Cardiac angiosarcomas are extremely rare in childhood, they are rapidlyprogressive tumours that often present themselves as diagnostic dilemmas,resulting in delayed diagnosis. Also, extracardiac manifestations, includingabdominal pain, are extremely rare in patients with intracardiac tumors. Weherein present the case of a 15-year-old girl who presented with abdominal pain.Echocardiography and thoracic computed tomography showed right atrial mass. Thepatient underwent surgery, chemotherapy, and radiotherapy. Eight months aftertreatment, abdominal recurrence was detected. The abdominal mass was resected,and radiotherapy and new chemotherapy protocol were given. The present caseillustrates a rare case of primary cardiac angiosarcoma posing a diagnosticdilemma in an adolescent girl. The majority of them are benign and sarcomas representthe most common malignant tumors. Among primary adult cardiac sarcomas, angiosarcoma ismore common than rhabdomyosarcoma, but it remains an unusual occurrence. In thisreport, we present a 15-year-old girl who was admitted to the emergency departmentwith a complaint of severe abdominal pain and who was diagnosed with cardiacangiosarcoma.Primary cardiac tumors are extremely rare in children, with an incidence varyingbetween 0.0017 and 0.28%A 15-year-old, Syrian refugee girl who was a high school student was admitted to theemergency department with a history of 15 days of abdominal pain. On physicalexamination, she is 160 cm tall and weighs 50 kg. She had no history of cancer inher family. She presented with abdominal tenderness, hepatosplenomegaly and muffledheart sounds. Abdominal and thoracic computed tomography (CT) showedhepatosplenomegaly and solid mass in the right atrium and in the left mediastinum.There was a massive pericardial and moderate right pleural effusion . EchocarThe patient was taken to the operation room under semi-urgent conditions. Tensepericardium due to excessive pericardial liquid was observed after midlinesternotomy. The pericardium was opened and 1500 cc of serous liquid wereevacuated from the cavity. Macerated epicardial appearance and probablemalignant infiltration areas inside the right ventricle wall were seen. Patientwas heparinized (3 mg/kg) and the activated coagulation time (ACT) obtained wasabove 400 seconds. Total cardiopulmonary bypass was started via aortic andbicaval cannulation. Cardioplegia was infused after crossclamping of theascending aorta. The right atrium was opened with vertical incision. A solidatrial mass that was completely invading the right atrial wall and alsoprolapsing through the tricuspid valve and causing partial obstruction of rightventricle inflow was observed. The mass was totally excised along with the rightatrial wall. This resected area was repaired by using glutaraldehyde-treatedautologous pericardium (0.1%) .After cThe mass in the right atrium was reported as an angiosarcoma. Onimmunohistochemical analysis, tumor cells were positive for cluster ofdifferentiation 31 (CD31), CD34, friend leukemia integration-1 (FLI-1) anderythroblast transformation specific regulated gene-1 (ERG), but they werenegative for keratin, desmin, smooth muscle actin (SMA), myogenin, Humanmelanoma black 45 (HMB45) and human herpesvirus 8 (HHV-8) . IfosfamPrimary angiosarcoma of the heart is an exceptional diagnosis in pediatricpopulation. Cardiac tumors, either benign or malignant, are difficult to diagnosedue to their rarity, variety and nonspecificity of the symptoms..The most common complaints presented are dyspnea and chest pain, usually related toa malignant cardiac effusion. The pericardium is frequently involved with a rightsided angiosarcoma; cardiac tamponade and pericardial effusion are commoncomplications,3. Our patient had a massivepericardial effusion and malignant cells were seen in cytologic examination.Extracardiac manifestations, including abdominal pain, are extremely rare inpatients with intracardiac tumors, like our case.Primary cardiac angiosarcomas in all age groups mostly occur in the rightatrium.The rarity of this diagnosis has made it difficult to standardize therapy, butsurgical treatment is the main option. A multimodality treatment includingpreoperative and/or postoperative chemotherapy and/or radiotherapy seems beneficialfor overall or progression-free survival. Using modern radiation techniques,radiotherapy on the heart seems to be safe, without major cardiactoxicity,5. The average age atpresentation is 12.3 years. There were 4 girls and 4 boys; one patient's gender wasnot determined. Eight patients had right atrium involvement. Most patients presentedwith dyspnea or chest pain. Our patient had an extracardiac manifestation. Six of 9patients had a metastatic disease at the time of diagnosis. Six patients died with aprogressive disease.To our knowledge, only 9 children cases of primary cardiac angiosarcoma were detailedreported, including ours.Preliminary outcomes in Syrian refugee children with cancer were similar to theoutcomes in Turkish children.A study about the frequency of cancer among Syrian and Turkish children has revealedthat most of cancer types were similar in frequency, but the percentage of childrenwith neuroblastoma and bone tumours was significantly higher inrefugeesAs a result, children with abdominal pain have to be examined for extra-abdominaldiseases and cancer.


Leiomyosarcoma of vascular smooth muscle is a very rare entity. A fair number of cases of vascular leiomyosarcomas have been reported, and the vast majority of these tumors arose from the inferior vena cava.We report the case of a 71-year-old female patient who presented with recurrent upper abdominal pain. A CT-scan demonstrated a heterogenous mass in the liver hilum. Liver function tests and hematology parameters as well as the tumor markers were normal. Due to the unclear diagnosis a percutaneous biopsy of this mass was performed and revealed leiomyosarcoma. The patient was treated by a right sided hemihepatectomy with portal vein reconstruction and an end-to-side hepatico-jejunostomy. Final histology confirmed complete (R0) resection of a moderately differentiated leiomyosarcoma of the portal vein. After complete (R0) resection of the lesion, the patient remained without any signs of tumor recurrence for a total of 36 months until detection of an unresectable local recurrence. After surgical re-exploration the patient was finally referred to palliative radiotherapy.Vascular leiomyosarcoma of the portal vein is an extremely rare tumor entity. We have described a case with no evidence-based neo/adjuvant treatment options, where aggressive surgery achieved a tumor-free margin (R0), performed in a specialized center for sarcoma and hepatobiliary surgery. Leiomyosarcoma is a malignant mesenchymal tumor of smooth muscle cells representing the second most frequent malignant soft tissue tumor in adults after liposarcoma. Perl initially described vascular leiomyosarcoma in 1871, which is a rare disease: so far, only a few hundred patients with vascular leiomyosarcoma have been reported in the literature. Vascular leiomyosarcoma most often arise from the inferior vena cava (IVC). Less frequently they have been described in the renal, mesenteric, hepatic and saphenous veins, or even in arteries . Only onWe report the case of a 71-year-old female patient who presented with recurrent upper abdominal pain. CT-scan demonstrated a heterogenous mass in the liver hilum, which infiltrated the main portal vein up to the right branch. The common hepatic artery was displaced to the left but not encased by the tumor. No signs of biliary obstruction were seen  with up to 15 mitoses in 10 high power fields was made. Necrotic areas were only found in about 5 % of the tumor volume (FNCLCC-score: 5/8). For the definition of resection status, the specimen was microscopically evaluated for the resection status by sampling of the distal and proximal resection margins of the portal vein, bile duct, right hepatic artery as well as the parenchymal resection margin of the liver. Complete resection (R0) was confirmed Fig. .Fig. 3aThe patient did not receive adjuvant treatment. A follow-up CT-scan 36 months postoperatively revealed tumor recurrence in the liver hilum Fig. . Due an Vacular leiomyosarcoma is a rare tumor entity, which predominantly occurs in the IVC: more than 250 patients have been entered into a patient registry for this disease , 7. An aIn addition to the rare incidence, the variable histological appearance may complicate the diagnosis of vascular leiomyosarcoma. Due to the etiology of leiomyosarcoma, it usually shares characteristics of benign leiomyoma such as bundles of smooth muscle cells with central cigar-shaped nucleus, but cells also have eosinophilic cytoplasm and often perinuclear vacuoles. Usually, leiomyosarcoma stains positive for vimentin and smooth muscle actin, and they typically express desmin. Commonly, these tumors are negative for protein S-100 and neuron-specific enolase. However, expression of protein S-100, Leu 7, and epithelial membrane antigen have also been reported for leiomyosarcoma . MorpholAlso due to the low incidence of this tumor, no adjuvant or neoadjuvant chemotherapy or radiotherapy regimen has been established for vascular leiomyosarcoma , 4, 7. UVascular leiomyosarcoma of the portal vein is an extremely rare tumor entity. In the absence of established neo/adjuvant treatment options, aggressive surgery seems to be the most reasonable treatment if tumor-free margins (R0) can be achieved. Based on the complexity of the hilar anatomy and the prognosis of unresectable disease, the treatment of this tumor entity should only be performed in specialized centres for sarcoma and hepato-biliary surgery.


