Torsion of the greater omentum is a rare acute abdominal condition that is seldom diagnosed preoperatively. We report the characteristic computed tomography (CT) scan findings and the clinical implications of this unusual diagnosis in a 41-year-old man, who also had longstanding right inguinal hernia. Awareness of omental torsion as a differential diagnosis in the acute abdomen setting is necessary for correct patient management. We report the case of a 41-year-old Malay man with secondary omental torsion due to longstanding inguinal hernia. A contrast-enhanced CT scan of the abdomen showed a heterogeneous fat-density mass, with a characteristic whirling pattern of concentric streaks within the greater omentum. On the basis of this preoperative diagnosis, the patient underwent a successful trial of conservative management. There have only been a few reported cases of successful nonsurgical management of this rare acute abdominal condition.1 MoreoverUltrasonography (USG) of the right inguinal region and scrotum was ordered, which confirmed the presence of an uncomplicated right inguinoscrotal hernia, and an elective hernia repair was planned after 10 days.A 41-year-old Malay man initially presented to our Emergency Department with nonspecific abdominal pain. He had an eight-year history of untreated right inguinal hernia. On this occasion, the patient’s symptoms settled with conservative treatment and he was discharged. He returned the following day with pain localized over the site of the inguinal hernia, and hence, was referred to the surgical team. A plain radiograph of the abdomen was unremarkable. 9/l, with neutrophil predominance (10.2 × 109/l).On the day of admission for hernia repair, the patient complained of fever (37.9°C) and he had been having right iliac fossa pain for four to five days. Local examination showed no abdominal guarding or tenderness over the site of the hernia, which was still reducible. Blood investigations revealed an elevated total white cell count of 13.5 × 10An urgent CT scan of the abdomen and pelvis was performed to exclude acute appendicitis. A CT scan revealed a hazy fat-density mass in the right side of the abdomen with a whirling pattern of concentric streaks , Video 1The patient was empirically treated with intravenous antibiotics and the elective hernia repair was deferred. Thereafter, the patient’s signs and symptoms improved, with a corresponding decline in the white blood cell counts. Unilateral herniorraphy was performed a few days later. Exploratory laprotomy and omentectomy were not performed, as the patient had no abdominal complaints by then and there was no intraoperative evidence of omental or bowel herniation.Torsion of omentum is a rare acute condition in which the organ twists around its long axis.4 The chaet al, concluded that obesity is an important risk factor for omental torsion in children.[Omental torsion is classified as primary or secondary,46 the la47children.6Secondary omental torsions are usually seen in the presence of a bulky abdominal tumor,58 hernia545Although the etiologies may be different in primary and secondary torsions, the precipitating factors are similar and include either a sudden increase in the intra-abdominal pressure due to exertion, coughing or sneezing, or the occupational use of vibrating tools.58 These 5The pathological process begins with omental congestion due to venous obstruction, which leads to an inflammatory response, adhesion formation, and finally, necrosis as a result of both venous and arterial obstruction.–8 Thus, Clinically, torsion of the omentum often mimics other more common acute abdominal conditions such as, appendicitis, cholecystitis, cecal diverticulitis, appendagitis, twisted ovarian cyst, and so on.6 The hig4A CT scan shows either an inflamed fat-containing mass with concentric streaks around a vascular pedicle or a whirling pattern of fibrous and fatty folds89 within86Complications of omental torsion include omental necrosis, peritoni3355Traditionally, omentectomy has been the treatment of choice for omen5In summary, an accurate diagnosis of greater omental torsion can be made with a CT scan. Although it is a rare acute abdominal condition, torsion of the omentum should be carefully excluded in patients with known predisposing factors, such as an inguinal hernia.Click here to view as Video 1


Hemangioma is a benign tumor of dilated blood vessels. It is most commonly seen in the head and neck region and rarely in the oral cavity. Hemangiomas in the oral cavity are always of clinical importance and require appropriate treatment. We report here a case of a 34-year-old female patient with a swelling on the lateral surface of tongue which did not respond to the sclerosing agent and was finally confirmed as cavernous hemangioma on histological evaluation. Hemangioma  by definition can be defined as “a benign tumor of dilated blood vessels.” Hemangioma of head and neck appear a few weeks after birth and they grow rapidly. It is also known as port-wine stain, strawberry hemangioma, and Salmon patch. They are characterized by hyperplasia of blood vessels, usually veins and capillaries, in a focal area of submucosal connective tissue. It is almost never encapsulated. Whether this condition is a neoplastic or reactive state is uncertain; a reactive cause is favored.Few of the reactive causes are, namely, hormonal changes, infections, and trauma. Clinically they may manifest as firm, pulsatile, warm masses and the venous malformations appear first in early childhood and clinically manifest as soft and easily compressible mass. According to the classification given by Mulliken and Glovacki in 1982, are divided the vascular deformities, into 2 groups: hemangiomas and the vascular malformations. The hemangiomas can also be classified depending on the vessel type involved or flow types such as the arterial and arteriovenous (high flow) type, capillary or venous (low flow) type [This paper describes a case of a female patient who had a growth on her lateral border of the tongue which was diagnosed as cavernous hemangioma.A 34-year-old female patient reported to the Department of Periodontology, Rajarajeswari Dental College and Hospital, Bangalore, India, with the chief complaint of swelling on the lateral surface of the tongue. The patient gave a history of trauma at the same site 10 years back. There was no history of associated pain or bleeding from the site. On general examination, the patient was normally built for her age with no defect in stature or gait. No relevant medical history was observed. On intraoral examination, there was a growth measuring about 1.5 cm × 1.5 cm, which was red in colour with a bluish hue present at the left lateral surface of the tongue which appeared to be sessile with no underlying attachment or relation with the muscles . The bor Initially a sclerosing agent was administered topically and the mass was observed for a period of 1 week . No chanHemangiomas are the most common benign tumours of the head and neck in children, but their occurrence on the tongue is extremely rare. The tongue requires special consideration because of its susceptibility to minor trauma and consequent bleeding and ulceration, swallowing difficulties, and breathing problem, although the major concern is cosmetic in most cases. The hemangioma appears as soft mass, smooth or lobulated, and sessile or pedunculated and may vary in size from a few millimeters to several centimeters , 3. They Various syndromes that are associated with the vascular malformation include the Osler-Weber-Rendu syndrome, Sturge-Weber syndrome, and blue rubber bleb nevus syndrome. A differential diagnosis of granuloma fasciale, insect bite, pyogenic granuloma, and angiosarcoma can be given for this condition. Clinical diagnosis was based on histopathological evaluation, which was confirmed to be a cavernous hemangioma. Histologically, the appearance of these lesions depends on the stage of the evolution. Early lesions may be very cellular with solid nests of plump endothelial cells and little vascular lumen. Established lesions comprise of well-developed, flattened, and endothelium-lined capillary channels of varying sizes in a lobular configuration. Involuting lesions show increased fibrosis and hyalinization of capillary walls with luminal occlusion . In caveThe appearance of cavernous hemangioma is a rare occurrence on the tongue. Early detection and biopsy are crucial in determining the clinical behavior of the tumour and potential complications. The treatment modality should be planned according to the diagnosis and prognosis of the particular vascular malformation.


Although advances in endocrinologic and neuroradiologic research allow easier recognition of pituitary adenomas, giant pituitary tumours are relatively rare. In the literature, the term “giant” is generally used when a pituitary tumour becomes larger than 4 cm in diameter. Cabergoline is a potent and long-acting inhibitor of prolactin secretion, which exhibits high specificity and affinity for dopamine D2 receptor. Herein, we report a 46-year-old woman with a giant lactosomatotroph pituitary adenoma, sized 6 × 5 × 5.5 cm, who is treated successfully only with cabergoline. The patient showed dramatic response to cabergoline treatment by means of clinical, biochemical and radiological imaging findings. Cabergoline seems to be safe and effective in the treatment of prolactin and growth hormone cosecreting pituitary adenomas as well as prolactinomas. However, surgical or more aggressive approach must be considered where indicated. Pituitary adenomas are classified as “giant” when their diameter exceeds 4 cm . The mosGiant pituitary tumors are very rare and usually invade the surrounding structures. These tumors are very difficult to treat and can behave aggressively , 5. UnleCabergoline is a synthetic ergoline that exhibits high specificity and affinity for dopamine D2 receptor. It is a potent and long-lasting dopamine agonist, which has an elimination half-life, ranging between 63 and 109 hours . When coHerein, we describe the case of a woman with an extremely large pituitary adenoma cosecreting prolactin and growth hormone (GH) who is treated successfully only with cabergoline as a first line treatment.A 46-year-old woman was admitted to our outpatient clinic with the complaint of swelling at her neck which she had become aware of recently. She had amenorrhea for fourteen years, as well as weight gain, frequent headaches, enlargement of the nose, increasing shoe size, and necessity to enlarge her rings within the past several years. She did not have galactorrhea or any visual symptoms. She had a history of hypertension for four years and dyslipidemia for one year. At her initial physical examination, thyroid gland was grade II palpable, and she had acral enlargement and central obesity. Depending on these findings, laboratory tests related to goiter and pituitary functions were performed. Her initial laboratory findings demonstrated hyperglycemia, hyperlipidemia, normal thyroid functions, low gonadotropin levels, and severe prolactin elevation with macroprolactin absence . The diagnosis of acromegaly was confirmed with elevated IGF-1 level  and failure to suppress GH levels with a 100 g oral glucose load. Accompanying Cushing's disease was excluded with a low-dose dexamethasone suppression test.Her thyroid ultrasonography revealed multinodular goiter with the largest nodule exhibiting 15 mm diameter. Magnetic resonance imaging (MRI) of the sella showed a pituitary macroadenoma which has maximum diameters of 6 × 5 × 5.5 cm extending to the sphenoid sinus via clival destruction, suprasellar cistern, and prepontine cistern. Left cavernous sinus, left middle cranial fossa, and left orbital apex were invaded, wherein optic chiasm and circle of the Willis were elevated. The macroadenoma was encasing the cavernous portion of the left internal carotid artery . A minimCabergoline treatment with a dosage of 2 mg per week was prescribed to the patient, as well as appropriate medical therapy for diabetes mellitus and hyperlipidemia. The patient was warned carefully about the symptoms of a possible pituitary apoplexy crisis. No side effects related to cabergoline treatment were observed during the follow-up period.After two months of therapy, her prolactin levels decreased to normal ranges (174.49 mIU/L) and the slight visual impairment in the right eye completely disappeared. Follow-up MRI study after 4 months of medical treatment showed prominent regression of the macroadenoma and presenting cystic degenerations, with a size of 3.5 × 2.5 × 2 cm. Suprasellar cistern was almost clear and optic chiasm was in normal location. There was a clear border between macroadenoma and adjacent left temporal lobe parenchyma . She losAlthough most of the pituitary tumors are microadenomas some grow aggressively invading the extrasellar tissues. Various classifications have been proposed but there is no evident terminology to describe large pituitary tumors . DespiteThis patient has not undergone surgery yet, so the exact histology of the tumor is unknown. Nevertheless, according to the extensive spreading of the tumor and hyperprolactinemia dominancy, an acidophilic stem cell adenoma may be responsible for this phenomenon . The natIt is well known that the majority of prolactinomas respond to dopamine agonists with a rapid lowering of prolactin. In addition to this effect, bromocriptine and cabergoline are capable of inducing significant tumor shrinkage within the first three months of therapy in the majority of tumors , 15. Als In conclusion, our case suggests that cabergoline may be effective and safe as a first line monotherapy in patients with giant pituitary adenomas cosecreting prolactin and GH. However appropriate followups and changes in treatment plan must be made in long term for such patients.


