Retention of surgical instruments, most commonly small laparotomy sponges, is a known complication of surgery. Such retained instruments may remain silent or may cause a variety of complications. We report a case in which a retained laparotomy towel migrated into the colon. This is an infrequently reported complication. We were able to document the passage of the towel through the colon on plain radiographs. The USG and MRI findings are also described. Migration into the bowel lumen is an infrequent complication seen with retained laparotomy sponges.2 The ileA 58-year-old woman underwent a partial cholecystectomy at a local hospital for gall bladder perforation following acute cholecystitis. As per the postsurgical notes, the surgeons were unable to perform a cholecystectomy and so they drained the abscess and sutured the rest of the gall bladder. Her recovery was uneventful and she was discharged after a month. Three months later she was readmitted to the same hospital with abdominal pain, nausea, and vomiting. Physical examination was unremarkable, apart from mild abdominal tenderness. She had mild leukocytosis of 11,000/μl. On review, we found that her first plain abdominal radiograph showed a linear, curved radiopacity resembling the marker of a sponge in the right side of the abdomen at the level of the second lumbar vertebra . AnotherBeing the most common retained surgical instrument, there are many reported complications of retained sponges, e.g., peritonitis, adhesions, abscess formation, vessel occlusion, etc. An unusual complication is migration into the gastrointestinal tract lumen and consequent intestinal obstruction; alternatively, it may be extruded via the rectum, as happened in our case.–3Since 1940, there have been only 24 cases reported of transmural migration of surgical sponges into the gastrointestinal tract. To the b1246Plain radiographs are the easiest way to identify a retained sponge with a radiopaque marker. However, even in the presence of the radiopaque marker, it is possible to over-read or under-read sponge presence, as happened initially in our patient. The sponge may also show peripheral calcification and a whorl-like appearance, but this was not observed in our case. A migrated sponge may show up as an intraluminal filling defect in a dilated loop of intestine and, in later images, may be seen as a barium-coated lesion with strands and air bubbles within.On USG, a retained sponge is seen as an echogenic mass with dense acoustic shadowing or, less commonly, as a cystic mass containing curvilinear and strongly hyperechoic content. MRI appe38In conclusion, when a retained laparotomy sponge has been diagnosed on plain radiographs, radiologists should keep in mind that transmural migration into the gastrointestinal system is possible. Barium enema, USG, CT, and MRI help in identifying the exact location and thus aid in selecting the best treatment option.


Diaphragmatic rupture is a life-threatening condition. Diaphragmatic injuries are quite uncommon and often result from either blunt or penetrating trauma. Diaphragmatic ruptures are usually associated with abdominal trauma however, it can occur in isolation. Acute traumatic rupture of the diaphragm may go unnoticed and there is often a delay between the injury and the diagnosis. A comprehensive literature search was performed using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". The diagnostic and management challenges encountered are discussed, together with strategies for dealing with them. We have focussed on mechanism of injury, duration, presentation and site of injury, visceral herniation, investigations and different approaches for repair. We intend to stress on the importance of delay in presentation of diaphragmatic rupture and to provide a review on the available investigations and treatment methods. The enclosed case report also emphasizes on the delayed presentation, diagnostic challenges and the advantages of laparoscopic repair of delayed diaphragmatic rupture. A Pubmed search was conducted using the terms "delayed presentation of post traumatic diaphragmatic rupture" and "delayed diaphragmatic rupture". Although quite a few articles were cited, the details of presentation, investigations and treatment discussed in each of these were not identical, accounting for the variation in the data presented below.Late presentation of diaphragmatic rupture is often a result of herniation of abdominal contents into the thorax. Sudden Diaphragmatic rupture with abdominal organ herniation was first described by Sennertus in 1541,8. DiaphBlunt trauma to the abdomen increases the transdiaphragmatic pressure gradient between the abdominal compartment and the thorax. This caGrimes in 1974 describeDue to co existing injuries and the silent nature of diaphragmatic ruptures, the diagnosis can sometimes be missed in the acute phase and may present later on with obstructive symptoms due to incarcerated organs in the diaphragmatic defect  or eventAlthough autopsy studies have revealed equal incidence of right and left diaphragmatic ruptures, antemortum study reports suggest 88–95% of diaphragmatic ruptures occurred on the left side  and thusThe systematic review of literature also confirmed intra abdominal and retroperitoneal contents in the hernial sac, which are summarised in the table below Table  35-37].-37.35-37The studies published before 1996 have quoted that 12–69% of diaphragmatic ruptures are missed at the pre operative phase -40. CT sThe systematic review of literature confirmed chest x ray findings of bowel loops in the left hemithorax ,13, abunSurgical treatment of long-standing post traumatic diaphragmatic rupture is the same as that applicable in diaphragmatic hernias . The firThe Laparoscopic surgery is now widely accepted as a preferable intervention in acute appendicitis, acute cholecystitis and most gynaecological emergencies. Likewise its role in evaluation of diaphragmatic injuries and its repair has been also been suggested. However, this should be carried out with caution and in the presence of required advanced laparoscopic skills. NeugebaCertain problems associated with laparoscopic repair have also been reported . HoweverThe advantages of using the mesh have been widely discussed in the literature and mesh repair has also been preferred because of the decreased risk of recurrence of the hernias ,53 In adLaparoscopic repair of diaphragmatic rupture has been carried out in the past . It is dA 63 year old man presented with a short history of left sided abdominal associated with nausea. It was colicky in nature and sudden in onset. There was no change in bowel habits. The patient weighed 74 kilograms, with a BMI of 25.6. On examination he was tender in left upper quadrant. He was haemodynamially stable. Baseline blood investigations were inconclusive. X-ray suggested non-visualization of left hemidiaphragm and bowel loops at the left lung base. Figure  The follTherefore, after confirming the diagnosis of delayed diaphragmatic rupture, the repair of the offending hernia was undertaken laparoscopically. A five port approach was used, employing two 10 mm ports . These were put in place and secured with protac stapler. A chest drain was also inserted in the left thoracic cavity. The patient remained stable during the intraoperative phase.The key operative findings included omentum and splenic flexure of the colon in the left chest through a previously ruptured diaphragm just lateral and above to the spleen. The lower lobe of the left lung was found to be collapsed. Omentum was dissected off its adhesions and retrieved. The splenic flexure was badly stuck posteriorly, however, was successfully dissected and retrieved into peritoneal cavity. Figure  The repaPostoperatively the patient developed minimal left basal consolidation but thereafter he had an uneventful recovery Figure . Later oA high clinical index of suspicion is needed to diagnose and effectively manage diaphragmatic rupture even with a remote history of high-velocity injury . This isWe do recommend that a high index of suspicion should be kept in mind while dealing with patients who do get readmitted with upper abdominal symptoms whenever there is a history of trauma or blunt injury regardless of the fact whether it was few days ago or many years ago. We consider laparoscopic repair to be a suitable and safe procedure for treatment of diaphragmatic rupture.The authors declare that they have no competing interests.FR and MMC performed the literature search, extracted the data and wrote the manuscript. RS helped with radiological images. SY Iftikhar performed the operation. FR, MMC, RS and SYI all helped in writing different subsections of the review. All authors contributed to the manuscript, and all read and approved the final version.


Large posterior mediastinal goiters are extremely rare. Progressive enlargement and possible compression of adjacent structures, as well as malignant potential necessitate that these goiters should be surgically excised. A review of mediastinal tumors, specifically intra-thoracic goiters is presented along with a case report of acute respiratory compromise secondary to tracheal compression by a large posterior goiter. A 59-year-old African-American man with past medical history significant for cervical thyroidectomy for goiter five years prior presented to the emergency center with acute strider and respiratory embarrassment. His oxygen saturations remained stable at 99% on a 50% non-rebreather face mask with a respiratory rate of thirty-two breaths per minute. The patient had been seen in consultation by the thoracic surgical service 6 months prior with the complaint of dysphagia and chest discomfort. He was found on computer tomography (CT) scan to have a large 9 cm posterior mediastinal mass adjacent to the trachea and displacing the esophagus. Serum markers were non-diagnostic. He was recommended for biopsy and surgical removal however he failed to return for any further surgical or medical intervention until his current presentation. The patient reported a recent upper respiratory tract infection including productive yellow cough, runny nose and subjective fevers. He had not sought any treatment until with continuous coughing overnight he experienced progressive stridor and respiratory distress which led him to his presentation to the emergency room. A repeat CT scan revealed the mass encroaching and compromising the tracheal lumen with displacement of the esophagus laterally .The patient was taken emergently to the operating room. Intubation was performed in the presence of the surgical team under direct fiberoptic visualization while maintaining spontaneous respiratory effort until the airway could be secured. A single lumen #6 endotracheal tube was passed beyond the tumor and positioned in the left main bronchus for single lung ventilation. A right posterior-lateral thoracotomy was performed through the fifth intercostal space giving good exposure of the mass. Gross distortion of the peri-tracheal structures was present secondary to the large space-occupying lesion . The masMany types of tumors and cysts occur in the mediastinum . These aThe diagnostic approach to patients who have mediastinal masses should include thorough imaging. CT is the imaging modality of choice for evaluating a suspected mediastinal mass and can provide useful information for surgical planning ,4. DiagnIntrathoracic ectopic goiters are rare, but have to be considered as a diagnostic possibility in all mediastinal masses. The displacement of the thyroid tissue inferiorly in connection with the embryogenesis of the heart and the large vessels explains the etiology of the disease . IntrathOnce the diagnosis of an intrathoracic goiter is obtained, the treatment is surgical. The propensity to enlarge and compress adjacent structures as well as the small chance of malignancy necessitates resection ,4,7,8. AThe only effective treatment for mediastinal goiter is surgical excision. Perioperative management should include careful evaluation of the airway as the extent of compression and deviation caused by the mass can lead to a difficult intubation. A multidisciplinary team approach is critical and includes the surgeon, anesthesiologist, and endocrinologist. Anesthesia for patients with mediastinal masses carries a significant risk for fatal or near-fatal cardiorespiratory events . CarefulBoth cervico-sternotomy and thoracotomy approaches have been described for excision -4,7-12. Goiter is an occasional finding with intrathoracic masses. These are most commonly anterior however a rare posterior mediastinal thyroid may be found. Malignant potential and a tendency toward enlargement and airway compromise necessitates treatment. Surgical excision is recommended to treat symptoms and avert complications related to their mass effect.