Actinomyces species supplemented with medicine prescription. A woman was referred for endodontic management of tooth #19. The tooth had a history of previous nonsurgical endodontic retreatment. Clinically, the tooth was very sensitive to percussion. Radiographic evaluation showed a large periapical lesion. Intentional replantation (IR) was planned. The tooth was atraumatically extracted. Without any curettage, through the blood flow coming out of the socket, a small yellowish granule was detected and sent for examination. After root-end preparations, the cavities were filled with calcium-enriched mixture cement and the tooth was carefully replanted. Histopathological assessment proved actinomycosis sulfur granule. According to infectious disease specialist recommendation, low-dose and long-term penicillin V was prescribed. Interestingly, at 2-month follow-up, remarkable bone healing was observed. In the cases of apical actinomycosis, IR in combination with antibiotic therapy, even without the curettage of the lesion, may be successfully employed. Actinomycosis is a rare lesion of the jaws and may present as periapical pathosis; therefore, it is essential to be correctly diagnosed and managed. This case presentation describes management of a tooth with a symptomatic apical periodontitis caused by  Actinomyces, which are gram-positive, slow growing, opportunistic, anaerobic or microaerophilic filamentous organisms [Actinomyces may live in the human oropharynx, gastrointestinal tract and urogenital tract as normal flora. Between the species, Actinomyces (A.) israelii is the most prevalent pathogen. The bacteria establishes a granulomatous inflammation distinguishable by swelling, sinus tract, and purulent discharge containing yellowish sulfur granule [Actinomycosis is an uncommon chronic infectious disease. The disease caused by species of rganisms . Actinom granule .A rupture in the mucosal barrier, or presence of necrotic tissues, can facilitate entry and spread of the infection ; cervicoThe role of actinomycotic organisms in failure of root canal treatment has been documented , 7-11. TIntentional replantation (IR) technique defines as extraction of an endodontically involved tooth, doing treatment procedures extra orally, and insertion of the tooth back into its alveolar socket. When endodontic surgery is necessary, but is not possible or practical, IR is a viable treatment option; with careful case selection, it has high success rate . via IR of the tooth.This manuscript is report of a patient who suffered from an endodontically retreated mandibular molar with a large apical lesion. Treatment plan was decided to be retrograde procedure A 22-year-old woman was referred with the complaint of having trouble with her mandibular left first molar for a while. Because of unsuccessful root canal treatment (RCT), non-surgical retreatment had done for the tooth by an endodontist. However, even after the retreatment, discomfort remained. The medical history was non-contributory. There was no history of soft tissue swelling, abscess formation or sinus tract. The teeth had a composite resin restoration. In clinical examination, normal mucosa in the adjacent vestibule could be seen. The tooth was tender so to percussion. The probing depth was normal, with no mobility. Radiographic evaluation  exhibiteTreatment procedure was performed by an endodontist. On the day of operation, after a 0.12% chlorhexidine mouth rinse, local mandibular block anaesthesia with 2% lidocaine plus 1:80000 epinephrine  administered. Then, the tooth with a slow rocking motion was extracted with a dental forceps. A 2×2 mm creamy yellowish-white granule was washed out from the socket through blood. It was immersed in 10% formalin solution and was sent for oral pathologist. Holding the tooth by the crown using the forceps, ~2 mm root apices were resected with a diamond bur in a high speed handpiece. Using Gates Glidden burs #2-4, 3-mm depth root-end cavities were prepared. The powder and liquid of the calcium-enriched mixture (CEM) cement were mixed according to manufacturer’s instructions and the mixture was inserted into the prepared cavities. After saline rinsing and aspiration of blood clot with suction, without any curettage, the tooth was carefully replanted into alveolar socket with the forceps. Normal occlusion was checked and precise repositioning confirmed with periapical radiography . No spliThe histopathological examination revealed sulfur granule specimen contained colonies of gram-positive branching filamentous organisms manifesting actinomycosis . A consuvia an endodontic flap surgery [Periapical actinomycosis is not a prevalent periradicular infection. Although the infection mostly involve cervicofacial region , only a  surgery -9, 11 coReaching the right diagnosis to this infection is a burdensome task . In histOne of the characteristics of actinomycosis infections is forming sinus tracts with purulent discharges . These iActinomyces species were present in the failed cases and in the most of failures, no other organism was proved to contribute [A long-term study about healing of periapical lesions demonstrated that the ntribute . Periapintribute . The extIn spite of any surgical debridement and curettage, this case demonstrated favorable treatment outcomes and considerable bone healing after just two months was obtained. This can be considered as a fast bone healing process which shows natural healing power of human bodies in the absence of etiologic factors. Healing after an endodontic surgery needs regeneration of periodontium, medullary/cortical bone regeneration and new cementum formation . An inveLong-term drug therapy is required for curing actinomycosis infections . CervicoBiocompatibility and sealing ability are necessary qualities for root-end filling materials in modern endodontics. CEM has demonstrated favourable characteristics in terms of sealability, cementogenesis/osteogenesis and maturogenesis -25; thesApical actinomycosis should be in mind as one of the reasons of persistent apical periodontitis. Even when curettage of the defect could not be carried out, IR might be considered as a successful treatment plan for such involved teeth. Antibiotic therapy could help elimination of the infection.


An inflammatory myofibroblastic tumor, also known as inflammatory pseudotumor, is a rare neoplasm characterized by myofibroblastic spindle and inflammatory cells that cause masses in many sites of body. It is often benign, but in some cases neoplastic transformation has been reported as a result of aggressive growing. In our case, an inflammatory myofibroblastic tumor was reported by biopsy of a 25 × 15 cm abdominal mass.Tastekin F, Ersoy M, Temel T, Ozgenel SM, Canaz F, Özakyol A. Abdominal Inflammatory Myofibroblastic Tumor: A Rare Case. Euroasian J Hepato-Gastroenterol 2016;6(2):183-185. Other names of this entity in the literature are inflammatory pseudotumor, pseudosarcomatous myofibroblastic proliferation, pseudosarcomatous myofibroblastic tumor, pseudosarcomatous reactive response, atypical myofibroblastic tumor, atypical fibromixoid tumor, plasma cell granuloma, and bladder nodular fasciitis.Inflammatory myofibroblastic tumor is a disorder that cause masses in many sites of body and that is not still to be proven whether it is an inflammatory course or a true neoplasm.A 60-year-old man has been examined due to complaints like oral intake disorder and weight loss, and an abdominal mass was detected. He was referred to our department  by the suspicion of cancer derived liver. A 25 × 15 × 24 cm mass, which has an undistinguishable tissue origin, was observed on dynamic magnetic resonance imaging (MRI)  to 3. Th2 Infection, trauma, irradiation, and autoimmune ground are considered in disorder’s etiology, but etiology is still not clear.3 Symptoms are varied based on involved body part. However, abdominal discomfort, dyspepsia, oral intake disorder, weight loss, and mass with palpation may be seen in cases with abdominal involvement, such as the case in our patient. When we examine patterns macroscopically, they are benign, restricted, and not encapsulated; also nodular and diffuse growing patterns are observed. If we investigate it microscopically, spindle cell proliferation and mixed types of inflammatory cells are there in collagenated loose stroma. Immunohistochemical investigation contributes to confirmation of diagnosis. Vimentin, Smooth Muscle Actin (SMA), and Cluster of differentiation 68 (CD68) are positive. In addition, anaplastic lymphoma kinase (ALK) reveals cytoplasmic staining in myofibroblastic cells.4 Ultrasonography, especially computed tomography and MRI, is necessary for diagnosis. Most common involved body part is lung, but involvement of larynx, spleen, breast, bladder, central nervous system, pancreas, orbita, mesentery, prostate, salivary glands, testes, and skin have been reported.56 First choice of treatment, if available, is complete resection in most patients; if not, radiotherapy and steroid use is recommended. The other treatment choices are immunomodulation (cyclosporine A), chemotherapy , and antimetabolite regimen.2 Early diagnosis and total excision are significant in good prognosis. Although pathogenic organisms are reported in most inflammatory myofibroblastic tumor cases, resection should be always considered due to presence of malignant transformation in some cases.An inflammatory myofibroblastic tumor is often referred as an inflammatory pseudotumor. It is a rare neoplasm characterized by myofibroblastic spindle and inflammatory cells and is particularly located in soft tissues. It is often benign, but in some cases, neoplastic transformation has been reported as a result of aggressive growing.We evaluated a rare inflammatory myofibroblastic tumor in our case. The tumor was large and had an interesting pathogenesis. Therefore, we decided to report it.


