The current study presents the first case of a lipomatous hemangiopericytoma (LHPC) developing in the parotid gland in a 33-year-old male. The patient presented with a 4-year history of a progressively growing painless and fixed mass in the left paratid gland region. The patient underwent radical parotidectomy and was followed-up for 12 months without any evidence of metastasis or recurrence. LHPC, a controversial rare HPC variant, is histologically characterized by a varying admixture of hemangiopericytomatous vasculature and the presence of mature adipocytes. To date, 51 cases of LHPC have been documented in the literature. Although the boundary between HPC and solitary fibrous tumors (SFTs) has become increasingly blurred, neither of these variant growth patterns has previously been recognized in the parotid gland. Lipomatous hemangiopericytoma (LHPC) is an uncommon, slow-growing, almost non-recurring, non-metastasizing mesenchymal neoplasm composed of mature adipocytes and HPC-like areas . The majA 33-year-old male presented with a four-year history of a progressively growing, painless and fixed mass in the left parotid gland region. The patient did not have any associated headaches, facial weakness or numbness, or impairments in speech or swallowing. A head and neck CT scan showed a 19.0×13.2-mm oval heterogeneous mass within the left parotid gland . A radicet al is often positively expressed in pleomorphic adenoma, and would be of additional assistance in excluding this diagnosis. S100, GFAP and p63 are positively expressed in myoepithelioma. Schwannoma and neurofibroma are strongly reactive with S100 protein, while lacking CD34. Angiomyolipoma reacts with HMB45, Melan-A, tyrosinase and S100 protein.The most common treatment for LHPC is complete local surgical excision. Although no LHPC patients developed recurrence during the follow-up interval and even though all patients were without disease, certain authors have recommended the use of a long-term follow-up ,5. In co


Carcinoid is an endocrine cell tumor with low-grade atypia, which is generally a low-grade malignant cancer with a good prognosis. Metastatic renal carcinoid is even rarer than primary carcinoids.We present our experience of a patient with metastatic renal carcinoid from the gastrointestinal tract.The carcinoid tumor of the kidney in our patient, who had a history of liver metastasis from rectal carcinoid, was considered metastatic based on the pathological findings. Carcinoid tumor was first detected as multiple tumors in the ileum by Lubarsch during autopsy more than 100 years ago . Here, wA 56-year-old man underwent resection of a rectal carcinoid twelve years ago, and subsequently underwent resection of liver metastases of rectal carcinoid twice, twelve and ten years ago. Two years ago, he was found to have a 3-cm mass in the left kidney on ultrasonography during a general checkup, and attended our department. Results of routine blood chemical analysis and urinalysis were unremarkable.Ultrasonography revealed a 3-cm relatively well-defined mass in the lower pole of the left kidney, and the interior of the mass was low echoic, unclear of margin, and hypovascular. Contrast-enhanced abdominal CT demonstrated a poorly enhanced, well-defined mass at the above-mentioned site in both the arterial and venous phases Figure . MRI shoSince these findings did not rule out malignancy, left renal cell carcinoma T1aN0M0 was diagnosed. According to the patient's strong wishes, left nephrectomy was performed laparoscopically through the retroperitoneal approach. Examination of the resected specimen revealed a 2 × 2 × 3 cm well-defined, solid tumor with a white capsule in the inferior pole of the kidney Figure .Histopathologically, hematoxylin and eosin staining revealed cells uniformly arranged in a trabecular or funicular pattern. The cytoplasm was ill-defined and showed eosinophilic staining. The nucleus was ovoid to short fusiform, with no obvious mitoses. The tissue was partly necrotic. Immunostaining was positive for synaptophysin and chromogranin A, and negative for p53 Figure . These fPostoperatively, blood tests, urinalysis, imaging, gastrointestinal endoscopy and other examinations showed no findings suggestive of recurrence of carcinoid while two years.et al. conducted a study in a total of 98 patients with gastric endocrine cell carcinoma or carcinoid tumor, and reported that patients with carcinoid tumor did not have any p53 protein overexpression or genetic mutation [Carcinoid tumors are generally considered to arise from neuroendocrine cells, and secrete different substances depending on their primary site. Such tumors characteristically secrete serotonin, although some of them are inactive. Accordingly, urinary secretion of 5-hydroxyindole acetic acid (5-HIAA), a metabolite of serotonin, increases. Other hormones and biochemical substances secreted from carcinoid tumors include corticotropin, histamine, dopamine, substance P, neurotensin, prostaglandins and kallikrein. Secretion of these vasoactive substances, including serotonin, may cause symptoms of palpitations, hot flushes, wheezing, diarrhea, and skin flushing, as well as carcinoid syndrome such as right-sided valvular disease. Since serotonin and other similar substances are metabolized mainly in the liver, carcinoid syndrome is observed only when such substances flow directly into the systemic circulation from metastatic lesions in the liver, lung, gonads etc., without involving the liver. From the perspective of a histogenetic pathway, carcinoid is a benign tumor originating from epithelial stem cells, and highly malignant carcinoids are referred to as endocrine cell carcinoma. For differentiation of malignancy, immunostaining for p53 is useful. Nishikura et al. investigated the association between differentiation of gastrointestinal carcinoid and MIB-1, p53, and bcl-2 in 58 patients, and reported that MIB-1 and p53 could be prognostic factors [Moyana  factors .et al. reported the first case in 1966 [Nearly 100 cases of primary renal carcinoid have been reported since Resnick  in 1966 . There het al. reviewed 56 case reports of renal carcinoid [et al. reported that renal carcinoid often complicates horseshoe kidney, polycystic kidney or renal teratomata [et al. reported the first case of renal carcinoid treated by laparoscopic partial nephrectomy [Romero arcinoid . The medratomata . In parthrectomy .et a l [To our knowledge, there has been only one reported case of metastatic renal carcinoid (metastasis from the lung to the right kidney) by Tal et a l . This paet al. reported that in appropriate patients with Stage T1b-T3 tumor >4 cm, laproscopic partial nephrectomy provides equivalent oncologic efficacy and superior renal functional outcomes compared with laparoscopic radical nephrectomy [In this case, we should choose and recommend laparoscopic partial nephrectomy even if the patient had strong wish to laparosopic radical nephrectomy. Because, Simmons hrectomy .The carcinoid tumor of the kidney in our patient, who had a history of liver metastasis from rectal carcinoid, was considered metastatic based on the pathological findings. In view of the tumor being p53-negative and no apparent recurrence to date, he seemed to have a good prognosis.The authors declare that they have no competing interests.YK drafted the report, and approved the final version of the manuscript.YY, GN, TY, KZ, RK, MT, SA, TT and NH cared for the patient and approved the final version of the manuscript.KN drafted the report, cared for the patient and approved the final version of the manuscript.Department of Urology, Aichi Medical University School of Medicine, Nagakute, Aichi 480-1195, Japan.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2490/10/22/prepub


Cutaneous metastases from large bowel cancer are uncommon and are usually associated with organ involvement. Localization of lesions to the skin is mainly attributed to vascular and anatomical relationship, since most of them are seen in the abdominal wall or in a surgical scar. We report a 73-year-old woman in whom metastatic nodules from a poorly differentiated adenocarcinoma of the right colon developed throughout the skin  and remained the only sign of extranodal tumor spread until patient's death, seven months later. This unusual behaviour suggests that localization of neoplastic cells to the skin may be a site-specific process, determined by adhesion molecules and/or by growth factors found at that site. Cutaneous metastases from large bowel cancer are uncommon, occurring in less than 4% of patients , 2. LocaA 73-year-old woman was admitted to our hospital with a few days history of fever and diarrhoea. She reported a 3-month weight loss of about 4 kg and complained of a mild abdominal pain in the right iliac fossa. A colonoscopy revealed an adenocarcinoma of the ascending colon. Chest X-ray and abdominal ultrasonography showed no pulmonary or liver metastases. A right hemicolectomy was performed. Histological examination of surgical specimen revealed a poorly differentiated adenocarcinoma, 4  ×  4 cm in diameter, with invasion of the serosa and metastases to mesenteric lymph nodes. A few days after discharge, the patient noted three nodules in her abdominal wall, chest, and back skin respectively. On physical examination, the nodules were indolent, elastic masses of about 2  ×  2 cm in diameter, not freely movable, with normal appearance of the overlying skin. Excisional biopsy revealed cutaneous metastases from adenocarcinoma. The patient refused any adjuvant treatment. Six months later, she was readmitted for removal of a large, firm, flesh, coloured mass of her left arm, limiting the movements. By that moment, multiple nodules were present throughout the skin of the buttock, trunk, abdominal wall, and neck . The lesions were varying in size from few millimeters to 10 centimetres. The overlying skin was normal or violaceous. A nodule on the chest wall was ulcerated. Chest X-ray and bone scintigraphy showed no metastatic lesions. Abdominal ultrasonography revealed no sign of abdominal relapse, in particular no liver secondaries. In the following days, the patient developed a rapidly increasing mild dyspnoea. Indirect laryngoscopy showed incomplete paralysis of the vocal cords. A tracheostomy was performed as an emergency procedure for an asphyxial crisis. On gross appearance, the trachea was compressed and infiltrated by large subcutaneous masses. Results of histological examination revealed metastases from adenocarcinoma. The patient died of respiratory failure before any other therapeutic options could be undertaken. Autopsy was not performed. Cutaneous metastases are rare. Their incidence report ranges from 0,7 to 10,5% in autoptic and retrospective studies , 7. In oThe case we report is unusual because remote cutaneous metastases are not associated with visceral secondaries. It seems unlikely that the tumor cells locate throughout the skin just for mechanical factors without hepatic or pulmonary involvement, since lung and liver receive all of the venous drainage from the colon, prior to distribution to the rest of the body. It seems reasonable to suppose that circulating tumor cells bind specifically to the skin by site-specific adhesion molecules and/or respond preferentially to growth factors found at that site.


