Sister Mary Joseph's nodule metastasis is a rather rare finding. The primary malignancy in women is usually ovarian, endometrial, gastric, or pancreatobiliary tree cancer. We present a case of an 87-year-old patient with Sister Mary Joseph's nodule metastasis caused by a primary peritoneal malignancy. Through a literature search, we also discuss the pathophysiology, diagnostic approach, management, and prognosis of such a condition. Sister Mary Joseph's nodule could be the first sign of internal malignancy which is usually found in the gastrointestinal tract 52%), female genital tract or genitourinary tract (28%), and nonspecified origin 18–20%) [8–20% [1]%, femaleSister Mary Joseph whose name was Julia Dempsey 1856–1939) was working as a superintendent nurse at St. Mary's Hospital in Rochester, Minnesota, when she identified that an umbilical nodule could be a sign of intra-abdominal or pelvic malignancy. Sister Mary Joseph was the first surgical assistant under the guidance of Dr. William Mayo who first reported the condition as “pants button umbilicus” in 1928. The eponym was coined to her by Hamilton Bailey in 1949 in his book entitled “Demonstration of Physical Signs in Clinical Surgery” [6–1939 waThe aim of this study is to present a case of a patient with Sister Mary Joseph's nodule and discuss the process from diagnosis to management, as well as the possible mechanisms of such a metastasis, differential diagnosis, and prognosis.This is a case of an 87-year-old patient who presented in our department with Sister Mary Joseph's nodule. The patient had a history of hypertension, hyperthyroidism, osteoporosis, and aortic aneurysm. The patient referred that she had appetite loss, vomiting, and weight loss. The physical examination revealed distended abdomen. Biopsies taken from the umbilical nodule under ultrasound guidance demonstrated a serous carcinoma of primary peritoneal/ovarian origin. Regarding tumor markers, CA 125 levels were 50 ku/L, CA 15-3 10 ku/L, and CA 19-9 <2 ku/L. The CT scan measured the umbilical node to be 21 × 22 mm . BecauseIt is estimated that 1–3% of patients with abdominopelvic malignancy could present with a Sister Mary Joseph's nodule [The possible mechanism of tumor spread to Sister Mary Joseph's nodule could be through lymph ducts, blood vessels, contiguous extension, or embryologic remnants in the anterior abdominal wall . More spAccording to a retrospective study including 77 cases of umbilical malignancies, 88% of such cases originated outside the umbilicus. From these, 85% patients with metastatic tumors had a recognized primary malignancy. In women, the three most common primary sites were found to be the ovary, the endometrium, and the pancreatobiliary tree . AccordiSister Mary Joseph's nodule is usually located several centimeters away from the possible omental disease. It can be seen or felt deep in the subcutis in the umbilical area. Incidental detection of such a metastasis for umbilical hernia repair is also described . It coulSimilar cases are described in the literature. Kurt et al. described a case of Sister Mary Joseph's nodule as a first sign of a stage IV mixed-type epithelial ovarian carcinoma which was the first case with serous component . MoreoveFine needle aspiration cytology and core biopsy are proposed as simple, fast, accurate, and inexpensive diagnostic tools. Handa et al. using this method identified primary carcinoma of the stomach in three cases, ovary in two cases and one case was of non-Hodgkin's lymphoma during a 5-year period . MoreoveDermatologists, general surgeons, gynaecologists, and general practitioners should be aware of such a relatively rare entity. Aggressive treatment is proposed combining surgical excision, radiotherapy, and chemotherapy; however as the disease is usually advanced and metastatic, only palliative treatment is offered. After multidisciplinary team decision and informed consent, our patient had palliative radiotherapy only, but the tumor persisted and increased in size. Surgical excision was decided in a day-case basis which was very well tolerated despite the coexisting very significant comorbidity. The mean patient's survival is 10–12 months . SurvivaCareful examination combined with fine needle aspiration or biopsy is proposed to further clarify the diagnosis of a Sister Mary Joseph's nodule. Although the prognosis is not favorable, palliative treatment is usually proposed.


Renal plasmacytoma is extremely rare, presenting diagnostic challenges due to its unusual location and non-specific or absent symptoms. To the best of our knowledge, only 24 cases of renal plasmacytoma have been reported in the literature. The present study reports a case of primary renal plasmacytoma in a 46-year-old female patient. Computed tomography (CT) revealed that the mass was located in the lower pole of the left kidney and metastasis was detected in an enlarged para-aortic lymph node. Following careful preparation, a partial nephrectomy was performed and the retroperitoneal lymph node was resected. A pathological examination revealed a renal parenchyma with lymph node involvement; this was confirmed by immunohistochemistry and nested polymerase chain reaction (PCR). Consequently, a diagnosis of a renal extramedullary plasmacytoma (EMP) was proposed. Following this unexpected diagnosis, various examinations were performed, but there was no evidence of systemic plasma cell disease. The patient refused further therapy, including external beam radiotherapy and chemotherapy. Abdominal CT was performed three months post-surgery and did not reveal any relapse. The patient remains disease-free at nine months post-surgery. The current study also presents a review of the literature. Although the general prognosis and outcome of EMP is good, a follow-up examination is recommended due to the possibility of relapse or progression to plasma cell neoplasm (PCN). Extramedullary plasmacytoma (EMP) is a rare malignant neoplasm that develops due to uncontrolled plasma cell proliferation and monoclonal plasmacytic infiltration . The maj9/l; percentage of neutrophils (NE%), 61.8; red blood cell (RBC) count, 3.58×1012/l; hemoglobin (HGB) level, 101.1 g/l; platelet (PLT) count, 187.6×109/l; and serum creatinine, calcium and phosphorus levels within normal ranges.A mass in the left kidney was detected in a 46-year-old female patient who underwent ultrasonography as part of a routine physical checkup. Computed tomography (CT) revealed that the mass showed enhancement, was located in the lower pole of the left kidney and measured 38×30 mm. Furthermore, metastasis was detected in an enlarged (20 mm) para-aortic lymph node . The radμg recombinant human granulocyte colony-stimulating factor and the complete blood count (CBC) was repeated. The new CBC results were as follows: WBC count, 6.2×109/l; NE%, 84.7; RBC count, 4.01×1012/l; HGB level, 110.0 g/l; and PLT count, 133.0×109/l. Subsequently, a partial nephrectomy was performed and the retroperitoneal lymph node was resected.The patient had a 19-year history of hyperthyroidism and an 11-year history of Henoch-Schönlein purpura. The patient had no known drug allergies and their family history was non-contributory. A bone marrow examination was performed next, but it did not reveal any evidence of lymphoma or a plasma cell neoplasm (PCN). The patient was subcutaneously injected with 300 The surgically resected specimen consisted of a segment of renal parenchyma and a 30-mm soft subcapsular mass anchored firmly to the parenchymal part of the kidney, with clear surgical margins. The section cut from the tumor was a light white and contained hemorrhagic foci . HistoloFollowing this unexpected diagnosis, a skeletal survey was performed to complete the tumor staging. The survey did not reveal any lytic bone lesions or evidence of active malignant disease elsewhere. In addition, the urinalysis was positive for Bence-Jones protein. Serum protein electrophoresis excluded MMs and there was no evidence of systemic plasma cell disease.All these observations were consistent with a diagnosis of an EMP involving the kidney. The patient refused further therapy, including external beam radiotherapy and chemotherapy. Abdominal CT was performed three months post-surgery and did not reveal any relapse. The results of follow-up blood tests were normal and no evidence of hematological disease was noted. The patient remains disease-free at nine months post-surgery.et al considered EMPs and MM to be part of a continuous spectrum of PCNs rather than separate entities . –28. 5–28Although secondary EMP is much more frequent than primary EMP, almost all cases of renal EMPs registered so far have been primary in nature, that is, without any evidence of an associated PCN.In cases of renal EMPs, the tumor mass is often confined to this anatomical area and only two cases have shown other organ involvement ,8. This The diagnosis of an EMP is complex and requires radiological, hematological, biochemical and histological investigation. Primary renal plasmacytomas are not distinguishable from other renal tumors in pre-operative imaging tests. In the present patient, an EMP was diagnosed on the basis of diffuse monoclonal plasma cell infiltration at a single site observed in the immunohistochemical staining for the κ and λ light chains and following the exclusion of a diagnosis of MM .There have been two cases in which an initial diagnosis of renal plasmacytoma was later revised to MM ,23.A renal mass in a patient previously diagnosed with EMP is markedly suggestive of tumor recurrence involving the kidney. Among the 24 cases of renal EMPs reported in the literature, five were cases of a renal recurrence of an EMP that had previously occurred at a different site ,10,17,18Further tests to rule out MM should include a CBC, serum and urine protein electrophoresis, immunoelectrophoresis, skeletal survey and bone marrow examination .As a result of the lack of typical clinical symptoms and evidence from specific laboratory tests, a diagnosis may be delayed, with potentially disastrous consequences for the patient. In the present study, the patient was initially misdiagnosed with clear cell carcinoma. However, the surgical observations and post-operative pathology confirmed the final diagnosis. Once the diagnosis has been confirmed, the EMP may be staged: stage I, tumors confined to the primary site; stage II, tumors showing local extension or lymph node involvement; and stage III, systemic spread ,31.et al reported that radiotherapy alone was sufficient to treat their patient  is an accepted treatment, depending on the resectability of the lesion. A combination treatment may provide the best results .EMP has a relatively good prognosis, but local recurrence and metastasis develop in 30 and 40% of patients, respectively . The fivThe periodic evaluation of patients with EMP is necessary due to the possibility of relapse and progression to MM. Physical examinations coupled with laboratory tests, including CBC, renal function tests, analyses of blood calcium, serum albumin and immunoglobulin levels, serum protein electrophoresis, free light chain assays and radiographic studies of the skeleton are required for follow-up.EMP of the kidney is a rare clinical entity, presenting diagnostic challenges due to its unusual location and nonspecific or absent symptoms. Imaging evaluations may illustrate the existence, size and location of the tumor but are unable to indicate a specific diagnosis. A review of the literature shows that there is currently no widely established standard treatment for EMP of the kidney. If the tumor is located in an area with restricted surgical access, a treatment regimen of local surgery, local radiotherapy or a combination of the two may be initiated. Surgery in combination with radiotherapy may be the best treatment. Although the general prognosis and outcome for EMP is good, a follow-up examination is recommended due to the possibility of relapse or progression to PCN.


