Melanotic schwannomas are rare nerve sheath tumors that differentiate themselves from classical schwannomas by harboring melanin-producing cells. Intracranial localizations are uncommon, especially on the Gasserian ganglion. We performed a literature review, presenting imaging characteristics, differential diagnosis, and immunohistochemical features for identification. These tumors carry the risk of recurrence and metastases. The prognosis is uncertain. We discuss recommendations for diagnosis and treatment. First identified by WG Millar in 1932, melanotic schwannomas (MSs) are rare peripheral nerve sheath tumors commonly found in the thoracic paraspinal region. Extraneural locations such as the skin, bones, and viscera have also been reported. Intracranial topography is extremely rare, with 18 cases out of 105 MSs described in the literature, according to Spina et al. [A 64-year-old woman was admitted to the neurosurgery department for V2–V3 right- sided trigeminal paresthesia, which had developed six months earlier. Magnetic resonance imaging (MRI) showed a well-circumscribed, fleshy, 36 mm tumor in the Meckel cavum involving the Gasserian ganglion, following the V3 nerve into the foramen ovale, and generating a mass effect on the temporal lobe. This lesion was discreetly hyperintense on T1-weighted images and iso- to hypointense on T2-weighted images, and it showed a slightly heterogeneous enhancement after contrast administration. Small cystic areas were noted. Diffusion-weighted imaging was negative. An abnormality was already seen on a computed tomography (CT) performed two years previously in the context of otitis, without any alarm in relation to the benign presentation, a well-defined petrous lacunar image, and the fortuitousness of the discovery , reticulin (Gomori), and periodic acid-Schiff. Psammomatous bodies must be searched. MSs also express S-100 protein, neuron-specific enolase (NSE), vimentin, and stain variably with Melan-A, HMB-45, and other melanocytic markers. Antigen Ki-67 shows a highly variable mitotic index between 1% and 20%, with an average of 3% [MSs may have a malignant clinical course even in the absence of histologic criteria of malignancy. Recurrence and metastases are observed 20 years after diagnosis. Furthermore, intracranial topography presents a higher risk 89. The m8Surgical resection is the treatment of choice. In the literature, out of 16 patients with intracranial MS who have undergone surgical treatment, total resection was completed in eight patients. In this resection group, recurrence was achieved in 25% compared with 50% in the subtotal resection group. Adjuvant radiotherapy remains controversial. Watson et al. [1In conclusion, intracranial MSs are very rare and can mimic classical schwannomas. Although the definite diagnosis is often based on immunohistochemical analysis, MRI can play an important role in the diagnostic approach if radiologists know of this entity’s existence. Recurrence and metastases are possible. Total resection is clearly recommended, and postoperative adjuvant radiotherapy should be considered in the histologic confirmation of the diagnosis, even if the imaging is reassuring and the resection macroscopically complete, the prognosis being uncertain. Long-term follow-up is required.


Gastric emphysema or air in the stomach wall is a rare condition resulting from the disruption of gastric mucosa and entry of air into the stomach wall which could be from severe vomiting, instrumentation or endoscopy, gastric ischemia, and dissection of air from the mediastinum. Treatment is usually conservative and supportive. We report the case of a 70-year-old woman with a three-day history of nausea and vomiting who presented with gastric emphysema on computed tomography (CT) imaging; she responded very well with conservative treatment and was discharged in a stable condition. Gastric pneumatosis is defined as the presence of air in the stomach wall. It is a rare radiological finding, and there are fewer than 50 cases described in the literature so far . It is cA 70-year-old Caucasian female presented to our facility from a nursing home with complaints of nausea, vomiting, and diarrhea for three days. She has a past medical history of vertical band gastroplasty, hypertension, bipolar disorder and traumatic brain injury that resulted from a gunshot wound to her head over 20 years ago. She initially presented for concerns of dehydration - her initial blood pressure was 111/56. In the emergency room, initial laboratory workup revealed an elevated white blood cell count of 14,700 cells per cubic millimeter of blood with 72.5% neutrophil differential, normal electrolytes, and a creatinine of 1.07 which was increased from her baseline. She appeared clinically dehydrated and was complaining of nausea and abdominal pain. She was started on intravenous (iv) normal saline for rehydration. Computed tomography (CT) of the abdomen and pelvis with IV contrast was ordered. It showed wall thickening of the stomach with gas within the gastric wall (Figures The imaging was not able to discern between gastric emphysema and emphysematous gastritis. Small bowel and colon were visualized and were normal. Findings were immediately discussed with the general surgeon and given the patient’s poor functional status as well as mild symptoms, she was deemed not a surgical candidate. She was continued on IV fluid resuscitation as well as started empirically on IV meropenem. She was followed closely that night with serial abdominal exams. She remained stable with improvement in blood pressure and creatinine. She was observed in our hospital for three days. Her diet was advanced slowly, and she was able to tolerate a regular diet with no nausea or vomiting. Her abdominal exam remained benign. Given the resolution of her symptoms, she was discharged back to her nursing home with a complete resolution of her symptoms.Gastric emphysema carries an excellent prognosis with conservative management . Most paEmphysematous gastritis is more severe than gastric emphysema and carries a mortality rate of 61% . PatientGastric pneumatosis is an uncommon radiological finding which can represent either gastric emphysema or emphysematous gastritis. These two conditions differ a lot in management and prognosis, so diagnosis should be made with a thorough history, physical examination, and clinical presentation. Our patient presented with a three-day history of severe vomiting; CT abdomen was positive for intraluminal gastric air and there were no signs of systemic toxicity. She did respond well with conservative treatment which led to the diagnosis of gastric emphysema.


Spigelian hernias are uncommon and predominantly affect the abdominal wall.The incidence of Spigelian hernias after colonoscopy is even rarer with only one case outlined in the surgical literature. This is the case of a 66-year-old man who underwent routine colonoscopy and presented to the hospital with systemic inflammatory response syndrome (SIRS). A computed tomography (CT) scan demonstrated a Spigelian hernia in the location of a prior left ventricular assist device (LVAD) placement. This required surgical resection and resulted in a complicated post-operative course. This case offers a unique perspective on a rare colonoscopic complication not well represented in the literature. It offers the learning point of remaining vigilant for a rare, but potentially deadly, colonoscopic outcome. This case also illustrates the decision-making heuristic of availability bias. Clinicians must be aware of potential rare complications after colonoscopy. This is particularly relevant because every patient is advised to get a screening colonoscopy at age 50, making this an exceedingly common procedure.Spigelian hernias are rare and comprise approximately 0.12% of hernias of the abdominal wall ,4. This This case discussion of a 66-year-old man who underwent routine colonoscopy, returning with worsening abdominal pain and systemic inflammatory response syndrome (SIRS) is a common scenario. This common presentation is what emphasizes the importance of this case. The primary teaching point of this case report is to expand on the heuristic of availability bias in medicine. Ruling out common things first without considering alternate etiologies is a hallmark of availability bias and will often lead to delayed diagnosis and management. This case demonstrates an example of how to avoid availability bias, which is generally seen when a rare diagnosis is excluded from thought processing initially as other more common etiologies are entertained.A 66-year-old man with a past medical history of heart transplant with coronary artery disease of a transplanted heart with prior LVAD placement presented to the gastroenterologist with one year of diarrhea and a reported history of colonic polyps. He complained of occasional stools with blood. Colonoscopy revealed a 12 mm soft, sub-epithelial lesion likely representing a lipoma. Also seen during the procedure were multiple angioectasias and general edema with an atrophic ileum. After the colonoscopy, he developed subjective fevers, chills, non-bloody emesis, and diarrhea. The next day he had abdominal pain and distension. He presented to the hospital, where he was found to be in SIRS with tachycardia and labs significant for leukocytosis of approximately 15000. The diagnosis of microperforation after colonoscopic insufflation was considered, and computed tomography (CT) of the abdomen was obtained to assess for free air in the abdomen to suggest perforation. This scan, seen in Figure The patient was admitted and started on ceftriaxone and metronidazole for suspected microperforation to cover for intra-abdominal pathogens such as enterococci and anaerobic organisms. Surgery recommended antibiotic coverage and serial abdominal exams as the small abdominal hernia was found to be easily reducible. Over the next 24 hours, the patient’s abdominal pain improved initially, but he then developed worsening tachycardia with chills and hypoxia to 88% on a non-rebreather mask. The patient was intubated with subsequent hypotension requiring norepinephrine pressor support. A repeat CT abdomen, shown in Figure Spigelian hernias are very rare and comprise only 0.12% of abdominal wall hernias . The locIn reviewing the literature, there is only one reported case of a Spigelian hernia occurring after a colonoscopy and there are no cases reported that have occurred at the site of a prior LVAD placement, such as in this patient. This single case of Spigelian hernia after colonoscopy was presented by Demuro in 2012 . There wAs patients live longer with more complicated histories, the incidence of unique presentations of procedural complications will only increase. Specifically, colonoscopy is a widely used tool with an estimated 15 million colonoscopies conducted in the United States in 2012 [Our patient is unique due to his prior history of LVAD, but had a relatively common historical complaint of chronic diarrhea. He is like many other patients who have had prior procedures including cholecystectomy, appendectomy, or other intra-abdominal surgeries, which could predispose one to abdominal fascial plane weakening and increase the likelihood to developing an incarcerated hernia. The patient underwent a routine colonoscopy with no findings to suggest the patient may be susceptible to herniation. On presentation, he met SIRS criteria. This would certainly be concerning in the post-colonoscopy period for a microperforation, and he was treated appropriately. In the initial emergency department documentation there was no mention of possible hernia through the LVAD operative site, likely because this is a very uncommon diagnosis and microperforation is much more prevalent. This is where the availability bias enters the medical decision-making. Microperforation is clinically intuitive, but one must also be cognizant to avoid availability bias when a diagnosis is made based on the frequency that conditions have been seen by a clinician in the past . It was This case of Spigelian hernia incarceration is important for clinicians to acknowledge as it may be more common than is recognized and can have grave consequences.This case contributes to a clinician’s diagnostic repertoire and places emphasis on other less common post-colonoscopy complications that may occur. It also emphasizes that clinicians should avoid falling victim to availability bias. Availability bias often leads to clinicians not considering a diagnosis that is less common, and is well-explained in medical decision-making heuristic literature. In our case, avoiding availability bias by keeping a broad differential would lead clinicians to consider that this may not have been a microperforation, but could have been a rarer entity such as Spigelian hernia incarceration. By entertaining all of the possible diagnoses, medical complications can be minimized, and ultimately patient care will be improved.


