A type III hemipelvectomy has been utilized for the resection of tumors arising from the superior or inferior pubic rami.In eight patients, we incorporated a type III internal hemipelvectomy to achieve an en bloc R0 resection for tumors extending through the obturator foramen or into the ischiorectal fossa. The pelvic ring was reconstructed utilizing marlex mesh. This allowed for pelvic stability and abdominal wall reconstruction with obliteration of the obturator space to prevent herniations.All eight patients had an R0 resection with an overall survival of 88% and with average follow up of 9.5 years. Functional evaluation utilizing the Enneking classification system, which evaluates motion, pain, stability and strength of the affected extremity, revealed a 62% excellent result and a 37% good result. No significant complications were associated with the operative procedure. Marlex mesh reconstruction provided pelvic stability and eliminated all hernial defects.The superior and inferior pubic rami provide a barrier to a resection for tumors that arise in the extra-peritoneal pelvis extending through the obturator foramen or ischiorectal fossa. Incorporating a type III internal hemipelvectomy with a simple marlex mesh reconstruction allows for complete tumor resection without functional compromise, acute infectious issues, obturator or abdominal hernia defects. A novel approach to the en bloc resection of extra-peritoneal soft tissue neoplasms, incorporating a type III internal hemipelvectomy, to achieve clear surgical margins, was performed in eight patients.The use of a type III internal hemipelvectomy in the resection of primary bone tumors has been widely employed. Type III resections, as classified by Enneking and Dunham involves resection of the superior and inferior pubic rami and obturator foramen. The useA type III hemipelvectomy is not without its associated complications, which include vascular, bladder and urethral injuries, as well as infections and wound issues related to the groin incision. No recoFrom 1987 to 2011 eight patients presented to NDB with soft-tissue tumors of the extra-peritoneal pelvis extending through the obturator foramen or into the ischiorectal fossa. We employed an operative technique in all of these patients that incorporated a central pelvic bone resection , to achieve an en bloc resection and clear surgical margins. This technique was employed because these tumors both extended into and through the obturator foramen into the adductor group, or below the ischium.Two cases illustrate these presentations and the surgical techniques involved. As an example of a tumor extending through the obturator foramen, a 36 year-old male presented with a slowly growing mass in his left upper thigh for six months. He had an unrecognized history significant for Von Recklinghausen’s disease, and manifested this with several neurofibromas throughout his body, in addition to scattered café au lait spots. His main complaints were of difficulties walking secondary to mass effect, and pain in his left thigh. Pre-operative imaging by computer tomography (CT) was significant for a dominant heterogeneous soft-tissue mass in the left inguinal region causing bony remodeling Figure.Intra-operatively, there was evidence of a large lesion occupying the adductor group of the left thigh with direct extension through the obturator foramen, with intra-pelvic tumor extension along the obturator nerve. The patient underwent wide resection of the lesion encompassing the adductor muscle group in continuity with the en bloc resection of the superior pubic rami, the entire obturator foramen, and the intra-pelvic tumor that extended along the obturator nerve. Once the specimen was removed en bloc, the reconstruction of the pelvic defect was undertaken Figure. After an uneventful hospital stay, he was discharged on post-operative day 7. He has had follow-up at three-, six- and nine-month intervals, and has been doing well. He reports occasional pain, however, is able to walk without assistance, has a well-healed incision with no signs of infection, and no evidence of a hernia. He has returned full-time to his occupation as an excavator.The second case is a 31 year-old woman who presented with a mass bulging into her ischiorectal fossa. Eight months earlier, she had undergone incomplete resection of an angiomyxoma via a lower midline abdominal incision. On clinical examination she had an obvious mass protruding into the ischiorectal fossa adherent to the lateral rectal and vaginal walls. Magnetic resonance imaging (MRI) revealed a large mass occupying the pelvis on the right with direct extension into the perineum . A single sheet of mesh was taken, and the anterior edge folded upon itself with 1-cm overlap. The primary structures to which the mesh was secured were the symphysis pubis medially and the anterior superior iliac spine laterally. Holes were then created in the mesh to allow passage of the femoral vessels and the cord structures. Next, a second piece of marlex mesh was utilized, and secured superiorly to the rectus abdominis muscles, and inferiorly to the superior border of the primary mesh Figure. The addFive patients had malignant tumors, the most common being a malignant peripheral nerve sheath tumor and three patients had locally aggressive benign tumors, two of which were desmoids and one angiomyxoma. The age of the patients ranged from 26 years to 58 years of age, six were male and the remaining two female. The average patient follow-up was 9.5 years. Seven of the eight patients (88%) had follow-up beyond 5 years. One patient in the series died of metastatic disease. Seven of eight patients received post-operative radiation therapy; one patient received intra-operative radiation in addition to post-operative radiation. The single patient that did not receive radiotherapy presented with a locally recurrent desmoid tumor, for which repeat resection was undertaken. One patient developed a superficial wound infection, and one developed significant leg lymphedema after radiation therapy Table.Patients undergoing limb salvage surgery for bone and soft-tissue sarcoma of the extremities can experience significant physical disability as a result of life-preserving treatment. The patients in our series all had good or excellent results. This objective evaluation was achieved using the modified Enneking classification for functional outcomes. The primary factors were motion, pain, stability/deformity, strength, emotional acceptance/functional ability and complications. DependiTumors of the extraperitoneal pelvis with extension through the obturator foramen, or into the ischiorectal fossa, present a surgical challenge to accomplish an en bloc resection. The intact pelvic ring prevents direct access for tumor resection. We have employed a surgical technique incorporating a type III internal hemipelvectomy to achieve an en bloc resection for tumors arising in this region.The internal hemipelvectomy has been widely employed in lieu of a traditional hemipelvectomy for malignant tumors arising from the pelvic bone. In 1978 Enneking classified the internal hemipelvectomy into three types. Type I involves resection of the ilium, type II involves a periacetabular resection, and type III involves resection of the superior and inferior pubic rami. In our series of eight patients, a type III internal hemipelvectomy was performed to achieve an en bloc resection of the primary tumor, despite the lack of bone involvement. This approach allowed direct access to, and complete resection of tumors that extended through or under the bony barrier.A simple technique utilizing Marlex mesh was used to reconstruct the bony defect and prevent obturator or ischiorectal herniations. Marlex mesh was utilized because it had been used extensively for the repair of primary or recurrent inguinal hernias. In a series of 3,000 patients there was an insignificant infection rate of 0.2%. Marlex More sophisticated reconstructive techniques employing autografts or allografts have been utilized for type III reconstructions. Based on 206 patients who underwent pelvic resection at Massachusetts General , Mankin reported a 20% infection rate in patients undergoing pelvic allografts. The majNon-union of pelvic allografts is another potential complication, as is graft failure. In our This operative approach allows for good to excellent functional outcomes without compromising tumor resection.The authors declare that they have no competing interest.All patients presented to NDB for operative planning. SSR conducted the retrospective analysis and drafted the manuscript. All authors read and approved the final manuscript.


Acute appendicitis is a rare condition in neonates, with a high mortality. If perforated, it seldom presents with radiologically significant pneumoperitoneum. An 11-day-old newborn presented with abdominal distension and reluctance to feeds. X-ray abdomen revealed significant pneumoperitoneum. After optimization of his condition, exploratory laparotomy was performed. Perforated appendix was found and appendicectomy done. Post operative course was stormy that lead to demise of the baby. Neonatal appendicitis (NA) is a rare clinical entity. It has a low incidence of 0.04 – 0.2% and is more common in premature male babies.[1] Less than 50 cases have been reported over the last 30 years, with just above 100 over the last century.[2] Neonatal appendicitis usually presents with non-specific symptoms and signs. Because of its rarity and low index of suspicion, it poses a great diagnostic challenge pre-operatively. The resultant delay in diagnosis and its complications like perforation and septicemia confers a high mortality rate of 28%.[3] Herein, we report a case of a newborn who was found to have perforated appendix at laparotomy.An 11-day-old male newborn weighing 2.4 kg was referred with abdominal distension and reluctance to feeds for 8 days. Antenatal history was insignificant. He was delivered at full term via Caesarean section. There was no history of birth asphyxia, cyanosis or seizures. Few hours after birth, he developed respiratory difficulty and admitted to NICU at a local hospital. He had passed urine and normal meconeum in time. Expressed breast milk was given via NG tube while he was at NICU. Laboratory results were within normal limits except leucocytes count of 14400/mm3 with 76% neutrophils and, x-ray abdomen was unremarkable. He received IV fluids and broad spectrum antibiotics. There was no history of fever and vomiting. Despite treatment, his condition worsened. Baby developed gradual abdominal distension and was shifted to another hospital. His repeat laboratory tests showed total leukocyte count of 7,900/mm3 and platelets count of 31,000/mm3. X-ray abdomen showed signs of significant free intra-peritoneal air and ultrasound abdomen was inconclusive. He was then referred to our hospital. On arrival at our facility, the newborn had a heart rate of 126 beats/min and respiratory rate of 38 breaths/min. He had mild dehydration. Abdomen was distended and tense. X-ray abdomen revealed significant pneumoperitoneum. Tube laparostomy was performed initially, which drained free air and only few ml of turbid fluid. After optimization of his parameters, exploratory laparotomy was performed at the 3rd day of admission. Hyperemic but normal consistency small bowel loops covered with flakes of pus were noticed. The whole colon was of normal caliber. A small perforation was found at the tip of appendix . Appendicectomy was performed. Post operatively, despite aggressive treatment his condition did not improve and expired on 7th post operative day. Histopathology of the appendix showed normally innervated appendix, with polymorphonuclear infiltration into serosal and muscle layers confirming the diagnosis of acute appendicitis.Neonatal appendicitis is extremely rare condition. Some authors consider it a secondary pathology, developing as a complication of an underlying disease , while others consider it as a localized form of necrotizing enterocolitis (NEC), limited to the appendix. The theory of localized NEC supports the pathology in our patient as no other cause could be identified. The newborns with early NA usually present with non-specific symptoms and signs. Abdominal distension however, is usually the most common presenting feature.[2] Plain abdominal roentgenograms are usually insignificant in initial stages. The vague clinical features along with low index of suspicion usually result in the delay in diagnosis, predisposing to risk of perforation which is reported to be as high as 80%. Similar was the presentation in the index case. As the disease progresses, respiratory difficulty, temperature instability, abdominal wall changes, a palpable abdominal mass, signs of sepsis may add to the clinical findings. Rarely could pneumoperitoneum be demonstrated on plain roentgenogram as was present in our case. Pneumoperitoneum has a reported occurrence of only 8% in the cases of perforated appendicitis.[8] Plain abdominal x-rays, ultrasound and CT scan abdomen all have been advocated in the radiological workup of a suspected NA, with CT scan abdomen being the most sensitive and specific tool.[2] Treatment aims at early recognition and appendectomy. In conclusion, involved clinicians should be aware of varied presentation of this lethal condition, must keep a high index of suspicion and include NA in the differential diagnoses. Using sophisticated modalities where available and early surgical intervention when the diagnosis is in doubt, may provide a favorable outcome.Source of Support: NilConflict of Interest: None declared