Spindle cell hemangioendothelioma (SCH) was originally described by Weiss and Enzinger (1986) as a low-grade angiosarcoma resembling both cavernous hemangioma and Kaposi's sarcoma. Recent studies suggest that SCH is a benign neoplasm or reactive lesion accompanying a congenital or acquired vascular malformation. Most SCHs present as one or more nodules affecting the dermis or subcutis of the distal extremities. Few reports describe SCH of the head and neck region; even fewer note intramuscular SCH. Here, we describe a case of SCH involving the temporal muscle mimicking soft tissue sarcoma, who had a successful surgical treatment with a coronal approach and zygomatic osteotomy. Spindle cell hemangioendothelioma (SCH) was first described in 1986 by Weiss and Enzinger as a vascular neoplasm, characterized by cavernous blood vessels and spindled areas reminiscent of Kaposi's sarcoma , 3. The  A 67-year-old female complained about swelling of the left temporal area with a 4-month history. She had no previous history of trauma in the region. On examination, there was a firm, hemispherical mass 40 mm in diameter in the temporal area; overlying skin appeared normal. The mass was immobile against underlying bone. Trismus or facial palsy was not observed .Magnetic resonance imaging (MRI) revealed a relatively well-demarcated mass in the left temporal muscle, which showed low signal intensity on T1-weighted images and high signal intensity admixed with irregular low signal areas on T2-weighted images . ComputeAn incisional biopsy was performed under general anesthesia to evaluate histology. The specimen revealed proliferation of dilated small vessels with hemorrhage associated with inflammatory components. Abnormal mitotic figures were not observed. Histological features suggested a benign or intermediate vascular tumor, particularly angiolymphoid hyperplasia with eosinophilia.Surgical excision was performed under general anesthesia. First, a hemicoronal incision of the scalp was made; subsequently, the superficial surface of the temporal muscle and zygomatic arch were exposed. A solid nodule was palpated in the temporal muscle and continued beneath the zygomatic arch . OsteotoThis case of SCH involving temporal muscle is extremely rare. According to the 78 series of SCH reported by Perkins and Weiss, four cases occurred in the head and neck region, while 62 cases involved extremities . Because Local recurrence is prevalent in SCH. Of the reports by Perkins and Weiss, 58 percent of patients developed recurrences in the same general area of the body . Because


A 45-day-old male infant presented with signs of acute intestinal obstruction for two days. Abdominal examination revealed a mass in the right lower abdomen. Ultrasound showed a cystic mass measuring 4x3 cm, in the right lower quadrant at the level of lower pole of right kidney. The plain abdominal radiograph showed haziness in the middle and lower third with bowel loops pushed to upper third of the abdomen Fig. .At operation, a cystic mass on the mesenteric side of the cecum was found. The small intestine was distended whereas large gut was collapsed Duplications of the alimentary tract are rare anomalies. They may be of cystic or tubular variety with an intimate contact with the adjacent gut; smooth muscles in their wall and mucosa resemble that of intestine. Most common duplications occur along the ileum. Colonic duplications are rare 13%); cecal duplications are even rarer as only less than 20 cases have been reported in English literature [3%; cecalThey usually present within first two years of life in 80% of cases but has been reported in adults as well. Cecal duplications usually present with acute intestinal obstruction. They communicate with gut in less than 20% of cases where the presentation may be with bleeding per rectum if an ectopic gastric mucosa is present in it. Cecum is also a site where some colonic tubular duplications are intimately attached , 5, 6.Ultrasound, CT scan, contrast bowel studies, technetium 99m radionuclide scan, and diagnostic laparoscopy are important tools for preoperative diagnosis; however, cecal duplications are diagnosed at operation in most of the cases. Our preoperative diagnosis was mesenteric cyst with a differential of alimentary tract duplication, not specifically of cecal origin.The mechanism of obstruction in case of cecal duplication depends upon the amount of mucous in its lumen. Fully loaded cecal duplication can obstruct the lumen of the normal cecum and may result in acute intestinal obstruction as in our case. Simple drainage of the mucus relieved obstruction in the index case.Various surgical procedures have been employed to deal with such lesions. Cecal duplications are commonly managed by limited right hemicolectomy and ileocolic anastomosis , 3, 4, 5Source of Support: NilConflict of Interest: None declared


Gastric duplication cysts are rare congenital abnormalities, and malignant transformation of these duplications is also thought to be rare.During a routine health checkup, a 28-year-old man underwent abdominal sonography followed by computed tomography (CT) with contrast agent, which revealed a cystic lesion with no enhancement. Laparoscopic surgery showed a 10 × 10 cm cyst adhering to the gastric corpus. However, attempts to remove the lesion en bloc were unsuccessful, and the ruptured cyst had contaminated the peritoneal cavity. Gastric duplication was diagnosed from microscopic examination of the cyst. Seven months later, the patient suffered a progressive increase in ascites, and repeated cytological analysis showed small nests of adenocarcinoma cells, with primary lesion unknown. Diagnostic laparoscopy showed multiple white nodules scattered over the surface of the liver, greater omentum, and peritoneum. Biopsy of the omental nodules confirmed adenocarcinoma, while carcinomatosis was diagnosed in the peritoneum.Clinical presentation and chronological developments indicated that the malignancy probably originated from the gastric duplication cyst. This case highlights the importance of accurate preoperative diagnosis and optimal surgical management for gastric duplication as well as considering the potential existence of malignant transformation during surgical evaluation of adult patients with gastric duplication cysts. Most cases of gastrointestinal duplication cysts, which are rare congenital anomalies, are identified at a very young age, and these cysts are rarely diagnosed in asymptomatic adults. MalignaA 28-year-old man had been well until 8 months ago, when he visited his physician for a routine health screening. Abdominal sonography revealed a cystic lesion in close proximity to the left adrenal gland. Subsequent computed tomography (CT) of the abdomen confirmed the presence of the cystic lesion with no contrast enhancement Figure. The cysSeven months after the surgery, the patient complained of abdominal distension as well as anorexia and dyspnea on exertion. A repeated abdominal CT scan showed a well-defined roundish low-intensity non-enhancing mass measuring 6.7 × 4.7 cm in the left adrenal area, along with massive ascites. On examination, the patient was found to be emaciated with positive shifting dullness. Laboratory examination showed normal liver function. Examination of serum tumor markers revealed that the carbohydrate antigen 19-9 (CA 19-9) level was 2145 U/L, while the levels of carbohydrate antigen 125 (CA 125) and carcinoembryonic antigen (CEA) were 209 U/L and 8.1 U/L, respectively. Peritoneal fluid analysis showed that it was yellow and turbid, and the exudates yielded a positive result in the Rivalta test. The levels of CA 19-9, CA 125, and CEA in the fluid were 12000 U/L, 1427.4 U/L, and 518 U/L, respectively. Acid-fast staining of the ascites yielded negative results. Multiple cytological analyses of the ascites revealed small nests of cells compatible with adenocarcinoma. Esophagogastroduodenoscopy, colonoscopy, and CT of the chest, abdomen, and pelvis failed to identify the primary lesion. A diagnostic laparoscopy showed multiple white nodules measuring 0.5- 1.5 cm scattered over the surface of liver, greater omentum, and peritoneum Figure . Biopsy Gastrointestinal duplications are mostly diagnosed during the first year of life, althougGastric duplication cysts are typically found in the greater curvature of stomach and always manifest as non-communicating oval cysts. The symPreoperative diagnosis of gastric duplication cysts is always challenging. Differential diagnosis includes tumors of the stomach, especially gastric submucosal tumors, and cysAs agreed by most researchers, gastric duplication cysts have malignant potential, for which the underlying mechanism is still unknown. Since they have mostly been reported in children, the malignant transformation tends to be underestimated due to surgical removal of the cyst after diagnosis. In contrast, detection of this lesion in adults should raise greater alarm regarding malignancy. Survey of the literature has revealed only 9 cases of malignant transformation in adults reported to date,14-18; tThe present case study pertains to an asymptomatic patient who was incidentally diagnosed with a gastrointestinal duplication cyst by ultrasonography, similar to the patient described by Zheng et al.. Only onhttp://metastastic adenoma noted several months later; lastly, the subsequent overall evaluation failed to identify any primary tumor, and the only findings were remnant cystic lesions and peritoneal adenocarcinoma. As seen in the cases presented in Table In our case, diagnosis of malignancy in the gastrointestinal duplication cyst was based on clinical suspicion rather than histologic confirmation, unlike the cases summarized above. Moreover, there were several findings to support our suspicion: firstly, The patient had been well until the duplication cyst was detected, with no signs of underlying malignancy; secondly, The cyst ruptured during initial surgery resulting in its incomplete removal, with the advent of peritonealIn our opinion, the metastatic adenocarcinoma with peritoneal carcinomatosis in this young male patient raised an important question about appropriate management of patients with gastric duplication cysts. Accurate preoperative diagnosis and optimal surgical management are the crucial lessons from this case. Some researchers have recommended that once a duplication cyst has been diagnosed, even if it is an asymptomatic one, it should be removed and managed like a malignant tumor,9. Our cIn summary, we report a case of a gastric duplication cyst and peritoneal metastatic adenocarcinoma in a young adult man. The malignancy probably developed from the gastric duplication cyst, as indicated by the clinical presentation and chronological developments. We recommend that the possibility of malignant transformation be considered during surgical evaluation of adult patients with gastrointestinal duplication cysts.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.The authors declare that they have no competing interest.LXC participated in the management of this case, designed this report , collected the materials of this manuscript and revised the manuscript; LKL participated in management of this case , collected the materials of this manuscript and drafted the manuscript; WJ and MMM participated in the management of this case and processing of materials in this manuscript; LH, SH and TWP participated in the management of this patient; CH contributed in the pathological diagnosis of this patient and supplied the pathological materials. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-230X/14/48/prepub


