Less than 1% of lung neoplasms are represented by benign tumors. Among these, hamartomas are the most common with an incidence between 0.025% and 0.32%. In relation to the localization, hamartomas are divided into intraparenchymal and endobronchial.Clinical manifestation of an endobronchial hamartoma (EH) results from tracheobronchial obstruction or bleeding. Usually, EH localizes in large diameter bronchus. Endoscopic removal is usually recommended. Bronchotomy or parenchimal resection through thoracotomy should be reserved only for cases where the hamatoma cannot be approached through endoscopy, or when irreversible lung functional impairment occurred after prolonged airflow obstruction. Generally, when endoscopic approach is used, this is through rigid bronchoscopy, laser photocoagulation or mechanical resection. Here we present a giant EH occasionally diagnosed and treated by fiberoptic bronchoscopy electrosurgical snaring. Most tumors of the tracheobronchial tree are malignant ,2. BenigFrom a previous paper reviewing a total of 215 cases of hamartoma reported in the literature, the endobronchial location was found in only 1.4% of cases . In contWe report the case of a giant hamartoma of the left main bronchus, diagnosed and removed by fiberoptic bronchoscopy electrosurgical snaring.An asymptomatic 65 year old man, previously treated by rectum resection for adenocarcinoma, during follow-up examination for his neoplastic disease underwent chest CT scan that documented a vegetating lesion of the left main bronchus with absence of extra-bronchial infiltration Figure . The patThe pulmonary hamartoma is a rare benign tumor, originating from the bronchial primitive mesenchymal tissue, which can differentiate into various mature mesenchymal components . In factEH is frequently asymptomatic, at least in the preocclusive early stage . When pret al. considered highly indicative the presence on CT scan of a mass at high fat density without contrast uptake [On CT scan, the EH appears as an endobronchial mass with or without signs of obstructive pneumonia or atelectasia . CT scant uptake .At bronchoscopic examination, the EH appears as a polypoid or pedunculated neoplasm, well-circumscribed, with a smooth and yellowish surface, without signs of submucosal infiltration ,2. BiopsThe traditional treatment has been by thoracotomy with broncotomy or lung resection 12). However, since this is a benign neoplasm, endoscopic treatment is now widely recommended as the first line approach 2. Howeve, also coLaser treatment through rigid bronchoscopy is considered the gold standard treatment for symptomatic patients with bulky masses on radiological examination . HoweverThe traditional surgical treatment (thoracotomy and bronchotomy) is currently indicated only in cases where the EH cannot be approached through endoscopy, or when lung resection is indicated due to irreversible parenchymal damage from longstanding airway obstruction ,20.The EH is a rare benign tumor that can cause bleeding or obstruction of the tracheobronchial tree.For these reasons, treatment should be performed even in asymptomatic patients. The choice of treatment should consider the location and extent of the tumor. Surgical therapy, by bronchotomy or resection, should be reserved only for cases where the hamatoma cannot be approached through endoscopy, or when irreversible lung functional impairment occurred after prolonged airflow obstruction. In all other cases, in consideration of the benign nature of the tumor, the gold standard treatment is endoscopic laser resection. Fiberoptic bronchoscopy electrosurgical snaring may represent an alternative approach in selected cases.Written informed consent was obtained from patients for publication of this report and accompanying images. A copy of the written consent is available for review by the Editor in chief of this journal.The authors declare that they have no competing interests.All authors: 1. have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2. have been involved in drafting the manuscript or revisiting it critically for important intellectual content; 3. have given final approval of the version to be published.


Renal cell carcinomas (RCCs) are known for their unpredictable metastatic pattern. We present the case of a 63-year-old woman who initially presented in 1992 with a metastasis in the left calcaneus that led to the discovery of RCC. In 1998, a new metastasis was found in the ovary. In 2008, the diagnosis of a gallbladder metastasis was made. All metastases were surgically removed; no additional systemic therapies were used. Aggressive surgical treatment can prolong the survival of patients with resectable metastases. Patterns of metastasis are discussed, and a brief review of the literature is given regarding each localization. In 2010 kidney cancer accounted for 4% and 3% of all newly diagnosed malignancies in men and women, respectively [In 1992, a 47-year-old woman presented with left heel pain. After further examination, the orthopedic surgeon identified a possible malignancy of the calcaneus. After wedge excision, histopathology identified the lesion as a metastasis originating from an RCC . FurtherFor the next 5 years, followup showed no recurrences. Nevertheless, ultrasonography in December 1997 revealed a large polylobular mass in close connection with the uterus. Tomography revealed multiple adenopathies and a fibromyomatous uterus . HystereFor the next 11 years, radiographic followup was uneventful. In August 2008, an abdominal CT scan identified a polypoid lesion in the gallbladder . A laparKidney cancer is one of the most deadly urological tumors. The 5-year relative survival rate for all stages is approximately 69.5% . At initThe most frequent localizations, in order of frequency, are the lungs, bones, liver, lymph nodes, adrenals, and brain. However, RCC metastases have been described in virtually every organ of the human body .In the case of bone metastases, the spine  and the long bones (10%) are most commonly involved; the distal bones of the hands and feet are very rarely involved. One study that examined 2800 bone tumors found only 19 in the foot, of which 11 were metastatic. The calcaneus is the most frequently affected bone in the foot, followed by the tarsal bones. Metastases of RCC to the calcaneus are very rare. They are associated with a poor prognosis, due to their relationship with diffuse metastatic disease , 7.Kollender et al. concluded that aggressive surgical excision of RCC bone metastases is justified for pain relief, local tumor control, and the prevention of morbidity associated with pathological fractures. Although the patient population was rather small, a relatively prolonged survival was shown . PatientIn our case radiotherapy was performed after the surgical excision of the calcaneal metastasis. Despite the general accepted fact that the renal cell carcinoma is radioresistant, several study groups have clearly showed a palliative benefit in symptomatic osseous metastases from these tumors. None of the mentioned reports investigated possible survival advantages –12. Ovarian metastases originating from RCC are very rare and to the best of our knowledge have only been described in few cases. Valappil et al. listed 12 cases, and Insabato et al. described another 3 cases. Involvement of the contralateral ovary is even rarer. In most of the cases, the ovarian mass was detected after the diagnosis of the renal tumor. RCC metastases in the ovaries are often misdiagnosed as primary ovarian clear cell carcinomas, due to the presence of clear cells in ovary tumors as well as in RCCs. With immunohistochemical techniques, the ability to differentiate between these tumors is improving –15.Gallbladder metastases due to primary RCC are rare. In the report of Ishizawa, covering a period of more than 50 years, 24 cases have been described. Almost all patients were men. In the present case, the time interval between primary tumor and gallbladder tumor is 16 years; only two authors have reported longer time intervals (27 years in both cases). In almost all cases, the gallbladder tumor was found in routine followup, without any associated symptoms. Followup in this group of 24 patients showed a maximum tumor-free period of 6 years after cholecystectomy. However, late recurrence of RCC can never be excluded [In metastatic renal cell carcinoma patients, the use of molecular targeted therapies that block the VEGF pathway or the mTOR pathway offers new perspectives. For the moment, different molecules are available, each with their own efficacy and side effects. Clinical guidelines for the first- and second-line treatment exist, but the real question lies in the individual treatment of each patient. There is a need for prognostic factors and biomarkers. Better results may be achieved by using combination or sequential therapy. And the search for other pathways and new agents interfering in these pathways should continue .Several studies have shown metastasectomy for resectable tumors to result in increased survival compared to no surgery. Especially in the case of lung metastases, 5-year survival rates of up to 50% have been reported . As mentGiven the poor 5-year survival in patients with metastatic RCC, it is rather exceptional that our patient is still alive 17 years after the initial RCC diagnosis. This woman has already presented with different metachronous metastases, emphasizing the importance of a strict radiographic followup. The use of radiotherapy in the case of osseous metastases is reserved for the palliative setting. We do not plead against the use of targeted therapies, but when technically feasible surgery should play an important role. Thanks to aggressive treatment of each metastasis, the life expectancy of our patient remains higher than the average life expectancy patients with metastatic RCC would indicate.


Patients with neurofibromatosis type 1 develop both benign and malignant tumors at an increased frequency. Most of the malignant peripheral nerve sheath tumors (MPNSTs) are considered as high-grade sarcomas originating from tissues of mesenchymal origin. It is generally accepted that MPNSTs occur in about 2% to 5% of neurofibromatosis patients. In this paper, we present a 16-year-old male patient with neurofibromatosis who developed MPNST of the retromolar area. The mass enlarged rapidly in a period of 6 weeks. The patient was treated surgically, and a tumor mass with a diameter of 7 × 6 × 4 cm was excised, but after 8 months a recurrence was observed at the same site. The sarcomatous change in a neurofibroma has an extremely poor prognosis, so patients with neurofibromatosis should be closely monitored for a possible malignancy. A rapid change in size of a preexisting neurofibroma, infiltration of the adjacent structures, intralesional hemorrhage, and pain indicate a possible malignant transformation to MPNST. Neurofibromatosis type 1 (NF1), an autosomal dominant neurocutaneous disorder, is commonly identified by the development of café-au-lait pigmentation of the skin, axillary freckling, optic nerve gliomas, Lisch nodules, distinctive bone lesions, and cutaneous or subcutaneous tumors called neurofibromas . Neurofibromas are the most common benign tumors in NF1 . These t In this paper, we present a 16-year-old male patient with NF1 who developed MPNST of the retromolar area. A 16-year-old male patient with documented NF1 was referred with a rapidly enlarging mass in the mouth causing severe dysphagia, mandibular and temporomandibular pain, and respiratory difficulty . The patα therapy 3 times between the ages of 11 and 14. The family history of the patient was positive for NF1. His mother had documented NF1 with multiple neurofibromas and café-au-lait spots. The patient's clinical history started at the age of 3 years with the complaint of walking difficulty. At 4 years of age, a 3 × 2 cm mass was recognized on the left gluteal region. A general body scanning with imaging showed a preorbital and a pelvic mass in addition to the mentioned gluteal mass. At the age of 5 years, the patient had spinal laminectomy for the excision of a neurofibroma infiltrating S2 and S3 roots. The patient had multiple and recurrent neurofibroma excisions  in the following 2 years. At the age of 10, a Lisch nodule of the right eye was revealed. The patient had interferon- His general physical examination showed a mass of the right gluteal region and thigh with an incision scar, multiple decubitus ulcers and necrotic areas present bilaterally on the gluteal regions and trochanters, a mass and an incision scar of the left lower quadrant of the abdomen, gynecomastia, multiple neurofibromas of the chest and trunk, multiple and diffuse café-au-lait spots of the axillary and gluteal areas and trunk (more than 10 spots determined to be larger than 1.5 cm), and scoliosis. The ophthalmologic examination revealed an optic glioma of the proptotic left eye and a Lisch nodule of the right eye. The otolaryngologic examination showed a mass of the right retromolar area with a diameter of 6 × 5 × 3 cm extending deeply from the posterior ridge of the left lower alveolar process and gingivobuccal sulcus . Head an The mass infiltrating the left retromolar area and the posterior part of the lower alveolar process was excised with wide free margins . The fir After 8 months, a mass with a diameter of 1 × 1 cm recurred in the same site. A cautious and conservative follow-up was planned, but the patient died in the intensive care unit 10 months after the operation due to sepsis following a severe infection of a large decubitus ulcer involving the sacral and gluteal regions. Oral manifestations are seen in approximately 72% to 92% of cases with NF1, usually presenting with an enlargement of the tongue and submucosal neurofibroma nodules . The ora A rapid change in size of a preexisting neurofibroma, compression or infiltration of the adjacent structures, hemorrhage, and unremitting pain indicate a possible malignant degeneration to MPNST . Most MPMPNSTs comprise almost 10% to 12% of all soft tissue sarcomas, which are primarily associated with NF1 . It is g Treatment is predominantly surgical –4. The g The neurofibrosarcomatous change in a neurofibroma brings about an extremely poor prognosis, and recurrences and distant metastasis are common –4. Studi


