caking, soft-tissue peritoneal nodules and scalloping of the serosal margins of the liver or spleen. The cystic component in cystic adenomatoid tumor is usually accompanied by a recognizable solid component. Malignant neoplasms are suggested by ancillary signs such as intramural nodules, ascites, necrosis or peritoneal carcinomatosis, and the source organ can usually be identified ,5-7,9,10Multicystic mesothelioma is seldom diagnosed at pre-operative imaging because it is exceedingly rare; the diagnosis requires histological evaluation.The treatment of choice is complete surgical excision. Complete removal of the cystic lesion, if possible, is the best treatment and the only hope in avoiding local recurrence. Aggressive surgical approaches including cytoreductive surgery with peritonectomy are recommended ,6. HormoAbout 50 percent of the patients experience a recurrence one to 27 years after the initial diagnosis and malignant transformation has very rarely been reported -3. Thus,The prognosis is excellent and the only death that has ever been reported in the literature occurred in the case of a patient who refused to undergo resection 12 years after diagnosis .Benign multicystic peritoneal mesothelioma is a very rare benign cystic tumor. This lesion has a non-specific appearance on imaging which does not permit differential diagnosis from other cystic lesions and always requires histological evaluation. It has a high recurrence rate after surgical resection but malignant transformation has very rarely been reported. A systematic follow-up of these patients is required and further resection or other therapy may be indicated.(CT): Computed tomography; (MRI): magnetic resonance imaging; (US): ultrasonography.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.XP performed the chart review and prepared the manuscript. EA, AE and CT carried out the operation. LP was the pathologist who examined the specimen. AP, NS and TC participated in the preparation of the manuscript. All authors read and approved the final manuscript.


A 66-year-old female patient was admitted to our department with a large tumor of the tongue measuring 10 cm in diameter. The tumor occupied nearly the entire oral cavity and showed exophytic and ulcerative areas. Histological analysis revealed a low grade squamous cell carcinoma (SCC) of the tongue. Bilateral enlarged cervical lymphatic masses were also present. The extent of the tumor infiltration was assessed by fluoro-2-deoxy-glucose-positron emission tomography (PET) scans showing an elevated activity of the tracer corresponding to the assumed cervical metastases. Additionally, pulmonary metastases were identified. Contrast enhanced computed tomography (CT) scans showed metastases in the soft tissues of the abdomen, legs and arms. Foci of distant metastases were found in the left upper anterior thoracal wall, near the intraabdominal portion of the aorta, near the right iliac crest and in both the right vastus medialis- and adductor magnus muscles. The final diagnosis was a T4N3M1(G3)(C3) SCC of the tongue with multiple distant thoracal, abdominal and intramuscular metastases. The survival expectancy was five weeks, and the patient finally deceased by cardiopulmonary complications. Patients suffering from a squamous cell carcinoma (SCC) of the head and neck region with distant metastases generally have a very poor prognosis . DistantIn summary, we report on a 66-year-old female patient who suffered from a terminal SCC of the tongue with multiple distant metastases which were localized mainly in the peripheral skeletal muscles and adjacent soft tissues of the lower extremities. Furthermore, we show an overview on the current literature on metastases originating from head and neck tumors Table .A 66-year-old woman was admitted with the symptoms of acute dyspnoe, orthopnoe and progressive dysphagia. The inspection of the oral cavity revealed an extensive lesion of the tongue Fig.  with areAltogether, one suspect soft tissue metastasis could be identified near the left upper ventral thoracal wall Fig. . A furthIn summary, the tumor staging according to the UICC  revealed a terminal cT4cN3cM1(G3)(C3) tumor. At this advanced stage, surgical therapy with curative intention was not indicated. At the same time, the patient strictly refused a surgical reduction of the tumor, a palliative radiochemotherapy as well as the application of a PEG-device. Therefore, she was transferred to the palliative care unit. The patient finally deceased after 5 weeks of hospitalization by a cardiopulmonary failure as a consequence of the tumor progression. The histologic confirmation of the suspect radiologic diagnoses, which included the spreading of the neoplasia, could be made only for the intraoral findings within the limits of the primary diagnostics, because the patient's relatives did not consent to perform an autopsy