Liposarcoma is one of the most frequently occurring soft tissue sarcomas in adulthood. The majority of liposarcomas arise in the lower extremities and retroperitoneum, while the incidence of this tumor in the head and neck region is reported to be extremely low, comprising 1.8%–6.2% of all cases. Nasopharyngeal liposarcoma is exceptionally rare, with only three cases having been reported in the English literature. This paper presents a case of a nasopharyngeal liposarcoma, treated with endoscopic tumor debulking, followed by adjuvant chemotherapy and radiotherapy, and reviews the current literature with regard to diagnosis and management of such lesions. Most authors agree that the imaging modality of choice is magnetic resonance imaging. Although radiographic findings usually support diagnosis, the imaging characteristics of such lesions may considerably vary, depending on the histological subtype and the macroscopic appearance of the tumor. The treatment of choice is complete surgical excision when possible. Although the role of postoperative radiotherapy is not clearly defined, some authors support that radiotherapy might delay or prevent local recurrence. However, there is no adequate evidence that the combination of surgery and radiotherapy lowers the possibility of distant metastasis of the head and neck liposarcomas. The role of adjuvant or neoadjuvant chemotherapy still remains controversial. Liposarcoma is a quite common soft tissue malignant tumor in adults. In fact, it is second only to fibrosarcoma, as the most frequently occurring soft tissue sarcoma in adulthood –3. The mA 58-year-old male presented to our department with a 6-month history of nasal obstruction and right otalgia. Subsequent nasopharyngeal endoscopy revealed a right-sided mass, situated at the posterior wall of the nasopharynx . High-reAs the tumor was not possible to be radically excised, our patient underwent an endoscopic biopsy of the mass along with tumor debulking, under general anesthesia.The histopathological examination showed a myxoid-round cell liposarcoma, with moderate differentiation and hemorrhage infiltration. Immunoperoxidase stains were positive for S100 protein, vimentin, CD68 in histiocytes, and Ki67 in less than 10% of tumor cells, being negative for SMA, NSE .Right after the operation, our patient underwent 6 cycles of adjuvant chemotherapy (a doxorubicin-based regimen was administered), followed by radiotherapy (66 Gy in 33 fractions). The patient showed no residual tumor on endoscopy and MRI imaging by the end of radiotherapy. There are still no signs of recurrence on follow-up endoscopy  and MRI Liposarcoma is the second most common soft tissue sarcoma, accounting for 14–20% of all soft tissue malignancies . LiposarThe review of the English literature showed that only a few publications have directly addressed head and neck liposarcomas, usually presenting quite limited patients' series . Based oThe mean age of presentation is between 40 and 46 years, with a peak at the 6th and 7th decades –10. LipoLiposarcoma originates from primitive mesenchymal cells. It is divided into five major histologic subtypes: well differentiated, myxoid, dedifferentiated, round-cell, and pleomorphic subtype , 4, 11. Well-differentiated, myxoid, and pleomorphic types are the most commonly found, while round-cell type lesions are quite rarely confirmed –10. The Early diagnosis of liposarcomas is quite rare mainly due to the fact that these tumors are usually painless, gradually developing lesions. Various compressive symptoms may be encountered, depending on the location and the size of the tumor. In the reported cases of nasopharyngeal lesions, as well as in our case, the main symptoms were progressive nasal obstruction along with unilateral persisting otitis media with effusion and referred otalgia , 5, 6.Most authors agree that the imaging modality of choice is MRI , 13, 14.Provided that nasopharyngeal liposarcomas are exceedingly rare, there are very limited reports in the literature with regard to the management of such malignancies , 5, 6. MLiposarcoma is, like other soft tissue sarcomas, primarily a surgical disease. The main goal of surgery is to remove the tumour entirely and prevent recurrence –10. IncoHowever, treatment strategies in head and neck liposarcomas are usually significantly different, compared to those related to similar lesions of other regions –10. ThisIn fact, all cases of nasopharyngeal liposarcomas, including the present case, were related with various difficulties, affecting treatment strategy. Management strategy and parameters, as well as final outcome of those four cases, are presented and commented below in detail. We also attempt to indicate how the outcomes of potentially altered treatment in such cases compare to the standard treatment of liposarcomas outside the head and neck region. In Knowles and Huggill's case  , the right-sided tumor was situated at the posterior wall of the nasopharynx. As the lesion was not possible to be radically excised, the patient was treated with endoscopic debulking and adjuvant chemotherapy (a doxorubicin-based regimen) and radiotherapy. The patient is alive, showing no signs of residual tumor, on both follow-up endoscopy and imaging studies, 14 months after radiotherapy.Obviously, radical tumor excision was not possible in all reported cases of nasopharyngeal liposarcoma, mainly due to anatomical limitations correlated with the site of the lesion , 5, 6. ROn the other hand, in most cases of liposarcomas outside the head and neck region, surgery alone or a combined modality approach of preoperative or postoperative radiation therapy is used by most authors , 18. TheA recent original study, conducted in the USA, came to an interesting conclusion, regarding the prognosis and the final outcome of liposarcomas in the head and neck region, compared to other anatomical locations: with a median follow-up of 45 months, Smith et al. (2011)  concludeAlthough surgery with negative margins is very well documented as the treatment of choice for all histopathological subtypes of head and neck liposarcomas, routine regional lymph node dissection is not generally recommended, as node metastases of head and neck liposarcomas are quite rare , 10. Pat Although the role of chemotherapy is not clearly defined, some authors support the use of neoadjuvant chemotherapy regimens (doxorubicin and dacarbazine based), in selected patients with high-grade tumours or lesions with complex anatomical subsites, reporting quite satisfactory results, especially in terms of local control of the disease , 21. In our case, although the liposarcoma proved to be of low-grade, we decided to involve adjuvant chemotherapy along with radiotherapy, because the tumor was quite large and radical excision was not possible to be performed, mainly due to the anatomical location of the mass.As far as the final outcome is concerned, the study of the literature concludes that both disease-specific and overall survival rates of low-grade head and neck liposarcomas (well-differentiated or myxoid subtypes) are much higher, compared to those in patients with pleomorphic or round-cell subtypes –10. DaviLocal recurrence is considered to be quite common (reported recurrence rates are between 36% and 63%), especially in younger patients and in more aggressive high-grade liposarcomas or tumors with local extension into surrounding tissues –10. Such The site of the lesion also appears to affect prognosis: scalp, facial, and laryngeal liposarcomas are reported to have a relatively better prognosis, probably due to earlier diagnosis, compared with intraoral, pharyngeal, or neck tumors . In our case, although the lesion was <5 cm in diameter and the histological subtype was of low grade, radical excision was not possible. We decided to use both adjuvant chemotherapy and radiotherapy because of the location of the tumor, which could make the identification of local recurrence very difficult, especially without the use of biopsies. The outcome is very satisfactory, as the patient is alive and disease-free , 14 months after radiotherapy.Liposarcoma is a soft tissue malignant tumor rarely occurring in the head and neck region. Nasopharyngeal liposarcomas are even more rarely diagnosed, with only three cases having been reported in the English literature. Treatment of choice is surgical excision with the wider possible margins, followed by postoperative radiotherapy and adjuvant chemotherapy in selected cases.


