Pituitary adenomas are the most common cause of a sellar mass. Metastases to the pituitary gland, a rare occurrence, may mimic benign pituitary adenomas. We report here a case of a 61-year-old woman with an 80-pack-year smoking history who presented with headache and diplopia. Visual field testing demonstrated bitemporal hemianopsia. Pituitary MRI revealed a 2.0 cm sellar mass impinging upon the optic chiasm. Hypopituitarism was present, with no evidence of diabetes insipidus. The patient was referred to our service for transsphenoidal resection of a presumed pituitary macroadenoma. As part of her preoperative evaluation, a chest radiograph was obtained, which showed a large hilar mass. In light of the patient's extensive smoking history, the differential diagnosis was expanded to include metastatic lesion to the sella. Transsphenoidal resection of the tumor was performed and histopathology revealed small cell carcinoma. The patient received chemotherapy, but died 18 months later due to widespread brain metastases. Although the presence of diabetes insipidus may help to discriminate between pituitary adenomas and metastatic lesions, this is not a sensitive finding. This case illustrates the need for maintaining a high index of suspicion for pituitary metastasis in patients with known risk factors for malignancy. The most common cause of an intrasellar lesion is a benign pituitary adenoma . These tWe present the case of a 61-year-old woman with an eighty-pack-year smoking history who developed fatigue, anorexia, nausea, and a 11 kg weight loss over the course of one month. She complained of new-onset frontal headaches, requiring acetaminophen twice daily, and nausea, mitigated by prochlorperazine. Prior to these symptoms, she was very active and was employed at a steel mill. She initially attributed her symptoms to a viral illness, however within a few days she began to experience diplopia and diminished visual acuity and sought evaluation from her regular optometrist. She was noted to have raised intraocular pressure and was referred to our eye emergency room. An ophthalmology exam confirmed that she had raised intraocular pressure and bitemporal hemianopsia by perimetry. Magnetic resonance imaging demonstrated a 2.0 × 1.2 × 1.1 cm bilobed homogeneous enhancing mass expanding the sella with compression of the optic chiasm, suggestive of a pituitary adenoma .The patient had a history of hypothyroidism subsequent to radioactive iodine therapy for Graves' disease. She was taking levothyroxine, and her previous thyroid function tests had been normal. She denied galactorrhea, bruising, acne, or striae. She had noted increasing thirst but denied polyuria. She felt that her shoes were slightly tighter, but she had no overt features of acromegaly. Trace pedal edema was noted. Although the patient had a history of hypertension, she had recently been experiencing postural hypotension off of all of her antihypertensive medications. Clinically, there was no evidence of a functioning pituitary tumor, though there was a clear concern about adrenal insufficiency.A hormonal evaluation showed serum prolactin 92.1 ng/mL , morning cortisol 4.6 mcg/dL (4.3–22.4), LH <0.2 mIU/mL, FSH 1.6 mIU/mL, estradiol <20 pmol/L , IGF-I 133 ng/mL (114–492), TSH <0.01 mIU/mL (0.5–4.7), and free T4 1.36 ng/dL (0.8–1.7). Serum sodium was 135 mEq/L, and potassium was 4.6 mEq/L.A preliminary diagnosis of a nonsecretory pituitary macroadenoma was made, with evidence of gonadotropin deficiency and probable central adrenal insufficiency. The hyperprolactinemia was attributed to stalk compression rather than a prolactinoma, as the prolactin level would be expected to be greater, typically above 200 ng/mL, in a prolactin-secreting tumor of this size. The possibility of the “hook effect” causing underestimation of the prolactin level was excluded by obtaining a diluted prolactin level . Since t This case illustrates the importance of considering pituitary metastasis on the differential diagnosis of a sellar mass. Our patient was initially suspected of having a benign pituitary adenoma, by far the most common cause of a sellar lesion. Were it not for a routine chest radiograph obtained prior to transsphenoidal surgery, her diagnosis of lung cancer would have been made unexpectedly on pathology. Pituitary metastases are rare with an incidence of 0.14% to 28.1% of all brain metastases in autopsy series and 1% to 3.6% of patients with cancer . They acIn the case of both primary and metastatic pituitary tumors, hypopituitarism may ensue from compression of the hormone-secreting cells of the anterior pituitary gland. Making the distinction between a pituitary adenoma and malignancy can be difficult, since the systemic complications of malignancy, including anorexia, weight loss, and vomiting, may overlap with anterior pituitary deficiencies, such as adrenal insufficiency. One helpful feature that points to the presence of a metastatic pituitary lesion is diabetes insipidus (DI), since only 1% of pituitary adenomas present with DI whereas up to 70% of metastases do so . This diTreatment options for metastatic pituitary lesions include surgical resection, radiation, and chemotherapy. The decision to perform surgery should be based on the clinical presentation, overall prognosis, and extent of the systemic disease. In our case, since a concurrent nonsecretory pituitary adenoma could not be ruled out conclusively on the basis of a lung biopsy alone, surgical decompression was performed with the intention of preserving vision and relieving her headaches, and also to establish a diagnosis. Indeed, after surgical debulking, her headaches and vision significantly improved. An alternative approach might have been transsphenoidal biopsy to confirm the metastasis from SCLC, followed by local radiation and systemic chemotherapy; however, biopsy of a sellar lesion is also high risk.External radiation and/or chemotherapy may be used after surgery. The prognosis is generally poor, with some series showing a 10% 1-year survival . FeatureThe sudden onset of headache, ophthalmoplegia, or diabetes insipidus in a patient with risk factors for malignancy should raise suspicion for metastasis to the pituitary . While d


Introduction. De Garengeot first described a femoral hernia containing the appendix in 1731. Appendicitis occurring in this rare clinical setting represents a challenge in diagnosis and management. Case Presentation. We present the case of a 71-year-old male with a three-day history of a nontender inguinal mass. Computed tomography (CT) suggested a femoral hernia. Intraoperatively, the hernia sac was noted to contain a perforated appendix. Discussion. This is an infrequently reported clinical scenario and only the 14th reported case in peer-reviewed literature which includes preoperative CT images. Our case adds to previously reported low sensitivity of CT for diagnosing De Garengeot's hernia. Furthermore, unlike our case the vast majority of previous reports noted a painful inguinal swelling. Conclusion. Perforated appendicitis in a femoral hernia is an extremely uncommon presentation. However, consideration should be given to De Garengeot's hernia in patients with a groin mass, even if nontender. De Garengeot's hernia is named after the 18th century Parisian surgeon Rene Jacques Croissant De Garengeot (1688–1759) .9/L. Renal and liver function tests were within normal limits. The provisional diagnosis was one of right inguinal lymphadenopathy. Computed tomography (CT) imaging was arranged  in the lower half of the midline laparotomy wound. This was treated successfully with intravenous antibiotics. The patient was discharged home well two weeks after procedure for followup in outpatients. Subsequent histological examination of the appendix confirmed acute perforated appendicitis.In the United States alone there are an estimated 27,000 cases of femoral hernia annually, accounting for 3% of all hernias. The appendix is noted as within the femoral hernia sac in less than 1% of these [Our case presented some interesting diagnostic challenges. The patient did not report any abdominal pain, and furthermore on examination the groin mass was not tender as might be clinically expected. A previous case series of 36 patients with De Garengeot's hernia noted the presence of a right groin mass in 97% of cases. However, the vast majority of these (97%) were painful, with only one patient presenting with a nontender mass as was the case with our patient .The majority of patients presenting with De Garengeot's hernia are brought directly to surgery with the diagnosis of incarcerated femoral hernia made based upon clinical exam , 4.Computed tomography findings of De Garengeot's hernia classically demonstrate intramural air density in an incarcerated hernia which indicates intestinal involvement but lacks obstruction of the small bowel , 6. In tPrevious alternative management options have included incision and drainage with delayed appendectomy . In our Perforated appendicitis in a femoral hernia sac is an extremely uncommon presentation. However consideration should be given to De Garengeot's hernia in patients with a groin mass, even if nontender. This is only the 14th reported case with preoperative CT imaging. Preoperative imaging may be beneficial in diagnosing a femoral hernia; however, sensitivity for CT diagnosis of appendicitis within the hernia would appear to be low.


