Ewing's Sarcoma (ES) is a highly malignant bone tumour. It may involve any part of the skeleton but the most frequent parts are the ilium and diaphysis of femur and tibia . Primary ES of the spine is extremely rare . It accounts for only 3.5 to 14.9 percent of all primary bone sarcomas. The age of presentation ranges from 12 to 24 years (median 21 years) . We report an unusual case of primary ES of the spine in a two-year-old boy, who presented to us with paraparesis and features of cauda equina syndrome. MRI scan showed a tumour mass arising from the pedicle of L4 vertebra invading the spinal canal. Tc-99 bone scan showed increased tracer uptake in L4 vertebra and normal tracer uptake elsewhere in the skeleton. After reaching the diagnosis of a space occupying lesion invading the lumber spinal canal, we performed a decompressive laminectomy and a biopsy was sent which confirmed the diagnosis of ES. Immunohistochemistry showed tumour cells staining positive for CD-99 (specific stain for ES). Gene testing showed an EWS-FLI 1 chimera. Surgery was followed by good improvement in motor signs. The child was then referred to a specialized oncotherapy centre for further treatment, radiation, and chemotherapy. To the best of our knowledge, we are the first to report primary ES of the spine at the age of two years. Ewing's Sarcoma (ES) is a highly malignant bone tumour. It may involve any part of the skeleton but the most frequent parts are the ilium and diaphysis of femur and tibia , 2. PrimA two-year-old male child, first issue of a nonconsanguineous marriage, was brought with a 15-day history of progressive weakness of both the lower extremities, difficulty in standing and walking, and progressive loss of bowel and bladder function. He had no history of trauma, back pain, and failure to thrive. No constitutional symptoms were present. He had no significant past, personal, or family history. All developmental milestones were achieved for his age.On clinical examination there was paraspinal fullness and complete loss of power below the level of the knee joint in both lower extremities.  Bulk was normal and tone was reduced. There were decreased sensations below the level of L3 dermatome in both the lower limbs. Perianal sensations were reduced. Ankle reflex and planter (Babinskis) response were absent bilaterally.His laboratory parameters were normal except for a raised erythrocyte sedimentation rate (48 mm/hour). X-rays of the whole spine, chest, and abdomen were normal. Ultrasonography of the abdomen and pelvis showed abnormal distension of the bladder suggestive of the possibility of neurogenic bladder.MRI of the lumbosacral spine Figures  revealedThe patient was without the evidence of metastasis at presentation as found by chest and abdominal radiographs, chest computed tomography scan, and Tc-99 bone scan Figures .The child underwent a decompressive laminectomy  as the fThe diagnosis of Ewing's Sarcoma was confirmed on histopathology, immunohistochemistry, and cytogenetic analysis. Histopathology showed small round cells packed in nests Figures . ImmunohFollowing decompressive surgery the patient had a good initial improvement in motor weakness. On postoperative day 15 the patient was referred to a specialized oncotherapy centre for radiation and combination chemotherapy.Ewing's Sarcoma (ES) is a small round cell tumour and accounts for one quarter of all primary bone tumours during childhood. Its peak incidence is during the second decade of life and it is very rare after 30 years of life . ES usuaIn a retrospective study of Widhe et al., at the first visit, a bone tumour was suspected in only 19 percent of the cases of primary ES of the spine , 11. A hHistopathology is the mainstay of diagnosis of small round cell tumours. The differential diagnoses of small round cell tumours include neuroblastoma, primitive neuroectodermal tumours of bone (PNET), malignant lymphoma, rhabdomyosarcoma, and ES. The differentiation between these tumours on the basis of light microscopy alone is not accurate.Current standards require evaluation by immunohistochemistry (CD-99) and cytogenetic analysis for the diagnosis of ES –17. ChroRadiographs usually show a lytic lesion but sometimes sclerotic changes are also seen. However these findings on X-ray appear late usually after neurological signs have become obvious .MRI scan is more sensitive than CT in the early detection on ES , 21. BonThese tumours have variable sensitivity to radiation and chemotherapy due to biological heterogenecity . The claThe purpose of this study was to report the incidence of such a rare tumour in a very young child. To the best of our knowledge, we are the first to report primary ES of the spine at the age of two years. Orthopaedic surgeons may encounter such a condition and should have a high index of suspicion to diagnose this rare tumour at its early stage for a better prognosis.


It must be included in the differential diagnosis of posterior mediastinal and retroperitoneal mass. We report a case of retroperitoneal ganglioneuroma involving the celiac axis and superior mesenteric arteries in a 40-year-old female.Ganglioneuroma is a rare neoplasm arising from the sympathoadrenal neuroendocrine system and has anatomic distribution paralleling the sympathetic chain ganglia and the adrenal medulla. In some cases, ganglioneuroma is the end stage maturation of less-differentiated neoplasms such as neuroblastoma or ganglioneuroblastoma, but based on age at diagnosis (over 10 years of age) and anatomic location, many of these tumors appear to arise


Parapharyngeal space masses account for 0.5% of all head and neck neoplasms. Pleomorphic adenoma arising from the epithelial rests of the salivary tissue in the parapharyngeal space is rare. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) allows a precise topographical localization of the mass and the diagnosis of its nature in the majority of cases. Treatment of parapharyngeal pleomorphic adenoma is primarily surgical excision. Tumor recurrence occurs in less than 10% of patients. We report a case of a 37-year-old man presented with dysphagia and disturbed sleep during night since last 6 months. The intraoral examination found a bulging submucosal mass underneath the right oropharynx crossing the midline and pushing the uvula to theluminal left side. CT and MRI scan revealed a heterogeneously enhancing tumor in the right parapharyngeal space measuring 4.5×5×6.4 cm and causing luminal narrowing of the oropharynx. The patient was operated through a transcervical approach to gain entry into parapharyngeal space without osteotomy of the mandible. The tumor was completely resected without rupture. The postoperative course was uneventful. Histopathological examination confirmed the diagnosis of a pleomorphic adenoma. At the 3 years follow-up the patient was free from disease.


To investigate the CT and MR imaging findings and differential diagnosis of malignant vascular tumors of bone.CT and MR imaging findings of 18 patients with histopathology-proven malignant vascular tumors of bone were examined. Assessed image features included age, sex, location, CT findings, and MR imaging appearances and dynamic contrast-enhanced MR imaging.The study group comprised 18 cases, of which 7 were categorized as low-grade malignant vascular tumors (LMT), and 11 were categorized as high-grade malignant vascular tumors (HMT). Malignant vascular tumors of bone showed osteolytic lesions with heterogeneous signs and enhancement, and frequently associated with soft tissue masses and peritumorous edema. The mean age of patient was respectively 34.7 years in LMT with 3 patients younger than 20 and 49.9 years in HMT with 3 patients older than 60 years. The mean lesion diameter was 3.6 cm (range 2–7.2) in LMT with two lesions <3 cm and 7.1 cm (range 3–13) in HMT with 3 lesions greater than 10 cm. LMT showed multifocal (57.1 %) and well-defined (71.5 %) lesions with residual bone (57.1 %), peripheral sclerosis (85.7 %), and slightly hetergeneous enhancement (71.4 %), compared to those of HMT with 9.1, 45.5, 27.3, and 72.7 %, and 9.1 % respectively. Also, HMT appeared as expansive (54.5 %), ill-defined (54.5 %), macroscopic necrosis/cystic (81.8 %) or hemorrhagic (27.3 %) lesion with pathological fracture (27.3 %), and often presented with obviously hetergeneous enhancement (81.8 %), compared to those of LMT with 42.9, 28.6, 42.9, 0, 14.3 and 14.3 % respectively.There are some differences in the imaging features between LMT and HMT, while unifocal/multifocal, expansive, ill-defined, necrosis/cystic, hemorrhagic features with age, lesion diameter, peripheral sclerosis, residual bone tissue, pathological fracture and slightly/obviously hetergeneous enhancement highly suggest their differential diagnosis. In the 2002 World Health Organization (WHO) classification, vascular bone tumors were formerly categorized as hemangiomas or angiosarcomas (AS), with endothelioma being subsumed by the latter Fletcher . The WHOMost published series of MVTB include both low-grade malignant vascular tumors (LMT) and high-grade malignant vascular tumors (HMT). HE, ES-H and epithelioid hemangioendothelioma (EHE) are usually considered LMT, whereas AS and epithelioid angiosarcoma (EA) are regarded as HMT. Because the biologic behavior of MVTB is also widely variable depending largely upon the grade of the tumor, it is important to effectively and accurately distinguish them from each other. Some imaging findings in vascular tumors of bone have been reported . MR scanning was performed with a 1.5 T or 3.0 T magnets .Among the 18 patients, CT scan was performed in 18 patients and MR imaging in 16 patients. Sixteen patients underwent contrast enhanced MR scans and 4 patients underwent contrast enhanced CT scans.In each patient the imaging findings were evaluated by two experienced radiologists  and the features were recorded by consensus. For all cases, the following information about imaging findings were noted by the radiologist: age, sex, location, size (the largest diameter), matrix , multifocality, expansion, presence of residual bone, margin, cortex, peripheral sclerosis, periosteal reaction, pathologic fracture, signal intensity of images on T1- and T2-weighted sequences compared to the intensity of the surrounding muscle, presence of macroscopic necrotic or cystic component , presence of macroscopic hemorrhagic component , peritumoral signal intensity, intensity of enhancement.The clinical features are summarized in Table The imaging findings of all cases were summarized in Table One of 2 cases with HE showed mild compression of the T8 vertebral body, with lattice-like coarse trabecular pattern Fig. a. In enhOne case with ES-H showed lytic, expansive, relatively well-defined lesion with cortical destruction. The lesion also showed cystic/necrotic components and thrombus inside the lesion Fig. a, b. TheThree cases with EHE showed multifocal, oval or lobulated, mildly expansive, and lytic lesions with peripheral sclerosis, partial cortical disruption and residual bone. The other one case manifested as aggressive behavior, showing multifocal, lytic, ill-defined and permeative, with a geographically pattern, disrupted cortex and residual bone Fig. a–c.Fig. Radiographs of AS showed lytic-sclerotic lesion in one case and lytic lesions in 8 cases Fig. a–c. MRI One of 2 cases with EA showed cortical destruction, pathologic fracture, and invasion of the tumor to the surrounding tissues with extensive hemorrhage and necrosis in central area Fig. a–c. Ill-Pathologically, some vascular tumors described above are remarkably similar, which makes differentiating them from each other very difficult. Most published series of MVTB include low-grade and high-grade lesions. Errani et al.  describeHMT is more likely to occur in elderly patient compared with LMT and there was no sex predilection in LMT but a slight male predominance existed in HMT (Errani et al. The imaging findings of MVTB have been reported in several previous literatures, and generally, it was considered very challenging to differentiate them from each other. According to the present 18 cases, MVTB usually reveal single or multifocal, osteolytic, and variably expansile lesions with heterogeneous signs and marked enhancement, and are frequently associated with soft tissue masses, without periosteal reaction. In our study, there was also one case of AS showing mixed lytic and sclerotic pattern. The reactive changes were seen in our series as ill-defined high signal on T2WI and enhancement on T1WI located in the surrounding bone and/or soft tissues, which may reflect the presence of reactive edema, neovascularization or diffuse tumor extension (Wenger and Wold Besides, we found that LMT tends to have multifocal and well-defined lesions with residual bone tissue, peripheral sclerosis, and slightly hetergeneous enhancement, whereas HMT is more likely to be associated expansive, ill-defined, necrosis/cystic, hemorrhagic, pathologic fracture and often presents with obviously hetergeneous enhancement. The incidence of expansion, peripheral sclerosis, disrupted cortex, pathological fracture, and homogeneous enhancement in LMT and HMT was almost similar. These similar or different imaging features of LMT and HMT were not summarized in the previous literatures.Although HE typically presents radiographically as single or multiple lesions with a lytic pattern of bone destruction, they may additionally present as mixed lytic and sclerotic lesions (Vermaat et al. This study has several limitations. Firstly, the patient population in our study is relatively small with limited statistical power. Secondly, the lack of uniform imaging modalities and scan protocols were also secondary to the retrospective nature of this study.In conclusion, there are some differences in the imaging features between LMT and HMT, while unifocal/multifocal, expansive, ill-defined, necrosis/cystic, hemorrhagic features with age, lesion diameter, peripheral sclerosis, residual bone tissue, pathological fracture and slightly/obviously hetergeneous enhancement highly suggest their differential diagnosis.


