Splenic Pseudocyst (SP) is a diagnostic rarity, with cystic lesions of spleen themselves being uncommon. Establishing a preoperative diagnosis could help in specific management but this is rather challenging. Here we present a common presentation of an uncommon diagnosis. A 47-year-old lady, previously well, presented to the outpatient clinic with intermittent left hypochondrial pain radiating towards left shoulder for 2 months not associated with fever, jaundice, or weight loss. Abdominal examination revealed nontender hepatosplenomegaly. The initial abdominal ultrasonogram (USG) was suggestive of a hydatid cyst, for which she received a course of antihelminthics. At follow-up, after finding no clinical improvement and radiological worsening, she underwent an exploratory laparotomy. A cyst replacing entire lower pole and a significant portion of splenic hilum was found. Total splenectomy was performed. The specimen was reported to be a SP. SP is a unique entity, usually misdiagnosed as a parasitic lesion and often treated with antihelminthic medicines. The natural course of disease, however, follows a subsequent failure of symptom resolution and radiological worsening that ultimately demands surgical attention. Based on size, location, and intraoperative findings, either total or partial splenectomy is required. The final histopathological report often presents a diagnostic surprise. Cysts in the spleen are uncommon, and amongst these one rare kind is SP , 2. PrevWe report an interesting case of a rare and expanding SP without history of previous abdominal trauma. The clinical presentations, investigative findings, and management are discussed with relevant literature review.The rarity of this case lies in the fact that it is often misdiagnosed and wrongly treated and eventually requires surgical exploration . Unless The peroperative findings and final histopathological report usually take the surgeon by surprise.A 47-year-old lady without significant past medical or surgical history presented to the outpatient clinic with intermittent episodes of left hypochondrial pain radiating towards the left shoulder for 2 months. She did not have associated fever, jaundice, or altered bowel habits. Some loss of appetite was noted without loss of weight. She could not recall any abdominal trauma in the recent past. Physical examination was unremarkable except for a nontender hepatosplenomegaly.Hematological and biochemical tests were normal. Abdominal radiographs were unremarkable. Abdominal USG revealed a complex cystic lesion in the spleen measuring 4 × 8 × 6 cm with poorly defined double wall and multiple internal septations suggesting a likely hydatidosis along with enlarged fatty liver.She was given a course of antihelminthics, vaccinated against capsulated organisms predicting possibility of a subsequent splenectomy, and asked to return a month later.At follow-up, her symptoms persisted and repeated abdominal USG showed expanding splenic cyst measuring 9 × 8 × 8 cm. CECT scan of the abdomen showed a nonenhancing cystic lesion arising from lower pole and hilum of spleen measuring 10 × 9 × 9 cm with multiple internal septations and abutting the tail of pancreas as shown in A list of differentials was considered that included a splenic hydatid cyst, pancreatic tail pseudocyst, and a mesenteric cyst. In view of clinical and radiological worsening, she was taken for an elective exploration through a left subcostal incision.At laparotomy, a huge splenic cyst was found occupying entire lower pole and significant portion of hilum and measuring 9 × 9 × 8 cm. The aspiration of this revealed a brownish translucent fluid as shown in The cyst was causing pressure atrophy of the residual splenic parenchyma and also had multiple dense perisplenic and pericystic adhesions. Total splenectomy was done. During intraoperative manipulation, the cyst wall got inadvertently ruptured. The image of splenectomy specimen is shown in She had an uneventful postoperative recovery and was discharged on the 7th postoperative day. At 2-week and one-year follow-up, she remained symptom-free.Histopathologically, gross examination confirmed the operative findings and showed a unilocular already cut-open cyst measuring 9 × 5 cm with wall thickness measuring 2–5 mm.Microscopic section showed a cyst wall that was composed of hyalinized fibrous tissue without epithelial lining. Also noted were plenty of extravasated red blood cells and hemosiderin laden macrophages over the cyst wall. There was no evidence of cellular atypia. The microscopic image of the SP is shown in The features confirmed a SP. Echinococcus granulosus [Splenic cysts have been a matter of curiosity, with a reported incidence of only around 800 globally , 5–7. Sianulosus . More reanulosus , 11.Of all the cysts, SPs constitute 70–80%, particularly affecting women, children, and young adults , 8, 15. In symptomatic 2/3rds, symptoms include left hypochondrial pain radiating to the left shoulder or chest , 8, 16. SP may also be incidental sonological finding or detected due to calcification on radiographs . USG, CEMost often, misdiagnosed as parasitic lesions, these cysts are often treated with antihelminthics only to find unsatisfactory response and radiological deterioration at follow-up. Our patient had a similar treatment course.Etiologically, SP represents a resolved hematoma in the parenchymal or subcapsular location due to a preceeding blunt injury , 2, 4. SIn gross appearance, majority of these are unilocular and smooth walled while microscopic findings consist of fibrous wall tissue without an epithelial lining , 8, 19.Traditional approach to SP larger than 5 cm has been total splenectomy. However, with growing knowledge about protective role of spleen as an organ of reticuloendothelial and hematopoietic importance, more specifically in terms of OPSI, the current approach has been of splenic conservation , 7, 22. Certain characteristics of SP like hilar location, large size with near complete replacement of parenchyma, associated hypersplenism, and doubtful diagnosis are the few important situations where total splenectomy may not be avoidable , 22, 25.In our patient, the likelihood of hydatid etiology was considered earlier in view of endemicity of infestation and hence was managed in similar lines. There was no way to prove or disprove this diagnosis, and the much talked about “Casoni's intradermal test” was also unavailable in a rural set-up like ours.At follow-up, since no clinical improvement was found predicting a possibility of life threatening complication like rupture or hemorrhage in future, elective exploration was considered. This was supported with evidence of expanding cyst dimensions and hilar location that made the decision of total splenectomy rather simple. Following this, the patient had an uneventful recovery and remained symptom-free at 1-year follow-up.In conclusion, SP is uncommon pathology that is capable of mimicking commoner conditions like hydatidosis. The clinical and radiological pictures may be frequently misleading with consequent mismanagement. A high degree of clinical suspicion is, therefore, as essential as the understanding of potential complications to avoid clinical mishaps.Definitive diagnosis is possible only on histopathology and usually poses a diagnostic surprise. However, once treated adequately, SP has a good outcome. Hence, awareness of its clinical presentation and good pathological expertise are important adjuncts in the diagnosis.


A 67 year old female was referred because of an incidentaloma on CT-scan and MRI which showed a 5.0 cm large mass in the wall of the distal stomach. After an initial work-up which suggested a gastrointestinal stromal tumor (GIST), a partial gastrectomy with a Billroth II gastrojejunostomy was performed. The histological diagnosis was a schwannoma. Gastric schwannomas are rare tumors which comprise 0.2% of all gastric tumors and 4% of all benign gastric neoplasms with a peak of incidence in the 4th and 5th decade of life. Gastric schwannomas are usually asymptomatic, but can present with ulceration and/or gastrointestinal bleeding. Clinical, endoscopical, surgical, radiological and histological features of this case are described and the relevant literature is reviewed. Peripheral nerve sheath tumors may arise from Schwann cells, perineural cells and fibroblasts. If a tumor originates from a Schwann cell, it is generally called a schwannoma, but may also be known as a neurinoma or a neurilemmoma. Schwannomas are benign, slow growing tumors and are generally found in the cranial vault. The most common localization if found extradural, is in association with large nerve trunks. The gastrointestinal (GI) tract is a relatively rare localization for schwannomas, but if found there the most common localization is the stomach. Gastrointestinal schwannomas are usually asymptomatic. The differentiation between a schwannoma and other submucosal tumors of the gastrointestinal tract, like gastrointestinal stromal tumor (GIST), can be difficult pre-operatively. The microscopic findings with aid of immunohistochemistry (S100 positivity) can however make a definite diagnosis.We present a 67-year-old woman with a gastric schwannoma manifesting with abdominal soreness and dyspepsia. The diagnosis was histologically confirmed after surgery. The relevant literature is reviewed.This 67-year-old woman was referred to our center after a mass was detected in the gastric wall on CT-scan and Magnetic resonance imaging (MRI) at a commercial imaging centre. Anamnestically she sometimes had vague abdominal soreness and periodic dyspepsia which she managed with over the counter antacids. There were no other complaints and there was no weight loss.The MRI and CT-scans, made at the commercial imaging centre, showed on the MRI a 5 cm, sharply demarcated mass adjacent to the greater curvature of the stomach. The overall signal pattern was inhomogeneous high on post gadolinium T1 weighted images (pre-gadolinium images were not available) and low to intermediate on T2 weighted images . On CT tAn endoscopic ultrasound was performed  and fineA partial gastrectomy with a Billroth II gastrojejunostomy was performed in order to remove the tumor . MacroscThe postoperative period was uneventful and the patient was dismissed from the hospital after five days.Schwannomas are benign, slow growing tumors arising from Schwann cells. In the gastrointestinal (GI) tract they are infrequently found with the stomach as the most common localization. Schwannomas comprise 0.2% of all gastric tumors and 4% of all benign gastric neoplasms . The peaThe differentiation between a schwannoma and other gastrointestinal mesenchymal tumors, like GIST, can be difficult pre-operatively. Most gastric schwannomas show CT features of hypodense, well-demarcated and homogeneous tumors with contrast enhancement, like the case was in our patient as well . EndoscoGastrointestinal schwannomas have an average size of 6 - 7 cm but range between 0.5 and 14 cm. Typical features of gastric schwannoma on gross pathology are submucosal localization with an intact mucosal layer. Schwannomas arise in the submucosa and muscularis propria . ImmunohIn conclusion, Gastric schwannoma is an uncommon type of gastric neoplasm. It is usually asymptomatic, but can present with gastrointestinal bleeding or a palpable mass. Definite diagnosis can only be made through histopathological investigation. This means that if discovered, most schwannoma are surgically resected to exclude other diagnosis like GIST. Surgical resection is therefore the definite treatment.


