This report describes a giant pleural lipoma that arose from the pleura of the 7th anterior intercostal space and occupied approximately 75% of the right pleural cavity in a 49-year-old woman. The tumor was completely excised by right thoracotomy. The complete histopathological investigation showed pleural lipoma, and we made a review of literature. Lipoma is mostly found within the subcutaneous areas of the body. Pleural lipoma is rare, which is usually located at the mediastinal, bronchial and pulmonary levels. The finding of a lipoma in the parietal pleura intrathoracic has been sporadically reported in the literature .Most patients remain asymptomatic and the lipomas are incidentally found in a chest radiograph or a computed tomography (CT) examination.Although pleural lipoma is benign tumor, it should be completely resected from diagnostic and therapeutic perspectives .Here we report a case of pleural lipoma successfully resected through right thoracotomy with a review of the literature.A 49-year-old Chinese rural woman was admitted to our hospital with chest tightness for 10 days, complaining of mild shortness of breath without past medical history. She was a nonsmoker, and maintained a healthy weight of 50 kg for her 163 cm height. On examination, the patient was found to have absent breath sounds accompanied by dullness on percussion in the right low lung field. Laboratory workup was normal. The results of lung function tests, which showed FEV1/FVC was 99%, furthermore FVC was 64.1% of its predicted value, were consistent with the impression of restrictive ventilatory disorder result from thoracic large tumor.A routine chest roentgenogram Figure A showed Right thoracotomy revealed a round, yellowish, consistently soft tumor which had a smooth surface Figure C, and ocFinal histologic result was pleural lipoma. The investigation of this tumor revealed an encapsulated tumor with abundant mature adipose tissue, a few scattered strands of fibro connective tissue, no presence of sarcomatous changes Figure D.The patient’s postoperative course was uneventful, with no recurrence on one-year follow-up.Lipoma is a benign mesenchymatous tumour. Clinically, a large number of lipomas are found within the subcutaneous areas of the body, but intrathoracic lipomas are rare and they can be located at the mediastinal, bronchial and pulmonary levels. A pleural lipoma is extremely rare ,4.Tateishi et al.  reportedAccording to their origin, intrathoracic lipomas are classified into several types, such as endobronchial lipomas, diaphragmatic lipomas and this case belongs to pleural lipoma which originates from the submesothelial parietal pleura and may extend into subpleural, pleural or extrapleural spaces .Lipomas can be also divided into two classes: (1) hourglass or dumbbell lipomas that pass through intercostal space or the thoracic inlet; and (2) purely intrathoracic lipomas. Our case belong to the latter type, since it was entirely within the right thorax ,8.Like our case, lipomas often grow slowly and subsequently are detected at a relatively late stage of evolution. But in Christophe’s opinion , such deMost patients remain asymptomatic, but since lipomas are able to grow to a large size, they may provoke compression symptoms, which depend on sites and sizes of lipomas. Symptoms such as dyspnoea and dysphagia are show due to local compression on adjacent structures, such as the trachea or oesophagus. Our patient’s complaint of mild shortness of breath maybe due to the huge tumor’s compression on the right lung.Jack et al.  reportedPleural lipomas also may cause complications such as intratumoral haemorrhage with pain and fever, moreover they can invade intercostal spaces and induce rib lysis .Although the tumor is usually detected incidentally in a chest X-ray, CT scan has replaced conventional x-ray and ultrasound scan for accurate detection of thoracic lipomas. CT allows a definitive diagnosis when it demonstrates a homogeneous fat attenuation mass  which formed obtuse angles with the chest wall and displaced adjacent pulmonary parenchyma and vessels . The denThe management strategy for pleural lipomas is still controversial. An observation principle with clinical and radiological follow-up may be suitable for elderly patients and those in poor general condition, especially in the presence of small and asymptomatic lesion .But most authors argued surgical resection, if possible, would be recommended for diagnostic and therapeutic considerations.In this case of large lipomas, surgical exeresis is then inevitable to diagnose and to treat prior to progression stage when complications may happen. It is also the reason why we did not performed fine-needle aspiration biopsy, which was such a less invasive method.Surgical resection can easily be performed via muscle-sparing or an open typical thoracotomy, as in our case. Video assisted thoracoscopic surgery (VATS) has become a common technique for thoracic tumor which was pedunculated in form and small enough in size because there is no infiltrating growth in this type. It is an effective well-tolerated procedure that is associated with less morbidity and mortality. Recently, successful extirpation of a pleural lipoma with a single-port VATS has been reported .The outcome of resection of lipomas is usually good. Recurrence rates after surgical excision have been reported to be less than 5% . Most caIncomplete surgical resection might be performed rather than complete extirpative procedures which may cause a serious functional disorder. Wurlitzer and colleagues  reportedAlthough pleural lipoma never evolves towards liposarcoma, surgical resection is still necessary due to the following reasons: firstly, preoperative diagnose is difficult to distinguish lipoma from well-differentiated liposarcoma; secondly, compression symptoms could be fatal; thirdly, complications such as intratumoral haemorrhage with pain and fever may exist during infiltrating development of the tumor preoperatively. During surgery, not only should we remove the tumor radically as far as possible, but we should also protect the surrounding tissues. After surgery, local recurrence of intrathoracic pleural lipoma is uncommon.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.CT: Computed tomography; BMI: Body mass index; cm: centimeter; kg: kilogram; FVC: Forced vital capacity; FEV1: Forced expiratory volume in 1s.The authors declare that they have no competing interests.MC and JY performed surgery. LZ carried out the patient diagnosis. MC and JY were major contributors in writing the manuscript. HZ Provide a lot of useful suggestions about this manuscript. All authors read and approved the final manuscript. Full list of author information is available at the end of the article.


Neuroendocrine tumors are a rare but diverse group of malignancies that arise in a wide range of organ systems, including the mediastinum. Differential diagnosis includes other masses arising in the middle mediastinum such as lymphoma, pericardial, bronchogenic and enteric cysts, metastatic tumors, xanthogranuloma, systemic granuloma, diaphragmatic hernia, meningocele and paravertebral abscess.We present a case of 42-year-old Caucasian man with a neuroendocrine tumor of the middle-posterior mediastinum and liver metastases, which resembled a lymphoma on magnetic resonance imaging.The differential diagnosis in patients with mediastinal masses and liver lesions should include neuroendocrine tumor. Neuroendocrine tumors (NETs) are a rare but diverse group of malignancies that arise in a wide range of organ systems. This can therefore include the mediastinum ,2.Differential diagnosis includes other masses arising in the middle and posterior mediastinum, such as lymphoma, pericardial, bronchogenic and enteric cysts, metastatic tumors, xanthogranuloma, systemic granuloma, diaphragmatic hernia, meningocele and paravertebral abscess. When a large mass is discovered, pathological conditions of the anterior mediastinum, such as thymoma, germ cell tumors, intrathoracic goiter, lipoma, lymphangioma and aortic aneurysm, should also be considered ,4. We prA 42-year-old Caucasian man was referred to our institution because of a recent onset of dysphonia. He had no significant past medical history and his physical examination was unremarkable. His erythrocyte sedimentation rate was increased . His blood cell count was normal as were the results of his other laboratory tests, including human immunodeficiency virus serology, urea and electrolytes, liver function tests and lactate dehydrogenase levels. Chorionic gonadotropin, neuron-specific enolase (NSE), prostate specific antigen, carcinoembryonic antigen, cancer antigen-125 and cancer antigen-19.9 were also tested and found to be negative. A noncontrast and postcontrast MRI of his mediastinum revealed a 6 cm × 4 cm × 5 cm solid lesion in the left paratracheal area, which appeared to enter and widen the aortopulmonary space. It also displaced his distal trachea and branches of his left bronchus medially and inferiorly, respectively. On T2-weighted images, the mass showed homogeneous high signal intensity. In contrast, a low intensity signal was noted on T1-weighted images and on the apparent diffusion coefficient (ADC) map when diffusion weighted images (DWI) were considered . Microscopic examination revealed small sized cells, some of them spindle-shaped, which were positive for cytokeratins AE1/AE3, chromogranin, NSE and synaptophysin on immunohistochemical analysis. Ten percent of the cells expressed Ki67 and none of them showed a CD3-CD20 pattern. According to the pathological response, the diagnosis was a NET with hepatic metastasis.Systemic chemotherapy based on cisplatin plus etoposide was started and then replaced by a new scheme based on capecitabine because of the progression of the disease, which was particularly noticeable in his liver. Therefore, a transarterial chemoembolization was considered as a suitable option to control the hepatic disease and then performed by emulsifying polyvinyl alcohol particles and doxorubicin .NETs are a rare but diverse group of malignancies that arise in a wide range of organ systems. Gut-derived NETs arise from the diffuse endocrine system and, according to the 2002 World Health Organization classification system , are mosThe case presented here was a suspected malignant mediastinal tumor, because of the young age of our patient and the presence of dysphonia. For this reason, MRI was also extended to his abdomen. Radiological features of low vascularization and the absence of involvement of the vascular and biliary structures shown by the hepatic and mediastinal lesions led to a first diagnostic hypothesis of mediastinal lymphoma with hepatic spread. The latter hypothesis was also supported by the fact that more than 80% of patients with Hodgkin's disease and almost 45% of patients with non-Hodgkin's lymphoma show intrathoracic involvement ,8. MoreoA multimodality approach is optimal for detecting the primary tumor and metastases and can include multidetector computed tomography (CT), functional imaging, MRI, ultrasonography, endoscopy, digital subtraction angiography and venous sampling.For the evaluation of liver metastases, the use of triple-phase multidetector CT and contrast material-enhanced MRI is suggested to establish a baseline, which can help assess disease extent and allow post-treatment comparison. The arterial anatomy of the liver and portal vein patency can also be determined. Liver metastases have low signal intensity on T1-weighted MRI and high signal intensity on T2-weighted images .The treatment of patients with liver metastases is complex, and there are often several factors that must be taken into account. Curative surgery should always be considered but is rarely possible due to the diffuse nature of the disease.NETs are relatively slow-growing tumors; therefore, patients can survive for several years with current treatment strategies. Interventional radiology has played an increasingly important role.111In-pentetreotide has been proven on a previous scintigraphy and trained staff is available. Radionuclide therapy should not be performed in cases of pregnancy and lactation, or bone marrow dysfunction  [Interventional radiologists could approach liver metastases by performing procedures such as embolization, chemoembolization, targeted radionuclide therapy and local ablative techniques  . Radiolo 100/mL) . Ablativ 100/mL) ,15.Mediastinal neuroendocrine tumors are a challenging disease for clinicians and radiologists. Although the clinical approach is still the mainstay both in the diagnostic and therapeutic phases, the radiological approach could provide valuable support. The differential diagnosis in patients with mediastinal masses and liver lesions should include neuroendocrine tumor.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.BV, FDG and SB analyzed and interpreted the patient data. RDV, RFG and BBZ performed the thorax and abdominal magnetic resonance. RDV and GC were major contributors in writing the manuscript. All authors read and approved the final manuscript.