Basal cell carcinoma (BCC) is the most common type of skin cancer in white-skinned individuals but is rare in blacks and Indians. There are only few case reports about bilateral BCC of lower eyelids. Here we present a case of BCC appearing sequentially in symmetrically identical positions in both lower eyelids. The patient was a resident of high altitude and had worked out doors for seven to eight hours every day. Environmental and occupational parameters may have an important role to play in this context. There was no evidence of local invasion or distant metastasis. Basal cell carcinoma (BCC) is the most common type of skin cancer common in white-skinned individuals but is rare in blacks and Indians. Skin cancers mainly affect sun-exposed areas like the neck and face (88–90%). BCC rare2A 51-year-old female, field worker, fair in complexion, and resident of the hilly region of Kumaun, India reported in March 2009 with a gradually enlarging mass in lateral portion of the right lower lid for last five years. The mass had rapidly increased in size in the three months prior to presentation. The patient also gave a history of itching, and occasional bleeding from the mass. There was a past ocular history of a similar mass in the left lower lid in an identical position, which appeared when she was around 20 years of age. It was excised at the age of 25 years for cosmetic reasons when it was pea-sized. Histological examination was not done at that time. After excision, the mass again recurred at the same location, continued to increase in size, and was associated with itching and occasional bleeding. Excision of mass with cheek rotation flap was done in 2001. Histological examination of this tissue revealed pigmented nodular variety of BCC of left lower lid.The patient had been diagnosed with hypertension and diabetes three years back and was on irregular treatment. Family history of skin carcinoma was negative.Examination of the right lower eyelid revealed an approximately 25 × 30 mm, pigmented ulcerated, and nodular mass in the lateral half. It was painless, firmly adherent to the lid, and restricting the active movements of lower lid. The lower lid was slightly everted due to weight of this mass . ClinicaSystemic examination was unremarkable. Routine investigation revealed raised fasting and postprandial blood sugar levels, a normal hemogram, liver and kidney function tests. Chest X-ray and ultrasonography of abdomen did not reveal any abnormality.An incisional biopsy was performed prior to definitive excision to confirm the clinical diagnosis of a periocular malignant mass. Histological examination of the tumor in the right eyelid revealed solid nests of darkly staining cells extending into the dermis. All the cells were similar to the basal cells  of the epidermis and few nuclei showed abnormal mitotic figures, which took up an in-tensely dark blue stain with hematoxylin. The cells at the periphery of the solid masses showed a typical palisade arrangement . These fClinically, a rough estimate of tumor margins were made with the skin of the right lower eyelid on stretch using the following guides - transition in surface contour; altered vascularization (fewer capillaries and more telangectasia); altered skin color; tumor depth was judged by the lesion’s mobility over underlying tissues. Standard surgical excision with frozen section control was done. A two-staged lower eyelid reconstruction was done with tarsoconjunctival flap and full thickness skin graft taken from the thigh . The tumBCC is the most common malignant eyelid tumor in the Caucasian population. The lower eyelid and medial canthus are the most frequent sites of origin. About 957Forty percent of patients with BCC have an increased risk of developing second skin cancers, in five years. In our pHyde (1906) recognized UV radiation as a carcinogen, which is currently believed to be the most important cutaneous carcinogen with both initiating and promoting effects especially at 290–320 nm wavelength. PotentiaClinically, BCC can be grouped into three types: nodular, nodulo-ulcerative (Rodent ulcer) and morpheaform (sclerosing type). Nodular BCC is the most common variety, appears as pink or pearly papule with overlying telangactesias. Black or brown pigmentation may also present. In our patient, it was black-pigmented nodular type of BCC. Nodulo-ulcerative type results from central ulceration of nodule. It is surrounded by rolled up borders, often described as Rodent ulcer. Morpheaform type of BCC is least common and appears as flat, indurated, yellow- pink plaque with ill-defined borders. The nodular subtype of BCC should be regarded as a potentially invasive and recurrent tumor. Histopathological examination and subtyping of all BCC tumors is recommended. DifferenWe have reported a rare occurrence of BCC in a bilaterally symmetrical position of the lower eyelids in a resident of hilly region of Kumaun, India. The initial appearance at a younger age is another unusual feature in our patient.


The occurrence of the intracranial, peripheral, primitive, neuroectodermal tumor, Ewing's sarcoma (pPNET-ES) of the dura, is very rare. Immunophenotypical as well as genetic analyses play key roles in its diagnosis and differentiation from central PNET. We describe here the CT scan and MRI findings of an interesting case of intracranial pPNET-ES arising from the anterior falx cerebri with a trancalvarial–subgaleal extension. The peripheral, primitive neuroectodermal tumor (pPNET), Ewing's sarcoma (ES) family tumor group, includes small round cell tumors of the bone, nerve, and soft tissues with morphological attributes of the germinal neuroepithelium. pPNET-ES also occurs in the central nervous system (CNS), including the meninges and the cranial and spinal nerve roots. The distAn 11-year-old girl presented with a 3-month history of a midline, frontal, non-tender scalp swelling with a rapid and recent increase in size. She had repeated episodes of headache, giddiness, and mild behavioral changes. In addition, epiphora, diplopia, and blurring were also present. Fundoscopy revealed bilateral papilledema. No focal neurological deficit was detected. Non-enhanced CT scan of the brain revealed a large 7.0 × 5.0 × 5.0 cm, densely calcified, mushroom-shaped, parasagittal, hyperdense mass arising from the anterior falx . The nonThe patient underwent subtotal resection of the tumor. Intra-operative findings confirmed the dural origin, extensive calcifications, high vascularity, and aggressive nature of the tumor with invasion of the adjoining brain parenchyma along all the margins. There was destruction of the overlying calvarium with an associated subgaleal mass. The anterior one-third of the SSS was also found to be thrombosed and encased by the tumor.in situ hybridization analyses, the tumor showed CD99 [MIC-2 antigen expression, and chromosomal translocation t(11:22)(q24:q12).Histopathological examination revealed a cluster of undifferentiated round cells . On immuwed CD99 , MIC-2 apPNET-ES primarily affects children and young adults aged 10–30 years with equal sex predilection.[MIC2 gene product (CD99) is highly expressed immunohistochemically in nearly all pPNET-ES.[Recent advances in molecular biology have allowed a clear pathological distinction between these two entities. The pPNET-ES. Central pPNET-ES. The chropPNET-ES. but is npPNET-ES. Our caseet al,[et al,[There is sparse literature regarding the radiological features of pathologically proven intracranial pPNETs. In 2006, Pekala et al, showed rl,[et al, reportedIt is not possible to make a prospective, definitive diagnosis of this condition on imaging. A lesion such as seen in our patient would have a differential diagnosis that would include c-PNET, aggressive meningioma, rhabdomyosarcoma, and esthesioneuroblastoma.In summary, we describe here a rare case of intracranial pPNET-ES of the dura with transcalvarial–subgaleal extension. Although it is only possible to make this diagnosis on immunohistochemistry and genetic analyses, knowledge of this condition will help radiologists understand the spectrum of intracranial round cell neoplasms better.


We report the case of a 6-year-old boy presenting with small bowel evisceration following a fall onto a bicycle handle-bar. His case is presented, a review of the literature performed and interesting photos pre and post-op are presented. A 6-year-old Caucasian boy was brought to the Emergency Department after falling onto his bicycle handlebar at the local skate park, suffering an evisceration injury. He had ridden his bicycle up a ramp and lost control, fell down from a height of about 1 metre onto the bicycle’s handlebar and immediately realised he had suffered a serious injury. He calmly got back on the bicycle and rode out of the park, where he collapsed at the gate after appealing for help from bystanders who then called an ambulance.On arrival at the Department of Accident and Emergency, he was conscious and his vital signs were stable. The obvious injury was the protrusion of the small bowels and some omentum on the abdominal wall, obscuring the wound beneath . HistoryAfter cervical and chest injuries were excluded, the resuscitated child was taken to theatre. The skin and subcutaneous tissue had been de-gloved into a 10 cm inferiorly based flap. The anterior rectus fascia was ruptured at its lateral margin in the left iliac fossa. The insertions of the external oblique, internal oblique and transversus abdominis muscles to the left rectus sheath were disrupted leaving a ragged defect 5 cm in diameter. The small bowel and a small amount of the greater omentum prolapsed through this defect. The wound did not need to be enlarged. The small bowel was not injured, nor was any other intra-abdominal organ.The bowel was inspected, cleaned and returned to the abdomen after peritoneal wash. The return was clear. The muscles and sheaths were repaired with a 1-PDS mass closure technique. The viable skin flap was heavily irrigated and repaired with a subcuticular suture over a small suction drain. , taken iMost instances of eviscerations encountered in trauma are caused by abdominal stab wound injuries, which generally requires laparotomy . EviscerHandlebar injuries to the abdomen from bicycle accidents are commonly seen in emergency departments but uncommonly result in rupture of the abdominal wall, as most sole bicycle accidents occur at low speed. When a rupture of abdominal muscle occurs, the skin remains intact most of the time, and only a herniation results. A report and review of 21 reported cases of closed abdominal herniation from handlebar injuries was published in 2004 . AbdominAlthough a handle bar can act as a sharp “spear”, the wound in this case was a raised flap, visibly resulting from the handle bar impact and, as such, is better considered a blunt rather than penetrating injury. The lateral part of the lower rectus sheath is where the abdominal wall is least protected by muscles and is the site of this evisceration. This is the location of a Spigelian hernia and a common site for closed abdominal herniation secondary to trauma. In our case and that presented by Lovell , the bowThe treatment of this injury is no different from other traumatic eviscerations. Prompt resuscitation, exclusion of other injuries, followed by early and careful laparotomy will allow the patients the best opportunity to make an uneventful recovery.There has been a proliferation of skate parks in Australia in recent years, as local councils try to separate bicyclists and skateboarders from cars and pedestrians. These parks are seen as good places to practice airborne bicycle tricks, potentially resulting in serious injuries.


