Peritoneal implantation from hepatocellular carcinoma has been rarely reported. It may occur at various sites. Here we present a surgically resected case of peritoneal implantation to the diaphragm from hepatocellular carcinoma. A 50-year-old woman underwent right hemihepatectomy extended to a medial part of Couinaud segment IV for hepatocellular carcinoma in May 2000. In December 2008, the elevation of alpha-phetoprotein and the appearance of a heterogeneously enhanced mass, with dimensions of 9 × 7 cm, and adjacent to the remnant liver and pericardium suggested intrahepatic recurrence with markedly enhanced growth. After transcatheter arterial embolization, surgical resection under laparotomy combined with median sternotomy was selected. Samples of pericardial fluid showed no malignancy after cytological examination. At the superior border of the tumor, the confluence of pericardium and diaphragm was displaced, but the tumor itself showed a generally expanding but not invasive growth. The resected tumor showed moderately differentiated hepatocellular carcinoma whose pathology revealed a peritoneal implantation to the diaphragm. The patient is in good health without any postoperative complications or any further sign of recurrence. Hepatocellular carcinoma (HCC) is the most preventable type of liver carcinoma in the world. Hepatitis virus-related cirrhosis is known as the leading cause of HCC carcinogenesis. The prognosis is poor while surgery remains the best curative therapy, because the recurrence rate is quite high even after complete resection. The recurrence in almost all cases is usually detected in the remnant liver, and then the tendency is for secondaries to be found in lung or bone . TherefoHere we report a case of solitary peritoneal implantation in the diaphragm due to HCC, and the preoperative imaging, the histopathologic findings of the resected specimen, and the surgical procedure selected will be discussed with a review of the literature.A 50-year-old woman positive for hepatitis B virus underwent a right hemihepatectomy extended to a medial part of Couinaud segment IV for HCC in May 2000. The initial tumor was mainly located in Couinaud segment V and was 10 cm in diameter with capsule invasion. Histologically, it was moderately differentiated HCC with thick trabecular pattern with microscopic vascular invasion. In January 2001, partial resection of the medial segment was performed due to recurrence in the form of intrahepatic metastasis. During a period of 8 years after second surgery, no recurrence sign was detected by 5-year regular imaging follow-up at our hospital. In December 2008, the patient consulted a home doctor for chest discomfort and then was recommended to our hospital again for the purpose of general examination. The serum value of alpha-phetoprotein (AFP) increased to 248369 ng/mL . Computed tomography (CT) revealed a heterogenous mass, 9 × 7 cm in diameter, in the remnant liver . The masThe recurrence from HCC is usually detected in the remnant liver and as secondary metastases in the lung or bone. In spite of the preoperative diagnosis as an intrahepatic mass, two doubts, the markedly extrahepatic growth formation and feeding routs depending on IPA and IMA, were indicated. The IPA is known as the most common source of extrahepatic collateral blood supply for HCC , and theThe mechanism of peritoneal implantation from HCC is suggested to occur following rupture or invasion to the peritoneal cavity through the liver surface . The hepIt has been reported that the 1-, 3-, and 5-year survival rates after resection of peritoneal recurrence of HCC were 62.5%, 34.1%, and 30.1%, respectively, and the presence of capsule invasion was found to be the most significant prognostic factor . However


Jejunal diverticula are rare and are usually asymptomatic. However, they may cause chronic non-specific symptoms or rarely lead to an acute presentation.We report the case of an 82-year-old Caucasian woman presenting with a one-day history of generalized abdominal pain, with three episodes of vomiting. An abdominal X-ray displayed multiple dilated loops of the small bowel. A subsequent computed tomography scan of the abdomen and pelvis revealed a thickening of the duodenum and dilatation of the proximal jejunum. Multiple small bowel diverticula were identified with surrounding pockets of free air adjacent to the jejunal diverticula suggestive of a small bowel perforation. Our patient underwent a laparotomy, which identified multiple jejunal diverticula with two pinhole jejunal perforations and associated fecal contamination. The perforations were repaired with primary closure and extensive washout was performed.Jejunal diverticulosis in the elderly can lead to significant morbidity and mortality and so should be suspected in those presenting with crampy abdominal pain and altered bowel habits. Jejunal diverticula are rare with an incidence of less than 0.5% . PatholoDespite most cases of jejunal diverticulosis remaining completely asymptomatic, complications are reported in 10 to 30% of patients -4. TheseWe present a rare cause of acute abdominal pain with a case of perforated jejunal diverticula. We also review the literature associated with the management of small bowel diverticular disease.An 82-year-old Caucasian woman of Irish background, presented to the emergency department with a one-day history of generalized abdominal pain, with three episodes of vomiting. The patient had a past medical history significant for hypothyroidism and hypoalbuminemia secondary to malnutrition.9/L), an impaired renal profile  and an elevated serum lactate (4.6 mmol/L).On physical examination our patient's vital signs were a temperature 36°C, heart rate 105, blood pressure 90/50 and respiratory rate 16 breaths/min. Abdominal examination revealed a generalized abdominal tenderness and signs of peritonitis. Laboratory investigations revealed an elevated white cell count  contributed intellectual content and have read and approved the final manuscript.


We present a rare case of extramedullary plasmacytoma of the palatine tonsil with cervical lymph node involvement treated by surgical resection. A 58-year-old Caucasian male presented with a solitary 3 cm × 3 cm jugulodigastric lymph node and was found to have an ipsilateral tonsillar swelling. The involved tonsil and lymph node were surgically resected after two inconclusive fine-needle aspirates, and plasmacytoma was confirmed histologically and by immunocytochemistry. Adjuvant radiotherapy was not indicated as adequate resection was achieved at surgery. We also highlight the challenges of diagnosis when fine-needle aspiration is inconclusive and the need for careful planning before surgery. Extramedullary plasmacytomas are rare tumours which usually occur in the upper aerodigestive tract; it is even much rarer for them to originate from the tonsil. It is important to exclude systemic myeloma or multilesional disease in these patients. Long-term monitoring is mandatory to detect early local recurrence or conversion to multiple myeloma.A 58-year-old Caucasian male was referred to the otolaryngology outpatient clinic from the oncology department with a complaint of a right-upper neck mass which had been growing for one year. The mass was painless and had rapidly increased in size during the preceding 3 months. The patient reported no loss of weight and had no other masses. He denied swallowing or breathing difficulties. There was no history of exposure to tuberculosis. He was a farmer and life-long nonsmoker. On physical examination, he was a well-nourished man with a palpable, freely mobile nontender right level II lymph node measuring 3 cm × 3 cm. Oropharyngeal examination showed a moderately enlarged right tonsil. The rest of the physical examination was unremarkable. Rigid direct laryngoscopy showed a normal laryngopharynx and hypopharynx.Due to a possible vascular relation to the mass, an MRI of the neck was done, showing a sharply defined ovoid 3 × 3 × 4.5 cm nonspecific soft tissue mass with heterogeneous enhancement, likely a lymph node, with a mass-like bulge in the right tonsillar fossa suspicious for a primary tumour . This suTwo previous fine-needle aspirates (FNAs) of the neck mass had already been undertaken by the oncologists, but these were inconclusive. The aspirates were heavily blood stained and showed small tissue fragments composed of small lymphoid cells admixed with histiocytes. The sparse material suggested an inflammatory/reactive process, and flow cytometry was nondiagnostic. Therefore an excision biopsy with frozen sections was recommended for definitive diagnosis. If this revealed a squamous cell carcinoma, the operation would proceed to a selective neck dissection. The patient consented to the procedure and underwent a right tonsillectomy and excision of the enlarged lymph node. Frozen sections suggested a plasmacytoma and therefore a neck dissection was not carried out.Histologies of both the tonsillar mass and the lymph node were similar, showing effacement of normal architecture and extensive infiltration with diffuse sheets of neoplastic cells possessing plasmacytoid morphology with eccentric nuclei exhibiting “clock-faced” nuclear chromatin pattern that typically represent plasma cells. Binucleate and multinucleate forms were also present . The tonFurther immunohistochemical analysis on the specimens showed CD138 plasma cell marker positivity , while CSix months after surgery the patient remained well. Repeat immunoglobulin assay at the 3-month postoperative review showed that the monoclonal IgG had returned to normal levels, with normal light chains and no evidence of multiple myeloma on bone marrow biopsy and no lytic lesions on skeletal survey. Repeat investigations at the 6-month mark remained negative.Plasmacytomas are malignant proliferations of plasma cells that occur either in bone (medullary) or in soft tissue (extramedullary). Medullary or extramedullary disease may present as either solitary or multiple lesions. The systemic disease involving multiple lesions in bones  is the commonest plasma cell dyscrasia, accounting for over 90% of all plasma cell malignancies. The exact incidence of extramedullary plasmacytomas (EMP) is unknown, but they are rare, accounting for only 3%-4% of all plasma cell malignancies , 2. It iEMP of the tonsil usually presents as a unilateral tonsillar swelling, but at least one case of bilateral involvement of the palatine tonsil has been reported . EvaluatFNA may provide inconclusive results as it is sometimes difficult to distinguish inflammatory or reactive conditions from evolving tumours. However, FNA may be useful in SCC or recurrent EMP, especially if used in conjunction with a core biopsy and subsequent immunocytochemistry , 7. Imaging studies such as computer tomographic (CT) scanning, magnetic resonance imaging (MRI), and positron emission tomographic (PET) scanning usually provide useful information on the extent of local disease. Anatomical localization is enhanced with integrated PET/CT scanning, especially when localising EMPs outside the head region where it is proven to be more sensitive than MRI . Preferably all patients should be referred to a hematologist for further workup to exclude multiple myeloma or disseminated disease. Baseline full blood examination, serum calcium, urea, and electrolytes should be performed in addition to serum protein electrophoresis and immunofixation, urine Bence-Jones proteins, skeletal survey, and bone marrow examination. The abnormal plasma cells of EMPs originate from one cell line and all produce the same immunoglobulin, usually an IgG kappa light chain. In some patients this can be detected as a small monoclonal peak on immunoelectrophoresis called the M spike. With successful eradication of disease, the M spike disappears and this can be demonstrated on subsequent followup. Solitary EMP is managed with radiotherapy, surgery, or both. If a complete surgical resection is achieved, then no adjuvant radiotherapy is required as in our case . HoweverWe recommend reviews at 3 monthly intervals for the first year, 6 monthly for another year, and yearly thereafter for life. At each visit, in addition to a history and physical examination, laboratory testing including complete blood count, urea, creatinine and electrolytes, immunoelectrophoresis, and free light chains should be performed. This will be in addition to yearly monitoring with MRI . At any hint of recurrence such as new M spike, a full reevaluation is required including bone marrow biopsy and an integrated CT/PET.