Meningioma is a central nervous system tumor that typically arises in proximity to meninges. Extracranial primary atypical meningioma of sinonasal tract is a rare one.  We discuss the clinical, radiological, and histological presentation of an elderly female with primary atypical meningioma of the nasal cavity, which was excised via endoscopic endonasal approach.  There was no recurrence even up to 20 months of follow-up after endoscopic excision.  Extracranial primary atypical meningioma should be kept in mind as one of the differential diagnoses of nasal mass. Histopathological diagnosis along with immunohistochemistry should be used for definitive diagnosis. Meningioma is a central nervous system tumor that typically arises in proximity to meninges. Rarely in less than 2% of the cases, meningiomas appear extracranially, especially in head and neck regions, sinonasal tract, ear, temporal bone, and scalp . HistopaHere, we are presenting a case of primary atypical nasal meningioma.A 63-year-old female presented to our outpatient department with complaints of right-sided nasal obstruction and intermittent epistaxis for 6 months. Her nasal obstruction was insidious in onset, gradually progressive, and for the last 3 months, there was complete obstruction. Epistaxis was intermittent, 1 episode in a month, spontaneous, and 250–500 ml in amount in each episode. There was no history of any systemic diseases.Examination of the nasal cavity revealed pinkish fleshy mass occupying the entire right nasal cavity that bled easily on touch. CECT (contrast-enhanced computed tomography) of the nose and paranasal sinuses  showed hTo confirm the diagnosis, biopsy of the mass was taken. Histopathological examination  revealedInitially, preoperative internal maxillary artery embolization was planned, but catheterization could not be performed due to tortuosity of the right common iliac artery. She underwent endoscopic excision of the mass. Preoperatively, there was a pinkish, vascular, and friable mass occupying the right nasal cavity, extending anteriorly up to the anterior end of the right middle turbinate and posteriorly occupying the choana along with extension towards the left side . SuperioMeningiomas are nonglial tumors of the central nervous system, representing 24–30% of all intracranial neoplasms. They arise from the arachnoid cap cells (meningocytes) that are derived from the neural crest. These tumors have a predilection for females and have bimodal age distribution with first peak at the second decade of life and second peak during fifth through seventh decades , 4. TheyThere are different mechanisms contributing to the development of the extracranial meningiomas. During embryogenesis, when arachnoidal cells that are present in the sheaths of nerves or vessels emerge through the skull foramina, the then displaced Pacchionian bodies are detached, pinched off, or entrapped in an extracranial location. It can also occur following a traumatic event or cerebral hypertension that displaces the arachnoid islets, originated from undifferentiated or multipotent mesenchymal cells, such as fibroblasts, Schwann cells, or a combination of these, perhaps explaining the diverse pathologic spectrum found in meningiomas , 6, 7.Bassiouni et al. have classified primary extradural meningiomas into four types: Type I , tumor located between the dura mater and the inner calvarial table; Type II , located between the outer and the inner calvarial table; Type III , located outside the outer calvarial table; and Type IV (mixed), tumor extending from the dura to extracalvarial space .n = 59) followed by middle ear (n = 26) and sinonasal tract (n = 25). Other rare locations in the head and neck are the temporal bone, mandible, nasopharynx, parotid gland, orbit, and neck [They have been reported to occur in the sinonasal tract, cranial bones, middle ear, scalp, and soft tissues of the face and neck, and parotid gland. An analysis of 146 cases of primary extracranial meningiomas showed that the majority of them originated from the skin and scalp n = 5 followedSymptoms depend on the anatomic site of involvement. Meningiomas involving the sinonasal tract may mimic sinusitis with patients presenting with the nasal obstruction, anosmia, facial pain, nasal discharge, and epistaxis , 10. SomIn the current WHO edition 2007), grade I meningiomas (benign) are recognized by their histologic subtype and lack of anaplastic features. Grade II meningiomas  are defined by one or more of the following four criteria: (1) chordoid or clear cell histologic subtype, (2) 4 to 19 mitoses per ten high-power field (HPFs), (3) brain infiltration, and (4) 3 or more of the following five histologic features: small cell change, increased cellularity, prominent nucleoli, sheet-like growth, or necrosis. Grade III meningiomas  are defined by rhabdoid or papillary subtypes, a histological picture of frank malignancy resembling that of carcinomas, melanomas, or high-grade sarcomas, or 20 or more mitoses per 10 HPFs 007, grad.In a study done in 163 cases, the most common histopathological subtype in primary extracranial meningiomas of head was meningothelial meningioma 53.4%) followed by transitional type (12.3%), psammomatous type (11.7%), and fibrous type (6.7%). Meanwhile microcystic, metaplastic, secretory, and regressive types were rare consisiting of 2.4% [% followeThe differential diagnosis of sinonasal tract meningiomas includes mucocele, olfactory neuroblastoma, carcinoma, hemangioma, sarcoma, and angiofibroma , 10. HisStudies have shown that the growth of the tumor is slow; hence, surgical extirpation without the necessity of adjuvant therapy is the treatment of choice, but complete excision is not always possible due to complex anatomy of nasal cavity and paranasal sinuses , 9. CompIn our case, there was no recurrence on subsequent follow-up of 20 months. Usually, recurrence occurs at the same anatomic site as the primary lesion, and depending on the time interval, it may be distinguished from the residual disease. A study analyzing the relationships between tumor sites and recurrence and death in 170 cases has found statistically significant difference among recurrence and type of removal. They found 9.7%, 14.3%, and 66.7% recurrence rates in total, subtotal, and partial removal cases, respectively. Further, they found death rates of 5.4% and 28.6% in total and subtotal removal cases, respectively. Recurrence was found to be 8% in benign meningioma, 11.1% in atypical, and 57.1% in malignant type [A 5-year disease-free survival rate was found to be 66.9% to 82.1%, and 10-year disease-free survival rate was found to be 54.6% to 78.6% [Primary sinonasal atypical meningioma is a rare condition. It should be considered as one of the differential diagnoses of a nasal mass. Histopathological diagnosis along with immunohistochemistry should be used for definitive diagnosis. Excision can be done by endoscopic endonasal approach.


A 55 year old male patient came for routine dental examination. History revealed that he was a heavy tobacco chewer for the past 20 years. During examination, several radiating white lines were found on top of a slightly grey background, in relation to the right buccal mucosa. The location of the lesion clearly coincided with the site of placement of quid. A differential diagnosis of lichen planus, oral lichenoid reaction and discoid lupus erythematosis were considered. On microscopic examination, there was focal perivascular infiltrate and plasma cells in the connective tissue. After correlating clinically, a diagnosis of "lichenoid reaction" was confirmed. Oral lichenoid reactions (OLR) can occur as a result of contact of an irritant such as tobacco. OLR to tobacco and betel nut products presents as a unilateral, wavy, nonelevated, non scrapable white lesion. These lines are arranged in tree like configurations or in the form of a lacy network- Wickham's striae. Wickham's striae most often are a diagnostic sign of lichen planus and lichenoid reaction.


Hepatic epithelioid angiomyolipoma (AML) is a rare, benign, mesenchymal neoplasm found in both males and females, and most commonly encountered in adult females. These lesions are difficult to diagnose by imaging, especially when fatty component is scant or absent. Histomorphologically, they resemble hepatocellular carcinoma. The tumor cells are strongly positive for homatropine methylbromide-45 (HMB-45) and smooth muscle actin by immunohistochemistry, which are the key markers for accurate pathological diagnosis. Hepatic AML should be considered in the differential diagnosis of a well circumscribed hepatic mass, even in the absence of an adipose tissue component. Angiomyolipoma (AML) is an uncommon benign mesenchymal tumor, found most often in the kidneys and has been associated with tuberous sclerosis . HepaticThree cases were identified from the review of our institutional database for mesenchymal liver tumors in the last 15 years.All three Patients in this series were females aged 38, 49, and 39 years presented with enlarging abdominal mass or masses. The most common symptoms were abdominal pain and discomfort. Case 3 presented with spontaneous hemorrhage into the lesion presented at one month postpartum. Laboratory investigations including liver function test were within normal limits in all three cases. CT scan imaging showed hypodense lesions . Prior tAll lesions were solitary, well circumscribed with soft yellow to tan color cut surface. Focal hemorrhage was evident in the large tumor. There was no necrosis noted, and the surrounding hepatic parenchyma appeared unremarkable. Light microscopy examination of sections from these lesions showed diverse cellular elements that are surrounded by normal looking hepatic parenchyma . A compoThe final diagnosis in all these cases was hepatic angiomyolipomas of epithelioid type. The follow-up of these cases exhibited a benign course with no sign of recurrence after a minimum following period of 36 months.AML is a mixed mesenchymal tumor that usually occurs in the kidney . Two typIn conclusion, hepatic epithelioid AML are rare mesenchymal tumours, which require careful clinical pathology correlation in order to reach a definite diagnosis. AML should be considered in the differential diagnosis of a well circumscribed hepatic mass lesion even in the absence of adipose tissue component.


