Bezoars represent the fifth most frequent cause of acute small bowel obstruction. Phytobezoar is the most common type of bezoar. It is a concretion of undigestible fibers derived from ingested vegetables and fruits. We report a case of a woman with a 1-year history of recurrent epigastric and periumbilical abdominal pain with intermittent vomiting caused by phytobezoar of the terminal ileum. After careful investigation of the case and review of literature, we identified the factor involved in bezoar formation as radiation-induced ileal stenosis due to previous treatment for a pelvic tumour. This report provides evidence to consider phytobezoar as a possible cause of small bowel obstruction in patients previously treated with abdominal radiotherapy. Bezoars are composed by ingested foreign materials that accumulate within the gastrointestinal tract . A phytoγ-globulins (0.46 g/dL). A plain radiography of the abdomen did not provide any diagnostic clue. She underwent an endoscopic study of the colon that was conducted up to the terminal ileum. An upper gastrointestinal endoscopy was also performed. Both studies did not demonstrate any relevant abnormalities. Computed tomography with contrast medium revealed an ovoid, nonhomogeneous, intraluminal filling defect about 3 cm in size at the pelvic level inside an ileum ansa (Figures A 60-year-old woman was admitted to our hospital with a 1-year history of recurrent epigastric and periumbilical abdominal pain with intermittent vomiting. No recent history of melena or mucus was reported. Importantly, the patient did not refer a vegetarian lifestyle, but she followed a “traditional” Mediterranean diet . Her med Figures  and 2. N Figures . At surgBezoars are composed by ingested foreign materials that accumulate within the gastrointestinal tract . They arBezoars consist of ingested foreign materials that accumulate within the gastrointestinal tract. Phytobezoars represent the most frequent type of bezoar and they can cause intestinal obstruction. Computed tomography has become the most useful tool of diagnosis, as in the case here reported. The best known risk factors are all the situations of impaired gastric motility. In the case that is shown, no conventional factor can be recognized. It is possible that other, not yet identified, predisposing conditions exist such as a radiation-induced altered peristalsis or small bowel stenosis. In the case of clinical presentation of intestinal subocclusion bezoar must be considered as a potential, although rare, tractable cause.


Sacral and presacral schwannomas are often found incidentally, because they present with vague symptoms or symptomless. Schwannoma occurring in this area occasionally presents with enormous dimensions, known as a giant schwannoma. The tumor removal is a surgical challenge due to the difficult approach and abundant vascularity. The aim of this study is to review cases of giant sacral schwannomas focusing the surgical management and outcome. Six patients with sacral and presacral schwannoma were treated surgically. The patients included two males and four females, and the mean age was 47.8 years. All patients experienced pain at the time of presentation. The tumors were classified as intraosseous type in one case, dumb-bell type in four cases, and retroperitoneal type in one case. The tumors were removed with a piecemeal subtotal excision in three patients, a partial excision in two patients, and enucleation in one patient. The surgeries were performed by the combination of an anterior and posterior approach in three patients, a posterior approach in two patients, and an anterior approach in one patient. The mean surgical time was 7.8 hrs, and the mean blood loss was 2572 g. The tumor recurred in one patient after the partial excision and was removed completely in a second surgery. No patient, including the patient who underwent the second surgery, presented with pain and obvious neurological deficit at the final follow-up. The surgical treatment of the giant sacral schwannoma with a piecemeal subtotal excision can achieve a good outcome, avoiding unnecessary neurological deficit. Sacral and presacral tumors are uncommon and occur in approximately 1 of 40,000 hospital admissions . SchwannThree types of giant sacral schwannomas have so far been described based on the anatomical findings: retroperitoneal schwannoma , intrasaThis report presents cases of giant sacral schwannomas. The tumor characteristics and clinical pictures are reviewed. The problems associated with the surgical removal of this tumor are also discussed.Six patients with sacral and presacral schwannoma were treated surgically. The patients included two males and four females, and the mean age was 47.8 (range 38–58) years. The tumors arose from L5 or sacral roots in all patients. Plain X-ray, computed tomography (CT) scan, and magnetic resonance images (MRI) were examined before surgery. Angiography was performed in four patients.Case 2. A 38-year-old male experienced right buttock pain for 23 years. Bilateral leg hypalgesia was revealed during a physical examination, but no motor weakness was observed. Plain X-ray and CT showed extensive bony destruction . CT showed the details of bony involvement and presacral extension. Sacral osteolytic lesions were obvious in five patients. Two patients showed bony involvement of the L5 vertebral body (cases 2 and 5), and one patient showed sacroiliac joint involvement case 5; .MRI revealed heterogeneous iso/high intensity on T1/T2 WI in all tumors. All tumors demonstrated a cystic lesion which showed obviously high intensity on T2 WI. Gd-DTPA enhancement was observed in all tumors. The extent of the tumor was demonstrated by MRI. A presacral tumor was demonstrated in five patients with a mean diameter of 9.6 cm, range 5.5–15.0 cm. Four tumors involving the spinal canal were located in the epidural space. Three tumors extended through the sacral body into the presacral region, and one tumor eroded the sacral body and formed a large intraosseous mass (case 1). One tumor was in the S1 foramen, expanded through the sacral body, and formed a presacral mass without epidural extension (case 4). One huge presacral tumor did not present with any bony extension case 6; . The tumThe tumors were removed with a piecemeal subtotal excision leaving a part of the capsule for preservation of the nerves in three patients, a partial excision in two patients, and enucleation with the capsule remaining in one patient. Tumor removal was performed by the combination of an anterior and posterior approach in three patients. The tumor was removed by a posterior approach in two patients. An anterior approach was used in one patient, who presented with a huge presacral mass without bony involvement (case 6). In this case, the resection and re-anastomosis of the sigmoid colon was performed to excise the tumor . LumbopeThere were no systemic complications. Pain decreased in all cases, and urinary disturbances also improved. One patient showed causalgia that was successfully treated by a caudal block (case 3). Although another patient experienced erectile dysfunction and motor weakness after surgery, both symptoms recovered after 2 years (case 2).The tumor recurred in one patient case 3; . A 51-yeNo patient, including the patient who underwent the second surgery, presented with pain and obvious neurological deficit at the final follow-up.A sacral schwannoma is uncommon and usually asymptomatic when it is small. The tumor is often found after presenting with pain and neurological symptoms ,5,13–16.MRI is helpful in detecting the specific characteristics of the tumor. It provides information about the size, exact location, and invasion of and relationship with other organs. Typically, a schwannoma is well encapsulated and solid when it is small, but may present cystic and necrotic changes in it when it is large. The purported mechanism of this phenomenon is that increasing tumor size results in vascular insufficiency. Hughes et al.  describeThe surgical approach is dependent upon the degree of intrasacral and retroperitoneal extension. The posterior approach should be used in cases of the tumor involving the spinal canal and intrasacrum. A tumor with a modest presacral component might be removed by the posterior approach. Generally, an anterior transabdominal or retroperitoneal approach should be performed for a presacral tumor to gain control of the vascular plexus that encompasses the tumor and to ensure identification and protection of the intrapelvic organs ,18,19. RThe optimal technique for the removal of a presacral and sacral schwannoma remains to be elucidated. Local recurrence and malignant transformation are extremely rare, so a piecemeal subtotal excision or simple enucleation should be the treatment of choice. At the same time, an aggressive approach with the aim of achieving a complete resection has also been reported ,15. PiecDespite the limitations due to the small number of patients in the current cases, the results indicate as follows: 1) The duration of symptoms in a patient with a giant sacral schwannoma is very long, and pain is a dominant presenting symptom in all cases. 2) MRI is a useful diagnostic tool, and these tumors tend to show specific features. In the same way, CT clearly demonstrates bony destruction and should be used in preoperative planning. 3) A piecemeal subtotal tumor excision via the anterior, posterior, or combined approach can achieve a good outcome, avoiding unnecessary neurological deficit.


Plexiform schwannoma is one of the least common variants of schwannoma. It is usually found on the trunk, head, neck and upper extremities. Most reported cases are small tumors, less than 2cm in maximum diameter, arising from superficial nerves. Trauma and neurofibromatosis type 2 are well-recognized risk factors for plexiform schwannoma. It is important to differentiate it from plexiform neurofibroma, because the former has neither an association with von Recklinghausen’s disease nor a malignant potential.We report a case of a large plexiform schwannoma arising from the posterior tibial nerve in proximity with the medial malleolus. The patient had no history of ankle strain, fracture or neurofibromatosis type 2. Magnetic resonance imaging demonstrated a multinodular, inhomogeneous lesion, measuring 6 × 4 × 2.8 cm. Fine needle biopsy was suggestive of a benign lesion, deriving from neural elements. The mass was excised marginally. Permanent section showed that the lesion was multilobular, surrounded by a thin fibrous capsule and consisting of elongated cells, rare typical mitosis, cells with degenerative features and stained positive for S-100 protein. The patient was not evident disease at the latest follow-up 2.3 years later, with an excellent functional result. No sensory or motor deficits were encountered.There are no reports in the literature for large plexiform schwannomas arising from the tibial nerve. Marginal excision seems to be the recommended therapy for this rare tumor. Plexiform schwannoma is a very rare, benign peripheral nerve sheath tumor, accounting for 5% of all schwannomas ,2. PlexiWe report a case of a sizeable plexiform schwannoma of the posterior tibial nerve in proximity with the medial malleolus.A 29-year-old white Caucasian male presented himself with a slowly growing mass in his right ankle. He was complaining of mild pain and paresthesia of six months duration. On physical examination a firm painless mass was palpable behind the medial malleolus. Magnetic resonance imaging (MRI) demonstrated a multinodular, inhomogeneous lesion, measuring 6 × 4 × 2.8 cm, which was isointense with muscles in T1-weighted images  but of vThe diagnostic process was completed with fine needle biopsy which was suggestive of a benign lesion, deriving from neural elements. We performed a marginal excision of this mass and monitored the post-operative period which was uneventful. Permanent section showed that the lesion was multilobular, surrounded by a thin fibrous capsule and consisting of elongated cells, rare typical mitosis, cells with degenerative features and stained positive for S-100 protein  but negaPlexiform schwannoma is a rare variant of schwannoma with a plexiform or multinodular growth pattern ,3. This In summary we present a rare case of a large plexiform schwannoma of the medial malleolus arising from the main bundle of the posterior tibial nerve. The patient had no history of trauma or NF-2 which are both well-known risk factors; marginal excision yielded an excellent oncological and functional outcome.