Hypercalcaemic hyperparathyroid crisis is a rare but life-threatening complication of primary hyperparathyroidism. Parathyroid carcinoma is a rare malignancy with an incidence of 0.5% to 4% of all reported cases of primary hyperparathyroidism.We report the case of a 60-year-old Caucasian man with hypercalcaemic hyperparathyroid crisis associated with parathyroid carcinoma. He presented with a classic hypercalcaemic syndrome and his serum calcium and parathyroid hormone levels were at 4.65 mmol/L and 1743 ng/L, respectively. He initially presented with a two-week history of weakness and lethargy and a one-week history of vomiting, polyuria and polydipsia. An emergency left thyroid lobectomy and left lower parathyroidectomy were performed. There was a prompt decrease in his parathyroid hormone level immediately after surgery. Histology revealed that our patient had a 4-cm parathyroid carcinoma.en bloc resection with ipsilateral thyroid lobectomy and removal of any enlarged or abnormal lymph nodes. Surgery is the only curative treatment. In our patient, prompt surgical intervention proved successful. At six months the patient is well with no evidence of disease recurrence. This case highlights the importance of considering a hyperparathyroid storm in the context of a parathyroid carcinoma. Parathyroid carcinoma is a rare entity and our knowledge is mainly derived from case reports and retrospective studies. This case report increases awareness of this serious and life-threatening complication. This report also illustrates how prompt and appropriate management provides the best outcome for the patient.In patients with parathyroid carcinoma, the optimal surgical treatment is  Hypercalcaemic hyperparathyroid crisis is a rare but life-threatening complication of primary hyperparathyroidism. The symptoms of hypercalcaemia are frequently non-specific and reflect multi-organ involvement. This condition should be suspected in acutely ill patients with profound dehydration, gastrointestinal manifestations, urinary symptoms, altered mental state, or cardiac arrhythmias. Parathyroid carcinoma is a rare malignancy with an incidence of 0.5% to 4% of reported cases of primary hyperparathyroidism ,2.en bloc resection with ipsilateral thyroid lobectomy and the removal of any enlarged or abnormal lymph nodes [In patients with parathyroid carcinoma, the optimal surgical treatment is ph nodes . Surgeryph nodes .A 60-year-old Caucasian man was transferred from a regional hospital to a tertiary referral centre for the emergency management of hypercalcaemic hyperparathyroid crisis. He initially presented with a two-week history of weakness and lethargy and a one-week history of vomiting, polyuria and polydipsia. He became acutely confused in the 24 hours prior to his admission to our hospital and registered 12 on the Glasgow Coma Scale. On examination he was normotensive with a regular pulse of 70 beats per minute. There was a left-sided mass in the anterior triangle of his neck measuring 3 × 3 cm. The mass was firm, regular, non-tender and mobile. See Figure An ultrasonography of his neck showed a 4 × 3 cm large cyst in the left lobe of his thyroid gland. His parathyroid glands were not visualised. A 99 mTc-sestamibi scintigraphy scan was performed, and no evidence of a parathyroid adenoma was found. An electrocardiogram revealed acute changes with ST depression in leads II, III, aVF and V2 to V6. An echocardiogram showed good left ventricular failure (LVF) with an ejection fraction of 63%.Initial management included aggressive fluid resuscitation, cardiac monitoring and the administration of intravenous bisphosphonates. A left thyroid lobectomy and left lower parathyroidectomy were performed. At the time of operation, a haemorrhagic cyst with a parathyroid gland within it was visualised. A biopsy was taken from the left upper parathyroid gland. Histology revealed a 4 cm parathyroid carcinoma within the cyst which was fully excised. The cyst had a macroscopic measurement of 6 × 6 × 5 cm. The wall of the cyst contained a well-circumscribed, unencapsulated soft tissue mass measuring 4 × 2.5 × 0.7 cm. It was light yellow-tan in colour and firm in consistency. There was a small amount of normal thyroid parenchyma within the specimen. The biopsy of the left upper parathyroid gland revealed normal parathyroid parenchyma without diagnostic abnormality.Our patient remained intubated and ventilated overnight in the intensive care unit. His metabolic laboratory profile resolved quickly following the surgery Figure . A lowerIn 1850, Sir Richard Owen was the first to describe the parathyroid glands after performing an autopsy of an Indian rhinoceros. The first parathyroid surgery was undertaken by Felix Mandl in Vienna in 1925.Parathyroid carcinoma is a rare malignancy with an incidence of 0.5% to 4% in patients with primary hyperparathyroidism. The clinical presentation of parathyroid carcinomas and adenomas can be very similar, although patients with parathyroid carcinoma register significantly higher serum calcium, parathyroid hormone (PTH) and alkaline phosphatase levels compared with patients with adenomas see Table. A palpaOur knowledge of this rare condition is based on case reports and retrospective studies. One centre affiliated to the University of Crete reported five cases of sporadic parathyroid carcinoma over a 12-year period. The clinical presentation of the disease in these five patients was varied. The imaging modalities utilised in these patients were ultrasonography, Sestamibi scan and computed tomography (CT), all of which were able to locate parathyroid carcinoma in the patients. Four lesions were localized using ultrasonography and Sestamibi scan and one by CT. This case series highlighted the need for a high index of clinical suspicion to allow for prompt surgical intervention. It also highlighted the importance of initial surgical management, as prognosis can depend on the success of the first operation. It is also important to remember the serious malignant potential of this lesion at the time of resection .There are many different modalities for the preoperative localization of the parathyroid lesions. In our patient, a Sestamibi scan was preformed. In several centres, CT is preformed in patients with parathyroidism as it allows for improved preoperative planning for directed parathyroidectomy with a four-dimensional CT. CT is able to depict hyperfunctioning glands and to search for metastasis and abnormal lymph glands. Four-dimensional CT is a unique tool that allows for a precise preoperative localization of hyperfunctioning parathyroid glands .In cases of primary hyperthyroidism, surgical exploration of the neck and resection of the hyperfunctioning parathyroid tissue should be undertaken without further delay (within 72 hours). Parathyroidectomy by an experienced surgeon usually has a low complication rate (2.3%) and results in the patient's prompt recovery. The cure rate is reported as being as high as 98% [en bloc resection with ipsilateral thyroid lobectomy and the removal of any enlarged or abnormal lymph nodes. Initial appropriate and aggressive resection can help reduce local and distant recurrence [In patients with parathyroid carcinoma, the optimal surgical treatment is currence . Care mucurrence ,11. The currence .A decline in serum calcium should be expected in the first 24-hour postoperative period. The half-life of PTH is so short that the serum PTH level falls within minutes of successful surgery. Our patient's PTH level fell from 1743 ng/L preoperatively to 59.3 ng/L in the immediate postoperative period. The clinical course of this particular malignancy can be highly variable. Persistent or recurrent disease can occur in up to 50% of cases, while some patients are completely disease-free after the initial surgery. This contributes to the importance that should be placed on regular follow-up. In the literature, it seems apparent that tumour size does affect prognosis. The management of recurrent or metastatic parathyroid carcinoma reflects the rather indolent and surgical biology of this cancer compared with many other tumours .The prognosis of parathyroid carcinoma is quite variable. Not one characteristic correlates predictably with the outcome of prognosis. Early recognition and complete resection at the time of the initial surgery carry the best prognosis. The average time between surgery and the first recurrence is approximately three years, although intervals of up to 20 years have been reported. Once the tumour has recurred, complete cure is unlikely. A survey by the National Cancer Database reported 10-year survival rate to be approximately 49% .Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.KR drafted the article, performed the literature search, compiled the data, and acquired the images cited in this case report. NF assisted in performing the surgery and reviewed the manuscript. DOM supervised and edited the manuscript. EMD performed the surgery. All authors read and approved the final manuscript.