A 60-year-old woman presented with a swelling in right paraumbilical region of one-year duration. Examination revealed a painless cystic swelling 15 × 10 cm with cough impulse. Ultrasound and CECT abdomen showed a subcutaneous cystic swelling with intramuscular extension. No other intraabdominal cystic lesions were found. Surgical exploration showed a cystic lesion adherent to peritoneum without any intraperitoneal extension. Cyst was carefully excised without any spillage. Gross specimen on opening showed multiple daughter cysts consistent with hydatid cyst, confirming the diagnosis of solitary abdominal wall hydatid cyst. Hydatid disease is a parasitic tapeworm infection that usually involves liver and lungs. Primary skeletal muscle hydatid cyst without liver and lung involvement is rare even in endemic districts. Muscular hydatosis has been well documented in literature but involvement of abdominal wall is a rare entity with about 5 cases reported till date. It is interesting to note that in all 5 cases the cyst location has been in right paraumbilical and iliac fossa. We report a case of abdominal wall hydatid with an attempt to explain the mechanism for this unusual location.A 60-year-old woman presented with swelling in right paraumbilical region evolving over a year . PhysicaEchinococcus granulosus species, which is responsible for cystic hydatidosis, has an almost ubiquitous diffusion. South America, Central Asia, and the Mediterranean basin FNAC has proved to be more sensitive and rapid. The hooklets present in necrotic lesions of echinococcus have refractile blades, handles, and guards, and Ziehl-Neelsen stain is particularly useful in identification of the elusive hooklets in necrotic lesions. Hira et al.  recommenThe treatment of choice in muscular hydatid disease is excision of the intact cyst and surrounding tissue. In one study, cure and mortality rates for the surgical treatment were reported to be >90% and <2%, respectively. Surgical procedures vary from radical procedures  to conservative procedures . Host capsule excision is rarely indicated because the capsule is a part of the host organ and is not infected; and finally, radical procedures require good patient status and surgeon experience .The rationale for albendazole therapy after percutaneous aspiration-injection-reaspiration (PAIR) or surgery is to inactivate viable scoleces in the residual cyst and prevent recurrence. A randomized trial comparing albendazole therapy and PAIR demonstrated maximum reduction in cysts treated with concomitant chemotherapy . RecommeAlbendazole has been shown to significantly decrease intracystic pressure when given for 3 weeks before surgery . Exposurin vivo in a rat model of hydatid infection. In contrast to monotherapy with either agent, combination treatment produced a significant reduction in both the number and viability of cysts [The benefit of treatment with albendazole after surgery is debatable; treatment with albendazole after surgery is likely to have most benefit in conservative procedures in which there is residual cyst tissue, for cysts in inaccessible anatomic locations, or when there is cyst spillage. The World Health Organization Working Group on Echinococcus recommends 1 month of treatment after surgery. The combination of albendazole and praziquantel has been investigated of cysts .in vitro and in vivo [Albendazole is rapidly converted to an active metabolite, albendazole sulfoxide, which achieves high concentrations in the cyst and is active against both protoscoleces and the germinal membranes . Praziqu in vivo , 44. The in vivo . In huma in vivo .In one study, patients with hydatid cysts were treated with a combination of albendazole and praziquantel. These were compared with historical controls treated with albendazole alone. The complete cure rates were higher in the combined group (47.4% versus 36.4%), although this difference was not statistically significant. In addition, the time to cure was 2–6 months in the combined group, compared with 6–24 months in the albendazole monotherapy group [This case illustrates that echinococcal disease should be considered in the differential diagnosis of every cystic mass in any anatomic location, especially when they occur in areas where the disease is endemic. Surgical excision is the treatment of choice with postoperative combined treatment with Albendazole and Praziquantel to prevent recurrence.


We report a rare patient of a simultaneous extradural and intradural compression of the cervical spinal cord due to co-existent intervertebral disc herniation and an intradural schwannoma at the same level. The intradural lesion was missed resulting in recurrence of myelopathy after a surprisingly complete functional recovery following anterior cervical discectomy. Retrospectively, it was noted that the initial cord swelling noticed was tumor being masked by the compression produced by the herniated disc. A contrast magnetic resonance imaging scan is important in differentiating intradural tumors of the spinal cord. A high index of suspicion is often successful in unmasking both the pathologies. Cervical disc herniation is the commonest cause of cervical radiculo-myelopathy that requires surgical treatment. Decompression produces excellent results. Intradural tumors are rare. Their incidence is highest in the cervical spine. Due to their slow, indolent growth a high index of suspicion is required to diagnose these tumors. Co-existence of these pathologies is unreported and may confuse the physician. We report a case where an intradural tumor was missed due to the presence of a concomitant cervical disc protrusion.A 55-year-old lady presented with clumsiness of fine motor functions of the hand and gait of two months duration. She was asymptomatic prior to this episode. On local examination there was no spasm, tenderness or deformity of cervical or dorsal spine. There was minimal spasticity and exaggerated deep tendon reflexes in all extremities. The plantars were extensor and the superficial abdominal reflexes were absent. The bladder and bowel functions were unaffected. The Japanese Orthopedic Association JOA scoreA diagnosis of anterior cord syndrome secondary to herniated cervical disc was inferred. An anterior C5-6 discectomy and uninstrumented fusion using iliac crest autograft was performed. The patient showed rapid recovery in the neurological status starting from the tenth postoperative day and regained independent ambulation by the third postoperative week. Bladder control was restored and the sensory deficit recovered. Patient was followed up regularly at six weeks, three months, six months, one year and two years. Follow-up at six weeks showed a JOA score of 15/17. Slight clumsiness of gait persisted till two years, which was perceived only on brisk walking (evident on detailed in depth questioning retrospectively). The patient also complained of urgency in micturition. The deep tendon reflexes remained exaggerated at two years. The lateral radiograph showed complete fusion of the graft.25 months postoperatively, the patient returned with increased symmetrical clumsiness of both hands and inability to walk unsupported on plain ground. The clumsiness of gait increased and was evident on routine daily activities. She complained of numbness in the upper extremities, trunk and the lower extremities. Bladder control remained status quo (slight urgency persisted). The JOA score was 7/17. A repeat MRI scan showed a right posterolateral 1.5 cm intradural tumor displacing the cord substance. The lesion was hyperintense on T1and T2 images. The tumor extended from C4-C6 Figures  and 4 inOn gross appearance the tumor felt soft and showed fine lobulation with a distinct pseudo-capsule. On the cut surface, the tumor appeared homogenous. The histopathology revealed a schwannoma with spindle shaped tumor cells and palisade pattern.The neurological status improved rapidly and the patient regained the preoperative JOA score of 15/17 by the sixth postoperative week. Two years after the excision of mass, the patient remained slightly clumsy in hand function and gait but led a normal active life style .This case report highlights a rare co-existence of two significant pathologies contributing to cervical cord compression. It is uncommon for an acute cervical disc herniation to produce a profound acute neurological deterioration without causing axial or radicular pain. Following an anterior cervical discectomy, the compressive factor was reduced. The cord edema resolved allowing neurological recovery. Most intra-dural tumors follow a slow progressive, indolent course and there may be lag period of several months before symptoms become obvious.Schwannoma and meningioma are the commonest intradural extramedullary tumors.5Acute neurological deterioration with involvement of the lower limbs more than the upper limbs (anterior cord syndrome)Complete recovery after surgery allayed suspicion and deferred postoperative MRIDefinition of the tumor obscured by a broad based disc herniation in all images.A gadolinium contrast MRI could not be obtained due to underlying renal disease.Co-existence of a lumbar disc herniation and a proximal dorsal or cervical intradural tumor is reported.3


A 5-½-month-old female Holstein-Friesian calf was presented with a history of recurring ruminal tympany and poor development. The absence of lung sounds on the right hemithorax suggested a right-sided intrathoracic pathology. Radiography and computed tomography revealed a large thin-walled cavernous lesion with a gas-fluid interface which almost completely filled the right thoracic cavity. Fluid aspirated from the lesion was clear, yellowish and odorless. These findings led to the diagnosis of a bronchogenic cyst. Thoracotomy was performed under general anesthesia. The cyst strongly adhered to the adjacent lung tissue. After removal of the free wall, the adjacent lung tissue was sealed using surgical stapling instruments, and the non-removable part of the wall was curetted and rinsed. The intensive postoperative management included antibiotic therapy, oxygen supplementation and regional lidocaine infusion. Anti-inflammatory drugs were administered for further pain control. The calf recovered well and was released from the clinic on postoperative day 11. Intra- or extrathoracic bronchogenic cysts result from abnormal budding during the embryonic development of the tracheobronchial system. Successful treatment of this calf despite the size of the lesion and the invasive character of the surgical intervention indicates that resection of bronchogenic cysts in cattle may be an option for valuable animals. Bronchogenic cysts, also known as foregut duplication cysts, result from abnormalities in the development of the tracheobronchial system during the embryonic period ,2. PulmoAbnormalities in budding during the embryonic development may lead to the formation of supernumerary bronchi when continuity with the developing tracheobronchial airway is maintained, or may lead to the development of bronchogenic cysts when this connection is lost ,3. BroncIn humans, pediatric patients with symptomatic bronchogenic cysts tend to present with respiratory dysfunction due to compression of the tracheobronchial tree by the cyst. In adults however, symptoms may develop as a result of infection of a formerly asymptomatic cyst .Few reports of bronchogenic cysts are available in the veterinary literature. An extrathoracic cervical bronchogenic cyst (11 × 7 × 4 cm) has been described in a calf with progressive enlargement of a mass on the ventral side of the neck . A seconThis is the first report describing the diagnostic approach, surgical treatment and follow-up of an intrathoracic bronchogenic cyst in a calf.A 5-½-month-old female Holstein-Friesian calf weighing 132 kg was referred to the Clinic for Ruminants of the Vetsuisse Faculty in Berne with a history of recurring ruminal tympany and poor