Mediastinal schwannomas are typically benign and asymptomatic, and generally present no immediate risks. We encountered a rare case of a giant benign posterior mediastinal schwannoma, complicated by life-threatening cardiac tamponade.We report the case of a 72-year-old Japanese woman, who presented with cardiogenic shock. Computed tomography of the chest revealed a posterior mediastinal mass 150 cm in diameter, with pericardial effusion. The cardiac tamponade was treated with prompt pericardial fluid drainage. A biopsy was taken from the mass, and after histological examination, it was diagnosed as a benign schwannoma, a well-encapsulated non-infiltrating tumor, originating from the intrathoracic vagus nerve. It was successfully excised, restoring normal cardiac function.Our case suggests that giant mediastinal schwannomas, although generally benign and asymptomatic, should be excised upon discovery to prevent the development of life-threatening cardiopulmonary complications. Mediastinal schwannomas are typically benign and asymptomatic, and generally present no immediate risks. We encountered a rare case of a giant benign posterior mediastinal schwannoma that was complicated by life-threatening cardiac tamponade.A 72-year-old Japanese woman presented at the emergency room with cardiogenic shock and hypoxia. She reported the presence of exercise-induced dyspnea and right chest pain for several weeks. Her history included discovery two years previously of a posterior mediastinal tumor, 130 mm in diameter; because she was asymptomatic, our patient had declined further detailed examination and treatment at the time.On physical examination, we found our patient's skin to be diaphoretic. She had a systolic blood pressure of 80 mmHg by palpation, atrial fibrillation with a heart rate of 130 beats/minute, and no detectable paradoxical pulse. She had severe hypoxia with an oxygen saturation level of 85% on 100% oxygen at 10 litres/min. Cardiogenic shock was strongly suspected.Laboratory values for blood coagulation and blood cell counts were normal. Chest radiography showed an enlarged heart with hypolucent areas in both lung fields, and bilateral pleural effusion Figure . ComputeA total of 1200 ml of cloudy fluid was aspirated, which was analyzed and found to contain 4.8 g/dl of total protein, 3941 cells/μl, with an erythrocyte volume fraction of 11.6%, implying that it was exudate fluid. Lymphocytes were the dominant cell type without any evidence of malignant cells. The fluid was classified as class II cytology. Bacterial and fungal cultures produced no growth.A transcutaneous ultrasound-guided biopsy of the tumor was obtained, and the histological findings were consistent with a benign schwannoma. Magnetic resonance imaging of the chest after pericardial drainage showed that the tumor occupied the posterior mediastinum of the left pleural cavity, and was clearly separated from the cardiac structures Figure .Complete surgical resection was carried out using a left thoracotomy approach, and the mass was found to be a giant tumor, 140 × 100 mm in size, originating from the vagus nerveFigure . AlthougThis was a rare case of a benign posterior mediastinal schwannoma, originating from the vagus nerve, complicated by life-threatening cardiac tamponade. Schwannomas are benign nerve sheath neoplasms of Schwann cell origin, and are the most common of the neurogenic mediastinal tumors. Nearly 45% of schwannomas occur in the head and neck, with 9% occurring in the mediastinum . GeneralThe hemodynamic clinical course of our patient was also unusual, as there are few reported cases of schwannomas with cardiac involvement. Two cases of benign tumors in the ventricle epicardium involving pericardial effusion have been described ,6, and tTo the best of our knowledge, this is the first reported case of a benign extrapericardial mediastinal schwannoma presenting with life-threatening cardiac tamponade caused by a large volume of pericardial effusion. Previous reported cases of malignant meidiastinal schwannoma presenting as cardiac tamponade in Recklinghausen's disease had a rapidly fatal outcome after pericardial drainage, whereas in our case, drainage produced rapid restoration of normal cardiac function as measured by echocardiography, with no recurrent fluid accumulation after complete excision of the tumor,.Cardiac tamponade can be induced by either slow or rapid accumulation of pericardial fluid. With slow accumulation, the volume can become quite large and still cause no symptoms ,10. ThusAlthough giant mediastinal schwannomas are usually benign, this case suggests that they can become life-threatening and thus should be aggressively and completely resected once discovered to prevent cardiopulmonary complications. Likewise, in cases of cardiac emergencies, the possible presence of large benign mediastinal schwannomas or other tumors should be investigated.In conclusion, we report a rare case of a giant benign posterior mediastinal schwannoma, originating from the vagus nerve, presenting with life-threatening cardiopulmonary complications of significant pericardial effusion leading to cardiac tamponade. Immediate drainage and complete surgical excision of the tumor successfully restored normal cardiac function and hemodynamic surgical intervention of benign giant posterior mediastinal schwannomas is recommended in similar cases to prevent the occurrence of cardiac tamponade.The authors declare that they have no competing interests.Written informed consent was obtained from our 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.MK and SS reviewed the clinical data and were major contributors in writing the manuscript. KS, HT, HM and KT were involved with patient management. MS performed the histological examination of the biopsy. KS was our patient's attending surgeon and provided information on our patient. TU analyzed histological data and performed the immunohistochemical analysis. All authors read and approved the final manuscript.


Segmental dilatation of the colon is a rare congenital disorder of colonic motility and often involves a short segment that causes chronic constipation in children. There are only 10 cases of neonatal colonic segmental dilatation described in literature. We managed a case who presented in the neonatal period with abdominal distension. There was dilatation of whole of the colon except part of ascending colon and the rectum. The case was managed by tubularization of the segmental dilatation of colon with stoma formation as first stage followed by delayed anastomosis during second stage.  Segmental dilatation of colon [SDC] is a rare congenital entity characterized by a segmental dilatation of variable length, with the proximal and distal bowel of normal caliber. Clinical and radiological features resemble that of Hirschsprung’s disease and hence labeled under ‘disorders related to Hirschsprung’s disease . It was first described by Swenson and Rathauser in 1959 [3]. These patients are managed by resecting the diseased segment and restoration of the continuity of the bowel by primary or delayed anastomosis. In this report, we present a case with near total SDC of colon managed by diversion stoma and colorraphy followed by restoration of continuity. A 4-day-old newborn weighing 2.8kg, presented with abdominal distension, respiratory distress with non-passage of meconium. Examination showed grossly distended and resonant abdomen with dilated veins on the surface. Anal opening was normal and a 10 size red rubber catheter could be passed without difficulty. There was no visible bowel loops or palpable mass. Nasogastric tube drained no aspirate. Clinically a diagnosis of neonatal bowel perforation was made. X-ray abdomen showed large gas and fluid level with deviation of nasogastric tube to right side . There was no rectal gas shadow. Possibility of gastric perforation or meconium cyst with communication with bowel was kept in mind. Fluoroscopic water soluble contrast gastrography was done on table that showed normal stomach with flow of contrast to small bowel ruling out gastric perforation. Contrast enema was done to look for microcolon assuming that meconium cyst as a possibility. It showed enhancement of the gas filled structure . A diagnosis of either meconium cyst, duplication cyst with communication and contained perforation was considered. Laparotomy was done via right upper transverse incision. The stomach and small bowel were normal looking. The incision was extended across the midline to deliver a spherical shaped large dilated segment measuring 17 cm x15 cm involving most of the colon except for the normal sized proximal 4 cm of ascending colon and distal rectum from the level of S3 vertebrae . The appendix was single and normal. The blood supply for the dilated part was from ileocecal artery. The inferior mesenteric artery was found running along the mesenteric side as an arcade and branching dichotomously on either side, to supply the bowel wall. There were no creeping or serpentine blood vessels on the antimesenteric side as in pouch colon. Malrotation was present with cecum in the left hypochondrium and thick Ladd’s bands. The colon was divided at the junction of ascending colon and dilated segment and proximal end colostomy was done. In view of near total colonic involvement, the dilated distal part was subjected to colorraphy and brought out as distal stoma. Ladd’s bands were divided and appendicectomy done. The excised part of the dilated colon and appendix were sent for biopsy which showed normal ganglion cells and muscle layer. Post operatively the proximal stoma functioned well. After 3 months, to assess the function of distal preserved colon, rectal biopsy, anorectal manometry and transit study were done. For transit study 10 capsules were loaded with barium into the distal stoma. X-ray abdomen was taken every 2 hour. All the capsules were expelled out of anus within 6 hours. Distal cologram showed normal caliber colon of adequate length with no retention of barium in 24 hours film. There was no recurrence of dilatation. The rectal biopsy and anorectal manometry were normal. Colostomy closure was then performed. In the post operative period baby passed liquid stool in 48 hours and then breast feeding was started. There was no constipation or other symptoms at one year follow-up. Repeat barium enema done at 6 months showed normal caliber colon.Brawner and Shafer summarized clinical and pathologic features of CSD of colon as: Lack of radiographically demonstrable motility of the dilated segment; Normal appearing and functioning colon both proximal and distal to the dilated segment;Absence of taenia coli in the dilated segment;Normal ganglion cells;Hypertrophy of the circular and longitudinal muscle layers in the dilated segment [2-5].The left side of the colon is affected more frequently, with sigmoid and rectosigmoid involvement in 45% of cases [6]. In our case there was involvement of whole of colon except part of ascending colon and rectum. Cases involving the colon have a clinical picture very similar to that of Hirschsprung's disease and usually present with constipation in childhood or later (6 month to 22 year) . Involvement of ileum or jejunum usually manifest as neonatal bowel obstruction. Neonatal presentation in SDC is rare and only 10 cases have been reported so far . The recommended treatment is resection of the dilated segment and end-to-end anastomosis with/without proximal colostomy . In our case the resection of SDC would mean total colectomy which is not desirable; moreover it would also result in operative difficulty as anastomosis of ascending colon and rectum in pelvis is considered difficult with high leakage rates. Therefore, we planned a staged reconstruction with colorraphy and colostomy in the first stage followed by restoration of the bowel continuity during second stage after ruling out Hirschsprung’s disease and other motility disorders. We opted this option based on our experience of colorraphy in congenital pouch colon where the total length of colon is short and colorraphy is a good option though many authors do not favor it on account of intractable constipation problems in the postoperative period [11]. There is also a case report of preservation of the dilated segment by plication [12]. The functional analysis of the preserved dilated segment with available investigation in our institute and good outcome after surgery support the possibility of bowel preserving surgery in segmental dilatation when warranted. Though many cases presented mention that the dilated segment has motility problem we feel that if motility is the issue then intestinal obstruction and presentation in neonatal period is inevitable. The dilated segment has normal ganglion cells with no hypertrophy of nerve bundle, muscle layer and hence motility should be present. The presence of hypertrophied muscle layer in affected segment in late presenting cases and absence in early presenting cases suggests that there is ongoing contraction in the affected part to tide over the chronic obstruction. There are many associated malformations reported in such cases [6]. In our case malrotation was found. Malrotation has been described in 3 other patients with SDC. The dilated segment of significant size would have been present in the early period of embryogenesis and thus preventing normal rotation and fixation of bowel. Presence of associated malrotation though explains that the dilated part would have been of significant size in-utero but those cases also present few days after birth and following passage of meconium. This adds to our view that the obstruction may have mechanical element due to accumulation of gas and feces in the dilated segment. If the dilated segment is nonfunctional then muscle hypertrophy and dilatation should be present in the proximal bowel contracting against the obstructed site as in Hirschsprung’s disease. Mahadevaiah et al described certain abnormalities in like hypertrophied muscularis propria, nerve plexus, and ganglion cells located within the circular layer rather than the normal myenteric location in SDC [9]. These findings are not made out in other studies and do not explain the normal motility after excision of the redundant part by colorraphy in our case or after plication in another reported case [12].Source of Support: NilConflict of Interest: None declared