Few cases of GIST bigger than 15 cm have been reported in medical literature, all primarily in elderly patients. We report an unusual case, in which a giant gastric GIST – in a young patient – presented as spontaneous intratumoral bleeding followed by intraluminal rupture.A 37-year-old man was admitted with an acute onset of abdominal pain. CT showed a 32 × 25 cm mass with some cystic lesions and areas of calcification. Twelve hours after admission the patient presented with an episode of upper GI bleeding, and a significant decrease of tumor size and hemoglobin level. An upper endoscopy showed a large bulge in the posterior aspect of the gastric wall, and a small ulcer with continuous bleeding coming from a central orifice. A subtotal gastrectomy was carried out. Pathological examination showed a giant gastric GIST measuring 32 × 25 × 21 cm and weighing 3.750 g. Immunohistochemical staining demonstrated positive reactivity to C-kit protein, CD34, and α-smooth muscle actin; but negative reactivity to S-100 protein.Intratumoral bleeding is a very rare presentation of GIST; preoperative diagnosis is always made difficult by the absence of pathognomonic signs or symptoms. Emergency local excision with negative margins associated with adjuvant therapy with imatinib mesylate remains the main modality of treatment for high risk GISTs. Gastrointestinal stromal tumor (GIST) is a generic name for a mesenchymal tumor originating in the muscular wall of hollow viscera that expresses the c-kit proto-oncogen protein -3. Most We report an unusual case, in which a giant gastric stromal tumor (diameter >30 cm) is presented in a young patient as spontaneous intratumoral bleeding followed by intraluminal rupture.3 (4 band and 70 segmented neutrophils), platelets of 495.000/μL. Coagulogram, liver function tests, creatinine, and BUN were normal.A 37-year-old man was admitted to the emergency department of the University of Santo Amaro Medical Center with symptoms of abdominal pain. The patient reported a progressive fatigue and increase of abdominal girth for the last 5 months. The day before his admission the patient reported nausea, vomiting, and vague but persistent abdominal pain. Upon physical examination the patient was fully conscious and alert with a heart rate of 100 beats/min, a blood pressure of 115/65 mmHg, afebrile, and slightly malnourished. Abdominal examination revealed abdominal distension with a firm 30 × 30 cm palpable mass in the upper abdomen with minimal intrinsic mobility. Bowel sounds were hypoactive and rectal examination revealed an empty ampulla. Blood tests included a hemoglobin level of 8.4 g/dL, a white blood cell count of 12.800/mmAn abdominal X-ray showed a diffuse opaque area in the upper abdomen without a gastrointestinal gas shadow; hepatic colon flexure was dislocated downward, and the stomach to the corner of the abdomen Figure . A CT-scTwelve hours after admission the patient presented with an episode of upper gastrointestinal (GI) bleeding, a significant reduction of the palpable mass to 25 × 25 cm, and a decrease of the patient's hemoglobin level to 6.4 mg/dl. Fluid resuscitation was started immediately and the patient was transfused with two units of red blood cells. After hemodynamic stabilization an upper endoscopy was performed, showing a large bulge in the posterior aspect of the gastric wall with a small ulcer (1 cm in diameter) with edematous margins in the posterior part of the antrum, and significant bleeding coming from a central orifice.Under the diagnosis of persistent GI bleeding an emergency laparotomy was performed. A large cerebroid and hypervascularized mass occupying the entire abdominal cavity was observed, arising from the distal part of the stomach. No other significant findings such as ascites or locoregional metastasis were found at this time. A subtotal gastrectomy and omentectomy was carried out, and the tumor was completely ressected Figure . The surThe ressected mass was a well-circumscribed tumor weighting 3.750 g and measuring 32 × 25 × 21 cm. Cut sections demonstrated a pink, gray, and fish-flesh appearance. The solid parenchyma had focal areas of necrosis, and several blood-filled cysts Figure . The smaMicroscopically, spindle-shaped tumor cells with acidophilic cytoplasm surrounded by a well-defined cell membrane were growing externally from the gastric muscular propria. Nuclear atypia was prominent with mitotic activity of 10 mitoses/50 high-power field. Immunohistochemical staining demonstrated positive reactivity to C-kit protein, CD34, and α-smooth muscle actin, but negative reactivity to S-100 protein.The patient had an uneventful postoperative course and was discharged on the eighth postoperative day. The patient was put on imatinib mesylate 400 mg daily, and followed up in the outpatient clinic without any signs of recurrence 12 months after surgery.Gastrointestinal stromal tumor (GIST) is a generic name for a mesenchymal tumor originating in the muscular wall of a hollow viscera that expresses the c-kit proto-oncogen protein. The expression of this protein distinguishes GIST from the true leiomyomas, leiomyoblastomas, and other mesenchymal tumors of the GI tract -3,6,7. MIn general, tumor size > 5 cm) and mitotic index (> 5/50 high-power field) are accepted as two independent prognostic factors of gastrointestinal stromal tumor  cm and m. FollowiTransarterial embolization could be a reasonable alternative to control the GI bleeding in patients with GIST. However, we decided to perform exploratory laparotomy for two reasons. First, the patient presented a significant drop of hemoglobin levels (8.5 to 6.9 mg/dl) requiring aggressive fluid resuscitation and blood transfusion in order to maintain hemodynamic stability. Secondly, the size of the tumor and the fact that the upper endoscopy showed a continuous and profuse intraluminal bleeding, which would prevent the utilization of transarterial embolization.et al., evaluated 708 patients who underwent complete gross resection of a primary GIST. This study did demonstrate that imatinib increases recurrence free survival . However, no differences on patient survival were observed in this study (ACOSOG Z9001). Therefore, some authors suggest that adjuvant therapy should be consider for at least 1 year in patients with intermediate or high risk [Several ongoing clinical trials have been designed to investigate the use of imatinib mesylate as adjuvant therapy for resectable GIST . Recently deMatteo igh risk ,12.GIST usually presents as gastrointestinal bleeding or a palpable abdominal mass. Other rare presentations include bowel or biliary obstruction, dysphagia, abdominal pain, intussusception, and hypoglycemia ,5,13-15.Spontaneous rupture of gastric GIST occurs infrequently, and the most common site of rupture of these tumors is the GI lumen . HoweverWe herein report a rare presentation of intratumoral bleeding followed by intraluminal rupture of a giant gastric GIST resulting in upper GI bleeding. The occurrence of intratumoral bleeding followed by rupture can be confirmed through a number of ways. First, by the macroscopic examination of the tumor, showing a large cystic cavity filled with blood that communicates to the stomach lumen. Secondly, by a reduction of the size of the tumor from 30 × 30 cm to 25 × 25 cm upon physical examination. Finally, by a significant decrease of hemoglobin levels less then 12 hours after the patient's admission. For these reasons, we believe that our patient presented intratumoral bleeding one day prior to admission, when the symptoms started, with subsequent rupture of a blood-filled tumoral cavity into the gastric lumen.In conclusion, intratumoral bleeding is a very rare presentation of gastrointestinal stromal tumor; preoperative diagnosis is always difficult by the absence of pathognomonic signs or symptoms. The diagnosis should be suspect whenever there is a presentation of sudden abdominal pain in patients with an intraabdominal mass. Emergency local excision with negative margins associated with adjuvant therapy with KIT tyrosine kinase inhibitor remains the main modality of treatment for high risk gastrointestinal stromal tumors.The authors declare that they have no competing interests.RJCJ, RV, BMK and ALC participated in the admission and the care of this patient, the conception, manuscript preparation and literature search. LAC performed histopathological analyses and helped manuscript preparation. All authors read and approved the final manuscript.


Acrochordons are usually small in size and are easily treated with electrofulguration under local anaesthesia. Here is a report of a giant acrochordon which posed problems in management. A technique to manage it under local anaesthesia in an office setting is described. Acrochordon is an extremely common, soft, skin colored, round or oval, pendunculated papilloma. It is usA 40-year-old female presented with the history of solitary, painless and bag-like growth over the right thigh. Starting as a small tag, growth had increased to the present size in the span of 25 years. Patient had seen several doctors who had advised excision under general anaesthesia. She had refused surgery because of fear of invasive procedure.On examination, patient had a soft, non-tender, pedunculated growth measuring 6 × 7 × 8 inches over upper part of right thigh . She alsInformed consent was obtained for excision under local anaesthesia. The lesion and the adjoining areas were cleaned using surgical spirit and povidone-iodine solution. Lesion was anaesthetized by infiltrating the base of pedicle by 2% xylocaine with adrenaline . Base of the pedicle was crushed and clamped by two large-sized artery forceps, pedicle was shaved parallel to the skin surface, with curved scissors.[Histopathology of the specimen revealed hyperkeratosis, acanthosis, loosely arranged collagen fibres. No malignant cells were seen. Follow-up after 1½ years showed a minor scar which was quite acceptable to the patient .Many patients are afraid of hospitalization and surgery because of fear of bleeding and possible complications. In the case reported herein, a giant acrochordon persisting for 25 years was completely removed, with no recurrence on follow-up for 1½ years. The minor scar left was quite acceptable to the patient. The case is reported because of rarity of giant size acrochordon (weight 2.5 kg) and very good cosmetically acceptable result by simple outpatient procedure.


The situs inversus is a rare congenital anomaly, which is a more or less complete inversion of the abdominal and thoracic organs. We report a case of 70 years old man, without pathological antecedents complaining about epigastric pains associated to haematemesis, and whose gastric endoscopy objectified a gastric tumor. The pulmonary x-ray and the abdominal computed tomography (CT) revealed the previously unrecognized situs inversus totalis. A subtotal gastrectomy was performed and patient had an uneventful postoperative course. Situs inversus totalis is a congenital anomaly, occurring at an incidence of 1 in 10 000–50 000 live births [3, blood urea of 12 mg/dL, a creatinine level of 0,7 mg/dL. Dextrocardia was seen on the chest x-ray , a blood pressure of 130/80 mm Hg. The patient was pale looking; the apex beat was in the right fifth intercostal space, midclavicular line. The heart sounds were normal. Nothing abnormal was found in the respiratory system. Abdominal examination revealed that the liver dullness was on the left side. There was a little tenderness in the epigastrium, but no mass was felt. On rectal examination the prostate was found to be moderately enlarged. The laboratory findings were: an hematocrit of 25%, an hemoglobin of 10 g/dl, a white blood cells of 8500/mmChest X-ray revealed a right sided heart fig. . The abdBased on the endoscopic and imaging findings we made a decision to perform a laparotomy. The abdomen was explored through a midline epigastric incision. There was complete transposition of the viscera fig. , the stoHistologic examination of the specimen showed a liberkunien middle differentiated adenocarcinoma, with serosal invasion and 3 lymph nodes metastasis . The patient's postoperative course was uneventful. She was commenced on chemotherapy.In 1600 the first known case of situs inversus in humans was reported by Fabricius . The terIn 1936, Allen described a case of a prepyloric carcinoma of the stomach in a 30-year-old man with situs inversus and who three weeks after gastrectomy died . There iThe diagnosis of complete visceral transposition itself should not be currently difficult. However, if abdominal viscera alone are involved, the incorrect position of the diseased organ may be suspected. In our patient, thoracic and abdominal situs inversus was detected during the physical examination and routine medical evaluations on admission.CT with multiplanar reconstruction (MPR) has become an established technique for the noninvasive imaging of abdominal vessels. With the availability of high resolution CT data sets, a wide variety of two-dimensional and three-dimensional reformations can now be acquired . BecauseThe operation itself presented little difficulty. Some surgeons recommend reversing the positions of the operator and the assistant during surgery, but this do not seem to be critical. Needless to say, careful and cautious assessment of abnormalities by preoperative examinations is very important before any surgical procedure is performed, especially for laparoscopic procedures .Subtotal gastrectomy with lymph node dissection (D2) is the preferred operation for malignant antrum cancer of the stomach due to the high incidences of multiple lesions of the stomach and involvement of the regional lymph nodes . ChemothSitus inversus presenting with gastric cancer is very rare. Preoperative information and good adaptation to the mirror image anatomy are essential for planning appropriate intervention.Written informed consent was obtained for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."The authors declare that they have no competing interests.EBB is a surgeon who was drafting the manuscript and revising it critically for content. FZ is a surgeon who was involved in literature research. KM, KA were surgeons treating of the patient and were involved in revising the draft critically for content. OA is a surgeon was getting photographs and was involved in drafting    manuscript. All authors have given final approval of the revision to be published.


