The Muir-Torre syndrome is a rare autosomal dominant condition and is currently considered a subtype of the more common hereditary nonpolyposis colorectal cancer syndrome, in which multiple primary malignancies occur together with sebaceous gland tumors.We describe a case of a 62-year-old woman with three primary colorectal tumors, genital tumor, and sebaceous adenomas and present her family history of three generations. Our case represents the first case reported from Greece in the international literature.Recognition of the syndrome in patients with sebaceous gland tumors should facilitate early detection of subsequent malignancies if the patient is entered into appropriate screening programs. Distinguishing cutaneous signs, which are associated with hereditary cancer syndromes, are known as cancer-associated genodermatoses. The Muir-Torre syndrome (MTS) is an example, and is defined by the combination of at least one sebaceous adenoma, epithelioma or carcinoma and at least one visceral carcinoma occurring in the same individual in the absence of other precipitating factors such as radiotherapy or AIDS . IndividA 62-year-old woman with a past history of adenocarcinoma of the rectum and genital cancer, underwent abdominoperineal resection with a permanent left ostomy and total hysterectomy in the age of 37. Some 9 years later she was found to have colonic polyps with malignant transformation and was treated by surgical resection (colotomy and polypectomy).In 1993 and 1997 she was found to have benign colonic polyps which were excised endoscopically, and in March and June 2003 she was referred to our surgical outpatient department with subcutaneus lesions, first on the left side of the abdominal wall and then on the right buttock. The lesions were excised under local anesthesia and were reported to be sebaceous adenomas, and the diagnosis of the Muir-Torre syndrome (MTS) was suggested. Ever since the patient was commenced on surveillance program that included annual clinical examination, CEA evaluation, chest radiography, urine cytology, colonoscopy and mammography.3N0M0, Dukes B). Screening tests for further malignancies, including chest radiography and upper GI endoscopy were all negative, and none of the tumor markers were elevated.In June 2005, an adenocarcinoma of the ascending colon was detected. An abdominal computed tomography (CT) scan showed no evidence of metastatic disease or paraaortic lymphadenopathy. A right hemicolectomy was performed, and the pathology report confirmed a poorly differentiated mucinous adenocarcinoma .All family members were suggested to undergo endoscopy and dermatological surveillance. A pedigree of four family generations is shown in Figure et al in their review study identified a total of 205 reported cases in the world literature [The Muir-Torre syndrome was independently described by Muir in 1967 and Torre in 1968, and has since been recognized as a subtype of Lynch Type II hereditary nonpolyposis colon cancer (HNPCC) ,5. AkhtaClinically the diagnosis of MTS is based on the presence of at least one sebaceous gland tumor associated with at least one primary visceral malignancy, as it happened in our case. Alternatively, diagnosis of the syndrome can be made if the patient has multiple keratoacanthomas with multiple internal malignancies and a family history of MTS . Muir-ToTypical skin tumors associated with this syndrome include sebaceous adenomas, epitheliomas and carcinomas. Keratoacanthomas and basal cell carcinomas with sebaceous differentiation may also occur. All these sebaceous gland tumors are rare in the general population and the finding of such a tumor may represent a marker for MTS and should prompt a search for occult malignancy . In addiColorectal cancer is the commonest visceral neoplasm to occur in MTS, and the most frequent initial cancer ,10. In cThe genetic disorder in MTS is an autosomal dominant inherited germline mutation in one of the DNA mismatch repair genes, MSH1 and MSH2 ,12. It iScreening for malignancy at all possible sites is impractical in MTS given the wide range of associated malignancies, and screening should probably concentrate on the colorectum, female genital tract and possibly urinary tract. In some families the occurrence of certain other tumors would be an indication for other screening modalities, for example upper GI endoscopy .et al [Cohen et al  suggesteet al . Besideset al ,14.The indolent course of cancers occurring as part of MTS is often commented on but has not been shown in any prospective fashion. It has been suggested that because of their relatively good prognosis and non-aggressive course, surgical removal of primary or metastatic cancers may be curative and should be attempted wherever possible ,15. AddiIn conclusion sebaceous gland tumors are rare and the diagnosis of such a tumor should suggest the possibility of Muir-Torre syndrome and prompt a search for associated malignancies, and for the underlying genetic mutation. Family members should be monitored to detect early cancers and perhaps should be enrolled in chemoprevention trials. Genetic studies can help identify the inherited molecular defect that causes the Muir-Torre syndrome.The author(s) declare that they have no competing interests.KT: conceived the study, performed the surgical management and revised the manuscript for scientific content.KB: participated in literature search, study design, and preparation of the manuscript.KV: participated in literature search, study design and in the revision of the study and preparation of its final version.TT: participated in study design, literature search and preparation of the manuscript.SA: participated in study design and literature search.DB: has given the approval for submitting the final version of the manuscript.


The histogenesis of the hepatic sarcoma and its association with hamartoma is not well understood. We hereby present a Chinese patient with hepatic angiosarcoma arising from an adult mesenchymal hamartoma of liver. A 33-yr-old woman was diagnosed hepatic hamartoma eight years ago and presented with epigastric distention recently. Now she was admitted to our hospital with some unusual features: (a) this patient was diagnosed in mid-twenties, (b) the tumor occupied the whole liver and most importantly (c) the hepatic angiosarcoma appeared 8 years after the diagnosis of hamartoma. Based on this case and some reports, hepatic hamartoma may develop to hepatic angiosarcoma. Mesenchymal hamartoma, mostly seen in young infants and exceptionally in adult patients, is a rare and benign developmental tumour of the liver. It usually presents as a large and multicystic mass of loose and sometimes nodular mesenchymal tissue. This tumor is thought to result from a developmental anomaly possibly related to abnormal vascular supply . HepaticA 33-yr-old woman was admitted to Department of Hepatobiliary Surgery at Cancer Hospital of Tianjin Medical University, China, with the diagnosis of hepatic hamartoma. Eight years previously, she was diagnosed with hepatic hamartoma by fine needle biopsy. She did not accept effective treatment, and subsequently presented with epigastric distention. A history of hepatitis  and hepatic cirrhosis were excluded with appropriate tests. Physical examination revealed slight paleness of the skin and mucosa and no jaundice. Abdominal palpation demonstrated the presence of shifting dullness and hepatomegaly without obvious tenderness. No other abnormal signs were found.The patients' blood results were as follows:12/L, Hb: 61 g/L, WBC: 4.40 × 109/L and PLT: 126 × 109/L. Biochemistry; showed: ALT 23 U/L, AST 35 U/L, ALP 386 U/L, ALB 28.0 g/L, TP 50.4 g/L, GLB 22.4 g/L and GGT 254 U/L. Serum markers for HBV and HCV were negative. AFP, CA125, CA199 and CEA were normal.Hematology; RBC: 3.64 × 10Both ultrasonography and spiral computerized tomography (CT) revealed an enlarged liver with rugositied surface. Multinodular focuses involved the whole liver accompanied with calcified plaques, cholecystolithiasis, multiple tiny nodules under the peritoneum and ascites figure .After a multidisciplinary consensus, the patient underwent surgery including omentectomy and excisional biopsy of liver tumors. In the operation, asymmetrical nodules were noticed on the whole liver and beneath the peritoneum. One was located at colic omentum with 1.5 cm diameter. Frozen section biopsy revealed angiosarcoma. Therefore, only colic omentum resection and hepatic multi-point biopsy were performed.Postoperative pathology revealed angiosarcoma figure  arising The patient survived 4 months after surgery, and died from liver failure.Mesenchymal hamartoma appears as a disordered arrangement of mesenchyme, bile ducts, and hepatic parenchyma in histology. Grossly, it has stromal and cystic components with no capsule and can grow to large sizes (16 cm being an average tumor size).Clinically, patients with mesenchymal hamartoma tend to present in the first 2 years of life, with a median age of 10 months (0–19 years). The right lobe is more frequently affected than the left (6: 1) [Surgical resection has been the standard treatment for this tumor. Although our patient had some typical clinical and radiological picture of mesenchymal hamartoma, there were three unusual features: she was diagnosed at a later age (25 years old), the tumor occupied the whole liver, and hepatic angiosarcoma arised 8 years after the diagnosis of hamartoma.Hepatic angiosarcoma is frequently associated with environmental carcinogens such as thorotrast, vinyl chloride and arsenic compounds ,4. ThereThe association between undifferentiated sarcoma and hamartoma of the liver has been much debated. Recently, discovery of a similar genetic abnormality in both lesions has supported the supposed link between them. Lauwers et al. reported a case of a hepatic undifferentiated  sarcoma arising within a mesenchymal hamartoma in a 15-year-old girl with the histologic, flow cytometric, and cytogenetic evidence and O'SulClinciains should be aware that hepatic angiosarcoma may develop from pre-existing hepatic hamartoma. Timely management of these lesions is important to prevent any possible malignant evolution.