We describe the case of a man who presented with back pain and acute kidney injury and was found to have bilateral ureteral obstruction, which initially corrected with ureteral stents. Imaging studies showed thickening of the bladder. Shortly thereafter, he developed obstructive jaundice, pancreatitis, recurrence of renal failure, and was diagnosed with advanced gastric cancer after a laparotomy revealed peritoneal carcinomatosis. The patient deteriorated rapidly after diagnosis. While peritoneal carcinomatosis, ureteral metastases, and extrinsic ureteral compression have been recognized in gastric cancer, obstructive renal failure due to tumor infiltration of the bladder wall is seldom described. We present this case as an unusual cause of acute renal failure and presentation of gastric cancer. Acute Kidney Injury (AKI) due to bilateral ureteral obstruction in older patients typically raises concerns of abdominal, retroperitoneal, or pelvic neoplasms. Malignancies cause hydronephrosis by compression, by direct extension, by lymph nodes, or by retroperitoneal fibrosis. It is rare for hydronephrosis, as a result of obstruction at the level of the ureteral bladder inlet, and back pain to be the presenting symptoms of gastric cancer . We descA 48-year-old Hispanic man with no significant past medical history started experiencing abdominal and back pain worse with exertion. He self-medicated with ibuprofen and sought medical attention after two weeks as the pain became progressively worse. At presentation, he was febrile, with nausea and vomiting, had some dysuria, postvoid dripping, and constipation. He denied any hematuria or rectal bleeding. Initial examination was unremarkable apart from right costovertebral angle (CVA) tenderness. The initial lab values are presented in The chest X-ray was unremarkable, and the abdominal X-ray showed evidence of ileus. A CT showed a thickened bladder wall with infiltration of the adjacent fat, bilateral hydronephrosis and hydroureters, hepatomegaly, and trace perihepatic ascites . A foley was inserted with minimal urine output. Bilateral JJ ureteral stents were placed two days after admission, and his renal function improved. Shortly thereafter, he started spiking fevers and was started on vancomycin and zosyn. Cultures were negative, and the patient was discharged on oral augmentin for a few more days with planned outpatient followup. He presented again to the same institution three weeks after discharge, complaining of nausea, vomiting, poor appetite, and abdominal pain. His admission laboratory results are presented in He was initially treated for a urinary tract infection. Ultrasound showed gall bladder sludge, but no stones, and a normal common bile duct (CBD). His HIDA scan showed total retention of Tech 99 in the liver suggestive of CBD obstruction. A CT scan showed pancreatitis, hepatomegaly with perihepatic and perisplenic ascites, esophageal and gastric varices, and intact bilateral JJ stents. A repeat ultrasound showed portal vein thrombosis. A liver biopsy showed histological changes consistent with large bile duct obstruction and focal cholestasis, without evidence of autoimmune hepatitis. Endoscopy, performed after coffee ground emesis, showed three nonbleeding gastric ulcers and duodenitis in the bulb. He was subsequently transferred to our institution. At the time of transfer, he was experiencing abdominal pain and drowsiness. He denied any other symptoms. Examination was significant for jaundice and diffuse abdominal tenderness without rebound tenderness or guarding. For the investigation and treatment of his obstructive jaundice, an ERCP was performed, revealing a large antral ulcer and edematous mucosa in the duodenal bulb which was biopsied. The duodenoscope could not be advanced past the pylorus because of pyloric narrowing. A follow-up CT scan showed thickening of the gastric antrum and proximal duodenum, a mesenteric haze adjacent to the head of the pancreas, dilatation of the CBD, moderate right-sided hydronephrosis, and bilateral ureteral stents Figures .Preliminary results from biopsies taken during the ERCP showed poorly differentiated carcinoma involving the duodenal mucosa and poorly differentiated gastric adenocarcinoma with signet ring cells. Laparoscopic surgery was recommended by the oncology consultants for diagnosis, staging, and palliative treatment. The procedure was converted to an exploratory laparotomy, colonoscopy, J-feeding tube placement, cholecystostomy, ileostomy, and the placement of a right-sided pleural drain. He developed bilateral deep vein thromboses after the procedure and respiratory distress, requiring reintubation. Inferior vena cava (IVC) filter placement failed because of a narrow IVC, likely due to external compression. Colonoscopy revealed a circumferential rectosigmoid mass extending 15 cm from the anal verge. Laparotomy revealed frozen peritoneal carcinomatosis, ascites, and frozen ascending and descending colon. The stomach was frozen as well, and an end-ileostomy was done in view of impending small bowel obstruction. A pathology slide from the abdominal wall is shown in His renal function started to worsen after the procedure, with a rising creatinine and decreasing urine output (FeNa was 0.51% at the time of transfer to our institution). This was attributed to hemodynamic renal failure in the face of extensive carcinomatosis and liver failure. A renal scan was done to see if there would be any benefit to percutaneous nephrostomy. The study showed slow uptake in both kidneys without evidence of transit or excretion. The persistent activity in the parenchyma was consistent with ATN. Dialysis was not done after a discussion about the patient's overall prognosis, and the patient's family elected comfort care and refused an autopsy.There are several teaching points that can be made in this case. Bladder wall thickening can be due to several causes, including acute or chronic infection or inflammation, muscular hypertrophy due to outlet obstruction, benign tumors like hemangioma or neurofibroma, or malignancies like transitional cell carcinoma, squamous cell carcinoma, or leiomyosarcoma . Our patRetroperitoneal fibrosis has many malignant causes, including gastric cancer, and can cause bilateral ureteral stenosis and renal failure. In one case, a sixty-two-year-old Japanese female who initially presented with fever, back pain, and renal failure . Imaging


Most tumorous lesions of the esophagus are esophageal cancers. Benign primary tumors of the esophagus are uncommon, and account for approximately 2% of all esophageal tumors. More than 80% of benign esophageal tumors are leiomyomas, with schwannomas being rare. A 55-year-old woman visited our internal medicine department with complaints of palpitations and discomfort during swallowing. A chest computed tomography scan showed a lobulated tumor (75 × 57 × 80 mm) in the upper to middle mediastinum, with homogenous inner opacity, compressing the esophagus. Upper gastrointestinal endoscopy revealed a smooth-surfaced elevated lesion covered with normal mucosa, and a schwannoma was diagnosed based on the biopsy result. The tumor was large. It was thus considered to be difficult to repair the esophagus by direct anastomosis after tumor resection. Therefore, subtotal esophagectomy and esophagogastrostomy in the right thorax were performed. Histopathological examination revealed spindle-shaped cells in a fasciculated and disarrayed architecture and nuclei in a palisading pattern. Immunohistochemical studies revealed S100 protein positivity and the absence of staining for α smooth muscle actin (αSMA), CD34 and CD117, thereby establishing the diagnosis of benign schwannoma. Her postoperative course was uneventful and there has been no evidence of recurrence to date. The incidence of benign primary tumors of the esophagus is low. Most are leiomyomas, and schwannomas are rare. We report a patient with schwannoma who was referred to us for evaluation of a mediastinal tumor. Detailed examination yielded a diagnosis of schwannoma arising from the esophageal submucosa and radical surgery was performed.A 55-year-old woman visited our hospital with complaints of palpitations and discomfort during swallowing. Her medical and familial histories were unremarkable. A frontal chest radiograph showed a smooth round mass, and a lateral radiograph showed a smooth mass slightly larger than 7 cm in diameter in the middle mediastinum between the trachea and the vertebral bodies. A chest computed tomography (CT) scan showed a lobulated tumor (75 × 57 × 80 mm) in the upper to middle mediastinum, with a homogenous inner component, compressing the esophagus Figure . MagnetiMost tumorous lesions of the esophagus are esophageal cancers. Benign primary tumors of the esophagus are uncommon, and account for approximately 2% of all esophageal tumors. More than 80% of benign esophageal tumors are leiomyomas, with Schwannomas being rare ,2. SchwaSymptoms of this disease include dysphagia, dyspnea, and chest pain, and are likely to appear and worsen as the schwannoma increases in size . FluorodIn general, histological features of schwannoma include spindle-shaped tumor cells arranged in a palisading pattern or with loose cellularity in a reticular array. Immunohistochemical stainings for S100 protein, αSMA, CD34 and CD117 are also useful .Chemotherapy and radiation therapy are ineffective such that surgical excision including the capsule is indicated for symptomatic cases and also for those with possibly malignant schwannoma. The use of enucleation with video-assisted thoracoscopic surgery is becoming common for small tumors (≤2 cm) . HoweverHere, we report a relatively rare case of schwannoma of the esophagus, initially identified as a large mediastinal tumor. The tumor was 80 mm in diameter and the post-resection defect of the adventitia and muscular layer was extensive. Esophagectomy and esophagogastrostomy were thus performed and good postoperative recovery was achieved.Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MK operated on this case and analyzed all data. YM, SH and KS assisted with the operation. KO and NM diagnosed the pathology of this case. All authors read and approved the final manuscript.


A 35-year-old female presented with pain and swelling of the distal left radius. A diagnosis of Ewing sarcoma was made and she underwent neoadjuvant chemotherapy and surgery. Macroscopic viable areas remained on the map of the surgical specimen; as such, she was classified as a poor responder and received high dose adjuvant chemotherapy. She remained disease-free for five years, until age 40. A vaginal polyp was then detected during a routine gynaecologic examination. It was removed and histopathology revealed metastatic Ewing sarcoma.To our knowledge, this is the first reported case of a vaginal metastasis of Ewing sarcoma. Ewing sarcoma (ES) is a small blue round cell tumor belonging to the Ewing Family Tumour (EFT) together with Primary Neuroectodermal Tumour (PNET) and ASKIN tumor . Eight hundred and ninety six cases have been reported in our institute since 1982. Ewing sarcoma has a distinct predilection for males and occurs in the first two decades of life in more than 75 percent of cases [Metastases are frequent  and are We present here the first description of a vaginal metastasis of Ewing sarcoma.A 35 year-old woman with no significant medical history presented with pain and swelling of the left wrist over the past year. A radiograph and computed tomography scan revealed a lytic lesion of the distal left radius Figure , with soA biopsy was performed and histological examination revealed a typical Ewing sarcoma. The diagnosis was confirmed by FISH analysis, which demonstrated the translocation t .Staging revealed a solitary non-specific pulmonary nodule of the inferior right lobe that did not change with time and was not considered metastatic.The patient underwent neoadjuvant chemotherapy and resection and allograft of the distal radius. She was considered as poor responder as macroscopic areas remained on the surgical specimen, but all margins were free of disease. High dose chemotherapy was then performed.After completion of her treatment, it was followed up as per protocol and remained disease-free.Five years later, during a routine gynaecologic exam, a vaginal polyp was found and removed. Histology revealed a ES metastasis Figure , as confNo treatment has been undertaken.Ewing sarcoma (ES) represents approximately ten percent of primaFrequently, the first symptoms are pain and swelling.Twenty percent of ES at diagnosis have radiographic evidence of metastasis. Lungs and bone are the main metastatic locations.Radiologically, an aggressive osteolytic lesion is commonly observed.ES is characterized by a morphologically uniform round cell proliferation with round nuclei containing fine chromatin.CD99 is expressed in nearly all ES and thereby is a highly sensitive immunohistochemical marker.Several studies have confirmed a characteristic 11, 22  chromosomal translocation in 85 percent of the cases ; the traNecrosis has a strong prognostic value . High doWe found 17 cases of primary ES involving the vagina and/or vulva in the literature. A few cUnusual metastasic locations have been described, for example, the breast , myocardThis case exemplifies the idea that every new lesion in a patient with Ewing sarcoma should be considered as a possible metastasis.The authors declare that they have no competing interests.NV wrote the article, VV checked the case, JK corrected the writing (English and scientific content) MG checked and selected the histology, SC checked and selected the FISH, CT checked the scientific content, DV proposed the subject and directed the article. All authors read and approved the final manuscript