development.Complete clinical examination of the calf revealed a thin body condition and a rough hair coat. Body temperature was within normal limits , and examination of the cardiovascular system revealed no abnormalities  [Clinical examination, in particular the absence of lung sounds on the right hemithorax, suggested a primary right-sided intrathoracic lesion and a ruminal tympany. For further characterization of the disease process, blood and rumen juice analyses, as well as thoracic radiographs were performed.a were within normal limits and the analysis of rumen juice revealed an inactive flora. Laterolateral thoracic radiographs on the standing animal showed a large (20×35 cm) cavernous lesion which almost completely occupied the caudodorsal thoracic cavity. The lesion was thin-walled and presented a gas-fluid interface in its ventral third d Figure . The visb with a peak kilovoltage (kVP) of 140 and 250 milliampere seconds (mAs). The study consisted of continuous 5 mm slices acquired with breathhold technique in dorsal recumbency. Contrast was not administered. The large cavitary lesion was localized to the right caudal hemithorax and measured approximately 21 cm in height, 17 cm in width and 19 cm in length. A regular wall, 2 cm at its thickest, encircled a single cavity containing fluid (27 Hounsfield units (HU)) in its ventral third, and gas in its dorsal portions  of the thorax was performed under general anesthesia using a 16 slice CT scannerThe differential diagnoses for the cavitary structure in the right hemithorax included a bronchogenic cyst or an abscess. In addition, the areas of alveolar pattern suggested either focal pneumonia or compression atelectasis of the lung tissue. In the dorsal lung fields, changes were attributed to hypostasis due to dorsal recumbency during CT.c for Mycoplasma bovis was negative.Fluid within the cyst was punctured under ultrasound guidance in the non-sedated calf. The aspirate was clear, yellowish and odorless. Its specific gravity was 1.032, total protein was 44 g/L and the white blood cell count was 0.92×10e9/L with 98% polymorphonuclear leucocytes. Few bacillary bacteria were found in the cytological analysis. Polymerase Chain Reaction (PCR)The clinical, radiographic and CT findings as well as the results of aspirate analysis were suggestive of a bronchogenic cyst. The recurring rumen tympany observed was considered to be secondary to esophageal compression and ructus impairment by the cyst. With the owner’s agreement, the mass was surgically removed.d (0.05 mg/kg body weight (BW) IV), and xylazinee (0.1 mg/kg BW IM) were administered for premedication, and the calf was preoxygenatedf with a face mask for 10 minutes until general anesthesia was induced with ketamineg (5.3 mg/kg BW IV). After intubation in sternal recumbency, the endotracheal tube was connected to a breathing systemh and 100% oxygen was given to the spontaneously breathing calf. It was then placed on the surgery table in left lateral recumbency, and volume-controlled ventilation was started. General anesthesia was maintained with inhaled isofluranei in 100% oxygen and constant rate infusions of butorphanold (0.02 mg/kg BW per hour IV), lidocainej , and ketamineg (0.5 mg/kg BW per hour IV). Intercostal nerve blocks were performed with a total volume of 15 ml of 2% lidocainej from the 4th to the 8th right rib spaces.The calf’s condition was reevaluated specifically prior to thoracotomy and the animal was assigned a category four out of five on the ASA Physical Status Classification System , indicatth and 7th rib and osteotomy of the distal aspect of the 6th rib was performed with an oscillation sawk to enable insertion of a Finochietto retractorl. The pleura was incised and exploration of the pleural cavity was performed. The cyst was embedded between the caudal part of the cranial lung lobe and the middle lobe, and adhered to the adjacent lung tissue, which prevented its in toto removal. The cyst wall was incised and the fluid aspirated. The free part of the wall was removed using surgical stapling instrumentsm to seal the adjacent lung tissue. The inside of the non-removable part of the wall was rinsed with sterile sodium-chloride solutionn and curetted. A chest tubeo was placed through the 8th intercostal space and connected to a silicone reservoirp providing negative pressure for 48 hours. The pleura and the intercostal muscles were adapted and sutured with resorbable materialq. The 6th rib was aligned and stabilized to the 5th and 7th rib using absorbable suture materialq in a circumcostal pattern. Muscles, subcutis and skin were closed routinely after installation of a perforated flexible plastic tuber with a diameter of 3 mm between the adapted muscle layers to instill lidocainej for postoperative analgesia.The skin was incised between the 6s, 30’000 IE/kg BW IV, q8h, for 12 days, and danofloxacint, 1.25 mg/kg BW, q24h IV, for 5 days) and oxygen insufflation through a nasal tube for 24 hours. Regional lidocainej infusion (1 mg/kg BW every 2 hours) was administered through the flexible plastic tube placed at surgery and anti-inflammatory agents were administered for further pain control , as well as butorphanold . Arterial blood gas measurements were used to monitor lung function.Postoperative management consisted antibiotic therapy . Ruminal tympany was not observed after surgery.No more spontaneous unproductive cough could be heard. The arterial blood gas analysis showed an oxygen saturation of 93.7% (reference range: >98%) and a partial oxygen pressure of 73.0 mmHg (reference range: 95 – 105 mmHg) . The calHistological findings of the extirpated cyst revealed a ciliated pseudostratified epithelium, glandular structures, goblet cells and granulation tissue. The wall was infiltrated with inflammatory cells Figure .The calf returned to the clinic for reevaluation 3 months after surgery. Its general condition was good, as confirmed by a weight gain of 133 kg since its release from the clinic, as well as by an appropriate size and muscle mass for its age. The respiratory rate was still above normal (48 breaths/min), and the respiratory sounds were slightly increased bilaterally over the entire lung fields, but no pathologic sounds such as wheezes or crackles were heard.. Because of the satisfactory clinical evolution and because a further intervention was not envisaged for this animal, no further examinations were undertaken to differentiate scar tissue from possible recurrence of a fluid-filled cyst.Thoracic radiographs revealed a homogenous structure of soft-tissue opacity at the former location of the cyst and increased radiopacity of the adjacent tissues Figure . BecauseThe development and the general condition of the calf were satisfying and it calved for the first time at the age of 24 months.In the presented case, the Holstein Friesian calf was referred to the Clinic for Ruminants of the Vetsuisse Faculty in Berne for clinical examination of recurring ruminal tympany and poor development.Bronchogenic cysts may present clinically with progressive dyspnea and decrease or absence of lung sounds on the affected side, as do also other intrathoracic space-occupying lesions like abscesses, seromas or neoplastic masses. Other clinical signs vary according to the specific location of the lesion and may include ruminal tympany  and congestion of the jugular veins as a result of compression by the space-occupying masses ,12. In tAlthough clinical examination and radiography revealed enough details to reach a suspicion of bronchogenic cyst in the present case, CT was helpful to better evaluate the cyst’s dimensions and its relation to the surrounding structures prior to surgery. Assessment of the thorax by CT is used in humans for differentiation between bronchogenic cysts, congenital lobar emphysema, and congenital cystic adenomatoid malformation . As cystDespite CT’s sensitivity, histopathologic examination of the excised material is still considered necessary to confirm a diagnosis of bronchogenic cyst . BronchoIn the present case, no cartilage was found in the tissues submitted for histology. Nevertheless, the presence of a ciliated pseudostratified epithelium, of glandular structures and goblet cells correlates well with published descriptions ,4,14.Bronchogenic cysts usually do not communicate with the tracheobronchial tree and are filled with serous or mucoid fluid ,14. An aTherapeutic options for bronchogenic cysts are limited. Complete surgical excision is recommended and should be curative, whereby aspiration of the cyst fluid seems to be an inadequate option as secretions likely will reaccumulate. In case of extrathoracic lesions without clinical signs, surgery may be performed for cosmetic reasons . Althougin toto, it cannot be excluded that later complications may affect this animal’s productive life. Furthermore, no information is available on potential heritability of bronchogenic cysts in cattle.Intrathoracic bronchogenic cysts may cause ruminal bloat in cattle, and they may be successfully treated, despite thoracotomy in calves being an invasive and expensive operation dependent on sophisticated anesthesiology equipment and surgical knowledge. In the light of the present patient’s uneventful recovery despite the size of the lesion and the invasive character of the surgical intervention, excision of bronchogenic cysts in cattle may be an option for selected cases. However, as the cyst could not be resected Written informed consent was obtained from the patient’s owner in keen for publication of this report and any accompanying images.aAdvia 120, Siemens Medical Solutions Diagnostics, Erlangen, GermanybBrilliance, Philips Medical Systems, Eindhoven, Netherlandsc7500 real-time PCR system, Applied Biosystems International Inc., Rotkreuz, SwitzerlanddMorphasol®-10 ad.us.vet, Dr. E. Graeub AG, Bern, SwitzerlandeXylazin Streuli ad.us.vet, Streuli Pharma AG, Uznach, SwitzerlandfSauerstoff O2, Carbagas AG, Gümligen, SwitzerlandgKetanarkon 100 ad.us.vet., Streuli Pharma AG, Uznach, SwitzerlandhFabius®-CE, Dräger Medical Schweiz AG, Liebefeld, SwitzerlandiAttaneTM Isoflurane ad.us.vet., Provet AG, Lyssach bei Burgdorf, SwitzerlandjLidocain 2% Streuli ad.us.vet., Streuli Pharma AG, Uznach, SwitzerlandkOscillating Saw Attachment with variable deflection, Synthes GmbH, Oberdorf, SwitzerlandlFinochietto rip spreader, Aesculap Inc., Center Valley, USAmSurgical Proximate linear cutter 75 mm, Ethicon, Medical&Medical GmbH, Norderstedt, GermanynNatrium chloratum 0.9% “Bichsel”, Dr. G. Bichsel AG, Interlaken, Switzerlando24CH, Mallinckrodt Medical, Athlone, IrelandpFortune Medical Instrument Corp., Jungjeng E. Rd. Danshuei Jen Taipei Hsien 251, TaiwanqPolydioxanon (PDSII), Ethicon, Medical&Medical GmbH, Norderstedt, GermanyrKatheter-Rüsch, Wirtschaftsgenossenschaft deutscher Tierärtzte eG, Garbsen, GermanysPenicillin Natrium Streuli ad.us.vet., Streuli Pharma AG, Uznach, SwitzerlandtAdvocid® 2.5% ad.us.vet, Pfizer AG, Zürich, SwitzerlanduFlunixine® Biokema ad.us.vet, Biokema SA, Crissier, SwitzerlandvDolovet ad.us.vet., Dr. E. Graeub AG, Bern, SwitzerlandwProcacillin ad.us.vet., Veterinaria AG, Pfäffikon, SwitzerlandBW: Body weight; CBC: Complete blood count; CT: Computed tomography; HU: Hounsfield units; PCR: Polymerase chain reaction; kVP: Peak kilovoltage; mAs: Milliampere second; g/L: Gram per liter.The authors declare that they have no competing interests.BB did the clinical examination, assisted the operation and followed up the post-operativ management and is the main author of the paper. KG carried out the diagnostic imaging. UM performed the general anesthesia. UR was the main surgeon for thoracotomy. MM supervised clinical management and editing of the report. BL supported and controlled the clinical examination as well as the post-operative management and assisted the operation. Furthermore she drafted and helped to write the final version. All authors read and approved the final manuscript.


