Teratomas are the commonest germ cell tumours and are most frequently found in the testes and ovary. Extragonadal teratomas are rare and mainly occur in midline structures. Uterine teratomas are extremely rare with only a few previous case reports, usually involving mature teratomas of the uterine cervix.We report an 82-year-old lady presenting with post-menopausal bleeding. Initial investigations revealed a benign teratoma of the uterus which was removed. Her symptoms persisted and a recurrent, now malignant, teratoma of the uterine corpus was resected at hysterectomy. Six months after surgery she relapsed with para-aortic lymphadenopathy and was treated with a taxane, etoposide and cisplatin-containing chemotherapy regimen followed by retroperitoneal lymph node dissection.In this report we discuss the aetiology, diagnosis and management of uterine teratomas, and review previous case studies. Mature teratomas consist of adult-type differentiated components such as cartilage and glandular epithelium. Immature teratomas contain tissue with partial somatic differentiation similar to that in foetal tissue. Teratomas with malignant transformation demonstrate aggressive neoplastic growth of one or more of the histological components.Teratomas -7 and the thyroid and lung marker TTFI. There was positive staining of the chondroid area for S100 protein, focal staining of dilated gland epithelium and stromal cells for oestrogen receptor and progesterone receptor, and staining of stromal cells for smooth muscle α-actin (SMA). Thyroglobulin, desmin, CK20 and CDX2 staining was negative. A diagnosis of benign teratoma with thyroid gland and cartilaginous elements was therefore made.Following hysteroscopy, the bleeding continued. A repeat ultrasound scan revealed that the teratoma had grown back almost completely filling the uterine cavity. A magnetic resonance imaging (MRI) scan in November 2007 showed the tumour filling and distending the endometrial cavity and extending down into the cervix Figure . There wThe patient proceeded to a total abdominal hysterectomy and bilateral salpingo-oophorectmy in December 2007. At operation, the uterus was found to contain a haemorrhagic polypoid tumour (110 × 80 × 70 mm) arising from the posterior aspect of the endometrial cavity Figure . UterineMicroscopically the tumour was a teratoma containing mature and immature elements with mixed malignant transformation Figure . The tisThe histopathological conclusion was of a poorly differentiated adenocarcinoma and a focal myogenic sarcoma arising in a polypoid uterine teratoma with mature and immature elements. A post-operative computer tomography (CT) scan of the thorax, abdomen and pelvis found no evidence of distant disease giving an overall International Federation of Gynaecology and Obstetrics (FIGO) disease stage 1C.2) and etoposide (100 mg/m2). This was well tolerated so one week later treatment was continued with a fortnightly alternating regimen of paclitaxel (135 mg/m2) and etoposide (150 mg/m2), followed by paciltaxel (135 mg/m2) and cisplatin (60 mg/m2). This treatment was chosen based on our experience of its effectiveness and tolerability in the treatment of relapsed germ cell tumours and gestational trophoblastic disease [The patient recovered well from surgery and was referred for oncological follow up. Given her age and performance status a surveillance approach was taken with regular clinical examinations, serial tumour markers and routine CT scans. Initially in remission, six months post-operatively para-aortic lymphadenopathy was detected on CT although she remained asymptomatic with an Eastern Cooperative Oncology Group (ECOG) performance status of 0. In view of her age and wishes for a treatment with acceptable toxicity, the patient was commenced on an initial dose of cisplatin 20 mg/m0 mg/m2 alitaxel 15 mg/m2 aAfter three cycles of chemotherapy there was a reduction in the size of the para-aortic mass, but an increase in the cystic component suggesting possible differentiation towards a mature teratoma. Consequently she underwent a retro-peritoneal lymph node dissection in October 2008. Histology from this confirmed the presence of metastatic teratoma. Unfortunately she had a turbulent post-operative course and, although she recovered well enough to return home a month later, she sadly died shortly thereafter.Extra-gonadal GCTs represent 1%–2% of all germ cell tumours . Their hTeratomas of the uterus should be differentiated from other tumours that can present with more than one germ layer, such as a mixed Müllerian tumour, and from perforated ovarian teratomas. The differential diagnosis of mature teratoma also includes neuroectodermal tumours.There are two hypotheses regarding the origin of uterine teratomas. The blastomere theory proposes that they arise from residual pluripotent embryonic cells left behind following a missed abortion or undelivered papyraceous twin. Foetal tissue could also be inadvertently implanted into the uterine wall during instrumentation ,10. ThisUterine teratomas usually present with abnormal per vaginal (p.v.) bleeding, p.v. discharge or pelvic pain. Although most ovarian germ cell tumours are diagnosed pre-operatively by ultrasound examination, in none of the previous reports of uterine teratomas was a correct pre-operative diagnosis made. Most were misdiagnosed as uterine or cervical polyps. This reflects the variable sonographic appearances of uterine teratomas which frequently lack the characteristic dense echogenic tubercle (Rokitansky nodule) projecting into a cystic lumen, the diffusely echogenic mass representing the presence of hair or sebaceous elements, and multiple thin, echogenic bands of hair within the cavity . MRI andTeratomas of the uterine corpus have been treated by tumour resection or total abdominal hysterectomy, with or without pelvic and/or para-aortic lymphadenectomy . Those oAlthough rare, uterine teratomas should be considered in the differential diagnosis of any intrauterine mass, even in the absence of typical radiological features.AFP: Alpha-fetoprotein; CEA: Carcinoembryonic antigen; CK: Cytokeratin; CT: Computerised tomography; ECOG: Eastern Cooperative Oncology Group; FIGO: International Federation of Obstetrics and Gynaecology; GCT: Germ cell tumour; LDH: Lactate dehydrogenase; MRI: Magnetic resonance imaging; p.v.: Per vaginaThe authors declare that they have no competing interests.TND, RG and DP are the main authors. KP, SBM, TC, MS and PT were all involved in patient management and provided critical review of the manuscript. IL and MA provided images/figures.Written consent was obtained from the patient for publication of their details.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/9/195/prepub


We report a rare appearance of cystitis glandularis forming a tumorous lesion with blueberry spots in the urinary bladder. A 49-year-old woman was admitted to our hospital with pollakisuria and recurrent gross hematuria. Urine examination showed no pyuria. Computed tomography (CT) scan showed an extravesical invasive mass and cystoscopy revealed a non-papillary tumor with blueberry spots in the bladder. Transurethral resection (TUR) was performed. Histopathological examination revealed cystitis glandularis with cystitis cystica in the part. Postoperative CT scan and cystoscopy showed reduction of the mass in the bladder without any treatments. She is currently well with no evidence of tumor growth three months after TUR. Cystitis glandularis is a benign proliferative disorder of the bladder. Cystitis glandularis is not a rare disease, but cases with the appearance of cystitis glandularis forming a tumorous lesion with blueberry spots suspected to be caused by endometriosis were not reported. We report a rare case of this appearance in the urinary bladder.∼19/hpf) and no pyuria. Blood laboratory data including the tumor markers of carcinoembryonic antigen and carbohydrate antigen 19-9 were within normal limits. Urine cytology revealed no atypical cells and urine culture yielded no microorganisms. Cystoscopy revealed a nonpapillary tumor with blueberry spots on the left posterior wall in the urinary bladder [A 49-year-old woman was admitted to our hospital with pollakisuria and recurrent gross hematuria. She had no previous history of recurrent urinary tract infections. She had a past history of right ovariectomy for ovarian cyst 15 years earlier and had received hormonal therapy for endometriosis of the uterus six months prior to presentation. Urine microscopic examination showed slight hematuria (Red Blood Cells: 10 bladder . Compute bladder . Althoug bladder . PostopeCystitis glandularis is not a rare disease, but a case forming a tumorous lesion with blueberry spots suspected to be endometriosis was a rare appearance of the disease not reported in the past literature. Although the etiology of cystitis glandularis remains unknown, a cause has been postulated that chronic stimulation of the bladder mucosa and chronic inflammation due to urinary tract infection may lead to the overproductive changes in the mucosal cells and glandular metaplasia of transitional epithelial cells. Chronic Cystitis glandularis has been regarded as a potentially premalignant condition predisposing to adenocarcinoma of the bladder. In contrOnly a TUR is performed in most cases for a diagnosis and a treatment of cystitis glandularis. However, there have been some cases in which total cystectomy was performed because of recurrence or continuance of tumor and symptoms despite frequent TUR of the tumor. In our c