A 2-year-old male child presented with a painless progressive mass in the inferolateral aspect of right orbit of three-month duration. Differential leucocyte count revealed raised eosinophil count (13%). On radiological examination, CT scan showed 25 × 27 mm round well-defined smooth-outlined homogenously enhancing extraconal mass arising from the zygomatic bone at the inferotemporal periorbital area of right orbit with bone erosion. Histopathological examination of the incision biopsy revealed characteristic Langerhans cells and immunohistochemical studies were positive for S-100 protein and adenosine deaminase. A diagnosis of Langerhans Cell Histiocytosis (LCH) was made and PET-CT revealed no other foci of uptake anywhere else in the body. The patient received 12 cycles of vinblastine, 0.2 mg/kg body weight, along with oral prednisolone, 1 mg/kg body weight. On completion of three cycles of chemotherapy, a reduction in size of the mass was noticed. A repeat PET scan was done 3 months after completion of chemotherapy did not reveal any activity noted previously. Langerhans Cell Histiocytosis (LCH) is an uncommon multisystem disorder of unknown etiology, characterized by accumulation of histiocytes in various tissues. It has a variable clinical course, and although it is occasionally seen in adults, it predominantly affects children.Three clinical forms of LCH have been identified ranging from localized LCH (eosinophilic granuloma), chronic recurring LCH (Hand–Schuller–Christian disease), and acute disseminated LCH (Letterer–Siwe disease).A 2-year-old male child presented with a painless slowly progressive mass in the inferolateral aspect of right orbit of three-month duration. There was no associated history of fever or any other systemic illness.General physical examination and systemic examination were normal. Local examination revealed fixed, firm, nontender mass in inferolateral orbit of approximately 25 × 20 mm.Differential leucocyte count revealed raised eosinophil count (13%). On radiological examination, CT scan showed 25 × 27 mm round well-defined smooth-outlined homogenously enhancing space-occupying mass arising from the zygomatic bone at the inferotemporal periorbital area of right orbit with bone erosion. The MR imaging showed an exophytic infiltrative mass with irregular margins arising from the anterolateral wall of right orbit. The mass was localized to the extraconal space sparing the intraconal compartment. The lateral rectus muscle was not involved and was distinctly visible and separate from the mass .Incision biopsy of the mass was done and histopathological examination of the specimen revealed characteristic Langerhans cells, 15–20 um in size with discrete nucleolus and homogenous eosinophilic cytoplasm. The immunohistochemical studies were positive for S-100 protein and adenosine deaminase . CD1a poA diagnosis of LCH was made and the patient was subjected to PET-CT to identify any other foci. The PET-CT revealed a single focus of uptake in the lateral wall of the orbit . No otheThe patient received 12 cycles of vinblastine 0.2 mg/kg body weight along with oral prednisolone 1 mg/kg body weight. On completion of three cycles of chemotherapy, a reduction in size of the mass was noticed Figures  and 5.A repeat PET scan was done 3 months after completion of chemotherapy. The PET scan did not reveal any activity noted previously.The patient is currently being followed up for last 2 yrs without any recurrence.The annual incidence of LCH has been estimated to be 2 to 10 cases per 1 million children aged 15 years or younger . The oveBezdjian et al. reviewed 201 patients from 45 published studies of isolated LCH bony lesions and formulated a systematic algorithm for diagnosis, investigations and management . HoweverLCH occurs predominantly in males  –8. PatieTreatment modalities available for isolated solitary orbital eosinophilic granuloma include surgical resection, resection with post-op chemotherapy, intralesional steroids followed by resection, radiotherapy, or a combination of two or more modalities with good prognosis while chemotherapy as a first line modality is primarily used only for multisystem disease –12. BezdThe Histiocyte Society , 14 has SS-LCH (single system LCH) with “CNS-risk” lesions;SS-LCH with MFB ;SS-LCH with “special site” lesions;MS-LCH (multisystem LCH) with/without involvement of risk organs.They reinstated that the following localizations and disease extent categories are considered indications for systemic therapy , 14:SS-L The guidelines , 14 upheIntralesional steroids carry a high rate of recurrence and were therefore avoided , 10–12. Diagnosed as an isolated solitary orbital eosinophilic granuloma, our patient received 12 cycles of vinblastine chemotherapy without evidence of any complications and without evidence of any recurrence over the 2 years of follow-up. In our opinion, chemotherapy is a relatively safe and effective treatment option in paediatric patients and may be considered as the primary modality of choice in isolated solitary as well multisystem LCH.


Esophagogastroduodenoscopy revealed a 4 mm duodenal polyp. Colonoscopy was terminated early secondary to a large circumferential obstructing mass found in the descending colon. Immunohistochemistry of the duodenal biopsy was positive for synaptophysin and chromogranin-A; consistent with the diagnosis of stage I carcinoid tumor. Biopsy results of the colonic mass showed a stage I well-differentiated adenocarcinoma. The patient underwent a left colectomy and partial duodenectomy; he remains in remission after 2 year of close follow up. When the diagnosis of small bowel carcinoid is made, further screening for other primary neoplasms should be sought to prevent potential late stage diagnosis of synchronous malignancies. This is crucial because patients’ demise usually result from the associate tumor and not the carcinoid component. Finally, we would like to raise clinician’s awareness regarding the incidence of this entity since some of the studies suggest that it is more common than it was previously thought.Carcinoid tumors are a histological subtype of well differentiated, low to intermediate grade, slow-growing neuroendocrine malignancies capable of secreting bioactive peptides, such as 5-hydroxytryptamine , chromogranin-A and chromogranin-C. Here we present a case of a duodenal carcinoid that simultaneously occurred with adenocarcinoma of the colon. A 59-year-old male with a past medical history of hepatitis C and hypertension presented complaining of worsening abdominal pain associated with 2 - 3 episodes per week of bright red blood per rectum for the past month. He also reported a 20 pounds weight loss in the last 6 months. Social history was significant for a 15 pack year history. Vitals on admission were within normal limits. Physical exam was significant for right upper quadrant tenderness without guarding, rebound, or organomegaly. Rectal exam revealed no blood or masses. Laboratory results showed iron deficiency anemia with hemoglobin of 9.6 K/mm Carcinoid tumors are relatively slow-growing neuroendocrine tumors that are capable of secreting bioactive peptides, such as 5-hydroxytryptamine , chromogranin-A and chromogranin-C. The most common site for carcinoid tumor origin is the gastrointestinal tract (73-85%) with the majority of patients being asymptomatic . While t3. Liver related tests and coagulation profile were within normal limits. Esophagogastroduodenoscopy revealed a 4mm duodenal polyp , rectum10-18.5%), colon(7.6-9.5%) and appendix2.4-7.6%); with duodenal carcinoids accounting for less than 2% of all carcinoids [.4-7.6%; .4-17.6%,%, colon. Larger masses (10 - 20 mm) with similar characteristics as above can be removed by endoscopy or surgery. Surgical management is the treatment of choice for duodenal carcinoids that are nonfunctional but more than 20 mm in size. Tumors extending beyond the submucosa (T2-T4) or that have metastasized to lymph nodes should be managed surgically -9.The incidence of synchronous tumors of the colon ranges from 2 to 11 percent . While aIn conclusion, when the diagnosis of small bowel carcinoid is made, further screening for other primary neoplasms should be sought to prevent potential late stage diagnosis of synchronous malignancies. This is crucial because patients’ demise usually result from the associate tumor and not the carcinoid component. Finally, we would like to raise clinician’s awareness regarding the incidence of this entity since some of the studies suggest that it is more common than it was previously thought.


At the time of diagnosis, giant gastric gastrointestinal stromal tumors are sometimes associated with severe peritoneal dissemination. Unresectable gastrointestinal stromal tumors are considered a systemic disease; therefore, imatinib therapy is currently the primary treatment option in these cases.A 49-year-old Japanese woman was referred to our hospital with symptoms of anorexia, abdominal discomfort, and a palpable abdominal mass. Contrast-enhanced computed tomography revealed a huge mass with an irregular wall, approximately 22 cm in size, located between the posterior gastric wall and her pancreas. The tumor grew rapidly, and her abdominal symptoms worsened; therefore, a semi-urgent laparotomy was performed. The tumor had arisen from her upper stomach and was removed by wedge resection of her stomach. In addition, widely distributed multiple white nodules were noted, which were resected as far as possible. Immunohistochemical staining of the resected specimen was positive for KIT and CD34. The resected white nodules contained the same cells as the primary tumor. Based on these pathological findings, a final diagnosis of a gastric gastrointestinal stromal tumor with peritoneal dissemination was made. Imatinib was administered at 400 mg per day from 1 month postoperatively. The disease progression of the residual disseminated lesions was favorably controlled, and our patient is now doing well, 12 months after surgery.Imatinib therapy following debulking surgery can show dramatic effectiveness in giant gastric gastrointestinal stromal tumors with severe peritoneal dissemination. Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract . PrimaryRecent progress in understanding the origin and molecular oncology of GISTs has contributed to a rapid improvement in their management . ImatiniPrior to the imatinib era, surgery traditionally played only a palliative role in patients with unresectable GISTs; however, with the introduction of imatinib, it may be necessary to reassess the role of surgery in these cases. Here we report the case of a patient with a giant gastric GIST with severe peritoneal dissemination, showing favorable progression control by postoperative imatinib therapy following debulking surgery. This case demonstrated that surgery can possibly play a role even in unresectable GISTs.A 49-year-old Japanese woman was referred to our hospital with symptoms of anorexia, abdominal discomfort, and a palpable abdominal mass. She reported a 7 kg weight loss in a few months and had a medical history of hypertension and hyperlipidemia as well as a maternal history of gastric cancer. On performing a physical examination, a palpable mass was detected in her left upper abdominal quadrant. She had regular bowel movements with normal stools.A complete blood count test revealed only mild microcytic hypochromic anemia . A blood biochemical test revealed no abnormalities, except for an elevated lactate dehydrogenase level of 401 U/L. Her levels of tumor markers were assessed, including carcinoembryonic antigen, carbohydrate antigen 19-9, and α-fetoprotein, all of which were within normal ranges.An abdominal X-ray revealed a diffuse opaque area in her upper abdomen without a gastrointestinal gas shadow; accompanying the finding, her transverse colon was dislocated downward Fig. . EndoscoThe tumor grew rapidly, and her abdominal symptoms worsened; therefore, a semi-urgent laparotomy was performed, although a definitive diagnosis could not be preoperatively made. After gastrocolic ligament division, a giant extraluminal tumor arising from the posterior wall of her upper stomach on the lesser curvature was noted. Furthermore, multiple white nodules, suspected of being disseminated lesions, were widely distributed in her greater omentum, lesser omentum, transverse mesocolon, and retroperitoneum. Serous ascites was also seen in the pouch of Douglas. The giant tumor adhered to her pancreas, transverse mesocolon, and transverse colon; however, the tumor was removed by wedge resection of her stomach following ligation of the vessels supplying the mass, without resecting other organs. The radical resection of the multiple white nodules was impossible; therefore, the nodules were resected as far as possible.The resected specimen was a well-circumscribed tumor Fig. . The cutThe microscopic findings of hematoxylin–eosin staining revealed a bundle-like growth of spindle-shaped tumor cells, with acidophilic cytoplasm and enlarged nuclei accompanying increased chromatin levels Fig. . NuclearOur patient had an uneventful postoperative course and was discharged from our hospital on postoperative day 15. Postoperative CT showed several recognizable disseminated lesions in her abdominal cavity Fig. . Treatmeet al. reported that the 2-year progression-free survival in patients with advanced GISTs who underwent surgery for residual lesions after having responded to imatinib therapy was higher than that in patients with advanced GISTs who received imatinib therapy alone (88.4 % versus 57.7 %) [et al. reported that the median survival in patients with advanced GISTs who underwent surgery for residual lesions after having responded to imatinib therapy was longer than that in patients with advanced GISTs who received imatinib therapy alone (87.6 months versus 59.9 months) [Complete tumor resection with negative margins is the principle treatment for resectable GISTs, whereas imatinib therapy is the principle treatment for unresectable GISTs , 12. Rec 57.7 %) . Further months) . HoweverIn our case, a precedent surgery was performed prior to imatinib administration for an unresectable giant GIST. As previously reported, serious adverse events, such as gastrointestinal or intra-abdominal bleeding due to tumor degeneration, occur in approximately 5 % of giant GISTs treated with imatinib . TherefoOur case demonstrated that surgery can possibly play a role even in unresectable GISTs. Prior to the introduction of imatinib, outcomes for patients with unresectable GISTs were exceedingly poor, with median survival times ranging from 10 to 20 months and a 5-year survival of <10 % , 18. WitAt present, 11 months following imatinib administration, the disease progression of the severe peritoneal dissemination in our patient has been favorably controlled. However, the appearance of resistant lesions may become a problem later as the median progression-free survival has been shown to be approximately 2 years for patients treated with imatinib , 12. ForAs this was a single-patient case report, these findings need to be confirmed by the accumulation of prospective evidence from more patients in multiple institutions. Gastric GISTs are relatively rare; therefore, the number of patients treated in a single institution is limited. However, the current findings provide important information that can contribute to the development of a treatment strategy for giant gastric GISTs with severe peritoneal dissemination.We reported the case of a patient with a giant gastric GIST with severe peritoneal dissemination showing favorable progression control by imatinib therapy following debulking surgery. The present case suggests that imatinib therapy following debulking surgery for giant gastric GISTs with severe peritoneal dissemination can show dramatic effectiveness.