Intracranial metastases from liposarcoma are rare and almost always preceded by the development of systemic tumour spread. We report here a case of liposarcoma with spread to the cranial nervous system 23 years after treatment of the primary tumour. The literature on brain metastases from soft tissue sarcoma is also reviewed. A 48-year old Caucasian female with activerheumatoid arthritis was diagnosed with a low-grade myxoidliposarcoma of the left thigh in 1981. This was treated with surgery followed byradiotherapy. In 1991, she was discharged from routine oncologicalfollowup. In 1998, she was rereferred by her GP for investigationof a left groin mass. Biopsy of the groin mass confirmed recurrentliposarcoma and restaging investigations confirmed that the lesionwas isolated. Surgery and radiotherapy (5000 Gy in 25fractions) were used to treat the recurrent liposarcoma. Thepathology report revealed that the tumour had transformed into a“high-grade myxoid/round-cell liposarcoma surrounding the iliacartery and vein, involving the deep resectionmargins.”Over the next 6 years, the patient continued on close outpatientfollowup with regular chest X rays. During this time, persistentleft leg oedema became problematic. In addition, her rheumatoidarthritis remained symptomatic despite treatment withhydroxychloroquine, methotrexate, and indomethacin.In October 2004, the patient was admitted as amedical emergency with a 5-day history of nausea and vomiting,severe occipital headache, photophobia, and diplopia. Inaddition, she described a strange sensation in her tongue withimpaired tongue movement. On examination, a 3 cm × 3 cm smooth mobile cervical neck node was noted inaddition to a left VI cranial nerve palsy, a right XIIcranial nerve pals, y and hypotonia of the left side of thetongue. A lumbar puncture, CT brain, and blood tests including avasculitic screen and viral serology were normal. An MRIdemonstrated a “high signal at apex of the temporal bone” butwas otherwise normal. Over the next 10 days, the patientcontinued to complain of a persistent dull throbbing headache anddeveloped a right-sided VI nerve palsy. FNA of the neck nodeconfirmed metastatic liposarcoma and a CT scan of thechest/abdomen and pelvis revealed “widespread tumour deposits inthe right psoas muscle and pelvis.” The lungs were clear ofmetastatic disease. A repeat MRI done 3 weeks following heradmission this time showed that “at the skull base, the clivusgives an abnormal marrow signal with infiltration, most likely dueto metastatic disease.” Due to intractable symptoms, she went onto receive palliative radiotherapy to the base of skull (30 Gyin 10 fractions). A repeat CT scan done 6 weeks after the lastscan showed progressive disease in the abdomen and pelvis with newlung metastases. Whilst waiting to commence palliativechemotherapy, the patient developed neurogenic dysphagia and diedfrom aspiration pneumonia. At postmortem, meningeal thickening wasnoted in the area of the mid brain . FurtherBrain metastases from soft tissue sarcoma (STS) are rare,occurring in 1–3% patients , 4. WhenPrevious studies have identified leimyosarcoma,liposarcoma, and malignant fibrous histiocytoma (MFH) as thesubtypes of STS most likely to metastasize to the brain .WronskiIn addition to the tumour subtype in STS, the site of initialdisease also appears influential in determining the most likelysites of distant metastases. The first site of distant metastasisfor patients with extremity and trunk STS is usually the lung withlocal recurrence rarely a problem in these patients, 7. In cThis case describes the development of intracranial metastases ina patient treated 23 years previously for a liposarcoma of thelower limb. Postmortem findings confirmed that this patient'sneurological signs and symptoms were due to meningeal metastaticdisease of the same histological subtype as the original tumour.The brain metastases became clinically apparent 23 years aftertreatment of the initial primary. Such a long interval betweentreatment of the primary tumour and CNS relapse has been describedelsewhere in patients with prolonged survival, either inassociation with the STS having a long natural history or as aresult of extended disease-free survival from effective localtreatment of the primary tumour , 13. OthThis case illustrates that STS can relapse in the CNS without thepresence of widespread disseminated disease. CNS relapse can occurmany years after treatment of the primary tumour and a high indexof suspicion should be maintained in any patient with an STSpresenting with neurological signs and symptoms. Early diagnosisand appropriate treatment of selected patients with STSBM canimprove survival.


Pleomorphic adenoma of the lacrimal gland is known to undergo malignant transformation when incompletely excised. Even if such a malignant change occurs, intracranial direct invasion and leptomeningeal seeding are seldom encountered.A 50-year-old woman presented with malignant transformation associated with both intracranial invasion and multiple intracranial and spinal disseminations in the third recurrence of pleomorphic adenoma of the lacrimal gland, 6 years after initial treatment. MRI demonstrated increased extent of orbital mass, extending to the cavernous sinus. The patient underwent intensity-modulated radiation therapy (IMRT) and Gamma Knife radiosurgery. Follow-up MRI showed multiple leptomeningeal disseminations to the intracranium and spine.It is important to recognize that leptomeningeal intracranial and spinal disseminations of pleomorphic adenocarcinoma can occur, although it is extremely rare. To our knowledge, we report the first case of pleomorphic adenocarcinoma of the lacrimal gland presumably metastasizing to the intracranium and spine. Pleomorphic adenomas are the most common benign epithelial tumors affecting the lacrimal gland ; howeverEven if such a malignant change occurs, intracranial direct invasion and intracerebral and spinal metastases are seldom encountered, because the tumor itself is well demarcated . We presA 50-year-old woman had lacrimal mass presented with progressive exophthalmos and visual disturbance in the left eye in 2000. Orbital CT scan showed a well-circumscirbed mass at lateral aspect of the left orbit without bone involvement Figure . She undSix month later, the patient complained of the left eye pain and the left facial paresthesia. An ophthalmological examination revealed ptosis, exophthalmos, and ophthamoplegia of the left eye. Facial sensory change on the left whole trigeminal territories was noted. MRI revealed a well-circumscribed mass of the left cavernous sinus extending to the infratemporal fossa and clivus. The patient underwent Gamma Knife stereotactic radiosurgery with a marginal dose of 15 Gy and maximum dose of 30 Gy to 29.7 ml of tumor volume. Dose was adjusted to the right optic nerve and optic chiasm (8.4 Gy) and to the left optic nerve (15 Gy)  declare that they have no competing interests.JYA conceptualized the study, gathered the data and drafted the manuscript. JHC participated in Gamma Knife radiosurgery and took charge of post-operative managements together with JYA. SHK carried out the pathologic studies. KSL supervised the process and finally approved the manuscript for been published. All authors have read and approved the final manuscript.


Inflammatory myofibroblastic tumour (IMT) is a benign, nonmetastasizing proliferation of myofibroblasts with a potential for local infiltration, recurrence and persistent local growth.We report a case of a 51 year-old female, who had excision of a gallbladder tumour. Histopathology showed it to be IMT of the gallbladder.The approach to these tumours should be primarily surgical resection to obtain a definitive diagnosis and relieve symptoms. IMT has a potential for local infiltration, recurrence and persistent local growth. Inflammatory myofibroblastic tumour (IMT) is a rare benign lesion that has been discussed in various organs and tissues. They are well recognised in lung and upper respiratory tract of children and young adults with a predilection for first and second decade. Intra-abdominal forms of the disease are reported to occur most frequently in the liver, followed by stomach, bowel, spleen, mesentery  and extrA 51-year-old female presented with history of acute right upper abdominal pain, localised abdominal signs and raised inflammatory markers. Ultrasound scanning suggested acute cholecystitis. The patient was explored initially by laparoscopy but converted to an open operation at the referring hospital. An irresectable mass, which was thought to be an advanced gallbladder carcinoma, was found. Several needle biopsies were taken from the tumour but the gallbladder was not excised. Histology of the biopsies showed features of IMT of the gallbladder. She developed obstructive jaundice postoperatively, ERCP showed a distal bile duct stricture which was stented. CT scan showed a mass lesion in the gallbladder area with direct involvement of the liver and no metastatic disease elsewhere , the locally aggressive fibromatoses  which share features of fibroblasts and myofibroblasts in varying degree and finally sarcomas showing myofibroblastic differentiation (low grade lesions – infantile myofibroblastic sarcoma, inflammatory myofibroblastic tumours, low grade myofibroblastic sarcoma, inflammatory fibrosarcoma  and highThe inflammatory myofibroblastic tumours are well circumscribed but rarely encapsulated. They usually have a homogenous consistency although areas of haemorrhage, necrosis or calcification may be found. Multicentric lesions are rare. IMT is composed of fascicles of bland myofibroblastic cells admixed with a prominent inflammatory infiltrate consisting of lymphocytes, plasma cells, macrophages and eosinophils. The lack of atypia, hyperchromasia and abnormal mitotic figures are pointers towards a benign lesion. The spindle cells stain positively for smooth muscle actin and vimentin but are negative for S100, desmin, CD100, cytokeratin, CD35 and latent membrane protein. Differential diagnosis includes calcifying fibrous pseudotumour  inflammaThere is no regular vascular pattern thus there is variable contrast enhancement on CT scans. On magnetic resonance imaging, hepatic IMT appears as a mass or as an area of periportal soft tissue infiltration. The mass is hypointense on T1-W and slightly hyperintense relative to surrounding liver parenchyma on T2-W image . The pro