Primary pancreatic hydatid lesions are very rare with an incidence of less than 1% in the adult population. We report an observation of a 5-year-old girl who consulted for isolated abdominal pain occurring for 2 weeks without vomiting, transit disorders or jaundice and evolving in a context of conservation of the general condition and apyrexia. Clinical examination and preoperative imaging have suggested the diagnosis of a choledochal cyst or duodenal duplication rather than a hydatid cyst of the pancreas due to the presence of a cystic hepatic image projecting into the liver hilum. During the procedure, a hydatid cyst was found occupying the head of the pancreas. Primary hydatidosis of the pancreas in children is extremely rare. Possible sources of infection include: blood diffusion, local spread via biliopancreatic ducts and peripancreatic lymphatic invasion. In the endemic areas, hydatid disease should be mentioned in the list of differential diagnoses of cystic lesions located around the biliopancreatic junction in children. Pancreatic localization of the hydatid cyst is rare, even in countries where hydatid disease is endemic. The hydatid cyst of the pancreas accounts for less than 1% of all the sites, which may explain the difficulties of diagnosis. This location affects the child exceptionally [This is a 5-year-old girl from a rural area in the province of Kenitra (West Morocco) with no previous history hospitalized in April 2014 for epigastric pain during the past two weeks associated with dietary vomiting and diarrhea for a month and a half. The clinical examination was unusual. Abdominal ultrasound showed a multilocular hepatic cystic mass projecting at the level of the heterogeneous hypo echoic liver of the duodenum and gallbladder 46mm long major axis and coming into contact with the anterior surface of the head of the pancreas , in addiThe pancreas is an organ rarely infected with hydatid cysts and figures from the literature show an incidence ranging from 0.19% to 2% of the various sites of the hydatid disease . InflammUltrasound, computed tomography (CT) and magnetic resonance imaging (MRI) make it easy to retain the diagnosis of a pancreatic cystic lesion , 11, 12.Pancreatic hydatidosis is exceptional , 3. It oThe authors declare no conflict of interest.


Echinococcus granulosus, which infects humans as intermediate hosts through the orofecal route. Carried by the intestinal venous blood, the embryos released by the eggs of the tapeworms can reach every organ, especially the liver, turning into a hydatid cyst. Usually asymptomatic, the cysts can be incidentally detected through radiological examinations performed for other reasons. We show an unusual case of superinfection of a hydatid cyst with typical radiological features of inactivity (WHO-type CE5) with an even rarer skin fistulization passing through a subcutaneous-abdominal abscess involving the right iliac muscle.Cystic echinococcosis (CE), also known as “hydatid disease” (HD), is a zoonotic infection caused by the larval stage of Echinococcus granulosus, which accidentally infects humans through the orofecal route.Cystic echinococcosis (CE), also known as “hydatid disease” (HD), is a zoonotic infection caused by the larval stage ofAlthough previously endemic in Africa, South America, and Eurasia, the disease is nowadays worldwide spread due to the increased migratory flows.Because of the intestinal absorption, the main organ affected is the liver (70% of cases), where the hydatid cyst can develop.In most cases, the disease is asymptomatic and the typical cystic lesion can be depicted as an incidentaloma while performing imaging examinations.Otherwise symptoms may be aspecific  or related to complications, such as rupture of the cysts , secondary infection, and cholangitis.The final diagnosis is reached matching patient's clinical history, specific serologic tests, and imaging evaluation, helpful in providing a complete clinical picture .According to the radiological findings, several classifications have been proposed, all in agreement in defining thick-calcified-wall cysts as inactive or dead.We show an unusual case of superinfection of a dead calcified hydatid cyst (WHO-type CE5)  with an A 68-year-old male patient suffering from chronic renal and heart failure and alcohol-related cirrhosis was admitted to our hospital with fever, abdominal pain, and a right-flank fistula, draining a huge quantity of purulent secretion.He had also a known history of CE with a calcified cysts of the liver, incidentally discovered a few years before at a chest X-ray in our department and confirmed at unenhanced CT-scan .N: 84%) and an electrolyte imbalance with severe hyponatremia.Laboratory tests showed a neutrophilic leukocytosis  examination of the abdomen was immediately performed, showing the presence of a subcutaneous abscess.b values , and 2D T1-weighted axial dual fast-field-echo (FFE) breath-hold sequence.To better evaluate the size and depth of the abscess he underwent an MR examination performed in our department using a 1.5 T MR Philips Gyroscan Intera  and phased-array abdominal coils. Different pulse sequences were applied: 2D axial and coronal T2-weighted turbo spin echo (TSE) sequences, 2D axial echo-planar imaging (EPI) sequence at different Intravenous injection of contrast medium was avoided due to the chronic renal failure of the patient.MRI confirmed the presence of an inhomogeneous fluid collection with irregular peripheral walls, indicative of abscess, extending from the subcutaneous tissues of the posterior right abdominal flank into the abdominal cavity, through the right iliac muscle. The abscess showed a middle-low T2 hyperintensity of the content while DWI study revealed diffusion restriction of the lesion .A long narrow fistula connecting the abscess with the hepatic hydatid cyst was also found.In order to better assess the route of that fistulous tract, a CT-fistulography was obtained catheterizing the external opening of the fistula with a thin cannula and injecting a water-soluble iodine contrast medium. The exam showed a progressive contrast filling of the abscess and the abdominal fistula , ascendi Pseudomonas aeruginosa and Klebsiella oxytoca, without any Echinococcus.The drainage culture test showed the presence ofAfterwards, the patient underwent an antibiotic therapy with percutaneous drainage of the cutaneous-abdominal abscess. After the complete resolution of the abscess, a surgical cystectomy was performed.Echinococcosis is a worldwide zoonosis, caused by Cestode parasites, commonly known as small tapeworms of carnivorous animals [ animals , that caThe liver is the most common organ involved (75% cases of HD), followed by the lungs (15%) .Although the course of the liver hydatid disease is usually asymptomatic, complicated forms are not rare, occurring in 30–60% of the patients .The main complications include traumatic or idiopathic rupture of the cysts into the biliary tract, which is the most frequent, or into peritoneum, skin, digestive tract, or thorax, due to a transdiaphragmatic involvement , 6.Large and superficial hepatic cysts are considered to be the most susceptible to break.“Mass-effect” of large lesions may also cause vascular complications, such as Budd-Chiari and vena-cava syndromes, and biliary obstruction that may lead to cholestatic jaundice, cholangitis, biliary colic, and fever .Suppuration of the cyst is caused by a cystobiliary communication and it is not a rare complication, with an occurrence of 5–40% .However, although the association between calcified hydatid cysts and suppuration is well known , to our Certainly, imaging techniques play a pivotal role in a comprehensive evaluation of hydatid disease.Though abdominal ultrasonography is considered the gold standard in identifying and characterizing the cysts, CT and MRI have reached an increasing importance over the years.In fact, while CT-scan has a good sensitivity and specificity in the evaluation of hepatic HD, especially in depicting wall calcifications, MRI is nowadays considered the best imaging investigation in differentiating the fluid content of the cyst from other components and in depicting vascular or biliary tree involvement and extrahepatic complications , 11.On the basis of imaging findings, several classifications have been proposed in typifying echinococcal cysts, but only few of them achieved a large consensus.Through a sonographic evaluation, Gharbi et al.  proposedIn order to establish a simpler and standardised classification, also able to reflect the stages of the disease and the related treatment, a new one was introduced in 2003 by the Informal Working Group on Echinococcosis (IWGE-WHO). Still relayed on ultrasound examination, this classification recognizes six categories of hydatid cysts: CL, a simple cyst with anechoic content and not clearly visible wall, suspicious for an early stage of EC; CE1, a cyst with visible wall containing an inhomogeneous fluid due to the presence of hydatid sand; CE2, a multiseptate cyst with daughter cysts inside, with variable appearance ; CE3, characterized by anechoic content with detached membranes within (3a) or daughter vesicle inside solid-echoic areas (3b), related to degenerated daughter cysts; CE4, hypoechoic or inhomogeneous content without daughter cysts; CE5, with thick calcified wall with a cone shadow. Moreover, these categories were grouped on the basis of their physiopathological behaviour into three types: active , transitional (CE3), and inactive  [However, the inclusion of CE4 type in the inactive group has raised some doubts, due to the presence of fertile liquid inside the vesicles; this implies a consequent “watch and wait” clinical approach .Another widely used brief classification, suggested by Precetti et al. , dividesGharbi's, IWGE-WHO, and Precetti's categorizes are summarized and compared in Apart from Gharbi's one, which merely consists in a morphological description, the other two classifications consider cysts with a peripheral thick calcified wall as inactive and therefore less likely to undergo changes or complications , 8, 14.Nowadays, three different options are available while treating uncomplicated CE: surgery, PAIR, and chemotherapy. CE4 and CE5 types are generally excluded from any kind of therapy and a “watch and wait” strategy is actually recommended.Surgical treatment consists of different approaches, from the conservative  to the radical ones (cystectomy or hepatic resections). Despite its invasiveness, it still remains the first choice in the treatment of large CE2–CE3b or complicated EC .PAIR  technique has gained momentum during the last two decades, due to its lower invasiveness . It consOn the other hand, chemotherapy consists in the administration of mebendazole (MBZ) or albendazole (ABZ) and it can be combined as an adjuvant to surgery or PAIR , 17.The treatment of CE2 and CE3b cysts has been discussed over the years, due to their typical trend to relapse. Although some works suggest to choose an expectant management, in particular for C3b types , Akhan eAs a matter of fact, in our case, the patient was affected by a hepatic hydatid cyst, previously demonstrated in a CT-scan performed in our department, completely surrounded by a thickened calcified wall.Nevertheless, at the patient's latest hospitalization, a very serious superinfection of that cyst was found. In particular, sonography and MRI showed the presence of a large abscessual collection located in the subcutaneous tissues of the posterior right flank and extending into the abdominal cavity through the right iliac muscle.Moreover, the abscess was in communication superiorly with the hydatid cyst of the liver, through a thin intra-abdominal fistula and inferolaterally to the skin surface.In order to completely assess the length, the size, and the orientation of that fistula, a CT- fistulography was obtained, which clearly enhanced the whole route.A cutaneous involvement with a spontaneous skin fistulization is considered a very rare complication of liver hydatidosis and only a few cases have been reported , 21.Skin fistulization generally occurs at the same anatomic level of the hepatic cyst, as a result of some pathophysiological steps: protrusion of the cyst into the innermost muscular layer of the abdominal wall, penetration into the muscular tissue, subcutaneous rupture, and/or skin fistula formation .In our case, a progressive cystic adhesion to the abdominal wall did not occur and the external opening was very far from the hepatic hydatid cyst, considering that the fistula was located in the lateral abdominal cavity and connected downwards to the subcutaneous-abdominal abscess which involved the right iliac muscle.To our knowledge, the involvement of the iliac muscle has never been reported in the literature up to now.In conclusion, we showed an unusual case of superinfection of an inactive calcified hydatid cyst with an even rarer abdominal-cutaneous fistulization passing through a subcutaneous-abdominal abscess involving the right iliac muscle.Furthermore, it demonstrates the usefulness of MRI not only in identifying the cystic content, the extension of the disease, and the related complications but also in identifying the thin fistulous tract in order to allow a better treatment planning.


