Cutaneous metastasis from colorectal cancer after excision of the primary is a rare occurrence and presents as cutaneous or subcutaneous nodules or as a rash commonly on the anterior abdominal wall.This is a case description of the management of a large fungating peristomal cutaneous metastasis occurring 14 years after abdomino-perineal excision of the primary cancer. The gross appearance initially suggested possibility of a true metachronous cancer with peristomal spread. But histopathology of the resected specimen showed no colonic mucosal involvement suggesting a true large cutaneous peristomal metastasis which has not been reported previously. Literature review of presentation, management and prognosis of cutaneous metastasis from colorectal cancer is describedCutaneous metastasis following colorectal cancer resection is a well-recognised entity though rare. Any unusual skin lesions especially on the abdominal wall skin, previous incision scars or near the stoma should be biopsied early to rule out metastatic disease and systematic work-up should be carried out to rule out any metachronous tumour or metastasis elsewhere in the body. Cutaneous metastasis arising from colorectal malignancy is a rare occurrence though well reported in literature. It is a pointer to more widespread disease and usually indicates a poor prognosis. Cutaneous metastasis can be the presenting feature before the primary is diagnosed e.g. Sister Mary Joseph's nodules. They can also occur late after the primary has been completely excised and can present either as cutaneous rash or as subcutaneous nodules in proximity to previous operative scars  or on the abdominal wall skin. This is an unusual presentation of a large fungating peristomal metastasis without any visceral involvement following abdomino-perineal excision of a large T4 rectal cancer done 14 years earlier.A 61 year old lady was referred by the General Practitioner as an emergency with a rapidly enlarging fungating mass around her end-colostomy site. She had undergone an abdomino-perineal resection 14 years earlier for a Duke's B rectal cancer. She had initially presented 14 years ago with features of large bowel obstruction secondary to a large rectal tumour. She had a defunctioning loop colostomy constructed followed by adjuvant radiotherapy to shrink the rectal tumour. At the time of the Abdomino-perineal Resection, the tumour was adherent to the uterus and she underwent hysterectomy with bilateral salpingo-oopherectomy with partial vaginectomy to achieve full surgical clearance. Histopathology of the original specimen revealed a T4 tumour with clear margins and no lymph node involvement. No chemotherapy was given after surgery.She was lost to follow-up till she re-presented with this peristomal mass. On clinical examination, she was found to have a large 12 × 12 cms mass, eroding through the skin in two areas, around the stoma, which appeared stenosed but was functioning normally  dressing and an end ileostomy was constructed in the right iliac fossa  presenting in the abdominal incision scars occurring 5 and 3 years respectively after the primary tumour resection [et al. described inflammatory subcutaneous mass > 10 cms diameter appearing 22 months after primary resection, growing in size rapidly on the scapular region within a documented period of 1 month duration [et al reported a case of peristomal erythema, ulceration and induration appearing 6 months after abdomino-perineal resection which on shave biopsy turned out to be metastatic disease and a tiny primary focus was found in the resected stump suggesting a true synchronous tumour (< 1 year of primary resection) with peristomal cutaneous metastasis [Rarely colorectal metastasis may present as a large cutaneous or subcutaneous mass (> 5 cms). Alexandrescu esection . At the duration . This watastasis .Our case is unique due to the size (> 10 cms), location (proximity to colostomy) and the time interval after resection of the primary (14 years). One of the possible mechanisms of spread of the tumour from the rectum to the colostomy site could be via the lymphatic channels in continuity with the loop colostomy that was constructed prior to the patient undergoing the abdomino-perineal excision. The second possibility is for micro-metastasis left behind in lymph nodes along the inferior mesenteric artery pedicle at the time of the abdomino-perineal resection. No specific mention was made in the initial operative notes of the curative or palliative intent of the operation, and if a high tie was carried out (ligation the inferior mesenteric artery flush with the aorta). This could lead to lymph node metastasis developing at a later date and could break through the skin presenting as a fungating mass. Histopathology did not reveal any evidence of lymphoid tissue either in the resected mass or in the remaining mesocolon of the completion colectomy to support these possible lymphatic routes. The third possible mechanism is by iatrogenic implantation of the colorectal cancer cells at the time of initial surgery. This is a well recognised problem and can present as metastatic recurrence in the midline incisions, perineal wounds, port sites and drain sites following surgery. The incidence of wound recurrence following open resection of colorectal cancer was 0.8% to 1.5% in two large series of total of 3314 patients and 80% of these recurrences occurred within 12 months of the initial surgery ,16. The et al found a mean survival period of 18 months in 18 patients with skin metastases from colorectal carcinoma [et al. the survival period was 2 to 4.5 months in 5 cases of colonic cancer [The survival period following diagnosis of cutaneous colorectal metastasis is 1 to 34 months. Lookingbill arcinoma . In the c cancer . The proWide local excision of the cutaneous or subcutaneous lesion is the preferred treatment option in isolated lesions. There are no clear guidelines for the optimum chemotherapeutic regimen for a non-resectable recurrence of colorectal cancer. Focal radiotherapy has been tried for cutaneous rash with poor response ,11. The Cutaneous metastasis following colorectal cancer resection is a well-recognised entity though rare. Any unusual skin lesions especially on the abdominal wall skin, previous incision scars or near the stoma should be biopsied early to rule out metastatic disease and systematic work-up should be carried out to rule out any metachronous tumour or metastasis elsewhere in the body. For isolated cutaneous or subcutaneous metastasis, wide local excision would be the preferred surgical option followed by adjuvant chemotherapy depending on the histopathological status.The authors declare that they have no competing interests.CV prepared the draft manuscript. SN helped in literature search and preparation of manuscript. MJC conceived the idea and edited the final version for its scientific content. All authors read and approved the final manuscript.


Fibroepithelioma of Pinkus (FEP) is a rare indolent variety of basal cell carcinoma that is typically polypoid and located on the trunk of adult males aged 40–60 years. Basal cell carcinoma (including FEP) is very rare in the pediatric population. We are reporting such a case occurring in a 9-year-old boy. A 9-year-old boy presented with a 6.0-mm polypoid erythematous nodule with ulceration on his left chest. An excisional biopsy was done. Histologically, the tumor revealed several foci of superficial basal cell carcinoma along the epidermis. In the dermis, the tumor was composed of basaloid epithelial anastomosing cords that were separated by fibrovascular stroma connected to the overlying epidermis Figure . The hispremalignant fibroepithelial tumor of the skin by Herman Pinkus in 1953 [Fibroepithelioma of Pinkus (FEP) was first described as  in 1953 .Typically, the patients are male, 40–60 years of age and present with a single or multiple pedunculated or sessile nodules with broad base on the trunk or extremities . The tumThe primary differential diagnoses of FEP include BCC, trichoblastoma, and trichoepithelioma. The histologic appearance of the tumor is usually distinctive. Androgen receptor is expressed both in BCC and FEP but minimally in trichoblastomas . On the TP53 might predispose to the development of FEP [PATCHED gene, which provides inhibitory signal in the Hedgehog pathway, could also lead to the development of FEP [The pathogenesis of FEP is still investigational. It is thought that a mutation in the tumor suppressor gene t of FEP ,3,5. FurThe definitive treatment for FEP is complete excision. The tumor is considered an indolent basal cell carcinoma with no metastatic potential. Other treatment options include electrodessication and curettage, cryosurgery, or Moh's micrographic surgery ,3.Written consent was obtained from the parents of the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.ZP reviewed the literature and prepared the photomicrograph, NH drafted the manuscript, and DPS conceived, revised, and submitted the manuscript. All authors have read and approved the final manuscript.


A case of 66-year-old South Indian post menopausal woman presenting a giant ovarian serous cyst adenoma weighing 23 kg is reported here. A 66-year-old woman was referred to our clinic from a local medical center. When she was seen first at our outpatient clinic, she had gross abdominal distension since 2 years and she was unable to walk. On abdominal ultrasound, a giant cyst was found which encompassed the whole abdomen. At laparotomy, a giant, totally cystic, vascularized and smooth mass attached to the right ovary was encountered. Staging laparotomy was performed. On the postoperative tenth day, she was discharged without any problem. Her pathology report disclosed a 60×47×30 cm serous cyst adenoma weighing 23 kg. This is the largest ovarian cyst that ever reported from our hospital and one of the largest among the reported cases in the literature. Ovarian neoplasms may be divided by origin cell type into three main groups: epithelial, stromal and germ cell. Taken as a group, the epithelial tumors are by far the most common type. The single most common benign ovarian neoplasm is the benign cystic teratoma; however, according to some studies it is serous cyst adenoma .A 66 year old South Indian post menopausal woman presented at the outpatient department with gradually increasing abdominal swelling first noticed 2 years back. Swelling was accompanied by vague pain all over the abdomen for 6 months and increasing in size from four months. Due to the huge mass she was unable to walk and had anorexia. There was no history of colicky pain, fainting attacks, vomiting or other gastrointestinal disturbances. Her bowel and bladder habits were normal. There was history of generalised weakness. She had no serious illness or operation before. She is P6L5D1, married since 47 years and attained menopause 20 years back. There was no family history of malignancies.On general examination, she was thin built and undernourished. She weighed 55 kilograms. Pallor was present; she was normotensive and had bilateral pitting pedal odema. On abdominal examination, abdomen was grossly distended, engorged veins present, Fluid thrill was present. Abdominal girth at the level of the umbilicus was 42 inches. Bowel sounds were heard in the flanks. Vaginal examination showed cystocoele, cervix was deviated to right flushed with vault and both the fornices were full. Pre operative investigations including liver and renal functions were normal. Ca125 was 46.61 ng/ml. Chest X-Ray showed cardiomegaly and elevation of both domes of diaphragm.On ultrasound examination, uterus was atophic and seen separate from the mass. Large cystic mass seen occupying the whole abdomen and with multiple septations. Abdominal organs were compressed by the mass. Right side pelvicalceal system dilatation was seen. A differential diagnosis of gross ascites and large ovarian cyst  were made. Magnetic resonance imaging confirmed the diagnosis of right sided ovarian cyst with multiple thin septations. Staging laparotomy was done. Abdomen was opened by a vertical midline incision extending above the level of the umbilicus. A tense smooth surfaced cystic mass measuring 60 × 47 × 30 cm extending up to then undersurface of the diaphragm was delivered out . The masGiant ovarian serous cyst adenoma of such a huge size is a rare finding. The most remarkable descriptions of large ovarian cysts are those of Spohn, who in 1922 reported one that weighed 148.6 kg (328 lb), and of Symmonds, who in 1963 reported encountering one that weighed 79.4 kg (175 lb) Such descriptions were among the curiosities reported in the 19th and early 20th centuries. They have become rarer as imaging modalities improve and diagnoses are made earlier [Our patient had delayed reaching the hospital due to financial constraints and did not want to take the risk of surgery and approached us only after it was totally debilitating and she was totally bed ridden. Ovarian epithelial tumors comprise about half of all ovarian tumors, accounting for about 40% of benign tumors and 86% of malignant tumors. Benign serous tumors include cyst adenomas, adenofibromas, cyst adenofibromas and surface papillomas. These tumors are common, accounting for about 25% of all benign ovarian neoplasms and 58% of all ovarian serous tumors. The serous tumors are bilateral in about 10% of cases of all serous tumors, about 70% are benign, 5-10% have borderline malignant potential and 20-25% are malignant, depending largely on the patient’s age. They tend to be multilocular but unilocular serous cyst adenomas are not uncommon. They present grossly as large as 35 cm in diameter, spherical or ovoid masses, like the one reported here [This is the largest ovarian tumour ever reported in our hospital and is one of the largest tumours reported in literature.