Background. The concept of fluorescence-guided navigation surgery based on indocyanine green (ICG) is a developing interest in many fields of surgical oncology. The technique seems to be promising also during hepatic resection. Case Presentation. We reported our experience of ICG-fluorescence-guided liver resection of metastasis located at VIII Couinaud's segment from colon squamous cell carcinoma of a 74-year-old male patient. Results. After laparotomy, the fluorescing tumour has been clearly identified on the liver surface. We have also identified that a large area of fluorescent parenchyma that gets from the peripheral of the lesion up to the portal pedicle such as the neoplasia would interest the right biliary tree in the form of neoplastic lymphangitis. This datum was not preoperatively known. Conclusion. Fluorescent imaging navigation liver resection could be a feasible and safe technique helpful in identifying additional characteristics of lesion. It could be a powerful tool but further studies are required. Indocyanine green (ICG) is a water-soluble, anionic, amphiphilic tricarbocyanine molecule that emits fluorescence upon illumination with near infrared light , 2.For several years, it has been used in ophthalmic angiography and for determining cardiac output and hepatic function . HoweverFocusing on liver metastases, many studies showed how near infrared fluorescence imaging using indocyanine green is a promising technique to intraoperatively visualize the contrast between hepatic lesions and normal liver tissue in real time and how it could be considered a powerful tool to help surgery in the “fluorescent-guided surgery” –12.Referring to the surgical treatment of colon cancer metastatic disease, liver resection is allowed in about 20% of patients . The proIn this case the “ICG-fluorescence-based navigation” can be a useful tool in order to locate supplementary lesions that could have been missed with current imaging techniques, such as computer tomography (CT), magnetic resonance imaging, and ultrasonography (US) .Based on recent studies that suggest the effective utility of Photodynamic-Eye (PDE) assessment of ICG fluorescence (PDE + ICG) combined with Intraoperative Ultrasound (IOUS) for ensuring the complete surgical removal of liver metastases from colorectal cancer –16, we rA 74-year-old male patient was admitted to our hospital in March 2017 to undergo liver resection to treat a malignant hepatic lesion diagnosed with CT and PET and a fine-needle biopsy positive for squamous carcinoma. The hepatic tumour discovered during follow-up for a previous bladder cancer submitted to endoscopic surgery three years before measured 22 mm in diameter and was located in the VIII Couinaud's segment [The case is discussed with radiologists, oncologists, and pathologists of our hospital. Even if the lesion had been the single site of disease; due to the proximity/doubtful infiltration of the lesion to the biliary tree, we decided to submit the patient to an explorative staging laparotomy and possible palliative surgery.Our internal protocol states that during the preadmission every patient who is a candidate for a liver resection is subjected to a routine liver function test with ICG to determinate the most appropriate surgical procedures : 0,5 mg/Thanks to the ICG property of being fluorescent with the light emitted from the photodynamic eye of the laparoscopic system in our possession, it is possible to visualize the lesion during the surgical procedure. To this target, timing of administration and dose of ICG are key points.Several studies have demonstrated that the effective dose of ICG depends on the timing of injection; in particular, if the function liver test had been performed more than 7 days before surgery it would have been necessary to administer an adjunctive dose  the day before . In thisA right hepatectomy would have been the oncologically correct surgical procedure due to the infiltration of right biliary duct. Considering the probable metastatic nature of the lesion, the absence of a clearly primary lesion, the age, the comorbidities, and the small size of residual liver, we have decided to perform an atypical segmental resection of S8 associated with cholecystectomy and lymphadenectomy of the hepatic pedicle nodes, including the area of impaired biliary excretion.At the histological examination, the lesion, the lymph nodes of the hepatic pedicle region, and the right biliary branch, respectively, resulted in hepatic metastases from squamous cell carcinoma and sites of metastatic location. As expected the resection margin was interested by neoplasia.Macroscopical exam: the neoplasia, in a site, appears to be in contact with the resection marginMicroscopical exam: parenchymal hepatic section that showed metastatic localization of squamous carcinoma moderately differentiated. The neoplasia interest the surgery resection margin.In particular, the histological examination showed the following: In this case, fluorescent imaging has revealed a fluorescing ring around the hepatic metastasis . The fluICG-fluorescent imaging techniques have begun to be used in hepatobiliary procedures in the last few years. These techniques are expected to complement conventional imaging techniques without having the purpose to replace all of the roles of conventional techniques. It provides simultaneous, real time, and high resolution identification of many type of different structures and, particularly during the navigation surgery application, could be a helpful tool to discover adjunctive lesions and identify segmental staining and biliary tree visualization , 19, 20.The major advantage of this system is that it overlays fluorescent images on the background colour images. This property can make it easier for a surgeon to understand the exact location of the fluorescing lesions (liver cancer/or bile ducts) on the surrounding structures as compared with that in the conventional fluorescent imaging system , 21.The fluorescent imaging of segmental cholestasis region, caused by the duct tumour invasion or thrombi and demonstrated at the intraoperative PDE-visualization, could be explained by the fact that ICG has been retained in the noncancerous liver parenchyma due to bile ducts obstruction and the consecutive altered biliary excretion in this tissue .Our case report shows how feasibility and safety of this procedure could help to identify additional characteristics of the lesion, such as the cholestasis area around the lesion itself and infiltration of the biliary tree too with minimal adjunctive costs –25. So iThe major advantages of fluorescent imaging are its feasibility and safety. Once ICG is preoperatively administered for liver function testing, we can obtain fluorescent images of tumour and cholestasis regions in real time by simply placing the camera imaging on the liver surface before the resection, during the liver resection, and over surgical specimens.Further and ongoing studies are required to better define the feasibility and usefulness of this technique.


Malignant transformation of endometriosis in the rectovaginal septum is rare and usually misdiagnosed as a colorectal or gynecological tumor. We report a rare case of primary endometrioid adenocarcinoma of the rectovaginal septum with invasion of the rectum.A 57-year-old overweight woman presented with vaginal bleeding and self-reported left lower abdominal pain during the previous 2 weeks. Preoperative imaging showed a large pelvic mass with invasion of the rectum, suggestive of a gynecologic malignancy. Multiple endoscopic biopsies and immunohistochemical analyses of specimens was performed. The patient received joint gynecological-surgical laparotomy, and there were no intra- or postoperative complications. The histopathological diagnosis was rectovaginal endometrioid adenocarcinoma with rectum infiltration. The patient received adjuvant chemotherapy and achieved good treatment response, with no early complications. At 12 months after surgery, there was no evidence of recurrence.A high index of clinical suspicion is required for the diagnosis of endometrioid adenocarcinoma in the rectovaginal septum. Surgery combined with additional chemotherapy or radiotherapy seems to be a standard treatment, and hormonal therapy is optional. The efficacies of other therapies, including targeted medication and immunotherapy, are unknown. Endometriosis is a chronic and benign gynecological disease most common in women of reproductive age, in which endometrial tissue occurs outside the uterine cavity. The most common locations are the ovaries, fallopian tubes, vagina, broad ligaments, cervix, pouch of Douglas, gastrointestinal tract, rectovaginal septum, and appendix , 2. ThisDeep-infiltrating endometriosis (DIE) is a sub-class of endometriosis which is defined by endometrial infiltration of the peritoneum by more than 5 mm , and end2). Her mother had a history of pancreatic carcinoma and her father had a history of hepatic carcinoma. She reported no history of weight loss or change in appetite.A 57-year-old post-menopausal woman  was admitted to the Gynecology Department of Shengjing Hospital  presenting with vaginal bleeding and left lower abdominal pain for the previous 2 weeks. She had a caesarean section and myomectomy more than 20 years ago and denied any previous hormonal therapy. She was 155 cm in height and 65 kg in weight (body mass index (BMI): 27.1 kg/mThe physical and vaginal examination indicated a pelvic mass on the left side with poor mobility. The gynecological examination indicated that the vagina, cervix, and uterus appeared normal. The laboratory tests showed the serum level of CA125 was 207.5 U/mL , CA199 was 59.9 U/mL , and HE4 was 206.9 U/mL , although the CEA and AFP levels were normal.A transvaginal ultrasound (TVS) showed an irregular complex mass (7.0 × 5.3 × 5.6 cm) in the recto-uterine pouch that had an unremarkable boundary, but had abundant vascularities on the septa and solid portion of the tumor Fig. a. There We suspected ovarian carcinoma with invasion of the rectum, and thus performed a whole body FDG-positron emission tomography (PET) Fig. . The F18Thus, we also suspected a pelvic malignant tumor infiltrating the rectum. A colonoscopy Fig.  indicateThe pathological report of the biopsy specimen indicated evidence of a metastatic adenocarcinoma from a gynecological malignancy with rectum involvement. Thus, a joint gynecological-surgical laparotomy was performed. Radical hysterectomy, bilateral adnexectomy, pelvic peritonectomy, pelvic lymphadenectomy, omentectomy, partial rectal resection with a low pelvic colorectal anastomosis protected by ileostomy, and appendectomy were performed. During this cytoreductive procedure, a 5.0-cm solid mass was identified in the recto-uterine pouch that closely adhered to the rectum and another 3.5-cm cystic mass on the upper rectovaginal septum. Because the mass did not invade the vagina, and considering the patient’s quality of life, an upper vaginal resection with anastomosis was performed, so that the middle and lower segment of the vagina were retained. There were apparent adhesions in the pelvic cavity, especially between the tumors and the rectosigmoid. The bilateral adnexa were atrophic, without any obvious macroscopic tumor. There was no evidence of residual macroscopic lesions or intraoperative complications after surgery.Analysis of the resected specimens indicated the rectal specimen had a thickened wall with coarse mucosa and serosa Fig. . When opImmunohistochemical studies performed using the avidin-biotin peroxidase complex technique indicated positive staining for cytokeratin 7 (CK7), estrogen receptor (ER), paired box gene 8 (PAX-8), and Wilms tumor protein (WT-1), weakly positive staining for progesterone receptor (PR), and no staining for CK20, caudal-related homeobox 2 (CDX-2), vimentin, P53 proteins, and villin  is a first-line technique used to examine a pelvic mass and DIE. In particular, TVS can evaluate the exact location and extent of infiltration, which is important for determining the type and difficulty of surgery . For insAfter biopsy or resection of the tumor, immunohistochemical staining (IHC) may be essential to confirm the diagnosis. IHC staining using antibodies against ER, PR, CK7, PAX-8, CK20, and CDX2 is extremely useful for the differential diagnosis of endometrioid adenocarcinoma and primary intestinal adenocarcinoma. In particular, IHC staining for CK7 and CK20 can differentiate endometrioid and primary rectal carcinoma . Many coThere is currently no consensus on the standard therapeutic approach to be used for treating extraovarian endometriosis–associated malignancies, and studies in the literature report the use of highly individualized treatments. However, primary surgical excision or radical resection of the tumor should be performed if feasible. Including our patient, 9 of 10 cases received surgery (Table In conclusion, endometrioid adenocarcinoma of the rectovaginal septum is a rare malignant tumor that requires a high index of clinical suspicion for successful diagnosis. Clinicians must differentiate this tumor from colorectal cancers so that the most appropriate treatment is administered. Because of the rarity of this tumor, we cannot draw any conclusions regarding preoperative diagnosis. We suggest clinical suspicion in patients previously diagnosed with endometriosis who present with abdominal pain and vaginal or rectal bleeding, especially in women taking unopposed estrogens. Several imaging techniques can help evaluate local and regional extension of the tumor. IHC staining is essential for the final diagnosis. Surgery combined with chemotherapy or radiotherapy seems to be the standard treatment for rectovaginal malignancies arising from endometriosis, but hormonal therapy could be considered depending on the individual patient. However, because of the rarity of this condition, identification and characterization of additional patients is essential. The application of targeted medication and immunotherapy may help to improve prognosis.


