In general, ocular complications of hematologic malignancies such as leukemia are well documented. However, reports of ocular involvement in such diseases as lymphomatoid granulomatosis and chronic myelomonocytic leukemia are uncommon. Here we present cases of these two relatively rare hematologic malignancies demonstrating clinical and subclinical ocular involvement.In the first case, a 54-year-old man with a previous diagnosis of lymphomatoid granulomatosis presented with a new-onset conjunctival lesion while his systemic disease was thought to be in remission. A biopsy was taken that revealed heavy infiltrates of B and T cells at the site of the lesion. Molecular analysis confirmed that these cells were positive for both Epstein-Barr viral DNA and immunoglobulin heavy chain gene rearrangement, consistent with a manifestation of his systemic disease. In the second case, a 51-year-old man with chronic myelomonocytic leukemia died after a waxing and waning clinical course. Post-mortem studies revealed the presence of atypical monocytes in the choroidal and subretinal spaces, consistent with his previous diagnosis.While ocular involvement in hematologic malignancies is not uncommon, these two cases describe involvement of the eye by two relatively rare neoplasms. We herein emphasize novel findings in each case, including conjunctival involvement as the first sign of recurrent lymphomatoid granulomatosis and the combination of subretinal and choroidal myelomonocytic leukemic infiltration. With the evolution of new antineoplastic therapies that may prolong life, these cases exemplify the importance of eye care in patients diagnosed with hematologic malignancies. Ocular complications of hematologic malignancies such as leukemia are well documented. It is estimated that 50% or more of all leukemias manifest some form of ocular involvement ,2. Here IgH rearrangement, and the presence of EBV DNA by PCR analysis, the patient's underlying disease was considered as a potential cause. He received palliative radiotherapy to the orbit.A 54 year-old man with a previous diagnosis of lymphomatoid granulomatosis (LYG) presented with a left conjunctival growth consisting of clusters of papillae with focal hemorrhages of several weeks' duration Figure , during A 51 year-old man with chronic myelomonocytic leukemia developed progressively worsening anemia, thrombocytopenia, and leukocytosis and subsequently expired. Post-mortem gross examination of the eyes was significant for multiple fresh and old retinal hemorrhages bilaterally. Microscopic examination revealed numerous atypical leukocytes within the choroidal vasculature Figure  and bilaThe first case demonstrates a LYG metastatic lesion to the conjunctiva. First described as a distinct clinical entity in 1972, LYG is a rare, angiocentric, angiodestructive disease that is infrequently associated with ocular manifestations . Though It should be noted that although ocular manifestations in LYG are uncommon, case reports do exist that document involvement of structures including the optic nerve , retina,The second case involves a patient with chronic myelomonocytic leukemia (CMML), a disease formerly classified solely as a type of myelodysplastic syndrome (MDS) but reclassified in 1999 as a mixed MDS/myeloproliferative disorder .Myelodysplastic syndrome (MDS) is a term that refers to a heterogeneous group of clonal bone marrow disorders associated with changes in marrow cellularity accompanied by dysmyelopoiesis and peripheral blood cytopenias . Many caIn contrast to MDS, ocular involvement in patients with CMML is rarely reported, perhaps owing in part to the fact that the severe, progressive illness faced by many of these patients limits the feasibility of ocular examinations. While the patient described in the second case had no documented visual symptoms, pathology demonstrates infiltration of atypical cells within the vasculature of the choroid bilaterally as well as a subretinal hemorrhage with leukemic infiltration in the left eye. To our knowledge, this combination of findings in a patient with CMML has not been previously reported.We herein describe several microscopic ocular pathologic findings associated with two relatively rare hematologic malignancies. These cases emphasize both the ability of these diseases to demonstrate ocular involvement as well as important clinical and subclinical findings that may be seen with each. Furthermore, we emphasize the importance of an awareness of newly recognized manifestations of disease in cases such as these. In particular, the advent of novel antineoplastic therapies, with their associated potential to prolong life, may lead to the recognition of previously unobserved clinical signs. Our pathologic findings support that a routine eye examination, when possible, should be encouraged for patients with hematologic malignancies.The author(s) declare that they have no competing interests.JEH was involved in writing the manuscript and performing a review of the literature. DS performed the molecular analysis for both cases. MSM performed routine histology and immunohistochemistry for both cases. RJB was involved in the care of the patient in Case 1 and the review of the manuscript. CCC was involved in obtaining funding  as well as conception of the report and critical review of the manuscript. All authors read and approved the final manuscript.JEH was a fellow in the 2006–07 Clinical Research Training Program, a public-private partnership supported jointly by the NIH and Pfizer, Inc. .


To the best of our knowledge, this case report describes the longest disease-free interval between primary diagnosis and metastatic recurrence of an osteosarcoma.A 35-year-old Caucasian American man presented with asymptomatic lung metastases 21 years after being diagnosed and treated for lower extremity osteosarcoma. He underwent curative lung resection, but 2 years thereafter developed metastatic disease in the scapula and tibia and, after resection and chemotherapy, is in remission 1 year later.This case highlights the importance of long follow-up periods and continued surveillance of osteosarcoma patients after initial curative treatment. Osteosarcoma is the third most common cancer in adolescence, after lymphomas and brain tumors. One-third of patients who present with osteosarcoma will have recurrent disease. Within the recurrent disease group, 95% of relapses occur within the first 5 years, with the lung as the most common site of metastases. Reported relapses beyond 10 years are rare in the literature. We describe the case of a 35-year-old man who presented with lung metastasis 21 years after undergoing surgical resection and adjuvant chemotherapy for osteosarcoma of the femur. The patient underwent a curative resection. Histological studies described this calcified lesion as osteosarcoma, thereby confirming, to the best of our knowledge, the longest known disease-free interval to metastatic recurrence reported in the English literature. We discuss the relevant clinical knowledge regarding late relapse of osteosarcoma.At the age of 14, the patient was diagnosed with osteosarcoma of the left femur. He received neoadjuvant chemotherapy consisting of doxorubicin and cisplatin, and underwent above-the-knee amputation of his left leg. Adjuvant chemotherapy included doxorubicin, methotrexate and vincristine.Twenty-one years after his initial osteosarcoma resection, the patient presented with cellulitis of his left thigh, which was treated successfully. During his hospital stay, a chest X-ray revealed a mass in the infrahilar area of the patient's right thorax Figure . A compuThe patient underwent curative resection, and pathology of the right middle and lower lung lobes revealed osteosarcoma with extensive chondroblastic differentiation Figure  and 3b. Osteosarcoma is the most common primary malignancy of the bone, with a peak incidence in the second decade and an additional peak of incidence in elderly individuals . Historiet al., which describes local recurrence 20 years after surgery [Late recurrence is usually described as occurring more than 5 years after primary osteosarcoma treatment. However, the recorded cases with the longest time spans before recurrence are all of local recurrence, such as the report by Lau  surgery . The Riz surgery .In 2004, Strauss and colleagues published an article describing eight patients seen at the London Bone and Soft tissue Tumor Service who had relapsed after long disease-free intervals . The artThe most recent study on late recurrence comes from the Rizzoli Institute in 2006 and included 648 patients with non-metastatic osteosarcoma to determine predictive factors for late recurrence [Our patient was initially treated for osteosarcoma with surgical resection and chemotherapy, and presented 21 years later with a single metastasis to the right lung. Osteosarcomas are the least likely bone tumors to relapse late, making this case even more unusual. This case represents the longest disease-free interval to metastatic recurrence in the English literature, and underscores the need for continued surveillance of osteosarcoma patients.The authors declare that they have no competing interests.SG performed the histologic examination of the pathology specimens and was a major contributor in writing the manuscript. SB, SM and AH contributed significantly to the concept, design and writing of 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 any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


We add a new rare illustrative case of osteosarcoma of the larynx to the literature.The patient  first underwent several biopsies, followed in the end by a total laryngectomy. Diagnosis was histological. The patient developed regional and distant metastases and died of disease after 3 months from surgery.Osteosarcoma of the larynx is a rare and aggressive tumour with a poor long-term prognosis. The preferred treatment for this tumour is aggressive surgery.To perform a diagnosis we must be in presence of osteoid or of neoplastic osseous tissue directly produced by the neoplastic cells. Osteosarcoma is a rare larynx tumor -9. From A 56 years old Caucasian man, butcher, weight 176 lbs, Height 6', came to our department after he had been suffering from acute dyspnea, dysphagia and dysphonia for 4 months. He did not smoke nor did he use to drink alcohol. He had hypertension, some months before he had undergone an angioplasty and a substitution of a cardiac valve.A physical examination performed by fiberoptic laryngoscopy revealed a diffused larynx oedema with reduction of glottic space and vocal cord mobility. No palpable laterocervical lymph nodes were observed. The first procedure to be performed was a tracheostomy to reduce the stridor. At the same time some biopsies were performed via direct laryngoscopy. The first biopsy revealed a mesenchymal neoplasia with spindle cells, showing slight atypias and low mitotic rate and which were negative to immuno-istochemical staining with S100, actin, and CK, with focal positivity on p53 and immersed in a myxoid stroma.Tumuor staging by means of total body CT scanning with contrast revealed a tumour mass affecting glottic and supraglottic larynx, which also affected the thyroid and circoid cartilages and extended to the paralaryngeal space Fig. . No regiFinally we got an informed consent for a total laryngectomy. Intraoperative frozen sections revealed a malignant mesenchymal neoplasm. The final diagnosis based on the permanent sections was osteosarcoma of the larynx Fig. .2 for 3 days i.v. – Farmorubicina 50 mg/m2 for a day) but the patient developed distant metastases to the lungs and died of disease after 3 months.We administer adjuvant therapy (Isofosfamide 3 mg/mOsteosarcoma of the larynx is a very rare and aggressive tumor because of hematogenous spreading, and as it is difficult to be diagnosed . Only feLocal recurrence occurred after an average time of 9.5 months ,3. AveraWe administer adjuvant therapy also if literature data are controversial and not reliable ,3,7. In The diagnosis of this tumour is very difficult because of the involvement of the submucosa. This is the reason why several biopsies performed via microlaryngoscopy are unreliable to stage the lesion.After total laryngectomy the back face of the larynx appears macrosopically evenly deformed by the presence of the tumor mass, superficially covered by pink mucosa, solid to cut, of hard-elastic consistency with calcific areas, of white-yellowish colour and with brownish foci.Histologically the tumour appears to be mostly build of spindle cells, which show the setting of bundles. The cells show plump, hyperchromatic and atypical nuclei with an increase in the mitotic index. A well differentiated chondroblastic neoplastic component is also present, with slight cytologic atypias represented by areas with binucleated cartilaginous cells, with many cells per laguna, and with focal areas of ossification and deposition of osteoid matter. The presence of osteoid tissue and neoplastic osteoid tissue, not connected with cartilaginous tissue, made diagnosis possible Fig. .Osteosarcoma of the larynx is a rare aggressive tumor that affects predominantly men -9. AnamnThe authors declare that they have no competing interests.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.GM and MC analyzed and interpreted patient's data; AMC, BA and GF performed the histological examination; GP, FV got literature dates; MI performed surgery. All authors read and approved the final manuscript.