Torsion and/or infarction of the greater omentum are rare but well-recognized clinical situations which present as an acute abdomen. The etiology is unknown and speculative. In most cases, the pathology is right sided and clinical presentation consists of an acute or subacute flank pain with mild peritonism usually evoking appendicitis or cholecystitis. Nevertheless, knowledge concerning these two problems can help the surgeon in proper diagnosis and treatment. Since the first report on primary torsion by Eitel in 1899, a few hundred more have been reported and some collective reviews published to date. Recently, ultra sonography and computed tomography have proved to provide sufficiently typical, consistent, and well-recognizable features to avoid unnecessary surgery. In this study, we will present a case diagnosed as primary omental torsion based on computed tomography, which underwent successful conservative management. Vascular accidents of the omentum including torsion, infarction, and hemorrhage are all rare causes of the acute abdomen. They are usually misdiagnosed in the majority of cases as acute appendicitis, followed by acute cholecystitis. Other differential diagnoses are perforated peptic ulcer, appendicular abscess, pancreatitis, torsion of ovarian cyst, and diverticulitis , 2. Ther Spontaneous detorsion is an expected possibility , 4. This In this study a case of primary omental torsion, conservatively managed is presented with a review of literature, indicating that unnecesseary surgery can be successfully avoided. 3.  A 74-year-old woman was admitted to hospital with a 4-days history of abdominal pain. The pain started suddenly in the upper abdomen, increased in severity and localized in the epigaster and right upper quadrant. The pain was constant, and associated with nausea, vomiting and back radiation. There was a previous history of diabetes mellitus (type II), ischemic heart disease, and chronic hypertension. On examination, blood pressure was 160/95 mmHg and other vital signs were normal. Abdominal examination revealed generalized guarding and tenderness with major severity and rebound tenderness in the right upper quadrant. Bowel sounds were hypoactive, and there was no abdominal distension. A tender and ill-defined fullness was palpable. Total white blood cell count was 9500/mm Ultrasound (US) examination was performed which revealed a heterogenous echogenic mass in the upper abdomen. No caecal and appendiceal abnormality was identified. Kidneys and hepatobiliary system were also normal.  As the patient's abdominal tenderness persisted the next day, a computed tomography (CT) scan was requested which demonstrated a 12 × 7 cm amorph and solid mass at the site of tenderness in the upper abdomen. It was adherent to the anterior wall of abdomen at the midline . There w The patient was managed conservatively with oral analgesic and antibiotics. The pain gradually resolved in 2 days and she was discharged after 9 days of hospitalization. Upon review in the outpatient clinic at 1 week, 1 month and 6 months after discharge, the patient remained well. She did not consent to perform CT scan for follow up. Acute conditions of the omentum including torsion, infarction and hemorrhage are all rare but well-recognized conditions. Omental torsion was first described in the literature by de-Marchetti in 1858 and primary torsion of the omentum by Eitel in 1899 [ Torsion of the omentum is usually segmental and may be idiopathic or secondary to intra-abdominal inflammatory foci, adhesions and internal hernias . The patThere are several clinical peculiarities of primary segmental omental infarction that have been established. Patients usually present with acute abdominal pain without other gastrointestinal symptoms. They are usually constitutionally well, without fever or leucocytosis. Focal tenderness with varying degrees of peritonism is found on examination. Given that segmental infarction is usually right sided, appendicitis is the usual presumed diagnosis or, rarely, cholecystitis. Since it is such a rare condition, the diagnosis is usually made at surgery, but is occasionally discovered preoperatively during cross-sectional imaging.  In recent years, the correct preoperative diagnosis of omental torsion via US or CT scan has increasingly been reported in the literature , 11. US  In this case, regarding the typical clinical manifestations, computed tomography was performed which demonstrated an amorph and solid mass at the site of tenderness in the upper abdomen, adherent to the anterior wall. The heterogenic mass seen on CT scan was corresponded to a focal, well-demarcated area of greater omentum. These findings suggest that clinical symptoms can clearly lead to pathologic diagnosis. Previously, omental torsion was almost always managed operatively as this condition was usually found unexpectedly during surgery . However In summary, we have reported a case of omental torsion diagnosed by CT scan and successfully managed nonoperatively. These imaging findings are important to recognize because unnecessary surgery may be avoided when the patient's clinical condition remains stable. However, if the diagnosis is uncertain, diagnostic laparoscopy or laparotomy should be performed to confirm the diagnosis and exclude other sinister causes.


Lymphadenoma of the salivary gland is rare, and the typical characteristics of lymphadenoma remain poorly understood. The aim of this study was to analyze the experience of a single institution in the clinical diagnosis, treatment and prognosis of this type of tumor of the salivary gland. All cases of lymphadenoma diagnosed at the institution between 1996 and 2012 were analyzed. The clinical information  and pathological features were evaluated. All tumors occurred in the parotid glands; three cases were sebaceous lymphadenoma  and seven were non-sebaceous lymphadenoma . The average ages of the patients were 68.3 and 42.4 years for the sebaceous and non-sebaceous groups, respectively. The majority of cases (90%) were diagnosed as pleomorphic adenoma or adenolymphoma prior to surgery, but were confirmed as lymphadenoma by pathological analysis following surgery. During the follow-up period, which ranged between 3 and 36 months with a mean of 30 months, no recurrence of the lesion was identified and the quality of life was good for each patient. In conclusion, the diagnosis of salivary gland lymphadenoma should be based on the clinical and, in particular, the pathological manifestations of the disease. Immunohistochemistry is considered as a practical and helpful adjuvant method of the diagnosis for this type of tumor. Complete surgical resection is the first choice of treatment. Further exploration of the histological origin of lymphadenoma of the salivary gland is necessary due to the insufficient number of reported cases. All patients provided written informed consent for their participation in this study.A specimen from each patient was submitted for histological examination and, following fixation in formalin solution and inclusion in paraffin, 3–5-μm sections were stained with hematoxylin and eosin for conventional evaluation. The histopathological diagnoses of all patients following the surgery were lymphadenoma. Immunohistochemical examination was performed in all patients, including the detection of cytokeratin 8 (CK8), CK19, Ki-67, CKpan, S-100, smooth muscle actin and vimentin. All patients were followed up by a return visit with a follow-up period of 3–36 months. When the patients returned, routine physical examination was performed, and if any suspicious mass was present in the parotid gland and neck region, image examination was suggested. Fine needle aspiration biopsy was also suggested if necessary.As shown in All tumors occurred in the parotid gland and presented as painless masses, which were slowly enlarging. The duration of the symptoms ranged from a few months to 20 years. All patients underwent surgical therapy for the tumors. The parotid lesions were excised by superficial or complete parotidectomy with dissection and preservation of the facial nerve.During the follow-up period, which ranged between 3 and 36 months with a mean of 30 months, no recurrence of the lesion occurred and the patient’s quality of life was good.All tumors were observed to be well circumscribed and 8 of the 10 tumors (80%) were encapsulated. The contents in the cystic tumors were gelatinous and yellow sebum-like.Microscopically, in the cases of sebaceous lymphadenoma the epithelial component comprised solid nests, tubular structures, glands, cords, and tubules of basal, glandular cells. There were always two cell layers, namely an outer basal cell layer and an inner luminal glandular cell layer that was typically composed of cuboidal or low columnar cells. This finding is similar to those of a previous study . In the Notably, no specific immunohistochemical indicators had been reported in previous studies, despite the salivary gland lymphadenoma having characteristic pathological features. However, in the present study, the majority of the tumors exhibited positive immunohistochemical staining of CK8 and CKpan, as shown in Lymphadenoma, including sebaceous and non-sebaceous lymphadenoma, is a rare type of salivary gland tumor. In the present study, this type of tumor was observed to be well circumscribed and exhibited typically benign behaviors, with the majority of the cases affecting adults aged >30 years (80%). Of the 10 cases, approximately one-third exhibited sebaceous differentiation to an extent, which was the opposite to the findings of a previous study (Dardick and Thomas  previousThe pathogenetic or histological origin of non-sebaceous lymphadenoma has been proposed to be embryonic salivary gland inclusions in the intraparotid or periparotid lymph nodes. A strong argument for this hypothesis are that studies have identified an unequivocal hilus structure with embryonic parenchymal inclusions, in conjunction with frequent secondary follicles and lymph vessels within the marginal sinus structures ,3,7,10. Thus far, to the best of our knowledge, only 37 cases of non-sebaceous lymphadenoma have been reported in the English language literature –8,10–16;Overall, the present study reported 10 cases of lymphadenoma, in which the patients typically presented with a painless mass for which complete surgical excision appeared to be curative, and attempted to discuss an exact method of diagnosis for this type of tumor, particularly for non-sebaceous lymphadenoma. Due to the similarity of the clinical features of lymphadenoma with those of other types of parotid tumor, cases of lymphadenoma are often misdiagnosed and there are no remarkable clinical features that completely distinguish lymphadenoma from other types of parotid tumor. The most effective approach of identification is by the pathology of the tumor. However, the exact mechanisms of the tumorigenesis of non-sebaceous lymphadenoma from salivary gland inclusions remain obscure. As there are few studies concerning cases of lymphadenoma, there is a lack of knowledge of this type of tumor. An improved understanding and a more in-depth investigation of lymphadenoma in the salivary gland requires further studies including larger numbers of cases.