Mesenchymal hamartomas of the liver is one type of rare liver tumor.Mesenchymal hamartomas of the liver (MHL) is rarely reported in the left lobe of the liver in children who are more than 2 years old. It is difficult to distinguish it from liver lesions such as hepatoblastoma in children, and hepatocellular carcinoma and focal nodular hyperplasia in adults. In addition, it is hard to correctly diagnose it without pathological examination.Mesenchymal hamartomas of the liver.This patient underwent an operation assisted by the Da Vinci surgical system and the tumor was completely resected.No tumor recurrence or metastasis was observed 14 months after operation.MHL is a benign tumor that is difficult to diagnose due to the lack of specific clinical symptoms and signs. The management of MHL remains controversial. To achieve a good long-term outcome, complete resection of MHL is recommended. It is the second most common benign tumor in children within 2 years old.,4 However, the tumor is rare in children more than 2 years old and adults. Only 46 adult cases have been reported up to now. About 75% of MHL was found in the right lobe of the liver. The clinical manifestations and radiological examinations of MHL are typically nonspecific. It is often misdiagnosed as other diseases, such as hepatoblastoma (HB) of children, hepatocellular carcinoma (HCC) of adults, or focal nodular hyperplasia (FNH).Mesenchymal hamartomas of the liver (MHL) was first reported in 1903 by Maresch.Here, we report a male child  with MHL in the left lateral lobe of the liver. The tumor size was 14 cm × 13 cm × 7 cm and was removed by an operation through the Da Vinci surgical system (DVSS). Interestingly, the patient had an identical twin who was admitted to our hospital to take a magnetic resonance imaging (MRI) test of his liver. The result showed no positive findings. We reviewed and analyzed the literature to provide useful information for doctors to distinguish the disease.2A 4 and a half years old male child presented to our hospital for abdominal swelling. The child occasionally felt stomach ache that was relieved for no reason. The child showed no obvious tenderness and rebound. He was born as a premature baby in the 32nd week of his mother's pregnancy. His medical history included inguinal hernia on 2 sides, but he had only received an operation for the left inguinal hernia. No family or genetic history was found. Physical examination of this child showed that the abdomen was obviously bulging. The mass could be touched below umbilicus about 3 fingers. There were no other positive signs. The results of laboratory tests were almost normal, including alpha-fetoprotein (AFP) level. The Child–Pugh score was less than 5. Abdominal ultrasonography showed an uneven lesion in the liver and a diagnosis of HB was considered. Enhancement computed tomography (CT) scanning showed a large mass in the left upper abdomen and left lobe of the liver with an irregular edge. The size of the mass was 12.3 × 10.2 × 7.2 cm .MHL was first reported in 1903 by Maresch. is observed for MHL. Here, some literature related to MHL is discussed (Table –28 Approximately 80% (14/18) of patients were less than 2 years old. All patients had neither brothers nor sisters. Approximately 80% (14/18) came to hospital for mass or abdominal distention. Only 23% (4/17) of patients had mass in the left lobe of the liver. Only 2 patients had a high level of AFP. Only 28% (5/18) of patients got correct diagnosis before operation. Almost all patients had no special medical history. Typical clinical manifestations included painless and progressive bloating and abdominal mass. However, they usually do not become emaciated, in contrast to HB. A small number of patients had a high level of α-fetoprotein. The size of MHL varied from a few millimeters to more than 15 cm, or even 30 cm. Seventy-five percent of cases occurred in the right lobe of the liver. Ultrasound scans often showed uneven lesions, maybe for reasons of unique cystic mass. There was no rich blood flow sign because of a lack of vessels. Clear blood flow could not be seen at the end of portal or hepatic vein, perhaps because of repression. MHL showed no specific characteristic under unenhanced CT, whereas it showed multiple small cystic lesions in a solid mass in enhanced CT scan. The MR image of MHL is also diverse, that the characteristic of MR image depends on cysts, protein content in the fluid, and stromal composition of the mass. Because of liver fibrosis, solid areas of MHL may show hypointense both on T1 and T2-weighted images. No doctor used the nuclear medicine method to confirm this. The pathological features are the following: the surface of tumor is smooth and soft, and cysts were found on the section. Those cysts contain mucus. Hematoxylin and eosin (HE) staining shows various kinds of mesenchymal components such as expand lymphatic, vessel, irregular bile duct, myxoid matrix, and collagen. Some liver cells scatter but some cluster together. The tumor never becomes malignant and relapses after an operation. An immunohistochemical study showed spindle cells positive for vimentin and smooth muscle actin and negative for CD31, CD34, and S100 proteins, while the ducts stain positive for CK7 and negative for CK20.,30MHL often occurs in children within 2 years old, with an average age of 15 months old. A slight male predominance The characteristic of this case was that, this patient was more than 2 years old, in contrast to most reported cases. Moreover, this patient had an identical twin, while all cases of MHL in the literature did not involve any twins. The tumor was in the left lobe of the liver, while for most cases (13/17) they were in the right lobe. He had no high-level AFP, which suggested that HB was not likely. The enhancement CT showed some characteristic of MHL. An uneven nodular shadow and edge was obvious when the mass was enhanced. The feature of enhanced CT images matched with Swiss cheese appearance. It pointed to the way to MHL.,31A limitation of the study is that we did not take MHL as a possible preoperative diagnosis because we lack experience. We propose the diagram for diagnosis of tumor in the liver of children Fig. . If we fHB is the most common malignant liver disease in children. It often occurs in children within 3 years old, and it composed 50% to 62% of malignant liver lesions in children. HB patient often becomes emaciated, anemic, and anorexic. Liver function is usually not affected. AFP is often positive and the hepatitis B virus surface antigen is negative  in our hospital with HCC. About 90% of patients have a background of HBV Fig. . The proIn MHL, lack of typical clinical manifestations and characteristic image appearances make doctors difficult of diagnose it.Some patients may show portal hypertension for the pressure of large MHL tumors. We summarized a distinguish table, which may help us to recognize it. The misdiagnosis of MHL usually shows a negative influence on patient's management. Most patients went to hospital for clinical manifestations induced by large tumors. Operations are necessary for such patients. If MHL patient was not able to or not willing to undergo liver resection, those clinical manifestations will be still or even worse. The tumor never becomes malignant. It does not relapse when it is removed totally.4This case suggests that surgeons should consider MHL as a possible diagnosis, although it is rare in more than 2 years old children, especially for those whose AFP is negative. MHL is a benign tumor that is hard to diagnose due to nonspecific clinical manifestations or examinations. The management of MHL remains controversial. Complete resection is recommended to treat MHL for good long-term outcomes. It is also suggested that parents take their children to hospital for examinations at least once a year.


Plasmacytoma of the calvarium is a well-described feature of multiple myeloma and in some cases has been reported as a solitary lesion. However, when associated with multiple myeloma these are typically identified after the initial diagnosis is made. This case is unusual in that the diagnosis of plasmacytoma was first suspected in a patient thought to have a meningioma on the day of surgery, when a magnetic resonance imaging (MRI) demonstrated spontaneous involution of the mass. Recognition of evolving changes in a calvarial or dural-based lesion should prompt the practitioner to consider alternative diagnoses other than meningioma prior to proceeding with surgical resection. Plasma cell tumors are monoclonal proliferations of plasma cells that are most frequently observed in the context of their disseminated form: multiple myeloma. However, they may also occur as solitary plasmacytomas. Cranial plasmacytomas may arise from the skull, leptomeninges, or the brain parenchyma . When obA 57-year-old man presented to the neurosurgical clinic complaining of headache after a workplace accident. He was found to have a right calvarial mass with compression of the right frontal lobe on head computed tomography (CT). A magnetic resonance imaging (MRI) of the brain demonstrated a contrast enhancing calvarial mass with features consistent with meningioma. In the context of the patient’s unremarkable medical history, poorly controlled headaches and age, he was scheduled for elective resection. Aside from acetaminophen he took no additional medications for pain and was not started on any anti-inflammatory or steroid medications.An MRI obtained three weeks later on the morning of surgery for use with intraoperative neuronavigation demonstrated a spontaneous reduction in the size of the lesion, raising the suspicion of an alternative diagnosis to meningioma Figure . In disc+, CD56+, Lambda+, Kappa-) with overall 30% Ki67 positivity, eight percent in the CD138+ population. The patient underwent a systemic evaluation postoperatively, which revealed multiple lytic lesions in the humerus, glenoid process, and ribs. Serum protein electrophoresis (SPEP) was positive for immunoglobulin G (IgG)-Lambda, establishing the diagnosis of multiple myeloma. He initiated therapy in consultation with his hematologist/oncologist during the postoperative period. At nine months follow-up, he was doing well with a Karnofsky performance status (KPS) of 90 and continuing maintenance chemotherapy.After permanent processing, the tumor was identified as a plasmacytoma (CD138Dural-based plasmacytoma mimicking meningioma has been described previously, typically involving the leptomeninges and skull concurrently -5. SolitBecause of their rarity, the literature on the management of cranial plasmacytoma is limited. One important facet of this discussion is the role of surgical resection. Consensus at this time suggests that for solitary plasmacytoma the management is gross total resection with adjuvant radiation therapy -2,7-8. HIn the case described here, the differential diagnosis at the time of intraoperative frozen section included meningioma and solitary plasmacytoma, and gross total resection was performed. However, given the subsequent diagnosis of multiple myeloma in the first several days postoperatively, we would recommend a preoperative workup for multiple myeloma prior to making treatment decisions when plasmacytoma enters the differential diagnosis.This case is unusual in that a tumor initially thought to be meningioma reduced in size substantially prior to surgery in the absence of steroid or other medical therapy. Identification of this finding preoperatively altered the initial operative plan, prompting a small preliminary biopsy prior to proceeding with resection. Recognition of such evolution of a dural-based or calvarial mass should prompt further evaluation prior to proceeding with surgery in order to identify occult cases of multiple myeloma.


Symptomatic Bochdalek hernia in pregnancy is quite rare. To the best of our knowledge, there are a total of 44 cases reported in the literature between 1959 and 2016 . Difficulty and delay in diagnosis may lead to life-threatening complications. We report a case of Bochdalek hernia during the 30 gestational weeks' pregnancy in whom pregnancy continued after surgical repair which resulted in term birth. Bochdalek hernia is diagnosed with an incidence of 1 in 2200–12500 live births, while symptomatic diaphragm hernia is much less in adults. The actual incidence of diaphragmatic hernias during pregnancy is still unknown. Symptoms may include abdominal distension, recurrent abdominal pain, nausea, vomiting, inability to defecate, dyspnea, and chest pain. The patient with diaphragmatic hernia may be asymptomatic until the late weeks of gestation, as in our case, or herniation may occur during advanced gestational weeks with increased intraabdominal pressure. In conclusion, diagnosis of the diaphragm hernia during pregnancy is very rare. Diagnosis is rarer in symptomatic patients due to its rarity and the duration of diagnosis may, therefore, be delayed. Diaphragm hernia should be kept in mind in symptomatic patients due to its high maternal and fetal mortality rates. Symptomatic Bochdalek hernia in pregnancy is quite rare. To the best of our knowledge, there are a total of 44 cases reported in the literature between 1959 and 2016 . The diaHerein, we report a case of a woman with Bochdalek hernia during the 30 gestational weeks' pregnancy in whom pregnancy continued after surgical repair which resulted in term birth.2 saturation, 96%, and body temperature, 36.8°C. Physical examination revealed that abdomen was normal without any defense or rebound. No contraction was detected manually. The height of fundus was measured as 30 cm. Her lung sounds were also normal in the right hemithorax, whereas the sounds decreased in the left hemithorax bases. Laboratory results were as follows: white blood count of 13∗109/L and hemoglobin of 11.2 g/dL. There was no abnormality in the other laboratory tests and complete urinalysis. Her medical history revealed no gas or stool discharge since the previous day. The fetus was positioned at the vertex position on obstetric ultrasonography, and the measurements were consistent with the gestational week. Amniotic fluid index was normal and cervical length was measured as 36 mm. No cervical opening and bleeding were observed in the pelvic examination. Nonstress test (NST) result was reactive. The patient was hospitalized for close monitoring. Repeated physical examination showed defense and rebound in the upper quadrant of the abdomen. Therefore, abdominal ultrasonography was planned. However, the abdomen was unable to be evaluated clearly due to intense gas. Respiratory sounds were slightly heard according to ultrasonography results of the left hemithorax. The posteroanterior chest X-ray with an abdominal shield was performed. On chest X-ray, diaphragm herniation in left hemithorax and herniated bowel loop were detected  pregnant woman was referred to Agri State Hospital Emergency Medicine Department with a complaint of abdominal pain radiating to the left side for one day. She previously underwent cesarean section due to breech presentation of her first baby three years ago. Vital signs were as follows: pulse rate, 110 beats/min, blood pressure, 110/60 mmHg, Odetected .Based on her clinical and imaging findings, she was diagnosed with diaphragm hernia and was scheduled for surgery. The initial dose of betamethasone was administered to the patient in the 30th gestational week of pregnancy to provide pulmonary maturation of the infant with the possibility of preterm delivery. The patient was then transferred to a tertiary hospital, Van Yüzüncü Yıl University, Department of General Surgery, as she might be required to undergo the operation and there might be a necessity for neonatal intensive care unit. According to the thoracoabdominal magnetic resonance imaging result in the general surgery clinic, the patient underwent operation with the diagnosis of irreducible Bochdalek hernia .Once entered into the abdomen with a median incision above the umbilicus, a 4 × 4 cm defect in the diaphragm was detected from which the transverse colon herniated into the thorax. The reduction of the transverse colon and the primer repair of diaphragm were then performed . CirculaThe patient was followed up in the general surgery ward for three days and had gas and stool discharge on the first postoperative day. Oral intake tolerance was good. At 31/3 gestational week, she had no additional complaints and was discharged on the fourth postoperative day. However, during routine follow-up, she was rehospitalized due to contractions at 37/5 gestational week. Based on her medical history of cesarean section previously, she gave a live term birth with a cesarean section. The infant had an Apgar score of 3 and 10 with a birth weight of 3,650 g. Both the patient and the infant were discharged on the second postoperative day uneventfully.Bochdalek hernia, the most common congenital diaphragm hernia in 95% of cases, is followed by Morgagni hernia and esophageal hernia . The actFor diagnosis of Bochdalek hernias, chest radiographs, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can be used. Chest X-ray examination can be used safely even during pregnancy with a sensitivity of 70%. Therefore, normal view of chest X-ray cannot exclude herniation. CT is gold-standard imaging in elective and emergency cases and is useful to show defects in the diaphragm and thickening of the diaphragm and the herniated organs. MRI may be applicable in patients who are hemodynamically stable and cannot undergo computed tomography  .During pregnancy, the management of Bochdalek hernia can be difficult. Follow-up and treatment at a tertiary healthcare center would be more suitable. If the pregnant woman is in between 24–34 gestational weeks, it is appropriate to initiate steroid treatment for lung maturation and perform nasogastric decompression to save time until transfer of the patient and surgery are planned.Treatment is planned based on the symptoms of the patient and gestational week. In the asymptomatic patients, elective surgery should be performed in the first or second trimester. In the third trimester, elective surgery also should be performed after fetal lung maturity is documented, with simultaneous cesarean section. Surgical treatment should be planned in emergency cases without considering the gestational week, as in our case in whom symptoms of obstruction developed .Transabdominal and transthoracic approaches are also available in repair of diaphragmatic hernia. However, transabdominal approach is at the forefront plan for its ease of surgical technique . LaparosReview of the literature reveals that the complication rates are more frequent in the third trimester of pregnancy: preterm labor was observed in 24% of these cases, while fetal death was observed in 13% . In our In conclusion, diagnosis of the diaphragm hernia during pregnancy is very rare. Diagnosis is rarer in symptomatic patients due to its rarity and the duration of diagnosis may, therefore, be delayed. Diaphragm hernia should be kept in mind in symptomatic patients due to its high maternal and fetal mortality rates.


