Primary retroperitoneal cavernous hemangioma (PRCH) in an adult is extremely rare. We report on the diagnosis and treatment of a patient with PRCH with subtle clinical features and atypical findings on imaging scans. A 38-year-old man was admitted to hospital with a 5-day history of epigastralgia after alcohol drinking. Using various imaging methods, we found a giant cyst-like retroperitoneal mass compressing the surrounding organs. Surgical resection of the tumor was performed, and the mass was found to be a cavernous hemangioma measuring 90 × 80 × 60 mm, with a thick fibrotic wall and extensive intracystic hemorrhage. Physicians should be aware that PRCH may mimic a cystic neoplasm, and that a large tumor size probably indicates intracystic hemorrhage. Surgical resection is a curative approach for PRCH. Hemangiomas are vascular tumors that rarely involve the retroperitoneal organs. The majority of reported retroperitoneal hemangiomas in adults originated from the kidneys, but hemangiomas can also originate from the adrenal glands and pancreas-3. Primafeatures. GeneralA 38-year-old man presented with a 5-day history of dull epigastralgia after alcohol drinking, without radiating to back. There were no signs of other disorders, including fever, chills, jaundice, nausea, vomiting, melena, or hematuria at this first visit. The patient’s medical history was unremarkable. On physical examination no abnormal signs were seen, except for mild tenderness of the epigastrium. Laboratory studies, including tests for serum amylase, creatinine, alanine and aspartate aminotransferases, bilirubin, and urea nitrogen gave normal results.Imaging studies were carried out. US showed a giant cystic mass in the right upper quadrant, accompanied by right hydronephrosis and right upper ureterectasia, but no additional abnormalities of the liver, cholecyst, pancreas, or urinary tract were found. Using enhanced CT, a cyst-like and well-circumscribed mass measuring 87 mm at the greatest diameter with low density (14.8 Hounsfield units) was found, which was adjacent to the inferior vena cava with its upper pole between the third part of the duodenum and the right renal hilum. Mild enhancement of the thick wall and consistent hypodensity within the inner component of the mass were seen during both the arterial and portal phases of CT. There was no evidence of feeding arteries from the surrounding organs or of adenopathy. The CT scan also confirmed the obstruction of the right upper urinary tract (FigureFurther treatments including surgical intervention were suggested, but the patient didn’t want to receive any invasive treatments at this first visit. Medication such as antispasmodic was prescribed and scheduled follow-up was required. A month later, the patient was readmitted to our department as the symptoms continued. During this second visit, there were no other physical symptoms or signs, except for mild epigastralgia. Results of tests for serum tumor markers, including carcinoembryonic antigen, carbohydrate antigen 19-9 and α-fetoprotein, were all within normal ranges. Enhanced CT was repeated, again showing that the giant cystic mass was compressing the duodenum, inferior vena cava, and right urinary tract. The case was reviewed, and the mass was considered to be a benign isolated retroperitoneal lesion. However, the definite nature of the lesion could not be established preoperatively. Laparotomy was required because of the size of the lesion and also for relief of the pressure on the surrounding organs.A vertical midline incision and extensive Kocher maneuver was used for the surgery. A giant tumor was found, lying inferior and posterior to the pancreatic process and the third part of the duodenum, inferior and anterior to the hilum of the right kidney, which was compressing anteriorly and laterally on the inferior vena cava, medially on the right upper ureter and posteriorly on the duodenum Figure. No metaExamination of the mass showed it to be a cystic, well-encapsulated tumor, with a yellowish to tan color, measuring 90 × 80 × 60 mm Figure. The tumVascular lesions are composed of two major types of abnormalities: hemangioma and vascular malformation. CH is aOur patient was a middle-aged man. No gender predilection has been found for retroperitoneal CH,9, excepet al. reported enhancement of a soft-tissue mass by enhanced CT scan in their PRCH case[We used several diagnostic imaging methods to characterize the tumor in this case. US showed a hypoechoic, homogeneous, and sharp-edged lesion, consistent with a cystic mass. On CT scans, a typical CH of the pancreas has strong contrast enhancement relative to the surrounding normal pancreas in the artery phase, and CH RCH case; howeverRCH case. In thisRCH case,8,14.Our first impression in this case was of a cystic tumor originating from the retroperitoneum. For such cases, the differential diagnosis includes malignancies such as liposarcoma, malignant fibrous histiocytoma, leiomyosarcoma, and neuroblastoma, or benign lesions such as paraganglioma, neurofibroma, lipoma, teratoma, and neurilemoma. Given tIn this study, we present a case of PRCH, a rare type of retroperitoneal CH, in an adult patient in our hospital. The tumor was separated from surrounding organs, thus it was diagnosed as a primary retroperitoneal CH. The PRCWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.HH, HSJ, and DY collected the information, reviewed the literatures and wrote the manuscript. YL, YF, LJ, and JYJ participated in analyzed the data and interpreted the imaging features. DZG carried out the pathological studies. JC and FDL edited the article, and gave the final approval of the version to be published. All authors read and approved the final manuscript.


Fibrolamellar hepatocellular carcinoma (FLH) is a rare primary tumor of the liver, which typically arises from noncirrhotic livers and affects patients below the age of 35. We report on a 29-year-old male patient who presented with a ruptured FLH and was treated with surgical resection. Options for treatment and review of the management are described. Fibrolamellar hepatocellular carcinoma (FLC) is a rare primary liver tumor presenting earlier in life than nonfibrolamellar hepatocellular carcinoma . RuptureμL. A FAST ultrasound performed in emergency showed an eight by five cm lesion in segments V and VI of the liver, with diffuse hemoperitoneum. An emergency abdominal CT scan was requested, and it showed evidence of an eight by five cm ruptured hepatic lesion with massive hemoperitoneum and leakage of contrast medium. The lesion had a big extrahepatic component with possible invasion of the hepatoduodenal ligament and gallbladder ( A 29-year-old male patient came to the Emergency Department complaining of a sudden onset of right upper quadrant pain, which was associated with nausea and vomiting. On history the patient reported some chronic pain in the right upper quadrant, which had been present in the previous days, which suddenly had become worse prior to admission to the hospital. Past medical history was completely unremarkable. On clinical examination the patient appeared pale and in distress. Blood pressure was 80/60 mm Hg, heart rate was 120, and respiratory rate was 40. The abdomen was painful with guarding and rebound in all four quadrants. Laboratory tests showed Hb of 69 g/dL and WBC 15.000 lbladder . While tlbladder . No othelbladder  and 4. TFibrolamellar hepatocellular carcinoma is a rare primary malignant tumor of the liver, which was first described in 1956. Unlike conventional hepatocellular carcinomas, FLC typically affects younger patients, often below the age of 35, without underlying liver disease, and both sexes are affected equally . FL-HCCsRuptured HCC is a complication burdened by high mortality. Treatment needs to be tailored to the hemodynamic conditions of the patients and to the liver function. TAE followed by staged hepatectomy might be the preferred approach in hemodynamic stable patients with advanced liver disease. Surgery should be the ideal treatment in patients with no underlying liver disease or preserved liver function.