Multiple diverticulosis of jejunum represents an uncommon pathology of the small bowel. The disease is usually asymptomatic and must be taken into consideration in cases of unexplained malabsorption, anemia, chronic abdominal pain or discomfort. Related complications such as diverticulitis, perforation, bleeding or intestinal obstruction appear in 10-30% of the patients increasing morbidity and mortality rates. We herein report a case of a 55 year-old man presented at the emergency department with acute abdominal pain, vomiting and fever. Preoperative radiological examination followed by laparotomy revealed multiple giant jejunal diverticula causing intestinal obstruction. We also review the literature for this uncommon disease. Multiple diverticulosis of the jejunum constitutes an uncommon pathology of the small bowel. The disease is often asymptomatic and must be taken into consideration in cases of unexplained malabsorption, anemia, chronic abdominal pain and discomfort. Related complications such as diverticulitis, hemorrhage, obstruction and perforation present high mortality and morbidity rates. We herein report a case of a 55 year-old man presented at the emergency department because of acute abdominal pain, vomiting and fever. Preoperative radiological examination followed by laparotomy revealed multiple and giant jejunal diverticula causing intestinal obstruction. We also review the literature for this uncommon disease.A 55-year old man arrived at the emergency department complaining of 48-hour lasting intense abdominal pain and vomiting. The patient had a free medical history and was not receiving any drugs at that time. He mentioned a two-year-lasting remittent abdominal pain, fullness and often abdominal distension. The patient also mentioned a particular intolerance of pulse and vegetables.3), anemia (Hct:30%), hypokalemia (3.2 mmol/l) and hypoalbuminemia (2.80 mmol/l). C-reactive protein was also elevated (4.57 mg/dl). A plain abdominal X-ray showed multiple air-fluid levels and dilated intestinal loops suggesting intestinal obstruction but not signs of perforation  while other vital parameters were within normal limits. Abnormal laboratory findings included leukocytosis 13300/mm3300/mm3,°C while The patient underwent laparotomy on day 9 after admission. Upon exploration, we found diffuse and giant jejunal diverticula with rare signs of diverticulitis Figure . A 80 cmThe patient's post operative course was uneventful. Pathology report described large diverticula and rare focus of diverticulitis. During 24-months follow-up, the patient was symptoms free.Diverticulosis of the small bowel is a rare disease with variable clinical presentations and often incidentally discovered during radiological investigations. The disease was first described by Sommering in 1794 and later by Astley Cooper in 1809. Gordinier and Shil performed the first operation for diverticula in 1906 .Jejunoileal diverticula (excluding Meckel's diverticulum) are pseudodiverticula, resulting from a mucosal and submucosal herniation through the muscular layer of the bowels' wall in places of minor resistance to the intraluminal pressure such as the anatomic points where blood vessels penetrate the intestinal wall . The etiThe incidence of jejunoileal diverticula in studies of the small bowel by enteroclysis is 2-2.3% which is comparable to autopsy data presenting an incidence of 1.3-4.6% for diverticula of the jejunum and ileum -20. The The disease is usually silent. Nevertheless, Rodrigez et al.  reviewedComplications such as obstruction, hemorrhage, diverticulitis and perforation occur in 10%-30% of the patients ,35. SomeIncidence of diverticulitis with or without perforation ranges from 2% to 6% . JejunoiMechanical obstruction can be caused by adhesions or stenosis due to diverticulitis, intussusception at the site of the diverticulum and volvulus of the segment containing the diverticula. In addition, sizable stones enclosed in the diverticula may apply pressure to the adjacent bowel wall or may escape from the diverticulum causing intestinal occlusion. Pseudo-obstruction, reported in 10-25% of cases, is usually associated with jejunal diverticulosis as a result of peritonitis (following diverticulitis), perforation, strangulation and incarceration of an enterolith within a diverticulum or related to the bacterial overgrowth and the visceral myopathy or neuropathy . A wide,Bleeding is a consequence of acute diverticulitis and due to the erosive results of the inflammation. Mucosal ulcerations compromise mesenteric vessels causing hemorrhage. Rodriguez et al., in a large series of 141 symptomatic cases, estimated bleeding in 2% .Suspicion of jejunal diverticulosis is difficult and often the diagnosis is missed or delayed. Considering that jejunal diverticulusis is asymptomatic for a long time in most of the cases, diagnosis is usually made when the disease becomes symptomatic or complicated. Simple radiographs are not suggestive to make the diagnosis despite the fact that Nobles et al.  describe99 RBC and mesenteric angiography seems do be specific [In cases of bleeding, a diagnostic and therapeutic approach with Tcspecific . Upper Gspecific . Recentlspecific . Wirelesspecific . Laparosspecific . A totalspecific .Asymptomatic jejunoileal diverticulosis does not require intestinal resection . Some auOur recent experience is limited in five cases of jejunoileal diverticulosis presented in our department in a three year period from December 2007 to December 2010. In two cases, jejunal diverticula were incidental findings during laparatomy for other reasons . In both cases, jejunal diverticula did not present signs of inflammation or perforation and resection was not performed. In one case, clinical and imaging findings of diverticulitis suggested jejunal diverticulitis, however, the age of the patient, co-morbidities and the relative' s will led us to a conservative treatment. Bleeding was the main symptom in the fourth case and exploratory laparotomy was performed because of the ileal intraluminal entrapment of an endoscopic capsule. Bleeding was due to adenocarcinoma of the ileum and multiple small diverticula of the proximal ileum were an incidental finding Figure . DivertiIn the case reported in this paper, the patient had a chronic abdominal discomfort or pain, however, he never visited the physician. The intestinal obstruction was the main symptom of presentation and obviously due to multiple overloaded jejunal diverticula and to pseudo-obstruction caused by the diverticulitis. The initial treatment with nasogastric tube and broad-spectrum antibiotics helped to limit inflammation and to avoid the extension of the diverticulitis, allowing us to perform an elective intestinal resection nine days after the initial admission. Anemia and hypoaluminemia were probably due to malabsorpion. CT scan demonstrated diverticula and excluded perforation. The enteroclysis confirmed the diagnosis.Jejunal diverticulosis is more common than reported, affects usually older patients and must be considered in the differential diagnosis in patients with acute or chronic abdominal symptoms. A high degree of suspicion is necessary in view of the high mortality and morbidity rates resulting from a delayed diagnosis of the disease. The treatment of choice is surgical excision of the affected jejunal segment.Written informed consent was obtained from the patient for publication of his medical data.The authors declare that they have no competing interests.EFand SMparticipated to the sequence alignment, researched sources for the reference and drafted the manuscript. KVLtook the photographs and drafted the manuscript. FA and CV helped in the interpretation of the photos and helped draft the final version of the manuscript.All authors read and approved the final manuscript form.


Extramedullary hematopoiesis is characterized by the presence of hematopoietic tissue outside the bone marrow. Extrathoracic extramedullary hematopoiesis is a rare and usually asymptomatic condition. We report a case of a 38-year-old female with paraspinal and presacral extramedullary hematopoiesis with polycythemia vera. Clinical and laboratory evaluation, along with radiological and histopathological findings are described. The diagnosis of the disease was confirmed by CT-guided biopsy. Review of literature is presented. Polycythemia vera is a myeloproliferative disorder of clonal origin arising at the level of pluripotential hematopoietic stem cell and resulting in neoplastic proliferation of erythroid, myeloid and megakaryocytic elements in the bone marrow, an increased red blood cell mass and usually raised blood counts of the three major hematopoietic cell lines . ExtrameA 38-year-old female presented in the Department of Radiodiagnosis with pain in the left upper quadrant of the abdomen for 3 months. The patient was a diagnosed case of polycythemia vera with a history of multiple phlebotomies in the past. On examination, she was afebrile and her pulse rate, respiratory rate and blood pressure were within normal limit. There was no evidence of lymphadenopathy, cyanosis, pallor, icterus, clubbing or any other significant relevant history. Her sensory and motor functions were normal. Abdominal examination revealed a moderate splenomegaly of 7 cm below the left costal margin.Laboratory data are mentioned in Ultrasonography (USG) of the abdomen and pelvis demonstrated moderate splenomegaly along with hypoechoic lesions sized 7.5×4 cm and 5.5×3.5 cm in the right paraspinal (lumbar) and presacral regions, respectively . Multidetector computed tomography (MDCT) of the abdomen and pelvis were performed from the level of the diaphragm to the coccyx. Non-contrast CT followed by contrast-enhanced CT was done by taking 10×10 mm axial sections. Images were reconstructed in thin sections (1.25 mm) in the coronal plane. MDCT revealed moderate splenomegaly  and an iCT-guided biopsy from the right paraspinal (lumbar) and presacral masses revealed hematopoietic tissue containing myeloid, erythroid and megakaryocytic lines showing maturation; an excess of immature cells was present in some microscopic fields . CorrelaEMH is a physiological compensatory mechanism in which there is formation of normal blood cells outside the bone marrow because the bone marrow isunable to meet the normal circulatory demands . EMH is The signal intensity of EMH on MRI depends on the activity of the hematopoietic cells . In actiPolycythemia vera is treated with alkylating agents, radioactive phosphorus (32P) and venesection. If there is compressive myelopathy, laminectomy is done. It commonly transforms from a proliferative into myelofibrotic stage. After treatment with alkylating agents or radioactive phosphorus (32P), upto 15% of cases of polycythemia vera can be transformed into acute myeloblastic leukemia (AML) , 29. In In conclusion, based on characteristic clinical, biochemical, radiological and histopathological findings, it is important to consider the possibility of extramedullary hematopoiesis in the differential diagnosis of paraspinal (lumbar) and presacral masses in polycythemia vera.