Malignancies, which present as deep neck abscesses are uncommon and may result in a delayed diagnosis or potentially a misdiagnosis. The present study describes a patient who exhibited a deep neck abscess as the initial manifestation of carcinoma of unknown primary (CUP). The aim of the present study was to raise awareness of this unusual presentation of CUP and emphasize the importance of repeating targeted fine-needle aspiration cytology or biopsies in patients presenting with a deep neck abscess suspicious for malignancy. Deep neck space abscesses are common and the majority of cases originate from infections or trauma to the head and neck structures –5. A nec9/l and the C-reactive protein value was 12.3 mg/dl . No additional clinical abnormalities, such as transnasal fiberoptic laryngoscopy, were identified as a result of the head and neck examinations. The patient provided written informed consent.A 71-year-old female, with a betel nut-chewing habit and a history of hypertension, presented with a fever and a painful swelling on the left side of the neck which had both lasted for three days. The neck mass, which was diagnosed as a cervical lymphadenitis at a local clinic, had been present for one week, had progressively increased in size and had become red. The physical examination showed that the patient had a temperature of 38.3°C and presented with a tender mass  and skin erythema on the left side of the neck at level II-III. The total white cell count was 18.7×10Staphylococcus aureus and the cytological examination via fine-needle aspiration revealed the presence of non-malignant inflammatory cells alone. Following adequate control of the infection, the patient became afebrile and the skin erythema ameliorated. However, the neck mass remained present and the possibility of a malignancy could not be excluded due to the patient regularly chewing betel nut and a concern regarding the lateral cervical cystic lesion that the patient exhibited. Therefore, an additional fine-needle aspiration of the lesion was conducted and the cytology revealed malignant epithelial cells, which were consistent with squamous cell carcinoma. The diagnostic procedures were conducted to characterize the occult carcinoma, although the results of the abdominal ultrasonographic scan, chest radiography and the bone scintigraphy were all observed to be normal. The primary fluorodeoxyglucose (FDG) uptake site was detected by F-18-FDG positron emission tomography in the lymph nodes of the left-sided level II area of the neck, with a maximum standardized uptake value of 5.7 (An ultrasonographic scan showed a hypoechoic and heterogeneous deep abscess between the left sternocleidomastoid muscle and the common carotid artery. A contrast-enhanced computed tomography scan of the neck was performed and a hypodense predominantly cystic lesion, exhibiting ring enhancement over the left carotid space, was observed . The puse of 5.7 . TherefoThe patient subsequently underwent a left side modified radical neck dissection, which was followed by radiotherapy treatment. The patient survived and showed no indication of recurrence within the five-year follow-up.Neck abscesses and deep neck infections are common diseases, which may arise from various head and neck regions, including the teeth, adenotonsillar tissues, the nasal cavity, pharynx, paranasal sinuses and the salivary glands. Odontogenic and tonsillar infections are the predominant causes; however, malignancies may occasionally present with one of the aforementioned deep neck infections. In previous studies, sporadic cases of metastatic carcinoma presenting as deep neck abscesses from certain head and neck regions were reported, such as the paranasal sinus, nasopharynx, tonsil, tongue base, pharynx, larynx, thyroid and parotid glands –5. HowevCUP was identified to account for ~3–5% of newly diagnosed cancer patients in the Swiss population , represeStaphylococcus aureus (Malignant lymph node metastasis, which presents as a deep neck abscess or cervical cellulitis, is rare and may be due to the relatively effective vascular supply to the head and neck region . The caus aureus .The infections that coexist with the malignancy complicate the clinical observations and may lead to a delayed diagnosis. This is due to the infection superimposing on the malignant process, which reduces the likelihood of obtaining a biopsy that exhibits a good representation . In patiIn the management of these cases of deep neck abscesses associated with malignancy, a definitive treatment for the tumor and an appropriate treatment of the abscess are required. In addition, detection of the primary site is critical as this may result in patients receiving site-specific treatment with a favorable prognosis. The majority of primary sites are able to be confirmed pathologically, shortly following the diagnosis of a cervical metastasis. Therefore, detailed medical history-tracing, careful investigation and pathological examination of tissues obtained from fine-needle aspiration or surgical biopsy in the suspected malignancy area, are important to reduce the time it takes to identify the primary malignant origin. Although the primary origin of the malignancy in the present study was not identified, a good recovery was observed following the modified radical neck dissection and the radiotherapy treatment.In conclusion, malignancies may present as deep neck abscesses and patients may, therefore, require a careful examination, particularly those who exhibit a high risk of head and neck carcinoma.


Objective. We report a rare case of Ewing's sarcoma of the zygomatic arch presenting in a 69-year-old patient. Method. Case report and a review of the world literature on Ewing's sarcoma incidence and management. Results. Ewing's sarcoma is a malignant round cell tumour of neuroectodermal origin that typically presents in the pelvis and long bones of children and adolescent boys. This report is the first to document the presentation of ewing's sarcoma of the zygomatic arch in a 69-year-old lady. Our patient underwent surgical excision and radiotherapy and at 4-year followup has no signs of recurrence or metastasis. Conclusion. To our knowledge this is the first case report to document Ewing's sarcoma of this location in a 69-year-old patient. This case report highlights the importance of diagnostic investigations in Ewing's sarcoma and discusses the management issues that this rare presentation raises. This is the first report to document Ewing's sarcoma presenting in the zygomatic arch in a patient of 69 years.Ewing's sarcoma of the bone is an undifferentiated round cell tumour of neuroectodermal origin. It is classified along with extraskeletal Ewing's sarcoma, Askin's tumour, and peripheral neuroectodermal tumour (PNET) into Ewing's family of tumours, first described by Ewing in 1921 [Ewing's sarcoma most commonly presents in children; incidence after the 3rd decade accounts for only 10% of cases and is limited to only a few case reports in those patients older than 60. Males have been shown to have a slight preponderance over females in developing the tumour, and the pelvis and long bones are the most common osseous primary site. Only 3% of cases involve the bones of the head and neck . In April 2007, a 69-year-old lady presented to the neck lump clinic with a right sided preauricular swelling. The swelling had been present for 26 weeks gradually increasing in size. Examination revealed a firm immobile mass located near the lateral border of the orbit in the superior masseter region. There was no cervical lymphadenopathy, and examination of the oral cavity, larynx, and pharynx was normal. There was no facial nerve weakness. The initial proposed diagnosis was of a metastatic tumor.Ultrasound showed the swelling to be 3 cm in diameter and homogeneous in nature. A guided FNA reported suspicious cytology showing sheets of undifferentiated cells amongst an infiltrate of uniform small blue cells with a high nuclear-cytoplasmic ratio . Given tA single-photon emission computed tomography (SPECT) scan demonstrated an increased tracer uptake in the right zygomatic arch with the bone being atrophic and irregular, eroded by a 2.9 × 1.6 cm nodule adjacent to the temporalis muscle . A stagiFollowing multidisciplinary team (MDT) discussion the decision was made to recommend surgery, with preservation of the facial nerve, to reduce tumour load followed by local radiotherapy. It was felt that neoadjuvant chemo/radiotherapy to shrink the tumour would not be appropriate due to the patients comorbidity (the patient was ASA grade IV).Using a nerve monitor/stimulator throughout, a pre-auricular incision was made and extended up into the hairline with anterior extension along a skin crease. A skin flap was elevated anteriorly and the temporal branch of the facial nerve identified overlying the zygomatic arch. The zygomatic branch was then defined by retrograde dissection. The tumour was found to be pushing up on the underlying fat pad and involving the masseter muscle and zygoma. After anterior mobilization of the facial nerve the involved portion of the zygoma and associated tumour was removed. All branches of the facial nerve were identified and tested prior to closure; all were intact.Histopathology confirmed the diagnosis of Ewing's sarcoma. Significant amounts of intracellular glycogen were present, and the sample was strongly positive for CD99/MIC2.Molecular genetic analysis performed by fluorescence in situ hybridization (FISH) revealed the translocation t(11:22) that is found in >90% of Ewing's sarcoma.Postoperatively the patient recovered well other than a slight neuropraxia of the temporal branch of the facial nerve.Two months later the patient underwent 54 Gy of external beam radiotherapy in 27 fractions. The only complication in our patient was a right ear infection and perforation followed by a mild right-sided sensorineural hearing deficit. She was treated with Gentisone HC and fitted with a hearing aid.Subsequently the patient has been followed up for 4 years. Facial nerve function has returned to normal and there are no significant cosmetic issues. CT and MRI coregistration scans show no evidence of local recurrence or metastatic spread.Primary Ewing's sarcoma involving the head and neck accounts for only 3% of Ewing's sarcoma cases of which the most commonly affected areas are the skull, maxilla, and mandible. The zygomatic region has only been reported in 6 previous cases to our knowledge in patients aged 2–31 years old . This caLymphoma would be a commoner cause of such a presentation in this age group, with cytological features that can easily be confused with Ewing's sarcoma. This case demonstrates the advantage of guided core biopsy in obtaining histopathological material over the more traditional open biopsy that in this case could have had significant management implications including the need for a wider surgical excision. This case also highlights the importance of a broad differential diagnosis and utilization of investigations such as immunohistochemistry and molecular genetics to facilitate a prompt and accurate diagnosis. Misdiagnosis like one previously reported case can be fatal due to the aggressive nature of the tumour and the poor prognosis associated with metastatic disease , 5. Accurate diagnosis is synergistic with appropriate treatment to improve overall survival. Studies have shown that Ewing's sarcoma requires risk-adapted treatment taking into account the tumour location, size, and presence or absence of metastasis. Those that are considered high risk should undergo high-dose intensive chemotherapy and radiotherapy if fit. Recent research has shown the combination of surgery, radiotherapy, and chemotherapy has been proven to yield best results, with 5-year survival reported as reaching 55–75%, a great improvement from the 10% which was achieved with single modality therapy in the 1970s . HoweverFirstly surgery may result in gross deformity and compromise facial function in order to obtain clear margins, especially if tumours are large or located near intricate structures. Each case needs to be considered individually in terms of tumour location and size along with the psychological effect that major facial surgery would have on the patient. It is well documented the negative impact facial disfigurement can have on a person's life especially in adolescents as well as the discrimination they face from the public, therefore such surgical excision requires a multidisciplinary approach with the option for reconstructive surgery explored early. Our patient had a small tumour in comparison to others noted and surgical excision without reconstruction was appropriate.The other issue this case raises about head and neck Ewing's sarcoma is the suitability of radiotherapy as part of treatment. Radiotherapy to the head and neck can result in many undesirable side effects. In younger patients the brain and facial skeleton is rapidly growing and exposure to radiotherapy may result in significant long-term side effects. Patients of any age may also experience adverse effects such as sensorineural hearing loss, cataracts, temporomandibular joint ankylosis, and secondary tumours. The standard treatment approach for Ewing's sarcoma is initial chemotherapy, followed by surgery if possible then further chemotherapy. Radiotherapy is added if surgery is not possible or if the surgery or chemotherapy results are not adequate. Disease-free survival has occasionally been reported after surgical excision alone and one such study has suggested that radiotherapy should be restricted to cases where margins at surgery are not clear or in cases of recurrence , 8. HoweLumps in the head and neck are a common presentation at ENT clinics. This case highlights the importance of maintaining a wide differential diagnosis in these cases and the importance of utilizing the appropriate investigations to obtain an accurate diagnosis. US-guided core biopsy together with immunohistochemistry reduces misdiagnosis and helps avoid the unnecessary complications that ensue, especially when the presentation is rare.