Plasmacytoma of the skull-base is a rare entity. Differential diagnosis includes chordoma, osteosarcoma, carcinoma nasopharynx, meningioma, metastatic carcinoma, lymphoma, and multiple myeloma. Accurate and precise diagnosis is extremely important for plasmacytoma of the skull-base as its treatment and prognosis is different from other skull-base lesions. A 41-year-old man presented with concerns of headache, diplopia, and left eye strabismus. A magnetic resonance image (MRI) of his brain showed a large expansile mass measuring 51 mm involving the clivus and central skull-base. Trans-sphenoidal tumor decompression was done. A biopsy confirmed the plasmacytoma. A positron emission tomography-computed tomography (PET-CT) scan showed a single 2-(18F) fluoro-D-glucose (FDG) avid lesion at the skull-base. The results of all other relevant investigations such as hemoglobin, renal function test, serum calcium, serum protein immunoelectrophoresis, serum quantitative immunoglobulin, bone marrow biopsy, serum lactate dehydrogenase, and beta-2 microglobulin levels were within normal limits. He was treated with radical radiotherapy. He developed complete clinical response after radiotherapy. Solitary plasmacytoma is characterized by the localized proliferation of neoplastic monoclonal plasma cells. It is a rare tumor and makes less than 10% of all plasma cell neoplasms .A 41-year-old man presented with concerns of headache, diplopia, and left eye strabismus lasting two months. There was no history of nausea, vomiting, and seizure. He had no other medical conditions such as hypertension, diabetes, cardiovascular disease or stroke. A neurological examination showed left eye sixth cranial nerve palsy. There was no sensory or motor deficit in his upper and lower limbs. A magnetic resonance image (MRI) of the brain showed a large heterogeneous, expansile lesion measuring 51 mm x 50 mm, involving the central skull-base and clivus with the erosion of adjacent bones, partially encasing the bilateral internal carotid artery (ICA) suggestive of chordoma , serum quantitative immunoglobulins levels, serum lactate dehydrogenase, calcium, albumin, renal function test, and beta-2 microglobulin levels were within normal limits. Bence Jones protein in the 24-hour urine sample was absent. The positron emission tomography-computed tomography (PET-CT) scan showed a single 2-(18F) fluoro-D-glucose (FDG) avid lesion at the base of the skull as described in the MRI of the brain. He was treated with radical radiotherapy with intensity modulated radiotherapy technique to a dose of 50 Gy in 25 fractions over a five-week duration by 6-megavolt (MV) x-rays on a modern linear accelerator (Figure After radiotherapy, he got complete symptomatic relief from headache and diplopia. A second MRI scan to assess the response following three months of radiotherapy showed complete remission of the lesion Figure . One year after radiotherapy, investigations including PET-CT scan, MRI scan, serum quantitative immunoglobulins level, SPEP, and beta-2 microglobulin level were within normal limits with no signs of the recurrence.Plasmacytoma of the skull-base is a very rare disease entity . The radTrans-sphenoidal surgery is required for diagnosis and tumor debulking in patients with neurologic deficits due to large tumor mass effect or in recurrent or residual lesions . RadiothAn accurate and precise diagnosis is extremely important for plasmacytoma of the skull-base as its treatment and prognosis is different from other skull-base lesions. Radiotherapy is the treatment of choice for the solitary plasmacytoma of the skull-base as it is a radiosensitive tumor.


To deepen the knowledge in obstetrics on a very rare pregnancy complication: umbilical cord hematoma.  A review of the case reports described in the last ten years in the literature was conducted in order to evaluate epidemiology, predisposing factors, potential outcomes, prenatal diagnosis, and clinical management.  Spontaneous umbilical cord hematoma is a rare complication of pregnancy which represents a serious cause of fetal morbidity and mortality. There are many risk factors such as morphologic anomalies, infections, vessel wall abnormalities, iatrogenic causes, and traction or torsion of the cord, but the exact etiology is still unknown.  Due to the rarity of this condition, every new case of umbilical cord hematoma should be reported in order to improve the knowledge of predisposing factors, prenatal diagnosis, and clinical management. Although very rare, umbilical cord hematoma (UCH) is a real serious complication of pregnancy. It represents a rare cause of acute fetal distress that may be shown by the decrease of fetal movement or fetal death .Lately, a case of UCH resulted in perinatal death at our department stimulating our interest in performing this review of the literature, emphasizing the research on pathogenesis, diagnosis, and management for UCH.The study by Dipple et al., with 36 cases, is the largest series published on this topic so far. It estimates an incidence rate of 1 in 5505. Although umbilical cord complications may be the second most common cause of stillbirth , umbilicOur review of the English literature resulted in 9 publications of 11 cases of UCH in the years 2008–2017 –11. Of thttps://www.ncbi.nlm.nih.gov/pubmed. The keywords used were as follows: “Umbilical,” “Cord,” and “Haematoma.” Different combinations of the terms were used. Moreover, references in each article were searched to identify potentially missed studies. We chose 2008 as a starting year point for our literature search because this year was marked by a review of the literature by Gualandri et al. [A review of the literature was conducted in order to identify the case reports reported in the English language. We searched PubMed MEDLINE electronic database published between 2008 and 2017 on i et al.  for the The exact etiology of UCH still remains unexplained. Many theories have been proposed but without final results. Probably a combination of different factors leads to UCH.Risk factors for spontaneous umbilical cord hematoma are various. They include morphologic anomalies of the umbilical cord (both in length and in thickness), true knots, cord prolapse, traction or torsion, velamentous insertion of the cord, vessel wall abnormalities, umbilical cord cysts, abdominal trauma in pregnancy, postterm pregnancy, infections (chorioamnionitis and funisitis), deficiency of Wharton's jelly, congenital defects, and many more remain unexplained . Fetal hSpontaneous bleeding in the umbilical cord is due to a disruption of the vessel wall through which, in most cases, an extravasation of blood into Wharton's jelly occurs. . A high In our analysis of 11 cases, 2 cases showed evidence of chorioamnionitis , 8, 1 caThe diagnosis is usually made postnatally, but in some cases it can be made by Doppler ultrasound scan prenatally, assessing the cord and the blood flow in the umbilical vessels , 12. CorDetailed physical examination of the placenta and cord confirmed the presence of the hematoma in all 11 cases described. During macroscopic examination, umbilical cord may have abnormal appearance with dark red discoloration and markedly increased thickness . It may Autopsy plays an important role in investigating the cause of stillbirth that occurs in the antenatal period.2).A 29-year-old multipara woman, with an uncomplicated pregnancy, presented at 41 weeks and 3 days of gestation for elective labour induction. The patient showed Grade 1 obesity  monitoring. After 24 hours from the labour induction, the Bishop score was unchanged and the vaginal insert removed. 3 hours later, the induction continued with intravenous injection of oxytocin 10 UI. After approximately 1 hour, spontaneous rupture of membranes with amniotic clear fluid was observed.8 hours after induction patient delivered a hypotonic, with no evidence of cardiac activity, male newborn. FHR corresponded to type 1 and 0 of Piquard criteria during the second stage of the labour.Venous pH at birth was 7.11 , and arterious pH was 6.96 . Apgar score at 1 minute was 0. After 40 minutes of continuous resuscitation, the fetus was still asystolic, and it was therefore decided to stop the resuscitation efforts.The gross examination of the placenta and of the umbilical cord revealed the presence of blackish-reddish material in the proximity of the placental insertion measuring approximately 3 cm. The umbilical cord presented vascular ectasia at 18 cm from the placental insertion. An hematoma of the cord was noted at 34 cm from the placental insertion; the hematoma was described as an infiltrate of 2 cm, in the tones of black and red, extended to the whole umbilical cord section.The histological examination of the cord highlighted oedema of Wharton's jelly, circumscribed hematic infiltrates, marked venous ectasia with delamination and hematic infiltration of the venous walls, extensive hemorrhage of Wharton's jelly within the whole portion of the cord. The lumen of the vein was completely occluded by coagulated hematic material.The histological examination of the placenta highlighted intense vascular congestion of villi and hematic infiltrates as for intervillous hematomas.Measurements of crown heel, crown rump, head circumference, foot length and weight indicated a regular intrauterine development.The internal gross examination and the hystopathological examination of lung tissue revealed elements indicating physiological respiration in presence of FHR. The above pattern confirmed that the fetus started the respiratory activity after being delivered before dying.The umbilical cord is called the fetal life line, and it is the vital link between the fetus and placenta. Various abnormalities are observed in the morphology and pathology of the umbilical cord but knowledge of them is quite poor.A considerable number of stillbirths that are thought to be unexplained may be attributable to placental or cord pathologies. UCH can compromise the maternal-fetal circulation by compressing the vessels or because of the blood loss within the cord itself, leading to perinatal asphyxia and stillbirth .Stillbirth can occur either antenatally or perinatally, but sometimes UCH is uneventful. In our case, the stillbirth was peripartum; the results from external inspection, hystopathological examination, and autopsy suggest the manifestation, before death, of a hyperacute asphyctic mechanism. Furthermore, macro- and microscopic analyses of the umbilical cord revealed pathological alterations indicating an acute trauma with compression, vascular laceration, and hemorrhagic infiltration.This must be due to the occurrence of mechanical compression of the umbilical cord during labour, with acute interruption of the fetoplacental circulation. The cause of death is therefore attributable to an intrauterine asphyxia caused by acute mechanical compression of the umbilical cord, difficult to detect antenatally.Cord accident  as a cause of stillbirth is underreported, mainly due to a lack of diagnostic criteria.A complete fetopathological examination can state causality between hematoma and stillbirth, exclude another fetal or placental cause of death and consequently reassure the parents for the prognosis of another pregnancy. The issue of hematoma-related complications is also important because of its medicolegal aspect since litigation may occur. Timing of delivery should be based on gestational week as long as the fetus shows well-being signs. Preterm or urgent delivery should be performed in case of fetal distress or reduced movements.Because of the rarity of this condition, every new case of UCH should be reported in order to improve the knowledge of predisposing factors, prenatal diagnosis, and clinical management.