despite our request.Importantly, in the case presented here, the pattern of an advanced hematogenous spreading of metastases is particular. The metastases were located mainly in the soft tissues of the lower extremities, in particular in the skeletal muscular system. A few small metastasis-like lesions were also found in the cardiopulmonary system, as shown by 18F-FDG-PET imaging and CT scans, but they were clearly of minor extent if compared to the prominent distant metastases in the peripheral skeletal muscles and adjacent soft tissues.The patient did not show any cardiac lesion in the CT scans. Thus, in case of the presence of masses of unknown origin in the lower extremities in patients who once suffered or are still suffering from a SCC of the oral cavity, a possible spreading of metastases should be taken into consideration. We would like to point out that the examination for such findings should be performed during the continuous tumor recall and control appointments. In the case presented here, a native computertomography of the neck was initially performed. It showed no obstruction or imminent obstruction of the airways. Therefore a tracheotomy was abstained from. In general and in accordance with the current literature, the authors prefer a preoperative tracheotomy in order to avoid postoperative airway difficulties and a tracheotomy in an emergeny setting .In the case of the patient presented here, the quality of life was limited mainly by the tumor of the tongue causing impaired ability to swallow, reduced function of speech and impairment by esthetic and functional disfigurement, three factors that contributed to a low quality of life in a considerable degree. Not the distant metastases were the life-limiting factor, but rather the extensive local findings in the oral cavity which caused considerable respiratory and nutritional limitations. A valuable alternative for patients with a stage IV tumor disease with distant metastases, where the primary tumor is mostly considered to be the survival-limiting factor, is to offer them both an immediate therapy of the primary tumor and an integral palliative care in order to improve the quality of life. Other authors also support these recommendations; e.g., it has recently been shown that patients whose loco-regional and remote metastases were operated had a high two-year surviving rate . This kiIt has recently been reported that some patients who suffered an untreated SCC of the head and neck region survived for more than five years. Studies in which the outcome of patients with a SCC who were not treated at all were compared to the outcome of patients who underwent a palliative therapy showed that the mean survival rate was 8.4 months larger in patients who underwent a palliative therapy . HoweverRapoport et al. (1975) compared recurring head and neck tumors in relation to the outcome . One groThe studies cited here support the ruling opinion that a meticulous staging is an essential aspect within the control of survival rates and quality of life. If the patient, as in the case presented here, refuses biopsy of suspected peripheral metastases, further costs can evolve later when other apparative examination means become necessary. This should be avoided, if possible, by an appropriate early education and guidance of the patient. However, the clinician is often confronted with the delicate task to choose a reasonable balance between minimal and maximal diagnostic means that are available and treat the patient with respect, which is a basic requirement. A PET-CT Scan could have been a cost saving, sufficient alternative. According to Nahmias et al. (2007), it shows a specificity of 99% and a sensitivity of 48% in a preoperative lymph node staging of the neck with oral squamous cell carcinoma. A positive PET-CT scan has a high positive predictive value . AlthougIn conclusion, we point out that distant metastases of SCC's of the head and neck region can manifest themselves in the peripheral skeletal muscles and adjacent soft tissues. Therefore, during performing a tumor staging and during aftercare, this possible localization of metastases should be taken into consideration if suspect lesions were found in the peripheral skeletal muscles and nearby soft tissues in a patient who suffers from or who had once suffered from a SCC. It has to be considered that distant metastases of head and neck tumors are probably not the limiting factor for the patient's survival prognosis since the local primary tumors in the oral cavity can importantly impair nutrition and breathing. Therefore, an early operative treatment should be an option for patients suffering from a progressive and terminal head and neck tumor, as a considerable good life expectancy can generally result and as the quality of life can be improved or at least upheld on an acceptable level as long as possible.All authors have declared that no competing interests, whether of financial or non-financial nature exist.RS and OM designed the study. MBG and MH analyzed the data. RS, OM, MBG and MH contributed to writing the paper. DR supervised the clinical treatment and data collection. RS and OM wrote the main part of the paper. All authors gave useful comment on the analysis of data and text of the manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


