Mesenteric cysts are rare abdominal benign tumours with an incidence of 1:100.000–250.000 surgical admissions located in the mesentery. Theirs presentations may range from incidental asymptomatic discovery during imaging to non-specific abdominal symptoms.We present the case of a 46 year old female who presented with 9 months history of progressive abdominal distension. CT scan showed a giant abdominal mass. After the necessary preoperative work up, a midline incision laparotomy was performed. Intraoperative findings were a mesenteric cyst originates from the transverse mesocolon. The cyst weighed 16 kg and histopathology analyses confirmed a lymphangioma mesenteric cyst.In low incomes countries like our own, the interval between the onset of symptoms and consultation is often significant, leading to unusual and sometimes spectacular presentations at the time of diagnosis. To our knowledge, it is the heaviest mesenteric cyst reported in the literature to date.Mesenteric cysts may present as giant abdominal masses. The publication of this atypical case is a plea for us for the establishment of universal health coverage in our country in particular and in Africa in general. It is aBecause mesenteric cysts are rare, very little information are available on them as most published studies consist of only a few cases. This has led to some false impressions and conclusions regarding these abdominal tumours . The rar2A 46 year old female G0P0 was referred by a gastroenterologist to our surgical outpatient consultation for management of a giant intraabdominal mass. The history dates back nine months prior to her consultation, where she noted a progressive abdominal distension associated with constant non-colicky abdominal pains, nausea and dyspeptic symptoms. Due to limited financial resources and lacking health coverage, she does not consult in a hospital, but turns to traditional healers for several months.The medical history was remarkable for a sudden acute flaccid lower limb paralysis since the age of 5 years, with an undetermined aetiology, having nailed her since then on a wheelchair. Physical examination showed a grossly distended abdomen , with a In front of this unusual case and having knowledge of the financial difficulties of the patient, our hospital decided to take charge of her free of charge.An abdominopelvic CT scan was then performed and showed an intraabdominal mesenteric cyst attached to the transverse colon . She wasGrossly , the mas3Mesenteric cysts are very rare intra-abdominal benign tumours that can pose serious diagnostic and therapeutic challenges . Since tThe presentation of a mesenteric cyst may range from incidental asymptomatic diagnosis during radiologic procedures to non-specific symptoms such as abdominal distension, abdominal pains and abdominal bloating. As a result to their non-specific symptomatology, there pose a great diagnostic challenge. Recent series suggests that the mean duration of symptoms at diagnosis is 2.6 months with a range of 12 h to 12 months . In our In 1880, Tillaux performed the first successful resection of a mesenteric cystic tumour and since then surgical resection has been the main stay of treatment . This caIn low-income African countries like ours, all of these "Western" treatment algorithms face an important challenge: health care financing. With a low health insurance coverage rate and often limited to the moneyed classes, the population is struggling to finance their health care. This leads to significant delays in consultation with unusual clinical presentations, but also increased morbidity and mortality. It is a sad daily reality for the physicians of these countries. In the past, unusual clinical presentation also due to a delay in consultation has been reported in our context . The pubIn the current case, histopathology confirmed a giant lymphangioma cyst of the transverse mesocolon. This is in conformity of recent theories which suggests mesenteric cysts arise from developmental abnormalities of the mesenteric lymphatics or from their traumatic rupture .Mesenteric cysts have a very low recurrence rate (0–13.6%) and patients have an excellent prognosis .4This case highlights the importance early clinical assessment and imaging in the management of patients with abdominal distension as practice in developed countries. However, limited resources common in low-income settings contribute to delayed consultations and then unusual presentations of diseases as shown in the present case: the heaviest mesenteric cyst reported to date.No Funding sources.Our study is exempt from ethical approval by the ethics committee of the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I (Cameroon)Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on requestThe patient was admitted and operated under the care of BANG Guy Aristide; he concepted the study. Paul TOLEFAC, Olivier FOLA and Marcella BIYOUMA collected data and wrote the paper. BANG Guy Aristide, BISAY Ulrich and marc le Roy GUIFO reviewed the paper. Arthur ESSOMBA gave the final approval.Our study isn’t a first-in-man One.Arthur ESSOMBA, Professor of general surgery at the Faculty of medicine and Biomedical Sciences of the university of Yaoundé I (Cameroon).Not commissioned, externally peer-reviewedThe authors declare no conflict of interest.


Leiomyosarcoma is a rare soft tissue cancer that arises from smooth muscle cells that form involuntary muscles. Here, we report a rare case of retroperitoneal leiomyosarcoma that mimicked a metastatic tumor arising from a gastric cancer.A 43-year-old man underwent radical total gastrectomy for gastric cancer. He underwent adjuvant chemotherapy with oral 5-fluorouracil (5-FU) for 2 years and regular follow-up. Twenty-nine months after gastrectomy, computed tomography (CT) was performed and revealed a solitary localized mass measuring 43 mm in diameter among retroperitoneal lymph nodes of the posterior inferior vena cava. This finding indicated that the previous gastric cancer recurred either in the lymph node or retroperitoneum. Second-line chemotherapy, consisting of oxaliplatin and 5-FU (FOLFOX) was administered in four cycles. However, serial CT scans showed increased tumor size. Retroperitoneal tumor did not respond to treatment, surgical resection was performed. Pathological findings led to a diagnosis of pleomorphic and epithelioid leiomyosarcoma without metastatic adenocarcinoma of the stomach.When a diagnosis of locoregional recurrence of gastric cancer in the retroperitoneum is considered, retroperitoneal leiomyosarcoma should also be considered in the differential diagnosis.Early diagnosis and concerted therapeutic efforts are important for managing misdiagnosed metastatic gastric cancer. It usuaOnly a few cases of retroperitoneal leiomyosarcoma that mimic gastric cancer recurrence after gastrectomy have been reported. Herein, we report a rare case of retroperitoneal leiomyosarcoma that mimicked a metastatic tumor arising from gastric cancer. This paper has been reported in line with the SCARE criteria .2A 43-year-old man underwent radical total gastrectomy for gastric cancer. He was not taking medications for specific diseases such as hypertension or diabetes, and had no other familial, environmental, or social problems. A postoperative intra-abdominal abscess developed around the anastomotic site due to an esophagojejunal anastomotic leak, which improved after percutaneous drainage and conservative therapy. Histopathological examination of the tumor revealed mixed differentiated adenocarcinoma; the tumor was classified as stage IB (pT1bN1M0) according to the 7th TNM classification of the International Union Against Cancer. He received adjuvant chemotherapy with oral 5-FU for 2 years. Analysis of tumor marker levels (CEA and CA19-9) was performed every 3 months and computed tomography (CT) imaging and gastrofibroscopy (GFS) every 6 months. About 29 months after gastrectomy, CT imaging was performed and revealed a solitary localized mass measuring 43 mm in diameter among the retroperitoneal lymph nodes of the posterior inferior vena cava (IVC) A. The paFinally, the patient was diagnosed with pleomorphic and epithelioid leiomyosarcoma with high mitotic activity. We assumed that the leiomyosarcoma was a second primary malignancy that developed from the retroperitoneum.The patient’s postoperative course was favorable. He received adjuvant chemotherapy and radiotherapy. He did not experience disease recurrence for 3 years and underwent surgical resection of locoregional and lung metastasis. He survived for 5 years.3Retroperitoneal leiomyosarcoma is a rare malignant cancer that develops in the soft tissue of the retroperitoneal cavity. Leiomyosarcoma accounts for approximately 50% of retroperitoneal tumors and can also arise directly from the viscera, including the gastrointestinal tract and uterus . LeiomyoGastric cancer recurrence is classified as locoregional, peritoneal seeding, hematogenous, and multiple metastasis . LocoregThe pathological diagnosis of retroperitoneal nodules by aspiration biopsy is difficult and can cause complications such as infection, metastasis, or hemorrhage in the abdominal cavity. In this report, the patient was initially managed with chemotherapy but follow-up imaging showed an increase in tumor size despite treatment. At that point, the tumor was completely resected for treatment and diagnosis. The patient was finally diagnosed with retroperitoneal leiomyosarcoma and then received appropriate chemotherapy and radiation for treatment.The most crucial treatment for retroperitoneal leiomyosarcoma is complete surgical excision. Prognosis depends on complete removal of the tumor without any complications such as perforation. Most studies have shown local recurrence within 3 years after excision of the primary mass. Zhang et al.  reported4We suggest that retroperitoneal tumors must be ruled out even if the tumor is highly suspected to be a locoregional recurrence. When a locoregional recurrence of gastric cancer in the retroperitoneum is considered, leiomyosarcoma should also be considered in the differential diagnosis. Early diagnosis and concerted therapeutic efforts are important for managing misdiagnosed metastatic gastric cancer.This study did not receive any funding support.This is a case report; therefore it did not require ethical approval from ethics committee.Informed written consent was obtained from the patient for publication of this report and any accompanying images.Lee WY and Lee HK were attending doctors for the patient. Lee WY performed the surgical operation and Lee HK prepared the pathologic report. Lee WY and Lee HK organized the report and wrote the paper. All authors were involved in drafting and revising the manuscript, and all authors read and approved the final manuscript.Not applicable.Woo Yong Lee.Not commissioned, externally peer-reviewed.The authors declare that we have no conflict of interest.


