Post-menopausal blood loss is a common complaint of patients seen in gynecological practice. The most frequent malignancy found in cases of post-menopausal bleeding is endometrial cancer. Other causes can be malignancies of the rest of a woman's genital tract or metastases from other tumors. To the best of our knowledge, it appears that this is the first published case of a post-menopausal primary appendiceal carcinoma presenting with vaginal blood loss.A 75-year-old Caucasian woman with a history of vaginal hysterectomy presented with a 10-month history of post-menopausal blood loss. After extensive examination and discussion, ovarian carcinoma was suggested. Microscopic examination of the tissue removed at laparotomy revealed an adenocarcinoma of the appendix. She was treated with adjuvant radiotherapy and with palliative chemotherapy after 14 months because of intra-abdominal metastatic disease.Post-menopausal blood loss in a patient with a history of hysterectomy is uncommon and always needs further investigation. Post-menopausal blood loss is a common complaint of patients seen in gynecological practice. The most frequent malignancy found in cases of post-menopausal bleeding is endometrial cancer. Other causes of malignant post-menopausal blood loss can be carcinomas of a woman's genital tract  or metastases from other tumors ,2. Post-To the best of our knowledge, it appears that this is the first case of a post-menopausal primary appendiceal carcinoma presenting with vaginal blood loss.A 75-year-old Caucasian woman was referred to our hospital with a 10-month history of vaginal bleeding. In 1986, she underwent a hysterectomy because of dysfunctional uterine bleeding. The cause of the blood loss was initially interpreted as vaginal atrophy which was unsuccessfully treated with estriol cream. She had experienced several urinary tract infections, which she never had before. She did not have any other complaints.On physical examination, it was found that there was no palpable abdominal mass. On vaginal examination, a crater-shaped lesion was found in the right upper part of the vagina, which indurated the surrounding tissue, with a fetid smell and necrosis. Rectal examination showed no abnormalities.Transvaginal ultrasound showed a 30 × 22 mm tumor on the top of the vagina. No ascites were seen. A biopsy revealed an adenocarcinoma. Immunohistochemical staining was positive for cytokeratin 20 and carcinoembryonic antigen (CEA), and negative for cytokeratin 7 and carbohydrate antigen (CA)-125, suggesting the origin of the tumor was more likely to be gastrointestinal than urogenital.Laboratory findings, including tumor markers, were all within normal values, except for CEA , which was raised at 16 μg/L .Pre-operative exams  did not show any characteristic malignancy or metastasis. A computed tomography (CT) scan showed a process in the right ovary bed reaching the vaginal vault and medial side of the urinary bladder Figure . It did During laparotomy, it was observed that the vaginal vault was infiltrated by an enlarged tumorous appendix, with two loops of the ileum attached to the process. No infiltration in the bladder was seen. A right hemicolectomy was performed on part of the upper vagina. Both ovaries had a normal atrophic aspect.Microscopic examination of the tissue showed a primary adenocarcinoma of the appendix, 1 cm in diameter, arising in a colonic type villous adenoma Figure . There wFourteen months after surgery, during a transvaginal ultrasound in a regular follow-up, the tumor was found to have recurred. Ascites were also seen. Abdominal and pelvic CT scans revealed extensive intra-abdominal tumor spread with deposits on the diaphragm, omentum, vaginal vault and the sigmoid colon.The multidisciplinary oncology team advised palliative treatment with the combination oxaliplatin-capecitabine, as the tumor was colon-like. After three cycles of chemotherapy, CA-125 levels decreased from 162 to 86 kU/L (Immulite 2500) and a CT scan showed significant reduction of the tumor deposits.Post-menopausal vaginal bleeding is a common complaint of patients seen in gynecological practice. It accounts for approximately 5% of all gynecological visits . Every cPrimary carcinoma of the vagina is rare. It represents only 2% of all gynecological malignancies . Most ofThe differential diagnosis included metastasis from an unknown primary tumor, carcinoma of the ovary and an intestinal tumor with infiltration in the vagina. Our patient had no complaints that suggested malignancy of the colon. Furthermore a colonoscopy showed no abnormalities. A recent mammogram was also normal. Only the raised level of CEA was suspicious, as was immunohistochemistry of the biopsies taken, which suggested a gastrointestinal origin for the tumor. During CT scan, a tumor originating from the right ovary was seen, suggesting ovarian carcinoma. However infiltration of ovarian carcinoma in the vagina is rare.It was unexpected that the tumor had its origin in the appendix. Appendiceal carcinoma is very rare; it has an incidence of 0.12 cases per 1,000,000 people per year . PrimaryMostly appendiceal carcinomas present with acute right lower abdominal pain suggestive of appendicitis. Appendiceal carcinoma can also present as a palpable abdominal mass, acute intestinal obstruction or ascites. Most appendiceal malignancies are diagnosed from histological analysis of surgically removed specimens after a simple appendectomy ,9.Our patient's previous hysterectomy probably allowed the tip of the appendix to move near to the vaginal vault thus causing the infiltration. Fourteen months after the initial diagnosis, our patient had recurrent disease with peritoneal carcinomatosis. The prognosis of peritoneal carcinomatosis of colorectal origin can be improved by peritonectomy followed by hyperthermic intraperitoneal chemotherapy, although this option was not considered appropriate for our patient because of her physical condition and the high morbidity and mortality risk of the procedure .In one previous case report, a patient with an appendiceal carcinoma presented with post-menopausal blood loss which was caused by a metastatic tumor affecting the uterus, fallopian tubes, ovaries and peritoneal cavity .Post-menopausal bleeding in a patient with a history of hysterectomy is uncommon. This case highlights the need to conduct careful examination of a patient to exclude the possible non-gynecological origin of vaginal bleeding.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.HvH and LvH were major contributors in writing the manuscript. MvD analyzed the pathology and contributed the pathology results. All authors read and approved the final manuscript.


Hemangiomatosis is an uncommon entity in which there is diffuse infiltration of soft tissue or bone by hemangioma. Kasabach-Merritt syndrome is an uncommon complication of large hemangiomas, in which there is thrombocytopenia and coagulopathy. Plain radiographs, in addition to showing a soft tissue mass, also show a variety of findings in the bones. MRI is the investigation of choice. A case of a 2-year-old child suffering from hemangiomatosis and a resultant Kasabach-Merritt syndrome is presented. Hemangioma is a commonly encountered benign vascular neoplasm. It is the most common soft tissue neoplasm of infancy. Diffuse 3). The blood counts were otherwise unremarkable.A 2-year-old female child presented with a history of easy bruisability. In addition, the parents had noticed a diffuse swelling over her chest and shoulders since birth; the swelling had not increased in size and there was no history of bleeding from it. On physical examination, a large ecchymotic patch was seen overlying the swelling; it was soft and there was no bruit. Hematological investigations showed thrombocytopenia (platelet count - 75,000/mmA plain radiograph of the chest and abdomen  showed dMRI showed a diffusely infiltrating lesion in the soft tissues of the lower neck, shoulder, both axillae, and the chest wall, with extension into the anterior mediastinum. It was predominantly hyperintense on the T2W images  with fewOn the basis of the above clinical, radiological, and hematological findings, a diagnosis of hemangiomatosis of the chest wall involving the mediastinum with a resultant KMS was made and the patient was prescribed steroids to reduce the size of the lesion. There was a mild reduction in the size of the lesion after initial therapy; unfortunately, the patient was later lost to follow-up.Hemangiomas are the most frequently encountered vascular soft tissue abnormality. They conOn radiographs , an indeMRI is the modality of choice for demonstrating the relationships between hemangiomas and the adjacent anatomic structures. Hemangiomas appear as ill-defined hyperintense masses on T2W images  because Angiomatosis is defined as diffuse infiltration of bone or soft tissue by hemangiomatous or lymphangiomatous lesions. The lesiKMS is an uncommon complication of large hemangiomas, in which there is thrombocytopenia and purpura. It is a coagulopathy consisting of intravascular coagulation, clotting, and fibrinolysis within the hemangioma.The goal of therapy in a patient with hemangiomatosis is to achieve involution of the lesions, usually with corticosteroids. Surgical resection, radiation therapy, laser therapy, and angiogenesis inhibitors such as interferon are other therapeutic options.Our patient had an uncommon manifestation of diffuse hemangiomatosis with an unusual complication: the Kasabach-Merritt syndrome. MRI was able to make the diagnosis of hemangiomatosis with ease, while the clinical features helped in diagnosing the associated complication.