Introduction: Primary extracranial meningiomas are rare manifestations of a central nervous system tumor. This article presents a case study of a soft-tissue primary extracranial tumor in the temporal region that was initially diagnosed as melanoma at an outside institution and whose definitive diagnosis proved difficult prior to successful excision. Methods: Temporal muscle biopsy, ultrasound-guided biopsy, and computed tomography were conducted at an outside institution prior to the patient's presentation to our care. Upon presenting to our institution a positron emission tomographic scan was then conducted prior to excision. After excision, the mass was sent to pathology and further immunohistochemistry was conducted. To ensure the mass was completely excised, magnetic resonance imaging was performed after its removal. Results: A 3 × 3-cm mass was excised in its entirety from the patient's temporal region and sent to pathology for immunohistochemistry and mutation testing. It proved to have the most common mutation for a primary extracranial meningioma, a neurofibromatosis type 2 frameshift. Conclusion: The presentation of a primary extracranial meningioma in the temporal region is a rare finding. Because of its slow-growing nature and generally asymptomatic presentation, it can be misdiagnosed. Utilization of radiological imaging is essential both pre- and postoperatively in order for its identification and complete excision. It measured approximately 5 × 4 cm and was not associated with any cutaneous changes. There was no history of trauma, radiation, infection, or genetic abnormality.Before presenting to our institution, the patient had visited with multiple outside specialists in the fields of primary care, neurology, and otolaryngology. These outside facilities conducted an extensive workup that included a computed tomographic (CT) scan, a temporal muscle biopsy, and finally an ultrasound-guided biopsy of the mass. CT findings showed a mass lateral to the lateral orbital wall that was deep to the temporalis muscle. The pathology of the muscle biopsy from the outside hospital was positive for S100, vimentin, and HMB45 markers. These results increased the outside facilities suspicion for a malignant melanoma. Histological sections from the ultrasound-guided biopsy showed fragments of poorly differentiated tumor cells within the fibroadipose tissue and skeletal muscle with an epithelioid morphology. After the patient had these studies performed at the outside facility, she presented to our institution for a second opinion to aid in the diagnosis of the mass.On presentation to our institution, a positron emission tomographic scan was ordered to look for possible malignancies. It showed a hypermetabolic soft-tissue swelling along the right temple with no other metastatic or primary lesions . The decPrior to excision, the patient was noted to have paresis of the muscles supplied by the temporal branch of the facial nerve. This may have been secondary to the previous temporal muscle excision, during the first surgical procedure.Upon excision, the mass was measured to be 3 × 3 cm and was sent for a frozen section procedure to determine the type of mass  and 3. IPostoperatively, MRI was conducted to confirm the complete excision of the mass and showed findings consistent with gross total tumor resection with expected postsurgical changes. We did not find intra-axial brain masses or enhancement throughout the brain or meninges. An incidental empty sella was found.-1,3,1,Meningiomas are slow-growing benign tumors that usually originate from arachnoid cells and reside in the dura. With a 2:1 female predominance, as well as a mean age of diagnosis of 51.4 years, they have a predilection to grow intracranially.4,Gross examination can be variable, ranging from gray to pink in color with a firm to rubbery consistency.8The symptom of extracranial meningiomas is variable due to its possibility for different anatomical locations. It often can present with nonspecific signs that may lead practitioners to manage a patient's symptoms without a proper diagnosis. It is not uncommon for a patient to go up to 10 years without a diagnosis of extracranial meningioma.8: (1) arachnoid cells are in fact present within nerve or vessel sheaths, allowing them to emerge from the skull; (2) throughout embryological development, pacchionian bodies are deposited extracranially; (3) the displacement of arachnoid cells may be due to trauma or cerebral hypertension; and (4) undifferentiated cells.8,There are 4 theoretical explanations for how primary extracranial meningiomas manifest as proposed by Rushing et alUpon further examination, an NF2 frameshift mutation was unveiled in our patient, which had been previously undiagnosed. This likely caused an abnormal growth pattern of arachnoid cells, leading to the development of the extracranial meningioma. Furthermore, the initial misdiagnosis may have been due to an inadequate biopsy or a reliance on the CT scan that has not proven to be effective on its own in the diagnosis of an extracranial meningioma.,This case report consisted of a rare manifestation of a primary extracranial meningioma. Preoperative and postoperative scanning with CT or MRI is vital to ensure that the entire mass has been or will be excised. This is because regrowth from incomplete excision is more common compared with recurrence.8


Chondrosarcomas (CS) are tumors affecting mainly pelvis, long bones and ribs in middle aged people; involvement of head and neck is rare and nasal septum location is exceptional. We report the follow-up of an 85-year-old patient suffering from head and neck CS. Magnetic resonance imaging (MRI) showed a mass originating from nasal septum. The patient underwent to debulking surgery and adjuvant hypofractionated radiotherapy with excellent tolerability and no evidence of recurrence after 16 months. Hypofractionated radiotherapy delivered with advanced technique  allowed to deliver high doses radiation in elderly patients with limited toxicity. Chondrosarcomas (CS) are non-epithelial malignant, slow growing tumors that usually involve pelvis, ribs, and long bones of extremities . They moThe patient reported history of nasal obstruction, mainly at right side since August 2015. Nasal endoscopic examination revealed a large submucosal mass of nasal septum with occlusion of the posterior third and extending to hard palate on the left side. Computed tomography (CT) scan detected a mass of about 4 cm with extension across the midline and erosion of the nasal septum, laterally extending into maxillary sinus with infiltration of the left one and invading inferiorly the hard palate especially on the left side. Magnetic resonance imaging (MRI) confirmed these data Figure . The treCS to the head and neck region are rare, with few series from a single institution being reported. The most common sites in this district are the larynx, maxilla and skull base; lesions arising from the nasal septum are, therefore, extremely rare . GeneralThe peculiarity of our case study was the patient age, the rarity of tumor location and the RT schedule. Some literature data reported unfavorable outcomes in older patients. A definitive conclusion cannot be reached with so few cases; we had good short term outcomes with combined treatment, excellent feasibility, and limited toxicity. We recognize the necessity of lifelong follow-up as late recurrence is likely, due to the prolonged natural history of the disease. As an alternative option to particle radiotherapy, slightly hypofractionated photon delivery with advanced IMRT may be of benefit in elderly patients with acceptable toxicity. Adaptive radiotherapy by small and stable daily IGRT shifts may further increase the treatment reliability and could maximize the probability of a long-term clinical advantage.