The oral cavity is a rare but occasional target for metastases, which may masquerade as various benign and inflammatory lesions, and sometimes also be asymptomatic. Oral metastatic lesions have been described in various cancers, particularly lung, breast and kidney carcinoma.We here describe an uncommon case of a hard palate mucosa and gingival metastasis from gastric carcinoma that was originally diagnosed as a periodontal disease.Histopathological examination of a biopsy of the lesion revealed a signet-ring cell carcinoma, and a subsequent biopsy of an ulcerated stomach lesion showed a poorly differentiated gastric carcinoma. The patient underwent gastric resection but died of heart failure on the tenth postoperative day; a post-mortem examination revealed a residual bilateral ovarian infiltration by gastric carcinoma (Krukenberg's tumor).An occult carcinoma of the stomach may rarely metastasise to the oral cavity even as a first and exclusive manifestation; it is important to bear this possibility in mind because such conditions may mimic a benign disease. Oral metastatic lesions from distant tumours are uncommon, accounting for only 1% of all oral malignancies. They mainly involve the bony structures (particularly the mandible), whereas primary metastases to soft tissues are extraordinarily rare  [We here describe an extremely rare case of an oral metastasis limited to the hard palate mucosa and gingiva that was originally diagnosed and treated as a periodontal inflammatory disease, but subsequently proved to be the first manifestation of a gastric carcinoma.In February 2003, a 61-year-old white female with a history of partial gastrectomy due to a peptic ulcer, and mastectomy due to breast cancer twenty years before, presented with an indolent erythematous mass on her left hard palate and attached gingiva. Her dentist had originally diagnosed periodontal disease, and she was unsuccessfully treated with antibiotics and non-steroidal anti-inflammatory drugs; she subsequently also underwent otolaryngological and radiological examinations of the mouth, but both were negative.In September 2003, a hard palate biopsy led to a histopathological diagnosis of a chorion metastasis from a breast adenocarcinoma, but the results of subsequent mammography, abdominal ultrasound, chest X-ray and neoplastic marker analyses did not reveal any evidence of a tumour. One month later, a second hard palate biopsy revealed an undifferentiated carcinoma with a focal microglandular and diffuse signet-ring cell growth infiltrating the subepithelial chorion mucosa consistent with a gastric origin Fig. . AlthougShe was admitted to our Institution in October 2003, when a physical examination revealed left supraclavicular adenopathy, left exophthalmus, and a firm and painless erythematous mass of nearly 4 cm on her left hard palate, with no evidence of bleeding at palpation , with no other abdominal or thoracic localizations.Although the incidence of gastric carcinoma has markedly decreased over the last twenty years in some countries such as the United States and Great Britain, it remains extremely high in others such as Italy ,2.The most frequent sites of metastases from gastric carcinomas are the liver, peritoneum, lung, adrenal gland and ovaries, but there have been some reports of unusual metastases in the uterine body or cervix . MetastaOur case is interesting because the metastatic lesion of the palate was diagnosed before the discovery of the primary tumour, whereas most other previously published reports involve gastric cancers that were already known or simultaneously discovered at the time of the manifestation of the oral lesion ,5,8,9. OAll of the patients died as a result of the disease and heart failure a few days later.In our case, seven months elapsed between the detection of the oral metastasis and the establishment of its gastric origin, possibly because of an initially incorrect interpretation of the clinical history and histopathological features.From a pathological point of view, both the primary and metastatic lesions had identical features: an undifferentiated pattern, with signet-ring cells mixed with moderately differentiated microglandular neoplastic structures. The oral cavity tumour was restricted to the gingival mucosa Fig. . In thisIt is clinically interesting to note that the oral metastasis was the first indication of an occult primary malignancy in nearly one-third of these patients .et al. indicating that the route of metastasis might be hematogenous [In line with the report by Shimoyama togenous , our castogenous -11.The discovery of an oral metastasis sometimes leads to the detection of an occult malignancy in other body sites, and so it is extremely important to identify it correctly, first clinically and then pathologically.We stress the peculiarity of hard palate mucosa and gingival involvement from a gastric signet-ring cell carcinoma because metastases from remote organ malignancies in this region may masquerade as various benign and inflammatory lesions . Oral soThe author(s) declare that they have no competing interests.PC, performed all histopathological examinations, revised the literature, drafted and edited the manuscript. LT, involved in the patient active management, revised the literature, edited the manuscript. GM, LR, AM, involved in the patient active management. DP, performed histopathological figures and carried out the literature search. AS, involved in the final revision of the manuscript and coordinated the submission.The pre-publication history for this paper can be accessed here:


Extrapulmonary tuberculosis is one of the great mimickers of medicine, and often masquerades as malignancy. As a result, patients may be referred to oncologists and surgeons for further evaluation and management, delaying the institution of appropriate anti-tuberculous drug therapy.Mycobacterium tuberculosis from tissue samples obtained under image guidance, enabled the correct diagnosis to be made.We present the case of a 21 year old man with tuberculous osteomyelitis, who was referred to the Bone and Soft Tissue Sarcoma Service at our institution with a provisional diagnosis of malignancy. Further investigation revealed extensive retroperitoneal abdominal and pelvic lymphadenopathy. The recognition of certain patterns on imaging, and finally the isolation of This case highlights the importance of remaining cognisant of the protean manifestations of extrapulmonary tuberculosis, and illustrates the advantage of a clinically directed multi-modality imaging approach to diagnosis. Mycobacterium tuberculosis and an increasing number of immune compromised individuals and immigrants from the developing world [Over the past decade, there has been a significant rise in the prevalence of extrapulmonary tuberculosis in the developed world, owing to the emergence of multi-drug resistant strains of ng world -3. DespiTo highlight these issues we present the case of a young male with pain and swelling of the right elbow, referred to the Bone and Soft Tissue Sarcoma Service at our institution with a presumptive diagnosis of malignancy. Further investigation revealed extensive retroperitoneal abdominal and pelvic lymphadenopathy. The case illustrates the importance of a clinically directed multi-modality imaging approach for the exclusion of malignancy and the accurate diagnosis of tuberculous infection, by identifying sites of pathology and obtaining adequate tissue samples for histological and microbiological confirmation.A previously well 21 year old East Timorese male presented to his local medical officer with a 2 month history of right elbow pain, associated with swelling and progressive limitation of movement. He also reported a 6 kg loss of weight during this time, but denied any other constitutional symptoms.He appeared well, was afebrile, and had no abnormality on chest or abdominal examination. Examination of the right elbow revealed a firm, tender swelling, approximately 2 cm in diameter, over the lateral humeral epicondyle, with associated limitation of elbow flexion to 60 degrees.Initial investigation with plain XR of the right elbow joint revealed a joint effusion Figure . As thesUltrasound examination of the elbow showed a large joint effusion Figure . ScintigCT scan confirmed the presence of cortical erosions involving the right lateral epicondyle of the humerus and the ulna. Further, there was increased attenuation within the proximal medullary shaft of the ulna, and diffuse soft tissue thickening around the proximal ulna and radial head, with an associated joint effusion Figure .Further functional imaging with Thallium 201 chloride revealed intense early uptake in the right lateral epicondyle of the humerus and proximal ulna Figure . The delMR demonstrated erosive changes involving the lateral epicondyle, a loculated joint effusion and thickening and enhancement of the joint capsule and the annular ligament of the superior radio-ulnar joint. These changes suggested either a neoplasm or possibly infection Figure .The patient was therefore referred to the Bone and Soft Tissue Sarcoma service for further investigation.Biopsy of the right elbow joint demonstrated chronic synovial inflammation and numerous polymorphonuclear cells in the synovial fluid, but no malignant cells Figure . MicrobiCT scanning of the chest, abdomen and pelvis, performed in light of the thallium findings, revealed extensive retroperitoneal lymphadenopathy. The lymphadenopathy was characterised by peripheral enhancement with prominent central areas of low attenuation Figures  and 10.Subsequent CT guided biopsy of the retroperitoneal lymphoid tissue revealed necrotising granulomatous lymphadenitis indicative of Mycobacterium tuberculosis infection Figure . While nA final diagnosis of disseminated extrapulmonary tuberculosis was therefore made. Anti tuberculous therapy was commenced with good clinical response.Extrapulmonary tuberculosis, a condition whose resurgence can be ascribed to the emergence of multi-drug resistance and an increasing number of immune compromised individuals and immigrants from the developing world, remains a difficult diagnosis to make -3. It isAlthough a positive tuberculin test and chest imaging findings are supportive of the diagnosis, absence of these does not exclude it ,5. ThereMusculoskeletal involvement occurs in 1 to 3 percent of patients with tuberculosis, usually due to haematogenous seeding ,6. In moWhile the most common site of osseous involvement is the spine, followed by the femur, tibia and the small bones of the hands and feet, any bone can potentially be affected ,4,6,9,10Plain XR findings in bony tuberculosis include osteopenia, osteolytic foci with poorly defined edges, and varying amounts of sclerosis and periostitis ,5,9. TheThere are a few radiographic features, however, that favour tuberculous infection over neoplasia. These include the presence of small juxtacortical abscesses or rings of inflammatory tissue, due to cortical destruction and spread of infection to the extraosseous tissues . RegardlNuclear Medicine techniques of value in the evaluation of tuberculous bony involvement include Tc99m methylene diphosphonate bone scanning, particularly in multifocal bone involvement. Sensitivity is reduced significantly however in pure septic arthritis and discitis without concomitant osteomyelitis. In these clinical situations, MRI is the modality of choice.Another useful radiotracer technique is functional metabolic imaging, which assesses the basal metabolic activity of inflammatory and neoplastic lesions. Thallium-201 chloride (TI-201) scanning is a good example of this modality. TI-201 is a potassium analogue that is actively concentrated in cells by the sodium-potassium ATPase pump and by a co-transport system mediated by a calcium-dependent ion channel . As enhaJoint involvement in skeletal tuberculosis occurs commonly due to direct invasion from an adjacent focus of osteomyelitis, as in the case presented in this report ,6. CharaAbdominal tuberculosis, like musculoskeletal involvement, is a difficult diagnosis to make, due to its varied clinical presentations, and is again often mistaken for malignancy. Lymphadenopathy is the most common manifestation, with up to two thirds of patients with abdominal tuberculosis demonstrating lymph node involvement ,16. The Certain features on CT imaging help distinguish tuberculous lymphadenopathy from these neoplastic causes. In tuberculous infection, the nodes are usually multiple and large, averaging 2 to 3 cm in diameter . PeripheBecause of this overlap in imaging appearances between extrapulmonary tuberculosis and malignancy, even in cases where the imaging and clinical features strongly suggest tuberculosis, the diagnosis requires histopathological and bacteriological confirmation. In the past, this often necessitated open surgical biopsy. Now core needle biopsy has been shown to be quick, safe and effective alternative for obtaining tissue specimens under image guidance .The clinical and radiologic features of extrapulmonary tuberculosis often mimic those of many other pathological processes, in particular malignancy. Oncologists and surgeons must therefore remain cognisant of the possibility of tuberculous infection, and of radiological features that help distinguish this condition from neoplastic processes. However, even with the use of multiple imaging modalities and laboratory diagnostic tools, a definitive diagnosis still requires a positive culture or histologic analysis of biopsy specimens in many cases. Image-guidance facilitates optimal tissue samples to be obtained for analysis.Tc99: Technicium 99TI-201: Thallium 201TB: tuberculosisThe author(s) declare that they have no competing interests.SAA drafted and revised the manuscript, and was involved in the editing of the images.PFC, PJS, GJP and JS critically evaluated and revised the manuscript. They also provided information from their respective areas of expertise, which was critical to the discussion section of the manuscript.SMS was responsible for the conception of this case report, and was also involved in the drafting and revision of the manuscript.All authors have read and given final approval of the submitted version of the manuscript.