With the progress made in treatments, the survival rate for patients with malignant lymphoma in the last 30 years has significantly improved. However, the risk of experiencing a second primary malignancy or other disease has increased significantly.A 44-year-old Mongolian man with a large mass in his right lower abdomen was admitted to our hospital 15 years previously. The mass was removed, and confirmed via pathological examination to be a malignant B-cell lymphoma in the appendix and distal small bowel. Post-operative chemotherapy with standard cyclophosphamide, hydroxydaunomycin, vincristine (Oncovin®) and prednisolone regimen was given for six cycles. No obvious recurrence was detected over the following 12 years. Subsequently, a mass in the right lung was found on a regular X-ray follow-up; our patient did not report chills, fever or cough. Chest computed tomography and positron emission tomography scans confirmed the mass. A primary lung carcinoma was considered to be the most likely diagnosis. However, after an exploratory thoracotomy and right upper lobectomy was performed a pathological examination of tissue samples demonstrated a lung cryptococcal granuloma, with positive staining for periodic acid Schiff and periodic acid-silver metheramine.Compared to the normal population, second primary malignancy (in particular leukaemia and lung cancer) in patients with malignant lymphoma during their long-term survival has been seen occasionally. However, other diagnoses should also be considered such as pulmonary cryptococcosis. Other than computed-tomography-guided needle biopsy, surgery for some patients is a much more appropriate choice, which could also help attain correct diagnosis and treatment. With the progress made in treatments, in the last 30 years the survival rate for patients with malignant lymphoma has significantly improved. Use of the targeted drug rituximab in CD20(+) B-cell lymphoma has greatly increased the efficiency of treatment and five-year survival rate. However, compared to the normal population, the risk of suffering a second primary malignancy, in particular leukemia and lung cancer, has increased significantly in patients with malignant lymphoma during their long-term survival after treatment -3. UsualA 44-year-old Mongolian man with a large mass in his right lower abdomen presented to our hospital 15 years ago. After completion of relevant physical and laboratory examinations, abdominal laparotomy was performed under general anesthesia, and the mass was removed. Pathological examination and immunohistochemical staining of tissue samples showed a malignant B-cell lymphoma in the appendix and small bowel. Post-operative chemotherapy with a standard cyclophosphamide, hydroxydaunomycin, vincristine (Oncovin®) and prednisolone (CHOP) regimen was given for six cycles. No obvious recurrence was detected during regular follow-up appointments over the following 12 years. Then, three years ago, a mass in the right lung was detected during a regular X-ray follow-up. Our patient reported no chills, fever or cough. The results of a physical examination were unremarkable. A chest computed tomography (CT) scan showed a mass with lobulation and burr in the dorsal section of the right lung, sized 2.4×2.0cm  and periodic acid-silver metheramine (PASM). No acid-fast bacilli were found. All the lymph nodes including six of the bronchial lymph nodes, two of group 2, two of group 3, five of group 4, five of group 7 and one of group 8 showed chronic inflammation (Figure Cryptococcus neoformans. Our patient denied an exposure history of bird secretions, dust and pollen. Previous studies have reported that T-cell-mediated immune dysfunction often occurs in patients with cancer after chemotherapy, who are susceptible to pulmonary cryptococcosis [Diagnosis of pulmonary cryptococcosis usually depends on the etiology of infected tissue cultures or pathology findings. Surgery, percutaneous needle biopsy, bronchoscopy brushing or biopsy, bronchoalveolar lavage fluid culture, smear or culture of cerebrospinal fluid and lymph node biopsy are all effective methods for diagnosis. Combined with the results of PET and lung CT scans, our patient was suspected to have a second tumor: primary lung cancer. However, pathological examination verified the primary pulmonary cryptococcosis, caused by infection of coccosis ,5. We beWritten 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.YY wrote the manuscript. HS, HH and XY participated in the clinical management of our patient. XZ was involved in the final editing of the manuscript. All authors approved the final manuscript.


Pancreatic sarcomas tend to be more aggressive and have a poor prognosis.the case of a 52 year old patient presenting with jaundice is presented and the available literature was reviewed.primary pancreatic sarcomas are extremely rare. Pancreatic sarcomas are more aggressive than other pancreatic neoplasms.primary sarcomas of the pancreas are extremely rare, are aggressive and are associated with very poor prognosis. Sarcomas represent a relatively rare malignant entity. Primary sarcomas of the pancreas are even rarer. Amongst pancreatic sarcomas, leiomyosarcomas have been most commonly reported. A review of the literature reveals seven cases of carcinosarcoma. We report a case of epitheloid carcinosarcoma in a young male patient presenting with pancreatitis and jaundice.A 52 year old male with a history of chronic alcohol consumption was admitted in the medical department of our community hospital with an acute onset of upper abdominal pain, nausea and vomiting. The diagnostic workup revealed elevated amylase and lipase of 1012U/l and 1160U/l respectively. A swollen edematous pancreas caput and gallbladder stones were evident on upper abdominal ultrasound. At the time of admission, an endoscopic retrograde cholangio-pancreaticography (ERCP) was performed. The common bile duct however could not be visualized. ERCP was repeated after three days with papillotomy. A narrow common bile duct without stones or stenosis was visualized [Figure The patient recovered fully and was discharged after 8 days. One month after discharge the patient was readmitted with right upper quadrant pain and jaundice. The routine workup revealed elevated liver enzymes and bilirubin . Cholecystitis was evident on upper abdominal sonography. Choledocholithiasis was present on ERCP, papillotomy and stone extraction were uneventful. Cholecystectomy was indicated.Laparoscopic cholecystectomy was performed. During laparoscopy the main bile duct appeared unusally wide even after papillotomy and stone extraction, thus an intraoperative cholangiography was performed. This revealed a significant stenosis in the distal end of the choledochus. The proximal bile duct branches were dilated Figure . An ERCPOn laparotomy a large tumor of the pancreatic caput enclosing the superior mesenteric and hepatic arteries with mesenterial infiltration was identified, making a complete resection unlikely. The tumor was left in situ and trans-duodenal biopsies were taken for histopathology. With a choledochus stent in place, a biliodigestive anastomosis was not indicated. To prevent future bowel obstruction, a gastroenteric anastomosis was constructed using small bowel 40 cm distal to the ligament of Treitz. The postoperative recovery was uneventful. A venous port system was implanted 10 days after laparotomy. The patient was discharged to our out-patient oncology. Chemotherapy with Gencitabine, 5-Fluorouracil and Folinic acid was initiated.Histologic sections revealed large neoplastic cells with epitheloid and sarcomatoid differentiation. Immunhistochemical staining demonstrated a co-expression of cytokeratin and vimentin. Stains for Caldesmon, CD 34, CD 31 and S100 were negative. A pure sarcoma or melanoma could be excluded on immunhistochemistry Figure .th case in the English literature [Sarcomas of the pancreas are exceedingly rare. Baylor et al reported a 0.1% incidence of pancreatic sarcoma after review 5000 cases of pancreatic cancer . Epithelterature . Thus thAccording to Feather et al sarcomas of the pancreas occur frequently in younger individuals. The pancreatic caput is most commonly involved followed by the tail and the body . These fClinically patients present with colicky pain, nausea and vomiting. These findings are basically similar to those of other pancreatic pathologies and are thus unspecific to sarcomas. Gray and many others consider a painless jaundice as a sign of an advanced lesion . This waThe diagnosis of pancreatic pathologies is usually confirmed using imaging techniques like ultrasound, computed tomography (Ct), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreaticogrphy (ERCP) -8.On initial presentation abdominal ultrasound and ERCP were not suspicious of a pancreatic malignancy as seen in figure Surgical resection is the only possible cure for pancreatic malignancies. Radical resections are done for localized lesions. Advanced lesions warrant palliation. Potts et al proved the importance of a palliative gastric bypass in advanced stages .In this case, the patient presented with an advanced tumor, so curative resection was not feasible. A palliative gastroenteric anastomosis was done. The common bile duct was not revised since a stent was placed during ERCP . A venouPancreatic cancers generally have a poor prognosis since they tend to be diagnosed in an advanced stage. Sarcomas of the pancreas tend to grow much more rapidly and are believed to be associated with an even worse prognosis .In the case presented, the sarcoma could have grown within three month, i.e between initial presentation in November 2010 and diagnosis in January 2011. This would support the notion that sarcomas tend to grow rapidly. The patient was discharged from the surgical department in a good shape and chemotherapy with Gencitabine, 5- FU and folinic acid was initiated.Primary sarcomas of the pancreas are extremely rare. Although little is known about pancreatic sarcomas, they appear to be more aggressive and are associated with a worse prognosis.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 journalDrs. Ambe, Kautz, Shadouh, Köhler and cand med. Heggemann have no conflicts of interest or financial ties to disclose.PA, CK and SH did the literature research, PA wrote the article, SS did the pathology, LK edited the article. All the authors reviewed and approved the end version