We report a case of vascular malformation arising from internal jugular vein presenting as mass at root of neck with no clinical stigmata which to the best of our knowledge is the first reported case of an intrinsic vascular malformation arising from the internal jugular vein. Magnetic resonance imaging features of this new entity have been described.A 27 year male presented with a gradually enlarging, asymptomatic swelling on left supraclavicular region with normal overlying skin. A soft mass, about 7 × 7 cm with restricted mobility was found with normal cranial nerve function. Fine needle aspiration cytology showed a hemorrhagic aspirate. Doppler showed a mass displacing left carotid artery posteriorly while left internal jugular vein was not visualized. Magnetic resonance imaging showed a well defined mass isointense to hypointense on T1 weighted and hyperintense on T2 weighted and STIR images with fluid-fluid levels. On exploration, a vascular mass arising from left internal jugular vein was found with good tissue planes, which was excised after ligating the patent internal jugular vein above and below the lesion. Histopathologic examination confirmed the diagnosis of vascular malformation.The diagnosis of intrinsic vascular malformation arising from internal jugular vein should be kept in differential while dealing with masses at root of neck and magnetic resonance imaging features may help in the pre-operative diagnosis of this entity. Vascular lesions have been classified as hemangiomas or vascular malformations depending on the presence of cellular proliferation . Venous A 27-year male presented with a gradually enlarging mass in left supraclavicular area for the last three years. There were no associated symptoms. On physical examination, there was a mass about 7 × 7 cm, soft and non tender on the left side of neck extending from mid neck down to the clavicle. Overlying skin was normal in colour and texture. There were no pulsations or bruit over the mass. Mass showed restricted side to side mobility but was not mobile in supero-inferior direction. There was no other palpable mass or lymph node detected in the rest of the neck. Examination of all the cranial nerves was normal. Doppler of the neck vessels showed that the left common carotid artery was displaced posteriorly by a supraclavicular mass. The mass closely abutted the artery and showed indistinct fat planes with the vessel wall at places but there was no evidence of luminal narrowing noted in the course of carotid artery. The common carotid artery, external and internal arteries showed normal colour, flow and velocity. The left internal jugular vein was not visualized.Magnetic resonance imaging (MRI) demonstrated a heterogenous well defined mass, 7 × 4 × 6 cm in size in infra hyoid neck on the left side. The lesion appeared isointense to hypointense to muscle on T1 weighted images Figure , 3 and SIntrinsic vascular malformations arising from the wall of internal jugular vein have not been described in English-language literature. Few cases of intrinsic vascular malformations arising from external jugular vein have been reported ,4. We deVenous vascular malformations are believed to be present at birth but may not become apparent until later in life. They may expand as a result of trauma, sepsis, hormonal changes or changes in venous pressure ,6. MR feSimilar MRI characteristics like an isointense T1 signal relative to skeletal muscle with hyperintense and slightly heterogenous T2 signal  have beeThe root of the neck is an uncommon location for a soft compressible swelling. Lymph node enlargement can occur in this region but will be firmer in consistency and very well defined. Various swellings, such as intramuscular hemangioma, lymphangioma, lipoma, rhabdomyoma are to be considered in the differential diagnosis. Also, oIn the present case, FNAC was performed pre-operatively but surgical excision rather than a guided biopsy is preferable because of the possibility of extensive bleeding of the punctured vascular lesion . Total eThis is first reported case of an intrinsic vascular malformation of internal jugular vein for which the diagnosis was possible only after surgical excision. This case report underlines the need for head and neck surgeons to be aware of such an entity and should be considered in differential diagnosis for neck masses with similar features.The authors declare that they have no competing interests.DP: was part of surgical team, designed the case report, carried out the literature research and manuscript preparation. CP: was part of the surgical team, guided in drafting the article and revising it critically for important intellectual content. PSP: carried out the literature research, manuscript editing and manuscript review. ND: was part of the surgical team, carried out the manuscript editing and manuscript review. JSL: helped in the radiological aspects of the present case and carried out the manuscript editing. RB: helped in the pathological aspects of the present case and carried out the manuscript editing. All the authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