Melorheostosis is a rare, nonhereditary, benign, mesenchymal condition of unknown aetiology affecting the bones and surrounding tissues. A male patient complaining of left shoulder pain, swelling, and mildly limited range of motion has an exclusive combination of the classic dripping wax lesion in the scapula and the myositis ossificans-like lesion in the deltoid muscle; this combination is the first to be reported in the shoulder. Both lesions showed typical findings of melorheostosis in radiographs, CT, MRI, and bone scan. This case has a stationary course over the follow-up period, and no specific treatment is needed in due course. It is cs [bone] . Radiolos [bone] . We presA 51-year-old male presented to our clinic with a painful swelling in his left shoulder. The pain started gradually ten months before presentation and was progressive in nature. There was no history of trauma. The swelling had been gradually increasing in size over a period of three weeks after which growth became static. The pain was provoked by activities requiring shoulder elevation and abduction. Shoulder rotation did not provoke pain. The patient has no clinically relevant past medical or family history.On examination, a swelling was identified in the antero-superior aspect of the left shoulder with redness of the skin overlying it. The swelling was firm, localised, and mildly tender. The patient demonstrated almost full range of motion with mild pain in abduction and internal rotation (impingement and the Hawkins test were positive) with negative tests for biceps tendonitis, rotator cuff tear, AC joint arthritis, and instability.Radiographs demonstrated calcification around the greater tuberosity and subacromial space as well as hyperostotic lesions in the scapula blade . A CT scMelorheostosis was described for the first time in 1922 by Leri and Joanny . It is cSeveral theories to explain the pathogenesis of melorheostosis have been proposed. In 1979, Murray and McCredie  suggesteLEMD3 gene which encodes for the inner nuclear membrane protein is responsible for controlling bone growth, and mutations in this gene can lead to a proliferation of hyperostotic lesions. Germline LEMD3 mutations were found in patients who had melorheostosis associated with Buschke-Ollendroff syndrome (BOS) or Osteopoikilosis  and magnetic resonance imaging [MRI] scans have a supporting role in diagnosing melorheostosis, CT commonly shows high attenuation cortical thickening occluding the medulla, and clear linear demarcation is seen between the lesion and the healthy bone. Soft tissue lesions are easily identified on CT. A degree of mineralisation is seen, and often the soft tissue lesions are not in continuity with the bone , 16. TheMRI of bone lesions in melorheostosis shows low signal intensity on all pulse sequences encroaching on the medullary canal which is typical for the scapular lesion of the case presented. Soft tissue lesions produce heterogeneous MRI patterns according to the degree of mineralisation. Low signal intensity is detected in mineralised lesions as is shown in our case. Intermediate to high signal is predominantly in the nonmineralised lesions , 16, 20.Since 1976, Tc-99m bone scintigraphy has been developed as a tool to confirm the diagnosis of melorheostosis and unveil other silent lesions , 30. MelIn this case, based on our findings, we concluded that this is a case of isolated melorheostosis. The common differential diagnosis of melorheostosis includes myositis ossificans, synovial osteochondromatosis, osteoma, parosteal osteosarcoma, focal scleroderma, and Caffey disease. Combined clinical examination and full radiological workup can accurately differentiate diagnoses. Osteoma presents with a smooth outline, focal, single vertebral involvement in the spine. Caffey disease affects infants with lamellated periosteal reaction, transient and less dense. Classic cauliflower-like ossified mass characterises parosteal osteosarcoma, a lucent line between lesion and cortex, increased uptake on bone scan. Osteopathia striata may be mistaken for melorheostosis, but striations in melorheostosis are much larger, broader, and unilateral, unlike the genuine osteopathia striata. Osteopoikilosis has numerous round to ovoid white densities of similar size spread throughout all bones; approximately 10% of osteopoikilosis is accompanied by skin elastic or collagen nevi, named as BOS. Tumor cacinosis is usually associated with a systemic disorder of calcium metabolism or renal dialysis, presents bilaterally and causes erosion of cortex, amorphous and cystic multilobulated calcification in periarticular distribution. Calcium pyrophosphate dihydrate deposition (CPPD) disease affects the elderly; with a characteristic affinity to ligamentum flavum and synovial joints of the spine is in ligamentum flavum and synovial joints , 19.There is no standard treatment for melorheostosis, and management plans must be made on an individual patient basis . The aimWe have followed our patient over six months, and radiologically, the findings are stationary. Clinically, pain has settled down, and he has nearly no mechanical symptoms, thus no rationale for any intervention in the meantime.Our patient has a unique presentation of melorheostosis presenting with two distinct coinciding lesions in the shoulder joint. Our case supports existing theories regarding the aetiology of the disease and contributes to the literature on the spectrum of possible presentations of melorheostosis.


Dear SirCholedochal cysts (CDC) are increasingly diagnosed in antenatal period [1]. Occasionally, these cysts may grow to a very large size and differentiation from other cystic masses of the abdomen can be challenging. There is also a debate regarding the timing of surgery, optimal management strategy, and the type of surgery. Enteric biliary diversion procedures are not only technically difficult but are also associated with the high rates of postoperative complications in the neonatal period [2].A 20-day-old female child, full term, born by normal vaginal delivery brought to us with complaints of gradually increasing abdominal distention since birth; with intermittent clay colored stools and discoloration of sclera for 10 days. Antenatal scans done at 13 weeks and 32 weeks did not show any abnormality. On examination, jaundice with a large cystic mass, with restricted mobility and involving more than right half of abdominal compartments, was found. Routine investigations were normal ex¬cept liver function test  and elevated liver en¬zymes. Ultrasound done elsewhere showed 10.4x7.4cms cystic area noticed around the region of common bile duct (CBD), but due to the large size of the cyst, its origin could not be ascertained. Magnetic resonance cholangiopancreatography (MRCP)  showed a 10.0x9.6x8.4cm thin walled cystic mass lesion in right side abdomen in region of CBD/porta-hepatis with marked dilatation of intra hepatic biliary radicles in both liver lobes. CBD could not be visualized separately and the mass was displacing bowel loops to left. Repeat USG revealed could not improve the diagnosis. Thus, differential diagnoses of giant CDC, Cystic biliary atresia(CBA), and omental cyst with compression of CBD were kept. Patient was taken up for surgery and on exploration a giant choledochal cyst  was found and after aspirating 350 ml of bile the cyst was excised and hapatico-duodenostomy (HD) was done. Postoperative period was uneventful.CDC usually presents in the first two decades of life; neonatal presentation is uncommon [4]. The classic triad of abdominal pain, right upper quadrant mass and obstructive jaundice is rare, but it was present in our case. The primary differential of CDC in the neonatal age group is CBA, and it is critical to distinguish these entities, as they have different surgical implications. Delaying surgery in CBA results in poor prognosis. USG plays an important role and is always the first investigation of choice, as most of the times it reliably distinguishes between CDC and CBA. However, USG has its own limitations and evaluating the entire biliary tree is difficult due to limited field of view and poor overview when compared with cross-sectional imaging modalities. MRCP is routinely done and it is considered gold standard as it better delineates the hepatobiliary system and gives an idea about the aberrant vascular and ductal anatomy. It has got high sensitivity (70-100%) and specificity (90-100%) for diagnosing CDC [4]. But sometimes when the cyst is so large that it occupies almost entire abdomen then in that scenario even MRCP fails to reliably pinpoint the organ of origin as it happened in our case. Excision of cyst and biliary enteric anastomosis is the procedure of choice, and it could be achieved either in the form of Hepatico-duodenostomy (HD) or Roux-en-Y Hepatico-jejunostomy (RYHJ). We preferred HD over RYHJ as it is more physiological, requires less operative time, fewer anastomosis, less chances of leak and less blood loss as compared to RYHJ. Though post of reflux and gastritis are common in HD, we did not find it to be significant. On two-month follow-up, baby has gained weight and thriving well.Source of Support: NilConflict of Interest: None


Hemangiopericytoma and solitary fibrous tumor are considered related variants on the same spectrum and both may essentially be the same tumor. They are infrequently encountered in the orbital region while the zygomatic bone is an extremely rare location for these neoplasms to occur.A 14-year-old boy presented with complaint of deformity of left infraorbital area and a firm, regular mass in the region. Orbital CT scan revealed a well-defined round isodense intraosseous lesion in the lowermost portion of the lateral orbital wall (zygomatic bone), expanding the bone and protruding anteriorly and medially. MRI showed the mass to be heterogenous and strongly enhancing with contrast medium. Inferior transconjunctival orbitotomy was performed and the mass was removed. The histopathologic examination and immunohistochemistry staining results  and desmin) confirmed the diagnosis of hemangiopericytoma. The postoperative course was uneventful, with no evidence of recurrence after 5 years follow up.This case represents the second hemangiopericytoma reported in the zygomatic bone. Although extremely rare, hemangiopericytoma/solitary fibrous tumor might be considered in the differential diagnosis of intraosseous lesions of the orbital and zygomatic region. Vascular tumors of the bone are uncommon, accounting for 1–2% of bone tumors . OccurreA 14-year-old boy was referred with complaint of deformity of left infraorbital region. There was fullness in the inferolateral orbital and periorbital areas  by a rare tumor (HPC/SFT) is reported and the relevant literature is reviewed. Complete surgical excision provides the most effective treatment, although postoperative follow up is required for a long period of time.