The tumor, which originated in the retroperitoneum in the region of the right kidney, was rapidly progressive and ultimately fatal within three months of its diagnosis. In addition to characteristic morphologic features, lipogenic and smooth muscle differentiation were confirmed with immunohistochemical stains for MDM2 and smooth muscle actin, respectively. The tumor also displayed diffuse immunoreactivity for β-hCG in both primary and metastatic sites. This case further expands the clinicopathologic spectrum of lipogenic tumors.Dedifferentiated liposarcomas may display a variety of “heterologous” lines of differentiation, including osseous, vascular, skeletal, and/or smooth muscular. There have been six previously reported examples of leiomyosarcomas associated with high levels of serum human chorionic gonadotropin (hCG) production, comprised of cases originating from the retroperitoneum, spermatic cord, small intestine, and uterus. This report describes the first example of a dedifferentiated liposarcoma that combined both of the aforementioned features: extensive heterologous (leiomyosarcomatous) differentiation and The term “tumor dedifferentiation” and itsunderlying concepts, as used by contemporary surgical pathologists, are basedon the paradigm originally outlined by Dahlin and Beabout in low-grade chondrosarcomas . Tumor dTumor dedifferentiation is probably most wellcharacterized in lipogenic tumors. Although it had been previously noted thatwell-differentiated and pleomorphic sarcomas may be admixed , 4, dediAs with their clinical spectrum, thepathologic spectrum of DDLS has been similarly expanded. Newer morphologicobservations have included a potentially poorly defined interface between theDDLS and its well-differentiated component ,whorledlipoleiomyosarcoma is commonly used formorphologic admixtures of well-differentiated liposarcoma and leiomyosarcoma.[Chondroid metaplasia, rhabdomyosarcomatous,and smooth muscular differentiation have been described in well-differentiatedand myxoid liposarcomas , 21–24; sarcoma.. Howeversarcoma., 11–16. sarcoma.β-hCG).This composite of findings has, to our knowledge, not been previously reported.This report describes an example of a retroperitonealDDLS with extensive leiomyosarcomatous differentiation that was accompanied byhigh levels of serum beta-human chorionic gonadotropin .In 2006, a 67-year-old Caucasian female presentedwith episodic right upper quadrant abdominal pain and associated nausea. Herpast medical history was significant for an infiltrating ductal breastcarcinoma , a stable plasma cell dyscrasia , and a hysterectomy/salpingo-oophorectomy (for benign indications). Acomputed tomographic (CT) scan of the abdomen showed a heterogeneouslyenhancing mass extending from the inferior right renal pole exophytically, withsignificant associated inflammatory changes and some peripheral coarsecalcifications. Portocaval and mesenteric adenopathy were also present. Serumlevels of alpha-fetoprotein, carcinoembryonic antigen, CA15-3, and CA27-29 werewithin normal limits. Notably, a serum β-hCG, which was measured 26 days after thefirst measurement and 25 days after her surgical procedure, measured 1046 mIU/ml. An abdominal CT scan performed shortly thereafter revealed multiple hypodenseliver masses measuring up to 5 cm, with an increase in the aforementionedportocaval adenopathy. Biopsy of one ofthe hepatic masses confirmed the presence of metastatic disease. The patientdeclined further therapeutic measures and expired 2 months later. An autopsywas not performed.Given the high suspicion for a renal cellcarcinoma, the right kidney was resected as well as all grossly identifiableperinephric tumor. Intraoperatively, the mass was noted to be prominently adhered to thesurrounding retroperitoneal tissue. A follow-up serum μ-thick sections were cut and mountedon a glass slide, deparaffinized and rehydrated. Appropriate negative andpositive controls were included. All assays were carried out in an Axiom 36autostainer . Thefollowing markers were evaluated in the liver biopsy and a representativesection of the retroperitoneal mass, in parallel: β-hCG , keratin cocktail comprised of clonesAE1/AE3  and LP34 , dilution 1 : 200, Smooth muscle actin: SMA , Estrogenreceptor-alpha: ER-alpha ,Progesterone receptor: PR , Desmin, Epithelial membrane antigen (EMA) , MDM2 ,and placental-like alkaline phosphatase: PLAP .Twenty sections of the retroperitoneal masswere routinely processed for microscopic evaluation. The liver biopsy was similarlyprocessed. For immunohistochemistry, 4-5 The kidney and associated perinephric tissue measured in aggregate 21 × 10 × 7 cm.Sectioning revealed an inferior pole mass measuring 9.5 cm in maximumdimension, which compressed and distorted the renal pelvis and the tissue inthis region. The cut surface of the mass was largely firm and solid, tan-whitein color, with hemorrhagic areas but no grossly identifiable necrosis.The retroperitoneal tumor displayed the characteristic morphologic features ofDDLS. In the well-differentiated component, large coarse fibrotic bands wereobserved irregularly, coursing through lobules of well-differentiatedadipocytes. Within the fibrous bands, the perivascular regions and within theadipocytic lobules were scattered cells with large irregular and hyperchromaticnuclei . The mitβ-hCG (The retroperitoneal tumor and liver massdisplayed an identical immunoprofile, consistent with the latter being ametastatic deposit from the former. Both displayed diffuse immunoreactivity fordesmin, SMA, β-hCG ,and MDMβ-hCG . The tumα and β—that are noncovalently boundto form a heterodimer [α subunit of hCG is identical to theα subunits of luteining hormone, follicle stimulating hormone, and thyrotropin; the βsubunit therefore provides hormonal specificity [β-hCG has its greatest clinical utility in thediagnosis of gestation, congenital disorders, and germ cell neoplasia. However,it has long been recognized that a wide variety of other nongerm cellneoplasms, predominantly carcinomas, may be associated with elevatedserum β-hCG, in which it appears to function as anautocrine growth factor by inhibiting apoptosis [β-hCG. Amongst the sixpreviously reported examples of β-hCG-producing leiomyosarcomas, two originated in theretroperitoneum [β-hCG remains unclear.hCG, a glycoprotein with a molecular weight of38 000, is comprised of two subunits—erodimer , 27. Thecificity , 27. Thepoptosis , 29. Thepoptosis –33. Rarepoptosis , 34–36,poptosis , and leipoptosis  have beeritoneum , 43, tworitoneum , 41, oneritoneum , and oneβ-hCG production, as evidenced by demonstration of β-hCG expression in the tumor and its metastatic deposit by immunohistochemistry, and an elevation of serum β-hCG thatwas temporally related to tumor progression. The diagnostic utility of MDM2, arecently described marker reportedly useful for distinguishing DDLS from theirhistologic mimics [In the present case, a DDLS with extensive leiomyosarcomatous differentiation was associated with c mimics , was conβ-hCG production by DDLS hasnot been previously reported to our knowledge and is presumed to represent“aberrant” differentiation in a high-grade tumor. Nonetheless, this findingexpands the clinicopathologic spectrum of lipogenic tumors in general.Furthermore, it suggests that liposarcoma should be a differentialconsideration when elevated serum β-hCG is associated with a radiographic mass lesion, especiallywhen the mass is retroperitoneal.


Choroidal metastases from gynaecological primary are extremely rare. There is no documented case in the literature of choroid metastasis in a patient with primary peritoneal carcinoma (PPC).We describe the first case of a 54-year-old woman with a history of borderline mucinous tumour who presented 17 months later with PPC and 21 months after with recurrent disease metastatic to the eye, and review pertinent literature.High index of suspicion is warranted when patients with history of primary peritoneal carcinoma present with visual complaints in order to treat and/or relieve symptomatology from metastatic eye disease. Primary peritoneal carcinoma (PPC) is a rare tumour that is histologically similar to primary epithelial ovarian carcinoma (EOC). Its diagnosis is based on the extent of gross ovarian involvement and microscopic invasion of the ovarian cortex. It diffusely involves the peritoneal cavity often with extensive disease in the upper abdomen affecting mostly the omentum, while sparing or minimally involving the ovaries with microscopic or small macroscopic cancer deposits on the surface of the ovary .It has been shown with the use of histopathologic criteria that these tumors appear more like Mullerian neoplasms than classic mesotheliomas .Since PPC has the appearance of a 'Mullerian' carcinoma and simulates ovarian cancer clinically, distant metastases may occur in the pleura, lung, liver and lymph nodes, while the central nervous system (CNS) remains one of the uncommon sites of metastases ,4. MoreoThere is no documented case in the literature of choroid metastasis in a patient with primary peritoneal carcinoma (PPC). This case represents the first documented report of choroidal eye metastasis from PPC. We also review briefly the related literature using a Medline search and discuss our findings in the present case.A 54-year-old Caucasian woman presented with abdominal distension and on clinical examination was found to have a large ovarian cyst extending up to the xiphisternum. Abdomino-pelvic ultrasound confirmed a multi-loculated cyst. Nineteen years previously she had undergone total abdominal hysterectomy and left salpingo-oopherectomy for endometriosis. The CA 125 level was within the normal limits at 25 u/ml. Laparotomy, washings, right salpingo-oophorectomy and omentectomy was performed. Histology showed a borderline mucinous tumour and the peritoneal washings showed reactive mesothelial cells, FIGO stage 1A. After the multidisciplinary team meeting, no further treatment was recommended. The CA 125 level reverted to normal and she was discharged from hospital follow-up in August 2004.Four months later she presented with right-sided upper abdominal pain. CA125 was found to be raised 2036 u/ml. Computed tomography (CT) of the abdomen and pelvis revealed ascites with disseminated peritoneal deposits and a solitary left lower lobe lung metastasis, but no evidence of malignant disease in the upper abdomen including pancreas. Diagnostic laparoscopy and biopsies were performed; the findings were those of miliary peritoneal and diaphragmatic disease and an omental cake adherent to anterior abdominal wall. The histology of the biopsy from the diaphragm and peritoneum revealed a poorly differentiated adenocarcinoma consistent with primary peritoneal carcinoma. The ascitic fluid was positive for malignant cells.The previous pathology including that of the right ovary from the first laparotomy were reviewed. The patient was confirmed to have had a borderline mucinous tumour of the right ovary with the tumour cells staining positive for cytokeratin 7 (CK7) and CEA but negative for CA 125 and cytokeratin 20 (CK 20) and showing a different immunostaining pattern to the previous ovarian borderline mucinous tumour with positive expression of cytokeratin 7(CK7) and CA 125 but negative for CEA and CK 20.  and B (brightness modulation) ultrasound scan of the eye  . The A sThe patient's condition steadily deteriorated from then on with pain in the right hypochondrium, right shoulder and right posterior chest associated with breathlessness. Computed tomography pulmonary angiography (CTPA) revealed left lower lung metastases with mediastinal encasement by metastatic disease with secondary pericardial effusion and a moderate left pleural effusion and small pulmonary emboli. The pleural and pericardial effusions were drained to control symptoms. The cytology of the pericardial fluid confirmed the presence of malignant cells. She subsequently developed refractory renal failure and died.The incidence of metastatic carcinoma to the eye varies by reports and ranges from 10% – 12.6% in autopsy studies of patients with disseminated cancer ,12 to 0.Ovarian cancer metastatic to the central nervous system (CNS) is reported to occur in less than 1.5% of all ovarian cancer metastases ,16. The Choroidal involvement from gynaecological malignancies is extremely rare. A review of the literature found only seven cases of choroidal involvement from ovarian carcinoma -9,19,20 We believe that the present case is the first reported case of PPC with metastasis to the choroid of the eye. Moreover, this patient is unique in that the choroidal metastases occurred within three years of having a borderline mucinous tumour of the ovary and primary peritoneal carcinoma. In respect to the patient's history of endometriosis it is possible that the disseminated peritoneal tumour may have originated from endometriosis of the peritoneal surfaces. It has been reported that 69% of the malignancy arising from extra-gonadal sites of endometriosis including the pelvic peritoneum show endometrioid differentiation .Although the primary mode of dissemination for EOC and PPC is by transcoelomic spread, haematogenous spread can occur. It seems that the high vascularity of the uvea and specifically of the choroid predisposes the eye to intraocular metastases. The average survival time of patients with choroidal metastasis from any primary carcinoma is 8–9 months after diagnosis . Review Although prognosis is poor, treatment of the eyes should be considered in order to preserve the visual function and/or relieve pain. Local radiotherapy has been shown to be an effective approach and provides significant palliation of symptoms , whereasSince the incidence of distant metastasis from PPC appears to be increasing , we beliThe authors declare that they have no competing interests.NT participated in the design of the case report, KG participated in the design of the literature review, GG participated by adding further ophthalmological infical analysis, RN participated in the design and coordination of the manuscript. All authors read and approved the final manuscript.Since the patient has died, consent was not obtainable, but the relatives has been informed, and are in agreement with the intention to write and publish this paper.