Rhabdomyosarcoma is the most common soft tissue malignancy of childhood, but may occur extremely rarely in the neonatal period. There are only a few reports of rhabdomyosarcoma in neonates. Although, it may arise anywhere in the body, the head and neck, and genitourinary regions are the most frequent sites. Truncal and chest wall rhabdomyosarcoma is relatively rare occurrence. We report a neonate with embryonal rhabdomyosarcoma arising from the posterior chest wall muscles at birth. Computer Tomography scan raised the possibility of rhabdomyosarcoma or neurofibroma, fine-needle aspiration cytology was inconclusive. Total excision was done and chemotherapy given. At 6 months child is without recurrence. Rhabdomyosarcoma (RMS) is the most common soft tissue malignancy of childhood, but may occur extremely rarely in the neonatal period ,2. Thereth post-natal-day day, total excision of the mass was done , a malignant tumor of immature mesenchymal cell origin, is the most common soft tissue sarcoma in the pediatric age group, accounting for approximately 3-5% of all childhood malignancies . The medRMS is traditionally subdivided into embryonal, alveolar and pleomorphic. Pleomorphic RMS, in contrast to embryonal and alveolar RMS, almost exclusively occurs in adults (median age sixth decade). Alveolar RMS represents about 20% of all RMS . EmbryonPrimary soft-tissue sarcomas of the chest wall are uncommon. RMS usually occurs in the head and neck region , bile ducts, retroperitoneum, urogenital tract and extremities . In the It has been noted in congenital RMS that the disease may be metastatic at the time of birth, with metastases described in a number of organs and in the placenta too .MRI is the primary imaging modality in RMS with its superior ability to depict soft-tissue changes. CT of the chest is mandatory in order to assess pulmonary metastases from RMS . In our Age less than one year has emerged as an independent poor prognostic factor for RMS ,15. RegaTreatment of neonatal RMS requires a multidisciplinary approach, where surgery and chemotherapy both have their own specific role. Complete resection of chest wall rhabdomyosarcoma is recommended . EmbryonIn conclusion, we report a rare case of posterior chest wall congenital embryonal rhabdomyosarcoma in a newborn, which responded well to surgery and chemotherapy. In a newborn presenting with a hard mass arising from chest wall, RMS should be considered as one of the differential diagnoses.


An 86-year-old man, a known case of hypertension and chronic obstructive pulmonary disease (COPD), on inhalational steroids, presented to us with history of fever, cough and vomiting of 1-day duration. On physical examination, patient had a pulse of 90 beats per minute, blood pressure of 140/ 88 mmHg and respiratory rate of 18 per minute. Respiratory examination revealed the patient to have an emphysematous chest with bilateral diffuse expiratory rhonchi, basal crepitations and decreased breath sounds accompanied by a dull percussion note in left lower lobe area.Routing blood investigations were normal except for mild leucocytosis. Chest Roentgenogram (PA view) showed a well-defined homogenous circular mass abutting lateral part of diaphragm and chest wall. In view of old age of the patient with risk factors including chronic smoking and COPD, a provisional diagnosis of bronchogenic carcinoma was made and a contrast-enhanced computerized tomographic (CECT) scan study was asked to confirm the diagnosis.What radiological abnormalities are present on these images?What is the likely diagnosis in this case?CECT scan showed a focal, rounded well-defined non-enhancing hypodense area (-30 HU) measuring 8 × 8 × 4.2 × 5 cm in the posterior and lateral basal segments of left lower lobe, abutting lateral chest walls . Since tPosterolateral diaphragmatic hernia - Bochdalek herniaBochdalek hernia is a congenital defect of the posterolateral region of the diaphragm, usually on the left side, and is most often seen in infants but is rare in adults. Developmentally, diaphragm is a mesodermal partition originating mainly from septum transversum, which forms the central portion of it. The posterior part of the diaphragm develops from dorsal mesentery of the esophagus. On each side of the dorsal mesentery and behind the septum transversum, a triangular gap exists in early fetal life - known as pleuro-peritoneal opening or canal. Persistence of this canal leads to herniation of intra-abdominal organs into thoracic cavity. On account of this, Bochdalek hernia has no peritoneal sac. Rarely, it can also result due to a posttraumatic defect in the diaphragm.Bochdalek hernias are uncommon and usually diagnosed on CT scan in about 5–10% of adults.1 They areMost of the adult cases are asymptomatic, and diagnosis is made incidentally during imaging. However if symptoms appear, they are generally non-acute and related to digestive tract, like dyspeptic symptoms, rarely necessitating emergency surgical treatment.4 There aIt may be difficult or impossible to distinguish a posterolateral diaphragmatic defect from the much less frequent eventration of the diaphragm or an intrathoracic posteriorly situated lung mass, and these should be considered in the differential diagnosis of a posteriorly situated chest mass. Mortality rate is lower than 3% in adults, although it could rise until 32% if diagnosis and treatment are delayed.CT scan is the technique of choice for prompt and correct diagnosis. However, contrast imaging to demonstrate the density; and reconstruction of images in sagittal and coronal planes, as in our case, may be required to localize the intra-abdominal origin of these lesions. Upper gastrointestinal barium study may show the stomach inside the thoracic cavity. The unusual aspect of our case was the large size of Bochdalek hernia on presentation, which is quite uncommon as they are usually smaller-sized lesions diagnosed incidentally during CECT scans. We want to emphasize that late presentations of the lesion coupled with the intrathoracic location and risk factors masquerading as a neoplastic lung mass can be misleading even to an astute clinician.In our case, the patient improved symptomatically with conservative management for chronic obstructive airway disease and was discharged from the hospital.


A rare complication of the compilation of high intrahepatic biliary pressure and the formation of a subdiaphragmatic abscess is that of pleurobiliary fistula. We present a case of 67-year-old male who presented with pleurobiliary fistula following transarterial chemoembolization in a patient with a large hepatocellular carcinoma, as well as the course of the diagnostic procedures and the therapeutics interventions which took place. Pleurobiliary fistula is a rare event related to high intrahepatic biliary pressure  and subdA 67-year-old Caucasian male presented with hepatitis B cirrhosis and a central tumor lesion in the liver. Radiologic imaging confirmed the diagnosis of HCC. The tumor, measuring 12 cm in diameter invaded both right and left liver lobe. Selective TACE was performed of the tumor feeding vessels from the right hepatic artery. TACE, performed by injection of lipiodol and epirubicin emulsion followed by cyano-acrylate particles, was successful.TACE was repeated twice in a 6 month period but after the last session the patient was admitted in the Liver Surgical Unit of “Agia Olga” Hospital with fever and shortness of breath. Computed tomography (CT) of the abdomen revealed a necrotic liver mass with left lobe biliary dilatation associated with bile duct invasion from the tumor. Chest X- ray and CT scan demonstrated significant right pleural effusion and localized pneumonia. Blood test exhibited hypoalbuminemia and mild liver dysfunction with increase of the cholestatic enzymes. A decision for chest-tube drainage of the pleural effusion was made due to hypoxia and high grade fever (T > 38.5 C). Two liters of bilious fluid were drained initially followed by 500 cc of daily drainage. Pleural fluid examination revealed high bilirubin level (17 mg/dl) associated with pleuro-biliary fistula. Endoscopic retrograde cholangiography (ERC)  confirmePleurobiliary fistula is a rare event usually presented in patients with liver hydatid disease. Hydatid cyst may rupture in the pleural space after invasion of the diaphragm. Two major factors are required such as the mechanical effect of an increased intraluminal pressure of the biliary system due to bile duct obstruction and the local inflammatory process triggering adhesion between the liver and the diaphragm. Bronchobiliary fistula was reported also in patients with large HCCs when they underwent TACE. In the present case invasion of the common bile duct from the HCC resulted in common bile duct obstruction with subsequent increase of the intrabiliary pressure. The formation of the subphrenic liver abscess was attributed to TACE. These predisposing factors led to rupture of the abscess in the pleural space. Invasion of the bile ducts due to HCC is a rare clinical picture occurred in 2% of all HCC cases. Intrabiliary tumor growth is related with necrosis and bile duct obstruction from devitalized fragments. This devastating situation correlates with early death as reported by Kojiro and associates.A diagnosis of bronchobiliary and pleurobiliary fistula is based on radiologic imaging findings. CT scan is non-specific to identify the biliopleural communication. Cholangiography and Tc-HIDA scan are the techniques of choice to establish the diagnosis.Treatment of broncho- and pleurobiliary fistula is surgical  althoughDeath is almost inevitable in these cases because of respiratory failure or disease progression.In our case, chest tube drainage of the pleural effusion documented the diagnosis of pleurobiliary fistula, which was further confirmed by ERC. Due to persistence of chest tube drainage, a stent was placed initially to decompress the biliary system followed by pleurodesis.Because of the poor liver function and sepsis, the patient eventually died; although pleural drainage was decreased with the previous mentioned conservative measures.