A 20-year-old female was referred to our hospital due to deformity and bulging in anterior aspect of chest wall in sternal area. Chest X-ray and CT scan confirmed a large mass with destruction of sternum. Pathologic diagnosis after incisional biopsy was compatible with aneurysmal bone cyst. We resected sternum completely and reconstructed large anterior defect by a cryopreserved sternal allograft. In follow-up of patient there was no unstability of chest wall with good cosmetic result. Radical resection of sternum is indicated in different situations such as primary or secondary malignant tumors, some rare cases of benign tumors, infection, radio necrosis, and trauma . AneurysVarious techniques have been described but all of them have advantages and disadvantages and at the present time there is no gold standard for managing these defects . There iIn this case report we have described a patient with sternal aneurysmal bone cyst that after complete surgical resection of tumor (sternectomy) reconstruction of chest wall was carried with a cryopreserved sternal allograft.A 20-year-old female patient was referred to our thoracic surgery unit due to deformity and bulging in the anterior part of chest wall in sternal area with mild pain. A tumor was suspected based on the chest X-ray and therefore a chest CT scan was done that revealed a large mass with differential diagnosis of primary sternal tumor in origin or anterior mediastinal tumor with invasion to sternum Figures .A core needle biopsy was performed with pathologic diagnosis compatible with giant cell tumor. An incisional biopsy was done based on pathologist's recommendation which revealed a highly vascular mass with final pathologic diagnosis of aneurysmal bone cyst.The best treatment option was deemed to be resection of lesion and due to the size of tumor, total sternectomy was planned.At the time of surgery a longitudinally elliptical midline incision was performed which included previous biopsy site. There was no infiltration or adhesion of mass to skin and subcutaneous tissue and a well-defined, capsulated but highly vascular mass was dissected from surrounding tissues. Due to large dimension of tumor, pectoralis major muscles were pushed laterally to nearly mid clavicular lines Figures . ThoraciIn serial visits 1, 2, 3, and 12 months after surgery the defect was completely stable with no complicating events. Final pathologic report was compatible with aneurysmal bone cyst . Serial Primary tumors of sternum are rare and include about 5% of all bony tumors. Benign sternal tumors are extremely rare. Aneurysmal bone cyst with an incidence of 2.5–5% of bone tumors is an extremely rare pathology in sternum and limited number of cases have been reported [Methyl methacrylate mesh or sandwiches, polytetrafluroethylene (PTFE), or polypropylene patches belong to routine thoracic surgical armamentarium and considering advantages and disadvantages of their use, extensive usage has been described. Recently metallic material such as titanium clips or plates and even moldable multiholed plates have been used for stabilization of chest wall . Turna eDue to complications related to using prosthetic material such as infection and rigidity, bone grafts have gained considerable attention in reconstruction of chest wall . Ribs caFinally in this case we have reported two rare events occurring simultaneously. The first one is rare occurrence of aneurysmal bone cyst in flat bones especially sternum and the second is the use of a new and less described substitute after sternal resection. Ishinada et al. have described an aneurysmal bone cyst that was treated by total resection and reconstruction of defect by autogenous fibula . Althoug


Angiosarcoma of the spleen is a rare malignancy that arises from vascular endothelial origin. This neoplasm is highly malignant and diagnosis is often delayed due to the vague presentation of clinical symptoms. A case report and concise review of the current diagnostic criteria and surgical treatment are provided to aid in the detection and treatment of this malignancy. We present a case of a 56-year-old female who presented with massive splenomegaly secondary to angiosarcoma of the spleen. The patient suffered from longstanding symptomatic anemia and thrombocytopenia. Diagnosis of a splenic angiosarcoma can be difficult due to the vague presentation and lack of concrete risk factors. Early identification and splenectomy are paramount. However, it is an aggressive malignancy with poor prognosis. We reviewed the literature of the current diagnostic and surgical treatment of primary splenic angiosarcoma. Primary malignancies of the spleen are categorized into vascular and lymphoid with the former originating from red pulp and the latter from white pulp . AngiosaA 56-year-old female presented to the hospital with the complaint of fatigue, chest pain, shortness of breath, and dyspnea on exertion. On further review of symptoms she admitted to diffuse left upper quadrant tenderness and unintentional weight loss of 15 pounds. Her past medical history was significant for anemia, hypothyroidism, and a 40-pack-year history of smoking. The patient was suffering from longstanding symptomatic normocytic anemia and was followed up by gastroenterology for a potential etiology. However she underwent several endoscopies and colonoscopies with unsuccessful attempts to diagnose her anemia. The patient received multiple packed red blood cell transfusion therapies for symptomatic relief.9/L, hemoglobin count of 7.1 g/dL, hematocrit of 23.4%, platelet count of 153 × 109/L, MCV of 83.4, and red cell distribution width of 19.7%. A computed tomography with contrast of the abdomen and pelvis demonstrated marked splenomegaly that is heterogeneous with multiple low attenuation masses (Pertinent laboratory findings included white blood cell count of 15.3 × 10n masses . In addin masses .With no resolution of her symptomology and radiographical evidence of an enlarged hypermetabolic spleen, the patient decided to undergo an elective splenectomy. Prior to the operation interventional radiology performed a splenic artery embolization to reduce blood flow to the spleen. The patient was taken to the operating room for a laparotomy. Upon entering the abdominal cavity the spleen was easily identified and had multiple omental adhesions. Due to the size, increased vascularity, and proximity to surrounding organs the splenic vein completely adhered to the distal pancreas and was unable to be safely dissected away. This resulted in a distal pancreatectomy. Once the spleen was removed the total weight measured 1,124 grams .The organ was sent for pathological analysis, with routine sections showing sheets and clusters of large atypical cells with vesicular chromatin and prominent nucleoli in a background of extensive necrosis, lymphodepletion, and abundant macrophages . The hisAngiosarcoma is a malignant neoplasm that originates from vascular endothelial cells. These uncommon neoplasms account for approximately 2% of all soft tissue sarcomas with an increase in incidence over the last 30 years . SplenicThe gross and microscopic features of primary splenic angiosarcoma vary considerably which often makes the diagnosis a challenge. Gross macroscopic examination following splenectomy often demonstrates enlarged spleens weighing 250 to 3,200 grams with massive splenomegaly defined as mass greater than or equal to 1,000 grams . While tHistologic examination shows splenic angiosarcoma is a morphologically heterogeneous entity. The prominent epithelioid and malignant mesenchymal features observed in these neoplasms emphasize the need to examine multiple sections of tissue. The most sensitive and specific means of defining the atypical cells as endothelial in origin is through immunohistochemical staining of tissue . HoweverDiagnosis is a difficult challenge due to the presence of nonspecific symptoms and the rarity of the disease. This often creates a large differential diagnosis that may not confirm splenic angiosarcoma until a more advanced stage. The spectrum of this disease is highly variable being similar in some aspects to vascular tumors such as hemangiomas, epithelioid hemangioendotheliomas, littoral cell angioma, and Kaposi's sarcoma or malignant nonvascular tumors like lymphangiomas, lymphomas, sarcomas, and secondary metastatic carcinomas . ImagingClinically, Falk et al. describe that the most common presenting symptom was abdominal pain that is localized to the left upper quadrant . Often cThe prognosis of splenic angiosarcoma continues to remain poor. The median survival of patients diagnosed with angiosarcoma is five to six months without treatment . This suPrimary angiosarcomas arising from the viscera are extraordinarily rare and there is no current chemotherapeutic standard. In the management of soft tissue sarcomas, doxorubicin and ifosfamide as single drugs were able to demonstrate response rates of 16–36% and are the most active agents . A largePrimary splenic angiosarcoma is a rare and aggressive neoplasm that has a dismal prognosis. Diagnosis and treatment pose a significant challenge. While angiosarcoma of other organs is often related to occupational exposure to vinyl chloride, arsenic, or usage of contrast agent thorium dioxide, this relationship does not exist for the spleen. Although there are many several symptoms associated with this malignancy, none is specific for splenic angiosarcoma. Angiosarcoma of the spleen should be suspected in patients with continuous left upper quadrant pain, splenomegaly, systemic symptoms of malignancy, and persistent hematologic abnormalities. Radiographical imaging is a useful tool in determining the composition of the spleen, size, and metabolism; it alone is not adequate for diagnosis. However definitive diagnosis is made by tissue analysis with immunohistological staining. The current and accepted therapy is splenectomy. While there are some studies using chemotherapy and radiation, there is no specific treatment for splenic angiosarcoma. Early diagnosis and surgical management remain paramount.