Intestinal obstruction in pregnancy is rare and is mainly caused by prior pelvic surgery. We herein report a case of intestinal obstruction in a pregnant female with a history of laparoscopic myomectomy, who presented with hypogastric pain, abdominal distension, and vomiting at 26 weeks of gestation. A simple intestinal obstruction was diagnosed by MRI. Conservative treatments, including intravenous hyperalimentation and the placement of an ileus tube, were provided and her abdominal symptoms improved for 14 days. After restarting oral intake, she had no abdominal symptoms. She gave birth to a 2,146 g female infant by caesarean section at 37 weeks and 1 day of gestation. Although an area of cicatrization, which was thought to have been the starting point of the occlusion that caused the intestinal obstruction, was found, the excision of the small intestine was not necessary. Her postoperative course was uneventful. Intestinal obstruction requires a prompt diagnosis and aggressive intervention may be necessary to minimize the morbidity and mortality associated with this rare complication of pregnancy. MRI can be safely used during pregnancy to diagnose intestinal obstruction and intravenous hyperalimentation may improve the maternal and fetal prognoses. Intestinal obstruction in pregnancy is rare, and it is mainly caused by pelvic surgery prior to conception. The appropriate diagnosis and management of intestinal obstruction during pregnancy are of paramount importance, as it is associated with significant maternal and fetal mortality . The diaWe herein report a case of intestinal obstruction in pregnancy in a patient who was diagnosed with a simple intestinal obstruction by magnetic resonance imaging (MRI) and who was safely delivered at term following successful treatment using conservative therapy, which included intravenous hyperalimentation and an ileus tube.μL and CRP level of 0.58 mg/dL. The other laboratory data were within the normal limits. Her cervix was uneffaced and the cervical os was closed. Because her symptoms were improved by intravenous feeding and the administration of an antispasmodic agent, she was diagnosed by acute gastroenteritis and discharged to return home. At that time, she had no sign of threatened labor. However, her abdominal pain and vomiting did not improve and she was hospitalized the next day. On the third day of hospitalization, her symptoms worsened. Her abdomen became distended and bowel sounds were absent on physical examination. Abdominal X-rays showed air-fluid level of small intestine  was referred to our institution at 25 weeks and 4 days of gestational age with symptoms of abdominal pain and vomiting. She had a history of appendectomy and laparoscopic myomectomy. Her body temperature was 36.6°C, her heart rate was 65 beats/min, and blood pressure was 120/67 mmHg. Her abdomen was soft, flat, and without tenderness; her bowl sounds were enhanced. She had a WBC count of 12,380/ntestine , and shee uterus , but no Conservative treatment was continued, a nasal ileus tube and central venous catheter were inserted and total parenteral nutrition (TPN) was initiated. TPN was used from the 8th day to the 20th day of hospitalization and was not changed to PPN. Her abdominal symptoms gradually improved, and on the 8th day of hospitalization  she showed flatus. On the 14th day of hospitalization , she resumed oral intake with fluid food. After the initiation of oral intake, her abdominal symptoms stabilized. The ileus tube and central venous catheter were removed on the 17th and 20th days of hospitalization, respectively. She felt irregular uterine contractions, and her cervical length shortened to 15 mm. Therefore, she remained hospitalized for tocolysis between the 21st and 80th days. The remaining course of her pregnancy was uneventful, without a relapse of the intestinal obstruction relapse or any signs of threatened labor. As she did not request vaginal delivery after myomectomy, she received caesarean section on the 81st day of hospitalization  and delivered a healthy baby girl weighing 2,146 g. The baby had a good APGAR-score 9 (1 min)/10 (5 min) and no fetal distress . The mesenterium and the uterus fundus were covered with fibrous material. We reported the case of a primiparous woman with simple intestinal obstruction that was diagnosed by MRI, who was successfully treated using a conservative approach that included TPN with intravenous hyperalimentation. She was able to safely deliver an infant at term.The diagnosis and management of acute abdominal pain during pregnancy are often challenging. The most common nonobstetric abdominal conditions that require surgical in pregnancy are acute appendicitis, bowel obstruction, cholecystitis, and pancreatitis. Intestinal obstruction in pregnancy is rare and is the second most common nonobstetric reason for surgical intervention during pregnancy . The incAlthough rare, intestinal obstruction during pregnancy is associated with a maternal mortality rate 6–20%, while fetal loss occurs in 26–50% of such cases . The earThe treatment of intestinal obstruction in pregnant women is similar to that of nonpregnant women. In the absence of signs of peritonitis, conservative treatment should initially be attempted. Since intra-abdominal surgery can lead to premature uterine contractions, tocolytic agents are administered prophylactically when conservative therapy fails and when there are signs of impending bowel strangulation . In the We reported a case of a primiparous woman with a simple intestinal obstruction that was diagnosed by MRI and who was successfully treated using a conservative approach that included TPN with intravenous hyperalimentation. An infant was safely delivered at term. In cases involving pregnant women with a history of abdominal surgery who have symptoms of intestinal obstruction, including abdominal pain, nausea, vomiting, and abdominal distension, the intestinal obstruction should be early diagnosed and treated in the same manner as in nonpregnant women.


Myxofibrosarcoma is an aggressive soft tissue neoplasm, classified as a variant of malignant fibrous histiocytoma. Most often, it occurs in middle to late adult life peaking in the seventh decade and involving the lower extremities (77%), trunk (12%), and retroperitoneum or mediastinum (8%). We report the first case of thoracic myxofibrosarcoma presenting as a Pancoast tumor.A 48-year-old non-tobacco smoking African-American man presented with a slow-growing mass in his neck along with 11 kg weight loss over 9 months. A review of his systems was positive for hoarseness and lowgrade intermittent fever without any shortness of breath or cough. A physical examination revealed a mass on the left side of his neck superior to his sternoclavicular joint measuring 3 × 3 × 1 cm. He had ptosis and miosis of his left eye. His breath sounds were decreased and coarse at the left apex. A neurological examination revealed 3/5 strength in his left upper arm. The remainder of the physical examination was unremarkable.Ultrasound of his neck showed an ill-defined heterogeneous mass lateral to his left thyroid lobe. A computed tomography scan of his chest showed a large multiloculated pleural-based mass in his left lung surrounding the adjacent neurovascular structures. A percutaneous biopsy was non-diagnostic. Subsequently, he underwent a left thoracotomy with biopsy. The mass extended from his anterior mediastinum medially at the level of the pulmonary trunk, superiorly into the superior sulcus and posteriorly into his chest wall. Surgical pathology confirmed the diagnosis of myxofibrosarcoma.Here we present a case of Pancoast tumor with myxofibrosarcoma as the underlying etiology. Pancoast syndrome generally entails an infiltrating lesion in the superior sulcus presenting with upper extremity pain, atrophy of the hand muscles, and Horner’s syndrome. The differential diagnosis of Pancoast syndrome includes inflammatory and infectious etiologies, as well as neoplasms of benign and malignant nature. Of the neoplasms implicated, the most common are non-small cell lung carcinomas; myxofibrosarcoma presenting as a Pancoast tumor has not been reported in the literature. Myxofibrosarcoma (MFS) is an aggressive soft tissue neoplasm classified as a variant of malignant fibrous histiocytoma (MFH). On histologic examination it is composed of both fibroblastic and histiocytic elements. Most cases occur in middle-to-late adult life with a peak incidence in the seventh decade , 2. TheyPancoast syndrome involves an infiltrating mass at the apex of the lung , 5. ClinThe majority of superior sulcus tumors are non-small cell lung carcinomas (NSCLCs) , 6. OtheA 48-year-old African-American man with no significant tobacco history presented with a slow-growing mass in his neck and 11 kg weight loss over a 9-month period  scan of his chest. A chest X-ray exhibited a mass extending from the hilum of his left lung with gross deviation of his trachea and elevation of his hemidiaphragm. A CT scan of his chest showed a large multiloculated pleural-based mass in his lungs surrounding his left common carotid artery, left subclavian artery, which interfaced broadly with the aortic arch and extended into the left neuroforamina of C4/C5 through T1/T2  approach followed by additional doses with conventional radiation.In conclusion, MFS is a relatively uncommon malignancy and has not been described as a Pancoast tumor in the medical literature. Surgical resection may result in insufficient margins when extensive invasion within the superior sulcus and critical structures of the thorax is involved. Given that this management is the mainstay for MFS, more research is necessary with regards to adjuvant therapies that can improve prognosis.


Gallbladder cancer is unusually seen but can result in highly mortality rate. It makes challenge to diagnose for clinicians due to present asymptomatic or non-specific clinical presentation including abdominal pain, anorexia. It usually also accompanies with cholelithiasis (incidence is 1–2%) and incidentally detected by radiologic examination such as ultrasound, computed tomography or intra-operative intervention accidentally. Gallbladder cancer results in highly fatal malignancy because it is difficult to early detect. The ovarian metastases from gallbladder mimics primary neoplasm isn’t seen before and mentioned in English literatures before.A 28-year-old woman suffered from intermittently lower abdominal tenderness and nausea after meals for 3 years. The abdominal ultrasound revealed a right ovarian mass with fluid accumulation and the contrast CT of abdomen revealed a gallbladder fundus mass and liver tumor lesion located at segment 4. We arranged surgical intervention with radical cholecystectomy and debulking operation with salpingo-oophorectomy. The pathologic report revealed adenocarcinoma of gallbladder with liver, peritoneum, and right ovarian invasion. After surgical intervention, she also received adjuvant chemotherapy with Gemcitabine, Cetuximab, Cisplatin and Cyberknife.The non-specific symptoms make the challenge to difference the primary malignant neoplasm. The rarely diagnosis must take in consider if the gastrointestinal tract tumours coexist with ovarian tumours. Carcinoma of the gallbladder is an incidental finding in 1% of patients undergoing cholecystectomy because of presenting cholelithiasis . PatientThe ovary is a site of metastasis for gastrointestinal neoplasms. It is known that gastric origin metastases to ovary as Krukenberg tumor . The adeThe 28-year-old woman complained intermittently lower abdominal pain combined with cold sweating and relieved after vomiting for 3 years. The painful sensation was description that lower abdominal tenderness without rebounding pain. There was no difficulty in urination. She had single sexual partner and no history of pregnancy. She didn’t take any oral contraceptives and regular menstruation. There was no dysmenorrhea and menorrhagia found. Her physical examination didn’t find obvious abdominal mass lesion and previous surgical scar. The labor test revealed normal result expect for mild elevated aspartate aminotransferase and alanine aminotransferase (AST/ALT: 128/132 U/L). Her abdominal ultrasound revealed a well-capsulized cystic lesion about 6 cm in diameter located at right ovary and mild fluid accumulated at pelvic region. The contrast abdominal CT also revealed a tumor lesions (2.3 × 3 × 2.1 cm in size) located at fundus of gallbladder with adjacent wall thickening and one small contrast decreased lesion located at segment 4 of liver . There were several literatures presented that hyperthermic intraperitoneal chemotherapy (HIPEC) post CRS may improve survival . This pa


