A ruptured aneurysm associated with a pituitary apoplexy is rare. We present the first case report of the coexistence of a ruptured posterior communicating aneurysm with a surgically discovered pituitary apoplexy where the pituitary apoplexy had not been diagnosed by a pre-operative computerized tomography scan.A 31-year-old right-handed Chinese woman began to experience severe headache, vomiting and blurred vision which continued for two days. On admission to the hospital, a brain computerized tomography scan demonstrated a small amount of increased signal in the basal cisterns; no evidence of intrasellar and suprasellar lesions was seen. The appearance of her brain suggested aneurysmal subarachnoid hemorrhage. She had nuchal rigidity and reduced vision. There was no extra-ocular palsy and no other neurological deficit. Our patient had no stigmata of Cushing’s syndrome or acromegaly. During an interview for further history, she reported normal menses and denied reduced vision.Cerebral digital subtraction angiography was subsequently performed, which revealed a 6mm left posterior communicating aneurysm. Urgent left pterional craniotomy was performed. The left ruptured posterior communicating artery aneurysm was completely dissected prior to clipping. At surgery, a suprasellar mass was discovered, the tumor bulging the diaphragma sella and projecting anteriorly under the chiasm raising suspicion of a pituitary tumor. The anterior part of the tumor capsule was opened and a necrotic tumor mixed with dark old blood was removed. The appearance suggested pituitary apoplexy.Histopathology revealed pituitary adenoma with evidence of hemorrhagic necrosis. Our patient made a good recovery.Our case report proves that pituitary apoplexy can be coexistent with the rupture of a posterior communicating aneurysm. This association should be considered when evaluating any case of aneurysm. A normal computerized tomography scan does not exclude pituitary apoplexy. Pre-operative magnetic resonance imaging interpretation is required if a pituitary apoplexy is suspected. Craniotomy allows a coexisting aneurysm and pituitary apoplexy to be simultaneously treated. Pituitary apoplexy is a rare clinical syndrome caused by acute ischemic infarction or hemorrhage of the pituitary gland. The classic presentation of apoplexy includes sudden onset of headache with vomiting, visual disturbance, ophthalmoplegia and altered consciousness. It is classically considered a life-threatening condition, but is commonly misunderstood and often misdiagnosed . It has A 31-year-old right-handed Han Chinese woman experienced severe headache, vomiting and blurred vision lasting for two days. On her admission to the hospital, a brain CT scan demonstrated a small amount of increased signal in her basal cisterns, but no evidence of intrasellar and suprasellar lesions were seen Figure B, C. TheThe clinical presentation of pituitary apoplexy can vary from patient to patient; some patients may be asymptomatic whereas others may present with features of a subarachnoid hemorrhage . Our patet al. [In previous cases, the vast majority of coexisting pituitary adenomas were diagnosed before surgery; most aneurysms were unruptured aneurysms and located close to the pituitary tumor ,6. Laidlet al.  reportedThe pathogenesis of the pituitary apoplexy is poorly understood. It is uncertain whether pituitary apoplexy was the result of the aneurysm or whether pituitary apoplexy resulted in the aneurysm. Some reports illustrated that pituitary apoplexy mimics an aneurysm ,8. HypotOn the other hand, rupture of an intracranial aneurysm may simulate pituitary apoplexy. Different mechanisms have been proposed and include acute dilatation of the artery aneurysm causing acute compression of the residual pituitary gland and inflicting direct tissue damage to the pituitary gland or stalk, or ischemic changes attributable to the raised intracranial pressure, and/or because of the later effects of vasospasm ,11,12.However, a clear mechanism of coexistence of two pathologies has not been found. In the present case, the development of the pituitary apoplexy is not clear, but we hypothesize that due to the raised intracranial pressure at the time of the subarachnoid hemorrhage, a compromised superior hypophyseal arterial and/or meningohypophyseal trunk may result in ischemia and the resultant apoplexy.Our case proves that a pituitary apoplexy can be coexistent with the rupture of a posterior communicating aneurysm; this association should be considered when evaluating any case of aneurysm. A normal CT scan does not exclude pituitary apoplexy. Pre-operative MRI interpretation is required if a pituitary apoplexy is suspected. Craniotomy allows a coexisting aneurysm and a pituitary apoplexy to be simultaneously treated.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 and will be provided on request.CT: Computerized tomography; ICA: Internal carotid artery; MRI: Magnetic resonance imaging; ON: Optic nerve.The authors declare that they have no competing interests.R-XS, D-KW and Z-WW were involved in the initial writing of the manuscript. R-XS provided major editing changes. ZW, S-XW and G-XW were primarily involved in the care of our patient. X-GL provided intellectual contributions to the content of the manuscript as well as editorial assistance. All authors have read and approved the final version of the manuscript.


A 46-year-old woman underwent upper endoscopy for evaluation of anemia, which revealed whitish granules at the duodenal papilla, diagnosed as duodenal follicular lymphoma (DFL) by biopsy. Computed tomography and abdominal ultrasonography revealed that follicular lymphoma was confined to the duodenum. Seven years after the diagnosis, fluorine-18 fluorodeoxyglucose positron emission tomography scanning revealed multiple lesions including in bone marrow and lymph nodes. Bone marrow biopsy of the right iliac bone revealed diffuse large B-cell lymphoma, indicating systemic dissemination and histologic transformation of the DFL. The patient responded to chemotherapy and has been progression-free for 2.5 years. Although DFL is usually indolent even without any treatment, systemic dissemination with histologic transformation can occur. This case suggests that the life-time follow-up that is usually done for patients with nodal follicular lymphoma should be provided to patients with DFL. Most patients with FL present with lymph node enlargement associated with bone marrow involvement. Recently, FL that affects the duodenum (DFL) has been recognized. DFL is reported to be localized around Vater papilla and consists of multiple small polyps. Primary DFL is an emerging clinical entity characterized by rare dissemination outside the gastrointestinal tract and by excellent prognosis. Because the disease frequently involves the jejunum and ileum, imaging of the entire small bowel by double-balloon enteroscopy or capsule endoscopy is encouraged.3 Systemic progression associated with histologic transformation of DFL has rarely been reported in the literature. Here, we report a case of DFL that transformed into DLBCL.It is possible for FL to undergo histologic transformation into diffuse large B-cell lymphoma (DLBCL). The reported incidence of histologic transformation varies, ranging from 16% to 60% depending on the length of follow-up and the rebiopsy/autopsy policy.IgH/BCL2 translocation, which was consistent with the diagnosis of follicular lymphoma. Lymphadenopathy was not detected by abdominal ultrasonography and computed tomography. On physical examination, there were no palpable superficial lymph nodes and no hepatosplenomegaly. Thus, she was diagnosed with DFL and was categorized as stage I according to the Lugano classification system. Hence, as her anemia was supposed to be not related to duodenal lesion, we chose to observe her without any local or systemic treatment. After 1.5 years of her DFL diagnosis, ultrasonography, and computed tomography revealed paraaortic lymph nodes 2 cm in diameter (Table 18F-FDG-PET) scanning was performed and revealed 18F-FDG accumulation in the iliac bone, left pubic bone, thoracic vertebrae, right neck and flank, and right iliac lymph nodes  carrier but had no notable past medical history. Her family history was significant for a mother and an older brother with hepatitis B cirrhosis and hepatocellular carcinoma. On upper endoscopy, multiple whitish granules were seen around Vater papilla Figure A. The bis Figure A and B. 2)–cyclophosphamide (750 mg/m2), doxorubicin (50 mg/m2), vincristine (1.4 mg/m2 (max 2.0 mg), and prednisolone (60 mg/m2) every 21 days, 6 cycles were administered. Entecavir 0.5 mg/day was initiated to prevent hepatitis B virus reactivation.As chemotherapy with R-CHOP regimen, rituximab  site is the second portion of the duodenum (81%), followed by the jejunum (40%).8 Because FL usually progresses gradually, delayed treatment (“watch and wait” policy) is a reasonable option for patients having asymptomatic nodal FL with low tumor burden.9 The optimal treatment of GI-FL remains controversial. A “watch and wait” policy has been adopted in asymptomatic patients with GI-FL,10 for those with nodal FL with low tumor burden. Damaj et al11 reported that 7 GI-FL patients did not receive any treatment, and 4 of them progressed after a median follow-up of 37.5 months, but despite this, overall survival was excellent. However, surgery, radiotherapy, and chemotherapy are also applicable for other patients.11In general, the decision to treat FL is made based on histology, presence, or absence of symptoms, disease burden, comorbidities, patient age, and patient preferences, with reference to the risks involved.1 showed that a watch and wait approach for primary DFL appears to be the most sensible strategy. Mori et al12 described a series of 27 cases of primary DFL; 14 patients received therapy . Their estimated progression-free survival rate at 3 years was 70%. The other 13 cases did not receive treatment and their progression-free survival rate at 3 years was 74%. Therefore, due to the usually fairly indolent clinical course of primary DFL, a watch and wait policy would be appropriate initial management.12 In the current case, we chose to watch and wait because there was a risk of HBV reactivation after rituximab and/or chemotherapy. The patient was progression-free for 7 years after the diagnosis until histologic transformation occurred.Treatment of DFL is also controversial. According to a retrospective analysis of 63 cases of primary DFL, all of which were low grade (1 to 2), the initial therapies included watchful waiting (24 cases), radiotherapy (19 cases), rituximab monotherapy (5 cases), CHOP (2 cases), R-CHOP (2 cases), radiotherapy and rituximab (1 case), mitoxantrone, chlorambucil, and prednisolon (1 case), chlorambucil and prednisolone (1 case), and unknown regimen (1 case). Schmatz et al13 Biological mechanism responsible for lymphomagenesis in patients with HBV infection, however, is still unclear.This patient was an asymptomatic HBV carrier. Recent meta-analysis revealed that HBV-infected people have higher risk for developing non-Hodgkin lymphoma with the odds ratios of HBV-infected population developing FL and DLBCL being 1.66 and 1.84, respectively.14 showed that, of 26 cases of DFL at various stages, 1 experienced transformation of DFL to DLBCL in a submandibular lymph node 4 months after the diagnosis of primary DFL. In addition, Mori et al12 reported that 1 of 27 cases of primary DFL developed histologic transformation. On the contrary, Schmatz et al1 reported that there was no transformation to high grade B-cell lymphoma among 63 cases of stage I DFL. It might be strange that histological transformation in this case was demonstrated in the bone marrow while the original lesion in the duodenum remained without transformation. Recently, using whole-exome sequencing, Pasqualucci L et al15 beautifully demonstrated that transformation of FL does not evolve as a linear process  but derives from the divergent evolution of an ancestral common precursor cell that acquired distinct mutations to become a FL or a transformed FL. Although bone marrow involvement had not been demonstrated at diagnosis in this patient, it might be possible that common precursor cell exists in the bone marrow.This case indicates that DFL can undergo histological transformation into DLBCL. There are few reports of the transformation of DFL into DLBCL. Sentani et alIn conclusion, although it is rare, transformation from DFL to DLBCL can occur. Thus, life-long follow-up with timely imaging, as is done for patients with nodal FL, is required for patients with DFL.