Intrathoracic gastric volvulus with herniation of colon and omentum in a paraesophageal hernia is a rare occurrence. It may present as an acute surgical emergency with life-threatening complications. The diagnosis is usually made by imaging studies and endoscopy. Definite treatment is surgery. We present the laparoscopic management of this case. Herniation of stomach and other viscera has been reported in type IV paraesophageal hernia, leading to serious complications such as perforation of the viscera, bleeding and gastric volvulus. The laxity of the supportive ligaments and diaphragmatic defect predisposes to gastric rotation and also the herniation of viscera. The herniation of viscera and gastric volvulus may be asymptomatic or present with chronic intermittent reducible hernia progressing to acute obstruction, as happened in this patient. The patient′s symptoms depend on the degree of obstruction and twisting. Clinically upper abdominal pain, retching and inability to pass a nasogastric tube would lead to clinical suspicion of acute gastric volvulus, but when associated with herniation of colon and omentum, the picture may be more confusing.2 X-ray cA 75 years old man who was previously asymptomatic, presented to us with, history of severe epigastric and chest pain, inability to eat, vomiting and acute constipation. His symptoms were getting gradually worse for last four days. On examination, he was moderately dehydrated and his vital signs were stable. Apart from upper abdominal tenderness, he had no other findings per abdomen. His investigations revealed hypokalemia, hyponatremia and hypoalbuminemia. The blood gases, serum amylase, ECG and troponin were normal. Chest X-ray showed a large air fluid level. After adequate resuscitation, a gastroscopy was arranged, which showed severe esophagitis, gastroesophageal reflux, a large hiatus hernia with the stomach in the chest and huge dilatation of stomach. The stomach was aspirated and a nasogastirc tube was inserted. An urgent CT scan of chest and abdomen with contrast, confirmed the intrathoracic volvulus of the stomach. The omentum was displacing the lower esophagus in the chest. Subsequently, a barium meal was arranged to define the exact anatomical problem. It confirmed the findings of endoscopy and showed an upside down stomach in the chest. The stomach was decompressed, draining out over two liters of fluid. This relieved the pain and discomfort in his upper abdomen and chest. Follow-up films showed complete reduction of stomach in the abdomen and a dilated stomach reaching to the pelvis with beaked pylorus, suggesting outlet obstruction secondary to organoaxial torsion. The colonic loops were seen entering the chest, which was not seen previously prior to the reduction of stomach. Late films showed the partially contrast-filled right colon entering the chest .The patient was placed supine in the 30° anti-Trendelenburg position. A 10 port was inserted a hands breadth below the xiphisternum for the 0° laparoscope and further five mm ports were inserted along the costal margin in the mid line, right and left midclavicular line and the left anterior axillary line. The diagnosis was confirmed at laparoscopy. The stomach had herniated again in the hiatus and only pylorus ends were intra-abdominal. The greater omentum and transverse colon were seen entering the hiatus. The greater omentum was easily reduced by hand-over-hand technique, followed by colon and stomach. The hernial sac was excised and cruroplasty was done by interrupted intracorporeal non-absorbable sutures. There was a huge hiatal defect left after the cruroplasty, which was bridged by a circular 10 × 10 cm. Polypropylene mesh.. The abdHis repeat barium studies, six months after surgery was normal.The decompression of the stomach was successful in this patient in reducing the gastric volvulus, which was confirmed by subsequent chest X-ray and follow up barium meal. But on laparoscopy, the stomach was seen to be rotated again on its long axis and had herniated in the chest. We think that this represents a sequential recurrent acute gastric volvulus in a para esophageal hiatus hernia. Most likely, explanation of this patient becoming symptomatic and progressing to acute obstruction, may be due to slow expansion of his chronic gastric volvulus, as well as the incarceration of colon and omentum or the combination of all. Surgery is recommended at the time of diagnosis because of the risk of strangulation and high mortality. A definitive treatment is always surgical. A laparoscopic approach has the advantage, as it minimizes the trauma and identifies the underlying predisposing conditions. The various laparoscopic therapeutic strategies adopted include: reduction, excision of sac, repair of hiatus with or without prosthesis, fundoplication, laparoscopic anterior gastropexy, laparoscopic gastrostomy fixation, laparo-endoscopic reduction and percutaneous gastrostomy, laparoscopic esophagocardiopexy and gastrectomy. All these modalities have been used alone or in combinations depending on case to case basis.The reduction may be successful after decompression through the use of nasogastric tube or endoscopy like in this case and should always be attempted; an elective laparoscopic repair can be performed later to allow time for stabilization of the patient condition. Failure of nasogastric and endoscopic decompression requires urgent surgery.A laparoscopic reduction and anterior gastropexy alone may be a satisfactory answer in an emergency situation. A fundopA fundoplication is recommended to secure the stomach in the abdomen and to prevent the existing or possible postoperative gastro-esophageal reflux. A temporary gastrostomy may be added in addition to hernia repair, to fix the stomach to anterior abdominal to prevent the recurrence. The location of gastrostomy tube is important, as recurrence of volvulus has been reported after fundoplication and gastrostomy, acting as two fixed points of the axis.The endoscopic decompression with percutaneous endoscopic gastrostomy or laparoscopic derotation and laparoscopic gastrostomy, has been shown to give satisfactory results in elderly medically unfit patients.Repair of hiatus is necessary to reduce the recurrence of volvulus. Prosthetic reinforcement of the hiatus hernia defect which cannot be closed primarily by cruroplasty, is safe and effective and should be the option in the treatment of a large hiatus hernia with intrathoracic stomach and colon. Several kinds of prosthesis are in use, the difference being in their foreign body reactivity and hence in their adhesive potential. Although in use for several years, the prolene polypropylene meshes are known to give rise to adhesions. Rarely has erosion into the esophagus, also been reported. The newer modifications of polypropylene meshes are claimed to be helpful in preventing these complications.


There has been a recent growth in the use of whole body Computerised Tomography (CT) scans in the private sector as a screening test for asymptomatic disease. This is despite scant evidence to show any positive effect on morbidity or mortality. There has been concern raised over the possible harms of the test in terms of radiation exposure as well as the risk and anxiety of further investigation and treatment for the large numbers of benign lesions identified.A healthy 64 year old lady received a privately funded whole body CT scan for her birthday which revealed an incidental mass in the right iliac fossa. This was investigated with further imaging and colonoscopy and as confident diagnosis could not be made, eventually excised. Histology demonstrated this to be a benign ancient schwannoma and we believe this to be the first reported case of an abdominal wall schwannoma in the English literatureAncient schwannomas are rare tumours of the peripheral nerve sheaths more usually found in the head, neck and flexor surfaces of extremities. They are a subtype of classical schwannomas with a predominance of degenerative changes. Our case highlights the pitfalls of such screening tests in demonstrating benign disease and subjecting patients to what turns out to be unnecessary invasive investigation and treatment. It provides evidence as to the consequences of the large number of false positive results that are created by blind CT scanning of asymptomatic patients i.e. its tendency to detect pseudodiesease rather than affect survival rates. Should the number of scans increase there may be an unnecessary burden on NHS resources due to the large numbers of benign lesions picked up, that are then referred for further investigation. In recent years private entrepreneurs have recognised, some might say exploited, a market for radiological screening tests ,2. One oA healthy 64 year old lady received a LifeScan (privately funded whole body CT scan) for her birthday which revealed an incidental mass in the right iliac fossa (RIF). This was investigated further with a colonoscopy which revealed small benign polyps only. Initially a putative diagnosis of GastroIntestinal Stromal Tumour (GIST) was considered and the patient referred to our NHS Colorectal outpatient clinic.Clinically, the lady was well with no weight loss, anaemia, change in bowel habit or loss of appetite. She complained of RIF discomfort but admitted that this had only manifested since her CT scan. She was extremely anxious about her condition and the underlying diagnosis. On examination, a non-tender 8 cm mass was palpable in the RIF and a routine blood screen was entirely normal. The case was discussed at the Lower Gastrointestinal Multidisciplinary Team (MDT) meeting and it was agreed that a repeat CT scan with contrast should be performed. The scan demonstrated a 6 × 5 cm heterogeneous mass in the RIF adjacent to the peritoneal wall Figure . No otheThe possible diagnoses were discussed with the patient and after consideration of the risks and benefits, she agreed to surgery by a laparoscopic approach. At laparoscopy a 6 × 4 × 3.5 cm extraperitoneal ovoid nodule was found on the abdominal wall in the RIF. In light of the unusual appearances, the procedure was converted to laparotomy but no intra-peritoneal pathology was noted. The lesion was excised and sent for histological examination. Macroscopically, it had a solid cut surface with tan, brown and cream areas and contained a 1.2 cm cyst. Microscopically, it was composed of hypocellular and hypercellular areas. The hypocellular areas were oedematous and myxoid, containing chronic inflammatory cells and spindle cells which were haphazardly arranged, aggregating in areas to form small focal palisades. The spindle cells showed hyperchromatic and irregular nuclei although no mitotic figures were seen ,  one has In this study we have presented the first reported case in the English literature of an abdominal wall ancient schwannoma and discussed the key clinical, radiological and pathological features of the condition. As this was picked up asymptomatically on a private health whole body CT screen given to the patient as a birthday present, we have extolled the pitfalls of such tests as well as offered an insight into the clinical, ethical and health economic issues that they raise. Wider marketing and availability of these services may lead to increased non evidence based patient-led screening in the private sector. Unfortunately, this may add an unnecessary burden to public health resources.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no conflicts of interest. The authors alone are responsible for the content and writing of this paperRKB was the principal author of the paper, carried out a literature review of the topic and produced the original manuscript. AB modified this. MR proof read the document and provided the pathological slides for inclusion into the manuscript. BEL gave final approval for the manuscript to be submitted. All authors read and approved the final manuscript.RKB is a house officer in General Surgery. BEL is a Consultant Surgeon. AB and MR are Specialist Registrars in General Surgery and Pathology respectively.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/10/1/prepub