An extrapulmonary small cell carcinoma is a rare condition. It has similar histological features to pulmonary small cell carcinoma and is equally aggressive.We present the case of a 60-year-old woman who presented with right upper quadrant pain. Computerised tomography revealed an appendiceal lesion and multiple liver metastases. Exploratory laparotomy and right hemicolectomy was performed with histopathological analysis confirming a primary small cell carcinoma of her appendix.This is the first reported case of a pure extrapulmonary carcinoma arising from the appendix. Extrapulmonary small cell carcinomas (ESC) are rare. Many different sites of origin have been described including kidney, bladder, prostate, endometrium, salivary glands, nasal sinuses and intestinal tract -5. PrimaA 60-year-old female was admitted with a 4-day history of right upper quadrant pain. She was treated with oral antibiotics for suspected acute cholecystitis. She had a past medical history of Type-2 diabetes and hypertension. She was a non-smoker. The patient had no fever, sweating or rigors but described similar intermittent pain with associated nausea and vomiting over the preceding 6-weeks. On examination, the patient was comfortable and well nourished. Her clinical parameters (pulse and blood pressure) were normal and she was apyrexic. Abdominal examination revealed right upper quadrant tenderness with a palpable liver edge. There were no other masses or organomegaly.9/l and C-reactive protein 19 mg/L. All other indices were normal as were the plain chest and abdominal X-rays. An abdominal ultrasound showed a markedly abnormal liver appearance with multiple hypoechoic lesions suggestive of multiple metastases. The remainder of the biliary tree was normal. A contrast-enhanced computerised tomography (CT) scan of the chest, abdomen and pelvis confirmed multiple liver metastases within both lobes of the liver but also a 6 × 7 cm tumour mass in the right iliac fossa  reported a 12.5% incidence of colorectal ESC with 3 patients affected from a retrospective review of 24 patients with ESC [Undifferentiated small cell carcinoma (SCC) is an aggressive lung tumour accounting for 15% of all lung cancers . Approxiwith ESC .Age and sex distribution for ESC are similar to that seen in adenocarcinoma of the colon . AlthougSCC is thought to originate from neuroendocrine cells, which are found in the epithelium of many mucosal surfaces including the gastrointestinal tract . Despiteet al and this was mixed with adenocarcinoma [Histopathological diagnosis can be confirmed by the classic appearance of small round to oval shaped cells with a finely granular and hyperchromatic nucleus, inconspicuous nucleoli and scanty cytoplasm on light microscopy . SCC's sarcinoma -14. To tarcinoma . AlthougUnfortunately clinical presentation of ESC carcinoma is usually at an advanced stage due to the aggressive nature of the disease. Therapeutic modalities are determined by the location and extent of disease. Chemotherapy remains the treatment of choice. The role of radiotherapy and surgical intervention remain limited, with surgery often only being used for the treatment of localised disease . CombinaThe prognosis for ESC is similar to pulmonary SCC's and remains poor with a rapidly deteriorating clinical course. Five-year survival is less than 13% . The meaThe author(s) declare that they have no competing interests.AOK: Involved in the literature review, manuscript preparation and manuscript editing. MEOD: Involved in the conception of the report, literature review, manuscript preparation, manuscript editing and manuscript submission. RS: Involved in the critical analysis of the histopathology in the case report and manuscript review. PDC: Involved in the manuscript editing and manuscript review. JL: Involved in manuscript editing and manuscript review.All authors have read and approved the final manuscript.


Primary appendiceal neoplasms are rare and usually found incidentally after appendicectomy for suspected appendicitis. We report a case of a perforated cystadenocarcinoma of the appendix occurring synchronously with caecal adenocarcinoma in an 81-year-old woman without abdominal symptoms or signs, who presented with iron deficiency anaemia. Primary appendiceal neoplasms are uncommon  and usuaAn 81-year-old Caucasian woman was admitted with a two week history of increasing shortness of breath and dizziness. Although frail she was otherwise medically fit, a non-smoker and had no significant family history. She had a history of endometrial cancer, treated 14 years previously with hysterectomy, bilateral salpingo-oopherectomy and adjuvant radiotherapy. The onset of her symptoms was gradual and comprised malaise, shortness of breath initially on exertion and more lately at rest and dizziness especially on standing up from sitting. She denied any symptoms related to her gastrointestinal tract such as haematemesis, melaena, change in bowel habit or abdominal pain. On examination she appeared pale and was dyspnoeic, tachycardic and normotensive. Examination of the abdomen revealed it to be soft and non-tender, with no palpable abdominal masses. Blood tests showed a microcytic, normochromic anaemia with a haemoglobin of 3.8 gm/dL and a carcinoembryonic antigen level of 15 ng/ml. Blood biochemistry was within normal limits. After blood transfusion sources of intestinal haemorrhage were sought; an upper gastrointestinal endoscopy was unremarkable and colonoscopy was unhelpful because a fixed rectum, secondary to previous surgery and radiotherapy for endometrial cancer impeded the progress of the scope. An air contrast barium enema examination was performed and this showed an indentation of the caecal wall  suggestiHistology of the resected specimen demonstrated a T3N1M0 adenocarcinoma of the caecum with 2 out of 14 lymph nodes containing tumour cells. Surprisingly a mucinous neoplasm of the appendix was also identified, separated from the caecal tumour by a segment of normal caecal mucosa. Each tumour had a distinct morphology. The cytological characteristics of the caecal tumour were typical of a moderately differentiated colonic adenocarcinoma , whist tNeoplasia of the appendix, although rare, is an important diagnosis to consider in patients with a mucocele of the appendix. The clinical presentation of tumours of the appendix can be similar to acute appendicitis and frequently the diagnosis is made incidentally . The freCystadenocarcinoma of the appendix is an important diagnosis to consider in patients diagnosed with a mucocele of the appendix. Although the these tumours usually present clinically like acute appendicitis, this case was interesting because the mucocele remained completely asymptomatic despite perforation and the patient presented with systemic symptoms related to a second colonic neoplasm.


Mesenteric panniculitis of the sigmoid colon is a rare occurrence in surgical practice. The aim of this article is to present a case of mesenteric panniculitis of the sigmoid colon and a short review of the literature.We reviewed the hospital record of a 63-year-old man who presented with a palpable mass in the left abdomen and clinical signs of a partial bowel obstruction. The pre-operative impression was a possible cancer of the sigmoid colon. A laparotomy was performed through a midline incision. The mesentery was found to be markedly thickened, constricted and puckered. The normal architecture of the adipose tissue had been lost and replaced with an irregular nodular mass. The microscopic pathologic sections demonstrated a chronic reactive inflammatory process with an exuberant proliferation of fibroblasts and fibrocytes. The adipose tissue contained scattered areas of steatonecrosis with foci of lipid-laden macrophages, lymphocytes and plasma cells. The sigmoid colon and its mesocolon were resected. The postoperative course was uneventful and the patient was discharged in good condition, and followed up for the next two years.Mesenteric panniculitis of sigmoid is an extremely rare entity of unknown origin in which the normal architecture of the mesentery is replaced by fibrosis, necrosis and calcification. On gross examination the alterations may be mistaken for a neoplastic process. A frozen section may be necessary for confirmation of the diagnosis. When the advanced inflammatory changes became irreversible and bowel obstruction occurs, resection may be indicated. Mesenteric panniculitis (MP) is a benign fibro-inflammatory process involving adipose tissue of the mesentery characterized by the presence of fat necrosis, chronic inflammation and fibrosis. It is known by several terms including sclerosing mesenteritis and mesenteric lipodystrophy. Although the disease occurs rarely, during recent years there have been a number of reports which suggests a growing interest in this clinical entity -7. We prA 63-year-old man was admitted to our hospital with a two month history of general weakness, intermittent left lower quadrant abdominal pain, weight loss, constipation and signs of partial bowel obstruction. Physical examination revealed a palpable tender mass in the left abdomen. There was no history of melena or mucus. The overlying skin and subcutaneous tissue were unremarkable. A barium enema showed narrowing of the distal sigmoid colon. Colonoscopy revealed inflammatory changes of the sigmoid colon – the mucosa was erythematous and edematous, but there were no colonoscopic features of Crohn's colitis or ulcerative colitis. Computed tomography was negative except for a small amount of free fluid present in the abdomen. Laboratory findings were normal. The pre-operative impression was of a possible cancer of the sigmoid colon although the pre-operative investigations were not conclusive, particularly because no mucosal mass was identified. Laparotomy was performed through a midline incision. The mesentery of the sigmoid colon was markedly thickened, constricted and puckered. The color varied from yellow to red-brown suggestive of fat necrosis. The normal architecture of the adipose tissue was lost and was replaced with an irregular nodular mass involving appendices epiploicae of the colon. There was a moderate amount of serous effusion in the peritoneal cavity. No enlarged lymph nodes were identified. On macroscopic pathological evaluation the mesenteric mass was composed of areas of pale yellow and reddish-brown color with focal hemorrhage. The blood vessel walls were thickened and congested. The bowel wall adjacent to the mesenteric mass was thickened, edematous and markedly congested figure .Microscopic pathologic sections from the involved mesentery demonstrated a chronic reactive inflammatory process with exuberant proliferation of fibroblasts, fibrocytes and fibrosis figure . ScatterThe postoperative course was uneventful, and the patient was discharged ten days after the operation in good condition. The patient's state of health was followed up for two years during which time he remained asymptomatic.Mesenteric panniculitis is known in the literature by a variety of terms – "mesenteric manifestation of Weber-Christian disease" – introduced by Herrington and associates , "IsolatMP affects predominantly the mesentery of the small intestine. This process rarely involves the large intestine. According to Wexner and Attiyeh  there haThe etiology and pathogenesis of the disease are very obscure. Various factors such as blunt abdominal trauma or prior surgery, cold, different drugs, vasculitis, vitamin deficiency, autoimmune processes and allergic disease have been suggested as possible causes. Some of the cases of MP were associated with abdominal tuberculous lymphadenitis . The assThe diagnosis is frequently made by abdominal exploration. A frozen section may be necessary for confirmation of the diagnosis. There is no specific treatment for MP. There are reports of response to steroids , immunosMP of sigmoid is extremely rare clinical entity. On gross examination, the alterations may be mistaken for a neoplastic processes. A frozen section study may be warranted. The intraoperative findings are very typical and once seen the picture is not easily forgotten. There is no specific treatment. Medical treatment may consist of therapy with anti inflammatory or immunosuppressive agents. When the advanced inflammatory changes became irreversible, and especially in case of bowel obstruction, we recommend partial resection.MP = Mesenteric panniculitis.The author(s) declare that they have no competing interests.AP participated in the sequence alignment, explored all possible sources for the references and drafted the definitive version of this manuscript.GC had a substantial contribution of the review of the histological section of the case. He performed the photos and their interpretation.All authors read and approved the final manuscriptWritten informed consent was obtained from the patient for publication of this study.