Primary Hodgkin's disease of the nasopharynx is a rare and uncommon event. It has a relatively favorable prognosis and represents less than 1% of all documented cases of Hodgkin's disease.A 40-year-old Arabic man presented initially with bilateral nasal obstruction, which was then followed by a significant involvement of his bilateral cervical lymph nodes. His nasopharyngeal biopsy together with immunohistochemistry analysis showed negative expressions of CD15, CD20 and CD3, but positive expressions of CD30 and epithelial membrane antigen. This confirmed the diagnosis of nasopharyngeal Hodgkin's disease of a mixed cellularity subtype. The disease was at stage IIEA. Our patient received four cycles of chemotherapy, which yielded a 75% response. This was followed by irradiation of his Waldeyer's ring and supraclavicular lymph nodes. He remains in good local control after 30 months of follow-up.The literature review and our case report discuss the optimal management of this rare and atypical localization of Hodgkin's disease, which should be differentiated from lymphoproliferations associated with Epstein-Barr virus and non-Hodgkin's lymphoma. The lymphoid tissues of Waldeyer's ring, including the nasopharynx, are rarely involved in Hodgkin's disease (HD). Primary nasopharyngeal presentation is extremely rare, occurring in less than 1% of all reported cases of HD. With appropriate treatment the prognosis for this particular type of HD is favorable. Most documented cases of HD are either stage I or II.We present the case of a patient with primary nasopharyngeal HD which was managed by a combination of sequential chemotherapy and radiotherapy. This treatment yielded optimal local control after 30 months of follow-up.We reviewed the literature and considered questions about the rarity of this case, the optimal management of its atypical localization, and the need for immunohistochemistry (IHC) analysis in differentiating HD from non-Hodgkin's lymphoma (NHL) and lymphoproliferations associated with Epstein-Barr virus (EBV).In October 2005, a 40-year-old Arabic man with a long history of smoking presented at the National Institute of Oncology for a consultation. Over a period of one year, he had developed progressive bilateral nasal obstruction with a secondary cervical left mass that was associated with headaches and hypoacusis. No fever, pruritus, sweat or weight loss was noted. His full blood count, biochemical tests and erythrocyte sedimentation rate were all normal. A clinical examination of our patient found his cervical left lymph nodes measured 8 × 5 cm and right submaxillary lymph nodes measured 5 × 4 cm.A computed tomography (CT) scan of his nasopharynx and nasofibroscopy revealed a posterolateral nasopharyngeal mass and bilateral cervical lymph nodes Figures  and 2. AThe results of his bone marrow biopsy, and chest, abdomen and pelvic CT scans were all normal. His disease was staged at IIEA according to the Ann Arbor classification system.Our patient was then treated using four cycles of chemotherapy every three weeks with an alternating regimen of cyclophosphamide, Oncovin (vincristine), prednisolone (COP) and Adriamycin (doxorubicin), bleomycin, vinblastine (ABV) . His radiological evaluation after the fourth cycle showed a complete resolution of the nasopharyngeal mass and a 75% response in his cervical nodes Figure . The treWe report the rare case of a patient with primary nasopharyngeal HD which was successfully managed by a sequential combination of chemotherapy and radiotherapy.Hodgkin's disease localized in the head and neck regions is mostly seen in the nodal tissues. Extranodal involvement is rarely reported. According to Eavey and Goodman, only two cases of nasopharyngeal HD have been identified in a study of 500 cases of HD localized in the head and neck regions .et al. reported only seven cases (0.32%) of nasopharyngeal HD in a large retrospective study involving 2150 cases of HD documented over a period of 24 years [Primary nasopharyngeal presentation is exceptional in HD cases, as it occurs in less than 1% of all reported HD localizations. In another case report, Anselmo cases 0.3% of nasoCompared with HD, NHLs are more frequently localized in the head and neck regions. A retrospective review of 311 head and neck lymphomas reported only three cases 4%) of HD whereas NHL cases were 24% of the total % of HD w  is the appropriate standard regimen; and involved field radiotherapy with target volume given as an intermediate dosage (25 to 40 Gy) targeting the Waldeyer's ring and cervical lymph nodes should be the first line of treatment for patients with nasopharyngeal HD. Furthermore, exclusive irradiation should be proposed for isolated cases of nasopharyngeal HD that do not involve the cervical lymph nodes and do not present with general symptoms.From data gathered through our case and literature review, we conclude that nasopharyngeal HD is an atypical and rare localization. The majority of cases reported are localized at stage I or II; our patient was diagnosed at stage IIEA.The optimal management of primary nasopharyngeal HD is still unclear. Its treatment, first with chemotherapy followed by involved field irradiation, appears to be an adapted therapy, especially when cervical lymph nodes are involved. This combined treatment is associated with the long-term cessation of the disease.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.YB was the principal physician who managed our patient, performed the literature research, and wrote the manuscript. KEH helped write the manuscript and performed the literature review. NI helped write the manuscript and analyzed the final results of our patient's examinations. IL helped with modifications and revisions to the manuscript, also in the final conception of the article, principally in the redaction of the manuscript. SB managed our patient's chemotherapy cycles and analyzed the literature. NB performed and approved the radiotherapy part of our patient's treatment. BKEG analyzed and interpreted our patient's data for the radiotherapy section of the manuscript. HE approved the treatment and analyzed the literature data. All authors read and approved the final manuscript.


Fibrous histiocytoma is a benign soft tissue tumour arising as a fibrous mass everywhere in the human body. The involvement of the oral cavity is rare. We report two cases of benign fibrous histiocytoma that localized in the oral cavity. The clinical and histological features of the lesion are reported. Finally, a literature revision of this pathology at the level of the oral cavity is reported. The term malignant fibrous histiocytoma (MFH) describes a soft tissue sarcoma arising from histiocytes and fibroblasts and many synonyms have been used with regard to potential malignancy -4. The cNowadays, BFH is included in the so-called "fibrohistiocytic tumours of the soft tissues" that are divided into cutaneous and non-cutaneous types, and in the "fibrohistiocytic tumours of the bone" -6. BFH iIn October 1998, a healthy 44-year-old male  was referred to our department of oral surgery for evaluation and treatment of a tumour involving the lingual mucosa of the left mandible in the premolar area. Intra-oral examination disclosed a nodular and sessil mass 3.0 cm in diameter; the overlying mucosa appeared normoemich, normotrophic and not haemorrhaging. No lymph nodes were palpable. There were no other abnormalities in the oral cavity and the systemic conditions of the patients were good. On palpation the lesion was not painful and of fibro-elastic consistency. The clinical appearance of the lesion suggested the possibility of a neoplasm of soft tissues. The treatment of choice was radical excision of the tumour with 2-mm free margins Figure  and negaIn January 1999, a healthy 34-year-old male  was referred to our department because of a slow-growing tumour in the mucosa located in the right side of the tongue Figure  and CD68In both cases treated, it was obtained clinical resolution and without side-effects or complications. Both patients are disease-free after 10-year follow-up.The mandibular and lingual sites are rare localizations for BFH. Among the lesions we observed, the one in the tongue was the biggest and the more defined. The most difficult site for surgery was that on the mandibular mucosa, because of the presence of the lingual nerve. Radical excision with wide margins was the treatment of choice. The aetiology of oral BFH is obscure. Chronic irritation, continuous trauma and spontaneous development have been reported for those located within the oral cavity ,4,13-16.The clinical diagnosis of oral BFH should shell out by clinical features as slowly enlarging, well-circumscribed lesion, no aggressive behaviour with overlying intact mucosa; however, at clinical level, the differential diagnosis with other soft tissue neoplasms is not possible. Histological examination as rare mitosis, absence of cellular atypia and immunochemistry patterns as high positivity for vimentin, CD38, factor XIIIa ,4,6. TheThe prognosis of oral BFH is very good. Metastases haven't been reported. Local recurrence is present when the excision is incomplete. Indeed, for the BFH of the buccal mucosa it's necessary that the specimen has wide margins; the simple enucleation of the tumour from the surrounding tissue may facilitate local recurrences ,6,10-12.Written informed consent was obtained from the patient for publication of these two cases and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DM, LL and SS performed the surgical procedures and contributed to the analysis of the clinical data. AM and GC performed the histological examination of the lesion. AB performed the histological examination of the lesion and was a major contributor in writing the manuscript together with DM. All authors read and approved the final manuscript.