Blue rubber bleb naevus syndrome is a rare vascular disorder associated with multiple gastrointestinal haemangiomas that have the potential for life-threatening haemorrhage. These may be difficult to diagnose, and have classically been described using computed tomographic studies and/or mesenteric angiography. Resected surgical specimens of these lesions, especially in the small bowel, have often been extensive and poorly localized. The recent advent and progressive development of double balloon enteroscopy has allowed the direct visualization and marking of these enteric lesions and serves as a valuable adjunct not only in diagnosis but also planning prior to surgery to allow accurate estimate of the extent of resection. Blue rubber bleb naevus syndrome, also known as Bean Syndrome was first described in 1958 on the basis of 1-2 cm violaceous cutaneous lesions, is a rare disorder consisting of gastrointestinal vascular malformations, which carry a significant potential for serious haemorrhage. The majority of cases are sporadic, however it has been postulated that this syndrome may manifest as a familial vascular malformation with autosomal dominance and associated with the TEK tyrosine kinase receptor which is almost exclusively endothelial and involved in endothelial-smooth muscle cell signaling [The predominant location of these lesions in the small intestine can make them difficult to diagnose. Double balloon enteroscopy was developed in 2001 as a technique to endoscopically visualize the small bowel in real time and allow therapeutic intervention such as biopsy, dilatation and placement of stents, and it has largely supplanted CT enteroclysis and angiography in the diagnosis of small bowel sources of blood loss [A 58-year-old female, Irish, Caucasian patient presented, on a background history of chronic anaemia, with fatigue, palpitations, dyspnoea and haemoglobin of 5.4 g/dL. She had received intermittent blood transfusions during the previous three years. Oesophagogastroduodenoscopy and colonoscopy were normal. She was positive for occult blood. Computed tomography (CT) enteroclysis was performed which demonstrated nodular thickening of the distal jejunum Figure . CT meseThe patient underwent a mini laparotomy via a 5 cm incision, with segmental jejunal resection and primary hand-sewn anastomosis. She made an uneventful post-operative recovery. Histology demonstrated sections of jejunal polyps showing multiple cavernous haemangiomas, many of which showed organizing thrombus. Given the multiplicity, these were consistent with the blue rubber bleb naevus syndrome.et al demonstrated the surgical resection resulted in elimination of bleeding in nine out of ten patients without recurrence over a five year follow-up period [Blue rubber bleb naevus syndromes affecting the gastrointestinal tract are uncommon and, present a diagnostic challenge to those investigating cases of occult gastrointestinal anaemia or haemorrhage. There have been a number of medical modalities employed to treat this condition using anti-angiogenic agents such as corticosteroids, interferon-alpha and octreotide, but to little clinical effect ,4. Some p period .et al, using DBE to identify gastrointestinal blood loss, localization of bleeding was provided in 95% (53/56) patients, and allowed prompt and accurate surgical resection in all but a single patient [In this report, we highlight the value of DBE in pointing the location and extent of this condition. In a retrospective study by Lin  patient . DBE appDBE is a valuable adjunct not only in diagnosis but also planning prior to surgery to allow accurate estimate of the extent of resection.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.FOK and KTL drafted the manuscript and prepared the figures. NR, NM and JVR reviewed and amended the manuscript. All authors read and approved the final manuscript.


The presence of primary aneurysmal cyst in soft tissues is a extremely rare and its presence in the soft tissues of hand has never been reported in literature before. We report the first ever case of extraosseous aneurysmal cyst in hand.A twelve years old girl presented with a swelling in the thenar region on palmer aspect of right hand growing slowly since three months. On X ray, CT scan and excision biopsy the lesion was found to be separate from bone and located in the soft tissue. Its diagnosis was confirmed on histopatholgical examination.Previously few authors have reported extraosseous aneurysmal cyst in the soft tissues of shoulder, hip and pelvic girdle but nobody has reported its presence in the soft tissues of hand. Aneurysmal bone cyst is defined as a lesion of bone characterised by the presence of spongy or multi locular cystic tissue filled with blood. The presence of aneurysmal cyst in soft tissues is a rare phenomenon and its presence in the soft tissues of hand has never been reported before.A twelve years old girl presented with slow growing swelling in the thenar palmer aspect of the right hand since three months. It was not accompanied by pain. There was no history of trauma. On palpation a bony hard, immobile mass, measuring 4.5 cm. in diameter was felt on the thenar eminence. It was non-tender and was not fixed to underlying bone.The X ray showed a lytic lesion with sharply circumscribed bony outline and accompanying mild periosteal reaction in the first metacarpal region fig. . A subseAneurysmal bone cyst arises usually as a primary benign tumour of bone. Lesion is usually primary and less commonly secondary, superimposed on pre-existing benign or malignant bone lesions .There are very few instances of aneurysmal cyst reported in soft tissue. Aneurysmal bone cyst is an infrequent finding in hand . Two autA thorough literature search and an exhaustive online search revealed no reported cases of aneurysmal cyst in the soft tissue of hand. If we encounter it in unusual sites like hand then it should be diagnosed based on its histology. Depending on symptoms we would advocate it to be treated with an excision surgery.CT scan: Computerised Tomographic scan."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."This is to confirm that the patient has given her informed consent for the case report to be published.The authors declare that they have no competing interests.AS analyzed and interpreted the patient data regarding the presentation and writing the report. SSG performed the literature search and wrote the discussion. SG performed the excision biopsy. He also helped in writing the clinical presentation and conclusion. All authors read and approved the final manuscript.The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK


Intramedullary spinal epidermoid cysts are rare, with only few cases having been reported in the literature. We are reporting a case of a 10-year-old female child who presented with symptoms of meningitis with progressive paraparesis. Magnetic resonance imaging of the spine revealed an intramedullary epidermoid cyst from C6 to D5. Near-total excision of the tumor was performed. Histopathological report confirmed the diagnosis of epidermoid cyst. The patient showed progressive recovery. Intraspinal epidermoid cyst is a rare tumor. The incidence of intraspinal epidermoid cysts in children is 3% and in adults is 1%.45 We rep4A 10-year-old female child was referred by a private practioner with history of high-grade fever on and off, pain in the nape of the neck and nuchal rigidity in combination with progressive spastic quadriparesis of 15 days duration. This constellation of symptoms pointed toward provisional etiology of meningitis or meningoencephalitis. Keeping a high probability of meningoencephalitis from this constellation of symptoms, the patient was initially evaluated and treated by pediatric side. The fever subsided with the conservative treatment. She did not have any cutaneous spine manifestation or any procedure on the spine in the past. She had a spastic paraparetic gait with power in both lower limb 4/5 and in upper limb 3/5 on the MRC scale. There was hypertonia in all four limbs, with all deep tendon reflexes exaggerated and symmetrical. Planters were extensor type. There was no sensory deficit except that the patient had occasional radiculitis of the bilateral upper limb. Sacral dermatomal sensations and bladder function was equally preserved.Initially, cerebrospinal fluid examination by gram staining, cytology and culture excluded an anticipated infective etiology. Plain X-rays of the spine were normal and not conclusive to final diagnosis. MRI revealed a well-defined nonenhancing intradural intramedullary oblong and oval cystic lesion extending from the lower border of C6 to the lower border of D5 vertebra with signal characteristics suggestive of intradural intramedullary epidermoid cyst, the lesion being hypointense on T1-weighted sequence and hyperintense on T2 sequence. The margins of the lesion had a shaggy appearance. The study did not show any spinal dysraphism .Tumor was approached by laminectomy from C7 to D5. There was a distinct bulge of the dura, which, after opening, revealed a widened cord with a bulge. A midline myelotomy was performed and a pearly white lesion within the substance of the cord was seen. The lesion expressed a yellowish-white pultaceous material on incision. Near-complete dissection of cyst was performed.Histopathological examination revealed fibrous tissue lined in combination with compressed stratified squamous epithelium. These findings were consistent with epidermoid cyst .The patient made an uneventful recovery with subsequent improvement in her neurological status. The patient was provided with SOMI brace for 2 months. At the end of 2 months, the pt gained 4+/5 power in lower limb and 4/5 in the upper limb, but some residual spasticity remained.Epidermoid cysts are mainly congenital as they take origin from anomalous inclusion of the ectoderm tissue during the closure of the neural tube in early fetal life and possibly may be associated with defective closure of the dural tube. This may have manifestations of other forms of dysraphism, such as syringomyelia, dorsal dermal sinus, spina bifida and hemivertebrae.7 Iatrogeet al. found 47 cases of spinal intramedullary epidermoid cysts in the literature and in their clinic. In our literature survey, we have found 19 cases since then.[14Epidermoid tumors rarely occur in the central nervous system, and are even rarer in the spinal canal. Even the largest series of neural tumor found an incidence of spinal epidermoid cyst at 0.7%. Intramedullary localization is extremely rare. In 1989, Roux ce then.14–9 The cce then.145There are other entities that may pose a challenge to preoperative diagnosis, like dermoid cyst, teratoma, ependymomas, astrocytomas and hemangioma, owing to their intramedulary localization. However, typical signal intensity, absence of peritumoural edema, sharp boundaries and minimal peripheral enhancement with gadolinium confine the diagnosis to an epidermoid cyst.10 Our caHistologically, epidermoid cysts are lined by the stratified squamous epithelium supported by an outer layer of collagenous tissue. Desquamation of keratin from the epithelial lining toward the interior of the cyst produces a soft white material. Absence of skin adnexa will rule out the diagnosis of dermoid cyst.The treatment of epidermoid cyst is essentially surgical. Literature shows radiotherapy as a modality in only one case. Emptying58