Focal orbital amyloidosis is a rare entity and little is known about its magnetic resonance imaging (MRI) features. In this case report, imaging features of a case of focal orbital amyloidosis presenting as a mass have been documented together with its histopathological findings. On MRI, a well-defined mass was seen as isointense with rectus muscle on T1-weighted images and heterogeneously hypointense on T2-weighted images. Punctuate calcifications were observed on the computerized tomography (CT) examination. Primary orbital amyloidosis is a rare disorder that is seen in the craniocervical region and is formed by focal accumulation of amyloid protein in the orbit. Amyloidosis is classified into two main clinical types; namely, localized and systemic. Although the prognosis of the disease is usually poor in the systemic form, better prognosis is observed in the localized form 2]3]4][3][4]2][[4][3][4][3][4]2]6]. Foca. Foca6].In the literature, the localized orbital amyloidosis, in which there is no systemic illness, appears in isolated case presentations. The magnetic resonance imaging (MRI) findings as regards focal orbital amyloidosis are little known in the literature 17]. On . On 17].A 60-year-old woman was admitted to our clinic with swelling in the left eye. On physical examination; exophthalmus, subconjunctival hemorrhage and restricted eye movements due to a mass localized in the medial side of the orbit were observed. The bulbus oculi was displaced to the anterior and lateral parts of the orbit. On CT examination, a homogeneous soft-tissue mass with regular contours causing minimal expansion in the medial orbit wall was observed at the intraconal region of the left orbit. The mass containing a few small punctate calcific foci  had dimeAfter biopsy by an endoscopic transnasal and transorbital approach , the micFocal orbital amyloidosis is a relatively uncommon entity and little is known about imaging features at MRI 17]. Mos. Mos17].The MRI appearances of focal orbital amyloidosis have been reported in a few cases. Okamato et al. reported a case of focal orbital amyloidosis presenting as rectus muscle enlargement . They obThe presence of punctuate calcifications on CT examination has been determined in eight of 18 cases of orbital amyloidosis [8]10][2[210]22]22]23]. . 23]. MaThe main differential diagnosis of focal orbital amyloidosis based on MRI findings includes pseudotumor, lymphoproliferative lesion, sarcoidosis and cavernous hemangioma. Pseudotumor shows isointense or slightly hyperintense signals to the rectus muscle on T2-weighted images . NeverthIn conclusion, focal orbital amyloidosis that appears as a rare condition among middle-aged females should be kept in mind in the differential diagnosis of orbital masses. The presence of heterogeneous hypointensity on T2-weighted images on MRI and punctuate calcifications on CT examination may be the important findings supporting the diagnosis of focal orbital amyloidosis.


Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous neoplasm associated with a high cure rate. We present a case of aggressive DFSP with fibrosarcomatous areas in the head and neck. A 28-year-old Mediterranean female presented with a 45-day history of rapidly growing cutaneous lesion of the face. Surgical biopsy confirmed the diagnosis of DFSP. Subsequently, the patient underwent wide local surgical resection, followed by reconstruction. Histopathology report revealed fibrosarcomatous transformation and the patient underwent adjuvant radiotherapy. The patient continues to be disease free at the 35-month follow-up.Although DFSP behave as non-aggressive malignancy, surgery with complete removal of the affected area is the intervention of choice. Moreover, adjuvant treatment and follow-up of the patient is essential in order to prevent recurrence. Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive, cutaneous, malignant tumor characterized by high propensity for local relapse and low metastatic potential. It was first recognized by Taylor  in 1890,Approximately 85-90% of all DFSPs represent low-grade tumours. The remaining 10-15% contains a component of high-grade fibrosarcoma. This transformation, presenting in more than 5% of tumour volume, is characterized by a higher incidence of local relapse and distance metastasis.The characteristic villous pattern of extension into the subcutaneous fat, fascia and muscles and at the same time preservation of healthy tissue from resection represents a surgical challenge, as failure of complete excision leads to local recurrence. We report a rare case of an aggressive head and neck DFSP with fibrosarcomatous areas. We also discuss the epidemiology, clinical and pathologic characteristics and treatment.A 28-year-old Mediterranean female with unremarkable medical history, attended the out-patients department, with a 45-day history of a painless rapidly growing lesion in the right cheek (infra-auricular area). Clinical examination revealed a protruding painless red-bluish mass, which was associated with the skin over the parotid area. The lesion (sized 10 × 5 × 4 cm) was firm, fixed to deeper tissues with propensity to bleed. No facial nerve involvement was noted . The defect was reconstructed with a large neck pedicle advancement flap Figure .Histopathological examination, of the completely excised tumour, revealed a nodular neoplastic lesion composed of large spindle-shaped cells with prominent nuclei, showing a high mitotic index and areas of necrosis, infiltrating into the subcutaneous fat and muscles Figure . FurtherFollowing the diagnosis, the multi-disciplinary team decided that an adjuvant therapy would be required. The patient, subsequently, received 60 Gy of radiation therapy and subsequent recovery was unremarkable. At 35-month post-treatment follow-up, the patient continues to be symptom free with no signs of tumour recurrence.The estimated incidence of DFSP is 4.5 cases per million persons per year in the USA , nearly DFSP is a dermis origin cutaneus neoplasm characterized by slow infiltrative growth with a tendency for local relapse, after surgical excision, with little metastatic potential. Clinically the appearance of the tumour depends on the stage of the disease. Initially it presents as a cutaneous pink to red-bluish painless trophic and/or sclerotic plaque-like mass that develops into lumpy nodular and over time into ulcerative hemorrhagic protuberant tumor. It develops superficially, mobile upon palpation as it is adhered with its overlying skin, but not with its underlying tissues. Unfortunately, fixation to deeper structures such as fascia and muscle may present in the later stage of the tumour. Scalp fixation caused by periosteal attachment may occur in early stages. Telangiectasia may be apparent on the surface or at the periphery.Since it is a slow growing tumor, the duration of development range from weeks to years. Delay in diagnosis and clinical misdiagnosis of the initial lesion is not uncommon, and is due to absence of symptoms. Pain and tenderness are rare, as only 10-25% of the patients reported these symptoms. In addition cachexia which usually characterizes advanced malignancies is also uncommon [The true cellular origin of this neoplasm is yet unclear. Evidence exists that its origin may be fibroblastic, neuroectodermal, histiocytic or from pluropotential progenitor cells that have the capacity to differentiate into these three cell-types. Microscopically it is characterized by the arrangement of spindle-shaped tumor cells in a "cartwheel" pattern , cytologImmunohistochemical staining demonstrates strong positivity for CD34 (sensitivity 84-100%) and vimentin and negativity for S-100, factor XIIIa and CD44 staining. Positivity of this last marker and stromelycin 3 (ST3) is useful for differential diagnosis of benign fibrous histiocytoma (dermatofibroma) . ApolipoBendar or pigmented DFSP represents an unusual variant distinguished by the dispersal of melanin-containing dendritic cells in an otherwise typical DFSP. It accounts less than 5% of all DFSP cases predominantly occur in Afroamericans (7.5 times higher than Caucasians). Other unusual histologic types include myxoid, giant cell angiofibroma, granular cell variant DFSP, palisaded (reminiscent of schwannoma), sclerosing and the atrophic type.A more aggressive subtype presents with fibrosarcomatous progression is called "fibrosarcomatous dermatofibrosarcoma" (FS-DFSP). Firstly reported by Penner  in 1951 Although an injury to the affected skin, such as surgical and old burn scars and sites of vaccinations may be predisposing factors for PDFS development ,23, its Since clinical diagnosis of the initial lesion is not always possible with certainty, open biopsy, excisional or incisional, is the diagnostic method of choice. Imaging using MRI to evaluate local extension is essential for the preoperative planning of large tumors and computed tomography is useful only when underlying bone erosion is suspected. Ultrasonographic examination may also be useful, mainly in detecting small lesions. Although lymphatic and hematogenous metastasis is uncommon, staging is always indicated.The American Joint Committee on Cancer has not yet set a system for the staging of DFSPs and DFSP-FSs. Until today it is in accordance with the American Musculoskeletal Tumor Society (MSTS) staging system, which takes into account tumor grade and compartmentalization: In stage IA tumors are low-grade intracompartmental (without extension beyond the subcutaneous compartment) lesions, that can be managed adequately solely with wide excision. In stage IB tumors are again low-grade lesions that exhibit extracompartmental extension, which involves the underlying fascia, muscle, or bone erosion . More reDFSPs show an extremely aggressive tendency to invade local surrounding tissue. Standard therapeutic approach used for the treatment of this tumor is wide and deep local excision (WLE), including the underlying fascia. In a retrospective study of 159 cases, although 99% of the cohort had complete surgical resection, pathologic review showed only 93 patients (58%) with negative microscopic margins . LindnerIn order to achieve negative resection margins and simultaneously preserve the uninvolved tissue from resection, some authors suggest the use of Moh's micrographic surgery (MMS). This method allows precise histological mapping of all margins, both deep and lateral. Classic technique requires continuing sequential horizontal sectioning during resection and immediate, frozen, microscopic examination, until free margin is obtained. Although ideal, especially for challenging areas such as head and neck region, it may be proven inadequate predictor of final resection margin status. A study involving intraoperative assessment of frozen sections concluded that accuracy was low - 80% (16 out of 20) . In contSince primary closure is not always feasible, reconstructive surgery, using local skin flap, skin grafting, mesh or myocutaneus flap may be required. Neck dissection is not necessary unless suspicious regional lymphadenopathy is present. Only in FS-DFSP cases sentinel lymphnode biopsy is recommended.The most significant prognostic factor for relapse has proved to be the extent of the initial resection as close margins (<2 cm) shows a statistically significant positive correlation with recurrence. Rutgers et al.  in an exThe Head and neck region is reported to be the site with the highest rate of local recurrence rate (LRR) after local excision. Barnes et al.  reportedFS-DFSP subtype is also considered to be a highly significant prognostic factor for relapse. In a large prospective analysis of 159 patients, 13 of 25 patients (52%) with FS-DFSP experienced relapse versus 21 of 134 patients (16%) with classic DFSP. In the same analysis the 5-year recurrence free survival rates were 81% for patients with DFSP and only 28% for those with FS-DFSP subtype . In addiOther unfavorable prognostic factors for local and distance