Primary malignant melanoma of the oesophagus is a rare neoplasm comprising less than 0.2% of all primary oesophageal neoplasms. There are fewer than 250 reported cases in worldwide literature. Several reports suggest that it has a mean survival rate of 2.2% at 5 years and a median survival rate of 10 months. A 48 year old male presented to our surgical service complaining of a three month history of progressively worsening dysphagia with associated regurgitation and unintentional weight loss of 14 kg. There was no prior history of cutaneous or ocular melanoma. He was treated with a combination of subtotal oesophageal resection and immunomodulatory therapy. We present herein a case of primary malignant melanoma of the oesophagus including the associated clinical, pathological and radiological findings. A previously healthy 48 year old male presented to our surgical out-patient service complaining of a 3 month history of progressively worsening dysphagia for solids with associated regurgitation and unintentional weight loss of 14 kg. Physical examination was unremarkable and there was no evidence of organomegaly or lymphadenopathy. Subsequent oesophagoscopy revealed a large polypoid pigmented lesion at 30 cm. The lesion did not impede the passage of the scope. Multiple biopsies were taken. Two pigmented cutaneous lesions (no sinister features present in either lesion) were also excised – histology showed benign lesions. No evidence of melanoma was found.A staging CT scan of his thorax, abdomen and pelvis showed a well-defined eccentric mass in the mid-lower oesophagus. There was no apparent local invasion or regional lymphadenopathy.Whole body FDG PET/CT body scan confirmed the mass in the oesophagus with increased uptake in a high abdominal pre-aortic and high right paratracheal node consistent with metastasis.  has proved to be an excellent method for staging of metastatic melanoma. Due to its high sensitivity for malignant lesions and the possibility of covering the whole body in one examination, it can supplement other staging tools.Because of the high tumour-to-background ratio, FDG-PET can highlight metastases at unusual sites that are missed with conventional imaging modalities.Furthermore, it provides information on the malignant potential of the detected lesion. Given the relative scarcity of primary melanomas of the oesophagus little is known about its application for these tumours ,6.Ott et al recently reported that in oesophageal cancer FDG PET/CT has been shown to detect metastatic disease in approximately 20% of patients who are considered as having only locoregional disease on CT, similar to the patient reported in this case. The sensitivity of computed tomography (CT) for detection of distant metastases ranges between <50% and >90%. They reported a specificity of 80% for locoregional pretherapeutic tumour staging .Classical histological appearances are seen with tumour marker staining. In the diagnosis of cutaneous melanoma many specialized immunohistochemical stains may be applied. S-100 staining has 95% sensitivity for melanoma. HMB-45 staining is used for detecting active melanocytes.Primary treatment is surgical excision with discretionary lymphadenectomy for operable melanomas, but total or near-total oesophagectomy offers the best survival outcome  . AdditioAdjuavant or neoadjuvant radiotherapy has been used but its utility is unproven .Interferon alpha is used in a range of neoplastic conditions, including renal cell carcinoma, cutaneous melanoma and chronic myeloid leukaemia. It stimulates humoral and cell mediated response and thus has anti-proliferative effects. However it is not curative. Well known side effects to this therapy exist include flu-like symptoms and fatigue but fortunately our patient tolerated his treatment well.The author(s) declare that they have no competing interests.JK collected all the included data, conceived of the study, carried out detailed literature review and coordinated the multi disciplinary approach to the manuscript.PB oversaw all aspects of the reports' design and helped to draft the manuscript.ML carried out and reported on this rare histopathological diagnosis.All authors read and approved the final manuscript


Warfarin is a coumarin anti-coagulant, used widely for the therapeutic and prophylactic anticoagulation. Although, it is considered as a life saving medicine, it is associated with the significant adverse effects including intra-abdominal bleeding, which have been very well documented in literature. However, the presentation of warfarin induced intra-peritoneal bleeding as an acute appendicitis has not been reported in English literature. We report this rare, spontaneous intra-peritoneal bleeding secondary to warfarin therapy, mimicking the signs and symptoms of an acute appendicitis for the first time in English literature.A 41 year-old female patient who was on warfarin for prophylaxis following the previous episode of pulmonary embolism, presented to the Casualty with the typical symptoms of an acute appendicitis. During operative intervention, we found it to be the spontaneous intra-peritoneal bleeding secondary to warfarin. The patient recovered well following the operation.We recommend the use of the radiological investigations in all the cases of acute abdomen who are on warfarin even if the INR is within the therapeutic range. Warfarin is a coumarin anti-coagulant, widely used for the therapeutic and prophylactic anti-coagulation. Although it is considered as a life saving medicine, it is associated with the several significant adverse effects. Intra-peritoneal bleeding is one of the complications, usually following trivial trauma. There are only very few reported cases of the spontaneous haemoperitoneum in English literature without any evident cause ,2. Spont9/l and INR of 2.2. The blood biochemistry did not reveal any abnormality.A 41 year-old Caucasian female patient was referred to us by general practioner (G.P.) with 2-day history of the migratory abdominal pain. Initially, the pain was constant and dull in the peri-umbilical region, which later became sharp and localised in the right iliac fosssa. She also complained of four episodes of vomiting and loss of appetite. She occasionally felt pain in her right shoulder. There was no history of even trivial trauma. In the past, she had 3 episodes of pulmonary embolism following hysterectomy and she had been on warfarin for the prophylaxis since then. She used to take tylex (paracetamol and codeine), pantoprazole, tramadol, senna, migraleve, zimovane and fentanyl citrate lozenges as her regular medications. She had 35-pack year history of smoking. On examination, she was afebrile  but tachycardic with pulse rate of 134/minute. There was no bruising or haematoma in the abdominal wall. The abdomen was distended with marked tenderness in the right lower quadrant. There were guarding and rebound tenderness in the right iliac fossa. The rectal examination revealed tenderness in the right pelvic wall. The urine dipstick was positive for the ketones and trace of protein. The pregnancy test was negative. The blood investigations showed haemoglobin of 10.8 gm/dl with reduced haematocrit of 32%, White Blood Cells of 11.8 × 102 size blood clot was evacuated from the pelvis. Despite thorough search for the active bleeding site, we could not find any cause for active bleeding. The final diagnosis of the spontaneous intra-peritoneal bleeding secondary to warfarin was made. The abdomen was closed with the low suction drain, which drained about 200 ml of the serosanguinous fluid over next 2 days. 2 units of fresh frozen plasma were transfused in the immediate post-operative period. The warfarin was stopped after the operation. The patient was re-warfarinised on 8th post-operative day and was followed up in the surgical and the haematology clinics. At 2 weeks follow up visit in surgical clinic; patient was doing well without any complaints and complications. The histology of the appendix confirmed normal appendix without any inflammation.The clinical diagnosis of acute appendicitis was made. She was scoring 8 according to modified Alvarado scoring system . The decWarfarin is a life saving drug, extensively used in the treatment and the prophylaxis for the various clinical conditions including deep vein thrombosis, pulmonary embolism, valvular heart disease, atrial fibrillation, recurrent systemic emboli, recurrent myocardial infarction, prosthetic heart valves and prosthetic implants -6. HowevThe two most important determinants of the warfarin induced bleeding is the intensity of therapy and the maximal time in therapeutic range . BleedinThis also raises a question about the present management of acute appendicitis in UK, as we have not yet accepted the CT scan as a mandatory investigation for the diagnosis of appendicitis. Although the modified Alvarado scoring system has been a useful means for the management of an acute appendicitis, we think, the CT scan and/or ultrasound in this case might have confirmed the diagnosis and patient would have been avoided the surgery and been observed with the reversal of anticoagulation . Use of This case provides a learning lesson to the young junior surgeons as well as to other specialists such as general practioners and physicians to consider this rare but significant complication of warfarin in the differential diagnosis of all the cases of acute abdomen/abdominal pain in patients who are on warfarin therapy, even if the INR is in the low therapeutic range. We also emphasize that one must consider intra-peritoneal bleeding in presence of anaemia and tachycardias in patients on warfarin therapy. We recommend the use of the radiological investigations such as CT scan or ultrasound in these cases to achieve diagnosis and to avoid unnecessary surgery.The author(s) declare that they have no competing interests.J S – As a main author, I have made substantial contribution in design and interpretation of this case report. I have drafted the manuscript and amended the manuscript in accordance to the reviewer's comments with intellectual content. I have given the final approval of the version to be published. As a main author, I have made sure that all the contributors have participated significantly in the preparation of the manuscript and given the final approval for publication.V K – As a co-author, I have helped in reference search and contributed significantly in the background part of the manuscript and given the final approval of the version to be published. I have also contributed in drafting and revising the manuscript in accordance to the reviewer's comments.D K S – As a co-author, I have helped in reference search and contributed significantly in the case presentation part of the manuscript and given the final approval of the version to be published. I have also contributed in drafting and revising the manuscript in accordance to the reviewer's comments.A B – As a co-author, I have helped in reference search and contributed significantly in the conclusion part of the manuscript and given the final approval of the version to be published. I have also contributed in drafting and revising the manuscript in accordance to the reviewer's comments.The pre-publication history for this paper can be accessed here:


Radiation induced sarcoma arise as a long term complication of radiation treatment for other benign or malignant conditions. They are of very rare occurrence in jaw bones and are even rarer in maxilla.Here we report a case of radiation induced sarcoma in a patient treated for squamous cell carcinoma of buccal mucosa with radiation who developed osteosarcoma of maxillary bone after six years. The patient was treated successfully with surgery.What should be the best treatment of radiation induced sarcoma is still debatable; however, surgery offers the best chance of cure. Role of reradiation and adjuvant chemotherapy needs to be further evaluated. Osteosarcoma of the head and neck are rare tumours and constitute <10% of all osteosarcomas . They inA well built 76-year-old otherwise healthy male who was a known case of node negative squamous cell carcinoma of the left buccal mucosa, involving left retro molar trigone region, anterior tonsillar pillar and soft palate, and was treated with 60 Gy of external beam radiation using photons over 30 fractions delivered using cobalt 60 source in 1998, presented six years later in 2004 with the gradually progressive swelling and pain in left malar region for last 3 months. He developed numbness of left cheek and blurring of vision in left eye along with epiphora of left eye and nasal obstruction of left nare. There were episodes of epistaxis. He was a chronic chewer and smoker for more than 30 years but quit the habit after diagnosis of squamous cell carcinoma in 1998. Examination showed a bony swelling in left malar region measuring 2 × 3 cm, with diffused margins and blunting of infra orbital rim. Parasthesia of cheek left side, epiphora, blurring of vision in left eye, and obstruction of left nare were also present. Overlying skin appeared normal. Intra orally a total edentulous mouth and tender bony swelling in left maxillary alveolar region involving both buccal and palatal aspect was noted. Swelling was more pronounced over the buccal aspect and extended along whole of the anterior wall of maxilla. Computed tomographic scan demonstrated radiodense mass in left maxillary sinus with expansion of the anterolateral and posterolateral wall  declare that they have no competing interests.OP: Prepared the draft manuscriptBTV: was the main surgeon managing the case and helped in preparing the manuscriptAM and NN: did the histopathology and prepared the photomicrographsKR: performed the imaging and provided the CT picturesMP: helped in preparing the draft and edited the final manuscript, besides helping in patient management.


