To characterize the imaging and clinicopathological features of primitive neuroectodermal tumors (PNETs) arising in intra-abdominal and retroperitoneal regions.Eighteen patients with histopathologically proven intra-abdominal and retroperitoneal PNET were enrolled; computed tomography was performed for all cases, and magnetic resonance imaging was performed for a single case. Typical computed tomography and magnetic resonance imaging findings, including morphology, texture and enhancement features, as well as clinicopathological characteristics and prognosis data were retrospectively analyzed.Of eighteen PNET patients, fifteen were male and three were female, with a median age of 36 years . The onset of symptoms was most often nonspecific and insidious. The mean tumor diameter was 7.2 cm , with necrosis in fifteen cases, cystic changes in eight, partition structure in five, calcification in five, hemorrhage in two, and mural nodules in one. Contrast enhanced computed tomography showed multiple tiny feeding arteries within the masses in six cases, resulting in a crab-like appearance, and mild ring enhancement pattern in five cases. Eleven cases showed surrounding invasion and metastasis. Of the eighteen PNET cases, nine cases showed smooth, well-defined margins, and nine cases had irregular, ill-defined margins. A median survival was 10.0±1.6 months. However, chemotherapy had efficacy on patients even those with advanced disease.Primary intra-abdominal and retroperitoneal PNETs are rare, and imaging features documented here may help the diagnosis of this severe disease. Notably, two signs present in retroperitoneal PNET tumors, including a mild ring enhancement pattern and a crab-like appearance of the tiny feeding arteries, may have the potential to help us improve the ability to make a relatively reliable diagnosis. Primitive neuroectodermal tumors (PNETs) are a group of extremely rare malignant tumors that originate from the neuroectoderm and are composed of primitive undifferentiated small round cells ,2. BasedAlthough some studies involving intra-abdominal and retroperitoneal PNETs have been reported and some radiological features of these tumors have been described, this disease is still poorly recognized and easily misdiagnosed due to the lack of a typical clinical presentation, a low incidence in the clinic and an insufficient number of radiological studies ,2,6,9–11Herein, we conducted a retrospective study of 18 patients with pathologically proven intra-abdominal and retroperitoneal PNETs at our hospital to identify computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of this rare disease. The treatment and prognosis of this disease are also discussed.Fig 1.The research design of this retrospective study is shown in Between March 24, 2011 and April 20, 2016, 70 consecutive patients with pathologically confirmed pPNETs (extraosseous primary tumors) were admitted to our hospital. The participant information was de-identified and obtained from our hospital database.The inclusion criteria were patients with PNETs originating in the intra-abdominal or retroperitoneal region. The exclusion criteria were patients without CT or MRI examinations before surgery or incomplete clinical data .CT scans were obtained using a spiral CT scanner . The scanning parameters were as follows: for Acquilion One—120 kVp, 200 mA, 1-mm section thickness and 5-mm reconstruction thickness; for Somatom Definition—120 kVp, 223 mA, 1-mm section thickness and 5-mm reconstruction thickness. All patients underwent unenhanced and enhanced scans. Iohexol, a nonionic iodine contrast agent, was used in enhanced scans at a dose of 1.5 ml/kg (iodine concentration of 300 mg/ml) and an injection flow rate of 3–4 ml/s. Images were obtained at each phase, which included plain scan, arterial phase (30 s), venous phase (60–70 s) and delayed scan (180 s).One patient was examined with a 1.5 T MRI unit  using an eight-channel array coil. The scanning parameters were as follows: 4-mm section thickness, 4-mm intersection gap, 30×30 field of view and 384×269 matrix. A respiration triggered turbo spin-echo (TSE) T1-weighted sequence  and a TSE T2-weighted, fat-suppressed (TSET2) sequence  were used. TSET1-enhanced MRI was performed using Gd-DTPA as the contrast agent. A dose of 0.2 mg/kg was used with an injection flow rate of 1.5 ml/s. Arterial phase imaging was performed approximately 25–30 s after injection, venous phase imaging approximately 50 s after injection and delayed phase imaging approximately 5 min after injection.CT and MRI images were reviewed independently by two experienced abdominal imaging radiologists (with more than 10 years of experience). The findings were recorded by consensus. CT and MRI characteristics were investigated, with emphasis on the location, size and margin of the lesion (well-defined or poorly defined); internal content ; pattern of enhancement; and changes of the adjacent structures. The lesion size was measured at its greatest diameter. For the internal content, the “cystic” lesions were defined as those containing typical fluid-like attenuation or signal intensity on CT or MRI and showing rim-like enhancement on contrast-enhanced CT and MRI. Density on non-contrast CT scans and signal intensity on T1- and T2-weighted MRI images were also documented subjectively, as were enhancement patterns on contrast-enhanced CT and MRI. The pattern of enhancement was categorized as homogeneous or heterogeneous. In addition, we evaluated the blood supply arteries and surrounding tiny feeding arteries of the tumor. The mild ring enhancement of the tumor was observed in the venous phase.The pathological sections (including the hematoxylin and eosin (HE) and immunohistochemical (IHC) staining) of all enrolled PNET patients were reanalyzed independently by two experienced pathologists. The findings were recorded by consensus. The expression of cluster of differentiation 99 (CD99), neuron-specific enolase (NSE), vimentin (VIM), synaptophysin and S100-protein was examined.Statistical analysis of survival was performed using the Kaplan-Meier method, and the results were examined using the log-rank test. A P value less than 0.05 was considered statistically significant. Statistics were calculated using SPSS 15.0 .This study was conducted in accordance with the Declaration of Helsinki, all its amendments and national regulations. This retrospective study was approved by the hospital’s Institutional Review Board (No. 201512538). Written or verbal informed consent was obtained from all patients or their immediate families.Table 1. Detailed data can be found in Table 2.According to the study design, 18 consecutive patients with pathologically proven PNET arising in intra-abdominal and retroperitoneal regions were enrolled in this study. The clinicopathological data are summarized in The study was composed of eighteen patients  with a median age of 36 years . The onset of symptoms was most often nonspecific and insidious, including mild low back pain or abdominal pain in eleven patients, hematuria and polyuria in two, and abdominal distension accompanied by bladder bowel dysfunction in one. The tumors in the remaining four patients were incidentally detected.). Detailed CT and MRI findings are shown in S1 Table.CT (n = 18) and MRI (n = 1) images obtained from these eighteen patients were retrospectively reviewed. Among them, fifteen had a mass located in the retroperitoneal space and three in the intra-abdominal region . DetaileFig 2F). Multiple retroperitoneal metastatic lymph nodes (mainly around the iliac vessels) were observed in the mesentery case.Tumors arising in the intra-abdominal region derived from intra-abdominal organs; one mass in the bladder wall , one in Fig 3). Clearly defined blood supply arteries, which are usually located at the edge of the tumor and are relatively dense in some regions, were found in six cases. The arteries were usually located on the side of the tumor, which was close to the artery supplying the corresponding region where the mass was located. Interestingly, tiny feeding arteries extending inside the tumor from such regions could be observed in six cases, and they presented with a crab-like appearance . A ring-like enhancement pattern was found in five cases, which indicates that the enhanced ring occupied more than a half circle surrounding the mass on portal venous phase images . Among the fifteen cases, multiple perirenal drainage veins were observed in one case, and an enlarged tortuous tumor-draining vein that converged into the right external iliac vein was observed in another case. In general, the majority of tumors displaced the surrounding tissues. However, tumor invasion into adjacent tissues and organs , celiac axis, renal pelvis, left renal vein and artery) was observed in four cases, and a left renal vein tumor thrombus was confirmed in three cases. Three cases with masses arising in the kidney showed increased volume of the kidney; however, they were well confined within the renal contour. A right pleural invasion was observed in one case.Of the fifteen retroperitoneal PNET cases included in this study, fourteen single solid masses and one single mixed solid cystic mass were detected. Among them, five were located in the adrenal region bilaterally, three in the kidney bilaterally, two in the renal hilum, two in the hepatogastric space, one in the presacral region, one in the head of the pancreas, and one in the lesser curvature of the stomach. The size of these masses ranged from 3.0 to 12.1 cm, with a mean diameter of 7.2 cm. Eight cases had a well-defined margin, and the other seven cases were ill-defined. On non-contrast CT scan (n = 15), the attenuation of all masses was mild-to-moderate, heterogeneous hypo-attenuated compared with the adjacent muscle. All fifteen patients underwent contrast-enhanced CT scan, and the masses exhibited mild or intermediate heterogeneous (n = 12) and homogeneous (n = 3) enhancement, whereas the cystic portion of the masses usually demonstrated a peripheral rim enhancement pattern. Necrosis was found in thirteen cases, partial or peritumoral cyst degeneration in seven, septa in five, calcification in four, hemorrhage in two, and mural nodules in one  and partial resection in six patients (group two). Biopsy was performed for seven patients (group three), four of which were performed during exploratory laparotomy. All patients were recommended to receive systemic chemotherapy; however, only six patients were eventually treated with chemotherapy, and the remaining twelve refused due to economic considerations. Detailed data are provided in Fig 6A) (detailed data are provided in Table 2). Group one had a relatively better prognosis . Only two patients were still alive at the end of this retrospective study, and they belonged to group one  and group three  , both of whom received systemic chemotherapy. The remaining sixteen patients ultimately died within 1.5 years of diagnosis . In addition, three patients of group three who underwent systemic chemotherapy appeared to have a relatively longer survival .The prognosis of these eighteen patients was extremely poor, with a median survival of approximately 10.0±1.6 months . Cells were arranged into nests or cords with rosettes (Homer-Wright rosettes) . Generally, a significant amount of space in the tumor was occupied by dense tumor cells with scattered stroma. Interestingly, stromal elements of the mass usually extended into the central region of the tumor, which showed a crab-like appearance similar to that observed on the CT images . IHC analysis of the eighteen tumors revealed that seventeen (94.4%) were positive for CD99, ten (55.6%) were positive for NSE, twelve (66.7%) were positive for vimentin and four (22.2%) were positive for S100 protein. Many cells demonstrated abnormal increased karyokinesis, with a Ki-67 index in the range of 20%-90%.Most masses showed vague boundaries between the tumor edge and normal tissue, with significant necrosis, which were mostly consistent with the appearance on CT and MRI. Microscopically, these tumors were composed of atypical small round cells with scant cytoplasm, which were arranged in nests with a small amount of stromal components (including collagen fibers and blood vessels)  usually present as local wall thickening ,17, as wMasses arose in bilateral kidneys of three renal PNET cases, resulting in an increased volume of the involved kidney. However, lesions did not cross the renal capsule, which indicates that they were well confined within the kidney contour. This finding is consistent with previous reports in the literature ,6 and suA large mass with cystic degeneration and necrosis is a common feature of CT imaging for PNETs in the abdominopelvic cavity , where cBased on our review of the literature, we identified two CT features in our fifteen retroperitoneal cases that have not been previously discussed seriously and may have the potential to become characteristic imaging features of retroperitoneal PNET. First, a mild ring enhancement sign was observed in 40.0% (6/15) of cases, including three cases located in both adrenal regions, two in the hepatogastric space and one in the pancreas. This CT feature may directly represent the enhanced tumor pseudo-capsule and may be a reflection of a high proliferative ability of the mass, as discussed above. Second, 40.0% (6/15) of cases clearly presented with tiny feeding arteries in the mass, which showed a crab-like appearance on enhanced images. This feature may partially reflect the distribution patterns of intra-tumoral stroma see . In 53.3The first-line treatment for pPNET is a multimodal treatment strategy consisting of surgery, neo-adjuvant or adjuvant chemotherapy or radiotherapy . In partWe acknowledge that the number of cases in this study was small, which may have affected the reliability of the conclusions. Due to the rarity of the disease, a small sample size is almost inevitable until a large multi-institutional randomized controlled trial (RCT) experiment can be performed. Therefore, further study with a large case number would be necessary to provide sound evidence for our results in the present study. Further limitations of the present study also include the lack of detection of translocation (EWS-FLI) in our patients at diagnosis, even though they were all evaluated with an extensive IHC panel.In summary, the imaging features of intra-peritoneal and retroperitoneal PNETs are nonspecific. They mainly occur in adults and usually present as large, ill-defined, irregular or lobular moderate heterogeneous masses with cystic and necrotic areas, and rarely calcification and hemorrhage, as well as mild to moderate heterogeneous enhancement. However, two signs present in retroperitoneal PNET tumors, including a mild ring enhancement pattern and a crab-like appearance of the tiny feeding arteries, may have the potential to help us improve the ability to make a relatively reliable diagnosis of this disease. The likelihood of PNET diagnosis should be considered when a diagnosis of a common tumor is not favored by imaging features.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 Fig(DOCX)Click here for additional data file.