On day 31 of induction chemotherapy, she was noticed to have enlarged right cervical lymph nodes (level 3 and 4). Fine needle aspiration cytology revealed leukemic infiltration. Whole-body positron emission tomography computed tomography showed intense fludeoxyglucose uptake in right cervical, bilateral axillary, and pelvic lymph nodes ; there was no history of any other drug intake in the past. Surgical history was noteworthy for cesarean section ten years back. She was hemodynamically stable; no pallor, goiter, or petechial spots observed on general physical examination. Systemic examination was inconspicuous. Hemogram , peripheral blood smear and coagulogram were normal. Urine for pregnancy test was negative; serum prolactin and thyrotrophin-stimulating hormone levels were normal. To rule out local genital lesion, a detailed pelvic examination (including speculum examination) was performed. The posterior lip of the cervix appeared bulky with a 2x1 cm reddish-pink, sessile, firm, nodular lesion arising from it. At this point, the possibility of cervical carcinoma versus benign cervical lesion  was considered. Brushed smear from the cervical lesion revealed high-grade dysplasia. Pelvic ultrasound revealed an ill-defined heterogeneous, hypoechoic soft tissue lesion involving the cervix; there was no vaginal or parametrial involvement. A total abdominal hysterectomy was performed. Surprisingly, histologic examination of the uterus revealed infiltration of muscle bundles, consisting of sheets of atypical cells reminiscent of lymphoid cells . Immunohph nodes . She wasGranulocytic sarcoma is an uncommon presenting manifestation of acute myeloid leukemia. In our experience, we have observed granulocytic sarcomas in unusual locations like orbit , mediast


Background. Intra-abdominal metastases of invasive lobular breast cancer (ILBC) may be insidious. We report a case of metastatic ILBC that presented with dysphagia within weeks of a negative mammogram and before the development of intra-abdominal symptoms. Case. A 70-year-old female developed esophageal dysphagia. She underwent EGD which showed a short segment of stricture of the distal esophagus without significant mucosal changes. Biopsy was unremarkable and patient underwent lower esophageal sphincter (LES) dilation. Severe progressive dysphagia led to esophageal impaction and three LES dilatations. CT scan showed bilateral pleural effusions, more prominent on right side, and ascites. The pleural effusions were transudative. Repeat EGD with biopsy showed lymphocytic esophagitis, and she was started on swallowed fluticasone. Abdominal ultrasound with Doppler showed that the main portal vein had atypical turbulent flow that was felt to possibly be due to retroperitoneal process. The patient underwent diagnostic laparoscopy which revealed diffuse punctate lesions on the peritoneum. Pathology was consistent with metastatic ILBC. Conclusion. Dysphagia in the setting of peritoneal carcinomatosis from metastatic ILBC is a rare finding. The case highlights the importance of metastatic ILBC as a differential diagnosis for female patients with progressive dysphagia and associated ascites or pleural effusions.  Breast cancer comprises 14.6% of total new cancer cases in the United States. Invasive lobular breast cancer (ILBC) is the second most common histologic type of breast cancer and accounts for 10–14% of all breast cancer cases . We repoA 70-year-old female with hypertension, psoriatic arthritis, and up to date breast and colon cancer screening developed difficulty swallowing, characterized by food “sticking” in her distal esophagus, while in Arizona for the winter season, she underwent initial evaluation there. Esophagoduodenoscopy (EGD) showed distal esophageal stricture and small erosions; biopsy was nonspecific. The CT scan showed moderate to marked bilateral hydronephrosis to the UPJ level without obstructing calculi, scattered colonic diverticulosis and bilateral pleural effusions right greater than left. She was started on a proton pump inhibitor for possible reflux-related symptoms without improvement. She subsequently elected to return home for additional evaluation. She underwent repeat EGD which showed a short segment of stricture of the distal esophagus and gastroesophageal junction (lumen 2 to 3 mm in diameter) without significant mucosal changes. Biopsy was unremarkable and patient underwent LES dilation. Due to persistent food impactions in the distal esophagus, EGD was repeated and showed distal esophageal stricture, small erosions, and mild gastropathy. The patient had a esophagogram which showed no ulceration, mass or constrictive lesion involving the esophagus, and was not suggestive of achalasia. Repeat abdominal CT scan was unremarkable except stable bilateral hydronephrosis and small bilateral pleural effusions, larger on the right side. She was evaluated by urology, who could find no specific cause of hydronephrosis and felt it was most likely congenital.The patient continued to slowly deteriorate. Severe progressive esophageal dysphagia led to hospitalization and subsequent esophageal disimpaction and three LES dilatations. Repeat CT scan showed worsening bilateral pleural effusions, most prominent on right side, and ascites. The pleural effusions were transudative, and necessitated six-large volume thoracentesis over four months due to shortness of breath. No paracentesis could be performed due to lack of distinct pocket. Due to history of psoriatic arthritis, autoimmune workup was done including antibodies for anti-smooth muscle, nuclear antigens, liver/kidney microsome type 1, alpha-1-antitrypsin, endomysial, and anti-mitochondrial but failed to explain dysphagia. Liver architecture, transaminases, alkaline phosphatase, and prothrombin time were normal. Because of ongoing progressive dysphagia and weight loss the patient was referred to a quaternary care center. The repeat EGD with biopsy showed lymphocytic infiltrates in the distal esophagus. She was diagnosed with lymphocytic esophagitis, started on swallowed fluticasone for esophagitis and furosemide for ascites and an appointment scheduled as an outpatient with a hepatologist for probable noncirrhotic portal hypertension. Additional bloodwork for causes of noncirrhotic portal hypertension was negative except elevated D-dimer of 5.52 mg/L. Abdominal ultrasound with Doppler showed that the main portal vein at the porta hepatis was patent but had atypical turbulent flow that was felt to possibly be due to proximal stenosis at the level of the splenic vein-portal confluence or a retroperitoneal process. Review of prior CT scans with interventional radiology and general surgery was not definitive for retroperitoneal infiltration of soft tissue. The patient underwent diagnostic laparoscopy which revealed diffuse punctate lesions on the peritoneum and liver and omental thickening. No discrete mass was identified. Ascitic fluid of 1800 mL was removed. Peritoneal, liver, and omental biopsies were obtained. Pathology was consistent with metastatic lobular breast carcinoma . ImmunopILBC differs in important ways from IDBC. ILBC has a different genomic profile compared with IDBC. ILBCs are characterized by 13q and 22q losses, resulting in loss of KLF5 which promotes cell proliferation. Biologically, most ILBCs lack expression of E-cadherin protein, which is responsible for cell adhesion and tissue binding [These characteristics may explain the different metastatic pattern of ILBCs. Clinically, it is more likely to present with bilateral or multicentric involvement, at an advanced stage, a lower histological grade, increased lymph node positivity, and less vascular invasion. The ILBCs tend to metastasize to the gastrointestinal system (4.5% versus 0.2%), female reproductive organs (4.5% versus 0.8%), peritoneum and retroperitoneum (3.1 versus 0.6%), adrenal glands (0.6 versus 0%), bone marrow (21.2% versus 14.4%), bone (50% versus 34%), and lung pleura (2.5% versus 10.2%) [The overall recurrence rate, proportion of local recurrence rate, and proportion of distant recurrences were found to be similar in ILBC and IDBC , 7. Due Approximately 95% of cases are usually ER/PR positive, with less than 5% HER2 positivity. In 55–100% of cases ILBC lacks expression of E-cadherin protein. The loss of expression of the E-cadherin in infiltrating lobular carcinoma results in the cell spreading and dissemination. The cancer infiltrates the breast stroma in a single file, encircling mammary ducts and lobules. This pattern of spread results in normal anatomic structure of breast, without mass lesions on physical examination and imaging studies. Mammography has a lower sensitivity for detecting ILBC similar to that happened in our patient. Metastatic ILBC infiltrates to the target organs in a diffuse process again without forming discrete tumor nodules. CT scan usually shows numerous tiny nodules infiltrating the peritoneum and diffuse infiltration of solid organ walls instead of extramural masses. Immunohistochemical staining of breast metastases is usually positive for CK7 and GCDFP-15 and negative for CK20 .Gastrointestinal tract metastases are rare and present in less than 1% of patients in clinical settings although they have been observed in 20–43% on autopsy series. Patients usually present with common symptoms like nausea and vomiting, diarrhea, and abdominal pain. This nonspecific clinical presentation can result in delayed diagnosis and treatment of metastatic disease .Dysphagia is a rare initial presentation of metastatic ILBC. Metastases to the esophagus usually occur via lymphangitic spread and present as submucosal lesions with normal mucosa, thus resulting in normal EGD and esophagography , 11. In Patients with metastatic breast cancer have poor prognosis due to late presentation and advanced disease. The median survival time is 28 months. Our patient started treatment with paclitaxel which resulted in improvement of her dysphagia. In some cases peritoneal carcinomatosis can be treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. However, our patient was not a candidate for that due to widespread peritoneal metastases, diffuse omental thickening, and failure to demonstrate a discrete mass lesion .Esophageal dysphagia in the setting of peritoneal carcinomatosis from metastatic ILBC is a rare finding. In our patient dysphagia might have been caused either by peritoneal carcinomatosis or by esophageal metastases, although the latter was not confirmed by the available pathologic specimens. As metastatic ILBC cells can easily be mistaken for lymphocytes, the surgical pathologist who interpreted the intra-abdominal biopsies also reinterpreted the esophageal biopsies from the quaternary care center. He felt strongly that the esophageal lymphocytes were typical and histologically dissimilar to the metastatic cancer cells. He declined additional staining. No additional surgical specimens of the esophagus were obtained.The case highlights metastatic ILBC as a potential cause of progressive esophageal dysphagia in women. While fewer than 5% of patients in a recent Swedish study had esophageal food bolus impaction as a result of cancer , metasta


