Schwannoma is a benign neurogenic tumor originating from Schwann cells. These produce the myelin sheath that covers peripheral nerves that are often affected. This latter localization is extremely rare, and only a few case reports can be found in the medical literature. Studies have shown that approximately 0.5% to 5% of schwannomas are retroperitoneal, constituting 0.2% of adrenal incidental tumors. These usually present as incidental findings, nonsecreting adrenal masses in asymptomatic patients. Diagnosis of a schwannoma is based on detection of spindle cells with Antoni A and Antoni B regions in histological sections and positive staining for S-100 protein by immunohistochemical analysis. We report a case of an incidentally identified during an abdominal ultrasound examination with schwannoma localized in the left adrenal gland. Schwannoma is a benign neurogenic tumor originating from Schwann cells. These cells produce the myelin sheath that covers peripheral nerves often affected.However, schwannoma arising from the adrenal gland is an extremely rare entity. Additionally, it may arise from the retroperitoneal space, spinal nerves, and less frequently the adrenal medulla , 2.This latter localization is extremely rare, and only a few case reports can be found in the medical literature. Studies have shown that approximately 0.5% to 5% of schwannomas are retroperitoneal, constituting 0.2% of adrenal incidental tumors .These usually present as incidental findings, nonsecreting adrenal masses in asymptomatic patients.Most often malignant schwannomas are associated with neurofibromatosis types 1 and 2 . HistoloDiagnosis of a schwannoma is based on detection of spindle cells with Antoni A and Antoni B regions in histological sections and positive staining for S-100 protein by immunohistochemical analysis .We report a case of an incidentally identified during an abdominal ultrasound examination with schwannoma localized in the left adrenal gland. A brief review of the corresponding literature is also presented.A 45-year-old man was referred to our institution with a retroperitoneal left adrenal mass that was incidentally found by ultrasound 3 mo earlier. His medical history revealed mild hypertension under medication and an operation of appendicectomy 37 y earlier. He had no remarkable family history. Physical examination of his abdomen revealed no palpable mass. The patient had no cutaneous lesions or palpable lymphadenopathy.Routine blood tests of the patient were normal, and the 24 h urinary catecholamines, cortisol, and chromogranin values were within normal ranges.Ultrasonography demonstrated a 12 cm in maximal diameter heterogeneous expansive mass near the left adrenal. A computed tomography (CT) scan of the abdomen confirmed the ultrasound finding and revealed a 14 cm diameter heterogeneous mass with both solid and cystic components arising in the right adrenal gland .Taking into account the size of the tumor and after informed consent was received from the patient, the authors proceeded with surgical treatment.The patient underwent a laparotomy resection of the lesion, as well as an en bloc excision of the left adrenal gland. Histological examination of the resected specimen revealed macroscopically globular mass with areas of necrotic colliquation, measuring 14 cm .Microscopic examination showed that the lesion was composed of Antoni A areas, where short spindle cells with a long conical nucleus and scant cytoplasm aggregated and formed a spiral structure, and Antoni B areas, where inflammatory cells were scattered within a loose matrix.In immunohistochemical analyses, the tumor did not stain for c-kit (CD117), CD34, or SMA but stained strongly for S-100 protein and CD68 ; 4.The patient, whose postoperative course was uneventful, was dismissed on the fifth postoperative day. Ultrasonic and CT checkups at 6, 12, and 18 months showed no signs of recurrence.The majority of the tumors originating in the adrenal medulla are pheochromocytoma, neuroblastoma, or ganglioneuroma. Schwannoma of the adrenal gland is rarely encountered, although it similarly originates from the cells of the neural crest.The origin of the adrenal schwannoma is considered to be either of 2 myelinated nerve systems innervated to the adrenal medulla: one is the sympathetic nerve from the upper lumbar plexus and the other is the phrenic or vagus nerve .Schwannomas constitute approximately 1% to 5% of all retroperitoneal tumors. Malignant degeneration of a schwannoma is infrequent; however, when it occurs, it acts as a high-grade sarcoma with a high probability of causing local dissemination and distant metastasis.Generally, malignant forms are suggested histologically by increased mitosis, pleomorphism, and vessel infiltration. Malignant schwannomas are typically found in the extremities, and often they occur in association with Von Recklinghausen's disease . AlthougPreoperative diagnosis of schwannoma of the adrenal gland is often incidental, because large, deeply situated tumors are usually present for long periods of time before patients complain of symptoms. The size of lesions at the time of diagnosis is frequently >4 cm in diameter. However, the size of the lesion and the depth of invasion are not associated with the possibility of malignancy . PatientIn cases of retroperitoneal schwannomas that appear to localize in the adrenal glands, the differential diagnosis, which may be made by magnetic resonance imaging (MRI), ultrasonography, and CT, includes tumors of the area, such as adenoma of the adrenal gland, pheochromocytoma, myelolipoma, metastatic lesion, neurofibroma, paraganglioma, lipoma, and malignant fibrous histiocytoma . PreoperIn cases of retroperitoneal lesions, MRI is the imaging modality of choice, because it allows better demonstration of their origin, vascular architecture, and relation to surrounding structures. MRI typically demonstrates benign schwannomas as well-circumscribed homogeneous masses that enhance slightly after intravenous administration of contrast material. Moreover, MRI shows low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. These findings, although nonspecific, are commonly exhibited by schwannomas and have been reported to be present in 57% of the cases .However, imaging modalities cannot provide a definitive diagnosis. Surgical resection of the lesion is necessary to make the diagnosis, differentiate it from other soft tissue neoplasms, palliate symptoms, and eliminate the possibility of malignancy. Biopsy is not recommended as a diagnostic tool, because hemorrhage, infection, and seeding of tumor cells are known risks of this modality, as are the lethal consequences if a pheochromocytoma exists .Conventionally, schwannoma are divided into 2 distinct subtypes: hypercellular “Antoni A” type and hypocellular “Antoni B” type. Spindle cells are arranged in fascicles in areas of high cellularity with little stromal matrix in the Antoni A type. Nuclear-free zones called “Verocay bodies” can also be found in between the regions of nuclear palisading. Tumor cells are less densely found, forming loose meshwork often accompanied by microcysts or myxoid changes in Antoni B type, and are considered to be a degenerated form of the Antoni A type .Both subtypes can be found as a mixture in adrenal schwannoma; 3 of 11 reported cases demonstrated both subtypes in a tumor. The differential diagnosis made using immunostaining should exclude gastrointestinal stromal tumor (GIST) or leiomyoma. Schwannoma positively stains for S-100. By contrast, GIST is positive for c-kit, and leiomyoma is positive for smooth muscle actin.As evident from the medical literature, schwannomas that arise from the adrenal medulla are very rare entities. Often, schwannomas from the retroperitoneum, especially in the juxta-adrenal space, can be misdiagnosed when they mimic adrenal lesions . In PolaThe ages of the patients ranged from 11 to 89 y, and no sex predilection was observed. The size of the lesions that are reported varies between 0.6 cm and 14 cm. All of the lesions are characterized by benign features –4, 9.The common surgical approach that was followed was laparotomy and complete excision of the mass and the adrenal gland, with controversy existing over the necessity of negative margins, especially when adjacent tissues were in close proximity. In one case, partial adrenalectomy took place. In less than half of the cases, the patients underwent laparoscopic excision.Retroperitoneal schwannomas are rare tumors that are difficult to diagnose. Preoperative workup is nondiagnostic and can only postulate a nonsecreting adrenal mass.Schwannoma of the adrenal glands is a very rare entity, which in the vast majority of cases possesses benign behavior. This lesion is found predominately incidentally, and the clinician must have a high index of suspicion to recognize it when special features are demonstrated in imaging modalities, especially MRI. Histological and immunohistochemistry analyses provide the definitive diagnosis.A nonsecreting adrenal mass >4 cm in diameter should be removed surgically with an added benefit of a definitive diagnosis.The common surgical approach that was followed was laparotomy and complete excision of the mass and the adrenal gland while in the partial adrenalectomy the patients underwent laparoscopic excision.


