Secondary cervical dystonia is induced by organic brain lesions involving the basal ganglia, thalamus, cerebellum, and brain stem. It is extremely rare to see cervical dystonia induced by a medullary lesion.We report a case of an 86-year-old Japanese woman who developed cervical dystonia following lateral medullary infarction. She developed sudden-onset left upper and lower extremity weakness, right-side numbness, and dysarthria. Brain magnetic resonance imaging revealed an acute ischemic lesion involving the left lateral and dorsal medullae. A few days after her stroke, she complained of a taut sensation in her left neck and body, and cervico-shoulder dystonia toward the contralateral side subsequently appeared. Within a few weeks, it disappeared spontaneously, but her hemiplegia remained residual.To date, to the best of our knowledge, there has been only one reported case of cervical dystonia associated with a single medullary lesion. It is interesting to note the similarities in the clinical characteristics of the previously reported case and our patient: the involvement of the dorsal and caudal parts of the medullary and associated ipsilateral hemiplegia. The present case may support the speculation that the lateral and caudal regions of the medulla may be the anatomical sites responsible for inducing cervical dystonia. Cervical dystonia is a focal dystonia characterized by sustained, involuntary contraction of the neck muscles, resulting in abnormal movements and postures of the head . It is kAn 86-year-old Japanese woman was admitted to our hospital with the sudden appearance of weakness in the left upper and lower extremities, numbness of the right upper and lower extremities, and dysarthria. Her family history was unremarkable. Particularly, she had no family history of movement disorders. She had hypertension, diabetes mellitus, and dyslipidemia. At age 82, she had developed hemiparesis caused by a lacunar infarction of the left capsulothalamic region, and her neurological symptoms fully improved without sequelae.On admission, her blood pressure was 202/98 mmHg, but her heartbeat was regular. Her other general status was unremarkable. A neurological examination revealed that she was alert and oriented, without dementia. Her cranial nerves were intact, but her speech was mildly dysarthric. Horner’s sign was not noted. Hemiparesis was assessed according to the Medical Research Council scale and was noted in the upper and lower extremities with manual muscle strength scale scores of 3 and 4 for the upper and lower extremities, respectively. No pathological reflex was noted. Her superficial sensation was disturbed in her upper and lower extremities and body on the right side. Her position sensation was disturbed in her left upper and lower extremities. Her vibration sensation was intact. Her National Institutes of Health Stroke Scale assessment yielded 3 points.Brain magnetic resonance imaging (MRI) at admission day 1) did not reveal ischemic lesions. However, brain MRI performed again at day 2 did reveal an ischemic lesion in the left lateral lower medulla , right hemisuperficial sensory loss, and disturbance of the left position sense.A few days after admission, the patient experienced sustained pain and a taut sensation, localized in her left neck. Several days afterward, her head was found involuntarily deviated to the right, with tonic contraction of her right sternocleidomastoid and trapezius muscles Fig. . On occaOur patient experienced secondary cervico-shoulder dystonia following acute lateral medullary infarction. In addition, the lateral medullary lesion did not induce Wallenberg syndrome, but it did produce Opalski’s syndrome.Opalski’s syndrome is a classically known syndrome, a rare variant of lateral medullary syndrome characterized by ipsilateral hemiplegia. Lesions responsible for Opalski’s syndrome are usually located within the sub-bulbar part of the medulla. From an anatomical perspective, it is presumed that the ipsilateral hemiplegia caused is due to the involvement of the lateral corticospinal tract after pyramidal decussation . Also, in = 8 [44.4%], including four infarction cases and four hemorrhage cases), brain tumor , multiple sclerosis (n = 1), and diffuse axonal injury (n = 1). This suggests that stroke and tumor are the most common etiologies. Outcomes are variable, but spontaneous improvement is reported in almost half of the cases. As shown in Table A comprehensive review of the literature has been published regarding cerebellar lesion-induced cervical dystonia . Howeverosis n = , and difHowever, of these patients with brain stem lesion-induced cervical dystonia, only one case had a single medullary lesion . It is iOne problem that should be considered is whether malfunctioning of the vestibular system possibly influences the head and/or truncal position in these patients with medullary infarction. Indeed, head leaning and body lateropulsion are known to occasionally be induced by a lateral medullary lesion, wherein the vestibular nucleus is located. However, we suspect that impairment of the vestibular system was not related to the mechanism underlying cervical dystonia in our patient or in the similar previously reported case, because the direction of head leaning was ipsilateral to the medullary lesion , whereasAlthough it remains uncertain whether cervical dystonia is more likely to be complicated by Opalski’s syndrome, this type of cervical dystonia might be overlooked in patients with acute stroke, particularly those with hemiparesis. We believe this case report contributes to recognizing the possible relationship between caudal medullary lesions and cervical dystonia, as well as facilitates the accumulation of similar cases for better understanding of secondary dystonia.


Leiomyosarcoma is one of the soft tissue sarcomas that could originate from different parts of body and are mostly presented as retropritoneal mass. Leiomyosarcomas of vascular origin are particularly rare tumors occurring mainly in inferior vena cava (IVC). Here, we report the case of a 35-year-old male patient who presented with ascites and jaundice. Further evaluation revealed large hepatic and cardiac masses with extension to IVC. Since it was not possible to determine the point of origin of leiomyosarcoma, the patient received chemotherapy under diagnosis of metastatic leiomyosarcoma but unfortunately passed away. Mostly presents as a large retropritoneal mass and the involvement of IVC but cardiac chambers are extremely rare. Here, we report a case presented with inferior vena cava (IVC) mass associated with hepatic and right atrium tumors. Leiomyosarcomas, which are characterized by smooth muscle differentiation, can be found throughout the body including the retroperitoneum and any location where there is a vein. A 35-year-old male patient presented with abdominal and lower extremity swellings. He stated that abdominal swelling started 15 days ago and then he observed an increase in the swelling. Meanwhile, six days before admission, he noticed swelling in both legs. He also complained of jaundice, dyspnea on exertion, loss of appetite and malaise. Abdominal ultrasound was performed and revealed severe ascites, splenomegaly and a hypoecho mass in the right liver lobe with extension to midline. On physical examination, the patient was conscious and a generalized icterus was seen. Abdominal distention, bilateral decreased breath sounds in basilar lung regions and pitting edema of both lower extremities were detected but the remainder of examination was normal.-ascites albumin gradient (SAAG) fluid and triphasic abdominal computed tomography (CT) confirmed a large mass in the right liver lobe with changes in inferior vena cava (IVC) and hepatic veins suggestive of tumor extension or thrombosis  in association with hypochrome microcytic anemia .Femoral vein catheterization was done to try biopsy of IVC mass, femoral vein catheterization was done to perform IVC mass biopsy but tortuous course of IVC made it impossible. Due to the location of hepatic mass, transjugular or percutaneous liver biopsy was not possible. So, CT-guided biopsy from IVC mass was performed. Pathologic examination and immunohistochemistry study revealed high grade leiomyosarcoma , 4, 5..The patient received chemotherapy regimen including gemcitabine and docetaxel under diagnosis of metastatic leiomyosarcoma. Due to tumor extension, patient was not a suitable candidate for surgery or radiotherapy; so, chemotherapy continued. He then developed hepatic encephalopathy and liver failure during hospitalization and unfortunately passed away. First degree relative of patient had given a written consent for publishing information1 The WHO classifies most soft tissue sarcomas according to presumptive tissue of origin that one of them is leiomyosarcoma.2 Leiomyosarcomas, which are characterized by smooth muscle differentiation, can be found throughout the body including the retroperitoneum, any location where there is a vein and the uterus. The most common presentation is an asymptomatic mass. Mechanical symptoms referable to pressure, traction, or entrapment of nerves or muscles may also be present. Sarcomas are rare and heterogeneous group of malignant tumors of mesenchymal origin that comprise approximately 1 % of all adult malignancies. Approximately, 80 % of sarcomas originate from soft tissue and the rest from bone.3 The most common presenting symptom is a pain in the right flank and other presentations are edema of the lower extremities, Budd-Chiari syndrome with hepatomegaly, ascites, and jaundice.4,5 Systemic metastasis occurs in less than 50 percent of patients in late stages and most common sites are liver, lung, lymph nodes or bone6 and propagation of the tumor to right atrium occurs in less than 20 percent of patients.7This case demonstrates the difficulty in distinguishing the origin of the tumor and its uncommon presentations. As we mentioned above, our patient presented with ascites and jaundice and further evaluation revealed IVC mass associated with hepatic and cardiac tumors. Leiomyosarcoma of the inferior vena cava (IVC) is the most common primary malignancy of the IVC and has an extremely poor prognosis.8 Surgical resection of metastases, whenever possible, is an integral part of the management. The two most active chemotherapeutic agents are doxorubicin and ifosfamide. Gemcitabine with or without docetaxel has become an established second-line regimen and is particularly active in patients with leiomyosarcoma.9,10Metastatic soft tissue sarcomas are largely incurable but up to 20% of patients who achieve a complete response become long-term survivors. The therapeutic intent, therefore, is to produce a complete remission with chemotherapy (<10%) and/or surgery (30–40%) although the efficacy of chemotherapy and radiotherapy is extremely low in leiomyosarcoma. Since leiomyosarcoma of vascular origin is an uncommon finding and metastasis to heart chambers is even more uncommon, we aimed to report this rare presentation of sarcomas of vascular origin.


We report a case of 61-year-old male who presented with chyluria after partial nephrectomy. During workup for appendicitis, an incidental exophytic renal mass was revealed on CT scan. The patient ultimately underwent uncomplicated open partial nephrectomy. Postoperatively, his JP drain output turned milky white with urine remaining clear. JP fluid analysis was consistent with lymph. At 3 weeks postsurgery, his drain output decreased, but his urine turned milky white. Urinalysis confirmed fat in the urine. CT imaging revealed chyloma/urinoma with extravasation. The patient was initially treated conservatively, with a medium-chain fatty acid diet and then ureteral stenting. His stent was eventually removed and his chlyuria resolved 14 weeks later.In nonendemic countries, nonparasitic chyluria is exceedingly rare and postsurgical chyluria even more so. We review the sequelae of untreated disease and surgical options for intractable chyluria not responsive to conservative management.In non-endemic countries, non-parasitic chyluria is exceedingly rare, and post surgical chyluria even more so. We review the sequelae of untreated disease and surgical options for intractable chyluria not responsive to conservative management.