Spleen leaves its normal anatomical position and appears in other locations, which is called ectopic spleen. It is most commonly found in the abdomen or pelvis with seeding of the peritoneum, omentum or mesentery. A few of cases of thoracic splenosis associated with traumatic diaphragmatic rupture have been reported.We make a report on a case of intrapulmonary thoracic splenosis. A 44-year-old male patient underwent splenectomy due to a high fall accident injury in 2008. After ten years, thoracic splenosis were found in the lungs and chest wall. Clinical diagnosis was unidentified masses, benign tumor of lungs and chest wall. The radiological imaging was suggestive of the thoracic splenosis, After surgery, the diagnosis of thoracic splenosis was confirmed by pathological diagnosis.Thoracic splenosis may occur after the injury to spleen and surgical treatment may not be the preferred method for asymptomatic or less symptomatic thoracic splenosis. Splenosis is the autotransplantation of splenic tissue following spleen rupture or splenectomy. Despite the relatively high incidence of splenic trauma, splenosis is still a rare condition. Ectopic spleen is a condition that spleen leaves its normal anatomic position and implants in other location such as a serosal surface, deriving a local blood supply and developing into nodules of differentiated splenic tissue . To our 44-year-old man had a history of trauma and splenectomy dating back to 2008 due to a high fall accident injury. The patient came to our hospital for routine follow-up health check for trauma. During the interview with the doctor, the patient had complaints of fatigue, flu-like symptoms and occasionally had the sense of thoracalgia for about a week. During the physical examination, a well healed laparotomy scar measuring about 10 cm in the upper left abdomen was identified. No spleen was palpable when palpation of left costal region was conducted by the doctor. No other significant findings were identified. All laboratory findings were within normal range. Hematology and biochemistry tests were within normal range. All other laboratory findings were within normal range too. Pulmonary function tests and cardiovascular examination showed the normal state. Plain chest computed tomography (CT) with an attenuation value 52HU was performed. There were multiple nodules under the left upper lobe tongue segment, lower lobe basal segment subpleural and right diaphragmatic, partial fusion showed wavy changes with uniform density. There were clear boundary and enhanced scanning lesions, measuring up to 18 mm, suggesting suspicious for primary lung cancer. There were old fractures of the left side 9th and 10th ribs, and no right sided pulmonary lesions or mediastinal lymphadenopathy were seen on CT. Contrast-enhanced CT scans showed obvious enhancement in soft tissue masses  was performed to remove the masses. During the operation, we found mass on the surface of the upper lobe of the left lung, and a large number of nodules that scattered on the surface of left lung surface, diaphragm and mediastinal pleura. The largest nodule was tough in texture, regular in shape, and was measured about 1.82.0 cm on pleura. (Fig. The patient had an excellent recovery after surgery and was discharged properly. Final pathological findings: Fig.  on H&E sTill now, there were only a few numbers of publications reporting perforation of thoracic splenosis that presents as pulmonary lesion. Trauma is currently considered to be the main cause of splenic implantation. Previous report introduced multiple ectopic splenomegaly in the abdominal cavity and pelvic cavity after splenectomy due to trauma . ThoraciSplenic implantation often occurs in the abdominal cavity, and often be misdiagnosed as malignant tumor of digestive system, such as liver cancer, gastric leiomyoma at the bottom, or mesothelioma. Ectopic spleen to the chest can be misdiagnosed as lung cancer . ThoraciUltrasound, CT, and MRI etc. The diagnosis of thoracic splenosis cannot be made clearly through ultrasound, CT, or MRI, etc . Digital


Biloma is used to describe abnormal accumulation of bile outside biliary tract. It is a very rare condition with extrahepatic diffused or encapsulated collection of bile, mostly post-operative or post traumatic. A 72-year-old woman was referred to our hospital with acute abdominal pain located in right upper quadrant. Clinical examination suspected abdominal collection. Imagery (ultrasound and computed tomography scan) demonstrated a large well-defined intra-abdominal collection. Percutaneous ultrasound guided drainage of abdominal collection revealed a bile fluid. Drain was removed a week later and complete resolution of symptoms was obtained in two weeks. Even in the absence of specific diagnostic indications, radiological images may play a key role in the evaluation of suspected biloma in patients with appropriate medical history and clinical characteristics. Biloma is a term used to describe the occurrence of biliary fluid outside the biliary tract. In 1889, there was a , who desA 72-year-old female previously healthy, was referred to our teaching hospital suffering from acute abdominal pain located in the right hypochondrium 6 days before. The patient was giving a history of minor abdominal trauma six months back for which monitoring and medical treatment were performed in a peripheral health center. However, the physical examination revealed the presence of pain and palpable mass in the epigastrium and upper right quadrant. Nausea and vomiting, respiratory gene and moderate jaundice were noted on arrival at the emergency room. Laboratory tests documented leukocytosis (12000/mL) with neutrophilia. Hemoglobin, serum electrolytes, indices of cholestasis, liver enzymes, kidney function, lipasemia, amylasemia and blood glucose were normal. Abdominal ultrasound and computed tomography scan findings included a large well-defined intra-abdominal (right quadrant) collection  overlyinet al. [It is named biloma any bile collection encapsulated or not in the abdomen, as a consequence of the biliary leak, from biliary tract, mainly of the extrahepatic segment or directly from the canaliculi. The most common etiology is surgical, endoscopic or traumatic lesions . The litet al.  reportedet al.  the lostet al.  pancreatet al.  choledocet al.  and chroet al.  as etiolet al. -14.Although the pathophysiology of spontaneous biloma remains to be clarified , one stuBiliary tract lesions remain a challenge, both diagnostic and therapeutic. Fortunately, with the advent of new technologies, this has been facilitated, so that today patients present adequate recovery and without sequelae, in most cases. Percutaneous treatment should be considered as the first-line option for patients with symptomatic biloma.The authors declare no competing interests.


Adult granulosa cell tumor (AGCT) of the testis represents a very rare testicular neoplasm that is poorly understood clinically. Here we report the case of a 22-year-old male who presented with unspecific scrotal symptoms. Scrotal sonography disclosed a 6 mm hypoechoic intratesticular lesion. Histological examination after orchiectomy revealed a homogeneous and well demarcated neoplasm with monomorphic cells with nuclear grooving and microfollicular formation of the so-called Call-Exner bodies. Immunohistology showed positive stainings of vimentin, calretinin, and inhibin with negative stainings of the typical germ cell tumor markers. Thus, the diagnosis of a benign AGCT was made. The patient is well one year after surgery. A total of 91 previous AGCT cases were identified in the literature. Median age of the cases reported to date is 44 years, median tumor size 3.2 cm. 54.3% of the AGCT cases were located on the left side. 12 cases (13.2%) were of malignant nature. Testis-sparing surgery would be the treatment of choice, but only two of all cases had received that procedure. The present report aims to increase the clinical knowledge of AGCT and specifically to increase the clinician's vigilance with respect to testis-sparing surgery in probably benign testicular masses. Histologically, about 90% of all testicular neoplasms comprise germ cell tumors (GCTs) while the remainder involves sex cord gonadal stromal tumors, malignant lymphomas, secondary tumors, and other very rare new growths , 2. AmonThis 22-year-old man of European descent presented with unspecific scrotal discomfort lasting for two weeks. Clinical history is uneventful. The patient is unmarried and has no children so far. He is an untrained workingman by profession. Both testicles were of normal size and nonsuspicious upon palpation with only some tenderness on the left scrotal side. Scrotal sonography revealed a 1 cm sized lobulated hypoechoic lesion at the cranial pole of the left testis  showing Pathohistological analysis showed a well demarcated solid neoplasm of 8 mm in size . HistoloA total of 91 cases could be identified from the literature by using the PUBMED database and by hand-searching the reference lists of previous reports . Not allThe first documentation of an AGCT is credited to Laskowski in 1952 . By the The age of the present patient is 22 years which is clearly lower than the median age of 44 years and even lower than the inter quartile range (26 -55 years) as observed in the literature survey. The lowest age ever observed in AGCT is 12 years  while thThe tumor size of 8 mm found in our case is clearly smaller than the median size of 3.2 cm observed in the literature survey and it lies in the lowest quartile of reported findings. Obviously, granulosa cell tumors of the adult type may occur with a wide variety of sizes since seven cases with tumor sizes of less than 1 cm were reported  and on tRegarding laterality of AGCT, our patient presented with a left sided tumor which corresponds to the findings in the majority of cases of the survey where 54.3% (95% CI 42.9–65.4%) had left sided tumors as opposed to 45.7% (95% CI 34.6–57.1%) right sided tumors. However, in view of the overall small database and overlapping confidence intervals of the proportions there is probably no clear evidence for a predisposition of one side. The same is true with germ cell tumors where no clear preponderance of one particular side has been found .The neoplasm detected in our patient was a clearly benign lesion. Among the 91 cases listed in the survey, 12 were malignant (13.2%). A 15% proportion of malignancy was likewise reported by Rove et al.  and two Histologically, AGCT consist of monomorphic cells identical with ovarian granulosa cells with a scanty cytoplasm. Many of the cells may show coffee bean-like nuclei with small grooves , 45. TheWith regard to treatment, testis-sparing surgery would be the treatment of choice, as only few cases are malignant. As age >50 years and tumor size are the most important characteristics of malignancy the cases qualifying for conservative surgery could in principle be easily identified, preoperatively.Hence, only two of the cases of the survey received that appropriate therapy and also the present case was submitted to orchiectomy. Clearly, in everyday clinical practice it is difficult to sort out benign tumors from malignant ones by means of clinical assessment only. As malignant tumors of the testis are far more common than benign growths most of the urologic surgeons will proceed to radical orchiectomy. However, as shown in the present case and in many cases of the survey, benign tumors of the testis do actually occur, and small size is one of the leading characteristics of benign nature though not specific. The present case report is thought to increase the overall knowledge of testicular granulosa cell tumors, and it particularly aims to increase the vigilance of urologic surgeons to consider conservative surgery in cases with small testicular neoplasms. Practically, a conservative approach with intraoperative frozen section examination could help to save more testicles and avoid unnecessary orchiectomies.