The occurrence of an intra-articular ossicle is not rare in the knee, with reports suggesting the existence of meniscal osscile. There are also reports describing the attachment of the posterolateral bundle of the anterior cruciate ligament (ACL) to an accessory ossicle. However, despite an extensive search of the English literature we did not find much written about an intrasubstance ossicle in the ACL. We present the case of a 13-year-old male with an intrasubstance ossicle in the anteromedial bundle of the ACL of his right knee. The anterior cruciate ligament (ACL) consisting of its two bundles, the anteromedial and the posterolateral, attaches to the lateral femoral condyle on its posteromedial aspect. Very few variations are seen in the anatomy of the ACL .It is not uncommon to find cysts within the ACL, their existence being around 1.3% on MRI studies . The occHowever, a detailed search of literature failed to reveal much about the incidence or pathogenesis of an intra-ACL ossicle.We, thus, present a case of a young male with chronic knee pain, with inconclusive history and physical examination, who on arthroscopic examination showed an ossicle within the substance of the anteromedial bundle of ACL.A 13-year-old student came to the outpatient department of our tertiary care institute complaining of pain along with clicking in his right knee for about 5-6 months. The patient was apparently well and had not noticed any discomfort in the involved knee more than 6 months back. He had been consulting local practitioners before he came to us, without much relief. The patient had mild pain in his right knee exaggerated by sporting activity and walking for long distances. He also complained of mild discomfort while walking. The pain had been nonprogressive for the past 5-6 months, with no relief with physiotherapy as was advised by the practitioners he had been consulting. He had absolutely no history of trauma to his knee or any swelling preceding the onset of the pain and discomfort. There was no history suggestive of any joint laxity or locking. The patient gave no history of any fullness or heaviness in his knee.The examination of the patient was inconclusive. There was no fullness or swelling in the joint. The local temperature was comparable to the general body temperature, and no tenderness could be elicited. There was no ligament laxity, and the range of motion was normal with only slight pain and restriction of terminal extension. McMurray and Lachman were negative. The pain was exaggerated by making the patient climb up and down the stairs; it, however, did not restrict his activities.With an inconclusive history and physical examination the patient was advised one month of physiotherapy and limited sporting activity. He was asked to come back after a month for follow-up. A month later the patient came back with not much improvement in his symptoms. A plain X-ray although revealed something that appeared to be a loose body and was inconclusive .1 and T2 images, in the substance of the anteromedial bundle of the ACL. The MRI also revealed a discoid lateral meniscus (An MRI was also advised and obtained. The MRI revealed a hypointense lesion of 1.3 cm by 0.8 cm, on both Tmeniscus .With a hypointense lesion in the MRI the diagnosis or nature of the lesion was yet in doubts. We thus decided to take a closer look into the lesion and the patient was worked up for a diagnostic arthroscopy and excision of the lesion.On entering the joint, a bulge in the substance of the anteromedial bundle of the ACL was evident, more clearly visible on 70° angle of the scope through the lateral portal . The resThe patient is doing well after the excision of the ossicle. The patient is completely relieved of pain and has full range of movement in the involved knee. The terminal restriction of extension as was present on initial examination has also resolved. In a year of postoperative follow-up, the patient is asymptomatic and enjoying his sporting activities to the fullest.An ossicle may be defined as a mature lamellar and cancellous bone with a covering of hyaline cartilage and fatty marrow within . Many auFollowing a detailed search of English literature, we could not come across any article talking about the occurrence of an ossicle within the substance of the ACL.We however found mention of heterogeneous calcification in ACL following trauma or even ACL reconstruction .Sarsilmaz and Gelal  had talkThe existence of intra-articular ossicles in knee is not very uncommon though. Meniscal ossicles although rare are not an infrequent occurrence . RohillaMost patients with such intra-articular ossicles present with pain and on X-ray are most commonly misdiagnosed as loose bodies. However, the absence of any suggestive symptoms or signs made it unlikely that the mass could be a loose body .MRI can be helpful in depicting the nature of the mass by localizing its site and showing isointensity to the normal bone marrow with a hypointense rim. It is a useful tool to differentiate it from other causes of loose bodies, chondrocalcinosis or osteochondritis dissecans. MRI also rules out the existence or absence of any other pathology in the joint .The lack of its mention and rare occurrence in literature, however, held us back from making the diagnosis of an intra-ACL ossicle although the MRI findings were quite suggestive.The occurrence of intra-ACL calcification leading to symptoms has been reported though. Tsujii et al  had descThus, based on the MRI appearance of the lesion and its physical appearance, we were prompted to make the diagnosis of an ACL ossicle.The occurrence of intra-articular ossicles in the knee though have been reported, we did not come across any mention of an intrasubstance ossicle in the ACL. We thus report a case of an ossicle in the substance of the anteromedial bundle of the ACL, in a patient with mild pain and discomfort, who got completely relieved of his symptoms after its excision. After one year of postoperative follow-up, the patient is asymptomatic and back to his sporting activity without any constrains.


Neuroendocrine tumors (NETs) of the ampulla of Vater are rare and difficult to diagnose. We report a rare case of a small NET of the ampulla of Vater with metastasis to distant lymph nodes.The patient was a 54-year-old man complaining of epigastric pain and melena. Upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding, which was diagnosed as a well-differentiated NET of the ampulla of Vater. An approximately 10-mm hypervascular tumor at the ampulla of Vater and a 41-mm cyst adjacent to the wall of the jejunum were revealed by abdominal computed tomography. We performed pylorus-preserving pancreaticoduodenectomy with lymph node dissection. Macroscopic examination revealed a 9-mm tumor of the ampulla of Vater and a 52-mm cyst adjacent to the wall of the jejunum. Histological examination revealed that the cyst was a lymph node metastasis. The final diagnosis was non-functional NET G1 of the ampulla of Vater, designated T1N1M0 stage IIIB. Postoperatively, the patient underwent no treatment and has had no recurrence for 4 years.This case demonstrates that sporadic NETs of Vater’s papilla have aggressive metastatic potential even with a small primary lesion, and radical resection with lymphadenectomy is recommended for all cases. Neuroendocrine tumors (NETs) of the ampulla of Vater are rare , 2. A toThere is no curative treatment for NETs, except surgical resection. In general, a tumor size greater than 2 cm in diameter, invasion of the muscularis propria, and presence of mitotic figures are correlated with metastasis of NETs . TherefoIn the cases of duodenal NETs, tumors smaller than 2 cm have limited metastatic potential , 8. HoweHerein, we report our experience with a rare case of 9-mm ampullary NET with lymph node metastasis and review the current literatures on the topic.A 54-year-old man presented with a history of epigastric pain and melena over the last few days. The patient did not have hormone-related symptoms. He had received treatment for a myocardial infarction at the age of 51 with an antiplatelet therapy; therefore, we considered that there was a possibility of tumor bleeding by antiplatelet therapy. Blood biochemical examinations indicated slight anemia. Serum carbohydrate antigen 19-9 and carcinoembryonic antigen (CEA) levels were not elevated. The 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) level was 3.2 mg. Upper gastrointestinal endoscopy showed a bulging papilla with bleeding Fig. . A biopsThe patient was referred to our hospital for treatment of the NET. We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node dissection. The operative time was 497 min, and the volume of blood loss during the surgery was 1220 ml. The resected specimen was macroscopically a 9-mm white solid tumor Fig. . Tumor cNETs of the ampulla of Vater are rare and difficult to diagnose , 2. JaunDiagnosis of NETs is established by histological and immunohistochemical analysis of endoscopic biopsy specimens . NETs ofPrevious reports have suggested that the biological behavior of ampullary NETs is distinct from that of duodenal NETs and they are more aggressive . Randle In the case of ampullary NETs, even in tumors smaller than 2 cm, a high percentage have lymph node metastases , 16–18. We performed a pylorus-preserving pancreaticoduodenectomy with regional lymph node resection and also resected a 52-mm lymphatic metastasis adjacent to the wall of the jejunum. Despite the lymph node involvement, the Ki-67-labeling index was low (2 %) and the patient has had no evidence of recurrence for 4 years after surgery.Randle et al. indicated that tumor size was correlated with poor prognosis, but the presence of positive lymph nodes was not a predictive outcome in resected ampullary NETs . Untch eIn conclusion, NETs of the ampulla of Vater, even very small tumors (<1 cm), may have aggressive metastatic potential. A radical resection with lymphadenectomy might be the appropriate treatment strategy for sporadic NETs of the ampulla of Vater.Written informed consent was obtained from the patient for publication of this case report and any accompanying images.5-HIAA, 5-hydroxyindoleacetic acid; CEA, carcinoembryonic antigen; CT, computed tomography; NET, neuroendocrine tumor


Although a solitary fibrous tumor of the pleura (SFTP) is a rare disease, and usually has a benign course, it has a malignant potential. We report a case of malignant SFTP treated surgically. A 75- year-old female was admitted with a chief complaint of hemoptysis of two weeks duration. Computed tomography of the chest imaged a large mass in the right hemithorax, which compressed adjacent organs; however, there was no evidence of invasion. We reviewed the patient’s medical records and found that the mass had been presented for 17 years. Complete resection was achieved through a right thoracotomy and histopathologic examination confirmed a malignant SFTP. A solitary fibrous tumor of the pleura (SFTP) is a rare disease entity that usually arises from the submesothelial mesenchymal cells; its incidence is < 5% of all pleural tumors. The clinical course is usually indolent, and prognosis is favorable if complete resection is possible. However, it has been reported that 10-30% of SFTPs are malignant. We presA 75-year-old Korean female was admitted to our hospital with a chief complaint of hemoptysis of two weeks duration. She had a history of mitral stenosis and atrial fibrillation treated with medications including digoxin and warfarin; seventeen years ago she underwent right leg amputation due to femoral artery thrombosis. A computed tomographic (CT) scan of the chest revealed a large mass in the right thoracic cavity. Its internal contents were inhomogeneous; however, invasion of the chest wall or mediastinum was evident Figure A. In addSFTPs arise from the mesenchymal cells of the pleura and are usually benign; they have a good prognosis with a 10-year survival rate up to 98%. Most ofMalignant SFTPs are diagnosed based on histologic finding including hypercellularity, mitosis, pleomorphism, hemorrhage and necrosis. Although some prognostic factors, such as over expression of Ki-67, extension beyond the capsule and negative conversion of CD34 have been discussed, based on the criteria of malignancy developed by England and coworkers,9. ComplThese tumors are sometimes rapid progression so theseAlthough the SFTP of our patient was malignant, the tumor could be completely resected, and prognostic factors other than England’s criteria were negative; therefore, a good prognosis is expected.We report a case of large malignant SFTP, which had been untreated for many years. The tumor was successfully treated by complete resection. However, long-term follow up is required, due to the potential risk of local recurrence or distant metastasis.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: Computed tomographic; SFTP: Solitary fibrous tumor of the pleura; PET: Positron emission tomography.The authors declare that they have no competing interests.HWJ reviewed the medical record and drafted the manuscript and SSK reviewed the medical record and carried out revision. YDK reviewed the medical record of the patient and carried out operation and revision of the manuscripts. All authors read and approved the final manuscript.


Anaplastic large cell lymphoma is a rare and account for 10 % of cases of cutaneous lymphoma T is characterized by the presence of anaplastic tumor cells, pleomorphic or immunoblastic for the majority of them (over 75 %) antigen CD30 . It is in the form of single or multiple nodules or as patches in adult patients.We report a patient of 43 years old followed for HIV + hypothyroidism who presented for 8 months multiple purplish nodules scattered all the body but especially in the left lower limb or there is a large ulcerated a budding and painful nodule the upper part of the inner side of the left thigh associated with lymphedema of the lower limb all concerned Clinically, it measured 3-5 cm in diameter, were clear limits, an erythematous ulcerated area with serosanglant flow and was fixed with respect to deeper level. We found nodular lesions on the abdominal and thoracic wall. He had no lymphadenopathy or hepato splenomegaly. We discussed the diagnosis of cutaneous leishmaniasis, epidermoid carcinoma, cutaneous tuberculosis and Kaposi sarcoma. Histological examination of a fragment of skin resection was in favor of anaplastic large T-cell lymphoma / No primitive according to OMS classification 2008 . Lymph node ultrasound, thoracoabdominal computed tomography showed thoraco-abdominal polyadenopathies with two right pulmonary micronodules. The treatment consisted in CHOP chemotherapy protocol.After four cycles of chemotherapy lesions disappeared completely with disappearance of lymphedema with a very good condition and weight regain. Thoracoabdominal CT scan was done showing the complete disappearance of thoraco- abdominal lymphadenopathy.Front dragging and recurrent chronic ulcers, the diagnosis of cutaneous lymphoma should be considered in the differential diagnosis and skin biopsy is needed.