Multiple endocrine neoplasia type 1 (MEN-1) patients are prone to develop carcinoid tumors. Few cases report the development of gastrointestinal carcinoid tumors in patients with MEN-1 syndrome related tumors. This is the first paper to report the occurrence of an intestinal carcinoid tumour in association with a pituitary adenoma.sixty eight year old female presented with intestinal obstruction four years after transphenoidal pituitary resection for pituitary adenoma. During surgical exploration and lysis of adhesions, we accidentally discovered an intestinal carcinoid tumour. Resection of the involved small bowel segment and the draining lymph nodes was undertaken. Postoperative follow up showed no biochemical or radiological evidence of residual tumor.A Neuroendocrine tumors (NETs) may occur as part of familial endocrine cancer syndromes including MEN-1. It is recommended that clinicians search thoroughly for MEN-1 in patients presented with NETs, however, there is no current consensus for screening patients suspected to have MEN-1 to rule out NET.We recommend screening patients suspected to have any familial type of endocrine tumors for the presence of NET. Multiple endocrine neoplasia type 1 (MEN-1) is an autosomal dominant disease with a broad spectrum of clinical manifestations . Though There are few case reports of the development of gastrointestinal carcinoid tumors in patients diagnosed with MEN-1 syndrome related tumors. Carcinoid tumor in these cases was located in the duodenum , and theOur patient was a 68 year old African American female who developed diffuse abdominal pain, associated with nausea and bilious vomiting, 24 hours prior to her emergency room visit. The pain was localized to the epigastric region and had a progressive course. Her last bowel movement was reported as four days prior and she denied any recent weight loss, wheezing, flushing, palpitation or change in bowel habits.The patient's past medical and surgical history included hypertension, hyperlipidemia, total abdominal hysterectomy and bilateral salpingoophorectomy secondary to fibroids.The patient also reported a history of progressive loss of vision ten years earlier that was investigated by brain MRI after an extensive ophthalmological evaluation. The MRI showed a pituitary tumor and the patient benefited from a transphenoidal pituitary tumor resection. The pathological examination revealed a chromophobic pituitary adenoma.The patient had a strong family history of cancer. Her father died from colon cancer, a brother died from esophageal cancer, an uncle died from brain tumor, one aunt had been diagnosed with breast cancer and one aunt with gastric cancer.Upon physical exam, the patient had a tense, distended abdomen, with a well healed paramedian incision and no bowel sounds. There was non localized diffuse tenderness with positive rebound and voluntary guarding. Rectal examination revealed no masses and an empty vault. Laboratory values revealed no leukocytosis, however the lactic acid level was elevated. A computed tomography scan of the abdomen revealed a small bowel obstruction. Subsequently, the patient was decompressed with a nasogastric tube and fluid resuscitation, and brought to the operating room for an exploratory laparotomy. Intraoperatively, there was significant small bowel congestion with no necrosis. One adhesive band was found and lysed at the mid jejunum where it was fixed to the pelvic wall. The bowel was thoroughly inspected to look for any other points of obstruction or abnormalities. A serosal lesion was found on the surface of the jejunum ten centimeters from the adhesion Figure . Also a Postoperatively, the patient did well, however, the pathological evaluation of both the serosal lesion and the mesenteric lymph node revealed carcinoid tumor.Three days later, the patient was brought back to the operating room for exploratory laparotomy and small bowel resection. During the surgery, there was no intestinal lesion noted, and about 15 cm of small bowel on each side from the previous serosal lesion was resected with its corresponded mesentery Figure . One enlThe pathological examination of the specimen revealed a carcinoid tumor approximately 0.4 cm in greatest dimension, penetrating subserosa five centimeters from the previously resected serosal lesion Figure  includinDuring the postoperative inpatient period, a 24 hour urine 5-Hydroxyindole Acetic Acid (5-HIAA) was within normal value and no focal area of increase uptake was noted on an octreotide scan.There was no postoperative morbidity, and the patient was followed as an outpatient at two and six month interval. During these follow up visits, the patient reported feeling better and denied any weight loss, wheezing, flushing, palpitations or diarrhea.A postoperative CT scan of the chest abdomen and pelvis six months after the surgery, revealed no evidence of recurrent disease, and no intra abdominal masses. A repeat octreotide scan at six months after the surgery did not show any area of increase uptake. Chromogranin A level was followed, and was decreasing from 142 ng/ml at two months post resection, to 64 ng/ml at six months post resection.Neuroendocrine tumors (NETs) constitute a heterogeneous group of neoplasms with common characteristics and biological features. NETs were previously referred as apudomas, by Pearse in 1969 , when heThis widespread phenomenon initially reported by Pearse himself in 1964, when describing the calcitonin-secreting parafollicular C cells of dog thyroid, was also found in other peptide hormone-secreting cells, for example in the corticotrophs of the anterior pituitary gland and in the b-cells of the endocrine pancreas. Currently, APUD cells including more than 40 cell types are best referred as a diffuse neuroendocrine system.Primary gastroenteropancreatic NETs can be asymptomatic but may present with obstructive symptoms, and carcinoid syndrome when tumors metastases to the liver with the subsequent release of vasoactive substances responsible of the classical picture of flushing, diarrhea, lacrimation, palpitations, and wheezing.Midgut carcinoid tumours have a wide range of presenting signs including abdominal pain, nausea and vomiting, weight loss, diarrhea, gastrointestinal bleeding and carcinoid syndrome. However, significant number are incidentally discovered in resected surgical specimens when surgery had been undertaken for other intra abdominal disease .Though the majority of NETs occur spontaneously, NETs may occur also as part of complex familial endocrine cancer syndromes such as MEN-1, MEN-2, Neurofibromatosis type 1(NFT type 1), Von Hippel Lindau disease, and Carney's Complex -11.The incidence of MEN-1 in gastroenteropancreatic NETs was reported to range from 30% in gastrinoma to virtually none in gut carcinoid . HoweverAt the same time, surveillance for persons known to have MEN-1 to rule out NET was previously suggested . The curFor persons suspected to have MEN-1, including those with a first degree affected relative but without gene testing, and members of a clinical group at risk, the current recommendations do not include screening for NETs .This case report is the first to report the occurrence of an intestinal NET in a patient previously documented to have a pituitary adenoma. In our patient, intestinal NET was found in a specimen taken during abdominal surgery for other reason. Surgical resection of the tumor with postoperative negative octreotide scan, decreasing chromogranin A level, and 5-HIAA within normal values reflects a favorable prognosis.We believe that screening patients suspected to have any familial type of endocrine tumors for NETs, could help early diagnosis in asymptomatic patients, and offer them the best chance for curative resection. The screening protocol can possibly include biochemical tests including 5-HIAA, chromogranin A, radiological evaluation including an octreotide scan, and endoscopic examination including endoscopic ultrasound. Screening large numbers of patients with either documented or suspected MEN-1 syndrome using biochemical, radiological and endoscopic tests will help to select the best, and the most reliable screening modality. A follow up of these patients could show a potential beneficial effect related to the early detection of NETs diagnosed by this screening protocol.A critical component in the diagnosis of a neuroendocrine tumor is suspicion of its presence. We believe that screening patients suspected of having any familial type of endocrine tumors for NETs could help early diagnosis in asymptomatic patients and offers these patients the best chance to have a curative resection. Further studies are required to investigate the best screening modality.The author(s) declare that they have no competing interests.Study conception and design: CB and RG were responsible for the study conception and design. DCR and CB acquired the data and drafted the manuscript. CB RG and DCR critically revised the manuscript. All authors read and approved the final manuscript.Written informed patient consent was obtained for publication