Nephrogenic adenomas are generally considered to be benign lesions, but there remains a risk for malignant transformation. Patients with immunosuppression in particular appear to be at a higher risk of malignant disease. We report a case of post-traumatic nephrogenic adenoma in a young patient without immunosuppression, which transformed into an adenocarcinoma of the bladder.A 25-year-old man had a traumatic bladder perforation caused by a car accident. After physical recovery from the accident, he developed a neurogenic bladder and recurrent urinary tract infections. He presented with nephrogenic adenoma of the bladder 18 months after the accident. The adenoma was treated repeatedly with transurethral resections. The initial pathologic findings were benign, however, the last resection revealed that the former benign adenoma had transformed into a moderately differentiated adenocarcinoma of the bladder . He subsequently underwent radical cystectomy and has remained tumor-free for the last 4 years.Nephrogenic adenoma is a rare disease with some potential for malignant transformation. However, patients with nephrogenic adenoma under immunosuppression and patients with neurogenic bladder dysfunction appear to be at a higher risk of developing bladder cancer. Nephrogenic adenoma is a rare tumor which usually occurs in the urinary tract, most frequently in the bladder. Its etiology is unknown, but association with trauma, nephrolithiasis, urinary tract infection and radiation has been reported . DiagnosA 25-year-old man had a car accident with severe head injury, pelvic fractures, rupture of the symphysis, partial urethral rupture and traumatic bladder perforation at the bladder dome with extension to the right bladder wall. The bladder perforation was treated with primary bladder closure, while the partial urethral rupture was treated with urethral catheterization. The patient's overall health status improved progressively, however, he developed neurogenic bladder dysfunction. Thus, a suprapubic catheter for continuous bladder drainage was necessary for 1 year. One and a half years after suprapubic catheter removal, he presented with sterile microhematuria confirmed by repeated urine examinations. Cystoscopy detected a papillary tumor at the right and posterior bladder wall with extension to the bladder base. The bladder dome was tumor-free. The tumor was removed by transurethral resection (TUR). The histologic diagnosis of nephrogenic adenoma was confirmed by two independent pathologists.Follow-up consisted of routine urine analysis, cystoscopy and cytology every 3 months. A second TUR was performed because of histologically proven recurrence. The upper urinary tract never showed any signs of tumor spread. Microhematuria occurred again 1 year after initial presentation of the tumor. Cystoscopy now found a diffuse and progressive growing exophytic tumor with extension almost throughout the entire bladder wall Figure . HoweverNephrogenic adenoma was described in 1949 as hamartoma of the bladder ; the terNephrogenic adenoma is a rare tumor, which usually occurs in the urinary tract, most frequently in the bladder. Its etiology is unknown, but association with trauma, nephrolithiasis, infection and radiation has been reported . Most paAlthough nephrogenic adenomas are considered to be benign lesions ,6, maligA recently described entity that may be similar histologically to adenocarcinoma is a fibromyxoid nephrogenic adenoma . The prePatients with neurogenic bladder dysfunction, and especially those with continuous urethral or suprapubic catheter drainage, are known to be at an increased risk of developing bladder tumors. The incidence increases 10 years after the initial catheter placement . The traFurthermore the primary tumor was at the right and posterior bladder wall and not at the bladder dome, the former cystostomy site. All these findings do not support the catheter as a primary cause for tumor development. However, etiological relevance of chronic catheter irritation in the development of the malignant transformation cannot be ruled out.It is reported that adenocarcinomas have their origin from the urachus. These tumors usually arise from the bladder dome, the insertion point of the urachus. The location of the primary tumor, however, does not support the hypothesis in this case. The adenocarcinoma rather occurred multifocally within the nephrogenic adenoma.Nephrogenic adenoma is a rare benign disease with some potential for malignant transformation. In particular, in patients under immunosuppression and patients with neurogenic bladder dysfunction, the risk of development of bladder cancer might be increased and should be kept in mind in the surveillance of patients with nephrogenic adenoma.The authors declare that they have no competing interests.EH designed this case report and drafted the manuscript. DZ carried out the operation of this patient and helped to draft the manuscript. CS and EB participated in the design of the study and helped to draft the manuscript. AH carried out the pathological examination. DF made the language corrections. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Mucocele of the appendix secondary to mucinous cystadenoma is a rare clinical finding. Clinical presentation is varied with more than half being asymptomatic.We report such a case presenting to the surgeons where initial clinical findings and investigations suggested an ovarian cyst. The patient was subsequently referred to the Gynaecologists for further management. In spite of extensive preoperative investigations, the diagnosis was only made at the time of surgery.In women presenting with a right iliac fossa mass and clinical features not indicative of gynaecological pathology, an appendiceal origin should be considered in the differential diagnosis. Mucocele of the appendix secondary to mucinous cystadenoma is a rare clinical finding and we report such a case presenting in a district general hospital. They can present as a pelvic mass and thus pose a diagnostic challenge.Currently, the assessment of pelvic masses relies heavily on USS as the primary diagnostic tool. This however may not always identify the origin of such a mass. In such cases, clinical findings and other investigative modalities are warranted to aid the diagnostic process. In spite of extensive preoperative investigations, the diagnosis may still remain elusive and may only be made at the time of surgery.An eighty year old woman was referred to the General Surgeons with right sided abdominal pain and weight loss over several months. There was no associated urinary or bowel symptoms. On examination, there was clinical evidence of weight loss with a suggestion of a fixed right sided pelvic mass per rectum. The CA 125 was within normal limits. An ultrasound scan showed a right sided mixed echogenic pelvic mass with an echogenic rim, possibly ovarian in origin, measuring 61 × 43 × 51 mm. A CT of the abdomen and pelvis suggested a calcified adnexal cyst 7 × 6 × 5 cm with no evidence of lymphadenopathy and she was referred to the Gynaecologist. When reviewed by the Gynaecologist, no mass was palpable per abdomen or per vaginum. She had an exploratory laparotomy where the only pathology identified was a distended appendix and a routine appendicectomy was performed. Histology showed mucocele of the vermiform appendix secondary to mucinous cystadenoma.Mucocele of the appendix is a descriptive term for an appendix distended by mucus, secondary to mucinous cystadenoma (63%), mucosal hyperplasia (25%), mucinous cystadenocarcinoma 11%) and retention cyst [1% and reMucocele can also occur due to occlusion of the lumen by endometriosis or carcinoid tumour.Overall, appendiceal mucoceles make up about 0.2%–0.3% of appendix specimen. Clinical presentation may include right lower quadrant pain, change in bowel habits, per rectal bleeding or a palpable mass . In our The initial detection of the lesion may be facilitated by radiological, sonographic or endoscopic means.On barium enema, there is usually non filling or partial filling of the appendix with contrast. The lesion may be seen as a sharply outlined sub mucosal or extrinsic mass indenting the caecum and laterally displacing it .CT of the abdomen usually shows a cystic well-encapslated mass sometimes with mural calcification, in the expected location of the appendix. It may be causing extrinsic pressure on the caecal wall without any surrounding inflammatory reaction ,5-7.Ultrasound findings can be variable. Purely cystic lesions with anechoic fluid, hypoechoic masses with fine internal echoes as well as complex hyperechoic masses can be seen depending on the contents . The oniColonoscopic findings include the 'volcano sign', the appendiceal orifice seen in the centre of a firm mound covered by normal mucosa or a yellowish, lipoma-like submucosal mass .In the above case report, USS and CT were unable to provide a preoperative diagnosis. The clinical suspicion of gastrointestinal pathology due to lack of pelvic findings, more closely correlated to the operative findings.In our case, the decision for excision of the appendiceal mucocele was made as a result of diagnostic uncertainty and a need to rule out malignancy.Surgical excision of mucocele of appendix can either be by laparotomy or laparoscopy. Laparoscopic surgery provides the advantages of good exposure and evaluation of entire abdominal cavity, as well as more rapid recovery with avoidance of a large incision and a better cosmetic outcome. However careful handling of the specimen is recommended as spillage of the contents can lead to pseudomyxoma peritonei. This can be achieved by atraumatic handling of the appendix and use of impermeable bag for removal of the specimen. Conversion to laparotomy should be considered if the lesion is traumatically grasped or if the tumour clearly extends beyond the appendix or if there is evidence of malignancy such as peritoneal deposits . InvolveMucocele of the appendix can mimic an adnexal mass and prove to be a diagnostic challenge. In a woman presenting with right iliac fossa mass and with clinical features not indicative of gynaecological pathology, an appendiceal origin should be considered in the differential diagnosis.CA 125 – Cancer Antigen 125CT – Computerised TomographyCEA – Carcino-Embryonic AntigenUSS – Ultrasound ScanThe author(s) declare that they have no competing interests.CEB – Literature review, conceived and drafted the manuscript.MM – Helped in collecting the records and preparing the manuscript.AEJ – Department chair who provided general support.All the authors revised and approved the manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Birt-Hogg-Dubé syndrome is a rare genodermatosis characterized by hair follicle hamartomas, renal tumors and spontaneous pneumothorax. We present the case of a patient with pulmonary cysts and recurrent spontaneous pneumothorax. She had typical skin lesions, and was found to have a hybrid oncocytoma which was surgically excised.A 60-year-old Caucasian woman had a 10-year history of cystic lung disease and recurrent spontaneous pneumothoraces. She was noted to have papular lesions over her face and forehead. The result of a biopsy showed these lesions to be fibrofolliculomas. A diagnosis of Birt-Hogg-Dubé syndrome was made and she was screened for renal tumors since these are a recognized association. A hybrid oncocytoma was detected which was surgically excised by partial nephrectomy.It is important to consider a possible diagnosis of Birt-Hogg-Dubé syndrome in cases of recurrent pneumothorax. Affected individuals must be screened for renal tumors, a potentially lethal consequence of this syndrome. Birt-Hogg-Dubé syndrome (BHDS) is a rare genodermatosis characterized by hair follicle hamartomas, renal tumors and spontaneous pneumothorax. We present the case of a 60-year-old Caucasian woman with pulmonary cysts and recurrent spontaneous pneumothoraces who had typical skin lesions. On screening, she was found to have a hybrid oncocytoma which was surgically excised. A diagnosis of BHDS should be considered in cases of recurrent pneumothorax, and affected individuals must be screened for renal tumors.Our patient was a 60-year-old Caucasian woman who presented with recurrent left pneumothoraces. She also had mild scoliosis, an increased metacarpal index and mitral valve prolapse. There was a family history of mitral valve prolapse affecting both her mother and one of her daughters. Her brother has Usher's syndrome. Her parents were first cousins. An initial presumptive diagnosis of Ehlers-Danlos syndrome type IV was made but no confirmatory tests were carried out.Over the next 10 years, our patient developed further pneumothoraces requiring video-assisted pleurodeses and bullectomy. Serial computed tomography (CT) scans showed the presence of cystic lung disease which was more marked at the bases; and development of mild bronchiectasis (Figure Our patient was noted to have pale, flat macules over her face and forehead Figure , which hIn 1977, Drs Birt, Hogg and Dubé described 15 adults in a kindred of 70 who developed skin lesions which came on after the age of 25. They had multiple, small, dome-shaped papular skin lesions over the scalp, forehead, face and neck, and with scattered lesions observed on the chest and back [Subsequently, BHDS was found to be a marker for an internal disease. Case studies of recurrent pneumothorax, lung cysts  and renaLung cysts are frequently seen in BHDS. A recent study found multiple pulmonary cysts in 89% of CT scans of BHDS patients . Cysts iBHDS inheritance follows an autosomal dominant pattern . It is cRenal tumors have been reported in as many as 34% of individuals with germline FLCN mutations . They arIn our case, the recognition of characteristic skin lesions in the context of recurrent pneumothoraces and pulmonary cysts led to the diagnosis of BHDS. Subsequent CT screening identified a renal tumor which was then excised. It is important that BHDS should be considered in patients with recurrent spontaneous pneumothorax, particularly if skin lesions are present, as screening is essential to identify renal tumors. Families of index BHDS cases and patients with a family history of recurrent spontaneous pneumothorax should be considered for screening for the FLCN gene, even in the absence of other features, in view of the potentially lethal consequences.The authors declare that they have no competing interests.LI and ES were involved in the clinical management of our patient. GW performed the literature review and prepared the manuscript. LI and ES critically appraised the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