The aim of this case report and minireview was to investigate the diagnosis of and therapeutic approaches for angiocentric glioma (AG) and to summarize the clinical manifestations and the pathological and imaging characteristics of the disease. Intraoperative cortical electroencephalogram (ECoG) monitoring was performed to locate the epileptic foci in a child with AG who presented with intractable epilepsy, prior to the total resection of the tumor being performed under the microscope. The clinical features, imaging characteristics, intraoperative conditions, surgical methods and pathological results were analyzed and compared with the literature. The review revealed that to date, the clinical features of the 52 reported cases of AG (including this case) have been mainly characterized by epilepsy. High T2-weighted image (WI) and fluid-attenuated inversion recovery (FLAIR) signals may be detected with magnetic resonance imaging (MRI) scanning of the cranium; however, no enhancement signals are detected by enhanced scanning. The prognosis following surgical resection is favorable. The lesions in the present case demonstrated clear boundaries with a central cystic affection accompanied by an arachnoid cyst on the left temporal pole. Pathological examination revealed that the lesion was positive for glial fibrillary acidic protein (GFAP), S-100 protein, vimentin, epithelial membrane antigen (EMA), cluster of differentiation 99 (CD99) and D2-40. The Ki-67/MIBk-1 labeling index was ~1%. In conclusion, AG exhibits characteristic features in imaging; however, its diagnosis depends on histopathological examination. The prognosis of total surgical resection is good and intraoperative ECoG may be used to assist positioning. Angiocentric glioma (AG) is a rare type of tumor of the central nervous system . It was A total of 52 cases of AG have been described in the literature ,5–20, inWe report a case of seven-year-old female patient who, according to the preoperative presentation, appeared to be suffering from drug-refractory epilepsy. Lesions were located near the central sulcus in the right parietal cortex, and were concurrent with a left temporal pole arachnoid cyst. Intraoperative cortical electroencephalogram (ECoG) monitoring was used to assist with locating the epileptic foci, prior to the tumor and epileptogenic lesions being surgically resected. A postoperative study was conducted into the cytology and immunohistochemistry and the presence of AG (WHO level I) was demonstrated pathologically. The majority of the tumors described previously have been distinct entities; few have been combined with cystic degeneration and a simultaneously occurring left temporal arachnoid cyst. These are manifestations that cause a clinical concern for the neurosurgeon. We used intraoperative ECoG monitoring to locate the epileptic foci, prior to surgically resecting the tumor and epileptogenic lesions. This was beneficial for the control of postoperative epileptic seizures. This study may be used as a reference for clinical neurosurgeons. The case is described in the following sections.A seven-year-old girl presented at The Department of Neurosurgery, Yuquan Hospital, Tsinghua University  with a three-year history of paroxysmal convulsions with loss of consciousness and a deterioration of the disease. The predominant forms of seizure were absence and whole body tonic-clonic seizures, while the main clinical presentation was a sudden bow  in a single or continuous cluster of seizures. The body sometimes dipped slowly to the left and then to the right side while the upper and lower limbs stiffened, presenting absence seizures. The seizures were maintained for approximately half a minute (not >1 min), prior to remission. The administration of oral drugs, such as oxcarbazepine, clonazepam, topiramate and valproate, controlled the symptoms poorly and the attacks occurred 4–10 times monthly. There was no previous history of dystocia, hypoxia, encephalitis or any other medical history. Written informed consent was obtained from the patient’s family.Brain MRI imaging revealed a clearly visible boundary in the right parietal region of the cerebral falx and the cortex. It appeared as a wedge, with the cutting-edge pointing to the white matter of deep lesions. The T1-WI had a low signal (long T1), while the T2-WI had a high signal (long T2) and FLAIR imaging showed a high signal, with a low signal in the center. No enhancement signals were detected by enhanced scanning. A visibly widened subarachnoid cyst was observed in the left temporal pole. Postoperatively, it was considered that there was an embryonic dysplastic neuroepithelial tumor and left temporal pole arachnoid cyst .The various periods of the bilateral sleep-wake cycle led to a large number of high volatility waves. Video electroencephalogram (VEEG) showed 1.2–2.5 Hz sharp wave and sharp slow wave (distributing or continuously appearing), which were obvious in bilateral central and front temporal regions. The occurrence in right side was a little earlier than left side. During the process of monitoring, the seizures occurred several times and the clinical onset was predominantly a sudden bow (slightly forwards and downwards to the left). Seizures occurred singly or in continuous clusters. EEG concurrently displayed the highest conductivity of the high-amplitude biphasic slow waves or irregular slow waves on the right side.Under general anesthesia, an incision was made in the right parietal lesions. During the surgery, local arachnoid thickening and subarachnoid widening were observed by cutting the dura mater. Intraoperative ECoG and deep EEG were monitored .The results demonstrated that local and deep spikes were emitted frequently and that fewer were recorded 1 cm away from the lesion edge. A few sharp wave and spike wave were visible in areas close to posterior part of precentral gyrus and postcentral gyrus. The lesions were located in cortical and subcortical regions; the size was ~2.5×3.0 cm and clear borders with the surrounding brain tissue were visible. Parts of the lesion were textured like a rotten fish and local central monitoring with the ECoG was repeated to reveal a small amount of spike-wave discharge in the central frontal gyrus on the midline at ~1 cm. There were no significantly abnormal EEGs monitored after using local cortical low power, bipolar coagulation and burning.The histological examination revealed that bipolar single cells in a monolayer or multilayers were centered around the cortical blood vessels in the form of ependymoma-like pseudorosettes along the vascular axis. The tumor cells were arranged in palisade-like structures in a swirling effect, giving the area of the tumor in the neural parenchyma a wide range of different cell densities. The nuclei of the tumor cells were elongated, the chromatin was finely granular, no or rare nuclear fission was present and no microvascular proliferation or necrosis was observed. There were no significantly heteromorphic neurons in the lesions.The tumor cells were positive for tumor cell glial fibrillary acidic protein (GFAP), S-100 protein, vimentin, human leukocyte differentiation antigen 34 (CD34), epithelial membrane antigen (EMA), cluster of differentiation 99 (CD99) and D2-40. However, the cells were negative for neuron markers, such as synaptophysin (Syn) and chromaffin protein/NeuN. There was no expression of oligodendrocyte transcriptor-2 (Olig-2), epidermal growth factor receptor (EGFR), neurofilament (NF), CD117, nestin or microtubule-associated protein 2 (MAP2) in the tumor cells. Furthermore, there were no visible changes in the p53 expression level. The Ki-67/MIBk-1 labeling index was ~1% .The recovery of the patient was good following surgery and follow-ups were performed for 12 months. No nervous system dysfunction, such as epilepsy attacks, dizziness/headaches or hemiplegia, was observed and there were no abnormal somatosensory manifestations. MRI review did not reveal any residual tumor or tumor recurrence. No abnormal EEG signals were detected in the EEG review.AG is a rare type of tumor with distinct clinicopathological characteristics. To date, there have been 52 cases of AG described in total ,5–20, inA search of the PubMed index indicates that 52 cases of AG, including the current case, have been reported to date. The patients were aged between two  years atThe combined analysis of the reported cases revealed that epilepsy was a predominant clinical manifestation for the majority of patients with AG, including 46 cases of intractable epilepsy ; in the parietal lobe in seven cases ; in the temporal lobe in 19 cases ; in the occipital lobe in two cases  and in the hippocampus in four cases 7.84%, 4/51). Furthermore, there was one case 1.96%, 1/51) of a lesion in the occipitoparietal lobe, three cases  in the frontoparietal lobe, one case  in the frontotemporal lobe, one case  in the occipital temporal lobe, one case  in the thalamus  and one %, 4/51. 7%, 11/51%, 1/51 oAlthough AG has been newly recognized as a distinct entity of tumor, compared with ependymoma , there are a number of similarities in clinical presentation and histopathology. However, AG has characteristic features, including mild visible atypia and local invasion of single and bipolar cells, as shown under the microscope. Furthermore, the cells of the tumor cluster around vessels and grow along the long axis of blood vessels in the network of nerve fibers. Immunohistochemistry has shown the tumor cells to be positive for GFAP , EMA 2323, monocAG, defined as WHO level I, has benign biological characteristics. The main purpose of therapy is to surgically excise the lesion and to control the seizures. Following the surgical excision of the lesions, the symptoms of epilepsy may be effectively controlled. Out of the 52 patients with AG, 34 patients underwent a complete surgical resection only (received surgery but not radiotherapy or chemotherapy) and 22 of the patients were followed-up for >12 months without suffering any seizures; nine patients underwent a partial resection (surgery plus radiotherapy and chemotherapy not included) and of the seven patients who received follow-ups for >12 months, two were seizure-free. These data show that full surgical resection of the tumor is more efficacious at controlling the symptoms of epilepsy. In the present case, intraoperative ECoG monitoring showed that the abnormal discharge range exceeded the area of the tumor, demonstrating that resection of the tumor alone does not completely eliminate the abnormal discharge. Since this may lead to epileptic seizures, surgical ECoG positioning may be used to determine the area requiring removal and to extend the target for resection, in order to ensure normal function. In the current study, low-power coagulation and cautery was performed, in order to obtain better clinical efficacy for the functional areas of the cortex that were unresected, but where abnormal discharge remained. This suggests that for AG, surgery and intraoperative stimulation, in the central area when necessary, are able to better ensure the efficacy of the surgery, with a smaller impact on the patient’s function. Previous studies have shown that in cases of AG with surrounding cortical dysplasia ,19,21, iThe prognosis of the patients who have undergone total surgical resection for AG is typically good. The longest follow-up of patients with AG has reached 165 months, and the patients have been seizure-free in this period. Two patient mortalities have been reported: One patient  succumbeThe main clinical manifestation of AG is epilepsy. The imaging studies of AG exhibit clear features; however, a definite diagnosis depends on histopathological examination. The most effective treatment approach for the control of the epileptic seizures is to perform a total resection of the tumor and the area presenting with abnormal discharge using intraoperative ECoG positioning. Following the total resection to remove the lesions, the prognosis of the majority of the patients is favorable; however, a long-term follow-up of the patients after the surgery is required.


Pneumatosis cystoides intestinalis is a rare gastrointestinal complication in the course of connective tissue diseases, especially in scleroderma, that can lead to pneumoperitoneum or obstruction. Findings on plain radiography may reveal radiolucent linear or bubbly circular air bubbles in the bowel wall, with or without free gas accumulation in the peritoneal cavity. Treatment of pneumatosis cystoides intestinalis ranges from supportive care to laparotomy. Pneumatosis cystoides intestinalis (PCI) is a rare gastrointestinal complication in the course of connective tissue diseases (CTD), especially in scleroderma. Pneumatosis cystoides intestinalis was first described by Du Vernoi in a cadaveric dissection in 1783. This complication is characterized by the presence of multiple gas-filled cysts in the submucosa and/or subserosa wall of the intestine . AlthougHere we describe a case of pneumatosis cystoides intestinalis in the setting of scleroderma.A 65-year-old female presented with leaking fluid and pain around her jejunostomy (J) tube. She had a long history of scleroderma requiring J tube placement for supplemental feeding. On examination, there were pain and tenderness around her J tube. Initial X-rays were done to assure proper location of her J tube and demonstrated contrast contained within loops of bowel; however, the bowel wall had a “mottled” appearance, and incidental note was made of pneumoperitoneum . Follow-The patient's past medical history consisted of presenting to another hospital with acute abdominal discomfort. She had a CT scan done that showed air in the peritoneal cavity suggesting a perforated bowel. She went for an exploratory laparotomy which showed no evidence of bowel rupture. A second exploratory laparotomy was done to ensure a correct diagnosis and also found no evidence of bowel rupture. The patient has a history of a severe form of scleroderma affecting the bowel with thinning of the wall and air dissection into the bowel wall  and with resultant air leaking into the peritoneal cavity. PCI is a consequence of bowel involvement in patients with scleroderma and can cause pneumoperitoneum with bowel cyst rupturing into the peritoneal cavity, mimicking bowel perforation.Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of air-filled cysts present in the bowel wall and mesentery and may occur anywhere in the gastrointestinal tract. The cysts (0.5–10 cm in size) are found most frequently in the terminal ileum and rarely in the proximal small bowel, stomach, and colon . It is aIntestinal involvement in progressive systemic sclerosis, dermatomyositis (DM) or polymyositis (PM), and mixed CTD may be complicated by PCI. The pathogenesis of PCI is not fully understood, but several mechanisms have been suggested. Mucosal break down from steroids and other immunosuppressive agents cause Peyer's patches in the bowel wall to shrink, leading to an alteration of mucosal integrity and the potential for air dissection. These immunosuppressive agents also impair tissue repair mechanisms, further exacerbating ulceration and bowel necrosis. The bacterial theory suggests that bacterial fermentation of carbohydrates within the gastrointestinal tract leads to excessive gas formation, inducing absorption of this gas into the bowel wall . The bacGastrointestinal involvement in scleroderma is characterized by atrophy of the muscularis propria and its replacement by collagen tissue. Manometric and electrophysiological studies have shown evidence of a neuropathy of the enteric nervous system in the early stages of the disease, resulting in disturbances of digestive peristalsis and leading to gastroparesis, bacterial overgrowth of the small intestine, or constipation. Although any part of the gastrointestinal tract may be involved, the organs involved in decreasing order of frequency are the esophagus, small bowel, colon, and stomach . Suggestive findings on plain radiography comprise different pattern of radiolucent linear or bubbly circular air bubbles in the bowel wall, with or without free gas accumulation in the peritoneal cavity. CT imaging is the gold standard procedure for the diagnosis of PCI. Furthermore, CT allows the detection of additional findings that may suggest an underlying potentially worrisome cause of PCI such as bowel wall thickening, altered contrast mucosal enhancement, dilated bowel, soft tissue stranding, ascites, and the presence of portal air.Treatment of pneumatosis cystoides intestinalis ranges from supportive care to laparotomy. PCI is often benign and only conservative treatment, and followup is warranted. Surgery is generally indicated in patients with severe pain. The decision to proceed with explorative laparotomy must be based on the thorough analysis of a detailed history, physical examination, laboratory tests, and radiological studies.