USP6-gene. Aggressive local growth and recurrences are common and therapeutic options may be limited due to the vicinity of crucial structures. We describe a case of a locally aggressive, multinucleated giant cell-containing lesion of the forearm of a 21-year old woman, treated with denosumab for recurrent, surgically uncontrollable disease. Under the influence of this RANKL inhibitor, the tumor showed a marked reduction of the content of the osteoclastic giant cells and an extensive metaplastic osteoid production leading to the bony containment, mostly located intracortically in the proximal radius. The diagnosis of a periosteal ABC was confirmed by FISH demonstrating USP6 gene rearrangement on the initial biopsy. Function conserving surgery could be performed, enabling reconstruction of the affected bone. Inhibition of RANKL with denosumab may offer therapeutic option for patients not only with giant cell tumors but also with ABCs.Aneurysmal bone cyst (ABC), once considered a reactive lesion, has been proven to be a neoplasia characterized by rearrangements of the  USP6 gene localized to 17p13[Aneurysmal bone cysts (ABCs) are rare benign skeletal tumors usually occurring in the first two decades of life and typically associated with a growing mass, swelling, pain and bone destruction,2. Approto 17p13.en bloc resection[Primary ABCs can affect any bone. Usually they arise in the metaphysis of long bones such as the femur, tibia and humerus; however, the spine may also be affected with compression/infiltration of nerves and spinal cord causing neurological symptoms. The magesection,14. Compesection. Clinicaesection, ABCs caUSP6 arising in the radius of a 21-year old woman with an impressive local response to denosumab treatment and a follow-up of four years.Denosumab, a monoclonal antibody specifically binding RANK-ligand, inhibits bone resorption and, therefore,-18 is usA 21-year old right-handed woman presented with a variable swelling and shooting pain in her right proximal forearm in May of 2009. Clinical examination showed a palpable swelling over the radial head mainly located over the biceps tendon and a supination deficiency. MRI revealed an extensive, deep seated, solid soft tissue tumor with contrast uptake, infiltration of the intra-osseous membranes, biceps tendon, contact with the neurovascular bundle, infiltration of the supinator muscle and deep extensor as well as deep flexor muscles  as described previously[USP6 locus (black arrow) and a pair of split green and red signals (white arrows) indicating a rearrangement of the USP6 locus consistent with the diagnosis of aneurysmal bone cyst.At first presentation in 2009, most of the exclusively solid tumor mass was localized in the soft tissues of the forearm on imaging Figure A, leadineviously, utiliziFurther follow up was unremarkable for another 19 months until a control MRI in February 2013 revealed a small (< 1 cm) lesion in the area of the distal osteotomy and the core biopsy confirmed the local recurrence of the ABC, which is currently being treated with denosumab.In this report, we describe a patient treated with denosumab for a locally aggressive, presumed giant cell tumor of soft tissue of the forearm. Evaluation of the resection specimen led to the final diagnosis of an intracortical aneurysmal bone cyst with massive infiltration of the soft tissue, a diagnosis which was also confirmed by FISH analysis.Histopathologic differential diagnosis of osteoclastic giant cell containing lesions of skeletal tissues is extensive  and the final diagnosis has to be made in close conjunction with clinical and radiological information. Giant cells occurring in both giant cell tumors (GCTs) and in ABCs are positive for markers of true osteoclasts, expressing RANK (receptor activator of NF-κB) and promoting bone destruction. The forDenosumab therapy was well tolerated by the current patient. The impressive positive treatment effects on the tumor tissue, as illustrated by marked reduction in the number of giant cells, were coupled with the bony demarcation of the tumor and facilitated subsequent function preserving surgery. The application of this form of the RANKL inhibition led to the transition of a locally aggressive and destructive tumor into a resectable lesion, thus preserving full function in our patient.Our observations support the hypothesis that not only patients with GCTs, but also those suffering from ABCs may benefit substantially from RANKL-inhibiting denosumab treatment. These findings may offer new therapeutic options for often young patients with these locally aggressive tumors, especially in uncontrollable, locally destructive or recurrent disease.Written informed consent was obtained from the patient for the publication of this report and any accompanying images.in situ hybridization; GCT: Giant cell tumor; H&E: Hematoxylin and eosin; MRI: Magnetic resonance imaging; RANK: Receptor activator of NF-κ; RANKL: Receptor activator of NF-κ ligand; USP6: Ubiquitin carboxyl-terminal hydrolase 6.ABC: Aneurysmal bone cyst; CT: Computer tomography; FISH: Fluorescence The authors indicate no potential conflict of interests.CP and BB performed histopathologicals studies and drafted the manuscript. BF and SH coordinated the management and the treatment of the patient, concerning the surgeries and denosumab treatment respectively. CP coordinated the imaging studies. JB carried out the molecular genetic studies. All authors read and approved the final manuscript.


Cerebellar glioblastoma is an uncommon adult lesion. The pathogeny and prognosis of cerebellar glioblastoma are still incompletely elucidated.We report the case of a 19-year-old Moroccan woman. A neurologic examination revealed the presence of cerebellar signs. A diagnosis of cerebellar glioblastoma is rarely made before surgery. An encephalic computer tomography scan and magnetic resonance imaging increased the accuracy of defining the nature of the lesion. Magnetic resonance imaging showed a heterogeneously enhancing mass in the vermis and the right cerebellar hemisphere. After surgery, glioblastoma was histologically confirmed. Post-operative radiotherapy followed. The outcome of our patient was favorable after one year of follow-up.We report an unusual case of cerebellar gliobastoma. Cerebellar glioblastoma multiforme should be considered in the differential diagnosis of a cerebellar mass lesion. Glioblastoma multiforme (GBM) is the most common primary brain tumor in adults. It usually affects the cerebral hemispheres, and the peak age of onset is the sixth or seventh decade of life. CerebelA 19-year-old Moroccan woman without any other medical history was admitted to our hospital with a two-month history of intracranial pressure with nausea, vomiting, and headache. A neurologic examination showed cerebellar signs, including cerebellar ataxia, dysmetria, and dysdiadochokinesia. The fundus oculi showed bilateral papillary edema. A cerebral computed tomography (CT) scan showed two lesions: one in the right cerebellar hemisphere and the other in the vermis. The lesions were spontaneously hypodense with a peripheral heterogeneous enhancement after contrast injection and mass effect on the fourth ventricle Figures . CranialOur patient first had a ventriculoperitoneal shunt. On the second day, a suboccipital craniotomy was performed while our patient was in the prone position. After opening of the dura mater and corticectomy, the lesion was white, infiltrative, crumbly, and not very hemorrhagic, had no planes of cleavage, and had indistinct margins from adjacent normal white matter. A subtotal tumor resection was performed. A histopathological examination revealed a cellular tumor, which was consistent with glioblastoma  and which was composed of elongated spindle-shaped cells with irregular, moderately pleomorphic and giant nuclei, and proliferative blood vessels and necrosis (hematoxylin and eosin stain (HES) ×100 and HES ×400). Immunohistochemistry was accomplished by means of the 3-amino-9-ethylcarbazole (AEC) peroxydase method and antigenic restoration, showing a marking of tumor cells with anti-GFAP  antibodies Figures  and7.The post-operative course was uneventful, and the neurologic signs gradually improved. Our patient received post-operative radiotherapy to the posterior cranial fossa. There was no tumor recurrence after 12 months.Glioblastoma, the most frequent tumor among all primary tumors of the central nervous system in adults, has a frequency of 50%,3,5. Adude novo (primary type) or from previous low-grade astrocytomas (secondary type)[et al.[The pathogeny and prognosis of cerebellar glioblastomas are still incompletely elucidated because of their rarity. Most aury type). Secondary type). Radiothry type),11. Maat[et al.. Our patSymptomatology of cerebellar glioblastoma, like that of any other cerebellar tumor, generally includes headache, gait disturbance, vertigo, nausea, vomiting, and ataxia (as in our case). Indeed, dizziness, neck pain, and mental confusion can be present,4,7. TheThe diagnosis of cerebellar glioblastoma is rarely made before surgery, even though CT scan and especially MRI have increased the accuracy of defining the nature of the lesion,3,6. MRIet al.[Proton spectroscopy of high-grade gliomas shows a significant reduction in NAA (N-acetyl aspartate), owing to the loss in neuronal elements, and a choline peak elevation that may reflect increased membrane synthesis. The presence of a lactate peak correlates with tumor hypoxia,3,6,13. et al..Cerebellar metastases are the most frequent posterior cerebral fossa tumors for adults and represent the most common differential diagnosis, particularly if the lesion is solitary and there is no history of primary lesion,4,6. HowDiagnostic difficulty also arises when there are several lesions, as with our patient. Other causes like abscesses, granulomas, or metastases should be considered, also primitive neuroectodermal tumor of the posterior fossa, medulloblastoma, ependymoma, pilocytic astrocytoma, or hemangioblastoma,2,4. As The treatment of cerebellar glioblastoma is usually palliative and encompasses surgery, radiotherapy, and chemotherapy. The dec2) administered with post-operative radiation therapy followed by one year of a dose of 150 to 200mg/m2 per day for five days each month[After surgery, the patient can be treated with fractionated external beam radiotherapy,7. TotalThe biological behaviors of cerebellar and supratentorial GBM are similar. On the other hand, the prognosis of cerebellar glioblastoma for younger patients is similar to that of anaplasic astrocytoma and probably has a better outcome than cerebral glioblastoma. The meaCerebellar GBM is rare and should be considered in the differential diagnosis of a cerebellar mass lesion. MRI can facilitate the characterization of the lesions and the differential diagnosis, particularly from metastases. Aggressive surgical treatment along with radiation therapy remains the established management strategy.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: Computed tomography; GBM: Glioblastoma multiforme; HES: Hematoxylin and eosin stain; MRI: Magnetic resonance imaging.The authors declare that they have no competing interests.AH wrote and revised the manuscript and provided comments. MJ prepared the figures and provided comments. AS prepared the biopsy and provided comments. My R El M revised the manuscript and provided comments. NF revised the manuscript and provided comments. RG revised the manuscript and provided comments. FB revised the manuscript and provided comments. All authors read and approved the final manuscript


