Bronchogenic cysts are a rare type of mediastinal mass thought to arise from abnormal budding of the embryologic foregut. This paper presents a rare case of a 32-year-old male who developed multiple serious complications from a bronchial cyst. This rare presentation is discussed and the role of CT and MR imaging in making the diagnosis is highlighted. Bronchogenic cysts are a rare cause of mediastinal mass ,2. The eStreptococcus salivarius and Streptococcus milleri was cultured from the aspirate and a diagnosis of an infected cyst was made. Retrospective and detailed review of all MR images yielded one sagittal view demonstrating a fluid level within the cyst.  showed a mediastinal mass . CT withhe cyst.  This hadUpon thoracotomy the mass was identified, but could not be removed because of its adherence to oesophagus, pericardium and pleura. It was thus marsupialised into the oesophagus. A nearby enlarged mediastinal lymph node was removed for histopathologic examination. Histopathology revealed a reactive lymph node and material taken from the cyst wall displayed pseudostratified ciliated respiratory type epithelium and glandular structures. No cartilaginous material was seen in the excised section of the cyst wall. There was evidence of inflammatory infiltrates in the sample. Post-operatively, the patient was anti-coagulated (due to the pre-operative presence of thrombus on the CT) and was discharged home once recovered 14 days after admission.Serious complications from bronchogenic cysts are rare, but can include SVC syndrome, tracheal compression, pneumothorax, pleurisy and pneumonia . In a seBronchogenic cyst of the mediastinum can present acutely with several complications. In this case, the mass effect and the presence of inflammation were likely related to the development of complications. The multiple complications observed in this patient were: atrial fibrillation, pericardial and pleural effusions, and pulmonary vein thrombosis. There was also radiologic evidence of left atrial compression and SVC obstruction without obvious significant clinical signs or symptoms. This case is of interest due to the multiple complications and the diagnostic dilemma this case presented. The diagnosis may be easily missed on CT and transthoracic ultrasound. MRI and endoscopic transoesophageal ultrasonography were in this case helpful in accurate characterisation of the mass.


Gastrojejunocolic fistula is a rare condition after gastrojejunostomy. It was thought to be a late complication related to stomal ulcers as a result of inadequate gastrectomy or incomplete vagotomy. We report a case of gastrojejunocolic fistula after gastrojejunostomy for peptic ulcer treated with one-stage laparoscopic resection.A 41-year-old Japanese man complained of diarrhea for 10 months, as well as severe weight loss and weakness. After admission, we immediately started intravenous hyperalimentation. On performing colonoscopy and barium swallow, gastrojejunocolic fistula was observed close to the gastrojejunostomy site leading to the transverse colon. After our patient's nutritional status had improved, one-stage surgical intervention was performed laparoscopically. After the operation, our patient recovered uneventfully and his body weight increased by 5 kg within three months.Modern management of gastrojejunocolic fistula is a one-stage resection because of the possibility of early recovery from malnutrition using parenteral nutritional methods. Today, laparoscopic one-stage en bloc resection may be feasible for patients with gastrojejunocolic fistula due to the development of laparoscopic instruments and procedures. We describe the first case of gastrojejunocolic fistula treated laparoscopically by one-stage resection and review the literature. Gastrojejunocolic (GJC) fistula is a rare condition after gastrojejunostomy. It was thought to be a late complication related to stomal ulcers as a result of inadequate gastrectomy or incomplete vagotomy -3. In thCurrently, surgical treatment for many gastrointestinal diseases can be performed laparoscopically. The aim of this study was to describe the first laparoscopic one-stage resection of a GJC fistula.A 41-year-old Japanese man was admitted to our hospital complaining of diarrhea immediately after oral intake (10 bowel movements per day for the last 10 months), weight loss (15 kg) and weakness. He reported a partial gastrectomy and gastrojejunostomy due to a duodenal ulcer 18 years prior to his current presentation. On physical examination our patient looked emaciated and dehydrated. Data from laboratory tests performed on admission revealed he had hypoproteinemia and hypoalbuminemia. Parenteral nutrition was started in order to improve our patients' nutritional status. On colonoscopy, the endoscope was able to pass into the remnant stomach through an abnormal fistula that occurred in the transverse colon Figure .When our patient's nutritional status had improved, a laparoscopic surgical resection was performed successfully. Trocars were placed according to laparoscopy-assisted distal gastrectomy Figure . Intra-oHelicobacter pylori and the limitation of surgical treatment in extreme cases [Gastrojejunocolic fistula is an uncommon late complication after gastrojejunostomy for peptic ulcer or malignant gastrointestinal diseases ,2. This me cases ,7. Howevme cases . Therefoet al. reported that a barium enema is useful in making a diagnosis of GJC fistula with significantly higher sensitivity than upper gastrointestinal series [et al. reported the usefulness of endoscopy together with colonoscopy in the diagnosis of GJC fistula [A barium enema or endoscopy are essential for the correct diagnosis of GJC fistula . Thoeny l series . Recentl fistula . However fistula . Thus, nSurgery is one of the curative treatments for GJC fistula. In the late 1930s, a three-stage procedure consisting of colostomy, resection of the fistula, and closure of the colostomy was defined . The disToday, surgical intervention for many gastrointestinal diseases can be performed laparoscopically. However, laparoscopic resection in a case of GJC fistula has not been reported. In our patient's case, moderate adhesion was seen in the area of the remnant stomach laparoscopically. All abrasion procedures were performed laparoscopically, and en bloc resection and reconstruction were performed via a small laparotomy (5 cm). Laparoscopic procedures are demanding for patients with a history of major abdominal surgery. However, we think that laparoscopic surgery for patients with GJC fistula, many of whom are malnourished, may be useful because it is less invasive than open surgery.Gastrojejunocolic fistula has been considered a rare complication after gastrectomy or gastrojejunostomy. Endoscopy and colonoscopy are useful diagnostic tools for GJC fistula, but negative findings from endoscopy do not exclude the presence of fistula. Modern management of GJC fistula is via a one-stage resection. Today, laparoscopic-assisted one-stage en bloc resection may be feasible for patients with GJC fistula.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MT, KM and TI collected the data, drafted and wrote the manuscript. GH, TN and MT contributed to our patient's post-operative management and approved the final manuscript. All authors read and approved the final manuscript.


Prostatic enlargement due to benign adenomatous hyperplasia is very common in elderly males. However, benign mesenchymal tumors especially true leiomyoma of the prostate are rare. We describe a 68-year-old male presenting a urinary obstruction lasting more than two years. The patient was referred for an acute urinary retention. The clinical examination was normal. The perrectal examination revealed an enlarged prostate without abnormalities. An endoscopic resection was performed. The histopathological examination revealed a benign smooth muscle tumor with absence of glandular hyperplasia; the result was confirmed by immunohistochemistry. Accordingly, the diagnosis of true leiomyoma of the prostate was made. Leiomyoma is a benign tumor arising from smooth muscle fibers. This tumor affects the prostate gland in two forms. The first form is the most frequent; it presents as small nodules leiomiomatosis associated with benign hyperplasia. The second form is the pure leiomyoma of the prostate; this form is avery rare entity . True prA 68-year-old male was referred to our department while presenting acute urinary retention. A urethral catheter was set up. The pathological background of the patient revealed diabetes mellitus type 2 and high blood pressure and urinary obstruction lasting more than two years.E. coli. A complete endoscopic resection was performed without complications.The per-rectal examination revealed an enlarged prostate without abnormalities. The physical examination was insignificant. The blood assessment was normal. PSA was at 0.3 ng/mL. The urine culture showed an infection with The pathology report revealed the existence of pure leiomyoma of prostate. The microscopy showed the proliferation of spindle cells, without nuclear atypia or mitosis . While nLeiomyoma develop in all organs containing smooth muscles. It is more common in the gastrointestinal tract and the female genital tract .Leiomyoma appears simultaneously in several localizations of human body, such as in the genitourinary system; it has been described in the kidney, ureter, bladder, urachus, prostate, urethra, and seminal vesicles , 4. The The pathogenesis is still unknown. Authors support that prostatic leiomyoma is exclusively originating from embryonic Müllerian remnants , while lThe clinical presentation prostatic leiomyoma is identical to the benign prostatic hyperplasia. The finale diagnosis is based on histological arguments. While there is no specific clinical, biological, and imaging characteristic's. The pathological diagnosis criteria of pure prostatic leiomyoma are abscence of glandular component, presence of capsule, or pseudocapsule weighting more than 1 gram .The prognosis of these tumors is excellent because of its benign nature and lack recurrence after the complete removal , 7.True leiomyoma is a rare tumor of the prostate that is diagnosed only by the histopathological examination. This pathological entity does not have any clinical, biological, or imaging characteristics. The treatment consists of a complete surgical excision. The prognosis, after appropriate treatment, is excellent without recurrence.