The differential diagnoses of acute abdomen in children include common and rare pathologies. Within this list, different types of bezoars causing gastrointestinal obstruction have been reported in the literature and different methods of management have been described. The aim of this article is to highlight a rare presentation of lactobezoars following prolonged percutaneous endoscopic gastrostomy feeding and its successful surgical management.A 16-year-old boy was admitted to a paediatric ward with abdominal distension and high output from his permanent gastrostomy feeding tube, with drainage of bilious fluids. The clinical, radiological and endoscopical examinations were suggestive of partial duodenal obstruction with multiple bezoars in the stomach and duodenum. Gastrojejunostomy was performed after the removal of 14 bezoars. The child had an uneventful postoperative course and was discharged on the sixth postoperative day in a stable condition.Lactobezoars should be included in the differential diagnosis of acute abdominal pain in patients with percutaneous endogastric feeding. Endoscopy is important in making the diagnosis of this surgical condition of the upper gastrointestinal tract in a child. Clinical assessment of acute abdomen in children poses a challenge to both the paediatrician and the surgeon. Foreign bodies are one of the main causes of acute abdomen in children. In general, most upper gastrointestinal (GI) tract foreign bodies are related to food impaction, with meat being the most frequent culprit . BezoarsA 16-year-old boy was admitted to a paediatric ward because of abdominal distension and a high output from his percutaneous endogastric (PEG) tube, with drainage of bilious fluids. He had been admitted twice over the last 6 months because of abdominal distension and constipation, and had been treated conservatively with intravenous fluids and enemas and had responded well.His past medical history was suggestive of cerebral palsy and convulsions. He had a significant surgical history of a ventriculo-peritoneal shunt, Nissen anti-reflux surgery, and insertion of a PEG tube at the age of 4 years.Clinical and radiological examinations indicated incomplete duodenal obstruction (see figures A bezoar is a concretion of foreign material in the GI tract. Depending on the material contained within, they may be trichobezoars, phytobezoars, lactobezoars or others. Phytobezoars are more common, while trichobezoars are rare. Common predisposing factors are previous gastric surgery, psychiatric illness, coeliac disease and metabolic disorders such as uraemia .Recurrent abdominal pain or acute small bowel obstruction is the usual presentation of a GI bezoar. A history of foreign body ingestion, especially in children and mentally impaired patients, is important . Rarely,A range of methods have been used in the management of bezoars. These include endoscopy, surgery, combined laparoscopy and surgery, and the use of emulsifying chemical materials. In uncomplicated cases, endoscopic or surgical removal can be appropriate . For ourLactobezoars should be included in the differential diagnosis of acute abdomen in children with PEG feeding. Early surgical assessment is important in the management of this condition. Endoscopy in children can be important in the diagnosis of surgical conditions of the upper GI tract.The authors declare that they have no competing interests.Written informed consent was obtained from the patient's next-of-kin 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.AH wrote the article, participated in the sequence alignment and drafted the manuscript, HM participated in the sequence alignment, formatted the pictures and performed language corrections, TS collected the data and investigation studies, participated in the article design and critically evaluated the article, SEH conceived the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


Mesenteric lymphatic malformations are rare, benign tumors that are most commonly found in children. The presentation of these tumors is variable and may either be innocuous or life threatening. It has been suggested that mesenteric lymphatic malformations are congenital; however, there is evidence that their growth may be stimulated by local trauma.We describe the first case of a mesenteric lymphatic malformation associated with acute appendicitis in a 13-year-old Caucasian boy. The patient is well six months after surgical excision of the tumor.The reader should be aware that growth and/or development of mesenteric lymphatic malformations may be associated with trauma and other pro-inflammatory processes. Mesenteric lymphatic malformations (MLM) are rare, benign tumors that most commonly develop in children . The nomA 13-year-old Caucasian boy presented with acute appendicitis, characterized by right lower quadrant pain. He underwent a laparoscopic appendectomy, and a pathology report confirmed the diagnosis of focal acute appendicitis. No intra-abdominal masses were noted at the time of surgery. However, after the operation, the patient experienced persistent drainage of serosanginous fluid from a trochar site. Once this drainage ceased, the patient was discharged home ten days after admission.During the next six months he continued to experience intermittent abdominal pain, which led to representation to the emergency room. Additionally, the patient experienced an increase in abdominal girth, abdominal pain, and weight loss. No constipation, diarrhea, nausea, vomiting or jaundice was reported. A CT scan of the abdomen and pelvis demonstrated a 23 by 12.5 cm fatty soft tissue mass surrounded by mesenteric fat  and vein (SMV). A frozen biopsy performed during the operation suggested that the mass was a lymphatic vascular malformation with a fibrous stroma and fibrous capsule consistent with a benign tumor. The operation was converted to a midline laparotomy for tumor resection. As mentioned earlier, the tumor was largely entangled with the mesentery. However, a circumferential dissection was performed through the creation of a plane between the tumor and mesentery. The SMA, the third and fourth portions of the duodenum, and the proximal small bowel were each affixed to the tumor but were successfully dissected off. The tumor was excised along with 50 cm of small bowel, and a primary anastamosis was performed Figure . The finMLM are rare with reported frequencies of 1 in 20,000 to 1 in 250,000 admissions . In factThe etiology of MLM is unknown, although it has been proposed that they may be associated with developmental anomalies of the lymphatic system, secondary to a failure of the lymphatic system to connect with the venous system. This theory may, in part, be supported by the predominance of MLM in children. Other possible causes include inflammation in the lymphatic channels, resulting in obstruction and subsequent lymphangioma formation . It has A highly unusual feature of this case report is that the patient's MLM apparently developed in connection with his appendicitis. This raises one of two possibilities. First, it is possible that the patient's mass was simply not seen during the first surgery. This is possible since persistent drainage from the trochar sites complicated the patient's condition after the operation, suggesting that the MLM may have already been present. The second possibility is that the appendicitis or the surgery and appendectomy triggered an exponential growth of the MLM. Since no imaging was obtained during the initial diagnosis, there is no way to determine conclusively whether or not the mass was absent. However, it certainly appears that the mass developed, or more probably, grew exponentially after the appendectomy.MLM are rare tumors that are more common among children. They may be associated with a range of clinical symptoms and are best treated with surgical resection since they may grow to a large size, compress vital structures and cause intra-abdominal catastrophe. We describe the first case of development of a MLM associated with appendicitis and suggest that the trauma of surgery may have triggered the exponential growth and development of this tumor. We recommend that surgeons and pediatric health care providers be aware of this association and consider it in their differential diagnoses.CT: computed tomography; MLM: mesenteric lymphatic malformations; SMA: superior mesenteric artery; SMV: superior mesenteric vein.The authors declare that they have no competing interests.Written informed consent was obtained from the patient's parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CH obtained the images and wrote the manuscript. LW prepared the images. MC, SL, and NN contributed significantly to the writing of this manuscript.


Ewing’s sarcoma is a malignant non-osteogenic primary tumor of the bone. It is one of the most common primary malignant tumors of bone. Peak incidence is noticed in second decade of life with male preponderance of 1.6:1. It occurs most frequently in long bones and flat bones of pelvic girdles. In 30% cases, Ewing’s sarcoma is multicentric in origin. In 14-50%, multiple metastases are present at the time of diagnosis. CNS spread is rare and isolated CNS involvement is not seen. Skull metastasis of Ewing’s sarcoma is not rare compared to primary Ewing’s sarcoma of the skull, but the actual frequency is unknown. We wish to report a case of “Primary Ewing’s sarcoma of scapula with metastasis to Skull Vault in a Child resulting in sutural diastasis” diagnosed by clinicoradiological examination and confirmed by histopathology. Ewing’s sarcoma is a malignant non-osteogenic primary tumor of the bone. It is one of the most common primary malignant tumors of bone. Peak incidence is noticed in second decade of life with male preponderance of 1.6:1. It occurs most frequently in long bones and flat bones of pelvic girdles. In 14-50Ewing’s sarcoma is a malignant non-osteogenic primary tumor of the bone. Originally, James Ewing described it in 1921 as a tumor arising from undifferentiated osseous mesenchymal cells; however, recent studies suggest that Ewing’s tumor may be neuroectodermally derived from the primitive neural tissue. Ewing’s 2The management of Ewing’s sarcoma includes multiagent neoadjuvent chemotherapy followed by enblock excision of the tumor mass. Postoperative radiotherapy is given if there is doubt of tumor residua. The most unfavorable prognostic factor in Ewing’s sarcoma is the presence of distant metastasis at diagnosis. Other unfavorable prognostic factors include an age older than 10 years, a size larger than 200 ml, more central lesions (as in the pelvis or spine), and poor response to chemotherapy.–7A 5-year-old boy presented with 5 months history of pain followed by swelling around the right shoulder girdle. 2 months prior to consultation at J N Medical College, AMU, Aligarh, patient’s mother noticed gradually increasing swelling over scalp. The patient had no history of headache, weakness of upper and lower limbs. There were no signs of raised intracranial tension. There was no evidence of weakness of upper and lower limbs and other localizing signs of intracranial mass. On clinical examination, the shoulder girdle swelling was diffuse with ill-defined margins, firm to hard in consistency with tense and shiny over lying skin . Scalp sEwing sarcoma is the most common primary bone tumor of the flat bones. Primary Ewing’s sarcoma of skull vault is very rare. Skull metastasis of Ewing’s sarcoma is not rare compared to primary Ewing’s sarcoma of the skull, but the actual frequency is unknown.–15et al, concluded that diagnosis of Ewing’s sarcoma by roentgenography alone is in some cases not warranted at all and in others it is, at best, a presumptive diagnosis which requires confirmation by histological examination in all.[In our patient appearance of a scapular lesion was consistent with osteogenic sarcoma, as the lesion is primarily sclerotic and it does not look like Ewing’s at all. Radiographic appearance of Ewing’s sarcoma in the thorax is quite variable and the lesion may be primarily lytic or sclerotic or may represent the mixture of the two.11 A univn in all.Secondry skull lesions presents with osteolysis with erosion of inner and outer table associated with soft tissue swelling on plain radiographs. In our patient metastasis from primary lesion resulted in sutural diastasis. Similar skull involvement may also be seen in lesions in Eosinophilic granuloma/Hand–Schuller–Christian syndrome, Burkitt’s lymphoma, fibrous dysplasia, aneurysmal bone cysts, osteoclastoma, and giant cell reparative granuloma. Radiologically it is difficult to distinguish them; however, they can be distinguished by a different pattern of destruction of skull vault, presence of soft tissue swelling, calcification, cystic component, and septations. However, histopathology is more specific for their differentiation. MRI is the imaging modality of choice for evaluating the extent of the primary tumor, to monitor the response to neoadjuvent chemotherapy and to follow up unresected Ewing’s sarcoma. Bone scintigraphy is necessary to detect skeletal metastasis at the earliest, and 201-thalium scanning has been shown to be sensitive in the monitoring of the response to treatSkull metastasis of Ewing’s sarcoma is not rare compared to primary Ewing’s sarcoma of the skull, but metastasis resulting in sutural diastasis is rare. Patient presents with scalp swelling with or without non-specific neurological signs. CT scan and MRI delineate skull vault lesion with associated epidural soft tissue mass. Histopathology differentiates it from other primary skull vault lesions.