Oral neurofibromas are peripheral nerve sheath tumors, similar to schwannomas. Histological variations in oral neurofibromas are relatively uncommon.Here, we present a case of unique variation in the observed characteristics of a neurofibroma, with no relation to neurofibromatosis type-1 or von Recklinghausen disease of the skin. The neurofibroma was observed in the right mandibular gingiva of a 32-year-old Japanese woman. Histologically, it differed from conventional neurofibromas in that the tumor was composed of a mixture of fine fibrillary collagen in sheets and/or cords of neoplastic Schwann cells containing numerous clusters of Meissner bodies. Histologically, these bodies were in contact with neoplastic Schwann cells. The Meissner bodies were immunopositive for S-100 protein, neuron-specific enolase, and vimentin, but were negative for calretinin. CD34-positive spindle cells were observed around the Meissner bodies. No recurrence or signs of other tumors have been observed in the patient for 5 years after tumor resection.To the best of our knowledge, no formal descriptions of sporadic, solitary neurofibromas containing numerous Meissner bodies occurring in the oral cavity are available in literature. We believe that an uncommon proliferation of Meissner bodies, as seen in the present case, may result from aberrant differentiation of neoplastic Schwann cells. Neurofibromas are benign tumors showing neural differentiation and they originate from the sympathetic, peripheral, or cranial nerves. The tumor typically presents either as a localized lesion or as part of a generalized syndrome of neurofibromatosis generally known as neurofibromatosis type-1 (NF1) or von Recklinghausen disease of the skin. NF1 is an inherited, autosomal dominant disorder characterized by multiple neurofibromas. Localized (solitary) neurofibromas most often occur as sporadic lesions in patients without NF1. In general, sporadic neurofibromas are histologically identical to those seen in NF1 -4, and aAlthough neurofibromas may often occur in the cervicofacial region, intraoral neurofibromas not related to NF-1 are relatively uncommon -10. ExceA 32-year-old Japanese woman was referred to the Oral Surgery Clinic at the Fukuoka Dental College Hospital in Fukuoka, Japan for a painless swelling on the right mandibular gingiva. She did not have a family history of neurofibromatosis and had been aware of the lesion for approximately 8 years. Intraoral examination confirmed the presence of a pendunculated swelling on the posterior mandibular facial gingiva, which was located between the first and second molars Fig. . The excHistologically, the lesion was found to be unencapsulated and showed diffuse, circumferential infiltration of the periosteal connective tissue surrounding the neurofibroma and was surfaced with stratified squamous epithelium. The tumor was composed of paucicellular and cell-rich areas Fig. . The pauOral neurofibromas, like schwannoma are peripheral nerve sheath tumors. The characteristics encountered in the present case are identical to those of localized (solitary) neurofibromas not related to NF1. Furthermore, the clinical findings and Ki-67 (MIB-1) labeling index in the present case observed are similar to those of conventional neurofibromas that are often diagnosed late because they tend to grow slowly as painless nodules that produce few symptoms. In the present case, the tumor was believed to have originated from a branch of the fifth cranial nerve, similar to that seen in other cases of intraoral neurofibromas . HoweverThe most prominent finding was the scattered presence of Meissner body clusters throughout the tumor. Meissner bodies are sensitive, tactile receptors concentrated in the dermal papillae of the digital tips, palms, and soles. Similar to their location in the skin, Meissner bodies are present at the apex of the gingival connective tissue papillae within the oral mucosa and function primarily as sensitive receptors for touch stimuli . HistoloBoth histological and immunohistochemical findings of the present case mimic those of diffuse neurofibromas. In general, diffuse neurofibromas are closely associated with NF1 -21. HoweThe remaining immunohistochemical results presented in this report may aid in distinguishing the tumor from schwannomas. Chaubal et al reported the presence of CD34-positive spindle cells in neurofibromas but not in schwannomas . SimilarNF1 gene, a tumor suppressor gene located in the pericentromeric region of chromosome 17 [ras-mediated cell growth pathway [NF1 gene in Schwann cells are responsible for tumorigenesis of NF1-associated neurofibromas [NF1 mutations produce abnormal neurofibromin, leading to increased levels of activating proteins  [in situ hybridization analyses, Storlazzi et al demonstrated that somatic inactivation of the NF1 gene occurred through chromosomal translocations in sporadic neurofibromas, thereby suggesting the importance of NF1 inactivation in the tumorigenesis of sporadic neurofibromas [NF1 gene may lead to the development of a unique neurofibroma, as the one presented in this report.NF1-related neurofibromas are associated with somatic mutations at the  pathway ,26. Recefibromas ,28. It hand p13) , which cand p13) . In contfibromas . This fiAn uncommon case of a sporadic, solitary oral neurofibroma with prominent Meissner bodies was identified. No formal description of a similar case was found in scientific literature. Both histological and immunohistochemical findings in this case suggest that the aberrant differentiation of neoplastic Schwann cells may be implicated in Meissner body clusters, which are uncommon in a solitary neurofibroma.Diagnostic Pathology.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 The authors declare that they have no competing interests.JO performed the histological examination, analyzed the case, and prepared the manuscript. TI and RO participated in the immunostaining. KO and KT participated in conducting pathological examinations. All authors have read and approved the final manuscript.


Liposarcoma is categorized as a soft tissue sarcoma and most commonly appears in the lower extremities and rarely in the foot during adulthood. We present a very rare case report of a primary well-differentiated liposarcoma arising in the foot on a 60-year-old female. Marginal resection of the tumor with metatarsal ray amputation was eventually performed. The patient's postoperative course was uneventful without recurrence 5 years after the original operation. The authors review the literature and also report on the low incidence of this tumor arising in the foot. A 60-year-old female presented to our institution with a history of a three year slowly growing mass to the dorsal aspect of the left foot. Prior to her visit, the patient had an excision of the soft tissue mass in a different facility but without any histopathological analysis. Patient did have a recurrence of the soft tissue mass and eventually presented to our institution four years after the original surgery. Plain foot radiographs were obtained and revealed cortical irregularities of the third and fifth metatarsals suggesting possible occurrence of the local soft tissue invasion . MagnetiLiposarcoma is considered as a secondary common sarcoma frequently accompanied by malignant fibrous histiocytoma. Liposarcomas are well known to arise in the lower extremities, particularly in the thigh , 3, but There are considerable histologic and imaging similarities between lipomas and a well-differentiated liposarcomas. A well-differentiated liposarcoma closely simulates the lipoma presentation except for a scattering of lipoblasts with irregulary shaped hyperchromatic nuclei and one or more lipid droplets in the cytoplasm . In the A type of dedifferentiated liposarcomas has been well documented to develop as a late complication of a pre-existing well-differentiated liposarcoma after a long interval. In addition, recurrent well-differentiated liposarcomas showed a tendency of exhibiting several characteristics closely associated with dedifferentiation , 10. SucFoot liposarcoma presents with a very low incidence and a high index of suspicion is required for its early diagnosis and prevention of its clinical entity and grade with proper surgical resection and treatment.


Cutaneous metastases in the facial region occur in less than 0.5% of patients with metastatic cancer. They are an important finding and are not often the first sign leading to diagnosis.We describe the case of a 64-year-old male patient who presented with dyspnea, pleuritic pain, loss of weight and a nodule on his left cheek. A chest X-ray revealed a left upper lobe mass with mediastinal lymphadenopathy. Excision biopsy of the facial nodule revealed small-cell lung carcinoma. Palliative chemo-radiotherapy was administered and the patient survived for 12 months.A high index of suspicion is necessary for the early detection of facial cutaneous metastases. Appropriate treatment may prolong patient survival. Cutaneous metastases in the facial region occur in less than 0.5% of patients with metastatic cancer, and they usually originate from malignant melanoma . VariousA 64-year-old man, a heavy smoker, was referred to our department with a short history of dyspnea, pleuritic pain and loss of weight, as well as a painful nodule on his left cheek which was noticed almost simultaneously with the principal symptoms. His general condition was good, although he suffered from coronary artery disease and diabetes mellitus type II. A chest X-ray revealed a left upper lobe mass with mediastinal lymphadenopathy without pleural effusion. Bronchoscopy revealed no evidence of malignancy, and bronchial biopsy and washings also proved negative for malignant cells. In order to perform pre-operative staging of the tumour, the patient underwent computed tomography (CT) scans of brain and abdomen, and a bone scan. All had normal results.Cutaneous examination at the time showed a 1.5 cm painful nodule on the patient's left cheek. The adjacent skin had inflammatory signs. Physical examination showed nothing abnormal, with no palpable lymph nodes or nodules.The patient underwent excision biopsy of the facial lesion Figure . SubsequSCLC results from bronchial epithelial cells, which are relatives of Kultchitsky cells, a type of intestinal epithelial cell. SCLC is fatal and most patients die within one year of presentation. When untreated, patients survive only for one to three months after diagnosis. Survival is short even when patients are treated, due to the aggressive biological behaviour of this type of tumour. The mainstay of treatment is chemotherapy combined with radiotherapy with a mean survival period of 8 to 15 months. The disease most frequently metastasizes to the central nervous system, bone marrow and suprarenal glands. SCLC may be accompanied by paraneoplastic syndromes, superior-vena-cava syndromes, compressions to the spinal cord and, very rarely, skin metastases . AccordiCutaneous metastases as a first sign of internal malignancy occur infrequently. Clinically, they manifest as nodules, ulceration, cellulitis-like lesions, bullae or fibrotic processes . The difGenerally, cutaneous metastases are early indicators of metastatic disease. Diagnosis may be delayed by several months, unless the skin lesion grows rapidly or other sites such as the lung or liver are affected by the tumour's spread . Early rDespite the fact that skin metastasis has poor prognosis, a high index of suspicion is necessary for its early detection. The aim is to start treatment as soon as possible before widespread visceral metastases occur. Therefore, close inspection of new skin lesions in patients with a history of malignancy is imperative, and diagnostic biopsy is always essential.CT: computed tomography; NSE: neuron-specific enolase; SCLC: small-cell lung carcinoma; TTF-1: thyroid transcription factor;Written informed consent was obtained from the patient's family 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.NB, GS, DP, ES, ZT and CA took part in the care of the patient and contributed equally to the medical literature search. PX was responsible for the pathology report. CT participated in the care of the patient and supervised this report. All authors approved the final manuscript.