A 31-year-old Caucasian woman suffered from severe recurrent pain in the upper abdomen, nausea and epigastric pain crisis for a period of about 10 years. On her own initiative, she visited the emergency department. On physical examination pain and tenderness on right paralumbar area was noted. Blood analyses failed to show any significant abnormality. She was scheduled for computed tomography (CT) to rule out nephrolithiasis or a lumbar disc hernia. Abdominopelvic CT revealed a heterogeneous mass of 10 x 8.5 cm in the left upper quadrant. The mass showed continuity toward the tail of the pancreas Figure  and probA complementary magnetic resonance imaging (MRI) showed a large, mostly solid, well-demarcated lobulated mass, heterogeneous on T1- and T2-weighted images. An intralesional haemorrhage was noted as hyperintense areas on T1-weighted images with fat saturation Figure . DynamicUnder the provisional diagnosis of a gastric gastrointestinal stromal tumor (GIST), laparotomy was performed. At surgery the pancreatic origin of the tumour was established and distal pancreatectomy with splenectomy was carried out.The diagnosis of solid pseudopapillary neoplasm (SPN) of the pancreas was made by pathological examination postoperatively. The patient didn’t receive adjuvant treatment. Follow-up abdominal CT six months after surgery showed neither recurrence nor distant metastases.Solid pseudopapillary neoplasm is a rare tumour of the exocrine pancreas. It affects mostly young females between the second and third decade of life. SPNs are fundamentally solid tumours, although with increasing size, they become solid-cystic with internal haemorrhagic contents. The enhancement of the solid components is heterogeneous and typically hypovascular with progressive and heterogeneous fill-in. Most of the SPNs are surrounded by a well-defined enhancing capsule and frequently contains peripheral or central calcifications. Usually SPNs do not cause biliary or pancreatic duct dilatation or pancreatic atrophy. SPN can be localized in any portion of the pancreas.Recently all SPN subtypes were classified as low-grade malignancies with excellent long-term clinical outcome . NeverthAlthough SPN is usually found in non-Causian women, the gender and age of our patient was typical for SPN. In additon, the absence of invasion into surrounding tissue and distant metastases were also in favour of the diagnosis of SPN. However, the imaging features of SPN and exophytic gastric GIST are similar. The enhancement in arterial phase suggests diagnosis of GIST, as SPN tends to be more hypovascular, with progressive and heterogeneous enhancement on portal venous phase. Preoperative biopsy should be considered in patients in whom the diagnosis is uncertain as it may affect the operative approach.


Synovial sarcomas are soft tissue neoplasms mostly located in the lower extremities of young adults.A case of synovial sarcoma of the thigh in a 35-year-old male with the predominant epithelial component is reported. Microscopically the tumor showed variable-sized well-differentiated glands lined by the cuboidal cells with small foci of spindle cell component between glandular structures. Immunohistochemically glandular components showed positivity for the pan CK and EMA while CD99 and TLE1 were positive in both glandular and spindle cell components.This type of synovial sarcoma could be indistinguishable from metastatic adenocarcinoma and malignant adnexal tumor, thus, immunohistochemistry and molecular studies play an essential role in the exact diagnosis of this type of tumor. Synovial sarcoma is a distinct aggressive neoplasm that occurs most often in teenagers and young adults mean age:35) . The eti5 . The eA 35-year-old male referred to our center with a painful thigh mass. He had first noticed the mass 8 years ago after minor trauma. The tumor was growing slowly during these years, until about 6 months ago that started to grow rapidly and became painful. On physical examination, a 10 cm, well-defined, firm movable and mildly tender mass was palpated in the medial aspect of the right thigh. Magnetic resonance imaging (MRI) revealed a large lobulated hypervascular mass lesion in the deep portion of the right rectus femoris muscle . ComputeSynovial sarcoma is an aggressive neoplasm that occurs at any age but it is most prevalent in teenagers and young adults.In spite of its name, the involvement of joint cavities and the synovial membrane is rare , 9 and tImmunohistochemical analysis and finding the specific chromosomal translocation is necessary for the exact diagnosis of this tumor. Most synovial sarcoma show immunoreactivity for the cytokeratins  and EMA. There is focal positivity for S100 and immunoreactivity for CD99 and CD56 .In a case report by Ishida T et al., a case of synovial sarcoma with predominant epithelial component was reported. In this case, they stated that presence of a biphasic pattern, even with few scattered spindle cell component has an essential role in the correct diagnosis of synovial sarcoma and its distinguish from carcinoma .In another case report by Salgaonkar G et al., a case of synovial sarcoma with the primary manifestation of the chronic non-healing ulcer of the foot was presented. By histopathologic examination and IHC study of this case, the diagnosis of epithelial predominant biphasic synovial sarcoma was made .Synovial sarcoma is aggressive soft tissue tumor with poor prognosis , 5 . SomWe report a rare case of predominant epithelial synovial sarcoma in a young man presenting as painful thigh mass with the previous history of minor trauma. It is considered that this tumor could be mistaken with other malignant tumors such as metastatic adenocarcinoma, malignant adnexal tumor, and malignant melanoma. Thus, the role of immuno-histochemistry and molecular study for the exact diagnosis of this tumor is important.