A 56-year-old male emigrated from Mali 6 years ago. He was admitted because of somnolence, confusion, decreased concentration, gait instability and weight loss over a two month period. He also spent his holidays in Mali in 2016. Examination revealed cervical and axillary lymphadenopathy and wide-based gait.3 (95% lymphocytes) and protein level of 0.9 g/L. CSF bacterial, fungal, and viral cultures were all negative. Thoracic and abdominopelvic CT showed thoracic and subdiaphragmatic adenopathies. Magnetic resonace imaging (MRI) revealed hyposignal of the dentate nuclei (DN) on fluid-attenuated inversion recovery (FLAIR) sequence (Non-contrast brain computed tomography (CT) was normal. Cerebrospinal fluid (CSF) analysis showed WBC of 107/mmsequence . In addiTrypanosoma sp. Blood smears and bone marrow aspirates showed numerous Trypanosoma. Brain MRI revealed a marked hypointense signal of the DN on FLAIR, surrounded by a hyperintense halo, also involving the inner cerebellar cortex. High FLAIR signal was seen in the corona radiata, midbrain, pons, medulla, cerebellar white matter (WM), caudate nuclei (CN), and hypothalamus, which were not observed previously in humans. Dentate nuclei exhibited a faint contrast enhancement  and fever of 38.9°C. Blood and CSF polymerase chain reaction were positive for ancement . Treatmeancement .5 Large WM hyperintensities are the most common finding . The BG is also often concerned (lenticular nuclei [LN]: 9/11) as the thalami (6/11). More rarely the BS is involved: FLAIR hyperintensities at the central pons (4/11) (present case4), at the anterior aspect of the midbrain (3/11) (present case1), and at the medulla oblongata (present case) have been reported. Other rare lesions, appearing as FLAIR hyperintensities, involve the CN (3/11) (present case4), bilateral middle cerebellar peduncles (2/11),5 and the corpus callosum.5 Another interesting finding was the symmetric distribution of the lesions on MRI in 6/11 cases (present case5) and almost symmetric in two other cases.1In patients with neurological deficits, MRI demonstrates specific findings .Different rare entities may affect the DN. Among them, metabolic, toxic and drug induced , inflammatory, and enterovirus 71 infection in children can lead to DN damage. Our patient had no evident intoxication and was not under previous treatment. In addition, in the present case, the MRI patterns of DN signal changes and of the associated brain lesions, along with the context, narrow down the differential diagnosis.6 but not on imaging: MRI involvement of the DN and hypothalamus and faint contrast enhancement of the DN (the only enhancing lesion) which appeared on follow-up imaging before treatment initiation. The timing of both appearance and regression of the DN and hypothalamic anomalies were the same as the other lesions on follow-up MRI.Our case highlights several new imaging findings of the disease, some of these findings were previously only described in postmortem autopsy studiesFurthermore, the present case shows a correlation between the clinical and radiological findings: involvement of the cerebellum, including the DN, was correlated with clinical findings of somnolence, memory, and gait impairment.


Dysgerminomas are malignant germ cell tumors of the ovary that most commonly occur in the adolescent population. Ovarian dysgerminoma presenting with complications like torsion is a rare entity in the pediatric age group. Cross-sectional imaging plays a crucial role in diagnosis, tumor staging before surgical resection, and for planning adjuvant chemotherapy. We report a case of a nine-year-old female who presented to the emergency room (ER) with abdominal distention and abdominal pain. Computed tomography scan revealed a large right-sided pelvic mass with areas of low attenuation, speckled calcification, peritumoral free fluid, and a twisted vascular pedicle that was likely originating from the left adnexa. The right ovary was normal in appearance. Suspicion of a left-sided ovarian tumor with torsion was raised, which was later confirmed on surgery and histopathology of the resected specimen. Ovarian germ cell tumors (GCTs) are derived from primordial germ cells of the ovary and can either be benign or malignant. Dysgerminomas are labeled as female counterparts of testicular seminomas and although accounting for only 1-2% of malignant ovarian neoplasms, they are the most commonly occurring malignant GCT in females less than 30 years with peak incidence between 15-19 years of age [Dysgerminomas are more frequently detected in adolescent women, especially during pregnancy and can be bilateral in 15% of the cases . Unlike A nine-year-old girl presented to the emergency department with abdominal pain and distention for the past one week, with sudden increase in intensity of pain for the last four hours. The patient had not yet reached the age of menarche. There was no associated nausea or vomiting and her bowel habits were not affected. Past medical, surgical, and family history was also insignificant. An abdominal examination revealed tenderness in the lower abdomen with a firm palpable mass occupying the right side of the abdomen. Her blood counts showed an elevated total leukocyte count of 13,000 cells/dL with neutrophilic predominance. Initial clinical assessment raised the possibility of an appendicular mass.The patient therefore immediately underwent a contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis, which revealed a large soft tissue mass measuring approximately 80 x 150 x 170 mm in anteroposterior, transverse, and craniocaudal dimensions, respectively, and was predominantly occupying the right mid and lower quadrant. The mass showed some areas of low attenuation, suggestive of necrosis/intratumoral edema Figure . There wAnteromedially, the mass had a tortuous, twisted vascular pedicle that was likely originating from the left adnexa Figure .Additionally, few speckled calcifications were noted in the mass Figure . No enhaNo evidence of regional lymphadenopathy or distant metastases was found on the CT examination. On the basis of the radiological picture, an impression of left ovarian tumor with torsion was suggested.The patient then underwent an exploratory laparotomy and left salpingo-oophorectomy along with partial omentectomy. Intraoperative findings included a large bilobed edematous mass weighing approximately 1.5 kg with a twisted, thickened vascular pedicle and varicosed vessels. The left fallopian tube was slightly thickened as well. No lymphadenopathy or invasion into the surrounding structures was seen.The surgically resected specimen was then sent for histopathological analysis, which revealed a neoplastic lesion in the left ovary arranged in nests and trabeculae separated by fibrous septa. The cells were polygonal with moderate amount of clear to eosinophilic cytoplasm. The nuclei were round to oval, showed moderate plemorphism with prominent eosinophilic nucleoli and frequently visible mitotic activity. Scattered plasma cells and lymphocytes were present within the fibrous septa. In areas, tumor cells were seen scattered against edematous stroma. Thin-walled dilated and congested blood vessels were seen, suggestive of vascular compromise secondary to torsion. The neoplastic cells showed diffuse nuclear positive expression for octamer-binding transcription (OCT) 3/4 immunohistochemical stain. Intracytoplasmic glycogen was highlighted on Periodic acid-Schiff special stain . The excised left fallopian tube, omentum, and peritoneal washout were all negative for malignancy.Postoperatively, the patient showed satisfactory progress and was therefore discharged in a stable condition. She is planned for on oncology follow-up visit as an outpatient.It is a well-known fact that mobile organs and pedunculated masses are prone to acute torsion, which leads to devascularization of the organ or tumor. The pathophysiology of acute torsion are initially venous and lymphatic obstruction, which result in massive intratumoral edema followed by progressive arterial compromise, which predisposes to gangrene, hemorrhagic infarction, and rupture . AdnexalDelay in the diagnosis may occur if the torsion is partial and intermittent with subsequent spontaneous detorsion, in which case the symptoms may subside, only to return within hours, days, or weeks. We believe our patient also had intermittent torsion and detorsion leading to on and off symptoms that lasted for a week before presentation. Moreover, the condition can be clinically mistaken for acute appendicitis, diverticulitis, tubo-ovarian abscess, ectopic pregnancy, and ruptured ovarian cyst given the similar clinical presentation. Ultrasonography is usually considered the initial imaging modality of choice and can demonstrate the twisted vascular pedicle with decreased vascularity of the tumor on color Doppler. However, ultrasonography may be equivocal and inconclusive depending on the degree of torsion and the experience of the operator. In such cases, and especially when patients present with an acute abdomen as in our case, CT can help to confirm the torsion, detect complications, and exclude other pathologic conditions quickly and effectively .The ovarian vascular pedicle anatomically comprises of the gonadal vessels exiting and entering the ovary. If an ovarian mass is present, the ipsilateral ovarian vessels may be enlarged. Therefore, the “ovarian vascular pedicle sign” as suggested by Lee et al. is also a useful sign to determine the exact site of origin of the mass, especially in cases of ambiguous locations due to large size of the mass or when complications like torsion arise . The preThe primary goal of radiological investigations includes characterization of the lesion, staging, and evaluation of possible acute complications like torsion, tumor rupture or hemorrhage, which if passed undiagnosed may significantly increase disease morbidity and mortality. According to a report by Takeda et al., unilateral salpingo-oophorectomy via laparoscopic approach has been proposed as a reasonable management strategy for stage IA disease rather than a more extensive exploratory surgery . HoweverIn summary, we report a rare presentation of ovarian dysgerminoma with torsion in a young child. Even malignant ovarian germ cell tumors like dysgerminomas can present with complications like torsion, rupture or hemorrhage and should always be considered in the differential diagnosis of young females presenting with acute abdominal pain and a palpable abdominopelvic mass. As the tumor is chemosensitive, early diagnosis by distinct radiological features can result in a good prognosis and thus reduce disease morbidity and mortality to a substantial extent.