Endometrial stromal nodule (ESN) is the least common of the endometrial stromal tumors. They are rare neoplasms which are diagnosed in most instances by light microscopy. Although such nodules are benign, hysterectomy has been considered the treatment of choice to determine the margins of the tumor required for diagnosis and to differentiate it from invasive stromal sarcoma Whose prognosis is totally different. We report a case of a 45 years old woman, with presurgical diagnosis of adnexal mass or uterine tumor. She underwent a total abdominal hysterectomy. Pathologic examination revealed an endometrial stromal nodule. Through this observation, we insist on the fact that the ESNs are rare and benign entities which must be differentiated from the other invasive malignant stromal tumors; this can change the final prognosis. Tumors of endometrial stroma are very rare mesenchymal tumors of the uterus with cytological and architectural features reminiscent of endometrial stromal cells .The classification of endometrial stromal tumor is difficult and complicated , 3. The ESN is cytologically similar to low-grade stromal sarcomas, but it is distinguished by its well-circumscribed, expansile margin, and it is considered clinically benign. In contrast, UES is a rare but highly malignant sarcoma lacking overt endometrial stromal differentiation .In this study, we describe a patient with a stromal nodule who underwent a total abdominal hysterectomy, and we insist on the fact that endometrial stromal nodule is a rare disease to be carefully differentiated from other stromal sarcomas, which can change the final prognosis.Mrs KR, 45 years old, divorced, G1P1, thyroidectomized under treatment, presented with dull pain and discomfort in the lower abdomen that had lasted for several weeks. The patient had her Menarche at the age of 14, and the menstrual cycles were regular without abnormal uterine bleeding. The abdominal and pelvic examination revealed the abdominal pelvic painless mass reaching the umbilical point, some parts of this mass are soft but the mass dependence on the uterus was not established; the rest of examination was without particularity. Abdominal and vaginal ultrasound showed a 15 cm heterogeneous but a well-circumscribed mass, consisting of cystic and solid parts whose relationship with the uterus is not well defined. No vegetation was noted either inside or outside of the mass. The ovaries was not visualized . MagnetiGross finding showed a polypoid and protrude tumor involving in the myometrium and tend to bulge above the surrounding myometrium. The tumor has a well-circumscribed contour, measuring 11 × 10 × 8 cm and has a fleshy yellow surface . This tuIn microscopic findings, the tumor consists of cells that closely resemble normal proliferative-phase endometrial stromal cells with areas of epithelial-like structures that have an appearance reminiscent of an ovarian sex cord-stromal tumor. The tumor cells have uniform, small, darkly staining round or oval nuclei with granular chromatin and inconspicuous nucleoli. Mitotic activity is less than 3MF/10HPF. The epithelial-like cells grow in cords and trabeculae, they are cuboidal with scanty amphophilic cytoplasm and nuclei resemble those of the surrounding stromal cells . The tumThe tumor was immunoreactive to CD10  and hormOne year after surgery, the woman remains asymptomatic, and is clinically and ultrasonographycally free of disease.Endometrial stromal tumors are among the least common neoplasms of the uterine corpus, with an annual incidence of about 2 per million women –4.Benign endometrial stromal nodule is a rare subtype that accounts for about one fourth of the endometrial stromal tumors which constitute less than 5% of uterine tumors .The diagnosis is in most instances established by light microscopy. The existence of circumscribed benign neoplastic proliferations of endometrial stromal cells, now known as “endometrial stromal nodules” has been known for many years but the literature on these lesions is scanty. Although large series of endometrial stromal tumors often include ESN, they are usually few in number  and therESNs like other uterine neoplasms of stromal origin, occur primarily in peri- and postmenopausal women. Tavassoli and Norris , 9 revieBecause the majority of patients are beyond childbearing years, a hysterectomy is usually required; it permits the thorough evaluation of the tumor margin too, which is necessary to distinguish a benign stromal nodule from a stromal sarcoma , 14. HowIn a curettage specimen, distinction between ESN and low-grade ESS is almost impossible, unless the tumor is very small and the margins can be fully evaluated. In women of reproductive age who desire to preserve fertility, diagnostic imaging and hysteroscopy may be used to follow up tumor growth. In some cases, hormonal therapy with local excision may be successful. In the series reported by Tavassoli and Norris, six patients underwent simple excision of the uterine nodules. One patient had a hysterectomy 4 years later for endometrial hyperplasia, and the pathologic evaluation revealed no evidence of stromal tumor. The other five patients were followed from 6, 2 to 10 years with no evidence of recurrence . SchildeOur patient aged 45 years was avid neither for pregnancy nor for a conservative treatment.Macroscopically, the tumor is characteristically a solitary, well-delineated, round fleshy nodule with a yellow to tan sectioned surface. The median tumour diameter is 4 cm (range 0.8 to 15 cm). It was 11 cm in our case. About two thirds are purely intramural without any apparent connections to the endometrium. Occasional tumors are cystic, but foci of necrosis and hemorrhage are rare.Differential diagnosis of an endometrial stromal nodule depends on microscopic findings.The histological appearance found endometrial stromal nodules with areas of epithelial-like structures that resemble ovarian sex cord tumors. The stromal nodules have expansile, noninfiltrative margins that compress the surrounding endometrium and myometrium. Minor irregularities of the margin are common, but invasion of the surrounding myometrium indicates that the tumor is a stromal sarcoma, not a stromal nodule , 15.Endometrial stromal tumors with sex cord-like elements exhibit a polyphenotypic immunophenotype. There is most often a mixed epithelial-myoid phenotype, with immunoreactivity for cytokeratin and actin, and, in some cases, desmin . Immune-In our case, the tumor expresses the CD10 and hormonal receptors. Immunostaining for AML , desmine, calretinin, cytokeratin AE1/AE3, and inhibin were negative.Endometrial stromal nodule with focal sex cord-like differentiation tend to relapse and metastase. In Clement and Scully initial report, three of five patients with followup had recurrences and two died .We present a patient with endometrial stromal nodule. There is no reliable preoperative diagnostic procedure to identify this tumour. Clinical presentation is nonspecific. Hysterectomy is the treatment of choice. The diagnosis is done on microscopic examination. The margins of tumour must be determinate to differentiate it from invasive stromal tumors.Considered as benign tumor, the prognosis is excellent when the diagnosis is sure.