A 30-year-old man presented with a fairly large intramedullary mass lesion involving virtually the entire spinal cord. It was hyperintense on both T1W and T2W sequences, with signal suppression on fat-saturation images. Subsequent noncontrast CT scan of the spine confirmed the presence of fat and calcification within the lesion, thus leading to the diagnosis of an intramedullary dermoid. Spinal dermoids are rare, benign, slow-growing tumors arising from more than one of three primitive germ cell layers. They areA 30-year-old male presented with pain in the right lower limb for 1 year. He also complained of difficulty in passing urine for 3 months. On examination, saddle anesthesia was noted, with grade 3 power in the left lower limb. MRI of the lumbosacral spine revealed a fairly large intramedullary mass lesion that appeared hyperintense on both T1W and T2W sequences, with signal suppression on fat-saturation images Figures  and 2A. Dermoid tumors constitute 1.1% of intraspinal tumors. They areAlthough dermoid tumors develop from the embryonic period, they are slow-growing lesions and do not cause symptoms till adult life. Most derThey may be associated with other forms of dysraphism and in about 20% of cases, a dorsal dermal sinus can be seen. Other asThe combination of fluid, soft tissue, calcium, and fat is diagnostic of a dermoid tumor. Because of the varying amounts of soft tissue, fat, calcium, and hemorrhage, MRI typically demonstrates heterogeneous signal intensity. The relaDermoid tumors may have two distinct portions: a lipid part and a more solid or more fluid part. In our case, the lipid component extended from the intramedullary portion of the cervical spinal cord to the thoracolumbar region, with the more solid portion of the tumor being seen in the region of the conus medullaris. The soft tissue component usually enhances after administration of intravenous contrast medium.To the best of our knowledge, a long-segment intramedullary dermoid is extremely rare. In our patient, the intramedullary dermoid extended from the cervical spinal cord to the conus medullaris; such a case has not been reported before.In conclusion, MRI is helpful in detecting intraspinal dermoid tumors and delineating their extent. CT plays an important complementary role in identifying areas of fat and calcification.


Pancreatic tumors usually display either a ductal, an acinar or an endocrine differentiation. Mixed exocrine and endocrine pancreatic tumors are extremely rare. There have been a few reports of the rare entity of mixed acinar-endocrine carcinoma of the pancreas, where the endocrine cells represent more than 30% of the tumor. We herein describe a case of such a pancreatic tumor in an asymptomatic patient.A 74-year-old male patient with no evident clinical symptoms was referred for surgical resection of a large mass located on the pancreatic head, which was confirmed by an abdominal U/S, CT and MRI. FNA of the mass under endoscopic ultrasound guidance showed the cytology specimen to comprise of cells with morphological and immunohistochemical characteristics of endocrine pancreatic neoplasms. The patient underwent a modified Whippleâ€™s procedure and his post-operative course was uneventful. Pathological examination of the tumor revealed a mixed acinar-endocrine carcinoma of the pancreas.Mixed tumors of the pancreas are extremely rare and their clinical features and pathogenesis remain unclear. The endocrine component seems to influence their prognosis favorably. Therefore, aggressive surgical therapy remains the only well established line of treatment for these tumors. Further accumulation of clinical cases will help clarify the clinical course and the optimal therapy for these unusual tumors.Most pancreatic tumors arise as a single cell type, either from the endocrine of exocrine pancreas, and can be categorized into three types: ductal, acinar or endocrine. -3] Acin Acin3] AA 74-year-old, white male of Greek origin, was admitted in our hospital in December 2008 in order to be treated for a large mass located in the head of the pancreas. The patient had been originally subjected to a routine blood check up, which revealed mildly elevated transaminase levels. He was then referred for an abdominal U/S and eventually for a CT scan on an outpatient basis. Both revealed a large, well circumscribed mass of 6.8 cm in diameter, which seemed to be in direct contact with the head of the pancreas and the inferior vena cava Figure . A subseEndoscopic ultrasound scan was performed which allowed FNA of the mass. The cytology revealed cells morphologically and immunogistologically indicative of a neuroendocrine pancreatic neoplasm. Subsequently, the patient was referred to our hospital for further surgical and possible antiproliferative therapy.On physical examination the patient was found to manifest periodic choreo - athetosic movements that had appeared in the 3 months that preceded the diagnosis of his pancreatic tumor, to together with polyarthralgia of his limbsâ€™ large joints. The rest of his neurological clinical examination as well as an MRI of the brain were normal. Serum amylase, bilirubin and transaminase levels and all serum tumor markers were within normal range.The patient underwent surgical resection of the tumor by means of a modified Whippleâ€™s procedure and Roux-n-Y reconstruction of the gastrointestinal tract Figure . His recPathological examination of the surgical specimen revealed a large pancreatic tumor, located in the head of the pancreas, measuring 12 Ã— 9 Ã— 6 cm. Microscopical examination showed a malignant neoplasm with morphological features of a mixed acinar-endocrine pancreatic tumor. The tumor was multilobular, well circumscribed and fully encapsulated. Numerous neoplastic emboli were present in the vascular and lymphatic channels of the adjacent pancreatic as well as peripancreatic fatty tissue and in the vessels of the outer muscular layer of the duodenum, which was resected en bloc with the tumor. Moreover, 9 out of 10 resected lymph nodes harboured metastases of the neoplasm. Immumohistochemistry revealed Figures ,4 intensThe patient remains well 3 months after his operation, with no evidence of recurrence. He also has a complete remission of his neurological symptoms.The pancreas is well known to be composed from two entirely different components, that is the exocrine and the endocrine pancreas. The exocrine pancreas comprises mainly from duct cells and secondly from acinar cells, while the endocrine pancreas consists of islet cells. Pancreatic tumors usually arise from one of these cell types, resulting in either ductal adenocarcinomas (>75% of pancreatic tumors), neuroendocrine carcinomas (about 7% of pancreatic tumors) and acinar cell carcinomas (about 1%).Acinar cell tumors show a male predilection, they tend to be larger than ductal adenocarcinomas and they are usually diagnosed between the fifth and the seventh decade of life ,9. TheirSurgical resection is the treatment of choice in these tumors, which are found to demonstrate a higher resectability rate of 64%, compared to that of ductal adenocarcinoma (10-20%) . MoreoveIt is well known that up to one-third of acinar cell carcinomas may express neuroendocrine markers ,9, whichMixed acinar-endocrine carcinomas are usually large tumors, located in the head of the pancreas (60% of the cases). They usually become clinically evident in middle-aged patients mean age 58 years). Like ACC, MAEC has no specific clinical symptoms. Patients complain of jaundice, weight loss, vague abdominal pain and only rarely do they present with an endocrine syndrome ,14. Spec8 years. It must be noted that most of the cases reported so far refer to tumors that were resected completely, thus allowing an accurate diagnosis. It is impossible to define whether more than 1/3 of a pancreatic tumor cells are neuroendocrine if it can not be resected completely. Therefore, it may well be that the true incidence of these tumors is underestimated.The differentiation of ACC and MAEC from endocrine neoplasms by means of standard histological techniques can prove rather challenging. The presence of cells containing periodic acid-Schiff positive granules which are immunohistochemically positive for pancreatic enzymes  as well as for endocrine markers (chromogranin and synaptophysin), together with evidence of endocrine hormones are indicative of tumor differentiation toward both acinar and endocrine cell carcinoma . FurtherRegarding the prognosis of patients operated on for MAEC, one report confirmed that out of the first 11 cases ever reported 4 patients died after 5 to 24 months of diagnosis, while 6 were reported to be disease free 4 to 72 months following the primary diagnosis . There hDue to the small number of cases reported to date and the relative lack of large scale follow-up data after operation, there are still many controversies on the matter of the optimal course of treatment. Surgery is the first line of treatment in all the cases that the tumor proves to be resectable, however there have been reports of patients benefiting from surgical tumor debulking and local and systemic antiproliferative therapy. It has been stated that the presence of a neuroendocrine component may be related to a more favorable outcome . The rarWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the journalâ€™s Editor-in-Chief.The authors declare that there are no conflicts of interests.MK: designed and drafted the manuscript.NA: responsible for critical revision of scientific content.VS: assisted in drafting the manuscript.AY: assisted in drafting the manuscript and acquisition of data.ND: made substantial contributions to manuscript conception and acquisition of data.TT: made substantial contributions to manuscript conception and acquisition of data.EKV: performed histopathological and immunohistochemical analyses and contributed to the pathology report content.VS: the surgeon, approved the final version of the manuscript for publication.All authors read and approved the final version of the manuscript.