A 73-year old man presented with dysphagia for liquid and solid food. Barium contrast study of the esophagus and esophagoscopy demonstrated a fibrovascular polyp. This, almost 10 cm benign esophageal tumor, was removed surgically by a cervical esophagotomy. A fibrovascular polyp is a rare benign tumor of the esophagus, which, however, may give serious complications as asphyxia resulting from laryngeal obstruction leading to sudden death. Dysphagia is a serious symptom and it can be caused by malignant process such as esophageal cancer or compression of the esophagus, neurological and motility disorders such as achalasia, or benign disorders like strictures, diverticula or esophagitis. However, seldom dysphagia is caused by a benign polyp, which protrudes in the esophagus.A 73-year old male patient presented with dysphagia that existed for about four months. He reported the sensation of a mass in his throat during swallowing of solid as well as liquid food. The complaints suggested an intraluminal tumor. Barium contrast study demonstrated a tubular intraluminal mass originating from the proximal esophagus distal to the crico-esophageal junction Figure . EsophagMacroscopically, an almost 10 cm sausage-shaped mass was removed Figure . HistoloBenign tumors of the esophagus account for 20% of the esophageal lesions. 60–80% of the lesions are leiomyomas, typically occurring as intramural lesions in the middle and lower esophagus . The secFibrovascular polyps are postulated to originate from two areas of lower resistance in the pharyngeal musculature. One is between the superior and inferior cricopharyngeal muscle (Killian's dehiscence), the other is between the inferior cricopharyngeus muscle and the proximal end of the esophagus (the Laimer's triangle). In these areas, nodular submucosal thickenings of submucosal folds may evaginate through the mucosa. Due to peristaltic activity and traction the evagination increases to a giant polyp up to 25 cm in length . HistopaSince the polyp is slowly growing, it may become symptomatic after years. The most common complaints include dysphagia and sensation of a mass. Other complaints are retrosternal or epigastric discomfort, odynophagia, vomiting, weight loss and respiratory symptoms such as persisting cough and shortness of breath. The most distinctive feature of a fibrovascular polyp is regurgitation into the mouth . A feareFibrovascular polyps are visualized by different modalities such as barium contrast studies, esophagoscopy, endosonography, CT scanning and MRI. A barium contrast study typically demonstrates a significant intraluminal-filling defect within the widened esophagus, from the upper esophagus till the gastro-esophageal junction, while on swallowing the defect moves along. The polyp is shown by endoscopy, however, since it is covered with normal mucosa, it is easily missed. Chest x-ray shows a posterior mediastinal mass. CT scanning, MRI or ultrasonography can be useful to diagnose the fibrovascular polyp. In particular, MRI might be decisive in the choice of treatment by demonstrating the composition of the polyp. If the mass consists predominantly of fat with a minimal blood supply, the risk of bleeding during an endoscopic treatment is small. In case the polyp is rich of vascular structures, endoscopic resection can be troublesome due to uncontrollable bleeding . TherefoA fibrovascular polyp is a seldom-occurring benign tumor of the esophagus causing dysphagia. It is to be removed by surgical excision preventing serious complications such as asphyxia and laryngeal obstruction.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 journalThe authors declare that they have no competing interests.MMJB was first author. CEJS was involved in collecting pictures, performing surgeon and was the second author. IPVM was involved in case preparation and was the referring gastroenterologist. TW was the performing surgeon and was involved in supervision