Spinal tumours and ependymomas in particular are rare causes of cauda equina syndrome that present with faecal incontinence.We present a case of a 45 year old gentleman who presents to a colorectal clinic with incontinence. We then present a review of ependymomas with particular reference to the symptoms they cause as well a review of the neurophysiology of faecal continence.Suspicion for non-colonic causes for faecal incontinence should arise when there is absence of other etiologic factors. Establishment of the diagnosis of spinal tumours is with neurological examination and MRI spine. Lower motor neuron symptoms such as lower limb weakness, loss of sensation, sphincter and erectile dysfunction can be caused by disruption of the cauda equina by a spinal tumour (cauda equine syndrome). The symptom of faecal incontinence due to primary spinal tumours however is rare. Is has been reported in lumbar schwannoma of the cauda equina,  lumbosacA 45 year old gentleman is referred to a colorectal clinic with diarrhoea and faecal incontinence for 2 months. He has also suffered with progressively worsening urinary symptoms: hesitancy, frequency and nocturia, poor stream and sensation of incomplete emptying and possible intermittent retention, with urge incontinence over 2 years. Previous review by Urologists revealed no abnormality on cystoscopy, X-ray KUB or renal ultrasound and a diagnosis of prostatitis was made. There was no history of pain, lower limb neurological symptoms and he had normal erectile function. There was no history of diabetes, multiple sclerosis or other neurological disease. On clinical examination, resting and squeeze anal tone were reduced. Perianal sensation was intact. Colonoscopy was requested which revealed a normal colon. Faecal calprotectin and stool cultures were normal. At this stage anorectal physiology was not requested as primary anorectal pathology was not thought to be the cause of these symptoms and there was a clear clinical picture of incontinence therefore manometry would not have altered management. A referral was made to Neurology and re-referral to Urologists.Neurological review 1 month later revealed newly developed mild lower limb numbness when sitting down which disappeared on walking. However there was no deterioration in function. Full central and peripheral neurological examination only revealed a brisker reflex in the right knee.An MRI of the spine showed a lesion just distal to the conus, causing the roots of the cauda equina to be displaced peripherally at the level of L1/2. The lesion enhanced fairly uniformly and appearances were thought to be in keeping with an ependymoma  with no myxopapillary regions Figure . PerivasSix months after initial presentation he had some residual urinary symptoms but his faecal incontinence had resolved.There are numerous causes of faecal incontinence ranging from anatomical , congenital , neurological  and a variety of functional causes Faecal continence is regulated through integrated and coordinated activity between the anal sphincters and rectum. Reflex and voluntary activity of the internal and external sphincters, the puborectalis sling, rectal capacitance and sensitivity also contribute to this. Any abnormality in these factors can results in faecal incontinence, which affects about 1.4% of the population over 40 years of age in the United Kingdom The nervous supply mediating faecal continence is also complex. The anorectum and pelvic floor are supplied by sympathetic, parasympathetic and somatic fibers. Sympathetic preganglionic fibers originate from the lowest thoracic ganglion in the paravertebral sympathetic chain and join branches from the aortic plexus to form the superior hypogastric plexus. The hypogastric nerves unite with preganglionic parasympathetic fibers originating from ventral rami of the second, third, and often the fourth sacral nerves to form the inferior hypogastric plexus, located posterior to the urinary bladder. The inferior hypogastric plexus gives rise to the middle rectal plexus, vesical plexus, prostatic plexus, and uterovaginal plexus. The nerve supply to the rectum and anal canal is derived from the superior, middle, and inferior rectal plexus. Parasympathetic fibers in the superior and middle rectal plexuses synapse with postganglionic neurones in the myenteric plexus in the rectal wall. The pudendal nerve branches into inferior rectal, perineal, and posterior scrotal nerves. The inferior rectal nerve conveys motor fibers to the external anal sphincter, and sensory input from the lower anal canal as also the skin around the anus While cadaveric studies suggested the puborectalis was supplied by the pudendal nerve, electrophysiological stimulation studies in humans suggest this muscle is supplied, strictly ipsilaterally, by branches originating from the sacral plexus above the pelvic floor.The anal canal itself is lined by numerous free and organized nerve endings . Sensory traffic is conveyed by unmyelinated small C fibres and larger A fibres. Anal relaxation induced by rectal distention is mediated by intrinsic nerves. This reflex is absent in Hirschsprung's disease. The extrinsic nerves are not essential for the reflex, as it is preserved in patients with cauda equina lesions or after spinal cord transaction The complexity of these mechanisms emphasise that defaecation is an integrated somato-visceral reflex and that the central nervous system plays a greater role in regulating anorectal sensorimotor functions compared with other regions of the gastrointestinal tract .The elaborate somatic defecation response depends on centres above the lumbo-sacral cord, and probably craniad to the spinal cord itself.Ependymomas are believed to account for 60% of all primary neoplasms of the spinal cord and filum terminale. Most inIntraspinal ependymomas are most easily grouped into 3 classes: intramedullary, myxopapillary ependymomas, and metastases from an intracranial origin. Intramedullary ependymomas commonly occur in the cervicothoracic part of the spinal cord ,14 whileThe most common symptom is pain in the back seen in 70–80% of patients, followed by sensory and motor neurological symptoms in 50–70% -20. AlthFaecal incontinence being the primary presenting symptom in the absence of other neurological symptoms or back pain has not been reported.MRI of the spine is the investigation of choice and complete surgical resection is the treatment for intraspinal ependymomas ,14,19,22Spinal tumours and ependymomas in particular are very rare causes of faecal incontinence. Although diagnosis is easy when the patient presents with full cauda equina syndrome, it may be missed when the presentation is more atypical. Unexplained coexistence of faecal and urinary symptoms in a male should raise suspicion of a spinal lesion particularly in the absence of obstetric trauma, pelvic floor or anal surgery.The author(s) declare that they have no competing interests.The patient was first seen by SP in a clinical context who provided initial consultation and further management.SJ was primary author, performed the review of medical records of the patient and a literature review for this article supervised by SP.AK was the histopathologist who diagnosed the tumour.All authors read and approved the final manuscript.


Splenic ruptures are mostly due to trauma and manifest at the moment of injury with symptoms of acute intraperitoneal hemorrhage and shock. Spontaneous/pathological and delayed rupture of the spleen is not unknown. A case of delayed spontaneous splenic rupture in a case of sickle cell anemia is being reported, which was treated with sub capsular splenectomy (from within the pseudo capsule formed due to inflammation). Many pathological conditions of spleen predispose it to spontaneous rupture, diagnosis of which can be delayed due to its unusual presentation. Splenectomy is often required for splenic rupture, both for its acute and chronic presentations. Chronic splenic rupture may be associated with dense peri splenic adhesions making this surgery a difficult one. In such a scenario, avoidance of iatrogenic trauma to neighboring organs is of paramount importance. Sub capsular Splenectomy (from within the pseudo capsule formed due to inflammation) is an alternative technique and allows a safe splenectomy in cases having dense peri splenic adhesions.KSM, a 50 year old man presented with severe pain over left hypochondrium and left lower chest wall, moderate fever on and off for one month. Pain increased on deep inspiration and radiated to left shoulder. There was no history of trauma or any disease process. On examination, only positive sign was some tenderness over left hypochondrium. Ultrasonography revealed chronic rupture of spleen with some hemoperitonem in the perisplenic area and small pleural effusion. Figure  BiochemiThere was 300 ml of sero-sanguinous fluid in the drain on first post operative day, which gradually subsided and drain could be removed on fourth post operative day. Patient made an uneventful recovery.Causes of pathological rupture of the spleen can be classified as 1) Infections e.g., viral (infectious mononucleosis), parasitic , bacterial (abscess); (2) Congenital (cyst); (3) Metabolic (Gaucher's disease); (4) Degenerative (Amyloidosis). (5) Hematological Malignancy , 6) Vascular , 7) Secondary to chronic pancreatitis, and (8) Miscellaneous causes like Sickle cell disease, Peliosis, cytoreductive chemotherapy etc [ Infectio Vascular SecondarMost patients thought to have delayed rupture of the spleen have, instead, delayed recognition of splenic rupture . Lesser Sub capsular nephrectomy is performed in cases of pyonephrosis with non-functioning kidney as tissue planes around the kidney are lost due to infective pathology. Presence of blood around spleen for one month may have led to dense perisplenic adhesions, which prompted the performance of SCS (from within the pseudo capsule formed due to inflammation), which led to safe and successful outcome in this case.Sub capsular Splenectomy (from within the pseudo capsule formed due to inflammation) is an alternative technique and allows a safe splenectomy in cases having dense peri splenic adhesions. This procedure avoids potentially dangerous attempts at removing all the dense adhesions and fibrin layer that might in some cases have formed a pseudo capsule. The knowledge of this procedure will be an additional weapon in the armamentarium of surgeons, when facing similar problem.The author declares 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.