We describe a seven years follow-up of a high risk gastrointestinal stromal tumor in a Meckel’s diverticulum in a 68-year-old man with abdominal pain and vomiting. The patient was operated in emergency for peritonitis due to perforation of small intestine and treated with imatinib mesylate. The metastatic progression of the disease demonstrated the value of prognostic indicators  for assessing risk of aggressive behaviour. Computed tomography was a valuable procedure for detection of local recurrence, the distant metastases and for surveillance after surgery in the follow-up. The review of the literature shows that this case has the longest follow up and consents the comparisons of the same neoplasm in other sites most frequent and better described than Meckel’s diverticulum. Gastrointestinal stromal tumors (GISTs) may be defined as mesenchymal tumors that express KIT protein or have an activating mutation in a class III receptor tyrosine kinase gene, the PDGFR-α gene, which encodes the platelet derived growth factor receptor-alpha, a tyrosine kinase protein. The KIT protein can be detected by immunohistochemical assays for the CD117 antigen (Incidence of GISTs within the Meckel’s diverticulum (MD) is 0.5 to 3.2%  2-12)..12).We present the clinical outcome of a high risk GIST in a MD, treated with imatinib mesylate, with a follow-up of seven years, as a first example of “disease biologic progression model” suggested by prognostic indicators.A 68-year-old man was referred to our institution in August 2001 because of abdominal pain and vomiting.A plain X-ray of the abdomen showed distension of the small intestine and colon; no air-fluid levels or subphrenic free air was revealed.Ultrasonography of the abdomen showed a voluminous (8 cm in maximum diameter) solid, heterogeneous, pelvic mass to the posterior side of the urinary bladder, probably arising from the small intestine Fig. .A moderate amount of free fluid in the right iliac fossa was revealed. As a result of the symptoms and radiological findings, preoperative diagnosis of peritonitis due to small intestine perforation and MD tumor with intratumoral necrosis was performed. The patient underwent an emergency surgical resection of the 4 cm ileum with MD neoplasm and lateral ileo-ileal anastomosis.The surgical specimen showed a well-circumscribed mass, measuring 8 × 3 cm, arising from the MD wall.The pathology report was of high risk GIST  Fig. . All marTwelve hours after surgery a fecal peritonitis due to perforation of the perianastomotic ileum was revealed.A second surgical operation with latero-lateral ileo-ileal anastomosis was performed.After 10 days the patient was discharged in good condition. Abdominopelvic helical Computerized Tomography (CT), performed 8-months after surgery, revealed a voluminous mass (10.5 cm in maximum diameter) in the right iliac fossa and two contiguous masses of 10 cm and of 2.8 cm in maximum diameter in the pelvis.On precontrast CT the masses were solid with heterogeneous content, well-defined margins and heterogeneous enhancement after intravenous contrast material administration Fig. . No distThe patient was treated with imatinib mesylate (400 mg/die for 4 weeks) and he did not present adverse effects to the therapy.Abdominopelvic helical CT, performed 18 months after surgery, revealed marked reduction in size of the masses. The histology of these masses showed regressive features as fibrosis and necrosis due to the therapy with the tyrosine kinase inhibitors Fig. .Appearance and size of the lesions did not change on CT scans obtained 5-years after surgery.In January 2008 the patient was referred to our institution because of fecal occult blood.Abdominopelvic helical CT, showed increase in size (11 cm in maximum diameter) of the mass localized in the upper abdomen and multiple hepatic metastases. The abdominal and pelvic masses were resected. The histology showed a proliferative pattern of high risk GIST metastases.The patient was discharged from the hospital 9 days after surgery.Today, on the basis of the pathological and immunohistochemical features, most gastrointestinal mesenchymal tumors are classified as GISTs .Since other mesenchymal tumors as leiomiosarcomas , fibrosaet al (In our case the outcome shows that the site is very important in determining the prognosis. Patients with a small bowel localization do worse than those with stomach GIST as reported by DeMatteo et al .et al (In a case of a MD localization, the treatment with imatinib mesylate has been reported by Khoury II et al , but theCT is a valuable procedure for detection of local recurrence, distant metastases and for surveillance after surgery. If a localized recurrence is detected, the patient may be treated with repeated resection to prevent complications and to attempt a cure.In conclusion, our case illustrated the first long term-follow-up in a high-grade GIST in MD and the histological features of the treatment with imatinib mesylate.


Ameloblastoma is a rare benign odontogenic tumor with locally aggressive behavior and a high recurrence rate. When metastases occur, which are uncommon, lungs constitute the most frequent site involved. Malignant ameloblastomas are different from ameloblastic carcinomas. Malignant ameloblastomas are tumors considered metastatic despite the appearance of well-differentiated or benign histology, while ameloblastic carcinomas are histologically malignant in both primary and metastatic sites.A 24-year-old Moroccan man presented a malignant ameloblastoma of the mandible. The tumor was entirely resected. Five years later, a local recurrence occurred. Our patient was treated by exclusive radiotherapy with persistence of a residual disease. After two years he developed multiple lung metastases. Our patient received a combination chemotherapy using doxorubicin and cisplatin.Less than 50 cases of ameloblastoma with metastases have been reported. There is still no standard treatment for metastatic ameloblastoma. Only through continuous reporting of such cases will clinicians be able to draw an optimal strategy for management of this pathology. Ameloblastoma, from the English word "amel" which means enamel and the Greek word "blastos" which means germ , is a raAmeloblastoma was first described in 1827 by Cusack . In 1885In the recent WHO classification, a distinction was made between ameloblastoma, malignant ameloblastoma and ameloblastic carcinoma . MalignaLocalized disease is treated by radical surgery. However, in metastatic settings, chemotherapy remains the only choice of treatment. Unfortunately, results are unpredictable. We report below a case of an ameloblastoma with metastatic evolution five years after initial surgical treatment.2 and cisplatin 100 mg/m2. The assessment of response to chemotherapy was made after two cycles. The pain disappeared, and tomography showed, according to RECIST criteria, local stabilization and partial response of the lung lesions (30%)  Figure . The resOdontogenic neoplasms are rare tumors of the oral cavity. Among these, ameloblastoma is the second most common entity after odontoma . AmeloblThe average age at diagnosis of patients with ameloblastoma is 34 years with a range of five to 74 years . Men andThere are several histological subtypes, including plexiform, follicular, acanthomatous, basaloid, granular cell, cystic and desmoplastic forms. So far, the natural course of the disease can not be predicted. The follicular entity is the most common . Basic sAmeloblastoma is described as a slowly growing, locally invasive benign tumor with a high propensity for local recurrence. There is a 50% to 72% incidence of local recurrence after initial therapy [Metastases are uncommon, which is why metastatic ameloblastoma is considered benign (in addition to the benign features on histology). They generally occur after an interval ranging from 10 to 12 years . Lungs aThe treatment for metastatic ameloblastoma remains delusive. When metastases are removable, surgery is the treatment of choice. Results of radiotherapy and/or chemotherapy are unpredictable and the data are poor. Less than 50 cases were reported and conclusions are disparate Table . Gall teA review of the literature made by Lanham concluded that chemotherapy failed to show any antitumoral activity, including doxorubicin, methotrexate, prednisolone, bleomycin, 5-fluorouracil and dacarbazin . MoreoveOur case illustrates the natural course of the disease. In spite of radical surgery, lesions recurred. The metastases were asymptomatic. They were discovered during a classical work-up. Our finding, concerning response to doxorubicin-cisplatin, is adding to the published evidence that platinum chemotherapy is active in metastatic ameloblastoma. Moreover, even though no objective response is seen, data show that chemotherapy improves clinical symptoms .There are too few cases of metastatic ameloblastoma to consider randomized trials. Platinum-based regimens could be proposed as a first line treatment. Another pathway to explore is epidermal growth factor receptor (EGFR)-targeting. Ameloblastoma is a tumor originating from EGFR-expressing odontogenic epithelium, with expression levels ranging from 0% to 100% in some studies .Despite the slowly growing nature of ameloblastoma, endocranial extension and/or occurrence of metastases cause pain and affect survival.In metastatic ameloblastoma, results are unpredictable. Surgery, when feasible, remains the mainstay of therapy. There is no sufficient data to support or reject the use of chemotherapy. The expression of EGFR by odontogenic tumors could be an interesting approach to explore.Written informed consent was obtained from our patient for publication of this case report and any accompanying images.The authors declare that they have no competing interests.MA performed literature review, the composition of this case report and manuscript writing.ZF, RB and MI were involved in the conception and design, collection and assembly of the data.


We present the case of a young man with Klinefelter syndrome, who was admitted to our clinic with renal colic. Shortly after admittance, spontaneous decrease in pain has occurred. Ultrasound and intravenous contrast computed tomography were performed, which showed the evidence of urine extravasation at the level of left renal pelvis and a 4 mm stone in the lower third of the left ureter. The management with a double-J ureteric stent for three weeks was successful. Then, the stent was removed and computed tomography confirmed the absence of urine extravasation. We also analyze the literature related to this case and discuss the main mechanisms of collecting system rupture. Renal colic is a common urologic emergency affecting 3–5% of the population in the developed countries . The mosA 29-year-old man presented with left renal colic as a complication of nephrolithiasis. The patient was brought in by an ambulance with complaints of acute left flank pain with radiation to the scrotum, nausea, and macroscopic hematuria. This was the first episode of renal colic in his life. At birth, he was diagnosed with a Klinefelter syndrome and was receiving testosterone substitution therapy for the five years before admission. Habitus: The patient was tall, slim, narrow shouldered, broad hipped, and with dense and small testes. Slight rebound tenderness to the left lower quadrant suspicious for peritoneal irritation was disclosed on examination; body temperature was 38°C.Laboratory investigation showed leukocytosis and pyuria. Admission ultrasound disclosed mild hydronephrosis on the left and raised a suspicion for fluid presence in the perirenal fat.Almost immediately after admission, before the pain was controlled with intravenous analgesics, there was a spontaneous decrease in pain. Computed tomography (CT) with contrast enhancement was performed 2 hours later and showed distribution of the contrast around the left kidney .Also lower third ureter scanning was performed showing a 4-millimeter obstructive stone at the left ureterovesical junction . A double-J ureteric stent was placed immediately after tomography without technical problems. On the next day, the patient did not have any discomfort and was discharged from the hospital with the prescriptions for peroral tamsulosin and diclofenac.Three weeks later, he had no complaints as well. Discharge of stone has not been observed during this period. The red blood cell count, serum creatinine, and urea were normal, and ultrasound of the upper urinary tract was unremarkable.Control CT showed a partial distal migration of the ureteric stent , which wThe patient was discharged from the hospital with recommendations .There are some data about spontaneous stone passage according to size and localization. The likelihood of expulsion for stones <5 mm is more than 70%  and 95% Wunderlich in 1856 was the first to describe spontaneous pelvic rupture . IncreasIn the present case, nothing of the aforementioned was evident, but the patient had an inherited abnormality Klinefelter syndrome. This is the most common disorder of sex chromosomes in humans, with prevalence of 1 in 500 males, which can lead not only to infertility but to structural alterations in tissues as well . EffectsThe mechanism of this phenomenon has not been studied, and the case reports in the recent literature are scarce. Probably, this could be associated with decreased muscle layer and fibrotic changes resulting from the compromised tissue oxygen utilization.As for diagnosis of this complication in this particular case, we have seen the sign of urinary extravasation on ultrasound which warranted CT scan. We consider that in some cases intravenous pyelography could be insufficient for proper diagnosis. Also, we could denote that spontaneous renal colic resolution in the presence of the stone in the ureter could also point at the diagnosis.Treatment should be individualized in each case. Some studies even describe an open surgery performed for this rare complication . NeverthRenal pelvis rupture as a result of renal colic is a rare sequel of an otherwise common pathologic process. Spontaneous rupture of the renal pelvis is a complication with few characteristic clinical signs. It should be differentiated from other causes of abdominal pain. CT with contrast enhancement is a useful tool in making diagnosis and it could be more sensitive compared to intravenous pyelography. The mechanism of spontaneous pelvis rupture has not been studied and probably could be a consequence of the histological alterations. One of such predisposing conditions could be Klinefelter syndrome as it apparently was in our case.We consider that in most cases this complication should be managed with minimally invasive procedures such as double-J ureteric stent placement.