Lymphoma with an initial manifestation of ascites and peritoneal invasion is rare.A 65-year-old woman presented to the emergency department with a 3-week history of abdominal distention, anorexia, and night sweating, and a 2-week history of melena. She was a silent hepatitis B virus carrier. Abdominal ultrasound showed massive ascites without cirrhosis. Abdominal computed tomography revealed ascites, infiltrative peritoneal lesions with omental cake appearance, and lymphadenopathies.We performed paracentesis and the ascites cytology was obtained. The patient also underwent esophagogastroduodenoscopy, which showed ulcerative tumors in the stomach. Both ascites cytology and pathology of the gastric tumors confirmed the diagnosis of B-cell lymphoma.This patient received 7 cycles of chemotherapy.Follow-up imaging studies revealed partial remission of lymphoma, but an enlargement of residual tumors in omentum and mesentery, which resulted in intractable ascites and rapid deterioration of performance status. Despite a change of regimen of chemotherapy, this patient expired 10 months after diagnosis.Lymphoma should be one of the differential diagnoses in patients with intractable ascites not attributable to other comorbidities. Diffuse large B-cell lymphoma (DLBCL) is the dominant histological subtype of primary extranodal lymphoma.,4 Malignant ascites indicates the presence of cancer cells in the peritoneal cavity and is an ominous prognostic sign. Tumors causing malignant ascites are more commonly from peritoneal surface malignancies such as ovaries, colorectum, and pancreas. Peritoneal lymphomatosis (PL), defined as the peritoneal spreading of lymphoma, is rare and receives much less attention. Lymphoma does not usually invade the omentum, because it is fibro-fatty in nature and lacks lymphoid tissue. It is important to differentiate PL from carcinomatosis, which commonly invades from the stomach, colon, or ovaries, as they require different chemotherapeutic intervention and have different potential curability. Here, we share a case of gastric DLBCL with an initial presentation of massive ascites. Informed consent was obtained from the patient and her family for the publication of this case report.The gastrointestinal tract is the most frequent extranodal site of lymphoma, accounting for about 40% of cases. In the gastrointestinal tract, the stomach is the most common involved site, followed by the small intestine and ileocecal region.23; red blood cells, 720/mm3; neutrophils, 1%; lymphocytes, 76%; monocytes, 23%; LDH, 1415 U/L; protein, 3.1 g/dL; albumin, 1.7 g/dL; serum-ascites albumin gradient (SAAG), 1.4; sugar, 10 mg/dL; and amylase, 25 U/L. No microorganisms were detected, and acid-fast stain of ascites was negative. Ascites cytology plus cell block was also obtained. She underwent esophagogastroduodenoscopy because of melena, and it showed a large confluent infiltrative lesion about 10 cm in length with several ulcerations and a giant fold at the greater curvature side of the lower body of the stomach. Another lesion 3 cm in size with ulceration at the high body was also discovered, along with much coffee-ground material , 10400/μL; neutrophils, 60.0%; lymphocytes, 24%; monocytes, 14%; hemoglobin, 11.4 g/dL; mean corpuscular volume, 91.4 fL; platelets, 417,000/μL; albumin, 3.4 g/dL; lactate dehydrogenase (LDH), 901 U/L; and β2-microglobulin, 3861 ng/mL. No other electrolytes or renal or liver function abnormalities were noted. Tumor marker examination revealed increased CA-125 (425.8 U/mL); CEA, CA-199, CA-153, and tissue polypeptide antigen were within the normal limits. She had previously undergone total hysterectomy and bilateral oophorectomy, which were confirmed by transabdominal sonography. Computed tomography (CT) revealed massive ascites and peritoneal lesions with omental cake, along with metastatic paraaortic and paradiaphragmatic lymph nodes  in only 8 cases (8%). In another analysis of 100 patients with ascites, Mahmood et al reported lymphoma as the underlying cause of only 2% of cases.Lymphomas presenting with serous effusion are common, but the prevalence varies in different cavities. The frequency of pleural effusion is 20% to 30% in NHL and Hodgkin disease; however, ascites is a rare presentation of lymphomas.,11,12 Second, the peritoneal invasion continuously spreads from an extranodal lymphoma of intra-abdominal origin. In a study of 400 patients with newly diagnosed or recurrent NHL, Glazer et al reported that the peritoneum and omentum were involved in 7 patients (1.75%), and ascites was observed in 4 patients (1%). However, development of serous effusion in the course of lymphomas, either primary or otherwise, is considered an adverse factor affecting overall survival.Malignant lymphoma can present with peritoneal invasion in 2 ways. First, a primary peritoneal lesion, also known as primary effusion lymphoma, is a rare type of NHL presenting with serous effusions without detectable tumor formation. It occurs in immunocompromised patients and is related to KSHV/HHV-8 infection and coinfection with Epstein-Barr virus or HIV. is calculated by subtracting the ascites albumin concentration from the serum albumin concentration. This is a more sensitive and specific measure for the differentiation of ascites due to portal hypertension from ascites due to other pathophysiological mechanisms . Peritoneal malignancy without overt liver masses typically has a fluid WBC count of 500/mm3 or greater, a SAAG of less than 1.1 g/dL, and total protein of 2.5 g/dL or greater.,17 In this patient, omentum cakes and thickening with positive malignant cells in the ascites confirmed malignant ascites, and neither liver problems nor cardiac diseases were found. Therefore, it is unusual that she also had malignant ascites presenting with a SAAG greater than 1.1 g/dL, which is more common in portal hypertension-related ascites. This may be because peritoneal lymphoma changes the permeability of peritoneal vessels and leads to fluid extruding from the vessels to the peritoneal cavity. Distinguishing between peritoneal carcinomatosis and PL is challenging but important, because their respective treatments and prognoses are quite different. CT findings of omental caking with homogeneous bulky masses, rather than a nodular pattern, diffuse lymph node involvement, splenomegaly, and the presence of tumors in the gastrointestinal tract, especially the stomach and terminal ileum, have been proposed to support a diagnosis of PL.,18 However, most patterns of tumor involvement are similar, and a definitive diagnosis of PL is impossible from imaging alone. The appearance of ascites can also provide some clues in the differential diagnosis. In a small analysis, approximately 20% of malignant ascites samples were bloody, and hepatocellular carcinoma was the underlying cause of the majority of bloody ascites. In contrast, lymphoma-associated bloody ascites was rarely reported. Chylous ascites is a rare form of ascites resulting from disruption of the lymphatic system. Milky appearing ascites with a triglyceride concentration above 200 mg/dL is diagnostic; abdominal malignancy, cirrhosis, and tuberculosis are the major causes in adults. Intra-abdominal solid organ tumors, such as malignancies in the stomach, esophagus, pancreas, endometrium, and prostate, account for 40% of all malignant ascites. However, the appearance of the ascites in our case was yellow and transparent, similar to the appearance of ascites due to cirrhosis or portal hypertension.Paracentesis is a safe, cost-effective, useful tool that should be considered as the first-line evaluation to survey ascites. The SAAG, which was first proposed by Hoefs et al in 1981, Ascites LDH has high sensitivity and low specificity for malignant ascites. Kim et al reported that the ascites LDH level is elevated in a few PL patients, supporting the idea that the ascites LDH level can be an important clue for differential diagnosis. In our case, the presentations of elevated protein and LDH levels in the ascites, low glucose concentration, and sterile ascites were compatible with the clinical features of PL.The relation between lymphoma and elevated serum LDH level is well established. In addition to being used for diagnosis, the LDH level may be an independent prognostic factor of lymphoma. Since elevated serum CA-125 can be found in patients with ascites or pleural effusion of any etiology, it is presumed to result from the shear force on mesothelial cells. Extensive peritoneal or omental lymphomatosis might lead to elevated serum CA-125. Our patient had increased CA-125, but she had previously undergone bilateral oophorectomy, and there were no gynecological lesions noted during sonography and physical examination studies. Evaluation combined with findings of ascites cells and CT scan suggested that the elevated serum CA-125 was related to PL.Serum CA-125 is a mucin-like glycoprotein antigen expressed in normal tissue originally derived from celomic epithelium, such as the peritoneum, pleura, fallopian tubes, and endometrium. It is elevated in ovarian cancer, but is not necessarily indicative of malignancy.,25,26 The cause of malignant ascites may also relate to the sensitivity. Lynch et al reported a series of 7 patients with NHL and PL where the cytology provided diagnosis in only 1 patient. Moreover, lymphoma can elicit florid mesothelial hyperplasia, confusing the cytology results and extending the diagnostic process. Therefore, if possible, histology is still the gold standard for diagnosis.Ascites cytology is important to diagnose malignant ascites. However, the sensitivity rate is affected by the number and quality of specimens processed. Review of the current literature suggests the overall sensitivity of cytology is around 60% to 70%.In conclusion, we provide a gastric lymphoma case of PL showing portal hypertension mimic ascites with high SAAG at initial presentation. PL is a rare presentation that mimics peritoneal carcinomatosis, but is different in terms of treatment and prognosis. Multidisciplinary evaluation of history, imaging findings, ascites analysis, and especially cytology should be performed to ensure proper diagnosis.Conceptualization: Wen-Chi Yang.Data curation: Jyh-Seng Wang.Supervision: Wen-Chi Yang.Visualization: Jyh-Seng Wang.Writing – original draft: En-Shao Liu.Writing – review and editing: Wen-Chi Yang.


Although nearly half of all schwannomas involve the head and neck region, nasal and paranasal sinus presentations are quite rarely seen. Cystic schwannoma, characterized by cyst formation lined by S-100 protein positive membrane-like structures is very uncommonly seen in sphenoid sinus with only a single previously reported case. Here we report a young patient of cystic schwannoma of the paranasal sinuses having epicenter in the sphenoid sinus. The tumor had caused extensive erosion of the skull base and paranasal sinuses and extended intracranially that radiologically mimicked as infected mucocele causing loss of vision. This case denotes the aggressive behavior of such uncommon tumors. Schwannomas are slow growing benign tumors originating from the peripheral nerve sheaths. Approximately 25-50% of schwannomas occur in the head and neck region, but tumors originating from the nasal cavity or paranasal sinuses are rare, with just over 100 cases reported in literature . Here weA 22-year old male was seen in our neurosurgical unit having complaints of dull-aching type of holocranial headache since past 6 months and gradually progressive painless diminution of vision of the left eye since past 2 months. He did not give any history of diplopia, nasal obstruction or epistaxis. Neuro-ophthalmologic examination revealed visual acuity of 6/6 in right eye and only light perception in the left eye along with relative afferent pupillary defect and features of optic atrophy on the left side. Neurological examination was otherwise unremarkable. Contrast-enhanced computed tomography (CECT) brain and paranasal sinuses were obtained which revealed a large infiltrative solid-cystic mixed density lesion epicentred in the base of skull predominantly involving the sphenoid sinus causing its expansion and ballooning. The lesion had caused erosion of the left lateral wall of the sphenoid sinus, left anterior and posterior clinoid process, floor of sella and sphenoid sinus and lateral wall of the left orbit with extension into the left antero-medial temporal lobe and left cavernous sinus . On contSchwannoma is a painless, benign slow growing tumor of the peripheral nerve sheath commonly associated with the cochlear nerve at the cerebellopontine angle. They rarely occur in the sinonasal cavities and in this location, they are typically described as solitary encapsulated lesions confined to the nasoethmoid region . SchwannOur patient's schwannoma, presumed to originate from the posterior ethmoidal nerve at the sphenoid sinus, appears to be unique in its presentation as an erosive fronto-ethmoidal mucocele and loss of vision and a location which is very uncommonly seen. The current case is one noteworthy example of mucocele formation secondary to the underlying schwannoma which may mimic features of the more commonly encountered lesions in this region that may cause diagnostic dilemmas and give intraoperative surprises. It remains to be seen if such unusual tumors can be studied in a more extensive way in their earlier juncture of development when the tumors are still small and if with the new radiological techniques like high-tesla MRI the nerves of their origin can be revealed and these tumors subclassified.The authors declare no competing interest.