Endocrine tumors (ET) of the digestive tract are rare. Gastric carcinoid was the most common form of gastrointestinal ET's. It is a rare complication of pernicious anemia but may reveal the disease. We report the case of a 57-year- old women, wich is referred for exploration of epigastric pain with persistent dyspepsia. Gastroscopy found polypoids lesions (A) and gastric mucosae was enlarged, on histological study, by a well-circumscribed neoplastic proliferation covered by intact surface epithelium (B et C). Tumor cells have central, uniform nuclei, a low mitotic rate and co-express cytokeratine and chromogranine A, concluding to well-differentiated neuroendocrine tumor. Pallor on examination led us to perform NFS showing aregenrative anemia (hemoglobin at 7.2 g/dl) with high mean corpuscular volume and megaloblastosis in myelogram. Serum vitamine B 12 level is 60 pg /l and homocysteine level is 57 μmol/l. Vitamin replacement treatment is given as well as endoscopic resection of polyps since assessment of extension is negative. The onset of pernicious anemia is difficult to establish because of its insidious presentation. This slow progression of vitamine B 12 deficiency, resulting from advanced autoimmune atrophic gastritis, explains the adaptation to anemic syndrome that does not represent the main complaint in this patient. This case confirm the importance of endoscopic evaluation at the diagnosis of pernicious anemia.


Bladder leiomyoma is a rare benign tumor and it could be easily misdiagnosed with many other pelvic diseases, especially obstetrical and gynecological diseases; abdominal, laparoscopic, and transurethral resection of bladder leiomyoma have been reported. Herein, we present a case of bladder leiomyoma misdiagnosed with a vaginal mass preoperatively; the mass was isolated, enucleated from the bladder neck, and removed transvaginally; to the best of our knowledge, this is the first case of intramural leiomyoma of bladder neck that has been enucleated transvaginally only without cystotomy. Bladder leiomyoma is a rare benign tumor; the symptoms depend on the location and size of the tumor; surgery is the standard treatment and the surgical approach depends on tumor size and localization at the bladder wall; this rare disease can be confused with many other pelvic diseases, especially obstetrical and gynecological diseases.A 22-year-old woman was referred to our outpatient department. She complained of lower left abdominal pain without radiating to other parts of the body, which had occurred for the previous 2 months. She did not complain of any urinary or bowel symptoms such as urinary frequency, urgency, dysuria, or incontinence. She denied any significantly surgical or medical history. Bimanual pelvic examination detected a well circumscribed firm and slightly movable spherical lesion located in the left of the vaginal wall. Urinalysis was within normal limits. Ultrasonography (US) revealed a relatively irregular and heterogeneous mass in the left posterior wall of the bladder. Contrast-enhanced computed tomography (CT) scan demonstrated a 3.2 × 2.5 cm soft, mild enhancement mass near the left posterior wall of the bladder, protruding into the bladder locally . The cysBladder leiomyoma is a rare benign tumor; the symptoms depend on the location and size of the tumor , 2. A diThe treatment of bladder leiomyoma depends on the size, location, and involvement of urinary sphincter or ureter orifices and the patient's preference . For smaMost bladder leiomyoma shows typical benign tumor characteristics and can achieve a definite diagnosis through preoperative biopsy. But some can be obscured with many other pelvic diseases. Lower urinary tract leiomyomata especially should always be considered in the differential diagnosis of an anterior vaginal mass. We cannThere are many proposed etiologies for leiomyoma, including chromosomal anomalies, hormonal changes, infection of bladder smooth muscle, perivascular inflammations, and dysontogenesis . Many fiIn conclusion, though TVR is recommended for extravesical tumors, we firstly present a transvaginal resection of an intravesical leiomyoma. TVR is another feasible, minimally invasive surgical approach for intravesical leiomyoma of bladder neck. Bladder leiomyoma can be obscured with many other pelvic diseases; it should be considered as a rare cause of uterine mass, ovarian tumors, acquired dysmenorrhoea, female pseudoprostate, stress incontinence, and even impotence. Steroid hormone is correlated with bladder leiomyoma; gonadotropin-releasing hormone may be a new choice for the prevention, diagnosis, and treatment of bladder leiomyoma.


Carcinoid is one of the most common tumors of the gastrointestinal tract followed by the tracheobronchial tree. Bronchial carcinoid compromises 20% of total carcinoid and accounts for 1–5% of pulmonary malignancies. Carcinoid can be typical or atypical, with atypical carcinoid compromises 10% of the carcinoid tumors. Carcinoid usually presents as peripheral lung lesion or solitary endobronchial abnormality. Rarely it can present as multiple endobronchial lesion. We hereby present a rare case of an elderly gentleman who had undergone resection of right middle and lower lobe of lung for atypical carcinoid. Seven years later he presented with cough. CT scan of chest revealed right hilar mass. Flexible bronchoscopy revealed numerous endobronchial polypoid lesions in the tracheobronchial tree. Recurrent atypical carcinoid was then confirmed on biopsy. The most common location of carcinoid tumors is the gastrointestinal tract, followed by the tracheobronchial tree . BronchiIn 2004, new criteria divided lung carcinoids into different groups: typical and atypical carcinoids, large cell neuroendocrine carcinoma, and small cell lung carcinoma . Of the 63-year-old nonsmoker male presented to the office with chronic cough of 2-month duration. The cough was dry with no sputum production. Patient denies dyspnea, wheezing, hemoptysis, night sweat, and weight loss. Seven years prior to this presentation the patient had resection of right middle and lower lobe for the solitary atypical bronchoscopic biopsy proven endobronchial carcinoid just below the right minor carina. On pathology the patient's lesion confirmed atypical carcinoid. The hilar and mediastinal nodes were negative for any tumor and the margins as well were free of any tumor. Computerized tomography (CT) scan and positron emission tomography (PET) scan showed no evidence of any local or distant spread. Patient besides the previous history of carcinoid also had history of hypertension and coronary heart disease. Patient was not on any angiotensin converting enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB) for the control of his blood pressure. Physical examination revealed decreased breath sound in the right lower chest. No wheezing or rhonchi were heard in both lungs.In view of his chronic cough, the patient underwent X-ray of the chest, which showed some hilar fullness. A computed tomography (CT) scan of chest revealed a new 8.1 × 7.4 cm right hilar mass, with no evidence of disease noted in trachea or left lung and no evidence of any endobronchial lesions . PET scaCarcinoid tumors are neuroendocrine tumors that typically arise from gastrointestinal tract and the bronchus. Bronchial carcinoid tumors comprise approximately 20% of all carcinoid tumors and approximately 1–5% of all lung malignancies in adults , 11. CarDue to the variability of clinical presentation of bronchial carcinoid, there can be a delay in diagnosing or even misdiagnosis. The differential diagnosis of a patient with symptoms of bronchial obstruction, bronchospasm, and hemoptysis is wide; it includes an obstructing bronchial carcinoma, endobronchial metastasis, hamartomas, aspirated foreign body, asthma, and COPD.While the 24-hour urinary excretion of 5-hydroxyindoleacetic acid (HIAA) is a useful initial diagnostic test for carcinoid tumors arising in the midgut , it is not as helpful for carcinoid tumors arising in the foregut  or hindgut , as they secrete less serotonin . TherefoThere are several differences between these two groups; in atypical carcinoids, the age of presentation tends to be much higher as in our patient's case. In one study the mean was 51 years for atypical versus 43 years for typical , 17. In Bronchial carcinoids have not been found to have any associations to smoking cigarettes or exposure to tobacco smoke , 20.They can present with symptoms or be asymptomatic. In several studies, 17–52% of patients presented symptoms. In our case, the patient had nonresolving cough, which was found to be the most common symptom besides hemoptysis. Other reported problems were recurrent pulmonary infection, fever, and dyspnea. Carcinoid syndrome associated with bronchial carcinoid is very rare and in most studies it was not present; only a retrospective study reported that it happened in one patient , 20–22.In asymptomatic patients, the disease is usually diagnosed with a simple chest X-ray, which would show a radiopaque mass . Our patThe management is very straightforward; surgery is the mainstay for the treatment of bronchial carcinoid, whether it is typical or atypical. Our patient did not undergo surgery as the lesion was involving trachea, vocal cords, and both mainstem bronchi. With the typical carcinoids, it is possible to remove less tissue, that is, bronchial sleeve resection, since they are not as aggressive, but, with the atypical, lobectomy and pneumonectomy are the most common options , 25. ForThe most important prognostic factor for bronchial carcinoid is the histology. As we had already discussed, typical carcinoids have a better prognosis and less rate of recurrence than atypical carcinoids . In our The 5-year survival ranges from 89 to 92% in the typical carcinoid group and from 66.7 to 75% in the atypical carcinoid group. The 10-year survival was 82–88.9% for typical and 50–56% for atypical, as we should expect, given the more aggressive behavior in the latter group , 20.However, as bronchial carcinoid tumors are a spectrum consisting of more indolent tumor to more aggressive tumors with the potential to metastasize or recur locally, long-term follow-up is needed as local or distant recurrence may occur many years after the initial diagnosis and treatment as in this case . There iThe most important prognostic factor for bronchial carcinoid is the histology. As we had already discussed, typical carcinoids have a better prognosis and less rate of recurrence than atypical carcinoids . In our