Minimally invasive procedures have been applied in treatment of gastric submucosal tumors. Currently, combined laparoscopic - endoscopic rendezvous resection (CLERR) emerges as a new technique which further reduces operative invasiveness.nd postoperative day.A-57-year-old female patient presented with epigastric pain. She was submitted to gastroscopy, which revealed a tumor located at the angle of His. Biopsy specimens demonstrated a leiomyoma. The patient underwent endoscopically assisted laparoscopic resection of the tumor. The operative time was 45 minutes. Diagnosis of leiomyoma was confirmed by the final histopathological examination. The patient had an uneventful postoperative recovery and was discharged on the 2Combined laparoscopic and endoscopic rendezvous resection appears as a promising alternative minimally invasive technique. It offers easy recognition of the tumor, regardless of location, safe dissection, and full thickness resection with adequate margins as well as less operative time. Minimally invasive surgery has become the gold standard in numerous procedures, including those associated with gastric disease. Laparoscopic approach has been applied in resection of gastric submucosal tumors. Still, combined laparoscopic - endoscopic rendezvous resection (CLERR) presents currently as a groundbreaking technique of gastric tumor resection.We present herein a case of endoscopically assisted laparoscopic resection of a gastric intraluminal leiomyoma.nd postoperative day.A-57-year-old female patient presented with epigastric pain. She was submitted to gastroscopy, which showed a tumor located at the angle of His. Biopsy specimens demonstrated the benign nature of the tumor, identifying it as leiomyoma. The patient underwent endoscopically assisted laparoscopic resection of the tumor along the lesser curvature, with adequate resection margins (2 cm) Figures a, 1b. Th0 camera. Then, four trocars were inserted, one in each abdominal quadrant, as shown in Figure Under general anesthesia, the patient was placed in supine position. Both endoscopic and laparoscopic monitors were arranged near the head of the patient so that the surgeon could watch both of them. The first trocar was inserted in the midline, one third of the distance from the umbilicus to the xiphoid process, using the Hasson technique, for insertion of a laparoscopic 30Combined laparoscopic - endoscopic rendezvous resection is a new treatment method for gastric submucosal tumors. Yet, careful patient selection, accurate preooperative diagnosis and operative strategy are required. Parameters taken into account should include size and histological type of the tumor, depth of gastric wall invasion and expansion.Specifically, small diameter 1–2 cm) locally limited, benign gastric mucosal tumors may be considered for CLERR. Additionally, this method is indicated for certain premalignant tumors and small locally limited submucosal gastrointestinal stromal tumors (GISTs). In fact, GISTs usually present as local gastric tumors without any infiltration of regional lymph nodes and consequently CLERR is clearly indicated in this respect –2 cm loc.On the other hand, CLERR is absolutely contraindicated for locally advanced and metastatic tumors, which should be managed using an open method ,2. For tAlthough endoscopic mucosa resection is nowadays quite acceptable for the treatment of early gastric cancer ,9–12], , 12], CLNevertheless, endoscopy appears to be valuable in guiding laparoscopic gastric resection. The gastric tumor is marked preoperatively using endoscopic tattooing and the exact position of the tumor is constantly localized intraoperatively via endoscopic transillumination. Finally surgical removal is confirmed by the endoscopist.In general, CLERR offers the common advantages of minimally invasive approach  along with easier recognition and dissection of the tumor, regardless of its location, ensuring less operative time and complete haemostasis. It renders full thickness resection with adequate margins leading to therapy or at least a reliable histologic analysis which may guide further therapeutic decisions ,15,16.In conclusion, combined laparoscopic and endoscopic rendezvous resection appears to be a quite promising method with the benefits of minimally invasive surgery. In any case, careful patient selection, correct preoperative diagnosis and appropriate operative planning are required.“Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal”.CLERR: Combined laparoscopic - endoscopic rendezvous resection; GISTs: Gastrointestinal stromal tumors.The authors declare that they have no competing interests.CK was the main surgeon. CE supervised the paper writing. GA was the assistant surgeon. KV wrote the main manuscript. TS wrote the supplementary information. GI gave technical support and conceptual advice. All authors read and approved the final manuscript.


This report presents the “penumbra sign” of a Brodie’s abscess in a 69-year-old male patient. The lesion was located in the proximal metaphysis of the left tibia. Histopathology confirmed the diagnosis of subacute osteomyelitis. The penumbra sign on magnetic resonance (MR) images is a helpful sign for the diagnosis of Brodie’s abscess. Brodie’s abscess is a bone abscess described as a localized primary purulent collection and a sclerotic wall. Brodie’s abscess is usually confined to the metaphysis . There mThe patient was a 69-year-old male retired military officer. His chief complaint was left knee pain. He had no systemic illness. On examination, he had crepitation and mild joint effusion in the left knee. The left knee had a normal range of motion. There was a surgical scar on the medial side of his left proximal leg. He had a parachute accident at age 33 causing trauma to his left knee. He remembered that he was told about developing a bone infection at his proximal tibia and had undergone surgery then. After being discharged, he was not given any medication and was not told about any further necessary treatment in the future. He returned to his service and continued his normal activities. During the following years he did not have any symptoms at his previously injured site and no systemic illness.At the time of examination, there was no sign of acute or chronic infection  around the left knee. Erythrocyte sedimentation rate (ESR), C-reactive protein and leukocyte count were normal.Plain roentgenograms of the left knee  showed aProximal left leg Computed Tomography (CT) scan without contrast  showed eLeft knee MRI demonstrated the penumbra sign. The MRI showed a well-defined central intramedullary cystic lesion in the proximal tibial metaphysis. The central part of the lesion was hypointense on T1-weighted images  and hypeThe patient underwent surgical drainage of the abscess cavity and reconstruction of the lesion site. Histopathology confirmed the diagnosis of subacute osteomyelitis (Brodie’s abscess). The patient is in good general condition and there has been no sign of recurrence of local complication as cutaneous fistula in a 2-year-follow up.The penumbra is defined as partial or lighter shadow of an eclipse. It refers to the thin layer of granulation tissue that lines the abscess cavity in subacute osteomyelitis 4]..4].Marti-Bonmati et al. are credited for the first description of the “target” appearance of Brodie’s abscess on MRI; a center, two rings and a peripheral halo . The “peThe “penumbra sign” is not pathognomonic but a characteristic MRI feature of subacute osteomyelitis 4]5]6][5][6]4][[6][5][6][5][6]4][7].[7].4][7]McGuinness B et al. reported that the penumbra sign has a high specificity of 96% and a low sensitivity of 27% for diagnosis of musculoskeletal infection .Radiologically, there is obscurity in distinguishing subacute osteomyelitis from other malignant and benign bone lesions. The radiologic manifestation of our case was similar to the previous cases 8]. Howe. Howe8].