Radicular cysts are the most common inflammatory odontogenic cystic lesions. It originates from epithelial residues in periodontal ligaments secondary to inflammation. The pathogenesis involves the activation of epithelial cell rests of Malaseez after physical, chemical or bacterial injury. Microscopically, the cyst is thin with smooth or corrugated inner surface. The most common epithelial lining is stratified squamous; with Rushton's hyaline bodies in 10% of the reported cases. Slow accumulation and deposition of cholesterol during the inflammatory process leads to the formation of "clefts" with acute and chronic inflammatory cells in the proliferating epithelium and connective tissue, respectively. The presence of hemosiderin usually indicates a previous micro-hemorrhage event. While the presence of lipid-laden macrophages or foam cells indicate the presence of cholesterol-removing mechanism from the lesion. We report a rare case of 38-year-old Mediterranean female presented with throbbing right maxillary pain. The diagnosis of radicular cyst was confirmed by the presence of atrophic non-keratinized stratified squamous epithelium. The radicular cyst was associated with hemosiderin, foam cells, subepithelial fibrosis and root canal dystrophic calcification. They represent uncommon synchronous histopathological features. Radicular cysts are the most common inflammatory odontogenic cystic lesions. It originates from epithelial residues in periodontal ligaments secondary to inflammation. Commonly found at root apices of involved teeth or lateral to the root. These cysts may persist even after removal of the problematic tooth; hence called residual cysts -3.th & 5th decades of life. All teeth-baring areas are susceptible to radicular cyst formation; but more than half of the reported cases were in the maxillary anterior segment [Nearly two thirds of the reported cases were in males in the 4 segment -3.Most of the small radicular cysts are asymptomatic and usually discovered during routine dental screening. Larger cysts cause swelling and bony expansion followed by erosion and fluctuation of the overlying soft tissue; this is usually associated with pain and infection with a discharging sinus. Radiographically, they appear as round or ovoid radiolucent areas surrounded by a narrow radio-opaque margin, extending from the lamina dura of the involved tooth -3.The pathogenesis involves the activation of epithelial cell rests of Malassez after physical, chemical or bacterial injury. Three phases of cystic formation has been described: initiation, cyst formation and cyst enlargement -3. This Histopathologically, the cyst is thin with smooth or corrugated inner surface. The most common epithelial lining is stratified squamous; with Rushton's hyaline bodies in 10% of the reported cases. Slow accumulation and deposition of cholesterol during the inflammatory process leads to the formation of "clefts" with acute and chronic inflammatory cells in the proliferating epithelium and connective tissue, respectively. The fibrous capsule is composed mainly of condensed parallel bundles of collagen fibres peripherally and a loose connective tissue adjacent to epithelial lining. Other reported structures include satellite microcysts, calcifications, mast cells and remnants of odontogenic epithelium . The proWe report a rare case of radicular cyst associated with hemosiderin, foam cells, subepithelial fibrosis and root canal dystrophic calcification.A 38-year-old Mediterranean female presented with throbbing right maxillary pain. Clinical examination revealed the presence of oral fistula in the upper right lateral incisor area. The tooth was severely decayed (unrestorable) and tender to percussion. The patient reported remarkable medical history and no allergies.Radiological evaluation revealed a periapical radiolucent lesion of upper right lateral incisor Figure . SurgicaHistopathological processing involved the immersion of the specimen in buffered formalin for 24 hours, followed by decalcification in EDTA (for hard tissue processing). A microtome was used to cut the specimen into 5 μm blocks and the paraffin sections were stained with hematoxylin and eosin (H&E) prior to histopathological examination.The diagnosis of radicular cyst was confirmed by the presence of atrophic non-keratinized stratified squamous epithelium. In the lamina propria, an oval fibrotic island was observed centrally, which was surrounded by multiple inflammatory cells Figure . In otheThe decalcified tooth sections showed the presence of dystrophic calcification into the canal with peripheral reactionary dentin against the root Figure . The apiRadicular cysts are common osseo-destructive jaw lesions. Uncommon microscopical features of radicular cysts include subepithelial fibrosis, topical hemosiderosis and lipid-laden macrophages in association with a root canal dystrophic calcification.Root canal dystrophic calcification in aggressive forms may cause obliteration of the root canal apex . In mostLipid-laden macrophages or foam cells are derived from the monocyte system and take part in removing the necrotic tissue . The phaAnother form of chronic irritability may be identified by the presence of subepithelial fibrosis. This is clearly associated with fibroblast stimulation creating fibrotic islands in the chorium . This apOther rare forms of chronicity may be the hemosiderin pigmentation which is related to the deposition of endogenous catabolic products. In cases where hemosiderin is found in multiple internal organs, the term "systemic hemosiderosis" seems to be more appropriate. The hemosiderin pigmentation indicates the presence of many micro-hemorrhages in the lamina propria. Cells of the defense mechanism (i.e. macrophages) react at the site of erythrocyte degradation; this starts "phagocytosis" . HemosidThis case report described the association of pulp dystrophic calcification with subepithelial fibrosis, lipid laden macrophages and hemosiderin pigments on the chorium of a radicular cyst. In conclusion, the synchronous existence of these pathological features in a radicular cyst may indicate the development of chronic irritation in periodontal tissues by the root canal microbial proliferation.EDTA: ethylenediaminetetraacetic acid; H&E: hematoxylin & eosin; PMN's: polymorphonuclear neutrophils."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.PK, SK, WJ, TU were major contributors in assessing the case data, reviewing and writing the manuscript. All authors read and approved the final manuscript.


A congenitally absent Inferior Vena Cava (IVC) is a rare anomaly that is recognised to be associated with idiopathic Deep Venous Thrombosis (DVT), particularly in the young. It may not be apparent until later in life. Retrospectively, as discussed in this case, there can be clues indicating the presence of such an anomaly from a young age. However, it is not clear whether early recognition of this condition would affect the prognosis and treatment.A 54 year old gentleman was admitted with 3 weeks of abdominal pain and localised swelling over the right flank. Examination revealed palpable 'snake-like' tortuous, tender lumps on the abdominal wall. Past history revealed chronic non-healing venous leg ulcers, and varicose veins necessitating varicose vein ligation at a very young age. The ulcers eventually needed skin grafting.During this, current admission he was investigated and diagnosed with Deep Vein Thrombosis (DVT). CT scan, performed to search for intra-abdominal cancer, revealed absence of the Inferior Vena Cava with extensive thrombosed collaterals of the superficial abdominal and azygous veins and a congenitally atrophic left kidney.This is a case of one of the oldest patient described in the literature to be diagnosed with absence of the IVC. It is thought that IVC anomalies are under-diagnosed, and may be commoner than once believed. However there were vital clues in his previous medical history suspicious for an underlying venous anomaly. Idiopathic DVT in a relatively young person with a past history of chronic leg ulceration or varicose veins should be investigated for congenital anomalies of the IVC. This is best achieved by CT scan of the abdomen. Anomalies of the IVC are well described and recognised but are rare causes of DVT. The prevalence of DVT in those above age 40 years is 1 in 1000 [Causes of DVT are multifactorial and associated with both environmental and genetic factors that alter the coaguability or flow of blood. When the major recognised risk factors for DVT are absent, in the younger age group presenting with DVT, a search for a genetic or congenital cause is sought.Here, we present a case of a late presentation of DVT with an underlying aetiology of an absent IVC. The patient lived a generally healthy life with a significant past medical history that could have potentially resulted in an earlier diagnosis of his congenital anomaly. Whether this would have altered the initial management or prognosis is open to debate.A 54 year old male presented to a busy district general hospital medical emergency department with abdominal pains and swelling over the right flank for a two to three week period. More recently he noticed swelling of his right lower leg and thigh. He was a non-smoker, and there was no significant family history of disease. He had no upper or lower gastrointestinal symptoms. There was no change in weight or appetite. There was no history of cardio-respiratory disease, and his exercise tolerance was not limited. He was not able to volunteer any further information as regards to his past medical history other than that he was under annual review by nephrologists for mild chronic renal impairment, due to an "atrophic left kidney". This was diagnosed by ultrasound of the renal tract. There was no evidence of any other imaging modalities or radiological investigations undertaken to investigate the cause of his atrophic kidney.On further review of his medical notes it was revealed that he had a troublesome childhood with bilateral Perthe's disease, and non-healing venous ulcers on the medial aspect of his right ankle.In 1973, aged 21 years, he underwent skin grafting of a non-healing ulcer. One year later he was re-admitted with recurrence of ulcers in the same region and was then noted to have dilated varicose veins and thrombophlebitis that was treated with crepe bandaging for 2 years. Treponemal serology then was negative. In 1977 he had ligation of the dilated varicose vein that was "feeding the ulcerated part of the leg". In 1979 he was discharged from follow up with complete healing of the leg ulcers.On examination he was noted to have bilateral lower limb varicose veins. Examination of the abdomen revealed large, tortuous, hard, "snake like" palpable veins over the right aspect of his abdomen with overlying bruising.  was greater than 2.0.Absent Inferior Vena Cava (IVC) is an uncommon but well recognised anomaly. Anomalies of the IVC have been described more frequently 0.6%-2%) in those with other cardiovascular defects % in thos.There is controversy as to whether an absent IVC is a true embryonic anomaly or whether it is the result of peri-natal IVC thrombosis causing regression and disappearance of the once present IVC .Kidney and IVC abnormalities with Leg Thromboses) syndrome.There has been one previous report in the literature of an absent IVC and left renal hypoplasia- and a right hypertrophic kidney ; but a cIt is estimated that DVT occurs one case per thousand patient-years , and in Chee et al  similarlBoth authors concluded that an absent IVC was more common than initially anticipated and may be underestimated or under-reported. Absence of the IVC cannot be detected by ultrasonography, and so a CT scan was recommended in all young patients with an idiopathic DVT.The ideal imaging modality to diagnose an IVC anomaly must have high diagnostic accuracy, and be safe and reproducible. It is difficult to diagnose any IVC anomaly by ultrasound scanning. Various clues are recognised on radiological imaging that could help diagnose an absent IVC or anomaly. One of the more common and helpful clues is well developed and possibly dilated intra-thoracic hemiazygous and/or azygous continuations. These collateral circulations as well as other retro-peritoneal venous pathways are usually well developed before symptoms present .The most reliable non-invasive methods for diagnosing IVC anomalies are CT with intravenous contrast or Magnetic Resonance scan. CT scan, unlike US, is a good imaging modality of the retro-peritoneal space . AnotherIt is hypothesized that blood return with an absent IVC is inadequate, despite adequate collaterals, resulting in chronic venous hypertension in the lower extremities causing venous stasis which precipitates thrombosis.Gayer et al  recommenThere have been three case reports in the English language medical literature of thrombo-embolism due to IVC anomaly . In all of these cases the thrombophilia screen was negative -16. It wThere is very little evidence available on the surgical correction or treatment of this uncommon anomaly. A case report  with comIn conclusion, this gentleman had an extensive past medical history of idiopathic varicose ulceration with evidence of chronic venous hypertension from a very young age. He was managed with difficulty but achieved eventual healing of his ulcers as a young adult. In later life he developed extensive DVT with worsening of his lower limb and abdominal varicosities.The very limited data from the literature suggests that in cases of an absent IVC in young people  the patient should have a CT of the abdomen.In this case, with a relevant and extensive past history, review of the limited literature would support further radiological investigations to exclude an intra-abdominal deep venous anomaly.It is unlikely that surgical correction has any role in the management of this patient in the long-term especially many years after healing of his ulcers. There is no consensus regarding the duration of anti-coagulation but it would seem sensible for him to remain on life-long anticoagulation given the on-going risk of further DVT and pulmonary embolism, even if his thrombophilia screen is negative.Knowledge of the association of other anomalies in those with an absent IVC, such as renal atrophy or agenesis can highlight an underlying vascular anomaly, and can themselves be of significant clinical importance. In this way, diagnostic and treatment pitfalls may be avoided.DVT- Deep vein thrombosis; IVC- Inferior Vena Cava; US- Ultrasound; CT- Computed Tomography.The author(s) declare that they have no competing interests.EN diagnosed the anomaly and supplied the radiographs. JI and EN contributed in preparation of the manuscript. All authors read and approved the final manuscript.Written and informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