The abscopal effect is a phenomenon observed in the treatment of metastatic cancer where localized irradiation of a particular tumor site causes a response in a site distant to the irradiated volume. The mechanisms of the abscopal effect are speculated to be of several origins, including distant effects on p53, elaboration of inflammatory agents including cytokines, and, most recently, secondary to immune mechanisms. In this case report, we present a rare report of a patient with hepatocellular carcinoma with lung metastases who, after receiving radiation treatment to the liver, had a treatment response in the liver and a complete response in the lung. Recent advances in the understanding of the primary role of immune-modulated cytotoxicity, especially with the success of immune checkpoint inhibitors, have the potential to turn the abscopal effect from a rare phenomenon into a tool to guide antineoplastic therapy and provide a new line of research. Hepatocellular carcinoma (HCC) is the sixth most common malignancy worldwide, and the third most common cause of death from cancer . The absThe London Health Sciences Centre Research Ethics Board approved this study . Patient information was collected and released under an ethics approved prospective database.In early December 2009, a 71-year-old man presented to the Emergency Department with dyspnea as well as right-sided chest wall and upper quadrant abdominal pain. He was diagnosed with pulmonary embolus and started on anticoagulation. His imaging investigations revealed multiple coalesced masses in the liver with the largest measuring 6 cm x 9 cm x 9 cm in the right lobe of the liver. Multiple lesions were also noted in the lung with bilateral pleural plaques consistent with asbestos exposure Figure . Alpha-fIn late January 2010, he met with a liver surgeon. A repeat CT scan of the thorax and abdomen in early February revealed the liver lesions had increased in size with the primary lesion now measuring greater than 14 cm. Furthermore, there was evidence of worsening metastatic disease in the lungs with innumerable lesions between 0.5 and 2 cm in size. These were non-calcified and non-cavitary lesions. With this rapid doubling time, there was some debate within the Multidisciplinary Tumor Board about the role of medical treatment with sorafenib. The patient was ECOG 1 and had only mild hepatomegaly. He had no jaundice or stigmata of liver disease but was experiencing significant fatigue. Liver enzymes were minimally elevated with ALT 31 IU/L , AST 73  IU/L , ALP 95  IU/L , and total bilirubin 8.1 µmol/L . His albumin was 35 g/L and INR was normal. His Child-Pugh Score was A6.  However, the combination of his hypertension and anticoagulation raised the concern of increased bleeding risk and potential difficulty controlling hypertension while on sorafenib. Therefore, in conjunction with the patient, it was decided to go ahead with radiotherapy alone.   The patient underwent 70 Gy treatment in 15 fractions to the liver, which was completed in April 2010 Figure . The patFrom August 2010 till March 2012, the man enjoyed stable disease with normal liver laboratory results (including an AFP of 3.1) and no imaging evidence of disease recurrence. In March of 2012, a small recurrent nodule was found in the right liver and he underwent hepatic artery embolization with doxorubicin and cisplatin in May of 2012. This resulted in a complete response at that location.In 1953, Mole described the phenomena of abscopal effect as an “action at a distance from the irradiated volume, but within the same organism” . It can One interesting report in the literature describes a man with HCC who had a mediastinal metastasis and a pulmonary mass in the right lower lobe. After receiving focused mediastinal radiation, the abscopal effect was observed with regression of the pulmonary mass, which was not in the irradiated field . HoweverThe mechanism of the abscopal effect is still not well understood, although major mechanistic categories have been proposed and opportunities for exploitation reviewed -37. ThesMore recently, the observation of unexpected abscopal response in patients receiving radiation during immunotherapy has attracted much interest. Many of these mechanisms have explicit support from animal studies -50, 65. We have reported a case of abscopal effect with focal radiation therapy to the liver causing regression of distant pulmonary metastasis in HCC. There is increasing evidence supporting the mechanisms of the abscopal effect as an immune-mediated process initiated by high-dose radiation. The recent elaboration and utility of immune checkpoint inhibitors in clinical practice provides significant optimism of a role of radiotherapy in combination with these therapies. This is a promising area of research and therapeutic development, which could lead us to take advantage of these phenomena in the treatment of cancer.


Thyroglossal duct cyst (TDC) is the most common congenital neck mass, approximately 7% of the Population has a TDC. It results from incomplete resorption of the thyroglossal duct during embryogenesis. A 31-year-old male patient presented with a painful left paramedian neck swelling for two months. Physical examination revealed a cystic mobile swelling; the lesion disappeared on hyperextension of the neck and reappeared on lateral rotation to the left side. Cervical CT scann revealed a bilobular cystic mass on the prominentia thyroidea, and extending deeply into the preepiglottic region, turning medially from the upper border of the thyroid cartilage . Surgery


Pneumopyopericardium is a rare disease with poor prognosis. The usual presentation is with fever, shortness of breath and haemodynamic compromise. The Electrocardiogram changes associated with this disease entity would be similar to pericarditis such as concave shaped ST elevations in all leads with PR sagging. Pneumopyopericardium mimicking an acute ST Elevation Myocardial Infarction, with regional Electrocardiogram changes has hitherto not been described in world literature.We describe the case of a 48 year old native Sri Lankan man, presenting with chest pain and Electrocardiogram changes compatible with an Acute ST Elevation Myocardial Infarction, subsequently found to have Pneumopyopericardium secondary to an oesophageal tear. Retrospective history revealed repetitive vomiting due to heavy alcohol consumption, prior to presentation. It unfortunately led to a fatal outcome.Pneumopyopericardium may mimic an acute ST elevation myocardial infarction with associated regional Electrocardiogram changes. A high degree of suspicion should be maintained and an adequate history should always be obtained prior to any intervention in all ST Elevation Myocardial Infarction patients. Cardiovascular disease is the leading cause of mortality worldwide . PericarA 48 year old Sinhalese man from Chillaw, Sri Lanka presented to his local hospital with a history of sudden onset retrosternal chest pain, shortness of breath and sweating. He was a heavy alcohol abuser, consuming 10 Units of Local Arrack (Ethanol) on a daily basis with occasional use of illicit alcohol (Methanol). An ECG taken at the local hospital is seen in Figure Pneumopyopericardium is an uncommon disease entity, with less than 20 cases reported to date in world literature. Our case provides insight in to a rare and never before described presentation mimicking an acute ST elevation myocardial infarction with regional electrocardiogram changes. Although falsely managed as an acute coronary syndrome initially, a diagnosis of pneumopyopericardium was retrospectively made. A focused history prior to intervention may have predicted the disease, as the patient complained of persistent vomiting secondary to heavy alcohol abuse. Consistent with other reported cases, this patient was also found to have an oesophageal rupture. A possible cause for acute ST segment elevations in this scenario could be a localized myopericarditis, which has been reported previously . RegionaPneumopyopericardium may present as an acute ST elevation myocardial infarction. A high degree of suspicion should be maintained in the correct clinical setting. The prognosis remains poor, despite maximal medical and surgical management for the condition.Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


EWSR-1 gene. The patient achieved complete remission following adjuvant chemotherapy and radiotherapy according to Euro-EWING 2008 treatment protocol. Intracranial Ewing sarcoma, although rare, should be an important differential diagnosis of intracranial tumors in childhood which requires aggressive multimodal treatment.Medulloblastoma, astrocytoma, and ependymoma represent the most common infratentorial tumors in childhood, while Ewing sarcomas in that localization are extremely rare. A large left infratentorial space-occupying lesion was diagnosed in a 12-year-old girl with signs of increased intracranial pressure. Following total tumor resection, histological and molecular examination revealed Ewing sarcoma with rearranged  Intracranial tumors represent the most common solid neoplastic lesions in children. Their incidence is in the range of 2–4 per 100.000 per year  whereas A 12-year-old girl was admitted with a several-weeks history of headache, vomiting, and abdominal pain. Neurological examination revealed slight ataxia but was otherwise normal. The past medical history as well as the family history was uneventful. Magnetic resonance imaging (MRI) of the brain revealed a large space-occupying lesion of the left posterior fossa measuring 5.4 × 5 × 3.9 cm. The lesion was based on the convexity of the left infratentorial space and extension into the posterior fossa with bone erosion extending towards the left occipital space. The intracranial tumor part consisted of two parts, enhanced gadolinium, and was accompanied by peritumoral edema mainly focused on the vermis and the contralateral white matter and dislocating the transverse sinus .The patient underwent total tumor resection via a left-sided suboccipital approach. First, an extracranial tumor layer overlying the left posterior fossa and infiltrating the muscle tissue was removed. The infiltrated bone segment extended from the posterior fossa to the left occipital region covering the occipital pole. All affected bone parts were removed. Then, an epidural tumor layer overlying the transverse sinus was removed. After decompressing the dura the transverse sinus was found to be intact. Intradural inspection at this site revealed no residual tumor. Then, the infratentorial intradural tumor was excised completely including the dura. The tumor was firm with only few small nutrition vessels originating from the leptomeninges. After tumor removal, the dural defects were covered with sutured Neuropatch. The resected bone was replaced with methyl-methacrylate pasty. EWSR-1 gene on chromosome 22q12 using FISH (fluorescence in situ hybridization) technique . Treatment consisted of six cycles of VIDE chemotherapy  , followe EWSR-1 gene  are known to cause ESFT as well as other mesenchymal tumors. The EWSR-1 gene region encodes for a multifunctional protein involved in multiple cellular processes including gene expression and cell signaling [ EWSR-1 gene are characteristic for tumors of ESFT [Ewing sarcoma belongs to the group of highly malignant small blue and round cell neoplasms. They most commonly occur in children and young adults , 9. Alth of ESFT .Limited data exists concerning the intracranial location of Ewing sarcoma. To our knowledge, only 39 cases have been published so far, plus our own case , 14. DatDespite their highly malignant nature, intracranial Ewing sarcomas have a fair chance of cure. Five-year survival rates are in the range of 60% given radical treatment with maximum surgical removal, chemotherapy, and radiotherapy .In conclusion, intracranial Ewing sarcoma is a very rare manifestation of this aggressive tumor. Treatment should be performed within prospective multicentric clinical trials and consists, if possible, of complete tumor resection and intensive chemotherapy and radiotherapy.Postoperative MRI findings in sagittal and axial views obtained at day 1 following tumor resection and 2 years later during follow-up showing no residual tumor manifestation are provided as Supplementary Material in the online version of the Journal.