Chronic low back pain is one of the leading chief complaints affecting adults in the United States. As a result, this increases the percentage of patients that will eventually undergo surgical intervention to alleviate debilitating, chronic symptoms. A 37-year-old woman presented ten hours postoperatively after a lumbar laminectomy with an acute abdomen due to the extraordinarily rare complication of small bowel injury secondary to deep surgical penetration. In the United States, back pain remains the second most common reason why patients visit a clinician and up to 84 percent of adults will eventually endure low back pain , 2. Appr3/μL, with a hemoglobin and hematocrit of 12 g/dL and 34%, respectively.A 37-year-old female, postlaminectomy status for the treatment of lumbar back pain, presented with unrelenting abdominal pain 10 hours after the procedure. The patient denied any nausea, vomiting, diarrhea, fevers, or chills at that time, but due to the acute nature of the pain it was evident to her that she had either developed some type of postoperative complication or was experiencing a nascent abdominal pathology that would require immediate medical attention. The patient's past medical history was significant for chronic back pain and lumbar disc disease, with no significant surgical history prior to the laminectomy. Vital signs upon admission and consultation were stable and the patient was afebrile. Physical exam revealed a well-nourished, well-developed female that was alert and oriented albeit in obvious discomfort. The patient's physical exam was unremarkable except that her abdomen was exquisitely tender to palpation without any distension and there was significant tympany upon percussion. The electrolyte profile was essentially normal, but total bilirubin was elevated at 2.1 mg/dL. Urine pregnancy test was negative and the complete blood count showed an elevated white blood cell count of 15.4 × 10Computed tomography (CT) of the abdomen and pelvis showed evidence of retroperitoneal air, which seemingly tracked back into the spinal canal . In addiAfter dissecting through the subcutaneous tissue and the anterior rectus fascia in a standard fashion, the Hassan trocar was inserted and a laparoscopic view of the abdomen was undertaken. There was a marked amount of seropurulent fluid extending from the right and left colic gutters down to the Pouch of Douglas. The appendix was visualized and appeared normal; however, while running the small bowel, beginning at the terminal ileum, a significant amount of inflammatory and fibrinous exudate was discovered . Upon apWhen considering the supportive anatomy of the vertebral column, specifically the annulus fibrosus and the anterior longitudinal ligament, it is not inconceivable that ventral perforation is a rather rare complication of laminectomy. In a study of 30,000 lumbar discectomies, there was a reported ventral perforation rate of 0.016%  and whenThe incidence of intestinal injury following lumbar discectomy was reported, in a large-scale study with 68,329 patients, to be 0.0015% by the German Society of Neurological Surgery , 13, 14.Neurosurgical intervention in the vertebral column will remain common as long as chronic low back pain is a leading chief complaint in the United States. While it is not a typical complication, perforation of the viscus is associated with a high mortality rate; therefore, the surgeon must maintain a high index of suspicion when a patient presents with an acute abdomen after lumbar spinal surgery and be prepared to emergently surgically diagnose and correct the injury in the operating room.


The extraventricular neurocytoma of the sellar region (EVNSR) is a rare disease, it is difficult to make exact diagnosis of and operate on patients. Retrospectively analysed the clinical manifestations, image features, therapy methods and outcomes among patients with EVNSR, to investigate the epidemiological characteristics, image features, diagnosis, treatment and prognosis.A 25-year-old man man with 7-month worsening vision of left eye, was confirmed EVNSR after subtotally resection from the neurosurgical department of Deji hospital.Nine cases of EVNSR were reported from this article and elsewhere. Ages of these patients were ranging from 25 to 66 (with an average of 45.67). The male–female ratio was 1–2. All EVNSR patients had visual damage. Images showed the tumors were in the sellar and suprasellar regions. Preoperatively, all patients were misdiagnosed as other diseases: such as pituitary tumor, craniopharyngioma, and meningioma. For tumor removal treatment, five patients received transpterional approach, one received subfrontal approach and three received transnostril–transsphenoidal approach. EVNSR was confirmed by pathological tests. The tumor was completely removed in one patient. During the 12–24 month postoperative follow up period, the recurrence or metastasis of the tumor was found in two patients.EVNSR is a rare disease. It occurs mostly in middle-aged women. EVNSR is likely to be misdiagnosed as pituitary adenoma preoperatively. The histological examination would help confirm the diagnosis. Using transpterional approach to remove tumor will help the prognosis, especially among patients with normal pituitary function. Both postoperative radiotherapy and long-term follow-up are recommended. The extraventricular neurocytoma of the sellar region (EVNSR) is a rare disease, with only eigh cases reported in literature up to now. It is difficult to make exact diagnosis of and operate on patients with EVNSR. We report one EVNSR patient receiving radiotherapy on the 5th months after subtotally resection from the neurosurgical department of Deji hospital, Shanghai. We also review the pertinent literatures to investigate the diagnosis, treatment and prognosis of EVNSR.A 25-year-old man had had worsening vision of left eye since 7 months ago. There was no history of headache, vomiting, polydipsia, polyuria or sexual dysfunction. The case was obese and well-nourished and appeared to be apathic. The visual acuity of right eye was 0.8, while the left eye could only count fingers within 30 cm. There were signs of bitemporal visual field defect, delayed light reflex of the left pupil and slight abduct limitation in left eye. Computed tomography scan showed a roundish homogenous and mildly high density mass in the sellar and suprasellar regions, with clear margin, intra-tumor calcification, but no periphery edema Fig. . The magA left transpterional craniotomy exposed the tumor, which was mainly located in suprasellar region and was partially extended into the intrasellar, anterior skull base, cavernous sinus and upper clivus Fig. a–c. The The resected specimen was grey and soft. Histopathologic examination (HE) staining showed that tumor cells were oval and well-differentiated with schistic distribution. Cytoplasm was sparse with mild acidophilia. Nuclei were oval, without obvious heteromorphosis and mitotic figures. Neuropil structure was observed in some region of the tumor tissues, without necrosis Fig. a. ImmunoThe patient’s visual acuity improved on the second postoperative day. The patient developed a mild diabetes insipidus but recovered after hypophysin therapy. Cranial MRI showed subtotal tumor removal, with a little tumor remained in intrasellar region Fig. e, f. OneThree-month postoperative follow-up showed patient’s left visual acuity increased to 0.12 with improvement on vision defect. The anterior pituitary hormone tests were normal. Cranial MRI results were similar as the one taken on the second postoperative day.Central neurocytoma (CN) is a neuronal and mixed neuronal-glial tumor. It is classified as a WHO II grade tumor . Nearly 100 cases of EVN has been reported, accounting for 0.02–0.10 % of patients with intracranial tumors. EVN is commonly observed among Asians, especially Japanese. The patients’ ages range from 5 to 76 years old with an average of 34 years old. There is no gender difference . EVNSR is a rare disease with only eight cases reported till now. The patients’ age range is from 25 to 66 years old with an average of 45.67 years old. The male–female is 1–2 Table . The tumEVNSR is recommended to be removed as much as possible with minimally invasive technique. Clinically, either surgical approach or endoscopic endonasal–transsphenoidal approach will be adopted based on tumor extending direction. The key of treatment is to decompress the optic pathway and to protect the neuro-vascular structure of surgical region. The endoscopic approach may be more effective to protect the optic nerves by causing lesser lesion compared to the craniotomy approach. However, the endoscopic approach may aggravate pituitary malfunction if the tumor evaded to the suprasellar region and remained pituitary tissue. Reconstruction of anterior skull base could be considered via the extended endoscopic approach. But it is not recommended in patients with uncertain diagnosis or in patients with tumor barely eroding the sphenoid sinus.In our reported case, the preoperative hormone test and image results showed the pituitary gland might remain functional. Instead of the endoscopic endonasal transsphenoidal approach, we decided to use transpterional approach, which we also had more experiences with. Since the tumor slightly predominated at the left side with decreased visual acuity of left eye, we adopted the left transpterional approach to decompress the left optic nerve and to protect the well-functional right one. Microscopically, we successfully resected the tumor in anterior skullbase, the interspace I, II, III, and partial ones in the intrasellar region and the cavernous sinus Figs. , 3. The The necessity of the postoperative radiotherapy is still controversial. Most scholars believed radiotherapy is effective, especially among cases with partial removal or tumor recurrence. While past cases indicated the total tumor resection to be a more important prognostic factor than postoperative radiotherapy Table , a smallSome authors believed EVN had ganglionic and neuroglial differentiation, with higher radio of pathologically atypical features and more postoperative recurrence (Chou et al.