Myositis ossificans circumscripta is a form of heterotopic ossification that is benign in nature associated to a trauma, but may appear clinically and radiologically as a malignant neoplasm. We describe a rare case of calcifying of myositis ossificans not associated to trauma in a 35-year-old woman with a mass in her upper third and external of right thigh. We discuss some of the difficulties of diagnosis and histological evolution of the lesion.Myositis ossificans; Thigh; Differential diagnosis; Nontraumatic Myositis ossificans circumscripta (MOC) is a form of heterotopic ossification that is benign in nature but may appear clinically and radiologically as a malignant neoplasm . It is mA 35-year-old caucasic woman, no previous personal or family history of interest, visited our hospital and presented upper third and external of right thigh mass. On physical examination, a slightly tender, hard, not well-circunscribed mass was palpated in the external of right thigh. She denied any previous history trauma including exercise-related trauma. The laboratory findings were normal. Computed tomography of the thigh showed a 42 × 27 mm mass. A faint calcification was noted in the peripheral area of the mass. Bone gammagraphy presented intense uptake in soft tissue with central area low uptake . EchograNontraumatic MOC is a rarely reported benign heterotopic ossification characterized by the aberrant formation of bone in extraskeletal soft tissues. It is usually confined to a single muscle or muscle group, and is most common in active male within the second and third decade of life . It usuaMOC is essentially a proliferative mesenchymal response to an initiating injury to the soft tissue, not necessarily to the muscle, which leads to localized ossification. In the first week, richly vascularised, proliferative fibroblastic cells are prominent. These primitive mesenchymal cells, with high mitotic activity, can mimic malignancy on biopsy. With maturation of the lesion, which is variable, a typical zonal pattern develops with three distinct zones: (1) the centre consists of rapidly proliferating fibroblasts with areas of haemorrhage and necrotic muscles; (2) the intermediate or middle zone is characterized by osteoblasts with immature osteoid formation and islands of cartilage due to enchondral ossification; (3) the peripheral zone is composed of mature bone, usually well separated from the surrounding tissue by myxoid fibrous tissue. Then, by the third to fourth week, calcifications and ossifications appear inside the mass; by the sixth to eighth week, a well-organized cortical bone with cortex and marrow space formation develops at the periphery .Computed tomography is the gold standard in characterizing typical findings of myositis ossificans such as extensive muscle and perilesional edema without bone marrow or cortical abnormalities. The magnetic resonance imaging (MRI) findings vary dependent on the stage of maturation and the histologic pattern of the lesion. For early stage lesions, T2-weighted images show a heterogeneous localized mass with high signal intensity in the central area. As the lesion matures, the peripheral ossification becomes denser, and the T2-weighted MRI shows a hyperintense area with surrounding hypointense rim. On T1-weighted images, the lesion is isointense to the muscle and can be identified by mass effect but it may demonstrate rim enhancement in the acute phase after contrast administration .Histologically, the differential diagnosis should include osseous osteosarcoma and fibro-osseous pseudotumour of digits. MOC tends to show a typical zonal pattern with a fibroblastic center and a broad zone of ossification at the periphery, while the central portion tends to show loosely arranged spindle cells with no cytologic atypia. Osteosarcomas have a disorderly growth with a reverse zoning effect. Immature woven bone or osteoid is found on the periphery, and mature osseous trabeculae are centrally located and also show proliferating cells with cytological malignant features.The most common treatment of MOC is a surgical excision. Various treatments such as physical therapy, acetic acid iontophoresis treatment, magnesium therapy, and etidronate disodium have been reported to be effective .Nontraumatic MOC of the upper third and external of right thigh is rare, and a thorough knowledge of the clinical-morfological study is necessary to differentiate this lesion from a malignant soft tissue tumor.


We present a case of angiosarcoma in small bowel, presenting with partial small bowel obstruction in a 79-year-old man with no history of radiation, chemotherapy, toxin exposure, or previous operative intervention. Angiosarcoma of small bowel is a rare entity which may present with nausea, abdominal pain, recurrent bleeding, and usually a history of prior radiation or exposure to specific toxins (polyvinyl chloride). Angiosarcoma of small bowel tends to spread rapidly and has a poor prognosis. We review the surgical and oncologic challenges. We report unique macroscopic findings of raised hyperemic margins, which are suggestive of a vasogenic lesion and the histologic feature of a partially retiform pattern with dense basement membrane material in an otherwise poorly differentiated lesion. Small bowel tumors of any type are infrequent, and the differential diagnostic evaluation at presentation has many challenges . AngiosaWe describe the clinical and pathologic features, as well as the differential diagnosis, of a rare case of angiosarcoma of small bowel in a 79-year-old man with no prior history of intra-abdominal radiation who presented with small bowel obstruction. 3/mm3. A computed tomography (CT) scan of the abdomen and pelvis with contrast showed air filled dilated loops of small bowel with scattered air-fluid levels felt to represent an early obstruction. The admission diagnosis was partial small bowel obstruction. After the initial 2 days of the hospital stay, the patient appeared to improve clinically with decrease in white blood cell count, decrease abdominal pain while tolerating an oral diet; however, a repeat CT scan now revealed an apple core lesion near the mid jejunum  and most often arises in subcutis. Involvement of internal organs is predominantly heart, liver, and spleen , 6. The We report a case of primary angiosarcoma of small bowel in a 79-year-old man who presents with partial small bowel obstruction. Presenting signs and symptoms for this rare entity, as reported in the medical literature, most often include abdominal pain, nausea, recurrent gastrointestinal bleeding, however, obstruction without intussusception or prior irradiation has not been documented. This tumor tends to spread rapidly and has a more advanced stage at diagnosis; therefore, prognosis is grim. In our review of English literature, most patients with angiosarcoma of small bowel presented with abdominal pain, nausea, and diarrhea. In addition, these patients may require frequent blood transfusions, and death often results from uncontrollable hemorrhage . There aAngiosarcoma may show features similar to spindle cell melanoma, spindle cell carcinoma, and mesothelioma. The cells stain for vascular markers such as CD 31 (90% angiosarcomas), CD34 (50% of angiosarcoma), and less often with von Willebrand factor and occasionally show cytokeratin immunoreactivity . CD 31 iMacroscopic findings generally include a markedly hemorrhagic appearance with poorly defined invasive margins. The histologic differentiation may vary from benign appearing vascular proliferation to undifferentiated malignancy. The histologic presentation includes vascular abnormalities of the small intestines which may present as florid vascular proliferation. These lesions show minimal nuclear atypia and low mitotic rate . Differential diagnostic considerations include hemangioma, Kaposi's sarcoma , lymphangiosarcoma, poorly differentiated carcinoma, or amelanotic spindle cell variant of melanoma. Among the three stages of Kaposi sarcoma (KS), the advanced patch stage of Kaposi sarcoma resembles the well-differentiated angiosarcoma. The histologic features that help differentiate angiosarcoma from KS are the presence of cavernous vessels and epitheloid endothelial cells seen in angiosarcoma and the presence of intra- and extracellular eosinophilic hyaline granules in KS . In addiSince the tumor of our surgical specimen is strongly positive for CD31, it confirms our diagnosis of a vasogenic lesion. The tumor is negative for S100, SMA, and CD117 and helps to exclude melanoma, Kaposi sarcoma, and an epitheloid gastrointestinal stromal tumors. The clinical course, for most well-documented sites, includes repeated local recurrences. Angiosarcomas tend to spread by hematogenous mechanism and the most frequent metastatic sites depend on site of origin. Angiosarcomas of small bowel tend to metastasize to liver, lung, lymph node, other intra-abdominal sites, skin, spleen, urinary bladder, bone, gall-bladder, pancreas, and brain. Although rare, patients with angiosarcoma of the gastrointestinal tract have a very aggressive clinical course with a 6-month prognosis following initial diagnosis. Death is most often related to refractory bleeding and metastasis . TreatmeThe French Sarcoma Group recently published a phase II study of targeted therapy with Sorafenib, a small molecule inhibitor of VEGFR and B-RAF in cutaneous and visceral angiosarcoma . The ratStaging follows the American Joint Cancer Committee format for visceral sarcomas of small intestine. A tumor perforating visceral peritoneum as seen in the present case should be staged as T4. Lymph node metastasis in soft tissue sarcomas is reported as N1; and presence of positive nodes (N1) in M0 tumors is considered Stage III. Whereas metastasis in 1 to 3 regional lymph nodes is N1, and metastasis in 4 or more regional lymph nodes is N2. In summary, we report unique macroscopic features of a small bowel angiosarcoma (presenting as obstruction) in an elderly male patient without either recurrent gastrointestinal bleeding, history of prior irradiation, or specific toxin exposure. This is not only a rare diagnostic entity in itself but also, we believe, a novel presentation of obstruction without a history of either prior radiation or toxin exposure. This entity usually has an aggressive course with a poor prognosis. This entity should be in the differential diagnosis or be a diagnostic consideration in a patient who presents with obstruction and a tumor with raised markedly hyperemic tumor margins.