We herein present a surgically treated case of huge adrenal myelolipoma. A 62-year-old woman presented to our surgical outpatient clinic with a retroperitoneal tumor. A clinical examination revealed an elastic soft, smooth-surfaced, painless, child-head-sized tumor with poor mobility, which was located in the left upper abdomen. Computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed an uneven tumor surrounding the stomach, spleen, pancreas, and left kidney, which was 20 × 18 × 10 cm in size. The retroperitoneal tumor was resected. The tumor was attached to the surrounding organs, including the pancreas, spleen, and left kidney, but had not directly invaded these organs. The tumor was yellow and elastic soft and covered with a thin film. The origin of the tumor was suggested to be the left adrenal gland. The weight of the excised tumor was 1500 g. The histopathological diagnosis was adrenal myelolipoma. The patient had an uneventful recovery and was discharged from the hospital on the thirteenth day after the operation. She has been followed up in our outpatient clinic. Adrenal myelolipoma (AML) is a relatively rare benign tumor composed of mature adipose tissues and a variable amount of hematopoietic elements. The male-to-female ratio is 1 : 1. The incidence of AML is reported to be 0.08–0.4% at autopsy –4. RecenThe largest AML  in a patient without endocrine disorder was described by Akamatsu et al. .We herein report a relatively rare case of a giant AML of 1500 g in weight in a patient without endocrine disorder and discuss our analysis of the literature.A 62-year-old Japanese female patient presented with a left abdominal mass. She was referred to our surgical outpatient clinic to undergo a detailed examination and treatment for the left abdominal mass. A clinical examination revealed an elastic soft, smooth-surfaced, painless, child-head-sized tumor with poor mobility, which was located in the left upper abdomen. Abdominal computed tomography (CT) demonstrated a child-head-sized mass with heterogeneous contrast at the left upper abdomen around the stomach, spleen, pancreas, and left kidney on a horizontal image  and coro3; hemoglobin, 12.8 g/dl; hematocrit, 36.5%; and platelet count, 182,000/mm3, with normal electrolytes, as well as normal blood urea nitrogen levels, but slight liver dysfunction. Her serum levels of corticosteroid and/or androgen were 13.3 ng/ml  and 173 pg/dl (35.7–240.0), respectively, which are within the normal ranges; however, her serum level of ACTH was elevated at 138.70 pg/ml (7.2–63.3).Magnetic resonance imaging (MRI) revealed a heterogeneously hyperintense mass on T1-weighted imaging , a relatThe retroperitoneal tumor was resected . The tumA histopathological examination with hematoxylin and eosin staining revealed that the tumor was composed of a proliferation of mature and variable-sized adipocytes admixed with aggregates of hematopoietic elements, associated with adrenal gland tissue in the peripheral region within the tumor . These fThe patient had an uneventful recovery and was discharged from the hospital on the 6th day after the operation. She has been followed up in our outpatient clinic without recurrence for approximately 12 years since undergoing the operation.The etiology of AML remains unclear. Some of the hypothesized etiologies include extramedullary hematopoiesis due to the autonomous proliferation of bone marrow cells transferred during embryogenesis, degeneration of epithelial tissues of the adrenal cortex, and adrenocortical cell metaplasia of the reticuloendothelial cells of the blood capillaries in response to stimuli such as necrosis, infection, or stress , 8–10. TAlthough the diameter of AMLs ranges from less than 1 cm to more than 30 cm, they are usually less than 5 cm in diameter , 14. AMLUltrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) are effective for diagnosing AML in ≧90% of cases , 17. RecManagement of AML should be individualized. Small lesions, which are asymptomatic and measure less than 5 cm, should be monitored over a period of 1-2 years with imaging controls . On the We reported a relatively rare case of a real giant AML that weighted 1500 g in a patient without an endocrine disorder. It is very important to provide suitable management on an individual basis.


Small bowel haemangiomas are benign vascular tumours that may cause gastrointestinal bleeding of uncertain origin, are frequently chronic, and are rarely acute. We report a case of an haemangioma located in the distal ileum of a 29-year-old male with a history of chronic anemia since childhood. Imaging studies showed a mural thickening in the distal ileum with phleboliths, which is a key finding of haemangioma. Surgery was performed, and histology confirmed the diagnosis. Haemangiomas are defined as vascular tumours that can appear anywhere on the body. In the small intestine they account for 7-10% of haemangiomas of the gastrointestinal tract and may be a cause of bleeding of uncertain origin  or cause massive bleeding .Its location in the small intestine explains why the diagnosis of these tumours has traditionally been possible only after surgery. Since the development of computed tomography (CT) and new balloon-guided endoscopic techniques, preoperative diagnosis has become more frequent.A 29-year-old male presented at our hospital with a history of chronic anemia since childhood. The patient underwent gastroscopy and colonoscopy with normal results. Due to the persistence of the anemia, despite symptomatic treatment with oral iron, it was decided to extend the study with imaging techniques. A simple abdominal X-ray was performed, and although at first it did not reveal any significant alterations, retrospectively, phleboliths were visualised in the right side of the pelvis Figure .A small bowel study (SBS) with barium was also performed, and it showed in the distal ileum the poor distensibility and irregular contour Figure .Because of these findings, computed tomography enterography (CTE) was performed, which showed phleboliths and transmural wall thickening in a 10-cm segment of the distal ileum with homogeneous contrast enhancement Figure .No inflammatory changes were seen in mesenteric fat. No abdominal lymph nodes suggestive of malignancy were seen, and there was no involvement of adjacent organs.Based on these findings, the most likely preoperative diagnosis was haemangioma of the distal ileum. A laparotomy and segmental small bowel resection was performed, which revealed a 10-cm ileum lesion that on pathology examination suggested a vascular nature due to its bluish purple coloration, compressibility, and presence of varices on its surface. The histopathological assessment revealed a vascular lesion compatible with haemangioma. After our patient recovered from surgery, he remained asymptomatic.Haemangiomas are hamartomatous vascular benign tumours that can appear anywhere in the gastrointestinal tract , 5, 6. AMultiple haemangiomas are usually associated with cutaneous haemangiomas and syndromes such as blue rubber syndrome, Osler-Weber-Rendu syndrome, Maffucci syndrome, Klippel-Trenaunay-Weber, among other syndromes , 7. ThesAt pathologic assessment, haemangiomas generally involve the intestinal wall from the submucosa to the muscular layer , 4, althClinically, haemangiomas are symptomatic in 90% of the cases, unlike other benign tumours of the small intestine that tend to present as an incidental finding . The mosOccasionally, these may cause intestinal obstruction, invagination, or recurrent abdominal pain and rarely platelet sequestration . Some ofThe diagnosis of these lesions is complex and there is no image study, to date, which allows us to reach the definitive diagnosis. Since the most frequent clinical presentation in these patients is gastrointestinal bleeding, they frequently undergo gastroscopy and colonoscopy studies with normal results as in the exposed case . A simplIn our case, phleboliths were visible in both simple abdominal X-ray and CTE. Phleboliths are secondary to thrombosis of the intralesional vessels and subsequent partial or total calcification of thrombus. Phleboliths are virtually pathognomonic of haemangioma if they are grouped and when they are seen in young patients, becoming key in the diagnosis of such cases , 6-8. SBIn non-intravenous (IV) contrast-enhanced computed tomography, haemangiomas may have a nodular or polypoid appearance or appear as wall thickening. Lesions show heterogeneous density (due to the existence of thrombosed zones) usually with luminal growth and rarely extending to the adjacent tissues. The non-IV contrast-enhanced CT can show the presence of phleboliths, which can be seen better than after the administration of intravenous contrast .Computed tomography with intravenous contrast (contrast-enhanced computed tomography/CECT) is a fundamental tool, especially in emergency situations, because of its speed, availability, and its ability to diagnose extra-intestinal pathologies . In the CTE allows a better evaluation of the intestinal lumen by using negative luminal contrast , which allows the distension of the loops, improving the detection and characterisation of diseases in the small intestine .To evaluate the colon and upper gastrointestinal tract, endoscopy and colonoscopy studies are used. Some lesions in the duodenum and ileum may be accessible. These techniques reveal bluish or reddish submucous that are compressible with air insufflation , 2, 6. TEndoscopic ultrasound exposes haemangiomas in the duodenum, allowing to define its submucosal origin and its degree of local extension to adjacent organs .Magnetic resonance imaging (MRI) shows wall thickening with low signal intensity on T1-weighted images and heterogeneous bright signal intensity on T2-weighted images. This last finding is more evident in fat suppression sequences . These lMRI unlike CT can demonstrate blood flow in the lesion without medium contrast administration . The endThe differential diagnosis of haemangioma includes both benign and malignant tumours: lipoma, leiomyoma, lymphangiomas or adenomas as benign tumours and adenocarcinoma, gastrointestinal stromal tumours, lymphoma, carcinoid tumours or metastases as malignant lesions (more frequent than benign tumours) . Other cBiopsy of small bowel haemangiomas has a very limited role due to the difficult access of these tumors and the high risk of uncontrollable bleeding , 4, 11.The treatment of choice of haemangiomas is surgical and resection of the affected segment , 3, 4, 6In some cases of polypoid lesions accessible to endoscopy, it may be possible to perform polypectomy and cauterisation , 2, 9. HSmall bowel haemangiomas are a rare cause of gastrointestinal bleeding. Diagnosis is often delayed or incorrect; so it is important that these tumours are considered in the differential diagnosis during the study of an anemia of uncertain origin.Diagnosis of these tumours is difficult at the beginning and a wide range of diagnostic studies  are needed and performed according to the features of the patient and the lesion. CTE is becoming the most accurate diagnostic technique for these tumours. Definitive diagnosis is histological and the treatment of choice is surgery.