Isolated duodenal perforation (IDP) in pediatric trauma is rarely reported. Since most of the children with blunt trauma are managed expectantly, timely diagnosis is imperative to avoid morbidity and mortality. We report a case of IDP and emphasize on certain specific clinical features indicating possibility of duodenal injury. We also stress upon the role of early contrast-enhanced computerized tomography (CECT) in such cases. Duodenal injuries are rare in pediatric population, and isolated duodenal perforation (IDP) is even rarely reported. Overall, duodenal injuries accounts for only 3–5 % of all trauma cases . Exact i3/μl, and serum amylase 30 U/L.A 7-year-old boy was brought to the emergency room with history of crush injury by bullock cart 1 h before presentation. The boy was complaining of severe pain in the upper abdomen and had two episodes of non-bilious vomiting. On examination, pulse rate was 130/min and BP was 110/70 mmHg. The abdomen was tender over the right hypochondrium and lumbar region. The right lower limb was flexed at the hip joint, and passive extension was painful. There was no pallor. An abdominal radiograph was nonspecific and without evidence of free air. Abdominal ultrasound demonstrated minimal fluid in the pelvis and unremarkable solid organs. In view of the hemodynamic stability and unavailability of expert radiologist, the child was initially managed expectantly. The investigations revealed—hemoglobin 120 g/dl, hematocrit 32 %, total leukocyte count 26 × 10He had few episodes of bilious vomiting in the next 12 h. The patient complained of increased abdominal pain and had local abdominal tenderness despite adequate bowel rest. Although the child was hemodynamically stable, he had fever spikes with temperature reaching up to 38.9 °C.A contrast-enhanced computerized tomography (CECT) of the abdomen was done, which revealed free fluid of high density in the peritoneal cavity around the hepato-renal pouch and localized free air in retroperitoneum around second part of duodenum, which was communicating with the lumen Fig. . An explSince the defect was less than 50 % of the circumference, duodenorrhaphy was performed by closing the perforation in a transverse fashion. A pedicled omental patch was added Fig. b. The paIDP in pediatric trauma is scarcely reported. Only isolated cases of IDP following blunt abdominal trauma exists in the English literature –4. DuBosRoad traffic accidents are the most common mode of blunt injury to the duodenum . In addiPresentation in IDP may be nonspecific initially. Specific signs of perforation may appear late. Symptoms may be mild at the outset and range from mild to severe upper abdominal pain with recurrent vomiting. There are reports of patients with milder symptoms having been discharged from the emergency department only to be readmitted a few hours later as the symptoms worsened , 12. An Abdominal radiograph and sonography may not be useful in diagnosis of IDP due to its retroperitoneal location . The rolIn most of the cases where the perforation is less than 50 % of the circumference, simple duodenorrhaphy is adequate . In addiTo conclude, in view of its rarity, a high index of suspicion is necessary to diagnose IDP in children. Since most of the children with BTA are managed conservatively, presence of clinical indicators like upper abdominal pain, vomiting, and raised leukocyte count should prompt an early CECT of the abdomen. “Psoas spasm”, when present, should always alert the surgeon.Written informed consent was obtained from the patient’s parents for the publication of this report and the accompanying images.


Ameloblastoma is an uncommon epithelial odontogenic neoplasm that is nonmineralized, locally aggressive, and, in most cases, benign. Most ameloblastomas develop in the molar-ramus region of the mandible with 70% of them arising in the molar-ramus area. Radiologically they are unilocular or multilocular radiolucency with a honeycomb or soap bubble appearance. The radiographic appearance of ameloblastoma can vary according to the type of tumor. CT is usually helpful in determining the contours of the lesion, its contents, and its extension into soft and hard tissues. Through this case we would bring to light some of the unusual CT findings which include the destruction of the surrounding structures by the lesion which appeared to be normal routine lesion when viewed clinically. Ameloblastoma is an uncommon epithelial odontogenic neoplasm that is nonmineralized, locally aggressive, and, in most cases, benign. Ameloblastoma accounts for approximately 10% of all tumors that originate in the maxilla and mandible . Most amA 27-year-old male patient reported to the Department of Oral Medicine & Radiology, with a complaint of asymmetric swelling on the lower left jaw. Patient stated that swelling was gradual on onset and progressed in size in a 2-year course. There is history of pus discharge from the lower left back teeth region since 2 years. He got his lower left back tooth extracted 10–12 years back and since then there is an unhealed extraction socket for which patient had consulted several dental practitioners by whom he was treated unsuccessfully without investigations and proper diagnosis. Patient was physically healthy and mentally alert.Extra orally there was ill defined solitary spherical swelling involving the left angle of mandible measuring 7 × 5 cm which was noncompressible, nonreducible, nonmobile, nonfluctuant, and fixed to the underlying structure with a notch in the body of mandible 3 cm anterior from the angle of mandible which was soft and fluctuant and there was deviation of jaw on the right side. Intraorally buccal plate expansion was felt from region of tooth 35 to the angle of mandible and the overlying mucosa was normal with egg shell crackling near region of tooth 37. Lingual cortical plate expansion in teeth regions of 37 and 38 and a yellow color discharge from socket of tooth 38 and root stump of tooth 36 were present. Pulp vitality test of tooth 37 revealed a nonvital tooth. Clinical provisional diagnosis established was ameloblastoma of left mandible with a differential diagnosis of residual cyst, dentigerous cyst, keratocystic odontogenic tumour, central giant cell granuloma, and radicular cyst.IOPAR  revealed a radiolucency extending out from the boundaries of IOPA film. OPG (orthopantomogram)  revealedSoft tissue incisional biopsy from unhealed socket of tooth 38 was suggestive of ameloblastoma. Selective resection of mandible was done in Department of Oral & Maxillofacial Surgery under general anaesthesia and excised sample was sent for histopathological examination where diagnosis was confirmed to be ameloblastoma of plexiform type.Although the term ameloblastoma was coined by Churchill in 1933, the first detailed description of this lesion was by Falkson in 1879 .The ameloblastoma usually occurs in persons between the age of 20 and 50 years with the average age being 39 years. About 80% occur in the mandible and the remainder in the maxilla [Radiologically, the lesions are expansile, with thinning of the cortex in the buccal-lingual plane. The lesions are classically multilocular and cystic with a “soap bubble” or “honeycomb” appearance. On occasion, conventional radiographs reveal unilocular ameloblastomas, resembling dentigerous cysts, or odontogenic keratocysts. The radiographic appearance of ameloblastoma can vary according to the type of tumor. CT is usually helpful in determining the contours of the lesion, its contents, and its extension into soft tissues .Ameloblastomas are treated by curettage, enucleation plus curettage, or radical surgery. , 7 CompaThe tumor found in our patient was an ameloblastoma of the plexiform type. The term “plexiform” refers to the appearance of anatomizing islands of odontogenic epithelium in contrast to a follicular pattern. The tumor was found to be extending from mandibular body up to ramus, coronoid process, and condyle. It was associated with unhealed extraction socket since 10 years. The unusual CT findings significantly were as follows: firstly, there was deflection of left maxillary posterior arch towards the midline because of medial expansion of ramus . SecondlOne possible reason for the above mentioned changes to appear on CT images may be because of the long standing course of the condition. These symptoms may have developed in a course of 2 years and define inferring and destructive expansible nature of the condition as how they can cause disfigurement of the surrounding structures due to pressure without actually invading them.According to our knowledge no such findings have been reported in literature where because of ameloblastoma of the mandible there is deflection of other surrounding structures specially the maxillary and those on the base of skull.The basic objective of reporting such a case was to discuss the advantage of CT imaging in such cases to see the extent of lesion and the extent of destructive effect caused on the surrounding structures because of unusual expansion of lesion which clinically appears to be a routine case and also add to the review of literature for such unusual findings.