Basal meningoceles are rare congenital defects and often clinically occult until they result in life-threatening complications. Therefore, it is important to know the diagnostic clues to early diagnosis.We describe three cases of congenital basal meningocele in a 3-year-old Japanese boy, a 1-month-old Japanese baby boy, and a 10-month-old Japanese baby girl. One of our patients died of sepsis due to traumatic rupture of the meningocele during nasal suction. His meningocele remained undiagnosed until it resulted in the fatal complication. The other patients underwent surgical repair without any complications. Their meningoceles were complicated by midfacial anomalies including cleft palate and hypertelorism, or a sign of nasal obstruction such as snoring.These clinical features may be a clue to the early diagnosis of congenital basal meningocele, which enables its safe preoperative management and provides an opportunity for surgical repair before the condition results in serious complications. Basal meningoencephalocele is a rare congenital anomaly characterized by the herniation of brain tissue through the skull, with an incidence of 1 per 40,000 live births . CompareOur patient was a 3-year-old Japanese boy who was born to non-consanguineous parents. A prenatal ultrasonographic examination revealed hydrocephalus and midline cleft lip. After birth he was found to have median cleft lip and palate, atresia of the anus, and micropenis. He also had facial dysmorphism including hypertelorism and a saddle nose Fig. . Brain mStreptococcus pneumoniae was isolated from blood culture. A computed tomography scan of his head demonstrated narrow ventricles, intracranial hemorrhage, and air in the lateral ventricle, suggesting the presence of a communication between the intracranial and extracranial cavities. An ethmoid defect and a frontoethmoidal meningocele were diagnosed on the basis of a retrospective review of the initial MRI . His Apgar score was 8 at 1 minute and 9 at 5 minutes; however, respiratory distress became obvious because a meningeal sac protruding through a wide cleft palate obstructed his oral cavity. Although he was intubated immediately in the operation room, he needed no more respiratory support; thus, he was extubated on admission to our neonatal intensive care unit.A physical examination revealed hypertelorism, a broad nasal bridge, midline cleft of the palate and upper lip, and V-shaped forehead hairline Fig. . This phA 10-month-old Japanese baby girl was referred to our hospital because of loud snoring. Her growth and developmental milestones were normal. A physical examination revealed hypertelorism, a slightly warped ala nasi, and a soft tissue mass in her left nasal cavity Fig. . MRI demWe reported three contrasting cases of congenital basal meningocele. The first case exhibited multiple congenital anomalies, and the meningocele remained undiagnosed until it resulted in fatal sepsis due to traumatic rupture. His watery rhinorrhea and intracranial air suggested meningitis although we could not collect spinal fluid. Meningitis is well known to be a serious complication of basal meningoceles  and can Congenital basal meningoceles are often clinically occult until they result in life-threatening complications. Therefore, it is important to know the diagnostic clues to early diagnosis. All cases exhibited facial anomalies including hypertelorism and a broad nasal bridge. Two of our patients further exhibited cleft lip and palate. It is important to note that basal meningoencephalocele is often complicated by such facial dysmorphisms , 8. ThusOur cases emphasize the potential risks of basal meningoceles. Early diagnosis of occult basal meningoceles enables their safe preoperative management and provides an opportunity for surgical repair before they result in serious complications. Facial midline deformities and signs of upper airway obstruction may be diagnostic clues to congenital basal meningoceles.


The mesenteric desmoid tumor requires special attention and the most demanding treatment.Here we present a rare case of a large mesenteric desmoid tumor secondary to familial adenomatous polyposis (FAP) in a 34-year-old man accepted the ex vivo resection, and intestinal autotransplantation.A 34-year-old man was referred to our department with a 6-year history of intermittent hematochezia without any other discomfort after undergoing partial colectomy in February 2013, and 5 endoscopic mucosal resections of colon polyps between May 2012 and July 2015 due to pathological diagnosis of FAP. A computed tomography scan showed a huge abdominal mass with indistinct boundary at the root of the mesentery. The adjacent organs were pushed and most of the superior mesenteric artery branches were infiltrated.An en bloc resection (R0 resection), and an ex vivo resection followed by intestinal autotransplantation was performed.The patient was discharged from the hospital on the 25th day after the operation, and was regularly followed up after surgery with abdominal ultrasonography and laboratory-biochemical tests every month, and serial CT scans every 3 months which showed no evidence of tumor recurrence, thrombus, intestinal obstruction or abdominal infection so far.An ex vivo resection and intestinal autotransplantation appear feasible for cases with pathological lesions involving the vessels at the root of mesentry, and represents an attractive alternative for the management of mesenteric desmoid tumors. Once the large and vital vessels of the mesentery are involved by desmoid tumor, complete resection is impossible by using conventional techniques which may result in uncontrollable bleeding and subsequent short bowel syndrome. Recently, small-bowel autotransplantation for tumor involving the mesenteric root has prevailed against specific technical obstacles; however, this surgical procedure was just performed on limited patients and recorded in few researches. Here we report a successful tumor extirpation with free surgical margins, and segmental intestinal autotransplantation of a large mesenteric desmoid tumor secondary to FAP.Desmoid tumor is the most common primary tumor of mesenteric fibromatoses, and tends to have a particularly high incidence in patients with familial adenomatous polyposis (FAP), especially after surgery.2The patient provided informed consent for the publication. The study was approved by the ethics institutional review board of the Union Hospital of Huazhong University of Science and Technology.A 34-year-old man presented a 6-year history of intermittent hematochezia without any other discomfort. He underwent partial colectomy in February 2013, and 5 endoscopic mucosal resections of colon polyps between May 2012 and July 2015, respectively. Postoperative pathological analysis showed mixed hyperplasia adenomatous polyps of sigmoid colon, and was finally diagnosed as FAP. An abdominal mass was palpated in June of 2017, and ultrasonography confirms a solid tumor. Needle biopsy showed a few spindle cells with enlarged and dense nucleus, but malignant tumor could not be excluded. Further examination by computed tomography scans demonstrated a large soft tissue mass with indistinct boundary at the root of the mesentery  and the superior mesenteric vein (SMV) were engulfed by the tumor. An en bloc resection was performed, including the whole small intestine, right and proximal transverse colon, while the SMA and SMV were resected at their root. The surgical specimen was removed and arranged to an ice salver on a separate specimen table, and flushed through the SMA with cold University of Wisconsin preservation solution  to protect isolated small bowel  to create a prolong time of intestinal cold ischemia status, avert irreversible damage and allow surgeon to resect the tumor with subsequent intestinal autotransplantation.,15 This technique has several advantages, such as excellent exposure of surgical field, optimum control of the critical step of tumor resection in a bloodless field, clear visualization of vascular pedicles, and arches to protect normal tissues or ensure accurate excision, and so on. Nevertheless, this procedure remains technically challenging because of its complexity which includes the involvement of multiple organs, prolonged operative time, and increased blood transfusions. Thus, only few case reports have described patients with mesenteric tumor encasing the blood supply of the small intestine, ex vivo resection, and subsequent intestinal autotransplantation.,16,17Although operative resection is regarded as the main treatment for symptomatic desmoid tumors, unfortunately, conventional resection can be complicated by excessive bleeding and ischemic damage to the intestine or a need for massive enterectomy.In this case report, we successfully performed such surgical procedure on a FAP patient who developed a large mesenteric desmoid tumor. The large mesenteric desmoid tumor was extirpated with free surgical margins, and about 150 cm jejunum with its mesenteric artery and vein branches was reimplanted into enterocoelia after cold flushing ex vivo to restore normal intestinal continuity. Different from other reports, we resolved to choose a distal jejunostomy instead of enterocolostomy to conveniently observe the status of the small intestine. So far, the patient recovered smoothly after surgery.There are few researches setting focus on the indications of ex vivo resection and subsequent intestinal autotransplantation. Whether pathological lesions involving the vessels at the root of mesentery is suitable for palliative treatment or curative excision remains controversial. We consider that patients with high-grade malignancy may not benefit from this technique, whereas low-grade especially insensitive to chemoradiotherapy ones, may obtain curative excision. For this case, it has been confirmed that the large soft tissue mass with indistinct boundary at the root of the mesentery pushing against the adjacent organs infiltrated most of the superior mesenteric artery branches as proven by ultrasonography and CT scans, respectively. Needle biopsy showed a few spindle cells with enlarged and dense nucleus despite the potential risk of malignancy. However, the patient presented in excellent general condition, well nourished, and extremely motivated for an aggressive surgical treatment to the tumor, and no other comorbidity factors contraindicated the operation. Therefore, the ex vivo resection and intestinal autotransplantation was performed.According to our clinical experiences combined with experiments on animals, we can conclude that: First of all, preoperative assessment must be rigorous. The tumor size, infiltrate condition, and encase degree of the vessels at the root of mesentery should be explicit by MRI, CTA or other necessary clinical examinations. Pathologic inspection on biopsy should provide a specific result as possible. For those lesions that extensively infringe the small bowel, and cause insufficient intestine to satisfy intestinal nutrition, this technique may have no effect, and also this new operation procedure is not suitable for patients with high-grade malignancy. After excluding surgical contraindications, surgeons should adopt effective measures to improve the nutritional status of the chosen patients to tolerate the surgery.Next, the superior mesentery vessels and well-vascularized small intestine must be preserved carefully for the sequence autotransplant during the operation. A direct anastomosis for vascular reconstruction is recommended to avoid the potential risks of infections and keep long-term vascular potency. We preferably choose small intestine ostomy to observe the survival status, and to avoid anastomotic leakage which is more likely to occur in this kind of patients due to the lack of anastomotic blood supply that might be a fatal complication to them. The borborygmus and the color, character and amount of excreta from the stoma reflects the recovery status of intestinal function. Based on the postoperative recovery status of patients, the small intestinal stoma closure operation could be performed 4–6 months after the jejunostomy.Furthermore, antibiotics and intravenous heparin should be routinely given to prevent infections and thrombogenesis after the surgery.In conclusion, ex vivo resection and intestinal autotransplantation seems to be a feasible technique for patients with pathological lesions involving the vessels at the root of mesentry. Careful preoperative assessment, refined operation, and meticulous postoperative care are the keys to the success of this aggressive and complicated surgery. Our experience may support the use of this technique as a potential option for the treatment of patients with a large mesenteric desmoids tumor which cannot be radically removed by conventional surgery.Methodology: Xiaoming Lu.Project administration: Xiaoming Lu.Resources: Jun Liu.Software: D. Eastman G.B. Kollie.Supervision: Jun Liu, Yong Xiao.Visualization: Jun Xiao.Writing – original draft: Shuang Guo, D. Eastman G.B. Kollie, Wanli Zhang.Writing – review & editing: Chao Cheng.