Pilocytic astrocytoma is a low-grade central nervous system tumor most commonly seen in children. Dissemination from a primary intracranial tumor along the neuroaxis has been described at both presentation and disease progression. However, the development of an intradural extramedullary pilocytic astrocytoma independent of a primary intraparenchymal tumor in an adult patient with no history of pilocytic astrocytoma has rarely been reported.A 69-year-old woman presented with progressive myelopathic symptoms and thoracic radicular pain. MRI imaging of the whole spine showed an enhancing intradural extramedullary lesion extending from the cervical cord to T11 causing cord compression. Laminectomies were performed for surgical decompression and histopathology was consistent with pilocytic astrocytoma. Complete staging was done that included imaging of the brain and cerebrospinal fluid cytology. No other tumor was found by these methods. Postoperatively the patient was treated with large field spinal radiation and concurrent chemotherapy followed by adjuvant chemotherapy. She has thus far been clinically and radiographically stable.This is a rare case of an adult with multiple spinal pilocytic astrocytomas in an intradural extramedullary location, typically the result of cerebrospinal fluid dissemination of neoplastic cells from a primary intracranial tumor site (i.e. drop metastasis). No conventional primary tumor was identified in this patient, suggesting these tumors may arise from heterotopic gliomas. Pilocytic astrocytoma (PA) is the most common central nervous system (CNS) tumor affecting the pediatric population but is rare in older adults . It corrHere we present a highly unusual multifocal intradural extramedullary pilocytic astrocytoma of the spine in an older adult. The location of the tumor in this patient suggested they were drop metastasis from a primary tumor, however imaging of the entire craniospinal axis revealed no other tumor site. This is a rarely reported presentation of pilocytic astrocytoma. In this report we discuss the case and review the relevant literature with a focus on possible mechanisms.The patient is a 69-year-old woman who presented to her primary care physician with worsening cough and pain wrapping around her chest to her back. The chest pain was initially thought to be pleuritic in nature and related to an exacerbation of her chronic obstructive pulmonary disease (COPD). When there was no improvement in her symptoms with treatment of her COPD, and considering the confounding radicular distribution of her pain, a plan was made to have an MRI of the spine performed to explore other possible etiologies of her pain.Prior to the scheduled MRI, the patient was seen in the emergency department and diagnosed with a myocardial infarction due to hypertensive emergency. During her admission to the hospital, the patient was noted to be experiencing neck pain, bilateral upper extremity pain in a C8-T1 dermatomal distribution and a loss of urinary and fecal urges. On examination, the patient’s force of flexion and abduction in her upper extremities were mildly reduced. The strength in her lower extremities was decreased. Her deep tendon reflexes were 3+ in her bilateral upper extremities and 3+ in her bilateral lower extremities with clonus at the ankles.She had bilateral extensor plantar responses. In light of these progressive myelopathic symptoms a spinal MRI was done.The initial pre and post -contrast MRI of the entire spine showed extensive, mostly brightly enhancing intradural extramedullary nodules extending from C5–6 to T11  of the chest, abdomen and pelvis showed no tumor, and two CSF specimens were also negative for neoplastic cells. A follow-up MRI of the spine was performed ten days later to determine the patient’s response to steroid therapy and this showed no significant change. Multiple spinal meningiomas were also considered due to the patient’s age, the intradural extramedullary location and the homogeneous enhancement seen on MRI.Of note, the patient did not have a history of neurofibromatosis or any other neurocutaneous disorders. The patient also did not have a past medical history of tumors and was never previously treated with chemotherapy or radiation. The patient does have a history of polio which she recalled contracting at about two years of age. The patient’s mother was diagnosed with a fast-growing brain tumor in her 80s but otherwise the patient’s family history was unremarkable.An initial T7-T8 laminectomy for partial excision of the tumor was done for tissue diagnosis. Once the lesion was determined to be a pilocytic astrocytoma, a decision was made to proceed with an extensive resection of the tumor. The residual tumor was removed in two stages. In the first surgery a multilevel laminectomy was done from T4-T10. After a midline dural opening was made, tumor was identified which was light silver in color and attached to the spinal cord Fig. . A carefRoutine hematoxylin and eosin–stained sections of the tumor samples showed multiple well-circumscribed masses made up predominantly of interlacing fascicles of spindle cells with thin wavy nuclei. The degree of cellularity varied greatly with some nodules exhibiting highly cellular compact areas and others showing more loosely arranged cells. Perivascular pseudorosettes were prominent in some areas, giving an ependymoma-like appearance. Foci of dense calcifications and microcystic degeneration were identified. Mitoses were elevated (up to 8 per 10 high power fields in the most cellular areas), nuclei were hyperchromatic, and the proliferation index was high in those areas signifying the presence of anaplastic features. The tumor cells were strongly and diffusely immunoreactive for S100, GFAP, and Olig2, confirming their glial nature. They were negative for EMA and progesterone receptors (meningioma markers) as well as CK18 . SOX10, a marker of peripheral nerve sheath tumors, was also negative. The diagnosis of pilocytic astrocytoma with focal anaplastic features was rendered Fig. .Fig. 3HiThe patient presented for a physician visit a month after the final surgical procedure. She was experiencing paresthesias in all four extremities, in addition to thoracic radicular type numbness bilaterally at T5. The patient was participating in physical therapy and had persistent bilateral lower extremity weakness.Radiotherapy with concurrent temozolomide chemotherapy was given to treat the residual tumor. The patient was treated with large field radiation to the spinal cord, receiving a total dose of 36 Gy in 20 fractions with daily dose concurrent temozolomide. Maintenance temozolomide was started, with a plan to treat the patient for six additional cycles. At the time of this writing it has been 13 months since her symptoms first began and six months since her final surgery.We present a case of an adult patient with a spinal intradural extramedullary multifocal pilocytic astrocytoma. The radiographic differential diagnosis for primary CNS tumors in this anatomic location is commonly meningioma or nerve sheath tumors . In thisIn 1951 Cooper et al. published one of the first series of primary extramedullary gliomas . They deHowever, given that the Cooper series is of patients treated between 1915 and 1941, the presence of an asymptomatic undiagnosed primary tumor in these cases is uncertain, although the authors do state that, “cases with any doubt as to their primary extramedullary origin were eliminated from the study”. Their report then is one of the first to suggest, that primary intradural extramedullary glial tumors can occur and should be considered as a rare possibility. This finding is supported by two, more modern case series describing primary intradural extramedullary gliomas published by Venkataramana et al. and Dinakar et al. which included MR imaging .Specific to spinal extramedullary pilocytic astrocytoma in adults, in 2005 Bohner et al. reported on a case of a 25 year old male with no previous diagnosis of PA, who presented with primary diffuse leptomeningeal gliomatosis with confirmed pilocytic astrocytoma histology . This paIt is appropriate to consider and evaluate patients with pilocytic astrocytoma for known tumor predisposition syndromes like neurofibromatosis type 1 (NF1). NF1 is associated with an increased risk of CNS malignancies, and common among CNS tumors in NF1 patients are low grade gliomas, with PA being one of the most common subtypes . AlthougDefinitive treatment recommendations cannot be made based on this small sample size. In our case of a nodular spinal tumor with cord compression, the decision was made to opt for maximal safe resection followed by combined chemoradiation given the patients age and the focal anaplastic histologic features of the tumor.This is an unusual case of an older adult with a pilocytic astrocytoma found in the intradural extramedullary space. This finding supports previous research that suggests gliomas originating in this anatomic location may result from glial cell heterotopias. Genetic studies could shed light on how these tumors develop as well as their clinical course.