Malignant rhabdoid tumor (MRT) is one of the most aggressive and lethal malignancies in pediatric oncology. Malignant rhabdoid tumor was initially described in 1978 as a rhabdomyosarcomatoid variant of a Wilms tumor because of its occurrence in the kidney and because of the resemblance of its cells to rhabdomyoblasts. The absence of muscular differentiation led Haas and colleagues to coin the term rhabdoid tumor of the kidney in 1981, Haas et al.. Rhabdoid tumor is a rare tumor that was first found to be in the kidney. Over the last several years, research has shown that it can also occur in the central nervous system  as well as other locations outside the kidneys such as the liver, muscle, heart, lung, soft tissues, and skin. If the tumor is in the kidney, it is called “rhabdoid tumor of the kidney (RTK)”, and if it is in the brain or spinal cord, it is called “CNS atypical teratoid/rhabdoid tumors (AT/RTs)”. If it occurs outside of the kidney or brain, it has the longer name of ‘‘non-CNS extrarenal rhabdoid tumors” .SMARCB1 gene indicates that rhabdoid tumors of the kidney and brain are identical or closely related entities. This observation is not surprising because rhabdoid tumors at both locations possess similar histologic, clinical, and demographic features. Moreover, 10%–15% of patients with malignant rhabdoid tumors have synchronous or metachronous brain tumors, many of which are second primary malignant rhabdoid tumors. Germline SMARCB1 mutations were detected in approximately 15%–30% of these patients. INI1 immunohistochemical studies can be used in conjunction with other studies to confirm the histologic diagnosis of malignant rhabdoid tumor [Considerable debate has been focused on whether extrarenal malignant rhabdoid tumors are the same as RTK. The recent recognition that CNS atypical teratoid/rhabdoid tumors (AT/RTs) have deletions of the id tumor .This is a 36-year-old married male. He is nonsmoker and nondiabetic. The patient is not known to have any medical illness and was in his usual status till 6 months prior to the presentation, when he started to complain of subjective fever at night, night sweating, headache, and generalized weakness, but that did not interfere with his daily activity and neglect his condition until 2 months back, he started complaining of intermittent dull acting central chest pain that was not related to exertion and associated with mild shortness of breath and intermittent cough. He had lost about 10 kg in the last 2 months. There was no history of recent traveling or contact with febrile patient. No history of palpitations, apnea or PND. He sought advice in a private hospital, and they did chest X-ray and CT scan that showed left lung upper lobe mass, hilar and mediastinal lymphadenopathy, and superior vena cava thrombosis. The patient is on vitamin supplements and multiple antibiotics; he was given there. There was no past history of admission, surgical intervention, or blood transfusion .Temperature 37°C, pulse of 75 beats per minute, respiration 16 per minute, BP of 121/80 mmHg and oxygen saturation was 96% on room air. He is a young male, lying in bed, not in distress, conscious, alert, and oriented in time, place, and person. Neck examination: Pemberton sign was positive. Neurological examination: normal Chest: showed normal S1 and S2, no murmur equal vesicular bilateral breath sounds with no adventitious sounds, and no conducting sounds. Abdomen: soft, lax, no tenderness, and no organomegaly.9/L, RBC 4.59 × 1012/L, hemoglobin of 11.9 g/dL, hematocrit 37.5%, MCV of 81.8 fL, MCH of 26 pcg, MCHC 31.8 g/dL, RDW 12.5%, platelet count of 453 × 109/L, mean platelet volume of 8.4 fL, neutrophils of 60.8%, lymphocytes 18.7%, monocytes 10.4%, eosinophils 7.1%, basophils 1.7%, lymphocyte count absolute 1.21, monocytes 0.67, that is 670, eosinophils 0.46, basophils 0.11, atypical cells 1.2% and nucleated RBCs per high power field.CBC showed WBC of 6.45 × 10Liver panel: bilirubin of 6.3 mcmol/L, alkaline phosphatase 99 U/L, ALT of 24 U/L, AST of 12 U/L, GGT of 29 U/L, total protein of 79 g/L, albumin of 29 g/L, and albumin/globulin ratio was 0.6. Coagulation profile: PT of 13.45 sec, INR of 1.07 sec, and PTT of 36.41 sec. Renal panel: sodium of 137 mmol/L, potassium of 4.6 mmol/L, chloride of 102.1 mmol/L, bicarbonate of 27 mmol/L, BUN of 3.3 mmol/L, and creatinine of 86 mcmol/L. MDRD calculated was more than 60 ml/min. Bone panel: Phosphorus of 1.24 mmol/L, ALP of 101 U/L, total protein of 70 g/L, albumin of 31 g/L, calcium of 2.04 mmol/L and corrected calcium of 2.25. Magnesium of 0.95 mmol/L.C-reactive protein = 80.9 mg/L. CMV IgG was reactive, CMV IgM non reactive. ESR of 16 mm/hr.The chest X-ray revealed ill-defined area of consolidation seen at the left hilar region, no evidence of rib destruction, no pleural effusion in comparison to previous radiographs as per the radiologist. Abdominal ultrasound was done and did not show any abnormalities.The patient underwent CT chest, abdomen, and pelvis. It showed left upper lung lobe mass, there was a nodular peribronchovascular infiltration involving the left lingular segment suggestive of lymphomatous infiltration, multiple enlarged mediastinal lymph nodes located at anterior mediastinal, paratracheal, peribronchial, subcarinal, and bilateral hilar groups, with the largest was at the paratracheal group measured 2.65 × 1.6 cm, still the thrombus in the right brachiocephalic vein and superior vena cava extended to the right atrium and the right subclavian vein with calcification of right axillary vein suggestive of chronic thrombosis with recanalization of the right subclavian vein. Minimal pericardial effusion was noted. No pleural effusion. The size and configuration of cardiac and mediastinal silhouette structures were maintained. The liver was normal in size in form of attenuation, no focal lesion, and no biliary dilatation. Inferior vena cava, hepatic, and portal vein were patent. Spleen, pancreas, both adrenals, and both kidneys were normal. No ascites was noted. The visualized thoracic bony cage, spine, and pelvis showed no focal bony lesions.The patient underwent bronchoscopy with transbronchial biopsy. The bronchoscopy showed the vocal cords were normal, trachea normal, carina shape normal, and in right and left lungs, no bronchial lesion was seen. Transbronchial biopsy was taken from the left upper lobe. The report of the bronchoalveolar lavage fluid showed excessive blood few scattered benign bronchial cells otherwise normal study. Microscopic description showed lung tissue with rhabdoid appearance, which was strongly positive for pan CK, vimentin, but negative for actin, myogenin, desmin, and myoglobin. Finally, the immunohistochemistry demonstrated lack of nuclear INI1 protein expression .The patient underwent mediastinoscopy and the pathological report of the biopsy of the mediastinal lymph node that was taken on the mediastinoscopy. The biopsy specimen was reviewed, gross specimens consisted of mediastinal lymph nodes; measuring in aggregate 1.5 × 0.5 cm, frozen section diagnosis was metastatic tumor, whereas the specimen received in formalin consisted a piece of brownish tissue measuring 0.7 × 0.4 × 0.3 cm, grayish brown tissue measuring 0.9 × 0.8 × 0.3 cm. Microscopic description showed lymph nodes in all the above with metastasis with rhabdoid appearance, which was also strongly positive for pan CK, vimentin, but negative for actin, myogenin, desmin, and myoglobin. Finally, the immunohistochemistry demonstrated lack of nuclear INI1 protein expression.Pathological diagnosis: Left lung upper lobe rhabdoid tumor with mediastinal lymph nodes nodal metastasis.Diagnosis: left lung upper lobe rhabdoid tumor with multiple mediastinal lymphadenopathies with superior vena cava thrombosis.Malignant rhabdoid tumor was first identified in the kidney of infants and children and was described in 1978 as rhabdomyosarcomatoid variant of Wilms' tumor , 4. HoweThe median age at presentation is 10.6 months, with a mean age of 15 months. Most patients are younger than 2 years. Malignant rhabdoid tumor has been reported in children older than this and in adults. As concern chemoradiotherapy, no consistently effective regimen has yet been established, and a standard regimen is not yet established. The prognosis for children with malignant rhabdoid tumors remains fair to poor, depending on the stage of the tumor at presentation, the patient's age at diagnosis, and possibly the genetic background.