We report a case of sporadic isolated hemangioblastoma arising from the retroperitoneum and provide a review of the scarce literature regarding this very rare tumor. Furthermore, we thoroughly describe the pathologic features and the broad differential diagnosis that should always be included in the study of any retroperitoneal soft tissue mass to arrive at the final diagnosis. Hemangioblastoma (HB) is a rare low grade neoplasm (WHO grade I) of uncertain histogenesis, characterized by the proliferation of closely packed capillaries admixed with large neoplastic stromal cells. HB most commonly arises in the cerebellum and less frequently in the brain stem, spinal cord, and supratentorium. Sporadic HB accounts for 50% to 75% of all cases and tends to present as a solitary cystic lesion with an intramural nodule within the posterior fossa, usually leading to obstructive hydrocephalus. The remaining cases (25%) occur in the setting of Von Hippel-Lindau disease (VHL) , an autoExtraneural HB is very rare. The first case of HB developing in the soft tissues was published by Brodkey et al., who, in 1995, described a case of HB arising in the radial nerve . ExtraneWe report a case of sporadic isolated HB arising from soft tissue of the retroperitoneum with its clinicopathologic features and review of the literature.A 79-year-old gentleman with multiple cardiac comorbidities underwent a computed tomography back in 2009 for evaluation of an infrarenal abdominal aortic aneurysm. Incidentally he was found to have a retroperitoneal mass posterior to the retrohepatic inferior vena cava measuring 6.4 cm × 5.9 cm × 6.6 cm. The patient was followed up with annual imaging and in 2011 the lesion measured 7.2 cm × 5.5 cm × 6.9 cm  and was Gross examination revealed a well circumscribed, pseudoencapsulated, 12.5 cm mass with variegated cut surfaces . The tumMicroscopically, the neoplasm was encircled by a thin fibrous capsule . It was HB is a very uncommon neoplasm, often located in the central nervous system, predominantly in the cerebellum. This tumor very rarely occurs outside the central neuraxis. After reviewing the English literature, we found a total of 12 cases of sporadic HBs arising in soft tissues, including the present case. This is the sixth case report of HB originating in the soft tissue of the retroperitoneum. All the reported cases of retroperitoneal HBs shared common features , 8–10. ODespite multiple studies, the histogenesis of the neoplastic stromal cells in HB remains obscure. Proposed origins include glial , endothePatton et al. were the first to delineate the most important clinicopathologic features of this entity . Soft tiThe diagnosis of soft tissue HB is very challenging, mainly because of the unexpected occurrence of this rare nervous system tumor in the soft tissue. Careful examination of the gross specimen is key to establish lack of communication with the adrenal gland and the kidney. Differential diagnosis includes metastatic clear cell renal carcinomas, paraganglioma, and pheochromocytoma. Additional considerations include lipogenic tumors with hibernomatous features, chondroid lipoma, solitary fibrous tumor, and cellular capillary hemangioma. Careful histological examination and the use of immunohistochemistry can aid in the diagnosis. Metastatic clear cell renal cell carcinoma (CCRCC) can bear a striking similarity to hemangioblastoma. CCRCC is usually positive for PAX8 and CAIX and negative for S100 and inhibin-A. Paraganglioma/pheochromocytoma expresses chromogranin-A and synaptophysin and lacks expression of inhibin in the majority of cases. S100 highlights sustentacular cells. Adrenal cortical carcinoma (ACC) also needs to be considered, especially when there is involvement of the adrenal gland. ACC is positive for MART-1, inhibin, Melan-A, and CAM 5.2 (30% of cases). STAT-6 immunostain can be useful to differentiate HB from solitary fibrous tumor . Once thα-inhibin by the stromal cells and diffuse S100 expression.In conclusion, we reported a case of extraneural HB arising from soft tissue in the retroperitoneum. Although very rare, this tumor should be considered in the differential diagnosis of retroperitoneal soft tissue tumors featuring multivacuolated cells and prominent vascular network and exhibiting cytoplasmic expression of


The accidental aspiration of a foreign body is a frequent domestic accident among children but a rare occurrence in adults. The laryngeal impaction of a coin is an unusual accident; only a few cases have been reported in the literature. Diagnosis is mostly achieved by clinicoradiological examinations. The authors report an uncommon case of laryngeal impaction of a coin in a 21-year-old patient, presenting with dysphonia without dyspnea or stridor. The extraction was performed by endoscopy. The accidental aspiration of a foreign body (FB) is a frequent domestic accident among children but a rare occurrence in adults. An impacted laryngeal FB in children is not uncommon. It represents 44.83% of FB of respiratory tract in Senegal . The larA 21-year-old patient, with no medical history, presented to our department with a sudden onset of change in his voice associated with a cough for 24 hours. The history revealed accidental ingestion of a coin that he was carrying in his mouth. Indirect laryngoscopy showed a metallic foreign body across the glottis. There were no dyspnea and no stridor. The clinical examination showed no other remarkable signs. X-ray of the neck  . The gloForeign body impaction in larynx in a child is not uncommon. It represents 44.83% of FB of respiratory tract in Senegal . Its occThe foreign bodies found are most usually of an organic, food, or bone nature . The preOpacity on lateral X-ray, around C4-C5 found in our patient, is present in all published cases. This could be explained by the fact that the coin can only access the glottal slit when it is disposed in the sagittal plane , unlike The treatment options depend on the habits of each ENT team and conditions of practice. Hathiram et al.  performeThe presence of a coin in the respiratory tract is an exceptional occurrence. Clinical signs are often insignificant and routine. The rule prohibiting children from carrying objects in the mouth also prevails among adults.


Congenital intracranial tumors as a group are quite rare, representing only 0.5% to 1.5% of all pediatric brain neoplasms.3 in size, located in the sellar region, regular shape, and slightly heterogeneous solid mass with a little cystic component. No color flow was present inside the tumor, but the peripheral encirclement by arterial circle of Willis. No other associated malformations were detected. Prenatal magnetic resonance imaging (MRI) which was taken subsequently confirmed the result of ultrasound and provided more detailed information such as fetal brain dysplasia.We reported a case of congenital mixed neuronal-glial tumor detected by ultrasound at 30 weeks of gestation. It showed that the tumor was 2.5 × 2.3 × 2.1 cmThe fetal chromosomal karyotype analysis is normal. Single-nucleotide polymorphism (SNP)-based chromosomal microarray analysis (CMA) detected a 0.72-Mb duplication at 4q35.2 in fetus which was associated with epilepsy and cardiac anomalies. It also revealed a 0.13-Mb deletion at 6q26 located in PARK2 gene, and the mutation of the gene is known to be related to autosomal recessive juvenile Parkinson disease.The parents chose termination of pregnancy (TOP). The histological examination showed a mixed neuronal-glial tumor.Prenatal detection of mixed neuronal-glial tumor is very rare. Ultrasound is of critical importance to detect the intracranial tumors, and MRI can give us some detailed information about the tumors. However, the precise histologic type was depended on the pathological examination. CMA should be necessary for the fetuses with congenital intracranial tumors, especially when the fetal chromosomal karyotype analysis is normal. However, the experience of prenatal diagnosis of fetal intracranial tumors is very limited because of the low incidence. The imaging appearances of various congenital intracranial tumors still overlap, and the final diagnosis still depends on the pathological examination. So far we have found few literatures about prenatal diagnosis of congenital intracranial tumors.2Informed consent was obtained from the patient. This case report was approved by the Medical Ethical Committee of Beijing Obstetrics and Gynecology Hospital, Capital Medical University.A 25-year-old gravida 1 para 0 woman who conceived naturally underwent routine obstetric ultrasonography at 30 weeks’ gestation that revealed an intracranial solid-cystic tumor. The mother suffered from anemia during pregnancy. The father was healthy.3 in size, located in the sellar region. It was regular shape and slightly heterogeneous solid mass with a little cystic component. No color flow was present inside the tumor but the peripheral encirclement by arterial circle of Willis. The lateral ventricles and the head circumference were normal. Fetal heart Tei-index was 0.32 . The evaluation of fetal Middle Cerebral Artery (MCA) and umbilical artery (UA) was normal. The amniotic fluid was normal, and no other associated malformations were detected.Ultrasound Fig.  showed tMagnetic resonance imaging (MRI) which was taken subsequently confirmed the result of ultrasound. Meanwhile, it also provided more detailed information on the fetal central nervous system (CNS) including fetal brain dysplasia and the possible compression of optic nerves caused by the tumor Fig. . The parhttps://decipher.sanger.ac.uk/patient/290426#phenotype/patient-phenotypes) and cardiac anomalies (https://decipher.sanger.ac.uk/patient/288182#phenotype/patient-phenotypes). It encompassed the FRG1 and FRG2 genes. In addition, the CMA also revealed a 0.13-Mb deletion at 6q26 which was located inside the PARK2 gene. The mutation in the PARK2 gene (OMIM ID: ∗602544) is known to be related to autosomal recessive juvenile Parkinson disease.,2 Neither the duplication nor deletion was inherited from the parents.The pregnant woman underwent cord blood samplings because of the congenital malformations. Single-nucleotide polymorphism (SNP)-based chromosomal microarray analysis (CMA) Fig.  was perfUltimately, the parents chose termination of pregnancy (TOP). The abnormal imaging findings were confirmed by autopsy Fig. . The his3 of which most were congenital intracranial teratomas.–8 Prenatal ultrasonography during the whole pregnancy is of particular importance for screening fetal central nervous system tumors. However, few examples of fetal intracranial mixed neuronal-glial tumors have been described by imaging and fewer cases have been confirmed by histopathological examination. Our case contributes to the limited literature focused on the imaging (ultrasonography and MRI), pathological and genetic discoveries of intracranial mixed neuronal-glial tumor in the prenatal period. Searching through the literatures, we only noticed that Chung et al reported a congenital gangliocytoma in 1998 which fell into this category of intracranial mixed neuronal-glial tumor. Its ultrasound features contained both cystic and solid components, located suprasellar and caused marked displacement of the circle of Willis.Congenital intracranial tumors as a group are quite rare, representing only 0.5% to 1.5% of all pediatric brain neoplasms,,6,10–16 Cassart et al retrospectively analyzed imaging findings of congenital craniopharyngioma which was a different pathological type. It showed supra-sellar mass with color flow in its periphery which had the similar sonographic features as our case.We have reviewed the literatures for fetal intracranial tumors which included primarily single case reports published in the last decade assessed by ultrasound Table .[4,6,10– It has been reported that more precise morphology could be provided by MRI at earlier stages of gestation, which makes earlier diagnosis and prompt initiation of treatment possible. Cassart et al noted that MRI was more sensitive than ultrasound for the detection of this heterogeneity. Although there are many advantages of MRI, it must be noted that fetal MRI does not replace ultrasound as a screening tool.Notwithstanding the ultrasonography has permitted description of fetal brain anomalies during the antenatal period, the imaging appearances of various congenital intracranial tumors still overlap. Subsequent prenatal MRI allows the confirmation of ultrasound findings and detection for other anomalies that may be present, in particular, intracranial tumor extension.,18 It has been strongly suggested by the early onset of these neoplasms and their embryonal appearance that prenatal factors are important, especially genetic factors. So CMA was performed after fetal chromosomal karyotype analysis was normal. A 0.72-Mb duplication at 4q35.2 was detected in fetus which was associated with epilepsy. It is consistent with the fact that epilepsy is the most common symptom for intracranial neuroepithelial tumor. The CMA also revealed a 0.13-Mb deletion at 6q26 located inside PARK2 gene, and the PARK2 gene mutation has involvement in autosomal recessive juvenile Parkinson disease.,2 The clinical phenotypes of this disease included shaking palsy, slow moving and myodystony, and so on. However, the microduplication at 4q35.2 and the microdeletion at 6q26 were still defined as being of uncertain clinical significance.Recently studies on application of CMA for various fetal anomalies have also been published.4Prenatal detection of mixed neuronal-glial tumors is very rare. Ultrasound and MRI are helpful for diagnosing intracranial tumors, but the precise histologic type of the tumor was depended on pathological examination. CMA should be necessary for the fetuses with congenital intracranial tumors. This finding not only provides information for clinical consultation but may also allow more accurate genetic diagnosis.