Ureteroiliac fistulas are rare but potentially life-threatening. Risk factors to develop a fistula are chronic indwelling ureteral stents, previous pelvic surgery and radiotherapy.We report a case of a patient with intermittent gross hematuria after previous abdominal surgery, radiotherapy and indwelling ureteric stents. After several diagnostic and therapeutic procedures an ureteroiliac fistula could be finally identified and treated by endovascular stenting.Ureteroiliac fistula should be considered in any patient with intermittent gross hematuria and any of the known risk factors. Ureteroiliac fistulas (UIFs) are uncommon and experience has been limited to case reports. However, the reported incidence has increased in the last years . PredispWe report diagnosis and treatment of an UIF, and review the literature.A 64-year-old Caucasian man from Austria was referred to the urological department because of episodes of intermittent gross hematuria. The patient had a colorectal carcinoma treated by rectum and ileum segment resection, chemotherapy and radiotherapy four years before. After radiotherapy ureteric strictures developed on both sides and ureteric stents were placed. At the time of admission the urine specimen showed few white and red blood cells and the urine culture was sterile. During the change of the ureteric stents a retrograde pyelography and cystoscopy were performed, showing a mild gross hematuria coming out of the right ureteric orifice but no further pathological findings. After the stent change, first the hematuria cleared but one day later again an episode of gross hematuria with blood clots in the bladder occurred. A transurethral catheter was placed and a multiphase CT of abdomen and pelvis was performed. CT detected no source of bleeding. The gross hematuria cleared again and an ureteroscopy on both ureteric sides were performed with special emphasis on the right ureter. Once again nothing suspicious could be found. Thereafter gross hematuria appeared again with massive hemorrhage and an arteriography was performed . But oncUIFs are rare but potentially life-threatening causes of hematuria . The exaAlso the pathophysiology behind the fistula development is still uncertain . It is bThe major problem is that fistula diagnosis is often delayed because of the intermittent nature of the condition and the difficulty in confirming fistulous communication . MassiveCystoscopy and retrograde pyelography were once thought to have the greatest sensitivity in diagnosis (between 45% and 60%) [Ureteroscopy is also not recommended because it can tear the fistula, leading to massive hemorrhage . Also thThe sensitivity of standard arteriography is between 23% and 41% for detecting UIFs. In single series provocative arteriography increased the sensitivity to even 100% [For the treatment of UIF different options are available . The vasIn summary UIFs are increasing due to chronic indwelling ureteral stents, pelvic surgery and radiotherapy. We presented a case in which even nephrectomy had been performed due to the massive hematuria. Increased awareness of UIF should prompt both diagnosis and treatment and can further decrease morbidity and mortality.


To the best of our knowledge there is no reported case of Meckel’s diverticulum (MD) in Cameroon. The prevalence of MD in the general population is 2–3 %. The aim of this paper is to recapitulate the role of this pathology in acute abdomens and abdominal pain of uncertain aetiology in young patients and to review the medical literature. Meckel’s diverticulum is considered as one of the most common gastrointestinal malformation with a prevalence rate of 2–3% , 2. AlthTJ a 26-year-old male was brought to the emergency department of the University hospital Center of Yaoundé (Cameroon) for acute diffuse abdominal pain of increasing intensity that started two days earlier. He had vomited and had not passed stool or flatulus for several days. On physical examination he looked very ill and had a temperature of 38.9º C. The blood pressure was 100/40 mmHg, pulse 78 pulsations per minute and the respiratory rate was 16 breaths per minute. The abdomen was slightly distended and moved with breathing. There was diffuse tenderness, no abdominal rigidity and rectal examination was painful with no blood on the glove. The hernia orifices were clear of any mass. An x-ray, ultrasound of the abdomen and the biological work-up with full blood count, coagulation profile were ordered. A nasal-gastric tube and a urinary catheter were inserted and an IV line set up for hydration with Ringer’s lactate solution.3 and 15.6g/dl respectively. Our diagnosis was non-specific intestinal obstruction.The x-ray revealed distended small bowels with air-fluid levels . UltrasWe decided to do an exploratory laparatomy. The findings were a volvulus of the small bowel with a gangrenous portion strangulating the normal looking loops. Upon relieving, we found an out-pouch of the intestine at the summit located about 100cm from the ileo-colic junction, compatible with Meckel’s diverticulum .The treatment was a resection and an end-to-end anastomosis. The convalescence was uneventful. We did not send the specimen to the pathologist due to the gangrenous nature of the diverticulum.Although well known before Meckel’s birth in 1781; the persistence of the omphalo-mesenteric duct can give rise to a large spectrum of diseases ranging from the diverticulum of the intestine or the vitelline cyst to the umbilical sinus . Meckel,From the review of literature and analysis of the above case, the surgeon must always bear in mind the possibility that Meckel’s diverticulum may be the aetiological factor in any acute abdominal emergency, especially when specific diagnosis is difficult. One forty abdominal emergencies may be a MD. A late diagnosis may reflect a long history of abdominal suffering calling for increased pediatric attention.


The metastases to the TMJ from a primary lung tumour is a very rare occurrence.This case is unusual in several aspects, as the non-reducible dislocation of the TMJ was the first clinical manifestation of the tumour. CT staging showed that this secondary tumour in the condyle was the only bone metastasis. Metastases involving the TMJ are rare, and only 40 cases have been reported in the international literature . The priThe patient, a 60-year-old male, underwent extraction of the lower first right molar. From that moment he suffered from right TMJ pain. At first his symptoms were associated to the intervention. Following this episode, the patient reported limitation of mandibular movements, with reduced mouth opening, inability to perform lateral movements, right crossbite and edge-to-edge occlusion. The oral examination revealed Class III malocclusion and left mandibular deviation. Fig.  On palpaAn orthopanoramic X-ray showed dislocation of the right condyle.After unsuccessful attempts to reduce the dislocation on an outpatient basis, it was decided to perform manual reduction under general anaesthesia, without positive result. Consequently an open reduction under general anaesthesia was performed.During routine preoperative exams, the chest X-ray showed an opaque area with microcalcifications. Given the high level of significance of the temporomandibular symptoms and the fact that the patient's cardiorespiratory parameters and blood tests were normal, after consulting with pulmonologists we decided to perform surgery on the condylar area and to postpone diagnosis and treatment decisions involving the lung until immediately after surgeryThe joint capsule was accessed through a pretragal incision, observing that the condyle was displaced past the eminence. An unsuccessful attempt was made to perform bimanual reduction. It was finally observed that there was a mass that completely occupied the intra-articular space. The tumour was thus circumscribed and resected, after which the dislocation was successfully reduced manually; Deutrey's procedure was then performed to constrict the condyle. Fig. The histological examination showed that the lesion was malignant and had metastasised from a primary lung tumour. Fig. A post-operatory chest X-ray appeared within the normal range, and only a post-operatory spiral CT scan succeeded in identifying the primary tumour The patient was referred to the pulmonary and oncology departments. Based on bronchoscopy and biopsy results, pulmonary adenocarcinoma was diagnosed. Given the presence of distant metastases, the patient was classified as Stage IV (TNM) . HoweverTumours of the TMJ – both benign and malignant – are rare but difficult to diagnose . In viewThis case is particularly interesting because it not only involves an uncommon secondary site, but onset was extremely atypical, as the clinical manifestation of bone metastasis preceded that of the primary carcinoma. What is even more significant is that the nature of the tumour involved was a non-small-cell carcinoma.The mandible and thus the condyle are unusual sites for metastases. Metastases to the entire maxillomandibular complex represent just 1% of metastatic cancers and 1% of all tumours in this area . MetastaTherefore, the case described here is a very significant example of the diagnostic challenges that TMJ lesions can represent. The authors underline the need to include condylar tumours in the differential diagnosis when the symptoms do not respond to treatment. A CT or MRI scan of the TMJ should be part of the diagnostic procedure.The case presented is the first example in literature of the clinical onset of lung cancer with a non-reducible dislocation of the temporomandibular joint.The authors declare that they have no competing interests.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.All the authors were involved in examination of the patient as well as in writing and reviewing the manuscript.