Thymoma, the most common neoplasm of the anterior mediastinum especially in adults, accounts for 20-25% of all mediastinal tumors and 50% of anterior mediastinal masses. These tumors are routinely asymptomatic for prolonged periods of time. Pericardial tamponade is a very rare initial manifestation of a thymoma. This report presents a patient who had hemorrhagic pericardial tamponade that likely resulted from the largest symptomatic mixed type (type AB) thymoma described in the literature. The thymus gland usually is found overlying the pericardium and great vessels in the anterior mediastinum. Tumors of the thymus, namely thymomas, may be of the benign or malignant variety. Of patients with a thymoma, one third to one half are asymptomatic, and one third of patients present with local symptoms related to the tumor encroaching on surrounding structures. Most tumors of the mediastinum are diagnosed accidentally by the routin chest x-rays. Chest pain, cough, dyspnea, myasthenia gravis, and weight loss are observed frequently in symptomatic patients. Pericardial effusion may be present in approximately 20% of cases. However, spontaneous hemorrhagic pericardial effusion is an unexpected clinical feature -3. TumorA 28-year-old man was admitted with sudden onset and severe complaints of orthopnea and palpitations because of a pericardial tamponade resulting from a massive pericardial effusion. He didn't complain any myasthenic symtom like muscular weakness, fatigability, diplopia etc. and trauma in his previous history. The pulse was rapid and weak (142 beats/min), and the neck veins were distended. The electrocardiogram showed sinus tachycardia and low voltage. The blood pressure was 80/60 mmHg. Chest x-ray showed that slightly widened cardio-thoracic index (0.62) and mildly expanded superior mediastinum. Laboratory findings were normal. Echocardiography showed biventricular collapse because of the widespread 4,5-cm pericardial effusion with anterior mediastinal mass. After the evacuation of pericardial hemorrhagic fluid (550 cc), the collapse disappeared, and the patient's symptoms were relieved entirely. The hematocrit value of the pericardial fluid was 36,1%. Cytological and bacterial evaluations were unremarkable. Recurrent pericardial effusion was observed twelve hours later without collapse. Computed tomography (CT) scans showed a huge antero-superior mediastinal mass with rough and longest dimensions of 17 × 12 × 7 cm; the exact dimensions could not be calculated because of the possible invasion into the pericardium, the innominate vein, the superior caval vein (VCS) and the sternum (Figure Hyperplasia, thymoma and hematopoietic neoplasms are the most common causes of thymic enlargement. The overall incidence of thymoma is rare, 0.15 cases per 100.000 ,4,5. SusThymomas account for approximately 20-25% of all mediastinal masses in people of all ages and 47% of all mediastinal masses in adults. These tumors are frequently asymptomatic -3. AlthoBecause complete resection and the type of the tumor are the most important factors determining prognosis, the resection should be performed with regard to pathological evaluation for thymic enlargements as much as possible. In this case, because of the size and the dissemination characteristics that were revealed by the CT scans, pericardiectomy and resection were unavoidable. Other diagnostic techniques, such as needle biopsies or VATS, were not used. Because of the pathological similarities between lymphoma and thymoma, we resected the tumor as much as possible, but according to the frozen sections, we did not achieve total resection. Additionally, lymphoma is more likely in this patient because of his age.The presence of hemorrhagic pericardial tamponade without any history of chest trauma or any coagulation abnormality, thymic pathologies should definitly be suggested at first sight. Also, to the best of our knowledge, this thymoma is the largest one reported that has been diagnosed based on the sudden onset hemorrhagic pericardial tamponade as an initial symptom. We believe that CT scanning should definitely be performed for all pericardial effusions with unknown ethiology. If thymoma is a possible diagnosis, the first aim in surgical therapy should be total resection since the heterogenity of thymomas pathologic structure. Histological heterogenity of thymomas may cause misdiagnosis since some parts involve lymphocitic and some parts thymic dominancy as in our case.The authors declare that they have no competing interests.MSB drafted the manuscript. OG conceived the study and participated in its design and coordination. AK collected data about the patient. YY participated in the patient follow-up. AÇ participated in the study design and coordination. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Simultaneous positron emission tomography (PET) and magnetic resonance imaging (MRI) is a new whole-body hybrid PET/MR imaging technique that combines metabolic and cross-sectional diagnostic imaging. Since the use of MRI in imaging of soft-tissue sarcoma is extremely beneficial, investigation of the combined PET/MRI is of great interest. In this paper, we present three cases and first data. Combined PET/MRI technique can support the process of clinical decision-making and give answers to some meaningful questions when treating patients with STS. Therefore, the combined modality of simultaneous PET/MRI offers new pieces to the puzzle of sarcoma treatment. Simultaneous positron emission tomography (PET) and magnetic resonance imaging (MRI) is a new whole-body hybrid PET/MR imaging technique that combines metabolic and cross-sectional diagnostic imaging. Recently, Buchbender and colleagues  presenteTo further address the potential benefit of combined PET/MRI in a disease, where the soft-tissue contrast in MRI could be extremely beneficial, we want to present our first data and discuss further fields of research.FDG-PET and PET/CT have been widely investigated in staging and restaging of sarcoma , 3. PET/Previously it has been demonstrated that FDG-PET and FDG-PET/CT can be used to predict metastases-free survival in patients with sarcoma of the extremities treated with neoadjuvant chemotherapy (CTX) , 14. PETMRI is the widely recommended and most valuable imaging technique for soft tissue sarcoma. It preferably gives additional information compared to a CT scan. MR imaging allows superior contrast imaging which can especially contribute to the preoperative situation. It also appears superior in delineating vascular and neural structures from tumour tissue. MRI has also been superior to CT in certain sarcoma subtypes with unique metastatic patterns. Schwab et al. strongly supported the use of MRI to more accurately detect spinal metastases in myxoid liposarcoma . MoreoveWe present first findings using combined PET/MRI technique to support the process of clinical decision-making. In this brief report, by presenting three case reports we want to focus on some meaningful questions when treating patients with STS.There is some evidence for the use of perioperative CTX, especially in younger patients. Several studies have shown conflicting results about adjuvant CTX in STS. Whereas some were in favor of CTX , other rTherefore, the treatment guidelines of sarcoma research and treatment organizations have recommended a shared decision-making process considering among others age, tumour-subtype, grading, and size . Accordi Nonetheless, there are still some problems and uncertainties about the neoadjuvant therapy. There is a substantial risk of progression with a potential risk of losing the chance of complete resection. Also, there are difficulties in the interpretation of response. RECIST criteria often do not match with clinical and histological responses to therapy. Cell death cannot be detected by conventional MRI diameter. Response in sarcoma can also occur with cystic changes that can mimic progressive disease.Case 1. A 51-year-old man presented with a rhabdomyosarcoma of the proximal thigh. The tumour measured 13 × 18 × 21 cm by CT scan with suspected metastases in the lung, lymph nodes, and bone. In order to improve knowledge about the actual tumour stage and plan possible multimodal treatment, functional imaging was additionally performed. PET/MRI showed a markedly elevated SUV uptake in the primary tumour  and less activity in the inguinal lymph nodes   . After tIt was decided to cancel further neoadjuvant treatment due to progression in size and move forward to resection. In the pathological report the tumour had 40% necrosis. Regional lymph nodes, which had been attributed to metastatic disease, were not involved. So far, there are no data of functional activity of the primary tumour compared to metastases in the same patient. Due to the discrepancy in activity of 4,0 in our patient, FDG-PET could help to distinguish between reactive and metastatic lymph nodes. Also, addition of a functional component could help to early detect responders in patients receiving neoadjuvant therapy. In this case, considering PET criteria could have given evidence to continue neoadjuvant systemic therapy. As outlined earlier, FDG-PET can give additional meaningful information for the decision-making process, but by today it cannot be considered the standard of care.The main goal in palliative treatment of patients with STS is to reduce symptom burden and prolong progression-free or even overall survival. In light of emerging therapeutic options, it is important not to stick to futile therapeutic regimens.Case 2. A 68-year-old patient presented with a recurrent, rapidly growing and inoperable G3 liposarcoma of the oropharynx. Primary resection and adjuvant radiotherapy had been completed one year before. After the initial CTX with epirubicine and ifosfamide the tumour remained stable (9 × 5 × 3 cm). The clinical problem was that a progressive tumour would rapidly cause a blocking of the airways. We therefore decided to use combined PET/MRI in addition to conventional imaging for early detection of tumour activity. After 6 months, the second followup showed a 67% increase in metabolic activity with no change in size at that time (hat time . We starCase 3. In a 68-year-old female patient, after previous gross resection and long-term stabilization of an abdominal/retroperitoneal highly differentiated liposarcoma MRI showed a massive progression within only three months with features like necrosis often seen in high-grade sarcomas. This was accompanied by pollakisuria due to compression of the bladder and severe abdominal pain. Transformation to a high-grade liposarcoma was suspected. Further biopsies would be at risk of not being representative for a tumour harbouring regions with a potentially different grading.The tumour was 23 × 19 × 10 cm in size, partly necrotic, and showed only a slight uptake of FDG . TherefoThe new combined PET/MRI technique offers some interesting and promising diagnostic and therapeutic information to all clinicians, which have to deal with a magnitude of individual scenarios of patients with soft tissue sarcoma. We report on one case, where PET/MRI was used to guide neoadjuvant treatment. This is even more important, since it has been formerly demonstrated that in neoadjuvant treatment of soft tissue sarcoma PET is superior to conventional imaging in predicting pathological response . Taking Furthermore, we report on a case with metastatic disease, where PET/MRI was able to contribute to the decision-making about the appropriate time for reinitiating chemotherapy. In clinical routine sometimes it might be of great value for the patient to anticipate the onset of progressive disease. Moreover, morphologic changes as part of response but mimicking progression defined by RECIST criteria may be misleading and prevent the patient from having clinical benefit by withdrawing an active drug.The third case demonstrates that in large and heterogeneous tumours PET/MRI can help to guide tumour biopsy or judge the grading and thereby assist the clinician when considering different therapeutic options , 29. So


Dermoid cysts are the most common orbital cystic lesions seen in children. While superficial orbital dermoid cysts present early in life, deep dermoid cysts remain clinically occult until adolescence or adulthood. We here present a case of a deep orbital dermoid cyst in a Nigerian child that became symptomatic early in infancy.A female Nigerian infant of Yoruba ethnicity presented at three months of age with left non-axial proptosis and a hazy cornea. A superotemporal cystic orbital mass was seen on ultrasonography, and her parents were counseled for simple tumor excision. They however defaulted, only for their child to re-present two years later with gradually progressive proptosis, an enlarged orbit and keratinized ocular surface, necessitating orbital exenteration.Deep orbital dermoid cysts may be symptomatic from birth. Late presentation may result in an irreversible loss of vision, as demonstrated in our case. The need for public enlightenment on early presentation and prompt management of such benign lesions is emphasized. Reporteet al.,7.Dermoid cysts are usually classified as juxtasutural, sutural or of soft tissue types, with further subdivisions, based on their relationship to the orbital bone and location within the soft tissues. HoweverOn histological examination, these tumors are seen as keratin-containing cavities surrounded by stratified squamous epithelial walls with skin appendages such as sebaceous glands and hair follicles.Dermoid cysts are generally benign noninvasive lesions that rarely cause orbital damage. However, a review by Bonavolonta and associates found thA three-month old female baby of Yoruba ethnicity presented to our Eye Clinic with gradually progressive left proptosis and a white spot noticed in her left eye from birth. She was the product of full-term pregnancy and normal vaginal delivery. She had no significant family history and an examination revealed an infant in good general health condition. She had left non-axial proptosis; a tense orbit; keratinized, hazy cornea; and inadequate lid closure. There were no masses palpable in her orbit. Ultrasonography revealed a 23mm superotemporal cystic mass with membranous speckled content in her left orbit, with a 9mm retro-ocular extension. Her left globe was distorted and irregular, but no intra-ocular mass was seen. Ocular axial length measurement with an amplitude modulation scan and computed tomography were not done due to financial constraints. She was scheduled for a detailed examination including intra-ocular pressure measurement, exophthalmometry and simple tumor excision under general anesthesia. The parents, however, defaulted.Our patient re-presented two years later with continued slowly progressive non-axial proptosis, worsening inadequate lid closure, corneal opacity and a keratinized ocular surface. A computed tomographic scan done at this time showed a huge, non-enhancing mixed density mass with areas of calcification. Her orbit was enlarged, with thinned walls, but no bone destruction was seen Figure a,b. She On gross pathologic examination her eyeball was surrounded by fibroadipose tissue and an extra-ocular tumor located posteriorly, measuring about 3×2×2cm in size. A cut section of the tumor revealed a cystic cavity containing hair shaft admixed with thick yellowish material and firm to hard tissue. Microscopic examination showed a cyst containing keratin material in the lumen, lined by keratinized stratified squamous epithelium. Sebaceous and sweat glands and hair follicles were associated with the wall (Figure Epidermal dermoid cysts are believed to develop from epidermal rest cells that get entrapped in the deeper tissues during embryonic development. This explains their tendency to occur in the orbit at sites of bony fusion, particularly along the zygomaticofrontal suture. Their net al.[Microscopic examination of such lesions reveals chronic granulomatous inflammation in the epithelial wall. These eet al.. One of et al. presenteet al..Late presentation has affected the management of many benign ophthalmic conditions in developing countries, and it is not unusual for the parents to have tried other remedies before finally presenting to the hospital or agreeing with the treatment offered. SuperstPreviously reported dermoid cysts in our environment,7 formedThere is an urgent need to educate the medical staff and general populace on these benign childhood orbital conditions and their uncommon presentation. Parents should be encouraged to present their children early to health facilities for treatment of this benign condition. This could have led to the preservation of visual function in our patient, and may preserve life in other potentially life-threatening conditions.Written informed consent was obtained from the patient’s father for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.OF analyzed and interpreted the patient’s clinical data regarding the ophthalmic condition. OGO performed the histopathological examination of the specimen, and was a contributor in writing the manuscript. Both authors read and approved the final manuscript.