Hemoperitoneum due to a ruptured retroperitoneal varix is an exceedingly rare condition and a poor prognostic sign with catastrophic and life-threatening complication of portal hypertension. We present a unique case of a 56-year-old female with cirrhosis secondary to primary sclerosing cholangitis who presented with acute abdominal pain and hypovolemic shock prior to a cardiac arrest following a ruptured retroperitoneal varix without prior esophageal varices and a newly identified intrahepatic cholangiocarcinoma. The clinical presentation with abdominal pain and hemorrhagic shock is consistently reported in the relevant literature. Early recognition affords appropriate management and urgent surgical intervention leading to survival. Variceal hemorrhage is a common complication of portal hypertension with reduction in mortality in recent decades secondary to early identification and surgical management. Spontaneous hemorrhage from ruptured retroperitoneal varices is a rare event with less than thirty-five reported cases in the literature since 1958 . The cli3; INR, 1.4; creatinine, 1.2 mg/dL; albumin, 1.6 g/dL; and bilirubin, 1.2 mg/dL. Initial resuscitation included three liters of normal saline (NS), two units of packed red blood cells (PRBC), and two units of fresh frozen plasma (FFP). Hemodynamics were stable following resuscitation and therefore computed tomography (CT) was performed (A 56-year-old female with cirrhosis secondary to primary sclerosing cholangitis without prior varices presented with acute onset of intense abdominal pain and dizziness. Pertinent presenting vitals and laboratory values included a systolic blood pressure of 60 mmHg; hemoglobin, 6.8 g/dL; platelets, 101,000/mmerformed . The repPortal hypertension in cirrhosis develops from the resistance to blood flow and diversion away from the liver through collateral circulation to low-pressure systemic vessels. Resultant increase in intravenous pressures may lead to the development and dilation of portosystemic collateral circulation. The anastomoses between portal and systemic circulations occur at locations in which veins draining into the dual systems are juxtaposed and are commonly encountered at the gastroesophageal junction, anorectal plexus, and umbilical vein , 7, 8. IHistorically, trauma and nonmalignant gynecological conditions account for more than 90% of intra-abdominal hemorrhage, whereas hemorrhagic ascites is encountered in only 5% of cirrhotic patients , 10. SpoIn nearly all instances, rupture of intra-abdominal varices has been encountered in the setting of cirrhosis with evidence of coexisting portal hypertension and esophageal varices. Prior variceal hemorrhage or variceal band ligation has not been present , 10, 11.The diagnosis has been established via paracentesis, angiography, ultrasound, computed tomography, or laparotomy. Literature notes that CT identifies the retroperitoneal varices more reliably than angiography , 13. Of Spontaneous hemoperitoneum in cirrhotic patients is a poor prognostic sign as it is associated with increased risk of hepatorenal syndrome and high mortality rate , 10. Uni


This case report presents the successful surgical treatment of a symptomatic open apex upper central incisor with a failed overfilled mineral trioxide aggregate (MTA) apical plug. Unintentional overextension of the MTA had occurred two years before the initial visit. An apical lesion adjacent to the excess MTA was radiographically detectable. Endodontic surgery was performed using calcium-enriched mixture (CEM) cement as a root-end filling material. Curettage of the apical lesion showed a mass of unset MTA particles; histopathological examination revealed fragments of MTA and granulation tissues. Up to 18-month follow-up, the tooth was clinically asymptomatic and fully functional. Periapical radiograph and CBCT images showed a normal periodontal ligament around the root. In conclusion, favorable outcomes in this case study suggested that root-end filling with CEM cement might be an appropriate approach; in addition, however many factors probably related to the initial failure of the case, the extrusion of MTA into the periapical area should be avoided. Traditionally, calcium hydroxide (CH) has been the material of choice for the management of non-vital teeth with open apices. However, CH apexification has several disadvantages: it takes several appointments to replace CH, there are concerns about patient cooperation, evidence shows dentin brittleness and coronal microleakage when CH is used, and there is an increased risk of cervical root fracture . Due to et al. [et al. [Obtaining an optimal apical seal in teeth with immature apices is challenging due to the wide apical foramen that requires a large volume of filling material that may extrude into the periradicular tissue thus eliciting foreign-body reactions . Specialet al.  showed t [et al.  describe [et al. , 16.This case report describes the successful surgical treatment of a symptomatic immature upper central incisor tooth with an overextended MTA apical plug and a periapical lesion using CEM cement.A 24-year-old female with a noncontributory medical history was referred to the Mehr Dental Clinic due to periodic swelling and discomfort associated with her upper left central incisor. The report from the referring dentist noted that the tooth had been treated with a white ProRoot MTA plug  two years ago. The records detailed a history of impact trauma and pulp necrosis 17 years ago. Initial radiographs showed an immature tooth with a periapical rarefaction and an extruded MTA plug . IntraorThe patient was presented with several treatment options including tooth extraction and implant replacement. However, patient elected to save the tooth, and therefore, endodontic surgery was recommended. The risk and benefits of the proposed treatment were described, and informed consent was obtained.The surgical procedure was performed by an Endodontist (S.A.). The patient was anesthetized with 2% lidocaine with 1:80,000 epinephrine  and an Ochsenbein Luebke flap was raised. Following reflection of the flap and initial curettage, a mass of dark unset MTA was found . MTA remThe patient presented for a recall appointment 1 year later. Clinical examination revealed no sensitivity to percussion or palpation, and the tooth was fully functional with normal probing depths. Radiographic examination showed the apical lesion had healed with a normal PDL established . The CBCThe presented case shows successful surgical management of a symptomatic central incisor with an open apex, poorly sealed apical filling and overextended unset MTA apical plug. In this case a considerable amount of MTA was extruded into the apical area during placement. MTA might be dislodged through the wide apical foramen or be pushed actively beyond the apical foramen. The extruded MTA seems to have been compressed or moved out from its original location. In some case reports with at least 12 months follow-up, apexification and periodical healing occurred even when a considerable amount of MTA was extruded into the periodical tissue , 18. SeaRevitalization and retreatment were not attempted for the present case because complete removal of root canal filling materials  from root canals and periradicular tissue without causing damage was impossible. Furthermore, previous root canal preparation, and particularly, overfilled unset MTA might have had adverse effects on stem cells and periapical healing. In addition, current literature regarding regenerative endodontics in retreatment cases is scarce.i.e. blood, serum and pus) as well as the pH of the treatment anatomy can affect the chemo-physical properties of the MTA [The nature of periradicular tissue fluids ( the MTA -26. Rese the MTA .In addition, blood contamination negatively influences the formation of CH in the early stage of MTA hydration process . CH inteCalcium-enriched mixture cement has been recently introduced as a hydrophilic tooth colored endodontic material. CEM cement is composed of calcium oxide, calcium sulfite, phosphorus oxide and silica as major elements . It has This paper describes the treatment outcomes of CEM cement as a root-end filling material in a failed apexification. In the presented case, use of CEM cement as a root-end filling material showed successful clinical and radiographic outcomes with 18 month follow-up. The CBCT image shows the complete healing of apical lesion and reformation of the PDL. This is consistent with the studies have shown that, like MTA, PDL regeneration, osteogenesis, cementogenesis and dentino-genesis occur in contact with CEM cement , 33-35.In conclusion, there is a chance that overextrusion of MTA can cause delay in healing of the apical lesion, and MTA can left unset in the periapical lesion. Regarding the advantages of CEM cement over MTA including improved color, easier handling, lower cost and antibacterial effects, CEM may be considered as a proper biomaterial to be used as a root-end filling biomaterial in teeth with open apices. However, more clinical studies with longer follow-ups are recommended.