Primary tumors of the appendix are unusual and most of them are carcinoids. Their main presentation is that of an acute appendicitis or as a palpable mass, mainly in the right lower quadrant.A female patient with mucous adenocarcinoma of the appendix, which primarily presented as atypical abdominal pain. Diagnosis of the disease was made after appendicectomy and histopathological analysis of the specimen. The patient finally underwent a complementary right hemicolectomy.Mucin producing adenocarcinomas of the appendix are a category of rare cancers of the gastrointestinal tract. Although at present they are a well studied pathologic entity, the crucial issue of their preoperative diagnosis remains unsolved. Primary tumors of the appendix are unusual and most of them  are carcinoids . AdenocaThe main presentation of these tumors is that of an acute appendicitis 30%-50%) or as a palpable mass mainly in the right lower quadrant 0%-50% or. Neverth3 , Hb:13,3 g/dl, Hct:40% and normal coagulation values. The patient was hospitalized for further investigation and underwent medical treatment for 6 days. Ultrasonography of the lesser pelvis showed a small quantity of free liquid located in the Douglas area and the right parametrium. Computed tomography of the pelvis reported normal internal organs  and the patient was relegated for gynaecological evaluation after the initial clinical symptoms were minimized. One month later the patient presented again with the same abdominal pain. The diagnosis of acute appendicitis was set and the patient underwent an open laparotomy on a Mac Burney section. During the operation a dense and diffuse myxomatous collection was found around the appendix. Appendicectomy took place as well as thorough cleaning of the peritoneal cavity. Histological examination of the specimen revealed a mucous adenocarcinoma of the appendix [Fig 3N0M0) on Duke's staging system (Astler Coller modification)[A Caucasian 64-year old female Greek patient presented with hypogastric and right lower quadrant abdominal pain, which started 24 hours before, without other pathological findings in the clinical examination. Laboratory tests on admission showed: WBC: 7.200/mmA retrograde study was performed concerning the appendicectomies that took place in General Hospital Sismanogleio over a ten year period between 1998 - 2008. A total of 2148 appendicectomies was performed . Eleven (12) cases of primary appendiceal neoplasms were identified , eight (8) of them being mucin-producing entities. Only one was positively identified as a mucous adenocarcinomas and right hemicolectomy with synchronous oophorectomy was performed as treatment of choice. Four (4) tumors of endocrine origin were recognized  three (3) of them being benign carcinoids and one of uncertain classification. For this last case, right hemicolectomy was performed and diagnosis of the tumoral character was set after proper laboratory analysis. Carcinoids of the appendix are of low malignancy  compared to those developing in other organs and simple appendicectomy is sufficiently curative when their size is not over 1,5 cm. They rarely reach sizes over 2 cm and in this case they are considered to be malignant and right hemicolectomy is indicated . ConcernPositive diagnosis for these tumors is generally set after their histologic identification; nevertheless criteria should be set for preoperative recognition, in order to perform the treatment of choice in the first place. Among imaging methods CT scan offers 95% sensitivity for carcinomas of the appendix. As reported in related studies of preoperative CT sections in patients diagnosed with appendiceal cancer, morphological changes and alterations in the dimensions of the appendix can guide the diagnosis. 100% of cases had evidence of altered morphology of the appendix and increased dimensions .Moreover, the presence of a cystic mass may suggest the presence of cystadenoma or cystadenocarcinoma. NeverthMucin producing adenocarcinomas of the appendix are a category of rare cancers of the gastrointestinal tract. Although at present they are a well studied pathologic entity, the crucial issue of their preoperative diagnosis remains unsolved.PMP: pseudomyxoma peritonei; WBC: white blood cells; Hb: Hemoglobin; Hct: hematocrit; CT: computed tomography; TNM: Classification of Malignant Tumours .Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.KA, NS, GA have had an equally substantial contribution to the clinical diagnosis, surgical management and post-op follow-up of the patient. MD and AK performed the histological examination KA, NS and MD performed the retrograde study, SCM and VT drafted the manuscript. NS and GA are guarantors of the paper. All authors read and approved the final manuscript.


Primary cardiac neoplasms occur rarely and most of them are benign. Malignant tumors including angiosarcoma are extremely rare and have a non specific clinical presentation and a poor prognosis.We present a case of a young male who was transferred to our hospital because of shock and multiple organ failure after a complicated pericardial biopsy. During the previous seven months he presented with recurrent episodes of pericardial effusions and tamponade. Chest computed tomography revealed a mass in the right atrium, infiltrating the myocardium and pericardium. During emergency surgery that followed, the patient died because of uncontrolled hemorrhage. Autopsy revealed the mass of the right atrium, which was identified on histological examination as primary cardiac angiosarcoma.This case highlights the difficulties both in early diagnosis and in the management of patients with cardiac angiosarcoma. Primary tumors of the heart are extremely rare and the majority of them are benign -7. AngioA 29-year-old male patient was transferred to our Intensive Care Unit (ICU) from another hospital, because of shock and multiple organ failure after a complicated pericardial biopsy. Seven months before, after a syncopal episode, he had been diagnosed with cardiac tamponade diagnosed by a transthoracic echocardiogram (TEE). Subxiphoidal drainage of 700 ml hemorrhagic fluid was performed resulting in hemodynamic stabilization. Cytologic examination of the fluid was negative for malignancy. Pericarditis was diagnosed caused by chlamydia; azithromycin and anti-inflammatory drugs were administered. For the next four months the patient was relatively well except for complain of easy fatigue. From that point on, he gradually presented dyspnea on exertion, along with pain in the back and spinal column. He also had two syncopal episodes. A new TTE showed recurrence of the pericardial effusion. Chest computed tomography (CT) scan disclosed a confluent mass of the heart with myocardial and pericardial infiltration. Thoracotomy and biopsy was then decided. Trauma of the cardiac cavity occurred intraoperatively, followed by hypovolemic shock and two episodes of cardiac arrest. Subsequently, he was transferred to our tertiary hospital for further cardiosurgical treatment.On admission, the patient was mechanically ventilated, hemodynamically unstable requiring vasoactive drugs, with a temperature of 39°C. Main abnormal laboratory findings were: serum glutamic oxaloacetic transaminase (SGOT) 555 U/l, glutamic pyruvic transaminase (SGPT) 800 U/l, bilirubin 25 mg/dl, creatinine 7 mg/dl, urea 330 mg/dl, aPTT 140 sec, and INR 3.4. A continuous veno-venous hemofiltration was immediately started. Right catheterization revealed equalization of diastolic pressures. Chest CT scan revealed an irregular heterogenous mass of the right atrium with ill defined margins, infiltrating the myocardium and pericardium on the outer wall of the atrium, the inter-atricular septum, and also a pericardial effusion , can precisely locate the tumor, define its extent, and may accurately predict tumor type ,7. Some CT and MRI have excellent diagnostic advantages with regard to tumor delineation and spread . More spThe main treatment strategy in cardiac angiosarcoma is surgical resection with or without chemotherapy and radiation. However, regardless of treatment, prognosis is poor with survival ranging from 6 to 12 months. Novel approaches, such as the use of interleukin-2, have been reported to be effective. In a case of cardiac angiosarcoma treated with a combination of chemotherapy and immunotherapy, survival of 30 months after surgery has been reported .Given the rarity of this fatal condition and the lack of a specific clinical presentation, the diagnosis of cardiac angiosarcoma requires a high degree of suspicion. Early diagnosis may facilitate the management of these patients.The author(s) declare that they have no competing interests.MK, JF and CR were involved with the patient's management. CC was the patient's surgeon and helped write the manuscript. DE provided the CT scan illustrations and reviewed the manuscript. DR carried out histopathological analyses. MK and CR wrote and prepared the manuscript. All authors have read and approved the final manuscript.


Lipomas are the most common benign soft tissue tumors and appear in any part of the body. They typically consist of mature adipose tissue. Osteolipoma is an extremely rare histologic variant of lipoma that contains mature lamellar bone within the tumor and osteolipoma independent of bone tissue are very rare. We report a case of histologically confirmed osteolipoma independent of bone located in the thigh.A 47-year-old male presented with a progressively enlarging, painful mass which approximately 10 cm × 8 cm over the anteromedial aspect of his right thigh. Plain films, Computerized Tomography, Magnetic Resonance Imaging and ultrasound guided needle biopsy were performed. Given the benign imaging characteristics and fine needle aspiration, an excisional biopsy was undertaken. The definitive pathologic diagnosis was intramuscular osteolipoma without evidence of malignancy. No recurrence was observed after 18 months follow up.Although ossifying lipomas are very rare, it is important to keep them in mind when a lesion with adipose tissue in combination with ossification is encountered. Lipomas are the most common benign soft-tissue tumors composed of only mature adipose cells without cellular atypia . HoweverSolitary lipomas are frequent, especially among adults. They can appear in any location of the body, but are usually found in the subcutaneous regions . Lipoma A 47-year old, Caucasian Turkish man presented with a progressively enlarging, painful mass over his right inguinal region which he first noticed 6 months ago. On physical examination, he had an athletic body habitus and a normal gait. He has exercised regularly for the past 27 years. A general physical examination was normal except for a firm, mobile and tender mass approximately 10 × 8 cm over the antero-medial aspect of his right thigh. It has increased slightly since its discovery. Hip and knee movements were in normal range. There were no lymph nodes palpable in the groin. No neurovascular abnormalities were found.Plain films revealed dispersed soft tissue calcifications close to the medial proximal thigh . ComputeThe pre-operative differential diagnosis was primarily a lipoma with tumoral calcinosis or an osteochondroma.After initial imaging, ultrasound guided needle biopsy was performed revealing only benign mature fat cells and evaluated as non-diagnostic. Given the benign imaging characteristics and fine needle aspiration, an excisional biopsy was undertaken. During the operation, the tumour was found to be located in the quadriceps. At the base of the tumour a pedicle with several blood vessels was attached. Neither the tumour nor its pedicle showed any connection to bony structures. It was removed surgically by blunt dissection and the pedicle was tied and excised. We performed a multi-layered closure and the postoperative course was uneventful.Grossly, the resected specimen consisted of a mass measuring 10 × 8 × 7 cm, with a smooth surface. Cut sections of the mass revealed mainly yellow soft tissue with numerous interlacing thin lamellar bony structures and surrounded with a thin fibrous capsule.Histological examination revealed that the tumour consisted largely of mature adipose tissue with surrounded by a thin layer vascularized fibrous tissue. A haphazardly distributed and interlacing thin vital lamellar bone structures were found throughout the tumour. In some areas, these bony structures were alongside the thin fibrous tissue with myxoid degeneration. No myeloid cell islands were determined. The adipocytes were uniform in size and shape. No nuclear atypia, hypercellularity, mitosis nor necrosis was seen . The defOsteolipoma have been reported in adult patients usually after long indolent courses. These tumors have origin from the deep soft tissue as well as from the subcutaneous plane. Osteolipoma are well encapsulated and have a sharp transition between bone and adipose tissue -20.Many cases of lipomatous lesions with osseos tissue have been reported in the literature. Most of them connected with bone (inside a bone or adjacent to bone) ,6,9. TheThe pathogenesis of osteolipoma is still not clear. Two main theories of the pathogenesis of ossifying lipomas exist. First these tumors may originate directly from multipotent mesenchymal cells since osteolipoma resembles a benign mesenchymoma ,20. AlteImaging features of osteolipoma are often pathognomonic but depend on the location of the lesion. Plain film X-rays are obtained first and yield a differential diagnosis of osteochondroma, lipoma with tumoral calcinosis, and myositis ossificans . On CompA differential diagnosis suggesting osteolipoma primarily depends on its location. Because of the various anatomic sites reported for this lesion, a very wide range of lesions can be included in the differential diagnosis, such as other benign tumors that may contain bone including teratoma or dermoid . In addiAngiolipoma, osteolipoma, and leiomyolipoma are benign processes but are often hard to differentiate from low grade liposarcoma on imaging alone, thus we recommend Computerized Tomography guided biopsy. Ultrasound fine needle aspiration is less useful given the solid nature of these tumors. If imaging is more suggestive of osteolipoma, serial magnetic resonance imaging studies are recommended so that a low grade liposarcoma is not ignored.Definitive diagnosis of osteolipoma can easily be done with histopathologic examination. A histopathologic appearance of diffuse, mature ossification within fatty tissue clinches the diagnosis . The adiIn conclusion, osteolipoma with independent bone is very rare. It has a characteristic radiological and pathological appearance. Osteolipoma has a same prognosis as simple lipoma and surgical excision is the recommended treatment. No recurrences have been reported.Although ossifying lipomas are very rare, it is important to keep them in mind when a lesion with adipose tissue in combination with ossification is encountered.