A 40-year-old male, with 3-month history of progressive dyspnea was admitted to our hospital, and there were no any other respiratory symptoms. Physical examination was unremarkable. Chest computed tomography (CT) showed that there was a papillomatous mass at the distal trachea. The lesion occupied 80% of tracheal lumen. This patient received cryotherapy and mechanical debridement under general anesthesia and postoperative pathology showed endotracheal papillomatosis. Patient was treated with interferon- Tracheal papilloma (TP) is a neoplastic lesion secondary to tracheal manifestation of recurrent respiratory papillomatosis (RRP) and characterized by papillomatous growth of the bronchial epithelium as a response to Human Papilloma Virus (HPV) infection. Recurrent bronchoscopic interventions and adjuvant medical therapy are needed in its management. It should be closely followed up since malign transformation is reported especially in smokers. Here we present a case of solitary tracheal papilloma that underwent bronchoscopic endobronchial therapy and had no recurrence during follow-up under medical therapy.40-year-old, active smoker male presented with progressive shortness of breath for the last three months. He had no other respiratory or systemic symptoms. His physical examination was unremarkable other than decreased lung sounds. Routine blood tests and chest X-ray were normal . At chesIn the pathology, squamous epithelial hyperplasia of bronchial epithelium with small papillomatous structures was seen . There wα (IFN-α) treatment was started in doses of 3 million units per square meter 3 times per week. Computed tomography and bronchoscopic evaluation at the 3rd month of the treatment showed no recurrence  is a rare tumor of trachea consisting of 0.38% of all lung tumors. It can be solitary, multiple, or as a form of recurrent respiratory papillomatosis (RRP). Respiratory papillomatosis is mostly seen in the larynx but it can affect any part of tracheobronchial tree. It is rarely isolated in trachea. Distal trachea involvement was reported only in the 5% of RRP cases. In a study, TP is reported in only 5 cases of 15.000 bronchoscopies [Although RRP can be seen in all ethnic and age groups, the majority of the reported cases are Caucasian and its distribution is bimodal as in childhood and adulthood. The incidence of RRP in childhood is 43/1.000.000, whereas in adults it is 18/1.000.000. Even though it is thought to be related to vertical transmission at vaginal delivery, there are also a small number of cases reported after cesarean section. Etiology of adulthood RRP is unknown, and it is not certain if the disease is due to sexual transmission or the activation of latent infection . Our patTracheal papilloma has no specific clinical presentations and has a wide range of symptoms from cough, shortness of breath at rest or with effort to stridor, and upper airway obstruction. Presentation as bronchial hypersensitivity is also reported in the literature. There is no specific finding at physical examination either , 7. Gao The role of imaging in differential diagnosis is limited. Tracheal lesions can be seen at chest X-ray, especially at lateral projection. Chest computed tomography (CT) may identify lesions at trachea and large airways. Fixed or reversible obstruction in the respiratory function tests may aid in diagnosis. The definitive diagnosis is made by FOB and in most cases no other method is needed for diagnosis –11. In oAlthough TP is known to be benign, there is a very low risk for malign transformation. Malign transformation is more common in HPV-11 than HPV-16 types and its frequency is 0.3–5% . In the Tracheal papilloma treatment is hard and generally requires recurrent endoscopic interventions as well as medical treatment. There are no therapeutic guidelines or randomized study comparing treatment options at this point. Treatment modalities change according to the type, severity, number, and location of the papillomas .In the management of TP, the first aim is to remove the tumor and sustain the airway patency. Since malign degeneration can occur in papillomas, their surgical excision is essential. In RRP, if the lesion is small, segmentectomy can be performed in order to preserve respiratory functions . Variousα (IFN-α) treatment was started as adjuvant therapy.Local recurrence is common in papillomas. Surgical or bronchoscopic excisions of the lesions are usually not adequate in controlling the disease. For this reason, close clinical follow-up of these patients is very important in the postexcision period. Long and Sani  reportedα (IFN-α) is a human leucocyte protein produced naturally as a response to viral infections in the body. It is one of the oldest agents used in the treatment of RRP and its mechanism of action is not fully understood. It binds to receptors at the cells and regulates the cellular metabolism, generating antiproliferative and immune-protective effects. In a multicenter study, solely surgical excision and surgical excision together with IFN-α treatment were compared. At the end of the study, regression of the lesions slowed down at the first six months but this effect did not last two years [α were reexamined 6 months after the initiation of the treatment. In their study, there was 75% complete response in one-third of the patients and it was declared that IFN-α treatment can be applied for six months for patients who need surgical excision every two or three months. In a prospective study, patients were followed up for 20 years, it was stated that IFN-α treatment was more effective in HPV-6 infection, and there was no adequate response in patients with HPV-11. Also since malign transformation is more common and mortality is higher in patients with HPV-11, determination of type of HPV is advised after the first sampling [α treatment was applied for six months in our case.Interferon-wo years . In a stwo years , patientsampling . In lighα treatment and his close clinical and bronchoscopical follow-up will continue.In conclusion, TP is a relatively rare disease that should be closely followed up because of its recurrence and malignant transformation. The present case was successfully treated with cryotherapy and IFN-


Hibernoma is a rare benign lipogenic tumor of brown fat that develops in a wide variety of locations. Although the features of hibernoma demonstrated by MRI resemble those of liposarcoma, recent FDG-PET/CT studies have documented higher radiotracer uptake than liposarcoma, suggesting that FDG/PET/CT is useful for differentiating hibernoma from liposarcoma. Here we report two cases of hibernoma that showed relatively lower SUVs than those reported previously, lying within the range for liposarcoma. Our findings emphasize that hibernoma needs to be included in the differential diagnosis of any fat-containing tumor showing intense accumulation by FDG-PET/CT. Although it is unlikely that such a rare condition could be reasonably diagnosed on the basis of MRI and FDG-PET/CT alone due to possible SUV overlap between hibernoma and liposarcoma, it is important to recognize this extremely rare lipogenic tumor for accurate diagnosis and appropriate management. Hibernoma is a rare benign tumor of brown fat that usually occurs in adults with a slight male preponderance . It deve18F]2-Deoxy-2-fluoro-D-glucose (FDG) positron emission tomography (PET) has been proven to be a valuable imaging method for evaluating the functional characteristics of soft tissue masses and providing information that is critical for patient management. In a FDG-PET study of 120 soft tissue tumors, Aoki et al. found a statistically significant difference (P < 0.0001) of standardized uptake value (SUV) between benign and malignant soft tissue tumors [[e tumors –5. Thesee tumors –8. HowevA 42-year-old man presented at our institution for evaluation of a left buttock mass that had been found incidentally at a general check-up. On physical examination, a nontender, deep-seated elastic soft tissue mass was palpable in his left buttock. There was no local lymphadenopathy. Tinel's sign was not present, and the patient had no discomfort attributable to the mass. Magnetic resonance imaging (MRI) revealed a well-circumscribed slightly heterogeneous mass 12 cm in diameter between the gluteus medius and maximus muscles. On both T1- and T2-weighted images, the signal intensity of the tumor was considerably higher than that of skeletal muscle but slightly lower than that of subcutaneous fat Figures . On fat-Core needle biopsy was performed and a histological diagnosis of hibernoma was made. The patient underwent excision of the tumor without any complications. Macroscopically, the tumor was yellow tan in color and had a fatty consistency. Microscopically, a mixture of brown fat cells (hibernoma cells) and mature white fat cells was observed. No cellular atypia or mitotic figures were observed. As the hibernoma cells were scattered among white fat cells, the tumor was classified as the lipoma-like variant . After 8A 50-year-old man presented at our institution for evaluation of a painless soft tissue mass in the anterior neck that had been present for three years. On physical examination, a nontender, egg-sized elastic soft mass was palpable in the right supraclavicular region. There was no local lymphadenopathy, and Tinel's sign was not present. Magnetic resonance imaging revealed a well-circumscribed mass 7 cm in diameter with a slightly irregular shape in the supraclavicular region. On both T1- and T2-weighted images, the signal intensity of the tumor was significantly higher than that of skeletal muscle but slightly lower than that of subcutaneous fat Figures . Fat-supHibernoma is a rare benign soft tissue tumor originating from brown fat. It usually manifests as a slowly growing and painless soft tissue mass with a peak incidence in the fourth and fifth decades of life. There is a slight male preponderance . The namOn CT and MRI, hibernoma usually manifests as a heterogeneous fat-containing mass with internal septations or fine enhancing strands. A large branching vessel is frequently found within the lesion after intravenous administration of contrast medium . AlthougRecently, several reports have suggested that the SUV shown by FDG-PET/CT can be used to differentiate hibernoma from liposarcoma –8, 14. PAlthough the SUVs of the two hibernomas we investigated were certainly high, as reported previously –8, 14, tFrom our experience of the present two cases and previous series, it is evident that hibernoma shows a wide variation of SUV in the high range relative to lipoma. However, it is difficult to distinguish hibernomas from liposarcomas on the basis of FDG-PET/CT findings alone, as the SUVs of hibernoma can overlap with those reported for liposarcoma. In view of the limited data currently available, further studies including a large number of cases are needed to clarify the clinical value of FDG-PET/CT for diagnosis of hibernoma.In summary, our experience with the present two cases emphasizes the need to include hibernoma in the differential diagnosis of any fat-containing tumor showing intense accumulation in FDG-PET/CT examination, as the SUV reflects metabolic activity and cellular components, rather than malignant potential. Although it is unlikely that this rare lipogenic tumor could be reasonably diagnosed on the basis of MRI and FDG-PET/CT findings alone due to the considerable overlap of SUV between hibernoma and liposarcoma, it is important for clinicians to be aware of it in order to arrive at an accurate diagnosis, provide appropriate management, and avoid any unnecessary cytotoxic or surgical treatment.