She reported weight loss of 4 kg over 2 months , fevers, and fatigue. Her medical history was significant for chronic constipation since age 20 years, and hemorrhoidectomy at age 59 years. Physical examination revealed moderate abdominal distension with mild tenderness. The patient recalled domestic exposure to asbestos from her husband, who was an insulation worker.Biochemical studies revealed deranged liver function test results, including albumin level of 30 g/L, alkaline phosphatase, 129 U/L; gamma-glutamyl transferase, 66 U/L; and ALT, 53 U/L. A computed tomography (CT) scan of the chest displayed atelectasis of the right lower lobe and right-sided pleural effusion. An abdominal CT scan revealed thickening of the omentum with fine nodularity in the left flank. Importantly, no ascites, lymphadenopathy, or ovarian pathology could be appreciated .Within the course of 6 weeks, thoracocentesis was performed on four separate occasions to manage pleural effusion. Each tap returned more than 1 L of pleural fluid. Atypical mesothelial cells were found in the pleural aspirate; malignant cells were absent. Surgical pleurodesis was performed to limit future effusion.Laparoscopic exploration of intra-abdominal contents was conducted because pleural fluid and CT scan had failed to establish a diagnosis. Gross appearance of the peritoneum revealed numerous peritoneal nodules in the left iliac fossa, several umbilical nodules, and apparent umbilical thickening. A small trace of peritoneal fluid was found in the pelvic region. The sigmoid colon was adhered to the anterior abdominal wall via filmy adhesions. The adhesions were surgically divided, and samples were collected for testing. Biopsy specimens were collected from 12 tan peritoneal nodules and ranged from 2 to 9 mm in diameter. A 12 mm by 9 mm section of variegated umbilical tissue was also collected. Both samples contained cells exhibiting neoplastic changes, and both immunostained positive for MPM markers. Peritoneal fluid showed clumps of malignant cells. After diagnosis, chemotherapy was commenced.2 Incidence among industrialized nations ranges between 0.5 and 3 cases per million in men, and between 0.2 and 2 cases per million in women.3The peritoneal cavity is the second most common site for mesothelioma. In the United States, of 10,589 mesothelioma cases reported between 1973 and 2005, 10.5% were peritoneal.4 Furthermore, approximately 80% of patients with mesothelioma report a history of asbestos exposure.5 The association between asbestos and peritoneal mesothelioma is less than that of pleural mesothelioma. This may be due, in part, to asbestos-induced MPM generally requiring a higher cumulative dose.6 Mesothelioma can also result from nonoccupational or para-occupational exposure to asbestos. For example, women whose husbands work in asbestos-related industries often come in contact with asbestos while laundering their husband’s work-related clothing7; this is the likely cause in this report.There is a strong relationship between asbestos exposure and mesothelioma. The lifetime risk of developing mesothelioma in asbestos workers is thought to be as high as 10%, with a mean latency period of 30 years.8 Genetic predisposition is related to mutations of the BAP1 gene9; however, the overall magnitude of risk remains undefined.Excluding asbestos, abdominal radiotherapy is the only well-documented cause of mesothelioma.Clinical presentation of MPM is generally nonspecific. Patients complain of abdominal distension, pain, nausea, anorexia, and weight loss. Complications of bowel obstruction, such as constipation and vomiting, tend to manifest with advancing disease. It is unclear whether our patient’s constipation was an independent symptom or a result of peritoneal disease. Left lower quadrant tenderness may be explained by the discovery of extensive nodular formations. Pleural spread of malignant disease was likely the causative factor behind this patient’s respiratory symptoms.MPM has been studied to a lesser extent than its pleural counterpart. Thus, there is no definitive guideline detailing the most effective diagnostic strategy. Radiographic findings are especially uncertain, and are often inconsistent between patients.10 As the tumor progresses, growth may extend to the visceral peritoneum of the bowels, resulting in the formation of abdominal adhesions. MPM also exhibits involvement of the omentum, diaphragm, liver, small and large bowels, and mesentery. Implication of the pleura is also a frequent finding in patients with MPM, specifically pleural calcification and recurrent pleural effusions.11 For our patient, CT findings were nonspecific, warranting further investigation.CT is an essential study in any patient with abdominal pain and distension. In some reported cases, MPM manifests as diffuse peritoneal disease with malignant infiltration and nodular thickening of the parietal peritoneum in a sheet-like fashion.12 Integrated positron emission tomography (PET)-CT has also been implemented in assessing pleural mesothelioma; however, it is unclear whether results are replicable in the peritoneum.13 Neither MRI nor PET are considered standard practice in Australia.Although CT is the gold-standard imaging modality in mesothelioma, research suggests imaging features are comparable with magnetic resonance imaging (MRI). MRI has been shown to more accurately predict burden of disease in posttreatment follow-up.14 However, minimally invasive laparoscopic exploration is associated with improved patient outcomes.Because of inconclusive radiographic evidence, direct visualization of intra-abdominal contents via laparoscopy was necessary to determine the cause of disease in this case. Both laparoscopy and laparotomy are associated with high diagnostic performance in the investigation of MPM.15 There are usually hundreds to thousands of nodules, which vary in size and consistency. Histologic examination of peritoneal nodules differentiates MPM into three subtypes: epithelioid, sarcomatoid, and biphasic.16 The epithelioid variant is most common, constituting up to 75% of cases. Epithelioid mesotheliomas are composed of flattened or cuboidal cells that closely resemble normal mesothelial cells. Mitotic figures are uncommon. Architecturally, they form a tubulopapillary or trabecular pattern and are predominantly composed of acinar structures.17 The morphology of epithelioid-type cells closely resembles that of an adenocarcinoma; hence, the presence of metastatic adenocarcinoma should be considered.The macroscopic appearance of MPM is typically characterized by the presence of white tumor nodules on the parietal peritoneum.In the present case, numerous peritoneal nodules were discovered throughout the left iliac fossa. These nodules displayed an outer layer of flattened mesothelial cells. Tissue fragments showed small acinar-like structures and irregular strands of cells showing uniform nuclei. Mitotic figures were inconspicuous, with cells displaying occasional prominent nucleoli. The stroma was mildly myxoid with a few hemosiderin-laden macrophages. Umbilical tissue displayed similar flattened cells with nuclear enlargement, moderate pleomorphism, large nucleoli, and surrounding desmoplasia. These findings were consistent with epithelioid-type MPM.18 Staining for pancytokeratins is especially useful because most epithelioid and sarcomatoid mesotheliomas will be positive. The suggested panel consists of a pancytokeratin in conjunction with at least two mesothelioma and two carcinoma markers. For epithelioid mesothelioma, the most common positive markers are calretinin, cytokeratinin 5/6 (CK5/6), Wilms tumor-1 (WT1) antigen, and podoplanin.18 All biopsy specimens obtained from our patient were positive for calretinin, CK5/6, and WT1 (Immunohistochemistry is required in combination with macroscopic analysis to differentiate MPM from neoplastic mimics, such as metastatic adenocarcinoma. There is no single marker with sufficiently high sensitivity and specificity for MPM. Therefore, standard practice dictates the need for a panel of markers, both positive and negative. The International Mesothelioma Interest Group recommends that markers considered in diagnosis should have either sensitivity or specificity greater than 80%. and WT1 , and negBAP1 can be used to support a pathologic diagnosis of abdominal mesothelioma over serous carcinoma.19 However, such findings were published after our diagnosis had been made. Furthermore, fluorescence in situ hybridization analysis of p16 gene deletion could have been used to expedite the diagnostic process.18Recent studies have shown that negative staining for 18 The significant morphologic overlap between nonmalignant reactive mesothelial cells and malignant mesothelial cells may be partly responsible for this high false-negative rate. Both cell types tend to exhibit cell clumps, intercellular windows, lighter dense cytoplasm edges, and low nuclear-cytoplasmic ratios. Fluid harvested in epithelioid mesotheliomas display large clumps of malignant cells, with most much larger than normal mesothelial cells.Mesotheliomas often present with serous effusions because of fluid produced by malignant cells. Fluid testing is generally unreliable in the diagnosis of malignant mesothelioma. Sensitivity reported in previous research ranged from 32% to 76%.11 In patients presenting with pleural effusion, clinicians should investigate whether the primary is located in the pleural or peritoneal cavity. Secondary pleural effusion is typically free of malignant cells.18Mortality from MPM is generally based on disease progression within the peritoneal cavity. During later stages of disease, MPM may extend into the pleural cavity, resulting in pleural effusion.Contrary to expected findings, our patient presented with recurrent pleural effusion and minimal peritoneal effusion. Pleural fluid analysis reported atypical mesothelial cells on a background of erythrocytes and mononuclear cells. These atypical cells exhibited reactive morphology, hyperchromatic nuclei, and enlarged nucleoli. Immunostaining revealed no evidence of malignancy. Peritoneal fluid obtained during exploratory laparoscopy demonstrated clumps of malignant cells on a background of erythrocytes, mixed leukocytes, and reactive mesothelial cells. The malignant cells stained positive for calretinin, CK5/6, CK7, and WT1. The patient is currently alive and her condition has stabilized after four cycles of carboplatin and pemetrexed.