Recognizing syndromes which mimic ALS is crucial both to avoid giving this diagnosis erroneously and since there may be appropriate treatments. We report a 63-year-old woman diagnosed with possible ALS five years ago based on upper and lower motor neuron signs with typical electrophysiology and normal cranial MRI. At reassessment, spinal MRI revealed a cervicothoracic cyst with cord compression that was successfully treated neurosurgically. Histopathology confirmed an arachnoid origin as suspected from MRI. Spinal cysts may mimic ALS and need to be thoroughly excluded by appropriate imaging. Amyotrophic lateral sclerosis (ALS) is a subset of motor neuron disease in adults and usually causes death within a few years . DefinitA 63-year-old woman was admitted to the clinic of the Max Planck Institute of Psychiatry with major depression. Her onset of depressed mood had been gradual after being diagnosed with ALS five years ago. The patient had noted intermittent cramp-like sensations round her chest and a weak, numb neck pain. These symptoms had been fluctuating but not clearly progressive, for about two years when she was referred to a neurologist. File review showed that clinical presentation at that time already comprised objective weakness, atrophy and fasciculations in the upper limb muscles, along with extremely brisk tendon reflexes. No unequivocal sensory deficit such as hypesthesia or dysesthesia was documented at that time. Electromyography showed abnormal spontaneous activity in the right deltoid muscle, abducens pollicis brevis and palmar interossei muscles, and signs of bilateral chronic denervation in the upper limb which in combination with a normal cranial MRI scan was interpreted as motor neuron disease by several neurologists. In addition, a bilateral carpal tunnel syndrome was presumed on the basis of increased distal motor latencies of the median nerve. About two years later she was diagnosed with “possible ALS” according to El Escorial criteria .Neurological examination at the time of admission to our clinic (about 7 years after the first symptoms) revealed normal cranial nerves with no signs of bulbar dysfunction and no fasciculations or weakness of facial, tongue, or neck muscles. Distinct muscle atrophy along with mild fasciculations of the upper limbs with right-sided, proximal accentuation was noted, particularly in the supraspinatus, deltoid and biceps muscles, and the finger extensors with motor strength reduced to 3-4/5. At the lower limbs, motor strength was of 4/5 of foot extensors, but no obvious atrophy or fasciculations was found. Weakness of the proximal lower limb muscles was suspected since she had difficulties in rising from sitting. She was able to walk independently but showed gait ataxia. Reduced vibration proprioception of all limbs and hyper- and dysesthesia of the shoulders and proximal arms were found. Deep tendon reflexes were symmetric, yet, extremely brisk, Babinski's signs were absent and superficial abdominal reflexes were retained. There were no symptoms of bladder or bowel dysfunction, but she reported neck pain and numbness and clumsiness of both arms.Proximal muscle atrophy in the arms together with sensory dysfunction and pain led anew to the suspicion of spinal pathology. Cervical MRI revealed a cyst in the dorsal intradural-extramedullary space of the cervicothoracic region. The lesion displaced the cervical spinal cord, and myelopathy was noted . MyelogrIntraoperatively, elevated pressure within the cyst was found. Cyst membranes were partially removed with fenestration of the remaining parts via a right C6/C7 hemilaminectomy. Histopathology confirmed the arachnoid origin of the cyst.Postoperatively, the patient reported major relief of her neck pain and regained strength in her arms. One year later, motor and sensory dysfunctions were minimal and no acute denervation was recorded on electromyography. After stabilisation of her general condition she also recovered from depression.The cervicothoracic cyst in our patient had mimicked ALS symptoms as progressive amyotrophy and fasciculations along with brisk tendon reflexes and electrophysiological signs of acute and chronic denervation. Only one case considering a spinal cyst as a differential diagnosis to ALS has been reported: Korosue et al.  describeArachnoid cysts are rare outpouchings of the arachnoid lining and may be congenital, secondary to trauma or infection, or acquired, though idiopathic . To dateThe hint for spinal pathology came from insistent focal symptoms without true spreading over time. Only about 10% of ALS patients present solely with amyotrophy in limb muscles; widespread involvement usually follows. Weakness and atrophy at onset are more frequent in the upper limbs than in the lower limbs or bulbar muscles . FurtherIt has been estimated that up to 10% of patients initially diagnosed as ALS are ultimately rediagnosed as having a different disease. Importantly, for about half of these patients potentially curative treatments exist . This laAnother essential precondition for a diagnosis of ALS is the “progressive spread of symptoms or signs within a region or to other regions, as determined by history or examination” . This crIn conclusion, cervivothoracic arachnoid cysts could be added to the group of treatable ALS mimic syndromes. Careful longitudinal clinical assessment, complete application of diagnostic measures including spinal imaging, and strict adherence to recommended diagnostic criteria of ALS as a minimum standard are essential. Specific attention to the possibility of ALS mimic syndromes is needed when there is clinical evidence of neuronal involvement outside the motor system, an unusual distribution of muscle atrophy with lack of spreading to other regions or persisting sensory or pain symptoms. Such clinical features should alert the physician to question the diagnosis and take further diagnostic measures.


Bleeding from pancreatic pseudocyst’s rupture into adjacent organs is a rare, but potentially fatal, complication of chronic pancreatitis requiring quick management. Timing of the rupture is unpredictable; early diagnosis and correct management is essential in preventing the bleeding.We describe the case of a 53 years old male patient successfully treated with emergency surgery for massive hematemesis due to a rupture of a bleeding pseudocyst into the stomach. Patient underwent emergency laparotomy and suture of the bleeding vessel. At 5 years follow-up patient is in healthy condition.This case shows to surgeons that pancreatic pseudocyst cannot be managed strictly with one rule and prompt surgical treatment is mandatory in case of haemodinamic instability. Pancreatic pseudocyst is a common finding in patients with previous acute or chronic pancreatitis, developing respectively in up to 15% and 40% of these groups of patients -4.This report detail a case of sudden haemorragic complication of pancreatic pseudocyst and its emergency surgical management.A 53-years Italian, white Caucasian, old male former alcoholic (stop drinking since 11 years) with known chronic pancreatitis came at our Department for mild abdominal pain, anorexia and bowel obstruction. Physical examination was unremarkable except for a mesogastric tenderness. Laboratory findings revealed an increase value of Amilase (148 mg/dl), with slightly increase levels of bilirubin (2.1 mg/dl) and transaminase . A CT scan revealed a 10 × 10 × 7 cm tail cystic esofitic lesion of the pancreatic tail in a pattern of chronic pancreatitis . PatientEcographic evaluation coupled with CT scan did not diagnose any fluid collection within the abdomen. A CT scan performed 4 weeks from the first diagnosis of acute on chronic pancreatitis, the day before hospital discharge, revealed a reduction of diameters (10 × 10 × 10 cm) and disappearing of infarcted areas within the spleen if compared with the previous one. Few hours after the examination patient presented hypotension, sweating, diaphoresis, massive hematemesis and subsequent haemorrhagic shock.Emergency laparotomy was performed. Surgical exploration of the pseudocyst was performed through an anterior gastrotomy, revealing a bleeding coming directly from the main trunk of the splenic artery; after adequate surgical vessel isolation the defect was sutured by means of not reabsorbable stitches (4/0 prolene).Post-operative course was uneventful. A color Doppler flow of splancic vessels performed 2 weeks after surgery demonstrated normal flow within all arteries with little reduced flow in part of the branches at the splenic hilum. CT scan examination revealed splenic diffuse hypodensity due to reduced blood flow . PatientPancreatic pseudocysts are common conditions following both acute and chronic pancreatitis or pancreatic trauma . DiffereThis case reminds to surgeons that pancreatic pseudocyst cannot be managed strictly with one rule , but str


Primary carcinoid tumor of the gallbladder is rare and comprises less than 1% of all carcinoid tumors. Preoperative diagnosis of carcinoid tumor of the gallbladder is difficult. The imageology findings are similar to those in other gallbladder cancers.A 46-year-old woman was hospitalized with a preoperative diagnosis of gallbladder carcinoma, The patient was referred for surgical opinion and laparotomy was subsequently performed. A 4 × 5 cm mass was found within the gallbladder, located on the free surface of the body and fundus of the gallbladder. Neither metastases nor direct invasion to the liver was found. The entire mass and gallbladder were excised and intact. Histologically, the tumor consisted of small oval cells with round-to-oval neclei and tumor cells formed small nodular, trabeculare and acinar structures. The tumor showed moderate pleomorphism with scattered mitotic figures, but no definite evidence of vascular permeation, perineural invasion or lymphatic permeation was seen. The tumor cells invaded the mucosa extensively, and some penetrated the muscular layer but not through the serosa of the gallbladder into the liver. Immunohistochemical studies revealed strong positive reaction for chromogranin A and NSE. This lesion was proved to be a primary carcinoid tumor of the gallbladder. A brief review of literature, clinical feature, pathology and treatment of this rare disease was discussed.Primary carcinoid tumor of the gallbladder is uncommon. The definite diagnosis is often made on histopathological results after surgery. Generally, carcinoid tumors are thought to arise from embryonal neural crest cells and may occur anywhere that these cells are found. For the most part they tend to be associated with the gastrointestinal tract and respiratory system; however, primary carcinoid tumors of the gallbladder are rare and comprises less than 1% of all carcinoid tumors. We herein present a classical carcinoid tumor found in gallbladder of a 46-year-old woman and review the relevant literature on this rare entity.A 46-year-old woman was hospitalized with a 2-year history of dull pain in the right upper abdomen. Her appetite was normal and she had no history of diarrhea, flushes or dyspnea. There was no pertinent past medical or surgical history. On examination, she was well nourished with stable vital signs, and no pallor, jaundice, or significant lymphadenopathy. Abdominal examination revealed no tenderness, organomegaly, or abnormal mass.Laboratory investigation revealed normal hematological findings and serum electrolyte levels. The laboratory data of Liver function were within normal limits. The results of assays for tumor-associated antigen revealed that the serum levels of CEA, CA-50, CA19-9 and CA125 were within normal limits. Urine and stool routine examinations proved normal. Because of no suspicion for the diagnosis of carcinoid tumor before treatment, we did not measure the levels of the urinary 5-hydroxyindoleacetic acid (5HIAA) and plasma serotonin. The chest X-ray revealed no unusual findings. Abdominal ultrasound showed a 4.5 cm protruding tissue mass in the body and fundus of the gallbladder lumen  to extensive hepatic lebectomy, which depended on the size and stage of the lesion, and particularly whether liver metastases were present -14. The Specific prognostic factors have not been identified in patients with gallbladder carcinoids, but increasing tumor size, depth of invasion and metastasis are probably associated with the prognosis ,16. TherAlthough, the study of neuroendocrine tumors has been advanced significantly by the elucidation of aspects of carcinoid biology and the development of novel diagnostic methodology, there appears to be little change in terms of outcome. The current optimal therapeutic strategy for carcinoid tumors should be based on the appreciation of the obviously malignant yet somewhat restrained biologic behavior of these lesions. It is suggested that the future of the elucidation of this disease process requires correlation with precise cellular and biologic determinants of malignancy as well as delineation of the specific cell of origin and its precise genomic configuration . It willPrimary carcinoid tumor of the gallbladder is uncommon. It is difficult to differentiate from adenocarcinoma of the gallbladder preoperatively. The definite diagnosis is often made on histopathological results after surgery.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.ZYP wrote the initial draft. All authors contributed to the intellectual context and approved the final version. ZYP is the guarantor.