Epidermal inclusion cysts are benign cutaneous lesions caused by dermal or subdermal implantation and proliferation of epidermal squamous epithelium as a result of trauma or surgery. They are typically located on the scalp, face, trunk, neck, or back; however they can be found anywhere on the body. Lesions are asymptomatic unless complicated by rupture, malignant transformation to squamous cell carcinoma, or infection at which point they can clinically appear as more sinister pathologies. We present the case of a 45-year-old laborer with a ruptured epidermal inclusion cyst, manifesting clinically and radiographically as a malignancy. Following MRI, definitive surgical management may appear to be a logical progression in management of the patient. This case however is a good example of why meticulously following surgical protocol when evaluating an unknown soft tissue mass is imperative. By following protocol, an alternate diagnosis was made and the patient has since gone on to a make a full recovery without life transforming surgery. A 45-year-old male presented to the orthopaedic outpatient department with an 18-month history of a gradually growing mass on the middle finger of his right dominant hand. The mass had grown at an increased rate over the previous 6 months culminating in self-referral to the emergency department after acute pain affecting his ability to complete work as a laborer at the local port. The patient identified a crush injury to his fingers involving a fridge approximately 6 months earlier; concluding the mass had extended in size from this time. After a failed attempt at aspiration the patient was discharged on oral antibiotics with orthopaedic follow-up. He reports no significant past medical history; however he smokes 10–15 cigarettes per day.On examination, a fusiform swelling of his right middle finger was present centred on a tender mass on the radio-volar aspect of the middle phalanx. There was no evidence of infection or vascular disturbance; however paraesthesia was noted distal to the mass on the ulnar aspect of his finger. Flexion at the interphalangeal and metacarpophalangeal joints was restricted secondary to pain and mass effect of the lesion.X-ray demonstrated a radial soft tissue swelling without bony involvement  whilst aUrgent magnetic resonance imaging (MRI) with contrast was requested demonstrating an extensive poorly defined infiltrating soft tissue mass around the middle phalanx, of intermediate T1 signal Figures  and 3 an Staphylococcus warneri, Staphylococcus capitis, and Staphylococcus epidermidis susceptible to flucloxacillin.The patient proceeded with incisional biopsy prior to likely ray amputation. A mid-lateral radial incision was made over the middle phalanx and four large pieces of tan coloured, friable, abnormal tissue were resected and sent for histology. Wound swabs and a small amount of necrotic tissue was sent for microscopy, culture, and sensitivity. Staging computed tomography (CT) of chest, abdomen, and pelvis showed no evidence of metastases. Microbiology samples identified light growths ofPathology reports showed sections of fibrovascular connective tissue with a small area of associated hyperkeratotic stratified squamous epithelium. Fragments of calcified debris were visible within an extensive foreign body type granulomatous inflammatory cell infiltrate. Findings were in keeping with a ruptured epidermal inclusion cyst with secondary inflammatory response.An excision of the soft tissue mass was performed after confirming benign nature of the mass with frozen section analysis. Intraoperatively a 3 mm sharp foreign organic body was identified in the mass, around an area of pus and necrosed tissue .The patient has since proceeded to make a full recovery and has returned to full time work.Epidermal inclusion cysts are subcutaneous lesions caused by dermal or subdermal implantation and proliferation of epidermal squamous epithelium as a result of trauma or surgery. They are typically located on the digits, scalp, face, trunk, neck, or back; however they can be found anywhere on the body. Occlusion of pilosebaceous units, human pappilomavirus 57, and HPV 60 infection are rare but significant alternate pathogenesis. Most patients present with an asymptomatic or incidental mass unless complicated by rupture, malignant transformation to squamous cell carcinoma, or infection , 2.Sonographically, the cysts usually appear as well as circumscribed hypoechoic masses. MRI scanning is the investigation of choice. T1 weighting shows low or intermediate signal whilst T2 weighting shows high signal. Differential diagnosis should include neurogenic tumours, Myxoid tumours, dermatofibrosarcomas, nodular fasciitis, and ganglion cysts [As with any lesion, it is imperative to meticulously follow surgical protocol in the diagnosis and management stages to minimise adverse outcomes, incomplete resection, seeding, bleeding, and infection. Most errors in management of an unknown lesion occur from incomplete or inappropriate presurgical diagnosis .Initial assessment should begin with comprehensive history and physical examination. Social history of environmental exposures and smoking status can be key whilst systemic features such as fever, weight loss, and malaise are infrequent but unforgiveable if missed.Large rapidly growing lesions should invoke immediate concern whilst tenderness is often pathognomonic of infection and inflammation or less commonly malignant infiltration. Lesions that are superficial, cystic, or less than 5 cm in size are likely to be benign whilst deep lesions larger than 5 cm have a higher malignant potential. Lymph node examination is imperative .Careful consideration of approach to avoid further neurovascular or compartmental contamination.Lesions extending to bone which should be sampled from soft tissue to avoid increasing the risk of pathological fractures.The track which should be excisable en bloc with the tumour.Avoidance of haematoma collection.CT staging of malignant lesions should be undertaken with chest, abdomen, and pelvic imaging to investigate metastases and is useful as an adjuvant to MRI for delineating tumour matrix and cortical destruction [Biplanar radiographs and ultrasound are suitable and cost effective initial investigations; however, magnetic resonance imaging is the imaging investigation of choice should any concerning features be raised. Biopsy and pathological evaluation should remain the last events in the evaluation of a soft tissue mass. It is good practice to discuss the biopsy procedure with pathology and radiology specialists prior to procedure to avoid tumour seeding and consideration of limb salvage procedures. Biopsy whether open or closed should be performed adhering to the following principles :Careful truction .It is likely that the small thorn-like structure identified on removal of the mass was responsible for an unnoticed penetrating injury to the finger some time earlier, implanting dermis deep in the digit. The incident with the fridge may have resulted in rupture of the ensuing epidermal inclusion cyst, propagating its extension along the length of the finger. This rupture in combination with chronic low grade infection secondary to foreign body and constant aggravation due to the physical nature of the patient's job resulted in the semiacute deterioration in symptoms and presentation.Complication of epidermal inclusion cysts with rupture, infection, or malignant transformation compounds clinical diagnosis. This case is a good example of why meticulously following surgical protocol when evaluating a soft tissue mass is imperative. Following MRI, definitive surgical management may appear to be a logical progression in management of the patient. In this case, a clinically and radiographic diagnosis of synovial sarcoma would have resulted in ray amputation extending into the hand. By following protocol, an alternate diagnosis was made and the patient has since made a full recovery without life transforming surgery.


Neuroendocrine tumor originates from the diffuse neuroendocrine system. Intracranial originating is lower to 0.74 %.We present two cases of primary intracranial neuroendocrine tumor A 39-year-old woman was admitted with headache, fever, polydipsia and polyuria. Biochemical and endocrinological results showed hyponatremia, hypothyroidism and hypopituitarism. MRI scans demonstrated an obviouslyenhancing lesion in seller and superseller area. Then a gross removal of tumor was achieved during the single nostril transsphenoidal approach surgery. Pathological diagnosis was high-grade small-cell neuroendocrine tumor. A 40-year-old woman presented with multiple symptoms and neurological deficit. Neuroimaging results demonstrated a huge obviously-enhancing tumor in anterior cranial fossa. Biochemical and hormone findings revealed hypokalemia, high glucose and hypercortisolemia. The intracranial surgery achieved a gross removal through a right frontal craniotomy. Pathological diagnosis was low-grade small-cell neuroendocrine tumor with immuno-negativity for ACTH.The mechanism, diagnosis, and treatment of neuroendocrine tumor are still challenging. Neuroendocrine tumor originates from the diffuse neuroendocrine system. Intracranial origin is lower than 0.74 %. Ectopic secretion of active adrenocorticotropic hormone (ACTH) or ACTH analogues from the non-pituitary tumors causes ectopic ACTH syndrome, resulting in the presence of Cushing syndrome. Anterior skull base reconstruction was performed during surgery in the second case. Reconstruction can be divided into soft-tissue reconstruction and bony reconstruction. We present two cases of primary intracranial neuroendocrine tumor and the specificities are intracranial origin, immuno-negativity for ACTH, high serum ACTH level, and anterior skull base reconstruction.A 39-year-old woman was admitted to our department with a 2-month history of headache, moderate fever, polydipsia, and polyuria. Biochemical and endocrinological results showed that hyponatremia, mild hypothyroidism, and 6 a.m. serum cortisol level was less than 80.00 nmol/L (83.00~359.00 nmol/L). Bone destruction was found in computed tomography (CT) scans Fig. . MagnetiA 40-year-old woman was admitted to our institute with a 6-year history of intermittent sniveling from bilateral nostrils; a 2-month history of gained weight, polydipsia, polyuria, and weakness; and a 2-week history of dimness. Examination revealed hypertension, dimness, bilateral exorbitism, left vision diminution, pigmentation in the face and trunk Fig. . Bone deHistological examination revealed that the tumor was comprised of small round cells with uniform nuclei and scant cytoplasm, with nidulant or stripe-shaped distribution Fig. , b. ImmuPostoperative abdomen CT scans demonstrated improved bilateral adrenal glands. Biochemical and endocrine results were normal.NET originates from amine precursor uptaking and decarboxylation cells (APUD cells), which are called diffuse neuroendocrine system –3. the iDiagnosis of NET depends on the pathological characteristics. Immunohistochemistry is one significant differential approach to neuroendocrine ingredients, epithelial ingredients, and neuropeptides. For NET in the sellar region, it should be necessary to discriminate it from esthesioneuroblastoma. Klimstra  thought Ectopic secretion of active ACTH or ACTH analogues from the non-pituitary tumors causes ectopic ACTH syndrome, resulting in the presences of Cushing syndrome . Overt aThe key point of diagnosis is how to differentiate between ectopic ACTH syndrome and Cushing disease. The ACTH level of overt ectopic lesion is distinctly higher than that of Cushing disease, but it is approximately the same as Cushing disease in occult lesion. In accordance with recent researches, the standard is that serum cortisol is shown to be 14 % higher than the base after CRH-releasing test is carried out 15 and 30 min later . The othThe optimal treatment of NET is surgical resection of hormone-secreting lesion. Peng et al.  reported90Y-DOTA-octreotide (OCT), 111In-DTPA-OCT, and 131I-DTPA-OCT, to complete the inner irradiation [Patients receiving comprehensive treatment, including extended resection of tumor and completion of chemo-radiotherapy, are expected to have longer tumor-free lives than those patients receiving single surgery , 15. PooThe mechanism, diagnosis, and treatment of NET are still challenging. Surgical resection followed by radiotherapy had demonstrated an effective treatment, and chemotherapy still needs researches to demonstrate its therapeutic efficiency.Written informed consent was obtained from the first patient’s parents because of her death and the second patient herself 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 ethical review has been approved by our ethics committee.