Chronic lymphocytic leukemia (CLL) patients are at an increased risk for developing more aggressive lymphomas via Richter’s transformation and of developing secondary malignancies. Despite the known association for secondary cancers, oropharyngeal cancers occur rarely. We present a case of a woman with a history of CLL who presented to our facility via transfer for impending airway compromise. Her initial workup was consistent with CLL; however, biopsies were taken of the neck mass because of its aggressive nature. She was treated with rituximab with good response. Final pathology showed evidence of CLL and tonsillar squamous cell carcinoma (SCC). Direct laryngoscopy and further biopsies yielded a diagnosis of unresectable oropharyngeal SCC. She was to be treated with chemotherapy and radiation for her SCC while holding treatment for CLL. This case demonstrates a rare and unexpected concurrent diagnosis. There is a predominance of males of Caucasian descent, with a median age of 70 years. The clinical course varies with a 5-year survival of 84.2% and median survival of 10 years.2 Deaths in patients with CLL are more commonly associated with complications of the disease, such as infection, than from the leukemia itself. Richter’s transformation is an infrequent but highly concerning entity as median survival is about 5 to 8 months.3Chronic lymphocytic leukemia (CLL) is a disorder in which there is an accumulation of mature, monoclonal B lymphocytes. It is the most common leukemia found in Western adults.4 Another retrospective study showed an increased risk of solid organs and Hodgkin lymphoma, but not for hematologic cancers.5 The cause of this apparent propensity for developing subsequent cancers is unclear. Some suggested theories included genetic predisposition, immunosuppression, and consequences of treatment. However, it is unclear as to whether there is an association with these factors due to conflicting findings.47Regarding complications, CLL has been associated with the development of secondary cancers. In a retrospective study, patients with CLL were shown to have more than twice the risk of development of a second malignancy. This includes solid organs and hematologic malignancies.This is a case of a woman with history of CLL and an enlarging neck mass who presented a diagnostic dilemma.Our patient is a 58-year-old African American woman who initially presented to an outside facility of difficulty swallowing, neck pain, fatigue, and shortness of breath for 3 months. She had bilateral neck swelling, greater on the left side, that started about a year prior to her presentation. This patient also had a 4-day history of productive cough and nasal drainage. She had a 30-pack year history and consumed approximately 12 beers daily for years.She reported a history of CLL and having been treated with chemotherapy, but she was unsure of the regimen. Examination findings and computed tomography (CT) scan of neck at the outside facility were concerning for impending airway compromise, and she was transferred to our hospital to be evaluated by an otorhinolaryngology or oral and maxillofacial surgery service.3. She was started on dexamethasone to reduce the compression of the neck mass on the airway. The oral and maxillofacial surgery service team evaluated her and determined that a definitive airway was not indicated. She was admitted to the medical intensive care unit for close airway monitoring.During her evaluation in our emergency department, she was noted to have a muffled voice with mild gurgling of secretions with speech. Large, fixed cervical and submandibular lymph node, and a large left neck mass were present. Enlarged axillary lymph nodes were palpated bilaterally. The uvula and posterior oropharynx were not visible due to her tongue and left neck mass. White blood cell (WBC) count was 83 600/mm12, and folate were normal. Flow cytometry was pending  if CLL or rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) if Richter transformation had occurred.Around this time outside records were received. Our patient had been treated with rituximab and chlorambucil 5 months prior after presenting with similar symptoms. She had been incidentally found with a WBC count of 40 000/mm3. Biopsy of the neck mass showed squamous cell carcinoma (SCC) with extensive necrosis involving lymphoid tissue.Flow cytometry showed a CD5+ mature B-cell lymphoma consistent with CLL, 13q deletion, and mild CD38 positivity. Over the next few days, she had improvement in her neck pain. The mass and lymph nodes decreased in size. The WBC count decreased to 40 000/mmWith evidence of a second malignancy with possible significant oropharyngeal involvement, direct laryngoscopy with biopsy was pursued  and 5.Direct laryngoscopy was performed and showed a large mass involving the right tonsil extending to midline of the posterior oropharynx. Biopsies were obtained. Posterior oropharynx, right tonsil, and right nasopharynx biopsy contained invasive keratinizing SCC, moderately differentiated, with basaloid features. The nasopharyngeal biopsy also included atypical lymphoid infiltrate consistent with involvement by CLL.2) weekly for 6 cycles and radiotherapy. Treatment was to be delayed for her Rai Stage III CLL out of priority since her airway compromise was attributed to the SCC and the CLL component had been partially treated with rituximab.This patient’s case was discussed at the tumor board. Given the widespread involvement of her disease, she was diagnosed with Stage IV oropharyngeal SCC. She was not at candidate for resection and was to be treated with high-dose cisplatin (25 mg/mAt time of discharge, she had continued improvement of her symptoms. The plan was for her to follow with our medical oncology and radiation oncology teams as an outpatient. However, due to long distance from home, she established care at an outside facility.3 Though her treatment was palliative in nature, she may have had a worse outcome if only her CLL was considered. There is a case in the literature involving a 62-year-old woman whose airway became compromised by a lymphoid mass related to CLL.8After determining whether our patient was able to protect her airway, it was crucial to evaluate for the exact etiology of her enlarging neck mass. One percent to 10% of CLL patients develop Richter’s syndrome, or transformation into an aggressive non-Hodgkin lymphoma.6 A study that evaluated secondary malignancies in 514 patients with CLL showed 1 case of tongue cancer.5 Curiously, another retrospective analysis using SEER data of different regions and timeframes, the longest being 1973 to 2008, showed rare occurrence of oropharyngeal malignancy.9Though there is an association between CLL and the development of second cancers, oropharyngeal SCC rarely occurs. An analysis of 46 164 patients with a histologically confirmed diagnosis of CLL drawn from SEER 18 registries between 2000 and 2014 does not mention oropharyngeal cancer. The 2823 individuals who developed solid tumors were diagnosed with either lung and bronchus, prostate, melanoma, bladder, kidney, or thyroid cancer.10 Developing CLL is associated with tobacco use.11 Though there is a case in the literature of a 52-year-old nonsmoker male who was diagnosed with small lymphocytic lymphoma during workup for an human papillomavirus–positive SCC of tonsillar primary.12 Alcohol consumption has not reliably been shown to have positive or negative association with CLL.14It is difficult to determine what shared risk factors were involved in her developing both malignancies. There is a paucity of similar cases in the literature, and the exact temporality of her diagnoses is unknown due to lack of continuous care. Our patient had a history of tobacco and alcohol abuse, which are known risk factors for oropharyngeal cancer.In a patient with a rapidly enlarging mass, such as in our case, it is important to rule out causes beyond CLL. It would be prudent to obtain biopsy in cases of uncertain diagnosis given the possibility for Richter’s transformation or a second malignancy.The development of concurrent oropharyngeal SCC and CLL is exceptionally rare. Given the association of CLL and secondary malignancies, one should be vigilant about continuing to screen patients after diagnosis with CLL. Though the exact cause of this process is not known, it is imperative to continue mitigating possible risk factors such as tobacco smoke exposure. There need to be further studies addressing risk factors associated with CLL and the development of second malignancies so that a better approach may be taken regarding risk reduction.


Urachal adenocarcinoma originates from the space of Retzius. It is a rare but aggressive neoplasm. Typical imaging findings of urachal cancer are difficult to find; this report provides an ultrasonographic (US) and computed tomographic (CT) description of the above. We present a case of a 45-year-old male patient presenting with painless hematuria of 1 week's duration and display the US and CT images. Imaging shows: (1) a solid, ill-defined, irregularly shaped mass invading the bladder wall located between the dome of the bladder and the abdominal wall, and which underwent significant enhancement; (2) hypo-echoic, heterogeneous echopattern with some calcifications and (3) patchy and short-line blood flow signals within the mass. Final histopathology confirmed urachal adenocarcinoma. The urachus is a tubular structure extending from the dome of the bladder to the allantois in early embryonic development. After birth, it becomes a fibrous cord located in the loose connective tissue between the transverse fascia and the peritoneum  –4. FailuBased on the statistics of the last decade, the case reports of urachal cancer are still rare each year since the seminal studies by Begg in the 1930s . UrachalA 45-year-old man presented to our hospital with 1 week of painless hematuria with no obvious cause. He was previously healthy with no known diseases. Physical examination showed no obvious abnormalities.6/L and white blood cells, 3 oun6/L. Tumor marker determination showed carcinoembryonic antigen (CEA) 2.8 × 10−3 ng/L , and prostate specific antigen (PSA) 0.48 × 10−3 ng/L .Urinalysis was positive for red blood cells, 814 × 10US examination showed a solid mass in the midline of the lower abdomen, invading the antero-inferior bladder wall. It measured 6.3 × 4.9 × 3.4 cm, with ill-defined, irregularly shaped protrusions outside the bladder extending to the umbilicus. Internal echogenicity was heterogeneous, and patchy calcifications and a small amount of point-like and short-line blood flow were observed within the tumor. No enlarged lymph nodes were noted in the abdominal cavity or retroperitoneum. We diagnosed an umbilical tumor .The diagnosis on contrast-enhanced abdominopelvic CT was also umbilical tumor. CT confirmed that there was an intra-abdominal mass with calcification, invasion of the adjacent bladder dome and peritoneum, and which underwent significant enhancement .The patient underwent surgery to remove the mass. The urachus, umbilicus, and part of the bladder dome 2.0 cm from the tumor were also resected. Intraoperative findings showed an ~5.0 × 5.5 × 5.0 cm mixed cystic and solid mass invading the dome of the bladder and adherent to the peritoneum gross pathology showed a 6.0 × 5.5 × 3.5 cm mass with a grayish-white cut surface, coated in a jelly-like substance. The tumor was friable. Histopathology of the tumor showed that part of the bladder mucosa was included in the tumor, without vascular and neurological invasion recidivism . AccordiUrachal cancers can originate from any of the various layers of the urachus tract and arise mainly from epithelial cells; 94% of umbilical urachal cancers are adenocarcinomas, the diagnosis of our patient . The tumUrachal cancer usually appears as an intra-abdominal mass adjacent to the bladder dome, extending into the space of Retzius. It can be cystic, solid, or mixed . US and This report provides the characteristic US appearance of urachal cancer. The main features of this patient's ultrasonographic imaging findings were: (1) a solid mass extending between the dome of the bladder and the abdominal wall, with an irregular shape and bladder wall invasion; (2) a hypoechoic, heterogeneous echo pattern with a small amount of calcification; and (3) patchy and short-line blood flow signals within the mass. These findings are consistent with previous reports , 9, 13 aThe US and CT examinations showed that the tumor infiltration reached the bladder muscle layer, without obvious lymph node involvement or spread to other organs, consistent with intraoperative findings and surgical pathology. Urachal tumors contain mucin, and calcifications are present in 70% of cases , 14. TheWe have described the typical imaging features of a case of urachal adenocarcinoma. Diagnosing urachal cancer is easier with imaging.All datasets generated for this study are included in the article/Supplementary Material.The studies involving human participants were reviewed and approved by appropriate institutional of Shanxi Academy of Medical Sciences and Shanxi DAYI Hospital. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.XC, CK, and MZ performed image acquisition and completed the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


It is widely accepted that chronic burn wounds may lead to the development of various malignant skin tumors. Deep stage 3 burned areas may facilitate deeper carcinogenesis. Deep tissues are probably less subject to severe insult than is the epithelial layer during physical insult, suggesting that soft tissues transform to a lesser extent during the late stages of tumoral development as in an immunocompromised district with altered local immune defense with both cellular and humoral defense affected. Most authors claim that tumors are almost squamous cell carcinomas, although other types of malignancies such as basal cell carcinoma and, to a lesser extent, melanoma can also be seen. However, malignant transformation of cutaneous soft tissue in a burn insult area has rarely been described. Similarly, burn-induced tumors of histiocytic origin have been reported in few cases and osteosarcoma only in two case reports. Here, we report a patient case suffering from severe large stage 3 burn after-effects on the leg. Fifty-five years after the injury, this patient developed a large extraosseous osteosarcoma on the scar. A 66-year-old phototype 6 woman from North-Africa was admitted to our department due to an indolent ulcerovegetative mass that developed on the anterior face of the right thigh. The lesion spontaneously exhibited greyish discharge. The patient anamnesis revealed that she had sustained a hot-water burn to her leg at the age of 11 years. She stated no definitive treatment by skin grafting and had only been treated conservatively following injury. The burned right thigh healed progressively, leaving a large scar on the skin surface. There had been no particular issues concerning the lesion until 2 months previously, at which point the patient noticed a progressive mass in the scar area but had not taken any steps to have it cured. Upon physical examination, the mass was 4 x 2 cm and suggested at diagnosis of Marjolin's ulcer Figures  and 4. AIn addition to the aesthetic disturbance and functional inconvenience caused by large burn scars, these lesions facilitate the development of skin malignancy. According to the current literature, the risk of malignancy transformation reaches 2%, while the mean latency interval between onset of original insult and secondary tumoral occurrence is approximately 30 years –3 exceptExtraskeletal osteosarcoma (EO) located in the soft tissues without attachment to the bone or periosteum is a malignant mesenchymal neoplasm that produces osteoid, bone, and /or chondroid material. EO occurs rarely with an incidence up to 4 to 5% of osteosarcoma and 1% of soft tissue sarcoma . It affeThe best prophylaxis for the development of malignancy in chronic burn scars is to achieve a stable covering of the burn wound, either by skin graft or flap coverage . HoweverIn conclusion, in case of change of appearance of the graft or the scar, patients should be reported to their physicians early  or even