The granulomatous inflammation of tuberculosis usually involves the lungs and the hilar lymph nodes. Musculoskeletal tuberculosis (TB) occurs in 1–3% of patients with TB, while TB of the chest wall constitutes 1% to 5% of all cases of musculoskeletal TB. Furthermore, nowadays it is rarer to find extrapulmonary TB in immunocompetent rather that non-immunocompetent patients. The present case reports a fifty-six-year-old immunocompetent man with an anterior chest wall tuberculous abscess. The rarity of the present case relates both to the localization of the tuberculous abscess, and to the fact that the patient was immunocompetent. The diagnosis of musculoskeletal tuberculous infection remains a challenge for clinicians and requires a high index of suspicion. The combination of indolent onset of symptoms, positive tuberculin skin test, and compatible radiographic findings, strongly suggests the diagnosis. TB, however, must be confirmed by positive culture or histologic proof. Prompt diagnosis and treatment are important to prevent serious bone and joint destruction. Musculoskeletal tuberculosis (TB) occurs in 1–3% of patients with TB , while TThis case report is interesting because it reports a case of chest wall TB in an immunocompetent patient.Mycobacterium tuberculosis grew on culture of a specimen of the tissue and this was further confirmed with PCR Amplicor (Roche). A drain was placed in the wound and a large dressing was applied over the right thoracic wall. The patient is currently receiving daily antituberculous chemotherapy, consisting of isoniazid (300 mg), rifampin (600 mg), pyrazinamide (2 g), and pyridoxine (50 mg). The postoperative course has been uneventful and a postoperative CT showed no recurrence of the drained tuberculoma.A fifty-six-year-old man who immigrated to Greece from Georgia (former USSR) came to the emergency department for evaluation of a gradually enlarging soft tissue mass in the right anterior thoracic wall. The mass had been present for fifteen years. During the last three months, it had grown more rapidly than before and the patient suffered from local pain. The medical history of this patient was unremarkable. He had no pulmonary symptoms, such as a productive cough, or other symptoms. Examination revealed that the patient was afebrile and well nourished. The findings on clinical examination were unremarkable, except for a large, firm, mobile , and tender soft tissue mass in the right anterior thoracic wall Fig. . The whiTuberculous abscesses of the chest wall can involve the sternum, costochondral junctions, rib shafts, costovertebral joints and the vertebrae. They are most frequently found at the margins of the sternum and along the rib shafts . The parTuberculous muscle infection may result from direct inoculation or hematogenous dissemination from a primary focus such as the lung . The onsTuberculous infections have been increasing in incidence during the last decades for a variety of reasons, including increasing numbers of patients with immunity-depressive diseases, drug resistance, aging population, and health care worker exposure . None ofThe granulomatous inflammation of tuberculosis usually involves the lungs and the hilar lymph nodes, and anterior chest wall involvement is very rare. Furthermore, nowadays it is rarer to find extrapulmonary TB involving immunocompetent patients than non-immunocompetent. The diagnosis of musculoskeletal tuberculous infection remains a challenge for clinicians and requires a high index of suspicion. The combination of indolent onset of symptoms, positive tuberculin skin test, and compatible radiographic findings, strongly suggests the diagnosis. TB treatment is often started immediately after the appropriate microbiological and histological samples have been obtained if the clinical suspicion is high. TB, however, must be confirmed by positive culture or histologic proof. Prompt diagnosis and treatment are important to prevent serious bone and joint destruction.The author(s) declare that they have no competing interests.Papavramidis T.S. 1) Received the patient to the emergency department and participated to the operation. Treating doctor. 2) Involved in drafting the manuscript and revising it critically for important intellectual content. 3) Have given final approval of the version to be published.Papadopoulos V.N. 1) Main surgeon. 2) Have been involved in revising the draft critically for important intellectual content. 3) Have given final approval of the version to be published.Michalopoulos A. 1) Auxiliary surgeon. 2) Have been involved in revising the draft critically for important intellectual content. 3) Have given final approval of the version to be published.Paramythiotis D. 1) Received the patient to the emergency department and consulted on the pharmaceutical treatment. 2) Have been involved in drafting the manuscript. 3) Has given final approval of the version to be published.Potsi S. 1) Performed all imaging studying. 2) Has been involved in drafting the manuscript. 3) Has given final approval of the version to be published.Raptou G. 1) Performed all pathologic evaluation. 2) Has been involved in drafting the manuscript. 3) Has given final approval of the version to be published.Kalogera-Foutzila A. 1) Evaluated the imaging studies. 2) Has been involved in revising the draft critically for important intellectual content. 3) Has given final approval of the version to be published.Harlaftis N. 1) Strategic planning for the treatment of the patient. 2) Has been involved in revising the draft critically for important intellectual content. 3) Has given final approval of the version to be published.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Peutz-Jeghers syndrome (PJS) is a rare familial disorder characterised by mucocutaneous pigmentation, gastrointestinal and extragastrointestinal hamartomatous polyps and an increased risk of malignancy. Peutz-Jeghers polyps in the bowel may result in intussusception. This complication usually manifests with abdominal pain and signs of intestinal obstruction.We report the case of a 24-year-old Caucasian male who presented with melaena. Pigmentation of the buccal mucosa was noted but he was pain-free and examination of the abdomen was unremarkable. Upper gastrointestinal endoscopy revealed multiple polyps. An urgent abdominal computed tomography (CT) scan revealed multiple small bowel intussusceptions. Laparotomy was undertaken on our patient, reducing the intussusceptions and removing the polyps by enterotomies. Bowel resection was not needed.Melaena in PJS needs to be urgently investigated through a CT scan even in the absence of abdominal pain and when clinical examination of the abdomen shows normal findings. Although rare, the underlying cause could be intussusception, which if missed could result in grave consequences. Peutz-Jeghers syndrome (PJS) is a rare familial disorder, with an incidence of 1 in 12-30,000 live births [PJS presents with characteristic flat, pigmented, freckle-like cutaneous lesions mainly on the lower lip, perioral area, buccal mucosa, periorbital area and eyelids. The syndrome is also associated with gastrointestinal and extragastrointestinal hamartomatous polyps. The typical pathological feature of Peutz-Jegher polyp (PJP) is a smooth muscle core arising from the muscularis mucosae and ramifying into the substance of the polyp like the branches of a tree.The World Health Organisation (WHO) clinico-pathological criteria for diagnosing this rare disorder are :1. Three or more polyps, which show histological features consistent with PJS.2. A family history of PJS with any number of PJPs.3. A family history of PJS with characteristic mucocutaneous pigmentation.4. Characteristic mucocutaneous pigmentation with any number of PJPs.Individuals with this condition carry a very high risk of developing not only gastrointestinal adenocarcinoma but also extra-gastrointestinal malignancies in the breast, pancreas, testes and ovary ,6. CompaPublished review articles can be referenced for further information about this disease ,8. Of thA 24-year-old Caucasian man presented with an acute onset of melaena to the Emergency Department of our hospital. He had no abdominal pain, or history of change in bowel habit or any significant loss of weight or appetite. He was previously healthy and took no regular medications. He had no family history of gastrointestinal disorders. Our patient was also a non-smoker and had no history of illicit drug use.Upon admission, he was hypotensive and tachycardic. However, abdominal examination was completely unremarkable. Rectal examination revealed black tarry stool. Multiple dark pigmented patches were noted on the buccal mucosa of our patient. Laboratory tests revealed microcytic, hypochromic anaemia with a haemoglobin of 7.6 gm%. Blood urea was elevated at 12 mmol/litre. Initial assessment showed no other abnormalities.He was resuscitated and required transfusion of six units of blood. Urgent upper gastrointestinal endoscopy revealed polyps in the stomach and duodenum, but no active bleeding sites were found. The presence of buccal pigmentation and multiple polyps on endoscopy suggested a diagnosis of PJS. A computed tomography (CT) scan of the abdomen of our patient was therefore performed. This confirmed multiple small bowel intussusceptions. Figure Urgent laparotomy was undertaken on our patient and the intussusceptions were reduced. Through enterotomies, eight polyps were removed from the affected segment of the gut. The affected segment of gut was found to be viable. He had a fairly uneventful recovery with no further bleeding. Pathological examination of the polyps confirmed hamartomas with smooth muscle arborisation, compatible with Peutz Jeghers polyps. No features of pseudo-invasion were noticed in any of the polyps. Figure Enteric intussusception in adults is very rare and more than 90% of cases are associated with a pathological leading point. In the study conducted by Chiang and Lin, nearly 18% of incidences of hamartomas caused enteric intussusception. Ileo-ileal intussusception was the most common type. About 90% of cases presented with abdominal pain, while 40% exhibited signs of proximal small bowel obstruction. Rare presentations were diarrhoea, bleeding and anaemia. Abdominal CT scan was shown to be the most effective diagnostic instrument .Our patient presented to the Emergency Department with melaena, and on clinical examination the abdomen was completely unremarkable. Since the presentation was that of upper gastrointestinal bleeding, initial management would normally be conservative, followed by endoscopy and further intervention according to need . HoweverThe CT scans obtained in this case showed presence of several ileo-ileal intussusceptions. Figure Management of melaena from non-variceal causes has been extensively reviewed in the literature . PrognosIt has been widely debated whether reduction of intussusception should precede resection. Reduction of large bowel intussusceptions runs the risk of perforation and contamination of the peritoneal cavity with faeces or tumour cells . Therefore, en bloc resection before reduction is advocated with large bowel intussusceptions, whereas reduction may be attempted in small intestine ,19. In oWe conclude that melaena in a case of PJS may indicate an underlying surgical emergency like intussusception, which if missed can result into bowel ischaemia with grave consequences. Though a series of similar cases would be needed to formulate a generalised treatment plan for all such cases in this category, the significance of an urgent abdominal imaging to exclude a surgical pathology is well-reflected in our case report.CT: Computed Tomography; PJS: Peutz-Jeghers Syndrome; PJP: Peutz-Jeghers polyps.Written informed consent was obtained from the patient for publication of this case and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.SB and SM prepared the manuscript and got the consent of the patient. RN, AP, VJ, GM and JRM independently reviewed the manuscript and made corrections. AP contributed the radiology images and ER contributed the histology images. All authors have read and approved the final version of the manuscript.Table S1. Rockall Score.Click here for fileTable S2. Blatchford Score - Scoring system identifying patients with upper gastrointestinal bleed, who would need intervention.Click here for file


Psammocarcinoma of ovary is a rare serous neoplasm characterized by extensive formation of psammoma bodies, invasion of ovarian stroma, peritoneum or intraperitoneal viscera, and moderate cytological atypia. Extensive medlar search showed presence of only 28 cases of psammocarcinoma of ovary reported till date.We herein report a case of psammocarcinoma of ovary with serous cystadenofibroma of contralateral ovary in a 55 year old Asian Indian female.To the best of author's knowledge, ours is the rare case describing coexistence of this very rare malignant serous epithelial tumor with a benign serous cystadenofibroma of contralateral ovary. Psammocarcinoma of ovary is a rare serous neoplasm. Diagnosis requires the psammoma bodies to be present in at least 75% of papillae which show a destructive invasion of the ovarian stroma. The neoplastic cells do not show more than moderate atypia. There should be no areas of solid proliferation of neoplastic cells. These tumors are associated with a better prognosis than conventional serous neoplasms with low recurrence following tumor resection . LiteratA 55-year-old Asian Indian female presented to gynecology clinic with complaints of menorrhagia, abdominal discomfort and pain. On Examination a mass was palpable in the lower abdomen which was non tender and fixed. Ultrasound (USG) examination revealed the presence of an abdomino-pelvic mass and ascites. Contrast-enhanced computed tomogram (CECT) revealed an abdominopelvic lobulated calcified mass measuring 17 × 15 × 16 cms Fig . ClinicaPsammocarcinoma of ovary is a rare serous neoplasm which can arise from both peritoneum and ovaries . ExtensiThis tumor can be misdiagnosed as other calcifying tumors of abdomino-pelvic region especially calcified leiomyomas, by radiological investigations, similar to our case. However if calcified abdomino-pelvic tumors are seen in association with an elevated CA-125 level, then a diagnosis of ovarian neoplasm can be made . In mostAlthough most of the cases reported are unilateral, rarely these are bilateral ,13.All but one, cases reported in the literature had FIGO stage III tumors showing clinical behavior similar to that of borderline serous tumors . Our casDespite the apparent low malignant potential of this tumor, there remains a need for patient's follow up data as aggressive behavior has been described in the literature ,15,16. IHistopathologic differential diagnosis of psammocarcinoma involves other serous epithelial tumors. Some rare cystadenofibromas have mild cytologic atypia and may also exhibit psammoma bodies, but they are generally inconspicuous. In the present case we have seen cystadenofibroma in the contralateral ovary with an occasional psammoma body formation. Earlier, association of psammocarcinoma with cystadenofibroma has been documented ,8. AlthoPotential mechanisms responsible for the characteristic, extensive psammoma body formation include the accumulation of successive layers of calcium on single necrotic or degenerated tumor cells. One hypothesis states that they arise due to accumulation of hydroxyapatite in degenerating cells . PsammomThe molecular features of psammocarcinoma include mutations of a gene belong to the cancer related RAF family, that is BRAF .Hiromura et al  describeLike with other serous epithelial tumors of the ovary, aggressive debulking surgery has been the initial treatment modality in nearly all cases. Postoperative therapies have included observation, tamoxifen and cytotoxic chemotherapy  .Psammocarcinomas are rare serous neoplasms. Due to the rare aggressive nature of the tumor, it is important to follow up the patient closely. Our case adds a new case of psammocarcinoma with contralateral cysadenofibroma in the literature.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.DJ, NK, VK, PA participated in conception of the idea, writing of the manuscript, and interpretation of histological assays. LA collected data. DJ participated in interpretation of biopsies, review of the literature, and writing of the manuscript.