Background. Spontaneous perforation of the extrahepatic biliary system is a rare presentation of gall stones. Very few cases of bile duct perforation have been reported in adults. It is rarely suspected or correctly diagnosed preoperatively. Case Presentation. A 66-year-old female presented at the surgical emergency with 3 days' history of severe upper abdominal pain with distension and repeated episodes of vomiting, as she had evidence of generalized peritonitis and underwent an exploratory laparotomy. A single 0.5 cm × 0.5 cm free perforation was present on the anterolateral surface of the common bile duct at the junction of cystic duct. A cholecystectomy and the CBD exploration were performed. Conclusion. Spontaneous perforation of the extrahepatic bile duct is a rare but important presentation of gall stones in adults. Therefore, awareness of the clinical presentation, expert ultrasound examination, and surgery are important aspects in the management. Spontaneous perforation of the wall of the extrahepatic or intrahepatic bile duct with biliary peritonitis is a rare event in infants and an extremely rare event in adults. It was first described in 1882 by Freeland , 4 and iThe presentation of biliary peritonitis varies and because of its rarity the correct preoperative diagnosis is often difficult and delayed. This along with the associated comorbidity of mostly the elderly, patients in whom it is seen, results in a mortality rate of 30–50% . We repoA 66-year-old female presented at the surgical emergency with 3 days' history of severe upper abdominal pain with distension and repeated episodes of vomiting. The abdominal pain increased in intensity and became continuous and more diffuse for the last two days. Her past medical, surgical, and family histories were unremarkable. General examination revealed that she was dehydrated, febrile (101 F), and having a pulse rate of 120/minute and blood pressure of 90/70 mm of Hg. She was not icteric and free of cervical lymphadenopathy. Her abdomen was distended with guarding and rebound tenderness mainly in the upper abdomen. There was no evidence of free fluid in the abdomen. Liver dullness was not obliterated. Bowel sounds were absent.3 (84% neutrophil)] with normal total bilirubin [10.2 μmol/L (5–21)], alkaline phosphatase [255 IU/L (70–360)], and alanine transaminase [14 IU/L (8–38 IU/L)]. Serum amylase level was normal. Her erect chest radiograph was normal without evidence of pneumoperitoneum but on USS abdomen showed small amount of free fluid in hepatorenal pouch. Therefore, definite preoperative diagnosis was not possible. As she had evidence of generalized peritonitis, she underwent an exploratory laparotomy, after adequate resuscitation and under broad spectrum antibiotic coverage.Hematological investigations revealed neutrophil leukocytosis [17700 cells/mmOperative findings included bilious peritoneal fluid in dependent parts of the peritoneal cavity with localized collection of bile inside the lesser sac. Gall bladder was distended with thickened wall and contained multiple stones. A single 0.5 cm × 0.5 cm free perforation was present on the anterolateral surface of the common bile duct at the junction of cystic duct . The comThe patient made a slow postoperative recovery. There was persistent drainage of bile through the subhepatic drain until the 10th postoperative day. T-tube cholangiogram performed on the 10th postoperative day showed leaking and the pooling of contrast at T-tube insertion site of CBD with leaking tract extending towards drain site . It alsoSpontaneous perforation of common bile duct is a rare cause of biliary peritonitis. It is rarely suspected or diagnosed preoperatively. Perforation of the biliary system is a recognized complication of cholelithiasis; the diagnosis should be suspected if a perihepatic abscess or peritonitis is combined with biliary stone disease. Kang et al.  reviewedPerforation of the common bile duct was most probably related to the abrupt increase in local intraluminal pressure causing erosion of the stones. This results in abrupt increase in intraluminal pressure and decreased blood flow in the vessels which run along the lateral border of the bile ducts, resulting in ischemia on the anterior surface of the bile duct . This miIn conclusion, spontaneous perforation of the extrahepatic bile duct is a rare but important presentation of gall stones but important condition in adults. Therefore, awareness of the clinical presentation and expert ultrasound examination are important adjuncts in the diagnosis. Conservative surgery is the mainstay of treatment in the acute presentation.


Introduction: The lesions of the salivary ducts may be idiopathic, post- traumatic, or iatrogenic and lead to sialocele formation with persistent painful facial swelling or cutaneous fistula formation. No consensus on treatment of this condition exists: the options of treatment include needle aspiration, pressure dressings, antisialogogue therapy, radiotherapy, botulinum toxin and surgical approaches as duct repair, diversion, ligation, different drainage systems and even parotidectomy/submaxilectomy. The management and special features of iatrogenic salivary duct injury in patients with oral cancer who underwent head and neck reconstructive surgery has not been described yet. Material and Methods: We present four cases of iatrogenic lesions of salivary ducts and its management in patients with oral cancer.Conclusions: The iatrogenic lesions of salivary ducts are to be taken into account in patients with oral cancer as the distal ends of salivary ducts could be involved in the margins of surgical resection. Different options of treatment of this complication are described. Key words:Sialocele, oral cancer, salivary duct. Salivary duct injury may be post- traumatic or iatrogenic . A contiThe patient, 54 year old female, was diagnosed for cancer of oral mucosa. She presented leucoplasic lesion of 1.5 cm of right buccal mucosa on the level of first upper molar. The squamous cell carcinoma diagnosis has been confirmed by biopsy. The patient underwent resection of lesion in oral mucosa with safety margins and unilateral modified neck dissection. The intraoral defect was reconstructed with radial forearm flap. The patients recovery was uneventful until the seventh postoperative day when she started with complaints of oedema and pain in the right parotid region where a fluctuating mass of 4 cm in the right parotid region was evidenced. The distal part of the Stensen’s duct was resected at the surgery and the radial forearm flap replaced the right buccal mucosa at the presumptive level of its opening. The urgent CT was performed which revealed Stensen’s duct dilation with presence of radial flap obstructing its distal end . The presumptive diagnosis of iatrogenic sialocele was done. The swelling persisted three days and resolved spontaneously with intraoral fistulization of the sialocele. No complications for radial forearm flap were produced. No recurrence of sialocele was observed during one year of postoperative follow up.The patient, 78 year old female, was diagnosed for recurrence of oral mucosa carcinoma. The patient was diagnosed for squamous cell carcinoma of the left tongue seven years before when she underwent resection of the tumour with marginal mandibulectomy and unilateral modified neck dissection. The surgical margins were clear and the patient was followed up. Three years after the recurrence of the squamous cell carcinoma in the left mandibular gingiva and left remanent tongue was detected. The patient underwent left mandibulectomy with reconstruction with fibular flap. Three years later the recurrence of squamous cell carcinoma was detected in the union of fibular flap and buccal mucosa. The patient underwent resection of lesion in oral mucosa with safety margins in block with posterior maxillectomy. The intraoral defect was reconstructed with temporal flap. The patient presented no complications in the early postoperative period. On the sixth day of the postoperative period a fluctuating mass of 5 cm in the left parotid region appeared Fig. . The perThe patient, 55 year old male, presented lesion in the oral mucosa less than 1 cm from Stensen’s duct orifice. He was diagnosed for squamous cell carcinoma of oral mucosa. The oral mucosa was resected in block with the distal end of Stensen’s duct. The defect was repaired with radial forearm flap. A rubber drain was placed intraorally above the radial forearm island and fixed with stitches Fig. . In the The patient, 59 year old male, presented lesion in the mucosa of the floor of the mouth. The biopsy confirmed squamous cell carcinoma of oral mucosa. Transoral laser resection was performed. In the postoperative period the swelling in left submandibular region appeared. The CT revealed left submandibular sialocele formation. The pathology reported the margins of the specimenm of resected oral mucosa affected by the squamous cell carcinoma, thus the extension of surgical margins with bilateral selective neck dissection involving submandibular gland with dependent sialocele has been performed.A number of papers exist about post traumatic silaocele. Iatrogenic sialocele have been described as complication of parotid surgery . There iIt is considered that in cases of facial injury the damage to the parotid duct is often overlooked or underestimated . In caseThe diagnosis of sialocele usually is not difficult if the history of possible parotid duct injury is taken into account. A sialocele presents as a swelling in the preauricular region which typically develops 8 to 14 days after the injury . In postoperative period it is frequently misdiagnosed as hematoma. On palpation the lesion is soft and mobile. No erythema of the skin, no fever, no supuration are observed. The patient can complaint of pressure sensation in the area . The amyThe management of salivary duct injury and resultant sialocele remains controversial. Various conservative and surgical methods have been described. In general the management of the duct injury depends on the age of injury, site of injury and mechanism of injury. Three methods generally employed are based on primary repair of the duct, creation of oral fistula and suppression of parotid gland function . It is cIf the salivary duct iatrogenic injury have been overlooked the sialocele may appear. The management of sialoceles includes multiple percutaneous needle aspirations, application of pressure dressings, use of antisialogogues drugs, injection of botulinum toxin . If thesThe method of intraoral fistula surgical creation was reported by Morestin in 1917 for the management of parotid fistula after facial wounds. This method has been recently described for treatment of post-traumatic sialocele . There w The method of itraoral fistula creation has not yet been described for management of iatrogenic sialoceles. We successfully applied this method in one of our patients [case 2]. We consider this method to be physiologically based as once we observed spontaneous intraoral fistulization of iatrogenic sialocele [case 1].Besides it seems to be more comfortable for both the patient and the surgeon in comparison with multiple needle aspirations. This method is not challenged by presence of fibrous scar tissue or interposition of flaps as the method of duct repair or recanalization. It is technically simple and doesn’t require general anaesthesia.The iatrogenic injury to the distal end of the salivary duct is observed in oncological surgery when oral mucosa is to be resected. If not treated duct injury may result in such complications as sialocele, salivary fistula or ductal cysts. The iatrogenic sialoceles in oral cancer patients who underwent reconstruction of defect with free flap or regional flap has not yet been described. A number of techniques for management of salivary duct injuries have been proposed. If the injury to the duct is detected at the surgery or is anticipated in surgical plan then it can be resolved simultaneously with resection of tumour by placing intraoral drainage or duct reimplantation. We propose the method of intraoral drainage with over-the-needle cannula for iatrogenic sialoceles in oral cancer patients. We consider that it is important to anticipate the salivary duct injury in oncological patients as its intraoperative management is effective and prevents development of postoperative complications.