Peripheral odontoma arising in the extraosseous soft tissues is rare and if not removed early, may enlarge over time and eventually erupt in the oral cavity.A 15-year-old girl presented with “denticles on the gingiva”. During the intraoral examination, seven small tooth-like structures were found. These were exposed in the anterior left gingiva between the permanent maxillary lateral incisor and canine teeth, and the left first premolar was absent. Radiographic examination revealed irregular tooth-like structures without evidence of bone involvement.The lesion was surgically removed, and the specimens were analyzed histopathologically. The diagnosis of compound odontoma was established.This is the twelfth reported case of peripheral odontoma in the gingiva and the first one that erupted in the oral cavity. Odontomas are the most common type of odontogenic tumors and they are often associated with permanent or temporary tooth eruption disturbances . AccordiClinically, odontomas are either intraosseous or extraosseous -5. The iWe report a case of a 15-year-old girl with a peripheral compound odontoma characterized by multiple rudimentary teeth which erupted spontaneously in the anterior maxillary region. Based in the related English literature, this is the first reported case of peripheral compound odontoma with several teeth erupted in the gingiva.The patient, a 15-year-old girl was referred to the Stomatology Clinic of Alfenas Federal University with the complaint of “denticles on the gingiva”. The patient reported that when she was 12 years old, she perceived the emergence of small asymptomatic mass in the anterior maxillary region and one year later multiple denticles erupted at the injury site. During the intraoral examination, the residual root of a deciduous tooth that had been destroyed by caries lesions and six small tooth-like structures were found exposed in the anterior left gingiva between the permanent maxillary lateral incisor and canine teeth Figure A. These Postoperatively there was no complication and the suture was removed ten days after surgery. At this time, there was satisfactory healing of the operated region. After one month, the patient showed complete healing of the lesion and the gingival contour in the region of the lateral incisor and canine teeth had been fully restored Figure . After tOdontomas are generally asymptomatic lesions and they constitute causal findings in the course of routine radiological studies, particularly in the second and third decades of life . CompounPeripheral or soft tissue odontomas are extremely uncommon with about twelve compound odontomas reported in the related English literature, including the present case, as summarized in Table Although peripheral odontomas have a limited potential for growth, Ide; Shimoyama; Horie, (2000), the case here reported reinforces the idea that if the lesion had not been surgically removed in early developmental stage, it might have erupted into the oral cavity. The eruptive mechanism of peripheral odontoma remains uncertain and it appears to be different from tooth eruption because of the absence of periodontal attachment in odontomas .The majority of erupted odontomas described are intraosseous and related to non-erupted teeth -5. ThereOn the other hand, the exposure of denticles from the peripheral compound odontoma in the gingiva, as illustrated in the present case, could represent a tendency to exfoliation, as suggested by Shekar et al., due to its growth over time, rather than a real process of tooth eruption.Histopathological analysis showed that the tooth-like structures were composed of enamel, dentin, pulp chamber, and cementum in the same order of arrangement as that in a normal tooth. These structures were surrounded by thin epithelium and embedded in dense fibrous connective tissue, demonstrating their peripheral origin. The rudimentary denticles that had erupted from the odontoma had a fragile insertion into the gingival tissue which was clinically confirmed by accentuated tooth mobility. The fibrous connective tissue contained mononuclear inflammatory infiltrate and bacterial colonies was clinically characterized by inflammation of the gums due to the presence of dental biofilm, probably caused by the difficulty of cleaning in the region.In summary, due to the rare occurrence of peripheral odontomas, the present case is the first report of an erupted peripheral odontoma. However, it is necessary for dentists to be aware that peripheral odontomas, if not removed early, may enlarge over time and eventually erupt in the oral cavity, compromising both periodontal health and esthetics. Moreover, it is important to note that the increased tooth mobility caused by these lesions may result in the spontaneous exfoliation of these denticles, which may lead to the patient swallowing them.This is the twelfth reported case of peripheral odontoma in the gingiva and the first one that erupted in the oral cavity.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.JACH operated and monitored the patient. DTO performed the microscopic diagnosis and assisted in drafting of paper. NGG accompanied the clinical case and drafted the article. MRGS accompanied the clinical case and drafted the article. AACP assisted in the surgery. All authors read and approved the final manuscript.


Primary cerebral intra-axial epithelioid angiosarcoma is an extremely rare malignancy. To the best of our knowledge we describe the first case of epithelioid angiosarcoma arisen in the septum pellucidum of a 54-years-old man. Albeit extremely rare, this neoplasia is a potential source of misdiagnosis for other aggressive malignant tumors, and it should be taken into consideration. Primary epithelioid angiosarcoma of the central nervous system (CNS) is an extremely rare malignancy; only one case was reported in literature showing immunoreactivity to epithelial markers . Here, wThe patient was a 54-years-old man presenting with severe headache and vomiting that lasted for three days. He showed signs of mental confusion and progressively worsening neurological symptoms. A CT scan performed in the emergency department showed a triventricular hydrocephalus associated with a solitary hemorrhagic lesion involving the septum pellucidum. The patient was treated with an external ventricular drainage that resulted in a prompt improvement of the clinical symptoms. A few days later, an MRI scan confirmed the presence of an inhomogeneous mass both in T1 and T2 WI, showing a strong enhancement after gadolinium injection. The lesion extended also into the third ventricle, thus causing a severe stenosis of both Monro's foramina. The patient was submitted to a right frontal craniotomy and, through a transcallosal approach, to a gross total excision of the bleeding neoplasm. Furthermore, a wide septostomy was performed, leaving the left external drainage in place. During postsurgical course, a total body-CT scan excluded the presence of neoplastic lesions other than that in the CNS. The tumor showed a rapid regrowth, and repeated further bleedings with consequent ventricular dilation, which required a right ventricular external drainage. About two months after surgery, the patient deceased, but an autoptic examination could not be performed.The histological examination highlighted an extensively necrotic and hemorrhagic neoplasms composed of large, pleomorphic, round to polygonal epithelioid cells, with vesicular and central to eccentrically located nuclei, prominent nucleoli and abundant eosinophilic cytoplasm Figures . NeoplasThe occurrence of a cerebral epithelioid angiosarcoma represents a rare event; however, several entities should be considered in the differential diagnosis. In this case, the location of the lesion and its histological epithelioid appearance suggested to take into account a diagnosis of anaplastic ependymoma. Further, ependymomas may be immunopositive for cytokeratins . HoweverAs previously stated, only one case of primitive cerebral epithelioid angiosarcoma expressing epithelial markers has been published in the literature : the neoIn conclusion, cerebral primitive epithelioid angiosarcoma, albeit extremely rare, could be considered as a potential source of misdiagnosis for other aggressive malignant tumors of the CNS.


Splenic metastasis is generally not a common clinical event. However, metastasis to the spleen from adrenal pheochromocytoma is extremely rare and has not been reported in literature. This report presents a case of a 58 year-old male patient who developed spleen-only metastases in July 2007. The patient had a previous history of left epinephroectomy for adrenal pheochromocytoma in January 2003. Abdominal computed tomography demonstrated multiple enhancing lesions suggestive of metastases; thus splenectomy was performed. Pathological examinations confirmed the diagnosis of splenic metastases from pheochromocytoma. The patient was alive without recurrence 48 months after splenectomy. This study is the first report on splenic metastasis from previous adrenal pheochromocytoma, and long-term survival was achieved by splenectomy. A history of malignancy indicates a high index of suspicion for splenic metastasis, and long-term survival can be achieved by splenectomy for spleen-only metastasis. Written informed consent was obtained from the patient.In January 2003, a 54 year-old Chinese male patient underwent from left epinephroectomy for adrenal pheochromocytoma. Postoperative histological examination showed pheochromocytoma with adrenal capsule invasion. Given this information and associated increased risk of recurrence, he received a follow-up of abdominal ultrasonography every six months postoperatively and remained disease-free for the next 54 months.In July 2007, splenic lesions were incidentally discovered via follow-up ultrasonography. Meanwhile, an increase in the fasting blood glucose (7.15 mmol/L) was also observed. The remainder of the laboratory tests, including liver and renal functions, blood cell counts, and epidemiological tests, was normal. Further abdominal plain computed tomography (CT) scans demonstrated an enlarged spleen with low-density and ill-defined lesions. Contrast-enhanced CT scans showed multiple moderately enhancing nodules that are suggestive of metastasis (The removed spleen macroscopically measured 15 cm × 11.5 cm × 6 cm. Serial slicing indicated grayish-white multiple nodules. The largest and smallest nodules measured 4.5 and 2 cm, respectively. Splenic metastases from pheochromocytoma were microscopically confirmed, and synaptophysin and chromogranin A were stained positive by immunohistochemistry. The tumor did not reach the splenic capsule, and no evidence of splenic hilar lymph node involvement was observed.A post-splenectomy follow-up was performed every six months via abdominal ultrasonography or CT scan. The patient was still alive without recurrence 48 months after splenectomy on July 2011.Pheochromocytoma usually originates from the adrenal medulla with pathological over-secretion of catecholamine, and only 10% of patients manifest malignant tumor,-Splenic metastasis is exceptionally rare. Several hypotheses have been proposed to explain the rarity of splenic metastasisThe wide and varied causes of splenic lesions present a diagnostic challenge. A splenic mass without any history of malignancy suggests a primary lesion, such as lymphoma, vascular tumors, or infectious lesions. By contrast, any past or present history of malignancy indicates a high index of suspicion for a splenic metastasisSplenic metastasis tends to have no clinical importance because it is often found in the context of disseminated malignancy. However, splenectomy is recommended in cases of isolated splenic metastases, which can achieve increased patient survivalIn conclusion, splenic metastasis in pheochromocytoma is extremely rare. It is incidentally detected on follow-up imaging findings without any symptoms. A long-term survival can be achieved by splenectomy in cases of spleen-only metastasis.