The main purpose of this study is to broaden the clinicopathological spectrum and increase recognition of follicular dendritic cell sarcoma (FDCS) through analysis of the clinical and pathological features of 50 cases.The clinicopathological features of total 50 cases of FDCS were analyzed including a review of 44 cases reported in Chinese literature before October 2009 and six original cases from the pathology files conducted by the authors.The youngest patient came under observation in this study is only seven years old. Including the cases contributed by the authors, our literary review indicated that male dominated the tumor cases (M: F = 3: 2). 28 cases (56%) present with this disease in extranodal sites. Tumor cells demonstrated positive staining for the follicular dendritic cell markers CD21 (47/49), CD35 (43/45), CD23 (20/23) and CD68 (23/25). In situ hybridization for Epstein-Barr virus-encoded RNA was performed in 10 cases. Nevertheless, EBV expression was absent in all these cases. The follow-up analysis of all cases shows that 26 (81.2%) patients were alive and disease free; 6 (18.8%) patients were alive with recurrent disease or metastasis; and nobody had died of this disease at the time of last follow-up.The diagnosis of the FDCS is based on the findings of morphology and immunohistochemistry. The FDCS occurred in China should be viewed and treated as a low-grade sarcoma, and the role of the EBV in the pathogenesis of this tumor is still uncertain. There is a possibility that the tumor might be racial or geographic correlated, because most cases were reported from Eastern Asia area; it's particular the case of the liver or spleen tumor. Classified as accessory cells of the immune system, the follicular dendritic cells (FDC), also known as dendritic reticulum cells, are essential for the function of antigen presentation and germinal center reaction regulation. Follicular dendritic cell sarcoma (FDCS) is an uncommon tumor that usually arises in lymph nodes, especially in the cervical, mediastinal, and axillary areas, but also in extranodal sites. The existence of a primary neoplasm of the follicular dendritic cell was first recognized in 1986 by Monda et al [To add to the existing literature on FDCS to deepen the understanding of the disease, we analyzed the clinical characteristics, pathologic features, immunophenotypic profile, treatments and outcome of 50 cases including our 6 cases and 44 cases from reviewing the Chinese literatures on the FDCS.The present study included a total of 50 patients with FDCS. Having not been reported previously, the first 6 cases were retrieved from the pathological files of the Department of Pathology, Xiangya Hospital of Central South University between 2004 and 2009. The other cases were obtained through the major indexed literature database CNKI  between 1994 and 2009 by searching the key words like dendritic cell, follicular dendritic cell, and sarcoma. The clinical characteristics of all cases of FDCS were summarized in additional file Routine histopathological and immunohistochemical analyses were performed from formalin-fixed, paraffin-embedded specimens. The panel of antibodies mainly included CD21, CD35, CD23, CD68, CD20, EMA, Vimentin, S-100 protein, Clusterin, and LMP-1. All the antibodies were products of DAKO and staining was performed with the DAKO En Vision Kit. The sections were developed with 3,3'-diaminobenzidine tetrahydrochloride and counterstained with hematoxylin.In situ hybridization for Epstein-Barr virus (EBV) -encoded RNA (EBER) was performed on paraffin sections using an EBER in situ hybridization and detection kit (DAKO), and the staining procedure was precisely done as recommended by the manufacturer. EBV-associated nasopharyngeal carcinoma was served as positive control.The present study contains 30 males and 20 females. The mean age of the patients was 44 years, ranging from 7 to 75. The 7 years old patient was the youngest observed so far. The constitutional symptoms, including low-grade fever, weight loss, epigastralgia, abdominal fullness, slight anemia, and so on, were nonspecific in patients with FDCS. Patients often presented with a slow-growing, well-circumscribed, painless mass. One case was complicated by Castleman's disease, which was discovered in chest wall. Of all cases summarized in this review, the most common site of tumor involvement was lymph node, for 22 cases (44%). The others  were located in extranodal sites, including liver (5), gastrointestinal tract (5), nasal pharynx (5), spleen (4), parotid gland (2), greater omentum (2), cavitas pelvis and abdominal cavity (2), tonsil (1), adrenal gland (1), and chest wall (1).The gross measurements of this tumor varied from case to case, ranging from 0.6 to 21 cm. Macroscopically, the tumor was characteristically well circumscribed or even had a capsule. It was soft to slightly firm and might contain areas of necrosis and hemorrhage. Microscopically, the tumor was composed of oval to spindle cells, regardless of the sites of involvement, arranging in storiform, whorled, and fasciclar patterns Figure . IrregulThree out of nine cases that involves the liver and spleen were distinct in that they often had histological features resembling inflammatory pseudotumor-4. In thImmunohistochemically, the FDCS exhibited unique histological immunophenotypic features Figures  and 6. TElectron microscopic examination was available in 4 cases in published literature -8. TumorIn situ hybridization for Epstein-Barr virus (EBV)-encoded RNA was performed in 10 cases. Nevertheless, EBV expression was absent in all these cases,9,10.Although various treatments including surgery, chemotherapy, radiation therapy, and combinations of these modalities have been used, complete surgical resection is still the mainstay of treatment for primary FDCS for most patients. In all 50 cases studied in this paper, the patients were all treated by surgical excision, while adjuvant radiotherapy or chemotherapy was supplemented in 13 cases. Follow-up information was available in 32 patients, with a time interval ranging from 1 month to 5 years. Twenty-six (81.2%) patients were alive and disease free after the treatment, 6 (18.8%) patients were alive with recurrent disease or metastasis, and nobody had died of this disease at the time of the last follow-up.FDCS is an extremely rare tumor and has been recognized with increasing frequency. Most of the data on FDCS are based on case reports or small case series since the first report in 1986. In recent years, FDCS is receiving increasing attention because of the availability of more sensitive markers to confirm the FDC lineage. Interestingly, there is a possibility that the tumor has a race-or geographic-correlation, because 17 cases were from Japan among the worldwide 50 cases reviewed in our study, despite the fact that accurate information regarding ethnic and living environment of the patients were not available. The tum's disease has been found in association with FDCS for a minority of case['s disease can form the background from which a FDCS develops. Perhaps the tumor arises through the sequence of hyperplasia-dysplasia-neoplasia. However, with only one patient presented FDCS complicated by Castleman's disease in our study['s disease specimen.At present, there is no definite etiology for most cases of FDCS. Cytogenetic abnormalities have been described in one case of FDCS in the spleen, displayy of case,34, whicour study, additioour study, with ovEBV has been documented to be positive in a small percentage of FDCS cases. It is nThe pathologic characteristics and immunophenotypic profile of FDCS in our series are similar to those in the literature. The most common histological feature is the presence of oval to spindle cells with elongated nuclei, delicate, dispersed chromatin and pale eosinophilic cytoplasm. Lymphocytes may gather around blood vessels, creating a cuffing pattern. Concentric whorl is also a characteristic growth pattern. Scattered multinucleated tumor cells may also be present. All these various morphologic features must be considered in the differentiated diagnosis of FDCS.To Sum up the literature, CD21 and CD35 are the most widely used markers. Other useful markers are vimentin, CD23, CD68, S-100 protein, fascin, Ki-M4p and Ki-FDC1p; however, these are unspecific. FDCS typically lacks expression of CD1a, desmin and CD45, which allows their differential diagnosis with interdigitating dendritic cell tumors, Langherhans cell tumors, histiocytic and lymphoid neoplasias. So the expression of non-typical FDCS markers should be taken into account in the differential diagnosis with other neoplasms.The diagnosis of FDC tumor is established basing on the findings of morphology and immunohistochemistry. Ultrastructural studies may be helpful but are not indispensable for accurate diagnosis. All neoplasms in the differential diagnosis lack follicular dendritic cell differentiation and are easily excluded if FDCS is considered and immunohistochemical staining with FDC markers is applied.The optimal treatment for FDCS is yet to be found due to the limited experience. Current best-available approach is to apply therapeutic guidelines similar to those used for soft tissue sarcomas of high grade. Our study does show some trends though. Both the analytic literature review and the cases conducted by ourselves suggest that FDCS can be effectively treated by surgery and no radiotherapy or chemotherapy after radical excision is required.Lymph nodes, lung, and liver are the most common sites for metastasis. In case studies conducted by our own team members, the clinical course of follicular dendritic cell sarcomas is akin to that of low-grade tumors. These figures are probably underestimates, because many cases in the literature had short follow-up periods.To conclude, FDCS is an extremely rare tumor of lymph nodes and extranodal tissues. Because of the scarcity of the identified cases, it is probably under recognized, particularly when happened in extranodal sites. Recently, the diagnosis accuracy has been significantly improved, thanks to the aid of IHC analysis and the two most reliable FDC markers CD21 of and CD35. Once FDCS is suspected histologically, immunohistochemical stains for follicular dendritic cell differentiation should be performed to avoid the risk of misdiagnosis. As noted previously, FDCS occurring in the liver or spleen may represent a variant subset that differs from the FDCS in other sites, producing a histological picture similar to inflammatory pseudotumor(IPT). They probably have different characteristics and causes. So it is important to consider the possibility of an IPT-like FDC tumor when making a diagnosis of a hepatic/splenic IPT-like lesion.FDCS has a slight recurrent and metastatic potential and it should be viewed as a low-grade malignancy. Literature shows that therapeutic modalities in this disease varied widely although complete surgical resection was often included. In addition, adjuvant chemotherapy and radiotherapy may be utilized; but the value of these adjuvant treatments to effectively improve survival rates has not been convincingly demonstrated.Most of the data on FDCS are based on single case report or small-group case series, further investigations are required to address the following questions: (1) more systematic data are needed to understand the role of the EBV in the pathogenesis of this tumor. (2) Further detailed cytogenetic studies of FDCS might reveal a specific chromosomal profile of these tumors, which in turn will yield new insights into the biology of FDCS and provide the pathologist with independent genetic markers. (3) additional studies needed to decide whether Asians would be susceptible to this disease.The authors declare that they have no competing interests.WHW carried out the in situ hybridization, performed the literature review, acquired photomicrographs, and drafted the manuscript. LBA conceived and designed the study. LBA and SZS conducted and reviewed the final histopathological diagnosis. HZL carried out and evaluated the immunohistochemical stains. WJF revised the manuscript for important intellectual content. All authors read and approved the final manuscript.The clinical characteristics of 50 cases of FDCS. The clinical characteristics of all cases of FDCS were summarized in additional file Click here for file