Hemo-lymphangiomas are rare benign tumors that arise from congenital malformation of the vascular system. They are usually diagnosed at birth or early in childhood. The management of hemo-lymphangiomas in children remains challenging because complete resection is often difficult to be achieved and recurrences are common.We present the case of two children with a mass on their left tibia. Imaging modalities, plain radiograph, Ultrasonography and Magnetic Resonance were used to investigate the nature of the mass, the anatomical relationship to the neighboring tissues and help planning the surgical resection. The dominant diagnosis was hemo-lymphangioma. Both lesions increased in size in a short period of follow-up thus we decided to proceed to surgical excision.The diagnosis of hemo-lymphangioma was confirmed by histological examination of the surgical specimen.Post-operatively, seroma was formed to the first patient, managed by placing a drainage and immobilizing the limb on a splint.The second patient experienced no complications post-operatively.After 12 months of follow-up both patients had no complications or recurrence.Very few cases of hemo-lymphangiomas of the extremities have been reported in the literature. Those tumors can grow slowly and remain asymptomatic for a long period of time or may become aggressive and enlarge rapidly, without invasive ability though.Radical resection is the choice of treatment offering the lowest recurrence rates. Other therapeutic methods are: aspiration and drainage, cryotherapy, injection of sclerotic agents and radiotherapy; although none of those offers better results that the surgical excision. Lymphangiomas are a heterogeneous group of vascular malformations of the lymphatic channels composed of cystically dilated lymphatics. According to Landing and Farber , those The latter, congenital malformation, can remain asymptomatic for a long period of time. On the other hand, it may grow rapidly, surrounding or infiltrating the neighboring tissues or other major structures, thus making the excision a real challenge for the physician ,3.Hemo-lymphangiomas are in most cases detected at birth or early in a child's life, usually before the age of two years. Alternatively, with the introduction of the prenatal ultrasound, the diagnosis can be placed in the uterus .This essay is a case report of two children with hemo-lymphangiomas of the lower extremities and its purpose is to define the most effective therapeutic approach of those lesions. Written parental permission was obtained to allow the use of confidential information held in the hospital's records, as Institutional Review Board (IRB) does not exist in our country.A two month old female infant presented to the orthopedic examination room with a palpated mass on the anteromedial side of the proximal left tibia. On the physical examination the lesion was found to be oval in shape, soft, compressible and painless. Anteroposterior and lateral plain radiographs demonstrated swelling of the soft tissue at this part of the tibia without signs of bony erosion Fig. . The ultDue to the continuous augmentation of the mass, surgical excision was decided. An MRI Fig.  was perfEn bloc resection was performed releasing the specimen from the adhesions to the subcutaneous tissues and the medial head of the gastrocnemious. Macroscopically, it was found oval in shape with harsh features and spotty surface Fig. .Histological examination described the resected tumor as a fibro-lipomatous mass containing dense fibrous conjunctive tissue with vascular areas of lymphatic cells and vessels filled in with red blood cells Fig.  &6. The Ten days post-operatively the trauma area was swelling; the seroma formed was aspirated and gave 20 ml of sterile, bloody fluid.A week later, the swelling recurred; surgical exploration and lavage was performed, while a drainage was placed. Intravenous Netilmicin and Cefamandile Nafate were administered for a total period of ten days, whereas the leg was immobilized on an above knee splint. The swelling was progressively decreased. A week after, the trauma area was examined by the ultrasound and 1,58 ml's of fluid were demonstrated. A full plaster was placed with the knee joint flexed in 90° for three weeks. At the end of that period of time the volume of the fluid was less that 1 ml. After two months of follow-up by clinical and Ultrasonography examination, the quantity minimized to zero, while in the yearly follow-up no recurrence was observed.The second case regards a 5 year-old male patient, with a palpable, painless mass on the anterior side of the proximal left tibia, located 2 cm below the tibial tubercle. The tumor, within a two month follow-up, was doubled in size; although it remained asymptomatic. A soft tissue swelling and intact bone cortex were demonstrated by the plain radiographs . The ultrasound performed depicted a cystic mass with moderate vascularization, measured 21 mm × 18 mm × 5 mm Fig. .The treatment decided was en bloc resection of the tumor, followed by rigorous cauterization of the blood and lymphatic vessels; a drainage was placed.Microscopically, the tumor examined, was described as a soft tissue cystic mass consisted of lymphatic and blood vessels; the stroma was infiltrated by lymphocytes. The histological diagnosis was hemo-lymphangioma.Cephalosporin was administered, in 3 doses totally, pre and post-operatively, while the limb was immobilized on a splint with the knee joint flexed in 30° for a total period of three weeks. In the trauma area no seroma was formed thereby, we removed the drainage.At the yearly follow-up no recurrence was observed, verified by the use of Ultrasonography Fig. .Hemo-lymphangiomas are rare benign tumors that appear to arise from congenital malformation of the vascular system. The formation of that tumor may be explained by obstruction of the venolymphatic communication, between dysembrioplastic vascular tissue and the systemic circulation . Hemo-lVery few cases of hemo-lymphangiomas of the extremities have been reported in the literature. A retrospective study of one hundred and eighty-six 186) patients' presenting one hundred and ninety-one (191) hemangiomas was published; their anatomical location was: 48% in the head and neck, 42% in the extremities and 10% in internal or visceral locations. Histological examination revealed that only three of them had combined hemo-lymphangiomas [ patientsThe incidence of hemo-lymphangiomas varies from 1,2 to 2,8 per 1000 newborns however,The clinical on set of hemo-lymphangiomas can vary from a slowly growing cyst over a period of years to an aggressive enlarging tumor, without invasive ability. Their size varies due to the anatomical location and relationship to the neighboring tissues. Small tumors are usually superficial, while the large ones are located deeper and have cystic texture. The most common complications are random or traumatic hemorrhage, rupture, infection and lymphorrhya. In the clinical examination they are usually described as soft and compressible masses, loculated in pattern. Histologically, hemo-lymphangiomas consist of dense fibrous tissue that grows in bands between the numerous vascular spaces and invades the subcutaneous fat. Some of those are blood vessels and the others lymphatic.Imaging modalities, Ultrasonography, Computed Tomography and Magnetic Resonance, are useful in confirming the diagnosis, describing the margins of the mass and planning the surgical strategy . The ulAs far as it concerns the therapeutic approach of localized hemo-lymphangiomas, the treatment of choice is complete surgical excision, which also presents the lowest recurrence rate. An important issue regards the time of surgery. Some authors express the aspect that the mass should be excised promptly after being diagnosed, while others prefer to wait and examine the size regularly. In the latter case, the risk of infection and hemorrhage remains, while complete surgical eradication may become more difficult. Other techniques available are: aspiration and drainage, cryotherapy, injection of sclerotic agents and radiotherapy , but none of them produced acceptable results. Radiotherapy is used when surgical excision is not feasible; the radio-sensitivity of hemo-lymphangiomas is not well understood, however in the past they were considered to be radio-resistant. In children, radiotherapy may lead to tumor retardation or to malignant transformation . When suAn important issue remains the continuous lymphorrhya during the instant post-operative period; attentive en bloc excision of the tumor, followed by rigorous cauterization of the blood and lymphatic vessels may reduce or eliminate the risk of recurrence. Other auxiliary measures are the application of a bandage under pressure, the prolonged drainage and immobilization of the extremity.In the treatment of hemo-lymphangioma, surgical excision appears to be the best choice of treatment, especially when the tumor increases in size, creating pressure to the surrounding tissues. Eradicate attentive excision offers the minimum risk of recurrence.The authors declare that they have no competing interests.IK, who is the corresponding author, was the surgeon of the first patient, gathered the articles used as references and compiled the manuscript. M.V was the surgeon of the second patient. A.K helped with the editing of the manuscript. KF, as the director of the orthopaedic department, guided us and helped in finalizing the manuscript.All authors have read and approved the final manuscriptWritten informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Duodenal gangliocytic paraganglioma is an extremely rare tumor and few cases have been reported to date.The authors report a case of gangliocytic paraganglioma verified by post-op pathology after pancreaticoduodenectomy for a tumor in the ampulla of Vater. The 56-year-old male patient concerned visited our emergency room with melena that started one week prior to hospitalization. The patient was diagnosed to have a tumor in the ampulla of Vater with bleeding on its surface. However post-op, he was diagnosed as having gangliocytic paraganglioma by immunohistochemistry.This tumor has precise clinical implications, and if continuous follow up is conducted after careful diagnosis and surgical treatment, invasive major operations, such as, radical pancreaticoduodenectomy can be avoided. Gangliocytic paragangliomas are rare tumors which are usually encountered in the second portion of the duodenum. They can be diagnosed histologically by the presence of epithelioid, spindle, and ganglion cells, which is similar to that observed for paraganglioma . AlthougA 56-year-old male patient visited our emergency room due to melena of duration one week. History taking revealed no particular issues other than antihypertensive medication after a diagnosis of hypertension five years previously. He did no smoke, but consumed a small amount of alcohol regularly. No specific features arose from his family or social history. He did not experience nausea or vomiting at the time of hospitalization, and only complained of mild indigestion. Furthermore, he showed no epigastric soreness, abdominal pain, or weight loss, and his vital signs at hospitalization were stable. His physical examination was uneventful. His hemoglobin was 10.4 g/dL, and renal and liver function, as determined by blood tests, were also normal. No lesions were found in the esophagus or stomach by esophagogastroduodenoscopy. However, an exophytic tumor with a bleeding surface ulcer was observed luminally in the ampulla of Vater in the second portion of the duodenum Figure  and 2B. Gangliocytic paraganglioma is a rare benign tumor of the digestive tract. Although some have reported cases of gangliocytic paraganglioma invading the proximal jejunum, about 90% are found in the second part of the duodenum, from where the tumor can invade the ampulla of Vater. In the Here we report a case of gangliocytic paraganglioma in the ampulla of vater. Although gangliocytic paraganglioma in the duodenum is an extremely rare disease, it shows a good prognosis as compared with other peri-ampulla of Vater tumors. Furthermore, if continuous follow up observation is conducted after obtaining a careful diagnosis, it can be treated only limited surgery like local excision, without performing pancreaticoduodenectomy or lymph node dissection.The authors declare that they have no competing interests.KJS conceptualized the study, gathered the data, and drafted the manuscript, LSE performed the literature search and helped to draft the manuscript, JJY supervised the process and finally approved the manuscript for publication, KMJ and KSW was involved in manuscript revision. All authors have read and approved the final manuscript.Written informed consent was obtained from patient for reporting of this case, the copy of consent is available with editor in chief.