An elderly female patient was referred to the author for the treatment of a large recurrent pyogenic granuloma in the sole of right foot for a period of 2 years. She underwent excisional surgeries at an outside facility twice in the past. This time, she was treated with wide excision biopsy and the surgical defect was closed with a new technique, the “adjustable suture technique”. Histopathology report confirmed “desmoplastic melanoma” with complete marginal clearance. The wound had healed uneventfully. There were no recurrences at 4-year follow-up. Conditions without characteristic clinical features, especially if they are rare, can lead to incorrect diagnoses and management. The consequences could be fatal, but might be preventable with a high index of suspicion that follows familiarity with the condition. To the author’s knowledge, desmoplastic melanoma, a rare and disastrous malignancy, presenting as pyogenic granuloma, a common and benign condition, has not been reported yet. This study reports one such case that had misled the treating doctors repeatedly.This article reports the case of an elderly woman who presented with a painless growth that used to bleed on touch in the sole of her right foot for a period of two years. It was excised twice earlier elsewhere. The details of the earlier presentation, surgery, or histopathology were not available.It resembled a large pyogenic granuloma at the junction of instep sole and weight-bearing heel . There wAt four-year follow-up, the wound had healed well and the scar was stable. There was no evidence of local recurrence. Systemic survey and hematological and whole-body CT scanning at four-year follow-up were negative for metastases.Separate Hematoxylin and Eosin stained sections from each lesion, the intervening tissue, and the surrounding tissues were examined microscopically.It showed extensively ulcerated epidermis, covered by necrotic debris and fibrinoid exudates. It had infiltrative and expansile growth patterns in the dermis, extending into the subcutaneous tissue. It mainly consisted of two populations of cells given as follows: (i) The spindle cell population was predominant . These cIt consisted of small-to moderate-sized cells with small, round nuclei, arranged in alveolar formations and nests . No spinIt was free of tumor cells .The tumor cells in both the lesions showed diffuse positivity for S-100  and vimeDetailed hematological and whole-body CT scanning both initially and at four-year follow-up were negative for distant metastases.Spindle cell variant of the “combined form” of cutaneous desmoplastic type of amelanocytic melanoma, in vertical growth phase, with marginal clearance and probable satellitism.Considering the history of repeated attempts at its excision, microscopic finding of scar tissue around the lesions, and the histopathological as well as immunohistochemical features mentioned earlier, the final diagnosis was made as recurrent cutaneous desmoplastic melanoma with macroscopic satellitism, which, as per the new AJCC classification, belongs et al. described “desmoplastic melanoma” in 1971.[Conley  in 1971. SubsequeIncidence: 1–2% of all melanomas, De Vita, 2005.Race: All races, but common in Caucasians.Sex: Male : Female ratio = 1.75-2 : 1.et al., 1989.[Age: Later age group, commonest in the seventh decade of life, Jain S l., 1989.It can occur in skin and mucosa of any region of the body. More commonly reported areas of occurrence are as follows:Males: Sun-exposed areas on the head, neck, and upper part of the trunk.Females: The extremities.Tends to be bulky, many lesions are not recognized until they have reached a substantial thickness.Neurectodermal tumor, Carlson JA, 1975 /Neural Locally aggressiveHigh incidence of local recurrences.Recurrences are attributed to inadequate excision of the primary lesion.History of repeated surgeries with erroneous/mistaken diagnoses.Possibility of aggressive local treatment producing cure.Lymph node metastases: Rare.Distant metastases: Rare. When present, they are common in the lungs.Radiotherapy and Chemotherapy: No proved effectiveness.Usually nonpigmented lesions.Often mistaken clinically for a scar, a fibroma, a basal cell carcinoma, a