NF-1 gene, a tumor suppressor gene located on chromosome 17q11.2. Hence, it can be considered as a familial cancer predisposition syndrome in which the affected individuals are at increased risk of developing malignancies. Intraoral neurofibromas associated with NF-1 are quite common, but the occurrence of malignant peripheral nerve sheath tumor (MPNST) in the oral cavity is very rare. Oral MPNST can occur either de novo or by malignant transformation of neurofibromas or very rarely can represent a metastatic lesion. Here, we present a case of MPNST involving the maxillary region, in a patient with NF-1. Since MPNST often creates a diagnostic dilemma, histopathologic criteria for the diagnosis of MPNST are also discussed.Neurofibromatosis-1 (NF-1) is a relatively common autosomal dominant disease characterized by multiple cutaneous fibromatoses and café au lait spots. It is associated with the mutation of  Oral neurofibromas are seen in 72% of the NF-1 patients.[The term “neurofibromatosis” refers to a group of genetic disorders that primarily affect the cell growth of neural tissues. Neurofibromatosis-1 (NF-1) is the most common type and accounts for about 90% of all cases. It is one of the frequent genetic diseases with a prevalence of 1 case in 4000 births.[patients. MPNSTs aWe report a case of multiple MPNST in a patient with NF-1, who presented with a swelling on the right maxillary region. Other sites involved include mediastinum, scalp and upper back region and all the lesions developed in a short span of 6 months.A 40-year-old male patient, a known case of NF-1, reported to our hospital with the complaint of a swelling on the right maxillary region in relation to upper back tooth. The swelling, initially noticed 3 weeks back, was small in size, but grew rapidly to reach the present size. He also gave the history of dull aching pain associated with the swelling. His past medical history revealed that multiple cutaneous nodules seen on the entire body Figures  were precafé au lait pigmentation was noticed on the axillary region and on the arms. A large pigmented macule was present on the right side chest [On general examination, the patient was poorly built and nourished. No pallor, icterus, cyanosis, clubbing, pedal edema or lymph node enlargement were noticed. Multiple cutaneous nodules of varying size were seen distributed on the entire body. Multiple de chest .On intraoral examination, an exophytic soft tissue mass measuring around 3 cm × 4 cm × 5 cm was present on the right alveolus in relation to 16 and 17. The lesion presented as a lobulated dumbbell shaped mass extending buccally and palatally. The buccal mass was found to be extending into the buccal vestibule, and the palatal mass involved the entire half of the posterior palate. The swelling was sessile, irregular in shape and normal in color. The surface was smooth with superficial candidal infection in some areas . On palpIntraoral periapical radiograph and orthopantamograph showed severe bone loss in relation to 16 and 17 with periapical radiolucency in relation to 16 .Based on the history and clinical examination, a provisional diagnosis of intraoral neurofibroma was given. Other diagnosis considered included MPNST, other mesenchymal neoplasms and odontogenic neoplasms.Incisional biopsy was done from the palatal aspect of the tumor. Microscopically, the lesion showed alternating fascicles of hypercellular and hypocellular areas arranged in a streaming pattern . The celThe patient was given radiotherapy for the oral lesion and was treated with 3000 cGy in 10 fractions. One month later, the patient developed similar lesions on the scalp and the right side of the upper back region and finally succumbed to death after 2 months.Neurofibromatosis, also known as VonRecklinghausen’s disease, named so after the person who described the disease in 1882, is an autosomal dominant disease of varied clinical manifestation. Two clinically and genetically distinct subtypes were identified and have been designated as NF-1 and NF-2.café au lait spots.[NF-1, otherwise known as the central form, is the most common single gene defect. It is clinically characterized by multiple neurofibromas along the peripheral nerves, optic gliomas, sphenoid wing dysplasias, pigmented iris nodules and hyperpigmented macular skin lesions known as it spots. All thesit spots. The neurThe peripheral nerve sheath tumors are the tumors arising from the nervous tissue outside the brain and the spinal cord. The term “malignant peripheral nerve sheath tumor” refers to all the spindle cell sarcomas arising from the peripheral nerve or neurofibroma or showing nerve sheath differentiation. Previously, various terminologies like neurogenic sarcoma, neurilemmosarcoma, malignant fibrosarcoma and malignant neurilemmoma had been used, but World Health Organization (WHO) has recently adopted the term “malignant peripheral nerve sheath tumor” to denote such tumors. MPNSTs aNF-1 gene, a tumor suppressor gene located on chromosome 17q11.2. This gene encodes a protein known as neurofibromin, which is believed to be important in the control of cell growth through their downregulation of ras gene product. Despite the fact that the precise chromosomal location of NF-1 gene of chromosome 17 is known, neither the primary defect in NF-1 nor the mechanism leading to malignant transformation is understood at the present time. Menon et al., based on their study, had proposed that an MPNST may result from several genetic hits. The first hit, a mutation in one or both copies of NF-1 gene, may lead to the formation of a benign neurofibroma. Additional genetic hits leading to the loss of one or both copies of tumor suppressor gene (p53 gene) on chromosome 17p may be required for the subsequent malignant transformation of a benign tumor.[Association of MPNST with NF-1 is well established. Around 40% of the MPNST cases were found to be associated with neurofibromatosis, though agn tumor.The diagnosis of MPNST is considered to be the most difficult and elusive in the soft tissue disease due to lack of standardized criteria. The clinDiagnosis of MPNST by histopathologic analysis is often complicated by its resemblance to other spindle cell sarcomas like fibrosarcoma, malignant fibrous histiocytoma, leiomyosarcoma and monophasic synovial sarcoma. However, certain histological features which are characteristic of MPNST (summarized in 3MPNSTs are locally invasive lesions, frequently leading to multiple recurrences and eventual metastasic spread. This tumPrognosis of MPNST is poor and survival is found to be influenced by tumor location, size and association with NF-1. The presence of neurofibromatosis negatively affects many of the clinicopathological features of MPNST, and survival has been reported to be worse for patients with neurofibromatosis. In our cNF-I may be considered as a familial cancer predisposition syndrome and the patients with NF-I need to be assessed periodically to rule out any malignant change. Histopathologic appearance of the lesional tissue still remains the mainstay of diagnosing MPNST, and careful and extensive microscopic study of the lesion may often give a conclusive diagnosis.


Primary non-Hodgkins’s lymphoma is a very uncommon lesion, accounting for 0.6% in jaws. As the lesions frequently resemble other disease such as chronic osteomyelitis, odontogenic or any secondary neoplasms, further evaluation and histopathologic examination allow early identification for appropriate treatment. The purpose of this case report is to describe a rare case of non-Hodgkin’s lymphoma of the mandible, explore the diagnosis and workup based on immunohistochemistry. Malignant lymphoma is a neoplastic process of the lymphopoietic portion of the reticulo-endothelial system. Most of them originate from B-lymphocytes. Lymphoma is the second common malignancy of head and neck. Primary The WHO diagnostic criteria for primary lymphoma of bone are a primary focus in a single bone and histologic confirmation and, at the time of diagnosis, no evidence of distant soft tissue or lympnode involvement. There are no pathognomonic radiographic findings. Paresthesia along the inferior alveolar nerve distribution is a common finding, with reports ranging upto 20%. We present a case with a dental complaint which was later diagnosed as primary non-Hodgkin’s lymphoma of the mandible.A 54-year-old male presented with a past history of non-resolving extra-oral swelling on the right of the face. He underwent surgical removal of impacted right mandibular third molar 2 months back by an outside practitioner. He was under antibiotics and anti-inflammatory drug coverage for a few days. Following extraction, the swelling did not resolve and, subsequently, they extracted 47 and 46 presuming some dental infection.On extra-oral examination, a diffuse swelling was noted on the right side of the face near the angle of the mandible. Intra-oHistopathology showed sheets of atypical lymphoid cells. The individual cells were polyhedral with scant eosinophilic cytoplasm. The nuclei showed irregular membrane, open chromatin and prominent nucleoli. Foci of atypical mitotic figures were also seen. The lymphoid cells were seen infiltrating the bone. Areas of sclerosis, necrosis and hemorrhage were seen amidst these cells. Bony trabeculae, fibro-collagenous tissue and neural elements were seen Figures  and 4. TThe patient’s general health was examined by a physician to find out involvement of any other site. Investigations like hemogram, radiograph and computed tomography (CT) scan were performed and no other site except the mandible showed involvement. Based on all the findings, a diagnosis of primary lymphoma of mandible was made. He was then referred to an oncologist for treatment.Primary non-Hodgkin’s lymphoma in extranodal sites accounts for 24–45% of the cases.4 The com5thand 7th decades of life. Our patient was in the 6thdecade of life.Primary bone lymphoma occurs in patients from 1 to 86 years  of age, with peak prevalence among patients in the 6et al. have discussed a case of primary lymphoma of the mandible presenting after tooth extraction.[et al. have reviewed 16 cases of malignant non-Hodgkin’s lymphoma of the jaws and found that diagnosis that was usually difficult and was often misleading and delayed before the first bone biopsy.[et al., in a case report of primary lymphoma of the mandible, emphasized that malignant lymphoma must be considered in the differential diagnosis of unexplained dental pain and swelling.[et al. have reported a case of primary lymphoma of the mandible with diffuse widening of the mandibular canal.[Most of the cases initially present as an odontogenic infection. Parrington traction. Leva Djae biopsy. Our caseswelling. Bertolotar canal. There arUsually, biopsy is carried out in the non-healing extraction site after repeated treatment for non-responding odontogenic infection.  HistopatWhen tissue diagnosis is confirmed as NHL of the mandible, determination must be made regarding orientation and spread of tumor. Overall assessment is essential to rule out nodal and visceral involvement.A CT scan and Positron emission tomography (PET) scan can be carried out to look out for extranodal involvement.  LaboratoIn our case, we ruled out any other site involvement with a general physician. Investigations like hemogram, radiograph and CT scan were performed.et al. have found that stage 1 NHL has a 5-year survival rate of 70%, and the median survival time for stage 1 is 10 years. The 5-year survival rate for stage 1 NHL of the maxillo-mandibular region is reported to be approximately 50%.[Accurate staging is essential to start the treatment and management. Staging takes into account the involved site and degree of dissemination. Primary NHL of bone as a single focus in an extranodal site is categorized as stage 1. Bachaud tely 50%.et al., in a long-term follow-up of 82 patients with primary bone lymphoma, have found that patient’s prognosis is excellent, with a 5-year survival rate of 95%.[The treatment of NHL is combination of surgery and chemotherapy-radiotherapy. In our case, after surgery, the patient was referred to an oncologist for chemotherapy and radiotherapy. The patient is responding well to the treatment. Beal e of 95%.Lymphoma of bone should be considered in the differential diagnosis of long-standing, non-healing extraction wound.