Caroli's disease is characterized by congenital cystic dilatation of the intrahepatic bile ducts. In 7% ofcasea a malignant tumor develops complicating the course of the disease.        We report the case of a 25 year-old woman in whom Caroli's disease was diagnosed at the age of 11.From that time on, she had several episodes of cholangitis. In 1989, the abdominal ultrasound and CTscan showed dilatation of the intrahepatic bile ducts, intracystic lithiasis and a solid mass. FNA cytologyshowed a papillary adenocarcinoma. At laparotomy a tumor was found occupying both hepatic lobes,and intraoperative US showed another two nodules in the left lobe. The tumor was consideredunresectable. Examination of the hilar lymph nodes was tumor-negative. Two weeks later, the patientunderwent an ortothopic liver transplantation (OLT). The pathological examination confirmed Caroli'sdisease with adenocarcinoma. Two years after OLT, the patient is alive with normal liver function andno evidence of disease.        To our knowledge this is the first case report of adenocarcinoma in Caroli's disease treated by OLT.


Heterotopic gastric mucosa (HGM) is commonly seen in the upper esophagus during endoscopyand is generally considered a benign disease. A hyperplastic polyp and an adenocarcinoma arising in heterotopic gastric mucosa are quite rare occurences.We present two cases: The first is a patient who suffered from dysphagia because of a large hyperplastic polyp that arose from HGM; the polyp was excised endoscopically. Secondly, we report a rare case of adenocarcinoma arising in HGM of the cervical esophagus.Morphologic changes or malignant transformation can develop in the inlet patch. Therefore, gastroenterologists should be aware of the possibility of HGM just distal to the upper esophageal sphincter. Heterotopic gastric mucosa (HGM) in the cervical esophagus appears to result from incomplete replacement of the original columnar epithelium by stratified squamous epithelium in the embryonal period. HGM is found throughout the gastrointestinal tract, the most common site being the cervical esophagus. In endoscopic examination, HGM is frequently seen as a patchy lesion that is salmon or red colored with a sharp border. Macroscopically visible islands of HGM, referred as "inlet patches" are often detected during endoscopic examination. There are morphologic changes  in patients diagnosed with HGM III according to the clinicopathologic classification of esophageal HGM. Malignant transformation via dysplasia and intraepithelial neoplasia (HGM IV) and cervical esophageal adenocarcinoma of the HGM (HGM V) are exceedingly rare as are polyps in the HGM ,2.We present the case of a patient who suffered from dysphagia due to a large hyperplastic polyp that arose from HGM; the polyp was excised endoscopically. Also, we report a rare case of a patient with an adenocarcinoma arising in HGM of the cervical esophagus.A 55-year-old man presented with intermittent dysphagia of two months duration. His dysphagia especially involved solid foods and appeared localized in the upper esophagus. He didn't have any other gastrointestinal disorders including reflux disease. He also suffered from chronic renal failure and hepatitis C. He had been attending a hemodialysis program thrice weekly, but treatment for hepatitis C had not yet been started. He didn't smoke tobacco or drink alcohol.An upper gastrointestinal endoscopy revealed a 5 cm polyp located 19 cm from the incisor teeth Fig. . AlthougPolypectomy was performed on an inpatient basis, due to the concomitant diseases. The patient underwent hemodialysis without heparin. The procedure was done with topical anesthetic and intravenous meperidine (30 mg). An upper gastrointestinal endoscopy was performed with a standard forward-viewing videoendoscope . After submucosal injection of diluted epinephrine (1:100 000), a snare polypectomy was performed using a monofilament polypectomy snare. The resection was performed using the ERBE-ICC 200 cautery device . No residual polyp was visible at the polypectomy site. There were no complications.The resection specimen was a sessile polyp (5 × 1 × 1 cm), with a granulated surface. Microscopically, it was a hyperplastic polyp consisting of gastric mucosa and intestinal metaplasia. There was no evidence of malignancy Fig. .A 57-year-old man underwent upper endoscopy because of odynophagia, dysphagia, nausea and vomiting. His past medical history was unremarkable. The patient did not report any symptoms suggestive of reflux disease in the preceding years. He had no relevant past or family history. His laboratory tests were normal except his hemoglobin . The endoscopic examination revealed a circular area of reddish-appearing mucosa from 21 to 22 cm in the esophagus with polypoid sessile bulgy lesions (each 2–3 cm in diameter) at the anterior wall Fig. . Endoscoet al., 2.2% of gastric hyperplastic polyps eventually transformed into gastric cancer. Thus, the lesion in our patient was considered to carry a small risk of malignant transformation.In the literature there have been five reports of a hyperplastic polyp in the cervical esophagus -7. In onet al. [Adenocarcinomas of the cervical esophagus are rare. Faintuch et al.  reportedet al. .et al. [There are several reports of dysplasia or adenocarcinoma in heterotopic gastric mucosa within the esophagus. 24 cases were reported in the literature . The patet al. . The plaPatients with hyperplastic polyps in the esophagus need to be observed regularly, and we suggest that lesions that cause discomfort or increase in size, as in the case we have outlined, should be excised. Also biopsies should be taken from all identified cases of HGM. Surveillance with repeated biopsies is indicated only when intestinal metaplasia or dysplasia is seen. Endoscopic diagnosis of HGM is difficult and in daily clinical practice HGM is overlooked by many endoscopists. HGM is more commonly seen during withdrawal of the gastroscope. Therefore gastroenterologists should be aware of the possibility of HGM just distal to the upper esophageal sphincter.The author(s) declare that they have no competing interests.HA and ME have been involved in literature search, writing, conception, upper endoscopic contribution; MC made endoultrasonographic contribution and supported conception; SU and SD made final approval; AP and AD made pathological contribution.


Epiploic appendagitis is a rare cause of focal abdominal pain which, depending on its localisation, can mimic a variety of abdominal diseases. We describe a patient with an inflamed necrotic appendix epiploicum with immediate contact to a non-inflamed appendix vermiformis mimicking acute appendicitis. Considering the rare localization, this is the first report of this kind in the literature.We present the case of a 50-year-old Caucasian man who presented with classic signs of acute appendicitis. On clinical exam, McBurney and Blumberg signs were positive. Additionally he had fever, leucocytosis (12/nl) and a slight increase in C-reactive protein (1 mg/dl). Based on the clinical presentation, the patient was taken to the operating room to perform an appendicectomy. Surprisingly, we found an inflamed necrotic appendix epiploicum, located immediately on a non-inflamed appendix vermiformis, which was ligated and excised.This case report demonstrates that epiploic appendagitis can mimic acute appendicitis on clinical exam and should be considered in the broad spectrum of abdominal disease presenting with right lower quadrant pain. Appendices epiploicae are 50 to 100 fatty appendages located on the three large muscle bands known as the taenia coli. They are supplied by small end-arteries originating from the colon. In cases of torsion, the blood supply of the appendage is altered and infarction of the appendage can result. This can be etiological for right or left lower abdominal quadrant pain which can mimic diverticulitis, appendicitis and a variety of other abdominal diseases clinically [The taenia coli mostly fuse together to become the appendix vermiformis. In this case report, we describe a patient with an inflamed, necrotic appendix epiploicum lying immediately on a non-irritated appendix vermiformis mimicking acute appendicitis.We report on a 50-year-old Caucasian man with a 72-hour history of right lower quadrant pain. Three days before presenting in our department, the pain had started in the mid-epigastrium and had gradually shifted to the right lower quadrant. There were no other signs of abdominal pathology, no nausea or vomiting. Bowel movements and micturition were described as normal. Besides his obesity, he was suffering from hypertension and hypercholesterinaemia. He had a history of previous abdominal surgery because of a stab wound injury 17 years ago.On clinical exam, the abdomen was markedly tender with rebound tenderness in the right lower abdominal quadrant (positive Blumberg sign) and positive McBurney sign. The remaining abdomen was soft. There was no sensitivity on percussion and psoas sign was negative. Peristalsis was normal in all four abdominal quadrants, the kidneys were non-tender on palpation, the recto-digital exam was normal. Echographic findings showed dilation of intestinal loops and pathognomonic pendulating bowel motion.Laboratory findings revealed leucocytosis  and a slightly elevated C-reactive protein . The patient had begun experiencing fever with the onset of pain 3 days before.The patient was clinically diagnosed as having acute appendicitis and was taken to the operating room. At diagnostic laparoscopy, we found a macroscopically normal, non-irritated appendix vermiformis. An inflamed, necrotic appendix epiploicum was found lying immediately above the non-irritated appendix vermiformis causing the patient's symptoms Figure . The necInflammation and necrosis of appendices epiploicae is one potential cause of acute abdominal pain and a differential diagnosis for a variety of abdominal diseases. It is a condition which is difficult to diagnose due to the lack of pathognomic clinical features. In addition, it is still a rare diagnosis with low awareness among general surgeons and emergency physicians often causing a diagnostic dilemma. However, there are some characteristics which have been described. Patients are middle aged 40 to 45 years) and present with sharp localized pain mostly in the right or left lower abdominal quadrant . Additio years anInflammation and subsequent necrosis of a pericecal appendix epiploicum should be considered as a differential diagnosis of right lower abdominal quadrant pain potentially mimicking acute appendicitis.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.MS documented and prepared the draft, made substantial contributions to interpretation. GB was the surgeon who performed the operations, made substantial contributions to interpretation and helped in preparing the manuscript. FGB was involved in drafting the manuscript and has made substantial contributions to interpretation. DS was involved in drafting the manuscript and has made contributions to interpretation, performed the literature search, revision of the bibliography and helped with editing of the manuscript. BM edited part of the manuscript and was involved in drafting the manuscript. All authors have read and approved the final version.