The mechanical stapler is routinely used in thoracic surgery practice to attend resection of bronchus and vessels. Herein, we reported a very rare complication as the migration of a titanium surgical clip through a right lobectomy stump. One year after the procedure, the patient complained of persistent cough. A misdiagnosis of asthma was made and she treated for 6 months with bronchodilators, corticosteroid and antihistaminic without success. Thus, patient re-referred of our unit. No clinical signs of infection as fewer, productive cough, dyspnea were present. The laboratory exams were within normal value including white cells. CT scan revealed no abnormalities. Bronchoscopy demonstrated a healed upper bronchus stump without evidence of an actual, open bronchopleural fistula but with clips apparently working their way into the airway, with approximately half of the clip visible within the lumen. The side of the clips that would be open before closure by the surgeon formed the leading edge of the clips visible in the lumen. The clips were successfully removed during flexible bronchoscopy with a forceps usually used for biopsy. After the procedure, the cough disappeared. The endoscopy check after 3 months showed a normal bronchial stump without evidence of fistula. The mechanical stapler is routinely used in thoracic surgery practice to attend resection of bronchus and vessels. Herein, we reported a very rare complication as the migration of a titanium surgical clip through a right lobectomy stump. One year after the procedure, the patient complained of persistent cough. A misdiagnosis of asthma was made and she treated for 6 months with bronchodilators, corticosteroid and antihistaminic. Symptoms disappeared after removing surgical clip with flexible bronchoscopy.A 75 year-old woman patient was referred to our unit for the diagnosis and treatment of lung lesion discovered at Chest/X ray. She complained of cough and fewer. All laboratory exams were within normal values. Chest tomography scan diagnosed the presence of lesion (size 3 cm) confined within upper right lobe without lymp node involvement. On PET scan, the lesion was FDG- avid with a standard uptake value (SUV) of 3.5. No other lesions were found. Fine-needle aspiration biopsy diagnosed (FNAB) CT guided diagnosed to be a atypical carcinoid. Cardiorespiratory evaluation did not contraindicate surgery. Thus, a right upper lobectomy via thoracotomy was attended in a standard matter. The bronchus was mechanically closed using a mechanical stapler. A radical lymph adenectomy was performed. No complications occurred during operation and in the postoperative course. In addition to peridural analgesia, a transcutaneous electrical nerve stimulation analgesia was applied to better control the postoperative pain . The patForeign body erosion into the tracheobronchial tree is uncommon and its presentation is highly variable. In literature few reports reported the expectoration of staples and dry bovine pericardial strips used for staple line reinforcement after surgery for emphysema ,3. SaundIn the present case the persistent cough, appeared after 1 year from the lobectomy, was misdiagnosed as asthma disease. The patient was treated for 6 months with medical therapy including bronchodilators, corticosteroid and antihistaminic without success. Then, she was re-referred to our unit. Despite the presence of cough, the diagnosis of bronchopleural fistula was unlike due to lack of fewer, of productive cough and of other clinical and laboratory signs of infection. Bronchoscopy showed a healed upper bronchus stump without evidence of an actual, open bronchopleural fistula but with clips apparently working their way into the airway, with approximately half of the clip visible within the lumen. The side of the clips that would be open before closure by the surgeon formed the leading edge of the clips visible in the lumen. Thus, the persistent cough was due to chronic irritation of bronchial mucosa by clips. Conversely to Ahmed et al  who deciThe authors declare that they have no competing interests.P.L. : conception and design, interpetration of data, given final approval of the version to be published. F. N.: acquisition of data, drafting the manuscript, given final approval of the version to be published. C.C. : acquisition of data, drafting the manuscript, given final approval of the version to be published. MD : acquisition of data, drafting the manuscript, given final approval of the version to be published. BA : acquisition of data, drafting the manuscript, given final approval of the version to be published. A.G. : acquisition of data, drafting the manuscript, given final approval of the version to be published. M.V. : acquisition of data, drafting the manuscript, given final approval of the version to be published. V.D.C.: critical revision, interpretation of data, given final approval of the version to be published.PL: Resident at of Thoracic Surgery - University of Salerno. FN: Resident at of Thoracic Surgery - University of Salerno. CC: Resident in Department of Clinical Medicine and Surgery -University of Naples. MD : acquisition of data, drafting the manuscript, given final approval of the version to be published. BA : acquisition of data, drafting the manuscript, given final approval of the version to be published. AG: Assistant Professor of Pediatric Surgery - University of Salerno. MV: Associate Professor of Endocrinology - University of Salerno. VDC: Assistant Professor of Thoracic Surgery - University of Salerno.


Pelvic actinomycosis constitutes 3% of all human actinomycosis infections. It is usually insidious, and is often mistaken for other conditions such as diverticulitis, abscesses, inflammatory bowel disease and malignant tumors, presenting a diagnostic challenge pre-operatively; it is identified post-operatively in most cases. Here we present a case that presented as pelvic malignancy and was diagnosed as pelvic actinomycosis post-operatively.Actinomyces. Penicillin therapy was given for six months without any complication.A 48-year-old Caucasian Turkish woman presented to our clinic with a three-month history of abdominal pain, weight loss and difficulty in defecation. She had used an intra-uterine device for 16 years, however it had recently been removed. The rectosigmoidoscopy revealed narrowing of the lumen at 12 cm due to a mass lesion either in the wall or due to an extrinsic lesion that prevented the passage of the endoscope. On examination, there was no gynecological pathology. Magnetic resonance imaging showed a mass, measuring 5.5 × 4 cm attached to the rectum posterior to the uterus. The ureter on that side was dilated. Surgically there was a pelvic mass adhered to the rectum and uterine adnexes, measuring 10 × 12 cm. It originated from uterine adnexes, particularly ones from the left side and formed a conglomerated mass with the uterus and nearby organs; the left ureter was also dilated due to the pelvic mass. Because of concomitant tubal abscess formation and difficulty in dissection planes, total abdominal hysterectomy and bilateral salphingo-oophorectomy was performed (our patient was 48 years old and had completed her childbearing period). The cytology revealed inflammatory cells with aggregates of Pelvic actinomycosis should always be considered in patients with a pelvic mass especially in ones using intra-uterine devices, and who have a history of appendectomy, tonsillectomy or dental infection. Surgeons should be aware of this infection in order to avoid excessive surgical procedures. Actinomyces. Abdominal disease is usually insidious and is often mistaken for other conditions such as diverticulitis, abscesses, inflammatory bowel disease and malignant tumor, presenting a diagnostic challenge pre-operatively [Actinomycosis is a chronic granulomatous disease caused by any of several anaerobic organisms from the genus ratively ; it is iratively . Here, wA 48-year-old Caucasian Turkish woman presented to our clinic with a three-month history of abdominal pain, weight loss and difficulty in defecation. She had a 16-year history of intra-uterine device (IUD) use, which had recently been removed. On physical examination, the abdomen was normal, without any mass; on rectal digital examination, there was a rigid, immobile mass in the anterior part of the rectum. Laboratory evaluation showed a white blood cell count of 12,400. A rectosigmoidoscopy revealed narrowing of the lumen at 12 cm due to a mass lesion either in the wall or due to an extrinsic lesion that prevented the passage of the endoscope. Histopathological diagnosis of tissue samples taken from the mucosa of the narrowed lumen was inflammatory pattern. On gynecological examination and endovaginal ultrasound there was no gynecologic pathology. Magnetic resonance imaging (MRI) showed a mass, measuring 5.5 × 4 cm, attached to the rectum posterior to the uterus. The ureter on that side was dilated .Actinomyces. Penicillin therapy was given for six months without any complication. She is well and has gained weight after one year.Her post-operative recovery was normal. Cytology revealed inflammatory cells with aggregates of Actinomyces. Although previously thought to be a fungal infection, these organisms are Gram-positive, filamentous bacteria. Disease in humans is most commonly caused by A. israelii [Actinomycosis is a chronic granulomatous disease caused by any of several anaerobic organisms from the genus israelii . These oActinomycosis is traditionally divided into three forms: cervicofacial, thoracic, and abdominogenital. The most frequent site of human infection is the cervicofacial area, accounting for about 40 to 50% of cases. Approximately, 15% of actinomycosis occurs in the thorax ,3. TwentA. israelii infects 1.65% to 11.6% of IUD users, and infection is more common in women who have had an IUD use in situ longer than four years. In females, Actinomyces is thought to be induced by oro-genital contact [Abdominal disease usually results from clinical or sub-clinical disruption of bowel mucosa. It often occurs as a firm mass that appears fixed to the surrounding tissue and can be mistaken for a tumor -6. Abdom contact .When pelvic actinomycosis occurs, it usually causes endometritis, salpingo-oophoritis, or tubo-ovarian abscess and a mass in the adnexa might be palpable, suggesting a pelvic malignancy ,9,10. UlDiagnosis of actinomycosis can be difficult because of the insidious nature of the infection. Usually, diagnosis is impossible pre-operatively, even after fine-needle aspiration . The finPenicillin is the drug of choice; resistance is rare. High doses must be given for prolonged courses. In those who are allergic to penicillin, options include tetracyclines, erythromycin, doxycycline and clindamycin. However, response to tetracyclines and ciprofloxacin is poor and a beta lactam antibiotic combined with a beta lactamase inhibitor, should be the first choice . ParentePelvic actinomycosis should always be considered in patients with pelvic mass especially in those using IUD, and who have a history of appendectomy, tonsillectomy or dental infection. Antimicrobial therapy should be initiated following surgery. Surgeons should be aware of this infection in order to avoid excessive surgical procedures.A. israelii: Actinomyces israelii; CT: computed tomography; IUD: intra-uterine device, MRI: magnetic resonance imaging.The patient provided written consent for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief.The authors declare that they have no competing interests.All authors planned to produce such a case report, analyzed and interpreted the patient data, reviewed the literature to design it and revised it for final approval of the version to be published.