Sarcomas of the broad ligament are very uncommon. To our knowledge, there are no cases published of undifferentiated round cell sarcoma of the broad ligament. Round cell sarcomas are a rare and very aggressive variant, which due to their sensitivity to chemotherapy, have an acceptable prognosis. We report the case of a 27-year-old woman who presented with a pelvic mass with a 7-cm diameter placed on the right broad ligament. After surgery, she was diagnosed with undifferentiated round cell sarcoma of the broad ligament. The patient received adjuvant chemotherapy and radiotherapy, and after 12 years of follow-up, she still remains asymptomatic. Proper differential diagnoses as well as an appropriate adjuvant therapy after surgical treatment seem to be essential to obtain good oncological outcomes in this rare entity. In 1957, Gardner . Round c2) and cyclophosphamide (dose 500 mg/m2). The planned six cycles could not be completed because the patient decided against them. Radiotherapy was combined with the second cycle, using telecobalt therapy combined with curie therapy in the vaginal cuff. Throughout the treatment, the values of analytical tests lay within normal limits. The patient was examined every six months for five years and annually after the sixth year. Follow-up was incident free, and the patient remains asymptomatic 12 years after surgery.We present the case of a 27-year-old woman who presented to our department reporting difficulty with urinating over the past fortnight. The patient had no medical or surgical background of interest. The physical examination was normal, although a vaginal echogram revealed a pelvic tumoural mass of mixed echogenicity, 8-cm in diameter and with a volume of 293.97 ml . A diagnRound cell sarcomas are a little known phenomenon owing to their low frequency. Having reviewed the literature, we can find no published case of an unclassifiable round cell sarcoma of the broad ligament, which is a further indication of their rarity.There is no consensus or specific approach published in the literature , 6, for In case of a tumour extending to other parts of the uterine cavity, all the visible tumours should be removed with a view to complete cytoreduction, together with a pelvic and para-aortic lymphadenectomy if tumours of a carcinosarcomatous type are involved. In our case, a hysterectomy with removal of the tumoural mass was carried out, since it was not certain that a malignant tumour was involved. However, following adjuvant treatment, it appears that extension of the surgery was probably not necessary.It appears that the use of adjuvant chemotherapy and radiotherapy may improve the prognosis, although we do not have sufficient evidence of its use in round cell tumours . DespiteDemonstrated survival in patients with broad ligament sarcomas ranges from 4 weeks to 33 months, with the best rates being associated with cases in which combined treatment was used . DespiteThe prognosis for these kinds of tumours in general is uncertain owing to the variability of tumour type. In our case, there was no recurrence after 12 years of follow-up, with the patient remaining asymptomatic, although this is probably due rather to the specific biology of the tumour than to the treatment received, since we know that other round cell tumours in other locations are extraordinarily aggressive despite correct treatment , 4.In conclusion, broad ligament sarcomas are an extraordinarily uncommon phenomenon. A correct differential diagnosis of tumours of the broad ligament and appropriate treatment, preferably involving surgery plus adjuvant chemotherapy and radiotherapy in the case of sarcomatous masses, is fundamental to obtaining adequate oncological results.Conflict of Interest: none


The neurofibroma is a tumour of neural origin. This kind of neoplasm, though, is generally skin located. Rare cases in deep organs or in the peritoneal cavity are also reported in the literature. There are two types of neurofibromas, localized and diffuse; the latter is associated with von Recklinghausen disease and always occurs together with skin neurofibromas. Here we report the case of a 47-year-old man affected by retroperitoneal neurofibroma, but not associated with von Recklinghausen disease. A computed tomography (CT) scan described a retroperitoneal pararenal lesion with no clear involvement of adjacent viscera. We describe the diagnostic modality, treatment planning and the timing of treatment of this neoplasm, reviewing also the literature. USultrasonographyCTcomputed tomographyCEAcarcinoembryonic antigenCA19.9carbohydrate antigen 19.9FNBCT-guided fine needle biopsyICVinferior cava veinRRVright renal veinNeuneurofibromaMRImagnetic resonance imaging3); the involvement of adjacent viscera was unclear, in particular the kidneys, renal vessels and right psoas muscle, while the cava vein appeared displaced in an anterior-medial direction  showed a benign neoplasm of peripheral nerves tissue, characterized by the presence of elongated and wavy cells positive of S-100 protein. For these symptoms, the patient underwent a surgical resection that started with a subcostal incision after right ureteral stent placement. At the intra-abdominal exploration, the lesion appeared to constrict the cava vein and displace the right kidney, the renal vein  and the Neurofibromas, in general, are rare neoplasm and arise in patients with von Recklinghausen disease, but a solitary variant has been observed in rare cases and its splanchnic location is very uncommon .Paraaortic–Pararenal Neurofibroma is an exceedingly rare tumour location . To our As a matter of fact, only histology can diagnose them and, if it is performed preoperatively, it can influence treatment. In particular, it is capital to discriminate between malignant and benign lesions thus modifying a surgical approach, conservative versus aggressive ones. In  our case, the absence of mitotic activity, lack of necrosis, pleomorphism and infiltrative pattern of growth allow us exclude malignity.Some authors say that using perfusion imaging may help differentiate renal parapelvic neurofibroma from the malignant lesions of the kidney .In our case, the renal parenchyma and pelvicalyceal system were seen intraoperatively to be uninvolved. Because of the specific radiological results, in order to preoperatively plan the best strategy for the patients, we performed a percutaneous CT-guided biopsy, which, while feasible, could be deceptive . Based oPlanning the best treatment based on clinical and radiological data is often impossible. The most common risk for surgeons is to put the patient through a demolitive surgery, often an unnecessary surgical intervention. Preoperative histological diagnosis can be a useful tool to  help the surgeon choose demolitive surgery not only in selected cases but also in cases where the therapeutical implications are conservative or demolitive.


Introduction. Gastrointestinal stromal tumors of the esophagus are rare. Case Presentation. This is a case of a 50-year-old male patient who was referred to our department complaining of atypical chest pain. A chest computed tomographic scan and endoscopic ultrasound revealed a submucosal esophageal tumor measuring 5 cm in its largest diameter. Suspecting a leiomyoma, we performed enucleation via right thoracotomy. The pathology report yielded a diagnosis of an esophageal gastrointestinal stromal tumor. The patient has shown no evidence of recurrence one year postoperatively. Conclusions. This report illustrates the complexity and dilemmas inherent in diagnosing and treating esophageal GISTs. Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract . After tEsophageal GISTs, in contrast, are rare, amounting to 12.7–28% of mesenchymal esophageal tumors or 2% of all GISTs  and theiA 50 year old Caucasian male was referred to the thoracic surgery department for evaluation of an intramural esophageal mass. The patient complained of atypical chest pain of gradual onset over the previous 6 months. He denied weight loss, dysphagia, upper GI bleeding, reflux, or other symptoms. The patient's medical history included hypertension and a 30-pack-year smoking history. After a chest radiograph failed to show any pathology, a computed tomography (CT) scan was ordered which revealed showed a 5 cm mass on the midesophagus at the junction of the azygos vein with the superior vena cava . EndoscoThe mass was approached via a right posterolateral thoracotomy . The subOn macroscopic examination, the mass was 5.5 × 3.5 × 1.5 cm in size and grayish in color with a fasciated texture . HistoloAfter a multidisciplinary meeting the patient received adjuvant therapy (imatinib mesylate 400 mg/d for 1 year). He is closely followedup with endoscopy and CT scans every 3 months and is currently free of disease one year after surgery.Esophageal GISTs are difficult to diagnose preoperatively since there are no specific findings to differentiate them from far more common leiomyomas when their clinical presentation, endoscopy, endoscopic ultrasound, or CT scan is reviewed , 4, 5. BAnother contentious point is the type of surgery indicated for esophageal GISTs. While the recommendation for GISTs found in other locations is a wide local excision, the increased morbidity of esophageal resection has to be taken into account. Conflicting data exist in the literature; while some authors report poor results with mortality of up to 59% , 4, it iThis case illustrates the complexity and dilemmas in diagnosing and treating esophageal GISTs. To accumulate high-level evidence sufficient to support specific guidelines, a multi-institutional study or even an international registry of such lesions is needed. Until then, each patient should be evaluated individually by surgical risk, tumor size and biology and should actively participate in the management decision process.


Dear Sir,Medulloblastomas are rarely seen in the adult population, accounting to less than 1% of primary adult brain tumors. It commo5A 22-year-old male patient presented with headache, vomiting, ataxia, and left facial weakness of one-month duration. Vision was normal. Fundus examination showed papilloedema. He had left lower motor neuron facial paresis, left IX and X cranial nerve paresis, and left cerebellar signs. Computed tomography scan of the brain showed a left CP angle mixed-density nonenhancing lesion (5.4 × 2.8 cm) with broad-based tentorial attachment and displacement of the fourth ventricle causing obstructive hydrocephalus . Findinget al. have reported a case of vermian medulloblastoma with metastasis to the CP angle.[Medulloblastoma usually occur in inferior medullary velum in the midline. However,5221Extra-axial site of this tumor is extremely rare but must be considered in the differential diagnosis of extra-axial CP angle lesions. Any neurological deterioration seen in follow-up patient must be evaluated for metastasis.


She presented to the general surgeons with a subcutaneous lump on the mons pubis that had been monitored for about one year. MRI showed a polycystic mass of 30 mm × 18 mm × 18 mm size that was excised and described as an adenocarcinoma on the basis of endometriosis  in-situ, which had been placed for contraceptive purposes only. PAP smear and tumor markers  were all normal. Repeat MRI showed partly solid, partly cystic post-operative residuals in the right inguinal region, extending up to the right edge of the symphysis pubis with uncertain boney infiltration. A PET and a CT scan revealed pathological lymph nodes on the right and one lesion in the left inguinal region. The patient was transferred to our Department for tertiary care. Following discussion by the Gynecologic Cancer Inter-Group (GCIC), the residual tumor was removed one month after the initial surgery. This involved a multidisciplinary team of gynecologic, orthopedic and plastic surgeons and included the resection of the mons pubis and the right pelvic and inguinofemoral lymph nodes. The symphysis pubis was partly removed and the right pectineus muscle was resected; the rectus sheath and the rectus muscle were refixated onto the remainder of the symphysis pubis. The skin of the left lower abdomen was transposed to cover the defect. A laparoscopic tubal ligation, removal of the LNG-IUS and dilatation and curettage (D&C) were also performed. During laparoscopy no evidence of endometriosis was seen; the D&C demonstrated a normal endometrial mucosa without atypia.The histology report revealed large areas of highly differentiated endometrioid adenocarcinoma and small areas of adeno-squamous as well as serous-papillary differentiation. The tumor margins were free. Furthermore, areas of endometriosis without atypia were seen. All 12 lymph nodes resected were tumor-free. Immunohistochemistry confirmed the presence of estrogen and progesterone receptors, as well as expression of the L1 cell adhesion molecule (L1CAM) in the endometriotic and the tumor tissue.Following a further discussion by the Gynecologic Cancer Inter-Group (GCIC) the patient was to receive six cycles of adjuvant chemotherapy with carboplatin/paclitaxel and local radiotherapy. During the first cycle of chemotherapy the patient developed a major anaphylactic reaction. She also reacted to the alternative option of pegylated liposomal doxorubicin and docetaxel. Finally a combination of epirubicin and carboplatin was tolerated well and the remaining cycles could be administered without unexpected toxicities. The patient received local radiotherapy with 5000 cGy in 25 fractions to the area of the previous malignancy as well as up to 6000 cGy in five further fractions to the whole operating field. She was followed up clinically and paraclinically for the last three years and remains well with no evidence of tumor recurrence.The current literature includes one case of inguinal endometriosis . HoweverEndometriosis usually affects women of reproductive age and has a prevalence of 10% . Its etiIn the malignant transformation of endometriosis the ovary is the primary site in 79% of all cases . ExtragoIn this case the possibility of metastasis from a uterine primary was excluded. Nevertheless, we cannot exclude the possibility of endometriosis implantation at the time of an earlier appendectomy. The surgical incision was thereby made in the right lower quadrant. An oophorectomy at the time of surgical resection was not considered in this patient, however, it could certainly be deliberated in future cases given that the ovary is the most common site of endometriosis-associated adenocarcinoma. There are multiple possible explanations for the pre-malignant potential of endometriosis. Pollacco et al., for example, propose an endometriosis-induced carcinoma (EIC) triad, with endocrinological and immunological factors as well as genomic alterations leading to the malignant transformation of the endometriotic tissue . CertainThe authors report no conflict of interest.