We report three cases of demyelinating disease with tumor-like presentation. This information is particularly important to both neurosurgeons and neurologists who should be aware that inflammatory demyelinating diseases can present as a mass lesion, which is indistinguishable from a tumor, both clinically and radiologically, especially when there is no evidence of temporal dissemination of this disease.The first patient was a 42-year-old Malay woman who developed subacute onset of progressive quadriparesis with urinary incontinence. Magnetic resonance imaging of her spine showed an intramedullary lesion at the C5-C7 level. She was operated on and biopsy was suggestive of a demyelinating disease. Retrospective history discovered two episodes of acute onset of neurological deficits with partial recovery and magnetic resonance imaging of her brain revealed demyelinating plaques in the centrum semiovale.The second patient was a 16-year-old Malay boy who presented with symptoms of raised intracranial pressure. A computed tomography brain scan revealed obstructive hydrocephalus with a lesion adjacent to the fourth ventricle. An external ventricular drainage was inserted. Subsequently, a stereotactic biopsy was taken and histopathology was reported as demyelination. Retrospective history revealed similar episodes with full recovery in between episodes.The third case was a 28-year-old Malay man who presented with acute bilateral visual loss and confusion. Magnetic resonance imaging of his brain showed a large mass lesion in the right temporoparietal region. Biopsy was consistent with demyelinating disease. Reexamination of the patient revealed bilateral papillitis and not papilledema. Visual evoked potential was prolonged bilaterally. In all three cases, lumbar puncture for cerebrospinal fluid study was not carried out due to lack of patient consent.These cases illustrate the importance of considering a demyelinating disease in the differential diagnosis of a mass lesion. Critical analyses of clinical presentations coupled with good physical examination are vital in assisting clinicians to reach the correct diagnosis. Inflammatory demyelinating diseases can present as a mass lesion, which is indistinguishable from a tumor, both clinically and radiologically, especially when there is no evidence of temporal dissemination of this disease, posing a challenge to the clinician . In counA 42-year-old Malay woman was referred to us for the surgical management of an intramedullary tumor of the spinal cord in July 2002. Her symptoms started in April 2002 as subacute onset progressive quadriparesis and by the time of admission, she had developed urinary incontinence and had become bedridden. A magnetic resonance imaging (MRI) scan of the spine was reported to show an intramedullary tumor at the C1-C5 level , bilateral pyramidal tract signs (more prominent on the right side) and cerebellar signs. Autoimmune antibodies and serology screening for HIV, syphilis and hepatitis B and C were negative. VEP was absent in both eyes. BAEP was suggestive of bilateral auditory pathway dysfunction. The MRI brain scan showed multiple small lesions in the thalamus, centrum semiovale and brainstem and an ill-defined lesion in the cerebellum which appeared to be hypointense on T1-weighted images and hyperintense on T2-weighted images, not suppressed by fluid-attenuated inversion recovery (FLAIR), and enhanced with contrast (Figure In May 2003, a 28-year-old man, known to sniff petrol, was referred to us for further management of a suspected brain tumor. His symptoms started as acute onset severe bilateral visual loss and confused behavior of two weeks' duration. Initial neurological examination showed reduced visual acuity to light perception only, symmetrical reactive pupils, bilateral swollen optic disc and left-sided pyramidal signs. The MRI brain scan on admission was reported to show a large mass lesion in the right temporoparietal region which was hypointense on T1-weighted images and hyperintense on T2-weighted images with heterogeneous enhancement after gadolinium and not suppressed on FLAIR sequence (Figure These three cases are examples of inflammatory demyelinating disease masquerading as lesions requiring neurosurgical intervention. Neurosurgeons should be aware of this and carefully review the patient's clinical history when making a diagnosis. In the first patient, a thorough and proper clinical evaluation should have identified the evidence of demyelinating disease In the second patient, a rare complication of an uncommon disease in this region misled the diagnosis. The third patient had an atypical imaging finding of a relatively uncommon disease which led to the initial wrong diagnosis. In all three instances, a very low index of suspicion for demyelinating disease, except for one case, contributed to unnecessary surgical interventions.et al.[Many criteria have been proposed to guide clinicians in making a diagnosis of MS but the current guidelines widely followed in clinical practice are the ones proposed by McDonald et al.. The criet al.,4. Usualet al..et al.[et al.[The first patient had spinal MS with a tumor-like presentation, clinically and radiologically with subacute onset progressive myelopathy and MRI evidence indicative of intramedullary lesion. The spinal MRI features of Asian patients with MS are slightly different compared with Western patients with MS in terms of the size and length of lesions and association with cord swelling. According to Chong et al., the avel.[et al. found thThe second case described here demonstrates that inflammatory demyelinating disease can present as a surgical emergency if a strategically located lesion causes obstructive hydrocephalus. Butler and Gilligan  reportedet al.[The third case described here highlights the fact that ADEM can present as a solitary mass lesion. ADEM is an acute demyelinating condition affecting the brain and spinal cord and usually occurs following an infection or vaccination. More importantly, it is a monophasic disease. Typically, the MRI findings of ADEM include lesions of the same age and no new lesions after the initial onset. The corpus callosum is usually not involved . Singh eet al. retrospeet al. estimateet al.. These fAnother issue that needs to be highlighted is regarding neuromyelitis optica. There is controversy as to whether the optico-spinal variant of Asian MS is a clinical subtype of MS or a distinct entity of neuromyelitis optica. Recent reports of detection of neuromyelitis optica antibodies in the serum of these patients favor the latter condition. Thus, the new diagnostic criteria for neuromyelitis optica are based on clinical, MRI and neuromyelitis optica antibody results .We conclude that demyelinating disease can occasionally present as a tumor and only a proper and thorough history coupled with good physical examination and MRI scanning will help clinicians reach the correct diagnosis.ADEM: acute disseminated encephalomyelitis; BAEP: brainstem auditory evoked potential; CT: computed tomography; FLAIR: fluid-attenuated inversion recovery; MRI: magnetic resonance imaging; MS: multiple sclerosis; VEP: visual evoked potential.Written informed consent was obtained from the patients for publication of this case report and any accompanying images. Copies of the written consent are available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SMA analyzed the cases, collected the images and formulated the manuscript. NMS completed the literature review. MM was the pathologist reporting the histopathology slides. JA carried out the literature review and corrected the manuscript. JKT reviewed and corrected the manuscript. All authors read and approved the final manuscript.