Malignant schwannoma of the anterior abdominal wall nerves is extremely rare. Malignant peripheral nerve sheath tumors (MPNST) represent approximately 10% of all soft tissue sarcomas and it is found in 4% of patients with neurofibromatosis 1. We present a case of malignant schwannoma in a 28-year-old female patient with neurofibromatosis 1. She presented with a painful mass in the right upper quadrant of her abdomen. The tumor location was in the abdominal wall in explorative laparatomy and malignant schwannoma was diagnosed in pathologic assessment. The tumor recurred in 3 months and computed tomography showed two masses in the right side of abdominopelvic cavity. Thereafter, second complete surgical resection was performed and pathologic finding was the same. In spite of administering chemotherapy after second surgery,the tumor recurred and magnetic resonance imaging finding showed a huge heterogeneously enhancing mass with adhesion to the inner side of the abdominal wall. The patient died because of acute respiratory failure due to multiple bilateral pulmonary metastases. Tumor location and rapid recurrence was unique in our patient.Malignant peripheral nerve sheath tumor; Malignant schwannoma; Abdominal wall A 28 years old woman with recurrent malignant schwannoma originating from anterior abdominal wall nervesis reported in our article. Malignant peripheral nerve sheath tumor also known as malignant schwannoma, are highly malignant sarcomas that tend to arise in the head and neck region or on the exterimities, and only very rarely in anterior abdomional wall. Almost 50% of cases are associated with neurofibromatosis. Although various radiologic imaging methods are helpful for identifying some features of the mass, definitive diagnosis requires histological examination and immunohistochemical staining. After treatment, the tumor recurs in 25% of patients. Five-year survival rates as high as 80% have been reported. Total excision and lack of invasion of surrounding tissue and vessels and absence of neurofibromatosis are features associated with better outcomeA 28 years old female was admitted for management of increasing abdominal distention and sustained pain in right upper quadrant of abdomen for two months. Her medical history included type 1 neurofibromatosis (NF1), also known as von Recklinghausen disease. She had not history of surgery or radiotherapy. On physical examination, there were multiple cafe-au-lait spots scattered over the patients entire body and axillary freckling, but no cutaneous neurofibromas was present . Lisch nThe sonographic and computed tomography findings showed a heterogenic solid mass in right upper quadrant (RUQ) of abdomen that extended down to the right lower quadrant (RLQ) of abdomen . LaboratRadiologic findings showed two masses in the right anterior pararenal space extending down to the lower abdomen. Thereafter the patient underwent second surgical resection. During the second operation, one white grayish well limited fish fleshy tumor measuring 6.1 x 5.5 x 4.7 having whitish out surface with gelatinous foci and the other mass measuring 2.1 x 1.9 x 1.8 cm, were detected in the abdomen and resected. Section showed a high grade spindle cell hypercellular sarcoma composed of rather monotonous spindle cells having atypical hyperchromatic nuclei with foci of perivascular palisading. Histological examination of the resected specimen revealed the tumor to be malignant schwannoma. The patient received chemotherapy (cyclophosphamide) for 2 months but there was tumor recurrence in less than two months. Magnetic resonance imaging showed the recurrent tumor as a huge heterogeneously enhancing mass with some necrotic foci which has filled the abdomen and pelvic cavities. The mass was located in right side of the abdomen with midline extension .There was direct contact with liver and gallbladder which were pushed superiorly. Adhesion to the inner side of the abdominal wall was seen. Retroperitoneal extension and lymphadenopathy was not noted. As a result, the tumor was considered to arise from the anterior abdominal wall nerves. The patient died about two months later because of respiratory failure due to widespread bilateral pulmonary metastasis.The occurrence of intraabdominal and retroperitoneal schwannomas is extremely rare. Intraabdominal schwannomas occur most frequently in the alimentary tract . GastroiNeurofibromas are tumors derived from Schwann cells, fibroblasts, and supporting cells known as perineural cells. Typically, theyare benign and manifest as multiple tumors. NF1 is an autosomal dominant genetic disorder with a prevalence of approximately 1 in 4,000 births and no racial predilection. NF1 is characterized by multiple neurofibromas along the peripheral nerves, optic nerve gliomas, sphenoid wing dysplasia, pigmented lisch nodules,and hyperpigmented macular skin lesions known as cafe-au-laitspots. It is associated with a gene on chromosome 17. Theformation of dermal neurofibromas is a hallmark of NF1 witha characteristic distribution on the trunk and sparing of theextremities. With time, neurofibromas may undergo malignantdegeneration .At gross examination, neurofibromas appear as firm, gray-whitemasses. At histologic analysis, neurofibromas contain Schwanncells and nerve fibers that grow in a disorganized fashion andappear as interlacing bundles of elongated cells with intracellular collagen strands.There are three types of neurofibromas: localized, diffuse, and plexiform. The vast majorities of these lesions are localized and have no association with NF1, althoughany of these lesions may occur in NF1 . LocalizConversely, up to half of all cases of MPNST are diagnosed in persons with neurofibromatosis 1. About one in ten cases are associated with irradiation .Tumor isSurgical resection is the first line of therapy, ideally withtotal removal of the tumor. Gross inspection of MPNSTs reveals a fusiform, fleshy, tan-white mass with areas of degeneration and secondary hemorrhage. The nerve proximal and distal to the tumor may be thickened due to spread of the tumor along the epineurium and perineurium. At histologic analysis, MPNSTs are unencapsulated infiltratingtumors composed of spindle cells arranged in a whorling pattern with irregular nuclei, cyst formation, and nuclear palisading. Mitotic figures are readily visible, with more than one per high-power field, and 50% - 90% of cases are immunoreactive with S100 protein staining. Owing to a high risk of recurrence with incomplete resection, postoperative irradiation and chemotherapy are necessary; however, they are often used as adjuvant therapy even if the tumor is completely resected. Even with aggressive therapy, local recurrence of tumor is seen in 50% of patients. Hematogenous metastatic spread occurs most commonly to the lungs. The reported 5-year survival rate for patients withMPNST without NF1 is as high as 50%. It drops to as low as 10% for MPNST patients with NF1 . The fiv


Perforation caused by capsule endoscopy impaction is extremely rare and, at present, only five cases of perforation from capsule endoscopy impaction are reported in the literature.We report here two cases of patients with undiagnosed small bowel stenosis presenting with acute perforation after capsule endoscopy. Strictures in the small bowel were likely the inciting mechanism leading to acute small bowel obstruction and subsequent distension and perforation above the capsule in the area of maximal serosal tension.Case 1 was a 55-year-old Italian woman who underwent capsule endoscopy because of recurrent postprandial cramping pain and iron deficiency anemia, in the setting of negative imaging studies including an abdominal ultrasound, upper endoscopy, colonoscopy and small bowel follow-through radiograph. She developed a symptomatic bowel obstruction approximately 36 hours after ingestion of the capsule. Emergent surgery was performed to remove the capsule, which was impacted at a stenosis due to a previously undiagnosed ileal adenocarcinoma, leading to perforation.Case 2 was a 60-year-old Italian man with recurrent episodes of abdominal pain and diarrhea who underwent capsule endoscopy after conventional modalities, including comprehensive blood and stool studies, computed tomography, an abdominal ultrasound, upper endoscopy, colonoscopy, barium enema and small bowel follow-through, were not diagnostic. Our patient developed abdominal distension, acute periumbilical pain, fever and leukocytosis 20 hours after capsule ingestion. Emergent surgery was performed to remove the capsule, which was impacted at a previously undiagnosed ileal Crohn’s stricture, leading to perforation.The present report shows that, although the risk of acute complication is very low, the patient should be informed of the risks involved in capsule endoscopy, including the need for emergency surgical exploration. Small bowel capsule endoscopy (CE) has become a commonly performed diagnostic test in patients affected by various small bowel diseases.Impaction of the video capsule in the small bowel is a potential serious complication of this procedure, occurring in 0.75% to 21% of cases as reported by previous studies; its incidence rate is greatly dependent on procedural indication and patient characteristics -7.We report here two cases of patients with previously undiagnosed small bowel stenosis presenting with acute perforation as a result of capsule impaction.A 55-year-old Italian woman was referred to our division when she complained of severe cramping abdominal pain and vomiting approximately 36 hours after ingestion of a capsule endoscope.Over the preceding years, she had undergone an extensive workup for recurrent postprandial cramping pain and iron deficiency anemia, including an abdominal ultrasound, upper endoscopy, colonoscopy and small bowel follow-through radiograph, all of which showed negative results. The physical examination on her admission revealed a mildly distended abdomen with increased bowel sounds. Laboratory tests showed normal results except for a red blood cell count of 3.15 million/mL  and hemoglobin of 9.8g/dL . A plain abdominal film demonstrated a retained capsule in her small bowel without clear-cut signs of bowel obstruction. The endoscopist obtained images from the CE revealing a suspected neoplastic-like stricture in her mid-small bowel  and hemoglobin of 10.7g/dL .A CT scan of his abdomen was performed and showed the presence of the capsule endoscope located in his distal ileum and a stricture along with extensive small bowel distension, a thickened bowel wall and loculated free air Figure . Our patCE is a safe and well-tolerated procedure. To date, in clinical practice, the risk of capsule retention at the site of a previously unknown small bowel stricture remains the main complication of CE. The International Conference on Capsule Endoscopy consensus defined capsule impaction as retention of a capsule endoscope in the small bowel for a minimum of two weeks or as capsule retention in the bowel for a shorter period requiring medical, endoscopic or surgical intervention . The freIn previously reported cases of capsule impaction, patients have generally been asymptomatic, even when the capsule has remained impacted for a very long time. However, some case reports described the possibility of acute obstruction or perforation due to capsule retention.Patients with abdominal pain, distension and vomiting after CE should be evaluated for impaction and small bowel obstruction or perforation. The diagnosis may be aided by examination of capsule images, which can reveal an obstructing lesion, or show repetitive images of the same area of mucosa. Abdominal radiography or CT will typically demonstrate the retention of the capsule in the small bowel in association with signs of bowel distension or perforation.To date, there have been five documented cases of small bowel perforation caused by an impacted capsule retention -7. PerfoIn the present cases, perforation occurred within 60 hours and 20 hours of the capsule ingestion in a patient with undiagnosed ileal adenocarcinoma and in a patient with undiagnosed Crohn’s disease, respectively. Strictures in the small bowel were likely the inciting mechanism leading to acute small bowel obstruction and subsequent distension and perforation above the capsule in the area of maximal serosal tension.Our patients had no history of obstructive symptoms and both had undergone extensive diagnostic work up before the CE, including negative comprehensive blood, endoscopic and radiological studies. Our case series supports previous claims that barium studies have limited sensitivity for predicting capsule passage. CT or magnetic resonance imaging enteroclysis are being investigated as potential alternative screening methods, with promising results. There is, however, no accepted method to safely avoid capsule retention at present .A newly designed non-visualizing dissolvable capsule  has been developed to minimize the risk of retention. This device starts its dissolution process 30 hours after ingestion even if one end of the capsule is impacted in a stricture. The patency capsule has been used as a screening test to assess the passage of an endoscopic capsule in patients at risk for small bowel strictures. There has been concern, however, about the efficacy and safety of this device because the patency capsule itself has also been shown to result in symptomatic small bowel obstruction in a few cases .In conclusion, although the risk of acute complication is very low, the patient should be informed of the risks involved in CE, including the potential need for emergency surgical exploration.Written informed consent was obtained from the patients for publication of this manuscript and accompanying images. Copies of the written consent are available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.GDDP, MP, SM, SC, FM and GP have made substantial contributions to the conception, design, acquisition and interpretation of data; GP, SM, FM and DE performed the surgical interventions; FS and DE have been involved in drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.