Malignant renal epithelioid angiomyolipoma (EAML) is an extremely rare disease with a poor prognosis, and currently there are no uniform criteria for its biological behavior. Here, we present a case of malignant renal EAML with TFE3 gene amplification in a 53-year-old woman. Four months after surgery, unenhanced computed tomography scans showed recurrence as well as metastasis in the abdomen and lung. The patient succumbed to rapid neoplastic progression of the disease 6 months later.  Epithelioid angiomyolipoma (EAML) is a rare variant of angiomyolipoma with malignant potential and is an independent tumor subtype within the family of perivascular epithelioid cell tumors . It has A 53-year-old woman presented with a 5-day history of whole range painless, gross hematuria with presence of lumbago and fatigue over the past 6 months. Sonography showed a solid mass in the left kidney. Unenhanced computed tomography (CT) scans showed an ill-defined, irregular, slightly hyperdense mass (with size 11.9 × 10.0 × 10.1 cm) relative to renal parenchyma in the left kidney with corticomedullary involvement a. The maLaparoscopic radical nephrectomy with tumor thrombectomy and retroperitoneal lymphadenectomy were performed. At surgery, the kidney was obviously increased in size. The left renal vein was dilated and completely filled by thrombi. Upon histological examination, the specimen was grayish yellow, and necrosis and hemorrhage were observed. Tumor cells were cytologically malignant and exhibited marked pleomorphism as well as atypical mitotic figures a. ImmunoFour months after surgery, an unenhanced CT scan showed recrudescence as well as multiple abdomen and lung metastases  and T2-hypointense, which is attributed to their epithelioid muscle component , 7. EAMLCurrently, there are no uniform histological criteria for malignant EAML with the exception of distant metastases. Histologically, EAML is characterized by the predominant presence of polygonal epithelioid cells with atypical nuclei, mitotic figures, necrosis, marked atypical large cells with abundant eosinophilic cytoplasm that stain strongly for HMB-45, and low number of adipose cells. In the present case, FISH analysis suggested X chromosome polyploidy resulted in TFE3 gene amplification without TFE3 gene fusion. The differential diagnosis of malignant EAML includes clear cell RCC and Xp11.2/TFE3 RCC. Clear cell RCC typically shows significant heterogeneous enhancement and a significant washout. Stronger enhancement equivalent to the renal cortex is shown only in clear cell RCCs and not in other subtypes. Xp11.2/TFE3 RCC usually affects children more than adults, showing heterogeneity moderately prolonged the enhancement on dynamic contrast-enhanced CT. Circular calcification around or within the tumor is a specific clue for CT diagnosis of Xp11.2/TFE3 RCC. Currently, there is no known effective therapy for malignant EAML other than surgery . HoweverThe recognition of EAML is important, as it is either premalignant or malignant. In our case, the growth pattern of malignant renal EAML with TFE3 gene amplification was more aggressive and the prognosis was poorer compared with typical EAML. Thus, whenever a solid renal mass with necrotic and hemorrhagic portion and no fat component are encountered, even if accompanied by renal vein thrombosis and enlarged lymph nodes, the possibility of malignant EAML with TFE3 gene amplification should be considered. We received institutional review board approval for this retrospective study. Shandong Research and Development Program (2016GSF201095). Research Award Fund for Outstanding Young-Middle aged Scientists of Shandong Province (BS2014YY004). None declared.


Ectopic adrenocorticotropic hormone (ACTH) syndrome is a challenging diagnosis only responsible for approximately 10% of Cushing syndrome cases. It has been associated with a variety of benign and malignant tumors including a carcinoid tumor accompanied by aspergilloma in our case that was significantly difficult to be detected. We report a patient over 70 years old with uncontrolled hypertension and hypokalemia presenting with generalized edema. Laboratory results revealed ACTH-dependent Cushing syndrome, but imaging studies did not show any discrete lesions secreting ACTH. The petrosal to peripheral ACTH gradient resulted in no evidence of pituitary adenoma. As the only lesion suspicious for ectopic ACTH secretion was a right lower round cystic lesion that did not appear to be a carcinoid tumor on computed tomography scan of the chest, the patient underwent video-assisted thoracic surgical resection to provide a definitive diagnosis. The final diagnosis was a small ectopic ACTH-secreting carcinoid tumor with unusual superimposed aspergilloma in the periphery of the lung. Postoperatively, the abnormal endocrine levels were normalized, and all of the clinical symptoms and signs were ameliorated. This is an informative case of ectopic ACTH syndrome (EAS) that was the cause of hypokalemia, hypertension, metabolic alkalosis, and hypercortisolism despite its poorly specific cushingoid morphology and uncommon imaging findings. Therefore, we recommend that clinicians investigate any possible lesion as a potential source of EAS. The differential diagnosis and proper management of adrenocorticotropic hormone (ACTH)-dependent Cushing’s syndrome is one of the most intriguing challenges for endocrinologists . Most caHere, we report a very rare case of EAS stemming from a peripheral lung lesion that had remained unchanged for 3 years and that was finally diagnosed as a small pulmonary carcinoid tumor adjacent to aspergilloma.A patient over 70 years old was admitted with bilateral pedal edema and generalized weakness that had become apparent 1 month earlier. There were no underlying chronic lung disease and no history of smoking. The patient also complained of unintentional weight gain (5 kg) with proximal muscle weakness. Upon physical examination, the blood pressure was 170/90 mmHg although a combination of four antihypertensives had been taken. The patient presented with a puffy face, central obesity without purplish striae, and thin skin with pitting edema, none of which are specific to cushingoid symptoms.3 level of 46.1 mmol/L. We investigated the status of mineralocorticoid excess. Plasma renin activity and aldosterone were within normal ranges (Table The laboratory results are summarized in Table 18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) or nuclear scans for financial reasons. Since no suspicious foci other than the chest lesion were found, a wedge resection under video-assisted thoracoscopic surgery was performed. Macroscopically, the tumor was a relatively well-demarcated and ivory-colored nodule measuring 16 mm × 15 mm. It was adjacent to another grayish yellow mass measuring 33 mm × 22 mm. Microscopically, the two lesions were in very close proximity, presenting as one lesion radiographically  and [18F] FDG-PET. The combination of two anatomic methods, CT and MRI, increases detection, with a per-patient sensitivity of 83% and a positive predictive value per lesion of 80%  and F FDG-PETn of 80% . In thisConcerning the management of EAS, surgical excision is the first treatment of choice once a single source of the ectopic tumor is successfully localized. Approximately 83% of EAS patients with bronchial carcinoid tumors recover after radical excision , 11. If We report a very rare case of covert EAS from a pulmonary carcinoid tumor with coexisting aspergilloma that was not in an endobronchial location. Fortunately, the resection of the lesion managed to resolve the hypercortisolemia. Although the diagnosis can be challenging, especially in the evaluation of patients with a hidden primary tumor, we must adopt a multidisciplinary approach to localize and remove the source of hypercortisolism to prevent serious complications, considering the possibility of a masked lesion as the etiology.This case report was carried out in accordance with the recommendations of the Institutional Review Board from the Korea University Medical Center.KJK is the first author for this case report. JAS is the corresponding author supervising this work. JHY, NHK, YSK, and YHK are coauthors performing analysis on all data interpretation and manuscript evaluation.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We present a rare case of intussusception in a 41-year-old man with acute myeloid leukemia without an evidence of leukemic infiltration of the bowel. The patient presented to the emergency room with right lower quadrant pain. Initially he was diagnosed with typhlitis. CT scan was done and showed ileocolic intussusception without a definitive lead point identified. Patient underwent hemicolectomy and histopathological study of the specimen did not show any leukemic infiltrate. High suspicion of intussusception should be kept in mind with leukemic patients presenting with abdominal pain. The gastrointestinal system can undergo various pathological changes in leukemia produced by the disease process or by its treatment. Leukemic gastrointestinal sequela can include leukemic infiltration, infections, hemorrhagic necrosis, and related surgical complications . VariousWe report a case of intussusception in an adult patient with acute myeloid leukemia presenting with right lower quadrant pain. Although this is an uncommon complication in adults, it should be suspected in patients with acute leukemia presenting with abdominal pain.A 41-year-old male patient presented to our hospital in January 2010, with left tonsillar mass, and a biopsy revealed a malignant lymphoma (DLBCL). There were no metastatic lesions except for few left cervical lymph nodes. The patient had a stage IAE DLBCL. He received chemotherapy which was followed by radiotherapy to the left tonsillar region and a complete response was achieved. In 2012, the patient was evaluated for easy fatigability. He was found to have therapy-related acute myeloid leukemia/myelodysplastic syndrome (AML/MDS) and was treated with multiple lines of chemotherapy and he achieved complete remission in January 2014. Six months later he was found to have AML/MDS in relapse. Patient was started on palliative azacitidine.In September 2014, he presented to the emergency room complaining of right lower quadrant abdominal pain, sudden in onset, moderate in severity, nonradiating, and associated with fever, chills, vomiting, and nonbloody diarrhea. Vital signs were significant for a heart rate of 122 beats per minute and a temperature of 38.3°C (102.4°F). On examination, he looked pale, fatigued, and distressed. He had conjunctival pallor, lungs were clear to auscultation, and his abdomen was soft and nondistended, with moderate right lower quadrant tenderness and no signs of peritoneal irritation. There were no palpable masses.µL, with absolute neutrophilic count of 320 neutrophils/µL. Hemoglobin level was 7.0 g/dL, and a platelet count was 1,000 platelets/µL. Chemistry and electrolytes panel showed no abnormality. Stool analysis was only positive for few red blood cells.Laboratory studies showed a white blood count of 1,600 cells/Initially the patient was diagnosed with febrile neutropenia with suspected typhlitis. Blood cultures were drawn and he was started on broad spectrum IV antibiotics. CT scan of the abdomen and pelvis was ordered and showed ileocolic intussusceptions  with no Intussusception in leukemia patients has almost exclusively been reported in the pediatric population but rarely reported in adult patients , 5. We hCompared to the pediatric population, intussusception is uncommon in adult population, contributing only to 5% of all intussusceptions . Most ofAnother important differential diagnosis for acute right lower quadrant abdominal pain in patients with leukemia is necrotizing enterocolitis (NEC). Necrotizing enterocolitis (typhlitis) is a necrotizing process that usually affects the ascending colon, cecum, and terminal ileum. Majority of cases involve hematological conditions, and 2.6% of patients with acute leukemia develop typhlitis , 13. PatBecause of the variety of pathological processes that may cause right lower quadrant abdominal pain in immunocompromised patients, reaching an accurate diagnosis may be problematic. Merine et al. reported usefulness of using CT scan in differentiating the various causes of right lower quadrant abdominal pain in the clinical setting in the immunocompromised patients . It can Treatment of adult intussusception almost always requires surgical intervention . Due to We described an interesting case of ileocolic intussusception in a leukemic patient without an evidence of leukemic infiltration of the bowel. Although it is a rare cause in adults, it should be kept on the differential of a patient presenting with abdominal pain. CT scan is a successful imaging study that can help in reaching a correct diagnosis.