P = 0.015). The survival time of patients with benign schwannomas was longer than the malignant group (P = 0.013), so gastric malignant schwannomas have a potential for recurrence and metastasis, with subsequently short survival. Complete resection with an attempt to remove all tumor tissue with negative margins is of paramount importance in the management of gastric schwannomas, particularly when they turn out to be malignant.Schwannomas are tumors arising from the nervous system that also occur infrequently in the gastrointestinal tract, most commonly in the stomach. This report characterizes 29 patients with benign or malignant gastric schwannomas. Surgical data and clinical follow-up information were available for 28 cases with a median postoperative duration of 57 months. Clinicopathological and immunohistochemical characteristics of benign and malignant schwannomas were analysed. Four cases (13.7%) were histologically diagnosed with malignant schwannoma. All tumors were positive for S-100 and CD56 proteins, displaying a diffuse staining pattern. Vimentin was expressed in 100% cases and all schwannomas were negative for smooth muscle actin, c-kit, and HMB-45. A significant difference was observed between the group of benign and malignant schwannomas as regards recurrences and metastasis after complete resection ( Schwannomas, also known as neurinomas or neurilemmomas, are tumors of spindle cells originating from any nerve that has a Schwann cell sheath. Schwannomas of the gastrointestinal tract are very rare tumors, with the stomach being the most common location. The incidence of gastric schwannoma is reported to be about 0.2% of all gastric tumors and 4% of all benign gastric neoplasms . GastricAlthough the majority of schwannomas are benign, a small proportion is considered malignant with a potential to local recurrence and distant metastasis. Generally gastric malignant schwannomas can be distinguished from benign schwannomas on the basis of histological and immunohistochemical features, not by clinical symptoms or imaging studies. But if on CT scan enlarged lymph nodes are seen, then this is a clear indication of the malignant potential. Preoperative differential diagnosis of gastric malignant schwannomas is generally difficult. Because of the low incidence of schwannomas and relatively limited number of cases previously reported, further analysis of larger cohorts is necessary to better understand the characterization of this particular sarcoma and diagnose it accurately. In this study, we analyzed 29 patients with benign and malignant gastric schwannomas in terms of clinicopathological and immunohistochemical parameters.Twenty-nine schwannomas occurring in Beijing Cancer Hospital and Shanghai Tenth people's hospital were retrieved from the consultation files of the institutional archives from 1997 to 2012. We selected the cases in which the diagnosis of schwannomas was confirmed by our pathologists. Clinical data and tumor size were recorded. Paraffin blocks or recently prepared histologic sections of primary tumors were available in all cases for the following histopathologic analyses. Hematoxylin and eosin slides were reviewed in all cases. The histological features such as mitotic count per 50 fields, presence of mucosa ulcer, lymphoid reaction, architecture, and encapsulation were examined.α-smooth muscle actin , anti-melanoma , anti-CD56 , anti-vimentin , anti ki-67 , anti c-Kit , and anti CD34 . Heat-induced epitope retrieval in a citric acid buffer solution was used for the latter five antibodies. Immunostaining was accomplished with streptavidin biotin complex detection system and 3,3′-diaminobenzidine solution, followed by nuclear counterstaining with hematoxylin.In our current immunohistochemical assessments, the following primary antibodies were applied with or without epitope retrieval pretreatments: anti-S-100 protein , anti-Clinicopathologic parameters such as age, sex, anatomic location, tumor size, mucosa ulcer, lymphoid reaction, and mitotic activity were analysed with the method of Fisher exact test to compare the clinicopathologic characteristic of benign and malignant schwannomas. The patient survival rate was displayed using the Kaplan-Meier method.n = 1), and weight loss (n = 1). The tumor in one patient was detected during CT examination for unknown symptoms. Nine cases were incidental findings during surgeries or examinations for unrelated diseases. The tumors in 6 patients were discovered incidentally during cholecystectomy (n = 3), laparoscopic appendectomy (n = 2), or colectomy for colon cancer (n = 1). Two cases were seen at the time of abdominal ultrasound for cholecystolithiasis. One gastric schwannoma was detected during CT as part of follow-up examination after surgery for lung cancer. None of the patients has history of neurofibromatosis type 1 (NF1) syndrome or neurofibromatosis type 2 (NF2) syndrome.The clinical features of the 29 patients are summarized in n = 13), gastric wedge resection (n = 8), subtotal gastrectomy (n = 7), and total gastrectomy (n = 1). The status at surgery and clinical follow-up information were available in 28 cases with a mean postoperative duration of 57 months (range: 6 to 157 months). The tumor locally recurred in one patient and liver metastases were present after surgery in another case. These two patients were diagnosed with malignant gastric schwannoma after operation and died of it. Our followup revealed 19 patients to be alive without recurrences for 6 to 157 months . Seven patients had died of unrelated causes which included cardiocerebral vascular accidents (n = 3), traffic accident (n = 1), lung cancer (n = 1), acute pancreatitis (n = 1) and diabetic kidney (n = 1), during 25 to 132 months . One patient was lost to followup.All patients were treated by surgery including partial gastrectomy , followed by greater curvature , gastric fundus , lesser curvature , and cardia . The tumors range varied in greatest diameter from 2.1 cm to 7.9 cm, with a mean of 5.06 ± 1.38 cm (median 5.2 cm). In nine cases, the tumors showed expansive growth with distinct margin, encapsulated by a thin membrane  and no definite true capsules were histologically detected in any cases. The tumors were composed entirely or mainly of short spindle shaped cells with no nuclear atypia in 21 cases. Spindle cells of neoplasm were described in a palisade manner in 19 patients. In 15 tumors, the tumors show a lymphocytic cuffing at the peripheral part. Diffuse intratumoral lymphoid infiltration was seen in all cases, with plasma cells present in 12. The tumor cells were mostly uniform, and had palisading nuclear. The median mitotic rate was 2 mitoses/50 high-power fields (HPFs) . Four tumors had 15–20 mitoses per 50 HPFs with high degree of nuclear atypia. Based on the presence of mitotic figures and nuclear atypia, four cases (13.7%) were diagnosed with malignant schwannoma. But without pathologic data were found about lymph nodes involved around specimen in malignant cases.The immunohistochemical results are summarized in P = 0.015). Median disease-free survival time of the benign schwannomas group was 132.0 months with no observed recurrence, while it was 58 months in the group of malignant schwannomas (P = 0.013) (As is shown in = 0.013) .Schwannomas are slowly-growing encapsulated tumors composed of Schwann cells in a collagenous matrix. As the tumor enlarges, it displaces the nerve to the periphery of the tumor, preserving neural function . AccordiThe most frequently ordered diagnostic test in our series was upper-GI endoscopy performed before surgical exploration. Endoscopy may identify submucosal lesions, with or without ulceration. Recently, endoscopic ultrasonography is evaluated in the diagnosis of gastric schwannomas . But in Laparoscopic gastric resection, including wedge resection, subtotal resection, or near-total resection, is the treatment of choice for gastric schwannoma. Complete resection of the tumor is of paramount importance . Like otMalignant schwannoma  is a high grade sarcoma with a potential for local recurrence and distant metastasis that may occur at any site in the body where there is neural tissue. The histological criteria for the diagnosis of a malignant schwannoma are based on the presence of mitotic figures, nuclear atypia, part of necrosis, and other pathological features, not on clinical symptoms or imaging studies . As a faOur experience confirmed that infrequently diagnosed gastric schwannomas have a female predominance. The clinic course of gastric schwannomas are usually benign, slow-growing, and asymptomatic. Gastric malignant schwannomas are extremely rare, reported with a high potential for recurrence and metastasis in our series. Histological and immunohistochemical features are of paramount importance to differentiate between benign gastric schwannoma, malignant gastric schwannoma, and other spindle cell sarcomas. Finally, complete resection with an attempt to remove all gross disease and achieving negative margin is a fundamental surgical principle in the management of gastric schwannomas. However, further research is necessary to better understand features of malignant schwannomas.