Perforation of descending colon cancer combined with iliopsoas abscess and fistula formation is a rare condition and has been reported few times. A 67-year-old man came to our first aid for an acute pain in the left iliac fossa, in the flank, and in the ipsilateral thigh. Ultrasonography and computed tomography revealed a left abdominal wall, retroperitoneal, and iliopsoas abscess that also involved the ipsilateral obturator muscle. It proceeded with an exploratory laparotomy that showed a tumor of the descending colon adhered and perforated in the retroperitoneum with abscess of the iliopsoas muscle on the left-hand side, with presence of a fistula and liver metastases. A left hemicolectomy with drainage of the broad abscess was performed. Pathologic report findings determined adenocarcinoma of the resected colon. Infections of the retroperitoneal space have troubled physicians in all disciplines for decades because of remarkable diagnosis and treatment problems along with a mortality rate which is around 20% . RetropeIn fact colon cancer, which represents the most frequent tumor of the digestive tract , involveHere is a case of cancer of the descending colon which was presented with an unusual abscess of the left iliopsoas muscle and ipsilateral obturator muscle.A 67-year-old man came to our first aid for an acute pain in the left iliac fossa, in the flank, and in the ipsilateral thigh. He had a 5-day history of pain in walking and in the left lower limb.At ER the patient showed no pathological vital parameters, with the exception of a body temperature of 37.5°C.The physical examination showed an abdominal distension localized in left iliac fossa and flank. A deep painful mass of stretched-elastic consistency was palpated on the left lower quadrant, anything of relevance in the remaining abdominal quadrants. The sign of Blumberg was negative. The femoral wrists were present.The clinical suspicion was a diverticulitis of sigma complicated by a perforation and peridiverticular abscess (Hinchey IIa-IIb). Then were performed laboratory hematobiochemical routine tests and we proceeded with diagnostic imaging: an abdominal ultrasound and CT with and without iodate contrast.3/mm3 (n.v. 4.50–10.80), with remarkable neutrophilia: 87.1% (n.v. 40.5–74.1%); C-reactive protein of 22 mg/dL (n.v. < 0.1 mg/dL); the erythrocyte sedimentation rate of 35 mm/h (n.v. 0–20 mm/h).On admission in ER the following hematobiochemical values were altered: the WBC of 21.23∗10The abdominal ultrasonography showed a thickening of the colic walls in left flank-iliac fossa with hyperdense appearance of perivisceral fat and neighboring fluid. We proceed to a computerized axial tomography performed with and without iodate contrast. The CT Figures  and 2 shSo was performed an emergency intervention. It proceeded with an exploratory laparotomy which emphasized left dolichocolon. It showed a tumor of the descending colon adhered and perforated in the retroperitoneum with abscess of the iliopsoas muscle on the left-hand side, with presence of a fistula and liver metastases. So was performed a left hemicolectomy with tying of the mesenteric artery below the origin, removal of the tablet seat of peritoneal perforation, drainage of the broad abscess of the iliopsoas muscle, removal of the pus to culture examination, and the washing of the abscessual cavity with double drainage of the same. A metastasis surfacing the IV hepatic segment was asportated. Citrobacter braakii and Escherichia coli. After antibiogram, the patient was treated with adequate targeted antibiotic therapy. The results of histopathological examination of the removed colic mass confirmed the diagnosis of adenocarcinoma with the following TNM classifications [The culture examination of the abscessual liquid was positive for the following bacteria:ications : T4 N2 MThe first abscess of the psoas was described by Mynter in 1881; he was talking about this clinical condition using the term “psoitis” . In gene Staphylococcus aureus [ Streptococcus species in 4.9% of the cases and E. coli in 2.8% [A recent study carried out in Taiwan shows a frequency of abscesses of the psoas muscle of 2.5 cases per year . In the s aureus , the sec in 2.8% .A relatively rare event  is insteThe psoas muscles abscess by perforation of the descending colon cancer may arise or be less with a fistula, in about 15% of the cases . In our  E. coli and Citrobacter braakii, was set.An accurate preoperative diagnosis of abscess correlated with a perforated colon cancer is extremely complicated, but the execution of laboratory tests that evidence a marked leukocytosis and especially the use of an abdominal CT is very useful in the diagnosis, in a precise location, and in the determination of the boundaries of the lesion and the dissemination of the surrounding soft tissues. In our case, considering the results of laboratory and instrumental tests and considering the patient clinical condition of acute abdomen we decided for emergency intervention. During the exploratory laparotomy the presence of a malignant perforated cancer and the fistula was evaluated which fired the abscess at the level of the left iliopsoas muscle and ipsilateral obturator muscle. The patient improved greatly his clinical conditions as a result of the intervention that it is concluded with a left hemicolectomy accompanied by a drainage and subsequent repeated washing of the large retroperitoneal abscess and by the removal of the tablet peritoneal seat of the perforation and the fistula. The removal en bloc of colonic tumor of the fistula and the wall of the abscess allowed a better oncological efficiency of the intervention. After surgery a target antibiotic therapy, suggested by culture of abscessual liquid positive forIn conclusion we have treated a case of perforated adenocarcinoma of the descending colon with an unusual formation of an abscess of the left iliopsoas muscle with involvement of the ipsilateral obturator muscle with relative fistula. The accurate preoperative diagnosis of these conditions clinic is extremely complicated because of the fuzzy clinical presentation, despite the ongoing developments in the context of diagnostic imaging. The importance is to focus on the differential diagnosis and keep in mind that a colon carcinoma can lead to a similar clinical condition. In the collection of the history and during the objective exam, signs of the presence of an abscess are the fever, pain, the presence of a palpable mass, and leukocytosis. The use of the CT can be very useful, even if the definitive diagnosis of colic perforated neoplasia may be evident only during surgery. It is good to intervene as soon as possible in similar conditions with a colon resection affected by neoplasia, with the resection of the fistula (if present), and with the drainage of the abscess to reduce significantly the morbidity and mortality associated with this fearful condition.


These findings led to a definitive diagnosis of leiomyoma with calcification and ossification. This is extremely rare and the preoperative differentiation from other tumors of the head and neck was very difficult. By resection of the submandibular tumor, both definitive diagnosis of leiomyoma by histopathological and immunohistochemical analyses and treatment could be carried out. However, as the tumor in the upper mediastinum was most likely to be leiomyoma with calcification, he did not wish to undergo its biopsy and resection immediately. We have continued the follow-up. We encountered a patient with primary cervical leiomyoma with remarkable calcification and ossification. A 68-year-old man presenting with induration and swelling of the left submandibular region was found to have nodular lesions with calcifications in the left submandibular region and the upper mediastinum on CT. Fine needle aspiration biopsies (FNAB) of the left submandibular lesion revealed no malignancy. Resection was performed for definitive diagnosis and treatment. The resected specimen contained a solid tumor, which was markedly calcified and ossified on the cut surface. Histopathological examination showed proliferating spindle cells in a tangled and crossed arrangement. Immunohistochemically, the spindle cells were stained intensely with  Leiomyoma is a benign and nonepithelial tumor that commonly arises from the uterus, esophagus, and skin. Primary leiomyomas of the head and neck account for 12% of all leiomyomas . HistopaThe patient was a 68-year-old man presenting with induration and swelling of the left submandibular region. His past medical history and familial history were unremarkable. At the age of about 25 years, he had noticed a small induration with an irregular surface in this region, but it was left untreated because of a lack of subjective symptoms. However, it also showed no tendency to improve, and then the swelling gradually worsened.At the time of his first visit to our department, except for the induration and swelling in the left submandibular region, there were no abnormal findings in the ear, nose, throat, head, and neck. CT revealed nodular shadows with marked calcifications in the left submandibular region and the upper mediastinum . No signBecause of the uncertain diagnosis, surgery was performed. After a skin incision of the left submandibular region, an irregularly surfaced firm mass in the deep submandibular space was revealed . First, α-SMA and h-caldesmon, consistent with smooth muscle cells , angiomyoma (vascular leiomyoma), and epithelioid leiomyoma (leiomyoblastoma). Leiomyoma has been shown to be the most common, and it differs from angiomyoma in terms of the degree of angiogenesis in the tissue . There iThe mechanisms of development of calcification with leiomyoma and multioccurrence of calcification are largely unknown. Calcification is frequently found in cells with nuclear atypia and degenerative changes . The mec“Nonepithelial tumor with calcification” is diverse , and theα-SMA and h-caldesmon is also precise and reliable for definitive diagnosis [α-SMA is most commonly used as a myogenic marker, and h-caldesmon is expressed exclusively in smooth muscle and is a highly specific marker for it [Proliferating spindle cells in a tangled arrangement are a characteristic histopathological feature of leiomyoma. In addition to histopathology, immunohistochemistry using iagnosis . α-SMA ir for it . Both arr for it . In addir for it , 9.As in this case, leiomyoma can be diagnosed definitively and treated radically by surgical resection , 11, 12.


An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Although they are considered as a rare cause of intestinal obstruction, paraduodenal hernias are the most common type of congenital hernias.A literature search using PubMed was performed to identify all published cases of left paraduodenal hernia (LPDH).In Literature search between 1980 and 2012 using PubMed revealed only 44 case reports before the present one. Median age was 47 years (range 18 – 82 years). Nearly 50% reported previous mild symptoms. Two-third of patients required emergency surgery in form of laparotomy or laparoscopic repair. Reduction of hernia contents with widening or suture repair of the hernia orifice were the most common standards in surgical management of LPDH.Intestinal obstruction secondary to internal hernias is a rare presentation. High index of suspicion and preoperative imaging are essential to make an early diagnosis in order to improve outcome. Internal hernia is, either congenital or acquired, a rare cause of small-bowel obstruction, with a reported incidence of less than 2%. ParaduoA 47 –year-old Caucasian male admitted with increasing severe colicky abdominal pain and bile stained vomiting of 2 days duration. He had no previous significant past medical or surgical history. He also denied any history of weight loss, or recent changes in his bowel habit. However, He described at least 4 previous episodes of upper abdominal distension and vomiting with spontaneous resolution over the previous 2 years. On examination, the patient appeared in moderate pain with normal vital signs. Abdominal examination revealed abdominal distension with a tender mass in the left upper quadrant. Laboratory studies were essentially normal. An urgent abdominal CT scan confirmed the diagnosis of small bowel obstruction secondary to what looked like a hernia into the left paraduodenal fossa (fossa of Landzert) Figure . At lapaInternal herniation of the small bowel is a relatively rare cause of intestinal obstruction and accounts for less than 2% of all causes. Among aLiterature search between 1980 and 2012 using PubMed revealed only 44 case reports before the present one,11-49 (TRadiological diagnosis of LPDH prior to surgery was achieved in 43% of patients. On CT scan, typical appearance of LPDH is an encapsulated sac containing clusters of dilated small bowel loops at or above the ligament of Treitz with a mass like effect compressing the posterior gastric wall and distal part of the duodenum. Besides, there is engorgement and crowding of the mesenteric vessels with frequent right displacement of the main mesenteric trunk and depression of the transverse colon Figure .Once a LPDH is identified, operative treatment is necessary, as patients with a LPDH have a 50% lifetime risk of developing small bowel obstruction with a 20–50% mortality rate for acute presentations,8. In thLeft paraduodenal fossa hernia is a relatively a rare cause of small bowel obstruction. In young patients with recurrent small bowel obstruction with no previous surgical history, it is crucial to consider internal hernias in the differential diagnosis. Furthermore, a timely and correct diagnosis is together with prompt surgical intervention is essential for achieving patient’s cure and prevents future complications.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.The authors declare that they have no competing interests.WAK, SA, JB, and TER prepared the manuscript. TER outlined the manuscript’s layout and supervised the work. All authors read and approved the final manuscript.