The current case report presents an account of a unique surgical procedure performed to remove an extremely rare occurrence of a transsacral abdominal mass from a 24-year-old female. The patient presented with subtle sacrococcygeal pain for two months and a presacral abdominal mass derived from the right ovary. The mass was misdiagnosed as a presacral tumor based on the results of magnetic resonance imaging (MRI) performed prior to the surgery. The patient also exhibited the symptoms commonly caused by a presacral mass, however, during the surgery, the mass was not initially located under the sacrum. An ultrasound examination and an analysis of an intraoperative frozen section indicated that the mass was a mature cystic teratoma (MCT) of the ovary, located in the peritoneal cavity between the rectum and uterus. The mass was successfully resected and removed from the affected ovary through the abdominal cavity via the sacral region. A pathological examination of the tumor section confirmed a diagnosis of a MCT of the ovary. Mature cystic teratomas (MCTs) are germ cell tumors that commonly occur in the ovaries, accounting for 10% of all ovarian tumors . TranssaA 24-year-old Mongolian female was referred to the outpatient clinic at Huashan Hospital  with mild sacrococcygeal pain that had been present for two months with no obvious causation. The individual had no fever, abdominal pain or changes in habitual normal bowel movement and urination. Magnetic resonance imaging (MRI) of the patient’s pelvis revealed a 53×40×33-mm pelvic mass, posterior to the sacrum and at the right side of the rectum . An enhaUpon admission to the hospital, no abdominal tenderness, rebound pain or palpable masses were identified by a physical examination. The initial rectal exam detected the inferior end of a non-mobile, non-tender and smooth-edged mass attached to the right posterior side of the rectum.The patient was scheduled for surgical treatment under general anesthesia two days after admission. Intraoperatively, the patient was placed in the prone jack-knife position. The surgery was performed with a 10-cm incision at the inferior margin of the fifth sacrum. The coccyx and the inferior margin of the fifth sacrum were removed. The right side of the wall of the rectum was dissociated from the presacral rectum by an incision into the gorge of the sacrum. No tumor mass was located by laparotomy or the initial examination during surgery. Next, an ultrasound examination was performed and the mass was visualized at the right side of rectum, posterior to the uterus. The right ovary was not located at its normal anatomical site. The peritoneum was opened and the enlarged right ovary was identified as a presacral mass with an irregular appearance. The mass had a diameter of 5 cm and its outer boundary was smooth with no feeding vessel or ligamentous connection to the surrounding organs, including the rectum, uterus, cervix and vagina. The sacrum and coccyx were unaffected . The lefThe right ovary tumor mass was resected and removed from the normal ovarian tissue by a gynecologist. The examination of an intraoperative frozen section indicated a possible diagnosis of a presacral MCT (dermoid cyst). A further pathological examination confirmed the diagnosis of a presacral MCT. The patient recovered uneventfully and was discharged 6 days after the surgery. Written informed consent was obtained from the patient for the publication of this case report.Teratomas arise mainly from totipotential gonadal cells, and while a number of them may have malignant potential, the majority are benign at the time of identification. The cause of teratomas remains unknown . These mAn accurate diagnosis of a presacral mass prior to surgical removal is extremely important. A number of standard diagnostic imaging methods, including ultrasonography , computed tomography (CT) and MRI, are readily available and must be used to generate a detailed image of the mass to facilitate pre-operative planning ,9. AlthoRadiological visualization techniques, including CT and MRI, enable us to generate a pre-operative diagnosis for presacral tumors ,12. CT sIn the current patient, MRI showed the fat-like and soft tissue components within the presacral mass. Since a diagnosis of a primary presacral MCT could not be ruled out, particularly due to the patient’s medical history and physical examination results, the transsacral approach was selected for the surgery.Surgical resection is the standard curative treatment for the majority of MCTs. For patients who are otherwise healthy and whose lesions appear resectable, the management of such lesions is almost always surgical resection. The approach depends on the nature and location of the lesion. Previous studies have reported that lesions which do not extend below S4 should be resected transabdominally, while lesions below S4 and <8 cm in diameter should be resected transsacrally and larger lesions or those in an intermediate position may require a combined abdominal and sacral surgical procedure ,16. AccoThe final diagnosis for this patient was a transsacral ovarian MCT in the presacral region. Ovarian MCTs mostly occur in the pelvic cavity and are commonly observed in the pouch of Douglas and occasionally in the uterosacral ligament . In rareIn addition, the most frequent symptom of MCT is lower abdominal pain , while tPerforming a laparotomy with an uncertain target and an unplanned surgical approach must be prevented to limit surgery-related trauma and complications. During transsacral surgery to remove a presacral mass, ultrasonography must be performed if the mass cannot be located initially.In the present case, no mass was located by the laparotomy or initial examination during the surgery. An ultrasound examination was performed, confirming that the mass was at the right side of rectum, posterior to the uterus and embedded in the predicted right ovary, which was not at its normal anatomical location. Since the tumor was covered by normal smooth ovarian tissue and had no adhesion to other organs and as the patient was in the prone jack-knife position, the likelihood that the tumor may have moved and descended into the abdominal cavity must be considered.We resected and dissociated the tumor mass from the ovary through the sacral region and returned the ovary to the normal anatomical location. The organs posterior to the bladder were exposed in a clear view to avoid injuring the ureters. As MCTs are curable in the majority of cases by a complete surgical resection of the tumor alone , and as Ovarian MCTs commonly occur in the pelvic cavity and are rarely identified in the presacral position. In cases where ultrasound and radiological examinations strongly indicate the presence of a teratoma, a diagnosis of a prescacral ovarian MCT must be taken into consideration.Pre-operative ultrasound and radiographic examinations must be performed in the supine and prone positions to assess the firmness and mobility of the presacral mass, as well as its derivation and relationship to the surroundings. Based on these efforts, the most efficient and least trauma-inflicting surgical approach must be determined prior to surgery.To dissect a transsacral abdominal mass, an ultrasound examination must be performed during the surgery to assist in the identification of the mass if it is not firmly attached, movable or is not able to be located directly during surgery initially. If the transsacral laparotomy fails to locate the mass, an additional surgical procedure, such as a transparietal laparotomy, should be performed. To assess a transsacral mass, it is feasible that, during transsacral abdominal surgery, the peritoneum is opened from the pelvic floor. By contrast, for a common MCT that may be curatively managed by complete surgical resection transabdomenally, the transsacral approach is unnecessary and may be relatively more traumatic.