Pulmonary artery intimal sarcoma is a rare disease with no characteristic symptoms. It is difficult to diagnose early and is frequently misdiagnosed as a pulmonary embolism.Here we report a case of pulmonary artery intimal sarcoma in a 54-year-old woman presenting with complaints of shortness of breath on exertion. Echocardiography and a computed tomography scan showed that the right pulmonary artery trunk was blocked by a low-density mass. The patient was diagnosed with pulmonary artery intimal sarcoma by pathology and a complete mass resection was performed. After experiencing 10 months of disease-free survival, she was re-admitted because of the recurrence and metastasis of the tumor. Radiotherapy and chemotherapy were performed; however, only limited success was achieved. The patient died 15 months after the initial onset of symptoms.Some patients with intimal sarcoma of the pulmonary artery can benefit from radiotherapy and chemotherapy as well as surgery. Intimal sarcoma of the pulmonary artery (PA) is a very rare tumor with poor prognosis. It is frequently misdiagnosed as pulmonary thromboembolism, and in most cases the definitive diagnosis is made during surgery or upon autopsy. The defining feature of this sarcoma is local growth with slight ability to metastasize . Here weThe patient, a 54-year-old woman, presented with shortness of breath on exertion over the previous three months. Physical examination revealed slight jugular vein distention (JVD); a grade III to VI systolic murmur, which was heard at the tricuspid area; and mild edema of both legs. Laboratory reports were within normal ranges. Echocardiography showed that the right PA (RPA) was almost completely obstructed by a low echogenic mass, and the left PA (LPA) was also partially obstructed, and the superior vena cava (SVC) was dilated with a diameter of about 23 mm. Right ventricle enlargement and tricuspid insufficiency were also revealed. A helical computed tomography (CT) scan showed that the RPA trunk was blocked by a soft tissue mass which grew circumferentially, with only line-like contrast passing through it Figure . The LPA3 was completely resected from the RPA. The diagnosis of intimal sarcoma was made by pathological examination  was performed on the mass in the liver. After treatment, the symptoms were relieved. Two months later, a further CT scan showed extensive metastases to lung, liver and both adrenal glands. The patient died 2 weeks later.Intimal sarcoma is a malignant mesenchymal tumor that arises in large vessels including the aorta and PA. These tumors are characterised by intraluminal growth with obstruction of the tract and seeding of emboli ,2. IntimPA intimal sarcoma arises from the intimal layer of the right, left and main PA. In rare cases, it extends in a retrograde manner to the pulmonary valve and right ventricle . ApproxiPatients with intimal sarcoma present with various symptoms. The most common initial symptoms are dyspnea, hemoptysis and chest pain . Due to Surgery offers the best way to prolong survival and is successful only if complete resection of tumor is performed . PostopeIn this case, the patient had a 10-month symptom-free period after surgery, even though the surgery was a simple local mass resection, confirming the positive role of surgery in the management of PA intimal sarcoma. When tumor relapse occurred in the pulmonary hilum, local 3D-CRT to the mediastinum successfully controlled symptoms of dyspnea and facial swelling. This suggests that intimal sarcoma of the PA may be sensitive to radiation in some cases. In addition, TACE of a metastasis in the liver also relieved pain for 2 months. Unfortunately, further systemic metastases finally developed, and the total survival time for this patient was approximately 15 months from the onset of symptoms.PA intimal sarcoma is a rare tumor. Surgery can prolong the survival of patients and therapies such as chemotherapy and radiotherapy may also contribute to the management of this disease, and where appropriate should be recommended. In addition, systematic evaluation of possible metastasis should be considered as this tumor has the capacity to metastasize.3D-CRT: three-dimensional conformal radiation therapy; CT: computed tomography; JVD: jugular vein distention; LPA: left pulmonary artery; PA: pulmonary artery; RPA: right pulmonary artery; SVC: superior vena cava; TACE: transcatheter arterial chemoembolization.Written informed consent was obtained from the patient's next-of-kin for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.HqL collected the data, QQ drafted the manuscript, and ChX revised and approved the final manuscript. All authors read and approved the final manuscript.


Oesophageal carcinomas represent 3% of all cancers in the UK accounting for 7650 new cases per annum. Oesophageal cancer may be associated with swallowing abnormalities, localised mass pressure effects, lymphatic or distant metastatic spread.We report a 50-year-old man who presented with a painful, enlarging, solid, fixed lesion adjacent to the left buttock with associated dysphagia. Initial endoscopic assessment suggested severe oesophageal inflammation while the lesion in the buttock area was presumed to be a primary soft-tissue neoplasm. However, subsequent histological assessment confirmed a primary oesophageal squamous carcinoma with metastatic spread to the buttock.We discuss the clinical presentation, investigative modalities, and current therapeutic guidelines associated with this rare metastasis and present other atypical oesophageal musculoskeletal metastases. We emphasise the need to consider all aspects of patient symptomatology during the investigation of any atypical lesion. Oesophageal carcinomas represent 3% of all cancers in the UK accounting for 7650 new cases per annum . OesophaA 50-year-old male Caucasian patient from Northern Ireland presented with a 6-month history of an enlarging firm tender swelling adjacent to his left buttock. He also described progressive dysphagia to solids with intermittent odynophagia. He had associated anorexia and weight loss of 7 kilograms over a 3-month period. He had no other gastrointestinal symptomatology. He had no other significant medical history but smoked 40 cigarettes a day. There was no history of oesophageal cancer but his father died from colon cancer aged 87. He drank alcohol occasionally and had no previous proton pump inhibitor usage.9/litre. Urea and electrolytes were normal. The alkaline phosphatase was 129 μ/L and corrected calcium was 3.07 mmol/L. Both carcinoembyronic antigen and CA 19-9 tumour marker levels were raised at 18.7  and 235  units/ml respectively.On examination, he was haemodynamically stable. Abdominal examination was unremarkable. However, he had a suspicious 18 cm × 12 cm mass arising adjacent to his left buttock that was tender on palpation and fixed to the underlying left sacroiliac joint. Initial haematological investigations demonstrated a haemoglobin level of 16.9 g/dl and a white cell count of 9.71 × 10A plain X-ray of the pelvis demonstrated a soft tissue density over the left sacroiliac joint without any evidence of definite bone destruction . An urgeUnfortunately with the advanced nature of the patient's neoplastic disease, aggressive surgical intervention was not appropriate. Oesophageal stenting was discussed with the patient and delayed due to a lack of complete obstructive symptomatology. He had a 2-week course of palliative radiotherapy (10 fraction course) to the posterior aspect of his left pelvis with a moderate response. Unfortunately he has developed a left foot drop which may be related to possible metastatic sacral nerve involvement. Although palliative chemotherapy was planned, he was not fit to undergo the treatment and was referred to the palliative care team. His prognosis remains guarded.Oesophageal cancer occurs in 3% of the population in the UK. In northern China and Iran, it exceeds 100 per 100,000 individuals. In America, the incidence is less than 5 per 100,000, although rates are nearly quadruple for African Americans. The commonest site of oesophageal cancer is the lower third of the oesophagus, followed by the upper and middle thirds. The Scottish Audit of Gastric and Oesophageal Cancer found that adenocarcinoma of the oesophagus was more frequent than squamous cell carcinoma (SCC) in a ratio of 5:4 .Predominant symptomatology includes dyspepsia and progressive dysphagia. Other symptoms include anorexia, weight loss, recurrent vomiting or gastrointestinal haemorrhage . Barium Our patient complained of a painful enlarging buttock mass which was assessed and biopsied radiologically. Although oesophageal adenocarcinoma metastasising to the gluteus minimus has been previously reported, this is the first case of SCC metastasising to the buttock . Other aThe prognosis of oesophageal cancer is poor with the majority of patients with an unresected primary surviving less than 6 months. A study of 838 patients with oesophageal tumours revealed that approximately 18% had metastases at diagnosis . Five ye


Gastrointestinal perforation due to a foreign body is not unknown. The foreign body often mimics another cause of acute abdomen and requires emergency surgical intervention. The majority of patients do not recall ingesting the foreign body. Perforations have been reported to occur in a pathologically abnormal colon.We report an interesting case of a 47-year-old Caucasian man who had a perforation of the sigmoid colon caused by an ingested chicken bone mimicking acute appendicitis. Our patient presented with right iliac fossa pain and local tenderness. When a laparotomy was performed, a chicken bone was found protruding through the sigmoid colon, which was found to lie in the right iliac fossa, thus mimicking acute appendicitis. Our case is different from previously reported cases in that perforation occurred in a non-pathological colon.Our case emphasises the fact that the operating surgeon has to be aware of various differential diagnostic possibilities which mimic acute appendicitis. This has implications on the training of junior surgeons who are often involved in performing these procedures, and may do so out of hours. Care needs to be taken while obtaining consent for the necessary operation. Sigmoid colonic perforation is an acute surgical emergency, the most common cause of which is diverticular disease. Patients present with left iliac fossa pain, raised inflammatory markers and localised peritonitis. Traumatic perforation of the colon due to a foreign body affects the narrowest portion of the bowel, namely the ileocaecal or rectosigmoid junction. Earlier case reports of traumatic perforation of the sigmoid colon emphasise the presence of a background pathology such as diverticular disease, cancer or a fistula. Sigmoid mobility can result in pathologies and present as acute appendicitis. This clearly causes diagnostic confusion and can present a challenge especially to a trainee-grade surgeon.A 47-year-old Caucasian man presented with a 3-day history of colicky generalised abdominal pain, gradually getting worse, eventually localising to the right iliac fossa. The pain was continuous, getting aggravated by movement and relieved at rest. There was no nausea or vomiting. There were four episodes of watery diarrhoea without blood or mucus, which stopped after administering anti-diarrhoeal medication.3 with neutrophilia. C-reactive protein was at 318 mg/L. Urea, creatinine, electrolytes and liver function test results were normal. Dipstick examination of urine was normal. A provisional diagnosis of acute appendicitis was made, and consent was taken for appendicectomy. Because of the physical findings of localised peritonitis, a decision was made to perform a lower midline laparotomy.The patient had no past history of any medical or surgical problems. There were no known drug allergies, and he was not on any regular medications at the time. Clinical examination revealed pyrexia of 39°C, tachycardia of 104 per minute and normal blood pressure. Abdominal examination showed localised tenderness and guarding in the right iliac fossa. Laboratory studies revealed a white blood cell count of 16,400/mmDuring the operation, a small 2 mm) perforation was found in the distal sigmoid colon through which a chicken bone was protruding outward Figure . There w mm perfoA variety of foreign bodies such as dentures, toothpicks, chicken bone, fish bone and cocktail sticks have been implicated in the pathogenesis of gastrointestinal perforation ,2. They Patients do not often remember having ingested the implicated foreign body, which is found either during radiological investigations or during surgery. Patients may have varied symptoms such as abdominal pain, nausea, vomiting, fever, haematochezia or melena. Foreign-body perforation of the bowel presents as acute abdominal emergency and often mimics conditions such as acute appendicitis, diverticulitis or perforated peptic ulcer. Free gas is not a common feature on the abdominal X-ray and was present in only 20% of patients ,7. One rDepending upon the extent of the perforation and its anatomical site, as well as on the basis of the presence of diffuse or localised peritonitis, the treatment of foreign-body perforation will vary from simple suturing, with or without a protective colostomy, to exteriorisation in the form of a colostomy, and the Hartmann operation . Our patDiagnosis of an intestinal perforation can be difficult and requires a high degree of suspicion and awareness on the part of the clinician. Particularly, it can be challenging for a trainee surgeon who is most likely to be involved in operating on patients with suspected acute appendicitis. Our case emphasises an increased awareness of this diagnostic possibility, taking into consideration due implications on obtaining full consent from the patients; this is particularly important when there is a diagnostic dilemma, as this may have future medico-legal implications. It is important to inform patients about an alternative diagnosis and the very occasional need for bowel resection and stoma formation. Previous case reports have shown foreign-body perforations occurring through pathologically abnormal colons  [7-9]. In our patient, the sigmoid colon did not have any abnormal pathology.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.SJ analyzed the patient's data, conceptualised the study and drafted the manuscript, IR performed the surgical procedure and helped in the literature search. SK helped in the literature search and obtained photos and images. SD supervised the process and finally approved manuscript for publication. All authors have read and approved the final manuscript.