Ichthyosis uteri is an exceedingly rare condition in which the entire surface of the endometrium is replaced by stratified squamous epithelium. Originally described as an endometrial response to iatrogenically-introduced caustic substances, similar changes have since been described in association with a variety of inflammatory conditions of the endometrium. We describe herein a heretofore undescribed example of a moderately differentiated squamous cell carcinoma of the uterine cervix associated with extensive ichthyosis uteri-like changes of the entire adjacent endometrium. Additionally, the squamous epithelium of the latter also showed multifocal changes diagnostic of a low-grade squamous intraepithelial lesion. The potential genesis of this composite of findings is discussed, as is the neoplastic potential of ichthyosis uteri. It is concluded that a squamous cell carcinoma of the cervix extended proximally into the endometrium, and that there was a colonization of a pre-existing ichthyosis uteri by associated human papillomavirus. The possibility of significant cervical pathology should be considered when plaques of squamous epithelium with low grade dysplastic changes are identified in an endometrial biopsy or curettage. A 38-year-old nulligravid female presented with complaints of a vague pelvic heaviness and a vaginal discharge. Her past medical history is significant for acquired immune deficiency syndrome (diagnosed 9 months previously) and Hepatitis A, B and C infections. Physical examination revealed a massively enlarged, barrel-shaped cervix with areas of ulceration on the ectocervix and a fungating mass protruding from the endocervical region. Following a biopsy, the patient underwent a type III radical hysterectomy, bilateral salpingo-oophorectomy and pelvic/paraaortic lymph node sampling. The procedure was well-tolerated and without any complications. She has had no evidence of tumor recurrence at last follow-up, 9 months after her surgery.Upon external inspection of the uterus, both the cervix and the inferior portion of the lower uterine segment were significantly enlarged. Sectioning revealed a 7 cm × 4 cm exophytic, friable, tan to tan-brown mass obliterating the endocervix and extending into the lower uterine segment Figure . SectionThe tumor was a moderately differentiated, large cell, keratinizing squamous cell carcinoma as previously described . NotablyThe term "ichthyosis uteri" was initially coined in 1885 by Zeller to refer to extensive squamous metaplasia of the surface endometrium following iatrogenically-introduced caustic substances such as formalin or iodine . Since tThe second, albeit unlikely, potential genesis of this tumor (i.e a squamous cell carcinoma arose form ichthyosis uteri in the lower uterine segment) caused us to re-evaluate the literature on the neoplastic potential of ichthyosis uteri. In the experience of some authors , ichthyoIn summary, a case of squamous cell carcinoma of the cervix with probable proximal extension into, and colonization of, a pre-existing ichthyosis uteri by associated HPV is described. The possibility of significant cervical pathology should be considered when plaques of squamous epithelium with low grade dysplastic changes are identified in an endometrial biopsy or curettage.The author(s) declare that they have no competing interests.Not Applicable


We present the case of a 46 year old woman with a giant, 23-centimeter, atypical carcinoid of the liver. A primary site for this neoplasm could not be identified despite multiple radiographic imaging studies, including a somatostatin scan, and a thorough inspection of the bowel during surgical resection of the lesion. Histologically, the tumor displayed mild cytologic atypia, abundant necrosis, and intravascular metastases, the last feature of which was identified by immunohistochemical markers for chromogranin and synaptophysin. Also described is the unusual sinusoidal infiltration, or "spillage," of tumor cells into the surrounding liver parenchyma, a feature that has not been described as far as we are aware but may suggest an aggressive clinical course. Even though an exact definition of atypia for these lesions apparently does not exist at this point, the multiple atypical features in this case strongly suggest the diagnosis of atypical carcinoid of the liver, thus far an altogether rare and vaguely reported entity. As more cases arise in the medical literature, it may be worthwhile to establish a set of guidelines to define atypical hepatic carcinoids and other gastrointestinal carcinoids, although survivorship data thus far indicates no significant difference in the prognosis between typical versus atypical variants. Primary hepatic carcinoid tumor is an incredibly rare entity but must be distinguished from other lesions such as hepatocellular carcinoma because of its different treatment and prognostic implications. At this time about 125 cases have been reported, but many of these may have been metastases or a neuroendocrine component of another neoplasm [The patient was a 46-year-old white female who presented with vague right upper abdominal pain and fullness for approximately one and a half months' duration. This pain intensified in a seated position. Besides having a chronic history of migraine headaches, she noted that she otherwise felt healthy and had not visited a physician for the past twenty years.Physical examination revealed a large, firm mass within the right upper quadrant that extended 10 cm below the right costal margin and stretched horizontally from the epigastric midline to the right lateral abdominal wall.An axial CT scan demonstrated a heterogeneous enhancement of a 22 × 14 cm hepatic mass involving the right hepatic lobe with a central region of hypoattenuation . The study identified an abundance of heterogenous activity within the hepatic mass but detected no extrahepatic foci of activity.Based upon the pathologic and radiologic findings, the surgical team decided to perform a right hepatic lobectomy.5-um sections from formalin-fixed, paraffin-embedded tissue were used for routine light microscopic study and immunohistochemical analysis including the antibodies specified in Table The 4300-gram right lobe partial hepatectomy specimen revealed a 23 × 17 × 14 cm dark brown-to-tan, multilobulated mass with abundant areas of hemorrhage and necrosis that nearly replaced the entire normal liver tissue Figure . A largeThe lesion was composed of a monomorphic cell population arranged in a predominately trabecular architecture and with some scattered acinar arrangements Figure . The borImmunohistochemical stains for chromogranin, synaptophysin, and NSE showed a strong, diffuse positivity for the tumor cells. Multiple intrahepatic, intravascular tumor cell metastases were visualized with these markers as well, especially with chromogranin Figure . Both thThe marker for cytokeratin revealed a cytoplasmic, granular staining pattern while markers for Hep-Par1, alpha-fetoprotein (AFP), and mucicarmine did not highlight the neoplastic cells.Approximately 125 cases of primary hepatic carcinoids have been described within the literature. Atypical primary hepatic carcinoids appear to be much less common, as the 19 cases reported by Soga in 2002 currently stand as the only such designated entities. Females are affected slightly more often than males (1.4:1), and the ages of the patients have ranged from 18 to 84 with an average age of 54 years [The most common presenting symptom is upper abdominal fullness, with or without hepatomegaly. Abdominal pain and discomfort, diarrhea, and weight loss can be invariably encountered as well. Only about 7% of these lesions manifest the carcinoid syndrome , the expThe cell from which this entity arises has not been proven, but there is evidence to support a derivation from bile duct epithelium ,4. UltraGrossly, hepatic carcinoids can vary widely in size, ranging from 1 cm up to 20 cm in greatest dimension , but appThe histologic architecture of hepatic carcinoid can vary among solid, nested, trabecular, and microacinar arrangements , as the Most primary hepatic carcinoids display typical histologic features. Soga, however, reported a group of 19 carcinoids designated as "atypical." We regret that the specific criteria used to designate such cases as atypical are not discussed. The lesion in this case showed few mitoses but revealed mild atypia and exuberant necrosis. Its massive size, sinusoidal infiltration, and intravascular metastases furthermore suggest that this tumor should be described as an atypical variant.The immunohistochemical characteristics of hepatic carcinoid include stain positivity for the neurosecretory markers chromogranin, synaptophysin, and neuron-specific enolase. Cytokeratin tends to impart a granular perinuclear staining pattern. Markers for gastrin, serotonin, carcinoembryonic antigen, and pancreatic polypeptide are inconsistently positive . Stains The neoplasm in this case mimics several more common hepatic malignancies that may need to be considered in subsequent cases. Grossly, the large irregular central scar brought to mind the possibility of a fibrolamellar variant of heptocellular carcinoma. Then, histologically, the predominantly trabecular architecture coupled with slight nuclear atypia and extensive necrosis was very concerning for HCC. Once the immunohistochemical stains were examined, HCC could be safely ruled out. The neuroendocrine marker positivity prompted us briefly to consider a neuroendocrine carcinoma, but these tumors are typically poorly differentiated and display prominent pleomorphism, nuclear atypia, and a high mitotic index. Because of the presence of scattered acinar-like structures, a mucicarmine stain was performed, the negative result of which ruled out cholangiocarcinoma.Currently, there do not appear to be any genetic studies conducted on primary hepatic carcinoids, likely a result of this neoplasm's rare occurrence. Multiple studies, however, have discovered cytogenetic and molecular aberrations in gastrointestinal carcinoids from other locations such as the ileum and pancreas -8. As a A complete and thorough autopsy is the only way to prove definitively that a carcinoid is truly primary to the liver, as rectal and ileal carcinoids as small as 1 mm or less have been known to produce large hepatic metastases and comprise the majority of carcinoids identified in the liver . Of courThe mainstay of treatment is surgical resection, although some reports have shown the added benefits of systemic chemotherapy and hepatic artery chemoembolus injection . When giThe overall five-year survival rate for primary hepatic carcinoids is excellent, averaging 92%, while the metastasis rate is 45% . SurvivaAt the time of this writing, our patient has reached the eight-month post-operative milestone and is both symptom-free and disease-free. Of course, it will be of great interest as we continue to follow her for survivorship comparisons and tumor behavior. Will these atypical pathologic features predict a worse outcome? Only time may tell.Here we have presented the case of giant primary hepatic carcinoid tumor with a number of atypical features including an enormous size, mild cytologic atypia, abundant necrosis, and intravascular metastases. We also describe the lesion's unusual sinusoidal infiltration of the surrounding liver parenchyma, a feature that has not been described as far as we are aware but could potentially serve as a future prognostic finding. As more cases arise, it may be possible to establish a set of guidelines to define atypia in hepatic carcinoids and other gastrointestinal carcinoids, similar to what has been done for their pulmonary counterparts. Thus far, however, based on the current survivorship data, a typical versus atypical diagnosis for these neoplasms may not be necessary other than for academic purposes. Finally, albeit rare, this entity should not be confused with other, more common hepatic lesions such as hepatocellular carcinoma, which carries a significantly worse prognosis and possibly a different treatment regimen.The author(s) declare that they have no competing interests.DL was the primary resident involved in working up this case and co-wrote the majority of the manuscript. LH was the primary medical student involved in the work-up of this case and structured a large part of the Discussion section. AV was the primary resident involved in the radiologic studies for this case and handled the write-up of the radiologic portion of the manuscript. WD was an attending pathologist involved in this case and was involved in structuring the final version of the manuscript. KL was the primary attending pathologist for this case and co-wrote most of the manuscript with DL. All authors read and approved the final manuscript.