Mucocele and traumatic neuroma are two lesions related to the traumatic events; however there is only one reported case in which these two entities were perceived simultaneously. The current study reported a 21-year-old man who complained of painless recurrent swelling, accompanied by paresthesia on his left lower labial mucosa. He had a previous history of similar lesion and had been treated with surgery and cauterization last year. The primary clinical impression was a recurrent mucocele. Microscopic surveys displayed a traumatic neuroma in the vicinity of a mucocele which seems to be arising from the previous surgical treatment. Mucocele is a common lesion in the oral cavity which develops after traumatic rupturing of a salivary gland duct and consequent accumulation of mucin in the surrounding soft connective tissue. The lesion is commonly described as a painless bluish, gray or normal-in-color swelling which may show intermittent rupture. The treatment of choice is surgery and if the feeding duct remains in place, the possibility of recurrence is high -2. SurgiA 21-year-old man presented who complained of a painless swelling with paresthesia on his left lower lip. He had a past history of similar lesion diagnosed as mucocele one year earlier, and the lesion was treated by surgery and electrocauterization. Eight months after his first surgery, a new swelling in the earlier place was aroused and remained for 4 months. The size of the lesion did not change during this period on the basis of what our patient reported. There was a hemispherical transparent swelling sized 1x0.7x0.3cm. It was firm and could not be easily ruptured by usual traumatic manipulations . The clinical impression was consistent with recurrent mucocele, however paresthesia was not justified. The lesion was removed by excisional surgery. The surgical specimen consisted of multiple pieces of a cyst-like creamy elastic soft tissue. It comprised of some small round structures similar to the minor salivaryglands with one bigger than the others, totally measuring: 1x 0.8 x 0.7 cm. Microscopic examination revealed a pool of mucin surrounded by granulation tissues. Adjacent minor salivary gland showed mild sialoadenitis . Close tOral mucosa has a rich nerve supply which lies in the underlying connective tissue or mucosal appendices such as minor salivary glands. Any surgical procedure is always traumatic to the hard and soft tissues and may lead to cutting the nerve fascicles. Rarely, the ends of the severed nerve cannot be re-established and abnormal proliferation of Schwann cells results in the formation of a mass of neural elements, named traumatic neuroma -6. The s


Our objective was to report a case of misdiagnosed temporal lobe necrosis (TLN) in a patient with nasopharyngeal cancer (NPC) after radiation therapy.We report a case of a 45 years old Chinese woman who developed moderate to severe headache and dizziness 1 year after 2D radiation therapy for NPC. Subsequent MRI scanning revealed a big enhancing mass in the right temporal lobe. The initial diagnosis was metastatic or intracranial extension of NPC, or a primary intracranial malignancy. She was referred to the neurosurgery department where a maximal surgical resection of the lesion was performed. A diagnosis of TLN was made according to the final histology.TLN still matters in the IMRT era. The diagnostic quagmire of TLN lies in its close resemblance to neoplasm on clinical presentation and imaging. Reviewing the patient's treatment plan to scrutinize the dose to the temporal lobes is an important prerequisite for diagnosis. Worldwide, nasopharyngeal cancer (NPC) is most common in South China in the provinces of Guangdong, Guangxi, Fujian, Hunan, and Hong Kong. Its incidence in these regions is 30 per 100,000 compared to just 1 per 100,000 in Europe -4. HowevThe first case of radiation necrosis was described by Fischer and Holfelder in 1930 in a 45 year old patient treated with radiotherapy for basal cell epithelioma of the temporal region with a total dose of 6840 cGy ,8 and thOwing to its close proximity to the skull base, the medial parts of bilateral temporal lobes are inevitably included in the target volume. Since the inferior portions of the temporal lobes lie within the portals of radiation therapy, TLN is normally seen to occur in bilateral inferomedial parts of the temporal lobes.Differentiating this condition from metastatic or primary brain tumor remains a clinical and radiological challenge due to their close resemblance. We hereby report the case of a 45 year old Chinese woman with NPC who received radiation therapy at a local hospital using 2D technique and developed severe radiation induced TLN. The diagnosis of TLN, in her case, was missed twice but was finally established by maximal surgical resection and histological examination, hence further laying emphasis on the reduced awareness and diagnostic dilemma of this entity.A 45 year old Chinese lady with a six months history of bilateral nasal obstruction, tinnitus, associated headache and dizziness presented to the local hospital on November 3rd, 2009. Nasoendoscopy revealed a large mass in the nasopharynx, a biopsy of which confirmed non-keratinizing squamous cell carcinoma, WHO type 2.2 , she wasHowever, 1 year after radiation therapy the patient developed moderate to severe headache and dizziness. She returned to the local hospital to seek medical intervention for her symptoms on March 2nd, 2010. There was no associated history of fever, blurring of vision, nausea or vomiting. Physical examination was unremarkable. No abnormal neurological signs were noted. Her hematological and biochemical profile as well as her liver function test results were normal. However, Brain MRI scan showed abnormalities in the white matter of bilateral inferior portions of the temporal lobes. A large heterogeneous lesion with circumferential rim enhancement surrounded by extensive edema was found in the inferior part of the right temporal lobe. Small homogeneous lesions with limited edema could also be seen in the left temporal lobe Figure . HoweverThe patient refused surgery or any further treatment. Subsequently, her clinical condition worsened with time. 2 months later she complained of more intense headache especially in the morning with accompanying dizziness, nausea and blurring of vision, which prompted her to return to the neurosurgery department at our hospital in May, 2010. Physical examination showed presence of papilloedema. There was absence of neck rigidity and other focal neurological deficits. Brain MRI re-scanning showed no other new lesions. In keeping with the initial diagnosis of temporal lobe malignancy, the attending neurosurgeon performed a maximal surgical resection of the lesion in the right temporal lobe on May 18th, 2010. However, histological examination confirmed the absence of neoplastic cells in the resected brain tissues. Instead, partial liquefactive necrotic tissue with lymphocytic infiltration was noted. Additionally, there was associated dilatation, congestion and hemorrhage of surrounding blood vessels which corroborated with a diagnosis of radiation induced TLN Figure . FortunaTLN, as a late potential sequalae of radiation treatment in patients with NPC, has experienced a down slope over the past decade. This has occurred with the growing worldwide use of IMRT for treatment of this carcinoma which has provided a potentially therapeutic benefit of dose escalation with reduced toxicity to normal tissues . SymptomUsing 2D radiotherapy technique, inferior parts of bilateral temporal lobes almost always receive the same dose as the tumor, especially for patients with locally advanced disease infiltrating the skull base or cavernous sinus. It has been reported that there is a 25% chance of developing TLN within 5 years following use of a total dose of equal to or more than 62.5 Gy . The patThe differential diagnoses of TLN include intracranial extension of NPC, second primary intracranial neoplasm, cerebral metastasis, meningeal spread and brain abscess . DiffereIn our case report, a brain abscess can be excluded as our patient had few symptoms and signs to support an infectious disease. Ruling out hematogenous spread of NPC is easy, as it is very rare and would unlikely be present bilaterally , while tTraditional treatment for TLN includes the use of steroids, hyperbaric oxygen, antiplatelets, anticoagulants, high dose vitamins and surgery, but all have shown a limited efficacy ,24. SterAlthough TLN has been dwindling since the introduction of IMRT, it should always be kept in mind when encountering temporal lobe lesions in NPC after radiation therapy. The diagnostic quagmire of TLN lies in its close resemblance to neoplasm on clinical presentation and imaging appearance. This can be achieved by combining the history, physical examination findings, with abnormalities seen on imaging tools like MRI.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.KY and GW have made substantial contributions to conception and design, and acquisition, analysis and interpretation of data. MD, ZY, HL, KY have been involved in drafting the manuscript or revising it critically for important intellectual content. All authors read and approved the final manuscript.