fleshy or firm nodule reminiscent of a scar, a sarcoma, or a dermatofibroma.de novo or in association with a pre-existing lesion such as lentigo maligna, in which case, a clue to the diagnosis will be available.Arise When de novo, they can present in an unsuspecting manner such as indurated, nonulcerated, and slightly elevated plaque, as a papule, or as a small nodule etc.Till date, to the author’s knowledge, no report exists describing it presenting as a pyogenic granuloma.et al., 2007[et al., 2008,[Desmoplasia, Busam, 2005, Markovical., 2007: Spindlel., 2008, macrophaThey include ulceration, neurotropism, neuroma-like features, cytological atypia, atypical nuclei, high mitotic rate, higher mitotic index, stromal myxoid change, sarcoma-like features, individual necrotic cells, areas of myxoid or storiform appearance, infiltration of the adventitia of the blood vessels, perineurium, endoneurium or local nerves, vertical growth phase while arising in a pre-existing lesion such as a lentigo maligna, common depth of Breslow’s measurement of more than 4 mm, and satellite lesions that are usually microscopic.Diffuse positivity for S-100 and Vimentin, weak positivity or negativity for HMB 45, and negativity for Cytokeratin.et al., 2004.[Clinical presentation of “desmoplastic melanoma” is a diagnostic trap for the unwary, Mc Carthy l., 2004. The clinet al., 2005.[Conventionally, the prognosis is considered poor, but it is a curable disease with aggressive local treatment alone, Arora l., 2005.It alone may be sufficient. To be effective, all the excised specimens must be biopsied, and marginal clearance must be ensured in all the excised specimens. In the absence of marginal clearance, excisional surgery must be repeated until marginal clearance is ensured. Inadequate local treatment leads to local recurrence. Repeated local recurrences can lead to increased incidence of distant metastases. Death is usually due to distant metastases.It is not usually helpful.A careful, long-term follow-up is mandatory.et al., the condition can be considered as “cured”.[In the reported case, the nature of initial presentation to dermatologists and operating surgeons of the outside facility was unknown. It had recurred twice after the earlier surgeries. The simple precaution of ensuring the histological “marginal clearance” after the current surgical excision seemed to have made the difference. The local and systemic surveys that were negative at four-year follow-up suggest that, as per Lens  “cured”.The “adjustable sutures” are mattet al., 2008.[In most cases, a DM is diagnosed only in established long-standing and thick melanomas. Therefore, dermatologists and dermatopathologists should be more aware of this clinicopathologic variant of cutaneous malignant melanoma, de Almeida l., 2008. Accordin


Gastrointestinal stromal tumors (GIST) are uncommon intra-abdominal tumors. These tumors tend to present with higher frequency in the stomach and small bowel. In fewer than 5% of cases, they originate primarily from the mesentery, omentum, or peritoneum. Furthermore, these extra-gastrointestinal tumors (EGIST) tend to be more common in patients greater than 50 years of age. Rarely do EGIST tumors present in those younger than 40 years of age.en bloc with its fused omentum and an adherent portion of sigmoid colon. Pathology results demonstrated a malignant gastrointestinal stromal tumor with positive CD117 (c-kit) staining, and negative margins of resection, and no continuity of tumor with the sigmoid colon. Due to the malignant and aggressive nature of this patient's tumor, he was started on STI-571 as adjuvant chemotherapy.We report a case of a large EGIST in a 27-year-old male. An abdominal pelvic computerized tomography imaging demonstrated an intra-abdominal mass of 22 cm, without invasion of adjacent viscera or liver lesions. This mass was resected Stromal tumors of an extra-gastrointestinal origin are rare. Of the reported omental and mesenteric EGISTs in four published series, a total of 99 tumors were studied. Of the 99 patients in these series only 8 were under 40 years of age, none were younger than 30 years old; and only 5 were younger than 35 years old. Our patient's age is at the lower end of the age spectrum for the reported EGISTs. Young patients who present with an extra-gastrointestinal stromal tumor (EGIST), who have complete resection with negative margins, have a good prognosis. There is little data to support the role of STI-571 in adjuvant or neoadjuvant therapy after curative resection. Given the lack of data, the use of STI-571 must be individualized. Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, although their overall incidence is low. In the United States of America, it is estimated that 3,300 to 4,350 new GISTS are diagnosed every year. It is well accepted that their cell of origin is the interstitial cell of Cajal. The commonality of these tumors is a positive immunohistochemistry stain to CD117 also known as C-kit located at 4q11-12. Mutations have frequently been identified in exon 11 of the C-kit gene, but also on exons 9 and 13 [Gastrointestinal stromal tumors can appear anywhere in the gastrointestinal tract, from the mouth to the anus, but also in extra-gastrointestinal locations such as mesentery, omentum, peritoneum -6. GastrWe present the case of a 27 years old Caucasian male that presented to our emergency department with chief complaint of right lower quadrant abdominal pain. The patient was referred with a 24 hour onset of colicky pain, of seven of ten in intensity. He denied bowel habit changes, fevers or chills, but he did complain of nausea, and postprandial fullness, but no vomiting. There was no history of weight loss over the last year and he denied any abdominal trauma or past surgeries. His family history was significant for colonic cancer in his father at age 47 and breast cancer in his mother at age 60.Examination showed a well-developed male in no acute distress with obvious abdominal distension. Abdominal palpation demonstrated a large mass extending from the right upper quadrant and epigastrium to the right lower quadrant. The mass was non-pulsatile, moderately tender, and non-mobile. No peritoneal signs were appreciated. His lower extremities showed no edema, and his rectal examination was negative for masses or gross or microscopic blood in the stools.A computerized tomography of the abdomen and pelvis was performed which showed a large ovoid intraabdominal heterogeneous mass measuring 22 cm in greatest length extending from the right upper quadrant to the pelvis without invasion into adjacent viscera Fig . Chest XThe patient was operated for resection of the mass. Upon gaining access to the peritoneal cavity, a moderate amount of serosanguinous fluid was evident and collected for cytology. A "muscular" mass was immediately apparent and occupied most of the peritoneal cavity Fig . The masen block with the greater omentum and the adjacent sigmoid colon. The margins were sent for frozen section and came back as negative for malignancy. Cytology of the peritoneal fluid revealed reactive mesothelial cells.The mass was removed Final pathology showed a malignant gastrointestinal stromal tumor with smooth muscle differentiation and negative margins of resection. Based on the size of the neoplasm and necrosis present, in spite of few mitoses, this tumor was best viewed as a malignant or at least an aggressive extra-gastrointestinal stromal tumor Fig . Immunoset al., [The extra-gastrointestinal stromal tumors (EGIST) studied by Miettinen et al.,   have included omental, mesenteric, and retroperitoneal tumors. The cellular origin of GIST from the interstitial cell of Cajal (ICC) raises the question of whether these EGIST are truly an entity analogous to GISTs. It is not well known if extra-gastrointestinal stromal tumors (EGIST) originate from pacemaker cells outside of the GI tract or if mesenchymal cells have the ability to recapitulate the phenotype.et al. [et al., [et al., [Sakurai et al. , publishet al. . These f[et al.,  undersco[et al., . The mos[et al., ,13. Acco[et al.,  demonstret al. found a mitotic rate of >2/50 HPF, the presence of necrosis, and high cellularity to be useful in predicting biologic behavior in EGISTs, which tend to have an aggressive behavior similar to distal GI tract GISTs [Mitotic activity, cellularity and presence of necrosis have been found to be associated with worse outcomes. C-kit gene mutations were not found to correlate with prognosis in patients with EGISTs according to Yamamoto . A high ct GISTs .Of the omental EGISTs reported by Yamamoto, Sakurai, and Miettinen ,12,13  as adjuvant postoperative treatment in a 65-year-old female with a primary omental stromal tumor after R0 resection with a disease free follow-up at six months [We achieved an R0 resection in our patient, but given the size and presence of necrosis in the tumor adjuvant STI-571 was started. There is no prospective data supporting the use of STI-571 in an adjuvant or neoadjuvant therapy after curative resection of GIST or EGIST. Yamamoto erations . Todorokx months . The Amex months . There hThe existing data on EGIST is not sufficient to make a significant conclusion on the prognosis and survival of these patients, but certainly cellularity, mitosis and necrosis of the tumor appeared to be a prognostic factor . While aEGIST: Extra-gastrointestinal stromal tumor; GIST: Gastrointestinal stromal tumor.The authors declare that they have no competing interests.MC–S, SM, and MYA participated in the care of the patient. MC–S performed the literature review and drafted the manuscript. SM, BA, BG, AWT assisted in the review of the literature and in revising the manuscript. All authors read and approved the final manuscript.