Echinococcus granulosus is the most common tapeworm causing hydatid disease in humans. Its least‐encountered complication is cutaneous fistulization. Omentoplasty, cyst, and fistulous tract drainage revealed successful in the management of this complication. Such intervention can be an alternative when conservative management fails, and a minimally aggressive procedure is required. Echinococcus granulosus is the most common tapeworm causing hydatid disease in the human species This is a case of a 68‐year‐old female patient, known to have coronary artery disease and multiple metabolic disorders, who presented for the management of a right breast cutaneous fistula.Four months prior to that our patient underwent a partial mastectomy for a fibroadenoma in her right breast that was complicated by a wound infection and persisted despite medical treatment, antibiotics, and superficial drainage. The wound had continuous purulent discharge.Ultrasound performed Figs  and 2 sh3, neutrophils 68.2%, platelets 283,000/mm3, SGPT 32 U/L, SGOT 16 U/L, direct bilirubin 0.09 mg/dL, total bilirubin 0.23 mg/dL, alkaline phosphatase 106 U/L, γGT 48 U/L, and CRP 4.27 mg/dL.Laboratory studies carried out were normal except for a mildly elevated CRP: hemoglobin 12.4 g/dL, hematocrit 37.0%, white blood cells 7000/mmEscherichia coli sensitive to all.A culture taken from the breast discharge revealed growth of Chest X‐ray performed Fig.  showed iPatient underwent a fistulectomy with a right lateral incision of the right breast. Intraoperatively, a stylet was inserted, as an attempt to follow the fistulous tract and remove the surrounding tissue. While following the tract deep into the tissues, the stylet was noticed reaching the intercostal space and going further down beneath the ribs in the extrapleural space. Significant amount of pus was suctioned and drained; a penrose drain was inserted in the wound. No perioperative complications were noted.At this point, further investigations were necessary for the proper management of this patient. A chest, abdomen, and pelvis CT scan Figs  and 5 weThe pathology result showed a fistulous tract with no evidence of malignancy from the right breast tissue; inflamed vascular granulation tissue with no evidence of mesothelial lining and no evidence of malignancy.Conservative management was initiated, with an attempt to drain the cyst, and pull the penrose progressively in order for the tract to heal. Albendazole was started as well. However, after few weeks of daily wound care, no progress was noted regarding the wound's secretion and no signs of imminent fistulous tract closure.At this point, operative management was decided. Due to the patient's multiple comorbidities, the relatively small left liver and the relatively large cyst, we chose to undergo the least aggressive surgical intervention.A right subcostal incision was performed. Liberation and mobilization of the liver was performed until reaching the posteriorly located cyst Fig. . The cysPatient was discharged on postoperative day 5 on Albendazole.On postoperative day 7, the first intra‐abdominal drain was removed, followed by the penrose drain, which was being progressively pulled out until it was totally out on day 12, and finally the second drain on day 19.Follow‐up visit 1 month postoperatively showed a clinically well‐doing patient with all wounds healed Fig. . At 2 moEchinococcus granulosus, in the larval form, is the active initiator of hydatid disease in the human species. Canine feces are the main delivery route, although contact with these animals is also a mode of transmission. When eggs from feces‐contaminated vegetables are ingested, they hatch into the small intestines, pass through its wall into the portal vein, where access to liver, lungs or any other organ is guaranteed The majority of hydatid cysts with cutaneous fistula have one or more of the following features: superficially located cysts, thick, calcified, and showing chronic inflammatory changes. Such characteristics add more sense to the cutaneous communication of these types of cysts Furthermore, of the 17 cases reported, none had a cutaneous fistulous tract opening at the level of the breast. Two of the 17 cases were sent on Albendazol only, and succeeded. In two other cases, a conventional treatment was attempted and consisted of cyst drainage through the fistulous tract In our case, we started with conservative management and failed. When we resolved for surgery, we decided to act the least aggressively by avoiding a thoracotomy, for fistulous tract excision, and a right hepatectomy. The patency of the fistulous tract was maintained by the cyst's secretions. So, on the one hand, we resigned to the idea that breaking the cystofistulous communication might allow the tract to close. This consisted of two steps: division of the cyst's attachment to the diaphragm then preventing the cysto‐fistulous connection with an omental patch. On the other hand, we needed to treat the hepatic hydatid cyst cavity. Scolicidal agent (citramide) was used, cyst content was drained, and partial cystectomy performed. No intrabiliary communication was noted, and a drain was inserted into the cyst.Omentoplasty, cyst drainage, and fistulous tract drainage revealed successful in the management of hydatid cyst with spontaneous cutaneous fistula. Such an intervention can stand as an alternative when conservative treatment fails, and a minimally aggressive procedure is required.AEA: did the literature review and corrected the article. EC: wrote the article and organized the figures, tables, and legends. MY: did the data collection and obtained the patient's consent. IH and MEK: performed the operation and reviewed the written article. WD and AEA: assisted in the surgical intervention.The authors declare no potential conflict of interest.


Giant ovarian adenomas are rarely observed today because of early diagnosis and treatment. Mucinous cystadenomas is a kind of tumor that mostly causes the ovary to enlarge. Theu can present with various and non-specific clinical manifestations such as deep vein thrombosis. The primary symptoms of giant ovarian tumors are abdominal enlargement and distension. Therefore, making the correct preoperative diagnosis is sometimes difficult. The appropriate treatment must include oncologic procedures and a multidisciplinary approach to minimalize complications and save the patient’s life.Herein, we report a woman aged 53 years with a 27-kg ovarian mucinous cystadenoma that presented as a left popliteal vein thrombosis. About 80% of mucinous tumors are benign and are common usually between the third and sixth decade of life,3. Mucinous tumors are usually unilateral and can exceed 30 cm in diameter. Although prognosis is very good, the clinical signs and symptoms of ovarian masses are generally nonspecific. Therefore, making the correct preoperative diagnosis is sometimes difficult, and early management may be necessary to save the patient’s life. The purpose of this case was to report a 27-kg ovarian MCA that presented as deep vein thrombosis (DVT).Giant ovarian tumours are now a rare condition because of early diagnosis and treatment. Mucinous cystadenoma (MCA), a tumor that causes ovaries to enlarge, accounts for about 15% of all ovarian neoplasmsThe patient was a woman aged 53 years with an abdominal mass that caused left popliteal and femoral vein thrombosis. She claimed stepwise enlargement of the abdomen and initially thought she had put on weight. However, when swelling progressed in her left leg, she was admitted to an internal medicine clinic. Her condition was diagnosed as DVT and she was referred to us upon finding an abdominal mass in her abdominal ultrasound (USG) examination. Abdominal enlargement and distension were observed, and abdominal USG revealed a 40×50 cm abdominopelvic mass, probably originating from her left ovary, with multiple septations and solid areas. Tumor markers  were within the normal range. A malignant ovarian tumor was initially suspected because of the size, and a positron-emission tomography-computerized tomography (PET-CT) was performed. The PET-CT revealed an enormous heterogenic mass with low metabolic activity in the left ovary, a 5×5 cm mass in the right ovary, and bilateral urinary stasis. A laparotomy with midline incision revealed a smooth-surfaced mass that filled the entire abdomen originating from the left ovary and confirmed the 5×5 cm mass in the right ovary . A detai. MCAs mainly occur during middle age, as in our case, and they are rare among adolescents. There was, however, a report of an ovarian MCA in a premenarchal girl. MCAs are usually unilateral, and are bilateral in 10% of cases (as in our case),7. MCAs can reach large sizes even though they do not have the potential for malignancy,3,8. The largest reported adnexal cyst was 148 kg. The mass in our patient weighed 27 kg.Giant ovarian cystadenomas are rarely observed today because of improved imaging techniques(5). Further, most ovarian cyst adenomas are epithelial cystadenomas, of which 25% are mucinous. In literature, there is no information about an ovarian mass presenting as DVT due to femoral vein pressure.In general, MCAs can be found incidentally in routine USG screenings; abdominal enlargement and distension are major symptoms. The most frequent complications are torsion, pressure to the adjacent structures like the viscera, which accounts for urinary stasis and rupture, and spilling of tumor into the peritoneum, known as pseudomyxoma peritonei.Ultrasonographic examination of ovarian cysts can exclude malignancy. In most cases, USG examination can reveal a complex adnexal mass, as in our case. When there is a diagnostic doubt, a CT or magnetic resonance imaging scan is performed. In our case, PET-CT scan was performed because of a suspicion of malignancy. Although tumor markers can identify cyst characterization in most instances, they are more important in monitoring postoperative relapse. Cystectomy cannot be performed because of the absence of normal tissue; adnexectomy is the classic treatment. If there is a suspicion of malignancy, a laparotomy with oncologic procedures is recommended. Although some studies suggest laparoscopy, there are still debates because of tumor size limitations. We preferred laparotomy owing to the tumor dimension and suspicion of malignancy,5.Large ovarian cysts traditionally require laparotomy because of their sizeGiant ovarian cysts have significant morbidity if not managed properly. A multidisciplinary approach must be taken preoperatively. Giant ovarian cysts can cause hemodynamic and pulmonary complications; therefore, central venous pressure monitorization is recommended during operations. The lateral decubitus position is preferred during the operation.MCAs can present as different clinical conditions such as DVT. The appropriate treatment must include oncologic procedures, and a multidisciplinary approach must be undertaken to minimalize complications.