Penile metastases are an extremely rare occurrence, and most primary malignancies are located in the urinary bladder, prostate, rectum, and rectosigmoid. Although very few cases of penile metastases have been reported, those of lung cancer as the primary tumor are very rare. Among the latter, squamous cell carcinomas constitute the majority, whereas adenocarcinomas are almost exceptions. To the best of our knowledge, only two cases have been reported.We report the case of a 59-year-old Greek man who presented with persistent cough and chest pain that had started one month prior to a medical appointment. A physical examination, complete laboratory work-up, computed tomography scanning , pelvic magnetic resonance imaging, penile ultrasonography, bone scanning, and histological analyses were conducted. Afterward, a lung adenocarcinoma metastatic to the bones, brain, adrenals, lymph nodes, and penis was diagnosed. The primary lesion was a mass of 4cm in diameter in the apical segment of the lower lobe of the right lung. The patient was treated with bone and brain radiotherapy and various cycles of first- and second-line chemotherapy, and partial response was achieved five months after the initial appointment.Although these metastatic sites are well known to occur from a primary pulmonary malignancy, penile metastasis is extremely rare. Its identification requires prompt awareness by the physician despite the dismal prognosis. Furthermore, since the penis usually is omitted from the physical examination and lung cancer is the leading cause of cancer-related deaths, more penile metastases may be detected in the future, making early detection and appropriate management of great importance. Metastatic neoplasms of the penis are extremely rare. To the best of our knowledge, about 300 have been reported worldwide. They are associated with advanced disease and poor prognosis, regardless of the tumor origin. When metastatic neoplasms do occur, the primary sites are the urinary bladder (in 30% to 35% of cases), the prostate in 28% to 30%), the rectosigmoid colon in 13%), the kidneys (in 8% to 10%), and the testes (in 5%) [3%, the k8% to 30%In a search of the MEDLINE database for reports of lung cancer that metastasized to the penis, we retrieved 24 cases , the vasA 59-year-old Greek man was admitted to our hospital nine months prior to the submission of this case report. He was complaining of persistent cough and chest pain that had started one month prior to a medical appointment. A physical examination on admission revealed enlarged left supraclavicular lymph nodes (approximately 3cm) and an asymptomatic firm subcutaneous mass on the dorsum of his penis, close to the glans, just left of the midline. No pain on his penis was mentioned at that time. Laboratory findings showed elevated serum levels of carcinoembryonic antigen (37.3ng/ml), neuron specific enolase (35.2ng/ml), and lactate dehydrogenase (1.590IU/L) and slightly elevated levels of creatinine (1.8mg/dL).A chest plain radiograph and chest computed tomography (CT) demonstrated a spiculated lung mass (with a maximum diameter of 4cm) on the apical segment of the lower right lobe and multiple metastatic pulmonary nodules, consistent with carcinoma of the lung, as well as enlarged mediastinal lymph nodes  and left supraclavicular nodes (of approximately 1cm)  given on day 1 in a cycle of three weeks (q21 days). After the third cycle of chemotherapy, restaging of the disease was performed as the clinical performance status was worsening; a chest CT scan confirmed progressive disease with several new lung lesions, but the lymph nodes of the mediastinum as well as the abdominal ones were minimized. Additionally, a CT scan of the brain showed metastatic lesions at the left frontal lobe and the corona radiata. After completion of the total brain irradiation, second-line chemotherapy was administered with paclitaxel (90mg/m2) given weekly on days 1, 8, and 15 (q28 days) for two more cycles. Restaging showed partial response , but bone marrow depression followed.Radiotherapy was used to treat the metastatic bone lesions three months after the medical appointment. Three weeks later, the patient was referred to us for treatment of lung cancer. He was treated with chemotherapy consisting of carboplatin (area under the curve of 5) and pemetrexed , swelling of the penis, erectile dysfunction, priapism (up to 45%), enlargement of inguinal lymph nodes, tenderness, ulcer formation, mass , poor or weak urinary stream, urinary infections, dysuria, pollakisuria, hematuria (less than 10%), urinary retention, or other unspecific obstruction symptoms. Penile mass is a common sign of penile tumor, although priapism is usually the most common symptom, resulting in thrombosis or emboli or congestion of the circulation . In contrast, perineal pain is not a typical symptom. Ulcer formation is usually a sign of disseminated disease and dismal prognosis. Most of the time, the quality of life is extremely impaired and the patient seeks help and palliation, although metastasis to the penis usually is considered a late complication and often is associated with multiple metastases in many distant organs.Diagnosis of metastasis to the penis must be established on biopsy. To differentiate metastatic lesions from primary penile tumors, an adequate specimen is needed as early as possible. A penile enlargement or mass does not always mean malignancy. Any of the following could be on the list of differential diagnosis of the clinician: benign tumors, syphilitic chancre, venereal or other infectious ulcerations, idiopathic priapism, Peyronie’s plaque, candidiasis, cavernositis, tuberculosis of the penis, sclerosing lipogranuloma, and other specific and non-specific inflammation together with all of the hematologic, metabolic, and pharmacological causes of priapism . It is iSeveral diagnostic modalities can be used to confirm the clinician suspicion. Magnetic resonance imaging yields higher accuracy in the differential diagnosis in comparison with ultrasound or CT scans and should be preferred. Other imaging techniques, such as cavernosonography, are not used nowadays, mainly because they do not provide higher diagnostic accuracy in comparison with other non-invasive procedures and are associated with a considerable complication rate .Therapeutic modalities that aim to provide local and systemic control of the disease are surgery, radiotherapy, and chemotherapy alone or in combination. All treatments may be considered palliative as published clinical cases report improvement of patient symptoms without any important prolongation in survival. Polonged survival is often possible only when a distal penile lesion or nodule is resectable; limited surgical excision or radiotherapy is usually the most useful modality. Partial or total penectomy will be required with highly invasive neoplasms involving the corporal bodies. Penile ulcer has to be taken out by local excision. However, surgical treatment is also recommended as an option after other treatments have failed and as a cure for intractable pain. A penile dorsal nerve block using local anesthesia may be of some benefit to control pain. Suprapubic urinary diversion would be the intended treatment for those patients with dysuria and urinary retention. Radiotherapy is used to reduce the size of the lesion as well as to improve pain control -10. SecoTumors metastatic to the penis are rare. Common primary sites are the genitourinary tract  and the lower gastrointestinal tract . Metastasis to the penis is extremely rare in squamous and non-squamous lung cancer. The fact that the penis often is not examined routinely leads to the low incidence of the disease. When recognized, penile metastatic lesions, regardless of the tumor origin, have traditionally been associated with advanced, metastatic, and disseminated disease and ominous prognosis. Palliative care and relief of symptoms must be the priority of the clinician since no treatment modality – surgery, radiotherapy, or chemotherapy alone or in combination – has been shown to significantly improve the overall survival. For patients with penile metastasis, the cancer-related death rate is still high. Since lung cancer remains the leading cause of cancer-related deaths worldwide and more penile metastases will be detected in the future, early detection and appropriate management of penile metastasis will be of great importance.Written informed consent was obtained from the patient for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT, Computed tomography; SCC, Squamous cell carcinoma; TTF-1, Thyroid transcription factor 1.The authors declare that they have no competing interests.CK was the main author of the paper and the referring radiologist. NP, EM, and CSB, radiologists, contributed to the manuscript by revising it and adding important information. DA and SL are assistant radiologists who contributed to analysis of manuscript data. NK is head of the histopathology department in our hospital. SX is head of the oncology department in our hospital. All authors read and approved the final manuscript.


Emergency surgery of the small bowel represents a challenge for the surgeon, in the third millennium as well. There is a wide number of pathologies which involve the small bowel. The present review, by analyzing the recent and past literature, resumes the more commons. The aim of the present review is to provide the main indications to face the principal pathologies an emergency surgeon has to face with during his daily activity. The small intestine is a complex organ with several functions. In fact it is capable of digestion, absorption and secretion, endocrine function and protects the internal environment against noxious ingested substances and against luminal bacteria and their toxins. The potential surface area available for digestion and absorption is amplified 600-times by circular mucosa folds, villus mucosal architecture and the microvillus surface of epithelium. Although specific properties are characteristic of specific segments of small bowel, like bile acid absorption in distal ileum, maximal resections are feasible without a significant morbidity because of the compensatory adaptation of remaining intestine. The small bowel measures about 120 cm in length from pylorus to ileocecal valve. The jejunum begins at ligament of Treitz. Jejunum and ileum are suspended by a mobile mesentery covered by a visceral peritoneal lining that extends onto the external surface of the bowel to form the serosa. Jejunum and ileum receive their blood from the superior mesenteric artery (SMA). Although mesenteric arcades form a rich collateral network, occlusion of a major branch of the SMA may result in segmental intestinal infarction. Venous drain is via the superior mesenteric vein, which then joins the splenic vein behind the neck of the pancreas to form the portal vein. Peyer's patches are lymphoid aggregates present on the antimesenteric border of distal ileum. Smaller follicles are present through all small bowel. Lymphatic drainage of intestine is abundant. Regional lymph nodes follow the vascular arcades and then drein toward the cysterna chyli. Jejunal and ileal wall consists of serosa, muscolaris, submucosa and, innermost, mucosa [®) with a follow-through study has not only a diagnostic but also a therapeutic role, because it is safe and reduces the operative rate and the time to resolution of obstruction, as well as the hospital stay [Acute mechanical obstruction of the intestine is a common surgical emergency and a major cause of admission to emergency surgery departments. Small bowel obstruction occurs when there is an obstacle to the flow of luminal contents caused by an extrinsic or intrinsic encroachment on the lumen . Adynamital stay -23. SurgThe role of laparoscopy in small bowel obstruction has still to be defined. Certainly, laparoscopy represents a diagnostic act and sometimes has a therapeutic role ,25. The Acute surgical emergencies in patients with inflammatory bowel disease are infrequent but may be dangerous for life. Crohn's disease is an important cause of small bowel acute surgery ,30-32. ITumors of the small bowel are a very rare entity, accounting for only 1% of all gastrointestinal neoplasms and 0,3% of all tumors -51. The Adenomas are the most common benign tumors of jejunum and ileum. Their histological subtype are either tubular adenomas with low malignant potential or villous adenomas with high malignant potential. Lipomas are more frequent in the ileum, have no malignant potential and do not require a surgical excision unless symptomatic.Malignant neoplasm present similarly to benign lesions. Diagnosis is often delayed conducing to advanced tumors, for whom surgical resection is rarely curative ,55-57. AGastrointestinal stromal tumors (GISTs) can arise anywhere in the gastrointestinal tract: 50-70% in the stomach, 20-40% in the small bowel, 5-15% in the colon and rectum, 5% in the esophagus and the omentum, and rarely in the mesentery or retroperitoneum ,63-67. TGastroenteropancreatic neuroendocrine tumors (GEP-NET) are a heterogeneous group of uncommon malignancies occurring in the gastrointestinal system. The incidence of GEP-NET is 2 to 3 per 100,000 people per year ,73. SympIntestinal involvement of metastatic cancer is common, mostly in the form of peritoneal carcinomatosis. Because of the continuous recirculation of peritoneal fluid through all the abdomino-pelvic cavity, small bowel is an elective site for peritoneal metastasis. All abdominal tumors can lead to peritoneal carcinomatosis, particularly colorectal cancer, ovarian cancer, gastric cancer, and primitive peritoneal neoplasms. The diagnosis of peritoneal secondary tumors as the cause of small bowel obstruction is often difficult. Obstruction in these circumstances never resolves by conservative treatment and surgical intervention is almost always indicated. Although peritoneal carcinomatosis has been for a long considered a terminal condition, in the latest years a new curative option consisting of extensive cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged for accurately selected patients -78.th to 7th week of life. It is localized on anti-mesenteric border of the distal ileum, usually 30-40 cm far from the ileo-cecal valve [Meckel's diverticulum is the most common congenital malformation of the gastrointestinal tract, interesting 2% to 4% of population . It is aal valve ,79,80. Mal valve ,80. Preoal valve ,79.Acquired jejunoileal diverticulosis (JID) is a rare entity often asymptomatic and treated conservatively. However, JID can develop a number of complications requiring acute surgical care -83. The Acute mesenteric ischemia (AMI) is an uncommon event, according for less than 1 case in every 1000 hospital admissions. Females are affected with three times the frequency of males and patients are usually between the age of 60 and 70 with several comorbidities . ArteriaPneumatosis intestinalis is the presence of gas within the abdominal wall of the bowel. Benign pneumatosis is an incidental finding without any underlying pathology. Conversely, when pneumatosis intestinalis is the result of primary intestinal pathology, urgent surgery is mandatory. The intramural gas can result from necrosis caused by ischemia, infarction, neutropenic colitis, volvulus, and necrotizing enterocolitis. Benign pneumatosis instead is related to a pulmonary source in patients with COPD, asthma, or cystic fibrosis. The intrathoracic air can dissect via the retroperitoneum and into the intestinal wall. It is generally accepted that patients with pneumatosis intestinalis associated with either bowel obstruction or ischemia usually require urgent surgery . The preSmall bowel ulceration is usually the result of ingested medications like enteric-coated potassium chloride, non-steroidal anti-inflammatory drugs, and corticosteroids ,95. ClinThe accidental or intentional ingestion of foreign bodies is not rarely observed in emergency departments. Although intestinal perforation is rare, the development of abdominal pain with tenderness and leukocytosis strongly suggests a perforation. In case of perforation, surgical resection is required, because antibiotic treatment is associated with chronic infection or stricture formation.The authors declare that they have no competing interests.VC, CoFe: Contributed both as first author, participating in study conception, in analysis and interpretation of data, in manuscript draft and revision and in giving the final approval.AL, CF, MG, SDS, PAD: Participate in manuscript draft and revision and in giving the final approval.