Introduction. Leiomyomas are common benign tumours of female reproductive tract and are rarely seen in extrauterine location. Case Report. We report an interesting case of a free lying abdominal leiomyoma presenting as a painless abdominal lump in an elderly gentleman. Discussion. Primary abdominal leiomyomas are uncommon and require surgical removal if symptomatic. Leiomyomas are the commonest benign tumour of the female reproductive tract and are found in 20% of women of reproductive age. Extrauterine leiomyomas are rare and usually benign and cause diagnostic dilemmas as they may mimic a malignancy . LeiomyoA 72-year-old male patient with no comorbid illnesses came with chief complaints of constipation since 1 year and left upper abdominal lump since 3-4 months. There was no history of bleeding per rectum, vomiting, or loss of weight. He had no previous surgical history. On examination there was a palpable lump of 9 × 9 cms in the left hypochondrium extending into the epigastrium and left flank. Lump was hard and surface was smooth, showing minimal mobility and upper border could not be defined. Patient had undergone a colonoscopy elsewhere which was normal. A contrast CT abdomen was done which showed a concentric calcified mass in the left hypochondrium, free from bowel, reported as a calcified mesenteric cyst . PatientExtrauterine leiomyoma is a rare entity. Disseminated peritoneal leiomyomatosis and parasitic leiomyoma are the variants of extrauterine leiomyoma that are found within the peritoneal cavity. A primary peritoneal leiomyoma was reported by Singh et al. in a 51-year-old woman . ParasitPrimary leiomyoma of the abdominal cavity is an unusual entity and surgical removal of the tumour is curative.


Actinomyces is a normal commensal of the upper aerodigestive tract, colon and female reproductive tract. It can give rise to invasive disease in case of any breach in mucosal integrity, as well as, in patients with immunosuppression. Rarely, actinomycosis can involve the pancreas especially after episodes of pancreatitis or in post operative patients. We observed a case of actinomycosis affecting recurrent intraductal papillary mucinous neoplasm (IPMN) of pancreatic remnant, 5 years after a Whipple's procedure. Our patient, a 66 years old male with a history of Whipple's procedure for IPMN of pancreatic uncinate process, presented with repeated episodes of acute pancreatitis. Repeated radiological investigations  revealed resolving pancreatitis with recurrent IPMN of the pancreatic tail. The patient underwent laparobotic assisted resection of the remnant pancreas and spleen 3 months later. Intraoperatively, in addition to the recurrent IPMN of pancreatic tail, we found a dense peripancreatic desmoplastic reaction with areas of thick yellow pus pockets in the remnant pancreatic body. Bacteriology and histopathology revealed it as a recurrent IPMN associated with actinomycosis of pancreas with chronic xanthogranulomatous changes. We conclude that actinomycosis of the pancreas is a rare entity with only 5 cases reported in English literature to the best of our knowledge. If diagnosed preoperatively, early institution of antibiotics can improve the surgical outcome. Fortunately, after diagnosis, we were able to start antibiotics in early postoperative period with successful outcome. Actinomyces is a normal commensal of the upper aerodigestive tract, colon and female reproductive tract. It can give rise to invasive disease after a breach of mucosal integrity, as well as, in patients with immunosuppression [pression -6.It causes an indolent, fibrosing infection of any organ, with formation of sinuses discharging pus with ‘sulfur granules’. It has been shown to form internal fistulae, mucosal/skin ulcers  and occaActinomycotic involvement of the pancreas is extremely rare. We report a case of actinomycosis of the pancreatic remnant having recurrent intraductal papillary mucinous neoplasm (IPMN). Our patient had pancreaticoduodenectomy 5 years ago for IPMN of the pancreas. Subsequently, he had several episodes of pancreatitis before being diagnosed with recurrent IPMN of pancreas. Actinomycosis was reported in the resected pancreas and the splenic hilum.A 66 years old man presented with recurrent epigastric pain. Computed tomography (CT) showed a 3 cm cystic lesion in the uncinate process of the pancreas. Endoscopic ultrasonography (EUS), further, revealed a 2.6 cm x 1.6 cm cyst in the uncinate process with an irregular wall and papillary growth.He underwent a Whipple's procedure at a different hospital. The cyst was found to be an IPMN. His postoperative course was stormy with pancreatitis of the pancreatic remnant, pulmonary embolism necessitating an IVC filter placement and prolonged hospitalization (2 months).Five years later he presented with symptoms of acute pancreatitis. A CT scan showed pancreatitis with a 15 mm acute fluid collection within the pancreatic remnant .The patient had an uneventful recovery from pancreatitis. He continued to have episodes of epigastric pain, malaise and weight loss over next 5 months. Follow up Magnetic resonance cholangiopancreatography (MRCP) two months after pancreatitis showed resolution of acute fluid collection. It also revealed a new cystic lesion in the pancreatic tail  with steThe patient underwent laparobotic assisted pancreaticosplenectomy 3 months later. Intraoperative findings included a cyst (recurrent IPMN on frozen section) in the pancreatic tail. Additionally, there was extensive fibrosis around the pancreas with adhesions to the surrounding structures including the stomach and the splenic flexure of colon. Several yellow pus pockets were found in the pancreatic tail extending to the splenic hilum .Histopathology revealed recurrent IPMN with colonies of actinomyces in the pancreatic tissue in a background of inflammatory infiltrate and foamy histiocytes - suggestive of chronic xanthogranulomatous pancreatitis .The patient was treated with intravenous penicillin for 4 to 6 weeks followed by oral amoxicillin for further 6 to 8 months. The patient is healthy at 2 years of follow-up.Actinomyces israelii. Other species in the genus Actinomyces which may cause human infections include: A. odontolyticus, A. naeslundii, A. meyeri, A. gerencseriae and A. viscosus [Actinomycosis is a rare opportunistic disease usually caused by the species viscosus . These oviscosus . Hence, They are gram positive filamentous bacteria. They are typically anaerobic or microaerophilic, hence surviving as commensal in oral cavity, gastrointestinal tract and female genital tract. In fact, oral colonization has been shown to occur in 97% of infants by 2 years of age . No knowThey can acquire pathogenicity after invasion of tissues. They are known to enter tissues with any mucosal breach due to dental procedures, oral surgery , after iInfection is usually chronic and slowly progressive. Due to its infiltrating nature, it causes a dense desmoplastic reaction in the surrounding tissue. It slowly grows by contiguous spread ignoring anatomical planes. With further growth, the center of the infection site liquefies to become purulent material.Indurated lesions are more apparent in abdominal or cervicofacial locations as compared with pulmonary or central nervous system (CNS) lesions. Sinus tracts might form to the skin or surrounding viscera due to its infiltrative nature.Microscopically, ‘sulfur granules’ are the hallmark of the disease. They consist of a conglomeration of filamentous bacteria. The filaments are better visualized at the margins of these granules. The surrounding tissues show dense inflammatory infiltrates of neutrophils, lymphocytes and foamy macrophages.Actinomycosis can involve any tissue of the body, but clinical patterns can be classified broadly into 6 categories in the order of frequency: Oro-cervicofacial (55%) , abdominIn oral and cervicofacial region, actinomycosis can present as a soft tissue swelling, abscess, sinus, mass  or an ulIn the thorax, the disease commonly presents as a pulmonary mass with ‘air bronchogram’  , pneumonRarely, the CNS is involved. Brain abscess is the most common presentation with CT showing ring-enhancing lesions.Abdominal actinomycosis commonly presents as a slowly growing mass mimicking malignancy or as an abscess. It can involve any site in the abdominal cavity but it is more frequent in the ileocecal region . Other aPancreatic involvement is extremely uncommon. It has been reported only 5 times in the past to the best of our knowledge . The earWe believe that our patient had the seeding of pancreas by actinomyces by repeated episodes of pancreatitis aided by reflux of gastrointestinal contents via the anastomosis of remnant pancreatic duct to jejunum.In a symptomatic patient who had a prior surgery and also who had recurrent episodes of pancreatitis, it is not unreasonable to consider actinomycosis of the pancreas in the differential diagnosis. A CT or EUS guided FNA of inflammatory collection around pancreas may yield the diagnosis of actinomycosis  which ca