The giant ovarian serous cystadenoma is a rare finding and often benign. The use of the laparoscopic approach versus open approach for the management of huge ovarian cysts is controversial. We report a case of a 27-year-old woman with a history of increasing abdominal girth over a period of two years along with radiological investigations revealed a large tumor arising from the right ovary treated by complete laparoscopic extirpation of a giant ovarian cyst. The complete laparoscopic approach for huge cyst is a feasible treatment when having a normal tumor marker profile and benign imaging appearance. In addition to the advantages of laparoscopic surgery, it is less invasive, with perfect cosmetic outcome and shorter hospital stay, which are particularly important for young women. The giant ovarian cyst is rarely found nowadays because of the improved imaging modalities and minimally invasive approaches so the diagnosis is made at an earlier stage. Serous cystadenomas are the most common types of epithelial neoplasms encountered with benign cystadenoma about 75% . ManagemWe report a case of a woman with a history of increasing abdominal girth over a period of two years along with radiological investigations revealed a large tumor arising from the right ovary treated by complete laparoscopic extirpation of a giant ovarian cyst.A 27-year-old single Saudi woman presented with her parents on September 2016 at the gynecology outpatient clinic of the King Fahad Medical city, Saudi Arabia, with a gradually abdominal distension and discomfort over two years. The swelling was accompanied by vague abdominal pain and breathlessness which worsened on recumbency leading to decreased sleep. She also complained of constipation and poor appetite. There was no history of vomiting or other gastrointestinal symptoms, urinary symptoms, colicky pain, and fainting attacks. She had no previous history of any illnesses, allergies, or operations. She denied the use of any medications. There was no family history of malignancies. Her menarche commenced at the age of 11 years with subsequent regular cycles.Her body weight was 71 kg, her height was 157 cm, and her BMI was 28.8. On physical examination, she was afebrile with a pulse rate of 79 b/min, blood pressure of 120/73 mm Hg, and respiratory rate of 20 cycles/min. There was no jaundice, edema, or lymphadenopathy. Secondary sexual characteristics were evident. Abdominal examination revealed abdomen was distended with large ill-defined pelvic-abdominal cystic mass extending from pubis to epigastrium with an abdominal girth of 106 cm with a dull note on percussion, without tenderness and the presence of dermal striae. Intestinal sounds were normal. The external genital examination was normal.Plain radiograph of the chest (P-A view) was within normal limits. Transabdominal ultrasonography verified a large pelvic cystic mass about 29 × 18 cm with no evidence of solid components or septations. The uterus was normal and endometrial thickness was 10 mm. CA-125 was 25.3 IU/ml and another tumor marker was within the normal ranges. Abdominopelvic computerized tomography (CT) findings were consistent with a large well-defined homogeneously cystic lesion originating from the right ovary measuring 15.6 × 26.3 × 31.7 cm in the AP, transverse, and craniocaudal dimensions, respectively . Most liIntraoperatively, the patient was in a supine position, prepped and draped in the usual sterile fashion. The bladder had been drained with a Foley catheter that was placed in the bladder. Attention was then turned to the abdomen where an approximately 10 mm skin incision was made in the umbilical fold. Entry into the peritoneum was done using the Hasson technique. The 10 mm trocar was placed through the umbilical incision. The abdominal cavity was visualized with huge cyst arising from the right ovary which was seen, extending up to the level of the xiphoid process, and the liver was not visualized due to the huge cyst. Peritoneal wash was sent for cytology. The 10 mm second trocar was applied in the suprapubic catheter with direct opening in the cyst and being drained around 10,050 ml. However, with suction, a large globular piece of the cyst was obtained that appeared to be coagulated blood which was sent for cytology. Two trocars 5 mm were inserted in the lower quadrant bilaterally. The cyst wall was identified and was removed using blunt dissection with countertraction. The ovarian bed was then irrigated and dried. There was slight oozing noted near the edge of the ovary, with hemostasis obtained using electrocautery. The Endo Catch bag was placed through the 10 mm port (suprapubic) and the cyst wall components, and the right ovarian cyst was placed in the Endo Catch bag and removed through the 10 mm incision which was sent for histopathology . After dShe was discharged on the 2nd postoperative day. The patient was advised to follow up after 4 weeks. Patient weighed 60 kg with an abdominal girth of 80 cm on day 28 after operation. Cytological examinations were negative for malignancy. Histopathological examination revealed serous cystadenoma of the ovary. She recovered completely from her surgery and has gone back to her normal daily activity.Small ovarian cysts are usually asymptomatic and found incidentally clinically or on ultrasound. They may sometimes cause pain or discomfort. The benign neoplastic cysts are most frequently endometrial or chocolate cyst or simple cyst. The most frequent complications of benign ovarian cysts are torsion, hemorrhage, and rupture . There aSerous cystadenomas are the most common types of epithelial neoplasms encountered with benign cystadenoma about 75% and mucinous cystadenomas were 25%. Serous or mucinous cystadenomas of the ovary, benign or malignant, are rare in children. They arise from Mullerian germinal epithelium . Giant oIn laparoscopic surgery with the availability of modern advanced techniques and expertise in minimally invasive surgery, laparoscopic excision is preferred in the management of giant ovarian cyst extending up to the level of the umbilicus mainly due to its least invasiveness, better cosmesis, and shorter hospital stay, but only a few cases have been reported . All repThe complete laparoscopic extirpation of a giant ovarian cyst is a feasible treatment when having a normal tumor marker profile and benign imaging appearance. In addition to the advantages of laparoscopic surgery, it is less invasive, with perfect cosmetic outcome and shorter hospital stay, which are particularly important for young women.


Cardiac calcified amorphous tumor (CAT) is an extremely rare benign intracavitary tumor of the heart. It may mimic other cardiac tumors and can present with signs or symptoms of systemic embolization. There are limited data regarding CAT in the literature. We report a case of a 68-year-old woman with a cardiac CAT and mitral annular calcification (MAC), who presented with acute ST-elevation myocardial infarction (STEMI) and occipital stroke. After extensive review of the literature, we believe that this case is possibly the first description of a cardiac CAT presenting with STEMI. The CAT was surgically removed, and the diagnosis was confirmed by histology. The patient tolerated the surgery and reported no events at 6-month follow-up. Cardiac calcified amorphous tumor (CAT) is a rare benign intracavitary tumor of the heart. Like other cardiac tumors, CAT may present with dyspnea, syncope, and pulmonary or systemic embolization and obstruction –4. HereiA 68-year-old woman with a 40-pack-year smoking history but no known medical problem was brought in by ambulance for sudden onset of persistent, severe left-sided chest pain without radiation. The patient also reported a new onset of blurred vision. She denied history of hypertension, dyslipidemia, diabetes mellitus, coronary artery disease (CAD), or chronic kidney disease or family history of premature CAD. Initial vital signs were normal with oxygen saturation of 98% on 2-liter supplemental oxygen via nasal cannula. Physical examination was benign, without murmur or abnormal heart sounds. There were no focal neurological deficits or signs of peripheral embolization noted. Initial electrocardiogram (EKG) showed 1-2 mm ST elevation in inferior leads  with reciprocal ST depression in leads I and aVL . Oral asThe patient recovered well without recurrent symptoms at her 6-month follow-up.4) metabolism [4 metabolism. However, more studies are required to determine the exact underlying mechanism. Unfortunately, as in most patients who underwent surgical resection of the CAT, only the tumor was removed and biopsy of the mitral annulus was not performed in our patient. Surgical resection of the tumor is generally recommended to prevent embolization in most patients [First introduced by Reynolds et al. in 1997, cardiac CAT is an extremely rare nonneoplastic primary tumor of the heart. It is characterized histologically by the features of calcified nodules and amorphous fibrinous materials . There htabolism . MAC hastabolism . MAC is patients –10, 14. The patient did not have any evidence of atrial arrhythmias on telemetry monitoring or intracardiac thrombus in TTE or TEE. Additionally, coronary angiogram showed isolated lesions at the third acute marginal branch and PDA of RCA and otherwise nonobstructive coronaries. Carotid ultrasound also showed normal bilateral vertebral and subclavian arteries, but there were mild stenoses (<50%) of bilateral internal carotid arteries (ICAs). Mild ICA stenoses could not explain the left occipital stroke as well. The occluded acute marginal branch of the right coronary artery was <1.5 mm in diameter angiographically. Therefore, no coronary intervention or aspiration was performed. The prognosis is generally good after complete removal of the mass lesion , 16. TheCAT of the heart is rare. Despite its benign nature, it can be highly mobile and consequently lead to systemic embolization, particularly in those with associated MAC. The prognosis is excellent with surgical resection in most patients. For those without ESRD or abnormal calcium metabolism, further studies may help determine whether cardiac CAT can involve the mitral annulus and result in an appearance similar to MAC on TTE.