The aim of this work was to assess the periodontal support of a central upper incisor recovered through a surgical-orthodontic approach compared to the spontaneously erupted contralateral incisor.This case study describes an 8-year-old Caucasian female with an impacted upper right central incisor. Surgical-orthodontic treatment was performed to reset the impacted dental element in the arch. Periodontal probing was performed of all sites  of the recovered impacted tooth and the contralateral tooth. The results were compared to determine whether the treated element showed signs of periodontal injury.Most of the probing results on both her right and left incisors gave values of approximately 3mm, which were not considered pathological. Both dental elements had adequate and physiological osseous attachments. The eruption of permanent teeth in the arch is regulated by strict genetic control, which guides the correct formation of the various dental gems and their eruption in the arch in the expected position. Under certain anatomical conditions, trauma or infective processes involving the corresponding deciduous teeth may cause alterations of the eruptive process, preventing the tooth from appearing in the oral cavity within the physiological eruption time frame and in an ectopic position. A tooth is considered to be "impacted" when it has not appeared in the arch within the maximum time limit of its physiological eruption, its root apices are closed and, consequently, it lacks eruption ability. The incidence of dental impactions has been reported to vary between 5.6% and 18.8%, with a higher frequency in women-4.Several classifications can be used to evaluate the degree of the impaction of the dental elements. These classifications are based on different factors, such as the degree of impaction , number Several therapies are possible, including classic orthodontic treatment, combined surgical-orthodontic treatments, conservative surgery, and radical surgical treatment. In the Here, we describe the case of an 8-year-old Caucasian girl, in the mixed dentition period. An extraoral examination did not reveal facial asymmetry. Intraoral examination showed that her dental development was age-appropriate, except for the absence of her central upper right incisor. The probable cause of the lack of eruption of her incisor was connected to a traumatic event that occurred during her childhood. As reported in her anamnesis, she fell at approximately 2 years of age. This trauma caused the impaction of her deciduous upper central right incisor, producing a delay in the formation of the corresponding permanent tooth and subsequent impaction. No pathologies or situations that may cause eruption anomalies were noted from her family or medical history.To determine an adequate treatment plan, a panoramic radiograph of her arches and a projection teleradiograph of her cranium in the latero-lateral position were needed for cephalometric evaluations. The panoramic radiograph confirmed the suspected diagnosis; her upper right central incisor was impacted, the incisor radicular apex was closed, and the tooth was unable to erupt Figure . A combiDuring the first session, an impression was taken with a band on her upper sixth to create a splint with an eyelet in zone 11, which was used later to apply traction to her impacted tooth. The splint was cemented Figures  and3. AOnce her incisor reached the proximity of the correct eruption position, the splint eyelet was removed, and the button was replaced with a bracket that was later directly tied to the arch Figure . About 3We continued with orthodontic treatment via two Schwarz’s plates, to obtain a slow expansion of the arches and improve their shape, postponing the final alignment of dental elements to a later stage when dental development was completed Figure . After tg, held parallel to the apical surface, and moved along the tooth surface until resistance was encountered. The probing depth was read on the probe, using the height of the colored area with respect to the gingival margin as a reference[To check if there had been a loss of tooth osseous support, periodontal probing of her two central upper incisors was performed. We compared the measurements to establish whether her right incisor had received any periodontal damage during traction. With a healthy periodontium, the distance between the gingival margin and the underlying bone should not exceed 3mm. When periodontal disease develops, there is a loss in the tooth bony support that partially or totally involves the root. The resulting "periodontal pocket", or deepening of the gingival sulcus, is defined as pathological when the loss of attachment exceeds 4 to 5mm. A graduated periodontal probe, with a 0.5mm-diameter rounded tip and a colored area extending from 3.5 to 5.5mm, was used for probing. All her teeth and all levels  were probed. The probe was gently inserted in the tooth-gingival sulcus, with a force of about 25 to 30eference-9.The results of the probing are shown in Table The aim of this work was to assess the level of osseous attachment of an impacted tooth recovered through a surgical-orthodontic approach, compared to its spontaneously erupted contralateral counterpart. After recovering the included tooth through a fixed orthodontics treatment approach, periodontal probing of the recovered and contralateral incisors was performed to determine whether the treatment had caused serious osseous damage. The orthodontically recovered tooth had adequate periodontal support that was very similar to that of the contralateral tooth. The probing results were physiological and demonstrated that no loss of osseous support had occurred. This result was due to a good surgical exposure, which was achieved as conservatively as possible. The periodontal tissues were respected throughout the treatment. Finally, the orthodontic treatment used anchorages and light and constant forces, without damaging the tractioned tooth or the adjacent teeth.Written informed consent was obtained from the patient's guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.MTD conceived of the study, and participated in its design and coordination and helped to draft the manuscript. ML conceived of the study, and participated in its design and coordination and helped to draft the manuscript. SDM conceived of the study, and participated in its design and coordination and helped to draft the manuscript. AM conceived of the study, and participated in its design and coordination and helped to draft the manuscript. GM conceived of the study, and participated in its design and coordination and helped to draft the manuscript. MTD, ML and SDM were involved in the writing of the manuscript, GM had the idea for the manuscript, and AM reviewed the manuscript. All authors read and approved the final manuscript.