Hydatid cysts most commonly present in the liver and the lungs; however, they can appear more rarely in other locations, such as the mesentery, with a rather unclear mechanism of manifestation. Herein, we present a case of simultaneous presence of hydatid cysts in the liver and the mesentery of a young man.A 39-year-old man was referred to our Department for further investigation of intermittent abdominal pain, especially in the right upper quadrant, and abdominal distension. Abdominal CT imaging revealed three calcified lesions, one in the liver, a similar adjacent to an ileal loop and one close to the urinary bladder, while antibody control was positive for echinococcal infection. The lesions were excised and the patient was discharged on the seventh post-operative day in good general condition. Post-operative control after 6 months did not show any signs of recurrence.Simultaneous presence of hydatid cysts in two organs occurs in 5–13% of cases. Presence in the mesentery is extremely rare, although, should be included in the classic differential diagnosis, especially in endemic areas. Hydatid disease, also referred as echinococcosis, is a chronic, cyst-forming, parasitic helminthic disease.Echinococcus granulosus, alveolar echinococcosis caused by Echinococcus multilocularis, and polycystic echinococcosis caused by Echinococcus vogeli or Echinococcus oligarthrus , hatch in the small bowel. These eggs release an oncosphere that penetrates the intestinal wall and migrates through the circulatory system into various organs, especially the liver and lungs , who was treated surgically in our department.A 39-year-old male patient was referred to our department with mild abdominal distention and pain that was located especially in the right upper abdomen. His symptoms were present during last year, with gradual deterioration. He did not present any fever and occurrence of symptoms was not related to food intake. In his clinical history, he did not mention any previous operations or other medical conditions, whereas he did mention owning two dogs in a rural area.Echinococcus rapid test based on ELISA IgG antibodies detection was positive (quantitative method). Upper abdominal ultrasound revealed a hepatic lesion with vague characteristics. An abdominal CT revealed a large hepatic lesion (9.5 cm × 6.2 cm × 6.8 cm) with a hyperdense wall and multiple internal calcifications  after 3 months which post-operative treatment with albendazole completed. Follow-up was recommended every 6 months for the first 2 years and then once a year.Laboratory blood examination showed results within normal ranges . Level of eosinophils cells was normal (0.7%), while eosinophilia is present only in 25–40% of all patients. An s Figure A,B. The Most common sites of hydatid disease are the liver (approximately 70%) and the lungs (15–47%). Kidney (2–4%), bones, and brain are less likely to be involved. Incidence of the disease in other sites, such as the heart, spleen, pancreas, and muscles, is extremely rare. In all cases, involvement of two organs occurs in about 5–13% of the cases .Humans are usually asymptomatic for long period of time while the cysts are growing slowly. In most cases, there is only one cyst, whereas in some cases, multiple cysts may be present (20–40%). Symptoms depend on the size and the number of cysts and possible compression of surrounding structures . As in ovia the hepatic portal vein into the peritoneal cavity was also referred  and ABZ are the benzimidazole compounds (BMZs) used for the treatment of hydatid disease . BMZs mas 1 year . A perioTarget of surgical procedures is the inactivation of infectious scolices and germinative membranes. Prevention of intra-operative contamination to peritoneal cavity is important while ruptured cysts can lead to systematic anaphylaxis. Recognition and management of complicated cysts requires specialized hepatobiliary surgical team . SurgicaMinimally invasive surgical approaches, utilizing laparoscopic techniques, have been also employed for patients with hydatid disease. There are promising results with laparoscopic treatment but further experience is required . ImagingSurgery is the treatment of choice of the rupture prone hydatid cysts, all complicated and the most complex cases of liver hydatid disease. Objectives of surgery are (a) inactivating infectious material, (b) preventing contamination, (c) eliminating all viable elements (endocyst), and (d) managing the residual cavity. Surgery is indicated for the treatment of large liver cysts with multiple daughter cysts. As in our case we have a large hepatic cyst and two others in mesentery we choose the open procedure.Due to the rarity of mesenteric hydatid disease, all the abdominal cystic lesions including mesenteric, pancreatic, gastrointestinal duplication, ovarian cysts, and lymphangiomas must be considered in the differential diagnosis .Simultaneous presence of cysts on different locations presents a low incidence in hydatid disease, while their presence in the mesentery is rarely reported. In endemic areas, this entity should be included in the differential diagnosis of cysts within the peritoneal cavity. Thorough imaging examination and surgical excision play a key role in the patient’s overall treatment.Our patient provide his consent for this study with a written informed consent, approved by AHEPA University Hospital of Thessaloniki/Greece Scientific Council.DP, KK, AK, and PB were responsible for the diagnosis and treatment of the patient and assisted in the preparation of the manuscript. VP, SA, and AM provided useful insights.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Sigmoid volvulus is an acute surgical emergency because delay in diagnosis and management can cause adverse maternal and fetal complications. Sigmoid volvulus typically presents with acute-on-chronic abdominal distension that may develop slowly over 3-4 days. An early and effective resuscitation with fluid replacement, electrolyte balance correction, prophylactic antibiotics and nasogastric decompression is necessary. The standard goals of treatment are to relieve the obstruction, avoid colonic ischemia, and prevent recurrence either by endoscopic decompression or resection with primary anastomosis. A pregnant woman with sigmoid volvulus at 34 weeks and 1 day of gestation presented to our hospital with abdominal pain, vomiting, and constipation. The patient was jointly surgically managed with laparotomy, cesarean section, and detorsion of the sigmoid volvulus, and was discharged in a healthy state on the 5 Symptoms arise either through bowel obstruction or ischemia. This case is presented to highlight that pregnancy can delay presentation and diagnosis, and nonsurgical management can be equally successful in the 3rd trimester provided there is no evidence of complication like gangrenous bowel or perforation. Endoscopic reduction of a sigmoid volvulus has been reported to be successful in 75-95% of cases. Fetal and maternal mortality rates have been noted to be high during pregnancy due to delayed diagnosis.Sigmoid volvulus arises when the air filled colon twists due to its narrow elongated mesentery and lack of colonic fixation to the retroperitoneum. Sigmoid volvulus is the most common cause of intestinal obstruction accounting for 25-44% of casesA woman aged 25 years, gravida 2, para 1, presented to the emergency department of our hospital at 34 weeks and 1 day of gestation with intermittent abdominal pain, nausea, and projectile vomiting, which she was having for 2 days, followed by worsening constipation. The patient’s previous delivery was by cesarean section for breech presentation, two years ago. On physical examination, she was afebrile and dehydrated, and her pulse rate and blood pressure were 86 beats per minute and 102/66 mm-Hg, respectively. The patient’s chest and cardiovascular examination was normal, but her abdomen had generalized tenderness and was distended. Bowel sounds were initially sluggish and became absent by the second day of admission. Her vaginal examination was unremarkable with a long uneffaced, closed cervix. Abdominal and pelvic ultrasound did not reveal any free fluid in the abdomen. Appendix appeared normal with no appendicular masses or cysts seen. The liver, gall bladder, spleen, and both kidneys were normal in appearance. The woman refused abdominal radiography in view of her pregnancy. Magnetic resonance imaging (MRI) could not be done due to unavailability of this facility in the hospital. At this point, a clinical diagnosis of bowel obstruction was inferred and a surgical consultation was requested. The rectum was found to be empty on examination with no palpable mass. Surgeons ruled out any evidence of bowel obstruction and recommended to continue symptomatic care and observation, nil oral, with intravenous fluid management.3/ ul (2.4-9.5), and platelets were 209.40 109/L (150-450). Serum urea, creatinine, and serum potassium levels were within normal limits. Other investigations including liver function tests, serum amylase, and blood glucose levels were also found to be normal. Routine urine analysis revealed a white blood cell count of 52/ul with a positive culture growth of mixed bacteria for which she was treated with growth sensitive antibiotics. High vaginal swabs were normal on both gram staining and culture.Routine laboratory examination revealed that her hemoglobin was 12.52 g/dL, white cell count was 6.21 10th postoperative day. Follow-up review in the surgical outpatient department was conducted six days later and she was found to have no problems. Her passing motion was normal. To date, there has been no report of recurrence. She has been fully informed about the possibility of recurrence and is being carefully followed-up in the surgical outpatient department.The woman stayed in hospital for 4 days and left the hospital against medical advice before a conclusive diagnosis could be made. She later reported to a higher tertiary center where she was seen in the outpatient department and was diagnosed as having a urinary tract infection. Patient then returned back to our hospital and was readmitted by us because there was no relief of her symptoms. A repeat abdominal and pelvic ultrasonography revealed the same findings as the first scan. Surgical team was consulted and a nonspecific clinical diagnosis of intestinal obstruction was made. She was planned for emergency cesarean section with exploratory laparotomy. No effort was made to use endoscopic detorsion in this case because the level and type of obstruction remained uncertain. Cesarean section was performed using a midline vertical incision and a 2000-gram, live, female baby was delivered with Apgar scores 8 at one minute, and 9 at 5 minutes. Sigmoid colon , 2 was f. Sigmoid volvulus is the most frequent site, followed by cecum, ascending colon, and transverse colon. Khan et al. found 84 cases in their latest review of the literature, whereas Ahmed reported fewer than 90 cases,7.Volvulus is twisting of a bowel loop on its own mesentry, which causes bowel obstruction, occlusion of venous return, and may lead to gangrene and perforation if it is not quickly relievedrd trimester and may sometimes mask the clinical picture because abdominal pain may be a normal finding, as happened in our case.Pregnancy increases the incidence of sigmoid volvulus because the enlarging uterus can cause a redundant or abnormally long sigmoid colon to twist. It is very often seen in multiparous women in the 3. A dose of 0.01 Gy is dangerous, with a 1/1000 risk of congenital malformation, whereas a low dose of 0.001 Gy is used in abdominal X-ray. The goal of evaluation is to urgently establish a diagnosis and to rule out other causes of abdominal pain. The other modalities of diagnosis are abdominal computerized tomography scan and MRI, which show characteristic whorls, representing the twist in the mesentry. A water soluble enema such as gastrografin may be useful in selecting patients. Sigmoidoscopy or colonoscopy are therapeutic procedures, but may be used to confirm diagnosis. Obstruction of the intestinal lumen and impairment of vascular perfusion occur when the degree of torsion exceeds 180° degree and 360° degree and a variant of sigmoid volvulus (ileosigmoid knotting) occurs when ileum wraps itself around the sigmoid, usually in a clockwise manner,10. Other than a redundant sigmoid loop and a narrow base of the mesocolon, none of the possible causes like adhesions, previous pelvic inflammatory disease or gastrointestinal abnormalities were observed intraoperatively in our case. Bowel ischemia, gangrene, and perforation leading to peritonitis are the complications of untreated volvulus, which lead to increased maternal and fetal death. A gangrenous bowel should not undergo detorsion but should be resected to avoid systemic dissemination of toxic substance. Many series highlight non-colectomy procedures that may be beneficial in individualized cases for management of sigmoid volvulus,8. Machado and Machado managed a case of sigmoid volvulus that complicated pregnancy by resection and primary anastomosis and encountered another case of ileosigmoid knotting with gangrenous ileum and sigmoid colon in a male patient who was chronically constipated later in the same year.In many series, reluctance for radiologic examination owing to pregnancy is observed,10. Samarakoon et al. experienced a similar case that resembled ours. Their patient had volvulus at 30 weeks of gestation and was managed by midline laparotomy with anterograde decompression and derotation with anchoring of sigmoid mesentery to the lateral pelvic wall. Volvulus is derotated and deflated by sigmoidoscopic placement of a rectal tube to postpone resection till the postpartum period, but studies showed that conservative decompression may be difficult as the large uterus hinders the untwisting of the colon in the last trimester. The reported maternal and fetal mortality are 6-20% and 35%, respectively, and Alshawi suggested that the preferred options might be nonoperative colonoscopic detorsion and rectal tube compression in the first trimester, colectomy in the second trimester, and non operative treatment in the third trimester till fetal maturity, followed by sigmoid colectomy after delivery,12.Bowel obstruction in pregnancy is mainly due to adhesions, volvulus, intussusceptions, hernia, appendicitis, and carcinoma and need surgical intervention, except in uncomplicated sigmoid volvulus, which can be managed non-surgically as in our case, and many other reported cases. Endoscopic sigmoidopexy has been used instead of surgical resection for patients who are at high risk for surgical complications.Recurrence of the volvulus is very common, so elective surgery to remove the redundant mobile sigmoid with anastomosis is often performed. The series of Liang et al. reported that laparoscopic elective surgery after successful colonoscopic decompression may be a good choice for a selected group of patients in terms of minimized surgical complications and quick recovery. Immediate laparotomy is needed if endoscopic detorsion fails or in patients with signs and symptoms suggestive of peritonitis. The presence of bowel gangrene and coagulopathy strongly predicts mortality, which suggests that prompt diagnosis and management are essential. The entire bowel should be examined for other areas of obstruction. Bowel viability should be carefully assessed as segmental resection with or without anastomosis may be mandatory in some cases.Atamanalp used flexible sigmoidoscopy and then performed definitive surgery to prevent recurrent volvulusAlthough it is not a common cause of bowel obstruction, sigmoid volvulus needs early diagnosis and treatment to avoid serious maternal and fetal complications. Urgent surgery in bowel obstruction in pregnant women is mandatory. Non-surgical management can have a successful outcome provided uncomplicated cases are selected. Resection with primary anastomosis is the gold standard management in the presence of gangrene and perforation. Awareness among clinicians needs to be increased to avoid catastrophic events in such cases.