Chordoma is a rare invasive bone tumor that may occur anywhere along the neuraxis. A total of three primary histological varieties have been identified: conventional, chondroid, and dedifferentiated.We report a case of an 8-year-old white girl who presented with conventional chordoma, was treated with surgical resection and mixed proton and photon beam therapy, and had a recurrence in the resection cavity 2.5 years later with dedifferentiated morphology. The recurrent tumor did not express brachyury, a recently identified protein specific to tissue of notochordal origin.The short time period between radiation therapy and dedifferentiation, low dose of photons, and rarity of dedifferentiated skull base chordomas in pediatric patients should alert clinicians to the possibility of chordoma dedifferentiation after proton beam therapy. Chordoma is a rare, locally invasive bone tumor of notochordal origin with an incidence of 0.1 to 0.8/1,000,000 . It is 4Skull base chordomas are typically surgically resected and proton beam therapy is often used to treat residual tumor , 9. We rAn 8-year-old white girl with no family history of skin cancer except for skin cancer in her grandfather complained of 4 weeks of pressure-like headaches, mostly in the posterior occipital area, and intermittent nausea with several episodes of emesis in June of 2012. A physical examination was significant for decreased sensation to light touch over the right side of her face and her right upper extremity. Magnetic resonance imaging (MRI) of her brain revealed a large heterogeneous skull base mass. Chordoma was suspected over chondrosarcoma, and the diagnosis was confirmed by pathology after tissue was obtained during an endonasal surgical resection. Resection of the chordoma left residual tumor in her lateral skull base at the hypoglossal canal and jugular foramen. She was referred to a proton facility where she received fractionated proton and photon beam therapy: 77.4 Gy total, 59.4 Gy  in 33 fractions with protons and 18 Gy in 10 fractions with photons. She was returned to our care afterwards. Scheduled MRIs showed decreasing lesion size through postoperative year 2. However, she experienced acute cranial nerve 6 palsy approximately 2.5 years after surgical resection. An MRI showed a 3×1.5×4 cm mass in the resection cavity with signal change suspicious for dedifferentiation. A subsequent biopsy obtained during a retrosigmoid craniotomy confirmed high-grade sarcoma. She has since completed 17 cycles of ifosfamide and etoposide alternating with vincristine, doxorubicin, and cyclophosphamide with the last round in April 2016. She began maintenance capecitabine on 26 April 2016. The most recent MRI, approximately 14 months after her second surgery, showed a mild interval decrease in tumor size.MRI of our patient’s brain with and without contrast at her initial presentation showed a large heterogeneous mass emanating intracranially from the base of her clivus and extending through the foramen magnum to C1–C2. A small portion was anterior to C1–C2 in her nasopharyngeal soft tissues with extension through her left hypoglossal canal. Posteriorly, the lesion displaced her pons and medulla. Multiple cranial nerves were not well seen and were either displaced or encased by the mass as it filled the right cerebellomedullary angle. The lesion was T1 isointense to muscle Fig. , and onlFollow-up MRI 2.5 years after the initial MRI, and after surgery and proton beam therapy, showed local recurrence. The recurrent tumor was centered at the rightward aspect of her clivus and extended superiorly to the dorsum sella and inferiorly to the level of the occipital condyle. The signal intensity of this mass was intermediate to dark, isointense to gray matter on T2-weighted images in contrast to the very T2 hyperintense signal like cerebral spinal fluid as seen on the initial presentation Fig. . In addiThe biopsy from the initial lesion showed classic chordoma histology with physaliphorous cells with multivacuolated cytoplasm mixed with epithelioid cells arranged in anastomosing cords, clusters, and chains. There was a myxoid matrix and occasional fibrous septa Fig. . No immuHematoxylin and eosin staining of the recurrent tumor obtained during our patient’s second surgery, however, showed a high-grade anaplastic spindle cell neoplasm. There were areas of geographical necrosis with no particular architectural pattern visible at low magnification Fig. . In the Less than 5 % of chordoma diagnoses occur in children under 10 years of age . Among cChordomas show dual epithelial-mesenchymal differentiation as they arise from embryonic remnants of the notochord . AlthougT1-weighted MRI shows chordomas as having predominantly intermediate to dark signal . They arMost recent research indicates the overall prognosis for younger patients is better than for adult patients with chordoma, although there have been contradictory findings , 23, 30.Our patient’s case is the first report, to the best of our knowledge, of a chordoma that dedifferentiated after protein beam therapy. There are reports of dedifferentiation after conventional radiation therapy, although the typical photon dose in those cases is severalfold greater than 18 Gy and disease progression much longer than 2.5 years , 38, 39.


Perforation of the horizontal duodenum is very rare due to the presence in retroperitoneal space. It depicts an unusual clinical picture and is difficult to diagnose, leading to increased morbidity and mortality. The treatment strategies are usually varied and based on small series of cases, literature reviews, and expert opinions.Here, we presented three cases of horizontal duodenal perforation in three different clinical processes. The first case, a 30-year-old male patient, presented with abdominal pain and hematemesis after experiencing a physical assault on the previous day. Computed tomography (CT) scan showed rupture of the horizontal duodenum. It was repaired by side-to-side duodenojejunostomy. Postoperatively, he had anastomotic leakage, disseminated intravascular coagulation, and pulmonary failure and recovered after a long hospital stay. The second case, an 81-year-old female, had duodenal perforation with endoscopic coagulation of the bleeding diverticulum. Segmental resection of the duodenum and side-to-side duodenojejunostomy were performed. Postoperatively, there was slight anastomotic leakage, but surgical intervention was not needed. The third case, an 89-year-old female, was a patient with obstructive jaundice due to pancreas head carcinoma, who developed perforation of the horizontal duodenum during endoscopic retrograde cholangiopancreatography (ERCP). After unsuccessful conservative management, duodenojejunostomy at the perforated site and gastric bypass were performed. The postoperative course was uneventful.Early suspicion and investigation is necessary for cases of abdominal injuries. CT scan is the investigation of choice. The management options should be based on the clinical condition of the patient, comorbidities, surgical expertise, existing guidelines, and available resources. It exteications . Endoscoications , 5. HereA 30-year-old male patient experienced physical assault while he was under alcohol influence, resulting in bruises all over his body. The next day, he developed abdominal pain and hematemesis for which he went to a nearby hospital where abdominal computed tomography (CT) showed free air in the abdominal cavity. He was then referred to our hospital for further management. The preoperative investigations are presented in Table An 81-year-old female patient with past history of abdominal surgery (details unknown) had presented with anorexia, general fatigue, and anemia. Upper gastrointestinal endoscopy revealed a diverticulum in the horizontal portion of the duodenum and bleeding from it. Endoscopic coagulation of bleeding was done, and she was kept nil per os for 2 days. The patient developed abdominal pain on the third postoperative day, with signs of peritonitis. Abdominal CT scan showed a diverticulum in the third part of the duodenum with perforation, retroperitoneal free air, and poor enhancement of the terminal ileum Fig. . She wasAn 89-year-old female patient, living in a retirement home, developed loss of appetite and jaundice. She was taken to a nearby hospital. Her CT scan showed carcinoma of the pancreas head, stage III (T3N0M0). She was referred to our hospital with diagnosis of obstructive jaundice with renal dysfunction with stage III pancreas head carcinoma for further management. Also, the laboratory data showed slight elevation of inflammatory responses and severe hyperbilirubinemia Table . She wasIt has been reported that the causes of horizontal duodenal perforation are trauma or iatrogenic injury due to ERCP mainly. Duodenal injury is present, on average, in 3.7–5% of abdominal injuries and may be due to either blunt trauma of the abdomen or penetrating injuries . Though Chest and erect abdominal radiography and ultrasonography are not of diagnostic value, and the modality of choice is CT scan with both oral and intravenous contrast media , 3. FactThe surgical options available for repairing perforation are simple repair (duodenorrhaphy), resection and anastomosis, repair and decompressive enterostomy, serosal or mucosal patch, pyloric exclusion, duodenal diverticulization, and pancreaticoduodenectomy . MajoritDamage control surgery consisting of an initial abbreviated surgery to control bleeding and contamination, followed by correction of hypothermia, coagulopathy, and acidosis in the critical care unit and timely re-exploration, has promising outcomes in the management of patients with critical trauma . EndoscoThe injury in the second case was due to therapeutic endoscopic coagulation which was diagnosed in the third postoperative day. Due to the presence of a diverticulum in the third part, unhealthy wound margins, and adjacent superior mesenteric artery, segmental resection of the duodenum was effective. It was important to make an anastomosis at the healthy descending duodenum. In the third case, injury to the third part of the duodenum during ERCP was most probably the result of a duodenal abnormality secondary to neoplasm. We preferred non-surgical management initially because of the elderly patient’s poor general condition and associated comorbidities, which ultimately led to a failure to respond. Due to the presence of a tumor site close to the perforation area, narrowing of the descending duodenum, and adhesions, we opted for duodenojejunostomy and gastric bypass by gastrojejunostomy and jejunojejunostomy.An association of duodenal rupture with other intraabdominal organ injuries and leakage of a large volume of pancreatic and biliary secretion causes severe sepsis, contributing to its significant mortality (6 to 25%) and morbidity 30 to 60%) 0 to 60% ), and thDuodenal injuries require a high level of suspicion and careful examination. The management options for such cases are variable and depend upon multiple factors and should be guided by existing literature reviews, clinical status of patients, presence of coexisting diseases, clinical judgment and expertise of the attending physician, and availability of resources.


A 21-year-old male was admitted to our department with headache and drowsiness. CT scan and MRI revealed acute obstructive hydrocephalus caused by a pineal region mass. The serum and CSF levels of beta-human chorionic gonadotropin (beta-hCG) were 215 IU/L and 447 IU/L, respectively, while levels of alpha-fetoprotein (AFP) were normal. A germ cell tumor (GCT) was suspected, and the patient underwent endoscopic third ventriculostomy (ETV) with biopsy. After four days from surgery, the tumor bled with mass expansion and ETV stoma occlusion; thus, a ventriculoperitoneal shunt was positioned. After ten months, the tumor metastasized to the thorax and abdomen with progression of intracerebral tumor mass. Despite the aggressive nature of this tumor, ETV remains a valid approach for a pineal region mass, but in case of GCT, the risk of bleeding should be taken into account, during and after the surgical procedure. Primary intracranial germ cell tumors (GCTs) are 3.1% of all primary brain tumors ; tumors A 20-year-old male was admitted to our department in January 2017 with a four-day history of headache and drowsiness. The computed tomographic (CT) scan and magnetic resonance imaging (MRI) demonstrated acute obstructive hydrocephalus due to a mass in the pineal region (maximum diameter of 1.5 cm) with signs of previous hemorrhage and without significative contrast enhancement . An exteThe serum and CSF levels of beta-hCG were 215 IU/L and 447 IU/L, respectively; the serum and CSF levels of AFP were within normal range. The full-body CT scans, spine MRI, and testicular ultrasounds were negative. Tumors of the pineal region may vary from benign to malignant lesions and are classified into four categories: GCT, pineal cell tumors , glial cell tumors, and miscellanea tumors , 15. In Staphylococcus haemolyticus isolated from CSF specimen), EVD was substituted and clinical picture improved with antibiotic therapy after ten days. MRI on the twelfth day after surgery demonstrated intratumoral hemorrhage with significative mass expansion, with blood in the third ventricle, and with mesencephalic aqueduct (Because of the onset of bacterial meningitis (aqueduct . The venaqueduct  showed raqueduct  and 6; tA second line of chemotherapy was started with partial decrease of serum beta-CGH until 1.883 UI/L without any decrease of cerebral or systemic lesions. At the present, after 10 months from admission, the patient is still alive with a poor prognosis.Taking into account the range of tumors which may occur in the pineal region, histologic diagnosis is necessary to get a correct management. Specimens for diagnosis can be obtained by an open procedure, a stereotactic biopsy or an endoscopic approach , 16. OpeIn cases of pineal region tumor, ETV and biopsy are valid options as primary surgical approach, but, because of the hemorrhage high risk, third ventriculostomy failure may occur, so a careful clinical follow-up is necessary for the prompt positioning of a ventricularperitoneal shunt.