Intentional tooth reimplantation can be an alternative treatment option for teeth with poor or hopeless prognosis where coronal and surgical endodontic treatment(s) are not possible. This technique may help to restore a natural tooth to function in preference to prosthesis/implant replacements. A 38-years old male was referred to private practice with persistent chronic apical periodontitis of a previously root canal treated mandibular left first molar. A furcal perforation and distolingual cusp fracture was previously repaired and treated with amalgam (~5 years ago). In view of the patient/tooth’s limitations, intentional reimplantation was planned using CEM cement retrograde filling. Clinical and radiographic follow-up during 2 years postoperatively revealed no sign/symptoms of infection or inflammation. Moreover, periradicular healing was evident on radiographs. Orthograde root canal therapy usually has a high success rate; however this treatment may at times fail . In the A number of studies advocated that IR should be reserved as a “last resort” after exploration and/or failure of other (re)treatments options 10]. An . An 10].This method involves atraumatic tooth extraction (i.e. evading unnecessary damages to the cementum/PDL) and rapid reinsertion into the alveolus immediately after endodontic treatment/apical repair outside the oral cavity. Teeth with divergent, long and curved roots are not apt for IR since they are prone to fracture during extraction; the success of this treatment directly depends on meticulous case selection thorough clinical/radiographic evaluations . Even witeeth. These complications are directly related to the time the tooth is retained extraorally for treatment; the longer the tooth is kept outside the socket, the poorer the prognosis .This case report presents a mandibular first molar associated with failed RCT, large periapical lesion, and a previous furcal perforation repair treated successfully with combined IR and root-end filling/sealing using CEM cement.A 38 years old male patient with a noncontributory medical history was referred to dentist with a chief complaint of periodic swelling and pain in the mandibular left molar region. The extraoral examination was unremarkable. In the intraoral examination, mandibular first molar was tender to percussion and the overlying buccal mucosa were sensitive to palpation; however, probing depth was not greater than 3mm. The distal half of the tooth had been replaced with large amalgam restoration. Radiographics showed an endodontically treated first molar with a large periapical lesion on the mesial root . SurprisPatient was prescribed 400 mg of Ibuprofen  a few minutes preoperatively to prevent postoperative pain. A 0.2% chlorhexidine rinse was carried out to control the oral microflora. After administering local anaesthesia , the mandibular first molar was intentionally extracted without any damage to the buccal/lingual plates of the alveolar bone. After root-end resections, 3mm deep root-end cavities were prepared and the root-ends were filled using calcium enriched mixture (CEM) cement . The tooth was then replanted into its alveolus; the accurate repositioning was confirmed radiographically . The whoThe tooth was inspected 1, 7 and 14 days postoperatively via routine intraoral examinations. At 6, 12 and 24 months postoperative sessions there were no clinical sign/symptom of inflammation/infection, tenderness to percussion or palpation, pain or discomfort, mobility, and sinus tract formation; the periodontal examination showed normal sulcular depth and normal gingiva. Two-years radiographically follow-up revealed no pathological findings and showed normal periodontium; most importantly, the vertical and sagital dimensions of the alveolar bone remained unchanged Intentional reimplantation may be conducted when routine RCT/endodontic surgery is impractical or impossible e.g. an obstruction of the canal 3]. This. This3].Endodontic literature has revealed a direct cause-and-effect relationship between treatment failure and presence of microorganisms and their by-products . The sucRetention rate of IR teeth is reported to be ~50-95% 17]18][[18][17][[[18][17]Periapical healing/periodontal health are more reliable factors for prognosis since slight external root resorption is usually not radiographically evident. Root resorption and replacement resorption (ankylosis) may be detectable within 3-4 weeks and 1-12 months, respectively 21]. A m. A m21].Intentional reimplantation is a treatment option which can be considered in the management of a hopeless tooth due to failed root canal (re)treatments. Annual clinical and radiographic follow ups should be carried out. More extensive studies are recommended.


Hemangiomas are rare benign vascular tumors; there are several types including the capillary hemangiomas, we present the case of an exceptional localization of capillary hemangioma in the middle ear. We report the case of a 60-year-old female which consults for episodes of pulsatile tinnitus, otorragies, and hearing loss of the left ear. The clinical examination revealed a reddish polypoid mass in the left external auditory canal, the radiological tests showed a vascular mass in the middle left ear. The tumor was surgically removed, the histological study revealed a capillary hemangioma. The incidence of hemangiomas in the temporal bone, especially in the middle ear, is exceptional. Medical imaging guides to the vascular nature of these tumors that make confusion with other vascular tumors such as tympanic paragangliomas. The management is often surgical and the final diagnosis is histological.  Hemangiomas are rare benign tumors growing in soft tissues and bones, there are several types of hemangiomas including the capillary type, hemangiomas are relatively common in head and neck, but they are exceptionally reported in middle ear , 2.We report the case of a capillary hemangioma of the middle ear, through which we analyze clinical, radiological, and therapeutic aspects of this entity exceptionally encountered by the otologist.We report a 60-year woman which presents, for six months ago, pulsatile tinnitus, hearing loss, and episodes of otorragies in the left ear. The otoscopic examination of the left ear revealed a reddish polypoid mass, sitting at the bottom of the external auditory canal and covered by a thin and inflammatory tympanic membrane. The examination of the right ear was unremarkable. The tonal audiogram showed a left conductive hearing loss of 30 dB, the audiogram of the right ear was normal. CT of petrous bone showed filling of the tympanic cavity without erosion of its walls and preservation of the ossicles . The MRIThe diagnosis of tympanic paraganglioma was suspected, in order to achieve a vascular mapping of this formation, an arteriography was performed and confirmed the vascular nature of the mass by giving a “vascular blush” image without being able to give a correct idea concerning the nurturing pedicle of this vascular formation .The management of this case was surgical; after retroauricular incision, tympanomeatal flap detachment, and tympanic cavity entry, we discover a reddish bleeding mass occupying almost the entire tympanic cavity. In order to obtain better exposure of the mass and the ossicles, an enlargement of the auditory canal was performed by milling the posteroinferior wall of the canal.The tumor was carefully peeled, using bipolar coagulation and fragmentation; it measures 1.5 cm in diameter and with intimate contact with the ossicles. The nurturing pedicle was provided by the tympanic artery.The histological study of the mass concluded that it was a capillary hemangioma of the middle ear.The postoperative period was uneventful; the evolution was marked by the disappearance of tinnitus and otorragies and also an auditory gain of 10 dB, there was no recurrences after 12 months of surveillance.Hemangiomas or angioendotheliomas are benign vascular tumors; they represent less than 0, 21% of all temporal bone tumors , we can Middle ear localization of these tumors is extremely rare, the tumor is usually unilateral, and symptoms can vary from asymptomatic mass to noisy tumors with pulsatile tinnitus, otorragies, hearing loss, vertigo, recurrent middle ear otitis, or facial palsy , 3, 5.The otoscopic examination shows usually reddish retro tympanic mass, more rarely; we can find a polypoid fleshy mass of the external auditory canal. The principal deferential diagnosis is the para ganglioma of the middle ear , 5.At CT, the hemangiomas have the same density than the cerebral parenchyma and can sometimes, contain ossifications. At MRI, these tumors appear as a moderate or intermediate T1 signal and as a hypersignal T2. The arteriography sowed “vascular blush” image similar to glomus tumors , 5.Histologically, the capillary hemangioma, the case of our patient, is characterized by well-differentiated vessels lined by a single layer of endothelial cells .The treatment of theses tumors is essential because of their destructive and hemorrhagic potential.The management is based on surgery which aims the complete resection of the tumor; indeed the recurrence rate, relatively high , depends directly on the quality of surgical resection .The surgical technique depends on the tumor seizes, the degree of hearing loss, and the situation of the jugular bulb , 6, 7.2 laser can be an interesting alternative to the conventional surgery; it allows better visualization of middle ear structures by reducing the bleeding [The CObleeding , 5, 8.The capillary hemangiomas of middle ear are extremely rare, the clinical and radiological features make confusion with other vascular tumors especially with the paragangliomas of middle ear. The definitive diagnosis is histological, and the management is based on surgery, the followup is capital because of the risk of recurrences.


Juvenile xanthogranuloma (JXG) is essentially a benign neoplasm arising from any site on the body; however, there has so far been only one report of JXG located on the chest wall involving a rib. This report presents a rare case finally diagnosed as JXG based on histopathological and immunohistochemical examinations. Pediatric chest wall tumors are relatively rare and include a variety of diseases. Malignant chest wall tumors, especially Ewing sarcoma and the primitive neuroectodermal family, are found more frequently than benign lesions. Therefore, a histopathological examination is often required in case the definite diagnosis is not revealed during clinical course. This report presents a rare case finally diagnosed as juvenile xanthogranuloma (JXG) based on a histopathological examination, although mesenchymal hamartoma (MH) was suspected from the clinical course and the radiological examinations.A 3-month-old female, with no complications at birth, was referred to our hospital for an enlarging right chest wall mass that had not responded to antibiotic therapy. A physical examination demonstrated an approximately 5 cm subcutaneous mass on the right chest wall, accompanied by skin redness and tenderness. Laboratory examinations demonstrated leukocytosis 11,000/μl) and high levels of CRP (4.8 mg/dl), whereas tumor markers showed levels within the normal range. A chest radiograph showed an increased radiolucent lesion on the right 8th rib. Chest computed tomography (CT) revealed a multicystic mass (28 × 27 mm) with enhanced homogeneously (Fig. 1,000/μl The histological findings showed cells with foamy cytoplasm in a sheet-like or lobular-like aggregation in the interstitium. Lymphocyte infiltration was observed on the periphery. The cells were composed of histiocytes Fig. a, b. ThePediatric chest wall tumors are relatively rare and only account for approximately 1.8 % of all solid tumors in pediatric patients . Benign The chest X-ray findings show a large expansive mass that has well-defined sclerotic margins. CT demonstrates a heterogeneous extrapleural tumor mixed with a solitary component and a cystic component filled with fluid characteristic of hemorrhaging. MRI also demonstrates a heterogeneous middle signal intensity mass in both T1 and T2 weighed images .On the other hand, JXG is known as a benign histolytic tumor, which develops within several months of birth and regresses spontaneously. JXG arises from any site of the body and is predominantly located on the surface of the skin, in particular, on the face, extremities and the trunk. In addition, this tumor is sometimes detected in the deep dermis or muscular layer, and has been found in organ tissues –7. A revThe prognosis of JXG is essentially good. However, despite its self-regressive nature, a tumor resection is frequently conducted to obtain a definite diagnosis in most cases even if located on the skin. Histiocytic nodular infiltration in all the layers of the dermis, accompanied by foamy cells and Touton multinucleated giant cells, are also observed .An osteolytic finding due to JXG is extremely rare, therefore, it is hard to obtain a definitive diagnosis by only radiological examinations. Surgical excision was required for the definite diagnosis in the current case, to determine the further therapeutic course . LCH shoThe histopathological findings show the proliferation of dendritic cells and also demonstrate giant cells similar to JXG. Therefore, an immunohistochemical examination is useful for further investigation to distinguish these tumors , 14. JXGThe clinical difference between JXG and LCH is that the common site: skin JXG versus bone LCH , 17. TheIn conclusion, a high proportion of the pediatric chest wall tumors are generally malignant. It is intolerable for clinicians to observe a growing mass over the long term without a definite diagnosis. Therefore, an incisional biopsy should not be delayed in order to achieve a definitive diagnosis and to initiate a prompt therapeutic course. JXG is essentially a benign neoplasm arising from any site on the body, whereas, there has been only one report of JXG located on the chest wall involving a rib. The present case demonstrated osteolytic findings, therefore, surgical excision was conducted to rule out the presence of malignant neoplasm and an immunohistochemical examination was useful for distinguishing the lesion from LCH. JXG should therefore be considered in the differential diagnosis of a pediatric chest wall tumor.