In humans, high-grade gliomas may infiltrate across the corpus callosum resulting in bihemispheric lesions that may have symmetrical, winged-like appearances. This particular tumor manifestation has been coined a “butterfly” glioma (BG). While canine and human gliomas share many neuroradiological and pathological features, the BG morphology has not been previously reported in dogs. Here, we describe the magnetic resonance imaging (MRI) characteristics of BG in three dogs and review the potential differential diagnoses based on neuroimaging findings. All dogs presented for generalized seizures and interictal neurological deficits referable to multifocal or diffuse forebrain disease. MRI examinations revealed asymmetrical (2/3) or symmetrical (1/3), bihemispheric intra-axial mass lesions that predominantly affected the frontoparietal lobes that were associated with extensive perilesional edema, and involvement of the corpus callosum. The masses displayed heterogeneous T1, T2, and fluid-attenuated inversion recovery signal intensities, variable contrast enhancement (2/3), and mass effect. All tumors demonstrated classical histopathological features of glioblastoma multiforme (GBM), including glial cell pseudopalisading, serpentine necrosis, microvascular proliferation as well as invasion of the corpus callosum by neoplastic astrocytes. Although rare, GBM should be considered a differential diagnosis in dogs with an MRI evidence of asymmetric or symmetric bilateral, intra-axial cerebral mass lesions with signal characteristics compatible with glioma. The callosum , 2. Anapsplenium . Glial tsplenium –8. HowevA 13-year-old, spayed female mixed-breed dog presented with a 10-day history of intermittent aggression and circling to the left. A cluster of three generalized seizures occurred the evening prior to evaluation. Neurological examination abnormalities noted at admission included obtundation, propulsive circling to the left, a left head turn, absent menace responses OU, diminished visual tracking OU, normal pupillary light reflexes OU, and postural reaction deficits in the right thoracic and both pelvic limbs. The neuroanatomic diagnosis was a multifocal or diffuse prosencephalic lesion that was suspected to be more severe on the left side. An MRI examination of the head was obtained under general anesthesia .Tracking throughout the white matter of the left parietal lobe was a markedly and homogeneously contrast-enhancing, T2 hyperintense and T1 hypointense intra-axial mass with lobulated margins that measured 2.4 cm × 2.9 cm × 2.2 cm at its largest dimensions  was 12/18, characterized by lateral recumbency with intermittent opisthotonus, bilateral unresponsive miosis, and periods of stupor characterized by constant vocalization. A diffuse or multifocal forebrain disorder was suspected. A brain MRI examination was performed under general anesthesia.On MRI images, two distinct intra-axial lesions were seen in the cerebral hemispheres Figure . On the Following the MRI examination, the dog’s SACS deteriorated to 9/18, and there was no clinical improvement following administration of mannitol (1 g/kg IV), furosemide (1 mg/kg IV), or dexamethasone (0.25 mg/kg IV q 12 h). Approximately 30 h after admission, the dog experienced cardiopulmonary arrest. A necropsy was performed.On gross examination, the external surface of right frontal cerebral cortex appeared swollen, and herniation of the cerebellum through the foramen magnum was observed. During transverse sectioning of the brain, a reddish-brown intra-axial mass centered in the subcortical white matter was observed extending from the dorsal aspect of the right frontal lobe Figure H caudallThe right cerebral lesion was composed of a pleomorphic population of neoplastic astrocytes that infiltrated and crossed the corpus callosum Figures D,L. CompA 7-year-old, castrated male Whippet presented with a 1-month history of visual dysfunction and generalized seizures, was evaluated. Neurological examination abnormalities observed were compatible with a diffuse prosencephalic disorder and included a pacing gait with mild generalized ataxia, proprioceptive deficits in all limbs, absent visual tracking OU, and absent menace responses OU associated with normal pupillary light reflexes and unremarkable ophthalmic examination.via the corpus callosum  and prednisone (0.6 mg/kg PO q 12 h) and discharged. Eleven days later, the dog developed status epilepticus and died. On gross necropsy examination, the dorsal surface of the cerebrum appeared diffusely swollen. Transverse sectioning revealed a poorly defined, symmetrical, gray–tan intraparenchymal mass that was centered in the frontoparietal regions of both the cerebral hemispheres and was compressing the lateral ventricles ventrally. On midline, the mass infiltrated the falx cerebri. In its course adjacent to the mass, the dorsal sagittal sinus was thrombosed.The corpus callosum was virtually effaced by continuous sheet of pleomorphic neoplastic astrocytes, with tumor cells extending throughout the white matter and obliterating the cerebrocortical architecture of both cerebral hemispheres. Regions of intratumoral necrosis, hemorrhage, and microvascular proliferation were present Figure D. Severavia white matter tracts, perivascular spaces, cerebrospinal fluid pathways, and subependymal routes, BG has not been an entity previously recognized in dogs  phenotype , which i in dogs –7.In this series of dogs, BG was clinically characterized by the presence of neurological dysfunction referable to multifocal or diffuse forebrain disease, and neuroradiologically there were lesions in both the cerebral hemispheres. These features are atypical in dogs with supratentorial gliomas, in which the majority have a clinical presentation reflecting lateralized or historical, non-localizing  forebrain disease, corresponding with a solitary intra-axial mass on MRI , 5. On MThere were variable degrees of lesion symmetry seen in the BG of these dogs, ranging from the GBM of Case 3, which displayed both interhemispheric uniformity in the anatomic distribution of the lesion as well as symmetrical intra- and perilesional signal changes, to the highly asymmetric tumor burden between cerebral hemispheres noted in Case 1. Despite the common inclusion of the “symmetric” term in the definition of BG, a recent study demonstrated that only 4/23 of human BG were symmetrical, with symmetry defined as having <10% difference in the contrast-enhancing tumor burden between cerebral hemispheres (In humans, the corpus callosum is resistant to the spread of edema and infection, and, thus, there is a limited list of imaging differentials for mass lesions infiltrating this structure . These dAlthough rare, BG should be considered as a differential diagnosis in dogs with intra-axial mass lesions with inherent signal changes consistent with glioma that extend through the corpus callosum to involve both the cerebral hemispheres. In both dogs and humans, the neuroradiological appearance of BG may often be asymmetrical and is frequently caused by GBM.All authors meet the criteria for authorship. JHR, TP, and SE participated in clinical case management. JHR, KC, and WD drafted the manuscript. KC reviewed the neuroimaging studies, and JLR provided the neuropathological interpretations. JHR and WD provided material support for performance of the immunohistochemical studies. All authors participated in the review and the editing of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Onchocerca lupi, a filarioid of zoonotic concern, infects dogs and cats causing ocular lesions of different degrees, from minor to severe. However, infected animals do not always display overt clinical signs, rendering the diagnosis of the infection obscure to the majority of veterinarians. Canine onchocercosis has been reported in the Old World and the information on its occurrence in the United States, as well as its pathogenesis and clinical management is still meagre. This study reports on the largest case series of O. lupi infection from the United States and reviews previous cases of canine onchocercosis in this country.O. lupi infection in dogs diagnosed in Minnesota, New Mexico, Colorado and Florida, from 2011 to 2014, was obtained from clinical records provided the veterinary practitioners. Nematodes were morphologically identified at species level and genetically analyzed.Information on the clinical history of a series of eight cases of O. lupi.All dogs displayed a similar clinical presentation, including subconjunctival and episcleral nodules, which were surgically removed. Each dog was subjected to post-operative therapy. Whitish filaria-like parasites were morphologically and molecularly identified as O. lupi is endemic in the United States, indicating that the distribution of the infection is probably wider than previously thought. With effect, further studies are urgently needed in order to improve the diagnosis and to assess the efficacy of therapeutic protocols, targeting the parasite itself and/or its endosymbionts.This study confirms that  Wuchereria bancrofti and Onchocerca volvulus, the agents of human lymphatic filariasis and river blindness, respectively, which are included in the WHO's priority list of the neglected tropical diseases 22]. In aOnchocerca sp. and microfilariae sent to the Centers for Disease Control and Prevention .An 8-year-old female dog, rescued in Hollywood (Florida) on June 2014, was presented to a local ophthalmologist due to the onset of conjunctival granulomas, which were surgically removed and histologically examined. The animal was treated for heartworm with ivermectin  and fenbendazole . A few months later, conjunctival lesions reoccurred OU and the animal underwent a second surgery during which nematodes were extracted. Samples were sent to Cornell University to be morphologically and molecularly identified. A gravid female worm was morphologically identified as A 7-year-old castrated mixed breed male dog from Oronoco (Minnesota) presented at the BluePearl Veterinary Partners hospital in Eden Prairie (Minnesota) with a 1-year history of red eyes that worsened into proliferative ocular lesions on the medial aspects of the globes OU. The owners reported that their pet was adopted one year before from the municipality of Durango (Colorado) and that it suffered mild scleritis. At the ophthalmic examination, both eyes appeared similar with two pink subconjunctival masses. The first (5 mm in diameter) was located immediately posterior to the nasal limbus, and the second, less dense, was located approximately 3 mm posterior to the temporal limbus . The animal displayed a red swollen left eye , where she was adopted about six weeks before. The animal was apparently healthy, apart for a slight squinting and disconformity in the size of the eyes. The animal was heartworm antigen negative. At the ophthalmic examination, the eyes presented numerous inflammatory conjunctival follicles, mild epiphora, mild diffuse conjunctival hyperemia and soft episcleral swellings in the temporal quadrant, larger in the right eye. During the incisional biopsy, some nematodes were detected and extracted. Oral treatment with ivermectin  and doxycycline  was performed. The animal was followed-up three months later and did not show any relapse.A 3-year-old neutered male Labrador retriever mix dog was presented on October 2012 with a complaint of recent conjunctivitis in both eyes. The animal was rescued from an animal shelter in Farmington (New Mexico), approximately one year before. At the presentation, no blepharospasm or significant conjunctival hyperemia were observed but large subconjunctival granulomas  was presented on May 2014 due to moderate chemosis and to an episcleral flocculent mass in the lateral portion in the right eye. The animal was heartworm antigen negative. A subconjunctival exploratory was performed and multiple thread-like nematodes were removed from the episcleral region in the right eye. The animal underwent the same therapeutic protocol and recheck examinations of case 4, being completely healthy at each follow-up.A 9-year-old neutered female red Australian cattle dog from Jerez (New Mexico) was presented on June 2013 with a history of a chronic waxing/waning episcleral mass in the left eye, which was firm on palpation Figure A. The anA 5-year-old neutered male German shepherd dog from Farmington (New Mexico) was presented on April 2011 due to chronic conjunctivitis in the left eye. Ophthalmic findings revealed a large flocculent episcleral mass in the left eye, occupying the entirety of the ventral episcleral mass and extending distally past the equatorial portion of the globe. The animal was diagnosed with keratoconjunctivitis sicca (KCS) but was heartworm antigen negative. A subconjunctival exploratory surgery was then performed and several thread-like nematodes were removed from the left eye. The animal was treated as in the cases above, along with tacrolimus  to address the KCS and was monthly rechecked for a period of four months. One year following the last monthly recheck examination, the dog displayed recurrence of conjunctivitis in the left eye, exhibiting moderate chemosis of the ventral bulbar conjunctiva. A second subconjunctival exploratory surgery was performed but no nematodes were detected. Monthly recheck examinations were performed for a period of three months. At each of these rechecks moxydectin was administered (0.22 mg/kg subcutaneously). Additional postoperative therapy was doxycycline, doxycycline  and neopolydex in both eyes, three times daily. Following monthly recheck examinations and the final moxydectin injection, prophylactic oral anthihelmintic therapy with ivermectin was initiated at 400 μg/kg orally every day for 30 days and recommended for life. The dog remained disease free.O. lupi. In addition, a 100% nucleotide sequence homology was recorded between pcox1 [cox1: JX080028- JX080031, JF758473-JF758475, KC763785-KC763786; 12S rDNA: KC763783).Specimens presented external round transverse ridges and two transverse striae per each outer ridge interval, with a typical body diameter/ridge distance interval of 7–10:1 . The nemen pcox1  and 12S O. lupi infection in dogs. Along with data in the literature , which is peculiar to this nematode, and to a retrospective analysis of the geographical origin of the infections. For example, O. lupi has been diagnosed in Palmdale, California [Onchocerca sp. was previously documented [Data reported provide new information on the clinical presentation of re Table , results species ,17-19, mlifornia , which iO. lupi in the United States deserves to be thoroughly assessed since it is likely more widely distributed than currently believed. Indeed, all the reports above were characterized by nodular lesions, but, in the only large epidemiological study performed in Portugal and Greece, where clinical cases were reported, up to 8.4% of the examined animals scored positive for O. lupi microfilariae [O. lupi [Consequently, the epidemiology of filariae . Certain[O. lupi  would ovO. lupi infection is usually long [O. volvulus  [D. immitis infection are not able to detect cross-reactions with O. lupi. Accordingly, since some of the dogs herein examined underwent chemoprophylactic treatment for the canine heartworm disease with ivermectin, this therapy is most likely ineffective against O. lupi. Indeed, to date the only treatment with reputed efficacy for ocular onchocercosis is represented by the surgical removal of the parasitic nodule followed by post-operative therapeutic administration of melarsomine , ivermectin , topical antibiotics and systemic prednisolone [Wolbachia endosymbionts were detected in O. lupi [Wolbachia endosymbionts of filariae was effective in damaging and even killing D. immitis adult worms [D. immitis, eventually reducing the risk of thromboembolism [D. repens, a cause of subcutaneous dirofilariosis [Cases herein reported were characterized by a similar clinical presentation, which included subconjunctival and episcleral nodules. In addition, all dogs examined were adults (from three to nine years of age), which may be due to the fact that the incubation period of lly long , as alre months) . The negnisolone ,14. The  O. lupi ,15,29 anlt worms  and succembolism ,32. Similariosis .O. lupi may be a risk for human health. Along with the human case reported from Arizona [O. lupi infection infection, to better define its pathogenesis, and to report the efficacies of therapeutic protocols, based on controlled clinical trials. These studies should target the parasite itself and/or its endosymbionts.Data herein reported indicate that  Arizona , other c Arizona ,34. Ther


Introduction. Enterovesical fistula is rare and is often caused by bowel inflammatory diseases and tumours in the urinary bladder or the intestine with local infiltration of bowel or bladder, respectively. The fistula usually presents with lower urinary tract symptoms, pneumaturia, and faecaluria or with food particles in the urine. Intra-abdominal retained surgical foreign bodies have also been reported as causes.  Case Presentation. A case of atypical presentation in a woman with enterovesical fistula following abdominal hysterectomy. Investigations confirmed the presence of surgical towel in the urinary bladder and a pair of artery forceps in the abdomen. The towel was removed at cystoscopy after which she presented with food particles in the urine. She later had laparatomy to remove the haemostat and to repair the fistula.  Discussion. A typical presentation of enterovesical fistula delayed the diagnosis and treatment in this patient.  Conclusion. Managing patients with recurrent urinary tract infection after abdominal operation should include appropriate imaging of the abdomen with emphasis on pelvic organs. Also, surgical operation should always be given the best shot the first time and strict operation room standards and guidelines should always be followed. Enterovesical fistula (EVF) is an abnormal communication between the intestine and the urinary bladder. It is rare and studies have reported an incidence of less than 4 cases per year , 2. EnteRetained surgical foreign bodies (RSFB) following operative procedures have been reported –11. The Intra-abdominal foreign bodies have been associated with erosion into luminal or hollow structures creating different forms of internal and external fistulae with various presentations depending on the structures involved. There have been reports of aortoenteric fistulae from RSFB manifesting as gastrointestinal hemorrhages . Entero-A 48-year-old obese woman was referred to our unit following an ultrasound finding of an echogenic mass in the urinary bladder while investigating her for a 10-month history of recurrent lower urinary symptoms. Her symptoms started a few weeks after she had abdominal hysterectomy. This was her third intra-abdominal operation. The record of the hysterectomy showed that it was difficult and prolonged arising from extensive intra-abdominal adhesions. The procedure lasted for several hours necessitating the change of scrub nurses and the invitation of a senior gynaecologist. The postoperative period was turbulent as the patient developed postoperative sepsis and surgical site wound infection and, subsequently, superficial wound dehiscence. She was discharged after secondary suturing of the dehisced wound and total hospital stay was one month. After her discharge, she continued to have a gamut of complaints including lower abdominal pain and irritative lower urinary tract symptoms. There was no associated pneumaturia, faecaluria, hematuria, necroturia, or leakage of urine per rectum. Serial urine cultures yielded different coliforms and her lower urinary tract symptoms responded fleetingly to antibiotics based on urine culture sensitivity pattern each time.Abdominal ultrasound scan done revealed an echogenic mass in the urinary bladder and urethrocystoscopy revealed a surgical towel in the bladder. A part of the towel was pulled out of the bladder by a grasper through the urethral meatus and then held by a pair of forceps. It was then pulled out gradually while being cut in bits and pieces were retrieved piecemeal endoscopically using a grasper and cut into bits and pieces with a pair of scissors as it was gradually retrieved Figures . A size The patient had laparatomy during which the haemostat was found buried in adhesions with small bowel looping around it. It was removed and a piece of degenerating surgical textile material was found between the jaws of the haemostat. With little manipulation, the jaw of the haemostat got broken. A fistulous connection between the ileum and the dome of the urinary bladder was also found. The segment of the small bowel contiguous to the fistula was resected and sent for histology, and intestinal continuity was restored through an end to end anastomosis. The bladder defect was closed in two layers. The patient did well postoperatively and was discharged after about 10 days on admission. She has since been lost to follow-up.Typically, patients with EVF will present with faecaluria, pneumaturia, dysuria, hematuria, and chronic abdominal pain in hypogastric and left iliac regions . HoweverThe simultaneous finding of intra-abdominal haemostat and intravesical surgical textile is quite rare. The explanation for the occurrence requires some deep thoughts and analysis. There are several reports of transmural migration of RSFB through several luminal intra-abdominal organs with various consequences , 9, 17. In this case, it was obvious that the operation was a difficult one which lasted for several hours, requiring the invitation of more experienced hands and a change of guards by the perioperative nurses. Such a scenario has at least three risk factors described by Stawicki et al.  in theirSurgical operation should always be given the best shot the first time and strict operation room standards and guidelines should always be followed.Since RSFB cannot be completely avoided in surgical practice, it should be given considerations in the list of differential diagnoses in order to make early diagnosis and treatment. This is because it has been a cause of untold suffering, morbidity, and mortality, especially when diagnosed late. Also, whenever there is recurrent urinary tract infection especially in a postoperative patient, abdominopelvic ultrasound scan should be done to exclude the possibility of an intravesical foreign body.


Inverted sinonasal papilloma (ISP) is a benign epithelial neoplasm arising from the Schneiderian membrane. We report a case of ISP in a 50-year-old male that clinically presented as a polypoid mass in the nasal cavity. Imaging studies revealed it to be an aggressive lesion showing intracranial extension. On histopathological examination of the excised specimen, a diagnosis of ISP was arrived at. However, an extensive sampling of the tissue revealed no evidence of any malignant transformation. Taking into account the suggested viral aetiology for such lesions and the aggressiveness observed in this case, human papillomavirus (HPV) profiling was done but it turned out to be negative. Only one other case of inverted sinonasal papilloma arising from the nasal cavity and involving the brain has been reported in the literature to date. Considering the alarming clinical course in spite of its benign nature, it is important for the pathologist and surgeon to be well informed about this lesion. Schneiderian papillomas or sinonasal papillomas are benign epithelial neoplasms arising from the Schneiderian membrane that lines the nasal cavity and paranasal sinuses. Histomorphologically, there are three types: exophytic, inverted, and oncocytic, with the inverted type accounting for about 47% of all sinonasal papillomas . InverteA 50-year-old male patient presented with complaints of nasal stuffiness and bilateral purulent blood-tinged nasal discharge of eight years duration. He experienced vomiting, occasional loss of consciousness, anosmia, and headache for the last one month. The patient also gave a history of undergoing an operative procedure for removal of a nasal growth 10 years ago. He had been under Siddha treatment  for the same problem since that time. On physical examination, a diffuse swelling was seen on the left side of the nose, obliterating the nasal fold and causing flaring of the left ala. A reddish pink polypoid mass partially filling the left nasal cavity, with associated purulent bloody discharge, was noticed  scan of the head and neck with contrast revealed an enhancing soft tissue mass arising from the left lateral nasal wall, filling the left maxillary sinus, and partially extending into the right nasal cavity Figure . It furtAn incisional biopsy of the tissue from the nasal region on histopathological examination revealed an extensive proliferation of thick, non-keratinizing squamous epithelium showing endophytic growth in most of the areas Figure . Goblet Following this, a wide excision of the lesion was planned. A bifrontal craniotomy was performed. A complete removal of the cranially extending polypoidal sinonasal growth was carried out by an open approach Figures -7. PostoISP is a benign lesion with a prevalence of 0.5 – 4% of all sinonasal tumors . CalifanAlthough many factors, such as allergy, chronic sinusitis, human papillomavirus (HPV), Epstein-Barr virus (EBV), environmental carcinogens, and tobacco smoking, have been proposed, the actual etiology of ISP is still unknown. Documented reports on the association of ISP with EBV and HPV are variable , 6. EverISPs predominantly occur in males with a peak incidence in the fifth and sixth decades of life . AccordiEarly diagnosis of ISP is necessary for optimum management. Clinical examination using nasal endoscopy may facilitate the assessment of the local extent of the tumor while also allowing tissue sampling for biopsy. However, aggressive ISPs located within the craniofacial skeleton cannot be accurately assessed using nasal endoscopes. Assessment of such cases can be achieved with the help of computed tomography (CT) scans and magnetic resonance imaging (MRI).Differential diagnosis of ISP includes antral choanal polyps, allergic fungal rhinitis, giant cell granuloma, and mucocele. A diagnosis of ISP just based on clinical and radiographic features without the histopathology report cannot be arrived at, as it lacks pathognomonic features . The WorMirza, et al. suggest that intracranial extension is rare unless malignant transformation is present . HoweverThe association of ISP with malignancy may be manifested either as synchronous carcinoma or as metachronous carcinoma, with squamous cell carcinoma (SCC) being the most predominantly associated malignancy. The frequency of carcinoma associated with ISP is reported to be 1 – 50% ; howeverLawson, et al. highlighted the likelihood of recurrence in ISP where HPV detection is positive . AccordiThe treatment of choice for ISP is a complete surgical excision using either an open or endoscopic approach. Staging allows the assessment of outcome following different approaches. Our case falls into Stage IV of the Krouse classification  and GrouThis case report highlights the deceptive behavior of inverted sinonasal papilloma. It is rare and unusual to encounter a sinonasal papilloma presenting as a space-occupying lesion in the brain and causing a major catastrophe. Although a benign lesion, local aggressiveness and a propensity for recurrence and malignant change typically differentiates inverted papilloma from the rest of the neoplasms in the sinonasal region and poses a real challenge to clinicians and surgeons. Association of HPV and ISP truly dictates the necessity for its profiling in identifying patients at risk for recurrence and to rule out malignancy.