Schwannoma, otherwise known as a neurilemmoma, is a tumor arising from peripheral nerve sheaths. Although commonly noted in association with the eighth cranial nerve as intracranial acoustic neuroma, cases of schwannoma arising in other locations have been reported in the literature. These tumors usually cause symptoms as a result of their mass effect and, since they are benign, encapsulated and non-invasive tumors, complete surgical excision is considered curative.We report the case of a 46-year-old Sri Lankan man who presented to our facility with recent onset of difficulty evacuating his bowels. He was noted to have a giant presacral schwannoma on magnetic resonance imaging scan. The mass was surgically excised with improvement of our patient’s symptoms. A subsequent histopathological examination confirmed the presence of a benign schwannoma.Although schwannomas commonly occur in the extremities, a rare case of occurrence in the pelvis is reported here. Due to the limited space in the pelvis, the local mass effect may be the presenting feature of such a lesion and surgical excision is curative. Schwannoma, otherwise known as a neurilemmoma, is a tumor arising from peripheral nerve sheaths. Although commonly noted in association with the eighth cranial nerve as intracranial acoustic neuroma, cases of schwannoma arising in other locations have been reported in the literature -7. TheseWe report the case of a 46-year-old Sri Lankan man who presented to our facility with recent onset of difficulty evacuating his bowels. He was noted to have a giant presacral schwannoma on magnetic resonance imaging (MRI) scan. The mass was surgically excised. Following surgical excision of the schwannoma, our patient showed marked symptomatic improvement. A subsequent histopathological analysis revealed features compatible with a benign schwannoma, without nuclear polymorphism or necrosis.A 46-year-old man presented to surgical unit of the National Hospital, Sri Lanka, with the primary complaint of difficulty in evacuating his bowels. He was paraplegic following laminectomy of the thoracic spine at the T4 to T8 level for removal of a lipoma in 1998, following which he had to rely on manual evacuation of the bowels. Recently, he was finding it exceedingly difficult to evacuate his bowels, and had sought medical advice. On examination, he was noted to have an empty rectum, and a mass was felt in the posterior rectal wall. Routine blood investigation results were within normal ranges. An ultrasound scan of the abdomen revealed a dilated sigmoid colon. Lower gastrointestinal endoscopy was attempted, which revealed external compression at 20cm of the sigmoid colon with a mass lesion posterior to the bladder. A contrast-enhanced computed tomography (CECT) scan of the pelvis showed a mass lesion in the presacral region, with a neurogenic origin. An MRI scan of the pelvic region revealed a presacral mass suggestive of a schwannoma causing anterior displacement of the rectum , with the most common location being the stomach and the small intestine . The mosSince the tumor is characteristically non-infiltrative, well encapsulated and benign when extra-intestinal, the symptoms are usually due to the mass effect of the tumor. Most often detection is late, and tumors may grow to a very large size before being symptomatic. Large tumors (greater than 8 to 10cm) with cystic degeneration, calcification, interstitial fibrosis and calcification are termed to be the ‘ancient’ variant . Antoni Although fairly distinct in clinical and histological presentation, pre-operative diagnosis of a schwannoma is not easy owing to a lack of distinguishing features on imaging studies such as ultrasound, CT or MRI between benign and malignant schwannomas as well as schwannomas and other soft tissue tumors such as fibrosarcomas and liposarcomas . There aAlthough surgical excision is curative in cases of benign schwannoma, malignant schwannomas carry a poor prognosis as they are commonly resistant to chemotherapy and radiotherapy . Even exAlthough schwannomas commonly occur in the extremities, more rare sites of occurrence such as presacral locations should always be considered in the differential diagnosis of a pelvic mass. Such lesions may produce a significant mass effect due to the limited space available to accommodate growth in the rigid bony skeleton in the pelvis. Identification is important because surgical excision, either open or laparoscopic, is curative.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.LS gathered data and prepared the initial manuscript. AW and RS performed the surgery and made critical revisions to the manuscript. AW, RS and SK were in charge of the surgical care of our patient. SK supervised the project overall. All authors read and approved the manuscript.


A transsphenoidal biopsy identified a germinoma. Four cycles of chemotherapy with bleomicine, etoposide, and cysplatin were given, followed by radiotherapy, but patients died due to a recidiva. Conclusion. Germinoma must be considered in patients with insipidus diabetes with a sellar mass with thickening of pituitary stalk; and ectopic germinoma must be suspected in patients with slowly progressive hemiparesis with cerebral hemiatrophy. Even with a rare condition, colocalization of midline and off-midline germinoma must be suspected in the presence of these typical signs of both localizations.Germinomas are malignant intracranial germ tumors, usually found in suprasellar regions. Less than 10% are localized in off-middle structures, and synchronous involvement of both structures has only exceptionally been published. A case of an 18-year-old male patient with progressive right-sided hemiparesis and panhypopituitarism was reviewed. Brain MRI showed a solid mass involving pituitary and hypothalamus with thickening of pituitary stalk, high intensity lesions on T2-weighted imaging in left internal capsule, caudate nucleus, globus pallidus, and mild atrophy of the left internal capsule and cerebral peduncle. Nonadenomatous lesions were considered in the differential diagnosis. Alfa-fetoprotein (AFP) levels were negative in both serum and cerebrospinal fluid (CSF), while  Germ cell tumors (GCT) represent approximately 3% of neoplasms in children's cancer registries . They coβ-HCG level ≥ 50 IU/l or greater than the accepted laboratory normal range. This has been shown to be related to prognosis and treatment response [CNSGCTs have been classified in “secreting” and “nonsecreting” tumors. Secreting tumors are defined as those presenting with an elevated CSF AFP ≥ 10 ng/mL or above the local laboratory's normal range and/or a CSF The most common sites of involvement of intracranial germinomas are the pineal or suprasellar regions, while some patients have both localizations at the time of diagnosis , 4. Off-We describe an unusual case of a male patient with a germinoma with a synchronous involvement of midline and off-midline structures. Such a case has only been described twice to our knowledge , 7.2). Blood pressure was 90/60 mmHcg, with a poor response to fluid administration. He had a Tanner-stage 3, with 6 mL testis, pubic hair: G-2, and axillary hair: G-2. On neurological examination he presented a right hemiparesis with hyperreflexia and dystonia.An 18-year-old male patient was admitted to the hospital with psychomotor excitement, polyuria, polydipsia, vomits, and a seven-month history of progressive right-sided hemiparesis with dystonia. He had poor school performance, anxiety, and emotional lability for the last two years. Brain nonenhanced computed tomography done seven months before admission was normal. On physical examination, he was in a poor general condition, pale, with a low low body mass index . The refractory arterial hypotension suggested adrenal insufficiency. Intravenous hydrocortisone was then started. Afterwards, levothyroxine and oral desmopressin acetate were added. Laboratory examination confirmed the diagnosis of hypopituitarism . ClinicaBrain magnetic resonance imaging (MRI) showed a solid mass with homogeneous enhancement after gadolinium, involving the pituitary and the hypothalamus with marked thickening of the pituitary stalk. The posterior pituitary hyperintensity was absent on T1-weighted images . A high With the suspicion of germinoma, a lumbar punction was indicated. Differential diagnosis with other nonadenomatous lesions was also considered: normal thoracic TC and angiotensin converting enzyme ruled out sarcoidosis; skull and long bones X-rays were normal, without typical lytic lesions of Langerhans cell histiocytosis. The CSF examination did not show atypical cells. AFP levels were negative in both serum and CSF, while HCG was slightly increased only in CSF. A transsphenoidal biopsy identified a pure germinoma. A spine MRI excluded metastatic lesions.A treatment of four cycles of chemotherapy every three weeks with bleomicine, etoposide, and cysplatin was given.An MRI study a month after chemotherapy showed a complete response with disappearance of the pituitary and suprasellar mass , while aAfter an improvement in his general condition, whole brain radiation therapy was indicated nine months after chemotherapy. Unfortunately, he died after a thalamic recurrence shortly after concluding this last treatment.Germinomas are the most common and least malignant intracranial germ tumors, usually found in the pineal and suprasellar regions. Five to 10% of the GCTs are ectopic, being localized in off-middle structures, like the thalamus, basal ganglia and internal capsule. Synchronous involvement of midline and off-midline structures, as described in this case, has only exceptionally been published , 7. ClinClinical manifestations of ectopic germinomas are insidious. Slowly progressive hemiparesis and neuropsychiatric symptoms such as dementia, psychosis, or cognitive decline with poor school performance are usually found; cognitive abnormalities are usually one of the earliest manifestations , 8–14. INeuroimaging studies are useful in differential diagnoses. But measurement of serum and CSF tumor markers and/or histological studies are required for the confirmation of the diagnoses of germinoma. In this case the MRI showed a solid sellar and suprasellar mass with marked thickening of the pituitary stalk tumor (in accordance with panhypopituitarism), in addition to high signal intensity lesions in the left internal capsule, caudade nucleus, and both globus pallidus with atrophy of the left internal capsule and cerebral peduncle, confirming the synchronous involvement of midline and off-midline structures (in accordance with hemiparesis and cognitive decline). In the early course of the disease, before the appearance of motor symptoms, MRI changes are not so evident. The earliest and most common feature on MRI is the atrophy of the basal ganglia as well as the presence of subtle signal intensity changes as hyperintensity on T1- and T2-weighted images . In our β-HCG was slightly increased in CSF. A transsphenoidal biopsy settled the diagnosis of a pure germinoma being negative for both β-HCG and AFP, but positive for placental alkaline phosphatase (PLAP). However, biopsy-proven germinomas can have nongerminomatous elements among the unbiopsied sites and nonsecreting tumors can also have nongerminomatous components with a less favorable prognosis [A tumor biopsy is required for the diagnosis, except in cases where tumor markers are elevated . In our rognosis . This waEarly diagnosis is very important because a delay in treatment can result in more severe neurologic deficits, as observed in our case. It has been demonstrated that, except for patients with small tumors, pituitary dysfunction before treatment persists or even worsens after tumor remission, mainly after radiotherapy. The earlier diagnosis and the prompt starting of treatment, before irreversible pituitary-hypothalamic damage occurs, contribute to improving the outcome of pituitary function in patients with neurohypophyseal germinomas . In our The optimal management strategy for CNSGCTs remains unsettled due to a lack of prospective trials, mainly due to the infrequency of these tumors . GerminoIn our patient, a treatment of four cycles of chemotherapy with bleomicine, etoposide, and cysplatin was chosen, with a very satisfactory initial response. Coadjuvant radiation therapy was administered nine months after, but he died because of a thalamic recurrence of the tumor.In conclusion, sellar germinomas must be ruled out in all young patients with isolated DI or in association with other pituitary deficits. Ectopic germinoma must be suspected in patients with insidious neuropsychiatric symptoms and progressive hemiparesis, particularly if it is associated with subtle focal lesions in the basal ganglia and cerebral hemiatrophy. Though infrequent, involvement of both midline and off-midline structures may be present. A prompt diagnosis can avoid clinical sequelae and diminishes long-term impairment. The optimal therapeutic strategy for CNS-GCTs is not established yet, and an individualized approach is recommended.