Vestibular schwannomas (VS) are benign tumours arising from the vestibulocochlear nerve. Among the management options available, surgical resection is often considered, especially if lesions are enlarging or symptomatic. Translabyrinthine (TL) resection of a vestibular schwannoma is one of three basic approaches available to the surgeon. Complications generally associated with this approach can include cerebrospinal fluid (CSF) leak, hearing and balance issues, infection, and facial nerve palsies. We present the case of a patient with a previously unreported type of complication: that of cystic CSF collection within the temporal lobe and associated oedema. Vestibular schwannomas (VS) are benign tumours that develop from the vestibular component of the eighth cranial nerve (VIII) . ManagemA 49-year-old male was admitted electively for a TL resection of a vestibular schwannoma. He had symptoms of a left sensorineural hearing loss and pain in the distribution of the trigeminal nerve, for seven months, prior to the diagnosis of a left intracanalicular vestibular schwannoma. The patient underwent an uneventful procedure. On the fourth day after the operation he became confused with mild dysphasia. A computed tomography (CT) of his brain showed a hypodense collection in the left temporal lobe Figures -2. FurthAt operation the pseudomeningocele was evacuated; a 2x2 cm craniotomy was performed over the squamous temporal bone. After elevation of the bone flap, a small dural tear was noted over the inferior temporal lobe and the temporal lobe was bulging against the dural margins. Bipolar cortectomy was performed and the cavity identified on MRI was entered with egress of clear CSF under high pressure. The temporal lobe immediately appeared relaxed and was seen to be pulsating normally. A cystosubdural shunt (CSS) was fashioned from two 5 cm pieces of a 1.9 mm diameter external ventricular drain. Both were inserted into the cystic cavity with the other ends placed in a subdural pocket and secured to dura with sutures. Haemostasis was achieved and copious washout of the surgical site was followed by layered closure with absorbable sutures and nylon and staples to the skin. After reversal of anaesthesia and extubation, the patient showed some improvement in his confusion. A CT scan of the head 24 hours postoperatively showed resolution of the cystic collection and improvement of the mass effect Figures . He was Typical complications of TL resection of VS include meningitis, CSF leak, headache, balance disturbance, tinnitus, and FN palsies. Additionally, one can expect hearing loss with the TL approach, often pre-existing and a contributing reason to the decision to operate via this approach ,2. CystiThe exact pathophysiology of this lesion is unknown. We postulate that a possible iatrogenic leucotomy was achieved through unrecognised injury to the cortex and overlying dura and arachnoid. The resultant lesion continued due to build up of CSF through a one way valve effect, which would account for the delayed presentation. The isolated temporal lobe oedema was similarly noted compared with previous reports ,4. In onCystic CSF collection in the temporal lobe is a previously unreported complication of TL resection of VS. This rare and unusual complication demonstrates significant morbidity to patients. The diagnosis can be suspected on CT, but MRI is useful to rule out venous infarction and abscess. Early treatment is warranted if clinical deterioration occurs, presumably due to increase in size and therefore mass effect of the collection. During surgery the overlying dural and arachnoid planes must be treated with care without undue pressure on underlying structures or repeated trauma to the dura with drilling and or other equipment, which can be transmitted to the cortical tissue and possibly cause inadvertent leucotomy and trapped CSF causing mass effect and venous insufficiency.This case demonstrated a rare complication of TL of a vestibular schwannoma with its associated features, clinical course, radiological findings, and a novel approach to shunting the cyst to the subdural space to relieve symptoms. The complication was recognised and with prompt treatment the patient made a good neurological recovery with gradual resolution of the temporal lobe findings and improvement in his speech and confusion.


We reported a case of multifocal carcinoid tumor of small intestine causing chronic obscure gastrointestinal bleeding, suspected on capsule endoscopy and diagnosed on double balloon enteroscopy. A 64-year-old man with bouts of obscure, overt gastrointestinal bleeding (OGIB) in the past was transferred to our medical center for persistent melena. Over the past five years, he had undergone extensive inpatient evaluations at several hospitals for OGIB without a cause identified. On this occasion, the patient was found to have a hemoglobin of 5.7. He underwent a push enteroscopy which showed no obvious bleeding source and colonoscopy which showed evidence of old hemorrhage. A repeat video capsule endoscopy  was performed which showed several polyploid lesions in the mid small bowel and continuing through the terminal ileum with fresh blood noted (see video).Following transfusion with 8 units of packed red blood cells, he was transferred to our facility for retrograde double-balloon enteroscopy (DBE). His study was significant for two large, friable, ulcerated sessile polypoid lesions in the mid ileum  and multCarcinoid tumors are a form of neuroendocrine tumors and can present a dilemma for clinicians because the disease can encompass a wide range of clinical behaviors. Midgut carcinoids are the most common form of carcinoid tumor and originate most frequently in the terminal ileum. Due to the indolent behavior of small bowel carcinoid tumors, patients usually have symptoms for a mean of 5 years before the diagnosis is made . CarcinoRecent literature suggests that the diagnostic yield of DBE for suspected primary small bowel neuroendocrine tumor is low . As illu


A featured malignant‐like granulation tissue can be the only preoperative clinical clue of a concealed foreign body in the nasal cavity. Thus, endoscopic Dacryocystorhinostomy (DCR) should be completed with intraoperative nasal exploration to reveal non‐apparent foreign bodies that might be the underlying etiology of chronic dacryocystocele. Dacryocystocele is a diffuse and centrifugal swelling of the lacrimal sac, which develops due to obstruction of lacrimal drainage system proximally and distally anywhere along the widespread canaliculi and nasolacrimal duct, respectively A 57‐year‐old woman presented to our ENT clinic complaining of a spontaneous onset of right eye tearing, sensation of mucus at the back of her throat, and foul smell emanating from her nose for the past 8 years. She was otherwise healthy with no prior ocular history. On direct questioning, the patient recalled that she had pushed a rubber stopper from a perfume bottle up her nose when she was aged 8 years. Surprisingly, she does not remember whether this stopper was ever retrieved since then. A clinical examination revealed a palpable right medial canthal swelling that was diagnosed as dacryocystocele later on as illustrated in Figure Then, an endonasal endoscope was employed revealing a granulation tissue in the nasal cavity with a minimal amount of catarrh. However, no evidence of a foreign body was identified using this endoscopic mean. The patient was then investigated by utilizing CT paranasal sinuses, which has reported features of a mass in the right nasal cavity with multiple erosions in the floor of the hard plate and was associated with dense calcification. Wherefore, a suspicion of malignancy was significantly raised as shown in Figures The patient underwent right nasal cavity endoscopic exploration under general anesthesia, and the mass, which was surrounded by granulation tissue, was excised completely. Interestingly, upon removal of the mass, a rubbery object was identified within the granulation tissue and measured at 3 × 1 cm Fig. . SubsequAfterward, the patient had an uneventful recovery, and the mass has not recurred within 3 years of follow‐up and no complications have been encountered.In most cases, dacryocystoceles transpire congenitally while only few cases have been reported for the acquired form Moreover, despite using a nasal endoscope, an important adjunct in the evaluation of dacryocystocele Scholars have investigated imaging features of dacryocystoceles and demonstrated that CT exposed various features including cystic medial canthal mass, dilatation of the nasolacrimal sac, fluid‐filled structure with slight rim enhancement, no solid components and so forth In this case, we conducted a right nasal cavity endoscopic exploration to remove the granulation tissue containing the foreign body and rule out the underlying malignancy. Tabatabaie et al. reported a forging body, which was surrounded by a granulation tissue. However, the object was located in the lacrimal system and did not show any susceptibility to malignancy After establishing the diagnosis using lacrimal excretion test as well as radiological assessment, the result of suitable surgical procedure must be useful. Acquired dacryocystocele can be managed by external or endoscopic approaches with equal success rates By and large, a long‐standing foreign body inducing acquired dacryocystocele should be suspected clinically in a patient with a remarkable history along with presence of granulation tissue. The use of a flexible endoscopic technique clinically along the nasal passage is not highly accurate for detecting an underlying foreign body provoking dacryocystocele. In such cases, CT imaging of paranasal sinuses could be misinterpreted in diagnostic purposes as some features of underlying malignancy might be identified in those patients who develop overlying granulation tissue. Appropriate surgical approach relies on accurate preoperative evaluation of the paranasal mass, which can be ensured by CT imaging in majority of cases.A patient's consent was sought to report this novel presentation.AAM: literature review, novelty determination and case report writing. AFA: literature review and writing the report. OAE: Case evaluation. OAM: Case evaluation, novelty specification and report review with multiple corrections.The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