Rectal neuroendocrine tumor (NET) is a relatively rare tumor. Well-differentiated NETs (G1 and G2) rarely display distant metastasis at initial diagnosis. Currently, treatment for the primary lesions of rectal NETs with liver metastasis remains controversial. The liver metastasis was resected in local hospital. Transanal endoscopic microsurgery (TEM) has emerged as an effective minimally invasive surgery for local resection of lower rectal lesions. Herein, we reported the initial application of TEM to remove the rectal primary lesion in patients with low rectal NETs (G2) with giant liver metastases.The patient, a 45-year-old woman, was primarily diagnosed with hepatocellular carcinoma and underwent curative resection of a giant liver lesion in a local hospital. Nevertheless, the postoperative pathologic examination revealed that the lesion was an NET (G2). The colonoscopy then showed a nodule 1.4 cm in diameter, 4 cm above the anal verge, located on the anterior wall of the rectum. The biopsy revealed that the nodule was also an NET (G2). However, the patient did not consent to abdominoperineal resection based on concerns for quality of life.Rectal NET with liver metastasis.The patient underwent curative resection of liver metastasis. And, TEM was adopted to resect the primary tumor in rectum.The patient has been disease-free for 2 years with a good quality of life and presents no local recurrence in the rectum.TEM is an appropriate palliative operation for therapy of rectal NETs with distant metastases, especially for primary rectal NETs located in low rectal. Due to the widespread use of colonoscopy as a screening tool, the rate of detection of colorectal NETs is increasing.,4 Basing on the Ki-67 proliferation index or the mitotic count, in 2010, the tumors were classified as NET G1, NET G2, and poorly differentiated neuroendocrine carcinoma (NEC G3) by the World Health Organization. Rectal NETs are mostly asymptomatic and are commonly diagnosed during routine health examinations.,7 Most of rectal NETs (80–88%) are localized, whereas the remaining NETs (12–20%) are diagnosed with regional lymph node spread and/or distant metastases. According to the SEER database analysis, the median survival of distant metastatic disease was 33 months in patients with NET G1-G2 but was only 5 months in patients with NEC G3. Oncological lymph node dissection and/or debulking surgery or locoregional therapies of primary tumor resection have been associated with a better prognosis.,11 Herein, we report a case of rectal NET (G2) with first clinical manifestation of giant liver metastasis that was treated with a curative resection of liver metastasis and local resection of the primary rectal tumor by transanal endoscopic microsurgery (TEM) with long-term follow-up.Neuroendocrine tumors (NETs), formerly called carcinoid tumors, are located most commonly in the gastrointestinal tract and bronchopulmonary system.2In April 2015, a 45-year-old Chinese female presented with intermittent constipation and hematochezia and was admitted to our institution. Three months before the admission, the patient was seen in the local hospital with a chief complaint of progressive abdominal distension for the past 3 months along with a loss of appetite. Computed tomography (CT) of the liver . After marking the resection area with coagulation dots using a needle cautery, ensuring a free margin area of 1 cm, the tumor was removed one at a time with a full-thickness excision. Defects in the rectal wall were irrigated and closed using running sutures with 3/0 absorbable monofilaments . The 5-year survival in distant metastatic disease is 35% in well-differentiated to moderately differentiated NET, and the median survival is 33 months. Liver surgery is generally proposed with curative intent to all patients with operable well-differentiated (NET G1/G2) metastases from NET regardless of the site of origin . Adjuvant therapies such as chemotherapy are sufficient to confirm metastatic rectal NET cases without obstruction or rectal hemorrhage, as suggested by the ENETS (European Neuroendocrine Tumor Society) guidelines. Smith et al supported this idea, and their research findings suggest that removing high-grade rectal NET lesions does not improve the prognosis of the patients. Meanwhile, the NCCN  proposed that certain managements be determined based on the resectability and symptoms of these patients. Primary and metastatic lesions should undergo radical resection whenever possible, while palliative resection is conducted only when resective problems are presented, such as combinations of severe local symptoms. Durante et al reported that early primary tumor resections, including oncological lymph node dissection and/or debulking surgery or locoregional therapies, were associated with a better prognosis. In our case, the patient underwent partial hepatectomy with pathology confirmation of a hepatic NET G2 tumor. Meanwhile, the colonoscopy showed a nodule 1.4 cm in diameter, located on the anterior wall of the rectum, 4 cm above the anal verge. The biopsy showed the nodule was also an NET (G2). SRS revealed abnormal uptake only in the left ilium. According to the results of the patient's examinations, we considered that the giant liver tumor might have metastasized from the asymptomatic rectal NET. However, well-differentiated NETs (G1 and G2) rarely display distant metastasis. Tumor size, depth of invasion, and lymph node involvement significantly predict malignant behavior in localized rectal NETs. According to 1 analysis of the literature, metastases were observed in 10% to 15% of patients with rectal NETs measuring 1.0 to 2.0 cm. Another article reported that metastases occurred in only 2% of tumors smaller than 2 cm that had not invaded the muscularis propria, compared with 48% in tumors invading the muscularis layer. Many previous studies have reported the presence of lymphovascular invasion in rectal NETs as a strong risk factor for metastasis.–22 Magnetic resonance imaging revealed that the rectal NET was staged as T1N0, and biopsy information through colonoscopy was limited. To confirm the primary tumor and control of local complications  and to avoid local complications, such as obstruction, TEM was performed to remove the rectal lesion completely. Another case report described a patient with rectal NET graded as G1 discovered by sporadic metastasis in the liver. The patient showed good progress with no recurrence after undergoing hepatectomy and endoscopic resection of the rectal NET. Nevertheless, the intrinsic limitations of the conventional endoscopic polypectomy result in a high chance of incomplete resection. Since its introduction by Buess et al in 1983, TEM has emerged as an effective minimally invasive surgery for local resection of rectal lesions. This technique enables full-thickness excision and ensures accurate resection with sufficient margins by applying the delicate instruments under superior visualization. In addition, TEM allows suturing of rectal wall defects after tumor resection, thus securing sufficient excision without worrying about rectal wall perforation. In comparison with endoscopic resection methods, including advanced techniques of endoscopic mucosal resection with cap and endoscopic submucosal resection with band ligation, TEM enables a much larger extent of resection, ensuring more satisfactory oncological results for lesions with malignant potential. In our case, the local lesion was resected completely. The postoperative pathology revealed a tumor 12 mm in diameter that was located beyond the muscularis propria and had invaded the adipose tissue with lymphovascular invasion. According to the previous research, invasion of the muscularis propria and lymphovascular system are risk factors for distant metastasis. We then considered that the liver tumor might have metastasized from the asymptomatic rectal NET. The invasion may also be the reason why a giant liver metastasis was found in the liver despite the primary rectal tumor being well-differentiated and small in size. Systemic chemotherapy has not shown efficacy against metastatic gastrointestinal NETs,27; an analysis showed long progression-free survival of patients who received everolimus plus octreotide, but further verification of these results is required. Adjuvant chemotherapy is only recommended in the treatment of patients diagnosed with NECs and NETs G2 with Ki-67>15%. The patient did not consent to a radical rectal resection. On the basis of these facts, our patient has been followed up carefully without chemotherapy.Rectal NET is a rare tumor with an incidence rate of 0.14 to 0.76/100,000 cases.To our knowledge, this is the first reported case of rectal NET with liver metastasis being managed by TEM. In our case, a high standard local tumor resection of the rectal NET was performed efficiently, with minimal operative trauma. The rapid and smooth recovery of the patient also indicated the advantages of the TEM technique. In this case, in addition to controlling the local complications, TEM, with its full-thickness excision and partial mesorectal excision, also provides more pathologic information, aiding in diagnosis and prognosis evaluations. The patient has been disease-free for 2 years with a good quality of life and presents no local recurrence in the rectum, which may imply that TEM is an appropriate palliative operation for therapy of rectal NETs with distant metastases, especially for primary rectal NETs located in low rectal. However, for further validation of the effects of this new strategy, prospective studies are needed in the future.4Treatment for the primary lesions of rectal NETs with liver metastasis remains controversial. As the unsatisfactory therapeutic effects and limited ranges of clinical applications of nonsurgical treatments, surgery remains the major current option for primary rectal NETs. The patient was always informed to a radical abdominoperineal resection when the rectal NETs located in lower rectum. Considering the surgical trauma and anal function, some patients say no to radical surgical treatment. In this case, TEM in combinations with careful followed-up achieve satisfactory anal and urinal function and good long-term prognosis. For the lower rectal NETs with distant metastasis, TEM could be the initial attempt as a debulking surgical treatment and maintain satisfactory anal and urinal function-preserving. Moreover, long-term outcomes still need to be determined using a larger series of patients. With further intensive study of targeted therapy and high-quality combination therapy, it is possible that the prognosis and quality of life of rectal NETs patients in advanced stages or with metastasis may be improved in the future.