Schwannomas (Neurilemmomas) are benign, encapsulated, slow-growing, and usually solitary tumours originating from Schwann cells of the peripheral nerve sheath with uncertain etiology. Approximately 25–48% of cases are seen in the head and neck region, of which 1% appears in the oral cavity. Lingual schwannoma can affect all age groups with peak incidence between the third and sixth decade. We report a rare case of lingual schwannoma in a 14-year-old girl complaining of asymptomatic swelling over lateral border of tongue since two years. Clinical examination revealed a nodule 1.5 × 1 cm in size, rubbery, nontender, smooth at right lateral border of tongue covered by normal mucosa, with no cervical lymphadenopathy. Excisional biopsy of the lesion was done under local anaesthesia. The histological sections spindle cells with thin wavy nuclei arranged as typical Antoni A (with Verocay bodies) and Antoni B areas. Nuclear palisading distribution  was readily identifiable. The patient was recurrence-free after one year. Schwannoma, also called neurilemmoma, is a solitary, benign, encapsulated, and slow growing tumor, arising from the neural sheath's Schwann cells of the peripheral, cranial (except for the optic and olfactory), spinal, and autonomic nerves . SchwannThe cause of the tumor is unknown. However, some etiological factors are conjectured, such as spontaneous growth, external injury, chronic irritation, or exposure to radiation . ApproxiThe size and locations of lesions determine the presence and intensity of symptoms. The tumour is normally solitary, smooth-surfaced, slow growing, and generally asymptomatic. It may occasionally cause pain or discomfort. The goal of treatment is complete excision, which results in low rates of recurrence . MalignaA 14-year-old girl presented to the department of oral and maxillofacial surgery for evaluation of a slow growing, occasionally painful nodule on right anterolateral side of tongue first noted 2 years back . ClinicaPatient had no difficulty in chewing, swallowing, and phonation and there was no sensory or taste abnormalities by the patient. The remaining physical examination was unremarkable. The differential diagnosis included traumatic fibroma, neurofibroma, and benign lesions like tumors of salivary gland origin, leiomyoma, rhabdomyoma, lymphangioma, and hemangioma. Considering the size of the lesion an excisional biopsy was planned under local anesthesia. The mass was submucosal and once a mucosal flap was raised, the tumor was readily shelled out using blunt dissection Figures , and 4.The procedure and postoperative period were uneventful. Histopathological examination of the surgical specimen revealed a schwannoma, mainly composed of Antoni A pattern with Verocay bodies and Antoni B .The patient has not shown any recurrence in follow-up period of 1 year.Almost a third of all schwannomas occurs in the head and neck region, but intraoral schwannomas are rare and account for 1% of the tumors growing in this region . Because2 laser was used, and in three other cases, the approach was transcervical (two submandibular and one transhyoid). All tumours in the tongue were treated with simple transoral excision. There were no reports of recurrence. There are only 13 cases reported in the literature categorized in the pediatric age group. The youngest of them were reported by Cinar et al. [The mean age at diagnosis was 27 years. The age groups most affected were the 2nd (29.54%), 3rd (18.18%), and 4th (25%) decades of life. There was no gender predisposition. Two-thirds of tumours  arose in the tongue with the remaining one-third  affecting the tongue base. Standard treatment was transoral excision, performed in 93.18% of cases. However, for tumours located at the base of the tongue, in 2 cases COr et al.  and Enozr et al. , of 7-yeLingual schwannoma can affect all age groups, being most commonly found between 30 and 40 years of age, without gender predisposition . In thisClinically, the schwannomas may be indistinguishable from other encapsulated benign tumors, so that biopsy and histological examination are essential to formulate a correct diagnosis. An excisional biopsy was performed in this patient, since treatment is exclusively surgical and usually enucleation of the mass is uncomplicated. In the present case, the patient did not present nerve injury after surgery, since the lesion was small and well defined. The option of complete resection was chosen on the basis of lesion form and size and to avoid recurrence.The histological aspect of the lesion reported here was typical, consisting of a thin fibrous capsule and a tumor like proliferation formed by two types of tissue arrangements: Antoni type A and type B. The Antoni type A tissues are closely packed, forming bundles with elongated, palisaded nuclei. Free bands of amorphous substance between the rows of nuclei constitute the so called Verocay bodies which under electron microscope, appear to be composed of thin cytoplasmic processes with small amount of collagen and basal laminar material showing frequent redoubling, while in the Antoni B tissue it has less number of cells and less organization, where the fusiform cells are widely separated, dispersed in a loose and random fashion with a network of delicate reticulated fibers. Nuclear palisading distribution  was readily identifiable. The acid S-100 protein test was not performed, as the hematoxylin-eosin stained sections conclusively confirmed the diagnosis.The schwannoma of the tongue is extremely rare, especially in children, and there are very few similar case reports in the present literature. Hereby we would like to add one new case of a schwannoma of the tongue as an example of a lesion which is often not taken into account during clinical practice or even considered as a possible diagnosis. Given the rarity of this lesion, a careful consideration is warranted as this may be clinically indistinguishable from fibroma, neurofibroma, and benign lesions like tumors of salivary gland origin, leiomyoma, rhabdomyoma, lymphangioma, and hemangioma. The definitive diagnosis requires a histopathological evaluation. Treatment is complete surgical excision of the lesion which does not result in any recurrence. The chance of malignant transformation of these tumors is unlikely.


The presence of squamous epithelium in the stomach is only occasionally encountered and is associated with prolonged mucosal injury. Squamous metaplasia in patients with cancer is relatively rare and only four cases have been reported in the stomach, all of which have been associated with squamous cell carcinomas. We present the first case of exuberant squamous metaplasia in a patient with gastric adenocarcinoma of the cardia.A 56-year-old woman presented with epigastric pain and weight loss. Endoscopy showed an irregular depressed hyperemic lesion covered with a whitish plaque on the cardia. A total gastrectomy was performed and the tumor in the subcardia was found to extend up to the proximal stomach with diffuse squamous metaplasia in the surface of the tumor and proximal gastric mucosa in contiguity with the esophageal squamous epithelium. It is believed that the squamous extension from the esophagus to the proximal stomach and the gastric adenocarcinoma occurred at the same time.Synchronous squamous metaplasia and underlying adenocarcinoma in the stomach is extremely rare. Recognition of this entity would be beneficial for clinicians to avoid unnecessary treatment.http://www.diagnosticpathology.diagnomx.eu/vs/1035146445160150.The virtual slide(s) for this article can be found here:  The presence of squamous epithelium in the stomach is only occasionally encountered and is associated with prolonged mucosal injury ,2. HowevA 56-year-old Korean woman presenting with epigastric pain and weight loss visited a local clinic and was transferred to our hospital for further treatment. The medical history of the patient did not include any significant prior illness. No significant positive signs were found on physical examination. Endoscopy showed an irregular depressed hyperemic lesion covered with a whitish plaque on the cardia Figure . The lesin situ hybridization and the entire tumor was negative. The tumor infiltrated into the muscularis propria although none of the 54 regional lymph nodes showed metastasis . The patient is alive without recurrence 3 month after gastrectomy.On gross examination, an irregular depressed lesion with a whitish plaque was detected in the high body Figure A. EntireAlthough the pathophysiology of squamous metaplasia in the stomach remains obscure, prolonged injury appears to be a prerequisite for this mucosal abnormality. The presence of squamous epithelium in the gastric mucosa has been described in patients with underlying diseases such as peptic ulcer , tubercuThe four patients with squamous metaplasia in the stomach and concurrent carcinoma who have been recorded in the literature are tabulated in Table In contrast to these previously reported cases, our case was unique in that the benign squamous epithelium covering the tumor surface was in continuity with the esophageal epithelium without any transition area. Endoscopic and microscopic findings revealed diffuse mucosal atrophy with intestinal metaplasia, which is considered to be a risk factor for gastric adenocarcinoma . Based oThe tumor topography of the border between the esophagus and stomach affects the treatment strategy that for patients with type II tumors by the Siewert classification, with esophagectomy offering no advantages over extended gastrectomy . The bioSynchronous squamous metaplasia and underlying adenocarcinoma in the stomach is extremely rare. Here, we describe the first case with unique endoscopic findings.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.


We rapport the case of a patient presenting intra-abdominal metastasis of a pinealoblastoma, via a ventriculo-peritoneal shunt, confirmed by an anatomo-pathologic exam. The patient presented an acute hydrocephalus secondary to DVP dysfunction. The surgical manipulation of this metastasis had caused an acute circulatory deficiency due to massive serotonin release. In this case we analyze pineal gland physiology and serotonin effect on different systems. Tumors of the pineal region are rare in adults: 0.4 to 1% of all brain tumors, but more commun in children: 3 to 8% , 3. In hPatient Z.B 14-year-old had presented, at the age of 6 years, an intracranial hypertension syndrome. The investigations had concluded for a hydrocephalus secondary to pineal tumor compression. She had a ventriculo-peritoneal derivation (DVP) which was complicated with postoperative meningitis and peritonitis. Bacteriological samples did not isolate germs at LCR and at peritoneal liquid. The evolution was favorable by antibiotics probabilistic treatment based on cefotaxim, Metronidazol and Gentamycin. Then, the patient was lost of view during 6 years.Six years later, the girl presented a second episode of intracranial hypertension syndrome secondary to the tumor volume increase. She had a tumor incomplete resection. Tumoral anatomopathologic exam objectified a pinealoblastoma, and then the patient had supplementary sessions of radio and chemotherapy.Two years later, the patient consulted for left iliac fossa (LIF) pain without fever. The abdominal scanography showed mesenteric lymphadenopathy and two intra peritoneal metastasis, the one measuring 78*78*59mm and other one 30*20*20 mm of big axle. 12 hours afterwards, the girl presents a third episode of clinical intracranial hypertension syndrome. The cerebral scanography showed an acute hydrocephalus with a derivation parried in place. The patient was proposed for review of DVP under general anesthesia. Surgical operation consists of two times, a first time for DVP cerebral end review and a second time dedicated for DVP peritoneal end review.The first surgical time took place without hemodynamic or ventilatory complications and objectifies a permeable valve. The second time showed DVP distal end obstruction by a tumor mass. The patient had a complete resection of this mass. The anatomopathologic analysis objectified a pinealoblastoma and confirmed the hypothesis of intra peritoneal metastasis tumor via DVP.The manipulation of the tumor mass had caused a circulatory deficiency marqued by an impregnable Sp02, low Pet CO2, a heart rate at 130 flapping / min and an impregnable blood-pressure requiring the administration of Noradrenalin at the dose of 2 mg/h, without important per operative bleeding (300 ml).The postoperative evolution was marked by an anasarca, a myocardial suffering with troponine at 7 ng/l, hemodynamic unstable state with systolic blood-pressure oscillating between 70 and 210 mm Hg and a sino-atrial tachycardia to 150-170 flapping/min slowed down by amiodarone. 48 h later the patient had become conscious with a correct hemodynamic state authorizing the stopping of catecholamine. Normalization of troponine and extubation at 4 days postoperative. To note that cardiac ultrasound scan was not made. After a week stays in intensive care the girl regained her domicile with a discovery, in post intensive care consultation, of a left lower limb thrombophlebite needing anticoagulation.The pineal region comprises several anatomical structures that are host to a spectrum of histologically different types of tumors: gliomas, epandymomas, dermoid cysts, meningiomas, cavernomas and metastases. The pineal gland may also present tumors that derive from their own histological components of different behavior. The pineal body parenchyma contains both a large cell, the pineocyte, and a small cell, the pinealoblast: an apparent immature form of the large cell. A pinealocytoma arises from the large cells and a pinealoblastoma from the small cells . TraditiThe pineal gland parenchyma tumor causes frequently ventricular obstruction. The obstruction may require shunting via a ventriculo-peritoneal shunt for relief of hydrocephalus. The complications of ventriculo-peritoneal shunting for hydrocephalus are numerous and include malfunction, infection, migration of shunt, perforation of viscera, bowel obstruction and metastatic tumor spread , 8, 9. IThe pineal bland is a central structure in the cardian system that is innervated by a neural multi-synaptic pathway originating in the suprachiasmatic nucleus (SCN) located in the anterior hypothalamus. The SCN is the major circadian pace maker of the mammalian brain and plays a central role in the generation and regulation of biological rhythms .The biosynthetic pathway of melatonin has been studied thoroughly . L TryptSerotonin receptors are classified into 7 types: 5-HT1, 5-HT2, 5-HT3, 5-HT4, 5-HT5, 5-HT6 and 5-HT7. Serotonin receptors are coupled to G proteins except 5-HT3 receptors which are receptor-channels also called ionotropic receptors. These receptors are localized in brain and in peripheral organs but their distribution are not homogeneous . The sig1°/ Oxidative deamination of the lateral amino chain by monoamine oxidase (MAO), leading to 5-hydroxy-indol-acetaldehyde which is then oxidized into 5-hydroxy-indol acetic acid (5-HIAA) found in urines in quantities normally lower than 10mg/ 24h. The 5-HIAA was not dosed in our case , 12.2°/ Conjugation by glucuronic acid or sulfate of the hydroxyl group OH in 5 position .Pinealoblastoma metastatic tumor can be considerated like neuroendocrin tumor which secretes serotonin and caused circulation deficiency, myocardial ischemia, bronchoconstriction, venous thrombosis, anasarca. The anaestisist may be confronted with these problems either in or after surgery.