Lipomas of the colon are relatively rare benign soft tissue tumors derived from mature adipocytes of mesenchymatic origin. During colonoscopy, surgery or autopsy they are generally discovered incidentally. Most cases are asymptomatic, with a small tumor size, and do not need any special treatment. However, in the cases with larger in size of tumor some symptoms such as anemia, abdominal pain, constipation, diarrhea, bleeding, or intussusception may be presented. We reported a 47-year-old woman with colonic intussusception in the descending colon caused by colonic lipoma and diagnosed after surgical exploration for obstructive colonic mass. Colonic lipoma is rare submucosal benign tumor of the gastrointestinal tract. It is the third most common benign tumor with the incidence ranging between 0.2% and 4.4%, following hyperplastic and adenomatous polyps , 2.As thA47-year-old woman was admitted to our hospital with four years history of constipation requiring laxative consumption. Her symptoms became severe in the last two weeks. Physical examination revealed abdominal distension and hyperactive bowel sounds. Laboratory results were within the normal range. Colonoscopy showed a large necrotic mass in proximal portion of descending colon, near splenic flexure with severe narrowing of lumen and bezoar like feces . HistopaColonic lipomas are infrequent benign adipose tumors with an incidence ranging from 0.2% to 4.4% around the world.They are mainly found in women between 50 and 60 years old , 7-9. GeAdult intussusception is rare clinical entities which constitute only 1–5% of all cases presenting as bowel obstruction. Lipomas are the most frequently occurring benign tumors of the colon which cause adult colonic intussusception. Contrary to other reported in the literatures , 13, surThe preoperative diagnosis is usually very difficult but is important for planning. There are different imaging modalities for the preoperative diagnosis of colonic lipomas. Barium enema is not specific and the lesion can be mistaken for any other type of colonic neoplasms. Computed tomography (CT) scan is considered to be the study of choice for colonic lipomas because the mass typically presents a characteristic fatty densitometric value. This test visualizes spherical or ovoid mass and homogenous internal lesions with an absorption density of -40 to -120 Hounsfield units. CT scan is particularly useful in the detection of lipomas larger than 2 cm.However, for small lipomas, the diagnostic value of CT is low. In fact, the diagnostic value is limited by the size and partial volume of the lesion.Some investigators have recommended enteroclysis for intussusception diagnosis, but only one case has been reported . MagnetiIn view of the uncertain etiology and diagnosis and high incidence of malignancy (approaching 50%), the treatment of intussusception in adults is invariably surgical resection , 4-6. Th


A 43-year-old woman, gravida 2 para 2 with no regular medical care, presented for 3 months of pelvic pain and vaginal bleeding. Pelvic examination revealed an 8-cm necrotic cervical mass. Biopsy of the lesion demonstrated high-grade large-cell neuroendocrine carcinoma (LCNEC) of the cervix. CT with contrast of chest, abdomen and pelvis showed extensive pulmonary , hepatic


Aligning a displaced maxillary canine into the dental arch is one of the most complicated problems in orthodontics. In cases of extremely high displacement, the tooth is frequently removed surgically. Because of the upper canines' significance to dental esthetics and functional occlusion, such a decision is a very serious one. The purpose of this report is to illustrate an interdisciplinary approach involving both orthodontic management and conservative tooth restoration. The case was treated through an orthodontic nonextraction fixed appliance mechanotherapy for successful alignment of buccally ectopic upper left canine followed by a conservative direct composite tooth buildup of peg lateral incisor associated with the upper left ectopic canine in a 16-year-old adolescent North Indian female. Posttreatment records demonstrated good alignment of the displaced tooth and restoration of normal anatomy of the peg shaped lateral incisor. An ectopic tooth is defined as a tooth that is following an abnormal eruption path whereas an impacted tooth is a tooth that is unable to erupt without assistance and is usually associated with an ectopic path of eruption. Since the permanent canines are the foundation of an esthetic smile and functional occlusion, their proper alignment into the arch becomes a priority for the orthodontist. The maxillary canine is present superior to the deciduous canine, angulated medially, with its crown lying distal and buccal to the lateral incisor. The canine follows a mesial path until the crown reaches the distal aspect of the lateral incisor root. The erupting canine is gradually uprighted to a more vertical position and is guided by the lateral incisor root, until it is fully erupted .Maxillary canine ectopia occurs as the result of divergence from the normal path of eruption of the tooth. Primary etiological causes include disturbances in tooth eruption sequence, trauma, retention of primary canine, premature root closure, rotation of tooth buds, localized pathological lesions  , long deA 16-year-old adolescent North Indian female presented with the chief complaint of the irregular teeth in relation to upper and lower arches.Extraoral examination showed no gross asymmetry, mesoprosopic facial form and straight profile, competent lips, and complex and nonconsonant smile with 1 mm of gingival display Figures . IntraorThe panoramic radiograph  showed nThe case was diagnosed with Class I skeletal bases: Angles Class I malocclusion with mild crowding in upper and lower anterior teeth, buccally ectopic 23, peg shaped 22, retained 63, mesiopalatally rotated 13 and mesiolabially rotated 22, retroclined upper and lower anterior teeth, decreased overjet and increased overbite, and retrusive upper lip. Clinical findings and radiographic examination indicated that the resulting buccal displacement was due to retained upper left deciduous canine and associated peg shaped permanent lateral incisor.The treatment objectives were to relieve the crowding in both arches, to align the buccally displaced right maxillary canine into the arch, to direct cosmetic composite buildup of the left maxillary peg shaped lateral incisor restoring it to normal anatomy, to obtain a normal overjet and overbite and pleasing smile, and to improve incisor inclination and improve facial esthetics.On the basis of clinical examination and diagnostic records, a treatment plan to correct the malocclusion through nonextraction fixed appliance mechanotherapy was selected. The rationale was to gain space for mild crowding by extraction of retained deciduous canine (63) and proclination of upper and lower incisors, to avoid compromising the patient's profile and to shorten the treatment time.Overretained deciduous canine (63) was extracted. Full fixed 0.022 inch MBT 0.0175 × 0.025′′ TMA wire brackets were bonded on both arches except 23. After initial levelling and alignment with 0.014, 0.016, and 0.018 nickel-titanium HANT archwires, both the arches were stabilized with coordinated 0.018′′ stainless steel wires. 23 was bonded. An auxiliary segmented T-loop made from 0.022 inch MBT 0.0175 × 0.025′′ TMA wire  from 26 22 was rebonded, levelled, and aligned and slight space mesial to 22 was closed . CoordinPosttreatment records revealed that treatment objectives were achieved. Facial photographs showed an improved profile and smile Figures . Class IPosttreatment lateral cephalometric analysis  and supeThe upper canine despite being the tooth of most frequent eruption anomalies after third molars was considered as one of the most important teeth of the dental arch. For a good treatment prognosis, the proper evaluation of canine position must be done through clinical and radiographic evaluation and treatment alternatives analyzed according to the particularities of each case after careful evaluation of the orthodontist and professionals of distinct areas. Various methods have been suggested for the traction and alignment of impacted canines, among which are the orthodontic removable or fixed appliances and the use of anchorage in the same arch or opposite arch. However, a fixed orthodontic appliance provides greater control and effectiveness of the force applied, and in most of the cases there is a need to correct some other type of associated malocclusion and to open and keep the space to apply traction on the tooth, using specific accessories as loops. With regard to the force system for traction of impacted or ectopic canines, one must be careful with the direction of the applied force, because this should not direct traction to the roots of neighbouring teeth, not to cause trauma and external root resorptions. It is recommended, initially, to gain space in dental arches before traction and also the use of force of low intensity (no more than 60 g) and the employment of sufficiently rigid archwires to prevent deflection which may undermine movement control .Direct composite bonding is a good treatment option for peg shaped laterals as it is conservative and can be placed directly onto the tooth. It also preserves sound tooth structure, is long lasting, can be repaired easily, and is cost effective , 17.The present case uses cantilever system that provides the proper control for canine movement, associated with a smaller load on anchorage units. It is constructed with titanium-molybdenum wire (TMA) of 0.017 × 0.025 inches. The advantage found in this method consists in the ability to work with a defined force system . To avoiThe successful treatment of a patient with an ectopic tooth can be a challenging task for an orthodontist. This case report has demonstrated careful planning in alignment of the buccally displaced canine with mild crowding and peg shaped lateral incisor by nonextraction fixed orthodontic mechanics to deliver light, controlled force, with good results. Thus, the planned orthodontic treatment resulted in correction of occlusion, harmony of smile, periodontal health, and stability after treatment.