Left atrial thrombi have traditionally been treated with heparin and warfarin, and many physicians have limited experience with direct oral anticoagulants such as apixaban. Furthermore, the efficacy of apixaban for the treatment of left atrial thrombi has not been established. We experienced a case of left atrial thrombus formation before breast cancer surgery, which was resolved by apixaban.Computed tomography for a 74-year-old Japanese woman with breast cancer incidentally revealed a left atrial mass with a root before the breast surgery. The mass was surgically removed and determined to be a thrombus. Before the breast surgery, transthoracic echocardiography was performed again, and the left atrial thrombus had recurred within only 14 days. It resolved after administration of apixaban.A left atrial thrombus might recur within a very short time. Apixaban might be an alternative to warfarin in patients with breast cancer and left atrial thrombus. Left atrial thrombus is one of the differential diagnoses of a left atrial mass and is usually observed in the left atrial appendage. Historically, left atrial thrombi have been treated with heparin and warfarin. Recently, direct oral anticoagulants (DOACs) have been developed, and the superiority of DOACs to warfarin in preventing stroke and reducing bleeding has been demonstrated . HoweverA 74-year-old Japanese woman  without systemic disease presented to our hospital with a palpable 15-mm mass in her left breast that was identified as stage I breast cancer. Before surgery for removal of the mass, a contrast-enhanced pulmonary computed tomography (CT) was performed and showed a mass approximately 30 × 30 mm in her left atrium , 1.04; activated partial thromboplastin time (APTT), 32.5 seconds; protein C, 113 %; protein S, 75 %; antinuclear antigen, 40; and lupus anticoagulant, 1.4 seconds. Her levels of cancer antigen 15-3 and NCC-ST 439 were 23.8 U/mL and 1.3 U/mL, respectively.Based on transthoracic echocardiography (TTE), her left ventricle ejection fraction was 65.3 % and her left atrial diameter was 42 mm; the mass was 33 × 30 mm, it had a root, it was located on the surface of the septal wall, and was oscillating (Fig. Cardiac surgery was performed 16 days after her first visit to remove the left atrial mass. On pathologic examination, the mass consisted of a thrombus, without tumor cells Fig. . After rFourteen days after her cardiac surgery, TTE was performed, showing a mass formation in the lateral wall of her left atrium Fig. . The masThis case highlighted three important clinical issues. First, apixaban effectively resolved the left atrial thrombus. DOACs such as apixaban have recently been developed and are superior to warfarin for preventing stroke and reducing bleeding . AlthougSecond, the cardiac thrombus relapsed in a very short time after removal. Our patient had paroxysmal atrial fibrillation and cancer. Malignancy has a significant role in a thrombus, and venous and arterial thromboembolisms are common complications for patients with cancer . In a noFinally, differential diagnoses of intracardiac mass are a benign tumor, malignant tumor, metastatic tumor, and thrombus. Atrial myxoma is the most common primary intracardiac tumor in adults; two thirds of myxomas arise in the left atrium . HoweverApixaban is a favorable alternative therapy for patients with a cardiac thrombus.


In the era of extensive imaging and increasing indications for performing PET-CT scans, the recognition of synchronous tumors may be greater than before. However, the majority of these tumors are seen to occur in the same organ system, likely because of sharing similar pathogenic mechanisms. Synchronous lung cancers of similar or differing histologies have been reported. Primary pulmonary lymphoma, which is a rare form of non-Hodgkin’s lymphoma, has also been seen with a synchronous primary lung cancer. However, we report a case of a 56-year-old male diagnosed with primary pulmonary lymphoma and on PET-CT imaging, found to have a cecal lesion, the biopsy of which showed adenocarcinoma. We discuss the incidence of the co-existence of multiple tumors, the pathogenic mechanisms involved, and approaches to the management of these rare clinical scenarios. Synchronous cancers, although rare, are usually seen within the same organ system or areas exposed to a carcinogen, such as the lung or the gastrointestinal tract. Among lung cancers, synchronous tumors are seen to arise on the same side of the lung and are usually of similar histology. Primary pulmonary lymphoma (PPL) is an extremely rare form of non-Hodgkin’s lymphoma arising from mucosa-associated lymphoid tissue (MALT). Although PPL with another primary lung cancer has been reported , our casPneumocystis jiroveci were negative. A bacterial culture showed growth of Staphylococcus aureus, and the patient was treated with Levaquin.A 56-year-old male presented to his primary care physician complaining of chest pain. The patient was a non-smoker with a past history of dyslipidemia, hypertension, and chronic obstructive pulmonary disease (COPD). Physical examination was normal. A chest x-ray revealed a small opacity in the right middle lobe, and a computed tomography (CT) scan of the chest showed bronchiectasis and atelectasis in the right middle lobe with acute cutoff of the right middle lobe bronchus. The patient was thereafter referred to our pulmonary office. A bronchoalveolar lavage (BAL) was performed which was negative for the presence of malignant cells. Obscuring blood was seen along with acute inflammation. Stains and cultures for acid-fast bacilli (AFB), fungi and Candida glabrata. The right middle lobe biopsy showed a clonal lambda (dim) B-cell population expressing CD10. Hence, a diagnosis of primary pulmonary lymphoma was made.An endobronchial biopsy of the right middle lobe lesion was performed which showed the presence of PAX-5 positive B-cells, and CD3 and CD5 positive T-cells. CD20 and CD43 stains were non-contributory because of crush artifact. BCL-6 demonstrated scattered staining. BCL-1 was negative, and many cells demonstrated staining for Ki-67. Since a definite diagnosis could not be reached, a repeat BAL and biopsy of the right middle lobe endobronchial lesion was performed. The brushings were negative for malignant cells with the presence of histiocytes and benign squamous cells. The CD4 to CD8 T-cell ratio was 0.67:1. An ultrasound-guided fine needle aspiration (FNA) biopsy of the right hilar lymph node did not reveal any evidence of malignancy. Mycology culture showed scant growth of A PET-CT scan performed to evaluate for any other sites of involvement revealed abnormal increased uptake in the right middle lobe bronchus with an SUV of 7.5, and focal increased uptake in the right hilar lymph node measuring 1.4 cm x 1.7 cm with an SUV of 17.3. In addition, focal increased uptake was also seen in the cecum with an SUV of 9.1 (Figure A colonoscopy with cecal biopsy showed adenocarcinoma, and the patient was referred to medical and surgical oncology for further management.The patient agreed to participate and was explained the nature and objectives of this study, and informed consent was formally obtained. No reference to the patient's identity was made at any stage during data analysis or in the report.Multiple primary cancers are a known occurrence and have long been studied in order to determine similar pathogenic mechanisms to guide a specific therapy. However, these cancers usually occur in the same organ or organ system, such as multiple pulmonary tumors or gastrointestinal tumors. This presentation of shared timing is termed synchronous as opposed to metachronous, wherein cancers of the same or different systems develop at intervals -3. The cPPL is a rare form of lymphoma with an incidence of 0.4%. It is a form of extranodal B-cell lymphoma, and about 70% to 80% are thought to arise from mucosa-associated lymphoid tissue. About 2% are Hodgkin’s lymphoma. In order for a diagnosis of PPL to be made, extrapulmonary disease must be ruled out. About two-thirds of patients present with symptoms being present for a mean duration of five months. Various radiologic manifestations have been described including a patchy opacity, single or multiple nodules, mediastinal mass, or pleural effusions. Unilateral and bilateral cases have been reported. Given the indolent nature of the disease, local treatment results in excellent outcomes .Zheng et al., reported the only case of synchronous PPL with pulmonary adenocarcinoma presenting as two FDG-avid lesions in the middle and lower lobes of the right lung which was treated with a right middle lobectomy, a partial lower lobectomy, and an adjuvant pemetrexed . Our casA decision of whether or not to pursue a lesion seen on imaging performed for another reason is a difficult one to make. The imaging characteristics, clinical information, and location of the lesion can guide further management. With PET-CT imaging being more widely available and used, distant synchronous pathologies may be detected incidentally. Chun-Sing et al., examined 1,522 PET-CT scans performed at their institution and found that 68 patients had synchronous lesions -8.In cases of synchronous cancers, the tumor biology and prognosis of one primary can have an impact on the management of the other. For instance, the more indolent of the two entities will be treated less aggressively if treatment strategies are not similar and lead to added toxicity. On the other hand, a definite pathologic diagnosis is essential in order to avoid erroneously upstaging the original primary, potentially leading to non-curative intent treatment. Hence, while a functional and anatomic study, such as the PET-CT, can initiate the speculation of a synchronous primary, further investigation must be sought especially in the absence of obvious widespread metastatic lesions.With patients living longer and widespread use of imaging, the rate of detection of multiple primary cancers is higher than before. Pursuing a prompt definitive diagnosis in these patients may enable effective treatment strategies.