Deep venous thrombosis (DVT) or pulmonary embolism (PE) is a rare, but not exceptional presentation of soft tissue sarcomas (STSs). Due to the remarkable difference in the incidence between DVT or PE and STSs, this type of STS presentation is usually associated with a considerable delay in tumor diagnosis and treatment.We describe two cases of STS who presented with DVT and PE. Physical and radiographic examination only showed the presence of DVT. Both patients were treated for DVT or PE for several months. Due to the persistence of symptoms and the inefficacy of anticoagulant therapy, magnetic resonance imaging (MRI) was performed, which revealed the presence of a lower limb mass in both cases. The definite diagnosis was reached via excisional biopsy and histological examination.In one case, MRI showed a large tumor in the anterior muscle compartment of the right thigh, with thrombosis of the right common femoral vein and involvement of the ipsilateral common iliac vein and inferior vena cava until the confluence of the renal veins. In the other case, MRI showed a large tumor in the middle third of the right thigh. The lesion was in close proximity to the superficial femoral vein that appeared compressed and showed signs of thrombosis. In both cases, histological examination revealed a high-grade leiomyosarcoma.STSs of the lower extremities can rarely present with DVT or PE. This possibility should be considered in the differential diagnosis of painful leg swelling, especially in patients with recurrent or refractory venous thrombosis. When a STS is suspected, MRI should be obtained followed by excisional biopsy of the eventual mass. A delay in diagnosis and treatment of STSs often results in very poor prognosis.Level of evidence. IV Sarcomas are relatively rare malignant tumors arising from the mesenchymal tissue, which encompasses muscle, fat, bone, blood vessels, and fibrous or other supporting tissue. Sarcomas display a wide variety of histological subtypes and frequently involve the limbs (55% of cases), especially the lower extremities -3.The incidence of soft tissue sarcomas (STSs) is approximately 15-35 cases per million person-years, accounting for less than 1% of all malignancies ,5. The iOverall, the risk of thromboembolic events in patients with STSs is comparable with that observed in other orthopedic conditions. However, STSs involving the hip or the thigh have been associated with a particularly high risk of thromboembolism .Deep venous thrombosis (DVT) and venous thromboembolism (VTE) are common causes of morbidity and mortality especially in bedridden or hospitalized patients. In the U.S., the incidence of DVT is approximately 80-100 cases per 100,000 person-years . The risDVT is a rare, but not exceptional presentation of a STS. Due to the remarkable difference in the incidence of the two conditions, this type of presentation is usually associated with a considerable delay in the diagnosis and treatment of the tumor. In the present study, we describe 2 cases of STS of the lower limb, the onset of which was characterized by DVT and VTE. Because of the unusual presentation, in both cases diagnosis and treatment of the STS were significantly delayed. We also provide a concise review of the literature about the association between STSs and VTE.Ethical approval was obtained by Ethical Committee of the Catholic University of Sacred Heart in Rome.Two cases of STS of the lower limb characterized by DVT and pulmonary embolism (PE) as the initial presentation were observed in our Orthopedic department: a 47-year-old man diagnosed with an idiopathic DVT of the right distal femoral vein and the popliteal vein Figure A-B and aIn the first case Figure C-D, MRI In the second case, MRI showed a large mass located in the middle third of the right thigh, with low signal intensity in T1- and T2-weighted sequences and enhancement after gadolinium administration  . Among tArumilli et al.  describeOther reports describe cases of leiomyosarcoma of the femoral vein, leiomyosarcoma involving the profunda femoris artery and the popliteal artery, fibular Ewing’s sarcoma, malignant epitheliod angiosarcoma, spindle cell sarcoma, pelvic and sacrum condrosarcoma, and liposarcoma -29. In aBoth the presence of cancer and cancer treatment, including surgery and chemotherapy, are major risk factors for DVT. Indeed, approximately 18% of incident DVT cases can be attributed to an active malignant neoplasm . RemarkaHowever, DVT is an unusual presentation STSs . The difThe two cases of leiomyosarcoma observed in our department support the notion that this histotype is the most frequently associated with unexplained DVT. The excision of the tumor followed by chemotherapy/radiotherapy or brachitherapy led to complete resolution of DVT and PE.In conclusion, STSs are rare, yet potentially fatal malignancies characterized by local extension and occasional distant metastases. STSs of the lower extremities can present with VTE or mimic DVT, which may result in substantial delays in the diagnosis and treatment of the tumor. The two cases described here, together with our concise literature review, highlight the importance of considering the presence of neoplastic masses in the differential diagnosis of painful leg swelling conditions. In particular, STSs should be excluded in young patients with no risk factors for VTE and in those with recurrent or refractory thrombosis. In these cases, a careful physical examination together with imaging-assisted techniques  are of utmost importance to promptly identify an eventual STS. Such an approach ensures the early diagnosis and management of STSs, which is essential to minimize morbidity and mortality -36.CT: Computerized tomography; DVT: Deep venous thrombosis; MRI: Magnetic resonance imaging; PE: Pulmonary embolism; STS: Soft tissue sarcoma; VTE: Venous thromboembolism.The authors declare that they have no conflict of interest.All authors read and approved the final manuscript. All authors contributed equally to this work.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/14/64/prepub


Extraskeletal chondrosarcoma in anterior mediastinum is very rare. A 45-year-old male patient was admitted to the hospital with precordial chest pain. A large and well-shaped mass in the anterior mediastinum was seen radiologically, and there was a clearly compression of the heart by the mass. The lesion was totally resected, and extraskeletal mediastinal chondrosarcoma was histopathologically diagnosed. We aimed to present and discuss the radiologic, clinic, and histopathologic features of unusual presentation of extraskeletal chondrosarcoma in a case. Chondrosarcoma is a malignant mesenchymal tumor arising from cartilage-forming tissues involving the bones (bone chondrosarcoma) or the soft tissues . Bone chondrosarcoma usually affects middle-aged to elderly adults, and the pelvic bones, ribs, shoulder girdle, and long bones are the most common locations. Extraskeletal chondrosarcoma usually affects the deep soft tissues of the extremities and the region of head and neck , 2. ExtrA 45-year-old, nonsmoker male was admitted to the hospital with precordial chest pain. Blood tests results were normal. Chest roentgenogram was initially thought to be normal. But a masslike opacity was seen on the heart . Thorax Pulmonary function tests revealed normal spirometric values. The fiberoptic bronchoscopy was performed, and it was normal. Whole-body PET-CT with low-dose CT protocol was performed before the surgery, and there was no F18-fluorodeoxyglucose (FDG) uptake in lesion or any part of body. The surgical excision was planned. There was no relationship between the mass and adjacent structures. An encapsulated mass was totally removed. Pathological examination revealed a well-differentiated chondrosarcoma with chondrocyte atypias and neoplastic chondrocytes Figures  and 4. NChondrosarcomas are presumably derived from primitive precartilaginous mesenchymal cells . It may Chondrosarcoma is more frequently found in patients from the fourth to seventh decades, with a male predominance , 5. LocaChest radiography, thorax CT, and MRI depicts lobulated, well-shaped soft tissue mass, as in our case. Mediastinal chondrosarcomas also shares imaging findings with other skeletal and soft-tissue tumors. Brenner et al. reported that the combination of pSUV on PET imaging and histopathologic tumor grading in chondrosarcoma might be helpful for determining a more accurate diagnosis . HistopaThe wide local excision is recommended for treatment. In the present case, mediastinal chondrosarcoma was totally resected. The patient did not receive radiotherapy because all the surgical margins were tumor-free. According to reported one article, the primary chondrosarcomas of anterior mediastinum may have a less aggressive clinical course than previously recognized . There iIn conclusion, the extraskeletal chondrosarcoma in anterior mediastinum is very rare and usually overlooked on chest radiography. The complete surgical excision is enough for treatment, and prognosis is better than other chondrosarcomas.


Cutaneous metastases from colorectal cancers are rare and are usually present on the abdominal wall or previous surgical incision sites. Remote cutaneous lesions have been reported, however, often occur in the setting of widespread metastatic disease including other visceral secondaries. We present a case of lower extremity cutaneous metastases as the first sign of metastatic disease in a patient with adenocarcinoma of the colon. This case illustrates that new skin lesions may be the initial presentation of metastatic disease in a patient with a history of cancer. Cutaneous metastases from colorectal cancers are rare, occurring in less than 4% of patients , 2. The A 36-year-old Hispanic male with no significant past medical history presented to the emergency department with complaints of intermittent hematochezia and an unintentional weight loss for nearly 2 months. He stated that he began noticing bright red blood intermixed with well-formed stool; also admitted to a 26 pound unintentional weight loss over 2 months. He denied any constipation, diarrhea, fever, or tenesmus. He denied the use of any medications, illicit drugs, alcohol, and tobacco. Family history was noncontributory, including the absence of any malignancy or gastrointestinal disorders. A colonoscopy performed during admission revealed a 3 × 3 centimeter friable mass in the ascending colon, with biopsies confirming the presence of a moderately differentiated adenocarcinoma. After a right hemicolectomy was performed, no evidence of serosal invasion, lymph node involvement, or distant metastasis was noted; thus the tumor was staged as T2N0M0. The patient was following with his oncologist for this sporadic colorectal adenocarcinoma and was being appropriately screened for cancer recurrence after surgical intervention.More than 2 years after hemicolectomy, the patient presented to the ambulatory clinic with complaints of a 2-week history of papules and nodules on his lower extremities. He stated that he initially noticed a 2-millimeter nonpruritic papule 3 centimeters above his right knee, which increased to approximately 5 millimeters within the next 24 hours. 48 hours after the appearance of this papule, the patient noticed a rapid onset of numerous follicular papules ranging from 1 to 5 millimeters in size. The lesions were now present on both the left and right lower extremities. He stated the lesions were erythematous, nonpruritic, nontender, and immobile. He denied the presence of any other lesions, unintentional weight loss, fever, or chills.Physical examination was remarkable for multiple, shiny, immobile, erythematous, follicular papules ranging from 1 to 5 millimeters in size on his bilateral lower extremities Figures . Some ofA 3-millimeter punch biopsy of a 4-millimeter papule on the right lower extremity was performed. The location of the papule was approximately 6 inches above the right knee. Histopathologic evaluation of the biopsy revealed the presence of glandular structures suggesting metastatic adenocarcinoma consistent with a primary colon cancer, with a desmoplastic reaction in surrounding tissue of the dermis . Subsequ3 months after initial biopsy, the patient returned to the medical emergency department with shortness of breath and pleurisy. Physical examination was significant for unresolved papular lesions on the lower extremities. The lesions were unchanged in size and number when compared to physical examination 3 months prior. Further examination was also significant for decreased breath sounds in the bilateral lungs. Imaging studies performed at that time revealed multiple lung masses with a histological confirmation of metastatic adenocarcinoma. The patient was intubated for respiratory failure and admitted to the critical care service. His hospitalization was complicated by massive hemoptysis, sepsis, and multiple organ failure leading to his eventual death on hospital day 12.The occurrence of cutaneous metastasis from internal malignancies is rare, being discovered in only 0.2–10% of autopsies performed on patients with cancer , 4. CutaColorectal cancer metastasizing to the skin is rare, with the more common sites of disseminated disease being the liver, lung, bone, and brain . In a stAlthough previous surgical scars and skin overlying the abdominal wall appear to be the most frequent sites of cutaneous metastasis from colorectal cancer, remote lesions have also been reported. Lesions involving the face, tongue, head, neck, and hands have been documented; however, these are usually associated with other visceral secondaries and are likely due to hematogenous spread of tumor cells and their trapping to capillary beds of the overlying skin . Remote The clinical presentation of cutaneous metastasis is varied, posing a diagnostic challenge to clinicians. Typically, lesions present as multiple, firm, nonulcerating nodules which may mimic lipomas, neurofibromas, and granulomas . LesionsAlthough cutaneous metastasis from colorectal cancer alone poses no medical harm, they often herald widespread metastatic disease and harbor a poor prognosis . SurvivaCutaneous metastasis from colorectal cancer is rare and may be the initial sign of metastatic spread. The case described illustrates that clinicians should maintain a heightened suspicion for metastatic disease in a patient with a history of cancer and new, evolving, or unresolving skin lesions –13. Earl