Mature cystic teratomas (MCTs) are the most common germ cell tumors of the ovary. Malignant tranformation occurs in 1-2% of these neoplasms. Although most of the malignancies arising from MCTs are squamous cell carcinomas, adenocarcinoma of the gastrointestinal type is extremery rare. We herein present a case of adenocarcinoma of the intestinal type arising from a MCT.A 49-year-old female underwent surgery for a left ovarian tumor. The histology of the cyst walls revealed a MCT with a few hair shafts and a squamous layer, while another part of the tumor showed adenocarcinoma of the intestinal type. Five years after surgery, she is alive without disease. Mature cystic teratomas (MCTs) are the most common germ cell tumors of the ovary. MCTs comprise 18% of ovarian neoplasms, and malignant teranformation occurs in 1-2% of these neoplasms. We hereA 49-year-old female, gravida 5, para 3, presented with dysuria and hematuria. Her past medical, surgical, gynecological, and family histories were all unremarkable. Her menstrual cycle was irregular. A bimanual pelvic examination identified a movable mass in the left adnexal region. Vaginal ultrasound confirmed the presence of a polycystic mass of 67 x 57 mm in diameter without a solid component, suggestive of ovarian tumor Figure. AscitesAn exploratory laparoscopy revealed an enlarged left ovary (80mm × 70mm). The surface of the tumor was smooth and well-circumscribed. There was no adherence to any other pelvic organs. A small amount of ascites was detected, and the cytology of ascites was negative for malignancy. A laparoscopic left salpingo-oophorectomy was performed, and the intraoperative diagnosis of frozen sections was suspicious of borderline malignancy. Therefore, we changed the procedure to a laparotomy and abdominal simple total hysterectomy, and a right salpingo-oophorectomy and partial omentectomy were carried out. The patient’s postoperative course was uneventful. The pathological findings revealed the tumor to be adenocarcinoma of the intestinal type arising from a MCT. The serum level of CEA was normalized 7 days after surgery. We explained to the patient that there was no evidence about the need for adjuvant therapy because the disease is extremely rare. She decided not to receive adjuvant therapy. The patient had no recurrence of the disease as of 5 years after the surgery.Macroscopically, the resected ovarian mass was cystic and contained sebaceous material, hair, and calcification. The inner surface of the mass was rough, and had partial thicking-like nodules Figure. The groIn the immunohistochemical staining studies, CK20 (Dako) and Muc-2 (Novocastra) were positive, and CK7 (Dako), Muc-5AC (Novocastra) Figure, Muc-6 .Malignant transformation of MCTs has been recorded as occurring in 1-2% of cases. AdenocaMCTs of the ovary represent the majority of benign ovarian neoplasms in females younger than 30 years of age, whereasRecently, laparoscopic surgery for benign ovarian cystic tumors has been performed rather than laparotomy. However, there have been concerns about artificial tumor rupture due to chemical peritonitis and the spread of tumor cells. Hackethal et al. reviewedSeveral reports suggested that the SCC antigen, either alone or in combination with other markers, such as macrophage-colony stimulating factor (M-CSF) and carcinoembryonic antigen (CEA), should be considered useful markers for squamous cell carcinoma arising from MCTs for making a preoperative diagnosis-12. On tMCTs might occur as a result of failure of the first meiotic division, but it is unclear how the malignant transformation of MCTs occurs. Rim et al. studied It is difficult to make a diagnosis of malignant transformation of a MCT preoperatively. MRI findings may be helpful to distinguish malignant transformation from benign neoplasms. Several reports have revealed that an important feature of the malignant transformation of MCTs was the existence of an enhanced solid component in MCTs-18. In oWhen malignant transformation of MCTs is suspected preoperatively, enhanced MRI, intraoperative consultation and a postoperative histological diagnosis are very important.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.MT, MK, YT and MO carried out surgery of the patient and drafted the manuscript. TY, MK, YT, ST and MT examined microscopically surgical specimen and performed the immunohistochemical staining of the tumor. MT, MK, FS and SY reviewed papers about the MCTs. MT, MK and MO conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


Intrahepatic gallbladder perforation with chronic liver abscess formation was anecdotically reported in the literature. The aim of this work is to report a case of intrahepatic gallbladder perforation and its atypical clinical presentation.A 62-year-old male patient came to our observation; his medical history showed intermittent fever up to 39-40°C of about 2 weeks and anorexia, with an overall weight loss of about 12 Kg. Physical examination of the abdomen was negative. An ultrasound of the liver and an abdominal CT angiogram detected a disomogeneous hypoechoic-hypodense area in the 5th segment of the liver. Differential diagnosis between hepatic abscess or gallbladder cancer remained open. A surgical exploration was planned. After laparoscopic exploration, a conversion to open procedure with an atypical resection of the 5th hepatic segment was performed. Histologic examination of the specimen showed an intrahepatic chronic perforation of the gallbladder with intrahepatic abscess.To the best of our knowledge, 18 cases have been reported in the literature as a Niemeier type I perforation. Clinical presentation, even in its extreme rarity, is more often acute. Differential diagnosis between gallbladder cancer versus liver abscess remains controversial. Open approach is mandatory in such cases. Perforation of the gallbladder has become a relatively uncommon complication of the natural history of cholelithiasis during acute cholecystitis (0.8-3.2% in recent reviews) . It usuaA 62-year-old male patient came to our observation with an initial diagnosis of clinically silent long-term inguinal hernia. His medical history showed intermittent fever and anorexia had been present for one year. In detail, the patient reported that over the previous year he had had alternating intermittent fever up to 39-40°C of about 2 weeks with quiescence periods of about 20–30 days, every few months together with an overall weight loss of about 12 Kg. These symptoms were not associated with any other abdominal or thoracic signs. Physical examination of the abdomen was negative. The fever disappeared after an empiric antibiotic therapy with third generation cephalosporins (1 gr. for 12 days) was started. Laboratory blood samples obtained when the patient was febrile, showed 12,000 WBC count; liver function tests were in the normal range and serologic screening for Salmonella and Brucella antibodies were negative. Blood cultures, antibiograms and tumor markers were also negative .An ultrasound scan of the liver and an abdominal CT scan Figure A detecteIntra-hepatic gallbladder perforation is generally considered to be a very rare evolution of cholelithiasis, in fact, to date, performing a Pubmed search using as key words: “Intrahepatic abscess, intrahepatic gallbladder perforations, Neimeir’s type I perforation, chronic gallbladder perforation” and then using “related articles” and “see reviews” functions of the database, 20 articles were selected but after reading them and avoiding the well-known confusion  and mistIntrahepatic gallbladder perforation with abscess formation should be considered an exceptional clinical entity. Despite new diagnostic tools, differential diagnosis with cancer sometimes remains challenging.It is our opinion that an open approach or early conversion should, in these cases, as in other Niemeier’s perforation type I , still bWritten 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 of BMC Surgery.Kg: Kilograms; Gr: Grams; CEA: Carcioembriogenic Antigen; WBC: White blood cells; CT: Computed tomography; US: Ultrasound scan; MRI: Magnetic resonance imaging; ERCP: Endoscopy retrograde colangiopancreatography.Marcello Donati, Antonio Biondi, Francesco Basile and Salvatore Gruttadauria have no conflict of interests.DM wrote the paper and made the final revision. BA collected data and reviewed the text. FB designed the study, chose figures and reviewed the paper. GS coordinated the study, performed the operation, made style and language revision. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/14/6/prepub