Congenital granular cell tumor (GCT) is a relatively rare intraoral benign tumor, approximately 200 cases of which have been reported in the neonatal period worldwide. The newborn infant may have feeding problems and respiratory difficulties due to airway obstruction. This lesion may be diagnosed by prenatal ultrasonography and simple resection is mostly required. We report a case of an adult type of GCT in a newly born infant, who presented with an intraoral protruding mass with a prenatal diagnosis. This article describes the prenatal course, clinical, and pathological characteristics, and management of the GCT. The most frequent locations are the tongue, skin, and soft tissue. The tumor typically develops in adults in the third and sixth decade of life and its occurrence in neonates is extremely rare.1,7 The histogenesis of this tumor has yet to be clearly defined, but various origins such as gingival endothelial, mesenchymal, mioblastic, odontogenic, neurogenic, fibroblastic, and histocytotic have been proposed as possibilities.2,6Because of female predominance, the influence of maternal estrogen and fetal ovarian hormones has been postulated in the pathogenesis of the tumor, with spontaneous regression after maternal estrogen withdrawal.8This possible influence of estrogen and progesterone receptors has been investigated through immunohistochemical studies.8 The tumor arises more commonly from the maxilla than the mandible with a 2:1 ratio,6with the involvement of both maxilla and mandible in 10% of cases.1,3,7 The typical location is the anterior alveolar ridge of the maxilla.3,7,8The GCT is usually single, but multiple tumors also have been  reported.8 The lesion may be sessile or pedunculated with pink, firm consistency and a smooth lobulated surface from a few millimeters to 9 cm.2,6,8Congenital GCT grows only in utero, especially during the 3rd trimester of gestation.We report a case of GCT in a female newborn, who presented in the prenatal period with an intraoral mass which was protruding from her mouth and was not congenital. We describe the prenatal course as well as the clinical and histological characteristics of the lesion and its management. st July, 2011 because of an intraoral mass. She was a product of Cesarean section because of transverse lie presentation at 38 weeks of gestation with a birth weight of 3150 g, head circumference of 35 cm, height of 50 cm, and APGAR scores of 9 and 10 at one and 5 minutes, respectively. Her mother, a 20-year-old primiparous woman, was referred to the prenatal clinic of another hospital due to a congenital oral mass, which was diagnosed in the 35th week of gestation .6The congenital GCT has also been reported. This tumor, also known as congenital epulis, is a rare gingival neoplasm that affects the alveolar ridge in the newly born. The congenital form is mainly located in the gingival of the maxillary alveolar ridge,2,9and it can rarely undergo malignant transformation.2,9By contrast, the congenital GCT has a benign clinical course and does not show malignant degeneration and recurrence, even with incomplete resection.2,6As long as the GCT has a benign clinical course, the incidence of local recurrence is 5-10% after surgical resection2 is strongly and diffusely positive for S100, which is specific for Schwann cells, the congenital GCT is negative for S1002,11 In the congenital form, the prenatal diagnosis by ultrasound has been reported mostly in the third trimester of pregnancy.2 It allows prenatal counseling with parents, referring for delivery to a well-equipped center with pediatric surgeons, and preparation of an expert team in the delivery room for potential airway obstruction.2,5 Because of the obstruction of the fetal oral cavity and the amniotic fluid, swallowing inability and polyhydramnios may occur2 Other oropharyngeal masses such as teratoma, lymphangioma, hemangioma, and neurofibroma should be included in the differential diagnosis.2,8Cytologic smear of the GCT is moderately to highly cellular, with cells in loosely arranged groups or lying singly in a granular background. Most cells are oval shaped, with relatively uniform nuclei with small nucleoli and moderate to abundant amounts of fragile granular cytoplasm. While the adult form of the GCT2,8After the complete removal of the tumor, microscopic examination demonstrated a granular cell tumor which had nuclear reactivity as well as fine cytoplasmic staining according to  S100 immunostaining, suggesting an adult form of the GCT2.We herein described a female newborn infant who had a prenatal diagnosis of an intraoral mass on ultrasonography. The prenatal sonographic imaging revealed a well-defined lobulated mass protruding from the mouth and with a branching pattern of the feeder vessels. The distinctly crowded branching vessel in the GCT is in contrast to the disorganized vascularization with a high flow seen in oral hemangioma.While an intraoral mass can be diagnosed by prenatal utrasonography, confirmation is only possible histologically after birth. The multidisciplinary team approach is important in the management of these cases. When there is a congenital mass in the oropharyngeal region, the possibility of the presence of the GCT should be contemplated.


Visceral myopathy is a rare chronic disease affecting the peristalsis of the bowel causing intermittent pseudoobstruction. We report an atypical case of an eighty-nine-year-old woman with no prior history of abdominal illness who was admitted to our hospital with 2 days of increasing nausea, abdominal distension, and abdominal pain. On arrival at the hospital, she was critically ill. Abdominal X-ray showed distended loops of the colon and liquid levels resembling colonic obstruction. A subsequent abdominal CT scan confirmed the colonic obstruction. A suspicion of sigmoid volvulus was raised, that is why a barium enema was performed but no lower colonic obstruction could be confirmed. Acute laparotomy showed perforated cecum without intestinal obstruction. Postoperatively, the patient became septic which was fatal for the patient. Pathology gave the diagnosis visceral myopathy. It is very difficult to make the diagnosis clinically and radiologically since visceral myopathy mimics other more common gastrointestinal diseases. It is important to consider visceral myopathy as a possible diagnosis in cases with recurrent episodes of abdominal pain, vomiting, and abdominal distension, but without actual intestinal obstruction. Visceral myopathy (VM) is a rare, severe, and often misdiagnosed pathological condition. Patients with VM suffer from recurrent disturbances of motility in the gastrointestinal tract which leads to failure in propulsive peristalsis and intermittent pseudoobstruction . The norAn eighty-nine-year-old woman was admitted to our hospital with 2 days of abdominal pain, nausea, vomiting, and fatigue. In the last 5 days, she had symptoms of constipation. She had no history of earlier abdominal diseases or symptoms. Abdominal plain X-ray in the upright position showed distended loops of the colon and liquid levels resembling colonic obstruction. An abdominal CT scan was performed which confirmed colonic obstruction and possible air entrapment in the right colonic wall which was interpreted as caused by sigmoid volvulus . A subseThe pathology examination was based on full-thickness biopsies obtained from the operative specimen. Tissue sections were cut into 3-4 microns and dyed with haematoxylin-eosin. In distended areas, the bowel wall was only 1 mm thick but the mucosa was intact with normal thickness and was fully vital with no signs of ischaemia. The submucosa showed hyperaemia and expansive bleeding, but no fibrosis. The inner and outer muscular layers were equally affected by necrosis showing vacuolar degeneration and abruption of muscle fibres together with bleeding, neutrophilic inflammation, and fibrosis. In some areas, the muscle layer was completely absent. The nerve ganglia were normal in number and morphology. The conclusion was nonfamilial visceral myopathy .VM is part of a heterogeneous group of diseases called intestinal pseudoobstruction (IP). This rare group of diseases can be inherited , primary idiopathic , or secondary to other diseases  –5. PatieTreatment of VM consists of fluid and electrolytes by IV infusions and gastric and colonic decompression by nasogastric and rectal tubes. Pitt et al.  showed tThe present case is clinically interesting and very exceptional because of several factors: the fast deterioration of the patient's clinical condition, the total absence of prior abdominal symptoms, and the late age of debut. To our knowledge, there are no reported cases of VM that debut with bowel perforation combined with no prior abdominal symptoms. The vast majority of the literature describes VM as a latent chronic disease with occasional relapsing attacks of pseudoobstruction and with slow progression of intestinal failure. Bowel perforation without any prior symptoms is a very atypical presentation of VM and is normally considered a differential diagnosis which should be excluded .VM is a very rare group of diseases, and they should be considered whenever a patient presents with uncharacteristic abdominal symptoms, recurrent attacks of abdominal distension, and pain with no radiological evidence of intestinal obstruction. This case, however, also shows that VM in extremely rare cases can present with sudden debut of acute abdomen and no prior abdominal symptoms.The symptoms of visceral myopathy are unspecific and often mimic other more common gastrointestinal diseases.In patients that present with recurrent episodes of abdominal distension with no evidence of mechanical obstruction, VM should be considered.It is important to consider VM no matter the patients age.Perforated bowel due to VM is very rare but should be considered in clinically relevant cases.


Juvenile xanthogranuloma is a rare disorder which may be present at birth, or appears in infancy. It can also occur in adults of all ages; appears with lesions that may be solitary or multiple nodules several millimeters in diameter. The predilection sites are head and neck, but it may occur on the extremities and trunk also. There can also be involved internal organs such as lung, kidney, gastrointestinal tract, etc. The most frequent extracutaneous location is the eye.We report a case of juvenile xanthogranuloma in a male child with onset in the fourth month of life. He presented with a nodule 8 millimeters in diameter, tan-orange in color, ulcerated in the centre, located on the left corner of the left eye. A biopsy without total excision was performed. After the biopsy, the nodule enlarged to 1.5 cm in diameter and became haemorrhagic. The histologic evaluation and immunohistochemistry analysis resulted in the diagnosis of juvenile xanthogranuloma. For aesthetic reasons the nodule was removed by surgical resection.Juvenile xanthogranuloma is on a spectrum of histiocytic disorders, which is necessary to differentiate from maligniances in childhood by biopsy. Juvenile xanthogranuloma (JXG) is a rare disorder, which belongs to the broad group of non - Langerhans cell histiocytosis . JXG mayHistologically, JXG is composed of collections of histiocytes, foamy cells and Touton giant cells. The diagnosis of JXG is mainly clinical, but sometimes a biopsy analysis is required .Skin lesions generally follow a benign course with spontaneous resolution. Extracutaneous lesions are rare and can be associated with morbidity.A five-month-old male presented with a nodule in the left corner of the left eye. He was born at 40 weeks’ gestational age, without any abnormality or history of trauma at birth. The lesion was first noted at four months of age. The nodule was 8 millimeters in diameter, tan-orange in color, with central ulceration.His parents consulted a maxillofacial surgeon, who took a partial biopsy from the nodule. After the biopsy, the nodule enlarged and became hemorrhagic and the parents brought their child to the Clinic of Dermatology Figure . In meanImmunohistochemistry yielded results immunoreactive for CD68, weak focal positivity for S-100 protein, but negative for Langerin. These results confirmed that the histiocytes are non-Langerhans cells.After the diagnosis was made, the child was treated by an ophthalmologist, and examination was within normal limits.JXG is a benign cutaneous fibrohistiocytic lesion and a type of granulomatous process . Even thJXG was reported by H.G. Adamson in 1905  and nameThe male to female ratio of cutaneous JXG is about 1.4:1 in children, while in adults no sex predilection exists .Since the disease is often clinically diagnosed and not always confirmed histologically, sometimes is misdiagnosed. On the other hand, spontaneous regression of the cutaneous lesions is frequent. Therefore, the incidence of the diseased with JXG is unknown. In a survey of 122 dermatologists with an average of 12 years of practice, less than two cases per dermatologist per year were reported [The diagnosis of JXG is mainly based on characteristic clinical features. The clinical differential diagnosis includes spitz nevi, mastocytomas and dermatofibromas .The confirmation of clinical diagnosis can be made by skin biopsy.Characteristic histologic findings in JXG are: dense dermal histiocytic infiltrate and Touton Giant cells which are multinucleated, with homogeneous eosinophilic cytoplasmic center and xanthomatization in the periphery .Immunohistochemistry has an important role in the differential diagnosis between Langerhans cell histiocytosis (LCH) and JXG . JXG lesJXG is self-limited disorder and skin lesions usually resolve spontaneously. Treatment is required on those with extracutaneous involvement, who may have increased morbidity. Sometimes the excision is performed for diagnosis and aesthetic reasons. In our case, the nodule enlarged and became haemorrhagic after partial biopsy. In order for proper diagnosis and for aesthetic reasons the removal of nodule must be complete.Written informed consent was obtained from the patient’s parents 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.JXG: Juvenile xanthogranuloma; LCH: Langerhans cell histiocytosis.The authors declare that they have no competing interests.LP, SR and AP analyzed and interpreted the patients’ data. LP was a major contributor in writing the manuscript. All authors read and approved the final manuscript.