Teratomas are a germ cell tumors composed of two or more tissues which originate from ectoderm, endoderm or mesoderm. These tumors commonly arise from the ovary although other extragonadal sites can be involved, especially in children.We report a case of a 21-year-old female of Sukuma ethnicity from the northern region of Tanzania who presented with abdominal pain and distension, fever, and abnormal vaginal discharge for the previous three weeks. The patient was also lactating for the previous 8 months following cesarean section delivery. Pelvic ultrasound suggested pelvic abscess but after laparotomy and histological analysis of a bulky uterus removed a diagnosis of mature uterine teratoma was confirmed.Although it is rare, uterine teratoma should be considered in differential diagnosis to any patient with uterine mass even without typical radiological findings. Teratomas are usually composed of two or more embryonic germ layers: ectoderm, endoderm, and mesoderm. Extragonadal teratomas are ectopic to the location in which they are found. Teratomas can be classified as mature or immature on the basis of the presence or absence of immature neuroectodermal tissues in the tumor. Mature tumors have far less tendency to develop into malignancy compared to immature tumors. Teratomas are the most common gonadal tumors. They usually arise in the gonads and often occur in infancy and childhood. Extragonadal teratomas are rare and commonly develop in midline structures . UterinePrimary teratomas of the uterus have rarely been reported since Mann’s first description of this entity in 1929 [A 21-year-old female of Sukuma ethnicity from the northern region of Tanzania presented at Bugando Medical Centre (BMC) outpatient clinic in Mwanza city with complaints of abdominal distension and pain, fever and abnormal vaginal discharge for the past 3 weeks. She was apparently lactating for the previous 8 months after cesarean section delivery of her first child. On physical examination, she appeared to be weak, febrile of about 38.5 °C with blood pressure of 110/70 mmHg. She was a blood group ‘A’ rhesus positive and her hemoglobin level was 6.3 g/dl.On abdominal examination, a sub-umbilical midline scar was seen, and palpable suprapubic mass of about 16 weeks size of the uterus. The mass was soft, tender and mobile. The digital pelvic and vaginal examination elicited a closed cervix with tenderness on mobility and a non-bulging posterior fornix. There was no adnexal mass detected and gloved finger stained with pus-like discharge. Pelvic gynecological ultrasound suggested pelvic abscess  and observed by a light microscopy. Histology revealed a cyst in a myometrium contained keratin debris, and it was lined by squamous epithelium with dermal skin appendages with areas of denudation with lymphocyte and neutrophil infiltrate. The myometrium and endometrium was normal. Diagnosis of infected mature teratoma (dermoid cyst) was made Figs.  and 3.FiThe patient has not shown any sign of disease recurrence for 8 months following hospital discharge.Mature cystic teratomas of uterus corpus are very rare and thought to originate from displaced germinal cells derived from pluripotential stem cells. The most commonly occurring mature cystic teratomas of the uterus are of the cervical part . The preOur patient was in reproductive age, recently delivered and lactating; the presentation which is likely to develop teratoma due to the possibility of products of conceptus being implanted at any part along the reproductive tract during the process of fertilization according to the Blastomere Theory –10. AlthUltrasound images of the patient suggested pelvic abscess, but an explorative laparotomy and histopathological analysis of the excised bulky uterus led to a diagnosis of teratoma. In centers with, CT and MRI, those imaging techniques could have led to a correct diagnosis because of their higher accuracy compared to the ultrasound imaging . Again, Due to its rarity of occurrence, there is no standard guideline for management of mature uterine teratoma. The few case reports, however, suggest that the best management is complete tumor excision or total abdominal hysterectomy , 4, 6–8.Although it is rare, uterine teratoma should be considered in differential diagnosis in any patient with uterine mass even without typical radiological findings."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 of this journal".


Introduction. Nonbacterial thrombotic endocarditis (NBTE) is a rare manifestation of hypercoagulability in patients with malignant neoplasms. Case Report. A fifty-six-year-old woman presented to the emergency service; the clinical workup revealed deep vein thrombosis in right leg and bilateral massive PTE. As the abdominal sections on the spiral CT revealed a giant pelvic mass of ovarian origin, she was referred to our hospital's gynecologic oncology department. She was scheduled for surgery under enoxaparin. She described numbness on one side of her face. Cranial imaging findings revealed acute ischemic cerebral lesions and transesophageal echocardiogram showed vegetation on the aortic cusp. Under anticoagulation treatment, she underwent hysterectomy with bilateral salpingo-oophorectomy and infracolic omentectomy. After tumor resection, her neurological symptoms dissolved with aggressive anticoagulant treatment. Pathology result was synchronous endometrial and ovarian adenocarcinoma. Discussion. NBTE is a rare condition often associated with advanced malignancies. Peripheral embolism and venous thrombosis are complications that have been associated with NBTE due to hypercoagulable state. These disorders could be resistant to routine anticoagulant treatment. In case of a thrombotic complication due to ovarian malignancy, surgical resection of the primary tumor may increase the effect of anticoagulant treatment. Thrombosis is a common complication in cancer patients, with 15% of all cancer patients developing clinically apparent thrombosis .Nonbacterial thrombotic endocarditis (NBTE) is a rare manifestation of hypercoagulability in patients with malignant neoplasms. Peripheral embolism and venous thromboses are complications that have been associated with NBTE due to a hypercoagulable state . SystemiHere, we report a rare association of NBTE in a patient with two primary gynecological cancers presenting with embolic stroke and pulmonary thromboembolism (PTE). To the best of our knowledge, such a case has never been reported in the literature.A fifty-six-year-old nulligravid woman was admitted to the emergency service of a community hospital with shortness of breath and mild chest pain. The clinical workup revealed deep vein thrombosis in her right leg and bilateral massive PTE. As the abdominal sections on the spiral computerized tomography (CT) scan revealed a giant pelvic mass of ovarian origin with septa, solid component, and ascites, she was referred to our hospital's gynecologic oncology department after initial anticoagulant treatment with unfractionated intravenous (IV) heparin. Her initial examination was remarkable for pelvic mass up to the level of umbilicus and mild orthopnea. In the repeated abdominal CT scan, a 165 × 130 × 90 mm solid cystic mass probably originated from the left ovary, ascites, and splenic infarcts were seen . Her CA-Two days before the planned day of surgery, the patient described numbness on one side of her face. The patient was examined by a neurologist and a cranial CT scan was found to be normal. In the night before surgery, the patient developed sudden aphasia and dizziness. In the cranial diffusion MRI, there were multiple lesions at the border zones and there was a huge acute infarct at right temporal zone. She was started on IV heparin treatment immediately after the diagnosis. Transesophageal echocardiogram (TEE) showed 7 × 2 mm vegetation on the mitral cusp. Despite IV heparin treatment for almost 48 hours, her neurological examination did not improve and got worsened. The patient became lethargic and she started to have episodic seizures. After an urgent bedside consultation with the neurology department and having informed consent from the patient, she was taken to the operation room and underwent hysterectomy with bilateral salpingo-oophorectomy and infracolic omentectomy under anticoagulation treatment with full dose IV heparin . After tPathology result was synchronous stage IA, grade 2, endometrioid endometrial adenocarcinoma and stage IC grade 2 endometrioid ovarian adenocarcinoma. She received six cycles of platinum based adjuvant chemotherapy. At one-year follow-up, her abdominal CT scan showed no evidence of disease and her aphasia almost disappeared with speech therapy.Over 90% of cancer patients develop laboratory evidence of coagulation abnormalities during the course of a malignant illness or its treatment . IncreasIn case of a malignancy, procoagulant activity increases and fibrinolytic activity decreases. This combination accelerates the prothrombotic potential of endothelial cells .NBTE is a rare condition often associated with hypercoagulable states or advanced malignancies and is characterized by cardiac vegetation along valvular coaptation lines without destruction of leaflets. NBTE vegetation is smaller and mostly detected by TEE, as in our case. Pathogenesis of NBTE is similar to the mechanisms underlying cancer hypercoagulability .Patients with adenocarcinomas are reported to be at fivefold higher risk for nonbacterial endocarditis than patients with other histological types of malignant tumors . NBTE, tCerebral infarction from NBTE presents acutely with focal cerebral symptoms and signs that can be a transient ischemic attack or completed infarction. Multifocal ischemic events can occur. Aphasia is the most common neurologic sign and correlates with involvement of branches of the middle cerebral artery. In many patients, multifocal thromboembolism culminates in widespread infarctions of varying sizes, producing confusion and lethargy .The treatment of NBTE includes anticoagulation and appropriate treatment of underlying cancer, although there is no established strategy for anticoagulation. A study performed using heparin versus warfarin in patients with NBTE and malignancy only showed benefit with heparin . A largeThe hypercoagulability disorders in cancer patients could be resistant to routine anticoagulant treatment and clinicians, especially oncologists, may need to react faster than usual when dealing with primary oncological cases that have thrombotic conditions due to underlying neoplasms. When the hypercoagulable state in patients with ovarian cancer could not be totally cured by standard anticoagulation therapy with heparin or coumarin derivatives, trying to treat the underlying malignancy could help control the hypercoagulable status .In conclusion, surgical resection of the primary tumor may prevent recurrent thrombotic events due to ovarian malignancy and may increase the effect of anticoagulant treatment. Oncologists should react promptly to break the circle of cancer, thrombosis, and inoperability.