Spigelian herniae are uncommon and frequently pose a diagnostic challenge.We report the case of a 71-year-old man in whom an ischaemic appendix was found within the sac of a Spigelian hernia during emergency repair.There are very few reported cases in which an appendix has been found within a Spigelian hernia, in the absence of inflammatory bowel disease. An awareness of the range of viscera which may be encountered in Spigelian herniae is important for safe repair. Spigelian herniae occur through slit-like defects in the anterior abdominal wall adjacent to the semilunar line. They are uncommon and frequently pose a diagnostic challenge. We report a case in which an appendix was discovered within the sac of a Spigelian hernia during repair. The range of viscera which have been found within Spigelian herniae is discussed. Awareness of possible contents of these herniae is crucial for safe repair.A 71-year old man presented with a 24-hour history of nausea, vomiting and a painful abdominal swelling located in the right lower quadrant. There was no history of a change in bowel habit and he was passing flatus. Past medical history consisted of open repair of an abdominal aortic aneurysm, cerebrovascular disease, diabetes, a myocardial infarct and atrial fibrillation. He was a non-smoker and consumed only a small amount of alcohol.On examination the patient was comfortable and not tachycardiac or febrile. Abdominal examination revealed the presence of a tender, irreducible mass located between the umbilicus and right anterior superior iliac spine. It was approximately 8 × 8 cm in diameter and had a positive cough impulse. A clinical diagnosis of an incarcerated right Spigelian hernia was made. Abdominal x-rays revealed dilated loops of small bowel.The patient underwent emergency repair of the Spigelian hernia. A transverse skin incision was made over the hernia and the external oblique aponeurosis was divided to reveal the hernial sac which was opened. It contained an ischaemic appendix and a knuckle of small bowel Figure . The appSpigelian herniae were initially described by Josef Kinkosh in 1764 and named after a Belgian anatomist, Adrian van der Spieghel, who had previously described the semilunar line. They account for 1-2% of all hernias and occur through slit-like defects in the anterior abdominal wall adjacent to the semilunar line. Approximately 90% are located in a 6 cm zone limited superiorly by the transumbilical plane and inferiorly by the interspinal plane. A particularly weak area is the intersection between the semilunar line and the arcuate line of Douglas. The majority of Spigelian herniae are intramural and remain deep to the external oblique aponeurosis. Usual contents are omentum or small bowel, however large bowel, stomach, gallbladder, ovary, testis, bladder, a Meckel's diverticulum and leiomyoma of the uterus although rare, have been described  some occPain which is exacerbated by contraction of the abdominal musculature is the most common symptom associated with Spigelian herniae and is described by over 60% of patients. The second most common clinical feature is a palpable abdominal mass which is present in approximately 35% of cases . SpigeliTreatment of a Spigelian hernia involves primary fascial closure, with synthetic mesh reinforcement if a large defect is identified. Recently, laparoscopic Spigelian hernia repair, using both intra-abdominal and extraperitoneal approaches, has been described. A randomised control trial, albeit involving a small number of patients, has compared outcomes following Spigelian hernia repair. There were no differences in recurrence rates between open and laparoscopic hernia repair, however, laparoscopic repair conferred benefits in terms of hospital stay and morbidity. An extraperitoneal approach was recommended for uncomplicated elective repair and an intra-abdominal approach if co-existent pathology requires surgery during the same intervention. In the case of emergency Spigelian hernia repair an open approach, as performed here, was advocated .Spigelian herniae are uncommon and frequently pose a diagnostic challenge. A range of viscera may be found within a Spigelian hernia; caution is therefore required when the hernial sac is opened to prevent damage to its contents.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 journal's Editor-in-Chief.The authors declare that they have no competing interests.All authors approved and equally contributed to this manuscript.


Solid pseudo-papillary tumors of the pancreas are rare and typically present in young female patients. They are slowly growing masses that may attain large size, and are of low malignant potential. Surgical resection is usually curative.A 71-year-old woman presented to the emergency department with an episode of hematemesis but was otherwise hemodynamically stable. Emergency gastroscopy revealed a bleeding mass projecting to the duodenum. Fluid, blood and electrolyte resuscitation followed. Computed tomography revealed a small mass in the head of the pancreas. A Whipple operation was performed. Pathology revealed a solid pseudo-papillary tumor. The postoperative course of the patient was uneventful and no recurrence was present a year after the operation.In our case, the most noteworthy observations concern the small size of the tumor, the age of the patient and the presenting symptom. However, pancreaticoduodenectomy in a 71-year-old woman is a major effort and should only be undertaken by centers and surgeons experienced in complex hepatobiliary surgery. Furthermore, the unique nature of this case reminds every clinician that each patient has to be considered separately and with extreme caution. Solid pseudo-papillary tumor (SPT) is a rare low-grade malignancy of the pancreas, accounting for 0.2% to 2.7% of the primary tumors of the organ . The larA 71-year-old woman presented to the emergency department with a single episode of hematemesis but was otherwise hemodynamically stable. Hematocrit was 23% with hemoglobin at 7.6 mg/dl. Fluid, blood and electrolyte resuscitation followed. Emergency endoscopy of the upper gastrointestinal tract revealed a small (about 2 cm), slightly bleeding mass projecting to the duodenum  . The meaSPT generally becomes clinically evident as a palpable mass at the epigastrium, the left or the right hypochondrium . FurtherConcerning the surgical approach, a great number of techniques are employed. The low grade of malignancy of this tumor has led some surgeons to perform simple enucleation of the neoplasm . HoweverIn our case, the most noteworthy observations concern the small size of the tumor, the age of the patient and the presenting symptom. However, pancreaticoduodenectomy in a 71-year-old woman is a major effort and should only be undertaken by centers and surgeons experienced in complex hepatobiliary surgery. Furthermore, the unique nature of this case reminds every clinician that each patient has to be considered separately and with extreme caution.The authors declare that they have no competing interests.SA was the main surgeon and was involved in revising the draft critically for important intellectual content. TSP received the patient to the emergency department, was advising doctor and was involved in drafting the manuscript and revising it critically for important intellectual content. AZ, AM and VNP were auxiliary surgeons and were involved in revising the draft critically for important intellectual content. DP received the patient to the emergency department and was involved in drafting the manuscript. NH carried out strategic planning for the treatment of the patient and was involved in revising the draft critically for important intellectual content. All authors have given final approval of the version 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.


Dementia is one of the most important neurological disorders in the elderly. Dementia of tumoral origin is rare and parkinsonism of neoplastic origin is unusual. We herein report a case of gliomatosis cerebri, a very rare brain tumor seldom affecting the elderly, which presented as rapidly progressive dementia and parkinsonism.An 82-year-old woman very rapidly developed progressive dementia and akineto-rigid parkinsonism. Brain CT scan was normal. Cerebral magnetic resonance imaging (MRI) with gadolinium injection highlighted a diffuse tumor-related infiltration involving both lobes, the putamen, the pallidum, the substantia nigra, and the brainstem, corresponding to the specific description and definition of gliomatosis cerebri.This atypical presentation of a gliomatosis cerebri, and the infiltration of the substantia nigra by the tumor, merits attention. Dementia is one of the most important neurological disorders in the elderly.In occidental countries, the most common forms of dementia are Alzheimer's disease and vascular dementia, with frequencies of 70 and 15%, respectively. Dementia of tumoral origin is rare. It may be related either to the tumour itself, especially primary central nervous system lymphoma or low grade glioma, or to the tumour's treatment . Secondary parkinsonism is frequent among elderly people. It includes drug-induced parkinsonism (due to Dopamine Receptor Blockers) and vascular parkinsonism. Nevertheless, parkinsonism of neoplastic origin is unusual. We herein report a case of probable gliomatosis cerebri, a very rare brain tumor seldom affecting the elderly, which presented as rapidly progressive dementia and parkinsonism.Following a fall, an 82-year-old woman was admitted to the Broca University Hospital. According to her family, she had exhibited cognitive impairment for several months. The patient was undergoing treatment for hypertension with Candesartan (Angiotensin Receptor Blockers) and her type 2 diabetes was satisfactorily controlled by diet. The physical examination at the time of admission revealed an akineto-rigid bilateral, symmetrical parkinsonism. Her gait demonstrated marked reduction in arm swing. She displayed bilateral bradykinesia, limb rigidity and hypomimia. Her voice was monotonous and hypophonic. There was neither tremor nor orthostatic hypotension. She scored 18/30 on the Mini-Mental Status Examination (MMSE) [Shortly following her evaluation, the akinesia and rigidity worsened, and a frontal syndrome developed. An L-dopa treatment was introduced as well as an anticholinesterase treatment  without any improvement noted.Two months after the hospital admission, the MMSE score was 5/30. Cerebral magnetic resonance imaging (MRI) with gadolinium injection highlighted a diffuse tumor-related infiltration involving both lobes, the putamen, the pallidum, the substantia nigra and the brainstem, corresponding to the specific description and definition of gliomatosis cerebri [Fifteen days later, the patient died of urinary sepsis just before the initiation of chemotherapy.The association of parkinsonism, falls and dementia is suggestive of a dementia with Lewy bodies . Indeed,Cognitive disorders are rarely caused by brain tumours but they have been reported as relatively common symptoms of primary brain lymphomas, low grade gliomas, or gliomatosis cerebri .Parkinsonism of neoplastic origin is also rare. Usually this is due to tumors not involving the basal ganglia, such as astocytomas, meningiomas, craniopharyngiomas, colloid cysts, and less frequently, metastases .On the other hand, tumours of the basal ganglia are rarely accompanied by parkinsonism , which iMoreover, in our patient, the MRI with gadolinium injection highlighted lesions of gliomatosis cerebri with the rarely observed involvement of the substantia nigra Figure . This toGliomatosis cerebri is a rare tumor. An extensive review encompassed 22 cases with a mean occurrence age of 49 years . The maiThis atypical presentation of a gliomatosis cerebri, and the infiltration of the substantia nigra by the tumor, merits attention.The author(s) declare that they have no competing interests.All authors participated in the care of the patient described. ED wrote the manuscript. AL, JYG, CR collected data and helped to draft the manuscript. OH and ASR critically revised the content of the manuscript. All authors have read and approved the final version of the manuscript.Written informed consent was obtained from the next of kin of the patient described in this case report for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in Chief of this journal.