Giant diverticulum of the colon is a rare but clinically significant condition, usually regarded as a complication of an already existing colonic diverticular disease. This is the first report of a giant diverticulum of the colon with a co-existing rectal carcinoma.en bloc anterior resection of the rectum along with sigmoid colectomy, partial hysterectomy and right salpingoophorectomy was subsequently performed due to extensive adhesions.We report a case of a 66-year-old Caucasian woman who presented with lower abdominal pain, chronic constipation and abdominal swelling. Preoperative abdominal computed tomography revealed a giant diverticulum of the colon with a coexisting rectal carcinoma and pulmonary metastasis revealed on a further thoracic computed tomography. An This report shows that the presence of a co-existing distal colorectal cancer can potentially lead to progressive development of a colonic diverticulum to become a giant diverticulum by increasing colonic intra-luminal pressure and through the ball-valve mechanism. This may be of interest to practising surgeons and surgical trainees. Giant diverticulum of the colon (GDC) is a rare but clinically significant condition, usually regarded as a complication of an already existing colonic diverticular disease. The etiology is not clearly understood but it occurs most frequently as a single giant diverticulum in the sigmoid colon and can present with a variety of symptoms and signs. Interestingly, there has been no previous report in the literature of this condition with a coexisting rectal carcinoma. In this article, we present the first published report of a patient with giant sigmoid diverticulum and a concomitant metastatic rectal carcinoma.A 66-year-old Caucasian (Irish) woman presented to our surgical outpatient clinic with lower abdominal pain, chronic constipation and abdominal swelling. She is an ex-smoker with a background history of diverticular disease and long-standing psoriasis.Clinical examination on presentation revealed a large, slightly tender, left-sided abdominal mass which was tympanic on percussion. Baseline blood tests were all normal. A plain film of the abdomen showed a large air-filled cyst displacing bowel loops Figure . A chestHer case was discussed in our departmental meeting and the decision was made to perform anterior resection of the rectum along with sigmoid colectomy. At surgery, a single GDC was found in the sigmoid colon with dense adhesions to the uterine fundus, the right ovary, the right fallopian tube and the posterior abdominal wall Figures  and 4. Sen bloc sigmoid colectomy, partial hysterectomy and right salpingo-opherectomy was performed  is a rare condition, with only less than 180 cases discussed in the literature since it was first reported by Bonvin and Bonte in 1946 . Most GDet al. as a cause of a gradual increase in the size of a colonic diverticulum until it transforms into GDC [The etiology of GDC is not clearly understood, although in over 90% of reported cases there has been associated colonic diverticulosis . Histolointo GDC .Higher pressures in the colon cause higher pressures inside the GDC by allowing air to pass through a one-way communicating stalk. Differences in the colonic pressure can also lead to differences in the GDC pressure leading to intermittently prominent abdominal mass or phantom tumor .Clinical features of GDC can be variable. While some patients remain asymptomatic for long periods of time, many others present with chronic symptoms of abdominal pain, constipation, abdominal distension or weight loss. Still others may have acute presentation with abdominal pain, diarrhea, fever, nausea and vomiting or rectal bleeding. The most significant finding on clinical examination is an abdominal mass which is reported in nearly 60% of patients .The investigations of choice for diagnosing GDC include a plain abdominal X-ray and an abdominal CT scan: both can accurately demonstrate the classical 'balloon sign' of GDC. Barium enema is useful in showing a communication with the bowel in most cases.The two main complications are perforation and abscess formation. Among the less frequent complications is intestinal obstruction ,5, intesTo our knowledge, there have been no previous reports in the literature describing a coexisting rectal or distal colonic carcinoma along with GDC. The presence of a distal colorectal tumour can lead - in theory - to increased air pressure in GDC by the ball-valve mechanism described above if the tumor is large enough to cause colonic luminal narrowing and not necessarily by colonic obstruction. Our patient complained of chronic constipation but had no clinical features of intestinal obstruction during the course of her illness. However, both the mechanism of the development of GDC and its relationship with rectal cancer are not the key problems. The screening and early detection of colorectal cancer in patients with colonic diverticular disease should be emphasised, because the symptoms and signs of both conditions are similar.Two major surgical approaches are recommended for the treatment of GDCs: diverticulectomy or resection of the involved colonic segment . Each caGiant diverticulum of the colon is a rare condition which usually occurs in patients suffering from a pre-existing diverticular disease. The best way to explain GDC progressive development is that of the ball-valve air mechanism, especially with increased colonic intra-luminal pressure. The presence of a coexisting distal colorectal cancer can potentially lead to the progressive development of a colonic diverticulum which may become a GDC. This case report may be of particular interest to practising surgeons and surgical trainees.GDC: giant diverticulum of the colon; CT: computed tomography.The authors declare that they have no competing interests.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.WS conceived the study and wrote the manuscript and is the corresponding author. IH provided information about the patient's clinical course, took the photos of the case and shared in the editing of the radiology slides. AQ carried out the radiological investigations and shared in the editing of the radiology slides. ARN supervised the preliminary manuscript and edited the histopathological report. All authors read and approved the final manuscript.