Inguinoscrotal bladder herniation has a reported incidence of 1 to 4%. Although small bladder herniations are noted at the time of inguinal hernia repair, large bladder herniation into the scrotum is rare. These patients have a unique presentation of signs and symptoms. We report a case of a male patient of age 64 years who had a large inguinoscrotal hernia with bladder. He successfully underwent hernioplasty after repositioning of the bladder. Now, he is symptom-free and on follow-up.How to cite this article: Mohan A, Srinivasan K. Scrotal Cystocele in a Sliding Left Inguinoscrotal Hernia: A Case Report and Review of Literature. Euroasian J Hepato-Gastroenterol 2017;7(1):87-88. Literatures have cited only about 7% of cases to have been diagnosed before surgery.4 Ultrasonography, voiding cystourethrography, and magnetic resonance imaging (MRI) play an important role in preoperative diagnosis.18 We report a case of scrotal cystocele in a 64-year-old patient who underwent hernioplasty after bladder repositioning.Inguinoscrotal hernias with bladder herniation are rare, with incidence of 1 to 4%.An elderly male patient aged 64 years presented to surgical outpatient department with history of an intermittent swelling in the left groin for 6 to 8 months. He gave a typical symptom of increase in size of the swelling and double micturition . By manual compression of the inguino-scrotal swelling, he noted decrease in the size of groin swelling following micturition. He did not have symptoms of thinning of stream, straining at micturition, or hesitancy. He was hypertensive and diabetic with regular treatment from the physician.Clinical examination showed a huge soft left inguinoscrotal swelling . On per The patient underwent inguinal hernia repair with prolene mesh after bladder catheterization. Operative finding was bladder herniation as the content in the indirect sac. Carefully, bladder was repositioned and posterior wall of the inguinal canal strengthened by prolene meshplasty . The pat3 It is usually seen in patients beyond 5th decade, with a reported incidence of 10%.45 This could be explained by the fact that advancing age weakens the bladder tone and supporting structures.6 The preoperative diagnosis is very important to avoid iatrogenic bladder injury. The typical symptom of two-stage micturition should give a clue to the diagnosis . These patients are habituated to a two-stage micturition as the weakened detrusor contraction may be inadequate to contract and pull back the herniated portion of the bladder into the normal position in the premicturition phase; therefore, the patient adopts to and is compensated by the manual compression technique.78 Ultrasound of the swelling can differentiate bladder hernia from a hydrocele. Voiding cystourethrography demonstrates a classical dog ear herniation of the bladder.8 The causes, such as stricture urethra and benign prostate hypertrophy have to be considered as an underlying cause. Hernioplasty is the treatment of choice with narrowing of the internal ring.8Inguinoscrotal hernias involving the bladder are a rare entity.A thorough preoperative evaluation is required to diagnose bladder hernia in all large inguinoscrotal hernias, especially in elderly patients to decrease the chances of injury at the time of surgery.


Apocrine hidrocystomas are rare benign cystic tumors originating from the secretory portion of apocrine sweat glands. To the best of our knowledge, there is no evidence currently available reporting the presence of apocrine hidrocystomas in the oral cavity. Therefore, this case report aims to describe the clinical and histological features of an apocrine hidrocystoma affecting the oral mucosa. A 69-year-old male patient presented with a 1-year history of a solitary, well-circumscribed, submucosal mass in the left posterior buccal mucosa. The clinical examination revealed a yellowish soft, fluctuant, and painless lesion with no clinical signs of erythema or ulcerations of the overlying epithelium. The entire lesion was excised and histopathological analysis confirmed the diagnosis of apocrine hidrocystoma. No recurrence was observed after a 1-year follow-up. Hidrocystomas are rare, benign, cystic tumors of sweat glands conventionally classified into apocrine and eccrine types according to their histological characteristics and presumed histogenetic derivation. Apocrine hidrocystoma (AH) has been described as an adenomatous cystic proliferation of the secretory coil of apocrine glands . ClinicaTo the best of the authors' knowledge, this could be the first case in literature reporting the clinical and histological features of an AH affecting the oral mucosa. However, this is difficult to ascertain due to the complex terminology in this field reporting abundant and repetitive terms used over time to indicate similar lesions.A 69-year-old male patient reported with a chief complaint of chewing difficulties due to a soft tissue mass in the left buccal mucosa, which had been present for 1 year. The cervical lymph nodes were not palpable and there was no swelling in the overlying skin. The medical records were noncontributory except for primary hypertension controlled with antihypertensive drugs.The clinical intraoral examination revealed a solitary, well-defined, movable, exophytic submucosal mass 2 mm below the opening of Stensen's duct. On palpation, the lesion was soft, fluctuant, and painless with clear margins. The mass had a yellowish appearance and the overlying mucosa was normal with no clinical signs of erythema or ulcerations. The overall clinical appearance of the mass suggested a benign lesion .Because of the need of a histopathologic analysis to confirm the final diagnosis, the surgical removal of the lesion was chosen among the possible therapeutic options. After bacterial decontamination with an antiseptic rinsing solution of 0.2% chlorhexidine digluconate for 1 minute, local anaesthesia was obtained by infiltrations of mepivacaine 2% with epinephrine 1 : 100.000. The cheek was then everted with digital pressure to increase the lesion's prominence. The lesion was clamped with Klemmer forceps and an elliptical half-moon incision was performed at the base. Flap was reflected cautiously with blunt dissection to avoid any tissue rupture. Thus, the buccal mucosa was undermined exposing an irregular, poorly encapsulated, and lobulated yellowish mass. The lesion was periosteum-free with no attachment to any contiguous structures including the mandibular bone. The entire lesion was then carefully dissected from the surrounding soft tissues and excised en bloc. A tension-free primary intention closure was accomplished with resorbable 4-0 single stitches. Stensen's duct papilla was identified and saliva was expressed by digital manoeuvre, confirming that it was not damaged. The excised specimen was sent for histopathological examination.From an initial macroscopic evaluation, the resected specimen consisted of a well-circumscribed and yellowish mass with a soft consistency. The histopathologic examination showed a multiloculated cyst characterized by a stroma composed of fibrous tissue with dilated blood microvessels. In the cystic lumen, proteinaceous fluid was present . MicroscApocrine hidrocystomas are benign cystic tumors of the apocrine sweat glands. The estimated incidence is one per thousand of submitted cutaneous biopsies; however the true value remains unknown and underestimated since many times apocrine hidrocystomas are seen in ophthalmology or surgery clinics or are diagnosed as Moll's gland cysts when located on the inner or outer canthus of the lower eyelid . AlthougWith respect to the etiopathogenesis, the lesion could be correlated with a trauma to the oral mucosa of the cheek during a masticatory act. This supports the hypothesis that AHs may be a consequence of an occlusion or blockage of the sweat-duct apparatus, resulting in retention of sweat and a dilated cystic structure. Apparently, the clinical features of the oral AH resembled those reported for the same lesion in different anatomical districts. It appeared as a slow-growing dome-shaped, solitary, well-delimited nodule with a cystic consistency. Though the most common presentation is a solitary lesion, some cases of multiple apocrine hidrocystomas have been described often in association with Gorlin-Goltz and Schopf-Schulz-Passarge syndromes . The lesMicroscopic examination showed that the lesion contained multilocular spaces while a sweat-duct-like epithelium with monomorphous cubic cells was observed. Further, the cyst wall was covered by apocrine-type epithelial cells with marked decapitation secretion identified by apocrine snouts. No cytologic atypia was detected. This histological pattern of the lesion has been similarly described in its skin counterpart. Indeed, the AH has been reported to be encapsulated, well-circumscribed with surrounding fibrotic tissue, and often multiloculated. Microscopically, cystic ducts are lined mainly by a double-layered epithelium, with no evidence of squamous or mucous metaplasia . A patho2, and Er,Cr:YSGG laser ablation, whereas nonsurgical treatment modalities are still under development. Focusing on AHs management in other districts, several treatment options have been documented including simple needle puncture, application of anticholinergic creams, trichloroacetic acid, and botulinum toxin, electrodessication, carbon dioxide laser vaporization, cryotherapy, and laser treatment [Although the lesion was asymptomatic the patient complained of impaired chewing abilities, which have a negative impact on the oral health related quality of life. For this reason, the mass was completely excised to reestablish a physiologic occlusion immediately after the surgical procedure and to prevent recurrence chances. This was accomplished through a split-thickness incision and blunt dissection followed by a tension-free suture. Other methods have been reported to treat intraoral lesions including marsupialization, COreatment .In case of a well-circumscribed, movable, exophytic submucosal mass with a yellowish appearance and no clinical signs of erythema or ulcerations, AH should be included in the differential diagnosis. Clinically, it appeared as a slow-growing asymptomatic lesion that could have followed a mucosal trauma. The histopathologic analysis is mandatory to obtain a final diagnosis due to its peculiar aspects. The surgical excision of the mass resulted in satisfying healing of the oral mucosa with no recurrence.