We report the first case of an endobronchial perineurioma, a rare benign neoplasm typically occurring in soft tissue. A 53-year-old nonsmoking female presented with a three-month history of persistent bronchitis. A CT scan followed by bronchoscopy demonstrated an endobronchial lesion involving the left mainstem bronchus. Removal of the lesion by bronchoscopy was accomplished. The tumor was composed of bland spindle cells in a variably collagenized stroma. These cells had long cytoplasmic processes. No mitotic activity or necrosis was observed. Neoplastic cells were immunoreactive for epithelial membrane antigen (EMA), CD34, and claudin-1. Smooth muscle actin (SMA), desmin, and S-100 immunostains were all negative. Based on the morphologic appearance and immunophenotype, a diagnosis of perineurioma was rendered. Perineuriomas are rare benign neoplasms representing a proliferation of perineurial cells. Two distinct subtypes are recognized and include soft tissue perineurioma and intraneural perineurioma. Perineuriomas most commonly occur in the dermis and subcutis of the limbs or trunk, but other locations have been reported. Herein, we describe the first case of soft tissue perineurioma occurring in an endobronchial location.A 53-year-old nonsmoking female presented to her primary care physician with a three-month history of a nonresolving upper respiratory infection. A chest-computed tomographic (CT) scan demonstrated a 6 mm endobronchial soft tissue abnormality with slight contrast enhancement at the periphery involving the left mainstem bronchus. Three-dimensional reconstruction of CT images showed similar findings . Bronchoscopic evaluation showed an endobronchial nodule involving the left mainstem bronchus . The lesBronchoscopic biopsies were fixed in 10% neutral buffered formalin then subjected to routine processing and paraffin embedding. Sections were stained with hematoxylin and eosin. Immunohistochemical stains were performed on paraffin embedded tissue using the avidin biotin peroxidase complex method . Antibodies used are shown in Sections of bronchial biopsies demonstrated a cellular proliferation that was situated in submucosal tissue beneath histologically unremarkable bronchial mucosa . The unePerineurioma is a rare benign tumor composed exclusively of perineurial cells. First reported by Lazarus et al., it is typically characterized by an unencapsulated yet circumscribed proliferation of bland spindle cells arranged in a storiform pattern within a variably collagenized stroma. Ultrastructural analysis demonstrates thin bipolar cytoplasmic processes, junctional complexes, and smooth vesicles , 2. In tSoft tissue and intraneural subtypes of perineurioma have been described. Soft tissue perineurioma itself has three types. The sclerosing variant of soft tissue perineurioma presents as a small painless dermal or subcutaneous mass involving the digits or palms of young adults . It is uThe second subtype of perineurioma is the intraneural perineurioma, formerly referred to as localized hypertrophic neuropathy , 17. It Immunohistochemistry is pivotal in the accurate classification of perineurioma. The majority of perineuriomas express EMA with variable expression of CD34 and smooth muscle actin (SMA). Glut-1 is a human red blood cell glucose transporter which is expressed in perineurial cells. In their study, Yamaguchi et al. demonstrated strong reactivity for glut-1 in the five cases they reported . No staiThe clonal nature of intraneural perineurioma has been confirmed by demonstrating a lack of all or a portion of chromosome 22 . DeletioPerineurioma is thought to represent a benign entity. Hirose et al. reviewed 121 malignant peripheral nerve sheath tumors (MPNSTs) from their files looking for cases having perineurial differentiation . A totalThe case presented in this paper represents an endobronchial perineurioma. While perineurioma usually occurs in the skin and superficial soft tissues, it has been reported in unusual sites and should be considered in the differential diagnosis of spindle cell lesions in any location.


Parosteal osteosarcoma is a low-grade malignant bone tumor arising from the distal femur and tibia. Wide resection of a parosteal osteosarcoma usually prevents local recurrence. In literature, hemicortical resections of low-grade malignant bone tumors and allograft reconstruction are described. We describe a new method of resection and reconstruction of parosteal osteosarcoma located in the popliteal paraosseous space of the distal part of the femur using cement and plate (LISS-SYNTHES) through dual medial and lateral incisions. The patient did not present infections and fractures and the functional results were good. After one year, no metastases developed and there were no local recurrences. Parostealosteosarcoma is a rare form of low-grade malignant osteosarcoma which usuallyarises on the surface of the metaphysis of long bones, representing 1–6% of allosteosarcoma . It affeA 34 year-old male arrived to our department after a 6months history of sever pain and swelling located on the posterior cortex ofthe distal right femur. Laboratory data showed a slightly increased value ofalkaline phosphatase. Local preoperative staging of the tumor was done usingplain radiography and MRI with T1 and T2 weighted sequences andcontrast-enhanced series with gadolinium. Preoperative radiography and MRI Parosteal osteosarcoma is an uncommonlesion, low-grade and well-differentiated tumor with rare or limitedinvolvement of the medullar canal . Many pr


We describe an original case of progressive severe dysphagia caused by a posterior mediastinal metastatic melanoma of unknown origin. To the best of our knowledge, such an event has never been described before in the literature.A progressive severe dysphagia case is reported induced by a melanoma of unknown origin . At the time of diagnosis, the lesion appeared as a large posterior mediastinal mass mimicking a neurogenic tumour with oesophageal involvement. After complete resection, pathological assessment of the tumour by immunohistochemistry was consistent with nodal metastatic melanoma.This report of a posterior mediastinal lymph node melanoma is unique. The nodal origin is definitely unusual: a primary melanoma should always be carefully ruled out. In fact no other evidence, a part from the absence of the tumour elsewhere, can support the diagnosis of a primary nodal melanoma. Twenty to thirty percent of all mediastinal tumours are posterior. Most of these (75%) are neurogenic, originating from the neural crest, and often benign (70 to 80%). The remaining histology is rather heterogeneous with lymphoma, teratoma and sarcoma being the most common causes .Symptoms, more often related to malignancies, are usually due to compression or direct invasion of surrounding mediastinal structures and include chest pain, cough, dyspnea or neurological abnormalities. Less frequently, paraneoplastic syndromes can occur.We describe an original case of progressive severe dysphagia caused by a posterior mediastinal metastatic melanoma of unknown origin.A 53-year-old Caucasian man was referred to our centre for absolute dysphagia. This, initiated 4 months before for both solids and liquids, had an insidious onset and was accompanied by a slight cough and persistent fever for which initial antibiotic therapy was prescribed. Fever, usually mild and constantly measured, peaked twice over 40°C.The initial radiological assessment consisted of a chest X-ray showing a large right paratracheal mass. A computed tomography (CT) scan confirmed, at the level of the thorax, the presence of a large (7.5 cm) lobulated mass of heterogeneous density located below the carina. This was clearly compressing the oesophagus. Figure . No evidA subsequent orogastric endoscopic ultrasonography revealed a hypoechogenic lesion 5 cm in maximum diameter and 25 cm from the incisor teeth, with regular margins, directly compressing the oesophagus. Fine needle aspiration cytology, with double sampling by CT guided transthoracic and ultrasound guided transparietal endoscopic procedures in two different regions of the mass, revealed a loosely dispersed population of rare epithelioid atypical cells with prominent nucleoli and abundant eosinophilic cytoplasm. No lesions or compressions were detected at fibro-tracheo-bronchoscopic examination.Because of the rapid worsening of symptomatology, the patient underwent surgical intervention with a minimally invasive approach, initially with diagnostic intent. Should resectability have been confirmed, a radical procedure was planned. A right video-assisted thoracoscopic biopsy was performed. The frozen section demonstrated a malignant epithelioid lesion. Lung origin was excluded and further thoracoscopic exploration confirmed the feasibility of a radical resection.The lesion was radically resected via an open thoracotomy. No signs of direct infiltration of the mass were confirmed at the level of surrounding organs. In particular, the surface of contact with the oesophagus, the right atrium, the main right bronchus and the pulmonary artery was carefully explored. The vagus nerve was identified. A single chest drainage tube was left in situ. The postoperative period was uneventful. The patient started oral intake of fluids on the first postoperative day.Gross pathologic examination of the posterior mediastinal mass showed a grey lobulated mass measuring 8 × 9 × 7 cm Figure . RoutineThe final diagnosis was malignant metastatic melanoma of a lymph node. No evidence of a primary tumour or superficial nodal involvement was detected outside the mediastinum. The patient is alive and well one year after the operation with no signs of recurrent disease in the mediastinum or appearance of other signs of disease elsewhere. Standard adjuvant immunotherapy has been administered.Metastatic melanoma arising from an unknown primary site (MUP) was first described in 1952 [et al. [Rare and sparse reports have reported the characteristics of metastatic melanoma occurring as a mediastinal mass. Lau et al.  discusseTo the best of our knowledge, we believe that this case report is unique even considering the large series reported by Baab and McBride , where oMetastasis to the mediastinal lymph node generally originates from primary thoracic malignancies. In the natural history of extrathoracic malignancies, pulmonary parenchymal metastases are more common than metastatic involvement of mediastinal lymph nodes . MelanomIn our case, the absence of a primary malignancy together with the lack of skin nodal basin involvement suggested a nodal origin rather than a metastatic localization from a skin or mucosal lesion which underwent spontaneous regression The focal presence of residual nodal tissue excluded the exceptional possibility of a clear cell sarcoma arising from mediastinal soft tissue.For the sake of completeness, it is worth mentioning that benign nevus cell aggregates in lymph nodes are believed to be able to instigate primary nodal malignant melanoma, without an obvious extranodal site of origin. This report of a posterior mediastinal lymph node melanoma is unique. The nodal origin is definitely unusual: a primary melanoma should always be carefully ruled out. In fact no other evidence, a part from the absence of the tumour elsewhere, can support the diagnosis of a primary nodal melanoma.The authors declare that they have no competing interests.EM was the principal investigator in the study, operated on the patient, and was involved in drafting the manuscript. AM performed the interpretation of stereomicroscopic information, compiled the technical report and was involved in drafting the article; CM performed the interpretation of stereomicroscopic information, compiled the technical report and was involved in drafting the article; SM operated upon the patient, helped in manuscript drafting and in the collection of the literature. AC has been involved in drafting the manuscript (reviewed the literature and completed the drafting of the manuscript) and gave final approval of the version to be published. All of the authors read and approved the final manuscript.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.