Coexistence of gastrointestinal stromal tumor with synchronous or metachronous colorectal cancer represents a phenomenon with increasing number of relative reports in the last 5 years. Synchronous occurence of GISTs with other gastrointestinal tumors of different histogenesis presents a special interest. We herein report a case of GIST in Meckel's diverticulum synchronous with colorectal adenocarcinoma.A 69 year old man, presented with abdominal distension and anal bleeding on defecation. Colonoscopy revealed colorectal cancer and a low anterior resection was performed, during which a tumor in Meckel's diverticulum was discovered. Histologic examination revealed GIST in Meckel's diverticulum and a rectosigmoid adenocarcinoma.Whenever GIST is encountered, the surgeon should be alert to recognize a possible coexistent tumor with different histological origin. Correct diagnosis of synchronous tumors of different origin is the cornerstone of treatment. Meckel's diverticulum is surgically removed only when a complication arises or a neoplasia develops. Neoplastic transformation has been reported, but gastrointestinal stromal tumors (GISTs) are exceptional in this location ,2. The mA 69 year-old-man presented with abdominal distension and anal bleeding on defecation. For the last six months the patient was complaining of flatulence, periumbilical pain and sensation of incomplete evacuation. Apart from tenderness on deep palpation, blood on PR examination and increased bowel sounds, all other systems were found normal on clinical examination.Colonoscopy revealed intraluminal stenosis of the colorectal junction and biopsy specimens were obtained. Biopsy confirmed a well differentiated mucinous adenocarcinoma of the rectosigmoid colon. There was no evidence of metastasis, based on abdominal computed tomography (CT), chest X-ray and endorectal ultrasound (US) 3D. Carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 19-9, and cancer antigen (CA) 50 were normal. Low anterior resection for colorectal carcinoma (CRC) with an end to end primary anastomosis was performed, while on exploration a mass in Meckel's diverticulum, 80 cm proximal to the ileocecal valve, was encountered Figure , while tThe lesion in the colorectal junction was a stage C2 (Astler-Coller) tumour, 8 × 6 cm in size Figure , located2(on day 1), leukovorin i.v., 200 mg/m2 , 5 FU (fluorouracil) i.v., bolus 400 mg/m2 , 5 FU i.v., 22 hours-infusion, 600 mg/m2 , every 2 weeks for 12 cycles.Patient's postoperative course was uneventful, and he was commenced on adjuvant chemotherapy with FOLFOX regimen  and small intestine (30%). The average presentation is in the sixth decade . Most GId desmin .The three most important factors in determining malignancy are mitotic rate, tumor size and site ,10-12. MSmaller GISTs are often incidental findings during surgery, radiologic studies, or endoscopy. Coexisting stromal tumors are usually very small and are detected incidentally during gastrointestinal surgery for carcinomas . In our The patient underwent an en-block resection of the tumor to avoid rupture and intra-abdominal spillage, as it is recommended . He was Despite the considerable development in the management of GISTs the last 10 years and the immense progress recently made in understanding the molecular biology of GISTs, little is yet known about their rare synchronous occurrence with tumors of different histogenesis. GISTs have been reported to occur synchronously with colon adenocarcinoma, gastric cancer, lymphoma and carcinoid ,15-18. TAlthough the synchronous occurrence of GIST and other abdominal malignancy seems to be just a coincidence, combined genetic deregulation or influenced neighboring tissues by the same carcinogen could be causative factors ,19. TherMost of the published cases describe gastric stromal tumors synchronous with another gastric malignancy. Our case describes a concomitant GIST in Meckel's diverticulum with a colorectal adenocarcinoma. As far as we could elicit from the literature, this is the first report of such tumor coexistence with regard to location.The role of thorough abdominal exploration despite advanced preoperative imaging techniques cannot be overemphasized. In case of colorectal cancer, the doctor should bear in mind the possibility of coexistent tumor with different histological origin elsewhere in the GI tract.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.KC and EC and BG performed the operation and together with AG and GM contributed to the conception and design of the manuscript. LS, BS, MM, and TI analyzed and interpreted the patient data regarding the disease. AG and LS were major contributors in writing the manuscript. ZT carried out the histology and immunohistochemistry examination. All authors read and approved the final manuscript.


A cutaneous angiosarcoma is a rare malignant tumour of vascular endothelial cells with aggressive clinical behaviour and poor prognosis. Diagnosis is often delayed due to its variable and often benign clinical appearance.This case presents a 64-year-old man with a six-month-history of a recurrent diffuse and erythematous painless swelling below the left eye. Several resections with intraoperatively negative resection margins followed, but positive margins were repeatedly detected later on permanent sections. Histopathologic examination of the specimen diagnosed a cutaneous angiosarcoma. Neither, finally achieved negative margins on permanent sections, nor a following chemotherapy could prevent the recurrence of the disease after five months and the patient's dead 21 months after the first diagnosis.The case elucidates the current diagnostic and therapeutic dilemma of this entity, which shows an unfavourable clinical course in spite of multimodal therapy. A cutaneous angiosarcoma (synonyms: lymphangiosarcoma and haemangiosarcoma) is a rare malignant tumour of vascular endothelial cells. It occurs predominantly in the elderly and is confined to the face and the scalp region in more than 50% of cases . Despite2) below the left eye to the Department of Dermatology, Regensburg University, Germany. Cervical lymphadenopathy was clinically not detectable. Routine laboratory results showed no abnormality. Presuming an allergic dermatitis, topical treatment with steroids was initiated. Because of the persistence of the lesion, an incisional biopsy was performed three weeks later  and postirradiation angiosarcoma . BesidesClinically the appearance of a cutaneous angiosarcoma of the skin and scalp can be variable. Early lesions most commonly present as single or multifocal ill-defined, bruise-like erythematous-purplish areas with indurated borders . In the Microscopically a cutaneous angiosarcoma is typically characterized by numerous, irregular and anastomosing vascular channels. These are lined by pleomorphic, hyperchromatic endothelial cells with variable mitotic activity . ImmunhiTreatment of the cutaneous angiosarcoma is generally based on radical surgery and postoperative radiation therapy. Surgery is postulated to attain a wide excision of the tumour with histologically negative margins ,4. UnforMore recently, chemotherapy and gene therapy are increasingly available. Doxorubicin is reported to be active in angiosarcoma , but didDespite multimodal therapy options, prognosis of the cutaneous angiosarcoma is still poor, with a 5-year-survival rate between 12% and 33%. About half of the patients are dying within 15 to 18 months of presentation . The mosIn summary, the present case of a cutaneous angiosarcoma of the face elucidates the current diagnostic and therapeutic dilemma of this lesion. Diagnosis is often delayed, due to its putatively innocous clinical appearance. Negative microscopic section margins are hardly achieved during surgery, resulting in multiple operations with large postoperative defects. Despite multimodal therapy concepts, the prognosis remains poor.The authors declare that they have no competing interests.TE drafted the manuscript. JK helped to the critical review of the article. RM helped to the critical review of the article. SS performed the histopathological investigations. TER helped to the critical review of the manuscript. OD performed the surgical procedure, helped to draft the manuscript, helped to the critical review of 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.


A 43 year-old male patient presented with small bowel obstruction while being treated for cervical tuberculous lymphadenopathy. Laparotomy revealed multiple adhesions and multiple jejuno-jejunal fistulae. Absence of previous abdominal surgery or other abdominal insult favoured an 'idiopathic' origin of these unusual lesions, although treated tuberculosis may have been the underlying cause. To the best of our knowledge this intestinal condition has never previously been reported in the medical literature. Adhesions are by far the commonest cause of small  bowel obstruction. Other causes include hernias, neoplasms, inflammatory causes, mesenteric vascular occlusion and intussusception. There are also reports of various unusual causes .A 43 year-old Ethiopian male presented with a 3 day history of generalized colicky abdominal pain and vomiting. The patient was on the third week of anti-tuberculous therapy for cervical tuberculous lymphadenopathy. There was no previous history of abdominal surgery or pulmonary tuberculosis (TB) and the patient's plain chest x-ray was normal. Physical examination was consistent with an intestinal obstruction. High resolution computed tomography (CT) of the abdomen was performed with oral water soluble contrast and this showed a distal small bowel obstruction with marked dilatation and no evidence of a focal mass lesion or free fluid figure . In viewth postoperative day. Three months after discharge the patient had no residual abdominal symptoms and was well nourished.Recovery of bowel motility and absorption was slow and the patient required parenteral nutrition for a period of 10 days. He was discharged home on the 20Clinical presentation of this patient in combination with his history of cervical tuberculous lymphadenopathy raised suspicion of abdominal TB. However, CT showed small bowel obstruction without appearances typical of TB . FurtherRegardless of their underlying aetiology, jejuno-jejunal fistulae are a very unusual pathology which can be associated with intestinal obstruction. To the best of our knowledge there are no previous reports of this condition in the literature.The author(s) declare that they have no competing interests.IEK prepared the manuscript and performed the literature search. SYC contributed to the illustration preparation. EAC critically reviewed the manuscript.Written informed patient consent was obtained for publication.