Paraganglioma of the urinary bladder is rare, accounting for <0.05% of all bladder tumors. Common clinical findings in patients with bladder paraganglioma include hematuria and intermittent hypertension during urination, along with generalized symptoms due to increased levels of catecholamines. Although unsuspected bladder paraganglioma may result in intraoperative hypertensive crises, these may be avoided if characteristic imaging signs are observed. The present study reports a case in which a patient with unsuspected paraganglioma experienced a severe hypertensive episode during cystoscopic tumor resection. Although this case had typical computed tomographic characteristics of the bladder paraganglioma, the possibility of the paraganglioma pre-operatively was not taken into account. Bladder paraganglioma (pheochromocytoma) is rare, accounting for <0.05% of all bladder tumors and ∼10% of extra-adrenal paragangliomas –4, partiA 26-year-old male patient was admitted to West China Hospital of Sichuan University on August 15, 2012 with a history of a bladder tumor and microscopic hematuria. The lesion was found 2 years before by abdominal ultrasonography (USG) and the size of the tumor was stable from then until 4 months prior to admission, when the tumor began to enlarge. Physical examination of the patient did not reveal any unusual findings; the blood pressure of the patient was 93/63 mmHg on admission and results of the urinalysis were normal. An abdominal CT examination was performed using a Philips Brilliance 64-slice CT scanner  with a slice thickness of 6 mm. This revealed a 26×22×25 mm nodular lesion originating from the right bladder trigone region, protruding into the bladder cavity. The tumor showed homogeneous soft-tissue attenuation  on a plain CT scan, the density of which was slightly lower than that of the internal obturator muscles. The lesion exhibited intense enhancement  in the arterial phase, which was significantly higher than that of the bladder wall and only slightly lower than that of the right femoral artery. Thickening of the bladder wall near the tumor was not observed . The priFollowing the preoperative examinations, an elective cystoscopic tumor resection was performed on August 17, 2012. During the surgery, the tumor was found in the trigone region of the bladder. The tumor had a pedicle, smooth surface, edema mucosa and varicose veins. On attempted surgical removal of a small part of the tumor, the blood pressure of the patient suddenly increased to 210/120 mmHg and the heart rate reached 145 bpm. The operative procedure was immediately terminated, and the blood pressure and heart rate gradually returned to normal over 10 min. Subsequently, an intraoperative biopsy using frozen sections indicated the presence of paraganglioma.Following surgery, the history of the patient was reviewed and it was noted that the patient had a history of post-micturition syncope. One day after the surgery, the erect and supine aldosterone levels of the patient were 15.51 ng/dl  and 17.57 ng/dl , respectively), and the plasma renin levels were 1.59 ng/ml/h  and 1.65 ng/ml/h , respectively. Four days after the surgery, the plasma norepinephrine and epinephrine levels were 345 ng/l  and 91 ng/l , respectively. A partial cystectomy with complete extirpation was performed on August 28, 2012. During the second surgery, no episodes of hypertension occurred. Convalescence was uneventful. Histological examination confirmed bladder paraganglioma .Bladder paragangliomas may occur in patients of any age, but typically occur between the ages of thirty and fifty . They arThe most common feature of bladder paraganglioma is a characteristic clinical picture resulting from a hypertensive crisis that may be accompanied by headache, palpitations, hot flushes and sweating. These crises are typically provoked by micturition or overdistention of the bladder. The classical triad of episodic hypertension, persistent hematuria and post-micturition syncope is almost diagnostic, but is extremely rare . In the The imaging modalities for the diagnosis of bladder paraganglioma include USG, CT, MRI and meta-iodobenzylguanidine (MIBG) scintigraphy ,4. The c


Pigmented villonodular synovitis (PVNS) is a rare, benign, proliferating disease affecting the synovium of joints, bursae, and tendon sheaths. Involvement of bursa  is the least common, and only few cases of exclusively extra-articular PVNB of the pes anserinus bursa have been reported so far. We report a case of extra-articular pes anserine PVNB along with a review of the literature. The lesion presented as a painful soft tissue mass in the medial part of the proximal leg. A magnetic resonance imaging showed areas of lowto intermediate signals in all sequences and the lesion enhanced heterogeneously with contrast. Diagnosis was confirmed by an incisional biopsy, and an intralesional resection was performed. The postoperative course was uneventful, and the patient is free of disease with no functionaldeficit at 2 years followup. As with other rare lesions, clinical and radiographic findings inaddition to histological examination are essential for correct diagnosis. Pigmented villonodular synovitis (PVNS) is a rare, benign, proliferating disease affecting the synovium of joints, bursae, and tendon sheaths. Jaffe et al.  regardedA 28-year-old female presented with a slowly enlarging intermittently painful mass over the medial aspect of her proximal right leg for the past three months. She denied any antecedent trauma. She denied any locking, clicking, loss of motion, or increased warmth around her knee. She denied any constitutional symptoms or any functional disability. On examination, there was a 4.0 × 3.0 cm relatively firm, tender mass on the medial aspect of the proximal leg at the level of the insertion of pes anserinus. The mass appeared fixed to the underlying tibia with no overlying warmth, erythema, induration, bruit, dilated vein, or significant regional lymphadenopathy. It was noncompressible with no change in size on limb elevation. Tinel's sign was negative, and distal neurovascular examination was unremarkable. There was full active painless range of motion at the knee without any instability or meniscal signs. The rest of her skeletal system examination was unremarkable. Radiographs were unremarkable. The magnetic resonance imaging (MRI) showed a 4.5 × 3.0 × 2.0 cm soft tissue mass at the insertion of pes anserinus conjoint tendon Figures . There wAn incisional biopsy was performed. The frozen sections showed it to be benign with multiple osteoclast like multinucleated giant cells in a mononuclear background, and a intralesional resection was performed. The specimen consisted of a brownish-yellowish lobulated multinodular mass in the pes anserinus bursa and measured 4.5 × 3.0 × 1.8 cm Figures . The knePigmented villonodular synovitis is a benign but potentially aggressive lesion, characterized by synovial villonodular proliferation with hemosiderin pigmentation and stromal infiltration of histiocytes and giant cells. Although it was suggested an inflammatory process , the insPVNB has shown a tendency to occur in young persons. Most of the cases are diagnosed prior to 40 years, with a mean age similar to PVNS . TypicalMRI is the imaging modality of choice and is helpful for diagnosis, surgical planning, and followup , 8, 24. The clinical differential diagnosis includes simple bursal cyst, neurofibroma, fibroma of tendon sheath, or a hemangioma –11, 14. Although much has been written about behavior and treatment of PVNS, the literature is sparse on PVNB. Recurrence has been reported to be as high as 40–50% for diffuse PVNS and most of them have been correlated with a location in the knee and incomplete excision . MorpholExtra-articular PVNB of the pes anserinus is a rare cause of medial knee pain and localized swelling about the proximal tibia. Awareness of this rare presentation is important because it will help in correct diagnosis and avoid overtreatment. An MRI is useful to delineate the soft tissue extent and bone involvement, and exhibits areas of low signal intensity on all sequences due to hemosiderin deposits. Marginal or intralesional resection of the lesion seems to provide excellent clinical results with no need for adjuvant modalities like radiotherapy. As with other rare lesions, clinical and radiographic findings in addition to histological examination are essential for correct diagnosis.


The retroperitoneum is an uncommon location for teratoma in adults. The current study presents the case of a rare giant primary retroperitoneal teratoma in a 55-year-old female. The clinical manifestations, diagnosis and surgical treatment procedure of this case are retrospectively reviewed. The patient presented with a complaint of an abdominal palpable mass and fullness for 1 month. The patient suffered a massive hemorrhage during the first exploratory laparotomyand only a small section of the tumor was resected. Pathology revealed a mature retroperitoneal teratoma. Eleven months after the first surgery, the tumor was resected successfully at the second laparotomy. The surgical specimen was a large tumor mass measuring 22×18×10 cm in size and weighing 6 kg. At follow-up, the patient was in a stable condition. This case study highlights the importance of imaging for the development of a pre-operative strategy and performing a safe surgical excision in giant retroperitoneal teratoma cases. Teratomas are congenital tumors consisting of derivatives from the ectoderm, endoderm and mesoderm germ cell layers ,2. A terA 55-year-old female  was referred to the First Affiliated Hospital  with a 11-month history of an abdominal palpable mass and no previous history of routine health examinations. The patient was diagnosed with a right retroperitoneal tumor and severe hydronephrosis, and consequently underwent an exploratory laparotomy for the purpose of excision at Yiwu Central Hospital on August 10, 2006. The tumor was not completely removed due to a severe hemorrhage during the surgery. However, a small section of the tumor was resected and a nephrostomy was performed for the hydronephrosis. The pathology report resulted in a diagnosis of a mature retroperitoneal teratoma. At 11 months after the first surgery, the patient was admitted to The First Affiliated Hospital, College of Medicine, Zhejiang University  for a whole tumor resection.A physical examination revealed a 25-cm mobile and solid mass with regular contours in the abdomen. A 20-cm vertical incision scar and a nephrostomy catheter were present on the right upper abdomen. The catheter drained ∼200 ml clear urine/day. Routine laboratory tests, including those for serum α-fetoprotein (AFP), were all within normal ranges. Abdominal ultrasonography revealed a parenchymatous irregular hypoechoic tumor in the right retroperitoneum. Abdominal spiral computed tomography demonstrated a large complex mass composed of multiloculated cystic components, soft tissue elements, inhomogeneous fatty tissue and calcifications in the right upper retroperitoneum. The remnant right kidney was encased by the tumor . MagnetiThe patient underwent a second laparotomy for the purpose of resection of the tumor on July 11, 2007. During the surgical procedure, a 25-cm long subcostal incision was made and the mass was found located in the retroperitoneal cavity, with adhesion to the adjacent structures. The tumor was resected successfully with a right nephrectomy. During surgery, the diaphragmatic muscle ruptured due to the adhesion of the mass, and thoracic closed drainage was performed. The patient had an uneventful post-operative recovery and was well at follow-up. The surgical specimen was a large tumor mass measuring 22×18×10 cm in size and weighing 6 kg. The specimen contained a hydronephrotic and distended kidney. The tumor consisted of fat, fiber and cartilage-like tissue . HistoloTeratomas have been identified in individuals from every age group, however, the peak incidence is reported at between 20 and 40 years old . The majThe diagnosis of a retroperitoneal teratoma is often made on the basis of investigative imaging ,7,8. RetThe primary treatment of retroperitoneal teratomas is surgical resection ,10. The