Hepatic pseudolesions detected by helical computed tomography (CT) are not rare, but it is difficult to make a final diagnosis when the hepatic lesion is complicated by the presence of greatly elevated alpha fetoprotein (AFP). Clinical treatment of non-typical hepatic pseudolesions complicated by greatly elevated AFP should confirm the diagnosis and minimize trauma.Non-invasive procedures including ultrasonography, CT, and micro-invasive digital subtraction angiography could not safely differentiate this lesion from a malignant focus when it was complicated by greatly elevated AFP. Laparoscopic hepatectomy was performed, and pathological analysis showed chronic hepatitis, nodular regenerative hyperplasia, focal nodular hyperplasia of the liver, and mild vascular malformation. The tissue was HbsAg(−), HbcAg(−), and AFP(+).Heightened awareness of hepatic pseudolesion complicated by primarily elevated AFP will help physicians avoid unnecessary invasive procedures. Hepatic biopsy is inevitable because of greatly elevated AFP. For suspected hepatic pseudolesion with elevated AFP, needle-core biopsy and follow-up surveillance instead of hepatectomy are recommended to find the source of AFP and make a final diagnosis of pseudolesion. Hepatic pseudolesions adjacent to the falciform ligament have been observed using computed tomography (CT) , but no Here we present a case of a non-typical hepatic pseudolesion observed on CT that was complicated by chronic hepatitis and elevated AFP. We aimed to identify rational clinical procedures that minimize trauma and that help diagnose a non-typical hepatic pseudolesion complicated by elevated AFP.A 23-year-old woman presented with elevated AFP during routine physical examination. There was no history of viral hepatitis, drug abuse, or abdominal surgery. Her AFP was 1,127 ng/ml, and she was negative for human chorionic gonadotropin, hepatitis B virus, hepatitis C virus, and hepatitis G virus. Her HbsAb was 748 IU/L. Her other biochemical measures were as follows: aspartate amino-transferase, 17 U/L; alanine aminotransferase, 13 U/L; albumin, 46 g/L; globulin, 31 g/L; and total bilirubin, 12.7 μmol/L. Diseases of the reproductive and urinary system that are associated with abnormal AFP levels were excluded. A lesion in the liver was not detected by ultrasonography, but we observed a blunt liver edge and rough echo patterns throughout the liver, suggesting chronic hepatic disease. Incremental helical CT was performed to characterize the hepatic disease. A suspected low-attenuated lesion of irregular shape was found in all phases of helical CT with a 32-row detector in section IV adjacent to the falciform ligament  to rule out obvious vascular malformation or a malignant lesion. The lesion was not obviously enhanced in DSA, and no clear blood supply or arterial-portal fistula was found Figure . After fHepatic pseudolesion detected by CT that is complicated primarily by elevated AFP is confusing since it is difficult to rule out a malignant lesion using routine non-invasive procedures. However, excessively invasive procedures are associated with increased health risks. Ideally, clinical procedures should confirm the diagnosis while minimizing invasion and cost.Abnormal AFP with normal liver function and negative viral evidence were the major factors that were confusing in this case. AFP is produced by normal gastrointestinal cells, yolk sac cells, and fetal hepatocytes after birth . AFP levElevated AFP is a typical sign of pregnancy and teratoma ,10. WhenUltrasonography is the first test that should be performed when a hepatic lesion is suspected. Some hepatic pseudolesions, such as the one caused by rib compression during CT, may be negative in non-invasive transabdominal ultrasound . In the CT and CT arterial portography images show hepatic pseudolesions as areas of low attenuation with a triangular shape located adjacent to the falciform ligament; these findings may indicate a pseudolesion with focal fatty infiltration . HoweverMRI can be used to detect a pseudolesion , and higDSA is a micro-invasive procedure that is usually utilized to diagnose and treat HCC. Although a false negative for HCC by DSA is a possibility, DSA can differentiate a hepatic pseudolesion caused by vascular malformation from a malignant lesion . UnfortuAlthough AFP levels might be elevated in patients with chronic liver disease, it seemed difficult to differentiate a benign tumor with abnormal AFP from a malignant hepatic lesion using only laboratory tests and non-invasive or micro-invasive procedures. Here, hepatic biopsy had to be performed since pathological results were needed to make a precise diagnosis.In the case reported here, the lesion observed on the CT images was interpreted as a suspected malignant lesion after we performed laboratory tests, non-invasive transabdominal ultrasound, and DSA. Laparoscopic hepatectomy without the Pringle maneuver and hepatic inflow occlusion was performed to avoid a false negative and possible implantation metastasis due to needle-core biopsy . The lesHere we present a case of hepatic pseudolesion observed by CT that was complicated by primary non-viral chronic hepatitis  with elevated AFP. This pseudolesion may have been caused by focal nodular hyperplasia of the liver plus mild vascular malformation. This condition can present as areas with low attenuation at all stages of enhanced CT. It is typically adjacent to the falciform ligament and negative on non-invasive ultrasonography and DSA.Heightened awareness of hepatic pseudolesion complicated by primary elevated AFP will help physicians avoid unnecessary invasive procedures. Diseases outside the liver that present with elevated AFP should be excluded first. MRI is recommended to provide clues of pseudolesion. Hepatic biopsy and follow-up surveillance rather than hepatectomy are recommended when non-invasive and micro-invasive procedures cannot provide enough evidence for a final diagnosis. More knowledge on primary non-viral  chronic hepatitis with greatly elevated AFP levels and Child A liver function is in need. Additional procedures that are less invasive are needed to better diagnose and treat hepatic pseudolesion complicated by primary hepatitis with abnormal AFP.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 Series Editor of this journal.The patient provided permission to publish this report, and the report was approved by the Ethics Board of the Third Affiliated Hospital of Southern Medical University, China.AFP: Alpha fetoprotein; CT: Computed tomography; DSA: Digital subtraction angiography; HCC: Hepatocellular carcinoma; MRI: Magnetic resonance imaging.The authors declare that they have no competing interests.XLL collected clinical data and composed the manuscipt. FQL reviewed the paper. Clinical treatment was performed under instruction from LXL and HYC. LYZ and YHL analyzed the images. QZW was responsible for the result of pathological consultation. All authors read and approved the final manuscript.


Rationale. The incidence of malrotation has been estimated at 1 in 600 live births. An increased incidence of 0,2% has been found in barium swallow studies, whereas autopsy studies estimate that the true incidence may be high as 1% of the total population. The clinical manifestations are elusive; therefore, the diagnosis must be based on the presence or absence of the acute obstruction. Radiologic investigations, especially those using contrast substances, are the ones used most often in the diagnosis of malrotation. Laparoscopy may give the clinician a valuable tool that will help him diagnose the rotational anomalies and correct the potentially obstructing lesions with minimal surgical trauma to the patient. The role of the surgical treatment is to prevent volvulus and to treat any kind of obstruction. Ladd’s procedure provides all the elements for reaching this goal.Objective. The following report describes a particular case of one female patient, 8 years old, admitted in our clinic with signs of intestinal obstruction. She had similar episodes in the last three months, but the symptoms had resolved spontaneously.Methods and results. Upper gastrointestinal series showed an anomaly of rotation and barium enema discovered a tight stenosis on the transverse colon. Emergency surgery using laparotomy enabled diagnosis. Intraoperatively, a right mesocolic hernia and a transverse colon extrinsic stenosis due to abnormal peritoneal attachments were noted. Discussion. Colon obstruction due to peritoneal bands is extremely rare. The clinical manifestations are not specific and we need radiologic procedures to help diagnose the disease. The cause of the obstruction is not always evident despite the availability of modern imaging techniques. Since preoperative diagnosis is difficult, morbidity and mortality can be decreased by an early surgical intervention. Malrotation is accompanied by abnormal bowel fixation by mesenteric bands or absence of fixation of portions of the bowel, leading to increased risks of bowel obstruction [2]. The vast majority of the complications associated with midgut malrotation present in the first month of life and 60-85% of the cases are diagnosed in this age group [3]. However, malrotation is a rare cause of intestinal obstruction – only 2% of the cases.Midgut malrotation has been estimated to occur in approximately one in 5000 live births. However, it is difficult to ascertain the true incidence because this condition will go undetected during childhood [4]. Lack of fixation of the mesentery of the right or left colon, or of the duodenum, may result in the formation of potential spaces for hernias. Internal hernias are associated with recurrent entrapment of bowel with partial obstruction, which may eventually progress to complete obstruction [5]. Anatomically, six different types of intra-abdominal hernias are distinguished: The left- and right-sided paraduodenal hernias and the transverse mesenteric hernias represent the most frequent form of internal hernia in children [6]. Signs and symptoms of an internal hernia are related to recurrent, intermittent bouts of intestinal obstruction characterized by recurrent colic [5].Clinical manifestations are not specific. It is important to determine if the disease is acute or chronic and to determine the eventual presence of midgut volvulus. Due to Ladd’s bands or intermittent midgut volvulus, the acute bowel obstruction can present with vomiting, can be typically bilious, as the commonest presenting feature accompanied by colicky abdominal pain and abdominal distention. Usually, it manifests itself in the first year of life. Older children without acute volvulus more often present with chronic episodic obstructive symptoms, failure to thrive, malabsorption, diarrhoea and non-specific colicky abdominal pain [4]. Apart from clinical symptoms, radiological procedures are most useful. A plain X-ray film of the abdomen and the use of intestinal contrast medium may show displaced small intestinal loops or signs of intestinal obstruction. CT and ultrasonography can be used as well in the preoperative diagnostic [6].The diagnostic is difficult because of a lack of specificity of the clinical manifestation, the malrotation being rarely considered a cause of intestinal obstruction. Up to 10% of the diagnoses of malrotation are made as an incidental finding [7].The surgical intervention must be an urgent procedure. The purpose of treatment of rotational anomalies is to prevent midgut volvulus and relieve any obstructions. Children with rotational anomalies without volvulus can be initially evaluated laparoscopically. Laparoscopy provides the surgeon a valuable tool that helps him diagnose rotational anomalies and the correct potentially obstructing lesions with minimal surgical trauma to the patient. If the midgut volvulus is found, the difficulty of laparoscopic procedure is highly increased, being recommended to the most experienced laparoscopists. In this case, we recommend an open surgical procedure . In our case, the intestinal obstruction was caused by a very tight stenosis of the transverse colon made by peritoneal bands. A high percent of the intestinal obstruction cases, same as our case, manifest themselves with recurrent abdominal pain, vomiting and constipation. The older children had a longer course of vague, antecedent symptoms such as the one described previously [9]. The pre-operatively diagnostic of intestinal obstruction was made with the help of radiologic procedures. In the same time, we established the diagnostic of malrotation. In a study made by Powell on 70 children with malrotation, the upper gastrointestinal (GI) series revealed the diagnosis in 41% cases, as did contrast enema in 34% [9]. The cause of obstruction may be difficult to establish pre-operatively despite the availability of modern imaging techniques [10]. The final diagnostic in our case was made intraoperatory because the internal hernia is a diagnostic difficult to make preoperatively [11]. CT is believed to facilitate the diagnosis of internal abdominal herniations. The use of CT could limit the rate of misdiagnosed internal abdominal herniations, because subtle transmesenteric internal abdominal herniations can be difficult to diagnose on laparoscopy [12]. The differential diagnostic of the patients with recurrent abdominal pain must always take into consideration malrotation. The awareness of this diagnostic may help reduce delays in diagnosis and surgical treatment [13]. A high index of suspicion in children with bilious vomiting, especially when recurrent, undelayed diagnosis and prompt surgical intervention may give a favorable prognosis in children with malrotation [14]. Laparoscopy has a role in diagnostic as well as treatment of the malrotation. In our case, due to emergency character of the disease – intestinal obstruction with undiagnosed cause – we chose open surgery. The surgical treatment must be prompt in order to prevent the devastating complications. The Ladd procedure is the treatment of choice in this case, and we did it as well in our case. The mortality and morbidity associated with malrotation can be lowered only with the help of surgical treatment.Malrotation is an unusual cause of intestinal obstruction; it represents 2% of cases. Colon obstructions due to peritoneal bands are extremely rare. There is just one case cited in the reviewed cases [