Dentinogenic ghost cell tumor (DGCT) is an uncommon locally invasive odontogenic tumor regarded by many as a variant of calcifying odontogenic cyst. The peripheral variant of this clinical rarity appears as a well-circumscribed mass mimicking a nonspecific gingival enlargement. Microscopic appearance of odontogenic epithelium admixed with focal areas of dentinoid formation and sheets of ghost cells giving the definitive diagnosis of dentinogenic ghost cell tumor imply that microscopic examination is compulsory for any gingival mass. Van Gieson histochemical stain further confirmed the nature of dentinoid-like material. A complete workup of a case of peripheral dentinogenic ghost cell tumor is presented in this paper and the current concept as well as the appraisal of literature is presented. Calcifying odontogenic cyst (COC) is a unique jaw lesion, first recognized as a distinct entity by Gorlin et al.  and hencThe term DGCT is commonly used, and the peripheral variant of this neoplastic entity is rare; only few reports with clinical, radiographic, and histologic documentation can be found in the English literature. A report of peripheral dentinogenic ghost cell tumor (PDGCT) and characterization of dentinoid material using Van Gieson special stain for the confirmation adds a new dimension to the diagnosis of DGCT.A 40-year-old male patient reported to the dental clinics at Manipal College of Dental Sciences, Manipal University, with a complaint of missing teeth. Clinical examination disclosed a swelling measuring about 5 mm in diameter in the region of lower left premolars which was non tender, and the over lying mucosa was normal in color. Clinically, a provisional diagnosis of epulis was made . The lesHistological examination revealed a solid well-circumscribed, encapsulated soft tissue mass surrounded by a dense fibrous connective tissue covered by stratified squamous epithelium . The tumDGCT is a distinct but a rare histological entity among odontogenic ghost cell lesions which have been recently classified into the simple cystic type or COC; cysts associated with odontogenic hamartomas or benign neoplasms; solid benign odontogenic neoplasm, which is same as COC but with dentinoid formation, the DGCT; malignant odontogenic neoplasm-ghost cell odontogenic carcinoma . The perThe usual presentation of the peripheral variant is a nodular swelling on the edentulous alveolar mucosa of denture wearers, a feature that implicates trauma/irritation. This clinical presentation could lead to the provisional diagnosis of epulis as was true in our case as well. Due to the dearth of documented cases, it is difficult to typify the exact location, age, and gender distribution of PDGCT. However based on the existing literature it appears to be more common in the canine-premolar region, with a predilection for the elderly age group , 14–23 . HirshbeBased on this histological diversity, the origin of this lesion has been attributed to cell rests of Serres or the surface epithelium , 26. TheDue to its biological behavior COC, and its variants are thought to resemble a benign odontogenic tumor rather than a cyst . PreviouIn our case as well, the presence of keratinizing ghost cells and mineralization was an outstanding feature. The lesion did not exhibit any cystic areas, and its features were consistent with those of DGCT. The calcifications seen as dentoid, frequently described in connection with masses of ghost cells, were a characteristic finding of this lesion. These calcified areas were thought to represent juxtaepithelial osteoid formation by granulation tissue due to induction by ghost cells . This viConservative but aggressive local resection has been the treatment of choice with no recurrences found in any patient. However patients with a DGCT should remain in long-term follow-up . Though


We report a case of a patient who presented with anterior mediastinal mass, seizure disorder, and mental retardation. Computerized tomography–guided fine-needle aspiration biopsy of the mass showed nonseminomatous germ cell tumor. Chromosomal analysis showed XXY karyotype. A diagnosis of Klinefelter syndrome and mediastinal germ cell tumor was made. A diagnosis of Klinefelter syndrome is rarely made before puberty due to the subtle manifestations in childhood and under-recognition by health care practitioners. LearningA 14-year-old boy was referred with history of dry cough, dyspnea, and fever of three months' duration, with seizure disorder since the age of two years. He also had delayed developmental milestones and poor scholastic performance. Physical examination revealed height and weight of 147 cm and 47 kg, respectively, which were below 5 percentile for his age. There was presence of gynacomastia. Vital parameters were within normal limits. Respiratory examination showed bulging of the chest wall with decreased breath sounds all over the right hemithorax. On further examination, a testicular swelling was noted.Investigations showed hemoglobin - 10.6 g/dL, white blood count - 12600/μL, blood urea nitrogen- 10 mg%, Lactate dehydrogenase (LDH) – 827IU/L; human immunodeficiency virus (HIV) was nonreactive. Chest X-ray showed anterosuperior mediastinal mass . UltrasoMediastinal germ cell tumors are a heterogeneous group of benign and malignant neoplasms thought to originate from primitive germ cells “misplaced” in the mediastinum during early embryogenesis. The anterior mediastinum, especially the anterosuperior position, is the most common extragonadal primary site. Lactate dehydrogenase and serological markers such as AFPs and beta HCG are frequently positive. In a serIn a recent study, DNA samples from 1205 patients of mental retardation of unknown etiology were screened for fragile X syndrome, and all were detected to have Klinefelter syndrome, emphasizing the importance of cytogenic testing of all prepubertal males with cognitive impairment, even without dysmorphic features. In most Bukowski and associates of the southwest oncology group treated 41 patients with extragonadal seminoma or nonseminomatous malignant germ cell tumors with four cycles of chemotherapy containing bleomycin, cisplatin, and various other agents, followed by surgical resection. The two- and five-year survival rates for the patients in this series were 67% and 60%, respectively. CurrentlRecognition, identification of early clinical characteristics and evaluation of mediastinal germ cell tumor for Klinefelter syndrome are important. Chest physicians should be aware of this association since they are often the first to evaluate patients with mediastinal masses.


They usually affect the face with an unspecific clinical aspect. The histological features include cellular or mixoid differentiation and immunohistochemistry can be positive for protein s-100, vimentin and epithelilal membrane antigen (EMA).Neurothekeomas are tumors of neural differentiation and of unknown origin that occur in females at the 2This case report presents a 13-year-old female patient with nasal neurothekeoma of cellular variety and strongly positive for vimentin and s-100; and negative for EMA. Neurothekeoma (NK) is a tumor of neural differentiation first described by Harkin and Reed in 1969 . Being eThe origin of this tumor is unknown. Some authors consider it as Schwann cells,  while otnd and 3rd decades of life). It is most commonly located is on the head, face and superior mid-body. To date, 21 reports have shown facial occurrence  and 31 reports demonstrate occurrence of NK in patients younger than 20 years old [NK presents frequently in females between 10–66 years  and mucin stain (Mucicarmin of Mayer) showing its dual differentiation: neural and myxoid.All author(s) read and approved the final manuscript.LDLC, made the clinical diagnosis, follow up of the patient, surgical treatment and writing the manuscript.GNF and JNS, made the histological diagnosis.JEM, planned and assisted the patient's surgical treatment.


We report a rare case of pheochromocytoma of the adrenal gland presenting as Cushing syndrome. A 30 year old woman presented with pain in the left loin and classical Cushingoid features. She was a diabetic and hypertensive on treatment. Magnetic resonance imaging of the abdomen revealed a 3.5×3 cm mass in the left adrenal gland. Urine analysis revealed an elevated 24 hr urinary cortisol level. Clinical diagnosis was Cushing syndrome due to functioning left adrenal tumor, and hence left adrenalectomy was performed laparoscopically. Histopathological examination revealed adrenal pheochromocytoma. Immunohistochemical analysis of the tumor was positive for adrenocorticotrophic hormone and chromogranin. Cushing syndrome may be due to ectopic secretion of adrenocorticotrophic hormone (ACTH) from bronchial carcinoid, islet cell tumor, small cell lung carcinoma, medullary carcinoma of the thyroid, thymic carcinoid, disseminated neuroendocrine tumors and disseminated gastrointestinal carcinoid. Ectopic secretion of ACTH may present with features of hypercortisolism similar to pituitary Cushing disease. Cushing syndrome due to ACTH-secreting pheochromocytomas have sporadically been reported in the literature and accounts for 3% of ectopic ACTH-dependent Cushing syndrome. We are rA 30 year old woman presented to us with a history of left loin pain for 9 months, associated with progressive weight gain. She was diagnosed with diabetes and hypertension three months earlier and started on treatment. She was monoparous and her menstrual cycles were normal. Physical examination revealed typical cushingoid features of centripetal obesity, moon face, buffalo hump, abdominal striae, excessive hair growth and ecchymotic patches in the forearm. Her blood pressure was 160/90 mmHg in the right upper limb, in supine position. Abdominal sonography revealed a 3.5×3 cm mixed echogenic mass involving the left suprarenal gland. Serum cortisol values at 8 am and 4 pm were 39.50 and 24.9 µgm/dl, respectively . A 24 h urinary cortisol level was 540.5 µgm (28.5-213.7). Serum adrenocorticotrophic hormone was 62 pgm/ml (7.2-63.3). A 24 h urine analysis for metanephrines was 1.1 µgm (<1.2) and vanillyl mandelic acid was 12.8 mg (13.6). Magnetic resonance imaging of the abdomen showed a 3.5×3 cm mass in the left adrenal gland. The mass was mixed intense in T1 and T2 weighted images. Contralateral adrenal gland was normal . With thEctopic ACTH-dependent Cushing accounts for 10%–15% of all cases of Cushing syndrome. Adrenal 3Cushing syndrome can be a rare presentation of pheochromocytoma as a result of ectopic secretion of ACTH. It is often difficult to diagnose this presentation preoperatively, especially in cases with a predominant secretion of ACTH rather than catecholamines. In such cases, the final diagnosis can be made only by immunohistochemical analysis.