We report a rare case of primary lymphoma of fallopian tube in a 68-year-old woman who underwent total hysterectomy and bilateral salpingo-oophorectomy for endometrial carcinoma. The specimen showed a well-differentiated endometrioid adenocarcinoma with superficial myometrial invasion. The left fallopian tube revealed a 1 cm nodule that histologically showed diffuse lymphoid follicles consisting of small cleaved lymphocytes and occasional larger cells. The cells were immunopositive for CD20, BCL-2, and BCL-6 but negative for CD3 and CD43. Polymerase chain reaction confirmed a monoclonal B-cell population. Fluorescence in-situ hybridization revealed at  translocation. The patient had absent lymphadenopathy and negative CT scan of chest, abdomen, and pelvis. The findings were consistent with a primary low grade follicular lymphoma of fallopian tube. She did not receive chemotherapy and remained disease free for 13 months after surgery. Our case suggests that primary lymphoma of fallopian tube may be associated with a favorable prognosis. Non-Hodgkin's lymphoma in the female genital tract is usually secondary, occurring as part of disseminated or systemic disease. The most common sites of involvement within the female genital tract are the ovaries and uterus. Lymphoma of the ovary extends to the fallopian tubes in about 25% of cases . PrimaryA 68-year-old woman with a past medical history of hypertension, atrial fibrillation, and coronary artery stenosis presented with postmenopausal bleeding. Her gynecologic history included three spontaneous vaginal deliveries, normal periods every 28 days lasting 3 to 4 days, and menopause at age 50. She denied any history of sexually transmitted disease or hormone replacement therapy. Endometrial curettings showed a well-differentiated endometrioid adenocarcinoma associated with complex atypical hyperplasia. The patient had normal pre-operative laboratory tests including serum electrolytes, liver enzymes, and complete blood count. Her peripheral blood cells showed no significant morphological abnormalities. No palpable peripheral lymphadenopathy was noted. She underwent an exploratory laparotomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. During intraoperative pathology consultation, we found an endometrial carcinoma with minimal myometrial invasion. The ampulla of the left fallopian tube showed a 1 cm nodule encasing the lumen. The nodule exhibited a white yellow and fleshy cut surface and was suspicious for malignancy. The question at the time of intraoperative consultation was whether this nodule represented metastatic carcinoma from the endometrium. A frozen section was performed and showed no evidence of carcinoma, but it displayed an atypical lymphoid proliferation. The left ovary and the right adnexa were within normal limits. Intraoperative exploration did not show evidence of extra uterine tumor or enlarged pelvic and periaortic lymph nodes. Based on these findings, surgery was concluded after total hysterectomy and bilateral salpingo-oophorectomy.Hematoxylin and eosin-stained permanent sections of the nodule in the left fallopian tube showed diffuse back to back follicles without well defined mantle zones Figures  and 1B, Permanent sections of the uterus showed a well differentiated endometrioid adenocarcinoma of the endometrium with less than one-third myometrial invasion Figure  and 2B.With absent lymphadenopathy and negative post-operative CT scan of the chest, abdomen, and pelvis, the lymphoma was considered a primary disease of the left fallopian tube and assigned stage IE according to the Ann Arbor staging system . ConsideThis was a rare case of primary tubal lymphoma incidentally discovered during surgery for endometrial carcinoma. At the time of surgery for endometrial carcinoma, surgeons often request an intraoperative pathology consultation for evaluation of disease extent that at least in part guides surgical management. Our patient showed a low grade endometrial adenocarcinoma with superficial myometrial invasion. With this finding alone, she would not need further staging surgery after hysterectomy and salpingo-oophorectomy. However, her left fallopian tube showed a small nodule suspicious for malignancy. Thus the intraoperative interpretation of this nodule became critical to the surgical management because a full staging procedure including pelvic lymph node sampling would be suggested if the nodule were metastatic endometrial carcinoma. Although carcinoma may show distinct gross features, accurate diagnosis relies on frozen section. In our case, frozen section of the left fallopian tube nodule displayed an atypical lymphoid proliferation instead of carcinoma, thus saving the patient from more surgery. The nodule on permanent sections proved to be a primary follicular lymphoma.Although primary extranodal lymphoma is not infrequent, primary lymphoma of the fallopian tubes is very unusual. Only rare cases of primary tubal lymphoma have been reported. In one case, a 68 year old woman underwent hysterectomy and bilateral salpingo-oophorectomy for a tubo-ovarian mass and was found to harbor a primary follicular lymphoma of the tube, associated with hydrosalpinx and tubo-ovarian abscess . TreatmeThe etiology of primary tubal lymphoma is unclear. The association between chronic inflammation and certain types of extranodal lymphomas may have implications for lymphomas of the fallopian tube. Indeed, one previously reported case of primary tubal lymphoma showed associated hydrosalpinx and tubo-ovarian abscess . It was,Lymphoma of the fallopian tube should be distinguished from other diseases. Carcinoma is usually easily distinguished from lymphoma because of the distinct histologic features between the two diseases. While carcinoma usually shows cellular cohesion, lymphoma often displays a diffuse pattern of noncohesive cells. Small cell neuroendocrine carcinomas may histologically simulate lymphoma, but nuclear molding, trabecular formation, and rosettes present in small cell carcinoma are absent in lymphoma. In difficult cases, immunostains for cytokeratin, CD45, synaptophysin, and chromogranin help make the correct diagnosis.Lymphoma of the fallopian tube should also be distinguished from a chronic inflammatory process. While an inflammatory process shows a cellular heterogeneity, lymphoma usually displays a diffuse infiltration by a monomorphic population of lymphoid cells. Immunostains can help determine the clonality of lesional cells in difficult cases. Diagnostic challenges may arise in evaluating chlamydial salpingitis with a florid lymphofollicular hyperplasia mimicking follicular lymphoma . Unlike Accurate subtyping of lymphoma is imperative because various types differ in their rates of progression, overall prognosis, and response to individual forms of treatment. Although different lymphomas may show distinct histologic features, special studies play an important role in subtyping. The lymphoma in our case histologically displayed a follicular pattern consistent with follicular center type. BCL-2 and BCL-6 immunopositivity and t translocation confirmed a follicular lymphoma.It is also important to distinguish a primary tubal lymphoma from secondary involvement. In general, distinction between primary and secondary lymphomas is facilitated by physical examination, radiologic imaging, and bone marrow biopsy. Since our patient did not show lymphadenopathy or evidence of lymphoma elsewhere, the tumor in the left fallopian tube was consistent with a primary tubal lymphoma. Our patient did not receive chemotherapy and remained disease free for more than 1 year.Primary fallopian tube lymphoma is rare, and reported cases indicate that various histologic subtypes can occur including MALT-type lymphoma, T cell lymphoma, and follicular lymphoma. Patients present with pelvic pain and/or a pelvic mass, but the lymphoma may be an incidental finding during pelvic surgery, as in our case. In this case it was important to distinguish this lymphoma from metastatic carcinoma at the time of intraoperative evaluation in order to spare the patient a staging procedure. The patient in this case did not receive chemotherapy and was disease free for more than one year suggesting a favorable biologic behavior associated with primary tubal follicular lymphoma.The authors declare that they have no competing interests.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of this written consent is available for review by the Editor-in-Chief of this journal.AA reviewed the fallopian tube lymphoma and confirmed this diagnosis. He also was a major contributor in writing the transcript. KH diagnosed and reviewed the endometrial adenocarcinoma, contributed to writing the transcript and is the corresponding author. CZ put the entire case in context, and contributed to the writing of the final transcript. All authors have read and approved the final manuscript.


Burned-out testicular tumour is a very rare clinical entity. There is no clinical finding in the testicle, because it regresses spontaneously with no treatment, and generally presents with metastases. Abdominal masses in young male patients may sometimes be caused by a metastatic burned-out testicular tumour. We report a patient with a burned-out testicular tumour that metastasized to retroperitoneal lymph nodes.A 28-year-old man complained of an abdominal mass and continuously increasing pain over the previous 2 months. A midabdominal mass, atrophy and minimal induration in the right testis were revealed on physical examination. Ultrasound findings revealed focally increased echogenicity, which is typical of burned-out tumours. Inguinal orchiectomy was performed, and the histological examination of the biopsy specimen revealed a large area of hyalinization, tubular hyalinization, interstitial fibrosis and focal Leydig cell hyperplasia, with no abnormal pathological findings in the epididymis and spermatic cord. The final pathological diagnosis was concluded as "burned-out" testicular tumour. Surgical treatment was followed by appropriate chemotherapy and in the follow-up, the abdominal mass was observed to regress. The patient is currently free of disease 5 years after diagnosis.For the detection of intratesticular lesions, especially in patients with extragonadal metastatic involvement and normal palpation findings for the testis, scrotal sonography is very important. A burned-out testicular tumour should be considered and testis biopsies should be performed if there is any risk factor of malignancy. Burned-out tumour of the testis is a very rare clinical entity. The term 'burned-out' tumour of the testis describes a spontaneously and completely regressed testicular tumour with no treatment. It presents by metastases to the retroperitoneum, mediastinum, lymph nodes, lungs and liver .We report a patient with a burned-out testicular tumour that metastasized to the retroperitoneal area. Testicular germ cell tumours metastasize predominantly to the retroperitoneal lymph nodes and subsequently to the lungs.A 28-year-old man complained of an abdominal mass and continuously increasing pain over the previous 2 months. Physical examination revealed a midabdominal mass on abdominal palpation, atrophy and minimal induration in the right testis on scrotal palpation. The left testis was found to be normal. No abnormal finding was noted on digital rectal examination. Examination of the other systems, including the endocrine system, was normal.His white blood cell count and urine microscopy were normal. Aspartate aminotransferase (AST): 56 mg/dl normally 1 to 40), alanine aminotransferase (ALT): 42 mg/dl , alkaline phosphatase (ALP): 768 mg/dl , gamma glutamyl transferase (GGT): 160 mg/dl  and lactate dehydrogenase (LDH): 6302 mg/dl  were found in the blood biochemistry. His erythrocyte sedimentation rate was high (110 mm/hour). Values for alpha-fetoprotein (AFP) ) and beta human chorionic gonadotrophin hormone (β-hCG) ) were within normal limits. Chest X-ray was normal. Scrotal ultrasonogram revealed minimal hypoechogeneity and non-homogeneity in the right testis. Abdominal computed tomography (CT) revealed a very large retroperitoneal mass (13×8 cm), extending across the midline  (-), vimentin (-), leukocyte common antigen (LCA) (-), β-hCG (-) and placental alkaline phosphatase (PLAP) (+) immunoreactivity were noted, indicating a germ cell tumour.Scrotal ultrasonogram revealed hypoechogeneity and non-homogeneity in the right testicle. Evidence of a tumour was not found. The left testicle and epididymis were normal. After pre-operative evaluation, right inguinal orchiectomy was performed to determine the primary site of the tumour. Histological examination of the biopsy specimen revealed a large area of hyalinization, tubular hyalinization, interstitial fibrosis and focal Leydig cell hyperplasia. There were no pathological findings in the epididymis and spermatic cord. The final pathological diagnosis was 'burned-out' testicular tumour Figure .Because of the large retroperitoneal lymph node metastasis, primary chemotherapeutic treatment was performed. Combination chemotherapy, consisting of bleomycin, etoposide and cisplatin, was given in three weekly cycles of four courses. After the four courses of chemotherapy treatment, the abdominal mass had regressed from 13×8 cm to 3×2 cm . After 6 months, tumour markers had increased  and β-hCG: 20.95 mIU/ml ). Because only the β-hCG level had increased, the histology of the primary tumour seemed to indicate a seminoma. For this reason, retroperitoneal lymph node dissection was planned. Exploratory laparotomy revealed a retroperitoneal mass which extended both sides of the midline and involved the major vessels and extended to the eosophogastric junction, indicating an unresectable mass. A biopsy was performed from the unresectable mass and histological examination of the biopsy specimen showed only necrotic tissue and no tumour cells.Salvage chemotherapy consisting of paclitaxel, ifosfamide and cisplatin (TIP) was given in monthly cycles of four courses. After this chemotherapy, an abdominal CT scan revealed regression in the para-aortic and para-caval lymph nodes . AFP and β-hCG levels were normal  and β-HCG: 0.180 mIU/ml ).The patient has been disease and recurrence free for 5 years since the primary surgical and medical treatment.Extragonadal germ cell tumours are rare but well-known neoplasms. Primary extragonadal germ cell tumours constitute 3% to 5% of all germ cell tumours. More than 60% of these tumours are seminomas arising in the anterior mediastinum and retroperitoneum . Visceraet al.[et al.[In 1927, Prym  reportedet al. have shol.[et al. reportedA burned-out testicular tumour is a spontaneously and completely regressed testicular tumour. It presents by its metastases to the retroperitoneum, mediastinum, lymph nodes, lungs, liver or prostate . UltrasoThe majority of mediastinal and central nervous system extragonadal germ cell tumours are believed to arise from primary lesions. Retroperitoneal germ cell tumours appear to arise from primary testicular lesions . PrimaryAccording to one hypothesis, these tumours arise from primitive totipotential cells during the morula or blastula stage that later transform into germinal cells . This hyet al.[Fabre et al. declaredIn the presence of retroperitoneal lymph nodes, a testicular ultrasound examination can detect tiny intratesticular lesions, minimizing the possibility of a primary extragonadal germ cell tumour. It is important to distinguish 'burned out' tumours of the testis from true extragonadal germ cell tumours because primary removal of the testicular tumour is necessary for treatment .Orchiectomy is generally completed with cisplatin-based combination chemotherapy protocols. This therapy is very effective in the treatment of seminomas and non-seminomatous germ cell tumours. We also treated our patient with combination chemotherapy with bleomycin, etoposide and cisplatin, and in a 4-year follow-up, no disease recurrence was observed.Scrotal sonography is very important for the detection of intratesticular lesions, especially in patients with extragonadal metastatic involvement and normal palpation findings for the testis. A burned-out testicular tumour should be considered when punctuate echogenic foci are seen without any evidence of hypoechoic mass lesions. Testis biopsies should be performed if there is any risk factor for malignancy.AFP: alpha-fetoprotein; β-hCG: beta human chorionic gonadotrophin hormone; AST: aspartate aminotransferase; ALT: alanine aminotransferase; ALP: alkaline phosphatase; CK: cytokeratin; CT: computed tomography; GGT: gamma glutamyl transpeptidase; LCA: leukocyte common antigen; LDH: lactate dehydrogenase; PLAP: placental alkaline phosphatase.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MY, US and EA have made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data. NKH, SY and SK have been involved in drafting the manuscript or revising it critically for important intellectual content. All authors read and approved the final manuscript.