Cystic tumors of the pancreas are rare and can be confused with pseudocysts.We present a 50 year old woman with a huge mucinous cystadenoma of the pancreas initially diagnosed and managed with a cystojejunostomy and cyst wall biopsy. She required another laparotomy and tumor excision after histological diagnosis. Sensitivity of radiological imaging in differentiating between cystic pancreatic tumors and pseudocysts is limited. Cyst wall histology is diagnostic and biopsy of cyst wall should be done in cases with inconclusive preoperative diagnosis or questionable operative findings. Cystic Neoplasms of the pancreas may be mistaken for pancreatic pseudocyst. Management of a pancreatic cystic tumor as pseudocyst may result in infection of the tumor or formation of gastric ulcers. Cross sectional radiological imaging may not be specific. Analysis of cystic fluid aspirate has improved diagnosis of pancreatic cystic lesions significantly. Biopsy and histology of cyst wall is diagnostic and should be considered in cases with inconclusive preoperative diagnosis and questionable intra operative findings. We present a patient with a huge mucinous cystadenoma of the pancreas initially mistaken for a pancreatic pseudocyst.A 50 year old lady presented with four months history of back pain radiating towards the epigastrium. She also noticed a gradually increasing abdominal distension. She had weight loss. Bowel habits were normal. She had no previous history of abdominal pains or jaundice. She had an abdominal hysterectomy with left salphingo oophorectomy for uterine fibroids and left ovarian cyst two years before presentation. She had a huge firm non tender central abdominal mass occupying the upper 2/3 of the abdomen. Abdominal ultrasonography and CT scan  suggesteHistology of cyst wall revealed Mucinous cystadenoma of the pancreas. She had another laparotomy and complete excision of an infected tumor. Tumor arose from the tail of pancreas and weighed about 3.6kg. Post-operatively, she had hypoproteineamia that improved before discharge. She was discharged fifteen days after the second surgery. She has been followed up for more than five years years and has remained well.Cystic neoplasms of the pancreas are rare and comprise 10% to 15% of pancreatic cystic masses and only 1% of pancreatic cancers . CommonlMisdiagnosis and maltreatment of pancreatic neoplasms as pseudocysts is not uncommon . Lack ofCystic neoplasms are rare but should be considered in cystic lesions around the pancreas. An absence of history of trauma or history suggestive of inflammation of the pancreas may suggest a cystic tumor necessitating a detailed preoperative evaluation. A biopsy and histology of cyst wall is diagnostic and is indicated in patients with inconclusive preoperative assessment or with questionable intraoperative findings.


Duodenal duplication is a rare congenital malformation and has been reported as a rare cause of recurrent acute pancreatitis. Hemorrhagic ascites has been reported in only one case of duodenal duplication.An 11-year-old Chinese girl presented with abdominal pain, hematemesis and dark stools. On admission, an abdominal examination revealed a moderately distended abdomen with diffuse tenderness. Biochemical investigations showed increased serum levels of amylase, lipase, and urine amylase. An abdominal computed tomography scan and magnetic resonance imaging scan revealed an enlarged and heterogeneous pancreas with poorly delineated borders. There was a cystic lesion measuring 25mm × 48mm × 28mm, located between the descending portion of her duodenum and the head of her pancreas. There were massive effusion signals in her abdominal cavity. An exploratory laparotomy was performed. A tubular cyst measuring 32mm × 52mm × 30mm was found in the second part of the duodenum, next to the head of her pancreas. The anterior wall of the duplication cyst was resected and anastomosis of the remaining cyst to the duodenum was performed for drainage. Histopathological examination of the excised cyst wall showed duodenal mucosa, submucosa and muscle coats, indicative of a duodenal duplication.It is important to be aware of duodenal duplication when evaluating a patient with recurrent acute pancreatitis accompanied by massive hemorrhagic ascites. Duodenal duplication is a rare congenital malformation. It is usually diagnosed in infancy and childhood , with 609/L with 54.1% neutrophils, a hemoglobin level of 110g/L and hematocrit of 35.8%. Examination of stool parasites showed Ascaris eggs: 0 to 2/high power field. Biochemical investigations showed increased serum levels of amylase , lipase  and urine amylase . Liver transaminases, total bilirubin, alkaline phosphatase, glucose, electrolytes and renal function tests were within the normal ranges. Diagnostic paracentesis revealed dark brown-colored fluid containing a great quantity of red blood cells and white blood cells (243×109/L). The fluid amylase was 15,240U/L. The result of her Rivalta test was positive.An 11-year-old Chinese girl presented with 6-months history of epigastric abdominal pain, and 4 days of hematemesis and dark stools. Her past medical history was unremarkable. On admission, physical examination showed a moderately distressed patient with a temperature of 36.8°C, a respiratory rate of 20 breaths/minute, a blood pressure of 95/65mmHg and a pulse rate of 108 beats/minute. An abdominal examination revealed a moderately distended abdomen with diffuse tenderness. There was positive shifting dullness and diminished bowel sounds, but no abdominal wall rigidity. A complete blood count revealed a white blood cell count of 10.6×10Abdominal ultrasonography revealed a slightly enlarged liver and heterogeneous echogenicity of her pancreas. Her main pancreatic duct was dilated. Her gallbladder, biliary duct system and spleen were normal. Severe ascites was detected. An upper gastrointestinal endoscopy revealed a swollen pancreatic papilla. There was no diverticulum or polypoid lesion protruding into the lumen of the second part of her duodenum Figure A. An abdAn exploratory laparotomy was performed. A tubular cyst measuring 32mm × 52mm × 30mm was found in the second part of the duodenum, next to the head of the pancreas. Its surface was adjoined with the pancreatic surface. The cyst was non-communicating with duodenum, stomach and pancreaticobiliary system. The anterior wall of the duplication cyst was resected and anastomosis of the remaining cyst to duodenum was performed for drainage. During surgery, biopsies were obtained and the remnant cyst wall was thoroughly examined to exclude any abnormalities or ectopic tissues. The gallbladder appeared enlarged and the wall was edematous. The gallbladder and bile duct were full of sand-like stones. Histopathological examination of the excised cyst wall showed duodenal mucosa, submucosa and muscle coats, indicative of a duodenal duplication. There was no evidence of malignancy or dysplasia. The postoperative course was uneventful and 15 days later the patient was discharged home. At one year follow-up visit, she remained asymptomatic with normal serum amylase and lipase. There were no clinical signs of ascites.Duodenal duplication is a rare congenital disorder and accounts for only 5% to 7% of all gastrointestinal duplications . They arAscaris infestation is probably an incidental finding rather than a cause for acute pancreatitis, because thorough examination during surgery did not find any adult Ascaris in the pancreaticobiliary system. We speculate that hemorrhagic ascites may have been the result of mucosal inflammation, necrosis and micro-perforation of the duplication cyst. Acute necrotizing pancreatitis can cause ascites but would be an unlikely cause of the hemorrhagic ascites in our case because neither imaging studies nor exploratory laparotomy revealed a necrotic pancreas.There are several possible mechanisms for pancreatitis to develop from a duplication cyst . In thiset al. [Multiple reports found that both CT imaging and MRI can adequately identify a duodenal duplication cyst ,6. Howevet al.  found 25et al. . In our et al. [The surgical intervention for duodenal duplication cyst includes complete or partial surgical resection of the cyst. The location of the cysts in relation to the duodenum, especially to the ampulla, is important to determine the treatment strategy ,6,8. Altet al.  reportedet al. . TherefoWe described a very rare case of a child who was diagnosed with massive hemorrhagic ascites secondary to a non-communicating duodenal duplication cyst, which may mimic pancreatic pseudocyst in a patient with acute pancreatitis. Both CT imaging and MRI can adequately identify a duodenal duplication cyst. Our patient underwent a successful partial surgical resection. It is important to be aware of duodenal duplication when evaluating a patient with recurrent acute pancreatitis accompanied by massive hemorrhagic ascites.Written informed consent was obtained from the patient’s parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MY contributed to conception and design of the manuscript, clinical management of the patient, and drafted the manuscript. YZ, PC, and LG contributed to acquisition, analysis and interpretation of data, and drafting of the manuscript. DL and SG contributed to critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.