The obturator nerve is an extremely rare location for schwannomas to originate, and such diagnosis is typically not considered among the imaging diagnostic possibilities for a cystic-solid pelvic mass. A 63-year-old female with a known pelvic mass presented with increasing pelvic pain. The mass, which had been followed by serial imaging over five years, was described showing mixed solid and cystic components, likely arising from the left ovary. Although the key diagnosis to be excluded was a primary ovarian malignancy, the patient chose to pursue active surveillance. Over the five years of close observation, the lesion increased slowly, while her CA-125 level showed no significant elevation. Increase in size of the mass and worsening pain and concern for a gynecologic malignancy on MRI led her to ultimately consent to a hysterectomy with bilateral salpingooophorectomy. During the surgery, the mass was noted to be contiguous with the left obturator nerve. Pathologic evaluation revealed a schwannoma (WHO grade I). The patient's postsurgical course was uneventful, without residual weakness in the left adductor muscles. The differential diagnosis for an unsampled, chronic pelvic mass is broad and includes various gynecologic causes such as benign adnexal cyst, endometriosis, and primary ovarian neoplasms including epithelial, sex chord-stromal, and germ cell tumors. Nongynecologic causes include colorectal masses, lymphoproliferative processes, and soft-tissue tumors . Among tA 63-year-old female with a history of coronary artery disease, diabetes mellitus type 2, and a slowly but progressively enlarging pelvic mass presented with a chief complaint of worsening pelvic pain. She had been clinically and radiographically followed for the pelvic mass over the past five years but had previously opted for observation instead of surgical intervention.The mass was first noted on a transvaginal ultrasound performed five years priorly. Ultrasound at that time demonstrated a soft-tissue nodule with a cystic component adjacent to the left lower uterine segment, measuring 2.7 × 2.1 × 2.9 cm that was not present on a prior CT scan of the pelvis from the past ten years. To further explore the mass, magnetic resonance imaging (MRI) of the pelvis was performed, which demonstrated a 2.6 × 2.1 × 2.7 cm mass adjacent to the left pelvic sidewall at the level of the left acetabulum. The mass demonstrated hypointensity on T1-weighted imaging, hyperintensity on T2-weighted imaging, and avid peripheral wall enhancement with gadolinium contrast administration.Due to patient preference, the mass was followed with serial pelvic exams, imaging, and CA-125 levels. Four CA-125 levels were checked over the next four years and ranged within 3.7–5.1 Units/millilitre (U/mL) (Reference Range: 0.0–35.0 U/mL). Repeat MRI from this most recent encounter showed an interval increase in the size, which now measured 4.3 × 3.8 × 4.1 cm . The masTo address her pelvic pain, the patient underwent exploratory laparotomy with hysterectomy and bilateral salpingooophorectomy, with the expectation that the mass in question would be revealed to reflect a primary left ovarian malignancy. On intraoperative exploration, the mass was noted to be contiguous with the left obturator nerve, either invading into the nerve or arising from the nerve itself. The uterus, fallopian tubes, and ovaries were removed to facilitate ease of resection of the retroperitoneal mass. The pelvic mass was separated from the left obturator nerve, which was left intact. Intraoperative consultation, performed on the 4.5 × 2.5 × 1.5 cm mass, showed a spindle-cell tumor.Permanent histologic sections of the mass demonstrated a proliferation of spindled cells with a fascicular architectural configuration. There are regions of higher, more compact cellularity interlaced with areas that are more loosely cellular, corresponding to the Antoni A and Antoni B patterns . There aThe patient tolerated the procedure well and was discharged to home on postoperative day three. She demonstrated no deficits in the muscles of adduction in the left lower extremity. Her postoperative follow-up at two months revealed neurologic deficits, with resolution of her pelvic pain.A diagnosis of a obturator nerve sheath tumor before resection is extremely rare, with only one reported case in the literature to date . It is mObturator nerve schwannomas are exceedingly rare, with only a handful cases published worldwide in the English language, with the first published in 1998 . SubsequIn the preoperative imaging of unknown pelvic masses, ultrasound remains the initial imaging modality of choice, as it can be performed more quickly and is more affordable than MRI, while offering similar diagnostic sensitivity , where MIn correlation with the imaging characteristics, schwannomas are typically encapsulated nerve sheath tumors composed entirely of well-differentiated Schwann cells. They usually grown in an extraneural configuration and, as such, may be amenable to resection without compromising the underlying nerve. In contrast, other peripheral nerve sheath tumors, such as neurofibromas, tend to grow in an infiltrative, intraneural fashion, increasing the risk neural compromise with attempts at complete resection. As neurofibromas show a mixture of Schwann cells, fibroblasts, and pericytes, immunohistochemistry for S-100 protein would demonstrate only patchy reactivity, as opposed to the diffuse reactivity that is expected for schwannomas. This pattern of immunoreactivity, along with morphologic characteristics, further facilitates the histopathologic distinction between these two entities .Although obturator nerve sheath tumors are rare, they should be considered in the radiographic differential diagnosis of a pelvic tumor.Contrast-enhanced MRI can be a useful imaging modality in differentiating nerve sheath tumors from other pelvic tumors, particularly when used in conjunction with ultrasound.It is important to pathologically distinguish schwannomas from neurofibromas; whereas schwannomas are usually extraneural and may be amenable to gross total resection without neurologic compromise, neurofibromas are typically intraneural and attempts at total resection may give rise to neurologic deficits.Experience with the few obturator nerve schwannomas that have been characterized have mostly described a benign behavior, although transformation to a malignant peripheral nerve sheath tumor can occur.Obturator nerve schwannomas, when occurring in isolation, are typically sporadic tumors that do not reflect a genetic predisposition syndrome such as neurofibromatosis.In summary, this rare case of obturator nerve schwannoma illustrates a few salient points to consider when evaluating and managing a pelvic mass lesion:


Porokeratosis is a skin disorder clinically characterized by annular plaques withkeratotic borders resembling the Great Wall of China and histopathologically bycornoid lamellae. The disease has several clinical variants. Porokeratosisptychotropica, which has recently become part of these variants, is quite rareand little known. The entity is characterized by verrucous plaques – which mayresemble a psoriasis plaque – that affect the regions of the buttocks, mostcommonly the gluteal cleft, with or without extremity involvement. Itching isoften present. We report a rare case of porokeratosis ptychotropica andhighlight its unusual manifestation (single plaque), the first case reported inthe Brazilian literature. Itching isoften present. Due to its morphology, it was also named hyperkeratoticporokeratosis, genitogluteal porokeratosis, porokeratoma, and follicularporokeratosis.8However, a quite rare and little known subtype of the disease has recently becomepart of these variants: porokeratosis ptychotropica.9Risk factors for the disease include exposure to ultraviolet radiation, organtransplantation, chemotherapy, repetitive trauma, liver failure, chronic renalfailure, hepatitis C, HIV, and other diseases associated with immunosuppression.However, its etiology is not well established.We report a 23-year-old male mulatto patient complaining of pruritus and lesions inthe right gluteal region for 9 years. The patient observed no lesions at thebeginning, only itching. However, he developed an erythematous plaque of slowgrowth, which now appears as an oval verrucous plaque, slightly hypochromic, withwell-defined thread-like borders of approximately 7cm x 4cm in diameter  and 2. TDiagnostic hypotheses included cutaneous tuberculosis, cromomycosis,paracoccidioidomycosis, leishmaniasis, squamous cell carcinoma, condyloma, andneurodermatitis.A punch biopsy revealed regular thickening of the skin with mild papillomatosis andagranulosis sections topped by broad parakeratotic columns, featuring cornoidlamellae .We started treatment with antihistamine – considering the remarkable itching – untilwe received the results of the anatomapathologic examination. After the diagnosis ofporokeratosis ptychotropica, we started treatment with topical tretinoin 0.5%. Thedisease remains unresponsive to treatment due to the short time (1 week).1 It was firstreported in 1985 by Helfman and Poulos, who described it as reticular porokeratosisaffecting the genital/pelvic region. Ten years later, Lucker et al.named the disease as “porokeratosis ptychotropica”, a porokeratotic lesion involvingthe gluteal region associated with severe itching presenting a different (verrucous)morphology.3 A few cases have been reported sincethen, sometimes involving both sides of the buttock.5Porokeratosis ptychotropica is a quite rare and little known disease with difficultdiagnosis.et al. in 2010, 90% weremale with a mean age of 46.7 years (between 27-84 years). The main affected regionswere: the buttocks (36.36%); genitogluteal region (31.82%); and buttocks region withextremity involvement (22.7%).2 However, porokeratosis ptychotropica is morecommonly described as numerous coalescing plaques accompanied by satellite lesions,unlike our case that presented a solitary plaque with no satellitelesions.9Out of the 22 cases reviewed by Takiguchi 8 The only case of successful therapy described in the literaturewas with the dermatome after lesion whitening with CO2 laser treatment, but withsubsequent relapse. In that same study, the use of 5-fluorouracil only decreased thelesion and relieved pruritus.8 However, steroids,PUVA, calcipotriol, tacrolimus, imiquimod, vitamin A and cryotherapy failedtreatment.9Therapy with good response is rather poor. Tentative therapies include5-fluorouracil, PUVA, Imiquimod and even CO2 laser.Our patient has been using tretinoin 0.5% for one week, but with no improvement sofar. Since it is a single lesion in the gluteal cleft region, we chose not to useimiquinod or 5-fluorouracil, which could injure the contralateral healthy skin.8It is worth mentioning that the malignant transformation of the porokeratotic lesioncan occur in 7.5% of cases, mostly associated with long-term, linear, large-sizelesions.The importance of our work is related to the rarity of the disease, as well as to itsunusual manifestation (single plaque). It is the first case reported in theBrazilian literature. We hope this report can help elucidate undiagnosed cases sothat physicians opt for the ideal therapy, which will provide comfort to thepatients and prevent malignant transformations.We suggest a unification of the nomenclature, as well as the inclusion ofporokeratosis ptychotropica as a subtype of porokeratosis since it is still notconsidered as such by some authors. Therefore, it will be more easily remembered incases of differential diagnosis of perianal rash.