Objective: Giant cell tumor of tendon sheath is a rare cause of ulnar tunnel syndrome. We present a case of a 37-year-old woman who presented with decreased sensation and weakness of grip of the right hand. Magnetic resonance imaging indicated the presence of a mass in the hypothenar eminence and showed that the mass was associated with the flexor carpi ulnaris tendon and displacing the ulnar neurovascular bundle. A differential diagnosis included desmoid tumor and sarcoma. Methods: Surgical examination showed a mass that was associated with the flexor carpi ulnaris tendon and flexor retinaculum located in the distal portion of Guyon's canal and intertwined with the ulnar nerve and displacing the ulnar artery. The mass was removed and Guyon's canal was released. Results: Histological examination indicated a diagnosis of giant cell tumor of tendon sheath (GCTTS). Postoperatively, the patient had fully restored sensory and motor function of the right hand. Conclusions: Although GCTTS is the most common solid, soft-tissue lesion of the hand, it is rarely diagnosed properly preoperatively. Therefore, it is imperative to always include GCTTS in the differential diagnosis of any mass of the hand. Giant cell tumor of tendon sheath (GCTTS) is the most common solid, soft-tissue lesion of the hand.A 37-year old, right-hand dominant woman who works as a buyer of candy and tobacco for a wholesale distributor presented with decreased sensation and weakness of right-hand grip. Upon examination, a proximal hypothenar fullness was noted. At the time of presentation, the patient indicated that this fullness has waxed and waned for the past 1 year. Over the past 6 months the patient had increased numbness and tingling in the ulnar 2 digits and generalized weakness of her right hand. Ultrasound examination was performed and showed a solid heterogeneous mass of the hypothenar eminence. A follow-up magnetic resonance imaging (MRI) noted a 2.2 × 2.4 × 2-cm bi-lobed mass within the hypothenar musculature, which appeared to be displacing the ulnar artery and ulnar nerve , slow-growing mass that is firm to the touch, non-tender, and is most often found on tendon sheaths or in the joints of digits.4The most common benign masses of the hand are ganglion, GCTTS, epidermal inclusion cysts, hemangiomas, fibromas, mucous cysts, and lipomas.15To our knowledge, there have been only 5 case reports on GCTTS located at Guyon's canal in the English literatureThe sites of ulnar nerve compression within Guyon's canal can be classified into 3 zones. Zone 1 is located distal to the bifurcation of the ulnar nerve into superficial and deep palmar branches. Compression of the ulnar nerve in zone 1 can produce complete sensory and motor deficits, purely sensory or purely motor deficits. Zone 2 surrounds the deep motor branch of ulnar nerve. Compression in zone 2 results in paralysis of the intrinsic muscles and may involve the hypothenar muscles depending upon where the compression occurs in zone 2. Zone 3 surrounds the superficial branch of ulnar nerve. Compression in zone 3 results in purely sensory deficits.26The most common method for treatment of GCTTS is surgical excision; however, the average recurrence rate is 26.5%  with an average time of recurrence of 2 years 3 months .Kitagawa et alThis case demonstrates that ulnar tunnel syndrome caused by GCTTS is a rare occurrence and that it is often misdiagnosed preoperatively. Since GCTTS is the most common solid, soft-tissue lesion of the hand, it should always be included in the differential diagnosis whenever a mass of the hand is presented. Regarding imaging, MRI with and without enhancement may be useful for diagnosis. Nevertheless, a definitive diagnosis can be provided only by pathologic evaluation. Surgical removal is the standard treatment of GCTTS and it is important that the entire lesion be removed. This is crucial to reduce chances of lesion recurrence. Lastly, release of Guyon's canal and the hypothenar tunnel may be indicated at the time of lesion excision to help relieve nerve compression symptoms.


The diagnostic efficacy of somatostatin receptor scintigraphy labeling with 111 indium in the localization of tumors has been assessed in a limited number of patients with contradictory outcomes. Here, we describe the case of a patient with an ectopic adrenocorticotropic hormone-producing bronchial carcinoid tumor diagnosed preoperatively using technetium-99m-labeled octreotide acetate scintigraphy.A 29-year-old Asian man presented to our hospital with the typical clinical features of Cushing's syndrome, which he had had for a duration of 18 months. The results of a biochemical evaluation revealed he had adrenocorticotropic hormone-dependent Cushing's syndrome. The results of a spiral abdominal computed tomography scan showed he had bilateral adrenal hypertrophy. A magnetic resonance image of the patient's brain showed he had a normal hypophysis. Whole body technetium-99m-labeled octreotide acetate scintigraphy was performed to check for the presence of an ectopic adrenocorticotropic hormone-producing tumor. The scan results showed a small focal increase in uptake in the lower lobe of our patient's right lung, just above his diaphragm. A spiral chest computed tomography scan also revealed a small non-specific lesion in the same region. A transthoracic biopsy was then performed. Pathological evaluation confirmed the diagnosis of a carcinoid tumor, of the adrenocorticotropic hormone-producing type. After surgical removal, the patient's symptoms resolved and significant clinical improvement was achieved.This case report shows that technetium-99m-labeled octreotide acetate scintigraphy can effectively detect an ectopic adrenocorticotropic hormone-producing bronchial carcinoid. The ectopic secretion of adrenocorticotropic hormone (ACTH) from nonpituitary tumors causes approximately 10% cases of Cushing's syndrome .Somatostatin receptor scintigraphy (SRS) using 111 indium (In)-pentetreotide and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) are the functional techniques currently used to detect ectopic ACTH-secreting lesions. However, the diagnostic efficacy of SRS labeling with 111In in the localization of such tumors has only been assessed in a limited number of patients, with contradictory outcomes .We describe a case of a patient with an ectopic ACTH-producing bronchial carcinoid tumor diagnosed preoperatively using technetium-99m-labeled octreotide acetate scintigraphy.A 29-year-old Asian man presented to our hospital with upper and lower extremity weakness, significant weight gain (20 kg over 18 months), dyspnea, insomnia, early-morning awakening, psychiatric symptoms , and erectile dysfunction. Physical examination revealed the typical clinical features of Cushing's syndrome: hypotension, moon face, buffalo hump, multiple purple striae on the flanks, proximal myopathy and oral candidiasis. He was admitted to our hospital with an initial diagnosis of hypercortisolism. Biochemical test results confirmed the diagnosis and revealed that he had elevated serum cortisol (8 a.m.) and ACTH levels on multiple samplings. Dexamethasone suppression test results were positive on two consecutive samplings. His urine cortisol level was elevated, but his vanillylmandelic acid and metanephrine levels were normal. Other laboratory tests were noncontributory to the diagnosis.An MRI scan of his brain found no pituitary defects, but a spiral abdominal CT scan revealed bilateral adrenal hyperplasia. The clinical and imaging findings raised suspicion of an ACTH-producing tumor. A bronchoscopy and alveolar lavage was performed to investigate the patient's lungs, but no bronchial lesion was found.Technetium-99m-labeled octreotide acetate scintigraphy was performed in the whole body planar Figures  and 2 anCorresponding transverse images from a chest CT scan showed a well-defined mass about 22 mm in diameter in the lower lobe of the patient's right lung Figure .A transthoracic biopsy was performed and histopathological evaluation established the diagnosis of a carcinoid tumor of the ectopic ACTH-producing type. After removal of the mass, the patient's condition improved significantly. His clinical symptoms diminished and the results of biochemical tests returned to normal ranges.Ectopic ACTH-producing tumors occur in approximately 10% of cases of patients with Cushing's syndrome. Although a biochemical diagnosis of Cushing's syndrome is easily achieved, localization of the tumor is more difficult . CushingFrom a literature review, we found limited studies have addressed the use of an octreotide compound with technetium labeling. Although In-111-labeled octreotide scintigraphy has been shown to be a helpful tool for the diagnosis of somatostatin-expressing tumors, and this method has been broadly used, it has several shortcomings such as high radiation dose, high cost and limited availability. To address these drawbacks, octreotide compounds have been labeled with Tc-99m.In one study, the diagnostic outcomes of In-111 octreotide scintigraphy and Tc-99m Hynic Toc/Tate scintigraphy in 24 patients with different pathologies including two cases of ectopic Cushing's disease, were found to be identical .18F-FDG dual-head coincidence imaging (DHC) of 44 patients with suspected lung tumors [18F-FDG DHC the values were 100%, 46.1%, 83.8%, and 100%, respectively [18F-FDG DHC coincidence PET [In another investigation, the clinical value of tomographic technetium-99m-labeled octreotide acetate scintigraphy was compared with Our case report shows the usefulness of technetium-99m-labeled octreotide acetate scintigraphy in the localization of ectopic ACTH-secreting tumors in patients biochemically and clinically diagnosed with Cushing's syndrome. However, further well-designed studies to evaluate its efficacy are required.Our case report shows that technetium-99m-labeled octreotide acetate scintigraphy can effectively detect an ectopic ACTH-producing bronchial carcinoid.The authors declare that they have no competing interests.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.AFE participated in the design and coordination of the study, drafting the manuscript and interpreting the radiological figures. MC participated in the design and coordination of the study, drafting the manuscript and interpreting the radiological figures. MHN participated in the design and coordination of the study, drafting the manuscript and interpreting the radiological figures. MS supervised the acquisition and interpretation of the radiological images. ME supervised the acquisition and interpretation of the radiological images. DB supervised the acquisition and interpretation of the radiological images. BF supervised the acquisition and interpretation of the radiological images. MA revised the article for important intellectual content and helped draft the manuscript. All authors read and approved the final manuscript.