Gastric cavernous hemangioma is a relatively rare benign gastric disease. Here we report the case of a 25-year-old male patient who had been admitted complaining of epigastric pain and hematemesis. Preoperative imaging indicated that the mass lesion palpated in the epigastric region was a probable mesenchymal tumor of gastric origin. Due to the hypervascular nature and submucosal localization of the mass, we did not obtain definitive preoperative diagnosis by endoscopic biopsy. The histologic diagnosis of cavernous hemangioma was confirmed by post-resection histopathologial evaluation of the mass. Intra-abdominal hemangiomas are rarely found outside of the liver . GastricA 25-year-old male with a history of intermittent abdominal pain for the last six months was admitted to our emergency department complaining of intractable postprandial abdominal pain, along with bloody vomiting. Having been subject to a preliminary evaluation in our emergency department, the patient was transferred to the gastroenterology clinic for further investigation and treatment, where oral intake was stopped and replaced with parenteral replacement therapy. The patient’s medical background revealed nothing remarkable other than recurrent epigastric pain. He also had a history of receiving proton pump inhibitor drugs on an irregular basis. Upon physical examination, his general clinical status was good, with stable vital parameters. A palpable mass of 5 × 5 cm, along with tenderness in the epigastric region on palpation, was detected during abdominal examination. The laboratory test results, including liver and renal function tests, complete blood count, coagulation profiles and tumor markers were within normal limits. Upper GIS endoscopy revealed a submucosally located mass lesion of dense vascularity at the antrum-corpus junction on the greater gastric curvature. The appearance of the mass evoked the impression of a gastrointestinal stromal tumor of mesenchymal origin . AccordiHemangiomas are congenital malformations that generally stem from the mesenchymal tissues. They may involve the skin, internal viscera, or both, with a predilection for the head and neck region (60%), the truncal region (25%), and the extremities (15%) . The livHemangiomas of the gastrointestinal tract can be classified as capillary-, cavernous- or mixed-type, with a predilection towards the cavernous type in the gastrointestinal system. Gastric cavernous hemangiomas, on the other hand, are rare 0.05%). First defined by Lambers in 1893, gastric hemangiomas are most commonly encountered in adulthood, although they can occur in any age group %. First . CT seemThe role of endoscopic biopsy in the preoperative histopathological diagnosis of hemangiomas is limited owing to the submucosal localization and dense vascular nature of such lesions . As suchOther gastric submucosal masses, especially those of gastrointestinal stromal tumors, leiomyomas, lipomas, varicous vessels and carcinomas should be kept in mind in the differential diagnosis of cavernous hemangiomas due to their frequent submucosal localization. Biopsy may yield equivocal results for especially small lesions covered by normal mucosa. Assessment of such lesions by endoscopic USG becomes increasingly significant. Boyce et al. evaluated 91 patients with gastric submucosal tumors by EUS, reporting that endoscopic ultrasound was useful for the evaluation of upper gastrointestinal submucosal mass lesions . Due to Surgery is the curative treatment. Accordingly, wedge resection, partial or total gastrectomy constitute the standard treatment modalities for isolated gastric hemangiomas . A surgeEndoscopic resection may be preferred for submucosal lesions less than 2 cm in diameter, which can easily be removed from the muscularis propria . Arafa eIn conclusion, gastric hemangiomas are rare and benign tumors of the stomach. Use of endoscopy in conjunction with CT is beneficial for diagnosis. The role of endoscopic biopsy, however, remains limited. Endoscopic resection can be undertaken in selected cases. Surgery is the curative treatment. Moreover, surgical treatment along with histopathological studies occupy an important place in the establishment of a definitive treatment.


An approximately 4-year-old castrated male, Saanen cross goat presented to the Colorado State University Veterinary Teaching Hospital for evaluation and removal of a 22 cm × 22 cm, dark red, thickened, and crusted cutaneous lesion along the left ventrolateral thorax. An initial incisional biopsy performed approximately 8 weeks earlier was suspicious for cutaneous hemangiosarcoma. Surgical excision was deemed to be the most appropriate treatment option for this goat. A complete physical exam, complete blood count, and chemistry profile were performed and results were within normal limits. Thoracic radiographs and abdominal ultrasound were performed to rule out metastatic disease and comorbid conditions; no metastatic lesions or other abnormalities were observed. En bloc surgical excision of the affected skin was performed and the entire tissue was submitted for histopathology. A final diagnosis of cutaneous hemangiolipoma was reached upon extensive sectioning and histologic examination of the larger tissue specimen. The goat recovered well from surgery and has had no further complications up to 9 months postoperatively. To our knowledge, this is the first case report of a hemangiolipoma in a goat and surgical excision for such lesions appears to be a viable treatment method. Angiolipomas are rare tumors of endothelial cells that have been documented in both humans and animals –3. TheseAn approximately 4-year-old, 100 kg castrated male, Saanen cross goat presented to the Colorado State University Veterinary Teaching Hospital (VTH) for evaluation and removal of a large cutaneous lesion along the left ventrolateral thorax. The lesion was first noted 1.5 years earlier and was thought to have started as irritation from a pack saddle. The lesion was not pruritic or painful; however, its location interfered with placement of the pack saddle. The referring veterinarian had performed an incisional biopsy 8 weeks prior to presentation at the VTH. Histopathology of the tissue was highly suspicious for a well differentiated hemangiosarcoma. On physical examination an approximately 22 × 22 cm, fairly discrete region of skin caudal to the left axilla was palpably thickened (approximately 1 cm thick) and firm, mildly alopecic, discolored red and purple, and densely crusted with dark red scabs . The remAn intravenous catheter was placed in the left jugular vein and the patient was prepared for general anesthesia and surgery. Sedation was achieved using hydromorphone  and diazepam . Induction was performed with ketamine , diazepam , and propofol . The patient was intubated and maintained on isoflurane during surgical excision of the mass. Surgical margins were drawn within 1 cm of the lesion in an elliptical shape approximately 25 × 35 cm, originating at the left axilla and extending dorsally along the left thoracic wall. Monopolar electrocautery was used to incise the skin along the margins. The skin incision was extended just deep to the panniculus muscle, and the flap of lesional tissue was dissected medial to this tissue plane. During dissection, mild areas of subcutaneous and dermal bruising were evident but did not extend into tissues deeper than the panniculus. Temporary margin apposition was achieved as the flap was dissected using large towel clamps. Once the lesion was completely excised, surgical closure began with tension-relieving cruciate and interspersed buried simple interrupted sutures using 0 monofilament polyglyconate  within the panniculus muscle fascia at either end of the ellipse. Once apposition of the skin was achieved, an intradermal horizontal mattress suture pattern was placed using 2-0 monofilament polyglyconate. A Ford interlocking pattern using 0 polybutester  was placed over the intradermal pattern. The resulting apposed incision was approximately 45 cm in length. Finally, 1 polybutester was used to place 12 tie-over bandage loops surrounding the incision. Four lap sponges were rolled and secured over the incision using umbilical tape. Perioperative medications included tulathromycin , flunixin meglumine , and morphine . The goat recovered well after surgery and anesthesia and returned home several days later on a course of oral meloxicam  for pain management. An incisional seroma developed at the most ventral portion of the incision approximately 1 week after surgery. The ventral-most sutures were removed to allow for drainage and the incision healed without further complication. Remaining sutures were removed 3 weeks after surgery. μm, and stained with hematoxylin and eosin for histological evaluation. The entire cutaneous lesion was fixed for >24 hrs in 10% neutral buffered formalin. Representative tissues were trimmed, embedded in paraffin, sectioned at 4 μm in diameter) supported by dermal collagen  [Other differentials considered for nonpruritic crusting lesions in small ruminants include hyperkeratosis secondary to trauma, dermatophilosis, staphylococcal dermatitis, zinc deficiency, pemphigus foliaceus, and ringworm (occosum) , 23. CloHuman and canine angiolipomas are considered benign neoplasms and surgical excision is curative . MinimalThe patient was allowed to return to normal activity following suture removal. Recurrence of the cutaneous lesion at the surgery site was not identified at a 10-month followup. Surgical excision appears to be a viable treatment method for cutaneous hemangiolipomas in goats; however long-term patient monitoring is recommended due to the lack of clinically described cases. Importantly, the initial incisional biopsy was reported as consistent with hemangiosarcoma, a significantly more serious disease with a median survival time of 170–300 days . Because