A case is reported on recurrence of a rare conjunctival fibrous histiocytoma (FH) in a 38-year-old man. The lesion was excised and subsequently sent for histopathology and immunostaining resulting in a diagnosis of fibrous histiocytoma (FH). Recurrence was detected 3 months postoperatively requiring a conjunctivosclerokeratomy with cryotherapy and flap. At 6-month followup there was no recurrence detected.  Fibrous histiocytomas are a heterogenous group of mesenchymal tumours composed of fibroblastic and histiocytic elements in varying proportions . They ofA 38-year-old male presented with an erythematous ocular surface lesion on the superior nasal aspect of the conjunctiva of the right eye, which had been present for three weeks. The patient had no prior ophthalmic or medical history. On examination the visual acuity using a Snellen chart was 6/6 bilaterally. The lesion was initially suspected to be a phlyctenule and the patient was trialled on dexamethasone eye drops 0.1%) four times a day for one week. After failing to resolve, the patient underwent surgical excision of the lesion. A piece of tissue excised measuring 5 × 3 × 1 mm was sent for histology. The specimen was confirmed to be conjunctiva with vascularised spindle cell proliferation within the stromal layer. At the margin of this proliferation was moderately intense lymphocytic infiltrate. Immunostaining showed the lesional cells to be negative for Keratin, S100, Melan A, and HMB45, excluding both epithelial and melanocytic differentiation. Further stains demonstrated the cells to be negative for CD4 but strongly positive for Factor XIIIa throughout much of the tumour. Based on the results of immunostaining, the diagnosis of a fibrous histiocytoma was confirmed (Figures % four tiThree months after surgical excision the lesion recurred. The patient subsequently underwent a right conjunctivosclerokeratomy with cryotherapy and flap. The second excision resulted in a crescent-shaped portion of pale tissue measuring 11 × 5 × 1 mm, which was shown to be conjunctiva. At the periphery of the limbal side there was a mild increase in stromal atypia and focal mild storiform arrangement. Staining was negative for CD4 and positive for factor XIIIa. The specimen contained residual fibrous histiocytoma along with features consistent with a hyperplastic scar. Six months following the second procedure there was no clinical evidence of recurrence.Conjunctival fibrous histiocytomas can resemble a variety of epibulbar conditions and in the past have been misdiagnosed as nodular episcleritis, juvenile xanthogranuloma, amelanotic melanoma, pterygium, carcinoma, inflammation, and leiomyoma . FibrousThe most appropriate management of FH at any site, particularly the conjunctiva, is complete surgical excision with tumor-free margins . The les


Lipoma is a benign soft tissue neoplasm that may contain mesenchymal elements, as a result of metaplastic process. Ossification in benign and malignant soft tissue tumors can also manifest due to metaplastic process.A 45 year old woman presented with a large thigh mass. The mass was developed one and a half year ago which insidiously increased in size and was associated with movement restriction. Radiological findings revealed soft tissue neoplasm on antero-medial aspect of thigh encircling the femur and displacing adjacent muscles. Fine trabeculations were seen in neoplasm suggestive of ossification. Excision of the mass was performed and histopathology revealed adipocytes with mature bony trabeculae possessing prominent osteoblastic rimming suggestive of ossifying lipoma.It is important to recognize this variant of lipoma as it is associated with a better clinical outcome in contrast to most of the deep seated soft tissue neoplasms. Secondly it should also be differentiated from myositis ossificans and heterologous differentiation in other soft tissue neoplasms. We suggest an algorithmic approach to the diagnosis of ossifying soft tissue neoplasms histopathologically. Mature bony trabeculae with prominent osteoblastic rimming in a soft tissue lesion are due to a metaplastic process and should not be confused with osteosarcoma. Lipoma is a benign tumor of mature adipose tissue mostly witnessed in superficial locations of the body. A variety of mesenchymal elements including smooth muscles, skeletal muscle, cartilage and bone may develop in lipoma, some of them as a result of metaplastic process . LipomasClinical presentation of ossifying lipoma depends upon the site of origin. Parosteal ossifying lipoma usually are in intimate contact with periostium of long bones. They may remain completely asymptomatic or erode adjacent bone and joint spaces producing symptoms of degenerative joint disease. While in other cases, it may compress adjacent nerves and present as a painful lesion especially if it occurs wrists where nerve bundles are running. Although variations seen in lipomas, don’t change the course of the disease significantly and therefore are of little prognostic significance, however it is very important to recognize these variants, as they may be clinically confused with other benign and malignant processes. Of these variants, ossifying lipoma is the least commonly recognized entity. Ossification in soft tissue neoplasms is not unique to lipomas and can occur in other benign and malignant processes like myositis ossificans, dedifferentiated liposarcoma, fibromyxoid sarcoma, synovial sarcoma and extraskeletal osteosarcoma, therefore high index of suspicion is needed to evaluate ossifying soft tissue neoplasms ,4. To daA 45 year old healthy woman presented with a thigh mass for one and a half year. The mass insidiously increased in size with no associated pain; however it was associated with difficulty in walking and maintaining upright posture during sitting. There were no associated co-morbids. The clinical suspicion was that of a malignant soft tissue neoplasm. Preoperative findings revealed that the mass was well circumscribed peripherally and not adherent to adjacent muscles, however it was firmly adherent to the underlying bone. Trucut biopsy of the mass was done and the diagnosis was suggestive of a lipomatous tumor.X-ray revealed a well defined radiolucent lesion in the soft tissues of lower one-third of the thigh along antero-medial aspect of the femur. It shows areas of ossification with fine trabeculations Figure .MRI revealed a well defined lesion with signal intensity suggestive of fat along the distal shaft of the femur, predominantly along its antero-medial aspect. It measures approximately 8 cm × 6.5 cm × 14 cm (APx TSx CC) displacing and wrapping the adjacent muscles. It shows lobulated and trabeculated areas which appear low on pulse sequences, most likely representing areas of ossification with no evidence of erosion of underlying bone Figure .Hematoxylin and eosin sections of the tumor revealed mature adipocytes having eccentric nuclei devoid of atypia and large clear cytoplasmic vacuoles intermixed with adipocytes, possessing mature bony trabeculae with prominent osteoblastic rimming. Zonation pattern was absent. Intervening fibrous septa were appreciated with absence of lipoblast, atypical cells in soft tissue component of the tumor and fibroblastic type stroma Figure .Lipomatous tumors range from benign lipomas to dedifferentiated liposarcomas. Lipomas are slow growing tumors which can achieve large sizes if left un-noticed as seen in our case and requires clinical attention primarily due to cosmetic reasons. Besides angiolipoma, they are not usually painful unless impinging on a nerve. Parosteal ossifying lipoma can present clinically with dual histogenesis for osteochondromatous component, however in our case H & E stain depicts adipocytes with bony trabeculae while no intervening cartilage.Ossifying liopmas are described at various sites including thigh ,7 hand ,9, groinPathogenesis of ossifying lipoma is largely theoretical and considered to be a metaplastic process. Ossifying lipoma can sometimes be wrongly interpreted as myositis ossificans when there is no association with the underlying bone, therefore high index of suspicion is prerequisite in analyzing benign ossifying soft tissue lesions so that distinction between myositis ossificans and ossifying lipomas can be ascertained. Ossifying lipoma should also be differentiated from secondary bone formation as a result of heterologous differentiation in other soft tissue neoplasms such as dedifferentiated liposarcoma and osteosarcoma.Therefore we recommend an algorithmic approach in assessing ossifying soft tissue neoplasms histopathologically. First, the soft tissue component should be analyzed for growth pattern, anaplasia and mitotic activity, followed by assessment of bony component. When the soft tissue component is malignant with mature bony trabeculae having osteoblastic rimming, the diagnosis will depend upon the growth pattern and immunohistochemical profile of soft tissue compartment and the bone is formed as a result of metaplastic process as seen in dedifferentiated liposarcoma, chondrosarcoma, synovial sarcoma, carcinosarcoma. A benign soft tissue component with mature bone will also point towards a metaplastic process. In such circumstances a fibroblastic stroma will lead to a diagnosis of myositis ossificans while a lipomatous soft tissue compartment should lead to a diagnosis of ossifying lipoma. A malignant/ immature bony component without osteoblastic rimming, formed directly by tumor cells should lead to a consideration of osteosarcoma. It is important to recognize this variant of lipoma because it is usually deep seated and adherent to periosteum, however in contrast ossifying lipoma is associated with a better clinical outcome at this location.Treatment modalities of periosteal lipoma depends upon the circumstances that mass presents, it needs to be removed in cases where it is painful or restricts movements. In our case periosteal lipoma was surgically removed by simple excision and no evidence of recurrence was observed.Ossifying lipoma is a rare variant of lipoma, diagnosis of which requires high index of suspicion as it can sometimes be wrongly interpreted as myositis ossificans or heterologous differentiation in other soft tissue neoplasms. We suggest an algorithmic approach to the diagnosis of ossifying soft tissue neoplasms. Mature bony trabeculae with prominent osteoblastic rimming is almost always due to metaplastic process and should not be confused with osteosarcoma.Patient has given their informed consent for the case report to be published.The authors declare that they have no competing interests.AAH: main author of manuscript, have made substantial contributions to conception, design and acquisition of data. BM: involved in drafting the manuscript and revising it critically for important intellectual content. MME: involved in drafting the manuscript and revising it critically for important intellectual content. NF: have given final approval of the version to be published. MA: have given final approval of the version to be published. All authors read and approved the final manuscript.