Primary gastrointestinal (GI) lymphoma is a heterogeneous disease with varied clinical presentations. The stomach is the most common GI site and accounts for 70% to 75% of GI lymphomas. We present a patient with gastric diffuse large B cell lymphoma (DLBCL) who presented with significant weight loss, early satiety, and multifocal ulcerated gastric lesions. Esophagoduodenoscopy should be performed in patients presenting with warning symptoms as in our case. Diagnosis is usually made by endoscopic biopsies. Multiple treatment modalities including surgery, radiotherapy, and chemotherapy have been used. Advancements in endoscopic and pathologic technology decrease turnaround time for diagnosis and treatment initiation, thus reducing the need for surgery. Health care providers should maintain a high level of suspicion and consider gastric DLBCL as part of the differential diagnosis, especially in those with warning symptoms such as weight loss and early satiety with abnormal endoscopic findings. However, extranodal disease is not uncommon.8 We highlight a patient with gastric DLBCL who presented with significant weight loss and multifocal ulcerated gastric lesions. The objective of this case report is to increase cognizance for the detection of gastric DLBCL.Primary gastrointestinal (GI) lymphoma is a heterogeneous disease.12 490 pg/mL. A chest computed tomography (CT) was unremarkable. An abdominal CT showed mild fat stranding as well as minimal fluid surrounding the ascending colon without any evidence of intraabdominal lymphadenopathy. He underwent an esophagogastroduodenoscopy (EGD) to investigate the cause for significant weight loss and early satiety. EGD demonstrated multiple ulcerated gastric lesions in the fundus and body  was started. He tolerated chemotherapy but presented with coffee-ground emesis, after completing 3 cycles of chemotherapy. EGD noted a bleeding ulcer, which was treated endoscopically. There was notable improvement in DLBCL-related ulcers compared to previous EGD , rates of DLBCL increase 1.4% per year.10 The molecular pathogenesis of DLBCL is a complex, multistep process that ultimately results in the transformation and expansion of a malignant clone of germinal or post–germinal B cells.7 Several genetic changes involving BCL-6 and p53 tumor suppressor genes have been found in DLBCL.1113DLBCL is the most common lymphoma, accounting for 25% of all non-Hodgkin cases.14 Extranodal disease can occur in up to 40% of cases with the stomach being the most common site.8 In general, patients with gastric DLBCL present with nonspecific symptoms, including epigastric discomfort, unexplained weight loss, anorexia, vomiting, and occult bleeding.15 Hematemesis and melena are uncommon. Additionally, the duration of symptoms preceding the diagnosis is varied.16 Diagnosis is usually made by endoscopic biopsies. The endoscopic findings of DLBCL may include mucosal erythema, gastric ulcer, polypoid mass lesion, and/or thickened gastric folds.17 It is recommended that both suspicious-appearing as well as normal-appearing mucosa be biopsied since the disease can occasionally present as a multifocal disease with involvement of tissue that appears to be unaffected on initial visualization.18 Gastric wall thickening can be found on radiographic imaging such as CT scan, though this was not observed in our case.19Patients with DLBCL typically present with rapidly enlarging lymph nodes in the neck or abdomen. Fever, weight loss, and night sweats are not uncommon and can be observed in up to 30% of patients.20 The immunophenotype of DLBCL can be confirmed by immunohistochemistry or flow cytometry ,22 but associated surgical complications makes it less suitable for frail individuals. Gastrectomy, gastrectomy with adjuvant radiation, and gastrectomy with adjuvant chemotherapy were compared to chemotherapy alone in a small controlled study.23 Ten-year overall survival data favored chemotherapy due to the acute and long-term complications of total gastrectomy.23 Advancements in endoscopic and pathologic technology decrease turnaround time for diagnosis and treatment initiation, thus reducing the need for gastrectomy. Gastric DLBCL is treated with conventional regimens used for nodal DLBCL, such as R-CHOP,24 with excellent response. Attenuated dosage may be required in frail, elderly patients.9 Short courses of immune-chemotherapy followed by involved-field radiation is the standard of care for limited stage nodal DLBCL. The 2 approaches, R-CHOP plus radiotherapy and R-CHOP, were compared in gastric DLBCL in a small retrospective study. Three to 4 courses of R-CHOP plus radiotherapy yielded similar 3-year overall survival of over 90%, compared to 6 courses of R-CHOP.25 In patients who have already achieved complete remission with immunochemotherapy alone, involved field radiation may not be necessary.26 Our patient responded to chemotherapy but still had residual tumors; therefore, radiation was pursued. He achieved pathological remission at the completion of radiation and remains well to date.Histopathology of DLBCL consists of large, transformed B cells with prominent nucleoli, basophilic cytoplasm, a diffuse growth pattern, and a high proliferation fraction .20 The iytometry . GastricGastric DLBCL is a rare disease and can present with nonspecific symptoms such as weight loss and early satiety, as in our case. The diagnosis usually requires an EGD with biopsy. Controversies as to standard therapy exist. Chemotherapy and/or immunotherapy, radiation, and surgery are all reasonable choices depending on patient presentation. For early stage disease, surgery is the most rational approach for curative resection, correct staging, and immediate treatment of bleeding or perforations. Adjuvant chemotherapy and radiotherapy are reasonable for advanced stage or residual disease. For stable cases where diagnosis is made by endoscopic biopsy, chemotherapy and radiotherapy can be an alternative primary, noninvasive therapy of choice while surgery is used for residual tumor post chemotherapy/radiotherapy or for treatment of perforation. Chemotherapy and/or radiotherapy is the most rational treatment for stage III and IV disease. Health care providers should maintain a high level of suspicion and consider gastric DLBCL as part of the differential diagnosis, especially in those with warning symptoms such as weight loss and early satiety with abnormal endoscopic findings.


To present a rare case of a pediatric tracheocutaneous sinus years after repair of a tracheocutaneous fistula and to review management strategies.  A tracheocutaneous fistula is a common sequela of pediatric tracheostomy and can occur in as many as one in three pediatric patients. There is debate in the literature regarding optimal surgical management.  An 8-year-old girl presented to the emergency department with swelling and erythema over the anterior neck. Clinical exam and diagnostic imaging revealed an underlying tracheocutaneous sinus.  Complications following pediatric tracheostomy are common and range in complexity from stomal granulation to tracheocutaneous fistula. There is some debate regarding the optimal surgical management of children with tracheocutaneous fistula following tracheostomy. This report discusses the management of a pediatric child with an unusual tracheocutaneous sinus and reviews the various surgical techniques which have been described for definitive repair. Advances in perinatal medicine and healthcare access have increased the number of premature infants requiring the assistance of prolonged ventilation. Pediatric tracheostomies are performed most commonly to address an upper airway obstruction, ventilator dependence, or central hypoventilation . It has An 8-year-old girl presented to the emergency department with swelling and erythema of the anterior midline neck over a previous tracheostomy scar . The chiA brief review of the child's medical and surgical history revealed underlying Stickler syndrome with Pierre Robin sequence. She had undergone a tracheostomy at 2 months of age to bypass an upper airway obstruction. At 2 years of age, the child underwent bronchoscopy and was soon after decannulated. The tracheostomy stoma did not heal spontaneously over 8 months. Therefore, she underwent surgical closure via fistulectomy with four-layered closure a few months before her 3rd birthday. The child did well after surgery. She was seen thereafter only for wellness visits until her emergency room presentation more than 5 years after decannulation at the age of 8 years old.While in the emergency department, the child underwent a computed tomography (CT) scan of her neck, which confirmed the presence of a TCS . The patRoughly 2 weeks later, the child returned to the operating room for definitive repair of the TCS, which was accomplished via a modified fistulectomy with four-layered closure and a penrose drain. The small tracheal defect was identified without concomitant bronchoscopy by filling the surgical field with normal saline followed by application of positive pressure ventilation. Once the location of the defect was known, the perichondrium around the tracheal defect was closed with a figure-of-eight absorbable suture, and the overlying soft tissue was closed sequentially in layers. The patient was discharged home the following morning without complication. At subsequent outpatient visits, the neck had healed well.A tracheocutaneous sinus is a rare sequela following a pediatric tracheostomy relative to TCF, which is a common late complication occurring with a frequency of 6–55% , 4. SubcSurgical repair of a TCF is important as it directly contributes to poor hygiene, poor phonation, intolerance to submersion, social isolation, and risk of aspiration and infection. TCF can be treated conservatively for the first 3–6 months after decannulation using local curettage, silver nitrate, and cauterization. There is some debate regarding the exact timing of repair; some authors recommend at least a 6-month trial of conservative management to ensure that there is no spontaneous closure .Various techniques for TCF repair have been described, including primary closure without fistulectomy, fistulectomy with healing by secondary intention , fistuleOne of the most commonly utilized surgical repair techniques—fistulectomy with multilayered closure—was first described by Joseph et al. . FistuleIn cases where the tracheal defect is large and/or the child has a chronic pulmonary condition associated with frequent and forceful cough, one should consider fistulectomy and healing by secondary intention. In these cases, it is reasonable to discuss standard fistulectomy with healing by secondary intention or fistula tract obliteration via electrocautery since both methods have reported success , 10. A 2A pediatric TCS following tracheostomy is a rare sequela of a pediatric tracheostomy. This case represents an unusual delayed dehiscence of a TCF repair resulting in a pediatric tracheocutaneous sinus. The prolonged cannulation in conjunction with an underlying collagen disorder—Stickler syndrome—may explain this rare TCS . Althoug