Hemangioma and vascular malformation are benign vascular lesions that often occur in cephalic and cervical region. Currently, surgical resection, laser therapy, angiographic embolization, use of steroids, and sclerotherapy are used as treatments.This study reports three cases of benign vascular lesions that are remarkably treated by sodium tetradecyl sulfate (STS) injection, of which occurred in oral cavity and around the mouth. Three percent of STS was diluted with 0.9 % of normal saline, and it was injected to the lesion site at least once. The result of treatment was evaluated based on clinical findings.Surgical treatment of hemangioma and vascular malformation occurred in oral cavity is not normally used because of esthetic issues and potential hemorrhage. On the other hand, sclerotherapy using STS is an effective therapy compare to surgical treatment. Despite the number of STS injection was different for each patient, all three patients had reached satisfactory level through the treatment with gradual diminution of lesions. Hemangioma and vascular malformation are common benign lesions of vessel that often occur in cephalic and cervical regions. The comprehensive term “hemangioma” was classified into two  by Mulliken and Glowacki in 1982 [Hemangiomas are endothelial tumors that exhibit endothelial proliferation with rapid growth and gradual regression. They are classified into superficial, deep, and compound hemangioma according to the depth of the lesion. These lesions are more common in females. Craniofacial region is the most affected site (60 %) . HemangiVascular malformations are structural abnormalities without endothelial cell proliferation. Vascular malformations can be sub-divided into two types  due to hemodynamic features . Low-floVarious methods for the treatment of hemangioma and vascular malformations have been introduced. There are continuous observation, radiation therapy, laser therapy, steroid treatment, sclerotherapy, and surgical resection.We report three cases of benign vascular lesions that are remarkably treated by sodium tetradecyl sulfate (STS) injection which occurred in oral cavity esthetically and functionally.3 of 1 % STS was injected into the lesion two times. When the first injection was administered, the patient complained about pain and burning sensation on the right buccal area. After 3 weeks of the first procedure, the size of the lesion decreased to 2 × 1.5 × 0.3 cm. After the second procedure was carried out, the size of the lesion had not altered yet the thickness was reduced. After 2 months of the second procedure, 1.5 cm3 of 1 % STS was injected to the remaining lesion. Comparing from the first visit, the size of the lesion was regressed to 0.5-cm nodule , deep , and compound  hemangioma . HistoloVascular malformations are benign lesions which are caused by structural anomalies of vessels. Like hemangioma, these lesions can arise anywhere in the body and can be found at birth, in infancy, and in adulthood. Most commonly affected intraoral tissues are anterior two thirds of the tongues, palate, gingiva, and buccal mucosa. Vascular malformations can be categorized as low-flow , high-flow , and combination lesions . In contrast to hemangioma, histologically, they do not reveal endothelial proliferation and do not multiply or regress throughout life .Prevent the complications that affect the patient’s well-being.Not to cause permanent physical deformities.Reduce the stress of patients and family from esthetic problems.Better to avoid treatments which leave scars.To reduce infection and pain, ulcer should be treated appropriately .The diagnosis of these benign vascular lesions requires clinical examination, biopsy, sonography, computed tomography (CT), magnetic resonance imaging (MRI), and angiography. The goals of treatment are as follows:Treatment options for small and peripheral vascular lesions are conventional surgical excision, laser therapy, cryotherapy, selective embolization, sclerotherapy, and medical treatment using beta blocker or steroid.When the lesions are larger and deeper, embolization or obliteration to adjacent vessel is required. These treatments lead to irreversible tissue injury and gradual fibrosis. Currently, surgical resection is considered as the best treatment for vascular benign lesions which occurred in the head and neck. Surgical resection should be performed to prevent recurrence. However, surgical resection is limited when complete resection is not possible, when it may cause critical bleeding problem or when crucial organs can be injured. Extensive surgery in the oral cavity can induce a problem of chewing or swallowing.For lesions that are small or located where esthetical conservation is required, sclerotherapy can be an alternative to surgical treatment . SclerotFor sclerotherapy, ethanol, sodium morrhuate, STS, and bleomycin can be used. STS is a sclerosant which has been used widely for the treatment of low-flow vascular lesion since 1940s. This acts on a lipid molecule of endothelial cells and induces surface injury and collagen exposure, causing inflammatory reaction and organization of thrombus . As a reKim et al. reported three cases that were treated by injecting 1 or 3 % STS in benign oral vascular lesions . They inSame for other sclerosing agent, STS occasionally can cause pain, ulceration, edema, cardiovascular collapsing, and anaphylaxis . In thesSTS is effective in treating benign vascular lesions of small size in oral cavity. Advantages of STS are that it is inexpensive and it makes possibility to avoid the risk of surgery. However, as it is not the definitive treatment that can completely remove the lesion, it is effective when the size of lesion is small, and the growth of lesion is slow. Therefore, in order to use STS, patient selection and evaluation of patient is important and thorough understanding of its side effects is necessary to prevent complications.


Hepatoid adenocarcinoma of the urachus is a rare condition. We present the case of a 51-year-old female who developed abdominal pain and hematuria. Pelvic magnetic resonance imaging (MRI) reported an urachal mass with invasion to the bladder that was resected by partial cystectomy. On light microscopy the tumor resembled liver architecture, with polygonal atypical cells in nest formation and trabecular structures. Immunochemistry was positive for alfa-fetoprotein (AFP) and serum AFP was elevated. Hepatoid adenocarcinomas have been reported in multiple organs, being most commonly found in the stomach and the ovaries. Bladder compromise has been rarely described in the literature, and it has been associated with poor prognosis, low remission rates, and early metastasis. Hepatoid adenocarcinoma (HAC) is an extrahepatic tumor that is morphologically similar to the architecture of hepatocellular carcinoma (HCC) . On lighOur patient is a 51-year-old Latin American female, who presented with a 6-month history of mild generalized abdominal pain and one episode of gross hematuria. On physical examination there was a distended abdomen and pain on deep palpation.Initial investigations included a transvaginal ultrasound, which revealed a pelvic tumor extending towards the abdominal cavity. Pelvic MRI showed a mass located in the bladder dome that measured 12 × 10 × 11 cm, with heterogenous signal in T2 and a necrotic center . The exoSubsequently, the patient underwent a transurethral resection (TUR) for a microscopic diagnosis. The initial pathology reported limited sample with insufficient material for diagnosis. Due to the tumor characteristics with evident invasion to other tissues, it was considered appropriate to perform a palliative surgery, consistent in partial cystectomy plus partial ileum resection.The pathology report from the partial cystectomy showed an ulcerated and hemorrhagic lesion measuring 11 × 9 × 7 cm macroscopically. Light microscopy revealed a neoplastic proliferation of large polygonal epithelial cells, arranged in a nesting and trabecular pattern, with central necrosis. These cells showed focal pleomorphism, prominent nucleoli, wide eosinophilic cytoplasm, and occasional hyaline PAS positive globules . More thImmunohistochemical study showed cytoplasmic positivity in the tumor cells against AFP and Pan-Keratin (AE1/AE3) , with a All the previous findings were consistent with invasive high-grade hepatoid adenocarcinoma of the bladder originated in the urachus. Stage was T3a N2, with free surgical borders.After surgery, the patient remained stable, with symptomatic improvement and no further complications. A subsequent abdominal Computer Axial Tomography (CAT) scan ruled out the possibility of a metastatic hepatocellular carcinoma or other abdominal lesions. Serum AFP was elevated.After four months of surgery, the patient has been treated with three cycles of chemotherapy, with Gemcitabine and Cisplatin, with adequate response and no adverse effects. Serum AFP level at this time is significantly lower compared to previous measurements.Hepatoid adenocarcinoma (HAC) is any epithelial cancer from a nonliver origin, which resembles hepatic cells morphology . One of In our case the tumor originated from the urachus involving the bladder. This location is very rare. Urachal tumors represent 0,01% of adult cancers and 0,17 to 0,34% of bladder cancers , 13. SinIn Our case is a high-grade/high-stage tumor, different from the usual behavior described of low-grade even in high-stage cases , 5, 6.On immunohistochemistry, AFP was positive and CEA was negative, as originally described by Prat et al. in hepatoid ovary tumors . We usedOur patient had a Ki67 proliferation index of 70%. Ki 67 has been characterized as a reliable indicator of muscle invasion and useful in confirmation of high-grade lesions in certain tumors . In our This type of tumor has a poor prognosis and low cure rates. The longest survival after diagnosis has been 26 months , 6. All Treatment for HAC in other organs has been characterized , but notIn summary, we present a case of hepatoid adenocarcinoma of the urachus with involvement of the bladder. The patient presented with abdominal pain, gross hematuria, and a bladder mass. On light microscopy the lesion resembled the histology of hepatocellular carcinoma. On immunochemistry AFP was positive and serum AFP was elevated.To our knowledge this is the second case of hepatoid adenocarcinoma of the urachus reported in literature and first case reported in Latin America.


Dear Editor,,2.A 38-year-old male sought treatment in the emergency room, complaining of abdominal painand bloating, accompanied by an inability to pass gas or eliminate feces. The patientunderwent multidetector computed tomography of the abdomen and pelvis, with and withoutthe administration of intravenous iodinated contrast media, which showed significantfluid distension of the stomach and duodenum, with abrupt narrowing of the duodenallumen at the transition from the second to the third portion of the duodenum . The duo-9. Intestinal malrotation is a rare congenital condition, occurring in 1out of every 200-500 live births. Most cases are diagnosed during the neonatal period,only 0.2% being diagnosed in adulthood. The condition can lead to chronic nonspecificsymptoms in young adults, making it difficult to diagnose,2,10.The evaluation of the musculoskeletal system by imaging methods has been the subject of anumber of recent studies in the radiology literature of Brazil,11.Intestinal malrotation typically manifests as nonspecific abdominal discomfort,occasionally provoking abdominal pain related to obstruction of acute onset. Generally,the obstructions occur during the neonatal period and should be considered in allinfants presenting with bilious vomiting and abdominal pain,12.The use of multidetector computed tomography in the emergency room has facilitated thediagnosis of malrotations, primarily in the context of congenital diseases that goundiagnosed until adulthood. This method, in addition to facilitating the evaluation ofthe loops, can aid in the assessment of the vasculature, which can be affected. Anotherimportant imaging method is radiological study with contrast, which can reveal avertical duodenum and the absence of a duodenojejunal angle, as are observed in 80% ofcases,11,12.The typical treatment for intestinal malrotation is Ladd's procedure, first described in1936, which involves classical laparotomy. It is considered the gold-standard surgicaltreatment in cases of intestinal malrotation and can currently be performed safely bylaparoscopy, as in the case presented here. The procedure consists in mobilization ofthe duodenum and right colon; the sectioning of adhesions ; and appendectomy. This aim of the treatment is to reduce therisk of acute-onset volvulus by placing the small intestine in a nonrotating positionand broadening the base of the mesentery. Appendectomy is performed because of potentialdifficulty in diagnosing appendicitis in the future, given that the appendix would befar from the correct positionThe diagnosis of intestinal malrotation associated with duodenal obstruction secondary toLadd's bands should be considered in adult patients presenting with duodenalobstruction, a vertical duodenum, and malrotation of the small intestine with the cecumin the medial position. We believe that computed tomography is now the method of choicefor the diagnosis of such malrotations.