Less than 200 cases of posttraumatic superficial temporal artery pseudoaneurysm have been described in the literature. The majority of these cases result from blunt head trauma and are diagnosed an average of three weeks following the inciting traumatic event. In this case report, we describe a superficial temporal artery pseudoaneurysm that developed and was diagnosed the same day of a blunt head trauma in a 54-year-old white male. This is the earliest formation/diagnosis of post-traumatic superficial temporal artery pseudoaneurysm yet reported in the literature. This case report demonstrates that this diagnosis should be kept in the list of differential diagnoses for a post-traumatic soft tissue mass of the face, even immediately following the traumatic event. Posttraumatic aneurysms do not commonly arise within the distribution of the facial artery, as the external carotid and its branches are protected in most locations by overlaying soft tissue. When they do occur, one of the most commonly affected vessels is the anterior branch of the superficial temporal artery (STA) because of its superficial course over the frontal bone, between the frontalis and temporalis muscles . The majA 54-year-old Caucasian male with a past medical history significant for anaplastic astrocytoma previously treated with chemoradiation was examined in the emergency department after experiencing two seizure-like episodes earlier that morning. These episodes involved rhythmic movements of the right arm, confusion, and aphasia. During the second episode, which occurred in the parking lot of the emergency department, the patient fell and repeatedly impacted the left side of his face on the pavement. Upon examination, the patient had significant abrasions to the left side of the face with a small, palpable subcutaneous mass over the left temporal region. The patient demonstrated no focal neurological deficits. A computed tomography (CT) scan of the patient's head obtained in the emergency department demonstrated a small focus of intraparenchymal hemorrhage for which the patient was admitted to the hospital for further observation and management.The following day, a clinical examination revealed that the small bulge over the left temporal region had doubled in size (1 cm × 1 cm), was pulsatile, and freely mobile with no obvious involvement of the overlying skin. No bruit or thrill was appreciated. The patient reported minimal pain associated with the mass. A magnetic resonance image (MRI) was obtained at the suggestion of the consulting neurologist that redemonstrated a focal hemorrhage in the vertex of the left cerebral hemisphere with surrounding edema Figures . The MRI The patient underwent surgical excision of the pseudoaneurysm under general anesthesia. The lesion was approached through an elliptical incision overlying the pseudoaneurysm, which included the skin and subcutaneous tissue down to the level of the pseudoaneurysm. Upon entering the pseudocapsule, there was a mild amount of oozing and a large hematoma and clot, which were all evacuated. The proximal and distal ends of the STA that had been feeding the pseudoaneurysm were identified and ligated. The wound was closed with vertical mattress sutures after hemostasis was verified. The patient's postoperative course was uneventful.Of the cases of traumatic STA pseudoaneurysm that have been reported in the literature, 95% have resulted from blunt trauma, while the remaining cases resulted from penetrating trauma or iatrogenic cause . The mos Patients typically present an average of three weeks following the inciting traumatic event. However, a literature review of STA pseudoaneurysms reported a range of two days to 17 years from trauma to diagnosis . Patient In a minority of cases of posttraumatic STA pseudoaneurysms, history of a head injury in combination with a focused physical exam was sufficient to make the diagnosis –6. If im Given the low incidence of STA pseudoaneurysm, no guidelines exist to direct management. However, given the risk of thromboembolism, spontaneous rupture, and hemorrhage in addition to the associated pain and cosmetic defect, it is necessary that STA pseudoaneurysms are accurately identified and treated , 2. Trea To our knowledge, the present case is the first report in the literature of a post-traumatic STA pseudoaneurysm that was present the day of the inciting trauma. On average, STA pseudoaneurysms due to trauma develop approximately three weeks following a traumatic incident, with the earliest report in the literature being two days after-trauma . This ca


In recent years, the synchronous occurrence of tumors of different histotypes arising in the same organ has been reported more frequently in the literature. In the stomach, adenocarcinoma has been described with coexisting primary rhabdomyosarcoma, carcinoid, and low-grade B-cell lymphoma of mucosa-associated lymphoid tissue. The simultaneous development of adenocarcinoma and gastric mesenchymal tumor has been documented rarely. We report one such case. A 65-year-old male was diagnosed with a proximal gastric adenocarcinoma and underwent subtotal gastrectomy. Subsequent histopathological examination revealed the presence of another tumor at the gastric antrum. This was a gastrointestinal stromal tumor of low risk category (GIST). The literature has only a few previous reports of this very rare association. It is not known whether this synchronicity is incidental or there is a causative factor inducing the development of tumors of different histotypes in the same organ. Pathologists, oncologists and surgeons should be aware of this interesting condition. Adenocarcinoma is the most common histological type of gastric tumor. It may coexist with another synchronous tumor of different histological type in a different part of the stomach. Gastric adenocarcinoma may coexist most commonly with lymphoma and less commonly with carcinoid and gastrointestinal stromal tumor (GIST). Rarely, 2A 65-year-old gentleman presented with a five month history of dyspeptic symptoms, and weight loss. Endoscopy showed ulceration along the lesser curvature of the proximal stomach. Multiple mucosal biopsies were obtained from ulcerated areas and histopathology revealed a poorly differentiated adenocarcinoma. Subsequently, the patient underwent an elective subtotal gastrectomy.Macroscopic examination of subtotal gastrectomy specimen showed firm texture of the proximal stomach and an excavating ulcerative growth measuring 40×30×12mm along the lesser curvature. Interestingly, a nodule of firm white tissue measuring 25 mm diameter, was present adjacent to the ulcerated area. Microscopically, the ulcerated area showed glands and sheets of neoplastic cells which had reached the serosal surface . HistoloIn our case, GIST tumor size was 2.5 cm and mitotic count was less than 5/50hpf. Applying these criteria, GIST was classified into low risk category as mentioned above.Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the digestive tract. Synchronous occurrence of a gastrointestinal stromal tumor with a tumor of different histogenesis is very rare and has been documented in the literature mainly in case reports. There are only a few previous reports of simultaneous adenocarcinoma and GIST in the stomach.–6In most of the reported cases of synchronous gastric adenocarcinoma and GIST, the preoperative biopsy fragments showed only adenocarcinoma. GISTs were detected only following laparotomy and examination of the resected specimens. In our case the total gastrectomy was performed for the proximal gastric adenocarcinoma and a small GIST was found incidentally with the histopathological examination of the specimen.et al.[The simultaneous finding of epithelial and stromal gastric tumors raises the question of whether such an occurrence is a simple incidental association or the two lesions are connected by a causal relationship. The suggestion that the stomach harboring a leiomyosarcoma may have a tendency to develop malignant epithelial lesions was put forward by Tada et al. Various et al. At preseN-methyl- N’-nitro-N-nitrosoguanidine induces the development of gastric adenocarcinomas after oral administration in rats.[An interesting hypothesis is that a single carcinogenic agent might interact with two neighboring tissues, inducing the development of tumors of different histotypes in the same organ. Experimental evidence for this possibility has been provided.  in rats.7 However in rats. Equally  in rats.


Inflammatory myofibroblastic tumor is a rare benign lesion whose tumor origin is now proven. It represents 0.7% of all lung tumors. We report the case of a three-year-old child who suffered from a chronic cough with recurrent respiratory infections. Chest X-ray and computed tomography revealed the presence of a left lower lobe lung mass. After pneumonectomy, histological examination combined with immunohistochemical study discovered an inflammatory myofibroblastic tumor.http://www.diagnosticpathology.diagnomx.eu/vs/8722069326962972.The virtual slide(s) for this article can be found here:  Inflammatory myofibroblastic tumor (IMT) is a rare benign tumor, accounting for 0.7% of all lung tumors. ,2 It hasIts clinical and radiological manifestations are diverse and non specific. That’s why diagnosis is difficult to establish unless a surgical resection is performed. ,5Through this observation, the authors recall the radio-clinical, histopathological, therapeutic aspects, and outcome of this rare tumor.We report the case of a three-year-old child, who has had a chronic cough with recurrent respiratory infections since the age of 1 year.Chest X-ray showed a homogenous opacity invading the entire left hemithorax. Chest computed tomography (CT) scan showed a left lower lobe tumor with a small calcification, associated with upper lobe atelectasis. This attracted the mediastinum content to the left side Figure . BronchoThe IMT is a rare benign lesion representing 0.7% of all lung tumors. It was previously called inflammatory pseudotumor, plasma cell granuloma, histiocytoma or fibroxanthoma. ,2,5,6 ItThere are many uncertainties about the pathogenesis of IMT. Several hypotheses have been proposed such as an auto-immune mechanism or infectious origin. Indeed, 30% of cases are closely related to recurrent respiratory infections which are caused by several microorganisms such as Mycoplasma, Nocardia, Actinomycetes, Epstein-Barr and human herpes virus ,3,5,6,10Patients are afflicted with nonspecific symptoms such as cough, dyspnea, hemoptysis, chest pain, fever and fatigue. Weight loss and anorexia are rare. -6 HoweveRadiological aspects are variable and nonspecific. Most patients (87%) have a mass or a pulmonary nodule, solitary, rarely multiple (5%), measuring 1 to 6 cm in diameter, sharply limited, smooth or bumpy. The lesion is located on the periphery with a predilection for the lower lobes. ,4,6Computed tomography shows the presence of a heterogeneous nodule or mass with variable contrast enhancement. It specifies the tissue or cystic nature of the tumor, its vascular behavior and it assesses the locoregional extension. Calcifications and cavitations are rare. Pleural effusion is seen in less than 10% and atelectasis in 8% of cases. Sometimes the tumor can extend towards the hilum, mediastinum, pleura or diaphragm. The treatment of choice for diagnostic and therapeutic reasons is a complete resection. An incomplete resection increases the risk of recurrence. -3,5 CortOn gross examination, the tumor is well circumscribed but not encapsulated, firm and homogeneous, with sometimes some foci of necrosis. Because of the diversity of clinical and radiological manifestations of IMT, diagnosis is difficult to establish without chirurgical management. It is therefore based on histological examination of the chirurgical resection specimen that shows a lesion formed of varying proportions of spindle cells of myofibroblastic type, arranged in a fibrous, myxoid or calcified stroma, associated with an inflammatory component predominantly lymphocytic and plasmacytic, with a variable component of eosinophils. ,4,5,10IMT includes three histological subtypes: one is a richly vascularized and myxoïde resembling fasciitis or granulation tissue; onother is a more compact fascicular spindle cell proliferation with variable collagenized regions and lymphoid nodules, resembling fibromatosis, and finally a very sclero-hyaline, slightly cellular pattern, looking more like a desmoid tumor. Immunohistochemistry showed reactivity for vimentin and smooth muscle actin. Immunohistochemical positivity for ALK is detectable in just over half of the cases with cytoplasmic staining, more rarely at the nuclear membrane. ,11Pathologic differential diagnosis includes organized pneumonia, lymphoma and solitary fibrous tumor. The mode of tumor growth, the low mitotic index, the polyclonality of lymphoid markers and the negativity of CD34 usually remove most of these diagnoses. Other differential diagnoses are desmoid fibromatosis, angiomyofibroblastoma, fibrosarcoma, leiomyoma, and malignant fibrous histiocytoma. ,4Despite IMT is a benign tumor, it is considered by some authors as a low grade tumor because of malignant features such as local invasiveness, recurrence (4% in cases of incomplete resection) or malignant transformation . The evolution depends on the tumor size  and the quality of surgical resection. The 5-year survival is 91.3%. -5.Inflammatory myofibroblastic tumor is a rare benign tumor. Clinical and radiological presentation is variable and nonspecific and the diagnosis is rarely made before chirurgical management. Only histological and immunohistochemical study can confirm the diagnosis. Despite being a benign lesion, its potential for recurrence and local invasion requires complete surgical resection.The authors declare that they have no competing interests.NH, LC and AA performed the histological examination of the lung and were major contributors to writing the manuscript. SB analyzed and interpreted the patient data. M R is the surgeon who operated on the patient and interpreted the patient data. MB performed the radiological examination. MH, YA, ST assisted in data interpretation and patient follow-ups. All authors read and approved the final manuscript.Written informed consent was obtained from patient's parents for publication of this case report and any accompanying images.