All past cases report the endometroid variant of endometrial adenocarcinoma as the primary tumor and our patient was a victim to the same variant.Metastatic involvement of the spleen by solid tumors is a rare clinical entity; those coming from endometrial adenocarcinomas are exceptionally rare. Spleen is an uncommon site for metastatic deposits due to its specific anatomy and microenvironment. Typically, splenic metastasis from endometrial carcinomas present months to years after curative surgery, chemotherapy or radiotherapy. The most common complaint in symptomatic patients is abdominal pain localized to the left hypochondrium. Most however, are asymptomatic only to be picked up on vigilant routine ultrasonography or computerized tomography during follow up. We report the case of a 54-year-old woman who presented to us after 50 months of total abdominal hysterectomy and bilateral salpingo-oophorectomy for an endometrial adenocarcinoma. She had severe abdominal pain localized to the left hypochondrium as the presenting complaint. To the best of our knowledge, this is the 1A 54-year-old, nulliparous widowed woman presented with severe abdominal pain in the left hypochondrium for the last 4 months. The pain radiated to the left shoulder and was exacerbated with deep breathing. She had a history of total abdominal hysterectomy with bilateral salpingo-oophorectomy done 50 months back for stage 1a endometroid endometrial adenocarcinoma. Clinical examination revealed tenderness in the left hypochondrium but no visceromeglay was appreciable. Ultrasonography and computerized tomography revealed a space-occupying lesion within the spleen with associated splenomegaly. Computed tomography further suggested a large splenic abscess however the patient did not have fever, vomiting or leukocytosis which are the hallmarks of a splenic abscess. A splenectomy was performed for her complaints. On histopathology a metastatic adenocarcinoma was identified consistent with the primary tumor. The tumor was CK7, CA-125 and epithelial membrane antigen positive (EMA). The patient was then referred for further chemotherapy.From this case we conclude, that although very rare, the spleen is a potential site for metastasis in endometroid endometrial adenocarcinoma. Since most patients are asymptomatic, routine examinations and imaging can identify its presence and avoid complications. If the practice is employed with vigilance, we may expect the clinical event to be diagnosed more frequently. The standard treatment is a classic splenectomy followed by chemotherapy. These deposits are always solitary in the spleen, invade the parenchyma only and metastasize via the haematogenous route. However, they do indicate a better prognosis [The spleen is a peculiar site for metastasis from solid tumors; most commonly though, they are from breast, lung, colorectal cancers and melanomas. The most cost common causes of solitary or isolated splenic metastasis are colorectal and ovarian cancers. These deposits are usually located on the splenic capsule and signify disseminated disease with a grim prognosis . Splenicrognosis . They usA 54-year-old, nulliparous and widowed house wife presented 4 years ago with post menopausal bleeding for 2 months duration. She underwent clinical evaluation and was diagnosed as a case of endometroid adenocarcinoma of the endometrium; stage 1a and moderately well differentiated. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathology confirmed the diagnosis, peritoneal washings for malignant cells were negative and computed tomography (CT) scan did not reveal any extra uterine spread of the tumor. Histopathology of the ovaries and fallopian tubes was unremarkable as well. Fifty months later she presented with severe abdominal pain in the left hypochondrium radiating to the tip of the left shoulder for 4 months. The pain was described as dull and dragging, aggravated by deep breathing and occasionally relieved by analgesics; during the last 2 weeks she had multiple acute flare ups. On examination her abdomen was tender in the left hypochondrium without any palpable visceromegaly. Ultrasonography showed an enlarged spleen with a space occupying lesion having well defined walls in its lower part. This was clarified by CT  and the remainder from endometrial (13 cases), cervical (6 cases) and tubal carcinomas (1 case) .Splenic metastasis are most commonly incidentally detected by ultrasound (US) or CT during follow up or work up of patients with cancer. When solitary, about 60% are asymptomatic. Prominent symptoms at presentation include fatigue, weight loss, fever, and/or abdominal pain while signs include splenomegaly with associated anemia or thrombocytopenia while rarely presentation may be with splenic rupture . OccasioUS, CT and magnetic resonance imaging (MRI) are the preferred diagnostic modalities while histopathology after splenectomy confirms the type of tumor. La Fianza and Madonia retrospectively compared US and CT in detection of splenic metastasis after curative surgery; both provided high accuracy, sensitivity and specificity however the micronodular pattern of splenic involvement gave false positive findings at US . It is tThe stage of endometroid endometrial carcinoma in our patient was 1 a and the tumor was moderately well differentiated. The literature as such does not predict any association between time of presentation and initial stage of tumor. The past reports in the literature all report the same histological type of the tumor.An interesting fact about solitary splenic metastasis from the endometrial adenocarcinoma is that they characteristically present after a period of clinical latency; the literature describes 14 such cases with a range of presentation times for relapse from 11 months to 120 months with a mean time of 34.8 months. Our patient presented after 50 months but started having symptoms at 46 months after surgery. This phenomenon has been postulated to be due to growth of early blood borne disseminated cancer cells within the spleen [The relative rarity of metastatic involvement of the spleen is speculated to be due to 2 reasons. Mechanical factors including a constant flow of blood through the sharply angulated splenic artery, rhythmic contractions of the splenic capsule and the lack of afferent lymphatics limiting lymphogenous metastasis all impede implantation of blood borne cancer cells. Secondly; the splenic microenvironment itself exerts an inhibitory influence to growth of metastatic cells .The treatment of choice is splenectomy; this not only alleviates the distressing painful splenomegaly like in our patient but it also acts as a precaution against dreadful complications like splenic rupture and splenic vein thrombosis. It also decreases chances of spread of the tumor to distal areas from the spleen and provides the potential for cure or extended survival .After splenectomy our patient was completely pain free; she was referred for chemotherapy and is currently undergoing treatment.In conclusion, although metastatic involvement of the spleen from endometrial adenocarcinoma is rare, it is still a potential site for disease asylum. The reported cases are increasing due to advancements in imaging modalities and more vigilant patient follow ups. Since the condition presents after a period of clinical latency after curative surgery for the primary tumor and the patients remain asymptomatic until the tumor increases in size and creates complications, these patients need prolonged follow up with serial imaging to identify recurrence. Once the lesion is diagnosed, splenectomy followed by adjuvant chemotherapy is the treatment of choice.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.CK-7: Cytokeratin 7; CA-125: Cancer antigen 125; EMA: Epithelial Membrane Antigen; CK-20: Cytokeratin 20; CDX-2: Caudal type homeobox 2; CEA: Carcinoembryonic antigen; US: Ultrasonography; CT: Computerized tomography.The authors declare that they have no competing interests.AA was part of the surgical team that operated upon and looked after the patient and reviewed the manuscript. ZUA drafted the manuscript, completed the literature review and was part of the surgical team that operated upon and took care of the patient. NZ and MAK were the principal surgeons and reviewed the manuscript. TNM and AZM reviewed and revised the manuscript critically, approved its final version for being sent for publication and were part of the consultant team that made pivotal decisions regarding the patient treatment. All authors read and approved the manuscript.