Excavated pulmonary metastasis are rare. We present two cases of excavated pulmonary nodules proved to be metastases from osteosarcoma and gallblader lymphoma.The first one is 39-year-old man in whom cholecystectomy made the diagnosis of primary non-Hodgkin's lymphoma of the gallbladder. He presented in chest CT scan excavated nodules that had been biopsied and confirmed the diagnosis of non hodgkin lymphoma. He underwent 8 courses of chemotherapy CHOP 21 with complete remission. The second one is an 21 years old man who presented a right leg osteoblastic osteosarcoma with only excavated pulmonary nodules in extension assessment. He had 3 courses of polychemotherapy API  with partial response. Unfortunately, he died following a septic shock.Review of the literature shows that excavated pulmonary nodules as metastasis are rare but we should consider this diagnosis every time we are in front of a cancer. Chest computed tomography is the best diagnosis imaging that could make this diagnosis. Differential diagnosis between benign and malignant bullous lesions is important because surgical excision affects survival in some malignancies.Although pulmonary nodules are the most common cancer metastasis, a differential diagnosis of a concurrent primary malignancy should always be considered every time we have excavated lesions, even in patients with known malignant disease. Thorough chest evaluation is important, as multiple primary malignancies may occur concomitantly. Metastatic causes of excavated pulmonary nodules are rare but must be considered in patients with a history of neoplastic disease.Excavated metastatic pulmonary lesions are described, but in a country of epidemic tuberculosis, or in front of smokers, it is necessary to raise differential diagnosis. Sometimes, chest scann permitt to elaborate a definite diagnosis, and sometimes, we must resort to a biopsy. We report here two cases of excavated pulmonary metastasis attendant to primary malignancies.2 Intraveinously (IV) day 1, doxorubicine 50 mg IV day 1, vincristine 1,4 mg/m2 IV day 1 and prednisone 40 mg/m2 per day from day 1 to day 5 per os, each cycle every 21 days). He was in uncertain complete response (more than 80% according to Cheson criteria) after 4cycles and had 8 cycles of CHOP 21 with a complete response. The patient tolerated chemotherapy well and he is currently free of disease 12 months after completion of chemotherapy and 15 months from diagnosis. Response was achieved by CT scan  and was scheduled for a cholecystectomy. Histopathology from his surgically removed gallbladder was consistent with a primary NHL T cell. Immunostaining showed a positive marking for CD45, CD3. He underwent further lymphoma staging including a computed tomography scans of the body which revealed lymph nodes with surrenal nodules and pulmonary excavated lesions figure . Our pat2 IV day 1, cis-platinum 75 mg/m2 IV day 1, and ifosfamide 7 g/m2 from day 1 to 5 IV with uromitexan to protect against hemorrhagic cystitis ) with partial response. Unfortunately, he died following a septic shock.A 21 years old man, with no particular medical history, who presented a right leg painful mass was consulting at our hospital. There was no history of trauma or infection. On examination, a great warm mass measuring 12 × 21 cm was found at the end of the right tibia. Signs of inflammation were observed with a large swelling and oozing. He had no lymphadenopathy and no other mass. He just accused intermittent cough lasting for two months. His blood parameters were correct. An MRI (magnetic resonnance) was performed to establish the nature of this mass and its locoregional reports, it objectived abnormal signal intensities with a cortical destruction. A biopsy was then realised and the histopathological study revealed a chondroblastic osteosarcoma with an hypercellular neoplasm. He underwent an extension assessement by chest CT scan, scintigraphy, that revealed bilateral excavated pulmonary metastasis with different sizes and location. A pulmonary biopsy was performed to eliminate infectious diagnosis or vascularite, and revealed a metastasis of osteosarcoma. He had 3 courses of polychemotherapy API . We report two cases with rare lymphoma of the gallbladder and osteosarcoma of the leg with pulmonary excavated metastasis emphasizing the role of CT in characterizing these lesions. Primitive tumor corresponds mainly to squamous cell carcinoma of the head and neck or cervix, rarely to colon . Metastatic sarcomas, especially osteogenic can disseminate as excavated pulmonary nodules with a high risk of pneumothorax. Excavation sometimes occurs after chemo-radiotherapy (4). A review of litterature shows that the primary site that metastasis to lung are excavated are bladder, kidney, breast, and ovary . CT scan is more sensitive than standard chest radiography for the detection of excavated metastatic lesions. It also allows aetiological diagnosis achieved by biopsy guided by the scan, as in our second observation.In conclusion, we recommend to realise chest CT scan and biopsy each suspected lesions to ensure diagnosis of metastasis."Written consent was obtained from the patient or their relative for publication of study".The authors declare that they have no competing interests.WA was in charge of the overall care of the patient, reviewed literature, and drafted the manuscript and revised it critically for important intellectual content. BE has participated in the histological diagnosis of the two cases. ASK carried out the literature review. IL participated in the literature review. HE carried out the conception of the case, revised it critically for important intellectual content. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2342/10/13/prepub


Ewing's sarcoma's relapse rarely occurs more than two years after the initial diagnosis. We report the case of a 26-year-old man with a history of Ewing's sarcoma of the left maxillary sinus at the age of 10 who presented with a very late local relapse, 16 years after the first occurrence of disease. Ultimate control was achieved after multimodal therapy including surgery, high-dose chemotherapy, and radiotherapy. This report indicates that local relapses of Ewing's sarcoma can be treated with curative intent in selected cases. Ewing'ssarcoma usually occurs before 30 with a peak incidence at 15 years of age. Itrepresents 5% of all primary bone tumors and is the second most commonmalignant bone tumor in children. It is extremely rare in the head and neck asit represents 3% of osseous Ewing's sarcoma (OES) . ChildreA 26-year-old man self-referred for isolated moderately paced painless swellingof the left nasal ala with no physical status deterioration. His past medicalhistory was remarkable for Ewing's sarcoma of the left maxillary sinus at theage of 10  and Musculoskeletal Tumor Society (MSTS)staging systems, resp.). The patient had been treated according to theSociété Française d’Oncologie Pédiatrique (SFOP's) protocol with chemotherapy,hemimaxillectomy and palatine prosthetic reconstruction, and postoperativechemotherapy without radiation therapy because of the absence of residualviable tumor cells in the tumor resection specimen. The protocol wasadapted from the SFOP guidelines and consisted of (1) initial chemotherapy withcyclophosphamide-doxorubicin, (2)radical surgery if possible  were considered goodresponders and were omitted local radiotherapy), and (3) maintenance chemotherapy(for up to 9 months) with actinomycin-vincristine.Swelling had worsened over the past three months anddischarge appeared over the past month. Examination was consistent with a large mucocele of the left nose area. On computerized tomography (CT) scan, a 19-mL contrast-enhancedlesion with central sunburst pattern and calcifications  was noteMultimodality therapy for Ewing'ssarcoma is associated with markedly improved survival rates. Surgery followedby adjuvant radiotherapy and multiagent chemotherapy has dramatically improved fiveyears survival rates to 70%, compared with single—or even dual—modalitytherapy . In our Early metastatic relapse has the poorest prognosis . CollinsFive-year survival after relapse is less than 10% butselected patients benefit from aggressive salvage treatment . In partFinally, the patient is well and free of disease 15months after relapse. While followup following treatment of relapse is stillshort, intensive salvage multimodality treatment including radiotherapy forlocal relapse was feasible and ultimate tumor control was achieved.Such pastmedical history as Ewing'ssarcoma must not beoverlooked when facing apparently benign tumor since very late local relapse ispossible. Ultimate control can be achieved for local relapses of Ewing'ssarcoma in the adulthood with aggressive salvagetreatment protocols. Further data are needed to assess the role of aggressivelocal treatment.


A 67-year-old Caucasian male was referred by the urology service with a history of incomplete bowel emptying. He complained of tenesmus. MRI scan suggested a leiomyoma lying anterior to the rectum. He underwent examination under anaesthesia and attempted endorectal ultrasound and biopsy. However, the lesion seemed to migrate cranially and was impalpable. At laparoscopy, a mobile, unattached, 5.5 × 5 × 3.5, cream-coloured ‘egg was retrieved from the retrovesical space. Histology confirmed a hyalinised fibrocollagenous lesion lined with mesothelium. A comprehensive review of the literature is presented. Peritoneal loose bodies or “peritoneal mice” are asymptomatic incidentalomas predominantly found at abdominal surgery or autopsy . They usA 67-year-old Caucasian male was referred from the urology service following a previous laparoscopic nephrectomy for clear-cell renal carcinoma. He complained of progressive narrowing of his stool with associated symptoms of tenesmus. He was intermittently distended. He denied rectal bleeding or weight loss. His past medical history was unremarkable apart from essential hypertension controlled with an ACE inhibitor. Digital rectal examination was poorly tolerated and subsequent flexible endoscopy suggested an extra rectal lesion encroaching on the posterior wall. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a smooth-surfaced, well-circumscribed egg-shaped lesion measuring 5.5 × 5.3 × 4.4 cms with central calcifications posterior to the bladder but anterior and separate from the rectum . ExaminaIt is generally agreed that peritoneal loose bodies arise from appendices epiploicae. These fat-filled visceral peritoneal pouches exist along the antimesenteric taenia of the entire colon . Their pThe current case describes a giant peritoneal loose body case masquerading as a pelvis lesion causing significant rectal symptomatology related to extrinsic compression. A pelvic MRI depicted the lesion with features consistent with leiomyoma. There was low signal on the T1- and T2-weighted images with central low signal consistent with central calcification. It is important to differentiate leiomyomas from other lesions such as fibromata, desmoid tumors, teratomas, metastatic lesions of ovarian cancer, calcification of lymph nodes, and mesenteric cysts . All of After the informed consent was obtained, the patient underwent laparoscopic evaluation. This revealed a mobile cream-coloured egg lying anterior to the rectum. This was removed. The rest of the peritoneal contents were normal. Microscopy of the lesion revealed hyalinised fibrocartilaginous tissue lined with mesothelial tissue. This lamellar pattern of fibrous tissue with a scarcity of cellular tissue is typical of what is seen histologically in a peritoneal body .Giant peritoneal loose bodies are rare clinical entities. Imaging is often inconclusive when symptomatic laparoscopic retrieval is recommended to alleviate symptoms and outrule malignancy.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.Dara O. Kavanagh performed the surgery mentioned in the paper. DC collected the images and made a comprehensive literature review. RF proofread the paper. PC contributed significantly to the writing of the paper. All authors read and approved the final paper.