Urethral prolapse (UP) is a circular complete eversion of the distal urethral mucosa through the external meatus. It is a rare condition seen mostly in African-American premenarcheal girls. Both a medical and a surgical approach to this condition have been described. We present a case of a spontaneous urethral prolapse in a 60-year-old postmenopausal Caucasian woman, who failed medical management and underwent successful surgical management. The patient is asymptomatic 18 months following the procedure. Urethral prolapsed (UP) is a rare and benign condition, with an incidence of 1 : 3000, especially among prepubertal, primarily African-American girls (~80%) , 3. In rUP presents as a circular and complete eversion of the urethral mucosa at the external meatus. On physical examination, this circumferential lesion of mucosa may look as a red/pink/purple ring, sometimes infected or ulcerated, around what appears to be the external meatus.The spontaneous postmenopausal cases tend to be symptomatic, with vaginal bleeding being the most common presenting symptom, although dysuria, hematuria, urinary frequency, urgency, and nocturia may also be present.There is still controversy regarding treatment of this rare entity ranging from conservative treatment options  as first-line  to diffeWe present a case of a large spontaneous UP managed successfully by a surgical approach.A 60-year-old Caucasian female presented with a few weeks of dysuria, frequency, urgency, and hematuria without fever or chills. She also reported a long standing “lump” in her vulva. Nitrofurantoin 100 mg TID combined with Phenazopyridine TID did not improve her symptoms, nor did topical ointments or sitz baths. Vaginal examination revealed a uterine and cervical prolapse of mild degree and a reddish partly necrotic lump 3 cm in diameter around the area of the urethral meatus.Transvaginal ultrasound demonstrated a normal sized uterus with thin layered mucosa without masses or pelvic fluid.Laboratory evaluation showed complete blood count and blood chemistry were within normal limits and urinalysis showed leukocyturia and erythrocyturia with no bacterial growth on culture.The mass was carefully dissected using four-quadrant excisional technique  Figure . The patGross pathological examination of the specimen showed irregular fragments of tissue in a total dimension of 3.5∗2∗1.5 cm with areas of bleeding.Histopathology showed fragments of urethra with severe inflammation ulceration and cavernous hemangioma.The urinary catheter was withdrawn at postoperative day 5. Within 2 weeks there was marked clinical improvement with reduction of the periurethral swelling; no mass was identified . On follUP is a rare encounter among adult female patients. In choosing this patient's management we had to bear in mind the severity of her symptoms, a high recurrence rate after pure medical treatment, and the differential diagnosis that includes, among others, urethral or vaginal malignancy, condyloma, and rhabdomyosarcoma.In this case we were faced with a highly symptomatic otherwise healthy patient, who failed prior medical treatment and was in need of prompt relief of her symptoms. According to the literature, surgical excision still remains the most definitive therapy. There are several surgical approaches described, especially among children, like tying the prolapsed tissue on a catheter . The mos


Background. Solitary fibrous tumors are ubiquitous mesenchymal neoplasms of putative fibroblastic origin. They were originally described in the pleura but subsequently have been reported in many extraserosal sites. Solitary fibrous tumors may also occur in the meninges, central nervous system parenchyma, and spinal cord. Case. A 67-year-old male patient with progressive lower extremity weakness, urinary urgency, and sexual dysfunction has been admitted to our hospital. On his lumbar MRI, we detected an intradural lesion posterior to the L3 vertebral corpus. We resected the lesion by L3 total laminectomy. Immunohistological findings revealed strong and diffuse immunopositivity with vimentin, CD34, and bcl-2. Ki-67 proliferation index was 5–8%. We did not detect any recurrence 12 months after his operation. Conclusion. SFT is mostly seen in young and middle-aged patients and should be considered among differential diagnosis in cases suffering from pain, hypoesthesia, and urinary dysfunction. Gross total resection should be primary treatment. Tumors that have high Ki-67 labeling should be followed up for potential recurrences. Solitary fibrous tumors (SFTs) are ubiquitous mesenchymal neoplasms of putative fibroblastic origin . They weWe describe a rare SFT case of the lumbar spine which presented with a few minor neurological deficits. We also discussed its surgery and histopathologic and immunohistochemical features that will likely be of utmost importance in the follow-up of the patient.A 67-year-old male patient was admitted to our department with progressive walking disability for the last 6 months. Moreover, the patient had experienced urinary urgency and sexual dysfunction for the last 3 months. His physical examination was within the normal limits. Neurological examination revealed paresis of bilateral iliopsoas and rectus femoris muscles. The iliopsoas muscle showed a 3/5 motor loss on the right side and 4/5 on the left side. Additionally bilateral rectus femoris muscle deficit was 4/5. The patient had hypoesthesia in areas that corresponded to the L3 and L4 dermatomes. His lumbar T2-weighted magnetic resonance imaging (MRI) showed a well-circumfluenced and hypointense lesion with 1.3 × 1.5 × 1.5 cm that was located in posterior of the L3 vertebral corpus. This lesion was pushing intradural neural structures to the left side and anterolaterally Figures . The lesA L3 total laminectomy was performed on the patient. Upon the 2 cm vertical incision of bulky dura, it was bulky and, during the exploration of dural sac, highly vascularized and well contoured lesion was pushing rootlets anteriorly. The lesion was brown discolored without invading dura and minimally adhesive. There was no evidence of mass effect or invasion over the root. Initially this particular lesion was released from dura and then from the adjacent arteries; venous connections of the lesion were completely resected. Clinical and neurological symptoms were related to cauda equina syndrome that was secondary to the mass compression. His postoperative neurological examination showed bilateral ameliorated muscle strength which was accompanied with 4/5 of iliopsoas and rectus femoris muscles.All formalin-fixed, paraffin-embedded (FFPE) surgical materials were sectioned and stained routinely with hematoxylin and eosin; selected sections from surgical material were stained with Gomori reticulin and Masson's trichrome stain. Immunohistochemical stains for epithelial membrane antigen , BCL-2 (SYCTEK [12  4]), vimentin (SYCTEK [v9]), S-100 (SYCTEK [4c4.9]), progesterone (NOVOCASTRA [PGR-312]), smooth muscle actin (SMA) (SYCTEK [sm-1]), desmin (SYCTEK [DE-R-11]), CD34 (SYCTEK [QBend/10]), p53 (SYCTEK [DO/7]), and Ki-67 (DAKO [MIB-1]) were performed on selected sections with appropriate positive and negative controls.Histological examination revealed uniform spindle cells arranged in interlacing fascicles with deposition of scanty collagen between cells . Tumor cImmunohistological findings revealed strong and diffuse immunopositivity with vimentin , CD34, aThe most recent neurological examination of the patient was performed at 12 months postoperationally. His muscle strength was 5/5. His control lumbar MRI showed no evidence of recurrence.SFT was defined for the first time in 1931 by Klemperer and Rabin as a tumor that originates from pleura . When weOur case differs from other spinal SFT cases by being located in lumbar area. Even though intradural localization is common on spinal SFT cases, only 37% of these cases are found intradurally and extramedullary . This raWhen we examined the initial symptoms at admission we appreciated that the majority of symptoms were pain, hypoesthesia, paresis, urinary dysfunction, or combination of these . SimilarMRI findings of SFT are usually similar to one another in literature. Fargen et al. reported that two-thirds of lesions were isointense on T1-weighted imaging with the remainder being either heterogeneous or hypointense. Nearly two-thirds of cases were hypointense on T2-weighted imaging with hyperintense being the next most common (17%). Over three-quarters of cases demonstrated diffuse or homogeneous contrast enhancement with gadolinium administration (78%); however, a significant portion demonstrated only partial or heterogeneous enhancement (21%) . SFTs haSFTs are just one of the vimentin/CD34/Bcl-2 families of tumors . SFT canImmunohistochemically, they are strongly stained with CD34 and vimentin but are unlikely stained with EMA or S-100 protein .Solitary fibrous tumors arising in spinal nerve roots must be differentiated from schwannoma, meningioma, and hemangiopericytoma. Albeit morphologic features may be helpful. Schwannoma often shows alternating Antoni A and Antoni B areas. Meningioma frequently reveals cellular whorls and psammoma bodies. Finally differential diagnosis depends on immunohistochemical features of this tumors. Schwannomas are invariably S-100 protein positive and meningiomas are epithelial membrane antigen (EMA) positive, whereas both antibodies are absent in SFT. About half of hemangiopericytomas are CD34 immunoreactive, at least focally. They also share many histologic features with SFTs, except for dense collagen bands, which are generally absent in hemangiopericytomas. They probably belong to the same tumor spectrum, and the same features  are predictive of malignancy in both hemangiopericytomas and SFTs. According to some authors, distinguishing between questionable cases may not be important.P < 0.05) [In our case, histopathologically, there were extensive fibrosis and hyalinization, staghorn like vascular channels. However, there was no evidence of mitotic figures or necrosis or psammoma bodies. Immunohistological findings revealed strong and diffuse immunopositivity with vimentin, CD34, and bcl-2. The tumor cells did not exhibit positive staining for EMA, S-100, smooth muscle actin, desmin, and progesterone. Desmin and S-100 immunoreactivity were also rare in the literature such as in our case . Liu et  < 0.05) .Spinal lumbar intradural extramedullary solitary fibrous tumor is very exceptional and should be considered among the differential diagnoses of spindle cell tumors. Immunohistochemistry is crucial for the accurate diagnosis of SFT.