Multiple different types of mediastinal masses may be encountered on imaging techniques in symptomatic or asymptomatic patients. The location and composition of these lesions are critical to narrowing the differential diagnosis.Radiological compartmentalisation of the mediastinum helps in focusing the diagnosis of masses on the basis of their site. Some diseases, however, do not occur exclusively in any specific compartment and can spread from one compartment to another.Tissular components of the mass, the degree of vascularisation and the relationships with mediastinal structures assessed by computed tomography (CT) or magnetic resonance imaging (MRI) are a leading edge of the radiological diagnosis. Special applications at MRI have been developed over the recent years in order to identify accurately tissular components of the mediastinal masses. The likelihood of malignancy of the mediastinal masses is influenced by the symptomatology and the age of the patient. This article reviews the most commonly encountered mediastinal masses considering clinical history and manifestations, anatomical position and certain details seen on different imaging modalities that allow correct diagnosis in many cases.Familiarity with the radiological features of mediastinal masses facilitates accurate diagnosis, differentiation from other mediastinic processes and, thus, optimal patient treatment.• CT and MRI are important for the diagnosis of mediastinal masses.• The location and tissue characteristics on imaging studies are critical to narrow down the differential diagnosis of mediastinal masses.• Symptomatology and patient age affect the likelihood of malignancy. Mediastinal masses span a wide histopathological and radiological spectrum. The most frequent lesions encountered in the mediastinum are thymoma, neurogenic tumours and benign cysts, altogether representing 60% of patients with mediastinal masses . NeurogeThe mediastinum is demarcated by the pleural cavities laterally, the thoracic inlet superiorly and the diaphragm inferiorly. It is further divided into anterior, middle and posterior compartments by many anatomists . AnterioUsual symptoms at presentation are cough, chest pain, fever/chills and dyspnea. Localising symptoms are secondary to tumour invasion , while systemic symptoms are typically due to the release of excess hormones, antibodies or cytokines.Many mediastinal reflections can be appreciated at conventional radiography (CR), and their presence or distortion is the key to the interpretation of mediastinal abnormalities . HoweverMany entities that involve the mediastinum correspond to anatomical variants or masses arising from the spine or from the digestive tract, and should not be considered true mediastinal masses Figs.  and 3. LLipomas predominantly occur in the anterior mediastinum and are reported to represent 1.6–2.3% of all primary mediastinal tumours [Liposarcoma frequently occurs in the posterior mediastinum and it is usually symptomatic at the time of presentation, in contrast to lipoma [ tumours . At CT, o lipoma . Inhomogo lipoma .Thymolipoma is a rare, benign, well-encapsulated thymic tumour that accounts for about 2–9% of thymic neoplasms [eoplasms , 12–14. eoplasms . AssociaMediastinal primary cysts represent 15–20% of all primary mediastinal masses [Bronchogenic cysts result from abnormal ventral budding or branching of the tracheobronchial tree during embryologic development [elopment –17. Theyelopment . The broelopment . The antDuplication cysts are uncommon lesions lined by gastrointestinal tract mucosa and generally asymptomatic. However, if they contain gastric or pancreatic mucosa, there is the added risk of haemorrhage or rupture of the cyst from mucosal secretions. The majority of them are detected adjacent to or within the oesophageal wall . The phenomenon known as rebound hypeplasia is defined as a greater than 50% increase in thymic volume over baseline after such stress [Thymic lymphoid (follicular) hyperplasia of the thymus refers to the presence of an increased number of lymphoid follicles. It is commonly associated with autoimmune diseases, being seen in up to 65% of cases with myasthenia gravis [al types , 14. Truh stress . Thymic a gravis .Fig. 16TIt is important for radiologists to be able to distinguish thymic hyperplasia from neoplasm. Diffuse symmetric enlargement of the gland, a smooth contour and normal vessels are the key morphological features of hyperplasia, whereas neoplasm tends to manifest as a focal mass with nodular contour and necrotic or calcified foci. Detecting fat in the thymus is particularly relevant in these situations. According to Takahashi et al. , chemicaThymoma is the most common primary neoplasm of the anterior mediastinum but accounts for less than 1% of all adult malignancies [gnancies , 23. Thygnancies . MyastheThe updated histological classification elaborated by WHO in 2004 classified different types of thymomas Table  on the bThymic carcinoma accounts for about 20% of thymic epithelial tumours with a mean age of 50 years [50 years . Typical50 years . Sadohar50 years  found thThymic carcinoids are rare, well-differentiated neuroendocrine tumours, which have a male predilection of 3:1 [n of 3:1 , 14. TheLymphoproliferative disorders. Primary mediastinal lymphoma usually occurs in the anterior mediastinum. Malignant lymphoma accounts for nearly 20% of all mediastinum neoplasms in adults and 50% in children [children . Hodgkinchildren . PleuralHodgkin disease (HD) has a bimodal distribution of incidence peaking in young adulthood and again after the age of 50 years [50 years . Most pa50 years , 5. CR i50 years . Charact50 years . Cystic non-Hodgkin disease (NHD) include diffuse large B-cell lymphoma and T-cell lymphoblastic lymphoma. T-cell lymphoblastic lymphoma mainly occurs in children and adolescents. The most common CT appearance is a large mediastinal mass representing thymic and lymph node enlargement, which compresses the airway and cardiovascular structures  mainly arise in gonads and in the midline of the body as well, the mediastinum being the most common extragonadal site. GCTs account for 10–15% of anterior mediastinal masses in adults and 25% in children [children . PatholoTeratoma is the most common mediastinal GCT [inal GCT . Mature inal GCT . They arinal GCT . On MRI,non-teratomatous germ cell tumours (NTGCT) are rare and malignant tumours which usually occur in young males and most frequently affect the anterosuperior mediastinum [The iastinum . These tiastinum  and occuiastinum . At imagiastinum . InvasioNeurogenic tumours represent approximately 20% of all adults and 35% of all paediatric mediastinal tumours and they are the most common cause of a posterior mediastinal mass [nal mass . Seventynal mass . These tPeripheral nerve tumours, which are the most common (70%) mediastinal neurogenic tumours and originate from spinal or proximal intercostal nerve; however, they rarely arise from the vagus, recurrent laryngeal and phrenic nerve [ic nerve   is recognised as a tool for detecting cervical parathyroid lesions. As it enlarges, an abnormal gland appears as a hypoechoic, and often anechoic, lesion, often posterior in location to the thyroid. As the gland enlarges, it can develop lobularity and foci of echogenicity. Colour Doppler assessment of parathyroid lesions is a useful integration of grey-scale US and may be helpful in featuring parathyroid lesions. The colour Doppler patterns termed “parenchymal”  and “vascular pole”  are typical of parathyroid lesions [Fibrosing mediastinitis is a dense fibrosis which progressively encases and eventually obliterates the lumen of the mediastinal vessels and airways (Fig. Haematoma. High attenuation of haematomas can be observed on unenhanced CT scans during the first 72 h (Fig. Haemangiomas in the mediastinum are rare and the may be associated with Rendu-Osler syndrome. Sarcomas other than vascular or neural origin, including fibrosarcomas, osteosarcomas and chondrosarcomas, are also very uncommon. Extramedullary haematopoiesis in posterior mediastinum is another entity to take into account. lesions . The difays Fig. . Haemato2 h Fig. . When thIn assessment of mediastinal disease, cross-sectional imaging techniques allow excellent visualisation of the mediastinum. CT is generally the first-choice modality of diagnostic imaging. MRI plays an increasing role in this disease due to the existence of new available MR techniques on mediastinum imaging.On each of CT and MR scanning, the size of tumour, contour, perimeter of capsule, septum, haemorrhage, necrotic or cystic component, homogeneity within tumour, presence of mediastinal lymphadenopathy, pleural effusion and great vessel invasion are assessed. In addition, presence of calcification are assessed on CT and signal intensities of the tumour are assessed on MRI.Imaging plays an essential role in the diagnosis, staging and follow-up of mediastinal disease. Complete resection is the mainstay of treatment in many mediastinal tumours and the ability to accomplish a complete resection appears to be the most important prognostic factor. Currently, CT is the modality most commonly used for follow-up after treatment. The goal of follow-up is to detect recurrence as early as possible. CT findings may serve as predictors of tumour invasiveness and of postoperative recurrence or metastases.In Table Tumours of the mediastinum represent a wide diversity of disease state. The location and composition of a mass is critical to narrowing the differential diagnosis. The clinical spectrum of mediastinal masses can range from being asymptomatic to producing compressive symptoms. Although many of these masses have similar imaging appearances, clinical history, anatomical position and certain details seen at CT and MRI imaging allow correct diagnosis in many cases.


The present study aimed to demonstrate why foreign-body granuloma induced by local hemostatic materials should be incorporated into the differential diagnosis of recurrent gastrointestinal stromal tumors post-operatively, particularly soon after surgical resection has been performed.Unexpected clinical and/or imaging evidence of the recurrence of gastrointestinal stromal tumors soon after surgical resection may be complicated due to certain biological behavioral features of gastrointestinal stromal tumors. However, local hemostatic materials routinely used in abdominal surgery to achieve hemostasis intraoperatively may cause a foreign-body reaction, which appears to be indistinguishable from recurrent tumors in imaging studies. Thus, a second examination may be necessary to settle the true nature of the findings in such cases. If the resection and examination reveals a recurrent tumor, further proper oncological treatment is warranted, whereas if a foreign-body reaction is observed, radical or potentially harmful therapy may be withheld or cancelled. The present study retrospectively analyzes the case of an 83-year-old male patient who presented with a recurrent gastrointestinal stromal tumor four months after surgical resection, which was later identified as an intra-abdominal foreign-body granuloma caused by retained Surgicel The patient complained that the pain was accompanied by nausea and vomiting post-prandially, as well as an intermittent low-grade fever for ∼4 months. The patient experienced weight loss of 3 kg, but no diarrhea, constipation, anorexia, chills or jaundice. According to the patient’s surgical history, surgical resection for GIST had been performed four months previously and right colon resection for ascending colon adenocarcinoma five years previously.At admission, the patient’s vital signs  were stable. An abdominal examination revealed a solid, firm, non-tender mass in the left upper quadrant. The remainder of the examination was normal.The only abnormal laboratory parameter was an increased neutrophil leukocyte measurement of 73.5% . The routine laboratory parameters, including the white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver and pancreatic enzyme and tumor marker  levels, were all within the normal limits.18F; FDG)-uptake pattern (A computed tomography (CT) scan with intravenous contrast medium revealed a heterogeneous mass, with a maximum diameter of 8.3 cm and a density of −24 to 35 HU, located between the stomach and spleen . A posit pattern . The abd pattern .Taking into account the previous observations, an explorative laparotomy was performed upon clinical diagnosis of a local recurrent GIST. During the exploration, a mass wrapped in a fibrous capsule that adhered to the gastric fundus and spleen was identified, with the same diameter as measured by CT. Following en bloc removal, the mass was dissected and identified as a quantity of retained local hemostat residue and pus . MicroscHemostat-associated masses, termed gauzomas, gossypibomas, textilomas or even Surgicelomas , are actSurgicel decreases the pH of its surroundings. This low pH has an antimicrobial effect against miscellaneous pathogenic organisms. However, the acidic character may also increase inflammation of the surrounding tissue and delay wound healing . Hill 77 reporteA Surgiceloma may present in either the immediate or delayed phase following surgery. The general complaints of patients may be nausea, vomiting, a palpable mass, rectal bleeding or changes in bowel habits. Surgiceloma may also present with a non-specific fever, anorexia and weight loss, which may mimic a malignant disease . The preet al(et al(et al(® chemotherapy, a diagnosis of recurrent GIST was made pre-operatively.O’Connor et al describe al(et al describe al(et al reported al(et al, with a In conclusion, Surgicel granulomas are uncommon and mostly cause surgeons to provide an inaccurate diagnosis. Surgicel granuloma should be included in the differential diagnosis of new or recurrent soft-tissue masses detected in patients with a history of prior surgery.