Background. Adrenocortical carcinomas represent rare malignancies. In cases of hormone-secreting tumors, the hormone in excess determines the nearly diagnostic clinical presentation. Biologically inert tumors are diagnosed either due to the mass effect or incidentally. The purpose of the present study was to present an extremely rare presentation pattern of adrenocortical carcinoma. Case Presentation. We present the case of a 35-year-old female patient that underwent emergency laparotomy due to signs of acute abdomen and concomitant cardiovascular collapse caused by a spontaneously ruptured large adrenocortical carcinoma. Conclusion. Spontaneous rupture of an adrenocortical carcinoma presenting with signs of acute abdomen is an extremely rare clinical scenario. Increased level of suspicion is essential in order to diagnose and treat timely this life-threatening complication. Adrenocortical carcinomas represent rare malignancies with two to ten new cases diagnosed per one million inhabitants every year . A dismaInterestingly, even large noncortisol-producing adrenocortical carcinomas have only a minimal effect on patient's well-being complicating the diagnostic process . On the 2 saturation of 99%, and a body temperature of 37 degrees Celsius.A 35-year-old, otherwise healthy, female patient was admitted in the emergency room department complaining of an excruciating abdominal pain reflecting at the back and lightheadedness over the last two hours. The onset of pain was suddenlly reaching a peak point over a couple of minutes and it was combined with diffuse perspiration and fatigue. Despite the fact that the patient reported a generalized sense of weakness, she remained alert and oriented. Upon arrival the patient had a BP of 80/55 mm Hg, 115 pulses/min, blood OPhysical examination revealed a relatively distended abdomen with absent bowel sounds. Marked tenderness was elicited during the deep palpation of the left lower abdominal quadrant and of the periumbilical area. The hallmarks of parietal peritoneal irritation, that is, tenderness on percussion and rebound tenderness, were present. Immediate intravenous assess was obtained and two large bore peripheral vein catheters were inserted in each forearm followed by the vigorous administration of crystalloid fluids. Blood samples were obtained for crossmatching and appropriate tests. Soon after, the administration of the first bolus of intravenous fluids the patient's hemodynamic status was stabilized with gradual normalization of vital signs. Urine human chorionic gonadotropin (h-CG) levels were within normal range and a gynecological consultation assisted by a transabdominal ultrasonographic assessment ruled out an occult pathology from the internal genitalia.Under these circumstances, an emergency computed tomography (CT) scan of the abdomen with intravenous contrast media was then conducted. A 9 cm in diameter adrenal tumor surrounded by a large retroperitoneal hematoma was observed (see Figures An immediate operative approach was decided and the patient underwent a laparotomy with a midline vertical suprainfra umbilical incision. A thin serosanguineous fluid was evident throughout the peritoneal cavity while a bulging tensed mass consistent with a contained retroperitoneal hematoma was identified in the anatomic position of the left kidney. With careful maneuvers, the sheath of the hematoma was opened and after the evacuation of blood clots with copious irrigation the mass in question was identified just above the left kidney in close proximity to the splenic hilum and the pancreatic tail. The tumor was dissected free from the adjacent structures with mainly sharp dissection revealing a deep oblique rupture on tumor's surface and obvious actively bleeding vessels. An en-mass removal of the tumor see  was follThe patient had an uneventful postoperative recovery in the surgical department's clinic and was discharged from the hospital on the 7th postoperative day. The histopathological examination of the surgical specimen confirmed the imaging diagnosis of an adrenocortical carcinoma. Subsequently, the case was thoroughly discussed in the setting's multidisciplinary meeting where a complete staging with CT chest and abdomen was decided. The findings were unremarkable. No picese of evidence of metastatic disease were observed. Unfortunately, the follow-up period is rather limited to provide solid data regarding the long-term results. Adrenocortical cancers are uncommon malignancies. Most patients, approximately 60%, present with signs emanating from hormone overproduction . A rapidHormonally inactive adrenocortical carcinomas are usually associated with nonspecific symptoms such as back pain, abdominal discomfort, nausea, vomiting, and an ill-defined sense of abdominal fullness. The so-called mass effect represents the impact and the effects of tumor enlargement in adjacent structures . RecentlEndocrine assessment is of paramount importance in the initial elective workup of adrenal lesions. Certain hormone secretion patterns may predict the malignant potential of such tumors. Increased plasma levels of estradiol in male patients, high concentration of serum dehydro-epiandrostenedione, or detectable compounds of steroid precursors can stand as valuable cancer markers . ImagingIn the present study we present an extremely rare clinical presentation of an adrenocortical carcinoma. The differential diagnosis of acute abdomen combined with hemodynamic instability in a young female patient in the absence of trauma classically includes pathologies emanating from the female reproductive system as well as intra-abdominal vascular catastrophes. Among the oncological/proliferating intra-abdominal entities that have been associated with the devastating presentation of spontaneous rupture, hepatic adenomas especially during pregnancy are the most frequent. However, the rare diagnosis of a spontaneously ruptured adrenal tumor that justified the patient's symptoms was surprisingly established after the emergent imaging investigation. Provided that an emergency presentation was the actual case, a prompt assessment and timely intervention were imperative. An emergency angiography with embolization would certainly be a valid option. Unfortunately, due to the logistics in our medical setting we do not access the angiography suite in the emergency setting. Within this framework, an open surgical approach was decided via a vertical midline laparotomy incision. Intraoperatively, when the source of hemorrhage was identified and controlled a proper oncological surgical resection of the ruptured adrenal tumor was successfully undertaken. Although drawing definite conclusions based on a single case is not only risky but also inappropriate, however, a logical assumption would be that the large size of the lesion could be considered as a predisposing factor for such kind of presentation . In conclusion, spontaneous rupture of an adrenocortical carcinoma presenting with signs of acute abdomen is an extremely rare clinical scenario. Increased level of suspicion is essential in order to diagnose and treat timely this life-threatening complication.


Castleman's disease (CD) or angiofollicular lymph node hyperplasia is a rare spectrum of lymphoproliferative disorders. CD tumors are commonly localized in the mediastinum and are usually asymptomatic. The mainstay of treatment is surgical resection and has typically been performed using open thoracotomy. Few reports in the literature describe video assisted thoracoscopic resection of these tumors. The differential diagnosis for mediastinal masses is extensive, and CD tumors, although uncommon, should be considered. We describe a case report of a posterior mediastinal Castleman's tumor adherent to the esophagus, which was resected thoracoscopically and review the literature. First described in 1954, Castleman's disease (CD)[Surgical resection is the mainstay of treatment for unicentric mediastinal CD and has A 54-year-old Hispanic male presented to the emergency department with abdominal pain. He denied any history of fever, night sweats, weight loss or fatigue. He denied any dysphagia but complained of mild anorexia. Physical examination was essentially normal except mild tenderness over the spleen. Complete blood count and comprehensive metabolic panel were within normal limits. A contrast-enhanced computed tomographic scan of the abdomen and pelvis incidentally detected a posterior mediastinal mass measuring 5 × 3 × 2 cm as well as moderate splenomegaly Figure . There wComplete surgical resection using VATS was undertaken under single-lung anesthesia using a 10-mm and two 5-mm ports. The mass was visualized and located between the azygous vein and the esophagus Figure . The parCastleman's disease (CD), also known as angiofollicular lymph node hyperplasia, giant lymph node hyperplasia, lymph node hamartoma, as well as benign lymph node lymphoma, was first described by Dr. Benjamin Castleman in a patient with solitary mediastinal lymph nodes in 1954. It is nPreviously classified broadly into unicentric and multicentric types, recent authors favor defining CD by histopathogenic type into hyaline-vascular CD, plasma cell CD, human herpes virus-8 (HHV-8) associated CD  and multicentric CD, not otherwise specified. The hyaline-vascular CD accounts for approximately 70% of patients with CD and involve men and women equally.While the etiology is uncertain, pathogenic factors such as HHV-8 and interleukin-6 (IL-6) have been associated with CD. The majority of HHV-8 associated CD is multicentric and has a risk of progression to large B-cell lymphoma. Human immunodeficiency virus (HIV) positive patients with CD are almost always coinfected with HHV-8. Although the role of IL-6 in the pathogenesis of CD is unclear, the systemic symptoms associated with CD have been linked to overproduction of IL-6. In addition, viral IL-6 has known hematopoetic and angiogenic effects and treaAlthough the mediastinum is the most common location for unicentric CD, it has been noted to occur in the cervical, axillary and abdominal regions,13,14. SMulticentric CD can present as multifocal lymphadenopathy and hepatosplenomegaly is common. In plasRadiologic evaluation mainly involves computed tomography (CT), magnetic resonance (MR) imaging and positron emission tomography (PET/CT). The typical feature on CT scan is a well circumscribed mass with soft tissue attenuation and rarely calcification. On MR imaging, these highly vascular tumors appear solid and have intermediate to high signal compared to muscle on T1 weighted images. Hyper intense signal is seen on T2 weighted images. PET scan is a useful modality for staging and monitoring response to chemotherapy.This case appears to represent an example of unicentric disease even though the spleen was enlarged, particularly since the patient did not have the characteristic constitutional symptoms of multicentric disease. Treatment options for unicentric CD include surgical resection ,2,13 andThe differential diagnoses for posterior mediastinal masses are extensive and include neurogenic tumors, sarcomas, lymphomas, pleural based tumors, bronchogenic cysts, enteric cysts, teratomas, arteriovenous malformations and metastatic masses. These tDiagnostic modalities in addition to imaging, for posterior mediastinal masses include ultrasound guided endoscopic fine needle aspiration and percutaneous transthoracic core biopsy. However, these can be technically difficult and specimens obtained by these techniques may not yield sufficient material for an accurate diagnosis. Excisional biopsy, particularly in unicentric disease, is preferred in order to assess cell type and tissue architecture, but can be associated with substantial bleeding as these tumors are known to be highly vascular.The technical aspects of this case underscore the characteristic features of this tumor and its location. For example, we elected to ligate the thoracic duct early and intentionally because its integrity could not be assured given its location and the extensive dissection required, thereby decreasing the risk of a postoperative chylothorax, a known complication of posterior mediastinal surgery. KnowledWe describe resection of a highly vascular posterior mediastinal Castleman's tumor with dense adhesions to the esophagus employing a minimally-invasive approach. Our case confirms that, using meticulous dissection and hemostasis, VATS resection can be performed safely. Particular attention to the thoracic duct with a view towards early ligation is necessary to prevent postoperative chylothorax. When the tumor is adherent to the esophagus, an esophageal leak test should be performed upon completion to assess the integrity of the esophagus. Minimally invasive thoracoscopic resection is a safe and feasible option in the management of posterior mediastinal CD. Mediastinal CD, although uncommon should be included in the differential diagnoses of posterior mediastinal tumors.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.Case report conception and design: SS, RAB, LP, JAS. Acquisition of data: SS, RAB. Drafting of manuscript: SS, RAB, LP. Critical revision: JAS. All authors read and approved the final manuscript.