Primary non-Hodgkin's lymphoma (NHL) of the bladder is a very rare entity. The clinical, radiological and endoscopic signs are not specifics. The diagnosis is exclusively histological. Chemotherapy, radiotherapy and surgery are the different therapeutic options used either alone or in combination. We report a 57 years old patient treated with chemotherapy (6 cycles of R-CHOP) for primary NHL of the bladder with a complete response while discussing the different specificities of this disease. Most bladder tumors are derived from the epithelium. Non epithelial tumors of the bladder are extremely rare; and primary non-Hodgkin's lymphoma (NHL) of the bladder is even more exceptional –3. Its pA 57-year-old woman with a history of recurrent cystitis which has been treated with repeated courses of antibiotics during a 5-year period. She has been experiencing 2 months of bladder irritation, dysuria, urinary urgency and terminal hematuria with presence of blood clots. Physical examination showed pelvic tenderness. Abdominal ultrasonography revealed a tumor of the right anterolateral wall of the urinary bladder that was confirmed by computing tomography (CT) scan . CystoscImmunohistochemical analyses were negative for cytokeratins and vimentine. This allowed us to retain the diagnosis of diffuse large B-cell lymphoma (DLBCL).2, cyclophosphamide 750 mg/m2, doxorubicine 50 mg/m2, vincristin 1.4 mg/m2 and prednisone 100 mg/day during 5 days; the protocol is repeated every 3 weeks) were given with complete response maintained after 48 months of follow up.There was no cervical, thoracic, abdominal or pelvic lesion in the CT scan. Bone marrow biopsy showed no abnormality. A complete blood count and routine blood chemistry were normal. The disease was classified stage IE according to the Ann Arbor Staging system and the patient had a score of 0 by using the international prognostic index (IPI). Six cycles of R-CHOP regimen (Rituximab 375 mg/mSecondary bladder involvement occurs in 10 to 20% of terminal NHL cases . This loThe etiology of primary NHL of the bladder has not been elucidated, because of the rarity of this pathology. According to some authors, lymphoma may be secondary to chronic cystitis , 4. ThisGenerally, primary NHL of the bladder affects six women for one man , 2. ClinThe location is most often retro-trigonal or lateral. The appearance on cystoscopy, ultrasound and CT scan is not different from that of urothelial tumors and it is histology combined with immunohistochemistry that affirms the diagnosis.Histologically, it's usually a B-cell lymphoma. Indeed, small cell lymphocytic lymphoma and DLBCL are the most common; they each represent 30% of cases . The BLBThe staging should eliminate the presence of any other lesions to confirm the primary origin of the bladder lymphoma. It must include a total scan and a bone marrow biopsy.Chemotherapy, radiotherapy and surgery, as well as combinations of these treatments are the therapeutics options for primary NHL of the bladder . HoweverThe optimum follow-up protocol for patients treated for primary lymphoma of the bladder has yet to be determined. Follow-up evaluations should take place every 3 or 6 months for the first 2 years and yearly thereafter, as is the case for transitional cell carcinoma. It must include at least ultrasound examination and cystoscopy.The prognosis is difficult to be determined given the rarity of primary NHL of the bladder. However, patients with high-grade lymphoma should be considered to have systemic disease and therefore, the IPI can be used to predict prognosis. In our case, the patient had an IPI score of 0; so it is part of the low risk with a 5-year survival estimated at 73% .Primary NHL of the bladder is a rare disease which diagnosis is exclusively histological. Chemotherapy should be used in first line especially in high grade or locally advanced tumor and it seems to give good results.


The abscopal effect is the effect of radiation therapy at a site distant to the area of irradiation. This is not a common event and has not been clearly defined, resulting in few reported cases in the literature. We discuss this phenomenon in a patient with hepatocellular carcinoma.A 63-year-old Japanese man underwent extended right hepatic lobectomy for hepatocellular carcinoma. During his follow-up examination, a single lung metastasis and a single mediastinal lymph node metastasis were found. Trans-catheter arterial embolization was initially attempted to treat the mediastinal tumor, however this approach failed to take effect and carried risks of spinal artery embolism. External-beam irradiation, with a dose of 2.25 Gy per fraction, was performed using an antero-posterior parallel-opposed technique . A computed tomography scan performed one month after starting radiotherapy showed a remarkable reduction of the mediastinal lymph node metastasis. In addition to this, we observed spontaneous shrinking of the lung metastasis, which was located in the right lower lobe and out of the radiation field. No chemotherapy was given during the period. There has been no recurrence of either the lung metastasis or the mediastinal lymph node metastasis during a follow-up 10 years after the radiotherapy.We observed a rare abscopal effect in a site distant from the area of irradiation. Irradiation of the mediastinum resulted in tumor mass regression in the untreated lung tumor. This patient was treated with external whole-pelvis and intra-cavitary irradiation to the primary pelvic lesion, successfully resulting in disappearance of the lesion. Moreover, para-aortic lymph node metastases outside the irradiated field also spontaneously disappeared [An abscopal effect has been defined as a reaction outside an irradiated area but within the same organism , that caappeared .The mechanism of the abscopal effect has not been clearly defined. We report here the case of a patient who showed an abscopal effect on lung metastases of HCC.A Japanese man, who had been followed since 53 years of age by the respiratory department of our Medical Center due to bronchial asthma, was hospitalized for progression of asthma at 63 years old. A suspected diagnosis of HCC in his right liver lobe was confirmed by abdominal computed tomography (CT). An extended right lobectomy was performed after three months in our hospital. Pathologic examination revealed an HCC, composed of a necrotic tumor that measured 10.5 × 9 × 11 cm. In addition, there were three daughter nodules with diameters of less than 1 cm each. The residual nodular tumor without necrosis was Edmondson grade II to III with nuclear atypia, and was moderately differentiated. Invasion of lymphatic and vascular channels was not obvious. Exposure to the surface of the liver capsule was not found. A single lung metastasis and a single mediastinal lymph node metastasis were found in a chest CT scan performed 18 months after the liver lobectomy Figures . Final dOur patient was admitted to our Department of Radiation Oncology for irradiation. His Karnofsky performance status score was 90% to 100%. He complained of a moderate cough and moderate bloody sputum but denied any dyspnea or chest pain. To relieve these clinical symptoms, external-beam irradiation, with a dose of 2.25 Gy per fraction, was performed using an antero-posterior parallel-opposed technique  Figures  and 4. TDuring follow-up as an out-patient, our patient was observed to have dyspnea (Hugh-Jones 1-2), slight cough and slight sputum. AFP levels had decreased to 23 ng/mL, and PIVKA-II to 13 mAU/mL.A CT scan performed four years after the radiation therapy showed a lymph node swelling with a diameter of 3.5 cm in the area of origin of the left gastric artery. At this time, AFP and PIVKA-II were elevated to 1990 ng/mL and 1990 mAU/mL respectively, but with no pathologic evidence of recurrence. Stereotactic body radiotherapy for the lesion was performed, with 30 Gy in three fractions. The recurrent tumor disappeared. Six and a half months after the stereotactic body radiotherapy, no obvious recurrent disease was found.et al. in 2009 [et al. proposed two mechanisms involving ischemia and an immune response [et al. presented the hypothesis that the type of dose fractionation regimen determines the ability of radiotherapy to synergize with anti-CTLA-4 antibody [Many case reports describing spontaneous regression of HCC can be found in the literature. Since 1982, about 60 cases have been reported as abscopal effects or spontaneous regressions. These cases were reviewed by Oquiñena  in 2009 ,4,6-8,10response . First, response . Second,response ,14. Dewaantibody . AlthougWe observed a rare abscopal effect in a site distant from the area of irradiation. Irradiation of a tumor in the mediastinal resulted in tumor mass regression in an untreated lung metastasis of HCC.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.KO undertook the gathering of information for this case and was a major contributor in writing the manuscript. HY conceived the manuscript and was a major contributor to the manuscript. All authors read and approved the final manuscript.