We present the case of a man with a leiomyosarcoma of the base of the tongue. We feel this case is important as this kind of pathology, though rare, can occur at a site where carcinomas are more frequent.A 77-year-old Caucasian man had been reporting difficulty in swallowing and hoarseness for a month before admission to our department. After several preliminary tests, including a biopsy which was positive for a malignant epithelial neoplasm which required further immunohistochemical study, we decided to operate, removing the base of our patient’s tongue and performing a total laryngectomy. Histological examination of the specimen revealed a high-grade leiomyosarcoma of the base of the tongue and of the free edge of the epiglottis.We wish to stress the rarity of this clinical case, related to the site of implantation of the tumor, as confirmed by the difficulties in finding reference to this topic in the international literature. In fact, several cases of leiomyosarcoma have been described, but in different locations from that seen in our patient’s case. Soft tissue sarcomas account for approximately 0.7 percent of all malignant neoplasms, and leiomyosarcomas have been reported to account for 3 percent to 7 percent of soft tissue sarcomas ,2. The mWe present the case of a 77-year-old Caucasian man with a leiomyosarcoma of the base of the tongue. He had reported difficulty in swallowing and hoarseness for a month before admission to our department. He also reported a history of dyspnea during exercise and chronic obstructive pulmonary disease (COPD) treated with salmeterol 50μg (two puffs/day). He was a long-term smoker, with lipid disorders and allergy to aspirin.Endoscopy and a computed tomography scan showed a mass on the basis of the tongue Figure , on whicOur patient was hospitalized and underwent surgery. Before the operation, we performed a percutaneous endoscopic gastrostomy (PEG) procedure to facilitate the nutrition of our patient after the intervention, since removal of the tongue base can be associated with difficulties in swallowing.After insertion of a central venous line in the right subclavian vein our patient underwent surgery consisting of a tracheostomy performed under general anesthesia, preparation of a cervical flap, bilateral neck dissections (levels 2 to 4) on which an extemporaneous examination was performed (proving negative for lymph node metastases), isolation of the hypoglossal nerves and examination of their entry into the tongue base to preserve these structures, total laryngectomy extended to the base of the tongue, preparation of a myofascial flap of the left pectoralis major muscle (chosen because our patient is right-handed) and its positioning at the base of the tongue, placement of drainages and trachea tube and dressing.The definitive histological examination performed on surgical specimens Figure  showed lOur patient had a regular post-operative course and was discharged from our clinic, able to use both PEG enteral and mouth feeding.To date, about eight months after surgery, our patient remains disease free.Leiomyosarcoma is a malignant neoplasm that originates from smooth muscle. It frequently occurs in the uterine myometrium, gastrointestinal tract, retroperitoneum, skin and subcutaneous tissue. It rarely occurs in the head and neck, probably because of the paucity of smooth muscle tissue in these sites . The mosPrimary leiomyosarcoma of the tongue is a rare lesion. The cause of leiomyosarcoma remains unknown, although cases have been associated with trauma, estrogenic stimulation, ionizing irradiation and Epstein-Barr virus ,12. DiagTable The age of these patients ranged from one to 80 years with a peak between the fifth or sixth decade of life, and there seems to be a slight gender predilection for men as seen in our experience. The sites of origin of the tumor lesions in the tongue include the tip, the lateral border and the base Figure . It is iThe main treatment is excision with sufficient tumor free borders and post-operative irradiation when necessary. Radical neck dissection is reserved for cases with regional node involvement. Chemotherapy is generally reserved for palliative care and occasionally improves the survival time and quality of life of patients with metastatic disease or inoperable tumors .The prognosis of oral leiomyosarcoma affecting the tongue is good if clear excision can be achieved.In our patient’s case, we decided to treat the tumor surgically by removing the base of the tongue after planning at the beginning of treatment the preparation and placement of a myofascial flap of major pectoralis muscle to the remaining tongue in order to limit post-intervention swallowing problems from loss of the muscle tissue involved in swallowing. In the same way, in the light of possible post-operative complications, total laryngectomy was performed together with the removal of the base of the tongue due to the high risk of aspiration related to swallowing problems after partial laryngectomy in our patient with chronic obstructive pulmonary disease (COPD).Our decision to remove the bilateral laterocervical lymph nodes was dictated by the response of the biopsy, which did not indicate sarcoma, but carcinoma; the high risk of bilateral lymph nodes metastases from base of the tongue carcinomas is well known.In addition, after a multidisciplinary consultation we decided not to subject our patient to radiotherapy; this was in light of observation of the negative margins of the surgical specimen, and respecting the wishes of our patient. This decision could possibly be questionable, given the tendency to local recurrence of sarcoma.The number of reported cases of this malignant lesion of the tongue remains extremely small, but it is interesting to underline that our patient is the oldest man among the cases reported and his base of the tongue tumor was treated surgically.Our surgical choices were based on the characteristics of lesions , but also on the overall health of our patient.Further data about these rare cases are needed to better understand their features in the future.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available if required by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.All authors contributed to the manuscript writing. All authors read and approved the final manuscript.


Although it is one of the most common benign tumors of bone in the axial skeleton, the osteochondroma is relatively rare in the maxillofacial region. Its discovery on the coronoid process is even more rare. First described by Jacob in 1899, it remains a rare entity as only a few reported cases have been described in the literature. Nevertheless, the symptomatic features remain relatively nonspecific: limited opening, tightness, and slight expansion of the affected area with or without pain. The demographic features are more established, as it affects younger males. Definitive diagnosis is made after histological analysis, post-resection of the growth. We report a 27 year-old male with a history of limited opening and tightness of the mouth. Computed Tomography (CT) imaging revealed a well corticated exophytic protuberance from the left coronoid process. Left coronoidectomy and excision of the exophytic growth was performed, and was confirmed by histologic analysis to be an osteochondroma, demonstrating Jacob's disease.  One of the most common benign tumors of bone is an osteochondroma, an osteocartilaginous exostosis. With its characteristic mushroom shape and cartilage-capped projection, it is a common tumor of the axial skeleton that is found most frequently in the metaphysis of the femur and tibia , 2. Its Jacob's disease is a benign skeletal tumor referring specifically to the formation of an osteochondroma of the mandibular coronoid process. While this tumor is relatively rare throughout the body, it is even more rare in the maxillofacial region and, specifically, on the coronoid process . AlthougWhether unilateral or bilateral, a common sign is expansion of the zygoma/zygomatic arch , accompaRegardless of etiology and demographics, the treatment of Jacob's disease remains coronoidectomy and excision of the tumor , with reA 27-year-old male was referred for evaluation and possible surgical treatment due to limited opening on the left side. The patient had experienced some pain and asymmetry on his left side. Physical examination revealed an interincisal opening of 10 mm  and leftThe patient was taken to the operating room and, after fiberoptic nasal intubation, was prepped and draped for transoral incisions. The first incision was made with a Bovie electrocautery along the left ascending ramus down to the body of the mandible. Subperiosteal dissection was carried out superiorly to the sigmoid notch and lower portion of the coronoid. A Bauer retractor was placed in the sigmoid notch in order to allow for direct visualization of the coronoid process. With a reciprocating saw, the coronoid process was osteotomized. Careful dissection allowed for removal of the attachments of the inferior portion of the coronoid process. A second incision was then made in the left maxillary vestibule, and a full-thickness mucoperiosteal flap was raised exposing the buttress and zygomatic arch. The osteochondroma was palpated and, using blunt dissection, was released from its attachments to the zygoma down to the coronoid and the whole process removed together . Histopathologic analysis was consistent with the dense bone and associated portion of cartilage. Postoperatively, after physical therapy with Therabite, the patient was able to obtain an opening of greater than 40 mm . Osteochondroma is a benign tumor of bone and cartilage that is more commonly seen in the axial skeleton than in the maxillofacial skeleton. This cartilage-capped mushroom-like growth is usually first noted during routine radiographic examination or during palpation of the affected area . Any of Although extraoral approaches have been advocated in the past , 15, we


Introduction. Gossypiboma (GP) is a term used to express the mass resulting from forgotten cotton sponge in operations. Rarely, a transmural migration may occur into the gastrointestinal lumen without creating any defect by GP. Laparotomy or endoscopic removal may be required, by the way it can be taken out of the body itself by intestinal ways. In this study, we reported a case of mechanical intestinal obstruction causing GP. Case. The fifty-one-year-old female patient admitted to the emergency department with the complaints of mechanical intestinal obstruction and had a history of open cholecystectomy 20 years ago. There were the findings of intestinal obstruction in abdominal plain radiography and computerized tomography. The sponge that obstructed the lumen completely 40 cm proximal to the ileocecal valve was identified in the laparotomy with the diagnosis of brid ileus. The small intestine was closed over double-fold after removal of sponge. Transmural migration of abdominal-remained sponge was thought to be occurred without creating a defect after cholecystectomy. Postoperatively, the patient was discharged without having any problems at 4th day of hospitalization. Conclusion. Although it is a rare situation in routine clinical practice, GP should be considered as a differential diagnosis in the patients who had a diagnosis of mechanical intestinal obstruction, and laparotomy was applied before. As GP may lead to situations which cause mortality, all precautions should be taken to prevent it. Gossypiboma  (GP) is a term used to express the resulting in mass by the remained nonradiopaque cotton sponge or forgotten abdominal compress device in operations. “Textiloma” or “cottonoid”  is also used for expression  . DeclaraThe female patient, fifty-one-year-old, admitted to the emergency department with the complaints of mechanical intestinal obstruction, such as nausea, vomiting, abdominal pain, abdominal swelling, and obstipation. The patient also had a history of open cholecystectomy 20 years ago. On physical examination, common abdominal distention and right subcostal incision were seen together. Hyperreactivity of intestinal sounds was heard in auscultation. There was no defense and rebound on palpation. And also, there was no abnormality in laboratory investigations. Air-liquid levels were seen on abdominal plain radiography. On abdomen computed tomography (CT), there was a dilatation in the small intestine at the level of terminal ileum, and there was an obliterating lesion at terminal ileum . The patThe risk factors such as emergency operations, exigency of applying unexpected surgical procedure, obese patient, poor organization, quick sponge count, failure in sponge counting, long operations, unstable patients and operations of the assistants were identified for abdominal-forgotten-sponge , 5. GP mRadiologic diagnosis of sponge is difficult without a radiopaque marker. It can be detected directly in X-rays when radiopaque marker is available. Especially in chronic cases, because of the probability of imitating the malignant mass, ultrasonography (USG), CT, or magnetic resonance imaging may be necessary. It is able to give us confirmatory evidence, in case we suspected a sponge remained in abdomen. In this patient, ileus was determined by taking abdominal X-ray and CT. In CT, spongiform structure containing the cystic lesions, air bubbles, hyperdense capsule, and spotted calcifications can be seen characteristically inside GP. The mass has got the features in the form of demarcated, hypoechoic sided, strong acoustically shaded, undulated internal echogenic focus in USG , 7. In tA sponge that is remained in abdomen may result in perforation of intestine or other organs, obstruction, sepsis, and even death. Additionally, it may migrate to ileum, stomach, colon, and bladder without creating any defect on surface of those. Migration to intestine may cause partial or complete obstruction and bleeding due to erosions of the mucosa. Besides, migration to bladder may result in urinary problems. Some patients can be detected incidentally after staying asymptomatic for many years. Another possibility is excretion of the sponge with peristaltic movements via rectum spontaneously, after its migration to any part of intestine . DefecatAlthough GP is a rare situation in routine clinical practice, it should be considered as a differential diagnosis in the patients who had a diagnosis of mechanical intestinal obstruction and laparotomy was applied before. As GP may lead to situations which cause mortality, all precautions should be taken to prevent it. This situation, depending on human fault, can be minimized by staff training, even though it is not prevented entirely.