Localized gingival enlargement is often associated with specific systemic medication, abscess formation, trauma or reactive lesions. Scant literature is available reporting enlargement of gingiva due the metastasis of adenocarcinoma from lung. The case report presents a unique case of an adenocarcinoma in the lung metastasizing to the buccal and lingual interdental papillae of teeth numbering 34 and 35. A 72-year-old female was referred to the Mayo Clinic with a recent diagnosis of metastatic stage IV adenocarcinoma of the left lung presented with an abnormal mass located on the left posterior buccal keratinized tissue adjacent to teeth numbering 34-35. Biopsy of the lesion was performed for CK7, CK20, TTF-1 and p63. The tumor cells were positive for CK7 and TTF-1, and weakly positive for p63 suggesting a diagnosis of adenocarcinoma. The periodontist may be in the unique position to be the first oral health care provider to evaluate any biopsy suspicious intra-oral lesions. Malignant metastatic involvement of the oral tissues has been infrequently reported. The overall incidence has been reported to be 1-3% of all oral malignancies.1 Previous2Furthermore, metastasis to soft tissue is less common compared to the osseous structures.–8Metastasis to gingival tissues is very rare consequently there are few documented cases of metastatic gingival tumors. Cases of intraoral metastasis have been reported from primary chondrosarcoma of femur, adenocarA 72-year-old female was referred to the Mayo Clinic with a recent diagnosis of metastatic stage IV adenocarcinoma of the left lung. The patient was a non-smoker, initially visited her primary care physician with a chief complaint of a chronic cough that did not respond to antibiotic therapy. On October 12, 2007, a chest CT scan was performed which demonstrated a left lower lobe mass, as well as a left pleural effusion, and a liver mass. On October 18, 2007, thoracentesis demonstrated evidence of malignant cells. Approximately two liters of fluid was removed. A PET scan performed on October 22, 2007 showed diffuse hypermetabolic uptake in the left upper chest wall, liver, left femur, and left lower lung. A repeat CT scan on October 25, 2007 demonstrated re-accumulation of the pleural fluid. A mass within the right lobe of the liver and lower lung was also evident. The patient was referred to an oncologist.On November 1, 2007, as a part of the examination, the medical oncologist detected an abnormal mass located on the left posterior buccal keratinized tissue adjacent to tooth number 34, 35. No lymphadenopathy was detected. On the same day, the patient was referred to the Periodontics division, Department of Dental Specialties, Mayo Clinic.An intraoral examination revealed an erythematous growth located on the facial and lingual interdental papillae of the teeth numbering 33 and 34  and 34 aImmunohistochemical stains were performed for CK7, CK20, TTF-1 and p63. Histologic section of the adenocarcinoma showed squamous mucosa on top with infiltrating sub mucosal tumor. Some tumor cells nests involve sub mucosal lymphatic spaces. The tumor cells were positive for CK7 and TTF-1, weakly positive for p63 and negative for CK20 Figures . These rMetastasis of adenocarcinoma from the lung to oral tissues has been rarely reported. Any suspA general dentist or primary care physician may refer suspicious intraoral lesions to the periodontist for further evaluation. The periodontist may be in the unique position to be the first oral health care provider to evaluate and biopsy suspicious intraoral lesions. While rare, primary and metastatic lesions occur approximately 1-3% of the time,1 it is ve


Ameloblastoma is a true neoplasm of odontogenic epithelial origin. It is the second most common odontogenic neoplasm, and only odontoma outnumbers it in reported frequency of occurrence. Its incidence, combined with its clinical behavior, makes ameloblastoma the most significant odontogenic neoplasm. Unicystic ameloblastoma (UA) refers to those cystic lesions that show clinical, radiographic, or gross features of a mandibular cyst, but on histologic examination show a typical ameloblastomatous epithelium lining part of the cyst cavity, with or without luminal and/or mural tumor growth. It accounts for 5-15% of all intraosseous ameloblastomas. We report a case of unicystic ameloblastoma in a 30-year-old female, and review the literature. Many benign lesions cause mandibular swellings, and these can be divided into those of odontogenic and nonodontogenic origin. Lesions include ameloblastoma, radicular cyst, dentigerous cyst, keratocystic odontogenic tumour, central giant cell granuloma, fibro-osseous lesions and osteomas . The mosThe vast majority of ameloblastomas arise in the mandible, and the majority of these are found in the angle and ramus region. There are three forms of ameloblastomas, namely multicystic, peripheral, and unicystic tumors . Multicyst premolar tooth. The oral mucosa was normal. No neck nodes were palpable. Systemic examination was normal. An orthopantomogram (OPG) was done, which showed large cystic lesion in the right side of mandible  is a rare type of ameloblastoma, accounting for about 6% of ameloblastomas. It usually occurs in a younger age group, with about 50% of the cases occurring in the second decade of life. More than 90% are located in the mandible . BetweenGroup I: Luminal UA Group II: Intraluminal/plexiform UA , andGroup III: Mural UA .Another histologic subgrouping by Philipsen and Reichart  has alsoSubgroup 1: Luminal UASubgroup 1.2: Luminal and intraluminalSubgroup 1.2.3: Luminal, intraluminal and intramuralSubgroup 1.3: Luminal and intramuralThe UAs diagnosed as subgroups 1 and 1.2 can be treated conservatively (careful enucleation), whereas subgroups 1.2.3 and 1.3 showing intramural growths require treated radical resection, as for a solid or multicystic ameloblastoma . FollowiThe authors declare that they have no competing interests.RSR participated in the surgical excision and drafted the manuscriptSM conceived the study and participated in drafting manuscript and co-ordinationTHU obtained consent and photographs and participated in the literature searchSP participated in surgical excision and in drafting manuscriptSK performed the surgical excision and participated in literature searchAll authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Mesenchymal tumors of the bladder are rare with leiomyoma accounting for most of these. We present a rare case of a bladder benign fibrous histiocytoma in a 52-year-old male. He presented with history of straining during micturition since two years. The magnetic resonance imaging revealed a large intravesical mass. The mass was excised. It weighed 600g, with a maximum dimension of 13cm. Histology was that of a benign fibrous histiocytoma. To our knowledge, only two cases of this tumor have been reported in the bladder so far. The clinical and pathological features are discussed. Mesenchymal tumors of the bladder are rare with leiomyomas accounting for most of the cases. Fibrous 2A 52-year-old male presented with complaints of straining during micturition for two years, with poor stream of urine and burning micturition on and off. There was no history of hematuria, pyuria or retention of urine. Systemic systems were not present. On examination, suprapubic lump was palpable, more on the right side. On cystoscopy, a large solid tumor arising from just above the bladder neck along the right lateral wall, going anteriorly was seen. The magnetic resonance imaging (MRI) revealed a large encapsulated intravesical mass . There wHistology of the biopsy revealed a neoplasm composed of neoplastic cells with uniform oval to spindled nuclei arranged in a striking storiform pattern . There wMesenchymal tumors of the bladder are rare with leiomyomas accounting for most of the cases. Other be2