It was aimed to report 5 cases of pharyngeal hairy polyps, and to summarize the characteristics combined with literature review.Five cases with pathological diagnosis of pharyngeal hair polyps were diagnosed and treated in our department from June, 2006 to October, 2016, and retrospective analysis of their clinical data was performed. Among the 5 cases, there were 1 male and 4 female, with the age of 2 days to 26 months old. After birth, these patients were accompanied by stridor, difficulty breathing, snoring, feeding difficulties, and slow weight gain.Gray mass in the stem original from the pharynx was found in all 5 cases, with the surface hair-covering. The polyp resections were performed under general anesthesia, with the complete removal of polyp along the pars basilaris during surgery smoothly. The operation during was 5 to 20 minute, with an average of 12 minute, and there was little hemorrhage during operation. Symptoms disappeared completely after the surgery, and follow-up was performed for 1 year without recurrence shown.Pharyngeal hairy polyp is a rare non-malignant clinical disease, mainly caused by symptoms in respiratory tract obstruction. Complete removal of polyps along the pars basilaris is an effective treatment, with no recurrence case reported after surgery. Missed diagnosis and misdiagnosis often occur, and surgical resection is an effective way to treat this disease. A total of 5 cases of pharyngeal hairy polyps diagnosed and treated in Department of Otolaryngology, Shenzhen Children's Hospital from June, 2006 to October, 2016 with satisfactory results, are summarized as follows.Pharyngeal hairy polyp is a rare developmental abnormality of epithelium, which contains ectoderm and mesoderm. In clinic, the manifestations are as polyps, with the skin-like tissues and covered with hair and sebaceous glands. Hairy polyps occur in newborns, infants and young children mostly, and the incidence of female is greater than male , without unknown origin.22.1Among the 5 cases in the current study, there were 1 male and 4 female, with the age of 2 days to 26 months old. They were hospitalized with the main complaints of stridor, snoring, and difficulty breathing etc. Clinical data of 5 patients are shown in Table 2.2Routine preoperative examinations were performed in all 5 cases. Under general anesthesia in tracheal intubation, pharynx was the exposed with mouth gag. The visible hairy mass is single, with long pedicle and skin-like surface . In the current case report, the ratio of male to female was 1: 4, which is consistent with the above-mentioned incidence. 60% of the pars basilaris of pharyngeal hairy polyps are located mostly in the nasopharyngeal wall or soft palate back, and partly in the hard palate, auris media, eustachian tube, tongue or tonsil. Most cases are located on the left side of nasopharynx or oropharynx, which is consistent with the pathogenesis of 5 children in this study. The polyp occurring in the tonsils has an earlier onset than in other parts. Planas et al reported 1 case occurred in the embryonic period, high-risk pregnancy after the termination of the diagnosis of hairy polyps.Pharyngeal hairy polyp is a rare congenital benign disease, with the incidence rate of 1/40,000 from foreign literature statistics,; 3. There was no malignant report on hairy polyps, but teratoma can be malignant. Hairy polyp is most likely to belong to teratoma in histopathology, which is benign mass with a normal tissue structure growing in the abnormal anatomical location. It is often considered as congenital malformations or dysplasia, instead of tumors like teratoma or dermoid cyst. This is similar to hairy polyp.Hairy polyp is a manifestation of rare developmental abnormalities in epithelium, which includes ectoderm and mesoderm. Ectodermal development and differentiation form squamous epithelial tissues, with the surface, showed gray. Endodermal development and differentiation contribute into fibrous fat including muscle, cartilage, glandular tissue, fat and a few neuroepithelial tissues. Hairy polyps have been classified as teratomas, dermoid cysts and choristomas. However, there are 3 differences between hairy polyp and teratoma, which are listed as follows: 1. The morbidity of teratoma with the ratio of male to female is quite similar, but that of hairy polyp is 6: 1; 2. Hairy polyp contains mesoderm and ectoderm, but teratoma contains all endoderm, mesoderm and ectoderm Currently, the pathogenesis of hairy polyps is not clear, but there are several possible opinions. On one hand, choristoma may be derived from the multifunctional tissue, among which, the multifunctional tissue with differentiating potentiality escapes in the form of irregular masses, thus forming a choristoma. They may also be a part of nasopharyngeal mucosa; the nasopharyngeal mucosa does not digest in 7 weeks of pregnancy normally, instead, they live with a long-term existence. On the other hand, another theory is due to malformation in the embryonic formation of the first and the second branchial arch. Some other symptoms include vomiting, feeding difficulties, nostrils incitement, cyanosis, recurrent cough, and snoring. Hairy polyp is usually presented as an independent disease, which is often combined with cleft palate, uvula dysplasia, microtia and facial development asymmetry; in addition; there were reports presenting the relationship with the rare hypothalamic neuronal hamartoma and the first branchial cleft fistula on the same side. In this paper, the 2-year-old patient with microtia in left ear, the pars basilaris of the mass in the right side of nasopharyngeal part was combined with the polydactyly of the right thumb; the remaining children showed no significant developmental abnormalities.Soon or shortly after birth, hairy polyps are usually diagnosed, and if the mass is small without symptoms, it may be found until growing up. In the current case report, among the 5 cases of children, 1 case was found due to upper respiratory tract infection until treated in the pediatric department after 2 years old. The clinical symptoms of hairy polyps depend on the size and location, and breathing disorder is the main feature of the disease. If the polyps are small, patients usually suffer from stridor and intermittent breathing difficulties after birth; if the polyps are large, suffocation can be caused.Radiology is important for the evaluation of the origin and extent of nasopharyngeal and oropharyngeal lesions in infants and young children, helping to identify the diagnosis and determination of intracranial violation, as well as the surgical program. Computed Tomography examination can assess the mass and its surrounding sclerotin, at the same time, X-ray radiation should be considered. MRI examination can figure out the characteristics and scopes, as well as the relationship with the blood vessels, helping for diagnosis and surgical program development. The dermatoglyphic image of hairy polyps is characterized as polypoid mass composed of fat and fibrous tissues, without intracranial or spinal violations. The high signal in the T1WI image is the expression of adipose tissues in hairy polyps. The high-fat component can narrow nasopharynx of infants and young children. The differential diagnosis of oropharyngeal masses is diagnosed as hamartoma, teratoma and dermoid cysts, which helps to exclude some diseases such as neuroblastoma, hemangioma, and encephalomeningocele, etc.Pharyngeal hairy polyp is a rare benign tumor, with slow growth and no bleeding; there are a few domestic cases reported. Clinical manifestations are mainly presented as airway obstruction caused by a series of symptoms, such as intermittent dyspnea, snoring and feeding difficulties. Complete resection along the pars basilaris is the best treatment, without recurrence shown, and 5 cases in this case report were followed up for more than 1 year without recurrence. Pharyngeal hair polyp is rare in clinic, but the possibility of hairy polyps should be taken into account in dealing with infants suffering from airway obstruction, because the nasopharyngeal hairy polyp is easy to be misdiagnosed. There was 1 case of newborn with dyspnea after birth reported, the symptom of dyspnea had a remission after tracheal intubation, but the patient had delayed treatment considering of laryngeal tracheal disease.5 Complete removal of polyps along the pars basilaris is an effective treatment, with no recurrence case reported after surgery.Pharyngeal hairy polyp is a rare non-malignant clinical disease, mainly caused by symptoms in respiratory tract obstruction. Accurate diagnostics must be performed in depth so that proper surgical treatment may be performed.Conceptualization: Saihong Han, Hongguang Pan, Lan Li.Data curation: Yishu Teng, Zhixiong Xian, Zhenjiang Liang, Hongguang Pan, Lan Li.Formal analysis: Yishu Teng, Zhixiong Xian, Saihong Han, Zhenjiang Liang, Hongguang Pan, Lan Li.Funding acquisition: Yishu Teng, Saihong Han, Zhenjiang Liang.Investigation: Yishu Teng, Zhixiong Xian, Saihong Han, Zhenjiang Liang, Lan Li.Methodology: Yishu Teng, Saihong Han, Zhenjiang Liang, Hongguang Pan, Lan Li.Project administration: Yishu Teng, Hongguang Pan, Lan Li.Resources: Yishu Teng, Zhenjiang Liang, Hongguang Pan, Lan Li.Software: Yishu Teng, Zhixiong Xian, Saihong Han, Lan Li.Supervision: Yishu Teng, Saihong Han, Hongguang Pan.Validation: Yishu Teng, Zhixiong Xian, Hongguang Pan.Visualization: Yishu Teng, Zhixiong Xian, Saihong Han.Writing – original draft: Yishu Teng, Zhixiong Xian, Zhenjiang Liang.Writing – review & editing: Yishu Teng, Zhenjiang Liang.