Angiomyxomas are relatively a group of uncommon myxoid mesenchymal tumors characterized by frequent local recurrences and show lack of malignant potential. Basically three types of angiomyxomas are recognized superficial, aggressive, and angiomyofibroblastoma. Though the angiomyxomas are rarely reported in the head and neck region, the paper shows reported cases intraorally in the buccal mucosa and floor of the mouth. Here, the authors report a rare case of angiomyxoma presenting as a growth in the upper posterior alveolar mucosa. Angiomyxomas are a group of relatively uncommon myxoid mesenchymal tumors characterized by frequent local recurrences and lack of metastatic potential. Three types of angiomyxomas are recognized: aggressive, superficial and angiomyofibroblastoma . SuperfiA 30-year-old male patient presented with a slow-growing, soft mass in the right upper posterior alveolar region, present since 2 years and which was associated with mild pain upon eating . PatientSuperficial angiomyxomas are rare distinctive, benign, cutaneous soft tissue lesions with a predilection for the trunk, head, and neck; other sites being lower extremities and genital area . CutaneoThe main histologic differential diagnosis for intraoral tumors includes aggressive angiomyxoma, soft tissue myxoma, angiomyolipoma, myxoid nerve sheath tumor (neurothekeoma), myxoid neurofibroma, oral focal mucinosis, and myxofibroma or odontogenic myxoma.Aggressive angiomyxoma can be distinguished from its superficial and angiomyofibroblastoma counterparts by the proliferation of spindle- or satellite-shaped cells that are widely separated by loose myxoid stroma in which there are prominent and large vascular components , 2.Angiomyolipoma is composed of a mixture of thick-walled blood vessels, smooth muscle, and adipose tissue found mostly in the kidney . NeitherSuperficial angiomyxoma is clearly a very rare neoplasm of the oral cavity and should be included in the differential diagnosis of myxoid intraoral soft tissue neoplasms.


Skeletal muscle haemangiomas are uncommon soft tissue tumors; more than 90% are misdiagnosed initially. They present as chronic pain and swelling in a muscle with or without a history of trauma. Plain X-rays, bone scans, computerized tomography (CT) studies, and angiography studies may not always be specific for this tumor. Diagnostic ultrasound is an appropriate initial imaging modality for suspected haemangioma, although magnetic resonance imaging is the investigation of choice. Many treatment modalities for the symptomatic haemangiomas are available of which surgical excision is the most preferred. We present an unusual case of pain, swelling, and restriction of movements in the right knee following an episode of trauma in a 12-year-old boy who was being followed for 1 year by a general practioner and later referred to us. The patient was diagnosed to have intramuscular cavernous haemangioma in the vastus medialis by us for which he was treated by surgical excision and followed for 1 year and found to have no recurrence. The clinical features, radiological picture, pathological histology, diagnostic tools, and treatment options have been discussed. Haemangiomas constitute 7–10% of all soft tissue tumors . There iCurrent literature reports intramuscular cavernous haemangioma of the vastus medialis in a 12-year-old boy for which surgical excision was performed. Patient was followed for 1 year and found to have no signs of recurrence.An 12-year-old boy was referred to us by a practioner with a swelling in the left knee region associated with pain which aggravates on running since 1 year with history of preceding trauma. There was no history of associated constitutional symptoms, bleeding tendencies, or other joint involvement. Patient was under treatment with the practioner for the past 1 year and during this period aspiration of the swelling was done thrice which revealed blood according to the patient's attendant. Throughout this period, swelling gradually increased in size inspite of aspiration.Examination revealed an asymmetric, boggy, noncompressible, and nonpulsatile swelling in the anteromedial aspect of left suprapatellar region measuring about 4 × 3 cms. The overlying skin was normal with no discoloration and no local raise of temperature. The fossae on either side of the patellar tendon were normal and the patellar tap was negative. There was no distal neurovascular deficit or bruit. Limb length was equal to the contralateral limb. Knee movements were of full range.With the differential diagnosis of suprapatellar bursitis, synovial dysplasia, and extra-articular soft tissue tumor, patient was subjected to further investigations.The patient had old X-rays of which the most recent was dated 5 months ago which was unremarkable except for minimal soft tissue swelling in suprapatellar region. Ultrasound revealed a hypoechoic irregular mass located in the muscular plane with evidence of increased vascularity and multiple calcific areas, all these features were favoring the diagnosis of haemangioma . As ultrT1, T2, and PD FAT SAT images, with hypointense calcifications within indicating the mass could be an intramuscular haemangioma in the vastus medialis (Figures Patient was planned for surgical excision and a preoperative MRI was done which revealed soft tissue mass of about 3.7 × 3.2 cms in the vastus medialis which was of high-signal intensity on  Figures . At operation, a vascular mass involving the vastus medialis muscles with calcifications was encountered Figures . Microscopically, skeletal muscle bundles interspersed with lobules of thick-walled blood vessels and few capillary-sized blood vessels filled with RBCs, areas of calcification, and a peripheral rim of adipose tissue was seen. No sign of inflammation were observed. These findings were in favor of cavernous type of intramuscular haemangioma .The patient had an uneventful postoperative course. He had been followed for one year and was found to be free of symptoms and showed no evidence of recurrence.Haemangiomas constitute 7–10% of all soft tissue tumors . The youClinically, haemangiomas present with swelling and pain, history of trauma is usually present in 17% of the patients . A noncoT1 and T2 images in contrast to most soft tissue tumors, which show intermediate signal intensity on T1 and high signal intensity on T2 [Radiographs are generally inconclusive revealing only an abnormal soft tissue mass. Occasional calcified phleboliths may be present in 25% of cases aiding in the diagnosis but does not appear to be a constant feature. Ultrasonograms may reveal complex hypoechoic mass and if phleboliths are present, acoustic shadowing may also be documented. MRI is very promising investigation, which is noninvasive, helps in diagnosing and defining the location and extent of the haemangioma though the cost and availability may be a limiting factor. Haemangiomas appear as areas of high signal intensity on both y on T2 , 6, 13.The term “haemangioma” is commonly misused to describe any type of vascular abnormality, including vascular malformation, in both medical and surgical fields, Hassanein et al. revealed in a study that the term was incorrectly used in 71.3% of publications on the PubMed database . HaemangIntramuscular cavernous haemangiomas do not undergo spontaneous regression; hence in symptomatic cases optimal treatment is the complete surgical excision of the tumor with a surrounding margin of the normal muscle –7. The 1Lesions arising in muscle may create significant diagnostic uncertainty, as on clinical examination they are little different from soft tissue neoplasms and often imaging features may not be fully appreciated or easy to interpret. Skeletal muscle haemangiomas are uncommon soft tissue tumors that are completely treatable, the knowledge of their natural history, clinical findings, and imaging appearances are of great importance for proper diagnosis. These lesions are often diagnosed late or misdiagnosed as abscess, lipoma, sarcoma, fibroma, muscle hernia, dermoid cyst, lymphatic glands, or even synovitis when presenting juxta articular.The aim of presenting this case is to emphasize that, in cases with chronic or recurrent painful swelling in a muscle or adjacent to a joint with or without an episode of trauma especially in a young individual should alert the surgeon to this diagnosis. Investigations such as ultrasound can diagnose the lesion but may not be able to delineate its extent, MRI is preferred for identifying the exact location, extent, and size of the lesion for planning surgical excision, which is the most preferred treatment for these lesions.


The cerebellar location of ganglioglioma (GG) is exceptional. We report one case of a 27-year-old man who underwent an intracranial hypertension syndrome and a static cerebellar syndrome. Brain magnetic resonance images revealed a cyst image in the vermis. Histological study after surgical removal, revealed a ganglioglioma tumor. Through this case and literature review, the authors discuss some epidemiological, histological, clinical, radiological and management features of this very rare tumor. Gangliogliomas occur frequently in temporal lobe, and induce incontrollable epilepsy. GG is very rare in cerebellum with 31 cases reported previously [A 27-year-old man complained of diffused headache for 5 months with some episodes of vomiting. There was no significant family history. On neurological examination, there was a static cerebellar syndrome associated with a papilloedema. Brain magnetic resonance (MR) images revealed a cyst lesion in the vermis with ring enhancement after gadolinium administration . The tumGanglioglioma is the most commonly encountered glial-neuronal neoplasm of the central nervous system, with its incidence of 0.4% to 4.3% . This tuBoth components usually exhibit low grades of malignancy, but it is the grade of the glial element that predicts the biological behavior. GG is part of the family of mixed glial ganglion cell tumors that are included within grade I or II of the WHO classification; however, occasional cases of anaplastic GG (WHO grade III) have been reported . MalignaThere are no specific clinical findings to indicate cerebellar GG and to discriminate that from other cerebellar lesions. Cerebellar GGs have a generally short mean history (1.6 years)  GG may bClinical presentation of infratentorial GG varies depending on the structures involved. Associated symptoms include cranial nerve deficits , hemiparesis, gait disturbance, and headache . There aAlthough the exact mechanism for the epilepsy arising in the cerebellum is not known, invasive electrophysiological monitoring with depth electrodes has confirmed the cerebellum as the site of seizure origin. It is thought that the seizure arises in the cerebellum and may generalize secondarily, spreading throughout the cortical surface. Surgical resection of GG has resulted in remission of the seizures in all reviewed cases . RadioloGadolinium enhancement of the solid component of the GGs is observed in about half of the cases, although the pattern varies from intensely homogenous to heterogeneous. Although there is considerable variability in the radiographic appearances of the cerebellar GGs, almost all tumors appear as a discrete, solid/cystic lesion with mild mass effect and little or no surrounding edema .The main differential diagnosis of cerebellar GG in children or young adults is typically the pilocytic astrocytoma . SurgeryNevertheless, the diagnosis of GG is of great importance because of its comparatively better prognosis than other tumors in this location. Radiotherapy is not recommended in management of GG because of the entirely radio-resistant nature. The radiotherapy doesn't affect the poetentiel growth of GG . Some reThe cerebella location of ganglioglioma is exceptional and a diagnostic surprise for the neurosurgeon. It is usually seen in children and young adults. Complete resection is the treatment of choice. Even with partial resection, prognosis remains favorable. Radiotherapy is not required.