This case report presents an uncommon case of maxillary molar with two palatal root canals and an enamel pearl in the furcation area. The article discusses root canal complexities of maxillary second molars as well as possibility of coexisting anomalies in the region that makes radiographic interpretation difficult and compromises the success of endodontic treatment. The main goal of endodontic treatments is prevention of apical periodontitis and/or healing of present periapical lesion. Several factors may influence the treatment success . One of Maxillary molars have one of the most complex root canal anatomies. Six different variations of a second maxillary molar have been reported in a retrospective study by Peikoff et al. . These vRostein and Libfild have reported a prevalence of 0.4% for second maxillary molar with four roots in a large series of 1200 teeth radiographic assessment -10.Second maxillary molars with three buccal roots , five roSometimes, complex root canal anatomy may be associated with other anomalies such as enamel pearls or palatogingival groove that may affect both diagnosis and treatment prognosis , 15.An enamel pearl is the ectopic enamel mass which can be seen in the furcation or other area of root surface . Single This case report presents an uncommon case of maxillary molar with two palatal root canals and an enamel pearl in the furcation.A 45-year-old woman came to endodontic department of Mashhad Dental School complaining of sever toothache especially during mastication. The patient medical history was negative. Clinical examination revealed extended mesial decay on the left maxillary second molar, tenderness to percussion and palpation of peri-radicular zone. Vitality tests were negative. Radiographic image  revealed radiolucency around palatal apex; moreover, there was the opacity in the furcation area which was detected as the enamel pearl .The tooth was diagnosed with symptomatic apical periodontitis with necrotic pulp. After 2% Lidocaine with epinephrine 1:100.000  was administered the tooth was isolated with rubber dam. As usual, in the initial access cavity, three orifices were found, but the palatal one was mesially deviated. So the access cavity was further prepared into a square shape . Second All canals were instrumented with stainless-steel hand k-files accompanied by Flex Master Introfile  rotary instrument using crown-down technique. Root canals were irrigated by sodium hypochlorite 5.25% and dried completely. Calcium hydroxide-distilled water paste was placed as an intra-canal dressing then access cavity was sealed temporarily with Cavit .After a week, patient was completely asymptomatic. Before root canal obturation, the working length was radiographically confirmed with gutta-percha . Root caSubsequently, patient was referred to restorative department for their final restoration. After six months, patient had no clinical symptoms and complete clinical and radiographic resolution was seen .Adequate knowledge and experience can improve the operator’s ability to find additional canals , 22 espeChristie et al. reported sixteen maxillary molars with two palatal canals during his forty-year experiences in root canal therapy and divided them into three different groups. Type I has two long divergent palatal roots which can be observed radiographically, Type II as two short parallel palatal roots which are mesially and distally divergent in the buccolingual radiographic view and Type III as mesiobuccal, mesiopalatal and distopalatal roots engaged in a web root dentin with radiographic similarities to Type II. Interestingly, the only other anomaly he reported in maxillary molars was double palatal roots due to the presence of an enamel pearl in the furcation of three patients. In one of the cases, it lead to periodontal failure .The present case described maxillary second molar with two palatal root canals with an enamel pearl in furcation region and no periodontal involvement.Enamel pearls are usually present in furcation area and are more common in second and third maxillary molars . HertwigInitial radiographic interpretation of the second maxillary molar root anatomy may be more complicated because of superimposition of roots on each other or adjacent bony structures. Clinicians encounter a dilemma when additional abnormality presents in the area. Thorough knowledge of anatomical variations and frequent anomalies in the region besides multiple radiographs with different angles or cone-beam computed tomography (CBCT) can be helpful , 30. MetThe possibility of two palatal roots and enamel pearls in the furcation should be considered in the second maxillary molars. Though enamel pearls are rare, periodontal evaluation is recommended for early diagnosis.


Vulvar aggressive angiomyxoma (AA) is a rare mesenchymal tumor of the vulva. Due to its slow-growing nature, it is often overlooked and misdiagnosed by primary care providers (PCPs). We describe a case report of vulvar AA in a 38-year-old woman who underwent complete surgical excision of the neoplasm with no evidence of recurrence on a 5-year followup. A literature review follows to provide PCPs with the clinical, radiologic, and pathologic features that this tumor displays. Our patient is a previously healthy 38-year-old, G2P2, Caucasian female. Her past medical history includes two cesarean deliveries, a tubal ligation, appendectomy, and excision of a benign breast tumor. She denied any family history of gynecologic cancers and any personal history of venereal disease. Her gynecologic history is otherwise normal. She had presented for her annual checkup with complaints of painless swelling of the left labia majora that had been progressively worsening over the past 3 years ever since her last cesarean delivery. She had raised this concern to several primary care providers (PCPs) and with previous physical examinations, she was reassured that it was likely postoperative labial swelling that followed the cesarean delivery and would likely resolve with time. Upon interviewing her, she reported numbness of the skin overlying the swollen area and denied any discharge, pruritis, pain to palpation, or any urinary symptoms. She did however complain of progressively worsening dyspareunia and consequently affected her quality of life. Gynecologic examination showed an enlarged left labia majora. It contained an elongated, soft, nonmobile, nontender, sausage-like mass measuring approximately 12 × 6 × 4 centimeters extending longitudinally between the mons pubis and the anal verge along the left labial fold. There was no evidence of any overlying skin infection, erythema, or drainage. Her physical exam was otherwise within normal limits. Abdominal and pelvic computed tomography (CT) with oral and intravenous contrast showed left labial edema, no ascites, and no inguinal or pelvic lymphadenopathy. This lesion was localized within the vulva and did not extend beyond the pelvic diaphragm . The CT “aggressive” refers to the locally infiltrative nature of this lesion and its tendency to recur [First described in 1983 by Steeper and Rosai  the vastto recur . Althougto recur  and haveto recur . With anto recur ; with onto recur , 5. AA hThe pathogenesis of vulvar AA is poorly understood; however genetic alterations along the 12q chromosome region have been implicated . MacroscSeveral imaging modalities have been used in identifying and describing AA. Sonography usually reveals a hypoechoic or cystic mass . CT scanMultiple treatment modalities have been described; however complete surgical excision—when possible—should be sought. Partial excision may be warranted when high operative morbidity is anticipated . UnfortuVulvar AA is a rare and intriguing finding when encountered in a primary-care setting. Misdiagnosis occurs in more than 80% of cases , 13, priUnlike most AA, our case was encapsulated by a fibrofatty layer, and there were no evident finger-like projections into neighboring tissues. Furthermore, the excised lesion had negative margins on pathologic evaluation. This may explain why there has been no recurrence in the last 5 years. On H&E staining, the tissue resembled a typical aggressive angiomyxoma, obviating the need for any further immunohistochemical analysis.Our patient required no additional treatment or any imaging postoperatively and remained asymptomatic throughout the subsequent 5 years after her surgery. Despite these facts, AA is notorious for local recurrence in approximately 70% of the cases after a period of 2 years postoperatively . Han-GueThere are no guidelines in the postoperative management of vulvar AA; however due to the high recurrence rate and potential morbidity associated with undiagnosed recurrences, several authors have recommended periodic evaluations with physical examination and MR imaging up to 15 years after treatment , 12.This case report illustrates the challenges that primary care physicians might face with vulvar masses. AA is a rare entity but should always be considered especially when it presents in an insidious painless fashion, particularly in premenopausal females in their 3rd-4th decades of life. PCPs should maintain a high index of suspicion and should perform a systematic clinical examination of the perineal mass. If a perineal mass is suspected, pathologic evaluation and radiographic studies using MR imaging or CT scan should help in reducing the number of misdiagnosed cases of AA preoperatively. Once its anatomical location is defined, any perineal mass—particularly AA—can be optimally treated by surgical excision while avoiding mutilating surgery. When complete resection is possible, it should be sought as it offers the lowest recurrence rate. AA is rarely life threatening and therefore partial resection is acceptable when high operative morbidity is anticipated. Regardless of whether the treatment is surgical, hormonal, or multimodal, it is clear that AA requires close and long-term followup.