Hepatic and splenic hemangiomas are common benign tumors that mainly affect female patients. Giant splenic hemangiomas are extremely rare, especially when correlated with multiple hepatic hemangiomas. Pathogenetic mechanisms between hemangiomas and oral contraceptives, as well as therapeutic approaches, are analyzed in this case report, in particular for the management of synchronous splenic and hepatic hemangiomas.We report here a 42-year-old woman with a giant splenic hemangioma, multiple hepatic hemangiomas and a history of oral estrogen intake for many years. At first it was difficult to determine the organ from which the giant hemangioma originated. Angiography proved extremely helpful in tracing its origin in the spleen. Hematomas in the giant hemangioma posed a significant threat of rupture and catastrophic hemorrhage. We left the small hepatic hemangiomas in place, and removed the spleen along with the giant splenic hemangioma.Diagnostic pitfalls in the determination of the origin of this giant hemangioma, attribution of its origin to the spleen angiographically, the unusual co-existence of the giant splenic hemangioma with multiple hepatic ones, and the potential threat of rupture of the giant hemangioma are some of the highlights of this case report. Estrogen administration represents a pathogenic factor that has been associated with hemangiomas in solid organs of the abdominal cavity. The therapeutic dilemma between resection and embolization of giant hemangiomas is another point of discussion in this case report. Splenectomy for the giant splenic hemangioma eliminates the risk of rupture and malignant degeneration, whereas observation for the small hepatic ones (<4 cm) was the preferable therapeutic strategy in our patient. Splenic hemangioma is a vascular malformation that represents the most common benign primary neoplasm of the spleen. Its prevalence at autopsy ranges from 0.03% to 14% and it is the hemangioma most commonly seen in adults in the mid-30- to mid-50-year-old range [Most hemangiomas are small asymptomatic lesions that are found incidentally. Previous studies have noted liver and spleen hemangioma augmentation during estrogen administration for endometriosis treatment, revealing a potential association . AdditioA 42-year-old woman presented with a left upper abdominal distention, early satiety and discomfort. There was no family history of hematological or splenic disorders. There was no evidence of thrombocytopenia, hemorrhagic episodes, hepatomegaly or lymphadenopathy. The patient had received estrogen therapy as treatment for endometriosis for 10 years, but she discontinued this medication 12 years prior to her presentation to our unit. The patient had a palpable mass in her left upper abdomen. The mass could be palpated approximately 9 cm below the left costal margin. Her full blood count was in the normal range.Initially a spiral computed tomography (CT) scan with IV contrast showed multiple hypodense lesions with centripetal filling in delayed venous phase compatible with hemangiomas. Two large lesions were located in the right hepatic lobe and multiple smaller ones in the caudate and left lobe. All these hepatic lesions were consistent with the features of hemangiomas.The CT scan also showed a large hemangioma-like formation in the left abdomen. It was difficult to determine whether this originated from the spleen or from the left adrenal gland, and a large cyst of the right ovary, suspicious of endometriosis Figure , was alsSelective arteriography of renal arteries, SMA (superior mesenteric artery), and the celiac trunk, undertaken to clarify the vascularity of the lesion, showed a giant splenic hemangioma with its vascular supply deriving from the splenic artery Figure .We decided to proceed to splenectomy because of the possibility of malignant transformation and of rupture and massive bleeding, complications which have been reported by other authors ,3,4. TheHistology of the spleen showed a large hemangioma with central foci of hematoma Figure . At the The first successful surgery for splenic hemangioma was reported by Hodge in 1895. Hemangiomas constitute the majority of benign hepatic neoplasms and are nine times more frequent in females than in males [Hemangiomas are often asymptomatic and undergo enlargement in fewer than 10% of cases, manifesting as a palpable non-tender mass in the left upper quadrant. Very rarely, splenic hemangiomas may become as large as 25 cm . GeneralCT and MRI failed to achieve appreciable sensitivity and specificity to define the origin of the giant splenic hemangioma we describe. Velkova and Neveda report a combined sensitivity of 61.3% for ultrasound and CT scan in the recognition of liver and spleen hemangiomas, leaving a substantial number of cases requiring further investigative procedures . They alThe presence of central hematomas in the giant hemangioma we describe showed possible rupture. Serious complications of hemangiomas include rupture and malignant transformation. Spontaneous rupture of a giant hepatic hemangioma (diameter >4 cm) with hemoperitoneum occurs very rarely. Willcox et al. report a spontaneous rupture incidence of 25% . MalignaSplenectomy may be efficacious in the correction of coagulation abnormalities in Kassabach-Meritt syndrome associated with ruptured giant splenic hemangiomas ,7. An alTo our knowledge, there is no specific report of giant splenic hemangiomas associated with administration of oral contraceptives. There are numerous reports of intrahepatic and extrahepatic hemangiomas associated with estrogen administration . The exaEstrogen administration represents a predisposing factor associated with the appearance of hemangiomas in solid organs of the abdominal cavity. Giant splenic hemangiomas are extremely rare, and require surgical intervention combined with observation or embolization of possibly synchronous multiple small hepatic hemangiomas. Alternative approaches are preoperative embolization and subsequent surgery, which minimizes the risk of intra-operative bleeding, and partial splenectomy or embolization in case of polar localization of small splenic hemangiomas.CT: computed tomography; OC: oral contraceptives.The authors declare that they have no competing interests.All the authors have been involved in literature search, writing and final reviewing of this manuscript. All authors read and approved the final manuscript.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.


A case of malignant pleural mesothelioma discovered because of a chest wall metastasis which developed over a previous pleural drainage site is presented. Imaging findings at sonography, contrast enhanced computed tomography and fluorodeoxyglucose - positron emission tomography are shown. A 64-year-old Caucasian male from Italy complained of onset of thoracic pain which gradually developed after undergoing a left-sided pleural effusion drainage 9 months earlier; at that time he was dismissed from the hospital without any further investigation since pleural fluid cytologic analysis did not show malignant cells.Because of progressive worsening of his symptoms he returned to medical attention. Complete cutaneous healing of the drainage insertion site was seen at physical examination which also revealed tenderness of chest wall exacerbated by digitopression.Ultrasound of the chest wall was performed showing an inhomogeneous hypoechoic subcutaneous soft tissue lesion with ill-defined borders  correspoA contrast enhanced chest multidetector CT showed left hemithorax volume loss with concentric nodular pleural thickening  involvinAn FDG-PET scan was performed showing increased left pleural and chest wall  radiotraCT-guided biopsy subsequently confirmed the diagnostic impressions.The patient was considered unresectable because of the extensive diaphragmatic involvement and was then referred to an oncologist who treated him with radiotherapy, chemotherapy and palliative care. He passed away 1 year later because of respiratory insufficiency.Malignant pleural mesothelioma (MPM) is a locally aggressive tumor of the pleura frequently associated to a prior asbestos exposure, which has been estimated to be responsible of about 70-90% of cases .Asbestos induces DNA damage and mutations in mesothelial cells. The carcinogenic effect may be the result of direct effect of asbestos fibers on mitotic spindle of cells disrupting mitosis or be secondary to formation of reactive oxygen species .Other risk factors include previous chest radiation therapy, exposure to Thorotrast contrast medium and SV40 virus infection .The tumor causes progressive nodular pleural thickening that may lead to encasement of the lung in advanced stages. MPM is locally aggressive, with frequent invasion of the chest wall, mediastinum, and diaphragm. Contraction of the affected hemithorax with associated ipsilateral mediastinal shift and hemidiaphragmatic elevation may be seen . HoweverMPM is associated with a poor median survival, ranging from 4 to 18 months. Treatment is difficult because of the natural resistance of this tumor-entity and single modality therapy gave disappointing results. Multimodality treatment approaches involving surgery with radiation and chemotherapy, seem to be promising in a selected group of MPM patients . ConventMagnetic resonance imaging can allow improved detection of tumor extension, especially to the chest wall and diaphragm but in the majority of the cases CT and MRI are nearly equivalent and provide similar diagnostic and staging information .FDG-PET is useful in the staging and preoperative evaluation of MPM because of its increased accuracy for detecting mediastinal nodal metastases and its ability to determine the most appropriate biopsy sites .Ultrasounds may show pleural effusions, areas of pleural thickening, calcifications and may be used to assess chest wall invasion with higher sensitivity than CT; drawbacks of sonography are lack of panoramicity and poor acoustic windows in certain regions of the thorax like the subscapular and paraspinal areas .It’s important to remark that pleural abnormalities seen in MPM are not pathognomonic and may be encountered in a variety of conditions like infections , fibrothorax, empyema and metastatic disease to the pleura  as well in asbestos-related pleural fibrosis .A tissue diagnosis is therefore required. Unfortunately it is not uncommon to have negative cytology after pleural drainage as it happened in the initial evaluation of our patient; diagnostic yield of pleural fluid cytology may indeed be as low as 20-30% .For this reasons an histological specimen by means of core-biopsies techniques is often necessary to achieve a correct diagnosis . MPM mayThese metastases may cause important pain and discomfort to the patient. For this reason prophylactic drain site radiotherapy in MPM, has been advocated in the past to reduce the incidence of tumour seeding  and has


Textiloma is defined as a tumor formed due to retained gauze. It is rarely reported in the musculoskeletal system. We are presenting a case with a soft tissue swelling over the lateral aspect of the lower third of the leg, come for implant removal of the distal tibia and fibular fracture. We removed the soft tissue mass enbloc thinking it to be a benign tumor. On cutting the mass on the operation table, a gauze piece encased by fibrous tissue was found. Textiloma can present as tumoral forms and can mimic as a pseudo-tumor. Textiloma is defined as a tumor composed of cotton matrix surrounded by granulomatous reaction.A 29-year-old man reported for implant removal of the distal end of the tibia. He had a symptomless swelling along the lateral aspect of the distal end of the leg. He was operated for distal end tibia fracture two years back by means of Ilizarov and fibular plate and again operated for tibial malunion by open reduction and plating one and half years back. The patient was having a normal gait. On examination a well-defined mass along the lateral aspect of the leg measuring 4 × 3 cm, oval to round shape, firm in consistency was found. There was no localized raised temperature, no abnormal vascularity. It was mobile painless and the skin over it was free and moving with the peroneal muscles. The surgical scar was overlying the mass. The laboratory investigation was normal. X-ray of the lower extremity and the ankle joint showed the soft tissue mass as a noncalcified tumefaction of the soft tissue adjacent to the fibular plate . SurrounSurgical excision along with the implant removal was planned. On surgery a well-defined mass was found in the peroneal brevis musculature with well-defined borders and adjacent to the fibular bone . It did On cutting the lesion on the operation table, gauze surrounded by the fibrous tissue was noted . HistoloA retained gauze is called textiloma. Glossypiboma Clinical picture of the textiloma may be acute (exudative) or delayed . The exudative form usually presents with early clinical manifestation because of possibility of secondary super infection resulting in sepsis or because of formation of the fistula. It can be diagnosed with clinical suspicion. The tumoral forms appear late and may remain latent for many years.5On X-ray it may show a soft tissue shadow or if calcified may show a whorl-like pattern. Radio marker can be seen if present.7Textiloma as a complication can occur in all forms of surgery. These are also seldom reported due to medicolegal problems. Only 6% of Textiloma are reported following orthopedic and spine surgery in comparison to 52% following abdominal surgery. No fatal complications have been noted in the muscular skeletal sites.8The best approach to prevent textilomas is by simple gauze counting. Eleven cases of retained sponge are reported in one series where eight had presumed incorrect sponge count.10