Sir,Brain metastases frequently occur after the diagnosis of systemic cancer. However, some patients with brain metastasis may be diagnosed before the primary tumor is found. ColorectA 55-year-old woman presented with sudden-onset bilateral blindness and altered sensorium of 15 days duration. On ophthalmologic examination, both pupils were normal and direct and consensual reflexes were present. Fundoscopy revealed bilateral optic atrophy secondary to papilloedema. computed tomography (CT) scan of the brain showed a large lesion occupying left parietal space with perilesional edema . StereotMetastatic brain mass is uncommon and frequently associated with metastatic disease elsewhere. Older estimates suggested that metastases constituted of 20–40% of all i


The case of a patient with a second recurrence of a chondrosarcoma of the pelvis and pubic symphysis is presented, in order to show the difficulties of the surgical treatment and the long course of the tumor.A 56-year-old woman having already been operated upon twice within two decades, presented with a large, mass of the pubic symphysis, extending into the left proximal thigh.Preoperative imaging revealed a large tumor occupying the pubic symphysis and the pubic bones up to the ischial tuberosities, extending into the soft tissues of the inner surface of the left thigh and displacing the urinary bladder, the urethra and the vagina.Intraoperatively, a radical excision of the tumor was performed, including removal of the osseous substrate of the anterior pelvis. The anterior abdominal wall was supported with a special synthetic mesh secured on the osseous stumps in order to prevent visceral herniation. Histological examination showed grade I to II chondrosarcoma, while the patient’s postoperative course was uncomplicated.At the latest follow-up two years postoperatively, the patient is pain-free and ambulatory with no signs of tumor recurrence, genitourinary complications or visceral herniation. It comprises a heterogeneous group of neoplasms that are characterized by cartilage matrix production from the tumor cells -3. The pAlthough the majority of these tumors grow slowly, rarely metastasize and have a very good prognosis after surgery, local recurrence is a quite common occurrence especially following inadequate excision. Since radiotherapy and chemotherapy have proved ineffective in the treatment of chondrosarcomas, wide surgical excision remains the treatment of choice ,5. The cWe hereby present a case of a twice recurrent pelvic chondrosarcoma occupying the pubic symphysis that was treated by wide marginal excision and abdominal wall reconstruction with the use of a special synthetic mesh in order to prevent a postoperative visceral herniation.A 56-year-old Greek woman presented with a large mass of the pubic symphysis, extending into the left hip . The patPreoperative imaging revealed a large bilobular tumor occupying the pubic symphysis and the pubic bones up to the ischial tuberosities, extending into the soft tissues of the left thigh inner surface and displacing the urinary bladder, the urethra and the vagina . No signThe tumor was approached through a modified Pfannenstiel incision extending into to inner side of the left thigh. Intraoperatively, a radical excision of the tumor was performed , includiHistological examination confirmed a large pelvic chondrosarcoma of the pubic symphysis, being mainly Grade I and with small areas Grade II that destroyed the cortex and extended into the surrounding soft tissues. Excisional margins were found to be free of neoplasmatic cells.The patient’s postoperative course was uncomplicated. Four months postoperatively she was able to ambulate full-weight-bearing. At the latest follow-up 2 years postoperatively, no urogenital complications or visceral herniation and no signs of relapse of the tumor were noted. The patient was symptom-free and satisfied with the results of her treatment.Wide surgical tumor excision with adequate margins appears to be the procedure of choice in chondrosarcoma treatment, since this is the most effective way of reducing tumor recurrence rate -8. AlthoA recent paper reported a recurrence rate of 100% in grade I pelvic chondrosarcoma following intralesional resection. Hence, although such a procedure may be considered a treatment option in some grade I chondrosarcomas of the long bones of the extremities, intralesional tumor resection should be avoided in the treatment of pelvic tumors . The facMost chondrosarcomas of the pelvis are considerably larger than their appendicular counterparts, averaging 11 cm in size at the time of diagnosis. This could be partly attributed to the poor compartmentalization of the pelvis and the fact that most such tumors, as in our case, give raise to symptoms only after they have reached a relatively large size .After inadequate initial excision there is increased likelihood of local recurrence because recurrent lesions have the propensity to implant in the pelvic soft tissues and do not remain as one isolated large lesion ,10. ThisThe fact that in our case the first recurrence of the tumor took place more than a decade and the second almost 20 years post initial tumor resection indicates another aspect of the natural history of such tumors. Indeed, it is pointed out in the literature, that the index recurrence was seen as late as 87 months after the initial resection, while second recurrence occurred up to 12 years after index recurrent surgery. Thus, patients with a known recurrence should be followed for at least 15 to 20 years, a time considerably longer then that required for most other types of tumors. Unfortunately, even 10 years of monitored relapse-free status does not ensure cure of the disease . Even inThe choice of surgical procedure constitutes a factor of paramount importance. The surgeon has to maintain a subtle balance between ensuring adequate resection margins and the risk of endangering adjacent vital structures as well as the structural stability of the pelvis.According to Enneking and Dunham  the pelvIn order to reduce the possibility of a postoperative visceral herniation due to the removal of the anterior pelvic osseous substrate, we supported the anterior abdominal wall with a special synthetic mesh that was fixed upon the pelvic osseous stumps. This porous, monofilament polypropylene mesh acts as a "scaffold" enhancing growth of the patient's own tissue, which eventually incorporates the mesh into the surrounding area. This technique is often used in abdominal surgery for treatment of sizeable hernias.In conclusion, this case highlights the long natural course of recurrent pelvic chondrosarcoma and supports the current trend that wide resection should be the treatment of choice for such tumors even in the case of recurrence; while a limited reconstruction of the abdominal wall with a mesh may alleviate the consequences of the unavoidable bony resection.


Osteochondroma is the most common benign tumor of the skeleton. However, calcaneal osteochondroma is very rare. Osteochondromas grow during childhood through adolescence, but usually growing ends when the epiphyseal plates close. In an adult, growth of an osteochondroma suggests the diagnosis of malignant transformation to a chondrosarcoma. However, enlargement of an osteochondroma reported as benign after skeletal maturity is present in literature.We report the clinical and radiologic findings of a calcaneal osteochondroma with an extremely rare placement and painfull, rapid reccurence following surgical excision in a skeletally mature female. The lesion showed growth the first-operation later and was re-operated. Histopathological examination did not show malignancy.It should kept in mind that benign osteochondromas can show symptomatic growth in skeletally mature patients without malignant transformation. Osteochondroma is the most common benign tumor of the skeleton. It usually rises from the metaphyseal or metadiaphyseal region of long bones of the appendicular skeleton and are most commonly seen around the knee ,2. OsteoA 25 year-old female patient was admitted to our hospital with painful, stiff mass which was described to be present for nearly one year but increased in size in the last 3 months and became painful recently. In her history no special feature was recorded. In physical examination, about 3 × 2.5 cm stiff, immobile, painful mass placed posteroinferiorly to the medial malleoli was palpated. The mass seemed to be placed on neurovascular structures of the medial ankle. The anterior-posterior (AP) plain x-ray radiography and computed tomography (CT) revealed a bony prominence 27 × 23 mm (cartilage cap thickness: 7 mm) in size raising from posteromedial of the calcaneus and reported to be an osteochondroma Figure , 2. In tOsteochondromas are developmental lesions rather than true neoplasms and they may occur solitary or as multiple lesions, associated with the syndrome multiple hereditary exostoses . OsteochThe evaluation of osteochondromas can generally help clinical findings, and imaging methods such as plain radiography, ultrasonography, CT, MR imaging and bone scanning -3]..3].Osteochondromas are usually asymptomatic, and are seen incidentally on radiography . The mosClinical features suspicious for malignant transformation comprise new onset of pain in a previously stable lesion, rapid or new growth, growth after skeletal maturity, and/or large lesions ,11. ThesAlthough radiography is often diagnostic alone, other imaging modalities may be necessary for surgical planning and to exclude sarcomatous degeneration. The radiographic appearance of this tumor is often diagnostic and reflects its pathologic characteristics. The lesion is composed of native cortical and medullary bone protruding from and continuous with the underlying bone and they appear as sessile or pedunculated ,2. HowevUltrasonography can be used in the measurement of the hyaline cartilage cap thickness ,15. HoweMR imaging is the best radiologic imaging method evaluating hyaline cartilage cap. It also important for visualizing the effect of the lesion on surrounding structures and shows cortical and medullary continuity between the parent bone and osteochondroma. The high water content in nonmineralized areas of the cartilage cap had intermediate to low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. Mineralized areas in the cartilage cap had low signal intensity on T1 and T2-weighted images ,19. HoweMultiplanar reconstruction and three-dimensional imaging features of CT give important information about determining of these lesions. It allows optimal demonstration of the pathognomonic cortical and medullary continuity of the lesion and parent bone as in our case. Murphey et al  believedThe treatment of osteochondromas in the foot is conservative or surgical (excision). Stable, small asymptomatic lesions can be treated conservatively. If the lesion is painful and growing after skeletal maturity, exhibit signs of malignant transformation should be treated surgically. A marginal resection is adequate and shows a low rate of recurrence. Any remaining cartilage cap may result in recurrence, especially in growing lesions .In our case, we thougt that there might be small residue after the first operation because of the difficult placement of the lesion for the surgery. We measured the cartilage cap thickness 4 and 6 mm at the 5th and 6th month of the first operation, respectively, Because of the lesion showed reccurrence and it was painful following the first operation, malignant transformation was clinically considered and the patient was re-operated,. However, histopathological examination did not show malign findings, and there was no recurrence during the 9-months followup.In conclusion, it should keep in mind that benign osteochondromas can represent symptomatic growth in skeletally mature patients without malignant transformation.AP: Anterior-posterior; CT: Computed tomography; MR: Magnetic resonance.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 journal's Editor-in-Chief.The authors declare that they have no competing interests.MK: Searching the literature. Detecting the radiological images and writing radiological parts of the text. ST: Searching the literature. Major contributor in writing the manuscript. Writing the case report and discussion section. Operator (1st operation). LS: Anaesthesist of the 1st operation. Contributor in writing (editing the style etc.). VK: Searching the literature. Contributor in writing the case report and discussion section. All authors read and approved the final manuscript.