Ex situ liver resection and autotransplantation is among the most advanced techniques which has been introduced in recent years.A 24-year-old male referred with chief complaints of abdominal pain, nausea, and vomiting from 1 month prior to admission. Computed tomography showed a large liver mass in the left lobe of the liver with involvement of retrohepatic inferior vena cava (IVC), in favor of hepatocellular carcinoma.After hepatectomy, the common bile duct was completely removed. A 4-cm Dacron graft was anastomosed to the inferior and top of the IVC. A temporary portocaval shunt was placed, and ex situ resection of the left lobe of the liver was done. Remnant of the liver was implanted. Reconstruction of the bile duct was done using a Roux-en-Y technique, and autotransplantation of the liver was then completed. During a 4-year follow-up, the patient had no complaints and is in good conditions.With appropriate consideration of patients, despite surgical complexities, ex situ resection of unresectable HCC can provide excellent prognosis. Hepatocellular carcinoma (HCC) treatment is widely based on the stage of the cancer. Although surgical resection is considered the optimal treatment, only a few patients qualify for surgery and this is associated with high rates of recurrence and poor intraoperative exposure .Ex situ liver resection is considered a solution to overcome these difficulties. This type of surgery was first performed by Rudolf Pichlmayr in 1988 . To thisInhere we report a case of ex vivo resection of HCC and autotransplantation who showed excellent postoperative results.A 24-year-old male referred with chief complaints of abdominal pain, nausea and vomiting, and a sensation of fullness from 1 month days prior to his admission.The patient did not report any diseases or hospitalizations in his past medical history; furthermore, the patients did not report any diseases in his family history.On physical examination, no abnormal finding was detected. The patient only expressed mild epigastric pain during examination.Lab data showed a normal liver function test as aspartate aminotransferase (AST) of 33, alanine aminotransferase (ALT) of 26, alkaline phosphatase (ALP) of 265, total serum bilirubin of 1.7, and direct bilirubin of 0.9. Alpha fetoprotein (AFP) was 720.During work-up, abdominal sonography and computed tomography (CT) was done which showed a large liver mass in the left lobe of the liver  which was in favor of HCC Fig. .Fig. 1CChest CT scan and bone scan was done for assessment of distant metastasis which was negative for metastasis.The patient underwent laparotomy and exploration was done which showed a large mass (20 cm) in the left lobe of the liver and in the caudate lobe with involvement of IVC and involvement of left and middle hepatic veins.Hepatectomy was done using a standard technique with extensive lymph node dissection around the superior mesenteric artery and celiac trunk. The common bile duct was completely removed up to the head of the pancreas. Frozen sections were sent from distal of the common bile duct which was negative for malignancy. After hepatectomy, a 4-cm Dacron graft was anastomosed to the inferior and top of the IVC so continuity of the IVC would be maintained. For prevention of bowel edema and a hepatic phase, a temporary portocaval shunt was placed, and ex situ resection of the left lobe of the liver was done with the Cavitron Ultrasonic Surgical Aspirator (CUSA) by a bipolar manner. Extension of the portal vein was done using a cadaver vessel bank.Remnant of the liver (right lobe) was implanted similar to a liver transplant. The right hepatic vein, portal vein, and hepatic artery were anastomosed. Reconstruction of the bile duct was done using the Roux-en-Y technique, and autotransplantation of the liver was then completed.Hemostasis was achieved and two JP drains were inserted. After which, closure of the abdomen was done and the patient was then transferred to the surgical intensive care unit. The cold ischemic time of the operation was about 90 min, and the warm ischemic time was 45 min.Pathology reported fibrolamellar HCC with well differentiation, tumor measuring 12 × 11 × 10 cm and 5 × 5 × 4 cm, with multifocal lymphovascular and perineural invasion. The surgical resected margin was free.Moreover, pathology also reported a mass in the hilum of the liver measuring 5 × 5 × 4 cm which includes a white appearance with hemorrhage and necrosis. Multiple lymph nodes ranging from 0.5 to 2 cm. None of the 31 dissected lymph nodes were involved with the tumor. Figure Other than intraoperative bleeding, the patient did not develop any major complications during the operation and the postoperative period. The patient was discharged after 14 days of hospital admission with a good overall condition and was referred to the surgery clinic for postoperative visits. Moreover, the patient was given adjuvant chemotherapy for a total of 6 weeks.During a 2.5 year follow-up the patient showed lymph nodes in the hilum of the liver in imaging, for which he underwent laparotomy, and three lymph nodes were removed. In pathology evaluation, one lymph node was involved with the tumor.During a 4-year follow-up, no recurrence of primary tumor was recorded, and the patient had no complaint and was in good conditions. Figure Additional files 1 and 2 show gross description of the tumor and surgery specifics.During recent years with advances in surgical techniques, liver function after surgical resection of tumors has improved significantly. The liver has a specific limitation for ischemic tolerance, and when the tumor is difficult to access, in cases of proximity to venous confluences or main hepatic veins, the use of conventional surgical techniques becomes problematic .Although multiple studies have reported on ex situ resection and autotransplantation , very feThis technique is considered to be associated with a high rate of mortality with a median survival of 25 months . MortaliPreoperative evaluation of patients who are candidates for this surgical technique is important, as this technique should only be considered for patients who have a normal liver function with non-resectable tumors .With appropriate consideration of patients, despite surgical complexities, ex situ resection of unresectable HCC can provide excellent prognosis.Additional file 1. This video shows the following sequences consecutively: Gross description of liver anatomy and HCC involvement; Hepatic vein involvement by HCC; Inferior vena cava involvement by HCC; Closure of orifice of middle hepatic vein.Additional file 2. This video shows the following sequences consecutively: Partial clamping of the IVC and prepping for anastomosis with portal vein; anastomosis of IVC and portal vein; transection phase at liver bench phase; right lobe of liver after tumor resection; and a phase after liver implantation and after anastomosis of port and hepatic artery.


Periapical granuloma is a pathological diagnosis associated clinically and radiographically with a nonvital tooth and a periapical radiolucency, respectively. It is frequently seen as a sequela of long-standing pulpal necrosis. Often times, a draining fistula is observed near the nonvital tooth. We report an unusual case of a large draining focal fibrous hyperplasia in association with a large periapical granuloma treated at our clinic. The diagnosis was made by the clinical presentation, radiologic and histopathologic findings. Periapical granuloma, also referred to as chronic apical periodontitis, is a defensive reaction in response to bacterial infection within the pulp chamber which spreads to the root apex . It is aA 59-year-old man presented to the urgent care clinic at the School of Dentistry complaining of an upper lip mass for one-year duration. The mass started out as a small bump and had grown steadily since then. 3 months prior to his presentation, a draining parulis developed on the mass. The patient had no history of systemic symptoms such as fever, chills, weight loss, or fatigue. He was aware of a dark-colored “dead tooth” for several decades in the area of concern but denied any previous history of swelling in the area. The patient had recently moved to the United States from Nigeria and had previously been without access to adequate dental care. The patient said that a doctor in Nigeria told him that the lesion was likely cancerous.On exam, there was a large, painless, fibrous, exophytic mass in the anterior maxillary labial vestibule Figures . The basA periapical radiograph revealed a large unilocular radiolucency associated with the apex of tooth #8 . Cone-beThe patient was referred to the oral surgery department for excisional biopsy. After tooth #8 was removed, an incision was made around the base of the stalk that connected the mass to the labial and alveolar mucosa. Sharp dissection was used to free the mass, and the specimen was sent for histopathologic analysis. The mass communicated with a cystic lesion of the maxilla. The cyst was enucleated with a curette and also sent for pathology. Perforation of the cyst through the buccal and palatal cortices was noted during the procedure. Slight undermining of the wound margins allowed for closure with resorbable sutures.At the patient's one-week follow-up , he was A search on PUBMED, google scholar, and google using the terms “focal fibrous hyperplasia” and “draining fibrous hyperplasia” yielded no reported cases of a similar occurrence in the English literature. Focal fibrous hyperplasia (FFH), is a reactive, inflammatory hyperplastic lesion of the connective tissue . It is pThe location of the periapical lesion is consistent with studies that confirm the anterior maxilla as being the commonest site for periapical granulomas and cysts . This isOn gross examination, the growth excised from the gingiva consisted of a yellowish-tan, irregular-shaped fragment of soft tissue measuring 1.5 × 1.2 × 0.9 cm. The intraosseous lesions curated from the cystic lesion of the anterior maxilla composed of multiple tan and irregular-shaped fragments of soft tissue measuring in aggregate 2 × 2 × 0.6 cm.Microscopic examination of the gingival growth revealed a soft tissue mass surfaced by parakeratinized hyperplastic stratified squamous epithelium . The undFew oral lesions are unique or distinctly remarkable in nature. Therefore, it is imperative for oral healthcare providers to follow well-established matrices when encountering atypical oral presentations. The literature strongly suggests high reliability of patients' self-reporting and a thorough account including medical history and the history of the lesion as essential to the diagnostic process. Of secondary importance is delineation of the physical characteristics of the lesion including the size, shape, color, and texture. Radiographic evaluation may assist in narrowing the differential. In our case, despite the atypical appearance, a presumptive differential was limited by the history of the lesion to a fibrous hyperplasia. We, however, advise vigilance in the need for histopathologic evaluation and proper referral when required.


In this study, we report a four-year-old male with D-2-hydroxyglutaric aciduria (D2HA) and enchondromatosis with a prior history of hyperpigmented, segmental whorls and streaks on his abdomen who later presented with an eruption of angiokeratoma circumscriptum within a similar distribution. His condition can likely be explained by underlying somatic mosaicism; however, a unifying culprit gene mutation has not yet been identified. To date, only 10 reported cases of D2HA with enchondromatosis are available in the literature with three reported skin findings. This is the first reported case of angiokeratoma circumscriptum associated with the rare condition of D2HA and enchondromatosis. D-2-hydroxyglutaric aciduria (D2HA) with enchondromatosis is a neurometabolic and skeletal disorder that has rarely been described in the literature in sporadic patients . It is cA four-year-old male with D2HA with enchondromatosis and acute myelogenous leukemia (AML) in remission presented to our clinic with a one-year history of hyperkeratotic, dark red papules coalescing into plaques primarily on his lower chest and upper abdomen Figure . These lBiopsy of one of the lesions demonstrated marked hyperkeratosis with dilated, blood-filled, endothelial-lined spaces presenting immediately beneath the epidermis, consistent with an angiokeratoma Figure . Due to https://www.jaad.org/article/S0190-9622(19)31186-7/fulltext).This case was presented as an oral presentation at the American Academy of Dermatology 2019 Annual Meeting . However, due to the similar distribution, it is unclear whether the angiokeratomas possibly evolved from these early lesions or arose independently as the patient was lost to dermatological follow-up until he presented to our clinic again at four years of age.Angiokeratoma circumscriptum neviforme is the rarest type of angiokeratoma, initially described by Fabry in 1915, and typically presents more commonly in females (3:1) in a linear or segmental distribution most commonly on the lower extremities and gluteal region, but it has also been reported on the neck, arm, and trunk . As in oThough the exact etiology of our patient’s condition has not yet been elucidated, it is important to document the association of his D2HA and enchrondromatosis with the novel cutaneous finding of angiokeratoma circumscriptum. Additionally, this is the second patient in the literature with D2HA and enchondromatosis with the cutaneous finding of whorled pigmentation. This seems to indicate that linear, whorled hyperpigmenation may be an associated finding of D2HA and enchondromatosis. Our patient’s family opted not to cosmetically treat his dermatologic manifestations; however, multiple options for treating angiokeratoma circumscriptum neviforme include cryotherapy, electrocoagulation, curettage, lasers, and surgery .In our opinion, his current lesions most likely represent angiokeratoma circumscriptum due to their well-demarcated, plaque-like appearance. This case is of particular interest because it represents a novel cutaneous finding of angiokeratoma circumscriptum associated with D2HA and enchondromatosis.