Diffuse parenchymal metastasis is an unusual pattern of liver metastasis that is capable of causing liver failure. In the present study, the authors describe malignant infiltration of the liver by primary breast carcinoma in an autopsy of a 49-year-old female who had a rapid onset of liver failure and died after three weeks. Ultrasonography and computed tomography (CT) scans of the abdomen, as well as macroscopic examination, failed to detect liver metastasis; while microscopic examination revealed diffuse tumor cells with a loss of E-cadherin expression infiltrating into the liver parenchyma. The prognosis of liver failure associated with malignant infiltration is extremely poor; the survival time of patients is extremely low. Liver biopsy may be the most efficient technique for confirming the diagnosis during the patient’s life. Although the liver is a common target for metastasis, acute or fulminant liver failure due to metastasis is a rare occurrence –7. Diffuμmol/l; direct bilirubin, 34.2 μmol/l; AST, 250 U/l; ALT, 63 U/l; ALP, 198 U/l). The patient received treatment for chronic cholecystitis and hepatitis; however, the symptoms progressed and the patient developed thrombocytopenia and coagulopathy. The liver function test results also worsened , while both ultrasonography and computed tomography (CT) scans of the abdomen were not able to detect any specific hepatic lesions. No evidence of viral hepatitis or any identifiable source of infection was observed. The patient’s condition deteriorated further; hepatic encephalopathy developed and the patient died within the third week following the onset of acute hepatic failure. The patient had a history of breast carcinoma stage I and had been treated by modified radical mastectomy (MRM), and had remained disease-free for 10 years following treatment.A 49-year-old Thai female was admitted to hospital due to a high grade fever, jaundice and abdominal pain in the right upper quadrant. Four weeks prior to admission, the patient suffered from malaise, anorexia and weight loss. An initial investigation revealed that the patient had anemia  and abnormal liver function test results . The liver capsule was smooth, the cut surfaces of which showed non-homogeneous dark brown and yellow tissue and no mass-forming lesions . An ill-Microscopic examination revealed diffuse infiltration of the liver parenchyma by pleomorphic cells with some glandular formation . ExtensiMetastatic tumor infiltration was also detected in the spleen and both adrenal glands. Sections from nodules in the pancreas and the lungs demonstrated metastatic carcinoma. In addition, microscopic foci of metastasis were observed in the uterine cervix, appendix, bone marrow, thyroid and intrathoracic lymph nodes. No evidence of carcinoma was identified in the breast tissue samples. Additional abnormal histological findings included pulmonary congestion with edema and focal hemorrhage, myocardial hypertrophy, acute tubular necrosis of both kidneys and hypoxic-ischemic changes in the brain tissue.Immunohistochemical staining for E-cadherin was also performed. Notably, tumor cells in the lung nodule strongly expressed E-cadherin , while tWith the exception of the lymph nodes, the liver is considered to be the most frequent site of metastasis –11. In bAcute liver failure rarely occurs in typical liver metastasis, although abnormal liver enzymes may be detected ,4,7, whiet al, concerning 21 reported cases of acute liver failure due to metastatic breast carcinoma, 18 cases died within three days to two months (The prognosis of acute liver failure secondary to malignant infiltration is extremely poor; the majority of patients do not survive shortly after the onset of liver failure –4,7,8. Ao months ,4.et al proposed a loss of cell surface adhesional molecule expression; the three cases in their study described as diffuse intrasinusoidal hepatic metastasis did not express both E-cadherin and CD44, which are glycoproteins involved in cell-cell and cell-extracellular matrix adhesion (The underlying mechanism of diffuse parenchymal metastasis remains unknown. Allison adhesion . In the In conclusion, although malignant infiltration of the liver is rare, it ought to be considered as a differential diagnosis in patients with acute hepatic failure. Liver biopsy may be the most effective technique to confirm the diagnosis during the patient’s life.


Paragangliomas are very rare tumors derived from neuroendocrine cells of autonomic nervous system. Extra-adrenal paragangliomas account for only 10 to 15% of all paragangliomas and may present incidentally as a mass. Typical triad of fluctuating hypertension, headache, and sweating is not always present which makes the diagnosis difficult sometimes. Definitive diagnosis is usually made with histologic findings and surgery is the treatment of choice. We report a case of a 53-year-old male who presented with chest pain and vomiting. Paragangliomas are rare tumors arising from the neural crest tissue that develops into sympathetic and parasympathetic paraganglia throughout the body. Paraganglioma of adrenal medulla is known as pheochromocytoma while paragangliomas located outside of adrenal gland are broadly classified as extra-adrenal paragangliomas. Paragangliomas are also further divided into functioning and nonfunctioning based on their ability to secrete hormones. Functional paragangliomas have shown to secrete norepinephrine and nor-metanephrine resulting in clinical manifestations such as fluctuating or episodic hypertension, headache, and sweating. On the contrary, nonfunctioning paragangliomas are mostly asymptomatic and found incidentally as a mass. When nonfunctioning paraganglioma gets enlarged it presents as abdominal pain secondary to compression of surrounding organs. A 53-year-old Caucasian male with past medical history of hypertension and hiatal hernia was brought to the hospital for evaluation of nausea and severe sharp chest pain. Chest pain was located retrosternally, radiating to both arm and back followed by episode of syncope.Patient's vitals revealed tachycardia with heart rate of 108 per minute and tachypnea with respiratory rate of 24 per minute. Patient blood pressure was 119/70 mmHg and was maintaining good saturation on room air. Physical examination was within normal limits. Patients' blood work was unremarkable including negative cardiac biomarkers. Computerized Tomography (CT) scan of chest with intravenous (IV) contrast was negative for pulmonary embolism, thoracic aortic dissection, or aneurysm. Cardiac stress test was also within normal limit. On hospitalization day two, patient started complaining of sharp abdominal pain located over the right upper quadrant (RUQ). Ultrasound of RUQ was performed which showed 4 cm mass located adjacent to gallbladder without any gallstone or common bile duct (CBD) dilation. Endoscopic ultrasound (EUS) was performed to further evaluate the mass which revealed 3.5 × 3.4 cm solid, hypoechoic and heterogeneous mass near gall bladder without involvement of gallbladder, biliary tree, or liver and without any local lymphadenopathy. The common bile duct measured 9.5 mm and there were no stones or sludge in the biliary tree. Preliminary findings of fine-needle aspirates done during the EUS were consistent with low grade neoplasm, possibly vascular in origin with carcinoid tumor as a differential. CT scan of abdomen and pelvis with contrast was performed to further evaluate the mass which showed well-defined 4.5 cm enhancing mass of mesocolon which was located anterior to descending duodenum, posterior to gastric antrum, and just medial to the hepatic flexure of colon . It alsoDecision was made to proceed with laparoscopic surgical removal of mass which was later on converted to open laparotomy through right paramedian incision. Peroperatively, 5.7 cm × 3.8 cm mass was found within the C-loop just inferior to stomach, medial to duodenum, and on top of pancreas without involvement of any structure. The mass was excised entirely and was sent to pathology for further testing. Pathology revealed that tumor was comprised of a relatively uniform population of cells arranged in the clusters and these clusters were surrounded by reticulin fibrosis. This appearance is known as Zellballen arrangement, which is typical of paraganglioma . The tumPathology also revealed that tumor was present within a fraction of a millimeter of the peripheral inked surgical resection margin. Positron emission tomography (PET) scan was performed for staging purpose which did not show any evidence of malignancy. Because of very close surgical margins of tumor cells, patient also received adjuvant radiotherapy. As there was no metastatic disease, chemotherapy was not provided. Patient is currently symptom free after 6-month followup and is closely followed by physicians. Extra-adrenal paragangliomas account for 10 to 15% of all adult paragangliomas with an incidence rate of 2–8 cases per million people/year [Genetic mutation within the succinate dehydrogenase B unit (SDHB) and succinate dehydrogenase D unit (SDHD) are associated with increased risk for extra-adrenal paragangliomas. It has also been reported that incidence and prevalence of malignant paragangliomas are higher in patients with SDHB mutation . There iAbdominal paragangliomas are mostly retroperitoneal in location, accounting for 85% of all extra adrenal paragangliomas. The most common site for retroperitoneal paragangliomas is between the origin of inferior mesenteric artery and the aortic bifurcation known as organ of Zuckerkandl. Paragangliomas arising from jugulotympanic body are called chemodectomas, whereas paragangliomas originating from the carotid body are known as carotid body tumors. Paragangliomas located in the second part of duodenum are called gangliocytic paraganglioma . As mentioned earlier different paragangliomas have different presentations based on location and ability to secrete hormones. Functional paragangliomas can be diagnosed based on presentation and subsequent laboratory investigation revealing elevated catecholamines and their metabolites in the blood and urine. Nonfunctional paragangliomas are mostly found incidentally or present as a mass with symptoms of surrounding organ compression. Recommended first imaging modality in evaluating extra-adrenal paragangliomas is magnetic resonance imaging (MRI) secondary to superior tissue characterization and absence of radiation hazards . ComputeExtra-adrenal paragangliomas also have potential to be malignant, although previously reported incidence of 10% is not accurate. It has been reported in the literature that around 20% of paragangliomas could be malignant with poor survival . While hSurgery with complete removal of mass either via laparoscopy or via traditional laparotomy is the treatment of choice for retroperitoneal paragangliomas owning to its malignant potential. Patient with metastatic disease will require adjuvant radiotherapy while chemotherapy is restricted to patients not accessible for surgery and resistant to radionuclide therapy . Because of malignant potential and higher recurrence rate in paragangliomas, lifelong followup is usually recommended .