Most gastric tumors are adenocarcinomas. Primary gastric adenosquamous carcinoma is a rare malignancy, mostly associated with Asian populations. It constitutes less than one percent of all gastric carcinomas and its clinical presentation is the same as adenocarcinoma. It occurs more frequently in the proximal stomach, usually presents with muscular layer invasion and tends to be found in advanced stages at diagnosis, with a worse prognosis than adenocarcinoma.We report the case of an 84-year-old Caucasian woman with an adenosquamous carcinoma extending to her serosa with lymphatic and venous invasion (T3N1M1). Nodal and hepatic metastasis presented with both cellular types, with dominance of the squamous component.Adenosquamous gastric cancer is a rare diagnosis in western populations. We present the case of a woman with a very aggressive adenosquamous carcinoma with a preponderance of squamous cell component in the metastasis. Several origins have been proposed for this kind of carcinoma; either evolution from adenocarcinoma de-differentiation or stem cell origin might be possible. The hypothesis that a particular histological type of gastric cancer may arise from stem cells might be a field of research in oncological disease of the stomach. Primary gastric adenosquamous carcinoma is a rare malignant neoplasia -3. Most Adenosquamous carcinoma is a mixed neoplasia (gland-like and squamous). Intestinal-type adenocarcinomas may present with variable areas of squamous differentiation. For a diagnosis, it has been established that the squamous component should be present in more than 25 percent of the tumoral sample .It appears more frequently in the esophagogastric junction but, due to its proximity with esophageal mucosa, a collision tumor  cannot be ruled out and the diagnosis of adenosquamous carcinoma should not be made. Adenosquamous carcinomas usually invade deep into the muscular layer, present with venous and lymphatic invasion and tend to be diagnosed later, in more advanced stages. Its biological behaviour is usually determined by the adenocarcinoma component ,6-10.Primary adenosquamous gastric carcinoma is extremely rare in female Caucasian patients, with no cases reported in the international literature.We report the case of an 84-year-old Caucasian woman with a previous history of arterial hypertension controlled with an angiotensin converting enzyme (ACE) inhibitor. She had no other known personal or family history. She was referred to our hospital after consulting another hospital for epigastric abdominal pain. An upper gastrointestinal (GI) endoscopy had revealed an extensive ulcer of the gastric antrum with signs of recent bleeding and the biopsy was not representative of the lesion, so the result was negative for malignant cells.Upon arrival at our hospital, she was pale and underweight. She presented with black stools and early satiety. A hard, well-defined abdominal mass was felt in her epigastrium. Laboratory tests revealed a hemoglobin of 7.1 g/dL, so she had a blood transfusion and was admitted to our hospital. An upper GI endoscopy with biopsy was performed, again with the same results.rd post-operative day.The upper gastrointestinal series was consistent with a mass in the antrum and the abdominal computed tomography (CT) scan revealed a thickening of her gastric wall and a mass without a clear interface with her liver. She underwent a sub-total distal gastrectomy with a Billroth type-2 anastomosis. Intra-operatively, she was found to have a perforated mass with extraluminal growth and adherent to the liver Figure , which lA macroscopic exam of the specimen revealed an ulcero-infiltrative lesion occupying most of the antrum, measuring 8 × 5 × 1.1 cm, and infiltrating her gastric wall to the serosal layer. On cutting the adherent liver fragment, a tumor was identified as a whitish nodular sub-capsular lesion of well-defined limits with a major diameter of 1.5 cm.A pathological exam revealed a poorly-differentiated malignant epithelial neoplasia of solid pattern  and focally glandular with expansive growth Figure . The lesHelicobacter pylori infection. No squamous metaplasia was identified. There was metastatic neoplasia in one of the eight identified lymphatic nodes, as well as in her liver fragment (without infiltration of the Gleeson capsule). A histochemical study with Periodic acid-Schiff (PAS) revealed (intracytoplasmic and extracellular) mucopolysaccharides  with a glandular component, but predominantly epidermoid (approximately 80 percent). No neuroendocrine differentiation was observed (Cromogranin A and Sinaptophysinwere negative) and gastrointestinal stromal tumor (GIST) and melanoma were excluded . The tumor extended to her serosa with lymphatic and venous invasion, and presented with nodal and hepatic metastasis. The nodal Figure  metastasAdenosquamous carcinoma is a rare clinical entity, especially in Caucasian patients. Its occurrence is more frequent in the proximal stomach and in male patients ,11. For We report the case of an 84-year-old woman with an adenosquamous carcinoma extending to her serosa, with nodal and hepatic metastasis (T3N1M1), and also with lymphatic and venous invasion.By reviewing her clinical records and the peri-operative findings, we can presume that her abdominal pain on presentation might be due to a perforation of the tumor next to the small curvature, contained by its close proximity with the right lobe of her liver. In spite of the negative biopsies, she was recommended for surgery due to the presence of obstructive symptoms and GI bleeding.The tumor can be classified as T3 (according to TNM classification) as it was perforated, without direct involvement of other abdominal viscera. As it was a perforated malignant neoplasia in stage IV, a curative resection was not intended and only eight lymphatic nodes were isolated. This quantity of lymph nodes does not allow a precise staging and probably yields it under-staged. Yet, there was metastization in one of the eight nodes studied N1). This finding is consistent with the reports in the literature; that the adenosquamous carcinoma usually behaves like an aggressive adenocarcinoma and presents with early lymphatic metastization . This fi,6,7,10.The presence of a liver nodule not contiguous with the primary tumor was not considered as local extension of the tumor. The absence of malignant cells in the interface between her liver and her stomach, and the presence of a tumor-free Gleeson capsule, reveals the hepatic nodule to be a metastasis and not directly involved. The adherence of her liver tissue to the tumor was probably due to an inflammatory reaction after perforation. As such, the disease was considered metastized and the neoplasia classified as adenosquamous gastric carcinoma, pT3N1M1 (stage IV), which suggests a survival rate below seven percent at five years.The prognosis for adenosquamous carcinoma is usually worse than the intestinal-type carcinoma, although its major biological determinant is the adenocarcinoma component ,10,12. IFive hypotheses have been postulated for its origin: 1) metaplastic transformation of an adenocarcinoma ,7,11,12;The reported findings are not in accordance with a cancerization of ectopic squamous epithelium or metaplasia, nor do they seem related to a collision carcinoma. It occurs where squamous cell metaplasia is almost non-existent (antrum), and when both cell phenotypes are present across all the tumor. There are cellular nests with both histological characteristics, and the metastization pattern is predominantly squamous.These findings support an origin from multi-potential cells suffering double differentiation or metaplastic transformation of adenocarcinoma cells. However, there are no isolated areas of gland-like and squamous differentiation, which favours an early occurrence of both components.The presence of nodal and hepatic metastasis as adenosquamous carcinoma with a large squamous percentage calls into question the hypothesis of the origin in a metaplastic transformation of an adenocarcinoma, as favoured by several authors ,7,11,12.We report the case of a woman with a primary adenosquamous carcinoma of the stomach; rare in Caucasians, in women and in the gastric antrum, and unique in its metastization pattern, which was predominantly squamous. The prognosis of these tumors could not be confirmed, as she died in the post-operative period due to a septic complication.The hypothesis that a particular histological type of gastric cancer might arise from stem cells could become a possible field of research in the oncological disease of the stomach.ACE: Angiotensin converting enzyme; CT: Computed tomography; GI: Gastrointestinal; GIST: Gastrointestinal stromal tumor; (PAS): Periodic-Acid Schiff; SIRS: Systemic inflammatory response syndrome.The authors declare that they have no competing interests.GF, CE and JP wrote the article. GF, EC and JB performed the surgery. GF, JP, TA and EC were the responsible clinicians. CE and MP made the histological diagnosis. MP, JR and AP supervised the paper. All authors read and approved the final manuscript.Written informed consent was obtained from the patient's next-of-kin 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.