A wide variety of anomalies may occur as a result of the vitellointestinal duct (VID) failing to obliterate completely. Most reports on symptomatic VID focus on Meckel's diverticulum, while other anomalies are given little attention. We report a case of a baby of five months who had an intestinal loop inverted through a patent VID. The inverted loop was reduced and ileostomy was done which was closed after 6 weeks. The midgut enlarges rapidly during the first 5 weeks of gestation and becomes too large for the abdominal cavity; subsequently, it is herniated into the umbilical cord. The apex of the herniated midgut is continuous with the vitellointestinal duct and the yolk sac. The axis of the herniated midgut is formed by the superior mesenteric artery. At approximately the 10th week of gestation, the midgut begins its return into the abdominal cavity. This return occurs by a highly complex developmental process, and as a result, numerous anomalies of the bowel may ensue. These include bowel atresias and stenoses, abnormalities of the vitellointestinal duct, failure of ceacal descent, malrotation, malfixation, reversed bowel rotation and exomphalos.5 months old male child came with unusual red colored 'Y' shaped loop emerging from the anterior abdominal wall with absent umbilicus. The parents reported that the baby had a small opening in the umbilicus since birth which discharged a sticky greenish material in very small quantity. The child was suffering from cough since 4 days leading to protrusion of the red colored mass from the umbilicus which was small initially but grew over these 4 days till it became carrot sized. Then a branch developed giving it a 'Y' shape.On careful examination we found that the loop was the 'y' shaped fork  declare that they have no competing interests.All the authors read and approved the manuscript.PNM: Did the surgery, prepared the manuscriptAMB: Guided during surgery, helped in searching references.VPH: Gave final touch to the manuscriptJHM: Assisted the surgery, assisted drafting the manuscript


Cholangiocellular cancers account for about 10-15% of primary liver cancers. Prognosis is poor, with expected survival of less than 5% at five-year.The case described shows remission of a disseminated cholangiocellular carcinoma  after neoadjuvant chemotherapy. The initial diagnosis was based on ultrasound examination and confirmed with computer tomography. Tumour biopsy and histopathological examination revealed cholangiocellular carcinoma. The patient underwent chemotherapy. After remission of lesions in lungs and reduction/regression of tumours in liver to one focal change, right lobe liver resection was performed. The histopathological examination did not reveal any viable carcinoma cells, only necrotic tissues in place of the primary tumour as well as in local portal vein branches was seen. Thirty months after the operation the patient is in a good overall condition and no recurrence has been observed.Appropriate neoadjuvant chemotherapy may allow radical resection in a previously unresectable cholangiocellular cancer. Intrahepatic cholangiocarcinoma (CCC) is a rare liver malignancy constituting about 10–15% of all primary liver cancers. It is far less common than hepatocellular carcinoma (HCC) which constitute over 80% of primary liver cancers . While sIn September 2003, a 33-year-old patient was admitted to internal diseases clinic. He had a 2-month history of pain in right upper abdomen radiating to thoracic spine and weight loss (30 kg within 2 months). There were no abnormal signs in physical examination, biochemical tests were within normal range.Computed tomography (CT) revealed multiple focal changes in liver, the largest lesion in the right lobe was 9.2 × 4.5 × 7 cm, and metastases in lungs Figure . GastrosIn December 2003, after 3 courses of chemotherapy, repeat CT scan showed partial remission of the neoplastic disease, after 6 courses further remission was visible on CT examination.Computed tomography after 9 courses of chemotherapy in May 2004 showed reduction of primary tumour as well as regression of metastases in lungs and other lesions in liver , mild increase in alkaline phosphatase (200 U/l) and alopecia. Repeat CT scan in August 2004 showed regeneration of liver parenchyma, there was no sign of recurrence of the neoplasm. Control examinations 12, 18, 24 and 29 months after operation did not show any signs of recurrence.Resection is the preferred treatment in the management of CCC; patients with resected CCC are the only long-term survivors -8. The pEffectiveness of chemotherapy is unsatisfactory - less than 30% responses to treatment, usually it does not significantly improve the prognosis. Currently, phase III clinical trials using Gemcitabine had been conducted and collected data allows expecting more encouraging results. -11Various chemotherapy regimes based on 5-FU in combination with cisplatin, interferon, and doxorubicin were reported to be active in CCC -15. AlthNecrosis was the only remaining focal change in liver along with presence of necrotic masses in portal vein branches around the tumour – this can be considered as a proof of chemotherapy effectiveness. Thirty months after operation patient is in good general condition and shows no sign of disease recurrence.The unusually good response of the neoplasm to chemotherapy is worth reporting, especially because systemic chemotherapy is considered little or non effective in disseminated cholangiocellular carcinoma and there is still no established protocol for it. Although this chemotherapy regimen can not be recommended as a treatment in case of CCC basing on a single case report, this patient's response shows that therapy of an advanced CCC is possible. This case may suggest that the chemotherapy scheme described could be considered as a therapy option for certain patients with advanced cholangiocellular carcinoma, possibly young ones who are more likely to tolerate the toxicity of this regimen.The author(s) declare that they have no competing interests.MS – carried out surgical procedure, provided data about surgical procedure and follow-up of the patient, helped to draft the manuscriptCS – carried out chemotherapy and provided data about chemotherapy treatmentMJ – drafted the manuscript, collected histopathological and radiological dataAll authors have read and approved the manuscript.


Metastatic hernia sac tumor from biliary malignancy is extremely rare with only one such case previously reported. We herein report an additional case of extrahepatic cholangiocarcinoma presenting as a hernia sac tumor.A 78-year-old man presented with an irreducible right inguinal hernia associated with a firm tumor, 2.0 cm in diameter. A computed tomography scan demonstrated a soft tissue density mass with heterogeneous enhancement within the right inguinal canal. The patient underwent a hernia repair and the hernia sac tumor was resected. Histological examination of the tumor revealed a metastatic adenocarcinoma suggesting the tumor was of pancreato-biliary origin. Further investigation using imaging studies disclosed a primary tumor in the upper bile duct. The patient died of the disease nine months after the resection.Hernia sac tumors should be considered when an irreducible, growing mass appears within an inguinal hernia. Computed tomography may be useful for the early detection of hernia sac tumors from undiagnosed intra-abdominal malignancies. Tumors associated with inguinal hernias are rare, occurring in less than 0.5% of surgically excised sacs . Thus faA 78-year-old man presented with a tender mass in the right groin that had appeared five months earlier and had gradually grown. He had a three-year history of right inguinal hernia. Physical examination revealed an irreducible right inguinal hernia associated with a firm tumor, 2.0 cm in diameter. A plain CT scan demonstrated a soft tissue density mass within the right inguinal canal, which had no connection with intra-abdominal organs Figure  and showintrasaccular, in which an organ bearing the tumor is incarcerated within the sac; saccular, in which the tumor encompasses the sac or spermatic cord structures; or extrasaccular, in which the tumor protrudes through the hernia defect but is located outside the sac [Hernia sac tumors can be classified into one of three groups:  the sac . Accordi the sac . Hernia  the sac ,4. The hCT features of metastatic inguinal saccular tumors have been poorly documented, and to our knowledge there are only two documented cases that present CT findings of saccular tumors ,3. YokotHernia sac tumors can be suspected when an irreducible, growing mass appears within an inguinal hernia. Since hernia repair offers an opportunity for peritoneal biopsy, selective microscopic examination of grossly abnormal hernia sac specimens is recommended. Preoperative CT imaging may also be useful for the early detection of hernia sac tumors from undiagnosed intra-abdominal malignancies.The author(s) declare that they have no competing interests.NY: participated in the operation, searched the literature, and wrote the original manuscript.YS: assisted in literature search and preparing the manuscript.HY: participated in the operation and performed chemotherapy to the patients.KH: supervised preparation of the manuscript and edited the final version for publication.All authors read and approved the final manuscript.