Liver masses in cirrhosis are increasingly being recognized with the use of new imaging modalities. The majority of these lesions are detected by ultrasound, enhanced CT and MRI. The most likely diagnosis of a solid liver lesion in a cirrhotic liver is hepatocellular carcinoma, followed by high grade or low grade dysplastic nodule, and cholangiocarcinoma. Lymphoma and liver metastasis are extremely rare. Diagnosis is made by contrast enhanced ultrasound, multi detector (MDCT) and MRI. Fine needle core biopsy (FNCB) or aspiration (FNAB) or both may be required in doubtful cases. If uncertainty persists on the nature of the lesion, surgical liver resection is recommended. This review discusses the main characteristics of the most common solid liver masses in cirrhotic patient. Liver masses are increasingly being recognized with the widespread use of imaging modalities such as ultrasonography, computed tomography, and magnetic resonance imaging . The mosA liver mass in a cirrhotic liver should be viewed as an HCC until proven otherwise. The diagnosis of liver masses in a cirrhotic liver includes malignant and benign lesions -8 Table. After dAlpha fetoprotein (AFP), PIVKA-II (protein induced by vitamin K absence or antagonist II), desgamma-carboxy prothrombin (DCP) are tumor markers for HCC . The comThe limitation of developing HCC markers is probably due to heterogeneity assay methods and result reporting, limited analysis of demographics and causes of liver disease as covariates in the expression of these biomarkers. In addition, these molecules need to be validated and cost-effectiveness especially those markers proposed as diagnostic or prognostic role. Further studies are needed to confirm the roles and to validate these biomarkers.Key features of imaging technique in the diagnosis of liver mass are shown in The gold standard for detection and location of focal lesions in cirrhosis is enhanced MRI or triple phase dynamic spiral CT . ConventFine needle aspiration and core biopsy (FNAB) is safe, accurate and cost effective. Its specificity approaches 100% and its sensitivity is 67-100% . FNAB unScreening for HCC in cirrhotic liver includes ultrasound plus AFP levels every 6 months. The AASLD guidelines recommend ultrasound only .Lesions more than 2 cm need just one imaging technique showing typical findings  or one imaging technique and AFP levels higher than 400 ng/ml in order to make a non-invasive diagnosis of HCC . More thSeventy-five percent of masses which are less than 2 cm in a cirrhotic liver are HCC . LesionsIn this case repeated dynamic CT or MRI every 3 months is the rule , 33. An HCC is a common tumor with an incidence of 1 - 6 % among cirrhotic patients . Risk faDysplastic nodule often occurs within regenerative cirrhotic nodules. They can show low or high grade dysplasia. A progression from regenerative nodule with low grade dysplastia, high grade dysplasia, well differentiated and poorly differentiated HCC is possible . MRI besCholangiocarcinoma accounts for 20% of primary liver tumors, arises as adenocarcinoma, papillary or mucinous carcinomas . Risk faLiver involvement is common in Hodgkin's disease including lymphoma infiltration , drugs, viral hepatitis, and sepsis. Cholestasis is uncommon and vanishing bile duct syndrome has been described . The difThe liver is the most common site of metastasis from the gastrointestinal tract, pancreas, breast, and lung . Only 20Other very rare malignant tumors in cirrhotic liver includes: epithelioid hemangioendothelioma, cystadenocarcinoma, and angiosarcoma, undifferentiated sarcoma of the liver, rhabdomyosarcoma, fibro sarcoma, and leiomyosarcoma.Haemangioma is found in 20% of the general population, more commonly in women . The majAdenoma occurs in women with oral contraception use more than 5 years or in diabetic patients . MultiplIn 10% of patients with fatty liver, fat accumulates focally or shows focal sparing, usually in the anteromedial segment of the left lobe. These patients usually have diabetes, hyperlipidemia, and obesity, drink alcohol or take steroids . On US, Other very rare benign tumors in cirrhosis includes: hepatobiliary cyst adenoma, bile duct adenoma (cholangioma), biliary papillomatosis, lipomas, myolipomas, angiomyolipomas, schwannomas, neurofibromas and chondromas, inflammatory pseudotumor, and pseudo-lesions.Before hepatic resection, lesions should be measured, counted and localized to the Couinaud segments. Their relationship to major anatomic structures  should be detailed . If maliThe Child-Pugh score helps selecting which patients should undergo hepatic resection. Survival depends on the regenerative potential and the presence of cirrhosis . TraditiPatients with compensated cirrhosis may benefit from liver resection, radiofrequency ablation (RFA), or transarterial chemoembolisation (TACE). Patients with decompensated cirrhosis would probably have no survival benefit . In seleThere are no clear cut indications when to use which imaging modality in differentiating benign from malignant lesion. Choice of modality depends on many factors including cirrhosis, steatosis, and the number of nodules. The most likely diagnosis of liver mass in cirrhotic patients is HCC, followed by high and low grade dysplastic nodule, and cholangiocarcinoma. Ultrasound is often the first diagnostic imaging and contrast enhanced US may answer your question. MRI or CT often allows the correct diagnosis of a primary liver tumor. PET/CT using FDG mainly used to exclude regional and distant metastasis in primary liver tumors. In cirrhotic liver, main objective of the biopsy of a nodule less than 2 cm is to ascertain a diagnosis of HCC, which is now improved by the use of specific molecular markers. In non-cirrhotic liver, liver biopsy is required for the differential diagnosis of liver cell adenoma with HCC, and cholangiocarcinoma with liver metastasis, respectively.


Introduction. Osteochondritis dissecans (OCD) of the capitellum is a localized disorder of the subchondral bone, in a region with limited healing capacity. Although its aetiology is still unknown, it has been associated with repetitive microtrauma. The natural history of this disease involves the evolution for degenerative joint disease in approximately half of the patients, with early identification and treatment being critical to optimizing the outcome. Case Presentation. We present a rare case in our practice, illustrating a capitellar OCD in a fifteen-year-old White male without an identified cause of repetitive microtrauma. Conclusion. In this case prompt diagnosis and arthroscopic-assisted treatment led to a successful result. Osteochondritis dissecans (OCD) of the capitellum is a localized disorder of the subchondral bone resulting in fragmentation of the articular surface and underlying bone –3.Although its aetiology is still unknown, there is strong suspicion of its relation with repetitive microtrauma with a valgus stress in a relatively poor vascularized subchondral bone , 4.This theory is supported by the fact that OCD of the capitellum typically affects the young athlete involved in high-demand, repetitive, overhead, or weightbearing activities, such as baseball and gymnastics , 5. In fThe capitellar lesion is focal and has limited capacity for healing . The repLong-term results show the evolution for degenerative joint disease and maintenance of elbow symptoms in approximately half of the patients , 10.We present a rare case in our practice, illustrating a capitellar OCD in a young male without an identified cause of repetitive microtrauma, with successful arthroscopic treatment.A fifteen-year-old White male presented to our hospital's emergency room (ER) with a history of right elbow pain, oedema, and limitation of active extension after carrying heavy weights the day before. The patient also mentioned a similar episode occurring two weeks earlier, which was solved with rest and a cycle of oral nonsteroid anti-inflammatory (NSAID) drugs. The physical examination at the ER demonstrated a limited range of motion of his right elbow (10°–130°) without pronosupination restraints (80°-80°). The X-ray of right elbow showed a small bony fragment anterior to the capitellum. An ultrasound was also performed demonstrating a small intra-articular effusion with nonpure characteristics. Conservative treatment was decided, including elbow rest, local ice packs, and another cycle of oral NSAIDs.The patient remained asymptomatic for nine months when, after another episode of heavyweight bearing, the symptoms recurred. At that time, a computerized tomography (CT) scan and a magnetic resonance imaging (MRI) of the right elbow were performed showing a small osteochondral capitellar lesion, intramedullary oedema, and an intra-articular loose body . In thisAfter another episode of pain, oedema, and locking of the right elbow, occurring three months after the previous, he was proposed for arthroscopic treatment. During the arthroscopic procedure, an intact and soft capitellar cartilage  was fouActually, with a two-year follow-up the patient is still asymptomatic, without any history of recurrence of pain, oedema, or locking of the elbow. He has regained full extension (0°) and flexion (150°). There was also a recovery and normalization of the radiographic findings with the MRI showing no intramedullary oedema and no loose bodies .Our case illustrates a patient with capitellar OCD treated arthroscopically with an excellent clinical result. Regarding the demographics of the disease, this case is representative of the typical elbow OCD patient, classically described in literature: male, aged between 12 and 17 years, with an osteochondral lesion of the capitellum associated with trauma , 12, 13.Concerning the classification and the severity of the disease we can argue that although clinical and radiographic findings would lead us to classify this lesion as unstable according to Takahara et al. —several Our strategy regarding this case is in line with the majority of papers published since the development of elbow arthroscopy techniques and follows the algorithm published by Baker III et al. , startinNumerous surgical treatments for these lesions have been described , 13, 16.In recent years, there has been a trend toward early surgical management for unstable lesions with increase in arthroscopic or arthroscopy-guided surgical techniques , 3. ThesThe aim of drilling is to promote a decompression that allows revascularization of the defect  and doinThe prognosis for osteochondritis dissecans of the capitellum remains reserved.Early identification and treatment are critical to optimizing lesion healing.With this report the authors pretend to demonstrate a successful case in which the early arthroscopic approach was essential to the final result. Although the absence of repetitive microtrauma would not suggest it, precise diagnosis was obtained with MRI. The excellent clinical result achieved also correlated with the imaging findings, with the control MRI showing full recovery of the lesions.


We describe a 47-year-old man who referred to the Emergency Department for sudden global amnesia and left mild motor impairment in the setting of increased arterial blood pressure. The acute episode resolved within 24 hours. Despite general recovery and the apparent transitory nature of the event, a persistent selective impairment in recollecting events from some specific topics of his personal life became apparent. Complete neuropsychological tests one week after the acute onset and 2 months later demonstrated a clear retrograde memory deficit contrasting with the preservation of anterograde memory and learning abilities. One year later, the autobiographic memory deficit was unmodified, except for what had been re-learnt. Brain MRI was normal while H20 brain PET scans demonstrated hypometabolism in the right globus pallidus and putamen after 2 weeks from onset, which was no longer present one year later. The absence of a clear pathomechanism underlying focal amnesia lead us to consider this case as an example of functional retrograde amnesia.