Intracranial capillary hemangioma (ICH) is a rare entity, with approximately 24 reported cases in the literature. There are only three reported cases of ICH in an adult male. In this case report, we describe the fourth documented case of ICH in an adult male and, to the best of our knowledge, the first ever documented case of ICH in the posterior fossa of an adult male. We also discuss its imaging appearance and differential diagnosis. A 40-year-old male with a history of hypertension and diabetes presented with a four-day history of right earache, headache, and vertigo. He was initially seen by his primary care physician and given antibiotics for an ear infection; however, when his vertigo worsened, he subsequently went to an outside hospital emergency department. After being diagnosed with hemorrhage in the posterior fossa, he was transferred to our institution.A head computed tomography (CT) without contrast demonstrated hemorrhage in the region of the inferior right cerebellar peduncle, which appeared intraparenchymal, with extension into the fourth ventricle . A head Magnetic resonance imaging (MRI) of the brain demonstrated an enhanced right cerebellopontine angle mass underlying the hemorrhage in the right cerebellopontine angle Figures . A cleftThe patient subsequently underwent resection of the mass. Histologic evaluation of the mass showed cytologically bland tumor cells with vascular proliferation, which were positive for cluster of differentiation (CD) 31 and CD34 as well as negative for inhibin, glucose transporter 1 (GLUT-1), and epithelial membrane antigen (EMA), consistent with a capillary hemangioma . FinallyA capillary hemangioma is a benign tumor consisting of an abnormal overgrowth of tiny blood vessels. They appear within the first 6 months of age, grow rapidly until about 12 months of age, and then usually undergo complete spontaneous regression by 5 years of age . FurtherWhile it is extremely unlikely for an ICH to be prospectively diagnosed based on imaging alone given its rarity and lack of pathognomonic features, it can be suggested based on its typical imaging appearance. The enhancement pattern of an ICH is as expected: an avidly enhanced mass, given its vascular nature. Likewise, it also has the capability to bleed spontaneously as manifested in our case by hyperdensity in the region of the inferior right cerebellar peduncle on the initial head CT. While the hemorrhage appeared intra-axial on CT, it was confirmed to be extra-axial on MRI. This is in keeping with the fact that most intracranial capillary hemangiomas are extra-axial . IntracrPathologic diagnosis was aided by CD31 and CD34, which highlight vascular architecture. Both immunochemical stains were positive in this case as is required for diagnosis of a hemangioma. Additionally, while GLUT-1 is typically positive in infantile and juvenile hemangiomas, it was negative in this case given the patient's adult age.There are a number of other diagnoses to consider for an enhanced mass in the cerebellopontine angle in an adult. Although the most common mass in this location would be a schwannoma, these rarely hemorrhage or have intratumoral hemorrhage and are typically hypovascular to avascular on catheter angiography . The maiIn conclusion, ICH is a rare entity. We presented the first ever reported case of a capillary hemangioma in the posterior fossa of an adult male. As such, a capillary hemangioma could be considered in the differential diagnosis for an enhanced extra-axial mass in the posterior fossa, particularly in the setting of spontaneous hemorrhage.


Dear Editor,A 64-year-old male presented with nasal obstruction, anosmia, and a reduction in visualacuity over the last few months, together with weight loss and a two-year history ofheadache. Computed tomography (CT) of the brain  showed a. It isbelieved that the neoplasm arises from the olfactory epithelium, originating in thesuperior portion of the nasal cavities, ascending across the cribriform plate, andextending into the anterior cranial fossa.Olfactory neuroblastoma, also known as esthesioneuroblatoma, is a rare malignant neoplasmof neuroectodermal origin and accounts for 3–6% of all malignant tumors of the paranasalsinuses. It has a bimodal age distribution, being most common among adults in the secondor fifth decades of life. Although there is no universallyaccepted staging system, the Kadish classification system, established in 1976 andconsidered an important prognostic predictor, is widely used. In the Kadish system,stage A indicates that the tumor is limited to the nasal cavity; stage B indicates thatit involves only the nasal cavity and paranasal sinuses; and stage C indicates that itextends beyond the stage B limits. The staging system proposed by Dulguerov employs thetumor-node-metastasis classification,4.Clinically, olfactory neuroblastoma manifests as nasal obstruction or epistaxis. It canshow indolent behavior, promote local invasion, and generate distant metastases. Ittends to invade the paranasal sinuses, orbits, and anterior cranial fossa. The mostcommon metastases are to the lymph nodes of the neck, lungs, liver, and bone, suchdissemination at the time of diagnosis being the main predictor of survival. An MRI scan providesmore accurate information on the extent of the tumor, especially in terms ofintracranial and orbital involvement. On MRI, the majority of olfactory neuroblastomaspresent a signal that is (in relation to that of muscle tissue) hypointense inT1-weighted sequences and hyperintense in T2-weighted sequences, as well as showingintense enhancement in contrast-enhanced sequences,7. MRI is also superiorto CT in the evaluation of recurrence after craniofacial resection, because of itsgreater ability to differentiate fibrous scar tissue from residual or recurringneoplasia. Cysts in theintracranial margin of the tumor have been reported in cases of olfactory neuroblastoma.Another relevant aspect is a dumbbell-like morphology, the tumor mass being dividedbetween the anterior cranial fossa and the nasal cavity, the cribriform plate formingthe “waist”.Bone destruction and calcification within the lesion can be characterized byCT.The main differential diagnoses of olfactory neuroblastoma include: squamous cellcarcinoma, typically in the maxillary antrum, with bone erosion; sinonasaladenocarcinoma, with heterogeneous enhancement, which has been associated withoccupational exposure to wood dust; undifferentiated sinonasal carcinoma, which affectsolder patients; and dural-based invasive meningioma, with poorly defined borders andareas of necrosis


Lobular capillary hemangioma is a benign lesion of the skin and mucous membranes. Subcutaneous lobular capillary hemangioma presents as a deeper nodule. Lack of the characteristic surface changes of this subtype of lobular capillary hemangioma makes the clinical diagnosis challenging. We describe clinical, radiologic, and histological features of a subcutaneous lobular capillary hemangioma tissue presenting as a facial mass in a 12-year-old male. The mass was a firm, nontender, immobile, subcutaneous nodule, with no color change of the overlying skin. CT imaging documented a hyperdense and nonlipomatous mass involving soft tissue of the left lateral nasal wall. An excisional biopsy was performed. Histologic evaluation showed subcutaneous lobular capillary hemangioma. Subcutaneous lobular capillary hemangioma, although uncommon, should be considered in the differential diagnosis of lateral nasal wall mass in children. Lobular capillary hemangioma (LCH), characterized by benign proliferation of capillaries with a lobular architecture, is a common benign vascular tumor of children and adults . The IntThe majority of LCH present on the head and neck, commonly involving gingiva, lips, tongue, and buccal mucosa. LCH is rarely located in the nasal cavity . The antA 12-year-old male with past medical history of type II diabetes mellitus presented with a gradually enlarging mass on the left lateral nasal wall for 8 months . The patIn the present study, subcutaneous LCH was documented in a child with a history of trauma to the nose. While no direct causal relationship has been identified, there is an association with estrogen exposure and trauma. Five percent of pregnant patients experience a new onset LCH, especially of the gingiva, hence the term “pregnancy tumor” . ExogenoHistologically, LCH consists of a benign proliferation of capillaries arranged in lobules separated by fibrous septa . SuperfiThe variants of LCH include oral mucosal, satellite, intravenous, dermal, and subcutaneous. Subcutaneous, as described in this case, is the rarest form of LCH and lacks the distinct friable, raised, easily bleeding appearance that is characteristic of the more common counterpart. A review of 106 LCH cases at a single institution found an incidence of 3.4% for the subcutaneous variant . The cliIn conclusion, subcutaneous mass can manifest as a lateral nasal wall mass in children, and excision of the mass forms the mainstay of treatment. Prompt diagnosis and treatment of subcutaneous LCH is essential to prevent complication or sequela.


Background: Paraganglioma of the urinary bladder (PUB) is exceedingly rare, accounting for <0.1% of all urinary bladder tumors. Various challenging treatment options are available.Case Presentation: A 67-year-old female presented with malignant hypertension on four medications for which investigation was done. An observation of having functioning PUB was noted. She was admitted and laparoscopic partial cystectomy was done with the guidance of flexible cystoscopy. She had a smooth postoperative course and was discharged home, then catheter was removed after cystogram. Histopathology confirmed the diagnosis of a bladder paraganglioma. Finally, during the last follow-up, the patient was asymptomatic with controlled blood pressure and normalized catecholamine levels with no evidence of recurrence.Conclusion: PUB is an exceedingly rare tumor that can be managed with minimally invasive techniques such as laparoscopic partial cystectomy with cystoscopy guidance. Laparoscopic partial cystectomy was conducted (she was placed in low lithotomy position and laparoscopic procedure was started by mobilizing the bladder in combination with flexible cystoscopy that showed a mucosal bulge located in anterior bladder wall with a wide base near the bladder neck. The light of the endoscope guided the start of resection with a safety margin and then we excised the mass completely with a good safety margin as shown in PUB is an exceedingly rare tumor that can be managed with minimally invasive techniques such as laparoscopic partial cystectomy with cystoscopy guidance.2 In our case study, the patient is a 67-year-old coping with the median age of other urothelial tumors. The clinical presentation of functioning paraganglinoma is manifested by a headache and uncontrolled hypertension despite medications. The use of MIBG and elevated urinary catecholamine levels help the tentative diagnosis of the case. Immunohistochemistry and characteristic histologic features are the cornerstones for confirmative diagnosis with high index of clinical suspicion.2 There are various treatment options for PUB, including transurethral resection, partial cystectomy, and radical cystectomy.3 Because the paraganglionoma of the urinary bladder in our case was preoperatively known to be functioning, a large size, and located in the anterior bladder wall, laparoscopic partial cystectomy was the preferred option of treatment, as intraoperatively uncontrolled hypertension may be disastrous in such cases. To the best of our knowledge, the only laparoscopically assisted partial cystectomy for a known preoperative functional paraganglinoma that was effectively treated without sequels under cystoscopic guidance was previously reported by Gofrit et al.4 for open partial cystectomy.PUB is rare <1% of bladder tumors and 6% of all paragangliomas. Out of these PUB, only 10% show malignant behavior. There are no specific sites inside the urinary bladder more vulnerable to PUB. However, it is commonly reported at the lateral wall, posterior wall, and trigone. PUB can be misdiagnosed with other urothelial bladder tumors. Most of the reported cases are younger than those of urothelial carcinoma with a median age of 43 years.