The authors report a rare case of primary spinal ependymomatosis in a young adult man. Multiple primary ependymomatous lesions were seen on magnetic resonance imaging and no anaplasia was identified on the surgical-pathological analysis. The aetio-pathological mechanism and surgical significance of this rare occurrence is discussed.A 26-year-old man of Polish origin presented with a ten-day history of pain in the left leg and lower back. This was followed by difficulty in urinating and a decrease in sensation in both legs. Examination revealed pyramidal signs and mild weakness in both lower limbs. He had early sphincter involvement requiring catheterization. Magnetic resonance imaging of the brain was normal. However, that of the spinal cord revealed multiple intradural spinal lesions, both intra- and extramedullary, extending from the cervical cord down to the cauda equina roots. T12-L1 laminectomy was performed. Multiple intradural, extra- and intra-medullary tumors were seen. After the operation, the patient deteriorated with a sensory level at T4. Post-operative cranio-spinal radiotherapy was administered but there was no clinical improvement in the lower limbs.Primary spinal ependymomatosis is a rare phenomenon involving multiple spinal segments in the absence of a primary intracranial tumor. Radical excision is unrealistic in this condition. Biopsy followed by radiotherapy is the preferred method of treatment. Ependymomas are usually solitary lesions that may metastasize within the central nervous system (CNS) via the cerebrospinal fluid (CSF) pathways. We describe a rare case of primary spinal ependymomatosis and discuss its clinical presentation and etio-pathogenesis, highlighting issues related to its management.A 26-year-old man of Polish origin, previously fit and healthy, presented with a ten-day history of pain in the left leg and lower back. This was followed by difficulty in urinating and decrease in sensation in both legs. Examination revealed pyramidal signs and mild weakness of both lower limbs. He had early sphincter involvement requiring catheterization.Magnetic resonance imaging (MRI) of the brain was normal. However, that of the spinal cord revealed multiple intradural spinal lesions, both intra- and extramedullary, extending from the cervical cord down to the cauda equina roots Figure . There wA T12-L1 laminectomy was performed. Multiple intradural, extra- and intramedullary tumors were seen Figure . After tSpinal ependymomas are rare tumors constituting 1.9% of all CNS tumors and 60% of spinal gliomas ,3. Rare Primary ependymomatosis is a rare phenomenon where the ependymomas are seen particularly involving multiple segments of the spine without any evidence of a primary intracranial lesion. In most cases of secondary ependymomatosis, multiple involvement of the spine is a result of drop metastases from a cranial or more proximal primary lesion. In our case, we could not determine if the ependymomatosis represented primary synchronous multiple ependymomas, or whether they were simply drop metastases from an asymptomatic cervical primary lesion. In this case, no definitive primary cranial lesion was identified. Also, there was very little anaplasia detected on histopathology. Therefore, we believe that this case represents true primary ependymomatosis of the spinal cord, and not simply a case of drop metastases. Histopathology was suggestive of a primary typical ependymoma and the multiplicity of the lesions in the spinal cord without cranial involvement implies the possibility of this rare phenomenon. In any event, multiplicity of the lesions meant that radical resection with a curative intention was an unrealistic goal. As predominant symptoms and compression were located at the conus level, limited decompression with biopsy of one of the compressive exophytic lesions was performed with no clinical benefit.Although primary surgical excision is the treatment of choice in most cases of spinal ependymomas, from our experience and in cases of primary ependymomatosis, radical surgical extirpation is not advised. A biopsy of the most accessible representative lesion followed by radiotherapy perhaps represents to be the most preferable option.Primary spinal ependymamatosis is a rare phenomenon involving multiple spinal segments without primary intracranial tumor. Radical excision, although recommended for ependymomas in general, is unrealistic and carries high risks of further neurological deterioration. Biopsy followed by radiotherapy may be the most preferred management of this rare condition.CNS: central nervous system; CSF: cerebrospinal fluid; MRI: magnetic resonance imaging.The authors declare that they have no competing interests.CK collected data and prepared the draft for the manuscript. NS prepared the discussion for the case report. BH is a neuropathologist and was involved in tissue analysis and slide preparation for this patient. KAC is the senior neurosurgeon involved in this overall management of the patient. KAC revised the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for the 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.


Hepatoid gastric adenocarcinoma is a distinct variant of gastric carcinoma which represents a comparatively small percentage of the disease and in many cases is producing high serum alpha-fetoprotein (AFP). We report a case of an 85 year old woman who presented with epigastric and right upper quadrant pain and was found in a CT scan to have multiple liver nodules and a gastric antrum mass as well as an elevated AFP level of 155000 IU/ml. An endoscopic biopsy of the antral mass showed hepatoid variant of gastric adenocarcinoma. The patient refused any further treatment and died 4 months after diagnosis. Hepatoid gastric adenocarcinoma is considered to have a poor prognosis, although cases with survival of several years have been reported. Poor outcome in most of the cases is due to the fact that, as in our patient, metastatic disease is already present at diagnosis. Hepatoid gastric adenocarcinoma is comparatively rare and most case reports come from the Far East -4 while An 85 year-old woman presented with epigastric and right upper quadrant abdominal pain of 3 days duration. The patient had no relevant medical history, except for mild hypertension and an excised squamous scin carcinoma of the right hand 4 years previously. Review of systems disclosed weight loss of 5 kgs in 2 months but no hematemesis, hematochezia or melena. Physical examination was positive for mildly anaemic sclerae. Laboratory investigation showed a hematocrit of 34% with hemoglobin of 11.5 g/dl, MCV of 113 fl and RDW of 13.5%. The AFP level was very elevated at 155000 IU/ml. Other tumor markers were normal. Hepatitis B and C panel was negative. An esophagogastroduodenoscopy revealed a gastric antrum mass, and an abdominal CT showed the mass to measure 7 cm and disclosed several liver metastases Figure . AdditioGastric hepatoid adenocarcinoma (GHAC) with elevated serum AFP, first described by Ishikura et al. 1985 , is a raRecently, glypican 3 (GPC3) has been evaluated as a sensitive marker for AFP-producing gastric carcinoma (GC) and its hepatoid component, and the authors support its usefulness for identifying this aggressive subgroup of GC . Both thIn terms of treatment, there are only sparse data in the literature pertaining specifically to GHAC and the disease should be in general treated similarly to common gastric adenocarcinoma. Surgical management of an early primary tumor, if feasible, is the indicated approach. Adjuvant chemotherapy and radiotherapy should be given according to current gastric cancer indications, despite the fact that no specific data on adjuvant treatment of GHAC are available. Palliative chemotherapy is the mainstay of treatment in inoperable, recurrent or metastatic cases. Concerning specific chemotherapy regimens, there are again few data specific for this sub-type of cancer . A case Liver metastasectomy of completely resectable metastases may be considered in selected cases. The first case of a long-term (11 years) survival of AFP-producing gastric cancer with successfully resected metachronous liver metastasis and gastric remnant carcinoma has recently been reported . In suchA multidisciplinary treatment approach modelled from other types of cancer should be instituted to obtain optimal results in hepatoid adenocarcinoma of the stomach. Further investigation in the molecular pathogenesis of hepatoid gastric adenocarcinoma is also of importance in order to elucidate its origin and introduce novel treatments.CT: computed tomography; MCV: mean corpuscular volume; RDW: red blood cell distribution width; MRI: magnetic resonance imaging.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.PJV and IAV contributed equally to this work. PJV performed the research and wrote the paper. IAV conceptualized and co-authored the paper, provided clinical care and performed research. SB and FK performed research and provided histopathological data. CNP revised the paper. All authors read and approved the final manuscript.