Background. Desmoids are benign tumors, with local invasive features and no metastatic potential, which have rarely been described to be pregnancy associated. Case. We described the rapid growth of an anterior abdominal wall mass in a 40-year-old pregnant woman. Due to its close proximity to the enlarged uterus, it was misdiagnosed to be a uterine leiomyoma by ultrasound examination. Final tissue diagnosis and radical resection were done at the time of abdominal delivery. Conclusion. Due to the diagnostic limitations of imaging techniques, desmoids should always be considered when the following manifestations are observed in combination: progressive growth of a solitary abdominal wall mass during pregnancy and well-delineated smooth tumor margins demonstrated by imaging techniques. This case emphasizes the importance of entertaining uncommon medical conditions in the differential diagnosis of seemingly common clinical manifestations. Desmoid tumors are benign slowly growing fibroblastic neoplasms that arise from muscle fascia or aponeurosis. Although they lack metastatic potential, they are known for their propensity for local recurrence, even after complete surgical resection. Despite being histologically benign, they are locally infiltrative and can cause death through destruction of adjacent vital structures and organs. These rare tumors occur in patients with familial adenomatous polyposis and in patients with previous surgical trauma (previous surgery). Although uncommon, desmoids are found to be associated with women of fertile age, especially during and after pregnancy –6.In this paper, we report on a desmoid tumor that developed during the course of pregnancy and was misdiagnosed to be a uterine leiomyoma by ultrasonography. Final diagnosis and treatment were made at the time of cesarean delivery.A 40-year-old woman presented for cesarean delivery for fetal breech presentation at 39 weeks' gestation under spinal anesthesia. Her previous obstetrical history included two previous first trimester abortions and a full-term pregnancy delivered by cesarean section due to breech presentation. Her present antenatal course was smooth, except for a progressive painless swelling in the right flank noticed at 20 weeks' gestation. Multiple ultrasound examinations were done at different intervals during the course of pregnancy. They demonstrated a rapidly growing sharply defined abdominal mass, heterogeneous in echogenicity and smooth in contour, highly suggestive of a subserosal uterine leiomyoma. No other signs and/or symptoms were reported. The patient denied smoking, drinking alcohol, or taking any medications besides her prenatal vitamins.Intraoperatively, the tumor was found to be extra-peritoneal originating from the right abdominal wall. It was whitish in color, hard in consistency, and fixed to its surroundings. It was arising from the lateral wall  reaching the vicinity of the anterior superior iliac spine. Following the delivery of a live male newborn  through a lower segment transverse uterine incision, a general surgeon was called in for an intraoperative consultation. Frozen sections revealed benign spindle cells suggestive of a desmoid tumor , althougGrossly, the tumor was a 12 × 9.5 × 7 cm mass weighing 457 g, ovoid in shape, firm in consistency, covered by a smooth glistening layer with some attached adipose tissue in areas. Cut sections showed tan fleshy softer tissue in the inside. This was surrounded by a capsule and an inner rim of brown gray firm tissue measuring 0.6 cm in average thickness. The final diagnosis of musculoaponeurotic fibromatosis/desmoid tumor was made.Two years later, the same women gave birth to her third child by cesarean section. Surgical inspection of the previous resection site was unremarkable. There was no evidence of tumor recurrence.This case report demonstrates that abdominal wall tumors detected after the first trimester of pregnancy may be clinically challenging and may be easily confused with subserosal uterine leiomyomata. Ultrasonographic features are all too often nonspecific in suggesting a definitive diagnosis. An abdominal wall solid mass exceeding 5 cm in diameter may be difficult to separate by imaging techniques from an enlarged second- or third-trimester gravid uterus. This case emphasizes the importance of entertaining uncommon medical conditions in the differential diagnosis of seemingly common clinical manifestations.Desmoid tumors are cytologically bland fibrous neoplasms of musculo-aponeurotic origin. Their incidence in the general population is relatively rare where it is detected in only two to four per million individuals each year .Although the etiology of desmoid tumors remains unknown, increasing evidence points to involvement of the APC gene and beta-catenin in the molecular pathogenesis of inherited desmoids (Gardner's syndrome) as well as in sporadic cases , 2, 5. SThe typical clinical manifestation of desmoids consists of a slowly growing deep-seated painless or minimally painful mass. The most common location of desmoids occurring during pregnancy is within the abdominal wall . Their cUltrasound remains the most frequently utilized imaging modality for initial assessment of masses compatible with a desmoid tumor. Cross-sectional imaging of the affected area with CT or MRI technology may be more helpful in defining the relationship of the tumor to adjacent structures in order to delineate surgical borders and determine surgical respectability –4. ThereFor asymptomatic desmoids, close observation is acceptable strategy . SurgicaAlthough a very rare entity, the diagnosis of desmoid tumors should always be entertained when the following clinical manifestations are observed in combination: mass located to the abdominal wall, progressive pattern of growth during the course of pregnancy, and well-defined smooth tumor margins demonstrated by ultrasound examination. Definitive treatment is wide surgical resection and may be deferred till after vaginal birth or during the course of a cesarean delivery. This case emphasizes the importance of entertaining uncommon medical conditions in the differential diagnosis of seemingly common clinical manifestations.


Desmoid tumours of the brachial plexus are rare and may occur in extra-abdominal sites. The tumours are of fibroblastic origin and, although benign, are locally aggressive. Their relationship to critical neurovascular structures in their anatomic locations presents a challenge to the operating surgeons trying to adhere to the principles of surgery. Surprisingly little neurosurgical literature exists which was devoted to this topic despite the challenge these lesions present in surgery both at surgery and in choosing adjuvant therapies. We report a case of a large brachial plexus tumour in a patient which was diagnosed radiologically and histopathologically and the patient underwent surgical excision with good outcome. Desmoid tumours histologically are benign and are usually composed of proliferating, benign fibroblasts in an abundant matrix of collagen. They do not transform into malignant tumours or metastasize. Surgery is the mainstay of treatment; however, adjuvant radiation and chemotherapy remain controversial. Many terms have been used to refer to desmoids tumours over the years, including fibromatosis, desmoid tumors, and aggressive fibromatosis. However, “Desmoid-type fibromatosis” has emerged as the designation of choice by the World Health Organization . c-KIT oncogene in hopes of establishing a basis for predicting which of these lesions would respond to the chemotherapy agent imatinib mesylate. In the third case series, Dafford et al. [A review of the literature identified three case series reporting the treatment of desmoids tumours involving the brachial plexus. The first series, reported by Binder et al.  in June d et al.  in June In this review, we document the clinical presentation, neuroimaging, surgical, and pathological findings in a patient with a desmoid tumour arising from the brachial plexus.Incidences of desmoids tumours are low and range from 0.2 to 0.4 per 100,000 with two peaks in incidence among individuals aged 6 years to 15 years and between puberty and the age of 40 in women [The mainstay of treatment is currently surgical resection with wide margins . For recOn histology, desmoid tumour is a proliferation of cytologically benign-appearing fibrocytes . These tumours can recur, but with surgery and postoperative radiotherapy, the progression-free survival was 95% at 5 years and 93% at 10 years [A 43-year-old man presented with a 10-year history of a left outer infraclavicular mass which was slow in progression. He also had difficulty in flexing the left arm, numbness, and pain in the left middle and index finger. Examination revealed a large mass in the outer 1/3 below the left clavicle. The mass was firm, fixed, and tender on palpation. Flexion movements at the elbow joint were limited. The brachial and radial pulses were palpable. There were no similar lesions or nodules elsewhere in the body. An MRI of the neck including the thoracic inlet Figures  revealedDesmoid tumours commonly involve the anterior abdominal wall and rarely involve the chest wall, axillary, infraclavicular, or supraclavicular areas. Risk factors for the formation of desmoid tumours previously identified include trauma and prior surgical procedures leading to scar formation .Histologically, they are benign, slow growing but are aggressive tumours that can encase or infiltrate the brachial plexus along its course. These lesions are described as well-differentiated fibroblasts or myofibroblasts in an associated abundant collagen matrix with scanty or absent mitotic activity or other atypical cytological features . DiffereEvaluation of the brachial plexus presents a great challenge to the clinicians and radiologists. Magnetic resonance (MR) imaging has become the method of choice for evaluating patients with brachial plexopathy . The mulc-KIT gene has been proposed, which would determine response to the imatinib mesylate therapy that is used in other gastrointestinal stromal tumors [Gaposchkin et al. in their study emphasise the fact that desmoid tumors present a surgical challenge in that they have a strong tendency for local invasion, surgical margins are poorly delineated, and complete resections are difficult . The mail tumors .Many benign tumors occur along the course of the brachial plexus and involve or impinge on its various components. In our case, the tumor was histologically confirmed to be a desmoid tumor. These tumors are slow-growing, fibrous, nonmalignant lesions with a low propensity for metastasis. Histologically, they are benign, slow growing but can be aggressive encasing or infiltrating the brachial plexus along its course. Imaging with MRI is superior and is for optimal surgical planning, allowing the surgeon to choose between gross total resection (GTR) and subtotal resection preoperatively. Resection is the mainstay of treatment. Residual tumor mass may be treated with radiotherapy or brachytherapy. Further investigation into the c-KIT gene will determine the role of imatinib mesylate therapy in these tumours.