Bezoar is defined as the accumulation of undigested foreign bodies or nutrients in the gastrointestinal tract. These foreign bodies can be hair (trichobezoar), fibers or seeds of vegetables and fruits (phytobezoar), or remnants of milk (lactobezoar) and stones (lithobezoar). Lithobezoar, the accumulation of stones in the digestive tract, is commonly seen in stomach. In this paper, a 7-year-old girl with colonic lithobezoar who presented with constipation, abdominal pain, and the history of pica was successfully treated by the extraction of the stones under general anesthesia. Colonic lithobezoar is a rare disorder and may cause mechanical intestinal obstruction in children . It is mA 7-year-old girl was admitted to the emergency room with abdominal pain and constipation. She had an absence of defecation for the past 3 days. In her medical history, she was treated for iron deficiency anaemia and she had the compulsive behavior of pica. Her vital parameters were normal and her general physical examination results were unremarkable. Abdominal examination revealed distention and mild tenderness with no signs of peritonitis. Irregular masses in the left lower quadrant of the abdomen were palpated. Rectal examination demonstrated hard masses like fecaloids. Some of these masses were extracted and they turned out to be stones along with stool.The laboratory studies revealed hemaglobin 6.8 g/dL, hematocrit 22.5%, MCV 53.4 fL, ferritin 9.0 ng/mL, iron 14 mg/dL, and iron binding capacity 415 mg/dL, pointing out an iron deficiency anaemia. Abdominal X-ray demonstrated radioopaque masses of various sizes in the distal colon. There was no noticed air-fluid level . Along these results, the diagnosis of intestinal obstruction due to lithobezoar was made. Under general anesthesia, following anal dilatation, manual evacuation, and colonic lavage were done. Approximately 2 kilograms of stones in various sizes were extracted . She wasBezoar is the accumulation of undigested foreign bodies or nutrients in the gastrointestinal tract. These foreign bodies can be hair (trichobezoar), fibers or seeds of vegetables and fruits (pythobezoar), or remnants of milk (lactobezoar) and stones (lithobezoar) . AlthougColonic lithobezoar can be seen as a result of pica , 5. PicaClinically patients present with signs and symptoms of colonic obstruction. In physical examination, abdominal distention and tenderness is mostly seen along with “colonic crunch sign” which is the palpation of the masses . Stones The treatment of colonic bezoars depends on the site of the colon and the type and the size of the substance . In the In summary of the literature, colonic lithobezoar cases present with constipation, abdominal distension, and painful defecation. These children usually have no peritoneal signs but irregular mass at abdominal palpation and prickly mass at rectal examination. Most of them have pica with or without iron deficiency anaemia. Abdominal X-ray is suitable for diagnosis. Anal dilatation and extraction of the stones is enough for the treatment. Colonic lithobezoar is a rare disorder but it must be suspected in children with mechanical intestinal obstruction and the history of pica. It can be lethal by causing colonic obstruction moreover perforation, if it is undiagnosed. Evacuation of the colon by anal dilatation is usually enough and surgery is not required. Treatment of iron deficiency anaemia and pica could be the key for the prevention.


Ovarian cancer is the most lethal gynaecologic malignancy. It usually spreads out of the abdomen involving thoraco-abdominal organs and serosal surface. This disease is poorly curable and surgery, at early stage, is supposed to achieve the best survival outcome. In systemic dissemination, chemiotherapy is indicated, sometimes with neoadjuvant aim. The most common clinical expressions of advanced ovarian carcinoma are multiple adenopathy, neoplastic pleuritis, peritoneal seeding and distant metastasis, mainly hepatic and pulmonary. Isolated adenopathy of the mediastinum is rare and isolated bilateral have never been described before. We report two cases of isolated bilateral cardiophrenic angle lymphnode metastasis from ovarian carcinoma, without peritoneal and pleural involvement. Both patients were successfully resected through minimally invasive thoracic surgery. About the role of surgery, few data are available but survival seems to be longer after resection thus, more investigation is required to make the indication to surgery more appropriate in advanced cases. The cardiophrenic angle lymphnodes (CPLN) were classified by Rouviere into two groups: anterior prepericardiac and middle latero-pericardiac. The afferent lymphatics of CPLN drain areas from the diaphragm, liver, pleura and anterior abdominal wall and they empty into the internal mammary chain. Malignant lymphoma and metastases of abdominal or thoracic neoplasms have been mentioned to be possible causes of CPLN enlargement. Most of the times the disease is unilateral.CPLN involvement may represent a staging and prognostic indicator for ovarian cancer . NaturalIn the present paper we report two patients with isolated bilateral CPLN metastasis from previously resected ovarian carcinoma, with no peritoneal and pleural involvement.A 50-year-old woman was referred to our service for bilateral cardiophrenic angle mass. Two months earlier, the patient had undergone laparoscopic left ovariectomy with incidental diagnosis of cancer. Postoperative CA-125 value was within the normal range. Thoraco-abdominal computed tomography (CT) scan revealed bilateral neoplasms in the cardiophrenic angles, 2.5 and 1.5 cm in diameter. Fluorine 18-fluoro-2-deoxy-glucose-positron emission tomography (FDG-PET) scan evidenced enhanced uptake in the above mentioned sites Figure . The casA 50-year-old woman, was admitted to our Hospital for bilateral cardiophrenic angle tumor. The patient had been submitted to laparotomic hysterectomy with bilateral salpingo-oophorectomy two years earlier, for ovarian papillary serous adenocarcinoma pT1bN0Mx). Preoperative Ca-125 value was 14.00 U/ml. Three cycles of adjuvant chemotherapy with carboplatin and taxol were administered. During follow-up, FDG-PET scan revealed an increased uptake in a bilateral 1.5 cm cardiophrenic tumor, not recognized on CT scan  entails a definite worsening of prognosis . CPLN coIsolated bilateral metastasis is to be considered anecdotical and, to our knowledge, bilateral involvement without pleural effusion was never reported in the English Literature. In our patients FDG-PET scan facilitated identification and proper diagnosis of CPLN metastasis. In one patient CT scan did not clearly demonstrate nodal disease. The possible anatomical pathway for tumor spread in the cases herein reported is an unanswered question, considering that serosal surfaces and intra-abdominal viscera were apparently unaffected by disease.An interesting, potentially misleading, feature of metastatic supradiaphragmatic nodes from ovarian primary, is calcification. Although not observed in our cases, such aspect is reported with an incidence up to 35%, and must not be overlooked. Calcified intrathoracic nodes in patients with previous ovarian serous adenocarcinoma cannot be ruled out as granulomatous disease, but metastatic deposits must be excluded. A hint to the latter hypothesis is the progressive growth of the involved station [Surgery is carried out in order to achieve histologic diagnosis, disease staging, and prolonged survival. Videothoracoscopy is specifically fit for such procedure, as recently stated by Lim et Al.. The minIn presence of isolated CPLN relapse, the patient may be included in the Isolated Lymph Node Relapse group, a subset appearing to gain from surgery in terms of survival . On the 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.CPLN: cardiophrenic angle lymphnodes; CT: computed tomography; FDG-PET: Fluorine 18-fluoro-2-deoxy-glucose-positron emission tomography;The authors declare that they have no competing interests.MR, JV and FP wrote the article, RC and ND collected the clinical information and selected the images, MR and NA analyzed the English Literature. FP drafted the final manuscript. All authors approved the final manuscript to be published.