Odontogenic cutaneous sinus tracts (OCSTs) are generally primarily misdiagnosed and inappropriately treated by virtue of their rarity and the absence of dental symptoms. Accurate diagnosis and treatment and the elimination of the source of infection can reduce the incidence of complications and relieve the pain of the patient.In this case report, we present the case of an 11-year-old patient with an apparent abscess but an unobvious draining sinus tract in his left cheek. Intraorally, a glass-ionomer-cement filling on the occlusal surface of the left mandibular first molar (tooth 36) was noted. Radiographic examination revealed a radiopaque mass inside the crown and pulp chamber and an irregular, radiolucent periapical lesion surrounding the distal root apex. He was diagnosed with an OCTS secondary to a periapical abscess of tooth 36. Precise root canal therapy (RCT) and chronic granuloma debridement was performed; 6 months later, the abscess and sinus had healed completely, and the periapical lesion had resolved.Odontogenic cutaneous sinus tracts are uncommon in the clinic. This case report reminds us of the significance of OCSTs and provides some implications for their diagnosis and treatment. Extraoral fistulas are typically characterized as erythematous, symmetrical, crusting, smooth, and nontender nodules with periodic drainage.3 However, they pose a diagnostic challenge because the lesions can be confused with pyogenic granuloma, foreign body reaction, deep fungal infection, squamous cell carcinoma, or osteomyelitis.4 Patients often fail to realize the odontogenic etiology and most likely seek help from dermatologists due to a consistent facial nodules but no dental symptoms. It has been evaluated that half of the patients with extraoral sinus tracts undergo numerous dermatological surgical operations and long-term antibiotic therapy—even radiotherapy, electrodessication, or cancer-directed therapy—before the true diagnosis is established, resulting in relapse of the basic problem and the chronic persistence of the lesion.5 Treatment of these fistulas involves either RCT of healable teeth or extraction of unrestorable teeth. Considering the scarceness and diagnostic predicament of OCSTs, we report a case of an 11-year-old male adolescent.Odontogenic cutaneous sinus tracts (OCSTs) are uncommon, but they are generally initially misdiagnosed and ineffectively treated.Written informed consent was obtained from the parents of the patient.An 11-year-old boy was referred to the Department of Stomatology, Guangzhou Women and Children's Medical Center, in Guangzhou, P.R. China, to confirm a probable dental cause of a skin lesion. The patient's chief complaint was the presence of a nonhealing extraoral swelling on his left cheek for 6 months, which periodically discharged pus and gradually grew larger. During history taking, his parents stated that a localized swelling abruptly arose on the boy's left cheek without pain, fever, or other discomfort. They also disclosed that he had been submitted to dermatological surgery for removal of a cutaneous lesion and had gone multiple regimens of antibiotic therapy, but the persistence of the lesion had brought him great suffering. Therefore, he was referred to our Conservative Dentistry and Endodontics Department.On extraoral examination, a reddish abscess 2.5 cm in diameter with an unobvious sinus tract on his left cheek 2 cm above the inferior border of the mandible was observed Figure . On palpMycobacterium tuberculosis and tuberculosis antibody detection were performed to exclude other diseases, and both results were negative. In addition, bacterial cultures of pus from the lesion proved that the infection rate of specific aerobic and anaerobic bacteria were 0%. The preoperative radiographic examination revealed a radiopaque mass inside the crown and pulp chamber, an irregular periapical radiolucent but non-noticeable area associated with the distal root apex  and 3% hydrogen peroxide , kept the pulp chamber patulous, and performed abscess incision drainage, making an appointment for him 5 days later. The patient returned with a remarkably reduced abscess. Unlike the first presentation, his parents were full of expectation and positivity. Hence, after situating a hygenic rubber dam , the root canals were cleaned and shaped with Protaper  Ni-Ti rotary instruments, using a crown-down technique under irrigation with 3% sodium hypochlorite solution  and 3% hydrogen peroxide to S2, up to a working length of 19.5 mm for 4 canals, namely the mesiobuccal (MB), mesiolingual (ML), distobuccal (DB), and distolingual (DL) canals. Working lengths were measured with a Raypex5 electronic apex-locator . The canals were dressed with Vitapex  medicaments. At the third visit, 2 weeks later, the OCST was closed, and the root canals were obturated with gutta-percha points  and Cortisomol sealer  using the cold lateral condensation method. Postoperative radiography indicated successful obturation Figure . The per6 Other etilologies consist of pyogenic granuloma, foreign body reaction, deep fungal infection, squamous cell carcinoma, osteomyelitis, and so on.4 OCSTs are typically caused by periapical infections around the root apices as a result of pulpal necrosis, nearby caries, pericoronitis, or traumatic injury.7 This chronic process slowly evolves through the cancellous alveolar bone, following the path of least resistance until it perforates the cortical plate of the mandible and forms an subperiosteal abscess.8 OCSTs have a greater likelihood of occurring than intraoral sinus tracts if the apices of the teeth are superior to the maxillary muscle attachments or inferior to the mandibular muscle attachments.9 Cutaneous fistulas then arise from the spread of infection into the surrounding soft tissues. When OCSTs occur, they develop from a mandibular abscess and drain onto the chin or the submandibular area (80%). In this case, a ruddy abscess without an obvious sinus tract on the patient's left cheek 2 cm above the inferior border of the mandible attracted our attention at the first presentation. OCSTs can also involve the nose, nasolabial folds, and inner canthi of the eyes.10If a draining lesion on the facial or cervical area, an endodontic origin should be considered a priority in differential diagnosis.9 However, in the case reported here, what could be seen on the patient's cheek was initially swelling with fluctuation but not an apparent sinus tract. A possible reason might be that the patient's immune system was immature, so his condition worsened. Serious or serve onset and the cutaneous tract and lesion are only rarely associated with symptoms from the oral cavity. Symptoms from the teeth only present in 50% of patients, which could explain why patients frequently consult with a physician first for help.5 Furthermore, OCSTs do not always occur near the original odontogenic cause. These 2 elements united may engender a postponed in diagnosis.11 Regrettably, delays in corroborating the factual diagnosis often lead to unnecessary antibiotic treatment and redundant surgical interventions. Appraisal of OCSTs must start with an intensive medical and clinical history, and odontogenic infection must be borne in mind in the differential diagnosis of such lesions on the face or neck.12 Hence, the clinician should pay extraordinary attention to oral clinical conditions, such as caries, deficient restorations, and periodontal conditions.13A sinus tract prevents swelling or pain from increased pressure because it provides drainage from the primary odontogenic site.9 In the clinical case described here, bacterial cultures of exudate from the lesion certified that M tuberculosis was negative; moreover, no specific aerobic and anaerobic pathogens were found. In addition, radiographic findings are also important for the diagnosis. In this case, panoramic radiography showed a periapical radiolucency connected to a suspected tooth, in which a pulp sensibility test was unresponsive. On the assumption that the relevant tooth cannot be ascertained by panoramic and periapical radiography, the tracking of the fistula can guide the ultimate diagnosis.14Because major infections are polymicrobial, microbiologic culture and sensitivity testing of the sinus tract pus should be performed to identify the microbial flora. Culture should also be performed for suspicion of fungal or syphilitic infections.15 In this case, prominent reduction of the abscess after nonsurgical RCT validated the primary dental origin of the skin lesion. Automatic closure of the tract should be anticipated within 5 to 14 days after RCT. Surgical excision of the cutaneous sinus is necessary if the fistula does not terminate, to eliminate the inflammatory tissue thoroughly, including apical debridement, apicoectomy, and fistula debridement.16 Eventually, in our case, chronic granuloma debridement of the lesion was performed complementally to eliminate infection completely, as mentioned above; thereafter, the lesion on the cheek recovered entirely leaving only a slight hyperpigmented region, and the periapical lesion disappeared on the radiographic examination.Eradication of the original source of infection is most important for the treatment of OCTSs, by means of nonsurgical RCT, sometimes complemented by surgery or dental extraction.14 Comprehensive learning of both normal and abnormal root canal morphology can play a crucial role in outstanding endodontic treatment.17This case emphasizes that maxillary or mandibular dental abscesses are a common cause of OCTSs. It also indicates the usefulness of microbiologic culture before administering antibiotic treatment or performing a surgical intervention.Odontogenic cutaneous sinus tracts (OCSTs) of dental origin are primarily misdiagnosed generally due to their rarity. Although the most considerable reason for a recurrently putrefying cutaneous sinus tract on the facial and cervical skin is persistent dental infection, chronically draining sinus tracts of the face and neck continue to defy diagnosis. Further confusion for clinicians arises because dental symptoms do not regularly occur. Worthless treatment and healing failure can be attributed to misdiagnosis of an odontogenic reason; therefore, obtaining an accurate diagnosis, providing appropriate clinical care, and extinguishing the source of infection are of great seriousness.In conclusion, due to their rare occurrence, the diagnosis of odontogenic OCTSs might become easier when clinicians are aware of the probability of a dental origin. A rigorous and exact diagnosis relies on concerted referrals and cooperation among physicians, dermatologists, surgeons, and dentists. Finally, integrated learning and the guaranteed technique of a dentist are as important as a correct diagnosis, promoting efficient treatment, maximizing patient contentment, and aesthetic appearance and decreasing the likelihood of additional complications. This case report reminds us of the significance of OCTSs and provides some implications for their diagnosis and treatment.