Esthesioneuroblastoma (ENB) is an uncommon aggressive malignant intranasal neoplasm that originates from neural crest cells of the olfactory epithelium. Although local invasion to the sinuses is common, spinal metastasis of ENB is rare with only 28 documented cases involving the spine spinal cord, or leptomeninges. We report a case of ENB with multiple drop metastases to the cervical and thoracic spine, and review the patient's disease, medical history, and multiple interventions during a span of 15 years following the initial cranial resection. Despite aggressive multiple surgical resections, radiation, and chemotherapy, the tumor had significant progression and recurrence. The literature is reviewed, followed by a discussion of the natural progression of the disease and various reported interventions. Although a combination of surgery with chemotherapy and radiation therapy has been recommended, no definitive management has been established for ENB. Further research is needed to determine decisive treatment for metastatic ENB to the spine.  Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is an uncommon aggressive primitive neuroectodermal malignant neoplasm that arises from olfactory epithelium cells of the upper nasal cavity . ENB is ENB tumors display varying clinical behaviors ranging from indolent growth to highly aggressive invasion . An apprUnfortunately, despite aggressive therapy, ENB has been noted to have a high local recurrence rate of 50–60% with 10–62% presenting as metastatic cases and 20–30% of those cases involving the CNS , 10. OncA 54-year-old male physician presented to the emergency department with a 4-day duration complaint of ataxia and bilateral lower extremities numbness (right greater than left) which had progressed. Additionally, he had experienced an episode of fecal incontinence without any bladder issues. The ataxia had been progressively worsening without significant focal weakness. His medical history was significant for ENB of the anterior cranial fossa treated with resection and radiation therapy 13 years prior to this admission. He then underwent left cervical lymph node resection and local radiation of his ENB metastasis 6 years after the initial craniotomy due to the finding of an anterior neck mass. Two years later, during a posttrauma evaluation for neck pain, it was noted on his bone scan that he had multiple metastatic lesions to the cervical spine without any cord compression. At that time, he started on chemotherapy with Cytoxan, adriamycin infusion, and DTIC. After some response in his cervical lymph nodes, he was taken off chemotherapy for a period. Due to progressive adenopathy, the patient started on cisplatin and VP-16 for several months. Once again, his symptoms stabilized. Three years prior to this admission, due to a diagnosis of leptomeningeal spread, the patient underwent a repeat craniotomy for resection of his anterior fossa recurrence, followed by whole brain radiation. Following a complaint of mid-lower back pain, he was diagnosed with a T11 lesion and had local radiation. To treat progression of his leptomeningeal disease, he completed three cycles of temodar in the year prior to this admission. His medical history also included scoliosis surgery with Harrington rods 25 years prior to his last admission.On physical examination, the patient had slight weakness of his left lower extremity, especially his left extensor hallucis longus. He had decreased light touch and pinprick sensation of his right T11 dermatome and diminished proprioception of his left lower extremity. He had decreased rectal tone and hyperreflexia of his left knee with trace right ankle reflexes. There was a positive Babinski sign on the left. Due to artifacts from Harrington rod scoliosis correction of his thoracic spine, we obtained a CT myelogram in addition to the MRI of his thoracic spine. The CT myelogram revealed a near-complete block of contrast at T8-9 . His cerGiven the patient's medical history and symptoms, surgical resection was recommended. He underwent a posterior laminectomy from T7–9. Epidural and intradural extension of the tumor to the ventral left side of the cord with significant cord compression was noted. With a finding of arachnoid plane between the tumor and spinal cord, microsurgical technique was used to remove 80–90% of the tumor and duraplasty was performed from T7–9 to create space in case of tumor recurrence. Microscopic examination of T8 lesion revealed a small cell tumor lacking necrosis . ImmunohPostoperatively, the patient did well with a stable neurological exam followed by completion of 2 cycles of chemotherapy with Cytoxan, adriamycin, and DTIC. At his follow-up visits every 3 months, his tumor remained stable on CT and MRI studies for a period of one year. Shortly thereafter, the patient presented with worsening ataxia and bilateral lower extremity numbness and paresthesias. His motor exam was worse indicating bilateral 4/5 strength diffusely in his lower legs. The MRI and CT myelograms of his thoracic spine revealed recurrent tumor extending above the resection cavity from T7-8 with significant cord compression . The patient underwent a microsurgical resection of his intradural tumor with extension of his laminectomy. Ventral-lateral extension of his tumor to the neural foramens was noted. The canal was widened and once again, duraplasty from T6–9 was performed. The histology was of a persistent esthesioneuroblastoma. Postoperatively, his exam remained stable and he was discharged to a rehab facility. The patient subsequently had local radiation to his thoracic surgical cavity and his lower cervical spine (C5-6), which showed progression of his tumor without significant clinical symptoms.A year later, despite radiotherapy and aggressive treatment, the patient again presented with worsening lower extremities weakness. His MRI and myelograms illustrated recurrence of his tumor in his upper thoracic spine and contrast block at the T8 level . ConsequEight months after his last resection, the patient's MRI studies showed progression of his tumor with soft tissue masses throughout his thoracic spine and diffuse gliosis. No further significant canal stenosis was noted . He was Esthesioneuroblastoma is a rare malignant intranasal neoplasm that originates from neural crest cells of the olfactory epithelium. Tumors are normally located high in the nose, above the middle turbinate, and fixed to the cribriform plate or ethmoid sinuses . Local iBerger and Luc first described ENB in France in 1924 , 18. SinThe best treatment modalities for ENB have not been well defined by prospective studies due to the low incidence of tumors . HoweverThe tumor is considered to be of neuroectodermal origin and to arise from the olfactory epithelium . ENB is Multiple staging systems have been designed to classify ENB. In 1976, Kadish et al. created the first staging system based on clinical grounds, classifying the lesions by anatomic location: Group A, tumor within the nasal cavity; Group B, tumor within the nasal cavity and paranasal sinuses; Group C, extension of tumor outside of the nasal cavity and paranasal sinuses . A modifThe UCLA staging system developed by Dulguerov et al. classified the tumor based on tumor invasion and related to the level of invasion into four clinical outcomes: T1, tumor involving the nasal cavity and/or paranasal sinuses (excluding the sphenoid), sparing the most superior ethmoidal cells; T2, tumor involving the nasal cavity and/or paranasal sinuses (including the sphenoid) with extension to or erosion of the cribriform plate; T3, tumor extending into the orbit or protruding into the anterior cranial fossa; T4, tumor involving the brain [The metastatic rate of ENB has been estimated to range from 10 to 62 percent . Spinal metastasis is rare. In the literature, twenty-one cases of metastatic ENB to the spine, spinal cord, and spinal meninges have been documented . The ratPrognostic factors must be considered when determining the best treatment for ENB. Murakami et al. reported that complete surgical resection and histological tumor grade are the two most important prognostic factors . To imprIn a retrospective study by Broich et al., the treatment and outcomes for 898 patients with ENB were reviewed . PatientIn a study of 49 patients with ENB by Morita et al., 38 patients who underwent gross tumor resection with or without radiation therapy had better survival and disease-free periods than patients who had partial tumor resection or biopsy with radiation therapy .In a study by Elkon et al., the best treatment modality was determined based on Kadish Stage . For patThe role of chemotherapy in treatment of ENB is not clearly defined but the literature suggests the use of chemotherapy for palliation in advanced disease or recurrent disease . ENB is In a 2004 study by Kim et al., nine out of eleven patients treated with a combination therapy of etoposide, ifosfamide, and cisplatin had a treatment response . There wWade et al. reported the response to chemotherapy in five patients with Kadish Stage B or C disease and eight cases of ENB treated with chemotherapy . CompletIn a 2008 study by Kim et al., expression of the bcl-2 tumor marker in ENB patients suggests better response to chemotherapy . One of Definitive treatment for metastatic ENB to the spine has not been well defined due to the scarcity of presentation and only twenty-eight cases were documented in the literature. Of the twenty-one patients, thirteen are dead, four are living, and the outcome of four patients is unknown . In one case of metastatic ENB to the spine, described by Rao et al. , the patIn a different case of metastatic ENB to the spine, described by Arnold et al. , treatmeThese case reports suggest that a combination of surgical resection, chemotherapy, and radiation therapy can be used to provide symptom relief, prolong life, and help to prevent recurrence of disease. A definitive treatment for metastatic EBN to the spine is needed, however, because thirteen of the 21 patients documented in the literature died and did not respond to these treatments. Perhaps, the expression of a genetic tumor marker, such as bcl-2, may hold the key to a cure. Further research is needed to outline a definitive treatment option for esthesioneuroblastoma.


We describe surgical resection of an extralobar pulmonary sequestration via single-incision thoracoscopic surgery (SITS), which we recommend as a suitable surgical option. A 45-year-old Japanese woman was admitted to our hospital for further examination of chest abnormal shadow. A rigid 5-mm 30° video-thoracoscope, an endograsper and an electric cautery were passed within the same single small incision. The tumor was suspended using articulating endograspers and resected after clipping and ligation of the anomalous vessel. The final pathology was determined an extrapulmonary sequestration. Pulmonary sequestration is a rare congenital abnormality of the lower respiratory tract and occurs in 0.15% - 6.4% of all pulmonary malformations[A 45-year-old Japanese woman was admitted to our hospital for further examination of an abnormal shadow found on a chest computed tomography (CT) scan, which indicated a homogenous, sharply-circumscribed mass in the posterior mediastinum. An aberrant feeder artery arose from the descending aorta into the lesion Figure . On the Pulmonary sequestration is a rare lesion of the lung parenchyma with an unknown etiology that lacks a normal connection with the tracheobronchial tree and has a blood supply directly from the descending aorta. Surgery is the treatment of choice, which is usually performed through a posterolateral thoracotomy, and morThere are obvious technical problems with SITS. It is not a naturally ergonomic procedure, because the traditional thoracoscopic principles of triangulation are omitted. In addition, positioning of multiple devices through a single small incision in the chest poses problems because instruments can often interfere with each other in the pleural as well as extrapleural spaces, where attachments, such as a camera light can often impede movement. Therefore, to overcome these limitations, the development of new instruments is needed. For example, increasing the length of the camera shaft will allow an assistant to assume a position that did not interfere with that of the surgeon. Furtheremore, the use of a roticulating endograsper aids in achieving triangulation, is compatible with the use of other devices, and can achieve good results.In the present case, the tumor was resected through a 2.5 cm incision, even though it was 4.2 cm in diameter. A wound retraction system should provide for wound dilation and protection when a specimen requires removal through a small incision. However when the diagnosis is suspected preoperatively, using single-port VATS can avoid obvious excessive invasion.In conclusion, we recommend minimally invasive single-port VATS for resecting an extralobar sequestration.We believe that single-port VATS is a great alternative to the traditional three-port VATS for extralobar sequestration.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.VATS: Video- assisted thoracoscopic surgery; SITS: Single-incision thoracoscopic surgery.The authors declare that they have no competing interests.YS analyzed and interpreted the patient data. MT performed the literature review, and was a major contributor in writing the manuscript. YH performed the final editing of the manuscript. All authors read and approved the final manuscript.