Complications of solitary or multiple osteochondromas are rare but have been reported in recent literature. Most reported complications arose in patients with multiple and/or sizable osteochondromas.A 22-year-old, female, Caucasian patient with obesity presented with intermittent knee pain and hematoma of the right calf. The MRI depicted a small, sharp exostosis tip of the dorsal distal femur with a surrounding soft-tissue mass. After profuse bleeding occurred during biopsy of the soft tissue mass, angiography revealed a pseudoaneurysm of the right popliteal artery. In a second-stage surgery the exostosis tip and pseudoaneurysm were resected.Complications can also arise in small, seemingly harmless osteochondromas. Surgical resection should be considered as a preventive measure when exostoses form sharp tips close to neurovascular structures regardless of total osteochondroma size. Complications arising from solitary or multiple osteochondromas are rare but have been reported in recent literature. Most often they are described to occur in patients with multiple or sizeable exostoses-3. In apWe present the case of a small solitary exostosis with a sharp tip that caused a pseudoaneurysm to show that severe complications can occur regardless of osteochondroma size. Thus, we propose that surgical resection is indicated as a preventive or therapeutic strategy in selected cases of small osteochondromas depending on their shape and site.In September 2011, a 22-year-old, female, Caucasian patient with obesity  first presented to our outpatient clinic with an unclear lesion of the right dorsal distal femur with a surrounding soft tissue mass. Patient history was empty except for intermittent arterial hypertension and having been treated for an inguinal hernia in childhood. The patient recounted that she had presented to her general physician with an onset of knee pain on the right side. She then received conservative treatment for the suspected diagnosis of a burst baker-cyst. In the course of treatment, plain x-rays and MRI imaging of the knee were obtained due to persistent pain.At first presentation at our outpatient clinic, the patient had a hematoma of the right calf. Due to pyknic habitus, the range of motion was limited and the lesion couldn’t be palpated in the right popliteal fossa. The peripheral perfusion was intact; there were no sensory or motoric deficits. The lateral radiograph of the right distal femur depicted what seemed like a broad-based exostosis with a small tip extending into the popliteal fossa Figure . The MRITo exclude a secondary chondrosarcoma or other malignancies the patient was scheduled to undergo an incisional biopsy. Surgery was performed using a lateral approach and a longitudinal incision in the right, distal femur.Intraoperatively, digital palpation of the soft tissue mass showed an arterial pulsation and profuse bleeding occurred upon palpation. A tourniquet was applied in the proximal thigh to achieve haemostasis and the leakage was sutured by a vascular surgeon.To verify the intraoperatively suspected diagnosis of pseudoaneurysm, the patient underwent a diagnostic angiography after surgery was concluded. The angiography depicted a polycyclic popliteal aneurysm with smooth margins in the P1 segment. There were no signs of active leakage outside of the aneurysm formation. Muscular branches of the superior femoral artery were in close location to the aneurysm cavity but showed no communication. The diagnosis of aneurysm spurium was confirmed Figure .After consultation with the vascular surgeons, another interventional surgical approach was planned. In a second surgery, the sharp exostosis tip and aneurysm spurium were resected. Figures –5 The eHistological examination confirmed a fresh thrombus with parts of necrotic and haemorrhaged adipocytic tissue.Post-operative follow-up on the hospital ward showed good wound-healing and mobilisation of the patient who was discharged nine days after interventional surgery. After vascular surgery the patient was recommended to take acetylsalicylic acid 100 mg 1-0-0 for 6 months. The postoperative X-ray shows the remaining broad-based exostosis without the sharp tip (Figure This case report presents a rare vascular complication caused by a solitary, broad-based osteochondroma with a small, sharp exostosis tip. The patient history of knee pain combined with the onset of a hematoma should lead to doubts regarding the initially suspected diagnosis of a ruptured baker cyst. In patients with unclear pain and hematoma as well as a suspected exostosis with soft tissue mass in MRI imaging, we recommend further MRI imaging with contrast agent in accordance to accepted guidelines for the diagnosis of a soft tissue mass - and a Therefore, in exostoses presenting with unclear knee pain we recommend taking a thorough patient history and careful review of the available radiographs and MRIs. Complications in patients with exostoses are most often reported in cases of hereditary multiple or sizeable exostoses,12 compaMost existing case reports refer to complications arising from sizable osteochondromas in patients with multiple hereditary osteochondromas. Common reasons for resections of osteochondromas are compression symptoms, pain, limited range of motion or suspected malignancy.We think it is important to consider that sharp tips in exostoses regardless of size may also be cause to complications and resection should be considered as a preventive measure or after complications like the formation of a pseudoaneurysm have occurred.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.The authors declare that they have no competing interests.WKG review of current literature conception and writing of manuscript AS critical review of manuscript from orthopedic point of view, GG critical review of manuscript from orthopedic point of view, MK critical review of manuscript from a radiologic point of view, DB critical review of manuscript concerning vascular surgery, MPH review of current literature, draft of manuscript JH conception, critical review of manuscript from orthopedic point of view. All authors read and approved the final manuscript.


Posterior meningocele is an uncommon form of spina bifida. Wepresent a case of unique posterior meningocele diagnosed at theearly second trimester anatomical scan using 2D and 3D ultrasound. The sonographic appearance resembled “lasso”. Theprenatal follow-up was uneventful, with no demonstration oftethered cord. Clinical, neurological and radiologicalexaminations following delivery and at the age of four months wereunremarkable. The differential diagnosis for a dorsal midline mass presenting in fetuses and newborns includes a wide range of pathological conditions, consisting of spinal dysraphisms, teratoma, hamartoma, disturbances in regression of fetal tail, and pseudotail formation .Posterior meningocele is the least common form of spina bifida. It appears as a sac or cyst which contains cerebrospinal fluid. The majority of cases have no underlying bony defect or communication to the meninges. The spinal cord and nerves are not involved and their function is normal. Its incidence is 1 : 1000 live births , 3.teratoma and other tumors of the sacrococcyx and of the presacral space and Currarino syndrome. Usually a meningocele has no negative long-term effects, although there are reports of tethered cord. Apart from spina bifida, causes of meningocele include We present a case of unique posterior meningocele diagnosed at the early second trimester anatomical scan using 2D and 3D ultrasound.A healthy 29-year-old woman presented to our ultrasound unit at her first pregnancy for a routine anatomical scan at 15-week gestation. The anatomical scan revealed a small cystic lesion with very tiny stalk close to the caudal aspect of the spine, “floating" in the amniotic fluid, with no flow when Doppler was applied. This lesion was suspected to be meningocele, and based on its appearance we have termed it as the “Lasso sign". No opened spina bifida was noted. 3D ultrasound using sectional planes and surface rendering was performed, and it demonstrated the same lesion and confirmed it to be meningocele alone. The anatomical scan of the brain including the posterior fossa was normal. During the present pregnancy she performed nuchal translucency of 0.8 mm.The triple test screen was normal and consisted of alpha-fetoprotein level of 0.95 MOM. The patient did not perform MRI due to claustrophobia.One of the complications of meningocele is tethered cord, caused by pathological fixation of the spinal cord, resulting in traction on the neural tissue which, in turn, leads to ischemia and progressive neurological deterioration. The prenatal diagnosis of tethered cord is based on ultrasound evaluations of the spinal cord and the conus medullaris at the level of L2-L3 at the second and third trimester , 5. RepeAt 40 + 2 weeks of gestation the patient underwent a cesarean section because of arrest of dilatation. A 3384gr female infant was delivered with Apgar scores of 9 and 10 at 1 minute and 5 minutes, respectively.The neonate's physical exam revealed an atretic string of about 2 cm on the lower aspect of her back in the midline, confirmed by a neurosurgeon to be meningocele. Additional evaluation included ultrasound of the brain which was normal, ultrasound of the sacrum which ruled out tethered cord, and X-ray of the spine which demonstrated normal structure of the vertebrae. Movements of four limbs and muscle tone were normal. There was no leakage of urine, and the tonus of the anal sphincter was good. The string dried out and fell 12 hours after birth. Pathological evaluation was not performed; therefore, the diagnosis was based on the prenatal ultrasound performed by gynecologists and pediatric neurosurgeons and by the clinical examination after birth by the pediatric neurosurgeon. Photos of the back of the infant taken at the age of 2 days were unremarkable, apart from a tiny scar at the middle of her lower back that disappeared after a few days. Followup examination including neurological examination at the age of two months and four months was unremarkable. MRI performed at the age of four months was normal.In summary, detection of the “Lasso” sign may indicate the diagnosis of posterior meningocele. Thorough evaluation of the fetal brain and spinal cord to exclude Chiari II malformation and spina bifida is mandatory. The use of colour Doppler to rule out the possibility of umbilical cord as part of the examination is necessary. Level of alpha-fetoprotein should be examined. Prenatal followup should include repeated sonographic evaluation of the brain and spinal cord with emphasis on the conus medullaris to rule out tethered cord. 3D ultrasound may aid both in the diagnosis and followup. MRI may also be offered in order to aid in the diagnosis. In general, posterior meningocele has no long-term effect. “Lasso" appearing meningocele should be included in the differential diagnosis of lower spine posterior cystic lesions.


Primary intraocular lymphoma (PIOL) is a subset of primary central nervous system (CNS) lymphoma which initially presents in the eye with or without simultaneous CNS involvement . It is cOptic nerve and optic disc involvement may occur in the PIOL , 5. HereA 52-year-old healthy female presented with a 2-month history of sudden and progressive painless visual impairment in her left eye. Careful review of history did not reveal additional clues except that she had been having mild frontal headache for 2 years. On examination, her visual acuity was 6/6 and light perception in right and left eyes, respectively. There was a grade 3 left relative afferent pupillary defect. The left anterior chamber had a few non-granulomatous keratic precipitates and +1 cells. Dilated fundal examination revealed a large yellow–whitish intraocular mass above the optic disc with overlying vitritis  revealed a cystic mass with an enhanced solid component in left caudate nucleus. There was also a smaller enhanced solid mass in the left eye over the optic nerve head Fig. .Fig. 2GaNavigation-guided (Stereotactic) biopsy of caudate nucleus lesion revealed a hypercellular lesion, consisting of sheets of large cells with pleomorphic vesicular nuclei and brisk mitoses. The histopathologic and immunohistochemistry features were consistent with the diagnosis of a large B cell lymphoma Fig. .Fig. 3HiSystemic examination and further extensive investigations did not show involvement of other sites. She was diagnosed with the primary intraocular-CNS lymphoma and was treated with the De Angelis chemotherapy protocol without adjunctive radiotherapy. One month later, the brain MRI revealed a remarkable decrease in the size of intracranial tumor, and fundus examination showed significant decrease in the vitreous haze with disappearance of the mass, but the visual acuity did not improve, and she remained with a pale optic disc and some peripapillary atrophic lesions Fig. .Fig. 4FuPrimary intraocular lymphoma is considered one of the most elusive ocular masquerade syndromes. The diagnosis is frequently delayed due to misdiagnosis and false-negative biopsy reports which may be a result of small sample size , improper handling of specimen , or prior steroid therapy , 3. To lIn our patient, the optic disc was infiltrated by malignant cells. This was revealed by close vicinity between the intraocular mass and optic disc in B-scan and magnetic resonance images. The profound loss of vision and significant relative afferent pupillary defect early in the course of the disease further support this assumption. However, due to lack of confirmatory vitreous biopsy, we considered the nature of the mass presumptive.Although optic nerve and optic disc infiltration have been reported in primary intraocular lymphoma , 5, this