Pheochromocytomas are rare tumors derived from chromaffin cells located in the adrenal and extra adrenal tissues. Pheochromocytomas are diagnosed biochemically and localized using different imaging modalities. The definitive management is surgical resection. Brown adipose tissues are normally present during fetal development, with regression over time. Brown adipose tissues are thermogenic and usually located in the neck, mediastinum, and retroperitoneum. Here, we report a case of a unilateral pheochromocytoma surrounded by brown fat. The abnormal stimulation of brown fat noted on positive emission tomography scan (PET) resolved after the pheochromocytoma was resected. Adipose tissue is usually classified as white adipose tissue (WAT) or brown adipose tissue (BAT). WAT is the major energy storing tissue while BAT is normally present in fetuses and mediates non-shivering thermogenesis . NorepinPheochromocytoma (Pheo) is an uncommon neoplasm that is derived from chromaffin cells. The annual incidence of pheo is about two million and the prevalence in the population is 1:6500 . In apprA 46-year-old female with an eight-year history of hypertension was referred to our surgical outpatient clinic upon detection of a large abdominal mass noted on a computed tomography (CT) scan of her abdomen and pelvis done during workup for nausea and vomiting. Her symproms also included 35 lb weight loss, palpitations, chest heaviness, sweating, facial flushing, flushing of skin, fatigue with slight exertion, and intermittent headaches over a period of three months. She is a current smoker. Physical examination revealed hypertension and sinus tachycardia, but no facial flushing. There was a flushed look to the forearms, hands, and pretibial lower extremities from the distal third of the lower extremities bilaterally. The abdomen was soft and nontender without masses; the rest of the exam was unremarkable.The CT scan revealed a large right adrenal mass measuring 11.5 x 6 x 9 cm with compression of the vena cava and displacement of the right kidney  in March 2016 revealed heterogenous moderate fluorodeoxyglucose (FDG) uptake in the large right adrenal lesion. There was intense FDG uptake localizing to the unusual and abnormal nodularity and low soft tissue densities surrounding both kidneys, with a standardized uptake value (SUV) of 10.2  after dexamethasone suppression (Table The patient was presented at our multidisciplinary tumor board. Upon further review of the imaging studies, the finding on the PET scan suggested the possibility of diffuse brown fat development and evidence of hypermetabolism, symmetric in the neck, retroperitoneum, and inguinal regions. Overall, this appearance was consistent with pheochromocytoma with brown fat stimulation and less likely suggestive of metastatic pheochromocytoma. Preoperatively, adequate catecholamine blockade was achieved using alpha adrenergic blocker and beta blockage. Her symptoms improved.A repeat PET/CT in April 2016 after adequate alpha and beta blockade revealed the stable size of the large heterogeneous right adrenal mass with moderate FDG uptake with areas of central photopenia, which likely correspond to central necrosis. No significant retroperitoneal or intra-abdominal lymphadenopathy was noted Figure .The patient was taken to the operating room in May 2016. An open right adrenalectomy was performed through right subcostal incision with extension up the midline to the xiphoid. A large adrenal mass was noted with significant periadrenal gland fibrosis. The mass was resected en bloc with a portion of the right hemidiaphragm. Intraoperatively, there were significant fluctuations in the patient’s blood pressure, which was appropriately managed by the anesthesia team. There were no other significant surgical complications, and the patient made an uneventful recovery. She was discharged on postoperative day 10. Five months later, the patient remained stable and had no symptom to suggest recurrence. A PET/CT scan in October 2016 revealed no focal abnormality in the resection bed, no gross evidence of metastatic disease, no significant retroperitoneal or intra-abdominal lymphadenopathy Figure . Given tPathological examination of the surgical specimen revealed an ovoid soft tissue mass measuring 12 x 9.3 x 5 cm and weighed 270 g. The capsule appeared intact. Sectioning revealed a red-brown-yellow, soft and lobulated cut surface with fibrous septae and focal areas of hemorrhagic degeneration. Immunohistochemistry revealed tumor cells positive for chromogranin and synaptophysin. The final pathologic diagnosis was pheo of the right adrenal gland with lymphovascular invasion and no perineural invasion; inked margin was uninvolved.Pheochromocytoma is an uncommon neoplasm that is derived from chromaffin cells. The annual incidence of pheo is about two million and the prevalence in the population is 1:6500 . It occuIn this report, we presented a case of a 46-year-old female with a large pheo that was surrounded by brown fat. The diagnosis of pheo was made by studying plasma and urine metanephrine levels while imaging studies were used to localize the mass. The management consisted of providing alpha blocker followed by surgical resection of the mass. Our patient remained stable and disease free five months after resection. The abnormal stimulation of brown fat noted on the PET scan resolved after the pheochromocytoma was resected.


Primary leiomyosarcomas (LMS) of the colon are rare and aggressive neoplasms and have been infrequently reported in the literature. These tumors are more aggressive and have poorer prognoses than adenocarcinoma of the colon and are often mistaken as such on initial evaluation. While the former has a clear association with inflammatory bowel disease (IBD), this correlation is not known to exist with LMS and IBD. Nor is there a known link between LMS and the immunosuppression for IBD, despite the known association between malignancy and immunosuppression for other diseases. Due to the low prevalence of this disease entity, there is limited knowledge and literature on the approach to diagnosing and treating these neoplasms, especially in the setting of the aforementioned comorbidities. Here, we describe two cases of this rare entity, presenting in two different circumstances: one in the setting of immunosuppression for IBD and arthritis, with a synchronous urothelial carcinoma, and the second appearing as the source of an acute abdomen. Both diagnoses were established following pathologic analysis. Primary mesenchymal sarcomas of the gastrointestinal tract are rare and constitute only 0.1–3% of all gastrointestinal tumors . AmongstA 57-year-old female with a past medical history significant for Crohn's disease and arthritis, currently being treated with Humira  and Lialda , presented for a screening colonoscopy and was found to have a friable mass 40 cm proximal to the anal verge. Initial pathology was consistent with a spindle cell tumor. Further imaging showed extension of the mass towards the bladder. At the time, the patient denied any symptoms of abdominal pain or change in bowel habits. On physical exam, she had a benign abdomen and no other significant findings. Pre-op lab values were within normal limits. The patient then underwent an elective, rectosigmoid colon resection with primary anastomosis, cystoscopy, and transurethral resection of the bladder tumor. Immunosuppression was held for the procedure. Final pathology showed a well circumscribed, pedunculated, firm rectosigmoid colon mass with slightly friable/ulcerated surface. The mass was found to be of high grade (mitotic count up to 40 per 50 high power fields) and showed high Ki67/MIB1 labeling index of up to 70% and stained positive for smooth muscle actin (SMA). The tumor cells were negative for c-KIT/CD117, DOG-1, pankeratin, CD34, and S100 stains . The blaAn 88-year-old male presented to the emergency room with complaints of abdominal pain, fever, and chills. He had an extensive past medical history including atrial fibrillation, obesity, hypertension, chronic kidney disease, hyperlipidemia, left ventricular hypertrophy, benign prostatic hyperplasia, and aortic and mitral valve disease. Abdominal/pelvic computed tomography (CT) revealed an 8.3 × 9.5 × 8 cm cecal mass with thickening of the ascending colon and pericolonic fat stranding. There was no evidence of pneumoperitoneum. There were also several masses in the liver suggestive of metastatic disease, the largest of which measured 12.7 × 11.7 cm . The patLeiomyosarcoma is a rare entity to arise primarily from the colon. It originates from the muscularis propria layer of the bowel. While it has been found throughout the colon, it most commonly originates primarily from the sigmoid and transverse colon , 5. It iThe typical presentation of leiomyosarcoma of the gastrointestinal tract is in middle-aged patients with a mean age of diagnosis of 50 years of age . InitialDue to the paucity of data, the prognostic factors have been poorly defined and vary by studies. Amongst those identified, poor prognostic factors include age greater than 45 years, necrotic areas within the tumor, dissemination of disease, and tumor size , 7. AccuWhile the more commonly prevalent colon malignancies, particularly adenocarcinoma, have an increased incidence in patients with inflammatory bowel disease (IBD), sarcomas arising in this setting are quite rare. To our knowledge and by review of PubMed literature, only eight cases of associated sarcoma and IBD have been reported, including three cases of LMS in ulcerative colitis and five cases of sarcomas found in the setting of Crohn's disease , 8. TherCurrently, the best treatment for leiomyosarcoma of the colon is surgical resection. This is true for both those LMS cases that arise independently and those that occur in the setting of immunosuppression and/or IBD , 5. HoweIn conclusion, leiomyosarcoma of the colon is a rare and aggressive neoplasm with poor prognosis. It can mimic other tumors and GI diseases but should be distinguished as a separate entity as the prognosis and treatment vary. While rare, it should be included on the differential diagnoses when a patient presents with a abdominal pain.


Dear Editor,An 8-year-old female patient presented with diffuse abdominal pain accompanied byprogressive distension. Physical examination revealed a large abdominal mass,predominantly in the mesogastrium, that was depressible and painless on palpation.Ultrasound showed a solid-cystic formation extending from the epigastrium to thehypogastrium, with a calcium component and an air-fluid level . Compute.The occurrence of an abdominal mass in a child should always be evaluated by apediatrician. The main differential diagnoses are organomegaly and fecal impaction. Whenabdominal palpation produces nonspecific findings, further investigation, employingimaging methods, is required. The cellular components of this lesion are pronounced and varied,potentially encompassing respiratory epithelium, skin, cartilage, mucosa, and neuralepithelium-5. It is a benign neoplasm, presenting on physicalexamination as a palpable pelvic mass, typically 5–10 cm in diameter, and occursbilaterally in 10–15% of cases. In10% of cases, it is considered an emergency, presenting the typical profile of acuteabdomen, due to torsion of the vascular pedicle that occurs secondary to itsgrowth. The clinicaldiagnoses of abdominal masses are diverse and imprecise, requiring complementarydiagnostic imaging.Ovarian teratoma is the most prevalent germ cell neoplasm, accounting for approximately32% of all ovarian neoplasms, and can be divided into mature or immature teratomadepending on its cellular differentiation. Thehistological study is also of importance, determining the macroscopic and microscopicaspect of the lesion, as well as the prognosis. Surgical treatment—excision of thelesion—is the gold standard.Abdominal X-ray is nonspecific for ovarian teratoma and can occasionally showcalcifications in the area surrounding the lesion. Ultrasound and CT are the mainimaging methods for the detection of this disease, the rapid detection of which demandsrecognition of the typical imaging patterns, particularly in cases of emergency (acuteonset). Although CT also has high specificity and sensitivity, particularly for thedetection of cystic teratoma, it is not routinely employed, because it involves the useof ionizing radiation. The combination of various imaging methods is an essential partof the surgical planning