In well-developed countries scant attention is currently devoted to the risk of unknown exposure to aflatoxins, highly toxic and carcinogenic compounds. Nevertheless, unexpected ingestion of foods contaminated by these toxins can occasionally occur virtually worldwide.A 38-year-old woman living in Northern Italy developed unexplained abdominal symptoms after ingestion of aflatoxin-contaminated meat. The possible relation between symptoms and aflatoxins ingestion, the potential risk of hepatocellular carcinoma and the medical management of the case are discussed.In well-developed countries aflatoxins exposure should be considered in case of unexplained abdominal symptoms. Cancer risk cannot be assessed, nevertheless individual counselling and periodical medical examinations are recommended. Aspergillus flavus and parasiticus. There are 4 primary AFs, but aflatoxin B1 (AFB1), the most toxic, is usually predominant in foods . Add. Add4]. Both in humans and animals exposure is related to consumption of contaminated food. Even if food contamination is more frequent in tropical countries, AFs can be found in a wide range of foods consumed in all world areas ,6.AFs are highly toxic in both animals and humans ,5, and aThe subject is a 38-years-old woman living in Northern Italy. She smokes about 20 cigarettes per day and usually drinks 1-2 glasses of wine per day during meals. Her dietary habits are peculiar: since long time she has been having a marked preference for beef meat, while she does not like other types of meat or fish, nor vegetables or fruit. Accordingly her diet is substantially unbalanced, consisting mainly in grilled or roasted beef meat. As her family has long since had a cattle breeding, she is used to eating almost exclusively meat from the family farm.In the winter of 2004 the family farm animals started to show various disorders, such as slowing growth rate, delayed sexual development, gastrointestinal tract disorders, increasing incidence of several infective diseases, abortions and increase of overall mortality. The veterinarians considered different causes and carried over various treatments, as antibiotic therapies, without significant results. Aflatoxicosis is a rare disease in the area, as a consequence the possibility of AFs intoxication was not considered at the time.For years the animal feed had been supplied by the same producer, but in the late spring of 2007, among the attempts applied to find a solution, the feed supplier was changed.In late summer of 2007 the cattle recovered and the disorders gradually subsided. Later on (autumn 2007) the patient's family acknowledged that some analyses performed on the animal feed back in 2006 had revealed AFB1 levels up to 25 µg/kg. The maximum level of AFB1 in animal feed permitted by the European Union (EU) is 5 µg/kg. Further data are missing, since the former supplier refused to produce records about other analyses in feed. Accordingly the possibility of higher concentrations of AFs in feed exists. After the finding of high AFB1 levels in feed, the symptoms and signs observed in the animals were reconsidered by the farm veterinarians, who agreed that an AFs intoxication was possible. Unfortunately it was not possible to perform specific laboratory tests in the animals since too much time had passed from the end of contaminated feed consumption. However a relation between the disorders observed in animals and AFs is supported by documented feed AFB1 levels exceeding the EU limit value, animal case history consistent with aflatoxicosis, temporal correspondence between onset of disorders and consumption of potentially contaminated feed, and submission of disorders after feed replacement, according to the temporality principle of causality.In the subject under examination, previous medical history did not account for any relevant disorder nor hospitalization before winter of 2004, when episodes of nausea, abdominal swelling, constipation alternating with diarrhea and abdominal pain appeared. The frequency of symptoms increased during the following months including several episodes of intense abdominal pain.The subject underwent several medical examinations to rule out major causes of abdominal pain. Repeated gastrointestinal X-rays and abdominal ultrasonography were performed from May to September 2005, along with a uterine ultrasound scan (November 2005), but they showed no apparent alterations. In September 2005 a stool examination was carried over and proved to be negative for pathological microorganisms or parasites, and no steatorrhea was observed. Antibody tests for celiac disease were negative. Repeated blood analyses were substantially normal, including pancreatic enzymes and liver function tests . Blood viral hepatitis antibodies were negative.During 2006-2007 abdominal pain was so intense that the patient repeatedly attended the Emergency Department of the local area hospital. Twice "mittelschmertz" was diagnosed, other times a generic diagnosis of "acute abdominal pain" was made. Tramadol was effective in pain reduction.During the whole period the subject's diet remained substantially unmodified, and she has never ceased eating meet from the family farm. Nevertheless, after the animal feed supplier was changed in autumn of 2007, the meat was no more contaminated. The abdominal symptoms subsided by October 2007, and no further episodes of abdominal pain have ever since been reported.The timing of signs and symptoms both in animals and in the case are described in Table The main target organ of AFs is the liver, and acute toxic hepatitis with high mortality rates have been reported . In addiAn assessment of the health risk possibly related to AFs exposure is difficult as the toxicokinetics in humans is complex and knowledge is incomplete . In addiDiet supposedly plays an important role as well . One casMoreover, adverse effects related to AFs exposure can easily remain unrecognized by medical professionals, especially in well-developed countries. In fact diagnosis may be difficult, and frequently the demonstration of the role of AFs may be possibly based on likelihood criteria only, as in the case presented here.In our patient it was impossible to measure AFs or their derivatives as exposure biomarkers  since thin vitro[The abdominal symptoms observed in our case are included among symptoms usually reported in AFs intoxication ,10, and in vitro and in ein vitro. The absin vitro.Causes of abdominal pain other than AFs were not identified despite repeated medical examinations and tests. No liver effects were observed performing blood analyses and ultrasound scans, but scientific literature has previously reported such findings in well nourished subjects .The association between the patient's symptoms and AFs ingestion is therefore supported by several facts: i) the patient consumed meat from contaminated animals; ii) the clinical history is consistent with AFs intoxication, according to literature data; iii) a temporal correspondence is observed between the onset of disorders and the consumption of contaminated meat as well as between the withdrawal of symptoms and the stop of consumption; iv) no other causes were identified.An open question is the risk of hepatocellular carcinoma (HCC). The carcinogenic activity of AFB1 is possibly related to its 8, 9-epoxide metabolite which can react with DNA. It can induce mutations in the codon 249 of the p53 gene ,13. The As to our case, the cancer risk assessment is impossible due to the lack of quantitative data about the ingested dose. Molecular cytogenetic tests were not performed in the patient. The diet of the patient was unbalanced, being poor in fruit and vegetables, which are known to reduce cancer risk .As regards the medical management of the case, the use of chemopreventive agents as oltipraz or chlorophyllin, proposed in exposed subjects in endemic areas , is not The case hereby presented emphasizes the possibility of missing AFs exposure in well developed Countries, and suggests the need to consider an unnoticed AFs exposure in case of unexplained abdominal symptoms.HCC risk related to AFs consumption cannot be usually assessed, nevertheless individual counselling for exposed people should take into account HBV vaccination, periodical medical examinations, alcohol restriction and a well-balanced diet.Written informed consent was obtained from the patient for publication of this case report. 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.Both authors gave the same contribution to the manuscript.


The rare pathology of seminal vesicle abscess is usually diagnosed with computerised tomography scan and confirmed with transrectal ultrasound. We report a recently encountered case where diagnosis proved difficult owing to the non-specific clinical presentation. Seminal vesicle abscess is a rarely encountered pathology with only 28 reported cases in the English literature. Commonly reported presenting complaints include; fever, dysuria and other urogenital symptoms. Here we present a case of seminal vesicle abscess that we believe to be the first reported case presenting with a tender lump in the groin. We describe the diagnostic challenge of this unknown presentation and its subsequent management.We report a case of a 49 year old childless Caucasian male who presented with a one week history of a gradually enlarging, exquisitely tender groin mass. The patient denied systemic, bowel or genitourinary symptoms except on deeper questioning when a two week history of darkened urine was described. Past medical history included bilateral groin hernia repair as a child and an incision and drainage of perianal abscess one year before.Clinical examination revealed a tender mass in the left groin extending into the left scrotum where a large cystic swelling was identified. A non-tender right testicle was palpated. The remainder of clinical examination including rectal examination was unremarkable.Haematological indices demonstrated a mild neutrophilia and abnormal liver function tests. In view of these findings, a groin exploration was performed demonstrating a thick walled sac adherent to the vas and vessels. Surprisingly when incised, this drained >100ml of frank pus into which a corrugated drain was inserted. The pus later cultured coliform bacteria.Computerised tomography of the abdomen and pelvis revealed a thick-wall collection between the urinary bladder and rectosigmoid colon. In order to further delineate the extent of disease magnetic resonance imaging  was perfIn view of the likely urological source, a cystoscopy, rigid sigmoidoscopy to 15cm and laparoscopic drainage of the abscess were performed. Laparoscopic findings suggested the source to be the seminal vesicle; this was later confirmed by histological analysis.A follow-up scan performed eleven days later confirmed successful drainage. Although there were no local complications, unfortunately the patient presented one month later with a pulmonary embolus and however made a good recovery.Raijfer et al  first reAlthough the exact aetiology of seminal vesicle abscess is unclear, reported predisposing factors include urinary tract infection, diabetes, indwelling catheters, urological instrumentation/surgery, intraabdominal carcinomatosis and anatomical abnormalities -8. FolloEscherichia coli. In fact, a study by Saglam et al. cultured Escherichia coli from the urine and abscess in 100% of cases [In previous documented cases the most common causative organism is of cases . This coComputerised tomography is the most frequently described diagnostic tool, although the most recent literature advocates the use of transrectal ultrasound . The unuTender groin lumps are common in general surgical practice. We describe the first case of a seminal vesicle abscess being the underlying pathology.


The case report describes the rare presentation of a 79-year-old patient with a locally perforated splenic flexure tumour of the colon presenting with an apparent empyema thoracis in the absence of abdominal signs or symptoms.Initial presentation was with a non-productive cough, anorexia and general malaise. An admission chest X-ray and subsequent computed tomographic image of the thorax showed a loculated pleural effusion consistent with an empyema. The computed tomography also showed a thickened splenic flexure. Thoracotomy was performed and a defect in the diaphragm was revealed after the abscess had been evacuated. A laparotomy was carried out at which point a tumour of the splenic flexure of the colon was found to be invading the spleen and locally perforated with subsequent collection in communication with the thorax. The tumour and spleen were resected and a transverse end colostomy was fashioned.One must consider the diagnosis of pathology inferior to the diaphragm when an apparent empyema thoracis is encountered even in the absence of clinical signs or symptoms. This has been described once in the past by Teruuchi et al. .This 79-year-old man presented to his local hospital in May 2007 with a 2-month history of a chronic non-productive cough, weight loss of 1.5 stone (9.5 kg) over 1 month, anorexia and general malaise. Other gastrointestinal or respiratory symptoms were absent. Examination was consistent with the finding of a left-sided pleural effusion and of note, abdominal exam was normal. An admission chest X-ray showed a left-sided pleural effusion with basal collapse. His inflammatory blood markers were also elevated . He was commenced on intravenous antibiotics but showed little improvement after 3 days of treatment, at which point a computed tomographic (CT) scan of the thorax and abdomen was performed. The CT showed a loculated pleural effusion consistent with an empyema plus thickening of the pleura and diaphragm as well as an abnormal thickened splenic flexure adjacent to the diaphragm (Figure On the day of transfer, the patient was taken to theatre for pleural decortication. A posterolateral thoracotomy was performed and the abscess collection was evacuated. A small perforation of the diaphragm was also found and it was established that the abscess cavity was extending through the diaphragmatic defect Figure . At thisThe patient made an uneventful postoperative recovery and was discharged from hospital 15 days after the operation having received the relevant vaccinations. Pathological assessment showed a Dukes B moderately differentiated adenocarcinoma with the pathological staging of T4 N0 M1. The label of M1 is derived from the fact that the thorax was breached. Adjuvant chemotherapy has been scheduled.et al. [The case highlights the rare presentation of an apparent empyema thoracis secondary to abdominal pathology. Technically, it is not a true empyema given that it originated and communicated with the abdominal cavity, hence its labelling as an 'apparent' empyema. The only previous example of this pathology was described by Teruuchi et al. , and wasWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.KM gathered the patient data, obtained consent from the patient and performed the literature review. MC was the major source of photographic images and was a major contributor in writing the manuscript. HPR was also a major contributor in writing the manuscript and was involved in the final histological assessment. All authors were intimately involved in the case, and read and approved the final manuscript.