A case of mesenteric cyst in a five-year-old male child who presented with acute abdomen due to an infarcted polyp present within the cyst is reported. To the best of our knowledge, such an event has never been reported in the literature previously. Mesenteric cysts are rare, intra-abdominal lesions arising with an incidence of 1/20,000 in children and 1/100,000 in adults.[A five-year-old male child was admitted with acute pain abdomen and vomiting of two days duration. The pain was severe, sudden in onset, non-radiating and was diffuse. The abdominal examination revealed tenderness in the abdomen with no rigidity, slight guarding, and no palpable mass. His pulse and respiratory rates were 120/min and 32/min, respectively. Routine hematological examination was within normal limits except for mild leucocytosis and slightly raised C-reactive protein. An ultrasonography (USG) of abdomen revealed a cystic lesion in relation to the small intestine mesentery. Computed tomogram (CT) scan showed evidence of intraperitoneal multiseptate cystic lesion measuring 7 cm × 4.10 cm, located at the region of small bowel mesentery and displacing the adjacent gut loops, predominantly consisting of water attenuation area interspersed with some septa, favoring the possibility of mesenteric cyst.At laparotomy, a thin-walled dumbbell-shaped mesenteric cyst was seen attached to the ileal mesentery 15 cms proximal to the ileocecal junction. The cyst was not communicating with the intestinal lumen and did not share the wall but had a common vascular supply. Surgical resection of the cyst along with a small part of the ileum was done followed by end-to-end anastomosis to restore the intestinal continuity. Postoperative period was uneventful and the patient was discharged on the sixth post-operative day.Grossly, the cyst was thin-walled, contained pale straw-colored fluid and was multiloculated. It measured 7.1 cm in its greatest dimensions. Cut surface revealed a small polyp measuring 1.4 cm in its greatest dimensions attached to the inner surface of the cyst wall through a small stalk. The cut surface of the polyp was grayish brown and congested . MicroscMesenteric cysts are rare benign tumors that can be classified histologically as lymphatic, mesothelial, enteric, urogenital, dermoid cystic and pseudo-cystic origin. They can2Mesenteric cysts commonly occur as single lesion, but multiple lesions have also been reported. They can be unilocular or multilocular and may contain serous, chylous, hemorrhagic, or infective fluid. Cyst contents are sometimes related to their etiologic derivation. Cysts that develop after occult trauma may contain hemorrhagic content; chylous fluid may be found in jejunal cysts and in cysts that are intimately involved in the lymphatic pathway; and serous fluid is typically encountered in cysts of the ileum and colonic mesentery. The presThe symptoms are variable, non-specific and include pain 82%), nausea and vomiting (45%), constipation 27%) or diarrhea 6%). An abdominal mass may be palpable in approximately 61% of patients.[%. An abd%, nausea% or diarIn suspected cases, the diagnosis should be confirmed with USG and CT scan.9 The treTo conclude, even though, mesenteric cysts are rare and usually lack symptoms, they must be kept in mind in cases of non-specific abdominal symptoms. Preoperative imaging usually provides the diagnosis, and surgical excision is the treatment of choice with excellent results. However, histopathology is the main stay for the diagnosis and may reveal an unusual pathology related to its acute presentation.


Hemangioma is a relatively common benign proliferation of blood vessels that primarily develops during childhood. Two main forms of hemangioma recognized: capillary and cavernous. The capillary form presents as a flat area consisting of numerous small capillaries. Cavernous hemangioma appears as an elevated lesion of a deep red color, and consists of large dilated sinuses filled with blood. The purpose of the study was to report the case of a capillary hemangioma in a patient and to describe the successful treatment of this case.The patient was a 19-year-old female who presented herself to the Atatürk University, Faculty of Dentistry, Department of Periodontology, with the complaint of bleeding and slowly enlarging mass on the upper right molar region. The lesion was diagnosed as capillary hemangioma after clinical examination and biopsy. Treatment consisted of scaling, root planning and surgical excision. Four months after surgery healing was occurred and two years later area of the lesion appeared completely normal as clinically.The surface is highly keratinized and no further growth was evidenced during the two year of follow-up. Early detection and biopsy is necessary to determine the clinical behavior of the tumor and potential dentoalveolar complications. A number of terms have been used to describe vascular lesions, which are classified either as hemangiomas or vascular malformations -3]. Hem. Hem3]. Althought hemangioma is considered one of the most common soft tissue tumors of the head and neck , it is rHemangiomas are also classified on the basis of their histological appearance. Capillary and cavernous hemangiomas are defined according to the size of vascular spaces ,6. CapilClinically hemangiomas are characterized as a soft mass, smooth or lobulated, sessile or pedunculated and may be seen in any size from a few millimeters to several centimeters . The colManagement of hemangiomas and the treatment of choice depend on several factors including the age of the patient and the size and extent of the lesions, as well as their clinical characteristics. Some congenital lesions may undergo spontaneous regression at an early age . If supeVarious treatments have been used in the management of hemangiomas, including oral corticosteroids, intralesional injection of fibrosing agents, interferon α-2b, radiation, electrocoagulation, cryosurgery, laser therapy, embolization and surgical excision -13]. Re. Re13]. The purpose of the study was to report the case of a capillary hemangioma in a patient and to describe the successful treatment of this case.In November 2000, a 19-year-old Turkish female was referred by her dentist to the Department of Periodontology of the Faculty of Dentistry, Ataturk University, for evaluation and treatment of the gingival bleeding and overgrowth.According to the patient, she suffered from excessive gingival bleeding during meals that had started four months ago, accompanied by elevated gingival reddish. A short time later, she discovered a dark red swelling on her upper right gingival tissues. The swelling in the associated region had been increasing gradually since that time. She did not give any relevant past dental history. The patient's medical history was non-contributory and she did not take any medications. She and her parents stated that, in March 1990 and June 2000, she had a lesion operated and diagnosed as congenital hemangioma on the right of her face.During physical examination Figure , a rightClinical evaluation revealed a mass on the buccal surface of upper right molar region Figure . It was An orthopantomograph radiograph demonstrated that there was localized crestal bone destruction in the area of the tumor, missing tooth germs in upper third molars Figure .A gingival biopsy was taken from the tumor zone, producing profuse hemorrhage controlled by pressure with gauze. The biopsy tissue was rinsed in formalin (10%), and sent for histopathologic examination. Histopathologic examination of the excised tissue revealed nonceratinize stratified squamous epithelium overlying on unencapsulated tumor composed of many thin-walled capillary channels. The capillaries were lined by a single layer of endothelial cells. Some areas showed marked endothelial cell proliferation. Sparse plasma cells and lymphocytes were seen scattered throughout stroma Figure .After having undergone clinical and physical examinations and laboratory evaluation in the pathology department, she was diagnosed as having capillary hemangioma.Periodontal therapy consisted of oral hygiene instruction, full-mouth scaling and root planning, and modified Widman flap surgery.Written informed consent was obtained from the patient after all treatment procedures had been fully explained.Before surgical treatment of the tumor, a thorough scaling and root planning were done carefully to remove any local irritating factors that may have been responsible for the gingival inflammation. The patient was educated regarding good oral hygiene maintenance practices.Periodontal surgery was done under strict aseptic conditions using local anesthesia. The modified Widman flap surgical procedure was performed as described by Ramfjord and Nissle . Initial£ 550 mg, every 12 hours, 5 days) and instructed to rinse twice daily with 0.12% chlorhexidine rinse for 2 weeks postoperatively and to avoid trauma or pressure at the surgical site. Toothbrushing activities in the operated sites were discontinued during this time. The sutures were removed 7 days after surgery, home care instructions were given. Professional prophylaxis was done weekly for the first month and then at 4-month interval.The patient was prescribed analgesics , epulis granulomatosa, varicocell, talengectasia, and even with squamous cell carcinoma. The most common vascular proliferation of the oral mucosa is the pyogenic granuloma. This is a reactive lesion that develops rapidly, bleeds easily and is usually associated with inflammation and ulceration. Clinically, it is often lobulated, pedunculated and red to purple and it may be hormone sensitive . There aIn addition, hemangiomas may be confused with the vascular-appearing lesions of the face or oral cavity, which may also represent the Sturge-Weber syndrome . They arPrecise diagnosis of the type of vascular lesion is important because it may influence treatment considerably. Angiographic studies are not strictly demonstrated for diagnosis of hemangiomas, and are utilized only to define the size and the extent of the lesion ,16. ThesIn the case presented here, treatment of the capillary hemangioma was done surgical periodontal treatment. The treatment of capillary hemangiomas varies considerably depending on the clinical features and the anatomic considerations. Surgical excision is generally the treatment of choice for capillary hemangioma ,4,15,16.Attempts to remove hemangiomas using surgical excision may lead to serious medical problems such as heavy bleeding. In addition, postoperative recurrence may encounter ,4,7. TheThe present case is of periodontal interest in view of the onset of the lesion on the gingival tissue, as well as the conservative treatment used.Early detection and biopsy is necessary to determine the clinical behavior of the tumor and potential dentoalveolar complications. Althought a rare bening tumor of the oral cavity, capillary hemangioma is important to the periodontist because of its associated gingival vascular features and complications in the form of impaired nutrition and oral hygiene, increased accumulation of plaque and microorganisms, and increased susceptibility to oral infections, which can impair the systemic health of the affected individual. In addition, the periodontal surgical management of hemangiomas should be performed with caution because the tissues may bleed profusely intraoperatively and postoperatively.CT: computerized tomography; LCH: lobular capillary hemangioma; MRI: magnetic resonance imaging.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of written consent is available for review by Editor-In-Chief of this Journal.The authors declare that they have no competing interests.AD conceived the idea of the report and wrote the manuscript. AD and TA performed local excision of the tumor with periodontal surgery. NG made the pathological diagnosis and performed histopathologic evaluation. All authors read and approved final version of manuscript.