Umbilical discharge in adult is rare and is usually induced by foreign material, most commonly hair. Rarely, it may be due to embryonal anomalies. We are reporting an unusual case of umbilical discharge in adult secondary to an impacted lint ball.A 55-year-old obese woman presented with a 4-month history of hemorrhagic discharge from the umbilicus. Deep from the base of the umbilicus, a 0.8 cm gray-tan mass was removed that on microscopic examination revealed a lint ball.An impacted lint ball may be a rare cause of umbilical discharge in adult. A 55-year-old obese white American woman of European descent presented with a 4-month history of slightly hemorrhagic discharge from her umbilicus. There was no history of fever, abdominal pain or any other systemic disease. Physical examination revealed a deep umbilicus with a barely visible opening. There was no redness, edema, or crusting of the periumbilical skin. The deeper aspect of the umbilicus was exposed by using a spatula. A dark, rounded polypoid mass was noted. The clinical impression was that of fibro-epithelial polyp or some other tumor. An attempt was made to remove the mass by excising the base; however, the mass easily came out of the umbilical cavity implying that either it was necrotic or it was not firmly attached to the umbilical tissue at the base. The gray-tan 0.8 cm size round mass on cut section revealed white fibrous appearance. On microscopic examination, it was composed of lint material with typical morphology of refractile bean-shaped and elongated colorless structures, red spindle-shaped keratin material, granular red debris, rare hair fragments and polymorphonuclear leukocytes . Under pThe patient remained completely asymptomatic at the follow-up visit one month later.Umbilical discharge in adult is rare but can be quite alarming. It may be caused by various congenital or acquired conditions. Patients with embryonal anomalies, such as patent urachus, urachal cyst or sinus, patent vitelline duct, vitelline cyst or sinus may present as umbilical discharge . HoweverThe present case is definitely a foreign body-induced omphalitis. Hairball is the most common type of foreign body seen in such cases. Most of the patients are young, hairy male with deep umbilicus with poor personal hygiene . One intWe could not find any reported case of ‘lint ball omphalitis’.Finding of ‘belly-button lint’ is quite common among hairy man. Usually it is washed off during bathing or shower and rarely does it cause any inflammation. Steinhauser has recently suggested that abdominal hair is mainly responsible for directing the fibers from clothes into the navel where they are compacted . ShavingObesity, deep umbilicus, and poor hygiene may have been the predisposing factors for developing lint accumulation and subsequent omphalitis in our patient.


The primary malignant melanoma of the esophagus (PMME) is a raremalignant disease, accounting for only 0.1–0.2% of allesophageal neoplasms, and the majority of the patients arediagnosed at advanced stages with poor prognosis. We present herea case of 56-year-old woman with epigastric pain and herendoscopic finding revealed several flat and black pigmentedmucosal lesions within the distal portion of the esophagus whichlooked like flat nevus. The histopathology and immunohistochemicalprofile of the tissue specimens were diagnostic of malignantmelanoma. The primary malignant melanoma of esophagus (PMME) is an extremely rare and highly aggressive tumor with the mean survival time of 10 months and the 5-year survival rate of only 4% . The inchelicobacter pylori since 2002. He took a medication of proton pump inhibitor. His physical examination was unremarkable and revealed no evidence of organomegaly or lymphadenopathy. He did not have any other comorbidities. Esophagoscopy revealed several flat and black pigmented mucosal lesions with a short shallow mucosal break in the distal esophagus and esophagogastric junction (Figures A 56-year-old man presented to our hospital complaining of epigastric pain for 10 days. He had been medically treated for reflux esophagitis, and the gastric ulcers infected secondary to  Figures  and 2. M Figures , ×400. EPMME is generally considered to be a highly malignant tumor which carries a poor prognosis and shows a rapidly fatal course . The rolApproximately 90% of the PMME are located in the distal two-thirds of the esophagus . In majoAt the time of presentation of PMME, metastatic disease is present in about 50% of the patients, 31% hepatic, 29% mediastinal, 18% pulmonary, and 13% cerebral . MetastaExtensive surgical resection, total or near-total esophagectomy with sufficient margin of resection, is first choice in treatment because of tendency to spread longitudinally along the submucosa . Althoug


A 75 year old gentleman who presented with an incarcerated paraumibilical hernia was found intraoperatively to have small bowel perforation due to a piece of china with a synchronous asymptomatic sigmoid carcinoma. There was no significant abnormality on the abdominal radiograph A 75-year-old man presented with sudden onset central abdominal pain described as gripping in nature and lasting for approximately 1 hour. The pain subsequently settled to a constant dull ache. He had a regular bowel habit and was otherwise fit and well. On examination the patient had a pulse rate of 94/min, a respiratory rate of 14/min, was afebrile and normotensive. An abdominal examination revealed a paraumbilical hernia approximately 1.5 cm in size, which was irreducible and tender. The rest of the abdomen felt soft with no masses. Bowel sounds were normal and there were no signs of peritonism. A digital rectal examination revealed soft stool. The initial blood tests revealed a raised white cell count of 14 × 10 Ingestion of a sharp foreign body is mostly accidental, though it may occur in mental impairment and alcoholism. Gastrointestinal perforations can occur at any site along the tract, mainly at narrowings, angulations or in anatomic cul-de-sacs.  The ileuThe authors declare that they have no competing interests.All authors were involved with the concept and design of this report and in the writing of the draft and final versions of the manuscript.Written informed consent was obtained from the patientfor publication of this case report and accompanying images. A copy of this written consent is available for review by the Editor-in Chief of this journal.


Patients with adrenal metastasis from various primary tumours are regarded as cases of diffuse systemic spread and considered unsuitable for surgical resection. We herein report an operable case of heterochronic adrenal metastasis from colorectal carcinoma in a 63-year-old woman.Sixteen months after low anterior resection for the primary tumour, left lower pneumonectomy was performed for a solitary lung metastasis. Four months later a right adrenal metastasis was detected by magnetic resonance imaging (MRI), as sole evidence of metastatic disease. A right adrenalectomy was performed. The histopathological examination revealed adenocarcinoma compatible with the colorectal carcinoma resected 19 months earlier. The patient received adjuvant chemotherapy after each operation and is alive and free of disease 21 months after the adrenalectomy.The possibility of adrenal metastasis should be considered in the follow-up of patients after primary surgery for colorectal cancer, even though other sites are the main metastatic sites. Although the prognosis of adrenal metastasis from colorectal cancer is poor, we suggest that patients with solitary adrenal metastasis may benefit from complete removal of it. Adrenal metastasis most commonly occurs in patients with lung, breast and renal cancer ,2. In ge2 (on day 1), leukovorin i.v., 200 mg/m2 , 5 FU (fluorouracil) i.v., bolus 400 mg/m2 , 5 FU i.v., 22 hours-infusion, 600 mg/m2 , every 2 weeks for 12 cycles.A 63-year-old-woman presented with lower abdominal pain and anal bleeding on defecation. Colonoscopy revealed intraluminal stenosis of the colorectal junction and biopsy specimens were obtained. Histologically, a well-differentiated adenocarcinoma was diagnosed. There was no evidence of metastasis, based on the results of abdominal computed tomography (CT) and chest X-ray, while (carcinoembryonic antigen) CEA was normal at 2.36 ng/ml. The patient underwent low anterior resection for CRC on 14 July 2004. The lesion was a stage Â2 (Astler-Coller) tumour, 3,0 × 2.5 cm in size, located in the rectosigmoid colon. Microscopic examination showed well-differentiated adenocarcinoma, penetrating the muscularis propria, without lymphatic and vascular invasion and without metastases to 15 dissected lymph nodes. According to the classification of TNM , the disease was stage II. Her postoperative course was uneventful, and she was started on adjuvant chemotherapy, comprised of oxaliplatin i.v., 85 mg/m2 (on day 1), leukovorin i.v., 200 mg/m2 , 5 FU i.v., bolus, 400 mg/m2 , 5 FU i.v., 22 hours-infusion, 600 mg/m2 , every 2 weeks for 6 cycles. Four months after the lower pneumonectomy a follow-up CT-MRI identified a nodule in the right adrenal gland, 2 × 1 cm in size  fluoro-2-deoxy-Dglucose (FDG) and positron emission tomography) 18F-FDG PET and (Computed Tomography-Positron Emission Tomography) CT-PET may offer better chances to detect clinically silent adrenal metastasis in the future.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 the ≪Cases Journal≫.The authors declare that they have no competing interests.All authors contributed the same.


Minimally invasive investigations, such as pleural fluid cytological assessment and closed percutaneous pleural biopsy, are often performed first in the investigation of suspected malignant pleural effusions. Malignant pleural effusions can be diagnosed with pleural fluid cytology alone in most cases; however, closed pleural biopsy is performed to increase the diagnostic yield when pleural fluid cytology is negative. This additional yield is at the expense of increased complication rates. We report a 64-year old man with a negative pleural fluid cytology but suspected malignant pleural effusion who underwent a closed pleural biopsy, which was complicated by pneumothorax, pneumomediastinum and severe subcutaneous emphysema. Pulmonary laceration by the pleural biopsy needle is the most likely aetiology of these complications. Our case report highlights an infrequent but significant complication of closed percutaneous pleural biopsy. Malignant pleural effusions typically indicate disseminated disease, with an expected median survival of 3–12 months [A 64-year-old-man was referred to our institution for investigation of a large left pleural effusion. Over the preceding two months, he had developed progressive dyspnea, left pleuritic chest pain and 6 kg weight loss. He was a reformed smoker with a 40-pack-year smoking history. He was admitted to the hospital, and a thoracic CT scan Figure  was perfTwelve hours after the procedure, he developed a high pitched dysphonia, severe dyspnea, and pleuritic left chest pain. On examination, there was extensive subcutaneous emphysema along the chest wall extending to the neck. An emergency thoracic CT scan Figure  was perfSubsequently, a CT guided FNA of the left lower lobe mass was obtained. This revealed non-small cell lung cancer, subtype adenocarcinoma. The patient is currently receiving palliative chemotherapy with symptomatic improvement and no recurrence of the pleural effusion.Malignant pleural effusions can be diagnosed by pleural fluid cytology alone in 60% of cases, and CPB can increase the diagnostic yield by 7%–27% . PleuralPneumothorax most commonly develops due to entry of air through the biopsy needle or laceration to the lung parenchyma. We hypothesize that in our patient, laceration to the lung parenchyma rather than air entry through biopsy needle is the most likely pathogenetic mechanism. The injury probably produced a bronchopleural fistula, allowing air to track along the continuum between the endothoracic fascia of outer chest wall, pleural space and mediastinum, resulting in subcutaneous emphysema, pneumothorax and pneumomediastinum . We beliBecause of the limited yield and risk of complications, CPB has been superseded by thoracoscopy in some centers. Thoracoscopy is diagnostic in 95% of malignant pleural effusions ,7. The hOur report illustrates the complications of pneumothorax, pneumomediastinum and subcutaneous emphysema after a non-diagnostic CPB. We believe that by being aware of the limitations of CPB, clinicians can better choose the appropriate test in the investigation of exudative unilateral pleural effusions.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.KBS reviewed the case notes and prepared the manuscript. HPAJ read and approved the final manuscript.