relapse, represents age older than 50 years, high mitotic rates and increased cellularity. Regional lymphatic metastasis is uncommon, approximately 1%, even less frequent than distant metastasis with only a few cases reported in the literature up to date ,34.Although very rare, DFSP do metastasize, principally to the lungs and bones. Rutgers et al.  reportedIn the past, radiotherapy (RT) was considered to have limited role in treatment of this disease. Recently published data demonstrated that DFSP is a radiosensitive tumour. An analysis of 10 cases, 9 DFSP and 1 FS-DFSP, established 90% local control of the disease, concluding that adjuvant radiotherapy reduces the risk of local relapse after resection of the disease in close or positive margins. Interestingly, 60% (6 patients) of these cases were located in the head & neck and the patient suffering from FS-DFSP, also located in head and neck, was the one who experienced the local recurrence after 3 months and died from the disease . SimilarPreferably the excision should followed by adjuvant radiotherapy, when margins are found close or persistently positive and repeat wider resection is not feasible due to anatomic limitations. Some authors also recommend the use of radiotherapy after wide resection in the fibrosarcomatous subtype, even with negative margins . German Although chemotherapy is proved to be ineffective, recently targeted therapy has shown very good results in disseminated cases. Imatinib mesylate, a selective tyrosine kinase inhibitor designed to treat chronic myelogenous leukaimia, resulted also in inhibiting PDGFR tyrosine kinase that plays a crucial role in the pathogenesis and tumor growth of DFSP cells.A phase II study published in 2005, reported 100% response in 8 local advanced DFSPs, partial response in a metastatic FS-DFSP, all with t translocation and no clinical response in another metastatic FS-DFSP lacking t, correlating the presence of this translocation with response. All patients were treated with 400 mg of imitinib twice daily, well tolerated, decreasing dosage into 600 mg in only one patient . It is gDFSP is a rare dermal malignancy with a propensity to be locally aggressive but rarely metastatic. Its fibrosarcomatous progression variant on the other hand has a more aggressive course in nature, with a significant elevated risk of both local and distance metastasis, usually followed by poor outcome.Wide local excision is the gold standard treatment and a policy of re-excision to obtain negative margins should always be followed. One of the most challenging areas is the head and neck, with increased rate of local failure, due to critical structures and aesthetic difficulties in reconstruction.We reported a case of an aggressive head and neck FS-DFSP, treated with wide local resection and adjuvant radiotherapy, without evidence of local or distance relapse after 35 months. Follow-up, even lifelong, remain essential.Written informed consent was obtained from the patient for publication of the case report in this review and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.NA, PK, WJ, TU, ST, GK, AN conceived of the study, and participated in its design and coordination. All authors read and approved the final manuscript.


Intraspinal dermoid cysts are rare and benign tumors that occur primarily due to the defective closure of the neural tube, an ectodermal derivative, during the process of development. They are slow-growing tumors manifesting in the second and third decades of life.We present here a case of a 14-year-old Sindhi boy with a six-month history of paraparesis of the lower limbs and a progressive loss of power of grade 3/5, and hypoesthesia in the L4/L5 dermatomes of his right lower limb. A plain magnetic resonance imaging scan revealed a well-demarcated intraspinal intramedullary cyst containing an abscess at the level of T12 and L1 causing localized cord compression, which was producing the symptoms. Near total excision of the cyst was successfully performed and was sent for biopsy, which revealed keratinocytes and keratin flakes. With one month of follow-up, along with physiotherapeutic management, the patient gradually improved and was able to walk without support.Critical evaluation of every case with aggravating symptoms should be carried out, and neurological and radiological examinations should be conducted to ensure the well-being of patients. Amid the numerous defects and deviations from normal development patterns, very few exist as uncommon in medical history as the dermoid cyst. There is no exact knowledge of the prevalence of intracranial dermoid cysts, however, the few studies reported to date propose it to be 0.3 percent . Only a Dermoid cysts can appear subdurally, extramedullary or intramedullary, with intramedullary presentations being relatively rare . PresentA 14-year-old Sindhi boy presented to our hospital complaining of having had lower back pain for six months. The pain was followed by the development of weakness and numbness in his lower limbs. He had been constipated for a week prior to reporting. There was no history of urinary incontinence, infection, lumbar puncture, spinal trauma or previous spinal surgery.The patient was initially diagnosed by a district registered medical officer (RMO) as having tuberculosis (TB) of the spine, the disease being endemic in the area, and was started on antituberculous therapy (ATT). In spite of three months of treatment, the weakness progressed until he became completely bedbound and unable to move. It was then that the patient was moved to a tertiary care hospital.The patient’s higher mental function was normal and his cranial nerves were intact. An assessment of his motor system revealed a reduced bulk of the flexor group of both lower limbs. There was hypotonia on the left side and power was grade 3/5 in both his lower limbs. Knee and ankle jerks of both lower limbs were absent. The motor examination of the upper limbs was unremarkable with the exception of areflexia, observed bilaterally. On sensory examination, there was hypoesthesia and decreased light touch and pinprick sensation in the L5/L4 dermatomes of his right lower limb. The sacral dermatomal sensations at S1 and S2 levels were also impaired. The overlying skin of the thoracolumber region was intact, showing no signs of inflammation, swelling or hairy nevi, or local hair growth. The rest of the systemic examination was unremarkable. There was no history of weight loss, night sweats, body aches or malaise. Baseline investigations revealed anemia and leukocytosis.2, and abnormal signal intensity within the spinal canal, which was intradural as well as intramedullary in nature, since there was a splitting of the cord into two layers along the superior aspect of the lesion. The lesion was on the posterior aspect of the cord compressing the conus medullaris at the D12 and L1 level. No perilesional edema was observed.On radiological investigation, an MRI scan of the dorsal spine was performed with T1- (TR/TE 410/19) and T2- (TR/TE 3700/134) weighted images. The MRI scan evidenced a focal, well-defined space-occupying lesion measuring 1.50×0.6cmThe tumor was heterogeneous in intensity, localized, and its boundaries were well demarcated. It was hypointense at the T1-weighted frequency with a hyperintense signal area at the caudal end (arrow) Figure .After all aseptic measures, surgical resection was accomplished through a posterior midline linear incision at the D12 and L1 level. All the layers of skin, the subcutaneous fat and the muscles were separated, the dura was opened and a laminectomy was performed. During the operation, the spinal cord was seen to be compressed and overdistended due to an intrinsic lesion. Myelotomy was performed and a well-demarcated, unilocular, grayish white intradural, intramedullary cyst was found involving the conus medullaris and extending from D12 and L1.The cyst was evacuated and near-total excision was done from the neuronal tissue. Some 0.5ml of thick grayish yellow pus was obtained and sent for histopathology, which revealed aggregates of keratinocytes along with keratin flakes that confirmed the diagnosis of dermoid cyst.A pus culture showed no growth after 48 hours of incubation at 37°C.After one month of follow-up, there was no abnormal neurological sequelae, the improvement in motor power was grade 4/5 in both lower limbs and there was restoration of light touch and pinprick sensation. The patient was able to mobilize and walk with support.Intraspinal dermoid cysts, also termed ‘spinal cutaneous inclusion tumors’ are rare, benign, slow-growing tumors that account for less than 1 percent of spinal tumors  and arisInclusion dermoids are characterized either into congenital or implanted arrays, the former being more frequent as well as important. A frequent cause of development of such cysts is assertive admittance of the ectodermal cells subsequent to an injury . The patIn the lumbosacral region, epidermoid tumor is more common, dermoid tumor is relatively uncommon and the intramedullary manifestation of a dermoid tumor is an exceptionally rare occurrence ,11.et al. presented a case report that corresponded with the MRI findings, however, our case is atypical with regard to the absence of bladder symptoms [et al. reported the case of a 3-year-old boy, indicating that symptoms may develop earlier in some cases [They remain clinically silent until symptoms appear in the second or third decade of life . Muthukusymptoms . Moreoveme cases .et al. also reported the case of a patient with a spinal dermoid cyst with a dissynergic bladder [These cysts are often diagnosed when presenting clinically as neurologic manifestations, ranging from paresthesias to paralysis and sphincter complications . In this bladder .This case gives an excellent clinical picture of a spinal intramedullary dermoid cyst without the classic symptoms of incontinence or signs of spinal dysraphisms.Our case report also calls attention to the diagnosis of dermoid cyst in spinal surgical patients with the help of MRI and histopathological evaluations. Our patient was initially diagnosed as having TB of the spine due to conventional conjecture and overlapping symptoms. In the case of misdiagnosis, the rupture of the cyst can result in arachnoid, meningeal or cerebral irritation as a result of dissemination through cerebrospinal fluid pathways .The pus culture did not reveal any bacterial growth (including acid-fast bacilli (AFB)) and further excluded the diagnosis of TB of the spine.The treatment of choice for the dermoid tumor is the total excision of the mass at an early stage. Total mass excision is possible for extramedullary dermoid cysts; however, in intramedullary dermoid cysts, the capsule adheres to the cord  and ofteIn conclusion, our case is unusual in relation to the absence of the classic features of dermoid cysts and with the atypical symptoms of fecal retention.The patient presented to us six months after the initial complaint, with a misdiagnosis of spinal TB. Such a delay can progressively worsen the condition. Therefore, these cases need appropriate diagnosis, which should entail the critical evaluation of every case, and for histopathology and radiological examinations to be conducted to ensure the well-being of the patients. It is extremely important to be cautious during surgical resection of such tumors, as a rupture can lead to severe consequences.Written informed consent was obtained from the patient’s legal guardian for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.AFB: Acid-fast bacilli; ATT: Antituberculous therapy; MRI: Magnetic resonance imaging; RMO: Registered medical officer; TB: TuberculosisThe authors declare that they have no competing interests.MS conceived the idea, reviewed and wrote the manuscript. SM and AA contributed to writing the manuscript. ASMH performed the surgery on the patient. SB critically reviewed the manuscript. All authors read and approved the final manuscript.