Small intestinal strictures secondary to mesenteric vessel thrombosis are a rare entity and thus often result in delayed diagnosis. We present two cases of ischaemic small bowel strictures secondary to mesenteric vessel thrombosis, and describe how they were subsequently managed.We present two cases of abdominal pain, one acute and one chronic, in which the eventual diagnosis was of bowel strictures secondary to arterial and venous vessel thrombosis. In both patients, a Caucasian male aged 67 and a Caucasian female aged 78, the diagnosis was delayed because of the infrequency of their presentation. Both patients eventually underwent a resection of the affected portion of bowel with primary anastamosis and made uneventful recoveries.There are multiple medical and surgical management options for small bowel strictures and these depend on the aetiology of the stricture. Ischaemic small bowel strictures represent a difficult diagnosis and the potential resulting delay may be partially responsible for increased morbidity. Barium small bowel follow-through should be used in making the diagnosis. Small intestinal strictures secondary to mesenteric vessel thrombosis are a rare entity and thus often result in delayed diagnosis. The patient often presents with chronic bouts of abdominal pain associated with symptoms of intermittent small bowel obstruction. Results of routine investigations are often normal and subsequently diagnosis and often treatment can be difficult. We present two cases and highlight possible investigative and management strategies.A 67-year-old Caucasian man presented acutely with a 5-day history of recurrent bouts of epigastric pain, nausea and vomiting. His previous surgical history included coronary artery bypass surgery, appendicectomy and open cholecystectomy with subsequent surgery for recurrent incisional hernia. No personal or family history of thrombosis-related conditions was given. On examination, he had low grade pyrexia but was cardiovascularly stable. Abdominal examination revealed mild distension with tenderness in the epigastrium and right hypochondrium.® stapling device.Initial investigations revealed leucocytosis and a raised C-reactive protein level. He underwent medical review to rule out a cardiac aetiology , negative troponin test). An abdominal ultrasound showed no abnormality. He was discharged with out-patient follow-up but continued to experience intermittent abdominal pains. A subsequent computed tomography (CT) scan revealed a small hiatus hernia, and thickening of the distal (third part) duodenum. On endoscopic visualisation, no abnormality was demonstrated. Eventually, a small bowel follow-through was performed Figure : this deMacroscopic examination of the resected specimen showed an area of ulceration and haemorrhage measuring 50 mm in length. Histology tests confirmed a deep chronic ulcer, granulation tissue and marked fibrosis disrupting the muscularis propria; mesenteric sections revealed organised thrombosis of medium and small vessels with mild to moderate recanalisation. A thrombophilia screen was found to be unremarkable. On the advice of the haematologist, the patient was commenced on warfarin and made an uneventful postoperative recovery; to date, he has experienced no relapse of his symptoms.A 78-year-old Caucasian woman presented with sudden onset abdominal pain with associated nausea and vomiting. She had a past medical history of a myocardial infarction, chronic obstructive pulmonary disease (COPD), transitional cell carcinoma of the bladder and an appendicectomy as a child.On examination, she was tachycardic with evidence of marked lower abdominal peritonism. Blood tests showed neutrophilia and mild acidosis; plain film radiology was diagnostically unhelpful. An ECG was obtained which showed ventricular ectopics and changes suggestive of lateral ischaemia: on cardiological review, these changes were consistent with an old infarct and troponin T levels at 12 hours were negative. A CT scan revealed a probable left ventricular aneurysm and evidence of a thickened loop of terminal ileum containing intra-mural gas, suggestive of ischaemia  and made an uneventful recovery. Results of a thrombophilia screen were negative and histological examination revealed intermittent full thickness necrosis with an atrophic and chronically inflamed mucosa consistent with the effects of chronic ischaemia. No venous thrombosis was seen. The patient made an uneventful recovery and was discharged 5 days later.Small bowel strictures associated with mesenteric vessel thrombosis are an uncommon entity, having been reported infrequently in the literature -4. In anIn cases of chronic bouts of abdominal pain associated with symptoms of intermittent small bowel obstruction, diagnosis can be difficult. The differentials include Crohn's disease, lymphoma, carcinoid infiltration, ischaemia, tuberculosis and radiation enteritis. Blood tests, routine radiological imaging or endoscopy may prove negative. A barium small bowel follow-through study can be the most useful test. A smooth uniformly narrowed segment of small bowel may be seen with evidence of proximal dilatation. An ischaemic stricture develops as an end result of inflammation and scarring, leading to rigid thickening and fibrosis of the locally involved bowel wall musculature. When the progress of a normal peristaltic wave is impeded, obstruction may ensue.The clinical management of such strictures is dependent on the diagnosis. Formal histological confirmation has to be sought so that the appropriate treatment can be commenced. Intervention is only necessary when an individual is symptomatic. Steroids, aminosalicylic acid preparations and immunomodulators have been used as part of the medical management of active Crohn's disease; surgical treatment options include endoscopic balloon dilatation to relieve the obstruction; strictureplasty and formal resection of the affected segment.The most important diagnosis to rule out in patients with small bowel strictures is malignancy. Although in these two patients, the diagnosis is of a stricture of vascular origin, small bowel strictures should be considered malignant until shown to be otherwise. In our patients, preliminary investigation by way of computed tomography scan and gastrointestinal endoscopy had shown this not to be the case and they were managed appropriately.The current literature on the management of malignant small bowel strictures is limited and thus management is complicated. Cases where malignant strictures are strongly suspected or proven should be managed by specialists in specialist centres.A greater awareness of the association between mesenteric thrombosis and intestinal strictures would reduce the delay in diagnosis and subsequent treatment. Careful CT scan interpretation may be of benefit but in this light, the barium small bowel follow-through is the investigation of choice.COPD: chronic obstructive pulmonary disease; CT: computed tomography; ECG: electrocardiogram; HDU: high dependency unit.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.SP collected data, wrote and edited the manuscript. SG was involved in the patients' care and wrote and edited the manuscript. Both authors read and approved the final manuscript.


Necrotizing sialometaplasia is a rare disease first described in 1973. It involves salivary gland in the oral cavity.We present a 32-year-old, white, male with rare bilateral localization of necrotizing sialometaplasia.Clinically and histologically necrotizing sialometaplasia may mimic malignant lesions. In the above presented case, the patient's history was suggestive of a malignant process. Thus, knowledge and experience of both clinicians and histopathologists are essential to establish a correct diagnosis, which helps avoid radical surgery. Necrotizing sialometaplasia is an inflammatory process first described by Abrams et al. in 1973. The condition most frequently involves minor salivary glands in the hard palate region -5]. An . An 5]. We report a case of 32-year-old white male who was seen in the Outpatient Clinic of the Maxillofacial Surgery Department in Katowice in April 2007 with a recurrent bilateral palate swelling which had appeared three years before. On the day of the examination the patient also complained of jelly-like nasal discharge and general malaise. The history was suggestive of neoplastic disease including a nondiagnosed palpable anal tumour and recent diagnostic procedures of lung lesions .(44035/BC Właszczuk). Therefore an incisional biopsy was performed with a diagnosis of necrotizing sialometaplasia (34685/K Pająk). The patient was hospitalized, and the lesion excised on the left side. Histologic features of the lesion were consistent with necrotizing sialometaplasia.The clinical examination revealed a soft-elastic symmetrical affection in the area of the maxillary tuberosities; the covering mucous membrane was of normal appearance Figure . The resThe location of necrotizing sialometaplasia was typical as most of the lesions were seen on the palate ,10. HoweClinically and histologically necrotizing sialometaplasia may mimic malignant lesions. In the above presented case, the patient's history was suggestive of a malignant process. Thus, knowledge and experience of both clinicians and histopathologists are essential to establish a correct diagnosis which helps avoid radical surgery.CT: computed tomography.Written informed consent was obtained from the patient for publication of this case report and accompanying image. 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.IN involved in clinical examination, fine needle aspiration biopsy, writing the manuscript. TJ involved in literature review, writing the manuscript, clinical examination. JM involved. in writing the manuscript, clinical examination. All authors read and approved the final manuscript.


Serous cystadenoma of the pancreas are rare tumors and have little or no malignant potential.We report our experience in the management of eight casses of these tumors in the last 22 years. All thepatients were women with a mean age of 59 years. All the cysts caused symptoms. Ultrasound and CTscanwere useful in the diagnosis of the pancreatic cystic tumor out not in determining the nature of theselesions clear. FNA-biopsy was performed in 6 cases but in only one c se was the diagnosis confirmed. Alltumors were resected. Four radical pancreatoduodenectomies, two distal pancreatectomies and twocystectomies were performed. Mean followup was 83.5 months. All patients are alive and with no signs ofrecurrence. Complications include an external pancreatic fistula, an acute cholangitis and a case ofdelayed gastric emptying. In all cases the histological diagnosis was serous cystadenoma of the pancreas.We conclude that resection of these tumors is mandatory although they are supposed to be benign, inorder to avoid complications and because malignant transformations has been related to nonresectivetreatment.