We report a case of a 79 year old man with a known benign anastomotic stricture presenting with large bowel obstruction. At laparotomy the obstruction was found to be caused by a large sesame seed bezoar. Seed bezoars are well known to cause impaction in the rectum but have never been previously reported to cause large bowel obstruction. We recommend that patients with known large bowel strictures should be advised not to eat seeds as this could ultimately lead to obstruction, ischaemia or perforation. A bezoar is a mass of swallowed foreign indigestible material found within the gastrointestinal tract. They have been known to occur in animals and man for centuries. Classification depends on content – phytobezoars (plant fibres), trichobezoars (hair), and lactobezoars (milk curds). They may occur in combinations like trichophytobezoars, and can result from virtually anything capable of forming concretions within the gastrointestinal tract, including medications . They arA variety of bezoars have been reported to have caused small bowel obstruction – medication ,5, cottoA 79 year old man presented four years previously to the Urologists with recurrent urinary tract infections and pneumaturia. Cystoscopy revealed a colo-vesical fistula and he was subsequently referred to the colorectal surgeons. Barium enema demonstrated a stricture in the sigmoid colon and computerised tomography revealed an inflammatory mass in the sigmoid colon with communication into the bladder. He underwent a sigmoid colectomy, with histology showing diverticular disease. Two years later he developed colicky lower abdominal pain and a change in bowel frequency. Barium enema and subsequent sigmoidoscopy revealed an anastomotic stricture, with biopsies demonstrating benign disease Figure . The str2 4.0 kPa p02 9.1 kPa Base excess -13.4 mmol/L Lactate 3.7 mmol/L HCO3 12.6 mmol/L) and a high white cell count (WCC 23 × 109/L). Abdominal X-Ray (AXR), performed in the resuscitation room, demonstrated distension of the colon to the level of the rectosigmoid junction with a point of transition in this region , extensive small bowel adhesions and a dense fibrous pelvis. A subtotal colectomy and ileostomy was performed and on resection it was found that the stricture was patent with a good luminal diameter. The obstruction was found to have been caused by a large bezoar of sesame seeds which had impacted within and above the lumen of the stricture.The gentleman has made an uneventful recovery and on further questioning he recalls regularly eating nuts and seeds as part of his healthy diet.Seed bezoars in the rectum have been considered an uncommon cause of faecal impaction in adults. Sunflower seed impaction in the rectum has been frequently reported, with all cases requiring either manual disimpaction under general anaesthesia or endoscopic management for resolution of their symptoms ,11. One In our case, it is difficult to say where the seeds formed into a bezoar. The most likely sites would be in the small bowel or the caecum, from where it travelled and lodged at the anastomotic stricture.Here we have reported the first case of large bowel obstruction secondary to a bezoar. The learning point should be that patients with known large bowel strictures should be advised not to eat seeds as this could ultimately lead to obstruction, ischaemia or perforation.The author(s) declare that they have no competing interests.AS wrote the manuscript;ML performed the laparotomy with ASGT took over the care and follow up of the patientJL, OP, ML and WS reviewed the literatureAll authors, contributed intellectual content, have read and approved the final manuscriptConsent was obtained from the patient for publication of the study and the X-rays.


Infantile haemangioma is the commonest benign tumour in infancy. While the management of the majority of small haemangiomas consists of simply watching or steroid treatment, giant and moderate size infantile haemangiomas are challenging problems, especially in health systems with limited resources in developing countries.A one-year old boy was presented to us by his parents with a moderate size haemangioma on the posterior triangle of the left side of the neck. Clinical assessment and radiological examinations were helpful in confirming the diagnosis. Surgical excision was performed successfully without major morbidity. Partial necrosis of the skin flap developed shortly after the operation but healing was complete in eight weeks. There was no residual problem on review five years after the operation.Early surgical excision of a moderate size infantile haemangioma may be justified especially when there is difficulty of follow-up, which can be a common problem in developing countries. This approach will prevent growth deformation, impact on nearby vital organs and psychological problems. Infantile haemangioma (IH) is the commonest benign tumour of infancy . KnowledA one-year-old boy was presented by his parents to the outpatient clinic at Alburaihy Hospital in Taiz in Yemen in October 1999. The family described a progressive enlargement of a lump on the left side of the neck of an otherwise healthy infant.Examination confirmed a 7 × 10 cm vascular tumour at the posterior triangle of the neck on the left side, are the most important morbidities. Skin and soft tissue complications are less risky and can be managed successfully in the majority of cases. Skin necrosis was reported in our patient. This was anticipated because of the size of the lesion and the adherence of the skin to the hemangioma. It was managed by frequent dressings and outpatient assessment. No plastic procedure was performed because complete healing was ensured two months after the operation.Early surgical resection of infantile haemangiomas can be a successful management option, especially for giant lesions. This approach will prevent growth deformation, impact on nearby vital organs and psychological problems.Infantile haemangioma (IH); Ultrasound examination (US); Magnetic resonance imaging (MRI)The authors declare that they have no competing interests. The authors confirm that there are no financial competing interests and no non-financial competing interests that may cause embarrassment were they to become public after the publication of the manuscript.HA carried out the figures formatting, participated in the sequence alignment. HM participated in the sequence alignment. AH drafted the article and conceived the study, and participated in its design and coordination. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.