The continuous development of highly sensitive clinical imaging increased the detection of focal lesions of the liver. These accidentally detected liver tumors without liver-specific symptoms such as cholestasis have been named “incidentalomas.” Diagnostic tools such as sonography, computed tomography, or magnetic resonance imaging are used increasingly in asymptomatic individuals without defined suspected diagnoses in the setting of general prevention or followup after a history of malignancy. But despite continuous improvement of diagnostics, some doubt regarding the benign or malign behavior of a tumor remains. In case an asymptomatic hemangioma or FNH can be preoperatively detected with certainty, the indication for surgery must be very strict. In case of symptomatic liver lesions surgical resection should only be indicated with tumor-specific symptoms. In the remaining cases of benign lesions of the liver, a “watch and wait” strategy is recommended. In case of uncertain diagnosis, especially in patients with positive history of a malignant tumor or the suspected diagnosis of hepatocellular adenoma, surgical resection is indicated. Due to the continuous improvement of surgical techniques, liver resection should be done in the laparoscopic technique. Laparoscopic surgery has lower morbidity and shorter hospitalization than open technique. In recent years the rapid development of highly sensitive clinical imaging has led to the detection of focal lesions of the liver more frequently. In addition, diagnostic tools are used increasingly in asymptomatic individuals without defined suspected diagnoses in the setting of general prevention or followup after a history of malignancy –4. UnforCurrently, there are no evidence-based guidelines regarding the appropriate approach to diagnosis, interpretation of imaging and laboratory findings, and the indication for surgical resection. Prospective, sufficiently powered, randomized controlled trials on the elective resection of benign liver lesions are lacking. Most recommendations are based on retrospective data with fewer than 60 patients or casuistic reports , 10, 11.Generally a primarily conservative approach is considered to be the method of first choice in the treatment of proven benign liver tumors , 10, 11.The cavernous and capillary hepatic hemangiomas, the focal nodular hyperplasia (FNH), and the hepatocellular adenoma are the most common benign lesions of the liver , 3, 11 aThese are usually diagnosed as asymptomatic incidental findings. In addition to nonspecific symptoms, hemangiomas also (rarely) rupture spontaneously or by trauma and then lead to acute hemorrhagic shock with upper abdominal pain , 10, 18.Hemangiomas rarely occur in association with clinical syndromes. These include most of all the Kasabach-Merritt syndrome and the Blumgart-Bornman-Terblanche syndrome. The Kasabach-Merritt syndrome is characterized by a hemangioma bleeding, thrombocytopenia, and coagulopathy , 10. TheHemangiomas generally have no growth tendency. In the literature, however, cases of hemangioma growth during pregnancy or after estrogen administration are described , 10. HemTreatment of choice is the parenchyma-saving enucleation or the sparing liver resection , 18, 21.10–20% of FNHs occur multifocally , 10 and In case of a FNH, there is primarily no indication for surgical intervention . SurgicaThis lesion of the liver is often diagnosed as an incidental finding in asymptomatic patients. In association with an adenoma often right-sided upper abdominal pain (80%) with normal liver function values occurs , 23, 24.Beside the risk of acute bleeding complications, hepatocellular adenomas have a malignant degeneration risk from 4.2 to 10%, especially in inflammatory adenomas on MRI and/or the possibility of beta-catenin expression , 24. GenThe adenomatosis, with more than 10 adenomas in an otherwise normal liver, is a special form. This is gender unspecific and has no association with the use of hormones , 27.The diagnostic differentiation from hemangioma is straightforward , 11. TheAtypical tumors of the liver, such as the angiolipoma or cystadenoma, often have an inhomogeneous structure that usually a precise preoperative classification of a benign or a malignant tumor is impossible. This is the reason why in case of these tumors oncologic resections with appropriate security clearance are recommended , 11.The conservative and surgical treatment of benign lesions of the liver includes several regenerative or real-neoplastic tumor entities. Depending on their origin, these tumors are divided in hepatocellular, endothelial, biliary, mesenchymal, and connective tissue tumors  Table 1Table 1.The benign lesions of the liver can be divided in solid tumors, in tumors with solid areas, or cystic tumors. They are uni- or multilocular , 32. As illustrated in Clinical symptoms of the patient are crucial for the extent and type of diagnostic measures to be executed. If the patient is burdened by severe symptoms of the tumor, resection is indicated and further diagnostic workup is dispensable. On the other hand, with an asymptomatic tumor and nonspecific findings, every attempt has to be made to ensure the diagnosis. The contrast medium- (CM-) based computed tomography (CT)  and magnetic resonance imaging (MRI), especially when using liver-specific CM ), are the methods of choice in the diagnosis of benign liver tumors , 34. In clinical routine, sonography is primarily used as screening method. Through the use of CM and technical enhancements, such as tissue harmonic imaging, the importance of sonography in the diagnosis of benign liver lesions has greatly increased. The disadvantage of this method of investigation is the investigator dependency , 36. Even nuclear medical procedures, such as the erythrocyte pool scintigraphy with 99Tc or hepatobiliary scintigraphy under the utilization of tumor-specific characteristics without precise morphological mapping of the lesion, can achieve a high sensitivity in diagnostics. Relatively high costs and limited availability preclude nuclear medicine procedures from more extensive use despite their proven diagnostic value , 38.  TaIn medical literature there are only few publications with larger numbers of cases that match radiological diagnosis with the corresponding histopathologic findings after surgical resection. Grimm et al. showed, in 26 cases of histological confirmed benign liver tumors, that the multiphase CT or MRI examination only in 54% of the cases produced the correct preoperative diagnosis . For the highest diagnostic “security” preoperatively, at least one imaging procedure should be performed using a suitable, liver-specific CM in combination with a nuclear medicine examination , 12. As In addition to liver enzymes, bilirubin, and cholestasis, the laboratory testing should include the determination of the tumor markers AFP, CA 19-9, and CEA to distinguish it from malignant tumors of the liver , 4, 10. In case of a symptomatic tumor, determinants of resectability such as size, location, relationship to the hilum, and the blood vessels are in the focus. Thereby a minimum of diagnostics, such as a sectional imaging, is sufficient. If in case of an asymptomatic neoplasia surgery is necessary, a graduated diagnostic procedure should be performed to determine the exact type of tumor and the subsequent appropriate therapy , 11.In the literature, the performance of a percutaneous fine-needle biopsy (FNB) is controversially discussed. Because of the insufficient validity and often missing therapeutic consequences, the FNB should not be performed , 40–42. In clinical practice preoperatively, the exact morphology of a tumor in up to 35–45% of cases is not clearly determined by radiological investigations. With the suspected diagnosis of a possible malignancy in these cases, often and completely understandable surgical resection of the lesion is indicated .In case of a suspected adenoma due to the possible risk of malignant transformation or occult malignancy, surgical resection should be done initially or rarely after transarterial embolization (TAE). In acute bleeding with hemorrhagic shock, the extent of the diagnosis depends on the one hand on the urgency of the operation and on the other if the entity of tumor is previously known. In case of a known hemorrhagic hemangioma instead of a risky emergency surgery, a therapeutic TAE could be tried , 46. In Because of preventive checkups, followup, and screening examinations, increasingly more asymptomatic liver lesions, especially in patients with a positive history of malignant tumor, are newly diagnosed. This has led to a shift in the spectrum of indications for surgery from symptomatic to asymptomatic patients. Depending on the tumor localization, specific symptoms such as a laboratory chemical cholestasis or portal hypertension are possible , 10, 11.The indication for surgery should be primary found in relation to the symptoms and the suspected diagnosis. In descending order in cases of an acute symptomatology such as bleeding, the suspicion of an adenoma or a lesion of unknown dignity, in particular with positive tumor history, a tumor-induced symptomatology, the progression of size, some nonspecific symptoms, or eventually also in case of a cancerophobia of the patient liver resection should be indicated –15.In case of a prior history of hemangioma, if a spontaneous or traumatic rupture happens, the indications are entirely provided for the conservative approach, eventually after successful TAE , 18. TAEThe recommendations for surgical management of benign liver lesions are based on the results of retrospective analysis or case reports with fewer than 60 patients  .If the indication for surgery was found, parenchyma sparing techniques for operation should be preferred. If the diagnoses of hemangioma or FNH are proven, enucleation is the method of choice. With the enucleation the loss of functional liver parenchyma and, at the same time, blood loss and the risk of bile leaks can be reduced , 42, 49.This study only mentioned patients with one of the three most popular benign liver lesions, the hemangioma, the hepatocellular adenoma, and the FNH. Not for all patients of our cohort, every diagnostic possibility, named in At the time of the liver resection, the age of the subjects in our series ranged from 23 to 72 years with a mean of 52.8 years. The ratio of men to females was 1.7 : 1. Tables In patients