Dermoid cysts are rare congenital lesions derived from pluripotential cells.We present a case of a female patient aged 30 years presenting for a lesion of the mandibula incidentally seen on a routine panoramic radiograph obtained for dental care. The instrumental, clinical and histological characteristics of the lesion are reported. Finally, a bibliographic revision of this pathology at the level of the oral cavity is reported.Dermoid cysts must be considered in the differential diagnosis of mandibula's lesions. Dermoid cysts are rare congenital lesions derived from pluripotential cells. Nowadays their etiology is unknown. Embriologically, the most reliable theory is that trapped pluripotential cells are a result of the inclusion error, during the early weeks of the intrauterine life, and then they develop into one or into all the three ectoderm, mesoderm and endoderm tissues. The differentiation of these germ layers can produce skin adnexa , muscle, bone, cartilage, teeth, and mucous membranes. The reason of this occurrence could be any trauma, infection or spontaneous autonomous new growth ,2.Therefore considering these lesions, three varieties may be classified by their histological aspects: epidermoid cyst is lined by stratified squamous epithelium and it's composed of one of the germinal layers (ectodermic); dermoid cyst is lined by stratified epithelium with skin adnexa; teratoid can be cystic or solid featured. In the current literature the term "dermoid cyst" often refers to all types of these lesions ,2.Dermoid cysts are frequently found in sites where embryonic parts fuse together. The majority of reported cases are in the midline of the body, as well as in the ovaries and in the testicles. There is no sex predilection. Their appearance occurs about the second or third decade of life as slowly enlarging masses. The treatment is surgical removal.In the oral cavity they are also classified as non-odontogenic cystic lesions ; the most frequent sites are the midline of the floor of the mouth  and hard palate . Rare caWe report on a very rare case of epidermoid cyst of the mandibula.A 30-year-old women was referred at the Oral Surgery Department of the Dental School of the Second University of Naples in January 2008, for the treatment of a lesion, that was incidentally seen on a routine panoramic radiograph obtained for dental care. The radiograph showed a radiotrasparent, monolocular area on the right side of the mandibula, located between the roots of a canine and the first premolar with a very large displacement of the roots of these teeth Figure . ClinicaThe occurrence of dermoid cysts in the oral cavity is extremely rare -5. DiffeIn conclusion, we describe a very rare case of dermoid cyst of the mandibula, successfully diagnosed and managed by surgical excision through intraoral access.The authors declare that they have no competing interests.DM and LL performed the surgical procedures and contributed to the analysis of the clinical data. NF performed the histological examination of the lesion. AB performed the histological examination of the lesion and was a major contributor in writing the manuscript together with DM. All authors read and approved the final manuscript.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.


We report a case of luteinizing thecoma in a 58-year-old postmenopausal woman who presented with progressive androgenic features and hypertension of one year duration. She did not notice a significant change in her body weight or appetite. Her total serum testosterone level was 4.5 ng/mL. Ultrasound scan revealed a normal-sized uterus and a right-sided solid ovarian mass of 5 cm × 5 cm. Left ovary was normal. She had a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and an omentectomy performed. Histological examination confirmed the diagnosis of luteinized thecoma. This case illustrates the necessity to consider the rare possibility of luteinized ovarian thecoma as a cause for virilization in a menopausal woman. Virilization due to hyperandrogenism caused bya luteinizedthecoma in a postmenopausal woman is extremely rare.A 58-year-oldpostmenopausal woman of two living children presented to the university gynecologicalunit, National Hospital of Sri Lanka, Colombo, complaining ofprogressive hair loss and male-type hair distribution of one year duration. Thesesymptoms were accompanied by lower abdominal pain for the last four monthsduration. She did not notice a significant change in her body weight orappetite. There was no postmenopausal bleeding or vaginal discharge.μgdaily.She was diagnosedto have hypertensionfor the last one and half year duration and was on regular treatment with agood control of blood pressure. She had undergone hemithyroidectomy at the ageof 44 years due to a cold nodule. Histology had revealed a follicular adenomaand she was treated with L-thyroxine 50 On examination,she had alopecia, frontal balding, and hirsuitism involving the face, chin,upper back, chest, upper and the lower abdomen giving a score of 14 frommodified Ferriman and Gallwey scoring system .She had clitoromegally. Her respiratory andcardiovascular systems were normal. Pelvic examination revealed a solid rightovarian mass of 5 cm size and it was confirmed by pelvic ultrasound scan. Itwas a solid mass with an intact capsule. The uterus and the other ovary werenormal and there was no free fluid. Liver and the other abdominal organs werenormal. Computed tomography (CT-scan) of the abdomen and pelvis revealed a well-definedsolid tumor of 5.5 × 3 × 6 cm in right adnexal region . Other pLaparotomyrevealed a solid ovarian tumor of 5 cm with an intact capsule in the right ovary. The left ovary and the uterus were normal . There wHistologicalexamination of sections from the right ovarian mass stained with haematoxyline andeosine revealed cell nets comprising uniform cells with round bland nuclei andeosinophilic cytoplasm. Mitotic figures were sparse. They were surrounded by aproliferation of elongated spindle cells with bland nuclei . AhistoThe patient was reviewed two months after the surgery. Hirsuitism was still there, but there was regression of virilism. Her serum testosterone was 0.09 ng/mL  whenshe was reviewed ten months after surgery and there was a significant decreasein both hirsuitism and virilism.Hyperandrogenismis one of the most common endocrine disorders in women accounting for largenumber of visits to the general practitioners and the gynecologists. Polycystic ovary syndromeaccounts for majority of them in the reproductive aged women. Virilization dueto hyperandrogenism is rare in postmenopausal women. Hyperandrogenism due to aluteinized thecoma in a postmenopausal woman is extremely rare. Review of theindexed literature  revealed only a handful of cases of luteinized thecomain a postmenopausal patient who had presented with virilization and alopecia . The hisOvarian thecomais a rare hormonally active tumor of stromal cell origin and represents less than 1%of all ovarian tumors. It occurs most often in perimenopausal andpostmenopausal women . SeventyThe diagnosis of a virilizing ovarian tumor is most often complicated by the findings ofclinical featuressuggestive of Cushing's syndrome. However, in our patient an adrenal tumor andCushing's syndrome were excluded by ultrasound scan, CT, of the abdomen and bybiochemical tests.Elevation of serumtestosterone level above 2 ng/mL has been proposed as a significant level whichindicates the presence of an androgen secreting tumor. Testosterone levels inpolycystic ovarian disease and stromal hyperthecosis are often below this level. Serumtestosterone level of 4.5 ng/mL in our patient was strongly indicative of thepresence of an androgen secreting ovarian tumor . Size ofSurgicalintervention is generally adopted as the primary mode of treatment. Owing tothe postmenopausal status of our patient, it was recommended to proceed withtotal abdominal hysterectomy and bilateral salpingo-oophorectomy as therapy fora presumed ovarian malignancy. However, histology of the affected ovary did notreveal any possibility of malignancy. Serum testosterone level returned tonormal after surgery and the patient was happy and contended when she wasreviewed ten months after surgery since there was significant improvement inher clinical status. This case illustrates the necessity to consider the rarepossibility of luteinized ovarian thecoma as a cause for virilization in amenopausal woman.


Schwannoma is a rare primary tumor originating in the neural sheath with a good prognosis. The management is surgical. We present a case in which a retroperitoneal mass arising from the adrenal gland was excised and histopathology revealed a schwannoma with coexisting tuberculosis. This case report highlights the need to be aware of the potential coexistence of tuberculosis in any case of incidentaloma, especially due to resurgence of tuberculosis as a global epidemic with the increasing incidence of HIV and AIDS. To the best of our knowledge, this is the first reported case of a schwannoma and tuberculosis coexisting in the adrenal gland. Schwannomas are usually benign tumors that arise from the nerve supporting the Schwann cell. Visceral schwannomas, in particular, juxta-adrenal and adrenal schwannomas are exceedingly rare. We report an unusual case of a schwannoma coexisting with tuberculosis in the adrenal gland, which is the first of its kind to be reported to the best of our knowledge.A 42-year-old Indian male presented with pain in the left flank after a trivial fall while walking. Ultrasonography of the abdomen incidentally revealed a well-defined mass arising from the right adrenal gland. The patient was not a known hypertensive and had no systemic or constitutional symptoms suggestive of tuberculosis.General physical examination was unremarkable. On abdominal examination, a 10 × 8 cm ill-defined, non-tender, hard mass was felt in the right lumbar region.Complete blood count, erythrocyte sedimentation rate (ESR), serum electrolytes, blood sugar, urinary catecholamines and vanillyl mandelic acid (VMA) were within normal limits. A contrast enhanced computed tomography (CECT) scan of the abdomen and pelvis revealed a mass with central necrosis and contrast enhancement arising from the right adrenal gland.Laparotomy was done and a well-encapsulated 12 cm × 10 cm × 4 cm tumor arising from the right adrenal gland was seen which was excised completely .Histopathological examination revealed an adrenal schwannoma with peripheral granulomatous inflammation comprising epithelioid cells and Langhans giant cells suggestive of tuberculosis . Ziehl-NSchwannomas make up approximately 1-5% of all retroperitoneal masses. Benign sMost patients with retroperitoneal schwannomas present with vague abdominal or back pain. Patients are usually diagnosed in the third through fifth decades and there is an equal predilection for men and women. Laboratory studies are typically unremarkable. The CT scan usually reveals a homogeneous, solid-appearing, encapsulated mass. As schwannomas enlarge, however, they may appear cystic, secondary to hemorrhage or central necrosis.The surgical approach should focus on complete excision of the mass. Patients undergoing complete surgical resection tend to do well without evidence of early recurrence.Tuberculous adrenal mass with no other extra-adrenal sites of tuberculosis is a very rare entity. Etiological diagnosis is usually established only after histological examination of the operative specimen. With theThis case report highlights the need to be aware of the potential coexistence of tuberculosis in any case of incidentaloma, especially due to resurgence of tuberculosis as a global epidemic with the increasing incidence of HIV and AIDS.