Liposarcomas represent a significant proportion of soft-tissue sarcomas. However, their occurrence in the head and neck is infrequent and they are exceedingly rare in the retropharyngeal space. The present study reports the case of a 58-year-old patient with retropharyngeal liposarcoma. Uniquely, the patient presented with rapidly worsening dyspnea. The diagnosis of liposarcoma was established following retropharyngeal tumor excision, although biopsies were performed twice. Adjuvant radiotherapy was refused by the patient. However, during the post-operative follow-up period, no sign of either local tumor recurrence or distant metastasis was observed. Previously reported cases were also reviewed to analyze the diagnosis, treatment and prognosis of this disease. Liposarcoma is the most common type of soft-tissue sarcoma. However, head and neck liposarcomas are unusual, accounting for only 1.8–6.3% of cases . Unlike A 58-year-old male patient presented with rapidly worsening dyspnea and total dysphagia occurring within several hours. Three years earlier the patient had noted bilateral neck swelling. The swelling grew slowly and one year later the patient developed mild dysphagia. As the patient was unaware of the potential severity of the symptom, a prompt examination and treatment were not provided. This symptom did not markedly progress until the occurrence of a traffic accident. Due to this accident, the patient underwent tibiofibular fracture surgery at a local hospital. Post-operatively, the patient recovered well and ate as usual. However, three days subsequent to the surgery, the patient suddenly developed rapidly worsening dyspnea and total dysphagia. Attempts at intubation failed, so a tracheostomy was performed under local anesthesia. The patient was then referred to the Department of Otolaryngology . A physical examination revealed an extremely large, soft, non-tender mass measuring ∼11×10×8 cm, involving the bilateral neck. A laryngoscopy showed a retropharyngeal mass that was reducing the space of the pharynx. A computed tomography (CT) scan of the neck revealed a large, well-circumscribed, fatty, dense mass measuring 11×11×9 cm, which extended from the retropharyngeal space to the sides of the neck and from the level of the hyoid bone to the superior margin of the mediastinum. The mass displaced the trachea and larynx anteriorly and the carotid arteries laterally. The mass was not enhanced following contrast agent administration . Due to An ultrasound-guided core biopsy of the mass revealed histological components of fibrous, vascular and fatty tissues. An incisional biopsy of the lesion was then performed with the patient under local anesthesia. The histology indicated a vascular fibrous lipoma. Subsequently, a surgical excision of the retropharyngeal mass was performed under general anesthesia using an H-shaped incision. The tumor was well-encapsulated and adhered to the posterior pharyngeal wall. The tumor was subsequently resected completely and measured as weighing 401 g . The posDuring the post-operative course, the patient developed vocal hoarseness. A laryngoscopy revealed right-sided vocal fold weakness, which the patient recovered from one month later. The patient was decannulated and the nasogastric tube was removed. Upon follow-up at 20 months, there were no signs of either local tumor recurrence or distant metastasis.The retropharyngeal space is the potential space lying between the prevertebral fascia posteriorly and the buccopharyngeal membrane covering the constrictor muscles anteriorly. It extends from the skull base to the mediastinum. The retropharyngeal space is separated from the parapharyngeal space by a thin fascial layer and closed by the internal jugular vein, common carotid artery and vagus nerve. Liposarcomas usually present as painless enlarging masses and when they arise in the retropharyngeal space they are difficult to detect early and are usually discovered incidentally. Patients with a retropharyngeal mass usually present with dysphagia and foreign body sensation and when these symptoms are not as clear the patients may become habituated to their symptoms. Physical findings include bilateral neck swelling and a reduced anteroposterior diameter of the pharynx, although these do not appear until the tumors have reached a large size –5. In thet al indicated that well-differentiated liposarcomas are frequently diagnosed in CT or MRI scans, with a largely lipomatous mass (>75% of the lesion) and non-lipomatous components in thick septa or focal nodules (Lipocytes of various shapes and sizes with nuclear atypia indicate a diagnosis of liposarcoma. The classification proposed by Enzinger and Weiss is widely accepted and has been adopted by the World Health Organization. This classification identifies four subtypes of liposarcoma: well-differentiated, myxoid, dedifferentiated and pleomorphic . The his nodules . The ide nodules ,9. Myxoi nodules . However nodules –5. In reet al observed that adjuvant radiotherapy significantly decreased the rate of local recurrence of head and neck sarcomas (The principal management approach for liposarcoma is wide surgical excision. However, in the head and neck, the lesion is usually close to vital neurovascular structures, so the extent of surgical excision is restricted to avoid severe complications and the use of adjuvant radiotherapy is increasing. Certain studies have demonstrated the effect of radiotherapy in reducing the rate of local recurrence of liposarcomas . Eeles esarcomas . Our presarcomas . Howeversarcomas . The majsarcomas ,15.Among the various series of retropharyngeal liposarcomas in the literature, only one patient received adjuvant radiotherapy in the initial treatment and the follow-up revealed no evidence of recurrence . Among tThe major prognostic factor for liposarcoma is the histological subtype. Well-differentiated liposarcoma is the most common subtype of all liposarcomas, recurring locally, but rarely metastasizing . PatientAlthough all six reported cases of retropharyngeal liposarcoma were of the well-differentiated subtype, certain characteristics of this unusual tumor may affect the prognosis due to its unique localization. Late detection may provide sufficient time for tumor invasion and metastases to occur. Misdiagnosis may lead to the diagnosis of a benign lesion, which may result in a limitation of the extent of surgical excision. In addition, liposarcomas located in deep anatomical sites, including the retroperitoneum and mediastinum, have a relatively unfavorable prognosis . This maIn conclusion, although well-differentiated liposarcoma is the most common subtype of liposarcoma and has an improved prognosis, retropharyngeal liposarcoma has a number of unfavorable prognostic factors due to its unique localization. No adequate evidence has demonstrated the value of adjuvant radiotherapy for treating retropharyngeal liposarcomas. However, for liposarcomas, adjuvant radiotherapy has been shown to decrease the rate of local recurrence in a number of literature studies.


Giant hepatic hemangiomas, though often asymptomatic, may require intervention if rapid growth occurs. The imaging studies including the computed tomography, magnetic resonance imaging, and ultrasonography, and so on are effective for the diagnosis and the management of this tumor; however, due to its size and various patterns of these studies, we need to carefully consider the therapeutic methods. Compared to the cost needed for these modalities, recently developed and approved Perflubutane- (Sonazoid-) based contrast agent enhanced ultrasonography is reasonable and safe. The major advantage is the real-time observation of the vascular structure and function of the Kupffer cells. By this procedure, we can carefully follow the tumor growth or character change in a hemangioma and decide the timing of therapeutic intervention, since abdominal pain, abdominal mass, consumptive coagulopathy, and hemangioma growth are the signs for the therapeutic intervention. We reviewed recent reports about Sonazoid-based enhancement and also showed the representative images collected in our department. This is the first review showing the detailed findings of the giant hemangiomas using Perflubutane (Sonazoid). This review will help the physician in making the decision, and we hope that Sonazoid will gain widespread acceptance in the near future. Hepatic hemangiomas are the most common benign tumors of the liver and usually do not grow . In caseHepatic hemangioma is the most common benign liver tumor and typically remains stable in size . HepaticSonazoid is the recently developed and approved phase contrast agent for the contrast-enhanced US. It is a powerful modality for the various liver tumors. Since the US is safe, inexpensive, has few side effects, and can obtain real-time images comparable to those of dynamic CT, it is useful for achieving meticulous follow-up care of various liver tumors, including giant hepatic hemangioma patients. This agent also provides the function of Kupffer's cells inside of the tumors; therefore, we can determine the possible malignancy. In this section, we show the representative images obtained from 2 tumors in our department.Representative images from tumor 1: multidetector CT (MDCT) revealed a giant hepatic hemangioma, 17 cm in maximum diameter, replacing the right lobe of the liver Figures . The hemRepresentative images from tumor 2: MDCT showed a huge hypodense mass in the right lobe of the liver measuring approximately 6 cm. In Sonazoid contrast-enhanced US examination , the imaContrast-enhanced US with Sonazoid is a useful modality for differentially diagnosing hepatic tumors , 7. GianWe are performing Sonazoid contrast-enhanced US on giant hepatic hemangiomas for the effective followup of the tumors. The giant hepatic hemangioma in representative tumor 1, when observed with Sonazoid contrast-enhanced US , showed In conclusion, even giant hepatic hemangiomas usually have nearly the same Sonazoid contrast-enhanced US findings as hepatic hemangiomas with smaller diameters. We observed the “cotton wool-like pooling” finding on Sonazoid contrast-enhanced US of giant hepatic hemangioma to be similar to the image obtained by angiography. This appears to be a very important image for understanding the histological structure of hemangioma. Moreover, Sonazoid contrast-enhanced US is also expected to be useful for the identification and examination of multiple liver hemangiomas. Although the ultrasonic contrast agent Sonazoid is currently a powerful and easy-to-use tool for diagnosis and meticulous follow-up observation of giant hepatic hemangioma, it is, unfortunately, only available in Japan. It is hoped that Sonazoid will gain widespread acceptance in the future.


Musculoskeletal hydatid cysts are rare, but being locally invasive, can potentially cause significant deformity or pathological fracture.A 39 y.o. male presented to our orthopaedic outpatient clinic complaining of severe right hip pain, and inability to ambulate. Symptoms were not preceded by trauma. Subsequent imaging confirmed a large, 17 × 3 × 5 cm echinococcus cyst in the vastus lateralis, causing erosion of the proximal metaphysis of the femur. As a consequence the patient suffered a non-traumatic pathological intertrochanteric femur fracture. The patient was treated with an en-bloc excision of the lesion - the affected soft tissue envelope containing the large cyst - and as a second surgical step a cemented total hip replacement (THR) was implanted under the same anaesthetic.The manuscript reviews the literature regarding musculoskeletal hydatid disease. Among Echinococcus species, E. granulosus and E. multilocularis are commonly reported to be responsible for human hydatidosis. The endemicity of this parasitic infection may vary across countries. Echinococcus larvae develop in cystic form, mostly in the liver or the lungs. The involvement of other organs, and particularly the muscles, is relatively rare. Only 0.5 to 2% of hydatid cysts are skeletally localized .In this paper we report a rare case of a hydatid cyst located in the soft tissues of the right thigh and involving the proximal femur.A 39-year-old male was referred by his family physician to our out-patient clinic, complaining of right-sided thigh pain. He had recently moved to our region from Romania (a hyperendemeic area for echinococcosis) and worked as a shepherd.His previous history included a routine right sided inguinal hernia repair, because of persistent groin pain 9 years previously. As there was no symptomatic improvement after his hernia repair anterior-posterior and lateral radiographs of the affected hip were obtained, showing a cyst in the femoral neck. A few months after the hernia repair, the cyst was explored, curreted and the cavity was bone grafted using corticospongiosus autograft from the iliac crest. The histological examination from the excised tissue showed the presence of Echinococcus granulosus.The radiographs taken at his recent presentation, 8 years after the previous surgery, showed a multiloculated cyst around a previously implanted cortical screw, which was fixing the bonegraft Figure .E. granulosus. Blood tests showed a high serological titer for E. granulosus, but otherwise normal values. To investigate for other potential parasitic sites a CT scan of the brain, skull, chest, abdomen and pelvis was performed, with special attention to the right thigh. The scan confirmed a large (17 × 3 × 5 cm) cyst in the anterolateral part of the proximal thigh within the vastus lateralis  approach, with distal extension. During the first part of the procedure an en-bloc excision of the cyst was performed. The lesion was localized between the vastus lateralis and rectus femoris muscles. It had eroded the anterior cortex of the proximal metaphysic, just above the lesser trochanter. After thorough debridement, an adjuvant was used, which is well-established in tumor surgery. The bony bed was exposed to a concentrated phenol solution (70%) via a soaked gauze, followed by copious lavage with a concentrated alcohol solution. No spillage or anaphylaxis was observed during the first part of the procedure.During the second stage of the procedure, a cemented THR was implanted using an Aesculap implant . The patient received oral Mebendazole , 400 mg bid, preoperatively for 5 days. Unlike with intraabdominal pathology, preoperative chemotherapy was only possible for a short period of time, as emergent fracture treatment was necessary. The chemotherapy was continued for 6 weeks postoperatively using the same agent and dose (Mebendazole). The role and length of post-operative adjuvant chemical therapy in musculoskeletal hydatid disease is unclear. In alveolar echinococcosis, it is recommended that chemotherapy is continued for up to 2 years after surgery. The role of life-long chemosuppression is being explored [Several samples were taken intraoperatively. The histopathological examination confirmed the suspected diagnosis Figure  and 5. TE. granulosus infect humans, as an intermediate host, giving rise to cystic lesions, which are most frequently found in the liver and the lungs, but very rarely in bone (0.9-2.5%) [E. granulosus larvae develop via exogenous vesiculation in bones, due to the mechanical stress present. This can eventually lead to mechanical weakening and destruction of the bone trabeculae. The lesions are infiltrative in nature and progress slowly, with the development of numerous microvesicles, but without the parasite encysting. The clinical signs are nonspecific and location-dependent.Echinococcosis (or hydatid disease) is a parasitic disease usually infecting mammals . The disease has a worldwide geographical distribution, with clear evidence of the emergence of the condition in parts of eastern Europe . In its .9-2.5%) . The E. In many respects, the disease is reminiscent of chronic osteomyelitis, fibrous dysplasia, osteosarcoma, benign cystic bone lesions, lesions caused by hyperparathyroid tumors and other neoplastic lesions . Due to In case of bony involvement, the disease has a high recurrence rate of 50%. It however, almost never recurs if the primary lesion is in muscle - 0% . If muscLocally aggressive, benign bone tumors require specific techniques to avoid recurrence, thus the experience from their treatment can be used as an analogy for the treatment of musculoskeletal hydatidosis. Surgeons usually perform intralesional curettage, together with some form of adjuvant therapy . The most commonly applied adjuvant therapies/procedures are cautery, high-speed burring, exothermic cement polymerization and the use of certain solutions  ,11. CapaIn our specific case, wide, radical surgical excision of the cyst would have necessitated removal most of the proximal metaphysis, and hence the implantation of a tumorprosthesis.In view of the patient's age and active life style, we opted to perform an en-bloc excision with a relatively small safe zone, thus sparing both trochanters (with the abductors) and the calcar. To reduce the likelihood of recurrence, 70% phenol solution was used as an adjuvant. The exothermic reaction of cementing can also contribute in preventing recurrence. Using a more limited excision, perhaps carries a higher risk of recurrence. In a young and active patient if the disease recurs, a tumoprosthesis remains a surgical option as a revision procedure. A THR provides a significantly better quality of life in the short term.The necessary long and extensive surgery carries a higher risk of infection and sepsis, with a substantial risk of death . The useIn the current English language literature, there are only two cases describing the removal of a primary echinococcus cyst which was eventually followed by successful hip replacement several years later ,15. ReplWe were unable to find a case report describing a primary echinococcus cyst causing a pathological femoral neck fracture where a single operation was successfully used to treat the cyst and to implant a THR.THR: Total Hip Replacement.The authors declare that they have no competing interests.All authors contributed to this work. JC, LB, KS, KT were involved in the direct clinical care  of the patient and/or the preparation of this manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/11/103/prepub