with asymptomatic liver lesions, surgical intervention was mainly indicated since a primary or secondary malignancy could not be excluded with certainty. In case of symptomatic liver lesions, the indication for surgery was conducted on the one hand because of clinical symptoms, but on the other because a primary or secondary malignancy could not be preoperatively excluded with certainty by means of morphological imaging. Most often patients of our series complained about right upper abdominal pain. Our patients also reported about indigestion, loss of appetite, and icterus. Beside the clinical and radiological diagnosis, the tumor location and size determine the extent and type of surgery. The distribution of the respective applied surgical procedure shows in our collective of subjects as well as the collective of the reference centers a selected group. Therefore, these results do not reflect the expected approach in the surgical treatment of benign liver lesions. Normally in the vast majority of cases, atypical resections or enucleations would be expected and less segmental resections, resections of more than one segment, or hemihepatectomies.The low mortality rates result from the generally good preoperative liver morphology and function in patients with benign liver lesions. The rate of postoperative complications (minor) in our collective amounts in total for more than 15%. These results emphasize the need of a strict indication for liver resection, especially in primary asymptomatic patients . The ratThe mortality and morbidity of laparoscopic liver resections in our own collective are presented in In 12% of cases a lesion of the liver was not known preoperatively and noticed during a laparoscopic cholecystectomy. In order to get histology, this incidental findings were completely laparoscopically, atypically resected. The subsequent histological examination showed uniformly the diagnosis of a hemangioma. In patients with a positive history of malignant disease, every intrahepatic mass of uncertain dignity was resected.Our high rate of 56% preoperative misdiagnosis for the hemangioma is therefore the result of including patients without a preoperative diagnosis and patients with limited preoperative imaging. If patients with a history of carcinoma or incidental perioperative findings are not considered in the analysis, there is an acceptable agreement of 76% of the results. With regard to FHN and adenoma, preoperative diagnosis was primarily uncertain or unreliable, this being particularly relevant forFNH with 58% and for adenoma with 72% when taking into account the patients with a history of cancer.The continuous development of imaging techniques enables to diagnose asymptomatic liver lesions with an increasingly high sensitivity and specificity –36, 38. P < .0001) [P < .0001) [In patients without history of malignant tumor, the FNH and the hemangioma are relatively straightforward to diagnose . In the < .0001) . In the < .0001) . Belghit< .0001)  offered < .0001) . These r< .0001) , 6, 11. < .0001) –9, 11 or< .0001) , 23–30. < .0001) , 11. Esp< .0001) , 10, 11 Initially often close monitoring of liver lesions occurs without any major risk to the patient , 54. In The recommendations for surgical management of benign liver lesions are based on the results of retrospective analysis or case reports with fewer than 60 patients  . At diagnosis of hepatocellular adenoma, surgical resection is indicated, because of the potential risk of malignant transformation and a possible life-threatening bleeding complication, even in case of a definite tumor regression and discontinuation of oral contraceptives , 55, 56 Necrosis, hemorrhage, and thrombosis of benign lesions of the liver may often complicate the diagnosis , 58. In The implementation of a percutaneous fine-needle biopsy (FNB) is discussed controversially in the literature. Due to the low expressiveness and lack of therapeutic consequences in most cases, FNB should not be performed , 40–42. Asymptomatic hemangiomas do not require therapy , 10, 11.At the diagnosis of FNH, primarily no surgical intervention is indicated . Large, low surgical mortality (<1%),low morbidity,avoidance of blood transfusion,good long-term results.Requirements for a surgical intervention of benign lesions  are as fOur study and the current literature revealed that these conditions are fulfilled see  and an eThe postoperative morbidity in our collective in total was 16.3%, whereas no major complications occurred and no revision surgery had to be performed. This result of the morbidity for liver resections at benign liver lesions is generally equivalent to medical literature (7–28%) , 47, 53.In case of symptomatic benign tumors of the liver, surgical intervention in 80% of cases leads to a decrease of complaints , 54. RarMedical literature offers a low postoperative complication rate, in laparoscopic and open liver resections , 60. WitDespite continuous improvement of diagnostic possibilities, the dignity for up to 40% of incidentally detected liver lesions cannot be determined reliably till the final postoperative histology. In case of uncertain diagnosis, especially in patients with positive history of a malignant tumor or the suspected diagnosis of hepatocellular adenoma, surgical resection is indicated. In case an asymptomatic hemangioma or FNH can be preoperatively detected with certainty the indication for surgery must be very reluctant. In case of symptomatic liver lesions, surgical resection should only be indicated with tumor-specific symptoms. In the remaining cases of benign lesions of the liver, a “watch and wait” strategy is recommended. Due to the continuous improvement of surgical techniques, liver resection should also be done in the laparoscopic technique in case of more than one liver-segment resection or hemihepatectomy. Laparoscopic surgery has lower morbidity and shorter hospitalization than open technique.


Anaplastic thyroid cancer (ATC) is rare but extremely aggressive, which accounts forabout 2% of all thyroid cancers yet nearly 50% of thyroid-cancer-associated deathsin the United States. The median survival time from diagnosis is 5 months, with a1-year survival rate of only 20%. We report here a case of ATC in a 56-year-old manwho survived a large ATC. Preoperative fine-needle aspiration biopsy study to alarge right thyroid mass suggested ATC. Total thyroidectomy with radical lateralneck and central neck dissection removed a well-circumscribed 9.5 cm tumorwithout extrathyroidal extension or lymphovascular invasion. All 73 lymph nodesremoved were negative for metastasis. The tumor consisted of highly pleomorphic,undifferentiated cells with large zones of necrosis and loss of thyroidtranscription factor-1 and thyroglobulin expression. A focal well-differentiatedcomponent and PAX8 expression confirmed its thyroid follicular cell origin. Ninemonths after postsurgical adjuvant concurrent radiation therapy and chemotherapy,the patient remained well without clinical, biochemical, and radiographical evidencefor cancer recurrence. This is an unusual case of ATC in that it is one of thelargest ATC tumors reported to display mild pathologic behavior and relativelylong-term patient survival. The patient is a 56-year-old white man who presented to his primary care physician one day after he noticed a mass in his right neck. Computed tomography (CT) scan confirmed a large mass in his right neck arising from the right thyroid lobe, measuring 5.4 × 5.2 × 9.1 cm . The CT 18F) positron emission tomography (PET) scan with high-resolution CT demonstrated the right neck mass to be hypermetabolic and revealed also a few hypermetabolic lymph nodes in the right neck and upper mediastinum with no distant metastasis. A Tc-99 MDP whole-body scan showed no metastatic disease in the skeletal system. The esophageal muscularis, trachea, and carotid artery appeared to be well preserved structurally on these imaging studies except for leftward deviation of the trachea. There were no abnormal imaging findings to suggest distant metastasis.The patient's history was notable for a 55-pound weight loss and fatigue, but he did not have compressive symptoms, such as dysphagia or dyspnea, due to the mass. There was no antecedent history of radiation exposure to the head and neck. Physical exam revealed a large, visible mass extending from the thyroid bed to the lateral aspect of the right neck, occupying virtually the entire right anterior and lateral neck. It extended also toward the left side beyond the midline. This large mass was firm and nontender upon palpation and was relatively immobile. The left thyroid lobe was unremarkable. The trachea was difficult to examine as it was covered by the mass anteriorly. Neck ultrasonography revealed a large, hypoechoic, irregular-shaped mass containing punctate calcifications. A whole-body fluorodeoxyglucose  were all undetectable during this course. ATC is a rare but extremely aggressive and rapidly lethal thyroid cancer derived from follicular epithelial thyroid cells; in fact, it is one of the most deadly human cancers , 3. AlthOur case of ATC was unusual in that although the tumor represents one of the largest reported to date, there was no local tumor invasion and even no extrathyroidal, venous, and lymphatic invasion. Extensive neck dissection removed a large number of lymph nodes, but none of them was found to have metastasis. There was also no evidence of distant metastasis either clinically or radiographically. Nine months postoperatively, there was no clinical, biochemical, and imaging evidence to suggest cancer recurrence and the patient lives an essentially normal life, being able to return to his work as a restaurant manager with normal function. Despite the limited followup time interval of nine months, the partially encapsulated nature and complete thyroidal confinement of this large tumor and absence of metastasis at the time of diagnosis predict a more favorable long-term outcome. As such, this case is outstanding and deviates from the normal disease course in classical ATC patients. There have been several case reports on patients with ATC that showed an indolent clinical course with long-term patient survival –13. MostGiven the lack of effective medical treatment for ATC currently, aggressive multimodal treatment customized on a case-by-case basis, particularly after early diagnosis, remains the treatment of choice for this cancer , 16, 17.