Background: Pheochromocytomas typically are diagnosed in the adrenal gland and from the sympathetic nervous system. Bladder pheochromocytoma is a rare location for this tumor.Case Presentation: We describe a 67-year-old Afro Caribbean woman referred to our hospital for an asymptomatic bladder tumor. Preliminary transurethral resection revealed bladder pheochromocytoma. After a comprehensive endocrine evaluation, we performed a robot-assisted laparoscopic partial cystectomy with ureteral reimplantation.Conclusion: We present a rare case of bladder pheochromocytoma treated effectively with minimally invasive techniques. When confronted with a solid bladder mass, apart from the more common urothelial malignancies, a differential diagnosis of bladder pheochromocytoma should also be considered. We herein report a totally atypical presentation of bladder pheochromocytoma.EA 67-year-old Afro Caribbean asymptomatic woman came to the urology outpatient clinic because of ultrasonographic finding of a bladder mass. In her medical history, we found diabetes mellitus, hypothyroidism, and well-controlled high blood pressure. She had no family history of pheochromocytoma or paraganglioma. She denied any low urinary tract symptom such as hematuria, dysuria, polyuria, or incontinence. The general condition was preserved, without appetite disturbance or weight loss.The patient had 135/88 mm Hg of blood pressure and no fever. Abdominal evaluation did not reveal any palpable mass nor tenderness. Palpation of thyroid and lymphatic areas were unremarkable. Digital rectal and vaginal examinations were normal. Likewise, the urinary output test showed a good flow. The ultrasound, however, revealed a 17 mm bladder mass on the right posterolateral wall .During cystoscopy procedure, we found a right periureteral submucosal lesion. We performed a transurethral resection of the lesion under general anesthesia. Because of the resection of the right ureteral orifice, we placed a Double-J stent. The blood pressure remained stable throughout the procedure and no variations were noted.Histopathologic analysis revealed the diagnostic of extra-adrenal pheochromocytoma of the urinary bladder. Immunohistochemical stains were positive for chromogranin A, Synaptophysin, CD56, and S-100 protein. Both urinary and plasma metanephrine tests were normal.A follow-up chest-abdomen-pelvis contrast-enhanced CT revealed the persistence of a 20 mm posterolateral bladder mass at the resection site . There wThe diagnosis of nonsecreting paraganglioma of the urinary bladder was confirmed. A multidisciplinary team was convened and recommended to perform a partial cystectomy.After a comprehensive anesthetic evaluation, we performed a robot-assisted laparoscopic partial cystectomy with relocation of the right ureter. The patient was placed in the Trendelenburg position (25 degrees angulation). With an intraperitoneal approach, we identified the ureter and dissected it carefully up to the bladder insertion. A cystostomy was performed to visualize the tumor intravesically . We exciThe final pathology confirmed a 5 mm paraganglioma. No mitoses and no lymph vascular invasion were identified. Immunohistochemical staining was strongly positive for chromogranin A, synaptophysin, and S-100 protein. The surgical margins were free of tumor. After a 24-month follow-up period, the patient was asymptomatic. The CT of urinary tract found an unremarkable urinary excretion and no recurrence of the tumor .Extra-adrenal pheochromocytomas, also called paragangliomas, are neuroendocrine tumors that usually develop from the chromaffin cells. Thus, the tumor could be located between the base of the skull and the pelvis.1 Most of these tumors are hormonally active, and secrete mainly noradrenaline , calcitonin and adrenocorticotropic hormone. Due to high catecholamine level, the common symptoms are micturition attacks, hypertensive crisis, hematuria, headache, or tachycardia triggered by urination. In our case, none of these symptoms was present. It was a nonfunctioning paraganglioma with an incidental finding. In fact, in addition to the absence of clinical signs, all endocrine tests, both serum and urine, were negative. When we performed the cystoscopy and transurethral resection of the bladder mass, we had no suspicion of this pathology. The absence of hypertensive crisis during the intervention is a further evidence of a nonsecreting tumor.Pheochromocytomas of the urinary bladder are exceedingly rare tumors accounting for less than 0.05% of all bladder tumors and less than 1% of all pheochromocytomas. Paragangliomas are generally benign tumors, with only less than 10% being malignant.2 Thus, in presence of submucosal mass of the bladder, the diagnosis of paraganglioma should be considered.The diagnosis of pheochromocytoma of the urinary bladder is confirmed with a combination of specific symptoms, laboratory tests, and image investigations. It is extremely difficult to preoperatively diagnose an asymptomatic bladder paraganglioma. In our case, the bladder resection gave us the diagnosis. The chest–abdomen–pelvis CT was used to search other extra-adrenal sites. In fact, this investigation gives a better sensitivity than the metaiodobenzylguanidine scan (89% against 81%).3 The laparoscopic robot-assisted surgery offers a safe way to realize this intervention with low blood loss and low postoperative complications compared to open surgery. This minimally invasive surgery offers possibility of enhanced recovery after surgery and anesthesia. Our case is unique for several reasons. First, many reviews of paragangliomas of the urinary bladder have been published but nonfunctioning paragangliomas are rarely reported. Second, to our knowledge, it is the second report of a robotic resection of a bladder pheochromocytoma with ureteric reimplantation.4The treatment requires a partial or total cystectomy after an adequate anesthetic preparation to make the surgery safe.In the presence of a solid mass in the bladder wall, a diagnosis of bladder pheochromocytoma should be considered, even with an atypical presentation. The laparoscopic robot-assisted surgery should be considered as a safe way to treat this pathology.


Pseudomyxoma peritonei (PMP) is a rare condition that is typically associated with appendicular adenocarcinoma. Other origins are rarely reported. Here, we report a rare case of abdominal PMP, which originated as gastric adenocarcinoma. The prognosis of the patient consisted of pathological diagnosis, with samples from exploratory laparotomy, radiological visualization, abdominal computed tomography (CT), and abdominal magnetic resonance imaging (MRI). We employed the standard treatment protocol for our patient, which was essentially surgical, applying a cytoreductive technique, in an attempt to remove all visible evidence of the disease, plus intraperitoneal chemotherapy. Pseudomyxoma peritonei (PMP) is a rare malignant growth of mucus-secreting tumor cells within the abdomen and pelvis. Typically, the primary site of PMP is the appendix. However, on rare occasions, it can metastasize from gastric and gallbladder adenocarcinomas to the peritoneal, appendix, liver, and pelvic regions, with more aggressive behavior.A 50-year-old African American male with a past medical history of gastric adenocarcinoma presented with left lower quadrant and peri-umbilical abdominal pain, which was chronic but had worsened over the two weeks prior to admission. He described it as sharp, intermittent, and non-radiating pain that was seven out of 10 in intensity. He also complained of poor appetite and vomiting at least once a day after eating for three months. He estimated that he lost 70 pounds during this same period of time. He denied fever, constipation, diarrhea, hematemesis, or blood in the stool.He had extensive medical and surgical history. He was diagnosed with gastric adenocarcinoma by diagnostic laparoscopy, with a biopsy, in March 2012. In January 2014, he was admitted to Singapore General Hospital for extensive surgical resection. He underwent partial gastrectomy, subtotal colectomy, splenectomy, cholecystectomy, complete omentectomy, partial peritonectomy, and temporary abdominal closure. He then received another surgery during the same hospitalization, which included more extensive peritonectomy and hyperthermic intraperitoneal chemotherapy. Afterward, he received chemotherapy on and off in Canada.On physical exam, he had a large midline incision with nodular hernias. There was mild tenderness to palpation in the periumbilical and left lower quadrant. Shifting dullness was present. The abdomen was firm, however, there was no guarding or rebound tenderness.Initial laboratory results were significant for mild leukocytosis (WBC 11000/uL), hypokalemia (potassium of 2.7 mmol/L), acidosis (bicarbonate of 12 mmol/L), hypomagnesemia (magnesium 1.1 mg/dL ), hypoalbuminemia , hypoproteinemia , and mildly elevated lipase (113 units/L). Liver enzymes and renal function test were within normal limits.Computed tomography (CT) scan of the abdomen and pelvis with contrast showed diffuse pseudomyxoma peritonei with a large, septated low-density mass Figure  and a feGeneral surgery was consulted. The patient was deemed a potential candidate for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). There was one surgeon in another hospital with more experience in this procedure so the patient was transferred there for further treatment. Over the other hospital, the patient developed hemoptysis and fever. The patient was diagnosed with pneumonia and was treated with broad-spectrum antibiotics. Unfortunately, the patient was deemed not stable enough for extensive cytoreductive surgery. He was discharged to a nursing home to follow up with the surgery team outpatient. Meanwhile, the patient was offered the option of systemic chemotherapy by an oncology team as an alternative therapy in case he could not receive surgery. Subsequently, we lost follow-up of the patient, as we were unable to get in touch with him from the second month after transfer.Abdominal pseudomyxoma peritonei (PMP) is, by definition, the presence of mucin produced by a tumor in the peritoneal cavity. It is considered a rare or “orphan” disease. Its occurrence is estimated to be two cases/one million/year .PMP develops most often in appendix tumors and ovarian tumors; rarely is it associated with digestive system tumors. It is not clear why certain tumors tend to cause PMP while others do not. Other reported origins include the ovary, colon, stomach, pancreas, and urachus -3. PMP iAbout one-third of the patients with PMP have widespread involvement of the peritoneal cavity. The malignant cells have low adhesive potential and thus high propensity to spread. Dissemination is initially locoregional. The privileged sites are areas that tend to be more static. Examples are the Douglas pouch and parabolic gutters, but all abdominal organs can be involved .The signs and symptoms of PMP are usually non-specific. There is no pathognomonic sign, which adds to the diagnostic difficulty. Patients can have abdominal pain or discomfort, nausea, vomiting, poor appetite, and weight loss. The complications of PMP include severe adherence between abdominal organs, small bowel obstruction, hernia, and ascites . As in oImaging  is very useful to visualize the lesions. The original tumor, disseminated implants, scalloping of the liver, peritoneal effusion, and mesenteric involvement can be seen in the images . Thus weComplete cytoreductive surgery (CCRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is the treatment of choice for pseudomyxoma peritonei (PMP) -8. PressThe prognosis of PMP depends on its origin. With CCRS and HIPEC, for appendiceal PMP, the median survival rate is around 16.3 years while median progression-free time is about 8.2 years . For gasPMP is a rare condition that occurs mostly in appendicular tumors and ovarian tumors. There are reported cases of PMP from gastric and pancreatic tumors, which are even rarer sites. PMP from malignancy other than that of appendicular origin tends to be more aggressive. Complete cytoreductive surgery (CCRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is the treatment of choice.