We herein report a patient with acute appendicitis who was diagnosed by colonoscopy: a 54-year-old woman with normal physical examination and laboratory results within normal limits. The case had shown an erythematous and edematous bulging polypoid lesion with purulent discharging from appendiceal orifice into the cecum. At colonoscopy, appendix appeared as an erythematous and edematous bulging polypoid lesion with purulent discharging from appendiceal orifice into the coecum. Surgeons exclude any emergency. Two weeks later, a colonoscopic second look was performed, and the same bulging polypoid lesion was found but without spontaneous purulent discharging. Appendiceal endoscopic pus drainage was then performed. A 54-year-old woman was referred for upper endoscopy for dysphagia. She had a history of esophagectomy with coloplasty for stenosis due to corrosive injuries 5 years ago. Physical examination was normal and laboratory results were within normal limits. Upper endoscopy showed an anastomotic esophageal-colonic stricture with a big diverticulum on the coloplasty. At this moment, our patient receives antibiotherapy for urinary infection. Three days later, there was no diverticulum and the colocolic anastomosis was without abnormalities at colonoscopy, but an erythematous and edematous bulging polypoid lesion  with purIt is an atypical case of acute appendicitis diagnosed and treated at colonoscopy, while initial presentation was without any suggestive symptoms. The diagnosis of acute appendicitis is frequently based on clinical criteria and often supported by results from simple blood tests. Ultrasonography and/or computed tomography are the main appropriate imaging modalities . For del


Bleeding per rectum is a common complaint in pediatric age group and mostly relates to benign conditions. Underlying colorectal carcinoma is a rare cause and carries a poor prognosis. We report two cases of mucinous adenocarcinoma of colon, one in a 9 years old male and other in a female of 12 years. The boy presented with rectal bleeding and increasing constipation of more than three years duration. He had mucinous adenocarcinoma (T3N0MX) of rectosigmoid region and underwent local complete resection of the tumor with colostomy. He also received postoperative chemotherapy and later underwent colostomy reversal. He is tumor free at two years follow up. The girl presented with signs of intestinal obstruction and at colonoscopy a stricture found in descending colon. The tumor was resected and biopsy reported as poorly differentiated mucinous adenocarcinoma with positive mesenteric nodes positive for tumor (T3N2MX). She is on chemotherapy. Adenocarcinoma of colon is a rare cause of rectal bleeding in the first decade of life. The reported incidence of this malignancy is about 1.3 -2 per million children. This tumor in pediatric age group shows a different behavior than adults and is associated with poor outcome. Literature is scarce on this condition in children from regional countries. Few cases have been reported from West and India . Here we report two cases of mucinous adenocarcinoma of colon with short term follow up highlighting various aspects of the condition and management provided. Case 1: A nine year boy weighing 18 kg, presented with bleeding per rectum, occasionally mixed with mucus, something coming out of anus, and constipation for three years.There were also complaints of passage of worms (ascaris lumbricoides) through nose and per anum, off and on fever, and significant weight loss during this period. For these problems he remained under treatment elsewhere but did not improve. With the suspicion of rectal polyp patient was referred to surgical department.Patient belonged to a low socio economic class and had six other siblings. Family history was insignificant though mother had episodes of bleeding per rectum for two years. Child was of thin built with severe anemia. On digital rectal examination a large fixed fungating mass, obscuring the lumen of rectum, felt at the tip of the finger. His hemoglobin was 4.4gm/dl. Patient received multiple blood transfusions. A small incisional, per rectal, biopsy taken from the fungating mass revealed mucinous adenocarcinoma of colon. In the meantime child was further investigated. Serum LDH was 680u/l. Carcinoembryonic antigen (CEA) was not done because funds were not available. Ultrasound abdomen, bone scan and chest x-ray were reported as normal. CT scan pelvis showed a soft tissue mass, 2.8 cm wide and 3 cm long, with rectal wall thickness of 1.2 cm and enlarged para-aortic lymph nodes. Rest of the abdomen and pelvis were reported as normal.Case was discussed with oncologist and after optimization and thorough counseling regarding the surgical option patient underwent laparotomy. Approximately 5 cm long sessile fungating lesion, situated at recto-sigmoid junction with moderately enlarged mesenteric lymph nodes was found. Rest of the abdomen was free of any metastasis. Tumor was excised along with segmental resection of the gut, with 2 cm proximal and 0.5 cm distal normal tissue beyond the margins of the lesion . End proximal colostomy with distal Hartmann’s procedure was performed. Postoperatively patient did well except for few episodes of loose motions that was managed conservatively. He was discharged home on 8th postoperative day. Histopathology report showed mucinous adenocarcinoma with clear margins of the resected bowel. Lymph nodes removed at operation were tumor free.Patient received six cycles of chemotherapy (5 fluorouracil and leucovorin). CT scan repeated three months after completion of chemotherapy, showed rectal wall thickness of one cm with multiple small lymph nodes in the vicinity. Further workup did not show any signs of recurrence or metastasis. Colostomy was closed after one year of initial surgery. Patient is under periodic follow-up and doing well with no recurrence or complications after two and half years of tumor resection.Case 2: A twelve years old female presented with recurrent episodes of abdominal pain, bleeding per rectum, and vomiting since the age of 4 years. For these complaints she received medical treatment in her native city. She was admitted in hospital received multiple blood transfusions but diagnosis could not be established. Her grandfather died of bleeding per rectum and no record of illness was available. Patient had colonoscopy six month earlier which showed stricture with suspicion of growth in descending colon . Biopsy was taken but reported as inconclusive. Later an ultrasound was done which showed a 2.7 cm x 2.2 cm gut related mass. CT scan revealed stricture with bowel thickening at the level of descending colon . There was no significant para-aortic and mesenteric lymph node involvement. Her CEA was 1.87 ng/ml and bone scan was negative for tumor metastasis. She was then referred to surgical department. She underwent laparotomy and resection of local tumor and regional lymph nodes was done. Divided colostomy was made. Patient did well in post-operative period. Biopsy revealed poorly differentiated mucinous adenocarcinoma of descending colon with margins of resected specimen free of tumor. There was significant lymph nodes involvement. Pathological TNM classification was, T3N2MX. Currently patient had received 2 cycles of chemotherapy (5 fluorouracil and leucovorin). She had single episode of intestinal obstruction during this period and in last follow up had complaints of mild dyspnea, chest and abdominal pain. She is under workup for residual disease and spread of tumor.Colorectal cancers, though rare, but do occur in pediatric age group. Youngest patient reported was of 9 months. From Pakistan a report of patient above 11 years of age was found on literature search. Based on scanty data available, most of the colorectal cancers in children are reported as sporadic in nature while familial cases do occur . Though not investigated, both of our patients had relatives with history of bleeding per rectum. The mother of the case one never consulted for per rectal bleeding while grandfather of case 2 had some treatment for his bleeding but no record was available.Most of the tumors in colon are mucinous adenocarcinoma and bear poor prognosis. In children it is rapidly growing tumor, mostly presenting at advanced stage and five years overall survival is reported to vary between 7 to 12% . Usually in pediatric age group patients have an early onset, short duration  and are at an advanced stage of disease when seek consult from a physicians. According to a study from United States approximately 86% presented in advanced stages.Most common presentation is with intestinal obstruction (up to 60% of cases), same occurred in our case 2. Abdominal pain, fever, bleeding per rectum, anemia, and unexplained weight loss are also the common symptoms . Both of our patients had similar symptoms for three years prior to diagnosis. In case 1 disease was still confined to the bowel wall with no signs of acute or complete intestinal obstruction which is contrary to general concept of colonic adenocarcinoma in childhood. Contrary to Western literature, cases from developing countries showed more of left sided tumors [8]. Similar was the observation in both of our patients, adding evidence to this behavior. Tumor markers like CEA are of no help as documented in literature in pediatric age [2]. This was also true for our case 2, who had normal levels.These cases are usually missed because most of the children remain under treatment for other benign conditions causing bleeding per rectum or constipation rather than suspicion of malignancy. This could be the reason for misdiagnosis. As no large series is available in pediatric population, treatment is thus based on the adult disease protocol. It depends upon the presentation and stage of disease. Till now surgery remained the mainstay of the treatment. Chemotherapy and radiotherapy are used as adjunct modes for the control of local and distant metastasis and recurrence. Sometimes neo-adjuvant chemotherapy may also be used to shrink the tumor size and facilitate resection. Segmental resection of the gut with end to end anastomosis is the preferred option in early stage of tumor after achieving clear margins. When tumor is non-resectable with local metastasis beyond lymph nodes, incisional biopsy with neoadjuvant chemotherapy is advised. In cases of obstruction and non-resectable tumor, permanent colostomy is preferred. In cases where tumor is resectable but with doubtful margins, as in our case, segmental excision with temporary stoma are advisable followed by chemotherapy [1-3].Although CT scan, gives a good clue of tumor stage a decision of resectibility can only be made per-operatively. It is therefore important to have a thorough counseling of the patient and parents regarding every possible option of surgical procedure. It is very difficult to accept a permanent stoma for these young children and sometimes they are lost to follow up. It took very long for us to convince the patient’s families for surgical procedures but once they understood the course became easy.Patient 1 responded to adjuvant chemotherapy very well. Although, he is tumor free for more than two years, recurrence of disease is very much documented in literature [6]. Now it is an important challenge to follow him regularly for early detection of recurrence, if occurs. In second case residual tumor in lymph nodes changed the stage of the disease and chances of abdominal organ system involvement shall remain. Thus a vigilant follow up is mandatory in this case as well.In conclusion, children with vague abdominal symptoms and bleeding per rectum should not be taken lightly. Digital rectal examination can be of great help if malignancy is suspected. A thorough investigation is required in doubtful cases. Effective counseling of the patient and family is very important. Collaboration between the physicians, surgeons and oncologists for early diagnosis and control of disease, cannot be underestimated. Source of Support: NilConflict of Interest: None declared