There are rare reports of necrotizing fasciitis (NF) following laparoscopic surgery. The clinical presentation of this condition may be delayed due to non-specific symptoms and sign. The diagnosis is essentially clinical and early recognition is crucial in the management. We present a case of NF of the lower abdominal wall extending to thigh, scrotum and perianal area following the laparoscopic extraperitoneal repair of left inguinal hernia managed with extensive debridment, removal of mesh, antibiotic, and skin grafting. He was seen 6 months after his surgeries and had no disability. The extensive search on Medline, Medscape, and Google engine revealed only one case report of NF following laparoscopic total extraperitoneal repair of inguinal hernia that died and this is the second case report and the only surviving one. Necrotizing fasciitis (NF) is a life threatening rapidly spreading soft tissue bacterial infection, progressing to extensive necrosis and gangrene of subcutaneous tissue and fascia. It is a deep-seated infection often mistaken as simple cellulitis around the wounds but the intensity of pain and toxicity is out of proportion to the local findings. Quite often the diagnosis is made in the presence of obvious signs. The lower abdominal wall and the perineum are by far the most affected parts of the body. The etiology of NF after surgery is polymicrobial in the majority of the patient and its progression is slower than that seen in monomicrobial infections. Gas in subcutaneous tissue is usually not a feature of polymicrobial NF after the surgery. There are several comorbid conditions, which can make the patients more susceptible due to lowered immunity such as contaminated operation, trauma, diabetes, and immunosuppression. The mortality is high when diagnosis and debridment is delayed.A 41 years old male patient previously healthy, presented with the history of laparoscopic repair of left inguinal hernia in a neighboring country 12 days ago. The patient noticed pain and redness around the port sites five days after the operation and reported to his doctor. He was given a course of antibiotics for one week but his redness, pain and swelling spread further on abdomen wall, thighs and scrotum. Two days prior to admission he was in severe pain, unable to move and had chills with rigor. He had nausea and loss of appetite. There was no known history suggestive of any pre-disposing- associated comorbid conditions.He was toxic, tachycardic, emaciated, and febrile. The cellulitis and tense edema with tenderness was noticed involving the whole of the lower abdomen, scrotum, perineum, and the upper medial aspects of thighs. Skin blistering and ruptured bullae with foul smelling serous discharge were seen on the inner thighs . No crepEscherichia Coli, Coliform, Klebsiella, Proteus Mirabilis, and Staphylococcus Aureus. A split skin grafting was done to cover the exposed area and muscles [He was resuscitated with IV fluids, oxygen, and parental broad-spectrum antibiotics, and was taken up for urgent surgical exploration. The diagnosis was established intra-operatively. Through a long left transverse inguinal incision the tissue planes were opened. The mesh was lying loose and infected and was removed. There was offensive smelling pus in all tissue planes sparing muscles. The incisions were extended further and all dead and necrotic tissues were excised . He had  muscles . No disaWith the development of laparoscopic approached the NF is considered a rare complication. There are only few case reports in the literature of NF after laparoscopic surgery. Although rare, the mortality is very high and death secondary to NF in laparoscopic surgery has been reported in unrecognized strangulated lateral trocar hernia, peritoneal contamination with intestinal contents and following total extraperitoneal repair of inguinal hernia.–3 Etiolo


Patellar tendinopathy is characterized by activity-related anterior knee pain. It is most commonly related to sports activity, but has also been reported in the non-athletic population. Most injuries are caused by microtrauma, resulting in tendinitis or tendinosis. Extraskeletal paraarticular osteochondromas, which occur in the soft tissues near the joint, are rare. The infrapatellar fat pad and joint capsule are the most common sites of these tumors. Here, a case of patellar tendinitis caused by an extraskeletal paraarticular osteochondroma is reported. The symptoms included intensifying pain upon flexion and a palpable click that was located at the medial side of the mass. The patient was pain-free within 3 weeks after excision of the tumor and the clicking disappeared. To our best knowledge, no other case of patellar tendinitis caused by an extraskeletal paraarticular osteochondroma has been reported in the English literature. Patellar tendinopathy (PT) affecting the patellar or tibial insertion of the patellar tendon is one of the most common causes of anterior knee pain. Chronic overload resulting in microtrauma is the primary etiological factor in this pathology .Extraskeletal paraarticular osteochondromas (ESPAOCs) are rare benign bone tumors that typically appear in the infrapatellar region. These tumors arise from the juxtaarticular soft tissue and may show histological features suggestive of a malignant process . AccuratA 60-year-old Turkish female presented with a swelling in the anterolateral region of the left knee. The swelling had been present for 10 years, and had been increasing gradually in size over the previous 3 years. Two years prior to presentation, the patient began to experience pain on the medial side of the swelling, which intensified upon flexing the knee.A palpable 5 × 4.2 × 3.5 cm hard bony mass was detected in the lateral infrapatellar area. The mass was partially mobile in the long-axis direction, but fixed with regard to lateral (side-to-side) motion. The range of motion was 130° and a click on the medial side of the mass was palpable at 70° of flexion.Radiographs revealed a large, well-circumscribed, mineralized mass inferolateral to the patella Figure . ComputeThe lesion was excised through a longitudinal anterolateral incision. Intraoperatively, the lesion was found to be separate from the patella and completely extraskeletal and extraarticular. During surgery, patellar tendon thickening near to the tumor was observed and lateral side of the tendon was contoured due to compression by the oval mass Figure .The resected specimen was a lobulated mass with a smooth fibrous outer surface. It measured 5 × 4.2 × 3.5 cm and the cut surface revealed approximately 0.2 cm thick, translucent, bluish cartilage at the periphery that merged into spongious bone and fatty marrow at the center Figure .Range of motion exercises began on postoperative day 1. The patient was completely pain-free within 3 weeks postoperatively and the clicking disappeared. Twelve months after surgery, there was no recurrence of the tumor and the patient was asymptomatic.PT is characterized by activity-related anterior knee pain, focal patellar tendon tenderness, and intratendinous imaging changes . PT is uHistopathological studies have consistently shown that the pathology underlying chronic PT is degenerative (tendinosis) rather than inflammatory (tendinitis) ,6. TendiOsteochondroma is the most common benign bone tumor and usually occurs in the metaphyseal region of the long bones . The vasImpingement symptoms or friction injuries related to osteochondromas are rarely reported. Onga et al  reportedESPAOC is a rare possible etiological factor in patellar tendinopathy. A careful radiological and histopathological work-up is important for making the correct diagnosis and preventing unnecessary aggressive surgery.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 journalThe authors declare that they have no competing interests.KEO operated the patient, collected data and prepared the manuscript, IY treated the patient and collected data, KG performed and analyzed the x-rays, CTs and MRIs, MG reviewed and corrected the manuscript, HC treated the patient, reviewed and corrected the manuscript, SD prepared, analyzed and interpreted pathological specimen. All authors read and approved the final manuscript.


This report describes a rare complication of colonoscopy and reviews the literature with regard to other rare causes of acute abdominal presentations following colonoscopy.After a therapeutic colonoscopy a 60-year-old woman developed an acute abdomen. At laparotomy she was discovered to have small bowel obstruction secondary to incarceration through a congenital band adhesion.Although there is no practical way in which such rare complications can be predicted, this case report emphasises the wide array of pathologies that can result in acute abdominal symptoms following colonoscopy. Colonoscopy is a widely used investigative procedure and has a relatively low complication rate. With the advent of the National Health Service Bowel Cancer Screening Programme  there wiA 60-year-old woman presented to an outpatient colorectal clinic with a 2-month history of rectal bleeding. Her past medical history included a colpopexy which had been performed via a Pfannenstiel incision 20 years earlier. On examination a large villous adenoma was palpable within the rectum. She was referred for a diagnostic colonoscopy. The colonoscopy was performed without immediate complication using 25 μg of fentanyl and 2 mg of midazolam. Bowel preparation was performed to good effect with 2 litres of polyethylene glycol solution. The exclusion value of the examination was reported as excellent. Caecal intubation was confirmed by visualisation of the ileocaecal valve. The terminal ileum was not intubated. Two 4 mm sessile polyps were located within the middle third of the rectum and these were removed using hot biopsy. The lower third of the rectum contained a large sessile villous adenoma which occupied 50% of the rectal circumference at this level (7 cm diameter). The lesion was sampled by plain biopsy. Histological analysis revealed the 4 mm polyps to be tubulovillous adenomas and the larger sessile polyp to be a villous adenoma.9/litre. Plain abdominal and chest radiography demonstrated several loops of dilated small bowel in the left upper quadrant but no evidence of free abdominal gas (Figure Eight hours after colonoscopy the patient developed gradual onset of abdominal pain associated with nausea and vomiting. She was admitted under the acute surgical service the next day. On examination she was afebrile with a heart rate of 130 beats per minute. Abdominal examination revealed diffuse tenderness with fullness and peritonism in the right iliac fossa. Peripheral blood analysis demonstrated a white cell count of 16.9 × 10The development of an acute abdomen after colonoscopy is a relatively rare event. Overall rates of colonic perforation are widely reported at being in the region of 0.12% (see [Mechanical bowel obstruction following colonoscopy has been reported by 21 other authors. Half of these have been related to volvulus of the caecum, sigmoid or entire small bowel mesentery. One case of caecocolic intussusception has been reported . Three cOur case is one of only five in the literature relating to the internal incarceration of small bowel as demonstrated at laparotomy. These include a case of colonoscopy-induced sigmoid mesenteric rupture and subsequent small bowel incarceration through the defect , one casAlthough there is no practical way in which such rare complications can be predicted, this case report emphasises the wide array of pathologies that can result in acute abdominal symptoms following colonoscopy. Such presentations require a high index of suspicion on the clinician's part with a low threshold for urgent investigation and intervention.The authors declare that they have no competing interests.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.IAH was responsible for drafting the manuscript and obtaining informed consent from the patient, RS contributed to research and review of the relevant literature, AS conceived of the report and edited the draft manuscript.