Brachial plexus schwannomas are rare tumors. They are benign nerve sheath tumors and only about 5% of Schwannoma arise from the brachial plexus. They pose a great challenge to surgeons due to their rare occurrence and complex anatomical location. We present two cases who presented with a supraclavicular swelling, that were proven to be schwannoma on histopathology. Schwannomas are relatively rare tumors and a high proportion of these develop in the head and neck . They usA 32 year old male presented with a painless swelling in his left supraclavicular region for the last 2 years. It had progressively enlarged from the size of an almond to that of a lime. There was no history of trauma, fever or systemic illness. He only complained of a visible swelling but had no weakness, numbness or loss of function of the upper limb. On examination, he had a 3.5 x 3.0 cm firm, mobile, tender swelling in his left supraclavicular region. Muscle power in all muscles was 5/5, sensations were intact and there were no signs of wasting. Tinel sign was positive with tingling sensation along the shoulder tip. FNAC showed spindle shaped cells and Schwan cells and a diagnosis of schwannoma was made. MRI neck showed a diffuse swelling involving the lower trunk of Brachial plexus. The tumor showed same intensity as skeletal muscle on T1 weighted images but increased signals on T2 weighted images (Figure The surgery was performed under general anesthesia and lazy S supraclavicular incision was made to expose the tumor. Anterior scalenotomy was performed to improve the exposure of the roots and trunks. Per-operatively, a well encapsulated mass was found lying centrally within the C7 root and was pushing the nerve fascicles towards the periphery Figure . The tumA 23 year old lady was referred to the plastic surgery department with complaints of a painful swelling in the right supraclavicular region of 2 months duration (Figure Anterior cervical approach incorporating the previous incision was used for exploration and excision of the lesion. Exploration revealed a lesion involving the C7 root and severed C5 and C6 nerve roots. Encapsulated tumor was enucleated with preservation of C7 root. Figure  C5 and CBrachial plexus tumors are uncommon and comprise of only 5% tumors of the upper limb . SchwannThe diagnosis of Schwannoma arising in the brachial plexus or the upper limb can be diagnosed clinically on following points; A firm non-tender mobile swelling with symptoms of pain and percussion producing paraesthesias along the nerve involved. MRI can sometimes be very helpful in confirmation of diagnosis. Mostly it presents as a well encapsulated solitary lesion causing displacement of the fascicles ,10.Surgery is indicated for tumors causing neurological deficit, discomfort, progressively growing lesions with a suspicion of malignancy and to prevent or minimize neural damage . CompletSchwannoma of the brachial plexus region is a rare entity. Proper diagnosis of the lesion must be established before surgery as it can be easily mistaken as enlarged supraclavicular lymph node as happened in one of our cases and can result in an iatrogenic injury. Schwannoma should be included in the differential diagnosis of supraclavicular swellings and MRI should be performed if there is any suspicion.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. Furthermore an approval from institutional review board was also taken from “Institutional Review Board and Ethics Committee, Shifa International Hospital, Shifa College of Medicine and Shifa College of Nursing” and can be sent on demand.The authors declare that they have no competing interests. MR final proof reading and final approval for publication. OS conception, design and final drafting. SY initial drafting and acquisition of data. UAQ Acquisition of images, literature search, proof reading. KY drafting and critical revision. All authors read and approved the final manuscript.


Clear cell tumor of the lung is a rare and benign pulmonary tumor; only sporadic cases have been reported. Here, we report the case of a 38-year-old man with recurrent cough, blood-streaked sputum and left chest pain. A chest computed tomography scan showed a round, homogeneous pulmonary mass in the left lower lobe, which exhibited intense heterogeneous enhancement in the arterial phase and homogeneous in the delay phase after injecting a contrast agent. The patient underwent a fine-needle aspiration biopsy and was diagnosed as having a benign clear cell tumor of the lung. The clinical presentation and radiographic investigation of this tumor are summarized in this paper to recognize this rare disease. Interestingly, we found some differences with previously reported cases. Clear cell tumor of the lung (CCTL) is a rare and benign pulmonary neoplasm, which was originally described by Liebow and Castleman in 1963 -4. As itA 38-year-old man was admitted to our hospital because of recurrent cough, blood-streaked sputum for 2 months, left chest pain for 10 days, and worsening health for 3 days. The patient, who had no known family history of cancer, was an 18 pack/year smoker. He did not report any fever, night sweating, chest tightness, weight loss, or wheezing. A physical examination did not show any abnormalities, and the results of laboratory studies were unremarkable. Chest non-enhanced computed tomography (CT) scans showed a demarcated, round, homogeneous lesion of approximately 3.4 cm in diameter without evidence of calcification, necrosis, cavitation, or satellite lesions in the left lower lobe  were reviewed ,4,6-27. 2 = 56.000, P = 0.000, Table 2 = 72.333, P = 0.000, Table Spearman’s correlation analysis showed that tumor size was most frequently associated with symptoms and tumor contours Table , whereasCCTL is a rare benign pulmonary neoplasm originally described in 1963 by Liebow and Castleman ,23,25,26Radiographically, CCTL presents as a rounded, smooth-walled peripheral parenchymal nodule, without evidence of cavitation or calcification. There are no specific lobar distributions according to the literature ,8,16,17.Based on a contrast-enhanced CT scan, the main features of this case were the intense heterogeneous enhancement in the arterial phase and washout in the delay phase, which were consistent with a previous report . This CTCCTL is usually diagnosed by thoracotomy, lobectomy, and segmentectomy. Partial resection and enucleation have been reported as treatments in previous studies . Only onMacroscopically, CCTL predominantly appears as well-circumscribed, peripheral nodules measuring ≤3 cm in diameter; cut surfaces are typically homogeneous and glistening, without evidence of hemorrhage, necrosis, cavitation, or calcification ,17. HistIn summary, we reported a case of CCTL and a literature review of 55 CCTL cases. We analyzed the patient’s clinical characteristics, the tumor’s radiological features, and the effects of CCTL tumor size. We conclude that the tumor has three characteristics: (1) most of the patients are middle-aged and elderly people  and are generally asymptomatic; (2) the tumor, which is usually located in both lower lungs, is round and homogeneous density on plain CT scan image; and (3) tumors ≥2.2 cm in diameter grow lobulated and have more aggressive symptoms.Written informed consent was obtained from the patient for publication of this case report and the accompanying images. Copies of the written consent are available for review upon request.CCTL: Clear cell tumor of the lung; CT: Computed tomography; PAS: Periodic acid-Schiff; PEC: Perivascular epithelioid cells.The authors declare that they have no competing interests.GW performed the research. LW designed the research study. XD performed the pathological examination. GW and DZ analyzed the data. All authors read and approved the final manuscript.


Metastasis to the seminal vesicle is extremely rare for hepatocellular carcinoma (HCC). To our knowledge, it has been not reported in literature. The purpose of the present paper was to report a case of metastasis to the seminal vesicle after HCC resection, along with its histological features and immunohistochemical characteristics.A 46-year-old Chinese man was admitted to our hospital due to abdominal distension. He had a history of HCC related to hepatitis B virus infection. Moreover, left partial hepatectomy was performed in another hospital 28 months ago, and right partial hepatectomy for HCC recurrence in our hospital 4 months ago. After resection, radiofrequency ablation therapy had been performed. About 27 months after the initial operation, contrast-enhanced computed tomography (CT) of the pelvic cavity revealed a mass with homogeneous enhancement in the seminal vesicle. Transrectal needle biopsy revealed a poorly differentiated adenocarcinoma. Therefore, seminal vesiculectomy was resected. The histological diagnosis of the removed tumor was compatible with the original HCC. Immunohistochemical examination demonstrated that the tumor cells were positive for glypican-3 (GPC3), alpha-fetoprotein (AFP), hepatocyte paraffin-1 (Hep Par 1), cytokeratin 18 (CK 18), and hepatocyte antigen, which confirmed that the seminal vesicle tumor was a metastatic tumor of HCC. However, CT subsequently revealed multiple metastatic foci in the abdominal and pelvic cavities in May 2009 and August 2009, respectively.The seminal vesicle is an extremely rare metastatic site for HCC, and the prognosis is very poor. A combination of clinical and pathological features is necessary for a correct diagnosis, and primary tumor should be excluded before diagnosing metastatic foci. Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, accounting for nearly one million new cases each year . The lon3/μl; aspartate aminotransferase, 42 U/L; alanine aminotransferase, 30 U/L  and has a poor prognosis . For unkTumors of the seminal vesicles may be primary tumors or secondary tumors originating from adjacent organs such as the bladder, prostate, or rectum. Primary seminal vesicle tumors are rare and may be benign  or malignant . Adenocarcinoma is the most frequent malignant tumor. Therefore, we first excluded it before diagnosing the mass as metastasis from HCC. In 1956, Dalgaard and Giertson [In the present case, the patient had a history of HCC. Moreover, according to the surgical doctor's introduction, the mass was only found in seminal vesicle during the operation. In addition, the histopathological characteristics of the mass from seminal vesicle were similar to that of primary HCC, although it had a poorly differentiated appearance. Immunohistochemically, the tumor cells were positive for GPC3, AFP, hepatocyte antigen, HepPar1, and CK18, but negative for CK7, CK20, PLAP, PSA, CA125, EMA, CD117, and CEA. Primary seminal vesicle adenocarcinoma expresses these markers as well as CK7, CA125 and CEA but not AFP, GPC3 and hepatocyte antigen . It is kNo sufficient data is currently available regarding treatment for HCC with metastasis to the seminal vesicle. However, the prognosis appears to be poor. In our case, the patient had undergone regular radiofrequency ablation since the diagnosis of HCC, but intrahepatic and seminal vesicle metastatic lesions were found after half a year and 27 months, respectively. It was worse that CT revealed multiple metastatic foci in the abdominal and pelvic cavities after 32 months and 3 years, respectively.In conclusion, the seminal vesicle is an extremely rare metastatic site for HCC, and the prognosis is very poor. Although AFP, Hep Par 1, hepatocyte antigen and GPC3 are useful markers for HCC. They are not, however, entirely specific, showing different extent staining in hepatoid adenocarcinoma and H-YST. Thus, a combination of clinical and pathological features is necessary for a correct diagnosis, and primary tumor should be excluded before diagnosing metastatic foci,AFP: alpha fetoprotein; CA125: cancer antigen; CEA: carcinoembryonic antigen; CT: computed tomography; CK: cytokeratin; EMA: epithelial membrane antigen; GPC3: glypican 3; HBV: hepatitis B virus; HCC: hepatocellular carcinoma; HCV: hepatitis C virus; Hep Par 1: hepatocyte paraffin-1; PLAP: placental alkaline phosphatase, PSA: prostate-specific antigen;The authors declare that they have no competing interests.GL carried out the whole study and drafted the manuscript. ZMW, LYH, ZWD and HY participated in drafting the manuscript. BWJ provided the patient's history and performed the immunohistochemistry. ZMW and SLF collected the CT picture. ZW participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/11/111/prepub