Thoracic outlet syndrome (TOS) is caused by heterogeneous factors that compress the brachial plexus and subclavian artery; tumor is rarely a cause of TOS. Here, we present the case of a 26-year-old man with secondary chondrosarcoma arising from osteochondroma of the left clavicle causing TOS, with a direct compression of the brachial plexus and subclavian artery. Immediately after surgery, the symptoms of TOS reduced. To our knowledge, this is the first case of a secondary chondrosarcoma of the clavicle causing TOS, which is possibly the key symptom for diagnosing malignant transformation of osteochondroma of the clavicle. Thoracic outlet syndrome (TOS) is caused by compression of the subclavian artery, vein, or brachial plexus. The compression may be caused by various pathophysiologies. In fact, a few cases reported a tumor of the first rib as the cause of TOS , 2.Secondary chondrosarcoma occurs in 0.5%–1% of patients with a solitary osteochondroma. Malignant transformation of osteochondroma is more common in hereditary multiple exostosis (HME) . Common We report a case with a secondary chondrosarcoma of the clavicle causing TOS. Tumor resection resolved both the neurologic symptoms and restriction of the range of motion of the shoulder.A 26-year-old man was referred to our hospital with complaints of progressive restriction of the range of motion of his left shoulder and worsening pain and dysesthesia of the left arm and hand. Eight years prior to presentation, he was diagnosed with HME in our hospital, and an osteochondroma of the right femur was resected. He had never been treated as he had not experienced any discomfort since that.Physical examination revealed a 10 × 10 cm fixed, hard mass in the left infraclavicular lesion, and the range of motion of the left shoulder was limited (flexion and abduction was 90°). Dysesthesia and radiating pain to the left arm and hand were observed when the arm position was dropped down for a few minutes and were relieved by elevating the arm. Slight weakness of the extensor digitorum communis and extensor carpi radialis brevis muscles was detected. Adson's test for TOS was positive with loss of radial pulse and numbness in the left arm and hand, and Wright's hyperabduction test was negative. Plain radiographs of the left shoulder showed that the bony mass adjacent to the clavicle had markedly increased compared with 8 years previously Figures . ComputeThe surgical procedure was performed through a transverse incision in line with the superior border of the clavicle, with osteotomy 3 cm from the proximal edge of the clavicle, and disarticulation of the acromioclavicular joint. The subclavian vessels and brachial plexus had been compressed downward by the tumor, and the compression worsened when his left arm was dropped as shown in the angiography. Because of this, we ensured that the arm remained abducted, and the subclavian vessels and brachial plexus were released easily because these structures were separated by the thin membrane enveloping the tumor when the tumor was resected en bloc. The clavicle was resected almost in entirety, and the coracoid process was resected from the scapula at its base Figures .On histological examination, the tumor was determined to be composed of cartilaginous tissue with mild nuclear atypia and increased cellularity showing a lobular growth pattern separated by fibrous bands . The hisThe radiating pain and dysesthesia of his left arm and hand disappeared soon after surgery, and the range of motion of the left shoulder improved to within the normal range. Muscle weakness also recovered approximately 1 month after the surgery. Neither local recurrence nor metastases were observed 3 years later , and theWe presented the case of a patient with HME presenting with TOS as a symptom of secondary malignant change in osteochondroma.The pathophysiology of TOS includes heterogeneous causes that compress neurovascular structures within the retroclavicular space. There are three frequent causes of compression: congenital abnormalities ; posttraumatic muscular hypertrophy and scarring; and posture and muscle imbalance . Tumor, Malignant transformation of osteochondroma in patients with HME is not frequent; the incidence has been reported as about 2% to 5% , 10. TheIn summary, this is the first case of TOS associated with secondary chondrosarcoma of the clavicle, and the neurological symptoms, such as TOS, may possibly be the key symptoms for diagnosing this type of malignant transformation.


A 45-year-old man presented with painless subcutaneous masses bilaterally on his hands and loss of motion or contracture of the fingers. Initially, drug therapy to reduce the serum uric acid was administered and was expected to reduce the tophi. However, during observation at the clinic, spontaneous rupture of an extensor tendon occurred, and surgical repair of the tendon and resection of the masses were performed. Surgical exploration of the right hand showed hypertrophic white-colored crystal deposits that both surrounded and invaded the extensor digitorum communis of the index finger, which was ruptured. Histopathologic examination of the specimen demonstrated findings consistent with gouty tophi. Tophaceous gout can induce a rupture of tendons during clinical observation, and surgical resection of the tophi might be needed to prevent ruptures. Gout is characterized by hyperuricemia and attacks of acute synovial inflammation secondary to the deposition of sodium urate crystals –3. With The patient was a 45-year-old man with a chief complaint of multiple masses on his fingers and hands. The first mass was noticed at 26 years of age, and although the patient was diagnosed with gout by his doctor, it was not treated. His first examination in our hospital was at 31 years of age, and drug treatment for hyperuricemia was administered. However, about five years later, he stopped this treatment by himself, and there are no records of consultations since then. At 45 years of age, the patient was reexamined at our hospital wishing to undergo surgery for tophi on both hands.Physical examination revealed multiple tophi on both hands  and simiAfter about two months, the patient complained about his index finger disorder and was referred to our clinic. His right index finger was difficult to extend actively, but it could be extended passively. An extensor tendon rupture of the index finger was suspected, and surgery for resection of the mass and repair of the extensor tendon was planned. Perioperative findings showed that the extensor digitorum communis of the index finger in the MP joint was invaded by a mass, and its margins were identified proximally and distally. The extensor indicis muscle tendon was found on the ulnar side of the mass and was not ruptured . FollowiGout is an inflammatory disease characterized by an elevated serum urate concentration and recurrent flares, including painful, hot, red, and swollen joints and surrounding tissue . In geneGouty tophi are usually treated conservatively using drugs . SurgicaThere have been reports that gouty tophi in the upper extremity were surgically resected because of entrapment neuropathy , flexionThe decision regarding whether to remove crystals from inside the tendons or ligament attachment sites is difficult because it is often necessary to destroy those tissues to remove crystals completely. Therefore, crystals cannot be removed frequently , 2. PrevWe performed surgical treatment for a case of multiple gouty tophi in the fingers complicated by rupture of the extensor tendon of the index finger. It should be recognized that gouty tophi might cause tendon rupture, and control of serum UA is important to prevent tendon rupture.


Lethal necrotizing pancreatitis postpartum due to primary hyperparathyroidism caused by a parathyroid adenoma can be considered as a rarity. Due to the unspecific clinical signs and uncommonness this disorder may be overseen very easily. The reported case illustrates the very importance of early diagnosis of this endocrine disorder in pregnancy in order to avoid a lethal course. Primary hyperparathyroidism is a common endocrine disorder. The vast majority of the cases are due to a single adenoma, followed by hyperplasia (15–20%) and parathyroid cancer (1%) . This diA 38-year-old woman presented in the gynecological emergency unit complaining about massive upper abdominal pain and vomitus. The pregnancy to date of admission developed without any pathological findings in preventive medical examinations. When premature contractions in cardiotocography were seen, a primary tocolysis was started. Results of blood tests and abdominal ultrasonography lead to the strong suspicion of a severe exsudative pancreatitis Table 1 . The patLethal necrotizing pancreatitis postpartum due to primary hyperparathyroidism caused by a parathyroid adenoma can be considered as a rarity. It is associated with a significant increase in morbidity and mortality of mother and child , 4], , , 11], , . Due to As a diagnostic investigation in case of acute abdominal pain in pregnancy an abdominal ultrasound should be performed. If there are signs of pancreatitis an MRI is required for clarification. Additionally in case of elevated serum calcium a measurement of the parathormone level and an MRI of the neck and mediastinum are indispensable , 2], , , 15], , . IncreasIn case of primary hyperparathyroidism without pancreatitis the adenoma should be surgically removed during gestation preferably in the second trimester. If pancreatitis occurs the parathyroid adenoma must be removed immediately. Parathyroidectomy carries a very low rate of complication even in urgent surgery , 5], , , 16], , . In contThe authors declare that they have no competing interests.


Desmoplastic ameloblastoma (DA) is one of the 6 histopathological subtypes of ameloblastoma. Hybrid lesions in which histopathologically conventional ameloblastoma coexists with areas of DA are rare. A 40-year-old male was referred to our hospital complaining of a swelling in the right premolar region of the mandible. A panoramic radiograph showed an area of radiolucency with a well-defined corticated border, whereas computed tomography revealed a unilocular radiolucent lesion and buccal expansion together with cortical perforation. The lesion was treated via enucleation and curettage of the marginal bone and fenestration. A histopathological examination showed a hybrid ameloblastoma with a pronounced desmoplastic pattern and follicular changes. The patient's postoperative course has been favorable up to now, and no marked changes have been observed. We presented a case of hybrid ameloblastoma and reviewed the 36 reported cases of hybrid ameloblastoma that have been reported in the English literature. Ameloblastomas are common benign neoplasms that frequently arise in the molar and ramus regions of the mandible. In 2005, the World Health Organization histologically classified ameloblastomas into solid/multicystic, extraosseous/peripheral, desmoplastic, and unicystic types. Solid/multicystic ameloblastomas were further divided into follicular and plexiform types. The follicular type has 4 subtypes, the spindle cell type, acanthomatous type, granular type, and basal cell type . DesmoplIn recent years, the literature has described hybrid lesions composed of DA and conventional ameloblastoma, which are histopathologically characterized by areas of follicular or plexiform ameloblastoma coexisting with areas of DA , 7, 8.In the present study, we describe a novel case of hybrid ameloblastoma and present a concise review in the scientific literature to summarize the clinicopathologic characteristics of hybrid ameloblastoma.A literature review revealed 34 cases of hybrid ameloblastoma according to database of PubMed . The preA 40-year-old male patient presented to our hospital with a complaint of swelling in the right lower premolar region . The patHis past medical history was noncontributory. A panoramic radiograph revealed a radiolucent lesion with a well-defined border and root displacement of the canine and first premolar without root resorption . ComputeDA is a rare variant of ameloblastoma, with an incidence of 4% to 13% among reported ameloblastoma cases –6. A paiHistologically, the odontogenic epithelium of DA forms irregular, stellate, or follicular islands and cords, and the centers of such lesions often appear hypercellular and contain spindle-shaped or squamous cells . The mosβ expression has been reported in DA but not in conventional ameloblastomas [β plays a part in the formation of the desmoplastic matrix perhaps by modulating the extracellular matrix in the desmoplastic regions of DA [The present case exhibited abundant collagen fibers in the connective tissue stroma. Marked tumor growth factor- (TGF-) lastomas , implyinns of DA . Scientins of DA . Unlike ns of DA . Previouns of DA ; decreasns of DA ; and strns of DA , caspasens of DA  expressiHybrid ameloblastoma lesions were first described by Waldron and El-Mofty  as a tumThe present case comprises both components intermingled with each other, indicating that the tumor was a true hybrid lesion rather than a collision lesion. Hybrid odontogenic tumors might result from the diverse differentiation potentials of odontogenic epithelial cells, whose multipotentiality is demonstrated by the number of different histopathological varieties of odontogenic tumors. The present case had an admixture of DA component with conventional ameloblastoma tissue, which is why we consider that it was a modulated tumor rather than a collision tumor.We performed a clinicopathological analysis of the approximately 30 cases of hybrid ameloblastoma reviewed by Rai et al.  and ChaiSeveral reports have described treatment algorithms for ameloblastoma , 25. Man