Trichophytobezoars are uncommon foreign bodies, formed by hairs and vegetable matter with impacted food particles. We report an unusual case of a 5-year-old girl with large terminal ileal trichophytobezoar causing perforation peritonitis. Trichobezoar is derived from trichos (hair) and bezoar (foreign body). The word bezoar is derived from the Arabic “badzehr” or from the Persian padzahr and it means antidote. Trichophytobezoar is composed of mixed hairs and indigestible vegetable fiber content. Other contents of non-biological origin (Iniobezoar) e.g, medications, foreign bodies such as coins, buttons, screws, parts of toys, bubble gum, etc. have also been described.2Clinically trichophytobezoars are found most commonly in stomach. We present a case report of a trichophytobezoar found in terminal ileum with a tail extending distally into cecum and ascending colon, causing a large perforation with perforation peritonitis. After evaluating the bezoar post-operatively, it appeared to be a very rare case of a gastric bezoar with tail (Rapunzel syndrome), passing off the pylorus in toto and causing small bowel obstruction distally.A 5-year-old girl was admitted with the complaints of chronic constipation with abdominal pain. Patient was a thin but otherwise healthy looking girl. She was admitted 3 months earlier with similar complaints and was treated conservatively with intravenous hydration. A plain abdominal X-ray showed dilated small bowel loops with no free air. There were no signs of generalized peritonitis. After initial resuscitation, a CT scan with oral and intravenous contrast was done. CT scan was suggestive of small extra-luminal air bubbles on the outside margin of a distal small bowel loop . Also a An exploration laparotomy was performed through the right lower quadrant transverse incision. A large trichophytobezoar was identified through the perforated terminal ileum . PerforaIn the pediatric population, the common types of bezoars are lactobezoars, trichobezoars, phytobezoars and foreign bodies. The first description of bezoars, as a human disease was done by the Frenchman Baudament in 1779. The removal of bezoars surgically, was first carried out by Schonborn in 1883.[In the pediatric population, trichobezoars are seen most commonly in females. According to the review by DeBakey and Ochsner, 18% of cases occurred during the first decade of life, 37% during the second and 27% in the third. The earliest occurrence was reported by Gaston in a one-year-old infant. Incidencet al. separated the complications associated with bezoars into mechanical and traumatic categories, the former incorporating gastric outlet and intestinal obstruction and the later necrosis, ulceration, hemorrhage and perforation.[Trichobezoar commonly forms in the stomach. Trichobezoar from stomach can pass into small intestine in three ways, when fraforation. Other coforation.The recommended treatment for large or complicated trichophytobezoars is surgery. Depending on the presentation, surgery can vary from simple gastrotomy and removal of bezoar to intestinal resection for multiple or large perforations. Gastrotomy is not indicated in all cases. If patient presents with small bowel obstruction, enterotomy may be required instead. Endoscop


Rheumatoid nodules are common extra-articular findings occurring in 20% of rheumatoid arthritis patients. They develop most commonly subcutaneously in pressure areas (elbows and finger joints) and may occasionally affect internal organs including pleura, lungs, meninges, larynx, and in other connective tissues elsewhere in the bodyWe present the case of a 62-year-old male who presented with a midline neck mass. Clinically it moved on swallowing and tongue protrusion-suggesting attachment to the thyrohyoid membrane. Ultrasound examination revealed a cystic lesion in the absence of cervical lymphadenopathy in a non-smoker. The neck was explored and histological examination of the excised lesion which was attached to the thyrohyoid membrane revealed a rheumatoid nodule.A rheumatoid nodule of the thyrohyoid membrane is very rare. The triple diagnostic scheme of clinical examination supplemented with ultrasound and guided fine needle aspiration for neck lumps remains valid in most cases. If excision is indicated we feel it should be performed in such a manner that the scar tract could easily be encompassed in a neck dissection excision should definitive histological examination be adverse. We suggest that when dealing with patients with established rheumatoid arthritis one should consider a rheumatoid nodule as a differential diagnosis for any swelling on the patient whether it be subcutaneous or deep. Rheumatoid nodules commonly occur on the extensor surface of the forearms, in the olecranon bursa, over joints and over pressure points . In almoBenign rheumatoid nodules however, can occur usually in healthy young people with no evidence of rheumatoid arthritis or systemic lupus erythematosus .Cases have been reported of rheumatoid nodules discovered at unusual sites which include upper eyelid, distal region of soles, vulva and internally in the gallbladder, lung, heart valves, larynx and spine. In some patients rheumatoid nodules were first detected in these sites .We report a case of rheumatoid nodule found in another unusual site namely attached to the body of the hyoid bone.A 62-year-old man with known rheumatoid arthritis on gold injection and indomethacin presented to the outpatient department with a painless swelling over left side of neck below the chin, which he noticed for the last 3 weeks. There was no history of dysphagia, hoarseness, and respiratory difficulty or weight loss. There was no other swelling in the head and neck region. The man was a non-smoker who did not take alcohol.On physical examination, a swelling the size of a grape fruit can be seen over the superior region of the left thyroid cartilage lamina. It was non tender, felt cystic, non fluctuant, and did not transilluminate. It enlarged when he blowed up his cheeks and it moved when he swallowed and also on tongue protrusion. He did not have cervical lymphadenopathy and examination of his pharynx and indirect laryngoscopy revealed no abnormalities. Ultrasound suggested that it was fluid filled Figure .At this point, the main benign differential diagnoses included a laryngocoele, thyroglossal cyst, plunging ranulae, simple cyst or lipoma. Exploration and excision was recommended and subsequently undertaken.At surgery, a soft rounded mass the size of a grape fruit was found deep to the thyrohyoid muscle. This was dissected all round and a pedicle from the mass was traced extending to the deep surface of the body of the hyoid bone. The hyoid bone was sheared and the pedicle divided Figure . The hisPatient made an uneventful recovery and follow up a year later showed no recurrence.The patient was asymptomatic from the swelling but was obviously very concerned. Clinically it did not appear to be malignant. As expected, the patient's rheumatoid arthritis was active at the time and interestingly there were no obvious rheumatoid nodules found elsewhere.A rheumatoid nodule of the thyrohyoid membrane is very rare . PatientIn this case, the nodule was traced to the thyrohyoid membrane; however, this does not preclude microscopic attachment to one of the intrinsic joints of the larynx undergoing rheumatoid degeneration. The fibrous attachment may occur either around the cartilages of the larynx or through the anatomical points of egress of blood vessels. This is because even the small joints of the larynx may be involved by the full spectrum of pathologic changes and that both cricothyroid and cricoarytenoid joints are equally prone to the various stages of inflammation, joint destruction and ankylosis that characterize the rheumatoid arthritis elsewhere .These lesions may represent significant diagnostic dilemmas in patients with clinical suspicion of malignancy. In this setting, fine-needle aspiration (FNA) of the nodules may be the simplest and most appropriate diagnostic approach .The triple diagnostic scheme of clinical examination supplemented with ultrasound and guided fine needle aspiration for neck lumps remains valid in most cases. If excision is indicated we feel it should be performed in such a manner that the scar tract could easily be encompassed in a neck dissection excision should definitive histological examination be adverse.As in this case the microscopic appearance of these 'extra-articular' rheumatoid nodules is varied ,6. NecroAlthough there are no clinical clues that would lead to the preoperative diagnosis of rheumatoid nodule of the vocal cord and larynx, the index of suspicion should be high in patients with rheumatoid arthritis who are hoarse. However, overt joint symptoms do not appear to be a necessary concomitant of these lesions .We suggest that when dealing with patients with established rheumatoid arthritis or systemic lupus erythematosis, one should consider a rheumatoid nodule as a differential diagnosis for any swelling on the patient whether it be subcutaneous or deep.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 author(s) declare that they have no competing interests.TU: contributed to conception and design, carried out the literature research, manuscript preparation and manuscript review.WJ: contributed to conception and design, carried out the literature research, manuscript preparation and manuscript review.FS: contributed to conception and design, carried out the literature research, manuscript preparation and manuscript review.SS: contributed to conception and design, carried out the literature research, manuscript preparation and manuscript review.CH: contributed to conception and design, carried out the literature research, manuscript preparation and manuscript review.AW: contributed to conception and design, carried out the literature research, manuscript preparation and manuscript review.AS: contributed to conception and design, carried out the literature research, manuscript preparation and manuscript review.All authors read and approved the final manuscript.


A 34-year-old tetraplegic patient with suppurative epididymitis was found on follow-up examination and ultrasonography to have a testicular mass. The radical orchiectomy specimen contained an undifferentiated spindled sex cord-stromal tumor arising in the rete testis. Testicular sex cord-stromal tumors are far less common than germ cell neoplasms and are usually benign. The close relationship between sex cords and ductules of the rete testis during development provides the opportunity for these uncommon tumors to arise anatomically within the rete tesis. This undifferentiated sex cord-stromal tumor, occurring in a previously unreported location, is an example of an unusual lesion mimicking an intratesticular malignant neoplasm. Physiciansfrequently encounter scrotal lesions which, despite a careful history, physicalexamination, and sonography, remain an enigma. The finding of a discrete massin the testis requires surgical exploration to exclude a malignant neoplasm. Wepresent a patient whose radical orchiectomy revealed a sex cord-stromal tumorarising within the rete testis, which to the best of our knowledge is apreviously unreported location for this uncommon tumor.A34-year-old man with C3-C4 tetraplegia presented with right hemiscrotalswelling and purulent drainage from the scrotal skin. Physical examinationdisclosed a firm right testis mass, a 2 cm scrotal fluctuance, and abscessdrainage through the skin at the dependent, posterior aspect of the righthemiscrotum. The abscess had spontaneously opened and drained to a degree thathe did not need a former incision and drainage procedure. An ultrasound  revealedThetesticle measured 2.5 cm by 2.1 cm and the attached segment of spermatic cordmeasured 7.3 cm × 2.1 cm × 1.1 cm. The epididymis was firm and slightly diffusely enlarged. A 0.9 cmwell-circumscribed, firm tan-white nodule was identified in the testicularhilum . The remMicroscopicexamination  and an extratesticular portioncomprised of several vesicular structures (extratesticular bullae retis) whichform the efferent ductules . As in tSex cord-stromaltumors (SCSTs) representapproximately 3% of testicular neoplasms and are rare outside the testicle . In the The behavior andprognosis of SCSTs is difficult to predict. As many as 80–90% of theselesions behave in a benign fashion, but they cannot be differentiated from germcell tumors and their behavior cannot be predicted clinically orsonographically . Feature