Retroperitoneal schwannomas are rare, usually benign tumors that originate in the neural sheath and account for only a small percentage of retroperitoneal tumors. The aim of this clinical study is to present our experience in managing retroperitoneal schwannomas with a review of the current literature and to point out the surgical technical difficulties we faced, due to the tumor's strange behavior that eroded the vertebra in two cases without causing malignant invasion.We reviewed the medical files of 69 patients treated in our department for retroperitoneal tumors from January 1991 until December 2006. Five patients had retroperitoneal schwannomas according to pathology report.There were two male and three female patients, with a mean age of 56 years (range 44–67 years). All patients were asymptomatic and none suffered from von Recklinghausen disease. Imaging workup included ultrasonography, computed tomography and magnetic resonance imaging. One patient, after having a non-diagnostic computed tomography fine needle aspiration (CT-FNA), underwent exploratory laparotomy and incisional biopsy that established the diagnosis of schwannoma. After complete excision of the tumors, postoperative course was uneventful in all patients. Tumors' maximum diameter was 12.7 cm (range 7–20 cm). No recurrences were detected during the follow up period (6–75 months).Preoperative establishment of diagnosis is difficult in case of retroperitoneal schwannomas, however close relationship of retroperitoneal tumors with adjacent neural structures in imaging studies should raise a suspicion. Complete surgical resection is the treatment of choice. Histology and Immunohistochemistry confirms the diagnosis. Neural sheath tumors are a subclass of soft tissue neoplasms that include both benign and malignant schwannomas and neurofibromas. Schwannomas are found most commonly in cranial and peripheral nerves and occur rarely in the retroperitoneum, the last comprising about 3% of all schwannomas . SchwannIn this study, clinical, imaging and histological characteristics, but mainly the treatment of five retroperitoneal schwannomas, are analyzed with a review of the literature.Sixty nine (69) patients with retroperitoneal tumors were treated in our department between January 1991 and December 2006. Five of them had retroperitoneal schwannomas. Preoperative imaging workup included abdominal ultrasound (U/S), computed tomography (CT) and magnetic resonance imaging (MRI). Pheochromocytomas were excluded by specific studies (urine catecholamines and MIBG). Treatment in all cases was complete resection of the mass, as well as en bloc excision of any involved adjacent structures or organs, when necessary. The diagnosis of schwannoma was based on detection of Schwann cells with Antoni A and B regions in histological sections and positive staining for S-100 protein in immunohistochemical analysis. Review of the literature was based upon research in PubMed.th lumbar vertebra  (Fig. A 52-year-old female patient complained of right flank discomfort and constipation. U/S revealed a well encapsulated, circumscribed mass located in the retroperitoneum. The mass had mixed echogenicity and measured 7.8 × 6.2 cm. CT scan showed a heterogeneous retroperitoneal mass measuring 8 × 6 cm, that was adherent to the right psoas muscle. MRI showed an 8 cm retroperitoneal tumor with hypointensity on T1 and heterogeneous hyperintensity on T2 weighted images. The solid peripheral elements of tumor were enhanced after intravenous gadolinium administration. During laparotomy a retroperitoneal tumor was found, located behind the ascending colon and adherent to the right psoas muscle. We performed a complete excision of the tumor with part of the psoas muscle and part of the adherent nerve. Postoperatively, the patient reported hypoesthesia on the medial surface of the right leg and weakness of the distal muscle. During a 9-month follow up period, the patient is disease free.th lumbar vertebrae whereas the bone scan was negative for vertebral invasion. The mass was homogenously hypointense on T1 and heterogeneously hyperintense on T2 weighted images with intense enhancement after gadolinium administration. With the CT angiography that followed we clarified the tumor's blood supply that was originating from the superior lumbar artery. During the laparotomy we found a retroperitoneal mass that had eroded the left side of the 4th lumbar vertebra and displaced the ipsilateral ureter and psoas muscle. The tumor was completely excised, while the vertebra was left intact with erosion of its left side due to tumor's pressure. The bone cavity that remained in the vertebral body was filled with bone wax. The patient had an uncomplicated recovery and remains free of recurrence during the 6-month follow up.A 63-year-old female patient presented with left flank pain. MR imaging revealed a retroperitoneal mass measuring 8.5 × 5.8 cm with erosion of the left side of the 4Schwannomas or neurilemomas are neoplasms that arise from Schwann cells of nerve sheaths and belong to the category of neural sheath tumors. They can be found in any nerve trunk, except for cranial nerves I and II, and their usual location is the head, neck, the flexor surfaces of the extremities and the posterior mediastinum or the retroperitoneum ,8. ThereSchwannomas are usually benign and are associated with von Recklinghausen disease in 5–18% of cases . MalignaPreoperative diagnosis based on clinical examination is very difficult and so the role of imaging is important. Ultrasonography is a cheap modality for revealing a mass with semisolid or cystic areas, but it is not used widely due to specificity limitations ,21. MixeDespite these accurate imaging techniques, the definite diagnosis of retroperitoneal schwannoma is uncertain and the surgeon should include in the preoperative differential diagnosis other tumors, such as neurofibroma, paraganglioma, pheochromocytoma, liposarcoma, malignant fibrous histiocytoma, and hematoma. CT-guided biopsy is a possible modality that can establish a preoperative diagnosis, under the limitation that the sample contains enough Schwann cells and not degenerative cells obtained from areas of cellular pleomorphism that can be misleading. CT-guided FNA is usually unsuccessful and unreliable. CT-guided core needle biopsy seems to have better results despite the existing controversy in literature. Some authors suggest that this diagnostic modality may not only be inconclusive, but may also have a high risk of tumor seeding, hemorrhage, and infection. For these reasons they encourage incisional biopsy, while others report interesting results in establishing a preoperative diagnosis . We perfThe pathologic examination of the tumor specimen reveals microscopically elongated bipolar spindle cells with a focal nuclear palisading pattern. There are areas of high cellularity named Antoni A and with low cellularity and myxoid matrix named Antoni B. This finding is suggestive of the benign nature of the tumor. Immunohistochemistry shows NSE, microfilament proteins and S-100 protein, which is the neural protein within the Schwann cell that differentiates schwannomas from neurofibromas, since the latter do not express it due to their perineural origin . HistoloA variant of the typical schwannoma is the "ancient type" or "degenerative neurilemoma" that presents with features of degeneration, cystic changes and hyalinization . In somThe surgical approach to retroperitoneal schwannomas remains debatable. It is well known that local recurrence and malignant transformation of retroperitoneal schwannomas in absence of von Recklinghausen disease is extremely rare, so local excision should be the treatment of choice, sparing the adjacent vital organs ,13. In tThere are also some reports of laparoscopic resections ,33. HemoIn our series we followed the approach of the radical resection of the tumor instead of enucleation assuming that we had to deal with a retroperitoneal tumor of unknown pathology. Based on this hypothesis, in order to ensure the optimum treatment and survival for our patients we performed laparotomy and complete excision with wide margins . In spitWe think that in our cases there are two points of interest. Firstly, the erosions of the lumbar vertebrae were due to tumor pressure and not invasion. Secondly the beneficial effect of tumor embolization in one case which according to our knowledge from the literature is not a widely or routinely practice.The authors declare that they have no competing interests.TT was responsible for critical revision of scientific content. VKS drafted the manuscript. PT participated in the design of the manuscript and helped to draft the manuscript. AY contributed substantially to manuscript conception and design. AM assisted in the preparation of the manuscript. APK performed histopathological and immunohistochemical analyses and contributed to the pathology content. AC performed the embolization of one of the tumors, the filter placement and have made substantial contributions to manuscript conception and design.EB participated in one of the surgical operation and participated in the acquisition of data and preparation of the manuscript. DV the surgeon, approved the final version of the manuscript for publication.


Primary pleural myxoid liposarcoma is a rare entity and no agreed treatment options have been formulated once diagnosis has been made. We report two cases with subsequent management and make recommendations for treatment pathways in these rare cases. Liposarcoma is a malignancy arising from fat cells and in adults it accounts for ten to twelve percent of soft tissue tumours. It appears mainly as a retroperitoneal or intra-abdominal mass. However, there are very few cases of primary intrathoracic liposarcomas arising from within the mediastinum. They are usually slow growing with an expansile rather than infiltrative behaviour; hence they present with pressure related symptoms to their neighbouring structures . We repoA 42-year-old male presented to the respiratory physicians with an eight-week history of malaise, left sided upper abdominal pain and increasing shortness of breath. He had an expectorant cough but no haemoptysis, fever, chills and rigors. He was a non-smoker with no significant past medical history.The chest film [CxR] was suggestive of a large left sided pleural effusion, and a computerised tomogram [CT] confirmed a loculated effusion. A pleural tap was negative for malignancy and a working diagnosis of left empyema was made; the patient was referred to the thoracic department for further management.At thoracotomy, the left lower lobe was collapsed by a well-encapsulated pedicled mass arising from the para aortic region. A frozen section confirmed the malignant nature of the mass, which was subsequently resected en-bloc and subjected to histology. The patient had an uneventful post operative recovery.The histological examination revealed a myxoid liposarcoma with some evidence of differentiation. The patient was referred onto the sarcoma team, for adjuvant treatment. At follow up, 2 months after surgery, the patient was making an excellent recovery. The patient however showed evidence of recurrence at his six month follow up and went onto have additional surgery and chemotherapy.An 80-year-old female presented with increasing shortness of breath over a period of three months, with an exercise tolerance of fifty metres. There was no associated cough, haemoptysis or weight loss. On examination there was decreased air entry on the left side. CxR revealed a large left sided pleural effusion and the CT scan showed a large fluid density mass in the anterior mediastinum. The patient was discussed in a multi disciplinary meeting and proceeded to surgery.An attempted left VATS was initially performed but this had to be converted to open thoracotomy due to the large nature of the mass. It was eventually excised confirming compression of the normal left lung.Histology revealed a myxoid liposarcoma and positive resection margins. The patient was deemed not fit for radical radiotherapy and best supportive care was offered. She died eight months after diagnosis from disease progression,A review of medline revealed a total of six reported cases of primary pleural myxoid liposarcoma .There seems to be a male preponderance [six out of eight] with the mean age at presentation being 55 years. The most common presenting feature is dyspnoea and cough, with an associated pleural effusion in most cases. There is often evident pleuritic pain and weight loss, although asymptomatic cases have been reported at presentation ,3.There seems to be no consensus regarding the postoperative management of these patients nor an agreed treatment pathway. Surgery seems to be the most common option, and offers the best chance of cure or disease control in these rare cases. Operative mortality though has been reported to be as high as 40% [et al showed a 54% tumour response and reduction after irradiation employing a total of 50gy and 2Gy fractions [et al showed that when radiation was offered a longer disease free interval was noted [Pitson et al, reported four patients with primary liposarcoma of which three were myxoid; two died between seven and nine months after initial presentation, with only one survivor at time of publication [et al reported a case without though mentioning the overall survival period [et al published a similar report with the patient alive five months following resection and radiotherapy [According to the current available literature, survival varies between 7 months and 8 years. Nader lication . Wouterslication . This pal period . Wong etotherapy  [Table 1We have therefore suggested a treatment pathway in patients with primary pleural myxoid liposarcoma based on personal experience and literature evidence Figure .To conclude myxoid pleural liposarcomas are rare entities and from the existing literature it is difficult to forecast prognostic factors which may correlate with long term survival. Although there is no common consensus, we believe that aggressive surgical management followed by radiotherapy is the best treatment modality. If the tumour is large or complex neoadjuvant radiotherapy could potentially identify responders; these patients could then be offered radical surgical treatment for potential long-term control of the disease.