Leukemia is a common hematologic disease that causes various systemic complications, such as ophthalmological disorders. The venous congestion is considered to be the main clinical sign that occurs during the initial stage of the disease, whereas white-centered hemorrhages are the most typical manifestations in leukemic retinopathy. These complications usually manifest when the disease presents with clinical and hematological symptoms. In the present study, we report a patient who was diagnosed with leukemic retinopathy. The initial signs of this disease were bilateral hemorrhages that occurred during complete clinical remission. Previous studies regarding this condition are quite rare.We report a 26-year-old man who was diagnosed with leukemic retinopathy and exhibited the initial signs of the disease, namely bilateral hemorrhages with a distinct appearance beneath the internal limiting membrane. In addition, flame-shaped hemorrhages were observed surrounding the optic discs and/or along the vessels in the absence of venous congestion. All these changes were present during complete clinical remission.Bilateral acute leukemic retinopathy, acute lymphoblastic leukemia .Clinical remission was achieved following effective systemic chemotherapy that was applied for leukemia in the hematology department. A dynamic observation was applied actively in the absence of surgery and/or medical treatment for ophthalmologic treatment.Best corrected visual acuity was 20/40 in the right eye and 20/60 in the left eye, which was considerably better than those noted at the initial visit of the patient (20/250 in the right eye and 20/400 in the left eye).The cautious expectant treatment is safe and helpful for acute leukemic retinopathy. A long-term follow-up is inevitable. Effective systemic chemotherapy that is required for leukemia treatment can achieve clinical remission, which might be helpful in controlling the pathological changes of the eyes. Previously reported findings that are associated with this conditions included venous congestion, retinal edema, hemorrhages, optic nerve infiltrates, and nonspecific uveitis.–8 These complications usually occur when the disease presents with clinical and hematological symptoms, and are rare during complete remission.,7 In the present study, we report a patient with bilateral intraretinal hemorrhages and acute lymphoblastic leukemia  in complete remission.Leukemia is a common hematologic disease that causes various systemic complications, such as ophthalmological disorders. According to previous studies, both acute and chronic leukemia can cause leukemic retinopathy, although acute leukemia is the main cause of this condition.29/L), thrombocytopenia (31 × 109 /L), and anemia (103 g/L) were present. The proportion of leukemic blast cells to the peripheral blood cells was 85%. During the next 5 months, he received 4 cycles of standard chemotherapy. Complete clinical remission was achieved during the chemotherapy and was based on bone marrow biopsy and flow cytometry. A total of 13 days following the last chemotherapy cycle, he suddenly developed a blurred vision. During the first eye examination, his best corrected visual acuity (BCVA) was 20/250 in the right eye and 20/400 in the left eye, which was later attributed to an acute intraretinal hemorrhage that was present between the nerve fiber layer and the internal limiting membrane. This hemorrhage formed a special “sunset sign” on fundus color photographs  by bone marrow biopsy, flow cytometry analysis of B cells, and genetic analysis, when marked leukocytosis 94.24 × 1009/L, thrA dynamic observation was applied actively without surgery and/or medicine for ophthalmologic treatment in the following months. The first follow-up eye examination was carried out 19 days later, and the second follow-up eye examination was 2 months later. BCVA, OCT, and fundus color photographs were also recorded during the 2 follow-up examinations. The institutional ethics review board policy was not required for the observational case report because it did not alter the patient management. Written informed consent was obtained from the patient for the publication of the findings.3On the first follow-up examination, BCVA parameters were very similar to those noted during diagnosis of the hemorrhage. OCT and fundus color photographs were carried out with the same scan settings in order to ensure comparability. The liquid of the subretinal hemorrhage was absorbed and the cellular components Fig. A and B f4–7 The retinal vessels are dilated, tortuous, and pale sheathed, due to the leukocytic infiltration of the vessel walls that produces a granular appearance of a blood column.,3 The white-centered hemorrhages (“Roth spots”) are typical in leukemic retinopathy, which is formed by accumulations of white blood cells and fibrous exudation in the center of the hemorrhagic area. Previous studies have reported that all the pathophysiological changes that have been associated with leukemic retinopathy may present with high viscosity, leukocytosis, thrombocytopenia, and severe anemia.,7Leukemic retinopathy is mainly characterized by marked venous congestion, retinal edema, and white-centered hemorrhages.,7,8 and the development of Roth spots is the most typical manifestation related to leukocytosis that is derived from leukemic retinopathy. Both of these symptoms exhibit a close relationship with leukocytosis. In the present case, Roth spots and venous congestion were not observed. We believe that this was due to the high level of the white blood cells of the patient who did not last long enough in order to cause pathological changes owing to his optimal response to systemic chemotherapy. The pathological changes of fundus in the early stage of the present case report were most likely caused by severe anemia. Furthermore, the intraretinal hemorrhage produced a characteristic “sunset sign” that was determined by fundus color imaging and a “rainbow sign” that was determined by OCT B frame. Moreover, uneven continent and liquid levels, frames, and round lesions with the thin wall were reported by Enface imaging. The massive intraretinal hemorrhage caused a sudden detachment of the internal limiting membrane, which in turn damaged the deep layer. The structures beneath the internal limiting membrane were expanded toward the vitreous cavity to form a nearly round mound. The sedimentation of the blood allowed the distinction of the hemorrhage by a characteristic line demarcating the superior transparent plasma from the inferior corpuscular part of the hematocele. The lower part of the mound shape structures beneath the internal membrane was internalized by the inferior corpuscular part of the hematocele, while the higher part was noted via the transparent plasma, forming a distinctive “sunset sign” on fundus color imaging. The shape of this structure on the cross-sectional OCT image resembled that of a “rainbow” straddling the macular.The present case report exhibits several distinctive clinical features. First, retina hemorrhage occurred during complete clinical remission, when the hematocrit (HCT) and the hemoglobin levels were 0.14 L/L  and 45 g/L , respectively. In addition, these changes were observed in the presence of slight thrombocytopenia and leucopenia. This suggested that retinal hemorrhage was closely associated with anemia, as determined by the decreased HCT and hemoglobin. It has been proposed that anemia plays an important role in leukemic retinal hemorrhage, notably in the decrease of HCT, which can cause retinal hemorrhage even during complete clinical remission. Second, the initial changes of fundus that were noted in the present case report, were bilateral hemorrhages beneath the internal limiting membrane and flame-shaped hemorrhages surrounding the optic discs and/or along the vessels. Previous studies regarding this condition are limited. The venous congestion is considered to be the main initial sign of leukemic retinopathy5Following a period of dynamic observation at the last follow-up examination, the BCVA of the patient improved (20/40 in the right eye and 20/60 in the left eye) compared with that noted during his initial visit (20/250 in the right eye and 20/400 in the left eye). This indicated that cautious expectant treatment is safe and helpful for this type of acute leukemic retinopathy. We suggest that the principles for expectant treatment are as follows: the risk/benefit ratio should be evaluated prior to the therapeutic decisions. Because patients with hematological disorders exerted a much higher risk of bleeding and infection than the normal subjects, noninvasive treatment strategy, such as the expectant ophthalmic treatment should be the first choice of treatment. The proper surgical treatment should be performed in case of active bleeding, vitreous hemorrhage, nonperfusion area, and/or neovascularization. A cautious strategy should be maintained and the purpose of surgery should be to preserve the existing vision and avoid serious complications rather than to eradicate the pathological changes. A long-term follow-up should be conducted in order to monitor the progression of the disease, because the pathogenic condition of leukemia is complicated and dynamic. Effective systemic chemotherapy for the treatment of leukemia can achieve clinical remission, which might be helpful in controlling the pathological changes of the eyes.


First described in 1925, giant condyloma acuminatum also known as Buschke-Löwenstein tumor (BLT) is a benign, slow-growing, locally destructive cauliflower-like lesion usually in the genital region. The disease is usually locally aggressive and destructive with a potential for malignant transformation. The causative organism is human papilloma virus. The most common risk factor is immunosuppression with HIV; however, any other cause of immunodeficiency can be a predisposing factor. We present a case of 33-year-old female patient, a known HIV patient on antiretroviral therapy for ten months. She presented with seven-month history of an abnormal growth in the genitalia that was progressive accompanied with foul smelling yellowish discharge and friable. Surgical excision was performed successfully. Pap smear of the excised tissue was negative. Despite being a rare condition, giant condyloma acuminatum is relatively common in HIV-infected patients. Anogenital warts, also known as condyloma acuminatum, are a common sexually transmitted disease among males and females caused by human papilloma virus (HPV) , 2. The Giant condyloma acuminatum (GCA) is an extremely rare clinical form of genital warts, characterized by growth that extends into underlying dermal structures . It is uWe report a case of a 33-year-old HIV-infected patient on ART for ten months, who presented with seven-month history of progressive growth in the genitalia that was found to be GCA. Surgical resection was done successfully.We present a case of a 33-year-old female patient, Para 3+0, HIV-infected woman with baseline CD4-count of 30 cells/ul who has been on antiretroviral therapy (ART) for ten months prior to her visit. She presented to gynaecology clinic at Bugando Medical Centre, Mwanza, Tanzania, with seven-month history of progressive growths around genital region. The growths were of insidious onset, initially painless, although they later became painful. The lesion was initially noted on the edges of vaginal introitus; however they continued to spread to involve the perianal region. The growths were associated with foul smelling yellowish discharge. She has no history of receiving HPV vaccine.On examination, there were huge multiple masses, friable, cauliflower-like in appearance, dark grayish-pink in colour on her vulva involving both labia majora, extending anteriorly to the mons pubis and posteriorly to the perianal region, completely obliterating the urethral orifice, vaginal introitus, and anal opening . Masses There was no peripheral lymph node enlargement. The vitals were blood pressure 110/65 mmHg, pulse rate of 78 beats per minute, respiratory rate of 20 cycles per minute, and temperature of 37°C. The diagnosis of GCA was reached. Due to the extensive nature of the lesions, surgical excision was planned and done successfully . The wouThe patient was seen at one month and two months at which point she was doing fine, still on her ART with no recurrence of the vulval lesions. She was counseled on safe sex and other preventive measures for STIs. She was then lost to follow-up after six months of follow-up.Anogenital warts are the most common manifestation of genital HPV infection. Estimates show that among patients who contact HPV, only 10% develop genital warts , with HIGCA is usually a benign lesion with 30–56% chance of malignant transformation , being mGCA is a rare tumor. It is even rare when in regions other than the penis like in our patient. Estimates show that GCA accounts for 5–24% of the penile cancers. The tumor has been shown to be associated with HPV subtypes 6 and 11 , the lowGCA usually starts to grow as a keratotic plaque that expands slowly into a cauliflower-like mass. The growth takes longer in immunocompetent individuals. In immunosuppressed individuals, however, the growth is commonly more rapid . The lesThe treatment of choice for the management of GCA is considered wide surgical excision , 12. SurDespite being a very rare manifestation, giant condyloma acuminatum of the vulva occurs, especially in immunosuppressed patients. Surgical excision remains the mainstay of treatment with adequate cure rate and limited recurrences. HPV screening should be done routinely to HIV-infected patients to increase the chances of early diagnosis and treatment.