Soft tissue metastases from pancreatic adenocarcinoma are rare lesions and can be the source of diagnostic confusion both clinically and pathologically. To our knowledge, one patient has been reported on with soft tissue lesions that ultimately disclose a pancreatic adenocarcinoma. We report here on a patient who presented with a metastatic soft tissue lesion in the trochanter, and the buttocks, as the initial manifestation of pancreatic adenocarcinoma. Soft tissue metastasis from pancreatic carcinoma is a rare finding. Clinicians should be aware that metastatic soft tissue lesions could be the initial presenting sign for pancreatic cancer. Also, the immunohistochemical staining for CK 7 and 19 may be helpful for the diagnosis of metastatic pancreatic adenocarcinoma. Soft tissue (ST) metastases from pancreatic adenocarcinoma are rare lesions and can be the source of diagnostic confusion both clinically and pathologically. The most frequent sites of metastasis for carcinoma of the pancreas are the lymph nodes, lung, liver, adrenal glands, kidney and bone .To our knowledge, one patient has been reported on with soft tissue lesions that ultimately disclose a pancreatic adenocarcinoma . We repoWritten 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.A 56-year-old woman, without a medical or surgical history developed since March 2008 two masses. One localized in the left trochanter, and the other in the right buttocks. They are bulky, firm in consistency, irregular and painful, measured approximately 12 cm in the largest diameter, infiltrated the skin, extended towards the anal area and the posterior aspect of the upper left thigh, associated with inflammatory signs, but no systemic symptoms.One month later the patient benefited from a computed tomography scan of the thigh which showed two soft tissue tumors, one in the trochanter and the other in retro ischiatic . In May Abdominal ultrasound and computed tomography scan showed a tumor at the head of the pancreas.The second reading of the anatomopathologic specimen was consistent with soft tissue metastasis of pancreatic adenocarcinoma . We concluded to a stage IV pancreatic cancer, and the patient was not operated.3 , after the first treatment , the clinical examination objectified a clear regression of the size and inflammatory signs of the buttocks’ tumor, the second treatment was envisaged but the patient died in October 2008 probably by acute severe anemia.According to ESMO guidelines, chemotherapy was started in September 2008 by gemcitabine at the dose 1000mg/mCarcinoma most commonly metastasises via the lymphatic system firstly to the regional lymph nodes and then into the general circulation. Dependent upon the primary site of tumour, metastases from carcinoma commonly occur to the lungs, liver and bone.Distant metastasis to ST, defined as metastasis to skeletal muscle and subcutaneous tissues, are an uncommon presenting feature for primary solid tumours , 4 and rIt is important to be able to distinguish the origin of a soft-tissue swelling as the management will depend significantly on the histological type. Although not in themselves infrequent, soft-tissue metastases are rarely encountered as a presenting sign of an occult cancer as by the time these appear, the patient has commonly developed symptoms pertaining to the primary tumour.The most frequently reported locations for ST metastasis have been the back, chest wall, and abdomen .The most commonly reported primary carcinomas to result in soft tissue metastases are those of the lung, kidney and colon , contrasWhen the muscular biopsy showed an “adenocarcinoma”, for men the primitive cancers were localized in the digestive tract (35%), kidney (20%), and lung 18%) and for women, the genital tract and breast (23.5%). When the muscular biopsy showed a “squamous-cell carcinoma”, the primitive cancers were localized in the lung (81%) for men and the cervix (64%) for women [% and forUse of a basic panel of immunohistochemical stains is recommended for defining the cell type and arriving at the correct diagnosis. Soft tissues metastasis has been reported as a common clinical presentation of occult malignancy and as an isolated metastasis in the patient with a known malignancy . Only a In a series of 91 cases reported by Timothy et al, only one case described a pancreatic adenocarcinoma metastatic to soft tissue . Mathis Recently, Jose Antonio Plaza reported One hundred and eighteen cases of soft tissue metastases. The primary tumor was located in the skin (19 patients), lung (13 patients), breast (13 patients), kidney (12 patients), colon and rectum (12 patients), uterus (8 patients), ovary (5 patients), head and neck  (5 patients), esophagus (2 patients), stomach (2 patients), cervix (2 patients), small bowel (2 patients), bone (2 patients), adrenal gland (1 patient), eye (1 patient), testis (1 patient), urinary bladder (1 patient), and salivary gland (1 patient) and no primary tumor was located in pancreas .The detection of soft tissues metastasis may affect staging and prognosis. Given the low-dose and non-contrast enhanced protocol, the computer scan (CT) helped localize the lesions and increase the diagnostic confidence as soft tissues metastatic lesions can appear hyperdense or hypodense as compared to the surrounding soft tissue.Although magnetic resonance imaging (MRI) is not specific for soft tissue metastasis, it has been advocated as an indispensable tool for the diagnosis and treatment planning in patients with soft tissue malignancy .However, a recent study showed that F-18 FDG PET/CT has higher sensitivity than MRI in detecting skin and ST metastasis . This isAlthough much rarer than primary soft tissue sarcomas, soft tissue metastases from carcinoma should remain a differential diagnosis in any patient presenting with a suspicious soft tissue metastases. Whilst the magnetic resonance scan appearances were suggestive of malignancy, they were not diagnostic of metastases.Any painful soft tissue mass occurring in patients with unknown history of carcinoma, particularly with extensive peritumoral enhancement associated with central necrosis, is highly suspicious for skeletal muscle metastasis. A needle biopsy is necessary for proper diagnosis. It is very important to make a differential diagnosis between metastasis and primary cancer in these cases .Treatment should be individualized according to the underlying disease and the prognosis.The treatment for patients with pancreatic adenocarcinoma metastatic to soft tissue did not differ to a stage IV pancreatic cancer. Treatment of these patients with stage IV disease is often aimed at controlling symptoms and pain from the cancer. Chemotherapy is based on gemcitabine, while treatment with gemcitabine may be a reasonable choice, the use of a combination of gemcitabine and other cytotoxic agents, such as 5-FU, irinotecan, cisplatin and oxaliplatin, is not supported by an advantage in survival apart from capecitabine. However, this combination showed a survival advantage in a trial although it was not confirmed in another one. A meta-analysis of randomized trials with a combination of gemcitabine and platinum analogues seemed to suggest a role for this combination for young patients with good performance status. Nevertheless, the results of a large randomized trial comparing gemcitabine alone with gemcitabine plus cisplatin, presented at the last ASCO meeting, failed to show any benefit for the combination. Another therapeutic possibility is a combination of gemcitabine and erlotinib, recently approved by the FDA and EMEA on the basis of a randomized trial from the NCI of Canada. However, the very modest survival gain (2 weeks) and the high economic costs of the treatment question the role of this combination in metastatic pancreatic cancer. At the moment there is no evidence supporting the use of either cetuximab or bevacizumab in the overall setting of pancreatic cancer .Certainly, the prognosis in the presence of ST metastasis should be considered, 77% of patients died of their disease within 1–22 months after ST metastasis was diagnosed . This coSoft tissue metastasis from pancreatic carcinoma is a rare finding. Clinicians should be aware that metastatic soft tissue lesions could be the initial presenting sign for pancreatic cancer. Also, the immunohistochemical staining for CK 7 and 19 may be helpful for the diagnosis of metastatic pancreatic adenocarcinoma.


Hydatid disease, also known as echinococcosis or hydatidosis, is an infectious disease caused by the cestode Echinococcus. Echinococcus granulosus is the most common Echinococcus species affecting human beings. It may affect any organ and tissue in the body, in particular the liver and lung. Musculoskeletal or soft tissue hydatidosis accounts for about 0.5% 5% of all echinococcal infections in endemic areas, and is almost always secondary to the hepatic or pulmonary disease. Even in regions where echinococcosis is endemic, hydatidosis of cervicofacial region is extremely rare. Herein, we present exceptionally rare case with an unusual localization of primary hydatid cyst in the left supraclavicular region of the neck.Hydatid cyst; Supraclavicular region; Neck; Unusual localization Echinococcus granulosus that lives in the small intestines of adult dogs [Hydatid disease, also known as echinococcosis or hydatidosis, is a zoonotic infection caused by the larval forms (metacestode) of ult dogs . Hydaticult dogs . The splult dogs , 3. Its ult dogs . DefinitEven in regions where echinococcosis is endemic, hydatidosis of neck is rare and its incidence is unknown. In this paper, a case with an unusual localization of primary hydatid cyst in the left supraclavicular region of the neck is presented and available diagnostic tests and therapeutic approaches are discussed in the view of literature.A 21-year-old woman presented to our hospital with a three month history of painless lump growing on the left lateral side of her neck. Upon physical examination, there was a uniform mobile, smoothly outlined mass with a diameter of 5 x 4 cm on the supraclavicular region of the left lateral neck. The mass did not reveal any findings of fluctuation, erythema, ecchymosis or regional lymphadenopathy. Ultrasonographic examination of the mass showed a homogenous and anechoic cyst with a slightly thick wall measuring 4 x 5 x 5 cm in the left supraclavicular region. Lateral X-ray of neck and cervical spine revealed a mass without bone involvement. A coronal T2-weighted magnetic resonance imaging (MRI) of the left anterior neck showed a unilocular, well-defined and high signal intensity cystic lesion with hypointense rim, which is a characteristic feature for hydatid cyst . A contrHydatid cyst is an infectious disease which is most commonly caused by the cestode parasite (tapeworm), Echinococcus granulosus and less commonly by echinococcus multilocularis . Dogs arEchinococcosis is diagnosed essentially by the patient's history, physical examination findings, radiologic imaging modalities, aspiration and serological tests. Radiologic imaging modalities generally include ultrasound, computerized tomography (CT) and MRI . SerologIn the period from the first infection to clinical symptoms, echinococcosis displays the characteristic symptoms of benign tumor that grows slowly. Clinical symptoms depend on the anatomic host area. It may imitate benign and malign tumors, cysts, abscess, hematoma, pseudocyst and congenital cysts , 9.Cystectomy  is the single effective treatment in hydatid cyst treatment and sufficient by itself. The prognosis is excellent in hydatid cyst cases who are treated by removal of cyst totally without rupture , 10, 11.In conclusion, hydatid disease is a widespread public health problem in developing countries. The possibility of hydatid disease, especially in endemic regions, should always be considered in the differential diagnosis of mesencyhmal neoplasms or soft tissue masses in the neck or in the other parts of the body. Radiologic imaging modalities in such cases are mandatory for the diagnosis of unilocular or multilocular hydatid cyst with thin borders, thin walls, inner membranes, and a distinct appearance of characteristic cystic mass. The prognosis is excellent in hydatid cyst cases treated with total removal of the cyst without rupture.