Blue rubber bleb naevus syndrome (BRBNS), is an uncommon condition characterised by cavernous haemangiomas of skin and gastrointestinal tract. The most common complication of this syndrome is gastrointestinal bleeding. Intussusception of bowel, although a known complication, has rarely been reported.We report the case of a 37-year-old man who presented with multiple intussusceptions of small bowel. He required an urgent laparotomy and bowel resections. He suffered from BRBNS. This is the first reported case of multiple synchronous intussusceptions affecting both jejunum and ileum, secondary to haemangiomas occurring in an adult with BRBNS. The underlying conditions of acute abdomen in patients with BRBNS may include intramural haemorrhage, infarction, volvulus or intussusception of bowel. Treatment options include pharmacological manipulation, bowel resection, and interventions such as sclerotherapy, angiographic embolisation, endoscopic ligation, electrocautery and laser photocoagulation for visceral lesions.A high index of suspicion is required whilst dealing with acute abdomen in patients with BRBNS. Clinical trials may provide some answers as to the preference of treatment in individual cases, as the current level of evidence does not offer a clear choice of optimal treatment. Management of acute abdomen in a patient suffering from blue rubber bleb naevus syndrome can be challenging. We report a unique case of intestinal intussusception in such a patient, who was treated successfully without any complication. We discuss relevant details and provide a review of literature. Optimal management of this condition remains unclear. We intend to make readers aware of potentially serious underlying conditions while dealing with acute abdomen in patients of blue rubber bleb naevus syndrome and highlight the need for optimising various treatment options.A 37-year-old male presented at Accident and Emergency department with chief complaints of colicky abdominal pain, nausea and vomiting of twelve hours' duration. The pain was generalised in nature, moderate in severity, and not associated with any aggravating or relieving factor. There was no alteration of bowel habit. His past medical history included multiple blood transfusions for 'anaemia' since childhood, Hepatitis C and blue rubber bleb naevus syndrome (BRBNS). The latter was diagnosed following 'bowel surgery for internal bleeding' seven years ago at a different hospital. He had been treated with endoscopy-guided argon plasma coagulation and interferon α therapy to induce regression of gastrointestinal haemangiomas with limited success. No other family member had suffered from a similar condition.9/l, platelet 144 × 109/l. Urea, creatinine, electrolytes, liver function tests, amylase and coagulation screen were within normal limits. Plain X-ray of chest was normal. Abdominal radiograph showed distended loops of small bowel. Computed Tomography (CT) of abdomen revealed i)dilated loops of small bowel ii)'doughnut' signs, suggestive of intussusception, affecting small bowel at three different levels iii)subcapsular hepatic haemangiomas affecting segment six and iv)intramuscular haemangioma involving right quadratus lumborum muscle  sclerotherapy, ii) angiographic embolisation, ii) endoscopic (sometimes assisted by enterotomy) ligation, electrocautery and laser photocoagulation ,21. BoweWe describe a unique case of blue rubber bleb naevus syndrome, a rare disease manifested by distinctive cutaneous and gastrointestinal haemangiomatous lesions. The commonest presentation is iron deficiency anaemia. The cutaneous lesions may serve as warning signs of possible intestinal intussusception, intramural haemorrhage, infarction or volvulus in patients presenting with acute abdomen. Many therapeutic options are available, but no single therapy has yet been established as the treatment of choice. Future research involving well designed trials may shed light in this area.BRBNS – Blue rubber bleb naevus syndromeCT – Computed tomographyThe author(s) declare that they have no competing interests.CL: Involved in peri-operative care including all investigations, designed the case report, collated the information, searched literature and drafted the manuscript.DD: Involved in peri-operative care including all investigations, designed the case report, collated the information, searched literature and drafted the manuscript.TW: Involved in peri-operative care and all investigations, assisted in providing a critical appraisal of the manuscript.MF: Made the radiological diagnoses and assisted in preparing radiology image, advised on the format and design of the manuscript.FG: Performed the surgery, involved in all investigations, assisted in literature search, writing and editing of the manuscript.All authors have reviewed and approved the final manuscript.


An 83-year-old man presented with worsening of respiratory discomfort and underwent close examination, which revealed a large mediastinal lipoma measuring 15 × 10 cm. The patient showed heart failure symptoms due to heart compression by tumor. The tumor was completely removed safely and reliably by cutting the ascending aorta, main pulmonary artery and superior vena cava. Although preoperative examination could not determine whether the tumor was lipoma or liposarcoma, we selected an invasive surgical therapy because neither radiation therapy nor chemotherapy was considered effective for either type of tumor. We report here a very rare case of heart-compressing mediastinal tumor. Mediastinal lipoma is a rare tumor of the mediastinum and causes few clinical symptoms . Even ifAn 83-year-old man showed sinus rhythm on echocardiography, but occasionally showed paroxysmal atrial fibrillation suspected to be due to left atrial compression. With respiratory discomfort worsened to NYHA III, the patient underwent close examination by computed tomography and was found to have a large tumor 15 × 10 cm) behind the ascending aorta and pulmonary artery and compressing the right and left atria  and adjacent to the posterior aspect of the left atrium, we considered it difficult to perform thoracoscopic surgery due to high risk of bleeding . There a cm and aWe encountered an aged patient with heart failure symptoms of NYHA III who was found to have a large mediastinal tumor and obtained a favorable outcome through complete removal of the tumor after cutting of the ascending aorta, main pulmonary artery and superior vena cava. Although we were aware of the high risk of surgery, we selected an invasive treatment option in consideration of the need for a good surgical field due to the large tumor and for complete removal of the tumor due to high possibility of recurrence. The selected treatment strate allowed the patient to return to his daily activities without recurrence for at least 18 mon postoperation.The authors declare that they have no competing interests.MN was the primary caregiver for this patient and reviewed the manuscript. KK and TH also cared for this patient. NM performed data collection and drafted the manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Choledochal cysts are rare congenital anomalies. Their diagnosis is difficult, particulary in adults.This case report demonstrates the diagnostic and therapeutic pitfalls.To prevent cost-intensive and potentially life-threating complications, a choledochal cyst must be considered in the differential diagnosis whenever the rather common diagnosis of a hepatic cyst is considered. Choledochal cysts are rare congenital, but not familial, anomalies of the intrahepatic or extrahepatic biliary tract. Cystic dilatation may affect every part of the biliary tree and may occur singly or in multiple numbers. The incidence in the population is 1:100000 to 1:150000 . The mosThe leading symptoms include cholestatic jaundice and abdominal pain. A palpable abdominal mass occurs in less than 20% of the cases. In adults, chronic and intermittent abdominal pain is the most common symptom. Recurrent cholangitis and jaundice may also occur. A choledochal cyst is rarely symptomatic, but should be considered if dilatation of the bile duct or the ampulla is demonstrated.The main diagnostic tool for detection of a choledochal cyst, especially in childhood, is ultrasonography. In adults, computer tomography can confirm the diagnosis; however, endoscopic retrograde cholangiography or magnetic resonance cholangiography are the most valuable diagnostic methods and can accurately show cystic segments of the biliary tree .Surgery is the treatment of choice for a choledochal cyst. Complete excision of all cystic tissue is recommended because of the risk of recurrent cholangitis and the high risk of malignant degeneration . ExcisioIn comparison, simple congenital hepatic cysts are very common. Their incidence is 1:40 in the population and simple congenital hepatic cysts represent the most important differential diagnosis . These cOur case report of a young female with a choledochal cyst emphasizes the difficulties of arriving at the correct diagnosis and documents the efficacy of surgical treatment.A 19-year-old Russian woman  with non-specific upper abdominal pain presented to a local hospital for evaluation. She complained of recurrent pain for weeks. Clinical examination revealed neither jaundice nor a palpable abdominal mass. The clinical laboratory data were normal.Ultrasonography revealed a hypoechogenic, nearly spheric, homogenous formation with a smooth contour in direct contact with the underside of the liver and without any intermediate layer. The finding was most compatible with a large hepatic cyst. Computer tomography showed a clearly limited, hypodense, homogenous structure with a transverse diameter of 11 cm in the immediate vicinity of the liver, anterior to the right kidney, and posterior to the gall bladder  was easily mistaken, as may frequently happen, for a much more common solitary congenital liver cyst (1: 1000), especially if typical symptoms are absent in a large cyst ,9.Ultrasonography is usually the first examination and is very sensitive in the detection of cystic structures, but rather non-specific in identifying their origin. The diagnosis of the choledochal cyst in our case report may have been missed because the technical quality of the examination may not have allowed for recognizing the anatomic pathology. A computer tomography usually can give more information and modern techniques, including reconstruction, should allow for establishing the diagnosis. However, the radiologist did not ascertain any signs of separation because the choledochal cyst had immediate contact with the liver and a simple liver cyst was suggested. Endoscopic retrograde cholangiography or magnetic resonance cholangiography can precisely visualize the extrahepatic bile duct and these are the most specific diagnostic procedures. Since endoscopic retrograde cholangiography and magnetic resonance cholangiography are more invasive, they were not done in this case because the computer tomography and ultrasonography findings were considered valid and reliable.The treatment of a choledochal cyst has changed. In the past, a cysto-jejunostomy was the standard procedure. Currently, excision of the cyst and reconstruction by hepatojejunostomy is the standard therapy .This case report also demonstrates the intraoperative difficulties in identifing a choledochal cyst. Retrospectively, an entire exploration, including elevation of the liver, should have been able to demonstrate a clear separation of the cystic structure from the liver. This intraoperative exploration should be performed and prompt any surgeon to dispute the preoperative diagnosis. Laparoscopic fenestration of a hepatic cyst is the appropriate approach. However, the finding of bile, and of even greater significance, two bile ducts, while possible, is so unusual for a hepatic cyst that it justifies an intraoperative re-evaluation by cholangiography. An intraoperative cholangiography in this case would have clarified the anatomy and pathology beyond any doubt.The case demonstrate the diagnostic and therapeutical difficulties in the treatment of choledochal cysts. To prevent such complications it is important to include the choledochal cyst firstly in the differential diagnosis.The author(s) declare that they have no competing interests.UW wrote the manuscript and did the literature search. DHB had a supervisory role. KB provided editorial assistance and was involved in the clinical treatment. All authors read and approved the final manuscript.The written informed consent of the patient was obtained for this publication.


A case is reported of a large hepatic tumor in a patient aged 71. Preoperative diagnostic techniques,including echography, CT and angiography, did not provide sufficient criteria for a precise diagnosis.The mass was removed with an extended right hepatectomy with no particular physiopathologicalconsequences. Histological analysis revealed that this was a metastasis from a melonoma of the choroid,operated on 17 years previously.