Horner’s syndrome is a very rare complication following surgery of the thyroid gland with only a handful of cases reported in the literature. Exact pathophysiology of post-thyroidectomy Horner’s syndrome is not fully understood, and once diagnosed, management remains mostly conservative.A 36-year-old Sri Lankan Sinhalese woman developed unilateral partial ptosis with enophthalmos and myosis one week after total thyroidectomy for a benign multinodular goiter. A clinical diagnosis of Horner’s syndrome was made. A postoperative ultrasound scan did not show a collection or hematoma compressing the sympathetic trunk. Our patient was managed conservatively and she had a slow and an incomplete recovery at 1-year follow up.This case report highlights the importance of being aware of the close anatomical relationship between the thyroid gland and cervical sympathetic trunk during thyroidectomy. This would enable the surgeon to undertake measures to minimize the risk of damaging the sympathetic trunk during thyroidectomy. Horner’s syndrome (HS) is characterized by myosis, eyelid ptosis, enophthalmos, with or without facial anhydrosis and vascular dilatation of one half of the face resulting from damaged ipsilateral cervical sympathetic chain. HS due to damaged cervical sympathetic trunk during thyroidectomy is a very rare complication with only a handful of cases reported in the literature , 2. A clA 36-year-old Sri Lankan Sinhalese woman underwent a total thyroidectomy for a benign, euthyroid, moderate-sized multinodular goiter with no retrosternal extension. She did not have any other medical illnesses or previous surgical procedures in the neck area. No undue difficulty or unexpected findings were encountered during the surgery. Both recurrent laryngeal nerves and superior parathyroid glands in both sides were identified and preserved with the standard technique and branches of both inferior thyroid arteries were ligated and divided close to the capsule of the gland.The early postoperative period was uncomplicated and our patient was discharged from the ward on the first postoperative day. Six days later (a week after thyroidectomy) she was detected to have left-sided partial ptosis with enophthalmos and myosis. However, there was no anhydrosis or vascular dilatation in the ipsilateral face. She did not develop other complications of thyroidectomy including hypoparathyroidism or vocal cord palsy. An ultrasound scan of her neck failed to demonstrate a hematoma or a collection which potentially could have compressed the sympathetic trunk. Pathological analysis of the specimen showed a multinodular colloid goiter without any evidence of malignancy.Our patient was managed conservatively and her recovery from HS was slow and incomplete. By 6 months she showed a slight improvement in ptosis and myosis, but no further improvements noted at 1-year follow up.Horner’s syndrome (HS) was described first in 1853 by Bernard, and then in 1869 by Swiss ophthalmologist Johann Horner [Although there are frequent reports of HS caused by compression of the cervical sympathetic chain by a large benign goiter or infiltration by a malignant goiter, HS as a complication of thyroidectomy as described in this case report is a very rare entity, with less than 30 cases so far reported in the literature . Furtheret al. has recently reported a case of HS following minimally invasive parathyroidectomy [Kappeler was the first to describe HS as a complication of thyroid surgery in 1865 and the first reported case of HS following thyroidectomy was by Kaelin in 1915 . While tidectomy , while Met al. have postulated a possible vascular supply to the sympathetic trunk originating from the inferior thyroid artery or its branches and ligation of these vessels may lead to devascularization and ischemic injury to the sympathetic chain leading to HS [There are several theories as to the possible reasons for HS after thyroidectomy. These include stretching of the cervical sympathetic chain during lateral retraction, postoperative hematoma compressing the cervical sympathetic chain, ischemia-induced neural damage caused by a lateral ligature on the inferior thyroid artery trunk and damage to the communication between the cervical sympathetic chain and the recurrent laryngeal nerve during its identification . The midng to HS .Fig. 1Anet al. have shown that the risk of HS increases with more extensive surgery or complicated thyroid surgery, for instance in malignant thyroid disease with level III lymph node dissection and with surgery for large goiters with retrosternal extension [In 1915 de Quervain described that the stretching of the sympathetic chain during lateral retraction of the carotid sheath to assist the exposure of the lateral aspect of the gland and its associated structures might be sufficient to cause trauma to the chain with a subsequent neuropraxic-type injury . In a rextension .nd to 4th postoperative day reflecting the possibility of different etiologies [There is no uniformity in the onset of HS after thyroidectomy and the literature shows most cases having the onset on 2iologies . The casMost reported cases of post-thyroidectomy HS patients did not have symptoms related to the vascular system that includes ipsilateral facial anhydrosis and cutaneous vascular dilatation , 2. The We suspect that HS in the patient reported here was produced by ischemic damage combined with possible local trauma to the sympathetic chain during retraction of the carotid sheath. Delayed onset, partial nature of damage to the sympathetic trunk and incomplete recovery support this theory. However, a postoperative hematoma compressing the sympathetic trunk is another possibility, although such an abnormality was not seen with the postoperative ultrasound scan.This case report highlights a rare but important complication of a very common surgery undertaken by general as well as endocrine and otorhinolaryngology surgeons. Although it is rare, the operating surgeon should appreciate the importance of avoiding injury to this at-risk structure since it leads to a significant cosmetic disfigurement, which could be permanent in a significant minority.


Uterine leiomyosarcomas do not frequently metastasize to the bone, and spinal column metastases are even less common. Surgery is the treatment of choice. Adjuvant radiation with or without chemotherapy depending on the extent of disease can be beneficial. We present the case of leiomyosarcoma metastasis to the spine with a previous history of known primary disease complicated by thrombocytopenia. Thrombocytopenia can present surgical challenges, but can also be present concurrently unrelated to the primary disease. A thorough evaluation is needed to rule out any underlying lymphoproliferative disorder or microangiopathic phenomenon. Intraspinal leiomyosarcoma metastases are rare -3. TheseAn 84-year-old female presented with severe low back pain and heaviness in the legs. Referral imaging had shown a spinal lesion and associated burst fracture at the L5 level with canal stenosis. Four years earlier she was diagnosed with uterine leiomyosarcoma stage I, for which she underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy. She denied bowel or bladder dysfunction; however, she admits that upon prolonged standing she experiences increased tenderness and heaviness in her lower extremities. On physical exam she had full strength and no loss of sensation in both upper and lower extremities.Computed tomography (CT) of the lumbar spine demonstrated a compression fracture at L5 with a soft tissue density mass causing significant canal stenosis at that level . An MRI She underwent L4-L5 laminectomy and right transpedicular approach for decompression of the burst fracture. Upon exposure of the burst fracture a soft tissue mass was palpated ventral to the thecal sac. The canal was decompressed and the sac was released of any pressure. L3 to iliac posterior spinal fusion with instrumentation was carried out with placement of bilateral pedicle screws . Graft aFinal pathologic analysis revealed a cellular spindle cell proliferation forming fascicles with mild nuclear atypia and rare mitoses. Tumor cells invades into marrow spaces with associated bony destruction, although apparent tumor necrosis is not seen . ImmunohThe patient tolerated the procedure well, was ambulating on postoperative day 2 and subsequently discharged to an acute rehabilitation facility. Interestingly, prior to her starting adjuvant radiation therapy, she developed worsening thrombocytopenia despite being transfused with two apheresis packs of platelets . Despite the drop in platelets and obvious impact on hemostasis she developed no postoperative bleeding diathesis.Radiation was recommended for her adjuvant therapy. She received 45 Gray of conformal radiation along with a 9 Gray boost. Chemotherapy was not recommended due to the low-grade nature of her pathology (low mitotic index) as well as her baseline performance status (KPS < 80%). Additionally, her underlying thrombocytopenia would have worsened further during expected bone marrow suppressive effects of cytotoxic chemotherapy.The present case reveals an elderly female with metastatic uterine leiomyosarcoma to the lumbar spine. The tumor invaded the spinal canal with resultant spinal stenosis and discomfort. She was effectively decompressed and fused. Post-operatively she received adjuvant radiation therapy. Leiomyosarcomas are uncommon malignant smooth muscle tumors that occur in approximately 1% of patients with uterine cancer . These sUterine sarcomas are uncommon neoplasms with an annual incidence of approximately 0.64 to 1.7 per 100,000 women . They arThe majority of patients who recur do so within two years of initial diagnosis, and up to 90% of patients who fail show distant metastases either alone or concurrent with pelvic recurrence , 9. Yet Bone and brain metastases are uncommon in leiomyosarcoma -5, 10-15Leiomyosarcomas, as evidenced in our case, can be destructive to the bone and in paravertebral lesions this most definitely contributes directly to a patient’s morbidity in terms of instability, pain and loss of function . The patLeiomyosarcoma can present as primary disease to the spinal column as reported in the sacrum -15, LumbSurgery is the mainstay of treatment in primary and metastatic leiomyosarcoma -3, 5. ThMany women experience long-term survival in spite of metastatic disease , as oppoOur patient was noted to have mild baseline thrombocytopenia, that became progressively worse in the weeks following surgery. During a literature review we found only one case of leiomyosarcoma associated thrombocytopenia from a low-grade rectosigmoid leiomyosarcoma metastatic to the heart . ThromboIntraspinal Leiomyosarcoma metastases are rare. Surgery is the treatment of choice. Adjuvant radiation with or without chemotherapy depending on the extent of disease can be beneficial. Thrombocytopenia can present surgical challenges, but can also be present concurrently unrelated to the primary disease.