Giant cell myocarditis is a rare and highly lethal disorder with resultantcardiac insufficiency. It necessitates aggressive immune suppression therapy,although the results are often fatal. When it affects only the atria, thecharacteristics of the disease changes completely. In this case report, wepresent atypical presentation of atrial giant cell myocarditis with mass lesion,which completely resolved after successful surgical resection without immunosuppression therapy. In this case, we present first-in-man successfultreatment of a 53-year-old male patient with the diagnosis of atrial GCM, presentingin the form of a tumor, and his status at the end of 24 months follow-up.Giant cell myocarditis (GCM) is a rare and highly lethal disorder with resultantcardiac insufficiency. It requires aggressive immune suppression therapy, althoughthe results are often fatal. Recently, a new entity of GCM was described. In thisform of the disease, when GCM affects only the atria, the characteristics of thedisease changes completelyth day.A 53-year-old man, who had non-exertional chest pain with positive exercise stresstest, was hospitalized by the cardiology department. Total occlusion of the rightcoronary artery (RCA) was detected in the cath-lab. After performing percutaneoustransluminal coronary angioplasty (PTCA), long segment drug-eluting stents (DES) andbare-metal stent (BMS) were placed. After the procedure he became hypotensive. Inorder to exclude pericardial effusion, transthoracic echocardiography was performed.In the left atrium (LA), a 6,5x4 cm mass was detected with LA dilatation andestimated systolic pulmonary artery pressure over tricuspid regurgitant jet was 43mmHg. Then, he was sent to our clinic for surgery with possible diagnosis of LAmyxoma. His left ventricular ejection fraction (LVEF) was 60%. We decided to performsurgical excision of the mass. Following median sternotomy, we reached the LA viatransseptal approach. We saw a giant mass in the LA, nearby the mitral valve. Themitral valve was intact without any deformation. We excised the mass, which invadedthe myocardium towards the posterior wall of the LA. The LA was hypertrophic innature, so all the mass with LA was resected. The mass consisted of central necroticparts which did not resemble to atrial myxoma. Intraoperative view of the mass isshown in th day, 1st month, and every 3 months thereafter. Heclinically improved after the operation, and still had LVEF of 55% at the end of 24months follow-ups. He took only acetylsalicylic acid (100 mg/day), ramipril (5mg/day) and bisoprolol (5 mg/day) treatment after the operation without immunesuppression therapy.Histopathologic examination of the specimen revealed necrotic areas, lymphocytic andhistiocytic infiltration and sporadic eosinophilia in the striated muscle fibers.There were also multinuclear giant cells. These giant cells showed positiveexpression with CD45 and CD68, with the final diagnosis of GCM -D. After[2]. The clinical presentation of GCM is usuallydramatic, but some may present an indolent course with the presence of symptoms formonths to years before the proper diagnosis is made[3]. The natural course israpid and mortality is high if left untreated, with an average transplant-freesurvival of <6 months. Ventricular assist device placement and immunosuppressiveregimens, including high dose steroids and cyclosporine have modestly improved theprognosis of GCM, to almost 12 months of transplant-free survival; nevertheless,they still need heart transplantation[2]. In 2013, Larsen et al.[1], stated that GCM locatedin the atrium have distinctive clinicopathologic features with a more favorableprognosis than classical ventricular GCM. After the first description of atrial GCMin 1964, the largest series of atrial GCM was published by Larsen etal.[1] with 6 consecutive patients and in the literatureonly 13 cases were found in the PubMed database search. After Larsen calledattention to distinct features of atrial GCM, Basso and Thiene[4] stated that atrial GCMmight be more common than generally believed. As reviewed, 5 of these literaturebased cases lacked history or evidence of rheumatic diseases, as did in our case.Our case also emphasizes that atrial GCM is a distinctive disorder with its owncharacteristics. As Basso and Thiene[4] stated, the disease might be attributable toatrium-specific autoantigens.Idiopathic GCM is a rare form of fulminant myocarditis which has a poor outcomewithout heart transplantation[5]. Tumors of the heart are divided into threecategories: benign tumors and tumor-like lesions, malignant tumors, and pericardialtumors. In benign tumors, tumors were classified as tumors showing differentiationinto muscle cells such as rhabdomyoma, adult cellular rhabdomyoma, hamartoma ofmature cardiac myocytes, and histiocytoid cardiomyopathy. Cardiac myxoma andpapillary fibroelastoma are classified as pluripotent mesenchymal origin, andcardiac fibroma and inflammatory myofibroblastic tumor were classified as tumorshowing differentiation into myofibroblastic cell.Tumors of the cardiovascular system are very rare diseases. There are many disordersthat do not fit into the concept of tumor or neoplasm. Among these cardiovasculartumors, 70% of these are benign, and when surgically excised, most of them arepathologically confirmed as benignAn atrial myxoma must be differentiated from a LA thrombus. Echocardiographically andsurgically, the presence of a stalk and mobility favors atrial myxoma whereas thethrombus is usually situated in the posterior portion of the atrium with a layeredappearance. On the other hand, myocarditis is a diffuse inflammatory process of themyocardium, although instances of focal myocarditis in the right/LV or LA may bepresent rarely as in our case.[6]. The absence of necrosis of rheumatoid myocarditiswithout Aschoff cells excluded the diagnosis of RF and the absence of granulomatousstructures in our case excludes sarcoidosis in the differential diagnosis. Both GCMand CS may present with ventricular tachycardia, presentation with acute-onset heartfailure is more commonly seen in GCM, while presentation with heart block is morepredictive of CS[6]. Although GCM does not form a mass lesion ingeneral, it is not a must and this is the first report of atrial GCM forming a masslesion in the literature.Rheumatic fever (RF), sarcoidosis, specific infections and gout should be consideredin the differential diagnosis. Both GCM and cardiac sarcoidosis (CS) are presentedin similarly aged patients. Unlike GCM, CS is characterized by tight nonnecrotizinggranulomas, with central multinucleated giant cells. Fibrosis is more pronounced inCS than in GCMWe believe that more case reports and possibly series will be reported in near futureas the importance and unique properties of this disease are learned. In this case,we clearly identified the borders of the mass limited in the LA and total removal ofthe mass improved patient's quality of life with no additional treatment.


Primary spinal cord glioblastoma multiforme involving the conus medullaris is an uncommon entity with poor outcomes. An aggressive multimodality treatment approach has been used, but prognosis remains same. There are no guidelines for the treatment of patients with spinal glioblastoma multiforme (GBM).We highlight the case of a child diagnosed with conal GBM. He was treated with definitive surgery followed by adjuvant concurrent chemoradiation. After completion of treatment, he showed a temporary symptomatic improvement, but later on his condition deteriorated. We elaborate the stepwise treatment approach employed in this patient. Spinal cord tumors in the pediatric population are rare, featuring less than 1% of all central nervous system tumors . AstrocySpinal cord glioblastoma multiforme (GBM) accounts for approximately 7.5% of all intramedullary gliomas and 1.5% of all spinal cord tumors . It has The aim of this paper is to present a case of a 15-year-old boy with intramedullary conal GBM and to discuss the clinical findings and therapeutic interventions used to treat this tumor. We present a review of the relevant literature.A 15-year-old boy, grade 9 student, presented in neurosurgery clinic with complaints of backache and left leg numbness. According to the patient’s father, his symptoms started three months prior when he developed pain in the lower back. Symptoms were gradual in onset, continuous and progressively increasing in intensity from moderate to severe. The pain was worse at night and was relieved by taking paracetamol (acetaminophen). It was also associated with weakness in the lower limbs, with a left-sided predominance. A week prior to presentation, the patient developed urinary retention and constipation. His birth and family histories were insignificant. Vaccination and developmental milestones were up to date. General physical exam was unremarkable. Systemic examination revealed decreased power in the lower limbs, bilaterally positive straight leg response and absent plantar reflexes.Considering the presenting complaints and examination findings, the patient was admitted for further workup. Magnetic resonance imaging (MRI) of the whole spine was performed which revealed an intramedullary lesion extending from T8 to L1 vertebrae involving the conus. The maximum dimension of the lesion was 138 mm Figure , 3.Immediate post-operative MRI of thoracic and lumbar spine demonstrated post-surgical changes along with hemorrhage at the site of surgery with cord edema Figure . MRI bra2 . A total radiation dose of 4500 cGy in 25 fractions at 180 cGy per fraction per day was given to the tumor bed along with concomitant temozolomide at a dose of 75 mg/mSix weeks post CCRT, the patient was reviewed in the clinic. There was clinically significant improvement in power of the lower limbs. MRI of the whole spine revealed interval development of cystic degeneration with peripheral enhancement in the irradiated area along with cord expansion and edema Figure . MaintenOn the subsequent follow-up, the patient complained of headache and pain in lower back. On examination, there was a substantial decline of power in the lower limbs. MRI showed interval development of two new rounded lesions at L2-L3 vertebral levels which were suggestive of disease progression Figure . The patPrimary intramedullary tumors in the spinal cord are rare entities . The mosReview of the literature demonstrates that spinal cord GBM occurs mainly in the cervical or thoracic segments , 12, 13.Radiology and histopathology are essential to establish the diagnosis of GBM. MRI is considered the gold standard imaging technique to diagnose intramedullary tumors , 14. CarAn aggressive therapeutic approach is recommended considering the likelihood of early spread and poor prognosis of spinal GBM. Available modalities include surgery, radiation therapy and chemotherapy. A systematic review conducted by Konar et al. has shown that surgery remains the definitive modality in spinal glioblastoma . Due to Subject to the rarity of this tumor, the optimum adjuvant therapy is not well defined, but the addition of radiotherapy provides better clinical outcomes and may prolong the survival in some cases . RadiatiSimilarly, the role of chemotherapy is not well established due to the paucity of cases, yet, most of the children with high-grade disease receive temozolomide with little improvement in outcomes . The ideWith our case report, we have documented all events with relation to time, which will help to further validate the prognosis and treatment outcome of this rare entity.Spinal cord GBM involving the conus medullaris carries a likely lethal prognosis with a short survival. There is a need for a multidisciplinary approach for the management of such patients. Even with the most aggressive treatment approaches involving surgery, radiation and chemotherapy, the outcome does not improve. Aggressive natural history, rarity and lack of management guidelines mandate a thorough discussion in site-specific multidisciplinary team meeting before embarking on to any modality of treatment.