Angiosarcoma occurs very rarely in the gastrointestinal tract and can present great diagnostic difficulty, especially when it is associated with intraabdominal abscess or granulation tissue.We report a case where the angiosarcoma was diagnosed after the occurrence of disseminated angiosarcoma and concurrent hemoperitoneum. The tumor developed in the fibrous capsule of a foreign body, which was possibly related to the previous appendectomy twenty years ago, and became a widely disseminated malignant neoplasm in the abdomen. After the operation, the patient's course was dominated by a fatal consumptive coagulapathy. Pathologic examination of the multiple intra-abdominal lesions showed the histological and immunohistological characteristics of the angiosarcoma.Even though angiosarcoma in the gastrointestinal tract is extremely rare, when dealing with intraabdominal abscess or the gastrointestinal bleeding in patients who have undergone surgery or radiation therapy in the past, the possibility of angiosarcoma should be considered. To make the definite diagnosis of angiosarcoma and to avoid the misdiagnosis of foreign body granuloma, thorough histological examination and immunohistochemical staining may be prerequisite. Angiosarcoma is a rare malignant tumor with the incidence of 1%–2% of all sarcomas. It occurs in the skin and subcutis in most cases, and less commonly, it occurs in the liver ,4, and tA 61 year-old male was admitted for constipation and a palpable mass in the periumbilical area. His medical history revealed the surgery for acute perforative appendicitis 20 years ago and occasional intestinal obstruction afterwards. He denied any history of radiation or occupational exposure to chemicals. The small bowel series showed an external compressive lesion in the distal ileum and the computerized tomographic (CT) scan revealed a 6 cm, well-marginated mass in the anteromedial aspect of the ascending colon  declare that they have no competing interests.YTJ participated in the serial operations of the patient, prepared the manuscript for submission and resubmissionCYJ participated in the serial operations of the patient, prepared the manuscript for submission and resubmissionEJ participated in the serial operations of the patient, prepared the manuscript for submission and resubmissionYJL participated in the serial operations of the patient, prepared the manuscript for submission and resubmissionSCH participated in the serial operations of the patient, prepared the manuscript for submission and resubmissionSKC, participated in the serial operations of the patient, prepared the manuscript for submission and resubmissionWH participated in the serial operations of the patient, prepared the manuscript for submission and resubmissionSTP participated in the serial operations of the patient, prepared the manuscript for submission and resubmission, and helped in the final editing process.All authors approved the final version.


Abdominal cystic lymphangiomas are uncommon congenital benign tumors.We present a case of a 4 year old female child with a cystic lymphangioma arising from greater omentum and occupying whole of the abdomen and protruding through labia mejora. Ultrasonography and CT scan confirmed the diagnosis. Complete excision of the cyst along with omentectomy done with no clinical or radiological evidence of recurrence till 6 months.Due to variable presentation of abdominal lymphangiomas, extensive imaging studies are necessary for evaluation and diagnosis. Complete surgical resection is a treatment of choice. Ninety-five percent of lymphangiomas occur in the head and axila, while intra-abdominal lesions  are rare. Lymphangiomas are hamartomas of the lymphatic vessels that have the potential to infiltrate surrounding structures. About 50% are present at birth and up to 90% become evident by the age of two years. The prognosis of lymphangiomas depends on the location and extent of the lesion and the presence of other associated abnormalities. Complete resection is the treatment of choice and has an excellent prognosis. Although an abdominal lymphangioma is considered benign, it may become locally invasive. Therefore any involved organ must also be resected. Incomplete resection may lead to recurrence. Follow-up imaging is advised, with ultrasound as the modality of choice.A 4 year old female presented with huge abdominal swelling first noticed by her parents at 2 years of her age  declare that they have no competing interests.All authors read and approved the final manuscript.1. PNM -Helped in radiological investigations-Helped in histopathological diagnosis-Assisted the surgery-Drafted the manuscript2. AMB -Gave guidance in surgery-Gave final touch and approval to the manuscript-Coordination3. SP -Did the surgery-Took postoperative care-Participated in designing and revising the manuscriptThe pre-publication history for this paper can be accessed here:


Intravenous cannulation is a very common procedure. Venous aneurysm secondary to peripheral intravenous cannulation is extremely rare. Moreover, venous aneurysm can mimic other conditions and may confuse the issue.We describe a case of a 45-year-old woman who was referred with the diagnosis of varicose vein of right arm. A history of intravenous cannulation at the same site was noted that raised suspicion. The swelling was compressible and turned out to be a venous aneurysm. The lesion was completely excised. Postoperative recovery was uneventful. Histology findings were in conformity with the preoperative diagnosis.Caution should be exercised in diagnosing varicose vein at a site that bears a history of intravenous cannulation. The case also raises an important issue regarding consent. Should patients undergoing peripheral intravenous cannulation be warned of this rare complication? Venous aneurysm is an uncommon condition that can present in a myriad of fashions and cause diagnostic challenge. We describe a rare case of symptomatic venous aneurysm of the median antecubital vein secondary to intravenous cannulation, which was initially referred by the general practitioner as a varicose vein. The aneurysm was excised successfully without any complication. Clinical features, treatment and complications of venous aneurysms have been discussed. The case raises the issue of warning patients of a rare complication of a common procedure. A review of literature has also been performed. The optimum management of venous aneurysms remains unclear. There are three objectives of reporting this case- i) to make readers aware of this rare but potentially serious condition; ii) to highlight the need for optimising treatment of venous aneurysms, and iii) to raise a debate whether such a complication should be routinely mentioned while obtaining consent for establishing peripheral cannulation.A 45-year-old woman presented with a swelling in her right antecubital fossa. The only relevant past medical history was an episode of gastroenteritis and dehydration, for which she required hospital admission eight years previously. During that admission she had received intravenous fluid therapy via a cannula in the right antecubital fossa approximating to the same area as the swelling. She recalled developing the swelling few months following the episode. The swelling had steadily grown over time and become painful. There was no history suggestive of deep venous thrombosis of the right arm. There was no other significant past medical history.2 in size, just distal to the right antecubital fossa [Figure General examination was unremarkable. Local examination showed a soft, non-tender, compressible lesion, 2 × 3 cma Figure . There wRoutine laboratory investigations, including coagulation profile, were within normal limits. She underwent a duplex scan that showed a venous aneurysm in relation to a large median cubital vein. The vein appeared competent. There was no evidence of ectasia, varicosity or thrombosis of any of the surrounding arm veins.The aneurysm was explored under general anaesthetic and was completely excised. The key operative steps involved identification and ligation of tributaries feeding the aneurysm, prior to excision of the sac Figure . She madHistology of the aneurysmal sac showed periphery of the blood vessel with congested lumen and thickened media Figure . All thrVenous aneurysms are relatively rare. An unrestricted electronic search of the Medline database till February 2007 showed that one case of pseudoaneurysm of the antecubital vein had been described in the literature .A venous aneurysm is defined as a dilatation of a localised segment of vein. Unfortunately there are no universally agreed size criteria to define a venous dilatation as an aneurysm. Aneurysm can be congenital or acquired, though the exact aetiology remains unclear. It has been suggested that aneurysmal dilatation is a response to increased haemodynamic pressure at a site of mural weakness . HoweverSites of aneurysm can be grouped as (i) central thoracic ; (ii) visceral ; and (iii) cervical  and (iv) peripheral  .A venous aneurysm can present as a soft, compressible, subcutaneous mass that decompresses with elevation and enlarges with dependency and the Valsalva manoeuvre . It can Reported histology has varied from the presence of an anomalous muscular layer to a diminution of muscle and elastin fibres ,11. It iThe complications of venous aneurysms include embolism, thrombosis and rupture -14. Veno99mTc human serum albumin angiography has also been used in certain circumstances [Duplex scanning, Computed Tomography, Magnetic Resonance Imaging (MRI) and venography are important diagnostic modalities . Isotopimstances . Krinskymstances . Duplex The treatment of venous aneurysms depends on the site and associated symptomatology. Many symptom-free, superficial, small fusiform aneurysms without thrombus are deemed to carry a low risk of complications and therefore may remain under close surveillance with duplex scanning. Symptomatic, enlarging, popliteal and saccular aneurysms of any size or those with large fusiform aneurysms should undergo surgery ,18. TherSurgical options for repairing venous aneurysms include: (i) excision; (ii) aneurysmorrhaphy; (iii) resection with end-to-end anastomosis and (iv) resection with interposition graft . In the An unrestricted search of the Medline database (from 1950 to February 2007) was performed by using the keywords 'peripheral', 'venous' and 'aneurysm'. A total of 172 articles were cited. However, only one article reported a case of venous pseudoaneurysm following venupuncture, where the patient was on long term anticoagulation [Usually, verbal consent is obtained while establishing a peripheral cannula. According to General Medical Council, patients must be given sufficient information...to enable them to exercise their right to make informed decisions about their care . This raAneurysms of the venous system can be potentially dangerous in view of possible complications. A symptomatic acquired aneurysm of the antecubital vein secondary to intravenous cannulation has been described that was excised without any complications. Further considerations are warranted to clarify the optimum management of this rare condition and address the issue of consent.CT – Computed tomographyMRI – Magnetic resonance imagingGMC – General Medical CouncilThe author(s) declare that they have no competing interests.DD: Performed the surgery, designed the case report, collated the information, searched literature and drafted the manuscript.SW: Assisted with the surgery, involved in all investigations, assisted in providing a critical appraisal and review of the manuscript.EM: Made the histological diagnoses and prepared the pathology images, advised on the format and design and assisted in providing a critical appraisal of the manuscript.FM: Supervised and assisted with the surgery, involved in all investigations, assisted in literature search, writing and editing of the manuscript.All authors have reviewed and approved the final manuscript.The pre-publication history for this paper can be accessed here:


We report the case of a male, low birth weight, stillborn fetus of 36 weeks gestation with limb body wall complex. An interesting and rare feature noted in the propositus was the absence of the left subclavian artery and complete absence of the left upper limb. These findings seem to favor the vascular theory in the pathogenesis of this condition. The Limb Body Wall Complex (LBWC) is characterized by severe congenital anomalies, chief of which are thoracoschisis, abdominoschisis, limb defects, and exencephaly . In our The mother was an unbooked, 24 year old primigravida, with an uneventful antenatal period. There was no history of consanguinity or family history of any malformations. There was no history of intake of drugs other than hematinics and calcium during the pregnancy. No antenatal ultrasonogram had been done. She had been clinically diagnosed to have polyhydramnios prior to being referred to our institute. At 36 weeks of gestation, she was admitted with preterm onset of labour and delivered a stillborn fetus weighing 1900 g.On external examination, the placenta was normal; the umbilical cord was short; two umbilical arteries and one umbilical vein were present in the cord. The head and facies were normal. There was amelia of the left upper limb. There was a large defect in the body wall involving the thorax and the abdomen. The sternum, the anterior costal parts of the ribs on the left side and the diaphragm were absent. There was ectopia cordis, evisceration of the lungs, stomach, liver, spleen and intestines Figure .At autopsy, the above mentioned findings were confirmed. Dissection of the heart revealed a patent foramen ovale. The arch of the aorta gave rise to the right brachiocephalic trunk and a small left common carotid artery. The left subclavian artery was absent. The right lung was normal, but the left was firm, hypoplastic and without lobations. The thymus was normal. The intestines were nonrotated, with the small intestine on the right and the large intestine on the left side. The small intestine was dilated and distended with thick meconium forming a cast of the intestine. The terminal ileum was stenosed. The large intestine was short, stenosed and ended in a blind pouch; the terminal part of the large intestine and the rectum were atretic; the anal canal was patent and the anal opening normal. The liver was trilobulated and the gall bladder was absent. The pancreas and spleen were normal. The kidneys and ureters were normal but the bladder was found to have a vesicourachal diverticulum arising from its apex. The external genitalia were male and both testes were intraabdominal. The cranial contents were normal. Scoliosis of the spine was present Figure . MicroscThe limb body wall complex is also known as the body-stalk syndrome. It is a rare entity characterized by severe malformations. Most fetuses are aborted, either spontaneously or by medical means. Most of the remaining are stillborn. Postnatal survival for a significant duration is extremely rare, but at least one such case is reported; the child has severe physical handicaps. The etiology is unknown. No teratogen has been implicated and no genetic abnormality has been identified . FamiliaThe diagnostic criteria for LBWC are still being discussed, but the most commonly quoted are those originally set forth by Van Allen et al in 1987, i.e., the presence of two of the following three malformations: (a) exencephaly/encephalocele and facial clefts; (b) thoraco and/or abdominoschisis; and (c) limb defects . Russo eTheories on the pathogenesis of the BWC include(a) germ disc defect with early embryonic maldevelopment ,(b) primary rupture of the amnion leading to the formation of amniotic bands ,(c) vascular disruption  and(d) disturbance of the embryonic folding process .Though limb defects are present in the vast majority of cases, absence of a limb is seen in less than a tenth  and uppeAntenatal diagnosis is usually made on ultrasound examination. Serum alpha fetoprotein levels are often elevated. The importance of early antenatal diagnosis in this severe condition with a poor prognosis lies in differentiating it from an isolated gastroschisis, which has a much better prognosis. Early diagnosis can be followed by medical termination of the pregnancy."Written informed consent was obtained from the patient for publication of this case report and accompanying figures. 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.NP did the literature review and prepared the manuscript, JJ made the diagnosis, critically reviewed and corrected the manuscript, SEJ conducted the autopsy, JC was involved in the literature review and manuscript preparation, SS made the final corrections, approved the manuscript and will act as guarantor. All authors read and approved the final manuscript.


The pancreas is a well-documented but relatively uncommon site of non-small-cell cancer metastases. However, at the time of diagnosis the disease is usually locoregionally advanced, therefore therapeutic management is mostly palliative and symptomatic.We report the case of a 77-year-old Caucasian male patient who presented initially with a clinical picture of acute cholangitis approximately 2 years after a left lower lobectomy for a low-grade squamous lung carcinoma. CT scan imaging of the abdomen and chest revealed an abnormal growth of the pancreatic head and distention of both the intra- and extra-hepatic billiary tree, whereas osteolytic abnormalities were observed of the 5th left rib, consistent with secondary deposits. Initially an endoscopic retrograde cholangio-pancreatography (ERCP) and sphincterectomy was performed and a plastic stent was placed in the common bile duct to decompress the biliary tree. Cytological examination of the aspirate collected by FNA of the pancreatic lession under EUS guidance revealed cells consistent with a low grade squamous lung carcinoma. Two months later an open cholecystectomy along with a gastrojejunostomy was performed to relieve the patient's gastric outlet obstruction symptoms. Following remission of the patient's attack of acute cholangitis and excessive vomiting he was released from the hospital and instructed to initiate chemotherapy with vinorelbine. The patient succumbed to disseminated disease almost 5 months later.Symptomatic metastatic lesions of the pancreas from squamous cell carcinoma of the lung are infrequent. Typically, the patients remain asymptomatic until their disease reaches a fairly advanced stage and therapeutic options are limited to palliative measures. A high index of suspicion is the only way of early detection and potentially effective treatment for this rare localization of metastatic squamous lung carcinoma. A variety of malignant tumors have been documented to metastasize to the pancreas. The most common primary site for pancreatic metastases is the lung 18-27%) [8-27% 1,. These cIn this report, we present the case of 77-year-old patient with non-small-cell lung carcinoma who presented with a metachronous solitary pancreatic metastases that became clinically evident with recurring episodes of cholangitis and obstructive jaundice, as well as symptoms of gastric outlet obstruction.A 77-year-old Caucasian male patient, with a history of triscupid deficiency, coronary heart disease, arterial hypertension and a permanent pacemaker placement due to bradyarrythmia was diagnosed with a solitary lesion of the lower lobe of the left lung on September 2006, an incidental finding in a routine chest x-ray. This finding was confirmed by a chest CT, which in turn revealed a 2.5 × 2 cm solitary lesion on the lower lobe of the left lung. At that time, no evidence of metastatic disease was demonstrated from the patient's additional radiologic examination. Subsequently, he underwent a lower lobectomy of the left lung with an uneventful recovery.Pathological examination confirmed a low-grade squamous carcinoma of the lung, with peripheral spots of adenocarcinoma with clear surgical margins and negative lymph nodes. Postoperatively the patient received a regime of adjuvant chemotherapy consisting of 4 cycles of Paclitaxel (Taxol) and Carboplatin.th left rib, consistent with secondary deposits [Figure For the following 2 years the patient did well without any evidence of local or systemic recurrence. On November 2008 a routine follow-up chest CT revealed osteolytic abnormalities of the 5s Figure . A few ds Figure , 4. Two The patient had an uneventful recovery and remained in good clinical condition for the following three months. Progressively he developed symptoms of disseminated disease and finally died five months post-laparotomy.The pancreas is a relatively infrequent site of distant metastasis. Moreover, metastatic tumors to the pancreas rarely become clinically evident, although their incidence has been reported to be approximately 12% in autopsy reports of patients suffering from other malignancies .The most frequent sources of pancreatic malignant metastases originate from the lung, breast, kidney, gastrointestinal tract, thyroid, melanoma, and liver. Melanomas and osteosarcomas are also among the tumors that metastasize to the pancreas. The route of metastases is lymphatic (28%), vascular (27%), lymphatic - vascular 19%) and by direct invasion (18%) 9% and by. The mosPrimary lung cancer metastasizes to distant organs quite frequently. The most common sites of lung cancer metastases are the bones, liver and adrenal glands. The pancreas is a rather uncommon location of metastatic lung cancer. Evidence about it is based on scattered case reports in the literature that usually concern patients at an advanced stage of their disease, thus eligible only for palliative treatment. It is estimated that the incidence of secondary pancreatic deposits resulting from the various types of lung cancer range from 14.2% - 18. 2% . The majSymptoms caused by metastatic pancreatic lesions are variable and most patients are free of organ - specific complaints. Metastatic disease is usually incidentally detected on abdominal CT scan during the follow-up period. Those patients that do have clinical manifestations may present with abdominal or back pain, nausea, weight loss, jaundice, gastrointestinal haemorrhage or intestinal obstruction . MoreoveThe diagnosis is usually confirmed by percutaneous fine needle aspiration of the pancreatic lesion under CT guidance or endoscopic ultrasound (EUS) or by cytological examination of brushing specimens obtained during endoscopic retrograde cholangiopancreatography (ERCP)).Treatment options for metastatic lung cancer lesions to the pancreas are mainly of palliative intent. They can be either non-invasive or invasine - surgical. Non-invasive treatment options can be chemotherapy and/or common bile duct stenting, in order to relieve the patient from jaundice and its symptoms. When surgical treatment is contemplated this is usually limited to by-pass procedures in patients with obstructive jaundice. There have been a few reports of patients who underwent pancreatic resections for metastatic lung cancer lesions, but this was either in ignorance of or overseeing the fact that the aetiology of the obstruction was of metastatic origin ,12. TherNon-small cell lung cancer with distant metastases (stage IV) has a poor prognosis. Platinum-based chemotherapy regimens have been shown to improve survival and enhance quality of life, and they are also cost effective. This treatment is most appropriate for patients with a good performance status. EGFR inhibitors are used as second or third line therapy. They are most effective in women, in patients who have never smoked, or are diagnosed with adenocarcinoma. Studies of other novel agents and non-platinum-based regimens are ongoing. Median survival has been reported to improve from 3.6 to approximately 6.5 months after chemotherapy . WhetherFinally, the information above highlights the fact that a high index of suspicion should be raised for every patient with a previous history of cancer, who presents with a pancreatic mass. Therefore, before making any therapeutic decision, any correlation of the pancreatic mass with the patient's previous cancer history should be thoroughly examined.Symptomatic metastatic lesions of the pancreas from squamous cell carcinoma of the lung are extremely rare. Typically, the patients remain asymptomatic until their disease reaches a fairly advanced stage, and therapeutic options are then limited to palliative measures. FNA of the suspsicious lession is fundamental in order to achieve differential diagnosis from other primary pancreatic tumors. A high index of suspicion is the only way of early detection and potentially effective treatment for this rare localization of metastatic squamous lung carcinoma.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 journal's Editor-in-Chief.The authors declare that they have no competing interests.MAK: designed and drafted the manuscript. CS: participated in the acquisition of data and preparation of the manuscript. MK: responsible for critical revision of scientific content.TK: assisted in the preparation of the manuscript. CZ: assisted in the preparation of the manuscript. ET: performed histopathological, immunohistochemical and cytological analysis.PD: participated in the acquisition of data and preparation of the manuscript. INN: the surgeon, approved the final version of the manuscript for publication. All authors read and approved the final version of the manuscript.