Glomus tumors are benign, slow growing tumors originating from paraganglionic tissue, mostly located at the carotid bifurcation, jugular foramen, cervical portion vagus nerve, and middle ear cavity. Radiotherapy is treatment of choice for patients with intracranial extension, and patients with bilateral and multiple tumors, or patients who are inoperable.We present a 53-year-old female patient with a glomus tumor treated with positron emission tomography computed tomography planning and 3D conformal radiotherapy, and the patient has remained free of disease progression 2 years after.It is suggested that radiotherapy is a good treatment modality in patients with glomus tumor, and metabolic imaging and treatment planning with positron emission tomography computed tomography is superior to other imaging modalities. Glomus tumors (GT), also named as paragangliomas and chemodectomas are rare tumors, accounting for 0.03% of all neoplasms and 0.6% of all head and neck tumors . These bFamilial occurrence is likely to occur in 10% of patients, with an autosomal dominant inheritance. Multiple tumors are seen in 78-87% of familial paragangliomas, and the incidence of bilateral GT is 32% for familial cases and 4% for non-familial cases [To our knowledge, we report the first case of a non-familial bilateral GT treated with Positron Emission Tomography (PET) based 3D conformal radiotherapy (RT), and treatment response assessed with PET.A 53-year-old Turkish female patient presented with bilateral neck masses for 10 years, which had been increased in size for the last 6 months. Patient was complaining about a moderate hearing loss and tinnitus on the left ear, and pain at the left side of the neck, besides no hoarseness, dysphagia, nasal obstruction and epistaxis were reported. There are no symptoms related with the carotid artery compression. No family history of glomus tumors or any cancers was present. On physical examination, semi-mobile, painless masses with a size of approximately 4 × 3 cm on the right side of the neck, and 8 × 6 cm mass extending from tip of mastoid to level IV inferiorly on the left side were palpated. On systemic evaluation only hypertension diagnosed for 3 years which was under control with medications. 24-hour vanilmandelic acid (VMA) levels and other endocrinologic findings were found to be normal. The magnetic resonance (MRI) studies revealed highly vascularised, intensely enhanced, hypointense and isointense with surrounding muscles 5 cm mass on the left carotid bifurcation compressing jugulary vein and carotid artery, and 2.5 cm mass at the left side ,1b. CervPatient had no gain with medical treatment and embolisation, and the masses were increased in size within last 6 months of period. Since the tumors are located at both sides of the neck, and are close to the vascular structures, the surgeons did not decide to make any surgical procedure; we treated the patient with 3D conformal radiotherapy with a total dose of 50 Gy with 2 Gy fractional daily doses with PET-CT planning. During treatment, acute ‘Radiation Therapy Oncology Group’ (RTOG) Grade II dysphagia and Grade I dry desquamation at neck were seen, which were clarified with adequate medications. At 6th month the pain at the neck region totally disappeared and loss of hearing and the tinnitus at left ear diminished. The PET-CT taken at last visit, revealed a 5 × 4 cm with necrosis at the central part (SUVmax: 7.7) at left side, and a 2 × 2 cm mass (SUVmax: 2.5) at right side of the neck . The patGlomus tumors are mainly presented in two locations; cervical  and skull base (jugular and tympanic) . These tCT and MRI are useful diagnostic tools for assessing suspicious paraganglioma. CT can reveal the invasion of the bony structures and intracranial extension, while MRI is better for evaluating vascular structures, extension along neural foramina, and detecting multicentricity . The chaThe optimum management of GT still remains controversial. The treatment options are surgery, RT and watchful waiting. Since the metastasis rate is rare, the main aim of treatment choice is to achieve good local control without increasing morbidity and mortality. Local treatment can be achieved with either surgically as total removal or long-term tumor control and tumor shrinkage with RT. Although good results were achieved with complete surgical removal and total excision with microsurgical approach can often be accomplished, there is a significant risk of morbidity (0-39%) and mortality (0-2.7%) with this approach -13. RadiGlomus tumors respond to RT slowly. Residual mass persisting after RT does not indicate treatment failure. Tumor may decrease in size, but rarely disappears. Disease control is defined as the absence of progression of symptoms without any increase in size with physical examination or radiological control . Also, PGlomus tumors are slow-growing lesions; therefore, it is necessary to be cautious about tumor control without increasing morbidity and mortality. Radiotherapy has become a primary treatment modality for GT in patients with unresectable symptomatic tumors, and bilateral tumors, in which, a good local control and reasonable tumor shrinkage was achieved in our case. Also we propose that FDG PET seems to be a promosing procedure for diagnosis and treatment response of GTs.


A rectus sheath haematoma is a rare condition that arises from the accumulation of blood within the rectus sheath from either muscular tear or rupture of the epigastric vessels. It is a known complication of either blunt abdominal trauma, anticoagulation therapy or the repetitive contraction of the rectus muscle such as paroxysms of coughing. It remains an uncommon and elusive entity and is often clinically misdiagnosed.An 80-year-old British man with a known aortic aneurysm was admitted with sudden onset of right iliac fossa pain. The patient was hemodynamically stable and underwent a computed tomography scan which revealed an intact aorta and an acute rectus sheath hematoma.To the best of our knowledge, no case has previously been reported involving the diagnostic challenge of a rectus sheath hematoma in a patient with a known aortic aneurysm. Here we discuss the symptoms and signs of a rectus sheath hematoma, as well as the radiological modalities that could be utilized to reach the diagnosis. A rectus sheath haematoma is a rare condition that arises from the accumulation of blood within the rectus sheath from either muscular tear or rupture of the epigastric vessels. It is a known complication of either blunt abdominal trauma, anticoagulation therapy ,2 or theAn 80-year-old British Caucasian man with a known abdominal aortic aneurysm was brought to the Accident and Emergency department in acute abdominal pain. His last ultrasound scan had measured the aneurysm at 5.8 cm and he was currently awaiting endovascular repair.The pain was located in the right iliac fossa, was of sudden onset, and was exacerbated by coughing and movement. He was, at that time, recovering from a chest infection and this had led to a non-productive cough for a week. There was no recent history of trauma.He had a past medical history of myocardial infarction, coronary artery bypass graft and a perforated duodenal ulcer. He was receiving only antihypertensive therapy and was not taking any anticoagulation medication.9/l) and a normal clotting profile .During examination, he was alert and in considerable discomfort. His pulse rate was 74/minute, his blood pressure was 147/81 mmHg, and his respiratory rate 16/minute. Oxygen saturations were 98% on air. Abdominal examination revealed a soft abdomen with a prominent mid-line laparotomy scar. Tenderness to palpation was present in the right iliac fossa, as well as guarding in this area. Blood tests revealed a normocytic normochromic anaemia (9 g/dl), a mild leucocytosis  should be performed first. This demonstrated a densely calcified infrarenal aortic aneurysm measuring 5.8 cm with no evidence of a leak, and an acute right inferior rectus sheath haematoma Figures  and 2.The patient was admitted to the Surgical Admissions Unit where a line of conservative management was followed and he was subsequently discharged a few days later.A rectus sheath haematoma in the initial stages can mimic an acute abdomen, including a ruptured aortic aneurysm , and a nIn 1926, Carnett first described a technique to differentiate between intra-abdominal pathology and pathology of the abdominal wall . The patDiagnosis of a rectus sheath hematoma is reached by combining medical history, examination and radiological investigation, which can be performed through ultrasonography or CT.Ultrasonography is usually the first radiological investigation of choice. In the presence of an aortic aneurysm, a FAST (Focused Assessment with Sonography for Trauma) scan can be performed as a first-line investigation. However, in this case, a FAST scan would only have confirmed that there was no intraperitoneal fluid and unless the operator had clinical awareness of the possible differential diagnosis, a rectus sheath hematoma certainly would have been missed.et al. compared ultrasonography with computed tomography for accuracy of diagnosis and avoidance of surgery for rectus sheath hematoma. They found that ultrasonography was diagnostically accurate in 71% of patients imaged, and CT was diagnostically accurate in 100% of cases [13].CT is considered a more sensitive investigation than ultrasonography. Gallego To the best of our knowledge, this is the first reported case of an acute rectus sheath hematoma with a concurrent abdominal aortic aneurysm. Even in a patient without known intra-abdominal pathology, a high index of clinical suspicion and correct radiological investigation is required to achieve the correct diagnosis. In our patient's case, an aneurysm rupture will always remain the diagnosis of exclusion and in the presence of a hemodynamically stable patient, a CT scan would differentiate between the two diagnoses negating the need for emergency surgery.CT: computer tomography; FAST: Focused Assessment with Sonography for Trauma.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.AS wrote the manuscript; SF contributed to the manuscript. SF, JL and MR reviewed the literature. All authors contributed intellectual content, have read and approved the final manuscript