Angiosarcoma is a rare vascular malignant soft tissue tumor, with highly malignant, invasive, and multifocal characteristics of biology, which is prone to local recurrence and distant metastasis, so the prognosis is extremely poor. It rarely involves the diaphragm. We present the case of an adult patient who had a primary giant angiosarcoma of the left-sided diaphragm. Angiosarcoma is a rare vascular malignant tumor originat-ing from the endothelial cells in small blood vessels, which represents 1-2% of soft tissue tumors . ClinicaA 58-year-old woman had a left-sided chest distress and short breath for more than one month duration. No other symptoms such as fever, ague, cough, emptysis, hemoptysis, night sweat, and fatigue were detected. High-density shadow was found in lower left chest after chest film examination, and the further CT revealed a mass opacities with inhomogeneous density and slight enhancement in lower left thoracic cavity, and no mediastinal lymph nodes, as well as a small amount of effusion see . We founUpright fluorescence microscope was used for watch. Biopsy of the lesion showed irregular channels and ecstatic vascular spaces lined by plump hyperchromatic endothelial cells. The histology results were most compatible with moderately differentiated angiosarcoma, as shown in After surgical treatment, the patient recovery was smoothly. Due to the multifocal and invasive characteristic of angiosarcoma, and combined with limited resection of the left-sided diaphragm, radiotherapy postoperatively 3 weeks later was used. The patient was treated by 3-dimensional conformal radiotherapy (3DCRT), the clinical target including the left side of diaphragm and the part of the lung tissues which adhered to the angiosarcoma. A dose of 60 Gy in 2 Gy fractions was given to 90% isodose volume in 3DCRT. In view of the effect is not clear, postoperative chemotherapy was not used. She was good by following up in outpatient department, and CAl25 was significantly decreased to 63.0 U/mL one month after radiotherapy.Angiosarcoma with low morbidity and high invasiveness is evolved from endothelial cells or their derivatives of mesenchymal cells. Its incidence may be related to these factors, such as long-term chronic lymphedema, ionizing radiation, chemical exposure, trauma, and chronic infection , but theClinical manifestations of angiosarcoma are diverse, and its clinical features and imaging findings are different from different parts , 5. The The diagnosis of angiosarcoma mainly depends on the histomorphological checks, and the immunohistochemistry has great significance for the diagnosis and differential diagnosis of angiosarcoma –7. Vimen∼70 Gy in order to achieve a better curative effect [There is still no standard therapeutic method of angiosarcoma to follow. Surgical treatment, radiotherapy, chemotherapy, immune therapy, and other comprehensive therapy treatment are often adopted. Surgical excision is the main treatments of angiosarcoma. Radiotherapy or chemotherapy before or after the operation may reduce the local recurrence and metastasis , 10, 11.e effect . In thisThe prognosis of angiosarcoma is bad , 5. The


Duodenal gastrointestinal stromal tumors are uncommon and a relatively small subset of gastrointestinal stromal tumors whose optimal surgical procedure has not been well defined. Because submucosal spread and local lymph node involvement are infrequent in gastrointestinal stromal tumors, wide margins with routine lymph node dissection may not be required. Various surgical procedures for duodenal gastrointestinal stromal tumor, pancreatoduodenectomy, pancreas-sparing duodenectomy, segmental duodenectomy, or local resection, have been described depending on the size and exact site of the lesion.We present the case of a 65-year-old African woman with a giant gastrointestinal stromal tumor involving the second and third portion of the duodenum successfully treated by partial duodenectomy with duodenojejunostomy. This surgical technique is ideal when a gastrointestinal stromal tumor does not involve the ampulla because it avoids a pancreatoduodenectomy, and has not been previously described for the management of this malignancy. Duodenal gastrointestinal stromal tumor should be suspected in any patient with a duodenal wall mass.Gastrointestinal stromal tumors of the duodenum should be suspected in any patient with a duodenal wall mass. Extramural growth and central ulceration with or without bleeding should alert the endoscopist to the possibility of a duodenal gastrointestinal stromal tumor diagnosis. Only 3% to 5% of gastrointestinal stromal tumors (GISTs) are located in the duodenum. They are associated with an increased risk of fatal gastrointestinal bleeding, which is a primary manifestation ,2. A smaA 65-year-old African woman presenting with abdominal pain was referred to our hospital. Her medical history and family history were unremarkable. She had no history of previous abdominal surgery. On examination she looked healthy with no clinical jaundice or pallor. An abdominal examination revealed a large upper abdominal mass with thinned overlying skin. It had minimal mobility and was not tender. The rest of the examination was normal. Her hemoglobin, on admission, was 7.0g/dL. She was transfused and underwent an esophagogastroduodenoscopy, which revealed a submucosal tumor at D2 and D3. A biopsy was obtained but was reported as nonspecific. A computed tomography (CT) scan of the abdomen revealed a 12×13cm retroperitoneal mass in the region of the head of the pancreas Figure . TherefoGISTs are defined as mesenchymal tumors arising from the gastrointestinal wall, mesentery, omentum or retroperitoneum. GISTs can be located anywhere in the gastrointestinal tract. The most common sites are stomach 40% to 60%) and small intestine 30% to 40%) 0% to 60% and ther0% to 40%Duodenal GIST should be suspected in any patient with a duodenal wall mass. Extramural growth and central ulceration with or without bleeding should alert the endoscopist to the possibility of this diagnosis. There is more than one surgical approach available, but the absolute requirement is complete surgical excision. Preoperative imatinib mesylate can be considered in unresectable or borderline resectable cases.Written informed consent was obtained from the patient for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CT: Computed tomography; GIST: Gastrointestinal stromal tumor; MRI: Magnetic resonance imaging.The authors declare that they have no competing interests.All of the authors were involved in the preparation of this manuscript. OM performed the operation and revised the manuscript. LC described histological finding and was involved in drafting the manuscript. All authors read and approved the final manuscript.


Granulocytic sarcoma also known as extramedullary myeloid sarcoma or chloroma is an uncommon manifestation of leukemia and presents as a deposit of leukemic cells outside the bone marrow. We report a case of a twenty-five-year-old pregnant woman who presented with progressive dysphagia and recurrent postprandial vomiting. Upper GI endoscopy had shown large flat laterally spread nodular lesions in the cardia and proximal body of stomach. Biopsies from the gastric lesion showed granulocytic sarcoma of the stomach. Concurrent peripheral and bone marrow picture was suggestive of acute myeloid leukemia (AML–M4). There is limited reported literature on granulocytic sarcoma of the stomach. Concurrent gastric granulocytic sarcoma involving cardia and AML in pregnancy has not been reported till date. Granulocytic sarcoma also known as chloroma or extramedullary myeloid tumor is a collection of leukemic cells outside the bone marrow. These tumors occur in 3–8% of acute nonlymphoid leukemia. The common sites affected by it are skin, lymph nodes, central nervous system, and reproductive organs. Involvement of gastrointestinal tract is relatively rare with small bowel being the commonest site. We report a case of gastric myeloid sarcoma in a young female at 17 weeks of gestation presenting with dysphagia, epigastric pain, and vomiting.A 25-year-old woman with 17 weeks of gestation (G3P2) presented with progressive dysphagia, epigastric discomfort, persistent postprandial vomiting, and weight loss for one month. Initial investigations were within normal limits. Upper GI endoscopy showed thickened nodular friable mucosa at cardia of stomach extending into the posterior wall . MultiplGranulocytic sarcoma is a rare malignant solid tumor composed of primitive precursors of the granulocytes deposited outside the bone marrow. It was called “chloroma” due to its green color. Rappaport renamed it “granulocytic sarcoma” because the color varied depending on the concentration of the pigmented enzyme (myeloperoxidase). It is more common in children than adults and often occurs concurrently with AML. They rarely present with relapse of leukemia, in blast crisis of myeloproliferative disorder, as leukemic transformation in myelodysplastic syndrome . Granulo The endoscopy findings can vary from normal to mucosal nodularity or mass lesions. It may precede hematologic leukemia by months or years . Tissue Systemic intensive chemotherapy is the first line of treatment . Our pat