Massive localised lymphedema (MLL) is considered a rare large, pendulous localised benign overgrowth of lymphoproliferative tissue commonly seen in patients with morbid obesity. Histologically, it may be mistaken for well-differentiated liposarcoma; hence, it is also known as pseudosarcoma.We describe the successful management of MLL of the left medial thigh in a 35-year-old man weighing 220 kgs (BMI 80.8 kgs/m2). He underwent a concurrent laparoscopic sleeve gastrectomy with surgical resection of the MLL. He recovered well and during our last follow up six months after the operation, he is ambulating well and weighs 148 kgs (BMI 54.4 kgs/m2).MLL is a form of secondary lymphedema resulting in disruption or compression of normal lymphatic drainage due to fat accumulation in obese patients. Patients usually delay treatment for even up to a decade, when it becomes sufficiently large enough to restrict mobility and daily activities, or when it becomes infected. MLL is primarily a clinical diagnosis. A detailed history regarding its slow growth spanning over the years makes malignancy less likely. However, if left untreated, MLL may progress to angiosarcoma. Imaging studies such as computed tomography (CT) and a Magnetic Resonance Imaging (MRI) are usually performed to rule out malignancy or vascular malformations. A tissue biopsy is not recommended unless there are suspicious pigmented lesions.MLL remains to be underdiagnosed. Due to the obesity epidemic, clinicians must be aware of this once rare disease. The role of concurrent bariatric surgery with surgical resection of MLL warrants further studies. •Massive localised lymphedema is a rare, benign overgrowth of lymphoproliferative tissue commonly associated with obesity.•Patients usually delay seeking treatment until it affects their daily activities, or when it becomes infected.•A tissue biopsy is not recommended unless there are suspicious pigmented lesions.•MLL remains to be underdiagnosed. Due to the obesity epidemic, it is essential that clinicians be aware of this disease.•The role of concurrent bariatric surgery with surgical resection of MLL warrants further studies. HistoloDiagnosis of MLL is primarily clinical, and it presents as a large painless enlarging mass slowly growing over many years . MLL may2A 35-year-old man with a BMI of 80.8 kgs/m2 (weight of 220 kgs) presented to us with a left thigh mass for the past four years. It has been slowly progressing in size and was associated with recurrent cellulitis requiring multiple courses of antibiotics and dressings. Due to the large size, the soft tissue mass severely restricted his daily activities; hence is he confined mostly to his bed. His medical history includes essential hypertension, ischemic heart disease  and dyslipidemia. On clinical examination, there was a large, pedunculated cutaneous mass located at the medial aspect of his left thigh. It measures 50  cm × 25 cm, and the overlying skin is thickened with peau d’ orange appearance . We procA computed tomography angiography (CTA) of the left lower limb was undertaken to exclude vascular malformation. The CTA showed a large hyperdense pedunculated soft tissue mass arising from the medial compartment of the proximal left thigh. It measures 27x32 × 33cm (AP x W x CC) with collateral arterial supply from the superficial femoral artery . There wLaparoscopic sleeve gastrectomy (LSG) and surgical resection of the soft tissue mass was performed in the same setting , Fig. 4.Interestingly, the preliminary histopathology report suggested it to be a well-differentiated liposarcoma. Fortunately, the final report concluded it to be a massive localised lymphedema. During our last follow up six months after the operation, the patient is ambulating well and weighs 130 kgs (BMI 47.8 kgs/m2).3Massive localised lymphedema (MLL) is a rare large, pendulous localised benign overgrowth of lymphoproliferative tissue commonly seen in patients with morbid obesity . It is aThe significant and localised lymphedema is so striking in appearance as well as its enormous size that often it is mistaken for a sarcoma . Some auPatients usually delay treatment for even up to a decade, when it becomes sufficiently large enough to restrict mobility and daily activities, or when it becomes infected . The oveMLL is primarily a clinical diagnosis ,11. A deHistopathological findings usually reveal a thickened epidermis, dilated lymphatics, fibrosis in the dermis and extensive interstitial oedema apart from vascular proliferation and inflammatory changes. In deeper soft tissue, fat lobules with thin intervening septa resembling well-differentiated liposarcoma without nuclear atypia may be appreciated ,8. One oThe standard treatment of MLL is complete decongestive physiotherapy (CDP) . This inA bariatric surgical procedure results in a more significant improvement in obesity-related comorbidities and weight loss when compared to non-surgical interventions . Surgica4MLL remains to be underdiagnosed and underreported in literature. Due to the obesity epidemic worldwide, clinicians must be aware of this once rare entity and have adequate knowledge in its management. MLL should not be mistaken for a malignant neoplasm. As MLL is intrinsically linked to morbid obesity, management of obesity plays a vital role in the prevention of MLL recurrence. Perhaps concurrent bariatric surgery with surgical resection of MLL leads to a better outcome than tackling one at a time conservatively. More studies are required to understand its pathogenesis better, and therefore, the optimal management of MLL.Ethical approval has been exempted by our institution's ethics committee  as this publication is a case report, provided that patients/patient's next-of-kin have given their informed written consent for the publication of this case report.No source of funding.Study concepts: Nik Ritza Kosai, Fatimah Binti Mohd Nor, Reynu Rajan, Study design: Nik Ritza Kosai, Fatimah Binti Mohd Nor, Reynu Rajan, Data acquisition: Anusha Prabakaran, Loo Guo Hou, Quality control of data and algorithms: Nik Ritza Kosai, Fatimah Binti Mohd Nor, Reynu Rajan, Data analysis and interpretation: Loo Guo Hou, Anusha Prabakaran, Statistical analysis: -Not applicable, Manuscript preparation: Loo Guo Hou, Anusha Prabakaran, Manuscript editing: Loo Guo Hou, Manuscript review: Nik Ritza Kosai, Fatimah Binti Mohd Nor.Not applicable.Loo Guo Hou.Not commissioned, externally peer reviewedWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.None.


We present a case of traumatic rupture of the spleen in a man with cleidocranial dysplasia. The computed tomography imaging showed multiple low-grade lacerations of the spleen which initially led to conservative patient management. However, with clinical deterioration, the patient underwent an emergent splenectomy. Post-operative histology revealed splenic peliosis with multiple lacerations. The radiological and surgical management of post-traumatic splenic peliosis may differ from those with an otherwise normal spleen. While peliosis may occur in any organ belonging to the mononuclear phagocytic system , isolated splenic peliosis remains rare1. There have been no published cases of patients with splenic peliosis associated with cleidocranial dysplasia. To our knowledge, only 21 cases of isolated splenic peliosis have been reported in the literature2. Radiological imaging can be non-specific in splenic peliosis, and the most common differential diagnoses include lymphoma, vascular tumours or infective pathology3.Splenic peliosis is an extremely rare benign condition characterised by the presence of blood-filled cysts varying in size from one millimetre to several centimeters4.Cleidocranial dysplasia, also known as cleidocranial dysostosis, is a congenital disorder caused by a genetic mutation. It is a rare generalized skeletal dysplasia with a bone developmental abnormality. The condition is characterised by widened sutures, multiple wormian bones, hypoplasia or aplasia of the clavicles, abnormal teeth, vertebral and pubic symphysis abnormalitiesA 35-year-old gentleman presented to the emergency department (ED) following a motor-bicycle accident (MBA). He was known to have congenital cleidocranial dysplasia, but an otherwise unremarkable history. On clinical assessment, the patient was haemodynamically stable with significant tenderness over the left lateral chest wall and left hip. Trauma computed tomography (CT) revealed multiple posterior rib fractures on the left side with a small haemopneumothorax, multiple splenic lacerations with a subcapsular haematoma  and a coHistopathology noted subcapsular haemorrhage and, on sectioning, the specimen showed multiple haemorrhagic cyst-like lesions of up to 35 mm in diameter and traumatic haemorrhage . These c5. The etiology of splenic peliosis is often unclear, however, causal links between chronic alcoholism, corticosteroids, AIDS and the oral contraceptive pill are thought to be linked 2. In some cases, no predisposing link can be found3. There is a view in the literature that these represent congenital or acquired vascular malformations which manifests into cystic dilation under raised local intravascular pressure6. Interestingly, our case had congenital cleidocranial dysplasia. Although there has been no reported associative link in the literature between peliosis and cleidocranial dysplasia, it is plausible that these patients may be predisposed to congenital vascular malformations and hence possibly a higher incidence of peliosis.Splenic peliosis is a rare condition and often clinically silent, until found incidentally on routine scans. Splenic rupture, either spontaneous or traumatic, may result in acute presentation1. If the cysts rupture, either spontaneously or secondary to trauma, subcapsular haematoma, splenic laceration, and intra-abdominal haemorrhage will be evident. The radiological diagnosis of peliosis, or any other incidental pathology, can be very challenging in the setting of abdominal trauma, as the findings might be obscured by co-existent splenic lacerations. CT imaging interpretation may upgrade the splenic injury due to the presence of congenital haemorrhagic cysts mimicking the appearance of multiple splenic lacerations. The main CT imaging findings of peliosis are multiple well-defined or ill-defined low-density lesions, high density in presence of haemorrhage, with a variable pattern of enhancement post contrast7. Magnetic resonance imaging can also aid in the diagnosis of peliosis, although CT imaging is routine in trauma1.The diagnosis of splenic peliosis relies on the radiological findings of multiple small hypo-attenuating cyst-like lesions with fluid levels mostly located around the para-follicular region of the spleen6. In the presence of trauma, surgical intervention and splenectomy is effective management, although where patients are haemodynamically stable, and resources permit, interventional radiology to perform splenic artery embolization can also be effective8.The surgical management in splenic laceration with peliosis may differ from those with a normal spleen with a lower threshold for splenectomy. This is to prevent organ rupture and reduce the risk of life-threatening morbidity and mortality. Prophylactic splenectomy has been recommended in those individuals with an incidental diagnosis of splenic peliosisIsolated splenic peliosis is a rare entity, which could predispose patients to life-threatening bleeding with or without significant trauma. CT imaging plays an important role in the diagnosis and patient management, and surgical intervention is the definitive management to prevent life-threatening morbidity and mortality.