Fetus in fetu is a rare developmental aberration, characterized by encasement of partially developed monozygotic, diamniotic, and monochorionic fetus into the normally developing host. A 4-month-old boy presented with abdominal mass. Radiological investigations gave the suspicion of fetus in fetu. At surgery a fetus enclosed in an amnion like membrane at upper retroperitoneal location was found and excised. The patient is doing well after the operation. Fetus in fetu (FIF) is an uncommon pathology that results due to abnormal embryogenesis in a diamniotic monochorionic twin pregnancy with an incidence of 1 in 500000 births. The commonly accepted theory states that unequal division of blastocoele results in monozygotic, monochorionic, and diamniotic twins of unequal sizes following which the smaller twin encases into the normally developing twin; the mechanism of which is not known. This is followed by arrest of further growth of the encased fetus due to improper blood supply or inherent defects of the encased twin. Few authors consider FIF as an advanced form of teratoma [1-3]. We report another case of fetus in fetu diagnosed preoperatively with the help of radiological investigations.A 4-month-old male baby presented to our hospital with the complaint of palpable mass in the right hemi-abdomen noted by the parents one day back. The patient was born at full term with uneventful birth history. The baby achieved milestones normally. Abdominal examination revealed a non-tender mass with vague margins in the right hemi-abdomen. Laboratory investigations including alpha-fetoprotein were within normal limits. X-ray abdomen showed mass impression pushing the gut shadows to one side. Bones and calcifications were also evident in the right hemi-abdomen. Ultrasound of the abdomen revealed a heterogeneous mass with calcifications suggestive of teratoma. Abdominal CT scan showed a 9.2cm × 10.0cm heterogeneous mass containing fat, bones and soft tissues. The various bones were vertebrae, long bones like femur, tibia and fibula, and bones of hand/feet . Provisional diagnosis of FIF was made.At operation, a mass covered in whitish-gray membrane, pushing the gut loops to the opposite side in the upper retroperitoneum, was found . The membrane was incised to find a fetiform mass floating in clear fluid having a few well differentiated and other rudimentary organs. The fetiform mass was suspended in the amnion like cavity with an umbilical cord like stalk . The mass with sac was mobilized and excised completely.Post operative recovery was uneventful. Patient was allowed orally on 3rd and discharged on 7th post operative day. The patient is currently being followed with alpha-fetoprotein and ultrasound abdomen. At six months follow up patient is doing well.The FIF was of 13.75cm×12.5cm×6.25cm size with a weight of 500 grams. It was anencephalic having otic and nasal placodes and optic vesicles. The left upper limb was meromelic; lower limbs were sirenomelic. The umbilical cord had two vessels in it. The FIF had a scrotum like skin at the site of genitalia that lacked gonad in it. The FIF also lacked anus and genitalia . Plain radiography of the specimen revealed axial skeleton in the form of vertebrae, along with ribs, long bones of upper and lower limbs, and facial bones .The term Fetus in fetu was coined by Meckel during the late 18th century following which Willis described it as a rare condition where a malformed parasitic twin is found encased in the host especially in the retroperitoneal space. The other reported sites are abdomen, scrotum, cranium, kidneys, adrenals, mediastinum, and lymph nodes etc. FIF usually occurs as a single lesion however multiple FIF have also been reported, highest being 5. FIF is always a curiosity and to date about 200 cases have been reported in literature [3-6].Most of the cases present during infancy, but late presentation has also been reported with the oldest patient presenting at 47-year. Male preponderance is noted in the reported cases. The major presenting complaint is a palpable abdominal mass, predominantly in upper abdomen. The other symptoms are secondary to the mass effect of the FIF such as, jaundice, hydronephrosis, intestinal obstruction, meconium peritonitis, respiratory distress, and vomiting [7-9].Few reports describe antenatal diagnosis of FIF. Preoperative diagnosis can be made on plain radiographs and CT scan/MRI. The presence of vertebrae, long bones, bones of hands and feet etc are the common radiological findings. Visualization of a non-homogenous mass with bones especially vertebrae is considered pathognomonic of FIF. Failure to visualize vertebrae however does not rule out possibility of FIF. The other frequent differential is teratoma .Most of the reported cases describe FIF suspended with an umbilical cord like stalk in an amnion like membrane containing fluid- equivalent to amniotic cavity. In few cases, the exact blood supply could be identified; in most of cases the blood supply was thought to come from the abdominal wall where amnion like membrane was in close approximation to it. Similarly, in our case the FIF was suspended in the fluid filled cavity with an umbilical cord like structure having two vessels in it. The FIF are usually anencephalic, with the vertebrae and limb-buds , and acardiac (rarely heart was found). In few cases vertebral column was not found however presence of mature enteric nervous plexi and melanocytes in the skin depicted the fetus would have passed the primitive streak stage of notochord development [1-5]. In our case the FIF was anencephalic, having primitive structures of nose, eyes and ears. One hand was well developed. The lower limbs were fused as in sirenomelia- long bones were palpable in the lower limbs.Careful dissection of FIF should be done to avoid injury to the surrounding structures. A case of bile duct injury has been reported in literature. Complete excision of FIF along with covering membrane is necessary, as a case of malignant transformation of left over membrane is reported in literature. These cases are monitored with alpha-fetoprotein or beta-HCG, along with ultrasound and other radiological investigations . We are following our patient on similar lines. Source of Support: NilConflict of Interest: None declared


Paraganglioma of the urinary bladder is a rare tumor. Herein we sought to describe a case of locally advanced paraganglioma of the urinary bladder managed by partial cystectomy and extended pelvic lymph node dissection.The case of a 43-year old Haitian male with locally advanced paraganglioma of the urinary bladder is presented in detail. Through surgical extirpation, our patient was rendered disease-free. Eighteen months later the patient is doing well without symptoms but is noted to have subcentimeter bilateral pulmonary nodules and retroperitoneal lymph nodes. No further therapy has been initiated at this time.Patients with localized tumors have an extremely favorable prognosis and may be managed by less aggressive modalities, whereas patients with metastatic disease have a significant reduced survival rate despite aggressive treatment. These tumors of the sympathetic nervous tissue may be non-functional or functional,  syncope. Typical syncope. Numeroue[et al.. Herein Paraganglioma (aka pheochromocytomas) of the urinary bladder are exceedingly rare tumors accounting for less than 0.05% of all bladder tumors and less than 1% of all pheochromocytomas. In the genitourinary tract, the urinary bladder is the most common site for paragangliomas 79.2%), followed by the urethra (12.7%), pelvis 4.9%), and ureter (3.2%).9%, and ,7.9.2%, fole.g., hypertension, he did have hematuria and lower urinary tract symptoms, testifying to the variability in which this disease can present itself. Furthermore, the consequences of hypertension itself may muddle the initial diagnostic picture of these patients. Patients often seek medical attention only when their hypertension has become so advanced as to cause syncope, retinopathy, or intracranial hemorrhage[Symptoms reported in the current literature range from the typical micturition attacks of headache and palpitations to more abstract signs such as paraesthesias and dyspnea. While our patient lacked some of the more common presenting symptoms of bladder paraganglioma, morrhage. Physicii.e. hypertension) and reducing tumor burden, but adjunct therapies are usually indicated[Reported treatment options for localized or locally advanced paraganglioma of the urinary bladder include radical cystectomy, partial cystectomy and transurethral resection. Approximately 3% of patients with reported follow-up died due to their cancer, illustrating that good survival rates can be achieved with the above therapies. It is important to note, however, that over 20% of patients did have recurrence or metastases at the last known follow-up,7. In thndicated. Thus paWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. After MD Anderson Cancer Center Orlando institutional review board approval, the clinical and hospital records of our patient, a 43-year old Haitian male who presented to our outpatient clinic in February 2011 were reviewed for demographics, clinical and pathologic information as well as outcome.A 43-year old Haitian male presented to an outside urologist for intermittent painless gross hematuria for the past six months. The patient reported some mild urinary symptoms . He denied a history of headaches, blurry vision, or other symptoms associated with micturition such as palpitations or dizziness. No abnormalities were noted on physical examination. The patient underwent a computed tomography of the chest, abdomen and pelvis without and with intravenous contrast that demonstrated a 3.7 cm by 1.8 cm mass on the anterior/superior aspect of the bladder associated with bulky bilateral pelvic adenopathy (Figure Approximately one month later, the patient underwent a partial cystectomy and extended bilateral pelvic lymph node dissection. Intraoperative frozen sections of the urinary bladder demonstrated negative surgical margins. The patient had an unremarkable immediate post-operative course and was discharge to home on post-operative day 6 with a urinary catheter in place. One week later the urinary catheter was removed. Final pathology demonstrated invasive paraganglioma 2.7 cm in maximum dimension. Final surgical margins are negative. The tumor cells are diffusely and strongly positive for CD56, Chromagranin A, and synaptophysin, but are negative for cytokeratin 7, cytokeratin 20, cytokeratin AE1/3, and S-100. Twenty-three lymph nodes removed with 13 of the nodes involved with metastatic disease. Pathologic imaging is illustrated in Figure In summary, paragangliomas of the urinary bladder tend to be functional. Initial presentation is extremely varied in these cancers, necessitating a low threshold of suspicion in the face of hypertension or hematuria. Patients with localized tumors have a favorable prognosis and may be managed by less radical modalities, whereas patients with metastatic disease have a significantly reduced survival rate. Moving forward, it would be helpful to standardize the reporting guidelines of paragangliomas cases to better understand the natural process and outcomes.AUA: American Urological Association; VMA: Vanillylmandelic acid; H&E: Hematoxylin and eosin; IHC: Immunohistochemical.The authors declare that they have no competing interests.All authors have read and approved the final manuscript. JB, BS Acquisition of data, statistical analysis and drafting manuscript. AL MD Pathologic interpretation of case report and acquisition pathologic images. JH, MD Analysis of data and drafting of manuscript. CJR, MD, MBA Study concept and design, drafting of manuscript.


Textiloma or gossypiboma is a retained surgical swab in the body after an operation and is a complication that can remain undetected for many years and may represent a diagnostic dilemma depending on its location. It may be confused with several focal lesions and an accurate history taking, combined with clinical and instrumental data, is key to suspecting the diagnosis. We report a case of abdominal textiloma that was initially misdiagnosed as echinococcal cyst and discuss the differential diagnosis based on sonographic features and the WHO-IWGE classification. The term textiloma or gossypiboma indicates a gauze pad that is left behind in a body cavity during a surgical operation. This type of complication is uncommon but may cause significant morbidity (close to 50%) and a high mortality rate 11–35%) , 2423, 2On closer inspection, though, parallel, wavy hyperechoic lines strongly reminiscent of a gauze pad were seen , which wThese two elements were enough to make a diagnosis with CT scan not adding much besides confirming the extrahepatic location of the lesion. In addition, US performs better than CT in staging the cyst  and stagDifferential diagnosis should take into account the different CE stages, understood not simply as different types of cysts, but as different phases in the natural history of a chronic disease  12]..12].Although there are reports of gossypibomas taken for CE because of serpiginous lines mimicking the waterlily sign of CE3a produced by the detached endocyst , our casThis case underlines that knowledge of the main sonographic features of echinococcal cyst should be part of the differential diagnosis and, in case of suspected echinococcal cyst, contacting a specialist from a referral center may shorten the time to diagnosis.