Colorectal lymphomas represent only 5% to 10% of gastrointestinal lymphomas, after the stomach and small intestine. Primary lymphoma of the colon and rectum is an unusual observation, constituting only 0.2% to 0.5% of all malignant tumors arising from the colorectal region. Very little is known about the correlation between adenoma and lymphoma in the colorectal tract. We report here a rare case of diffuse large B-cell lymphoma developing within a solitary tubular adenoma with low-grade dysplasia of the rectum.An 83-year-old Caucasian man was referred to our hospital intermittent anal bleeding and irregular bowel. Colonoscopy revealed a 1cm solitary rectal polyp, which was completely removed by endoscopic resection. Histologic studies revealed low-grade intraepithelial dysplasia; the stroma of adenoma showed focal localization by highly proliferative lymphoid cells. Immunohistochemical analyses demonstrated that lymphoid cells were positive for CD20 and bcl2, whereas they were negative for CD3, CD5, CD10, CD23, CD30, CD138 and cyclin D1. Approximately 90% of the neoplastic cells reacted positively when stained with an antibody to Ki-67. Molecular studies showed the presence of a monoclonal immunoglobulin heavy chain gene rearrangement.To determine primary or secondary lymphoma localization, Dawson’s criteria were applied to the case. A diagnosis of primary diffuse large B- lymphoma Ann Arbor stage 1A was established. Subsequently, the patient was referred to oncology to establish the stage and to select appropriate treatment.The case of diffuse large B-cell lymphoma developing within a tubular adenoma, as reported here, is considered a rare event. Little about the prognosis of primary colorectal lymphomas is available and therapeutic treatment protocol is unclear. This case report provides more information on the history and macroscopic appearance of lymphomas presenting in an unusual location. To report additional cases in the future would be helpful in redefining the diagnostic, prognostic and therapeutic approach. Colorectal lymphomas constitute only 5% to 10% of gastrointestinal (GI) lymphomas, after the stomach and small intestine. Of these large bowel lymphomas, 60% are located in the caecum, 20% in the rectum, and the remainder throughout the colon.The most common symptoms in more than half of patients are abdominal pain and weight loss or a change in bowel habits. Lower GI bleeding can be found in 13% to 82% of patients. As with GI malignancies, the initial clinical manifestations and the gross appearance of the lesions appear to be related to the site of GI involvement. Thus, obstructing masses or wall thickening are more frequent in small bowel involvement, whereas polyps are predominant in the colon and rectum.Most colorectal lymphomas are secondary involvement by widespread diseases. Primary lymphoma of the colon and rectum is an unusual observation, constituting only 0.2% to 0.5% of all malignant tumors arising from the colorectal region with caecum, ascending colon and rectum more often affected. On histological examination, almost 90% of the primary GI lymphomas are of B-cell lineage with very few T-cell lymphomas and Hodgkin lymphoma -8. AlthoAn 83-year-old Caucasian man, in otherwise good health, was referred to our hospital with intermittent anal bleeding and irregular bowel patterns. A colonoscopy revealed a 1cm solitary rectal polyp, which was completely removed by endoscopic resection  was detected, demonstrating malignancy and clonal association of the lymphoma infiltrates in the adenoma Figure . MoleculThe patient underwent full staging for lymphoma. Dawson’s criteria were used in the differential diagnosis between primary colorectal involvement and GI tract involvement secondary to systemic lymphoma . He had In this article we report a case of primary DLBCL developing within a tubular adenoma with low-grade dysplasia.Most studies report that lymphomas comprise only 1% to 4% of malignant neoplasms in the GI tract.Although the GI tract is the most common extranodal location for the development of non-Hodgkin lymphoma (NHL), in adults only 10% to 20% of the primary GI lymphomas occur in the colon. A primary lymphoma of the colon and rectum is an extremely rare entity.The ileocecal area and ileum are the regions most frequently affected by primary small-intestinal and large-intestinal NHL . Colorecet al. report a case of abdominal non-Hodgkin DLBCL in a child [et al. report a case of a 62-year-old Caucasian man showing the presence of a nodule in his rectum that was found to be follicular B-cell lymphoma [et al. report 25 patients with primary follicular lymphoma of the GI tract [et al. report a primary DLBCL of the rectum simulating a rectal adenocarcinoma [Bollen  a child . Sikder lymphoma . Damaj eGI tract . MultiplGI tract ,13. Somearcinoma .Many factors and mechanisms may play a role in the occurrence of synchronous colonic carcinoma and lymphoma . Among tet al. present a rare case of synchronous occurrence of a DLBCL initially presenting in a tubular adenoma of the large bowel [et al. document a case of T-cell lymphoma associated with a rectal adenoma [Little is known about the association of adenoma and lymphomas in the colorectal tract and, to the best of our knowledge, few cases have been reported previously in the literature. Roeb ge bowel . Sato et adenoma .In our case, we did not find a specific familial, medical and social history. We have no attractive hypothesis to explain in this patient the synchronous occurrence of dysplasia and lymphoma. It is probable that the factors implicated in the onset dysplasia are the same triggering the carcinogenic process in lymphoproliferative disease. In addition, we consider that the correlation between decreasing immunity and increasing age may be the risk factor for this case.In general, comprehensive history taking and physical examination may reveal the possible etiologies of some specific lymphoma types and provide information for their further assessment and management.In this clinical case, a crucial role is represented by stadiation pathology. When a patient is suspected to have a GI lymphoma, staging evaluation for lymphoma is performed, including physical examination; documentation of B symptoms; laboratory evaluation; chest radiograph; CT scan of abdomen, pelvis, and usually chest; bone marrow biopsy; lumbar puncture in lymphoblastic, Burkitt’s lymphoma and DLBCL with positive marrow biopsy; and gallium scan (single photon emission computed tomography) or positron emission tomography scan in large B-cell lymphoma .Although Ann Arbor staging with Musshoff modification is commonly considered the best classification to stage GI lymphomas, the question about the staging strategy remains open due to various available staging systems . GI lympThe optimal management of primary lymphoma of the colon and rectum has never been determined by randomized trials. In fact, the small number of patients with various histological subtypes and different stage at presentation results in an unclear protocol for the treatment of primary colorectal lymphoma .Little evidence is available regarding the prognosis of primary colorectal lymphomas. We believe that the case reported here will provide additional information on the history and macroscopic appearance of lymphomas presenting in an unusual location. The epidemiology, clinical presentation, histopathologic subtypes, as well as radiological presentation of GI lymphomas are very important to formulate accurate diagnosis, staging and treatment of the disease with the promising novel techniques. To report additional cases in the future would be helpful in redefining the diagnostic, prognostic and therapeutic approach.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.TFG performed immunohistochemical and molecular assays, analyzed data, molecular studies and wrote the manuscript; CN, GB and GO contributed to the histological examination; BG contributed to perform histological techniques; GS contributed to perform immunohistochemical techniques; EV analyzed and interpreted the clinical data of the patient; VT analyzed and interpreted the patient data regarding histological and immunohistochemical examination and wrote the manuscript. All authors read and approved the final manuscript. VT and FG contributed equally to this work.


Mediastinal mature teratoma is a benign, slow-growing tumor typically affecting 20- to 40-year-old adults. Fluid examination from the cystic masses rarely shows enzymatic activity as we describe in this report.We report a case of a giant mediastinal germ cell tumor (measuring 15 cm × 14 cm × 8 cm) detected in a 35-year-old Caucasian woman. Microscopic examination showed that the lesion resembled a mature cystic teratoma with areas of pancreatic tissue with mature ductal and acinar structures intermixed with islets of Langerhans. Fluid from the cysts in the mass was examined after removal showed amylase activity of 599 U/l despite normal serum levels. The post-operative period was free of complications, and the patient was discharged on post-operative day 10.Complete surgical removal is the treatment of choice for mature cystic teratomas, with optimal results and acceptable surgical risk. Exocrine pancreatic function may be an aid to pre-operative or intra-operative diagnosis; however, these findings have no impact on survival or the therapeutic pathway. Primary germ cell tumors (GCTs) of the mediastinum are rare tumors , and they usually appear during the third to fourth decade of life . The majWe present a case of a giant mature teratoma of the anterior mediastinum in a 35-year-old Caucasian woman. Following the onset of an episode of influenza associated with productive cough, the patient, an ex-smoker, underwent a chest X-ray which revealed the presence of a severe increase of the frontal cardiac area, with particular involvement of the atrial sectors and evident divarication of the sternal angle. Subsequent transthoracic echocardiography showed a rounded parenchyematous extra-cardial formation measuring approximately 9 cm in diameter and pressing against the lower posterior wall of the right atrium, with the chambers and valves of the heart being within the norm (Ejection Fraction = 71%), and an anomalous movement of the inter-ventricular septum. A thoracic computed tomographic scan with contrast medium confirmed the presence of a voluminous expansive formation with a maximum diameter of 125 mm, liquid contents, clear contours, multiple compartments, and parietal calcifications. This tumor was causing compression of the adjacent pulmonary parenchyma, the vascular and bronchial structures of the right lung (subsequently confirmed with fibrobronchoscopy), and the superior vena cava, without signs of infiltration , with approximately equal frequency in men and women . Histologic examination of mature teratomas reveals malignant transformation in less than 1% of cases and is usually characterized by the malignant degeneration of the squamous epithelium . Most paWritten 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.FS chose the surgical strategy (median sternotomy) and played the greatest role during the surgical operation.FD was a major contributor to the writing of the manuscript and to collecting all the data about the patient that suggested the particularly high levels of amylase in the cystic fluid; he also reviewed the literature. All authors read and approved the final manuscript.


Foreign body (FB) ingestion is a common clinical problem and most FBs pass through the gastrointestinal tract without the need for intervention. A wide spectrum of clinical presentations may be possible and these can be either acute or chronic. We present a case of an 83-year-old woman featuring insidious abdominal discomfort who was hospitalized in our institution due to worsening symptoms. She underwent contrast-enhanced computed tomography (CT) evaluation which showed the presence of a significant parietal thickening of the transverse and descending colon, a mesenteric loose tissue imbibition, venous engorgement, and no filling defect of visceral arteries, suggesting a condition of nonocclusive colon ischemia. A hyperdense FB was identified in the sigma and was associated with a small pseudotumoral mass. The patient underwent surgical exploration which confirmed the hypoperfusional state of the colon, showing the presence of a chicken bone perforating the sigma and lying in the context of a pseudotumoral mass. Our experience shows how contrast-enhanced CT is feasible and can be strongly recommended as a first-line imaging tool on suspicion of colon ischemia and also how it can easily identify the underlying cause, in our case a FB sealed perforation of the sigma with pseudotumoral mass formation. Foreign body ingestion and food bolus impaction commonly occur, and while more than 80% of foreign objects pass through the gastrointestinal (GI) tract without the need for intervention, 20% and 1% of them will, respectively, need endoscopic or surgical procedures. The most frequently ingested foreign bodies in adults are fish bones (9–45%), bones (8–40%), and dentures (4–18%). Ingested foreign bodies mostly cause nonspecific symptoms; however, when accompanied by GI perforation, patients may complain of abdominal pain (95%), fever (81%), or localized peritonitis (39%). Imaging plays an important role in the diagnostic process of both FBs localization and identification of related complication such as perforation and bowel ischemia. While other imaging techniques lack sensitivity and specificity, contrast-enhanced CT with postprocessing reconstructions is of choice permitting achieving a good grade of accuracy.2 of 29 mmHg, pO2 of 84 mmHg, Na+ of 139 mmol/L, K+ of 3.5 mmol/L, Cl− of 104 mmol/L, and Lactates of 3.0 mmol/L and SpO2 of 94.7%. Blood test results were as follows: Hb 17.60 g/dL, hematocrit 51.90%, white blood cell count 22.710 μL (neutrophilia 83.3%), PT-INR 1.78, glucose 158 mg/dL, blood urea 54.00 mg/dL, and creatinine 1.50 mg/dL. Upon clinical suspicion of bowel obstruction or infarction, the patient underwent contrast-enhanced CT examination  which showed the presence of a significant parietal thickening of the transverse and descending colon, a mesenteric loose tissue imbibition, venous engorgement, no filling defect of visceral arteries, and the presence of fluid collections in the Douglas pouch and perihepatic space. As a collateral finding, a hyperdense sharp-pointed curvilinear foreign body was identified in the sigma and was associated with a perifocal persistent contrast-enhancement (CE) within a pseudotumoral mass  tract without the need for intervention, 20% and 1% of them will, respectively, need endoscopic or surgical intervention –5. The m