Echinococcus and presented with disseminated disease. A fistulous communication developed between one of the hydatid cysts present in the retrovesical region and the bladder, because of which the patient presented with hydatiduria.Disseminated hydatidosis is a rare disease and may involve any organ of the human body. In this case, an elderly female got infected by  Echinococcus granulosus.1 Cystic hydatid disease is a widely distributed endemic parasitosis. Humans become accidental intermediate hosts owing to ingestion of eggs of E. granulosus, and rarely of E. multilocularis and E. oligartus.2 In terms of frequency, renal involvement follows hepatic, pulmonary and peritoneal involvement.3 Retrovesical hydatid cyst is an unusual entity even in endemic areas. Possible theories on its aetiology include rupture and subsequent seeding in the pouch of Douglas,4 haematogenous seeding or direct spread through the rectosigmoid mucosa to the pelvis and perivesical venous plexus.5Hydatid disease is a zoonotic infection caused by the tapeworm A 73-year-old female from a rural region of north India presented with vague abdominal pain, burning micturition and urge incontinence. She gave a history of intermittent passage of small, white, balloon-like, grape-sized structures in the urine for the past 6 months. Her previous medical and family history were unremarkable. Physical examination revealed a visible lump in the epigastric region on the right side and a palpable lump in the left flank. All biochemical and haematological parameters were normal. Chest X-ray was normal. On ultrasonography (USG), two adherent multicystic intraperitoneal lesions were seen occupying the right hypochondrium and the epigastric region , and oth6 Dissemination in the peritoneum can occur owing to rupture of already present cysts in other abdominal organs and the cysts can be seen in any peritoneal recess. In the present case, the calcified hydatid cyst was likely the primary site, which led to intraperitoneal involvement. Retrovesical cyst is an unusual entity even in endemic areas and accounts for 0.1–0.5% of hydatid cases. Fewer than 15% of retrovesical hydatid cysts can fistulize, particularly to the bladder,8 with hydatiduria being a pathognomonic sign of vesicular cystic fistula.9 Grape-like material is found in the urine as a result of the cysts rupturing and draining into the urinary tract. Hydatiuria also has been reported in 5–25% of all renal hydatidosis cases. There is no serological and immunological test pathognomonic for hydatid disease.10 A negative serological test does not rule out echinococcosis, as our case was also seronegative. Therefore, the test result must always be compared with the radiological findings. The role of plain X-ray in the diagnosis of disseminated abdominal hydatidosis is very limited and non-specific. On X-ray films, only calcified hydatid cysts can be seen as a rim/ring calcified lesion in the respective organs in various quadrants of the abdomen. On the contrary, ultrasound imaging is the main modality used in diagnosing hydatid disease, as it is cheap, non-invasive and easily available. USG helps in the diagnosis of hydatid cysts as the daughter cysts can be demonstrated. On real-time imaging, there is shifting of hydatid sand, appearing as snowstorm in the cyst with postural change of the patient. USG imaging findings range from purely cystic lesions to solid-appearing masses. CT scan has an accuracy of 98% and sensitivity to demonstrate the daughter cysts. Calcification of the cyst wall or internal septa is easily detected on CT scan. The hydatid cysts on plain CT scan are seen as well-defined lesions with or without calcification and with varying attenuation, depending on the contents of the cyst.Intraperitoneal hydatid disease is seen in 13% of all cases of disseminated abdominal hydatidosis.T2 weighted image but demonstrate a low signal-intensity rim, which has been proposed as a characteristic sign of hydatid disease. Appearance of the hypointense rim is due to the presence of a collagen-rich pericyst, which is generated by host reaction when hydatid cysts are present in the liver.11 Also, internal smaller daughter cysts or multicystic appearance of the lesion can be seen on MRI. The fluid-sensitive sequences demonstrate the lesions and help in determining the fistulous communication, as in the present case, owing to the high internal contrast between structures. These cysts can give rise to certain complications, which include rupture leading to anaphylaxis or superinfection, which may lead to increased morbidity and mortality in the patients.On MRI, the hydatid cysts are usually hyperintense on Hydatid cyst in the retrovesical region is a rare condition and the diagnosis is made by USG and MRI, which help in delineating the exact location of the cyst and its early management. Early diagnosis and optimal choice of surgical management reduce the morbidity and mortality associated with this disease.Hydatiduria can also occur without renal involvement if there is a fistulous communication between the abdominal hydatid cyst and the urinary tract.A negative serology does not rule out echinococcosis, so serology should be correlated with radiological findings.Informed consent has been obtained from the patient.


Even if tuberculosis is a major cause of morbidity and mortality, nasopharyngeal location is unusual and extremely rare. We report four new cases observed with short time interval suggesting a trend towards increased frequency. The diagnosis was confirmed by histological analysis after a biopsy. The evolution was favorable after anti tuberculosis chemotherapy. In the light of those observations and a review of the literature, we will discuss different characteristics of this disease and we will highlight the need of a systematic biopsy in order to confirm diagnosis and exclude undifferentiated carcinoma especially in endemic regions for both diseases. Mycobacterium tuberculosis. It is one of the oldest human diseases, and still represents one of the major causes of morbidity and mortality worldwide. Approximately 9 million people contract TB and 2 million die of it yearly [Tuberculosis (TB) is a chronic bacterial infection due to t yearly . It can The first patient was a 15-year-old boy with no family history of TB. He suffered chronic snoring since the age of six. He presented with headache, asthenia and weight loss. Examination on admission revealed multiple bilateral cervical lymphadenopathies in jugular areas. Nasal endoscopy  discoverThe second patient was a 17-year-old girl without family history of TB. She presented with numerous bilateral cervical lymphadenopathies and nasal obstruction. Nasal endoscopy found a polypoid uprising of the superior and posterior nasopharyngeal walls. CT scan showed a nasopharyngeal mass with central hypodensity suggesting tissue necrosis , with muA 22-year-old man without past medical history was hospitalized for nasal obstruction with purulent rhinorrhea lasting for three months. Clinical examination found congestive nasal mucosa, purulent postnasal drip and a bilateral secretory otitis media with an average hearing loss of 25 dB, cervical palpation did not find any lymphadenopathy. Endoscopy objectified the presence of a tumor occupying substantially all of the nasopharynx, with irregular surface, covered with mucopurulent secretions and obstructing both choanae. CT scan showed a mass taking all the walls of the cavum without bone lysis. A biopsy was performed.A 45 years old patient, chronic smoker, presented with unilateral lymphadenopathy gradually increasing in size with weight loss, associated with nasal obstruction and hearing loss of the right ear. Clinical examination found a painless firm lymphadenopathy of the right jugular era measuring 3cm and a secretory otitis media. The endoscopy found a tumor in the right posterolateral wall of the nasopharynx. CT scan showed a mass in the posterior wall of the nasopharynx with retropharyngeal lymphadenopathies. A biopsy was performed.In four cases, histopathological study showed nasopharyngitis and granulomas with histiocytic, epithelioid, and giant multinucleated Langhans cells as well as caseous necrosis . FurtherMycobacterium tuberculosis, their involvement is rare (less than 2%) [Up to 10% of TB cases have a presentation in head and neck region . Cervicathan 2%) . NasophaLermoyes was the first to describe a nasopharyngeal TB in a 6-year-old child . Since tMycobacterium tuberculosis can cross mucosal barriers by endocytosis in sites such as lymphoid pharyngeal tonsil, and phagocytes containing intracellular mycobacteria disseminate the infection [TB infection can be contracted by inhalation, ingestion or inoculation. Inhalation is the major mode, ingestion has become rare due to the pasteurization of milk, as well as cutaneous inoculation ,5. Uppernfection .Clinically, nasopharyngeal TB declares in 50% of cases by the presence of high jugular lymph nodes, followed by nasal symptoms  and otologic symptoms ; headache, sore throat and cough can also be observed ,3,6-8. EThe diagnosis of pharyngeal TB is usually confirmed by histological examination of biopsy and culture on specific environment . PCR (poOnce diagnosis of pharyngeal TB is confirmed, search for other locations is essential to adjust the treatment. Seeking HIV should be systematic . The treWe tend to believe that the frequency of rhinopharyngeal TB is increasing but it is difficult to prove because of the lack of data in the literature. This diagnosis should be considered in endemic areas and in immunocompromised patients. Clinical symptoms and radiological findings are not specific, and it is difficult to distinguish from undifferentiated carcinoma, particularly in areas where both are endemic, such as in North Africa, which makes necessary to perform a biopsy of every unusual nasopharyngeal aspect for histological but also bacteriological analysis. Association of nasopharyngeal carcinoma and TB is possible but rare.The authors declare no competing interests.